Prevalence of tobacco use experiences and/or the number of cigarettes smoked by individuals are commonly used measures to monitor the effectiveness of tobacco control, prevention, and cessation efforts. However, prevalence of cigarette smoking, either in one's lifetime or in the last 30 days, is a rather insensitive measure of the activities and experiences that facilitate the process of change that moves a person toward smoking initiation or cessation. The Stages of Smoking Initiation take into account smoking-related attitudes, intentions, and behaviors and offer a more sensitive measure of change than smoking prevalence rates alone.
- These stages of initiation have been examined in the State of Maryland, using data derived from the 2000 and 2002 Maryland Youth Tobacco Survey (MYTS).
- Please see reports in section on Maryland State Specific Prevalence Data for more detailed information about these surveys (Initial Findings from the Baseline Tobacco Study, First Annual Tobacco Study, Monitoring Changing Tobacco Use Behaviors in Maryland and 2000-2008 Monitoring Changing Tobacco Use Behaviors).
Stages of Smoking Initiation
How Adolescents Start Smoking: The Stages of Smoking Initiation
Up to 5,000 youth begin experimenting with cigarettes and approximately 3,000 youth move from experimentation to regular smoking every day in the United States.1 One-third of these young smokers will become tobacco dependent.2 Eighty percent of regular smokers initiate cigarette use by the age of 18,3 a statistic that has led the Surgeon General to identify cigarette smoking as a pediatric epidemic.4
Adolescence is often cited as a time of great upheaval due to social, emotional, cognitive, and physical changes in development. It is during this time of massive change that adolescents begin defining their identity.5 For example, adolescents are thought to smoke in order to assert their maturity and to strive for autonomy and independence. Social modeling of adult and peer behavior is hypothesized as another important reason for adolescent smoking initiation.6
Over half of those adolescents who smoke regularly want to stop smoking.3 However, when they attempted to quit smoking, more than 90% of adolescent daily smokers reported experiencing at least one symptom of nicotine withdrawal (e.g., difficulty concentrating, irritability, cigarette cravings).7 While approximately 60% of adolescent smokers have attempted to stop smoking during the past year, less than 5% of those who quit were successful in maintaining their abstinence for more than 3 months.3
Behavior changes related to cigarette smoking, including both initiation and cessation, are often viewed as occurring in a series of stages.8 According to the Transtheoretical Model adolescents move through five Stages of Smoking Initiation on the road to developing a regular pattern of behavior: Precontemplation, Contemplation, Preparation, Action, and Maintenance.9
Precontemplation 
Precontemplation describes the stage in which an adolescent is not considering smoking. An adolescent in Precontemplation is a non-smoker who is not thinking about smoking any time in the foreseeable future.
Contemplation 
As an adolescent enters Contemplation, he or she becomes more aware of cigarette smoking, is open to considering smoking, and/or experiences a desire to experiment with cigarettes. This stage describes a large number of adolescents who think about trying smoking, may have experimented, but are undecided and lack a commitment to adopt cigarette smoking.
Preparation 
The Preparation stage includes adolescents who not only are interested in smoking, but also have some intention to smoke in the near future. Someone in the Preparation Stage of Smoking Initiation might seek out others who smoke and they may begin to experiment more regularly with cigarette smoking.
Action 
The Action stage is defined by a pattern of regular smoking behavior lasting up to six months. If smoking is not considered rewarding or causes too many problems, adolescents may move back into one of the earlier Stages of Smoking Initiation.
Maintenance 
During the Maintenance stage, adolescents incorporate cigarette smoking into their daily lives. Adolescents in this stage have an established pattern of regular smoking that has lasted for more than six months and would be considered dependent on cigarettes.
Algorithm for Classifying Stages of Smoking Initiation
The following flow-chart shows how the questions from the 2000, 2002, 2006 and 2008 MYTS were used to create the algorithm that classified adolescents into the five Stages of Smoking Initiation. Initially, the classification consisted of 11 groups, which considered both Level of Experience with cigarette smoking (i.e., Inexperienced, Exposed, and Experienced) and Stage of Smoking Initiation (i.e., Precontemplation, Contemplation, Preparation, Action, and Maintenance).
Consistent with the five stages proposed by the Transtheoretical Model, the groups were collapsed into five Stages of Smoking Initiation. Accordingly, all adolescents in the Precontemplation Stage of Smoking Initiation (i.e., Inexperienced, Exposed, and Experienced Precontemplators) were collapsed to form one group of Precontemplators. All other Stages of Smoking Initiation were collapsed in a similar fashion, producing the five Stages of Smoking Initiation: Precontemplation, Contemplation, Preparation, Action, and Maintenance.
Definition of Stages of Smoking Initiation:
- Precontemplation (PC) – Youth who are not currently smoking and have no thoughts of smoking a cigarette within the next year. This includes both youth who have never smoked a whole cigarette in their entire life and youth who have smoked less than 100 cigarettes in their entire life, but have not smoked in the past 30 days.
- Contemplation (C) – Youth who are not currently smoking but have some thoughts about smoking a cigarette within the next year. This includes both youth who have never smoked a whole cigarette in their entire life and youth who have smoked less than 100 cigarettes in their entire life, but have not smoked in the past 30 days.
- Preparation (P) – Youth who have tried more than one puff from a cigarette but have smoked less than 100 cigarettes in their lifetime, who may be currently smoking (5 days or less out of the past 30 days), and have expressed some thoughts of smoking a cigarette within the next year.
- Action (A) - Youth who have smoked more than 6 cigarettes in their entire life, and have smoked for more than 6 but less than 20 days during the past 30 days, and have expressed some thoughts of smoking a cigarette within the next year.
- Maintenance (M) - Youth who have smoked more than 100 cigarettes in their entire life, and have smoked on 20 or more days during the past 30 days, and have expressed some thoughts of smoking a cigarette within the next year.
School Status In general, smoking prevalence rates have been found to differ between Middle School and High School students, such that the uptake of cigarette smoking is much greater in High School students. Accordingly, the present analyses considered the relation between smoking status (i.e., Stage of Smoking Initiation) and school status (i.e., Middle School vs. High School). Middle School (MS) status was defined as grades 6 through 8 while High School (HS) status was defined as grades 9 through 12.
Results: Stage of Smoking Initiation Using data derived from the 2000 MYTS, the 2002 MYTS, the 2006 MYTS and 2008 MYTS surveys respondents were classified into one of the five Stages of Smoking Initiation according to the Stages of Smoking Initiation algorithm. These four surveys will be distinguished using the terms Wave 1 (2000), Wave 2 (2002), Wave 3 (2006) and Wave 4 (2008).
Methodology
Survey Methodology – Wave 1 (2000) The MYTS 2000, designated Wave 1, was a classroom-based survey, conducted in randomly selected public schools throughout the state of Maryland between October 2 and November 15, 2000. 55,967 Maryland students enrolled in grades 6 through 12 participated in the survey. 89.5% of eligible Middle School students and 84.8% eligible High School students chose to participate. See Initial Findings from the Baseline Tobacco Study (2001) http://crf.maryland.gov/pdf/Tobacco_Program_Annual_Report_2001.pdf from DHMH for more information.
Survey Methodology – Wave 2 (2002) The second survey was the MYTS 2002. Because the survey was revised between the two data collections some of the survey questions were different. The MYTS 2002, designated Wave 2, was a classroom-based survey, conducted in randomly selected public schools throughout the state of Maryland between October 8 and November 26, 2002. 66,272 Maryland students enrolled in grades 6 through 12 participated in the survey. 89.9% of eligible Middle School students and 84.2% eligible High School students chose to participate. See Monitoring Changing Tobacco Behaviors in Maryland: A Report on the fiscal year 2001 and 2003 Maryland Tobacco Surveys https://phpa.health.maryland.gov/ohpetup/Documents/4%202000%20to%202002%20Report.pdf from DHMH for more information.
Survey Methodology - Wave 3 (2006) The third survey was the MYTS 2006. Because the survey was revised between the two data collections some of the survey questions were different. The MYTS 2006, designated Wave 3, was a classroom-based survey, conducted in randomly selected public schools throughout the state of Maryland between October 30 and December 15, 2006. 82,500 Maryland students enrolled in grades 6 through 12 participated in the survey. The MYTS school response rate was 100%. The statewide student response rate was 89.2% of eligible Middle School students and 85.7% eligible High School students chose to participate. See Monitoring Changing Tobacco-use Behaviors in Maryland: A Report on the 2000 - 2006 Maryland Tobacco Studies appendices from DHMH for more information.
Survey Methodology - Wave 4 (2008) The fourth survey was the MYTS 2008. The MYTS 2008, designated Wave 4, was a classroom-based survey, conducted in randomly selected public schools throughout the state of Maryland between October 20 and December 9, 2008. 86,748 Maryland students enrolled in grades 6 through 12 participated in the survey. The statewide student response rate was 90.5% of eligible Middle School students and 84.7% eligible High School students chose to participate. CLICK HERE for the 2000-2008 Monitoring Changing Tobacco Use Behaviors report from DHMH for more information.
Limitations of the MYTS Surveys Because Waves 1 (2000), Wave 2 (2002), Wave 3 (2006), and Wave 4 (2008) of the MYTS were conducted in public schools, the results underrepresented individuals who do not attend school, those whose parents did not elect for them to participate in the survey, and those absent on the day of the survey administration. The survey also underrepresented those who attend special and private schools.
Weighting For the adolescent data, a sampling weight was used (see Monitoring Changing Tobacco Behaviors in Maryland: A Report on the fiscal year 2001 and 2003 Maryland Tobacco Surveys https://phpa.health.maryland.gov/ohpetup/Documents/4%202000%20to%202002%20Report.pdf and appendices for more information for more detailed information on weighting procedures) in order to take information from the sample and generalize it to the general state population. Weighted data was analyzed at the county level only.
Shifts in Stages of Smoking Initiation Over Time
Examination of the percentage of youth in each of the Stages presented in this Table reveals that the statewide smoking prevalence (e.g., percentages of youth in Action and Maintenance) has decreased over time. Inspection of the stage distributions among individual counties shows that the majority of the counties evidenced a reduction in the percentage of youth in Maintenance (i.e., long-term regular smokers) among both Middle School and High School students.
Along with decreases in the percentage of High School youth in Maintenance, there were corresponding statewide increases in the percentage of High School students in the Precontemplation Stage of Smoking Initiation, suggesting a decline in the number of High School students who are thinking about smoking.
- All counties showed an increase in the percentage of Middle School & High School students in Precontemplation.
- Almost every county showed a decrease in the percentage of Middle School & High School students in Action and Maintenance.
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