Child and adolescent smoking: An evolving international problem
Smoking is becoming epidemic among children and young adolescents in developing and emerging countries. Research suggests that one in six children in the United States will smoke, even though the effects are well-known and well-publicized. At least 30% of these children will eventually die from a disease caused by smoking. The cost in terms of years of productive life lost, the care of individuals with chronic disease, and human suffering is not currently measurable. Primary care providers in countries where childhood and adolescent smoking is not yet widespread have a unique opportunity to intervene through culturally appropriate counseling and health education.
KEY WORDS: Adolescent; Child, Culturally Appropriate; Health Education; Smoking
Consumption of tobacco has been common in the Americas for eight thousand years. American Indian shamans first used tobacco ritually to produce hallucinations (Goodman, 1993). Columbus brought back information about tobacco smoking in 1492 and by 1558 the tobacco plant had found its way to Europe (MacKay & Crofton, 1996). The prevalence of smoking tobacco among those of European ancestry increased dramatically in the early 1890’s. Prior to that time tobacco was consumed mostly by chewing or as snuff.
Tobacco marketing throughout the last one hundred years has specifically targeted youth. Adolescents have become the primary target of tobacco companies who seek to replace smokers lost through quitting and death. In the US, 5,000 new smokers must be recruited every day to replace smokers lost through attrition. Historical analysis has determined that when a particular sex is the focus of a marketing campaign, the identified group will have an increase in smoking initiation (Pierce & Gilpin, 1995). Cartoon characters such as “Joe Camel” are recognized by very young children. The Joe Camel campaign resulted in 32.3% increase in young smokers who chose Camel cigarettes as their brand (Unger, Johnson & Rohrbach, 1995).
Koop, Kessler and Lundberg (1998) describe the tobacco industry as ruthlessly marketing an addictive lethal product, denying health evidence, and obstructing government action to prevent and reduce the smoking epidemic. Well crafted and sophisticated tobacco advertising has resulted in a worldwide exposure to smoking.
Tobacco companies are promoting and marketing overseas in ways that are currently banned in the US, e.g., television advertising and selling cigarettes without warning labels on the packages. The industry sponsors highschool sporting events, distributes free cigarette samples, and arranges for discotheques to grant free admission in exchange for empty carton of cigarettes (Connolly, 1989; Davis, 1986).
Cigarette markets are shrinking in the West, prompting the industry to expand into the huge populations of the developing world. US based companies currently supply about 20 percent of the nearly 6 trillion cigarettes smoked in the world each year (Philip Morris, 1985– 1996). Tobacco companies have increased their exports by over 260 percent in recent years. In 1996, Philip Morris sold 70 percent and the RJ. Reynolds Tobacco Company exported 57 percent of their products overseas (Lobe, 1998).
The total number of smokers in the world will rise from 1.1 billion today to 1.64 billion in 2025, due to an increasing population and increasing numbers of women who will begin to smoke. Three times as many people will die of tobacco related causes in the year 2025, compared with today. Tobacco related deaths will rise from 3 million to 10 million per year, and China is anticipated to lead the world in tobacco related deaths. The developing nations will bear the burden of the tobacco epidemic, as they are projected to contain 85 percent of the world’s smokers (MacKay, 1998). The World Health Organization predicts that by the year 2030 tobacco related diseases will claim10 million lives annually, 70 percent in the developing world (MaKay, 1999). It is predicted that tobacco poses the greatest future health risk to the developing world, and will eventually surpass malnutrition and communicable diseases in magnitude (Makary, 1998).
In 44 developed countries, smoking has been linked to 24% of all male deaths and 7% of all female deaths. Smoking is strongly implicated in attempting to explain the rising mortality rates among males in Eastern and Central Europe (Watson, 1995). While these countries have the highest male cigarette consumption rate in Europe, females are also starting to smoke in greater numbers (Reynolds, 1995). With the increase in lung cancer, higher prevalence of young smokers and high-tar dark tobacco cigarettes, Eastern Europe is a prime area for smoking prevention and cessation campaigns (Negri & Vecchia, 1995). During 1995 a cross sectional survey in Budapest, Hungary, documented that one-third of all students smoked; half of all 18-year-olds smoked; and of those students who smoked, 41 percent most frequently smoked an imported, internationally recognized brand (CDC, 1997).
Current statistics indicate that one in six children in the United States will become regular smokers. Of those, approximately five million will die from complications of smoking. The U.S. Guidelines for Adolescent Preventive Services recommends screening and counseling for tobacco and abusable substances for individuals ages eleven to twenty-one. However, a study (Gregario, 1994) of pediatricians, family practitioners and dentists revealed that counseling occurred infrequently in this at risk group.
Healthy People 2010 Objectives:
Draft for Public Comment (US Department of Health and Human Services, 1998) has a number of goals related to tobacco smoking and children. They are to:
Reduce the proportion of young people in grades 9 through 12 who have used tobacco products from 42.7 percent to 28 percent is sought.
Increase by at least 1 year the average age of the first use of tobacco products by adolescents (Baseline: 12.4 years among 12 to 17 year olds).
Increase to 40% the proportion of young people in grades 9 to 12 who have never smoked (29.8 percent did in 1997).
Reduce to no more than 15 percent the proportion of children aged 6 and younger who are regularly exposed to tobacco smoke at home. (Baseline: More than 27 percent exposed in 1994).
Increase to 100 percent the proportion of schools with tobacco-free environments that include all school facilities, property, vehicles and school events. (Baseline: 36.5 percent of middle/junior high schools in 1994).
Include evidence-based tobacco use prevention in the curricula of all elementary, middle, and secondary schools, preferable as part of comprehensive school health education. Enact and enforce in 50 states comprehensive laws prohibiting the sale and distribution of tobacco products to youth younger than age 19. Enforce minors’ access laws so that the buy rate in compliance checks conducted in all 50 states and the District of Columbia is no higher than 5 percent.
Increase to at least 75 percent the proportion of health care providers who routinely advise cessation and provide assistance, follow up, and documented charts for all of their tobacco-using patients.
The International Union Against Cancer has declared smoking cessation therapy as an important priority of all health professionals (Kunze & Wood, 1984). Former Surgeon General C. Evert Koop has called smoking the greatest public health problem facing society today.
Most researchers believe that a combination of psychological and sociological factors is necessary to create a teenage smoker. One theory is “accelerated maturity”. In junior high school, students seek independence and identity. They want peer acceptance, respect and to appear older. Many attain this through academic or sports achievements. For others with poor academic or sports records who are left out of the popular peer groups, smoking becomes a way to look more mature. The psychological factors involved in smoking include the intention to smoke, increased stress, decreased self esteem, and inadequate coping skills (Winkelstein, 1992).
Adolescents at high risk for smoking are more deviance prone, have a greater external locus of control, are less successful academically, and live in family and peer environments which are low in personal control (Winkelstein, 1992). They also have more role models who smoke, stronger intentions to smoke and more positive attitudes about smoking. Smoking among school dropouts is over 80% (Karle, Shenassa, Edwards, Werden, Elder, & Whitehorse, 1994).
Parental smoking has been linked with a number of childhood diseases. Babies whose mothers smoked while pregnant are typically small for gestational age. Infants of smokers typically have more incidents of respiratory illnesses and have decreased lung development and may be more prone to expire from Sudden Infant Death Syndrome. Children absorb greater amounts of nicotine and other toxic substances in their lungs and inspire more per kilogram of body weight than adults. The more the parents smoke the greater the effect of this dose-response relationship (Glantz, 1992). The U.S. Environmental Protection Agency published a report in 1992 that second-hand smoke causes over 26,000 new cases of asthma and contributes to one million asthma attacks in children each year. Passive smoke is also tied to increased rates of otitis media in children.
Even though most elementary age children believe smoking is harmful, 16% of them will become regular teenage smokers. Most start in junior high school between 12 and 14 years of age. Very few start after high school and/or age 19 years or older, high school dropouts are more likely to smoke (Karle, et al, 1994).
Although trying smoking is commonly thought of as a rite of passage, experimenting adolescents often become addicted to nicotine and turn into regular smokers (Kessler, 1995). Contrary to thoughts of immortality, smoking teenagers autopsied show pathological lung changes. Increased small airway dysfunction and increased respiratory symptoms are common.
A progression through four stages leads to regular smoking:
Preparation and anticipation – the child is observing peer and family members model smoking.
He/she notices tobacco advertisements.
Initiation – when first cigarette is tried, usually with a friend.
Learning or experimentation – when smoking occurs less than once a week and;
Habituation or maintenance – when smoking occurs regularly each week. (Winkelstein, 1992).
After overcoming the initial discomfort of smoking, teenagers learn to use smoking for stimulation and relaxation as well as a coping mechanism. Nicotine dependence can occur after only a few cigarettes. Of the adolescents who experiment with two or more cigarettes, one to two thirds of them will become regular smokers. The physiologic effect combined with the social reinforcement from peers virtually guarantees habitual smoking (McGee & Stanton, 1993).
Peer influence affects the anticipation, initiation and experimentation stage. Over half of all adolescents reported smoking their first cigarette with a friend. Peer pressure is responsible for many teenagers’ decision to smoke.
Parental smoking also influences smoking. Adolescent girls are more likely to smoke if their mother smokes. Smoking parents and siblings provide models for the anticipation stage. When both parents smoke, a child is more likely to smoke than one whose parents don’t smoke or only one smokes. If the child’s older siblings and parents both smoke, that child is four times more likely to smoke than if the family has no smokers (Winkelstein, 1992).
Easy availability plays an important part in encouraging adolescent smoking. Despite law (which makes it illegal to sell tobacco to children), retailers continue to sell cigarettes to minors (DeFranza & Brown, 1992). There is now an emphasis on passing laws to eliminate vending machines that dispense cigarettes in areas that cannot easily be monitored.
Interventions for Primary Care Providers
All smoking interventions should begin with the parents. If parents smoke, they should be encouraged to stop. Education about health risks and copying behavior should be emphasized. Assist the parents to develop good parenting skills, especially in the area of self esteem.
The professional should be vigilant about inquiring about smoking status and the effects of cigarette smoking on the body and appearance. It is imperative that they understand smoking is habit forming. Engage the help of older siblings or peers to influence the younger adolescent by pointing out the social unacceptance of smoking in many places. Analyze advertisements of cigarettes. Role play ways to fend off peer pressure. Stress reduction classes may be helpful to young smokers trying to quit. Schools should make an antismoking contract with each adolescent and send letters home congratulating teenagers who don’t smoke (Rasco, 1992).
The health care provider’s office should be smoke free. Smoking prevention posters should be displayed. Magazines that promote cigarette advertisements should not be displayed. The primary care provider should increase his/her own knowledge of smoking’s effects and make public presentations. Supporting antismoking legislation helps everyone; by getting involved with national approaches, health care providers can multiply their efforts (Nelm, 1993).
Health education in school settings should institute antismoking programs that would teach children and teenagers how to resist the peer pressure of smoking. The optimum age for introducing smoking prevention is at ten years of age (Chen, Schroeder, Glover, Bonaguro, & Capwell, 1991 ). Previously devised programs have included communication and problem solving skills, media influences, values clarification, improving self image, anxiety reduction and assertiveness training. Many methods, such as role playing, debates, peer testimonials, skits and group discussions, have also been used to get the point across. Such behavioral programs have shown better results than just disseminating information. One such program is the Child and Adolescent Trial for Cardiovascular Health (CATCH). CATCH is a combination school and home based program that focuses on health topics including smoking prevention (Johnson, Osganian, Budman, Lytle, Barrera, Bonura, Wu, & Nader, 1994). All of these programs should include social reinforcement, social norms, or development orientation (Bruvold, 1993). If antismoking classes are held, it may be helpful to have an older adolescent serve as a role model to influence the younger adolescent.
Gaining the respect of adolescents is important for success. Young people should be treated as responsible persons. By talking about attitudes and values about smoking the practitioner can discover why an individual chooses to smoke or not. Interventions should be tailored for that particular individual. Smoking status should be recorded on each visit demonstrating to the patient and his parents the impact of smoking on his/her health (Rasco, 1992).
These interventions can be summed ur) with the 5 A’s:
Anticipate the risk for tobacco at each develop mental stage. Determine the risk factors such as parental or peer smoking, poor school performance, and positive attitudes toward smoking.
Ask about exposure to tobacco smoke and tobacco use at each visit. Ask if the risks of tobacco is discussed in school and about other school issues.
Advise all smoking parents to stop and all children and adolescents not to use tobacco products. Underscore the bad effects of smoking such as odor of breath and clothes or yellow fingers.
Assist children and adolescents in resisting tobacco use and assist tobacco users in quitting. Point out the false views of tobacco advertising
Arrange follow up visits as required especially for those children already experimenting with tobacco (Epps & Manley, 1992; Adams, 1995).
The evidence clearly reveals that the world is in the grip of a tobacco epidemic with far ranging consequences for the health and economies of many nations. Through political action, culturally sensitive education, and primary care interventions, inroads can be made in this most preventable of international problems.
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Martha Neff Smith, PhD, MPH, RN, CS, FAAN
Gale A. Spencer, PhD, RN
Charles O’Donnell, PhD-s, RN, FNP, CS
Essie A. Riley-Eddins, PhD, RN, SM
Martha Neff Smith, PhD, MPH, RN, CS, FAAN, Research Associate; Gale A. Spencer, PhD, RN, Director, Kresge Center for Nursing Research; Charles O’ Donnell, PhD-s, RN, FNP, CS. All authors are with the Decker School of Nursing, Binghamton University, Binghamton, New York. Essie A. Riley-Eddins, PhD, RN, SM, Founding Editor, Journal of Multicultural Nursing & Health, Chautauqua, New York.
Copyright Riley Publications, Inc. Center for the Study of Multiculturalism and Health Winter 2000
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