A randomised controlled trial of a community intervention to prevent adolescent tobacco use

OBJECTIVE: Experimental evaluation of comprehensive community wide programme to prevent adolescent tobacco use. DESIGN: Eight pairs of small Oregon communities (population 1700 to 13 500) were randomly assigned to receive a school based prevention programme or the school based programme plus a community programme. Effects were assessed through five annual surveys (time 1-5) of seventh and ninth grade (ages 12-15 years) students. INTERVENTION: The community programme included: (a) media advocacy, (b) youth anti-tobacco activities, (c) family communications about tobacco use, and (d) reduction of youth access to tobacco. MAIN OUTCOME MEASURE: The prevalence of self reported smoking and smokeless tobacco use in the week before assessment. RESULTS: The community programme had significant effects on the prevalence of weekly cigarette use at times 2 and 5 and the effect approached significance at time 4. An effect on the slope of prevalence across time points was evident only when time 2 data points were eliminated from the analysis. The intervention affected the prevalence of smokeless tobacco among grade 9 boys at time 2. There were also significant effects on the slope of alcohol use among ninth graders and the quadratic slope of marijuana for all students. CONCLUSION: The results suggest that comprehensive community wide interventions can improve on the preventive effect of school based tobacco prevention programmes and that effective tobacco prevention may prevent other substance use.     

Investing in youth tobacco control: a review of smoking prevention and control strategies

OBJECTIVE: To provide a comprehensive review of interventions and policies aimed at reducing youth cigarette smoking in the United States, including strategies that have undergone evaluation and emerging innovations that have not yet been assessed for efficacy. DATA SOURCES: Medline literature searches, books, reports, electronic list servers, and interviews with tobacco control advocates. DATA SYNTHESIS: Interventions and policy approaches that have been assessed or evaluated were categorised using a typology with seven categories (school based, community interventions, mass media/public education, advertising restrictions, youth access restrictions, tobacco excise taxes, and direct restrictions on smoking). Novel and largely untested interventions were described using nine categories. CONCLUSIONS: Youth smoking prevention and control efforts have had mixed results. However, this review suggests a number of prevention strategies that are promising, especially if conducted in a coordinated way to take advantage of potential synergies across interventions. Several types of strategies warrant additional attention and evaluation, including aggressive media campaigns, teen smoking cessation programmes, social environment changes, community interventions, and increasing cigarette prices. A significant proportion of the resources obtained from the recent settlement between 46 US states and the tobacco industry should be devoted to expanding, improving and evaluating "youth centred" tobacco prevention and control activities.     

State variation in retail promotions and advertising for Marlboro cigarettes

BACKGROUND: There is some evidence that tobacco companies marketing efforts undermine the effects of comprehensive tobacco control programmes. OBJECTIVE: To determine whether point-of-purchase advertising and promotions are more pervasive in states where comprehensive tobacco control programmes are underway. DESIGN: Cross sectional survey using 1996 data, with merged records of the existence of local tobacco advertising restrictions. PARTICIPANTS AND SETTING: 581 tobacco retail stores located in close proximity to high schools in mainland USA. MAIN OUTCOME MEASURES: Existence of gift-with-purchase, number of interior advertisements, and exterior store advertisements for Marlboro cigarettes. RESULTS: After controlling for store type and existence of advertising restrictions, offer of a gift-with-purchase for Marlboro cigarettes was significantly more likely in states with comprehensive tobacco control programmes than those without programmes (odds ratio 2.59, 95% confidence interval 1.57 to 4.26). Although not significant, results show an increase in the number of interior and exterior store advertisements for stores located in states with a comprehensive tobacco control programme than those in other states. CONCLUSION: Results suggest some point-of-purchase tobacco promotions and advertising are more pervasive in states with comprehensive tobacco control programmes. These efforts are likely to act against the objectives of programmes and need to be accounted for in programme evaluations.     

What public health strategies are needed to reduce smoking initiation?

Smoking initiation is a key behaviour that determines the future health consequences of smoking in a society. There is a marked difference in smoking patterns around the world, driven by initiation rates. While a number of high-income countries have seen smoking prevalence decline markedly from peak, many low-income and middle-income countries appear to still be on an upward trend. Unlike cessation where changes are limited by nicotine dependence, rates of smoking initiation can change rapidly over a short time span. Interventions that can be effective in achieving this include increases in the price of tobacco products, mass media anti-smoking advertising, smoke-free policies, smoking curricula in schools, restrictions on marketing opportunities for the tobacco industry as well as social norms that lead to restrictions on adolescents' ability to purchase cigarettes. Comprehensive tobacco control programmes that aim to denormalise smoking behaviour in the community contain all of these interventions. Rapid reductions in smoking initiation in adolescents have been documented in two case studies of comprehensive tobacco control programmes in California and Australia. Consistent and inescapable messages from multiple sources appear to be key to success. However, the California experience indicates that the rapid decline in adolescent smoking will not continue if tobacco control expenditures and the relative price of cigarettes are reduced. These case studies provide strong additional evidence of the importance of countries implementing the provisions of the Framework Treaty on Tobacco Control.     

Sharing the blame: smoking experimentation and future smoking-attributable mortality due to Joe Camel and Marlboro advertising and promotions

BACKGROUND: Despite public denials, internal tobacco company documents indicate that adolescents have long been the target of cigarette advertising and promotional activities. Recent longitudinal evidence suggests that 34% of new experimentation occurs because of advertising and promotions. OBJECTIVE: To apportion responsibility for smoking experimentation and future smoking-attributable mortality among major cigarette brands attractive to young people (Camel and Marlboro). DATA SOURCES, SETTING, AND PARTICIPANTS: Data were from confirmed never-smoking adolescents (12-17 years old) responding to the 1993 (n = 2659) and 1996 (n = 2779) population-based California Tobacco Surveys. MAIN OUTCOMES: Adolescents named the brand of their favourite cigarette advertisements and tobacco promotional items. Using these "market shares" and the relative importance of advertising and promotions in encouraging smoking, we estimated how many new experimenters from 1988 to 1998 in the United States can be attributed to Camel and Marlboro. From other data on the natural history of smoking, we projected how many future deaths in the United States can be attributed to each brand. RESULTS: Although Camel advertisements were favoured more than Marlboro and other brands in 1993 and 1996, the "market share" for promotional items shifted markedly during this period from Camel and other brands towards Marlboro. We estimated that between 1988 and 1998, there will be 7.9 million new experimenters because of tobacco advertising and promotions. This will result in 4.7 million new established smokers: 2.1, 1.2, and 1.4 million due to Camel, Marlboro, and other brands' advertising and promotions, respectively. Of these, 1.2 million will eventually die from smoking-attributable diseases: 520,000 from Camel, 300,000 from Marlboro, and the remainder from other brands. CONCLUSIONS: Our analysis provides a reasonable first estimate at sharing the blame for the long-term health consequences of smoking among the major brands that encourage adolescents to start smoking.     

Comparison of physician based reporting of tobacco attributable deaths and computer derived estimates of smoking attributable deaths, Oregon, 1989 to 1996

BACKGROUND: Tobacco use prevention programmes need accurate information about smoking related mortality. Beginning in 1989, Oregon began asking physicians to report on death certificates whether tobacco use contributed to the death. OBJECTIVE: To determine the long term comparability of this method of estimating tobacco attributable mortality to estimates of smoking attributable mortality derived from a computer model. DESIGN: For the period 1989 to 1996, we compared mortality resulting from tobacco use reported by Oregon physicians to estimates of smoking attributable deaths (SADs) derived by "Smoking attributable mortality, morbidity and economic costs" software version 3.0 (SAMMEC 3.0), a widely used software program that estimates SADs on the basis of smoking prevalence and relative risks of specific diseases among current and former smokers. MAIN OUTCOME MEASURES: Numbers of deaths, age, sex, and category of disease. RESULTS: Of 212, 448 Oregon deaths during 1989-1996, SAMMEC 3.0 estimated that 42, 778 (20.1%) were attributable to cigarette smoking. For the same 27 diagnoses, physicians reported that tobacco contributed to 42, 839 (20.2%) deaths-a cumulative difference of only 61 deaths over the eight year period. The age and sex distributions of tobacco and smoking attributable deaths reported by the two systems were also similar. By category of disease, the ratio of SAMMEC 3.0 estimates to physician reported deaths was 1.11 for neoplasms, 0.88 for heart disease, and 1.04 for respiratory disease. CONCLUSIONS: Physician reporting provides comparable estimates of smoking attributable mortality and can be a valuable source of data for communicating the risks of tobacco use to the public.     

The California Tobacco Control Program's effect on adult smokers: (3) Similar effects for African Americans across states

Objective

To compare trends in African‐American (AA) and non‐Hispanic white (NHW) smoking between states categorised as having three different levels of tobacco control practice in the 1990s.

Setting and participants

Analysis of 1992–3 to 2001–2 Tobacco Use Supplements to the Current Population Survey for differences in adult (20–64 years) daily smoking prevalence for AAs and NHWs across states: California (CA; high cigarette price/comprehensive programme), New York (NY) and New Jersey (NJ; high cigarette price/no comprehensive programme), and tobacco growing states (TGS; low cigarette price/no comprehensive programme).

Results

From 1992–3 to 2001–2, there were large declines in AA smoking across states (2.7–3.8% decrease/year, adjusted for age, income, education, gender; p<0.05). Adjusted NHW smoking prevalence declined significantly only in CA. AA prevalence declined significantly and did not differ across state groups. In all years, in all state groups, adjusted prevalence was either not significantly different or was lower for AAs than for NHWs. More recent cohorts of AAs appeared to have taken up smoking at lower rates than older cohorts.

Conclusion

There were uniformly large declines in AA smoking from 1992–3 to 2001–2 across states, independent of type of tobacco control strategy. Further research is needed into factors associated with smoking declines among AAs.Historically, smoking prevalence and smoking‐related diseases have been higher in the US African‐American (AA) adult population compared with the non‐Hispanic white (NHW) population.^1,2 However, in recent years the prevalence gap between AAs and NHWs has closed.³ Apparently, lower initiation rates among AAs have persisted resulting in lower adult prevalence rates.^4,5 These changes in AA smoking behaviour may be due to an increased response to tobacco control measures, including higher cigarette prices. An important question is how the smoking rates have changed for AAs and for NHWs across states with different tobacco control strategies.The first comprehensive state‐wide tobacco control programme designed to increase social norms against smoking in the US began in California (CA) in 1989.⁶ This programme was unique in spending an average of US$3 per person per year on a public health programme to discourage smoking through the 1990s.⁷ It is the largest and the longest running programme in the US and its components include mass‐media programmes, clean indoor air laws, community and school programmes, and increased excise taxes. Thus, it might be expected that CA would have shown a greater reduction in smoking than states without such a tobacco control programme.New York (NY) and New Jersey (NJ) are adjacent states with a combined population size similar to CA. Neither state supported a major tobacco control programme in the 1990s, but both were similar to CA in the amount of excise tax levied on cigarettes⁸ and had similar high cigarette prices during the 1990s. It might be expected that these states would also have greater reductions in smoking than states with lower excise taxes during the study period.There are six US states that had significant economic activity (>US$100 million/year) from tobacco‐related agriculture during the study period.⁹ These tobacco‐growing states (TGS) were Kentucky, Tennessee, North Carolina, South Carolina, Virginia and Georgia, which together had a population slightly larger than either CA or NY and NJ. The TGS have consistently had some of the lowest excise taxes in the nation,⁸ and none had a major state‐specific tobacco control programme in the 1990s. There is also evidence that social norms are more supportive of tobacco use in these tobacco‐growing regions.¹⁰We used data from the Tobacco Use Supplements (TUS) to the Current Population Survey (TUS–CPS) from 1992–3 to 2001–2 to examine age‐specific smoking rates and particularly, how reductions in AA initiation previously reported for the 1980s and 1990s might be impacting prevalence rates compared to those among the NHW population. We compared trends for CA, a state with a comprehensive programme designed to increase social norms against smoking, with NY and NJ, states that markedly increased the price of cigarettes during this time period but limited tobacco control activity, and with the TGS, serving as a control group of states with low prices and limited state‐wide tobacco control activities.     

Emotions for sale: cigarette advertising and women's psychosocial needs

Objective: To explore messages of psychosocial needs satisfaction in cigarette advertising targeting women and implications for tobacco control policy.

Methods: Analysis of internal tobacco industry documents and public advertising collections.

Results: Tobacco industry market research attempted to identify the psychosocial needs of different groups of women, and cigarette advertising campaigns for brands that women smoke explicitly aimed to position cigarettes as capable of satisfying these needs. Such positioning can be accomplished with advertising that downplays or excludes smoking imagery. As women's needs change with age and over time, advertisements were developed to reflect the needs encountered at different stages in women's lives. Cigarette brands for younger women stressed female camaraderie, self confidence, freedom, and independence; cigarette brands for older women addressed needs for pleasure, relaxation, social acceptability, and escape from daily stresses.

Conclusions: Psychosocial needs satisfaction can be communicated without reference to cigarettes or smoking. This may explain why partial advertising bans are ineffective and comprehensive bans on all forms of tobacco marketing are effective. Counter-advertising should attempt to expose and undermine the needs satisfaction messages of cigarette advertising campaigns directed at women.

     

Effects of market liberalisation on smoking in Japan

OBJECTIVE: To document the effect of the liberalisation of the Japanese tobacco market on Japanese smoking rates and on Japanese tobacco industry practices. DATA SOURCE: Asahi Shimbun (major daily newspaper) from 1980 to 1996. STUDY SELECTION: Review of media coverage on the effects of market liberalisation following the imposition of the USA's section 301 trade sanction. DATA SYNTHESIS: The opening of Japan's tobacco market to foreign cigarette companies stalled a decline in smoking prevalence. Smoking rates among young women increased significantly, and also appear to be on the rise among adolescents. Aggressive marketing and promotional activities by US and Japanese tobacco companies in response to trade liberalisation appear responsible for these adverse trends. Steep increases in sales through vending machines were also possible contributors to the rising smoking prevalence among adolescents. On the positive side, market liberalisation indirectly promoted smoking control efforts in Japan, by causing an anti-smoking movement to coalesce. CONCLUSION: Market liberalisation in Japan played a significant role in increasing smoking prevalence among young women and adolescents while helping to transform the issue of smoking in Japan from a matter of individual choice to a public health problem.     

Evolution of a comprehensive tobacco control programme: building system capacity and strategic partnerships--lessons from Massachusetts

BACKGROUND: Since the passage of a voter approved state referendum in 1992 to establish a 25 cent increase on the excise tax on cigarettes and smokeless tobacco, Massachusetts has received an average of $40 million annually for its tobacco control programme. This funding allowed Massachusetts to expand and develop its tobacco control programme to become one of the most comprehensive in the world. OBJECTIVES: The development of the Massachusetts Tobacco Control Program is outlined, focusing on three stages of development: formation, strategic partnership building, and shared leadership. METHODS: The development of management structures, programmatic infrastructure, communication and partnership networks, and advisory structures are tracked throughout the three phases. RESULTS: The use of pre-existing public health resources, implementation of a strong training component, a geographical management structure, the creation of public and private partnerships, and the development of a shared leadership model contributed to building consensus and provided the foundation for coordinated approaches to tobacco control. CONCLUSION: Other states and countries can use lessons learned from Massachusetts about the organisational development of a comprehensive tobacco control programme as they embark upon similar efforts.     

Arizona's tobacco control initiative illustrates the need for continuing oversight by tobacco control advocates

BACKGROUND: In 1994, Arizona voters approved Proposition 200 which increased the tobacco tax and earmarked 23% of the new revenues for tobacco education programmes. OBJECTIVE: To describe the campaign to pass Proposition 200, the legislative debate that followed the passage of the initiative, and the development and implementation of the tobacco control programme. DESIGN: This is a case study. Data were collected through semi-structured interviews with key players in the initiative campaign and in the tobacco education programme, and written records (campaign material, newspapers, memoranda, public records). RESULTS: Despite opposition from the tobacco industry, Arizonans approved an increase in the tobacco tax. At the legislature, health advocates in Arizona successfully fought the tobacco industry attempts to divert the health education funds and pass preemptive legislation. The executive branch limited the scope of the programme to adolescents and pregnant women. It also prevented the programme from attacking the tobacco industry or focusing on secondhand smoke. Health advocates did not put enough pressure at the executive branch to force it to develop a comprehensive tobacco education programme. CONCLUSIONS: It is not enough for health advocates to campaign for an increase in tobacco tax and to protect the funds at the legislature. Tobacco control advocates must closely monitor the development and implementation of tax-funded tobacco education programmes at the administrative level and be willing to press the executive to implement effective programmes.     

New Zealand's tobacco control programme 1985-1998

OBJECTIVE: To review the impact of New Zealand's tobacco control programme from 1985 to 1998 on smoking prevalence and tobacco consumption, and to estimate the scope for further reduction. DESIGN: Country case study; interventions, with outcomes ranked internationally across time. SETTING: New Zealand 1985-98; for 1985-95, 23 OECD countries. INTERVENTIONS: Between 1985 and 1998, New Zealand eliminated tobacco advertising, halved the affordability of cigarettes, and reduced smoke exposure in work time by 39%. MAIN OUTCOME MEASURE: Reduction in adult smoking prevalence and in tobacco products consumption per adult. RESULTS: Changes in prevalence 1985-98: in adults (aged 15+ years), -17% (from 30% to 25%) but short of the 20% target for 2000; in youth (aged 15-24 years), -20% (from 35% to 28%); and in Maori adults (aged 15+ years), -17% (from 56% in 1981 to 46% in 1996). Changes in consumption 1985-98: tobacco products per adult aged 15+ years, -45% (2493 to 1377 cigarette equivalents); cigarettes smoked per smoker, -34% (22. 7 to 15.0 per day). Between 1985 and 1995 New Zealand reduced tobacco products consumption per adult more rapidly than any other OECD country, and reduced youth prevalence more rapidly than most. The acceleration of the decline in cigarette attributable mortality rates in men and in women age 35-69 years averted an additional 1400 deaths between 1985 and 1996. Between 1981 and 1996 smoking prevalence among blue collar workers decreased only marginally, and in 14-15 year olds, rose by one third between 1992 and 1997. CONCLUSION: In 13 years, New Zealand's tobacco control programme has been successful in almost halving tobacco products consumption, particularly by lowering consumption per smoker. With strong political support for quit campaigns, increased taxation, and the elimination of displays of tobacco products on sale, the consumption could theoretically be halved again in as little as 3-6 years.     

Adult smoking intervention programmes in Massachusetts: a comprehensive approach with promising results

This paper provides a brief overview of the history of Massachusetts' opposition to smoking. It describes the current Massachusetts Tobacco Control Program and its smoking intervention programmes; changes in public opinion, perceptions and attitudes toward smoking; and programme impact. Massachusetts has been successful in developing a comprehensive intervention that has had encouraging results in changing public attitudes about smoking and in helping smokers to quit.     

Development of a state wide tobacco treatment specialist training and certification programme for Massachusetts

OBJECTIVE: To describe the research conducted to structure and develop a statewide tobacco training and certification programme for tobacco treatment specialists (TTSs) in Massachusetts. DESIGN: Qualitative research strategies were used to obtain information on certification development and opinions regarding TTS training and certification from key informants. A role definition and validation study was then conducted to determine the core competencies for TTSs. A comprehensive training programme was developed, piloted, and finalised, and a certification programme was initiated. PARTICIPANTS: Key informants included: individuals involved in the development of their professional certification programmes; tobacco treatment providers from across Massachusetts; and national tobacco treatment experts. MAIN OUTCOME MEASURES: Participants' opinions about the need for and structure of a training and certification programme for individuals specialising in the provision of moderate to intensive tobacco treatment; delineation of core competencies for TTSs, using the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) clinical practice guideline as a foundation for the development of evidence based standards of practice for the treatment of nicotine dependence. RESULTS: The data support a comprehensive training and certification programme for TTSs in Massachusetts. Main concerns include the cost of obtaining certification, the potential to exclude uncertified healthcare professionals from delivering basic tobacco treatment, and the role of the TTS in the healthcare delivery system and the community. The training programme developed for Massachusetts was piloted, and the structure of a statewide training and certification programme for TTSs was finalised. CONCLUSIONS: The research provides support for the need and acceptance of a training and certification programme for TTSs in Massachusetts, and presents the challenges to be addressed. We demonstrated the feasibility of developing and implementing an evidence based training programme, and of initiating a statewide certification programme in Massachusetts. This work will add to a national dialogue on the development of a training and certification programme for tobacco treatment providers and encourage further research into the potential impact of statewide and national certification.     

Cigarette advertising and promotional strategies in retail outlets: results of a statewide survey in California

OBJECTIVE: To examine the extent and types of cigarette advertising materials in stores and to assess tobacco company compliance with the 1998 Master Settlement Agreement (MSA). DESIGN: A cross-sectional analysis of a random sample of 586 stores that sold cigarettes. SETTING: US state of California. MAIN OUTCOME MEASURES: Trained data collectors classified cigarette advertising materials by type (signs, displays, functional items), location (interior or exterior), and placement (below 3 feet (1 m) or near candy). RESULTS: California retail outlets featured 17.2 (SD 16.1) tobacco advertising materials on average, and 94% of stores featured at least some advertising. About 85% of these were within 4 feet (1.3 m) of the counter. About 50% of the stores had ads at or below 3 feet, and 23% had cigarette product displays next to candy. In violation of the MSA, 3% of stores featured signs with cartoons and 11% had large exterior signs. CONCLUSIONS: Tobacco companies are aggressively using stores to market cigarettes. Moreover, the spirit of the MSA-to protect children from cigarette advertising-has not been realised. Future studies should monitor industry use of this venue and assess the impact of exposure to cigarette advertising materials in stores on adult smokers and youth.     

Question 1 tobacco education expenditures in Massachusetts, USA

BACKGROUND: In 1992, voters in Massachusetts (United States) approved Question 1, a state ballot initiative, which raised the state excise tax to provide funds for tobacco education. OBJECTIVE: To examine Question 1 expenditures for tobacco-specific programmes in the 1994, 1995, 1996, and 1997 fiscal years. DESIGN: This study examined trends in Question 1 expenditures. Data were collected from the Massachusetts Department of Public Health and the Massachusetts Department of Revenue for the 1994, 1995, 1996, and 1997 fiscal years. MAIN OUTCOME MEASURES: The amount of spending on tobacco-specific programmes. RESULTS: Excluding the 1994 fiscal year because the state allocated 18 months of new revenues, from the 1995 fiscal year to the projected 1997 fiscal year, the state will have spent 22% of Question 1 funds for tobacco- specific programmes. Question 1 expenditures for tobacco-specific programmes have declined by 15%, whereas Question 1 expenditures for the other programmes decreased only 0.4%. CONCLUSIONS: The legislature has established a trend that has produced real reductions in Question 1 funding for tobacco education, which appears contrary to the mandate of the voters when they enacted Question 1 in 1992. These reductions undermine the effectiveness of tobacco-specific programmes that are an integral part of the Massachusetts Tobacco Control Programme. These results also highlight the fact that the initial compromises made after initiatives such as Question 1 are adopted have important long-term consequences for funding of tobacco control initiatives.


     

Impact of the Tobacco Price Support Program on tobacco control in the United States

OBJECTIVES—To evaluate the impact of the United States Tobacco Price Support Program (TPSP) on domestic cigarette consumption and the potential political impact of the TPSP on efforts to reduce smoking.
DATA SOURCES—Published studies known to the authors and a search of AGRICOLA from 1980 to 1996.
STUDY SELECTION—Studies published in a refereed journal or research reports published by an accredited university or institution.
DATA SYNTHESIS—The TPSP decreases cigarette use by increasing the price of cigarettes. The price increase resulting from the TPSP, however, is small—about one cent per pack. The resulting decrease in cigarette consumption is also very modest—an estimated 0.23%. However, the TPSP creates tobacco quota owners, who have a strong financial interest in opposing measures to reduce smoking. The TPSP also changes the political influence of tobacco farmers by keeping a large number of small farmers in tobacco production.
CONCLUSIONS—The negative impact of the TPSP (opposition to tobacco control measures) is probably greater than the positive impact of the programme (reducing smoking). Therefore, the net impact of the TPSP on tobacco control efforts is likely to be negative.


Keywords: cigarette consumption; Tobacco Price Support Program; United States     

How effective are tobacco industry bar and club marketing efforts in reaching young adults?

Objective: Recently, the tobacco industry has focused marketing efforts on young adults through bar and club promotions, such as advertising and distribution of free cigarettes in these settings. This study estimates the fraction of the California young adult population that might be exposed and potentially influenced by these efforts.

Design and participants: Data were from 9364 young adult (18–29 years) respondents to the cross sectional population based 2002 California Tobacco Survey. As background, we analysed social smoking (only smoke with other smokers), and enjoyment of smoking while drinking. Our main focus was on bar and club attendance, what was observed in bars and clubs, and how this might differ according to respondents' risk for future smoking.

Results: Social smokers comprised 30.0 (2.2)% of all current smokers, including experimenters. Nearly three quarters (74.5 (2.3)%) of current smokers/experimenters said they enjoyed smoking while drinking. About one third (33.8 (1.2)%) of all young adults said they attended bars and clubs at least sometimes; attendance was significantly higher among smokers and those at risk for future smoking. Close to 60% (57.9 (2.2)%) of bar and club attenders reported seeing cigarette advertising and promotions in these settings. Again, smokers and those at risk were more likely to report seeing such advertising and promotions in these settings.

Conclusions: About 20% of all young adults and about 30% of those at risk for future smoking (including current smokers) were exposed to tobacco advertising and promotions in bars and clubs. These California results may be conservative, but nonetheless indicate that the group potentially influenced is sizable.

     

Tobacco use among youth: a cross country comparison

Methods: The GYTS employs a standard methodology where self administered questionnaires, consisting of a set of core questions, are completed by a representative school based sample of students primarily between the ages of 13–15 years.

Results: Data are presented from 75 sites in 43 countries and the Gaza Strip/West Bank region. Current use of any tobacco product ranges from 62.8% to 3.3%, with high rates of oral tobacco use in certain regions. Current cigarette smoking ranges from 39.6% to less than 1%, with nearly 25% of students who smoke, having smoked their first cigarette before the age of 10 years. The majority of current smokers want to stop smoking and have already tried to quit, although very few students who currently smoke have ever attended a cessation programme. Exposure to advertising is high (75% of students had seen pro-tobacco ads), and exposure to environmental tobacco smoke (ETS) is very high in all countries. Only about half of the students reported that they had been taught in school about the dangers of smoking during the year preceding the survey.

Conclusions: Global youth tobacco use is already widespread throughout the world, but there is great variation among nations. Valid and reliable data on the extent of youth tobacco use, and correlates of use, are essential to plan and evaluate tobacco use prevention programmes. The GYTS has proven the feasibility of an inexpensive, standardised, worldwide surveillance system for youth tobacco use. The GYTS will be expanded to the majority of countries in the next few years, and can serve as a baseline for monitoring and evaluating global and national tobacco control efforts.