Adolescent Smoking

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 middleincome 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 Developing World Total 2 2 4 3 7 10 1 in 2 long-term smokers killed by their addiction Source: Peto, Lopez, and others 1997; WDR 1993 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 focused on children and adolescents 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-ofschool 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 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 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% Tobacco control programs focused on adolescents Community interventions combination with stronger advocacy, taxation, media interventions and evidencebased 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 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 As Cigarette Tax Rises, Revenue Increases 4000 Tax per pack and cigarette tax revenues in Norway, 1990-1998 35 Cigarette tax revenue in local currency (millions) Tax per pack in local currency 3500 30 3000 25 2500 20 1992 1994 1991 1995 1996 1990 1993 1997 Cigarette tax revenues Tax per pack Source: World Bank, 1999 1998 2000 15 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 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 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 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 schoolbased 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 smokingrelated 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 PREVENTION IN RUSSIA Smoking prevalence, 2003 Group % Male adults Female adults Adolescents, 13 years old Adolescents, 15 years old • Boys • Girls 67 10 12 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 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 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 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 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 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 NoTobacco 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