Preventing smoking and tobacco usage in youth.

Tobacco use is responsible for about 430,000 deaths among adults in the United States (United States Department of Health & Human Services [USDHHS], 2001). Tobacco use in adolescents occurs mainly in the form of cigarette smoking, cigar smoking and tobacco chewing, also known as spit tobacco. Health effects of direct smoking through inhaling the cigarette contents as well as effects due to second hand smoke exposure are well established and range from coronary heart disease to cancer of mouth, stomach and esophagus (USDHHS, 2001).

The Youth Risk Behavior Surveillance Survey (YRBSS) done to study priority health risk behaviors among adolescents between October 2004 and January 2006, found that 54.3% of students nation wide had ever tried cigarette smoking (life-time cigarette use), 23.0% of students had smoked cigarettes on [greater than or equal to] 1 of the 30 days preceding the survey and 9.4% of students had smoked cigarettes on [greater than or equal to] 20 days of the 30 days preceding the survey (current cigarette use) (Centers for Disease Control and Prevention [CDC], 2006a). It was also documented that nationwide 14.0% of the students had smoked cigars on [greater than or equal to] 1 of the 30 days preceding the survey. It is seen that smoking addiction begins in adolescence and majority of smokers start using tobacco in the age group between 11-13 and about 10-15% starting after age 19 (CDC, 2006a). The Global Youth Tobacco survey begun in 1999 by the WHO (World Health Organization), the CDC, and the Canadian Public Health Association, which is a school-based survey, includes questions on prevalence of cigarette and other tobacco use in 132 different countries (CDC, 2006b). The salient findings of this survey conducted from 1999-2005 found that any form of tobacco use was highest in the American and European regions (22.2% and 19.8%, respectively) and lowest in the South-East Asian and Western Pacific Region (12.9% and 11.4%, respectively). Furthermore current cigarette smoking was highest in the European and American regions (17.9% and 17.5%, respectively). Boys were significantly more likely to smoke cigarettes in South-east Asian, and Western Pacific Region. Finally, in the Healthy People 2010 Report that documents national objectives in United States, the objective is to reduce past month tobacco use by students in grades 9 through 12 from a 1999 baseline of 40% to 21% by 2010, reduce past month cigarette use from 35% to 16%, past month spit tobacco use from 8% to 1% and past month cigar use from 18% to 8% (USDHHS, 2001).

Several studies have been done to identify determinants of tobacco use in adolescents. A study using population based cohorts of early adolescents, found that among many predictive determinants, lesser academic achievement and fewer environmental barriers most strongly predicted smoking (Carvajal & Granillo, 2006). Some of the other determinants for smoking initiation are socio-demographic factors like coming from a family of low socioeconomic status and personal factors like low self-image, low self-esteem and inadequate refusal skills (USDHHS, 2001). It is seen that if the adolescents come from immigrant families they are less likely to smoke inspite of economic hardships. Protective factors for these adolescents are found to be lower rates of parental tobacco use and less exposure to peers who smoke (Georgiades, Boyle, Duku, & Racine, 2006). Interpersonal influences such as peer smoking, attitudinal and cultural influences such as academic achievement, initial liking for smoking, to find a meaning (experimenting) with smoking and intrapersonal influences like susceptibility to smoking or difficulty in quitting smoking were found to be important around the world. Other important determinant of smoking initiation in adolescents is whether its related to a particular racial and ethnic subgroup as we can direct are prevention strategies and programs in that particular sub-group. In a study conducted among nationally representative sample of adolescents aged 12-17, the prevalence of smoking ranged from 27.9% among American Indians and Alaskan Natives to 5.2% for Japanese. White and African American boys initiated smoking a few months earlier than white and African American girls (Carabello, Yee, Gfoerer, Pechacekt, & Henson, 2006). These determinants are important to acknowledge as they may guide us in developing prevention interventions in this age group of students.

There are a number of smoking prevention strategies targeted towards the youth such as school-based educational interventions, community-based interventions, advertising restrictions on tobacco use, youth access restrictions and public health education. Reviews of these approaches have shown that most of the adolescent/youth community prevention programs had mixed results (Lantz, et al., 2000). The programs which emphasized a social model, along with a community-based health program were found to be somewhat effective but again a majority of this school-based and community based programs haven't been adequately evaluated in the long-term and the impacts if at all seen are all short-term effects. This is corroborated by the first large scale randomized trial which looked at the social influences approach to smoking prevention (Flay, Koepke, Thomson, Santi, Best, & Brown, 1989). In a review of 94 randomized controlled trials, which focused on school-based prevention programs, thirteen studies used social influences intervention of which nine found some positive effect of intervention on the prevalence and four failed to detect any influence (Thomas, & Perera, 2006). There was a lack of quality evidence about effectiveness of combinations of social influences and social competence approaches. The multi-modal approaches also provided limited evidence. Similarly among study of 13 studies which compared community interventions to no interventions or controls, two reported lower smoking prevalence. Of three studies comparing community interventions to school based programs only one found differences in reported smoking prevalence (Sowden & Stead, 2003). Among other programs used to prevent smoking among adolescents/youth are mass media programs. In a Cochrane review of mass and media programs targeted for adolescents, where the inclusion criteria were randomized, controlled trials where unit of randomization was school, community or a geographical region, controlled trials without randomization and time series (Sowden & Arblaster, 2000). The primary outcome measures were saliva thiocyanate levels, alveolar CO and self-reported smoking behavior and intermediate measures were knowledge, attitude and intentions to smoke along with refusal and self-efficacy skills. The main results indicated that only six studies out of 63 studies (meeting the inclusion criteria) used a controlled design. Two studies concluded that mass and media programs were effective in influencing smoking behavior of adolescents but overall it seemed that the evidence was not very strong.

In conclusion it can be said that several approaches for tobacco and smoking prevention in adolescents have been tested. These approaches have shown mixed results and need to be bolstered if the Healthy People 2010 objectives have to be accomplished.

REFERENCES

Centers for Disease Control and Prevention. (2006a) Youth Risk Behavioral Surveillance-United States, 2005. Morbidity and Mortality Weekly Report, 55(5), 1-108.

Centers for Disease Control and Prevention. (2006b). Use of cigarettes & other tobacco products among students-aged 13-15 years world wide, 1999-2005. Morbidity and Mortality Weekly Report 55(20), 553-556.

Carvajal, S. C., & Granillo, T. M. (2006). A prospective test of distal and proximal determinants of smoking initiation in early adolescents. Addictive Behavior, 31(4). 649-660.

Caraballo, R. S., Yee, S. L., Gfoevrer, J. C., Pechacekt, T.F., & Henson, R. (2006).Tobacco use among racial & ethnic population subgroups of adolescents in United States. Preventing Chronic Disease, 3(2), 39.

Flay, B.R., Koepke, D., Thomson, S. J., Santi, S., Best, A. J., & Brown, K. S. (1989). Six-year follow up of the first waterloo school smoking prevention trial. American Journal of Public Health, 79, 1371-1376.

Georgiades, K., Boyle, M., Duku, E., & Racine. (2006). Tobacco use among immigrant and non-immigrant adolescents: individual and family level influences. Journal of Adolescent Health, 38(4), 443.

Lantz, P., Jacobson, P. D., Warner, K. E., Wasserman, J., Pollack, H. A., Berson, J., et al. (2000). Investing in youth tobacco control: A review of smoking prevention and control strategies. Tobacco Control, 9, 47-63.

Sowden, A. J., & Arblaster, L. (2000). Mass media interventions for preventing smoking in young people. Cochrane Database of Systematic Reviews, 2, CD001006.

Sowden, A., Arblaster, L., & Stead L. (2003). Community interventions for preventing smoking in young people. Cochrane Database of Systematic Reviews, 1, CD001291.

Thomas, R, & Perera, R. (2006). School-based programmes for preventing smoking. Cochrane Database of Systematic Reviews, 3, CD001293.

United States Department of Health and Human Services. (2001). Healthy People 2010. Washington, DC: US Government Printing office.

Manoj Sharma, MBBS, CHES, Ph.D.

Editor, Journal of Alcohol & Drug Education

& Amar Kanekar, MBBS, MPH

University of Cincinnati

526 Teachers College

PO Box 210068

Cincinnati, OH 45221-0068