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.

     

The development of tobacco use in adolescence among "snus starters" and "cigarette starters": an analysis of the Swedish "BROMS" cohort

Whether the use of smokeless tobacco can facilitate the transition to cigarette smoking and/or to prolonged tobacco use in adolescence is unclear. We analyzed data from a cohort of 2,938 Swedish adolescents, with six follow-up assessments of tobacco use between the ages of 11 and 18 years. The majority of tobacco users (70%) started by smoking cigarettes, 11% took up snus before smoking, and 19% used both tobacco types close in time. Ever users of tobacco at baseline had a higher risk of being current smokers and/or smokeless tobacco users at the end of follow-up compared with never users, with the highest excess relative risk for "mixed users." Adolescents who initiated tobacco use with cigarettes had a non-significantly increased probability to end up as current smokers compared with snus starters (adjusted OR=1.42; 95% CI 0.98-2.10) The OR of smoking for "mixed starters" was 2.54 (95% CI 1.68-3.91). The risk of becoming current user of any tobacco was also significantly enhanced for "mixed starters." Marked sex differences were observed in these associations, as initiation with cigarettes rather than with snus predicted current smoking or tobacco use only among females. Progression of tobacco use in adolescence is not predicted by onset with snus or cigarettes, but rather by initiation with both tobacco types close in time and/or at young age. The proportion of adolescent smoking prevalence attributable to a potential induction effect of snus is likely small.     

What the public thinks about the tobacco industry and its products

Objectives: To assess public attitudes toward the tobacco industry and its products, and to identify predictors of attitudes supportive of tobacco industry denormalisation.

Design: Population based, cross sectional survey.

Setting: Ontario, Canada.

Subjects: Adult population (n = 1607).

Main outcome measures: Eight different facets of tobacco industry denormalisation were assessed. A denormalisation scale was developed to examine predictors of attitudes supportive of tobacco industry denormalisation, using bivariate and multivariate analyses.

Results: Attitudes to the eight facets of tobacco industry denormalisation varied widely. More than half of the respondents supported regulating tobacco as a hazardous product, fining the tobacco industry for earnings from underage smoking, and suing tobacco companies for health care costs caused by tobacco. Majorities also thought that the tobacco industry is dishonest and that cigarettes are too dangerous to be sold at all. Fewer than half of the respondents thought that the tobacco industry is mostly or completely responsible for the health problems smokers have because of smoking and that tobacco companies should be sued for taxes lost from smuggling. In particular, less than a quarter thought that the tobacco industry is most responsible for young people starting to smoke. Non-smoking, knowledge about health effects caused by tobacco, and support for the role of government in health promotion were independent predictors of support for tobacco industry denormalisation.

Conclusions: Although Ontarians are ambivalent toward tobacco industry denormalisation, they are supportive of some measures. Mass media programmes aimed at increasing support for tobacco industry denormalisation and continued monitoring of public attitudes toward this strategy are needed.

     

Seeing,wanting, owning: the relationship between receptivity to tobacco marketing and smoking susceptibility in young people

OBJECTIVE—To assess the effect of the tobacco industry''s marketing practices on adolescents by examining the relationship between their receptivity to these practices and their susceptibility to start smoking.DESIGN—Paper-and-pencil surveys measuring association with other smokers, exposure to tobacco industry marketing strategies, experience with smoking, and resolve not to smoke in the future.SETTING—25 randomly selected classrooms in five middle schools in San Jose, California.SUBJECTS—571 seventh graders with an average age of 13 years and 8 months; 57% were female. Forty-five per cent of the students were Asian, 38% were Hispanic, 12% were white, and 5% were black.MAIN OUTCOME MEASURES—Exposure to social influences, receptivity to marketing strategies, susceptibility to start smoking.RESULTS—About 70% of the participants indicated at least moderate receptivity to tobacco marketing materials. Children who are more receptive are also more susceptible to start smoking. In addition to demographics and social influences, receptivity to tobacco marketing materials was found to be strongly associated with susceptibility.CONCLUSIONS—Tobacco companies conduct marketing campaigns that effectively capture teenage attention and stimulate desire for their promotional items. These marketing strategies may function to move young teenagers from non-smoking status toward regular use of tobacco. Our results demonstrate that there is a clear association between tobacco marketing practices and youngsters'' susceptibility to smoke. The findings, along with other research, provide compelling support for regulating the manner in which tobacco products are marketed, to protect young people from the tobacco industry''s strategies to reach them.     

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.     

Patterns of smoking in Bulgaria

BACKGROUND: Although the rate of smoking-related deaths in Bulgaria is still relatively low, in international terms, it has been rising rapidly. This is likely to become worse in the future as Bulgaria faces growing pressure from transnational tobacco companies. There is, however, little information on patterns of smoking, which is necessary for development of effective policies to tackle tobacco consumption. OBJECTIVE: To describe the pattern of smoking in Bulgaria and its relationship with sociodemographic factors. DESIGN: Multivariate analysis of data on patterns of tobacco consumption from a multi-stage nationwide survey of 1550 adults. SETTING: Bulgaria, in 1997. MAIN OUTCOME MEASURE: Prevalence of current cigarette smoking. RESULTS: 38.4% of men and 16.7% of women smoke. Smoking rates are strongly associated with age, with 58% of men and 30% of women aged 30-39 smoking whereas only 5% of men aged 70 years and older and almost no women of this age smoke. Smoking is more common in cities, among those who are widowed or divorced, or who do not own their home. There is no clear association with household income or, for men, with education, although there is a suggestion that smoking may be more common among more highly educated women. CONCLUSIONS: The observed pattern of smoking indicates the need for a robust policy to tackle smoking in Bulgaria, especially among the young in large cities, informed by a better understanding of why smoking rates vary among different groups.     

What should be the elements of any settlement with the tobacco industry?

Litigation and regulatory assaults on the tobacco companies may create a willingness among tobacco manufacturers to bargain resources and acceptance of public policy changes for limitations of liability, as has been seen by the recent settlement with the Liggett Group. Two elements absolutely critical to any plan are the elimination of tobacco advertising and promotion and the removal of addiction as a reason for tobacco use. Minimal components of any settlement should include: (a) acceptance by the tobacco manufacturers of the causal relationship between tobacco use and disease, and the addictive nature of nicotine; (b) a total ban on tobacco advertising and promotion; (c) FDA jurisdiction over tobacco products and their nicotine content, with the intent of removing nicotine as soon as acceptable nicotine substitution products are available; (d) reimbursement to the states for Medicaid and other state expenditures attributable to smoking, to the maximum extent feasible; (e) funding for local, state, and federal programmes and research in tobacco control; (f) acceptance of legislation and regulations protecting the right of non-smokers to breathe air free of tobacco smoke; (g) funding for a large, national, media-led, anti- tobacco campaign; and (h) cessation assistance for addicted smokers. If negotiations toward a settlement proceed, it is essential that the public health community participate in defining the elements of any agreement to ensure that whatever agreement develops is focused on reducing tobacco-related disease rather than continuing the profitability of American tobacco companies. That participation requires articulation of the core elements essential to an acceptable agreement. If resolution of the public health issues surrounding continued sale of tobacco products can be reached in the United States, it may provide a model for similar resolution in other countries.


     

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.     

The potential of the internet as a medium to encourage and discourage youth tobacco use

The internet is fast becoming a new battleground between tobacco control advocates and pro-tobacco forces, and this new media will certainly have a greater impact on tobacco use behaviour in the future. This paper reviews how the internet can encourage youth smoking by providing youth access to tobacco products and offering content that glamorises smoking lifestyle and culture, particularly in hundreds of websites and chat rooms. These sites feature pictures of celebrity smokers, provide information about smoking in movies, and provide smoking advice to teen smokers. In contrast, youth smoking is discouraged on online grassroots advocacy and countermarketing websites. Although these strategies show promise, more research is needed to evaluate their impact. Recommendations are made for future research to study pro-smoking internet content and ways to counteract it, as well as to monitor the online activities of the tobacco companies. Finally, some of the challenges in addressing tobacco related internet content are discussed.     

Tobacco point-of-purchase promotion: examining tobacco industry documents

In the face of increasing media restrictions around the world, point-of-purchase promotion (also called point-of-sale merchandising, and frequently abbreviated as POP or POS) is now one of the most important tools that tobacco companies have for promoting tobacco products. Using tobacco industry documents, this paper demonstrates that tobacco companies have used point-of-purchase promotion in response to real or anticipated advertising restrictions. Their goal was to secure dominance in the retail setting, and this was achieved through well-trained sales representatives who offered contracts for promotional incentive programmes to retailers, which included the use of point-of-sale displays and merchandising fixtures. Audit programmes played an important role in ensuring contract enforcement and compliance with a variety of tobacco company incentive programmes. Tobacco companies celebrated their merchandising successes, in recognition of the stiff competition that existed among tobacco companies for valuable retail display space.     

Tobacco industry consumer research on socially acceptable cigarettes

Objective: To describe tobacco industry consumer research to inform the development of more "socially acceptable" cigarette products since the 1970s. Methods: Analysis of previously secret tobacco industry documents. Results: 28 projects to develop more socially acceptable cigarettes were identified from Philip Morris, RJ Reynolds, British American Tobacco, and Lorillard tobacco companies. Consumer research and concept testing consistently demonstrated that many smokers feel strong social pressure not to smoke, and this pressure increased with exposure to smoking restrictions. Tobacco companies attempted to develop more socially acceptable cigarettes with less visible sidestream smoke or less odour. When presented in theory, these product concepts were very attractive to important segments of the smoking population. However, almost every product developed was unacceptable in actual product tests or test markets. Smokers reported the complete elimination of secondhand smoke was necessary to satisfy non-smokers. Smokers have also been generally unwilling to sacrifice their own smoking satisfaction for the benefit of others. Many smokers prefer smoke-free environments to cigarettes that produce less secondhand smoke. Conclusions: Concerns about secondhand smoke and clean indoor air policies have a powerful effect on the social acceptability of smoking. Historically, the tobacco industry has been unable to counter these effects by developing more socially acceptable cigarettes. These data suggest that educating smokers about the health dangers of secondhand smoke and promoting clean indoor air policies has been difficult for the tobacco industry to counter with new products, and that every effort should be made to pursue these strategies.     

Characteristics associated with rapid transition to tobacco dependence in youth.

Epidemiologic data suggests the smoking trajectory for some adolescents escalates rapidly and that tobacco dependence can develop quickly after initiation. In this study, we examine variation in cigarette consumption and individual characteristics associated with the rapid development of tobacco dependence, focusing particularly on the 24-month interval after tobacco initiation. The analysis is based on public use data files of the National Household Survey on Drug Abuse conducted in 1994-1996. Representative samples of adolescents aged 12-17 years old, totaling 13,831, completed a standardized interview assessing demographic characteristics, tobacco involvement and past year dependence, and psychological functioning over the preceding 6-month period as assessed by the Youth Self-Report. Analyses were restricted to the 1,734 youth who had started smoking within 0-24 months prior to being assessed, of which the onset for 70% of them was between 11-24 months. Logistic regression models took into account sample weights and used a variance estimation procedure appropriate for the complex multistage sampling design. Overall, 210 recent initiators met dependence criteria (13.5%, 95% CI = 12.0-15.2). Dependent smokers had greater cigarette involvement than youth who had not transitioned to being tobacco dependent by the time of assessment. Variation in mental health and sociodemographic characteristics were also detected. Disruptive behavior (p = .05) and being female (p = .02) were associated with being tobacco dependent. The rapid transition to dependence in youth depends not only on cigarette consumption features, but may also be associated with individual characteristics.     

Adolescents' perceptions about smoking prevention strategies: a comparison of the programmes of the American Lung Association and the Tobacco Institute

OBJECTIVE: To evaluate components of the teenage smoking prevention programmes of the American Lung Association (ALA) and the Tobacco Institute (TI). DESIGN: Group administration of written questionnaires in school. The components of the ALA's and TI's programmes were presented to students in seven strategy vignettes, covering the following topics: peer pressure/enhanced communication; parents as role models; health consequences of smoking; cost of smoking; smoking as an illegal act; tips for quitting smoking; and responsible decision making. SUBJECTS AND SETTING: 172 seventh-grade students (mean age = 12.3 years) from six parochial schools in Memphis, Tennessee, United States. MAIN OUTCOME MEASURES: Student ratings of the perceived effectiveness of the ALA and TI approaches (in helping to stop teens from smoking) within each strategy vignette, and students' choice between these two approaches as to which was the better smoking prevention technique. RESULTS: Although there were some moderating effects of gender and race, participants overall strongly favoured the ALA programme over that of the TI. Of the seven programme components, the ALA's approach was rated more effective on six (peer pressure, parents as role models, the health consequences of smoking, the cost of smoking, tips for quitting smoking, responsible decision making) and the TI's was rated more effective on one (not smoking because it is illegal). CONCLUSIONS: The ALA's programme was perceived to be much more effective than the TI's programme by those whom these programmes are ultimately intended to influence-young people. Future research in this area should pursue longitudinal designs to determine if programme endorsement is predictive of smoking status.


     

Consequences of marketing exceptions in the Master Settlement Agreement: exposure of youth to adult-only tobacco promotions.

The Master Settlement Agreement between a consortium of tobacco companies and 46 states contains many restrictions on tobacco sales and advertising that were designed to reduce youth exposure to tobacco promotions. Most of the restrictions include an exception for "adult-only" facilities. The present study investigated the extent to which youth are being exposed to marketing that is presumably limited to adults. Using data from a statewide random-digit-dialed survey of 3,863 Massachusetts youth aged 12-17 years, we found that about half of all youth in this age group reported seeing cigarettes advertised at events, concerts, bars, or clubs in the past 12 months, and that about 5% of youth in this age group reported being present at a venue where free samples of cigarettes were being distributed. Youth exposed to this marketing were those most at risk for progression to established smoking. To our knowledge, this is the first study to estimate youth exposure to advertisements designed for adult-only venues. In light of the large body of evidence that exposure to tobacco advertising and promotion increases tobacco use among youth, our findings demonstrate the need to close the "adult-only" loophole.     

Industry sponsored anti-smoking ads and adolescent reactance: test of a boomerang effect

Objective

To examine whether adolescents'' exposure to youth smoking prevention ads sponsored by tobacco companies promotes intentions to smoke, curiosity about smoking, and positive attitudes toward the tobacco industry.

Design

A randomised controlled experiment compared adolescents'' responses to five smoking prevention ads sponsored by a tobacco company (Philip Morris or Lorillard), or to five smoking prevention ads sponsored by a non‐profit organisation (the American Legacy Foundation), or to five ads about preventing drunk driving.

Setting

A large public high school in California''s central valley.

Subjects

A convenience sample of 9th and 10th graders (n  =  832) ages 14–17 years.

Main outcome measures

Perceptions of ad effectiveness, intention to smoke, and attitudes toward tobacco companies measured immediately after exposure.

Results

As predicted, adolescents rated Philip Morris and Lorillard ads less favourably than the other youth smoking prevention ads. Adolescents'' intention to smoke did not differ as a function of ad exposure. However, exposure to Philip Morris and Lorillard ads engendered more favourable attitudes toward tobacco companies.

Conclusions

This study demonstrates that industry sponsored anti‐smoking ads do more to promote corporate image than to prevent youth smoking. By cultivating public opinion that is more sympathetic toward tobacco companies, the effect of such advertising is likely to be more harmful than helpful to youth.     

Sociodemographic predictors of success in smoking intervention

AIM: To examine the role of sociodemographic factors as predictors of sustained smoking cessation for the population who volunteer to participate in intervention programmes. METHOD: Data for the 3575 smokers who participated in the CEASE (collaborative European anti-smoking evaluation) trial, a European multicentred study that used transdermal nicotine patches as an adjunct to smoking cessation in the chest clinic, were analysed. The effects of age, sex, smoking habit, socioeconomic status (housing conditions, education, and employment), disease, smoking habits of relatives, and baseline markers of tobacco use on sustained smoking cessation (self-reported abstinence and expired carbon monoxide < 10 parts per million) were assessed using logistic regression modelling (odds ratio (OR), 95% confidence interval (CI)). RESULTS: 477/3575 smokers were sustained abstainers one year after the intervention (overall success rate 13.3%). In the univariable logistic regression models an effect of active treatment on smoking cessation was observed (OR 1.50, 95% CI 1.15 to 1.96), and additional effects on outcome were found for age (OR 1.02, 95% CI 1.01 to 1.03), sex (men v women: OR 1.38, 95% CI 1.14 to 1.68), housing conditions (OR 1.43, 95% CI 1.25 to 1.65), current respiratory (OR 0.79, 95% CI 0.67 to 0.92) or cardiac disease (OR 0.46, 95% CI 0.28 to 0.75), and markers of tobacco use (cigarettes per day: OR 0.79, 95% CI 0.69 to 0.90; expired carbon monoxide: OR 0.98, 95% CI 0.97 to 0.99). Education and employment did not have a significant effect on the outcome. The effect of the variables associated with success in smoking cessation persisted after adjustment for covariates. CONCLUSION: Age, sex, and housing conditions have a major effect on smoking cessation in European smokers participating in smoking cessation programmes.     

Impact of smoking images in magazines on the smoking attitudes and intentions of youth: an experimental investigation

Objective

To determine the effect of magazine incidental smoking imagery on youths'' smoking intentions.

Methods

A magazine was developed incorporating photographs of smokers (Smoking Magazine). A second version of the magazine (Non‐smoking Magazine) included these photographs with the tobacco paraphernalia digitally erased. Equal numbers of smokers and non‐smokers aged 14–17 years (n = 357) were randomly assigned to look through one version of the magazine and then asked a series of questions.

Results

Smokers made more unprompted mention of smoking imagery than non‐smokers after viewing Smoking Magazine (52% vs 34%; p<0.05). Smokers viewing Smoking Magazine were more likely to report an urge to smoke (54% vs 40%; p<0.05). Female non‐smokers who viewed Smoking Magazine were more likely than those who viewed Non‐smoking Magazine to state a future intention to smoke (13% vs 0%; p<0.05). Female smokers were more attracted to the male models appearing in Smoking Magazine than Non‐smoking Magazine (49% vs 24%; p<0.05) and the opposite was true for female non‐smokers (28% vs 52%; p<0.05). Female smokers were also marginally more likely to desire looking like the female models in Smoking Magazine (64% vs 46%; p = 0.06) but no difference was observed in the non‐smoking females (46% vs 46%). Male smokers and non‐smokers did not differ in their responses by magazine type.

Conclusions

Incidental positive smoking imagery in magazines can generate the same sorts of consumer effects attributed to advertising in general, including tobacco advertising. Sex specific results of our study may be explained by the choice of smoking images used.With a view to reducing tobacco related harm, a number of countries around the world have implemented comprehensive advertising and sponsorship bans of tobacco in accordance with the World Health Organization''s Framework Convention on Tobacco Control (FCTC). Even with comprehensive tobacco control legislation, loopholes remain that can be exploited by the tobacco industry to circumvent comprehensive advertising restrictions. For example, product placements in movies and television programmes popular with adolescents are a noted tactic of the tobacco industry.¹ Furthermore, incidental depictions of tobacco in popular media, although not necessarily instigated by the tobacco industry, can serve to counter restrictions on advertising. Smoking depictions within youth oriented advertisements for non‐tobacco products are common, being used as a device by advertisers to focus on the lifestyle and image of the user, rather than on the intrinsic value or merits of the product itself.² Incidental images of smoking are also common in editorial and feature components of youth oriented entertainment media, including movies, television, magazines and the internet. Although social determinants such as having parents, older siblings and peers who smoke are the best predictors of smoking initiation in youth,³ portrayals of smoking in popular media appear to contribute by presenting socially attractive images and inflating the perception of smoking prevalence.^2,4,5Studies consistently suggest that incidental smoking is depicted far more commonly than is normal within the actual population, and that the majority of depictions are associated with popular and desirable role models with positive attributes such as fame, attractiveness, sexiness, sophistication and glamour.^6,7,8 For instance an analysis of popular Hollywood movies in the late 1990s suggested that one in two heroes smoke, including 80% of leading male characters.⁸ In the early 1990s an audit of Australian youth oriented magazines suggested that photographs featuring smoking were “infrequent” (one depiction per 147 pages). An increase of 12% in smoking depictions was noted between 1990 and 1993 in the period after the introduction of the complete tobacco advertising ban but, as this increase was non‐significant, natural variation could not be discounted.⁹ However, a similar audit of magazines conducted a decade later suggested that far from being infrequent, depictions of smoking were commonplace: 96% of a sample of youth oriented magazines included at least one depiction of incidental smoking (average 3.5 per magazine; one per 50.3 pages), with 97% of these depictions being favourable.¹⁰ Although the methodologies differed between the two studies, it appears that the tobacco advertising ban in Australia was followed by an increase rather than decrease in prevalence of smoking portrayals in magazines.There is clear evidence that exposure to positive portrayals of smoking in movies and on television increases adolescents'' positive attitudes towards smoking, the likelihood of smoking initiation, and imitation of modelled smoking actions.^11,12 However, research investigating the impact of incidental portrayals of tobacco use in magazines is sparse. Amos and colleagues¹³ assessed adolescents'' perceptions of photographs of models using tobacco products and compared these to adolescents'' perceptions of identical photographs but with the tobacco paraphernalia digitally removed. They found that the presence of a cigarette affected how the model in a photograph was perceived: when tobacco products were present, models were associated with “drug taking,” “wildness” and being “depressed,” and to a lesser extent being “vain,” “tarty” and “posers.” Without the smoking paraphernalia the same models were perceived as being more “healthy,” “rich,” “nice,” “fashionable,” “slim” and “attractive.” Although traits such as “druggy,” “wild” and “tarty” may appear to be negative associations, smokers sampled in the study were found to be more drawn to such traits than non‐smokers, and were found to rate themselves less negatively in terms of these traits than non‐smokers. The authors concluded that although young smokers and non‐smokers associated the same attributes to the smoking models, smokers identified more strongly with these attributes than did non‐smokers, and hence the smoking imagery served to positively reinforce the self identity of young smokers. In a later complementary study,¹⁴ Amos and her colleagues conducted focus groups with young smokers and found that smoking imagery in magazines helped reinforce positive perceptions of smoking as attractive, sociable and reassuring thereby reinforcing young smokers'' own identities. Furthermore the lack of obvious vested interests in incidental smoking portrayals meant that such were potentially more powerful than tobacco advertising imagery.The present study aims to extend the studies of Amos and colleagues by using a randomised controlled trial to assess the impact of smoking images in magazines on smoking and non‐smoking youth, and particularly their intentions for future smoking. We hypothesised that positive smoking imagery in a youth oriented magazine would:

• lessen young smokers'' future intentions to quit;
• increase non‐smokers'' future intentions to take up smoking;
• increase young people''s perceptions of the prevalence of smoking;
• increase young smokers'' urge to smoke while reading the magazine; and
• increase young smokers'' positive perceptions of the depicted models but decrease young non‐smokers'' positive perceptions of the depicted models.

     

Smoking cessation with smokeless tobacco and group therapy: an open, randomized, controlled trial

Smokeless tobacco might be effective as an adjunct for smoking cessation. We evaluated the efficacy of smokeless tobacco and group support for smoking cessation in an open, randomized study that compared smokeless tobacco plus group support versus group support only. The study enrolled 263 healthy smokers (M (age) = 49 years) who smoked a mean of 24 cigarettes/day, with a mean of 31 pack-years. Smokeless tobacco was provided for 7 weeks (or up to 12), combined with eight group support visits provided by nurses. The control group received group support only. Smoking cessation rates were statistically significantly better in the smokeless tobacco group than in the control group during the first 7 weeks. Point-prevalence abstinence rates at 7 weeks were 36.4% versus 20.8% (OR = 2.52, p = .001), respectively; and continuous abstinence rates from weeks 4 to 7 were 31.5% versus 19.2% (OR = 1.94, p = .023), respectively. The primary outcomes (i.e., 6-month point prevalence) were 23.1% versus 20.8%, respectively (OR = 1.31, ns). Smokeless tobacco was relatively well tolerated, although 15 subjects (11.2%) stopped use due to adverse events. A total of 25 subjects (17.5 %) were still using smokeless tobacco after 6 months. This trial demonstrated short-term efficacy of smokeless tobacco in combination with group support for smoking cessation but no long-term efficacy.     

Differences in prevalence of tobacco use among Indian urban youth: the role of socioeconomic status

This study examined whether the distribution of tobacco use and related psychosocial risk factors among youth in urban India vary by socioeconomic status (SES). Data were derived from a cross-sectional survey of students enrolled in the 6th and 8th grades in 32 schools in Delhi and Chennai (N = 11,642). The survey was conducted in 2004, before the implementation of a program designed to prevent and reduce tobacco use (MYTRI). Mixed-effect regression models were used (a) to determine the prevalence of tobacco use among private (higher SES) and government (lower SES) school students, (b) to investigate whether certain psychosocial factors were associated with increased tobacco use, and (c) to determine how these factors varied by school type. Ever-use of multiple forms of tobacco (e.g., gutkha, bidis, and cigarettes) was more prevalent among government school students than private school students. After adjusting for city, gender, grade, and age, we found the prevalence rate for ever-use of any tobacco product to be 18.9% for government school students, compared with 12.2% for private school students (p<.01). Students in government schools scored lower than private school students on most psychosocial risk factors for tobacco use studied here, indicating higher risk. Government school students scored the lowest for refusal skills, self-efficacy, and reasons not to use tobacco. Social susceptibility to chewing tobacco and social susceptibility to smoking were strong correlates of current tobacco use among government school students. Exposure to tobacco advertising was also a strong correlate of current tobacco use for government school students but not private school students. In two large cities of India, students attending government schools are using many forms of tobacco at higher rates than private school students. The psychosocial risk profile of government school students suggests they are more vulnerable to initiation and use and to outside influences that encourage use.