Preventing Uptake of Smoking Research Paper

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Introduction

The significance of smoking by adolescents goes beyond the specter of introducing yet another generation to a habit that will kill prematurely around half of those who continue to indulge in it (Doll et al., 1994). The prevalence of smoking among young people is regularly cited as evidence of the futility of public health and primary prevention approaches to the control of major health problems. The argument is constructed thus: (1) the public health community regularly states that:

every reputable medical and scientific organization that has reviewed the evidence has concluded that tobacco smoking is the leading cause of premature mortality and avoidable morbidity in developed countries (Tobacco Advisory Group, n.d.)

(2) the definitive solution to this situation is to raise a smoke-free generation, (3) despite all current investments of time, effort, and resources, the prevalence of smoking among teenagers remains high or even continues to increase, and (4) it follows that if public health and its commitment to primary prevention cannot solve this single most important problem, such approaches must be inherently weak and flawed, and it would be wiser for the community to rely on biomedical strategies for the control of noncommunicable diseases.

This argument is a clever and seductive one because, until quite recently, its first three elements have all been true, suggesting that the conclusion is a reasonable one. But the significance of the critique lies in it obliging those concerned with control of smoking among teenagers to reconsider their basic premises. A critical review of public health practice in relation to smoking by teenagers shows that, while the observational epidemiology of young people’s smoking has been well-described for over 40 years (Bynner, 1969), the interventions based upon those data have been naive, misguided, and largely ineffectual. At the same time, there is now a growing body of evidence that the best way to reduce the uptake and prevalence of smoking among young people is to bring about significant and sustained decreases in the prevalence of smoking among adults. Furthermore, we also know a great deal about how, and how not, to achieve that intermediate goal.

The Misguided Past

Three key principles have tended to shape past efforts to reduce the uptake of smoking among young people. These relate to intergenerational patterns in smoking, the purported influences that lead children to try their first cigarette, and notions about the uniqueness of teenagers as a target population for health promotion strategies. This body of received wisdom may also have contributed to relative neglect of one possibly important opportunity to reduce the proportion of adolescents who emerge into adulthood as regular smokers.

Intergenerational Patterns Of Smoking

It has long been known that the children of smokers are themselves much more likely to become smokers (Bynner, 1969). This has been interpreted in two ways, one relating to access to tobacco products, and the second to exposure to adult role models of smokers. Apart from occasional references to the potential toxicity of cigarettes when they are eaten by infants and young children (Lewander et al., 1997), and the consequent need of parents who smoke to store their cigarettes safely, preventive approaches concerning access to tobacco products have dwelt mainly on purchase of cigarettes outside the home. However, there are inconsistencies between jurisdictions in regard to the minimum age necessary to buy or sell cigarettes, and tobacco vending machines have been allowed to persist despite abundant evidence of their being inadequately supervised and a significant source of cigarettes for some teenagers (Robinson et al., 2006). Most importantly, however, enforcement of laws regarding sales of tobacco products to minors has often been minimal, and courts have appeared reluctant to impose significant fines even on serial offenders. The absence of licensing systems for tobacco retailers in at least some jurisdictions means that temporary or even permanent suspension of the ability to sell tobacco products has not been available to some enforcement agencies. In combination with systems of official warnings followed by often relatively trivial fines for continued breaches, the regulation of access to tobacco products by young people outside their homes has frequently lacked real teeth. Aside from isolated examples, attempts to control sales of cigarettes to minors have had limited effect on the smoking behavior of young people (Stead and Lancaster, 2005).

Although ‘‘don’t smoke in front of the children’’ is an oft-used line in situation comedies, this advice has never formed the basis of any serious tobacco control activities. This is only sensible given the abundance of other adult role models who smoke and the difficulty that parents who smoke would have in concealing the habit from their children. The evidence that infants and young children are particularly sensitive to harmful effects of passive smoking, available since at least 1974 (Colley et al., 1974; Harlap and Davies, 1974), has prompted some urging of adults not to smoke around children, but these campaigns have been concerned more with the youngsters’ physical health than with issues of role modeling. Despite some promising findings, there are too few studies of adequate quality to know whether direct interventions with families to discourage the uptake of smoking by children might represent a useful strategy to reduce the prevalence of smoking by adolescents (Thomas et al., 2007).

At the end of the day, therefore, the observation that children of smokers are much more likely to become smokers themselves has led nowhere in terms of effective tobacco control interventions.

Influences Leading To The First Cigarette

Many anti-smoking activities directed to young people have been guided by the finding that a very large proportion of those who have ever tried a cigarette retrospectively ascribe the event in significant part to social pressure from immediate peers who were present at the time. This has led to innumerable mass media and classroom-based campaigns intended to enhance the capacity of teenagers to resist such pressure through combinations of enhanced knowledge of the dangers of smoking and insight (and even rehearsed practice) related to the social dynamics of being offered a cigarette. Rigorous evaluations of such strategies have been far from universal, and all too frequently such evaluations as have been undertaken have been limited to short-term follow-up assessments of awareness, knowledge, or attitudes. Notwithstanding the multiplicity of factors influencing or associated with recreational drug use in adolescence, the proof of the pudding in regard to any intervention directed at tobacco is its effect on smoking habits in the early to mid-20s, the age group in which smoking habits finally stabilize. It is extraordinarily rare to see adequately large and controlled intervention studies that include sufficiently complete follow-up over the eight to ten years that are required to evaluate smoking prevention initiatives properly. Thus, we do not really know if some of the very creative mass media and peer-led programs aimed at the early high school years truly are effective. The limited high-quality evidence that is available suggests that they are not (Wiehe et al., 2005; Thomas and Perera, 2006), and, in any case, the gainsayers look at the population-wide statistics on adolescent smoking and are confident in their conclusion that nothing works.

Health Promotion For Adolescents

The final principle that has shaped tobacco control activities aimed at adolescents is that this group constitutes a unique, and uniquely difficult, audience. This has contributed directly to a plethora of peer-led programs, because of a public disinclination of teenagers to accept any message delivered by adult authority figures, together with a reasoned cynicism that governments that were seriously concerned with the threat to health posed by smoking would take more effective and direct action against tobacco products. Similarly, the perceived ephemerality of what is fashionable among the allegedly most fashion-conscious sector of the population has fostered huge investment in developmental work for all types of anti-tobacco communication directed at teenagers and has led to creation of materials that inevitably have very short shelf lives. In working with such a fast-moving audience, postcampaign evaluation is significantly devalued because of the rapidity with which ‘everybody’ moves on. The chances that good money is poured in after bad are significant indeed.

A Neglected Opportunity?

Despite all of the effort that has been expended in trying to reduce the uptake of smoking by teenagers, there has been at least one major aspect of the phenomenon that has been somewhat overlooked. This concerns the fact that, in developed countries at least, while the great majority of young people try at least one cigarette, frequently around the age of 12 or 13 years (or soon after the transition from primary to secondary school), well over half of them do not go on to become regular daily smokers. This phenomenon is under-researched and inadequately understood. We do not know whether it represents a failure of acquisition of a smoking habit, or something much closer to the process of quitting, now completed successfully by many millions of adult smokers. Probably the population of noncontinuing smokers at the end of the teens is a combination of both non-acquirers and quitters, but where the balance lies and how it might have changed over time remains mysterious. But, if we are to continue to focus any tobacco control efforts directly at adolescents themselves, it might be very sensible to explore these issues further, work from the premise that most teenagers will try at least one cigarette, and devise, test, and implement strategies that will enhance the proportion who do not emerge into adulthood as daily smokers (Grimshaw and Stanton, 2006). Whether such an effort is necessary at all, however, is cast into significant doubt by the emerging evidence that the most effective strategy to deal with smoking by young people is an indirect one, one that deals primarily and effectively with smoking by adults.

Emerging Evidence

In the early 1990s, focus groups conducted in Western Australia in the developmental phase of yet another adolescent-specific tobacco control campaign turned up a phenomenon that none of the internationally seasoned tobacco control activists in that State had encountered before. Asked what they do, or would do, when offered a cigarette, some teenagers responded that they would say, ‘‘No thanks, I’ve quit,’’ even though they had never smoked. This was the first evidence that a decade of quite generously funded mass media campaigns directed to adults in Western Australia were beginning to change social norms in relation to smoking, and that teenagers were alert to, and had begun to follow, the change. Put another way, it was suddenly much clearer that social influences do play an important role in the uptake of smoking in adolescence, but that the appropriate scale on which to consider their impact is not the micro dynamics within a young person’s peer group but the macro dynamics of population-wide attitudes and behavior.

From that first indication over a decade ago, the evidence has grown steadily that the smoking behavior of adolescents is primarily a reflection of the behaviors of all of the adults that surround them. Thus, we see reports from California that the children of parents who quit smoking are considerably less likely to take up smoking than are the children of continuing smokers (Farkas et al., 1999). Furthermore, in California, Massachusetts, and Australia, the prevalences of smoking among adolescent boys and girls are now falling quickly and significantly (Drug and Alcohol Office WA, 2007; Wakefield and Chaloupka, 2000). What distinguishes these communities is their combination of sustained, sophisticated mass media anti-smoking campaigns directed to adults, increasingly stringent regulatory control of the activities of tobacco companies and their client commercial entities, and systematic extension of smoke-free policies to almost every aspect of extra-domestic life. These changes have seen all three populations pass the turning point whereby, among adults, ex-smokers come to outnumber continuing smokers (National Heart Foundation, 1991; Messer et al., 2007; Weintraub and Hamilton, 2002), and nonsmokers (never and ex-smokers combined) very much form the healthy majority. All the indications are that when nonsmokers dominate the available role models and the possibility of living a smoke-free life becomes an everyday reality, adolescents become smoke-free. If the aim is to achieve a smoke-free generation of young people, the challenge is to reduce the prevalence of smoking among adults as far and as fast as possible.

The Way Forward

The blueprint for effective tobacco control was laid out as long ago as 1976, with the publication by the International Union Against Cancer of its Guidelines for Smoking Control (Gray and Daube, 1976). At the core of this document is the recommendation that, to have maximum impact on the prevalence of smoking, tobacco control campaigns need to be comprehensive, and should combine legislative, education, and cessation activities. This is largely the approach that has been followed in California, Massachusetts, and Australia for up to 2 decades, with dramatic impacts on smoking, first among adults, and, more recently, among adolescents as well (Wakefield et al., 2003). By contrast, until mid-2007, when significant smoke-free policies were introduced, England had followed a strategy based almost entirely on encouraging and facilitating cessation of smoking, and certainly one that conspicuously lacked the intensive and polished mass media campaigns that have been so prominent in Australia, California, and Massachusetts. Coincidentally, the prevalence of smoking among adults in England remains close to 50% higher, in relative terms, than in the other three places (Office of National Statistics, 2007), and the turning point of ex-smokers outnumbering current smokers was reached only in 2002, some 13 years after the same landmark occurred in Australia. Not surprisingly, therefore, the prevalence of smoking among British adolescents has only recently shown any evidence of a downward trend (Hublet et al., 2006).

The primary focus of tobacco control efforts in the United Kingdom has been to reduce deaths and morbidity caused by smoking, and it is undeniable that the faster and more effective way to do this is to convince current smokers to quit rather than to reduce the overall prevalence of smoking via the advent of a new generation that has never smoked (Peto et al., 1997; Hill, 1999). By contrast, changing social norms in relation to smoking has been an explicit aim of tobacco control policy in California (California Department of Health Services, 2006). The evidence so far strongly suggests that more comprehensive approaches not only make much greater inroads into the prevalence of smoking among adults, and hence into death and disease caused by smoking, but they also seem to be the first effective intervention to reduce the prevalence of smoking among adolescents. The lessons seem clear. It is futile to attempt to reduce the uptake and continuation of smoking among young people by relying on strategies directed to young people themselves. The key to that problem appears to be smoking by adults, but the impact of narrow interventions aimed principally at encouraging cessation by adult smokers is very modest at best and probably much more akin to trying to dig a garden with a one-tined fork. On the other hand, provided they are systematic, sustained, and adequately funded, multipronged strategies addressing all of legislation, education, and cessation hold great promise of fulfilling the long-held aim of creating a new generation that is truly smoke-free.

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