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Title: Adolescent Smoking


1
Adolescent Smoking
  • Dr. Lyudmila Ivanova, Russia
  • Dr. Yehuda Neumark, Israel

2
Why is tobacco control a public health priority?
  • Tobacco 2nd leading cause of death in the world
  • Currently responsible for the deaths of 1 in 10
    adults worldwide (5 million deaths annually)
  • If current smoking patterns continue, 10 million
    deaths predicted each year by 2025
  • 70 of these deaths in developing countries
  • 50 of current smokers (650 million people) will
    eventually be killed by tobacco

Source WHO, Tobacco Free Initiative
3
Why is tobacco control a public health priority?
  • Tobacco also takes an enormous toll in health
    care costs, lost productivity and the intangible
    costs of the pain and suffering inflicted upon
    smokers, passive smokers and their families

4
Global trends in tobacco use
  • Currently about 1 in 3 adults, or 1.1 billion
    people, smoke
  • 80 of these live in low- and middle-income
    countries
  • Total number of smokers is expected to reach 1.6
    billion by 2025
  • Chewed and pipe tobacco practices are declining
    in some countries

Source Curbing the epidemic Governments and
economics of tobacco control. World Bank, 1999
5
Global trends in tobacco use (contd)
  • Smoking more common among less educated
  • Smoking accounts for much of the rich-poor
    mortality gap
  • Tobacco addiction starts early in life - every
    day 80,000 to 100,000 youths become regular
    smokers

Source Curbing the epidemic Governments and
economics of tobacco control. World Bank, 1999
6
Annual Tobacco deaths (in millions)
2000 2030
Developed 2 3
Developing 2 7
World Total 4 10
1 in 2 long-term smokers killed by their
addiction
Source Peto, Lopez, and others 1997 WDR 1993
7
Tobacco cost to the economy
  • Estimated health care costs attributable to
    tobacco (US)
  • USA 76.0 billion
  • Germany 14.7 billion
  • Australia 6.0 billion
  • China 3.5 billion
  • UK 2.3 billion
  • Canada 1.6 billion

8
Effective interventions to reduce tobacco
consumption
  • Measures to reduce demand
  • Higher cigarette taxes
  • Non-price measures
  • Consumer information
  • Cigarette advertising and promotion bans
  • Warning labels
  • Restrictions on public smoking
  • Increased access to nicotine replacement therapy
    (NRT) and other cessation therapies

Source The World Bank. Economics of tobacco
control, 1999
9
Cessation vs. Prevention
  • Absolute number of current smokers who quit is
    low (even with intervention)
  • 4 out of 5 persons who use tobacco start smoking
    reaching adulthood
  • People who begin smoking at younger ages are more
    likely to become regular smokers and less likely
    to quit

tobacco-prevention activities focused on
children and adolescents are more effective
10
Smoking among adolescents
  • 50 teen smoking rate in some Latin American
    cities
  • In Kenya, smoking rate in primary school children
    40 in 1999 up from 10 a decade earlier
  • Smoking rates among male Korean teenagers rose
    from 18 to 30 in one year after entry of USA
    tobacco companies. Among female teenagers rates
    increased from lt2 to nearly 9
  • Each day, 3,000 children in the United States
    become regular smokers

11
Reasons for smoking
  • Urban community disorganization
  • Poverty
  • Personal factors
  • Emotional and psychological problems
  • Lack of school involvement, academic failure, and
    dropping out
  • Antisocial behavior
  • Young pregnancy and parenthood
  • Family homelessness, stress, lack of cohesion and
    supervision
  • Familial use of cigarettes, alcohol, and other
    drugs
  • Heredity?

12
Tobacco control programs focused on adolescents
  • Educational interventions
  • significant short term reduction in smoking
  • delay in initiation
  • change in attitudes toward tobacco use
  • Social influences prevention programs conducted
    with adolescents can be effective even in high
    tobacco production regions

13
Main issues
  • Format of the intervention
  • combination of in-school and out-of-school
    activities is effective especially in
    interventions targeted to elementary school
    children
  • Providers
  • health professionals?
  • Nurses
  • Primary care physicians
  • Community pharmacy personnel
  • teachers?
  • assistance of parents and peers
  • Target population
  • Children ?
  • Adolescents ?

14
Main issues
  • Length of the educational program
  • average duration 6-12 months
  • Brief intervention - short effect.
  • Tar War Program (New York State) - one-time
    intervention. Effect lasted lt4 months
  • prevention messages require repetition and
    reinforcement - "booster lessons

15
Main issues
  • Sustainability of the program
  • Programs that vary in format, scope, delivery
    methods and community setting produce
    intervention vs. nonintervention differences in
    smoking prevalence ranging from 25-60, and
    persisting for 1-5 years after completion of
    program
  • Effect of the program dissipates over time
  • school-based tobacco prevention programs are
    strengthened by booster sessions and community-
    wide programs involving parents and community
    organizations and including school policies, mass
    media, and restrictions on youth access

16
Successful interventions
  • Project Toward No Tobacco (TNT) USA
  • Target population 12-13 years old
  • Focus Smoking prevention
  • Design classroom-based curriculum (10 lessons)
  • Effect Reduction in initiation of smoking and
    smokeless tobacco by 30 and weekly use by 60
    across the 2-year junior high to senior high
    school period
  • Life Skills Training Program USA
  • Target population 13 years old
  • Focus prevention of tobacco, alcohol and drug
    use
  • Design 15 session 10 boosters
  • Effect Reduces pack-a-day smoking by 25

17
Tobacco control programs focused on adolescents
  • Community interventions
  • combination with stronger advocacy, taxation,
    media interventions and evidence-based policy
    formation is needed
  • Mass media campaigns
  • Difficult to evaluate
  • Necessary conditions
  • campaign strategies based on sound social
    marketing principles
  • target groups carefully differentiated
  • messages for specific target groups based on
    empirical evidence of needs and interests
  • sufficient duration of the campaign

18
Tobacco control programs focused on adolescents
  • Raising taxes and increasing the price of
    cigarettes
  • ?er taxes induces quitting prevents starting
  • A 10 price increase reduces demand by
  • 4 in high-income countries
  • 8 in low or middle-income countries
  • Young people and the poor are the most price
    responsive
  • Useful yardstick tax ?2/3 to 4/5 of retail price

Source The World Bank. Economics of tobacco
control
19
As Cigarette Tax Rises, Revenue IncreasesTax per
pack and cigarette tax revenues in Norway,
1990-1998
Source World Bank, 1999
20
Tobacco control programs focused on adolescents
  • Public smoking bans
  • effective in reducing non-smokers' exposure to
    environmental tobacco smoke
  • influence on teenage smoking?
  • banning smoking at home (even when parents smoke)
  • restrictions on smoking in public places
  • school smoking bans effective only when strongly
    enforced

21
Tobacco control programs focused on adolescents
  • Smoking cessation intervention
  • Usually are focused on adults
  • Importance of targeting adolescents who are at
    the transition point before or after habitual
    smoking begins
  • Extensive research is needed to evaluate benefits
    of NRT behavioral interventions in adolescent
    smokers

22
Tobacco control programs focused on adolescents
  • Changing the overall environment
  • changing the social context of smoking
  • Emphasize smoking cessation among adults (role
    models for children)
  • Expand of state/local clean indoor air laws
  • Enforce illegal tobacco sales to minors
  • Especially important in developing countries
    with high smoking rates

23
Main strategies for preventing tobacco use among
youth
  • Develop and enforce school tobacco policy
  • Establish educational program
  • Start smoking prevention education early
    (kindergarten?)
  • Provide program-specific training for teachers
  • Involve parents in support of school-based
    prevention programs

Source CDC, 1994
24
Main strategies for preventing tobacco use among
youth
  • Support cessation efforts among students and
    school staff who already use tobacco
  • Assess prevention program at regular intervals
  • Combined efforts of health care workers, mass
    media, government and community enthusiasts are
    required in order to achieve a significant
    improvement

Source CDC, 1994
25
China setting for 2004 COPC project
  • Smoking is culturally acceptable
  • Ever smoking 67 men, 4 women
  • Current smoking 63 men, 3.8 women
  • 1 million deaths attributed to smoking yearly
  • 18 of adolescent boys smoke lt0.5 girls
  • 72 of Chinese population aged 15 is exposed,
    directly or indirectly, to the harmful effects of
    tobacco

National prevalence survey, 1996
26
Nay to Yan program
  • One-year educational program
  • Target population
  • students 1-6 grades of primary school in
    Santanxiang Township, Gansu Province
  • Goal to delay smoking onset among children 7-13
    years in order to reduce the proportion of
    eventual smokers, so as to decrease burden of
    smoking-related diseases

27
Nay to Yan program
  • Two integrated parts
  • Educational component
  • 12 sessions in-school curriculum
  • Extra-curricular activities (drama club,
    creativity club)
  • Storekeepers targeted
  • Government support necessary

28
SMOKING PREVENTIONIN RUSSIA
29
Smoking prevalence, 2003
Group
Male adults 67
Female adults 10
Adolescents, 13 years old 12
Adolescents, 15 years old Boys Girls 17 26
WHO European country profiles on tobacco
control, 2003
30
Global Youth Tobacco Survey, Russia, 1999
  • Prevalence
  • 67 of students ever smoked cigarettes -
    boys71, girls62
  • 31 of never smokers likely to initiate within 1
    year
  • Environmental Tobacco Smoke
  • 55 live in homes where others smoke
  • 72 are around others who smoke in places outside
    their home
  • 71 think smoking should be banned from public
    places
  • 35 have most/all friends who smoke

CDC. Report on the Results of the Global Youth
Tobacco Survey in RF, 1999
31
Global Youth Tobacco Survey, Russia, 1999
  • Knowledge and Attitudes
  • 23 think boys who smoke have more friends 15
    think girls who smoke have more friends
  • 11 think boys who smoke look more attractive 5
    think girls who smoke look more attractive

CDC. Report on the Results of the Global Youth
Tobacco Survey in RF, 1999
32
Global Youth Tobacco Survey, Russia, 1999
  • Access and Availability - Current Smokers
  • 6 usually smoke at home
  • 63 buy cigarettes in a store
  • 81 who bought cigarettes in a store were NOT
    refused purchase because of their age

CDC. Report on the Results of the Global Youth
Tobacco Survey in RF, 1999
33
Global Youth Tobacco Survey, Russia,1999
  • Media and Advertising
  • 75 saw anti-smoking media messages in past month
  • 94 saw pro-cigarette TV ads in past month
  • 76 saw pro-cigarette ads in newspapers/magazines
    in past month
  • 17 were offered free cigarettes by a tobacco
    company representative

CDC. Report on the Results of the Global Youth
Tobacco Survey in RF, 1999
34
Global Youth Tobacco Survey, Russia,1999
  • School
  • During the past year 33 were taught in class
    about dangers of smoking
  • 23 discussed in class reasons why people their
    age smoke

CDC. Report on the Results of the Global Youth
Tobacco Survey in RF, 1999
35
Activities on tobacco control
  • Legislation on advertising and distribution of
    tobacco products and smoke-free environments
  • Direct advertising of tobacco products banned on
    National and Cable TV and partially restricted on
    National radio
  • But
  • No restriction on ads in international magazines
    and newspapers
  • Tobacco companies may sponsor sport events
  • Tobacco brand names are used for non-tobacco
    products and non-tobacco product brand names for
    tobacco products

36
Activities on tobacco control
  • Smoke-free areas
  • Health care institutions
  • Educational institutions
  • Government facilities
  • Public transport except trains
  • However,
  • laws not always maintained!

37
Problems
  • No national interventions to protect nonsmokers
    (except World No-Tobacco Day)
  • No available data on NGOs active in tobacco
    control
  • Lack of information about tobacco control
    programs in Russia

38
Problems
  • Tobacco control programs targeted at adolescents
    are sponsored by tobacco companies
  • No evaluation of these interventions
  • Educational program My Choice
  • 100,000 pupils
  • 8,000 teachers
  • 31 regions
  • sponsored by JTI - world's 3rd largest tobacco
    company

39
Summary
  • Tobacco control and smoking prevention must be
    priority issues for public health agencies in
    Russia and elsewhere
  • Prevention is more effective than cessation!
  • Prevention activities should target young
    children prior to smoking initiation
  • School-based programs can be effective if
    comprehensive, maintained over time, and geared
    to the specific target population
  • Evaluation of interventions needed
  • In Russia, more legislation needed and enforced
    regarding public smoking and advertising
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