adolescent smoking dr. lyudmila ivanova, russia dr. yehuda neumark, israel

Adolescent Smoking

Dr. Lyudmila Ivanova, Russia

Dr. Yehuda Neumark, Israel

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

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

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

Global trends in tobacco use (cont’d)

• 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

Annual Tobacco deaths (in millions)

2000 2030

Developed 2 3

Developing 2 7

World Total 4 10

Source: Peto, Lopez, and others 1997; WDR 1993

1 in 2 long-term smokers killed by their

addiction

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

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

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 tobacco-prevention activities focused on children and focused on children and adolescents are more effectiveadolescents are more effective

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 <2% to nearly 9%

• Each day, 3,000 children in the United States become regular smokers

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?

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

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 ?

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 <4 months

– prevention messages require repetition and reinforcement - "booster“ lessons

Main issuesSustainability 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

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%


Community interventionscombination with stronger advocacy, taxation, media interventions and evidence-based policy formation is needed

Mass media campaignsDifficult to evaluateNecessary 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


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

As Cigarette Tax Rises, Revenue IncreasesTax per pack and cigarette tax revenues in Norway, 1990-1998

2000

2500

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1990

1991

1992

1993

1994

1995

1996

1997

1998

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Cigarette tax revenues Tax per pack

Source: World Bank, 1999


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


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


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

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

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

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; <0.5% girls • 72% of Chinese population aged 15+ is

exposed, directly or indirectly, to the harmful effects of tobacco

National prevalence survey, 1996

“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

“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

SMOKING PREVENTIONIN RUSSIA

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

Global Youth Tobacco Survey, Russia, 1999

Prevalence• 67% of students ever smoked cigarettes -

boys=71%, girls=62%• 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


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



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


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


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


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

Activities on tobacco control

Smoke-free areas

• Health care institutions

• Educational institutions

• Government facilities

• Public transport except trains

However, laws not always maintained!

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

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

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

adolescent smoking dr. lyudmila ivanova, russia dr. yehuda neumark, israel

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