Patterns of cigarette and smokeless tobacco use among children and adolescents

Differences in Cigarette Use and the Tobacco Environment Among Youth Living in Metropolitan and Nonmetropolitan Areas

PURPOSE

To examine cigarette use and the tobacco-related environment among adolescents living in metropolitan and nonmetropolitan areas.

METHODS

Data from adolescents ages 14-17 that completed the 2012 Florida Youth Tobacco Survey were analyzed (n = 40,746). This includes a representative sample of middle and high school students throughout the state.

RESULTS

Nonmetropolitan adolescents were more likely than metropolitan adolescents to report lifetime smoking, past 30-day smoking, daily smoking, initiating smoking at younger ages, having smoked a greater number of cigarettes in their lifetime and in the past 30 days, friend acceptance of adult smoking, a parent offering them a cigarette, living with a smoker, and that smoking was allowed in their home. Nonmetropolitan adolescents were also more likely to have seen tobacco ads the last time they visited convenience marts, gas stations, grocery stores, and big box stores, and flavored tobacco products or ads for them. These differences persisted after controlling for demographics.

CONCLUSIONS

The present results suggest vast differences in smoking behavior among nonmetropolitan and metropolitan adolescents and that targeting social and environmental factors may be beneficial for reducing tobacco disparities among nonmetropolitan adolescents.

Smokeless Tobacco Decision-Making Among Rural Adolescent Males in California

Smokeless tobacco (ST) use among US high school males living in rural areas exceeds national levels. Subgroups at heightened risk of ST use have been identified, but less is known regarding ST decision-making within high-risk groups. The study objective was to describe rural adolescent males' perceived ST acceptability, health risks, and social implications and how those perceptions differ between ST users and never-users. Semi-structured individual interviews were conducted with a purposeful sample of 55 male students (32 ST ever-users) at three rural California high schools. Interviews were audio recorded and professionally transcribed. Investigators collaboratively developed a codebook based on thematic content and then independently coded transcripts, reconvening frequently to achieve consensus. Coded text was systematically organized into themes following a general inductive approach. ST users and non-users shared multiple ST-related perceptions, including: that ST is a common, normative way of life in rural "country" culture among certain groups; that ST use conveys oral health risks; and that the decision to use (or not to use) is rooted in personal choice. ST users' and never-users' perceptions differed regarding the immediacy, severity, and inevitability of health risks, particularly relative to cigarette smoking. Other differences included perceived parental permissiveness and the expected social benefits of ST use, such as peer acceptance and conveying maturity. Within this population of rural male adolescents, ST users emphasized the social benefits of ST use, while acknowledging but discounting health risks. Differences and similarities in tobacco perceptions among adolescents living in similar environments may inform effective health communication.

Threshold of adulthood for the onset of nicotine self-administration in male and female rats

The great majority of tobacco addiction begins during adolescence. More heavily addicted smokers begin smoking earlier, but differentiating the neurobehavioral impact of nicotine self-administration during adolescence from self-selection bias (whereby people more prone to heavy addiction also begin earlier) cannot be ethically unconfounded in humans. The goals of this research were to determine the age threshold for the adult-like nicotine self-administration and determine sex differences. Male and female Sprague-Dawley rats were tested for nicotine self-administration starting at 4, 5, 6, 7, and 8 weeks of age in an operant FR1 schedule for IV nicotine (0.03 mg/kg/infusion) in 45-min sessions for 2 weeks, with 1 week of enforced abstinence and 1 week of resumed access. This study replicated our earlier work that nicotine self-administration was increased in adolescent vs. adult rats and that the effect was more pronounced in adolescent males, but the increased nicotine self-administration was more persistent in adolescent-onset females. The age threshold for adult-like behavior was 6-7 weeks of age. Adolescent-onset nicotine self-administration had persisting effects of eggaurated increases of nicotine self-administration when fixed-ratio requirements for self-administration were lowered. Female rats that had begun nicotine self-administration during adolescence showed exaggerated increases in nicotine self-administration after a switch back to FR1 from FR8, indicating a lessened control over their self-administration. Adolescent-onset nicotine self-administration was not found to potentiate cocaine self-administration. Adolescent-onset nicotine self-administration causes persistent increases in nicotine self-administration in female rats even after they reach adulthood and disrupts control over self-administration behavior.

Current use of smokeless tobacco among adolescents in the Republic of Congo

BACKGROUND

Tobacco use is a leading cause of global morbidity and mortality. Much of the epidemiologic research on tobacco focuses on smoking, especially cigarette smoking, but little attention on smokeless tobacco (SLT).

METHODS

Using data from the Republic of Congo Global Youth Tobacco Survey (GYTS) of 2006, we estimated the prevalence of SLT use among in-school adolescents. We also assessed the association between SLT use and cigarette smoking as well as the traditional factors which are associated with cigarette smoking among adolescents (e.g. age, sex, parental or peer smoking). Unadjusted odds ratios (OR) and adjusted odds ratios (AOR) together with their 95% confidence intervals (CI) were used to measure magnitudes of associations.

RESULTS

Of the 3,034 respondents, 18.0% (18.0% males and 18.1% females) reported having used smokeless tobacco (chewing tobacco, sniff or dip) in the last 30 days. In multivariate analysis, no significant associations were observed between age and sex on one hand and current smokeless tobacco use on the other. Cigarette smokers were more than six times likely to report current use of smokeless tobacco (AOR = 6.65; 95% CI [4.84, 9.14]). Having parents or friends smokers was positively associated with using smokeless tobacco (AOR = 1.98; 95% CI [1.51, 2.59] for parents who smoked cigarettes, AOR = 1.82; 95% CI [1.41, 2.69] for some friends who smoked cigarettes, and AOR = 2.02; 95% CI [1.49, 2.47] for most or all friends who smoked cigarettes). Respondents who reported have seen tobacco advertisement on TV, billboards and in newspapers/magazines were 1.95 times more likely to report current use of smokeless tobacco (AOR = 1.95; 95% CI [1.34, 3.08]). Perception that smoking was harmful to health was negatively associated with current use of smokeless tobacco (AOR = 0.60; 95% CI [0.46, 0.78]).

CONCLUSIONS

Prevention programs aimed to reduce teen [cigarette] smoking must also be designed to reduce other forms of tobacco use. The teenagers environment at home, at school and at leisure must also be factored in order to prevent their uptake or maintenance of tobacco use.

Adolescents' perceptions of smoking and stress reduction

The present study examined how adolescents perceive the relationship between smoking and stress and where they learn that smoking cigarettes may be an effective stress-reduction mechanism. Eight focus groups were conducted with low-income African American and European American 14- to 16-year-olds in urban and rural locations, in which they suggested that the primary reasons why they smoked-namely, as a coping mechanism (to calm nerves), for social acceptance, and because of environmental influences. Family issues, boyfriend/girlfriend problems, and school were common stressors. Although participants overwhelmingly believed that people smoke to reduce their stress, a few believed that cigarettes do not actually reduce stress. When asked for examples of smoking in popular media, teens predominantly generated examples of individuals smoking to reduce stress. Ethnic and gender differences were found among the types of media in which they had seen smoking, their opinions of anti-smoking messages, and the media's perceived influence.

Smoking Initiation Prevention Among Youths: Implications for Community Health Nursing Practice

Cigarette smoking among youths has long been documented as a national problem affecting health and economic status in the United States. A number of studies have documented that cigarette-smoking initiation occurs primarily between late childhood and young adolescence. This evidence has brought about the need for awareness among community health nurses to find and deliver effective antismoking programs to reduce the prevalence of youth smoking initiation. Generally, community health nurses are in an excellent position to help the nation achieve its goals in terms of reducing the incidence of youth smoking initiation. However, current knowledge about community health nursing practice and smoking initiation interventions is limited. This article raises awareness about smoking initiation prevention in youth and the need to implement effective smoking prevention programs in practice settings and encourages community health nurses to increase their involvement in antismoking initiation research and interventions.

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.

Prevalence and correlates of lifetime smokeless tobacco use in female military recruits

Although considerable research has been conducted on smokeless tobacco (ST) use in males, much less is known about the characteristics of female ST users. The present study examined the prevalence and correlates of lifetime ST use among female Air Force recruits (N=9,087). Participants were surveyed during Basic Military Training regarding their history of tobacco use and other health risk behaviors. Although the prevalence of current ST use was low (<1%; n=34), 6.6% (n=599) had tried ST. Multivariate logistic regression analysis indicated that lifetime ST use was related to ethnicity, with Native Americans and Whites being most likely to have tried ST. Additional correlates of lifetime ST use included post-high-school education (OR=1.26, 95% CI=1.03-1.55); weekly acts of road rage (OR=1.48, 95% CI=1.06-2.06); frequent arguing (OR=1.71, 95% CI=1.18-2.48); daily or near-daily alcohol consumption (OR=1.71, 95% CI=1.03-2.82); current cigarette use (OR=3.80, 95% CI=2.42-5.94); and experimental use of cigars (OR=4.01, 95% CI=3.22-5.01), pipes (OR=2.23, 95% CI=1.64-3.03), and clove cigarettes (OR=1.23, 95% CI=1.01-1.49), all of which were associated with an increased likelihood of ST use. Results suggest that female recruits who have ever used ST engage in a variety of risk behaviors including use of other tobacco products and alcohol, as well as additional harmful behaviors.

Modulation of annexin I and cyclooxygenase-2 in smokeless tobacco-induced inflammation and oral cancer

Smokeless tobacco usage is a growing public health concern in the United States. Epidemiological evidence shows a correlation between use of chewing tobacco, lesions of the oral cavity and the incidence of oral and other cancers. However, the molecular mechanism(s) underlying the oral cancer causation are yet unknown. The major constituents of tobacco are known to cause inflammation, DNA damage and cell death. We propose modulation of inflammatory mediators by smokeless tobacco as a novel mechanism for the development of oral cancer. Exposure of hamster cheek pouches to smokeless tobacco extract (STE) results in cleavage of the anti-inflammatory peptide from the anti-inflammatory protein annexin I. Annexin I is produced from cultured oral epithelial cells and its expression is modulated by STE. We further show that STE exposure of oral epithelial cells results in upregulation of the pro-inflammatory protein COX-2. COX-2 is also upregulated in immortalized human oral epithelial cells, human squamous cell carcinoma cells and in primary tumor tissues from head and neck cancer. In summary, we find that exposure to smokeless tobacco results in loss of the anti-inflammatory activity of annexin I and upregulation of the pro-inflammatory COX-2 in oral cells. The dual effect of these regulatory events leads the cells down the carcinogenic pathway.

Prevalence of cigarette smoking among rural adolescents in the United States

Results are reported from a national U.S. study of cigarette smoking carried out from 1996 to 2000 involving 68,270 adolescents. Hierarchical linear modeling was used to model smoking as a function of grade, gender, region, and community size (rurality). Significant effects were found for rurality, region, grade, and gender. The highest levels of smoking were found for rural adolescents, and adolescents living in the South. Males smoked more than females in all regions except the West, where the reverse was true. Given that rural adolescents smoke more "heavily" than do their nonrural peers, researchers must devote more attention to understanding the factors that underlie smoking initiation in rural youth.

Cardiovascular disease risk factors and obesity of rural and urban elementary school children

Previous studies on the influence of a rural/urban setting on the prevalence of cardiovascular disease risk factors in children have not sufficiently controlled for socioeconomic status, race, gender, and perhaps, may not have included a representative sample of rural and urban children. This study compared the cardiovascular disease risk factors and rate of obesity of children living in rural and urban settings. It also determined the magnitude of the effect of the rural/urban setting on cardiovascular disease risk factors and obesity when controlling for race, socioeconomic status, and gender. The subjects were 2,113 third- and fourth-grade children; 962 from an urban setting and 1,151 from a rural setting. Height, weight, skinfolds, resting blood pressure, and total cholesterol levels were measured. Aerobic power (pVO2max) was estimated from cycle ergometry. Physical activity and smoking history were obtained from a questionnaire. Clustering analyses using adjustment for sample error indicated that total cholesterol, blood pressure, smoking, and physical activity levels of rural and urban children were not different (P > 0.10); however, body mass index and sum of skinfolds was greater for rural youth (P < 0.004). Logistic regression indicated that rural children had a 54.7 percent increased risk of obesity (P = 0.0001). This study's results indicate that, in children, a rural setting is associated with obesity, but not with the major risk factors associated with cardiovascular disease.

Coaches' attitudes toward smokeless tobacco and intentions to intervene with athletes

Smokeless tobacco use among athletes is alarming. Most of these athletes report beginning smokeless tobacco use in middle or high school. West Virginia has significantly higher rates of smokeless tobacco use among adolescent and adult males than the general population. Since West Virginia athletes may be particularly vulnerable to smokeless tobacco use, West Virginia coaches can be critical agents in smokeless tobacco prevention and intervention. This study surveyed West Virginia middle and high school coaches' 1) attitudes toward smokeless tobacco, 2) actions toward athletes who use smokeless tobacco, 3) intentions to provide intervention for users, and 4) tobacco use history. Results indicated coaches had unfavorable attitudes toward smokeless tobacco, perceived it as a problem, and were willing to help athletes quit. These findings provide support for development of training programs for middle and high school coaches to act as smokeless tobacco intervention agents.

Role of nitric oxide in the induction of apoptosis by smokeless tobacco extract

Smokeless tobacco usage is a growing public health concern in the United States. Lesions of the oral cavity have been clearly linked to smokeless tobacco use. The objective of this study was to determine the biochemical effects of smokeless tobacco extract (STE) exposure upon hamster cheek pouch cell (HCPC-1) cultures. HCPC-1 cells were exposed to a 5 -fold dose-range of STE (0.5, 1.0 and 2.5%) over a time-course of 24-96 h. Following each exposure we measured various biochemical parameters of cell proliferation and cell death. Cell viability, cell cycle progression and S-phase DNA synthesis were measured as markers of cell proliferation. We measured lactate dehydrogenase leakage as a marker of cell membrane damage and cell death due to necrosis. No significant alterations were observed in cell cycle progression and cell proliferation as a result of exposure to STE. LDH measured colorimetrically indicated no significant effect with the lower doses(0.5, 1.0 and 2.5% STE). Apoptosis measured as the A0 peak and by the TUNEL procedure revealed that STE caused significant rates of apoptosis. Maximal apoptosis was noted between 48-96 h. In order to probe the mechanism further we measured the levels of nitrites as an indicator of nitric oxide (NO) in the media. NO levels were significantly elevated at the doses that caused an induction of apoptosis. The results from this study indicate that STE causes a dose-dependent induction of apoptosis and that this is mediated by nitric oxide.

Reasons for quitting and smoking temptation among adolescent smokers: gender differences

Adolescent cigarette smokers from randomly selected classrooms from 24 California and Illinois high schools were assessed regarding their interest in cessation, reasons for quitting, and smoking temptation circumstances. These data were analyzed by gender. Males and females were not found to differ in quit stage or perceived likelihood of ever quitting smoking, although males reported being somewhat more likely to have ever tried to quit in the past. The associations of reasons for quitting were not found to vary by gender in most comparisons. On the other hand, the associations of smoking temptation circumstances with gender showed that a greater percentage of females than males reported more circumstances that would make them tempted to smoke. Smoking cigarettes to regulate one's affective states, and to avoid nicotine withdrawal, may be functions of smoking that impede efforts at quitting, particularly among adolescent females.

The effectiveness of a tobacco prevention program with adolescents living in a tobacco-producing region

OBJECTIVES

This study investigated the efficacy of a social-influences tobacco prevention program conducted with adolescents living in a high tobacco production area.

METHODS

Students in 10 experimental schools completed the tobacco prevention program and a booster intervention. Control students received health education as usual.

RESULTS

After 2 years of treatment, smoking rates in the treatment group (vs the control group) were lower for 30-day, 7-day, and 24-hour smoking. The intervention had more of an impact on those who were involved in raising tobacco than it did on those not involved in raising tobacco.

CONCLUSIONS

Although modest, effects were achieved with minimal intervention time in a high-risk group, indicating that social-influences prevention programs may be effective in such groups.

Self-initiated quitting among adolescent smokers

OBJECTIVES

This paper reviews the literature regarding predictors of adolescent self-initiated smoking cessation and investigates self-initiated smoking cessation among a large sample of alternative high school youth in southern California. Youth transfer to alternative schools because of academic or behavioral problems, and they are at relatively high risk for cigarette smoking.

METHODS

Several demographic (e.g., gender), behavioral (e.g., level of smoking), and psychosocial (e.g., risk-taking) predictors of adolescent smoking cessation were investigated. The alternative high school cohort provided a sufficient sample size of quitters (defined as no use in the past 30 days, measured after a 1-year period) to permit a prospective examination of adolescent smoking cessation.

RESULTS

Although nine demographic, behavioral, or psychosocial variables discriminated among quitters and nonquitters in univariate analyses, only level of baseline smoking, smoking intention, and perceived stress were predictors in a final multivariable model.

CONCLUSIONS

Based on the literature review and findings among the cohort, smoking cessation programs for adolescents should include counteraction of problem-prone attitudes, support of wellness attitudes, provision of motivation to quit strategies, and assistance with overcoming withdrawal symptoms.

A longitudinal study predicting patterns of cigarette smoking in late childhood

Early initiation of cigarette smoking so strongly predicts future smoking that several investigators have advocated delaying the age of initiation as a prevention strategy. To complement retrospective studies of early initiation, this study assessed prospectively patterns of smoking behavior in a sample of 401 children who were surveyed in the fifth, sixth, and seventh grades. The principal findings were (1) modeling of smoking by parents and friends is sufficient to influence children to initiate smoking, particularly when children also have low behavioral self-control, and (2) when modeling occurs in combination with poor adjustment to school, low parental monitoring, easy access to cigarettes, and other risk attributes, early initiators are significantly more likely to continue smoking. The results suggest that delaying initiation of smoking without also modifying child attributes and socialization factors that predict early initiation and persistent smoking is unlikely to reduce the proportion of children who become habitual smokers.

Factors associated with smoking among children and adolescents in Connecticut

INTRODUCTION

The age of smoking initiation has dropped over the past four decades. Since behaviors and attitudes adopted in late childhood or early adolescence predict future smoking, it is important to understand the smoking and other risk-taking behaviors and attitudes of children aged 12 and younger. The goal of the analyses presented here was to describe behavioral and attitudinal factors associated with smoking among elementary school (grades 4-6), middle school (grade 7-8), and high school (grades 9-12) students in Connecticut.

METHODS

We have used data from 8 years (1988-1996) of an anonymous, self-administered health risk appraisal survey given to children and adolescents in self-selected public and private schools. We compared the proportion of smokers and nonsmokers who reported various behaviors and attitudes and compared them with the chi-square test.

RESULTS

Fifteen percent (n = 4,884) of the total population (n = 31, 861) were current smokers. At all grade levels, current smokers were more likely than nonsmokers to engage in risk-taking behaviors, and to report more stress and depression. Indicators of risk-taking and stress were also associated with the intent to smoke among children in grades 4-6.

CONCLUSIONS

Smoking occurs within the context of other risk-taking behavior and psychological distress, among both children and older adolescents. Our data provide support for the idea of early identification and targeting of children at high risk of smoking in elementary school, possibly as early as grade four.

[Smoking prevention in the school: results of a 3-year program]

Tobacco use poses one of the greatest health problems at school. Its prevention through health education should be assumed up by all members of the school community and health personnel (especially family and respiratory physicians). We designed an anti-tobacco program lasting three years aimed at all the students of the 6th, 7th and 8th grades at school as well as those in the pre-university years that was implemented in a rural area. This study reports the results of the attitudes of the 610 students (256 boys and 354 girls, between 11 and 20 years old) collected at the end of the program. 59.4% of the boys and 44.1% of the girls reported having smoked on some occasion. The mean age at the time of the first contact with tobacco was 11.8 +/- 2.4 years, this being significantly different between the boys and the girls. The main reasons for starting to smoke tobacco were quoted as peer pressure (57.1%) and curiosity (55.5%). That their parents smoked was only adduced as a reason by 29.5% of the students. Knowledge of the harmful effects of tobacco was limited and only 57% related tobacco smoking to lung cancer and only 41% to coronary pathology. At the end of the program 13.6% of the students involved smoked. 93.9% of those who quit smoking related this event to the program. Of those still smoking, 63.6% said they would like to quit. This justifies the need to reinforce the knowledge that will allow them to switch attitudes and stop smoking. Intervention programs in school populations have proved to be useful in the struggle to decrease smoking among school children. If an adolescent can avoid smoking it is likely that s/he will not smoke in adulthood. It is necessary to further develop this type of anti-tobacco program as reflected in this paper.

[Prevalence of smoking among adolescent students in Navarra]

This paper reports the prevalence of smoking among adolescent students in Navarra, analyzing the data by sex and geographic area. A sample representative of Navarran adolescent school children between 12 and 18 years old was identified. The prevalence of smoking was measured by way of an anonymous self-administered questionnaire filled out at school. A chi 2 test and analysis of variance were performed. Three hundred students (180 girls, 51.43%; 170 boys, 48.57%) were surveyed. Mean ages were 14.35 +/- 1.82 and 14.15 +/- 1.93 years, respectively. Smoking prevalence was 35% among girls in the Foral Community of Navarra and 28.82% among the boys. The age of initiation to smoking and frequency of smoking are analyzed for the five geographic areas of the Navarra province. The prevalence of smoking is higher among girls. Children are tending to start smoking at earlier ages (primary school). No differences in smoking frequency were observed for rural and urban areas.

Cigarette smoking attitudes and first use among third- through sixth-grade students: the Bogalusa Heart Study

OBJECTIVES

This study examined cigarette smoking attitudes, peer and parental influence, and first use among children in southeastern Louisiana.

METHODS

Data from 933 children in grades 3 through 6 in the Bogalusa Heart Study (1993 through 1994) were analyzed.

RESULTS

Fifteen percent of the children had tried smoking. Of these, 40% first smoked with a family member, and 46% obtained their first cigarette from a family member or from home. Correlates of ever having smoked were race, sex, having a best friend or family member who smoked, and attitudes that smoking is disgusting and that nonsmokers get better grades.

CONCLUSIONS

Prevention programs should begin early and focus on family and peer influences as well as attitudes.

Relationship of personal tobacco-raising, parental smoking, and other factors to tobacco use among adolescents living in a tobacco-producing region

This study examined factors related to tobacco use among youth from tobacco-raising (TRH) and nonraising households (NRH). The subjects were 3,851 seventh-grade students from 19 middle schools located in a tobacco-raising region. Valid self-reports of tobacco use were encouraged by the use of a test for carbon monoxide in expired air. Cigarette use was higher when (a) at least one parent smoked, and/or (b) the student personally raised tobacco. A boy who personally raised tobacco and had at least one parent who smoked was 10.2 times more likely to have smoked in the last 7 days than a boy from a nonraising household in which neither parent smoked. For girls, the odds ratio was 5.6:1. Tobacco use among students in this high-risk group was higher than rates reported in national or regional studies. Other results were: (1) use began very early--16% of the students had tried cigarettes and 13% of the boys had tried smokeless tobacco (SLT) in Grade 3 or earlier; and (2) users reported more lenient rules at home regarding tobacco use than did nonusers. Years from now, these high-risk students are likely to be major contributors to increased morbidity and mortality due to tobacco use. Implications for tobacco prevention in tobacco-raising areas are discussed.

Adult smokeless tobacco use and age of onset

To determine if an earlier age of onset is associated with greater levels of adult smokeless tobacco (SLT) use and to evaluate if this relationship differs by SLT type, 345 current adult SLT users were interviewed to obtain the age at first onset and current frequency of SLT use. The results indicated that more than twice as many SLT users began during adulthood than during preadolescence. Although preadolescent onset was associated with greater chewing tobacco use than adolescent onset, the greatest levels of both chewing tobacco and snuff use were associated with adult onset, suggesting an increased need for SLT prevention programs for young adults.

[Smoking of school children in rural Castilla-León environment. Attitudes of the school population]

Tobacco smoking is the most important health problem among school-age children and educational programs aiming at prevention must be taken up by all members of the school community (parents, teachers and students) as well as by health providers. We designed an anti-smoking campaign lasting three years directed towards sixth, seventh and eight-grade elementary school students and secondary school pupils attending classes in the area of Vitigudino (Salamanca). We report the results of student attitude surveys done at the beginning of the program. Sixty-eight percent of boys and 50.7% of girls have smoked at some time. The average age of first contact with tobacco was 12.1 +/- 2.4 years, with boys starting to smoke at a significantly younger age (p < 0.001) than girls. At present, 13.7% of school children smoke. The main reasons given for starting to smoke were that friends smoked (56.9%) and curiosity (55.4%). Tobacco smoking in the family was mentioned by only 29.5% of the students surveyed. Knowledge of medical problems related to smoking was limited. Intention to smoke upon leaving school was reported by 9%, while 46.7% did not know if they would smoke. The fact that only 44.1% of school children believe they will not smoke upon leaving school highlights the need to provide support information that will help students abstain. Programs aimed at school children have been shown to help reduce tobacco smoking in this population. An adolescent who learns to avoid tobacco is unlikely to be a smoker in adulthood.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiovascular health promotion in children: program and policy implications

Cardiovascular disease is the leading cause of death in the United States; it is also a major factor in rising health care costs. Risk factors for the disease are present in childhood, at the time when lifelong health habits are forming. Thus, strategies for improving the cardiovascular health of children through programs and policy may be expected to have a maximum effect. The cardiovascular health in children study identified the prevalence of cardiovascular risk factors in 2209 children age 8 to 11 years, attending 21 rural and urban public schools in North Carolina. Schools were randomly selected from three regions of the state (coastal, piedmont, mountain) in which the frequency of cardiovascular disease differs. Initial results of the study demonstrate the use of such findings in formulating health policy and in designing intervention programs.

An evaluation of a tobacco use education-prevention program: a pilot study

This study was designed to implement a psychosocial approach to primary prevention of cigarette and smokeless tobacco use among seventh-grade students. The prevention program was presented by peer leaders who were older high school students. Program intervention addressed parental, peer, and media influences on tobacco use, and taught refusal skills for resisting social pressures to smoke or chew tobacco. Program effectiveness was examined in terms of three variables: knowledge (basic knowledge about tobacco facts), refusal skills (degree of self-reported assertiveness in refusing to use tobacco), and attitude (positive and negative attitudes toward tobacco). These variables were assessed at pre- and posttests, and 1-month follow-up to program termination. It was found that students who received the intervention reported increased knowledge and improved resistance skills regarding the use of tobacco, as compared to a control group. Attitudes toward tobacco were initially negative and did not change over the course of the intervention in either group. In addition, 1-year follow-up was conducted on the intervention group, indicating that treatment gains were maintained.

Tobacco and myocardial infarction: is snuff less dangerous than cigarettes?

OBJECTIVE

To estimate the risk of myocardial infarction in snuff users, cigarette smokers, and non-tobacco users in northern Sweden, where using snuff is traditional.

DESIGN

Case-control study.

SETTING

Northern Sweden.

SUBJECTS

All 35-64 year old men who had had a first myocardial infarction and a population based sample of 35-64 year old men who had not had an infarction in the same geographical area.

MAIN OUTCOME MEASURE

Tobacco consumption (regular snuff dipping, regular cigarette smoking, non-tobacco use) and risk of acute myocardial infarction.

RESULTS

59 of 585 (10%) patients who had a first myocardial infarction and 87 of 589 (15%) randomly selected men without myocardial infarction were non-smokers who used snuff daily. The age adjusted odds ratio for myocardial infarction was 0.89 (95% confidence interval 0.62 to 1.29) for exposure to snuff and 1.87 (1.40 to 2.48) for cigarette smoking compared with non-tobacco users, showing an increased risk in smokers but not in snuff dippers. Regular cigarette smokers had a significantly higher risk of myocardial infarction than regular snuff dippers (age adjusted odds ratio 2.09; 1.39 to 3.15). Smoking, but not snuff dipping, predicted myocardial infarction in a multiple logistic regression model that included age and level of education.

CONCLUSIONS

In middle aged men snuff dipping is associated with a lower risk of myocardial infarction than cigarette smoking.

[Characteristics of tobacco smoking in schools in Andorra]

1600 schoolchildren aged 13 to 18 answered an anonimus, self administered questionnaire, in a cross sectional study to estimate the prevalence of cigarette smoking in the high grades schools in Andorra. 46.6% answered they did smoke cigarettes, either daily (11.2%) or occasionally (35.4%). Ten per cent of actual smokers did already smoke at age 10, and 50% at age 13. More girls (48.8%) than boys (44.4%) smoked (p less than 0.05) but boys smoked a greater number of cigarettes (p less than 0.001). Ninety five percent smoked Virginia tobacco, and little more than 50% used filter tipped cigarettes. Two thirds of smokers inhaled the smoke of cigarettes; this was more common among daily smokers. Again two thirds of smokers answered they would be prepared to quit smoking. 31% of those who had tried smoking said they believed they would smoke in the future, while only 5.6% of those that never smoked previously said so (p less than 0.001). Actual smokers answered they believed that they would not smoke in the future much less often than non smokers. Parents let boys smoke more than girls when the children started doing so, particularly before age thirteen and after age fifteen. These are the first available data about the community studied describing some features of its cigarette smoking habit. Their knowledge may well help to plan disease protection and health promotion developments addressed to youngsters in Andorra.

Demographic and socioeconomic differences in beliefs about the health effects of smoking

To assess sociodemographic differences in beliefs about the health effects of cigarette smoking and passive smoke exposure, we recently surveyed 2092 adults in St. Louis and Kansas City, Mo. The percentages of respondents who knew that smoking causes lung cancer, emphysema, and heart disease were 76.7, 74.1, and 67.2, respectively. After multivariate adjustment, knowledge about smoking's health effects was generally lower among women, older respondents, those of lower education level, and current smokers. Blacks were generally less likely to appreciate the health effects of active smoking, but were more likely to acknowledge the health effects of passive smoking.

Underestimates of student substance use by school personnel: a cause for concern?

The present study was designed to compare school personnel's (i.e., principals, counselors, teachers) estimates of student substance use with student self-reported data. Comparisons were made in 78 schools between 5431 student self-reports of tobacco, alcohol, and drug use and 170 school personnel's estimates of student substance use. The results indicated that a significant number of school personnel were unable to estimate student substance use. Personnel who did provide estimates typically underestimated the degree of substance use, in comparison to student self-reported substance use. School personnel did not significantly overestimate use in comparison to student self-reported substance use for any substance in any grade or geographic area. It is suggested that school personnel may resist the adoption of prevention programs because of a perceived lack of need due to underestimation of the substance use problem.

Smokeless tobacco: current status and future directions

Smokeless tobacco is addicting, can cause physical dependence, and is associated with many health risks. In spite of these concerns over its use, minimal research has been conducted to understand the effects from and factors associated with smokeless tobacco use. Additionally, relatively few studies have examined potentially effective treatments for the smokeless tobacco user. This paper reviews the existing literature in this area and considers future directions for research.

Psychosocial factors in the use of smokeless tobacco and their implications for P.L. 99-252

This article briefly reviews the prevalence of smokeless tobacco use by males in the United States, the relationship of smokeless tobacco use to cigarette use, and patterns of use that include dosage, topography, products, and function of use. The primary focus of the article is to describe the concurrent and predictive factors associated with onset, use, and cessation of smokeless tobacco. The implications of P.L. 99-252, the Comprehensive Smokeless Tobacco Act of 1986, are discussed in the context of what is known about the psychosocial variables associated with the use of smokeless tobacco.