Smoking behaviour among young adults: beyond youth prevention

Objective: There is a widespread assumption that smoking behaviour is largely established by the age of 18 years. As a result, smoking prevention has focused almost exclusively upon youth. However, recent trends suggest that young adulthood may be an important—and largely overlooked—period in the development of regular smoking behaviour. The current study sought to examine patterns of tobacco use among young adults (aged 18–29 years) and to address the implications for tobacco control policy.

Design: Data are presented from the 2003 Canadian Tobacco Use Monitoring Survey, a national survey of smoking behaviour (n = 10 559, response rate 89%).

Main outcome measures: Measures of smoking behaviour, smoking initiation, susceptibility to smoking, and occupational status.

Results: A total of 1.4 million or 28% of young adults in Canada currently smoke, the highest proportion among all age groups. The prevalence of daily smoking rose from 8% among youth to 22% among young adults, and approximately one fifth of smokers tried their first cigarette after the age of 18 years. Smoking behaviour among young adults was also distinct from older smokers: young adults were more likely to be occasional smokers and reported lower daily consumption. Finally, smoking prevalence and cessation rates varied substantially within subgroups of young adults, as characterised by occupational setting.

Conclusions: Dramatic increases in the proportion and intensity of smoking occurs after the age of 18 years. Smoking behaviour among young adults is distinct from both youth and older adults, and warrants immediate attention from the public health community.

     

Tobacco use among young adults in Norway, 1973-95: has the decrease levelled out?

OBJECTIVE: To describe the prevalence of tobacco use among young Norwegian adults, 1973-1995. DESIGN: Cross sectional personal and telephone surveys. SETTING: Norway, 1973-1995. PARTICIPANTS: Population based samples of Norwegians aged 16-74 years. RESULTS: A trend to a decline in tobacco use among young adult Norwegians during the 1960s and 1970s levelled out during the 1980s. Hence, the total prevalence of smoking in Norway decreased by only two percentage points from 1980 to 1993, as compared to approximately 10 percentage points in many other European countries. An increase in smoking prevalence (and in the use of snuff among males) in the age group 16-19 years has been observed in recent years. Thus smoking prevalence among young males and females in 1995 was comparable to that observed in the early 1980s. CONCLUSIONS: Trends in tobacco use reflect an underutilization of preventive measures in general, and health education measures in particular. Financial resources appropriated for health education and information were reduced by 90% during the 1980s.


     

Cigarette smoking patterns among young adults aged 18-24 years in the United States.

Most tobacco control programs focus on prevention for children or cessation for adults. Little is known about cigarette smoking among young adults. This study examined sociodemographic variables associated with current, daily, heavy, and light smoking among young adults in the United States. Data from the 1998-1999 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) were used to examine cigarette smoking patterns and correlates of smoking among 15,371 young adults aged 18-24 years. We found that 26% of young adults were current smokers, 20% were daily smokers, and 8% were former smokers. Current smoking rates were higher among American Indians/Alaska Natives (33%) and Whites (31%) than among other racial/ethnic groups. Compared with white-collar workers, blue-collar and service workers were more likely to report current and daily smoking. Blue-collar workers also were more likely to report heavy smoking (OR = 1.97). The unemployed (those in the labor force but not currently working) and those reporting an annual household income of less than US$20,000 were more likely to report current, daily, and heavy smoking, compared with those not in the labor force and those reporting an annual household income of $20,000 or more, respectively. Young adults not currently enrolled in school were more than twice as likely to report current (OR = 2.36) and daily (OR = 2.90) smoking, compared with those currently enrolled in school. Differential cigarette smoking patterns by race/ethnicity, occupation, employment status, household income, and school enrollment status should be considered when developing interventions to reduce smoking among young adults.     

Sex and race differences in young people's responsiveness to price and tobacco control policies

OBJECTIVE: To determine if there are differences in young people's responsiveness to price and tobacco control policies for population subgroups and to examine whether or not these differences, if they exist, can explain sex and racial differences in trends in the prevalence of smoking in young people in the United States. DESIGN: Use cross-sectional and intertemporal variation in local and state tobacco control policies and prices to calculate demand responses to these policies using regression analysis techniques. SUBJECTS: A nationally representative sample of American eighth grade (ages 13-14 years), 10th grade (15-16 years) and 12th grade (17-18 years) students obtained from the 1992-1994 Monitoring the Future surveys. MAIN OUTCOME MEASURE: Thirty-day smoking prevalence. RESULTS: Young men are much more responsive to changes in the price of cigarettes than young women. The prevalence elasticity for young men is almost twice as large as that for young women. Smoking rates of young black men are significantly more responsive to changes in price than young white men. Significant differences in responsiveness to particular tobacco control policies also exist. These differences, however, explain relatively little of the differences in smoking prevalence among young population subgroups. CONCLUSIONS: Policymakers need to keep in mind that there is not a "one-size fits all" strategy for discouraging smoking among young people.     

What fraction of young adults are at risk for future smoking, and who are they?

Recent evidence indicates that higher smoking rates among young adults in the United States may be related in part to increased initiation during young adulthood. The tobacco industry, restricted from overtly targeting adolescents, appears to be focusing on young adults. Thus it is important to estimate the percentage and identify the characteristics of the young adult population (aged 18-29 years) at risk for future smoking. This group would include all current established smokers (smoked at least 100 cigarettes in their lifetime), current experimenters, former established smokers, and former experimenters at risk for smoking again, as well as never-smokers who do not rule out future smoking. Using data from the population-based 2002 California Tobacco Survey (N = 9,364 young adults aged 18-29 years), we designated groups of young adults at risk and identified factors associated with risk. Altogether, 86.7+/-1.5% of current and former established smokers were at risk for future smoking, and 59.6+/-4.3% of former established smokers were at risk. Over half (52.2+/-2.0%) of all experimenters but only 9.0+/-1.2% of never-smokers were at risk. Overall, 43.0+/-1.2% of the young adult population was at risk. Although different demographic and other factors were associated with risk among former established smokers, experimenters, and never-smokers, three factors were consistently associated in each group: Younger age, not having a smoke-free home, and going to bars and clubs. We conclude that the group of young adults at risk for future smoking is sizable and presents a fertile target for tobacco industry efforts to promote smoking. Counter-efforts might include promotion of smoke-free environments.     

Effects of market liberalisation on smoking in Japan

OBJECTIVE: To document the effect of the liberalisation of the Japanese tobacco market on Japanese smoking rates and on Japanese tobacco industry practices. DATA SOURCE: Asahi Shimbun (major daily newspaper) from 1980 to 1996. STUDY SELECTION: Review of media coverage on the effects of market liberalisation following the imposition of the USA's section 301 trade sanction. DATA SYNTHESIS: The opening of Japan's tobacco market to foreign cigarette companies stalled a decline in smoking prevalence. Smoking rates among young women increased significantly, and also appear to be on the rise among adolescents. Aggressive marketing and promotional activities by US and Japanese tobacco companies in response to trade liberalisation appear responsible for these adverse trends. Steep increases in sales through vending machines were also possible contributors to the rising smoking prevalence among adolescents. On the positive side, market liberalisation indirectly promoted smoking control efforts in Japan, by causing an anti-smoking movement to coalesce. CONCLUSION: Market liberalisation in Japan played a significant role in increasing smoking prevalence among young women and adolescents while helping to transform the issue of smoking in Japan from a matter of individual choice to a public health problem.     

Smokeless tobacco use among professional baseball players: survey results, 1998 to 2003

Objective: The use of smokeless tobacco (ST) (snuff and chewing tobacco) has long been associated with baseball in the USA. This article reviews six years of survey data from major and minor league baseball players to evaluate trends in tobacco use and quitting patterns over time in order to gain insight into the effects of past interventions and to document continued intervention needs.

Method: Surveys were distributed by athletic trainers to major and minor league professional baseball players during spring training session in the six years from 1998 to 2003. The surveys were anonymous and identified only by team, level of league, and other self reported demographic data.

Results: ST use among professional baseball players remains much higher than among young males in the general population, and use is most prevalent among white non-Hispanic players. There was a significant decrease in ST use among minor league players from 1998 to 2003, with seven day self reported use declining from 31.7% in 1998 to 24.8% in 2003. No significant year to year changes were observed for major league players. Major league players' self reported past week use rates, estimated at 35.9% in 1998 and at 36% in 2003, were consistently higher than those of minor league players. Self reported prevalence of past month cigarette and cigar smoking was much lower than ST use for both major and minor league players.

Conclusions: Six years of survey data confirm a continuing high use of ST among professional baseball players. Results suggest that the effects of the broad spectrum ST control efforts launched over the past decade may have been stronger among minor than major league players. Stronger policy interventions at the major league level and multi-level efforts, including programmes to increase the use of effective quitting aids and assistance, at both levels of play are needed. Future research is needed to further clarify changes in ST practices among professional players and set policy intervention directions.

     

Tobacco control policies and the concurrent use of smokeless tobacco and cigarettes among men, 1992-2002.

Accelerating the decline in smoking prevalence requires an understanding of changes in the concurrent use of and the substitution between different tobacco products, such as smokeless tobacco (SLT) and cigarettes. SLT could play an important role in reducing the toll of smoking-related illness and premature mortality. Research examining the role of tobacco control policies in explaining concurrent use of SLT and cigarettes has been minimal. Using the Current Population Survey Tobacco Use Supplements (CPS-TUS), we examined tobacco control policies in relationship with adult males' SLT use concurrent with smoking over the period 1992-2002. Consistent with the decline in smokeless-only and cigarette-only rates, concurrent use of SLT and cigarettes declined during the period. SLT users, faced with home or workplace smoking bans, are less likely to report smoking. Smokers with a home ban appear more likely to use SLT, but in more recent years, smokers with a workplace ban are less likely to use SLT. Tobacco excise taxes do not signal substitution between cigarettes and SLT products. Understanding current use patterns of the range of tobacco products, including their interaction with available policy levers, is vital in assessing whether changes that might promote substitution of arguably less toxic SLT products for highly toxic cigarettes are likely to lead to net public health gains or losses. Findings of the present study, in concert with other research about transitional probabilities between behavioral states, will inform the design of an effective policy framework that supports the objective of reducing tobacco-related death and disease.     

Prevalence and characteristics of smokers at 30 Pacific Northwest colleges and universities.

College is an important transition period during which young adults explore tobacco use. Few large-scale studies have been conducted among college students regarding tobacco use. We initiated a study examining tobacco use in 30 colleges and universities in the Pacific Northwest. We conducted a baseline survey among students. Sample size varied by the school size; for the 14 largest schools, we drew a random sample of all students, oversampling freshmen (n approximately 750) so that we could recruit and follow a cohort to assess smoking onset during the college years. Of the remaining students, we sampled equivalent numbers of sophomores, juniors, and seniors (n = 200 each). For the 16 schools with fewer than 1,350 students, we surveyed all students. We found overall smoking rates of 17.2%. Males (18.6%) were more likely to smoke than females (16.6%; p = .03), and public college students were more likely to smoke (20.5%) than those who attended private independent schools (18.9%; p = .61), whose rates were higher than those of private religious schools (11.6%; p = .001). Overall, college students are light smokers who do not smoke every day of the month. Further, they tend not to be highly dependent on tobacco, do not consider themselves regular smokers, and plan to quit before they graduate (56.8%). School type should be considered when estimating smoking rates among 4-year college students. Data indicate that college smokers wish and plan to quit before graduation, suggesting that efforts to assist smokers in quitting during the college years may be fruitful.     

Trends in adolescent smoking initiation in the United States: is tobacco marketing an influence?

OBJECTIVE: To compare recent trends in smoking initiation by adolescents with trends in inflation-adjusted cigarette pricing and tobacco marketing expenditures. DESIGN: We examined smoking initiation trends in demographic subgroups of adolescents aged 14-17 years during the decade 1979-1989. Data on cigarette pricing and tobacco marketing expenditures were adjusted for inflation and plotted over this same period. SETTING: Large population surveys, United States. SUBJECTS: 140,975 ever-smokers aged 17-38 when surveyed in 1992 or 1993, who reported on age of smoking initiation during the decade 1979-1989. MAIN OUTCOME MEASURE: Initiation rate was calculated as the number in an age group who reported starting to smoke regularly in a year, divided by the number of never-smokers at the start of the year. Trends were evaluated by linear and quadratic models. RESULTS: From 1979 to 1984, adolescent initiation rates decreased, but increased thereafter, particularly among males, whites, and those who, as adults, reported never having graduated from high school. Cigarette price increased throughout the decade as did tobacco marketing expenditures, especially for coupons, value-added items, and promotional allowances. CONCLUSION: Availability of cheaper cigarettes is not likely to be a cause of increased smoking initiation by adolescents. Although other influences cannot be ruled out, we suspect that the expanded tobacco marketing budget, with its increased emphasis on tactics that may be particularly pertinent to young people, affected adolescent initiation rates.


     

Consensus for tobacco policy among former state legislators using the policy Delphi method

OBJECTIVE: To test a novel approach for building consensus about tobacco control policies among legislators. DESIGN: A pilot study was conducted using a two-round, face-to-face policy Delphi method. PARTICIPANTS: Randomly selected sample of 30 former Kentucky legislators (60% participation rate). MAIN OUTCOME MEASURE: Consensus on tobacco control and tobacco farming policies. RESULTS: Former state legislators were more supportive of tobacco control policies than expected, and highly supportive of lessening the state's dependence on tobacco. Former state legislators were in agreement with 43% of the second-round items for which there was no agreement at the first round, demonstrating a striking increase in consensus. With new information from their colleagues, former lawmakers became more supportive of workplace smoking restrictions, limitations on tobacco promotional items, and modest excise tax increases. CONCLUSIONS: The policy Delphi method has the potential for building consensus for tobacco control and tobacco farming policies among state legislators. Tobacco control advocates in other states might consider using the policy Delphi method with policymakers in public and private sectors.     

Patterns of smoking in Bulgaria

BACKGROUND: Although the rate of smoking-related deaths in Bulgaria is still relatively low, in international terms, it has been rising rapidly. This is likely to become worse in the future as Bulgaria faces growing pressure from transnational tobacco companies. There is, however, little information on patterns of smoking, which is necessary for development of effective policies to tackle tobacco consumption. OBJECTIVE: To describe the pattern of smoking in Bulgaria and its relationship with sociodemographic factors. DESIGN: Multivariate analysis of data on patterns of tobacco consumption from a multi-stage nationwide survey of 1550 adults. SETTING: Bulgaria, in 1997. MAIN OUTCOME MEASURE: Prevalence of current cigarette smoking. RESULTS: 38.4% of men and 16.7% of women smoke. Smoking rates are strongly associated with age, with 58% of men and 30% of women aged 30-39 smoking whereas only 5% of men aged 70 years and older and almost no women of this age smoke. Smoking is more common in cities, among those who are widowed or divorced, or who do not own their home. There is no clear association with household income or, for men, with education, although there is a suggestion that smoking may be more common among more highly educated women. CONCLUSIONS: The observed pattern of smoking indicates the need for a robust policy to tackle smoking in Bulgaria, especially among the young in large cities, informed by a better understanding of why smoking rates vary among different groups.     

Teen penalties for tobacco possession,use, and purchase: evidence and issues

A handful of empirical studies have related changes in youth smoking to popular laws that penalise tobacco possession, use, and purchase (PUP). In this paper, we review the literature and outline reasons why PUP laws may be unlikely to reduce youth smoking significantly at the population level. In theoretical terms, we argue that PUP laws lack important features required for punishment to be effective in changing behaviour. In practical terms, PUP transgressions seem difficult to detect. Conceptually, there is potential for PUP laws to undermine conventional avenues of discipline, such as the parent-child relationship and the school environment. Strategically, PUP laws may divert policy attention from effective tobacco control strategies, relieve the tobacco industry of responsibility for its marketing practices, and reinforce the tobacco industry's espoused position that smoking is for adults only. To assist further debate and discussion, we identify research issues requiring attention.     

Changes in smoking prevalence in Ukraine in 2001-5

Objectives

To analyse trends in smoking prevalence in Ukraine from three surveys conducted in 2001–5, and to explore correlates of observed changes, in order to estimate the stage of tobacco epidemic in Ukraine.

Design

Repeated national interview surveys in Ukraine in 2001, 2002 and 2005.

Main outcome measure

Prevalence of current smoking among the population aged ⩾15 years.

Results

The age‐standardised prevalence of current smoking in Ukrainian men was 54.8% in 2001 and 66.8% in 2005. Among Ukrainian women, prevalence increased from 11.5% in 2001 to 20.0% in 2005. ORs for yearly increase in prevalence were estimated as 1.164 (95% CI 1.111 to 1.220) for men and 1.187 (1.124 to 1.253) for women, which implies that, on average, 3–4% of men and 1.5–2% of women living in Ukraine join the smoking population each year.

Conclusions

In Ukraine, smoking prevalence is increasing in most population groups. Among men, the medium deprivation group with secondary education has the highest smoking prevalence. Among women, while the most educated, young and those living in larger cities are the leading group for tobacco use, other groups are also increasing their tobacco use. Tobacco promotion efforts appear to have been significantly more effective in Ukraine than smoking control efforts. The decrease in real cigarette prices in Ukraine in 2001–5 could be the main factor explaining the recent growth in smoking prevalence.Ukraine is a large eastern European country with high smoking prevalence. Tobacco products are widely available at very low prices, and the transnational tobacco industry is extremely successful in promoting its products and lobbying for its interests in the legislative field. Advocacy of tobacco control has only recently achieved some success in the legislative field, with the first tobacco control law being adopted in late 2005. Ukraine ratified the Framework Convention on Tobacco Control in 2006, but there is still much cause for concern regarding the enforcement and effectiveness of the adopted legislative measures. Unfortunately, the government is not yet involved in nationwide surveillance of the tobacco problem, and the available data have mostly been gathered with funding from foreign donors. Several attempts have been made to measure the extent of the tobacco epidemic in the countries of the former Soviet Union (FSU).^{1,2,3,4,5,6,7} Most of these studies have shown rather high smoking prevalence among men (50–70%) and comparatively low prevalence among women (5–20%). Most countries in the FSU have similar smoking rates, while certain trends are shown to be related to the differences in how the transnational tobacco industry succeeds in every national tobacco market.⁶ Unfortunately, few studies have been published showing trends in smoking prevalence in the FSU.⁷ In Ukraine, two studies^3,4 provided point estimates of smoking prevalence.The aim of this study was to analyse trends in smoking prevalence in Ukraine, on the basis of three surveys conducted in 2001–5, and to explore correlates of observed changes in order to estimate the stage of the tobacco epidemic in Ukraine.     

Smoking,social class,and gender: what can public health learn from the tobacco industry about disparities in smoking?

Objective: To discover how the tobacco industry considers social class and gender in its efforts to market cigarettes in the USA, particularly to socially disadvantaged young women. Methods: A systematic on-line search of tobacco industry documents using selected keywords was conducted, and epidemiological data on smoking rates reviewed. Results: The two largest cigarette manufacturers in the USA consider "working class" young adults to be a critical market segment to promote growth of key brands. Through their own market research, these companies discovered that socially disadvantaged young women do not necessarily desire a "feminine" cigarette brand. Conclusions: Considering the tobacco industry''s efforts, alongside the persistent and growing disparities in cigarette smoking by social class, and the narrowing of differences in smoking by gender, it is concluded that additional tobacco control resources ought to be directed toward working class women.     

Current situation and future challenges of tobacco control policy in Thailand

In Thailand, the prevalence of smoking has steadily declined over the past 20 years, suggesting an effective tobacco control policy. However, the prevalence has recently stabilised and youth smoking now appears to be on the rise. Tobacco use is the third highest risk factor contributing to the burden of disease in the country. This is an issue of concern and led to the present review of tobacco control measures in Thailand. The present evidence-based review shows that Thailand's tobacco control measures are relatively strong and comply well with the WHO Framework Convention on Tobacco Control in terms of taxation, advertisement through popular media, and warning labels on cigarettes and other tobacco product packages. However, challenges remain in dealing with highly prevalent roll-your-own cigarettes, strict prohibition of tobacco sale to underage youths, household smoking, illicit trade of tobacco products, viable tobacco crop diversification for domestic tobacco growers and liability. If these challenges are met, the prevalence of tobacco consumption could possibly be further reduced.     

A method to guide community planning and evaluation efforts in tobacco control using data on smoking during pregnancy

Background: Effective community based tobacco control programmes are critical for state and nationwide impact. However, there is little discussion in the literature of methods for setting local objectives which use locally collected data and account for historical variation in progress.

Objectives: To develop and illustrate a method that uses locally available birth certificate data to model trends in tobacco use during pregnancy among women giving birth, predict future prevalence, and use predictions to set community specific tobacco control objectives.

Data source: Vital statistics. Wisconsin standard birth certificates, 1990–2000, which record the smoking status of the mother during pregnancy.

Data analysis: Trends in the prevalence of smoking during pregnancy in Wisconsin statewide and in all counties (n = 72) were modelled using linear regression of log prevalence on year. Model fit was assessed using R². Regression slopes, indicating estimated relative annual percentage change in prevalence, were used to predict prevalence in 2005, and objectives were calculated as a 20% reduction from the predicted prevalence in 2005.

Conclusions: Modelling trends in the prevalence of smoking using locally collected data enables communities to set reasonable future tobacco control objectives that account for historical trends in progress.

     

Trends and determinants of second-pregnancy smoking among young-adult mothers who smoked during their first pregnancy.

We examined the trends and determinants of second-pregnancy smoking behavior among Michigan young-adult mothers who smoked during their first pregnancy (N = 14,731). Maternally linked Michigan birth certificate data (1989-2004) were used to identify first and second pregnancies for young-adult mothers. ZIP code data were merged with census data to proxy for median household income and population size at the ZIP code level. For first-pregnancy smokers, linear and logistic regressions were used to analyze (a) the determinants of second-pregnancy smoking and (b) the association of birth outcomes with second-pregnancy smoking. Among young adults who smoked during their first pregnancy, second-pregnancy smoking was (a) inversely related to income and population, (b) less prevalent after 1997, (c) more likely after a low-birthweight first birth, and (d) less likely after a premature first birth. Despite recent declines in second-pregnancy smoking rates among young adults who smoked during their first pregnancy, these rates remain disturbingly high (more than 70%). Future smoking cessation efforts should target mothers who have lower incomes, live in less-populated areas, and have previously had low-birthweight babies. The results suggest that higher cigarettes taxes would also further reduce recurrent smoking.     

Waterpipe tobacco smoking: knowledge, attitudes, beliefs, and behavior in two U.S. samples.

Despite evidence of increasing waterpipe tobacco smoking prevalence among U.S. young adults, little is known about the knowledge, attitudes, beliefs, and smoking patterns of waterpipe users in this population. To address this lack of knowledge, two convenience samples of U.S. waterpipe users were surveyed--one from a Richmond, Virginia, waterpipe café (n=101), the other from an Internet forum called HookahForum.com (n=100). Sixty percent reported first-time waterpipe use at or before age 18. Daily waterpipe use was reported by 19%, weekly use by 41%, and monthly use by 29%. Waterpipe use was more common during the weekend (75%) than during weekdays (43%). Forty-four percent reported spending >or=60 min smoking tobacco during a waterpipe session. The majority of waterpipe users owned a waterpipe (57%) and purchased it on the Internet (71%). Many waterpipe users smoked the sweetened and flavored tobacco (i.e., maassel), and fruit flavors were the most popular (54%). Past month use of cigarettes, tobacco products other than cigarettes or waterpipe, and alcohol was 54%, 33%, and 80% respectively, and 36% reported past-month marijuana use. Most waterpipe users were confident about their ability to quit (96%), but only a minority (32%) intended to quit. Most waterpipe users believed waterpipe tobacco smoking was less harmful and addictive than cigarettes. These results are from small convenience samples; more detailed study of a larger group of randomly sampled U.S. waterpipe tobacco smokers will be valuable in understanding this behavior and developing effective strategies to prevent it.     

Prevalence of tobacco use in Eritrea: results from a noncommunicable disease risk factor survey.

The prevalence of noncommunicable diseases in Eritrea is increasing. Tobacco use is a recognized risk factor for most of these diseases, especially cardiovascular disease. No data have been published on tobacco use in Eritrea. The present study sought to establish the prevalence of tobacco smoking in Eritrea. The World Health Organization STEPwise approach was used for the survey, conducted in 2004 on a random national sample size of 2,460 subjects (response rate = 93.7%). The prevalence of tobacco smoking in the general population was 8.1%; the prevalence was 15% among men, compared with 0.6% among women. Prevalence rates were higher in those older than 45 years of age. The prevalence of tobacco smoking was higher among Muslims (11.4%) than Orthodox Christians (5.8%), and among alcohol drinkers (10.2%) than nondrinkers (6.6%). The majority of tobacco users (89.3%) used commercially available cigarettes. A study on knowledge, attitudes, and practices regarding tobacco use is needed to determine the behavioral factors leading to tobacco smoking among the vulnerable groups.