Described as one of the core aims of tobacco control,1 the term 'prevention' is generally used in tobacco control to refer to any interventions or efforts to deter smoking. It includes within its spectrum the following when applied to youth smoking in particular.
'Prevention' as it applies to youth smoking
Preventing those who have never smoked from trying it or starting
Discouraging those who have tried smoking once or twice from continuing
Deterring continuation among those who have 'taken up' smoking
Encouraging and assisting young smokers to quit
Adolescents may be at any point along this prevention spectrum. It is important to recognise and understand these nuances in the youth smoking trajectory, as they have significant implications for the appropriateness and efficacy of programs and interventions. Moreover, the predictors that precipitate smoking initiation or 'first try' are not necessarily the same drivers associated with progression to more regular smoking.2 Thus some of the factors discussed in preceding sections of this chapter are highly predictive of a first try (such as having family members who smoke), while others play more of a role in facilitating continuation (like ease of access) or deterring it (e.g. an unpleasant first experience).
As evident in the continuum above, the conventional distinction between smoker and non-smoker is also more of a grey area in relation to adolescents; not only are there varying definitions of what degree of smoking constitutes a 'smoker', research also suggests that some young people who smoke only intermittently or socially do not regard themselves as smokers.3 This has implications for youth smoking interventions and the way in which messages are framed.
Vardavas3 describes a 'tobacco control funnel' depicting three groups of policies through which adolescent smoking can be prevented and reduced at the population level. As illustrated in Figure 5.19.1, the three key avenues are restrictions to denormalise smoking (e.g. through price increases, bans on sales to minors and restrictions on areas where smoking is permitted), education to increase awareness (e.g. at school and through mass media campaigns) and 'disruption' to de-glamorise smoking (such as through the use of graphic warning labels and tobacco advertising bans).
Tobacco control funnel
Source: Reproduced with permission, Vardavas C 20103 Figure 1: Tobacco control funnel, page 2
As almost all smokers start young, preventing children and young people from smoking initiation is crucial in achieving significant long-term reductions in smoking prevalence.1 In addition, since young people who live with adult smokers are much more likely to start smoking than those who live in smokefree homes, decreasing adult smoking prevalence is essential.1 Indeed, due to difficulties encountered in smoking prevention, it has been recommended that the focus should be on adult smoking programs ahead of prevention in adolescents.4
Traditionally, youth smoking strategies have concentrated on keeping young people from trying their first cigarette;5 however, some of the drivers of the 'first try' are difficult to prevent. Curiosity, for example, is a natural part of growing up and a normal part of the teenage trajectory.6 Curiosity was one of the predominant reasons given for trying smoking (even among non-smokers) in two qualitative studies conducted among young Australians.2,6 'Seeing what it is like' is perceived by young people as part of making an 'informed choice'; hence even ardent non-smokers accept 'just having a try' in the context of curiosity and life experiences, and don't see experimentation as a 'big deal' per se.6 Moreover, among the adolescents interviewed in the Western Australian research undertaken for the Smarter than Smoking project, there was very little perceived risk of trial leading to regular smoking, or becoming addicted, even though the risks of smoking were well known and accepted among this group.6
In the broader drug education field, there is debate around the extent to which interventions and programs should focus on preventing ever or first use of a substance, or whether it is more realistic to acknowledge that some experimentation and use will occur, and the emphasis shifted more to reducing harm and levels of use. Within tobacco control, there has typically been considerable resistance to harm minimisation approaches, in part because there is no safe level of use even for adults (which differs from alcohol), and due to concern that harm minimisation programs may lead to increased experimentation among non-users due to perceived weakened social norms.7 To date there has not been much research to help refute or confirm these concerns. An exception is Western Australian research that provides some evidence for the potential effectiveness of a harm minimisation intervention tackling adolescent smoking.8 The two-year school-based study compared the results of a harm reduction intervention (involving classroom, school nurse and parental harm reduction intervention materials and training) with a more conventional abstinence-oriented program. Among student participants who were never-smokers at baseline (age 14–15 years), those in the harm reduction group were less likely to experiment and less likely to smoke heavily, while there was no significant difference in smoking uptake between the groups.7
There is a relative research and intervention void in the published literature relating to experimental smoking and the progression to regular smoking.9 Figure 5.19.2 depicts some of the factors influencing whether young people who have tried cigarettes continue to smoke, as identified in Western Australian qualitative research with young people aged 13–15 years.6
Factors influencing continuation of smoking after experimentation
Source: Wood L, Lang A and Coase P, 2005 Reproduced with permission10
A number of the factors depicted above present opportunities to 'intercept' young people between experimentation and continuation. For instance, predisposing attitudes towards or against smoking are factors that influence continuation, and are amenable to intervention.10 Enjoyment of the initial smoking experience also influences continuation but is less amenable to intervention (other than through product taste regulation: see Chapter 12, Section 12.8 for information on flavours added to cigarettes in the Australian market).
For some youth from Indigenous and lower socio-economic status (SES) backgrounds, stresses and troubles in life also appear to influence smoking experimentation and continuation,10 mirroring recognised barriers to cessation among Indigenous adults11 and disadvantaged population groups.12 While current generations of young people place a high value on individual choice,13 there may be opportunities to further challenge the sense and consequences (for self and others) of choosing to smoke tobacco.10
The standard adult dichotomy between smoker and non-smoker is somewhat less clear in the youth smoking area: adolescents' definitions of what constitutes a smoker and what constitutes smoking often differ from clinical or research definitions.14 Intermittent patterns of smoking and lower consumption are more typical in younger smokers.15 Moreover, qualitative research from Western Australia found that young people who smoke 'socially' or intermittently often do not regard themselves as smokers or have any intention of becoming a regular smoker.10 There is also some evidence that adolescent cigarette smokers may have more daily variability in their smoking patterns than adults, such as significantly more weekend than weekday smoking.16 These findings have implications for assessing adolescent smoking patterns as well as maximising the effectiveness of youth-centred smoking prevention and cessation initiatives; for example, prevention messages need to avoid simplistically cataloguing young people as either smokers or non-smokers.
While youth smoking campaigns and programs have not traditionally focused on issues of addiction or cessation, there is a cohort of young people who smoke with some regularity, and a subset of these who are actually addicted. Addiction in young smokers has been poorly researched and understood until recently,17 but there is accumulating evidence of nicotine addiction in adolescent smokers18–20 and an emerging imperative to address this within a comprehensive approach to tobacco control. Qualitative studies with young people provide further evidence of the validity of addiction experiences in young, regular and irregular smokers.6,17
Research suggests that children's ideas and expectations of addiction influence their predisposition and likelihood to smoke.17 There are marked differences in perceptions of the addictive nature of smoking between adolescents who have smoked or intend to smoke and those who are resolved not to try it.21,22
However, young people's understanding of addiction (including its likelihood, processes and consequences) is poor.17,23 Adolescents generally do not recognise or comprehend the addictiveness of smoking for people their age, and tend not to see addiction as a likely outcome of 'just trying it' or experimenting.6 Notions of what it takes to become addicted seem primarily based on opinion or observation, rather than 'known facts'6, 17 and research with young smokers indicates that addiction is an unanticipated consequence.17, 18 Young people often believe that they can smoke during adolescence without becoming addicted24 and that they can easily give up at any time.22,25,26 Addiction and cessation tend to be viewed by teenagers as issues only for adult smokers.17
While addiction and cessation might be seen by some to sit at or outside the margins of smoking prevention, recent Australian studies with young people highlight the importance of addressing understanding of addiction within primary prevention interventions.2,6 Traditionally addiction has not often been explicitly addressed within the rubric of youth tobacco-control programs27, but there is growing recognition of the validity of addiction experiences in young smokers, even among those who smoke irregularly.28,29 This supports the need therefore to include issues of addiction as part of the youth prevention remit. Issues of addiction can for example be incorporated into school-based programs, information on websites and youth resources and woven into mass media messages, as they have been in the 'Bus Stop' advertisement developed by the Western Australian campaign Smarter than Smoking with the tag line 'Wouldn't it better to quit before you started?', which has been used in several states and territoriesi.
There are few effective or well-evaluated youth cessation interventions in the literature.30,31 An Australian exception (mentioned in Section 5.19.1) 7 entails a whole-of-school approach utilising school nurses in the delivery of cessation strategies.32,33 While the presence of withdrawal symptoms among adolescents who are trying to quit smoking supports the appropriateness of using nicotine replacement therapy,34 some debate surrounds the acceptability of this, and ethical issues preclude controlled pharmacological trials with adolescent smokers.31
The following sections (Sections 5.20–5.32) examine some of the ways in which programs and strategies for intervention have been developed and discuss their efficacy.
i Ad can be seen via http://www.oxygen.org.au/resources/media-materials
1. Action on Smoking and Health. Beyond smoking kills: protecting children, reducing inequalities. London: ASH, 2008. Available from: http://www.ash.org.uk/files/documents/ASH_691.pdf.
2. Eureka Strategic Research. Youth tobacco prevention research project. Undertaken for the Australian Government Department of Health and Ageing. Canberra: Department of Health and Ageing, 2005. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/phd-pub-tobacco-literature-cnt.htm
3. Vardavas C. Key points in preventing tobacco use among adolescents. Tobacco Induced Diseases 2010;8(1):1. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2819233/?tool=pubmed
4. Hill D. Why we should tackle adult smoking first. Tobacco Control 1999;8(3):333–5. Available from: http://tobaccocontrol.bmj.com/cgi/content/full/8/3/333
5. Hammond D. Smoking behaviour among young adults: beyond youth prevention. Tobacco Control 2005;14(3):181–5. Available from: http://tc.bmjjournals.com/cgi/content/abstract/14/3/181
6. Leavy J, Wood L, Rosenberg M and Phillips F. Try and try again: qualitative insights into adolescent smoking experimentation and notions of addiction. Health Promotion Journal of Australia 2010;21(3):208-14. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21118068
7. Hamilton G, Cross D, Resnicow K and Shaw T. Does harm minimisation lead to greater experimentation? Results from a school smoking intervention trial. Drug and Alcohol Review 2007;26(6):605-13. Available from: http://informahealthcare.com/doi/abs/10.1080/09595230701613585
8. Ilomäki R, Riala K, Hakko H, Lappalainen J, Ollinen T, Räsänen P, et al. Temporal association of onset of daily smoking with adolescent substance use and psychiatric morbidity. European Psychiatry 2008;23:85-91. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18082380
9. Brook JS, Morojele NK, Brook DW, Zhang C and Whiteman M. Personal, interpersonal, and cultural predictors of stages of cigarette smoking among adolescents in Johannesburg, South Africa. Tobacco Control 2006;15(suppl.1):i48-53. Available from: http://tc.bmjjournals.com/cgi/content/abstract/15/suppl_1/i48
11. Briggs V, Lindorff K and Ivers R. Aboriginal and Torres Strait Islander Australians and tobacco Tobacco Control 2003;12(suppl. 2):ii5-8. Available from: http://tobaccocontrol.bmj.com/cgi/reprint/12/suppl_2/ii5.pdf
12. Stead M, MacAskill S, MacKintosh A-M, Reece J and Eadie D. 'It's as if you're locked in': qualitative explanations for area effects on smoking in disadvantaged communities. Health and Place 2001;7:333-43. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11682332
14. Lee J and Halpern-Felsher B. What does it take to be a smoker? Adolescents' characterization of different smoker types. Nicotine & Tobacco Research 2011;13(11):1106-13. Available from: http://ntr.oxfordjournals.org/content/early/2011/08/17/ntr.ntr169.full?sid=1485b814-0c13-492e-b572-d1798f04cb0d
15. Ling PM and Glantz SA. Tobacco industry research on smoking cessation. Journal of General Internal Medicine 2004;19:419. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15109339
16. Bailey S, Jeffery C, Hammer S, Bryson S, Killen D, Ammerman S, et al. Assessing teen smoking patterns: the weekend phenomenon. Drug and Alcohol Dependence 2011;120(1-3):242-5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21885211
17. Wang C, Henley N and Donovan R. Exploring children's conceptions of smoking addiction. Health Education Research 2004;19:626-34. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15199004
18. Moffat B and Johnson J. Through the haze of cigarettes: teenage girls' stories about cigarette addiction. Qualitative Health Research 2001;11:668-81. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11554194
19. Colby S, Tiffany S, Shiffman S and Niaura R. Are adolescent smokers dependent on nicotine? A review of the evidence. Drug and Alcohol Dependence 2000;59(suppl.1):S83–95. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10773439
20. Johnson J, Bottorff J, Moffat B, Ratner P, Shoveller J and Lovato C. Tobacco dependence: adolescents' perspectives on the need to smoke. Social Science & Medicine 2003;56:1481-92. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12614699
21. Halpern-Felsher B, Biehl M, Kropp R and Rubinstein M. Perceived risks and benefits of smoking: differences among adolescents with different smoking experiences and intentions. Preventive Medicine 2004;39:559-67. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15313096
22. Arnett J. Optimistic bias in adolescent and adult smokers and nonsmokers Addictive Behaviours 2000;25:625-32. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10972456
23. Rugkasa J, Knox B, Sittlington J, Kennedy O, Treacy M and Abaunza P. Anxious adults vs. cool children: children's views on smoking and addiction. Social Science & Medicine 2001;53:593-602. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11478539
24. Kropp R and Halpern-Felsher B. Adolescents' beliefs about the risks involved in smoking "light" cigarettes. Pediatrics 2004(114):e445-51. Available from: http://pediatrics.aappublications.org/cgi/content/full/114/4/e445
25. Weinstein ND. Accuracy of smokers' risk perceptions. Nicotine & Tobacco Research 1999;1(suppl.1):S123-30. Available from: http://ntr.oxfordjournals.org/content/1/Suppl_1/S123.abstract
26. Paavola M, Vartiainen E and Puska P. Smoking cessation between teenage years and adulthood. Health Education Research 2001;16:49-57. Available from: http://her.oxfordjournals.org/cgi/content/full/16/1/49
27. Ling PM and Glantz SA. Why and how the tobacco industry sells cigarettes to young adults: evidence from industry documents. American Journal of Public Health 2002;92(6):908–16. Available from: http://www.ajph.org/cgi/content/full/92/6/908
28. Fidler JA, Wardle J, Henning Brodersen N, Jarvis MJ and West R. Vulnerability to smoking after trying a single cigarette can lie dormant for three years or more. Tobacco Control 2006;15(3):205-9. Available from: http://tc.bmjjournals.com/cgi/content/abstract/15/3/205
29. Buller D, Borland R, Woodall W, Hall J, Burris-Woodall P and Voeks J. Understanding factors that influence smoking uptake. Tobacco Control 2003;12(suppl. 4):iv16-25. Available from: http://tobaccocontrol.bmj.com/cgi/content/abstract/12/suppl_4/iv16
30. Stanton W and Smith K. A critique of evaluated adolescent smoking cessation programmes. Journal of Adolescence 2002;25:427-38. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12175999
31. Garrison M, Christakis D, Ebel B, Wiehe S and Rivara F. Smoking cessation interventions for adolescents: a systematic review. American Journal of Preventive Medicine 2003;25:363-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14580641
32. Hamilton G, Cross D, Resnicow K and Hall M. A school-based harm minimisation smoking intervention trial: outcome results. Addiction 2005;100:689-700. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15847627
33. Hamilton G, O'Connell M and Cross D. Adolescent smoking cessation: development of a school nurse intervention. Journal of School Nursing 2004;20:169-74. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15147225
34. Patten C. A critical evaluation of nicotine replacement therapy for teenage smokers. Journal of Child & Adolescent Substance Abuse 2000;9:51-75. Available from: http://www.tandfonline.com/doi/abs/10.1300/J029v09n04_04