1. Adolescent Smoking Dr. Lyudmila Ivanova, Russia Dr. Yehuda Neumark, Israel

2. Why is tobacco control a public health priority?  Tobacco: 2 nd 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

3. 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

4. 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

5. 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

6. Annual Tobacco deaths (in millions) 20002030 Developed23 Developing27 World Total410 Source: Peto, Lopez, and others 1997; WDR 1993 1 in 2 long-term smokers killed by their addiction

7. 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

8. 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

9. 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

10. 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

11. 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?

12. 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

13. 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 ?

14. 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

15. 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

16. 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%

17. Tobacco control programs focused on adolescents Community interventions combination with stronger advocacy, taxation, media interventions and evidence- based 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

18. 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

19. As Cigarette Tax Rises, Revenue Increases Tax per pack and cigarette tax revenues in Norway, 1990-1998 2000 2500 3000 3500 4000 1990 1991 1992 1993 19941995 19961997 1998 Cigarette tax revenue in local currency (millions) 15 20 25 30 35 Tax per pack in local currency Cigarette tax revenuesTax per pack Source: World Bank, 1999

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. “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

27. “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

28. SMOKING PREVENTION IN RUSSIA

29. Smoking prevalence, 2003 Group% Male adults67 Female adults10 Adolescents, 13 years old12 Adolescents, 15 years old Boys Girls 17 26 WHO: European country profiles on tobacco control, 2003

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. Activities on tobacco control Smoke-free areas Health care institutions Educational institutions Government facilities Public transport except trains However, laws not always maintained!

37. 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

38. 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 3 rd largest tobacco company

39. 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