Pediatric Pulmonology, Supplement 23:52-53 (2001)

Epidemiology of Cigarette Smoking in Adolescents: The German Experience

Theodor Zimmermann

Scientific evidence has shown that smoking, the major preventable cause of disease worldwide, has a profound impact on public health. Data from the World Health Organization (WHO) estimate that about one third of the global adult population, or 1.1 billion people, of whom 200 million are females, are smokers. Each year, tobacco smoke causes 3.5 million deaths, or about 10000 deaths per day worldwide. One of every two smokers who starts at a young age and continues smoking throughout his life will be killed by a tobacco-related illness. On average, smokers who begin smoking in adolescence and continue to smoke regularly have a 50 percent chance of dying from tobacco. Half of them will die before age 70, losing around 22 years of normal life expectancy. Not only the smoking individual can be harmed by tobacco smoke, but passive smoking has been shown to cause sudden infant death, respiratory illness and middle ear disease in babies and children, and lung cancer and heart disease in adults.’ Children are put further at risk because smoking by their parents increases the likelihood that they themselves will in time take up smoking.

SMOKING BEGINS IN CHILDHOOD

Although the epidemic of disease and death from smoking is played out in adulthood, it begins in childhood. Every day, another 3000 people become regular smokers in the United States.’

A person who has not started smoking as a teenager is unlikely ever to become a smoker. Many young people progress steadily from experimentation to regular use, with addiction taking hold within a few years.3 Between one third and one half of adolescents who try smoking, even just a few cigarettes, soon become regular smoker^.^ Young people are the tobacco industry’s primary source of new customers replacing adults who have either quit smoking or died.

ADVERTISING

The tobacco industry is aware of the addictive quality of cigarettes, but very few consumers are aware of the effects of nicotine. Tobacco products are carefully marketed into a successful social and behavioral niche. Once addicted to the nicotine in cigarettes, smokers have a difficult time ending their habit, both behaviorally and 0 2001 Wiley-Liss, Inc.

physiologically. A Tobacco Company Executive writes: “hitting the youth can be more efficient even though the cost to reach them is higher, because they are willing to experiment, they have more influence over others in their age group than they will later in life, and they are far more loyal to their starting brand”.5 It is well known, that today’s teenager is tomorrow’s potential regular custo- mer, and the overwhelming majority of smokers first begin to smoke in their teens. It is during the teenage years that the initial brand choice is made.6 Conse- quently, advertising campaigns focus on children. More than half of the children aged three to six who were presented with a variety of products matched the Camel logo with a photo of a cigarette. Six year-old children were found to be nearly as familiar with Camel as Mickey Mouse. A study found that when children were shown Camel advertisements, 96 per cent correctly identified the brand, compared with only 67 per cent of a d ~ l t s . ~ Camel Cartoon character has had an astounding influence on children’s smoking behavior. The proportion of smokers under 18 who choose Camel Brand has risen from 0.5% to 3 2 . 8 % ~ ~ Children are receiving the positive message from cigarette advertisements as young as the age of nine years, when they are most likely to try their first cigarette. They may see these messages as generic to smoking and the positive impressions they gain from them could be one of the important influences in their decisions to smoke.8 Furthermore, a US Study of Children finds that school children who wear sports clothing and other items with cigarette names and logos on them are four times more likely to smoke than other children.”

CIGARETTE SMOKING IN GERMAN CHILDREN AND YOUNG ADOLESCENTS

In former West Germany, two out of five adolescents are smokers at the age of 12-25 years, 41% of them are either chronic or at least occasional smokers. In the younger age group, 7% of the 12-13 years of age, 28% of the 14-15 years, and 47% of the 16-17 years are smokers. At least 50% of the young adults between 18 and 25 years

From Erlangen, Germany.

Address correspondence and reprint requests to Dr. T. Zimmermann, Klinik mit Poliklinik fur Kinder & Jugendliche, Erlangen, Numberg, Germany.

Cigarette Smoking 53

smokers more frequently have peer groups consisting primarily of other smokers (12-25 years: 1993 72%, 1997 78%). To justify their smoking, smokers increas- ingly refer to those motives communicated by cigarette advertisements as incentives to buy (12-25 years: “like it” 1993 59%, 1997 66%,; “tastes good” 1993 53%, 1997 60%,; “keeps cool” 1993 48%, 1997 49%).

In summary, there are a few positive trends in the children’s and young adult groups in Germany encoura- ging non-smoking. Anti-smoking programs must be intensified to prevent children and adolescents from this world wide accepted kind of addiction.

of age smoke regularly. The number of smokers over all age groups had decreased slowly by 11 percent between 1973 and 1997. But in East Germany, however, a two-fold process of adaptation has occurred in recent years. The number of smokers among young East Germans has increased so drastically that it now exceeds that of young West Germans (34% east, 26% west). The smoking habits of young women in the new Federal Liinder have now come to match those of the young men. In general, the proportion of smokers among the younger age groups (12-17 years) rose between 1993 and 1997 (21-26% west, 19-34% east).

Two trends of significance for disease prevention can

The proportion of those who have never smoked is increasing more rapidly (west 12-25 years 20% in 1973 and 42% in 1997), than the proportion of smokers is decreasing (permanent and occasional smokers 12-17 years: 36% in 1973 and 26% in 1997; 18-25 years: 62% in 1973,49% in 1997) Smokers are starting to smoke later (younger than 14 years when smoked first cigarette: 1986 14% and 1997 36%).

The average age of smoking onset is rising slowly but steadily. Above all, the proportion of those who smoke their first cigarette before the age of 14 is on the decline. Apparently, young people are increasingly deciding not to smoke right from the start. This statement is supported by the fact that nearly all those who have never smoked do not expect to smoke in the future. Non-smoking is primarily based on health-related arguments. Further- more, the social support of non-smoking is particularly strong among those who have never smoked. On the other hand, young smokers are also becoming “more con- scious” smokers. A smaller proportion expects to give up smoking (12-25 years: 1993 26%, 1997 15%). The social support provided by friends to quit smoking is also decreasing (12-25 years: 1993 86%, 1997 73%), and

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