Smoking in Cape Town: community influences on adolescent tobacco use

The State of Norm-Based Antismoking Research: Conceptual Frameworks, Research Designs, and Implications for Interventions

This synthesis review examined 189 qualified studies on norms and smoking in terms of conceptual frameworks, types of social norms, research designs, dependent variables, independent variables and covariates, and findings related to norms. Results show that 7.9% were experimental, and the remaining were cross-sectional. By far, the reasoned action approach (RAA) was the most-cited theory, but RAA was not used to guide experimental designs. The social norms approach, norm focus theory, social cognitive theory guided the intervention experiments. Harmful norms were more frequently examined than healthful norms. Pro-smoking norms positively predicted smoking intentions and behaviors, whereas antismoking norms positively predicted antismoking intentions and behaviors. The over-application of RAA in cross-sectional antismoking research has yielded repetitive findings. Norm-based experiments can adopt other theoretical perspectives to offer insights into antismoking interventions. The RAA constructs are still applicable and can be integrated into intervention designs.

Tobacco and alcohol use among adolescents in South Africa: shared and unshared risks

OBJECTIVE

Tobacco and alcohol use by adolescents are major public health concerns in South Africa. However, the extent to which key psychosocial risk factors for tobacco use and alcohol use by adolescents in South Africa are shared or unshared is unclear. This study sought to examine the shared and unshared risk factors for tobacco and alcohol use among adolescents in Johannesburg.

METHOD

Participants comprised 736 males and females aged 12-17 years who were recruited via a household survey conducted during 2004. The participants were interviewed using a questionnaire comprising measures of personal, family (parental bonding and family legal drug use) and contextual (school and neighbourhood) factors. Separate multiple logistic regression analyses were conducted to predict lifetime alcohol use and lifetime tobacco use from variables within each domain (personal, family and contextual), controlling for demographic factors.

RESULTS

Personal, family (parental bonding) and contextual factors (school factors) were primarily shared risk factors for tobacco and alcohol use, while family legal drug use and neighbourhood factors were largely unshared.

CONCLUSIONS

Interventions addressing personal, parenting and schooling factors are likely to have an impact on preventing both tobacco and alcohol use, whereas interventions focused on ameliorating family drug use and neighbourhood factors may need to be more substance-specific.

Community influences on adolescents' use of home-brewed alcohol in rural South Africa

Background

Alcohol represents a major public health challenge in South Africa, however little is known about the correlates of alcohol use among rural adolescents. This article examines community influences on adolescents’ use of home-brewed alcohol in a rural region of South Africa.

Method

A total of 1600 high school adolescents between 11 and 16 years of age participated in this study. Seven hundred and forty (46.3%) were female and 795 (49.7%) were male. Data on gender were missing for 65 students (4.0% of the sample). The age range was 11–29 years (mean age 16.4 years; Standard deviation = 2.79). A survey questionnaire on adolescent risk behavior that examined adolescents’ use of alcohol and various potential community influences on alcohol use was administered. Factor analysis was used to group community-level variables into factors. Multiple logistic regression techniques were then used to examine associations between these community factors and adolescents’ use of home-brewed alcohol.

Results

The factor analysis yielded five community-level factors that accounted for almost two-thirds of the variance in home-brewed alcohol use. These factors related to subjective adult norms around substance use in the community, negative opinions about one’s neighborhood, perceived levels of adult antisocial behavior in the community, community affirmations of adolescents, and perceived levels of crime and violence in the community (derelict neighborhood). In the logistic regression model, community affirmation was negatively associated with the use of home-brew, whereas higher scores on “derelict neighborhood” and “adult antisocial behavior” were associated with greater odds of drinking home-brew.

Conclusion

Findings highlight community influences on alcohol use among rural adolescents in South Africa. Feeling affirmed and valued by the broader community appears to protect adolescents against early alcohol use. In contrast, perceptions of high levels of adult anti-social behavior and crime and violence in the community are significant risks for early alcohol initiation. Implications of these findings for the prevention of alcohol use among adolescents in rural communities are discussed.

Multi-level influence of school norms on tobacco use in South Africa: an ecometric consideration of group differences

OBJECTIVES

Tobacco use has been found to be related to contextual-environmental characteristics. This study focuses on the influence of contextual norms on adolescent smoking behavior with consideration of racial differences.

METHODS

Data for this study were derived from the South African Community Epidemiology Network on Drug Use survey. Students (n = 1,277) completed a self-administered questionnaire (available in Afrikaans, Xhosa, and English). School-level aggregate measures were developed from the items: whether they thought smoking was wrong, whether they thought they would be seen as "cool" if they smoked, how many of their closest friends smoked, and whether they had repeated a grade level in school.

RESULTS

The results of this analysis revealed that after controlling for demographic characteristics, aggregate measures of importance for ever smoking were whether there were school norms of perceiving that smoking was not wrong, perceiving that smoking was cool, and high prevalence of having friends who smoke. Recent smoking was only predicted by attendance at schools with increased levels of academic failure. Black South Africans were less likely to ever smoke than Coloured or White.

CONCLUSIONS

This study highlights the saliency of both compositional (academic failure) and ecological (collective perceptions about smoking) characteristics in predicting ever and recent smoking. Collective perceptions of smoking in a predominantly Black school were largely negative. These findings can be used to target school norms regarding tobacco use in Cape Town.

The incidence of experimental smoking in school children: an 8-year follow-up of the child and adolescent behaviors in long-term evolution (CABLE) study

Background

Studies have established that most regular adult smokers become addicted in their adolescent years. We investigated the incidence of and risk factors associated with initial experimental smoking among a group of school children who were followed for 8 years.

Methods

We used cohort data collected as part of the Child and Adolescent Behaviors in Long-term Evolution (CABLE) study, which selected nine elementary schools each from an urban area (Taipei City) and a rural area (Hsingchu county) in northern Taiwan. From 2002 to 2008, children were asked annually whether they had smoked in the previous year. An accelerated lifetime model with Weibull distribution was used to examine the factors associated with experimental smoking.

Results

In 2001, 2686 4^th-graders participated in the study. For each year from 2002 to 2008, their incidences of trial smoking were 3.1%, 4.0%, 2.8%, 6.0%, 5.3%, 5.0% and 6.0%, respectively. There was an increase from 7^th to 8^th grade (6.0%). Children who were males, lived in rural areas, came from single-parent families, had parents who smoked, and had peers who smoked were more likely to try smoking earlier. The influence of parents and peers on experimental smoking demonstrated gradient effects.

Conclusions

This study used a cohort to examine incidence and multiple influences, including individual factors, familial factors, and community factors, on experimental smoking in adolescents. The findings fit the social ecological model, highlighting the influences of family and friends. School and community attachment were associated with experimental smoking in teenagers.

Tobacco

Anthropologists have long studied tobacco, what is today the world's greatest cause of preventable death. Their publications have garnered modest attention, however, even as the academy is increasingly interested in global health, transnational commoditization, pharmaceuticals, and the politics of life and death. We take stock of anthropology's tobacco literature and our discipline's broader appetites. We review how colleagues have studied health issues related to tobacco and engaged with theory and policy pertaining to the production, consumption, and regulation of drugs. We assess ways scholars working at the interface of anthropology and cigarettes have analyzed gender and ethnicity, corporate predation and industry-related harm, governmental management of disease, and the semiotics of misinformation. We discuss why anthropology has not more broadly and ardently engaged the study of tobacco. And we identify areas for further research capable of illuminating more fully tobacco's analytical potential and toxic effects.

Current smoking behaviour among rural South African children: Ellisras Longitudinal Study

BACKGROUND

The use of tobacco products is the major cause of chronic diseases morbidity and mortality. Most smokers start the smoking habits from childhood and adolescent stages.

METHOD

This was a cross-sectional study. A total of 1654 subjects (854 boys and 800 girls), aged 11 to 18 years, who were part of the Ellisras Longitudinal Study completed the questionnaire. Association between tobacco products use and habits, attitudes and beliefs were explored in this study. Logistic regression was used to estimate the association.

RESULTS

The prevalence of tobacco product use increases with increasing (4.9 to 17.1%) age among boys whereas girls do not smoke cigarette but only considerable number (1.0 to 4.1%) use home made tobacco products (pipe and snuff) among the Ellisras rural children. Parents and grand parents play a significant (about 50%) role in influencing smoking behaviour among the Ellisras rural children. Seeing actors smoking on TV shows was positively associated (p < 0.05) with smoking (OR = 2.3 95%CI (1.3-4.1 and OR = 2.3 95%CI 1.3-4.1 after adjusting for age and gender). However, women who smoke cigarette were significantly (p < 0.001) associated with success and success and wealth (OR = 2.8, 95% CI 1.5-5.2) even after adjusting for age and gender (OR = 2.9 95% CI 1.5-5.4).

CONCLUSION

The usage of tobacco products was high among older boys. Girls did not smoke cigarette. This tobacco use behaviour mirrors the cultural norms and adult behaviour. The association of this tobacco used products with biological parameters will shed more light on the health of these children over time.

Environmental stressors, low well-being, smoking, and alcohol use among South African adolescents

This is the first study to examine the pathways from environmental stressors to substance use among a sample of South African adolescents (N = 2195). The study objective was to assess how environmental stressors might affect cigarette smoking and alcohol use among South African adolescents, and to focus on one mechanism, low well-being, which might mediate this association. Participants consisted of 2195 Black, mixed ancestry ("Colored"), Indian, and White youth, aged 12-17 years old (mean age = 14.6; SD = 1.8), recruited via a multi-stage stratified sampling procedure in Durban, Cape Town, and Johannesburg, South Africa. Data were collected via individual in-person structured interviews, administered by trained interviewers in the participant's preferred language. Structural equation modeling was used to analyze the interrelationships of environmental stressors (violent victimisation, legal and illegal drug availability) and low well-being (depressive symptoms, low self-esteem, health problems) with respect to adolescent cigarette smoking and alcohol use. The results supported our hypotheses: Environmental stressors were related to low well-being which, in turn, was linked to both adolescent smoking and alcohol use. There were also direct pathways from environmental stressors to both adolescent smoking and alcohol use. Smoking and alcohol use were significantly correlated. The findings suggest that environmental stressors may be associated with diminished psychological and physical well-being, as well as smoking and alcohol use, among South African adolescents. Longitudinal research is warranted to further understand the interrelationship of environmental stressors, low well-being, and adolescent substance use, so that these issues may be addressed by South African programmes and policies.

The Relationship Between Receptivity to Media Models of Smoking and Nicotine Dependence Among South African Adolescents

The purpose of this study is to determine the association of receptivity to media models of smoking and nicotine dependence among South African adolescents from four ethnic groups. A stratified random sample of 731 adolescents aged 12 to 17 years (mean=14. 55, SD=1.68) was drawn from Johannesburg, South Africa. A structured questionnaire was administered to the participants in their homes by trained interviewers. Receptivity to media models of smoking was assessed with a three-item Likert scale. The dependent variable, nicotine dependence, was assessed with the Fagerström Test for Nicotine Dependence (FTND). Regression analyses showed a positive relationship between media receptivity and nicotine dependence, with control on demographic variables and hours of TV watched by the adolescent. This relationship was found to be strongest among White adolescents and weakest among Black adolescents. Though equally receptive to media models of smoking, Black adolescents have lower FTND scores than their peers from other South African ethnic groups. This may be related to the low prevalence of images in South Africa depicting Black people smoking cigarettes. Cultural norms against smoking among Black adolescents may also serve as a protective factor.

Associations between maternal closeness, suicidal ideation, and risk behaviors in Cape Town

Health compromising behaviors, such as smoking and other risk behaviors tend to co-occur, and contribute to the leading causes of preventable death, disease, and disability among adolescents and young adults worldwide. The present study assesses a model of the direct and indirect effects of maternal closeness with suicidal ideation on smoking and risky behaviors. The sample consisted of 657 South African youth assessed over two time points with comparison of effects between males and females. Maternal closeness had a significant effect on suicidal ideation among females. Suicidal ideation had a significant effect on risky behaviors among males and lifetime smoking among females. A significant indirect effect was observed from maternal closeness to lifetime smoking among females. These results indicate that suicidal ideation is associated with lifetime smoking and risky behaviors separately among male and female adolescents and highlight the need to focus on the development of mental health preventive interventions for both genders.

A prospective longitudinal model of substance use onset among South African adolescents

Substance use onset among Colored adolescents between eighth and ninth grades in an urban area of Cape Town, South Africa was examined using latent transition analysis. Longitudinal self-report data regarding substance use (N= 1118, 50.9% female) were collected in 2004 and 2005. Results indicated that the pattern of onset was similar across genders; adolescents first tried either alcohol or cigarettes, followed by both, then dagga (cannabis), and then inhalants. The prevalence of lifetime cigarette use was slightly greater for females; dagga (cannabis) and inhalant use were greater for males. The similarity of developmental onset in the current sample to previous international work supports the promise of adapting prevention programs across contexts. The study's limitations are noted.

Perceptions of sexual risk behaviours and substance abuse among adolescents in South Africa: a qualitative investigation

The study examined South African adolescents' beliefs and attitudes regarding drug use, sexual risk behaviour and relationships between the two behaviours. Eleven single-gender focus groups were held among male and female Grade 8 and 11 students from three schools in Cape Town. The adolescents' opined that drugs' reinforcing effects were the main factor underlying their use, and that sexual risk behaviours resulted from girls' limited power in sexual relationships and boys' perceived invulnerability to HIV infection and the positive status associated with having multiple partners. Drug use was considered to exacerbate underlying vulnerabilities to risky sexual behaviour mainly due to drugs' effects on adolescents' inhibitions, rational thinking, and safer sex negotiation skills. The findings suggest that adolescent HIV intervention programmes should address the risks posed by drug use on sexual behaviour.

Personal, interpersonal, and cultural predictors of stages of cigarette smoking among adolescents in Johannesburg, South Africa

OBJECTIVE

This study examined the personal, parental, peer, and cultural predictors of stage of smoking among South African urban adolescents.

DESIGN

A cross-sectional design was employed. A stratified random approach based on census data was used to obtain the sample. Analyses were conducted using logistic regression.

SETTING

The study took place in communities in and around Johannesburg, South Africa.

SUBJECTS

Participants consisted of 731 adolescents in the age range of 12-17 years old. The sample was 47% male and 53% female, and contained four ethnic classifications: white, black, Indian, and "coloured" (a South African term for mixed ancestry).

METHODS

A structured, in-person interview was administered to each participant in private by a trained interviewer, after obtaining consent.

MAIN OUTCOME MEASURES

The dependent variables consisted of three stages of smoking: non-smoking, experimental smoking, and regular smoking. The independent measures were drawn from four domains: personal attributes, parental, peer, and cultural influences.

RESULTS

Factors in all four domains significantly predicted three different stages of smoking. Personal attributes (internalising and externalising) distinguished among the three stages. Parental factors (for example, affection) reduced the odds of being a regular smoker compared with an experimental smoker or non-smoker, but did not differentiate experimental smokers from non-smokers. Findings from the peer domain (for example, peer substance use) predicted an increase in the risk of being a regular smoker compared with an experimental smoker or non-smoker. In the cultural domain, ethnic identification predicted a decrease in the risk of being a regular smoker compared with an experimental smoker, whereas discrimination and victimisation predicted an increase in the risk of being an experimental smoker compared with a non-smoker.

CONCLUSIONS

All the domains were important for all four ethnic groups. Four psychosocial domains are important in distinguishing among the three stages of smoking studied. Some predictors differentiated all stages of smoking, others between some of the stages of smoking. Therefore, intervention and prevention programmes which are culturally and linguistically sensitive and appropriate should consider the individual's stage of smoking.

Abuses of the girl child in some African societies: implications for nurse practitioners

The definition of a child in African societies varies. From the moment the girl child can talk and walk, she is allocated responsibilities within the family. Westernized cultures view such responsibilities as forms of abuse. Thus, various reports had been written about girl children and had been critical of African societies without acknowledging that Africa is a very large continent. This paper sets out to identify, explore, and present potential areas of abuse of the girl child, for example, female circumcision, child slaves, rape survivors, child soldiers, child prostitution, teenage pregnancy, and arranged marriages. This paper suggests strategies that healthcare professionals could initiate in situations where a girl child is being abused.

Predictors of cigarette use among South African adolescents

This study assessed the interrelation among domains of ethnic factors; the individual's sense of well-being; personality, attitudes, and behaviors; sibling and peer smoking; and adolescent smoking behavior. The sample consisted of 1,468 South African adolescents selected from 4 ethnic groups self-identified as defined by current South African usage: Black (mainly Zulu and Xhosa), Indian, White, and Colored (mixed ancestry). In accordance with family interactional theory, there was a sequence of patterning from ethnic factors and the individual's sense of well-being to adolescent personality, attitudes, and behaviors and models of smoking. All of the 4 domains in the model also had a direct effect on adolescent smoking behavior. The findings suggest 4 possible targets of therapeutic or preventive intervention with regard to adolescent smoking: ethnic factors; the individual's sense of well-being; personality, attitudes, and behaviors; and smoking within the peer group.

Determinants of smoking cessation among adolescents in South Africa

Data is required on the motivational determinants of smoking cessation among a multi-ethnic sample of adolescents in South Africa. The I-Change Model was used to explore the determinants of smoking cessation among a sample of 1267 Black African, Colored and White Grade 9-11 monthly smokers and former smokers in the Southern Cape-Karoo region. Across the ethnic groups, former smokers displayed a more positive attitude toward non-smoking, were surrounded by a social environment that was more supportive of non-smoking, displayed higher self-efficacy not to smoke in stressful, routine and social situations, and were more positive about their intention not to smoke in the next year. The I-Change Model can be used to address the cognitions of smoking in a multi-ethnic society like South Africa. However, some ethnic tailoring will be required. Black African students will benefit from a focus on attitudinal cognitions and cultural factors that motivate smoking. Colored students require the involvement of their social environment, while White students will benefit from the development of refusal skills in social situations.

Health behaviour and lifestyle of Pacific youth surveys: a resource for capacity building

The changing global socio-economic environment over the last two decades has had significant ramifications for the health and development of youth in lower- and middle-income countries. In the Pacific region, young people are exposed to similar causes of ill-health as their peers in developed countries. This paper describes the development, implementation and major findings of the Health Behaviour and Lifestyle of Pacific Youth (HBLPY) surveys, a regional initiative to obtain representative data about health-related behaviour and needs of adolescents in Vanuatu, Tonga and the Federated States of Micronesia. The Pacific HBLPY is modelled on the WHO Europe Health Behaviour in School-aged Children (HBSC) surveys. The surveys, undertaken in 2000-2001, were built upon strong local partnerships and were undertaken with youth participation to ensure survey ownership. A regional technical group was formed to provide training and support to strengthen health survey capacity of youth and their agencies. The findings showed that tobacco was most commonly used substance, with 29.7% of 15-year-old boys and 15.7% of girls smoking weekly. Over half of the students did not engage in physical activity for at least 2 h per week; these rates are substantially lower than those usually found in Europe. Dietary habits among this group are also of concern, reflecting international trends away from highly nutritious traditional diets. The HBLPY surveys have shown that it is possible to collect population-based data in lower- and middle-income countries so that appropriate youth health programmes and policies can be developed. Implementation of an ongoing surveillance system similar to the HBLPY model in these countries warrants further investigation. Such initiatives should be supported at the regional and global level.

Cities and population health

A majority of the world's population will live in urban areas by 2007 and cities are exerting growing influence on the health of both urban and non-urban residents. Although there long has been substantial interest in the associations between city living and health, relatively little work has tried to understand how and why cities affect population health. This reflects both the number and complexity of determinants and of the absence of a unified framework that integrates the multiple factors that influence the health of urban populations. This paper presents a conceptual framework for studying how urban living affects population health. The framework rests on the assumption that urban populations are defined by size, density, diversity, and complexity, and that health in urban populations is a function of living conditions that are in turn shaped by municipal determinants and global and national trends. The framework builds on previous urban health research and incorporates multiple determinants at different levels. It is intended to serve as a model to guide public health research and intervention.