The tobacco industry spends a substantial amount of money on advertisement and promotion of its products. Despite assertions that the advertisements are aimed at maintaining brand loyalty, the tobacco industry recognizes that 14- to 18-year-old consumers are critical to its long-term performance. Persons in this age group are much more likely than those in older groups to have a positive attitude toward tobacco advertisements, to use more brand-name tobacco products, and to identify with the imagery of tobacco advertisements that make smoking look appealing. The decision to smoke is also influenced by peer pressure, family, school environment, and participation in religious activities. Kaufman and colleagues examined the effect of various risk factors and demographics on different stages of smoking in adolescents.

The Robert Wood Johnson Foundation's National Survey of Tobacco Price Sensitivity, Behavior, and Attitudes Among Teenagers and Young Adults was administered to a national, cross-sectional sample of adolescents 13 to 19 years of age. A seven-level variable was developed to measure an adolescent's progress toward regular smoking (see the accompanying figure). Eight risk factors were used in the analysis, including smoking in the home, smoking behavior of friends, school rules about smoking, poor school performance, skipping school, lack of attendance at religious activities, a favorable response to cigarette advertisements, and the influence of tobacco industry promotions.

There were 17,287 adolescents who participated in this survey. Of those identified as nonsmokers, 32 percent were considered susceptible to smoking, with younger adolescents almost three times more susceptible than older adolescents. Girls were more susceptible to smoking than boys. Other risk factors included exposure to other persons' smoking, owning or willingness to own tobacco promotional items, having a favorite cigarette advertisement, skipping school, poor school performance, and lack of attendance at religious activities.

The authors conclude that physicians and tobacco control advocates need to understand the risk factors associated with tobacco use. Their results suggest the need for increased efforts in asking preadolescents and young adults about smoking and the likelihood of smoking. If any of these adolescents are identified as nonsmokers, they still should be advised about the addictive nature of tobacco products and be made aware of risk factors.