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
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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