A comparison of adolescent smoking initiation measures on predicting future smoking behavior

A four-year longitudinal analysis examining the effects of e-cigarette advertisements and disparities among youth with internalizing problems

BACKGROUND

Prior research indicates a direct, short-term effect of e-cigarette advertising on e-cigarette use among youth. This study seeks to investigate the long-term effects of e-cigarette advertisements and disparities in exposure among adolescents with different levels of internalizing problems.

METHODS

Panel data of the Population Assessment of Tobacco and Health (PATH) Study Waves 3-5 (2015-2019) were analyzed. Youth aged 12-17 who were non-e-cigarette users at the time of Wave 3 were included (n = 4,678). A moderated mediation model was employed to examine the mediating role of perceived harm of e-cigarettes and the moderating effect of internalizing problems.

RESULTS

Exposure to e-cigarette advertisements in Wave 3 predicted lower harm perception of e-cigarette in Wave 4 (bp = -0.055, p <.01), leading to more e-cigarette use in Wave 5 (bp = -0.042, p <.001). While e-cigarette advertisements exhibited a lasting indirect effect (bp = 0.002, p <.05), there was no long-term direct effect (bp = 0.017, p >.05) on youth e-cigarette use. Furthermore, a moderating effect of internalizing problems was observed (bp = 0.107, p <.05).

CONCLUSIONS

E-cigarette advertisements can exert a lasting influence indirectly by diminishing harm perception, particularly among those with lower internalizing problems. Adolescents with higher internalizing problems exhibit lower susceptibility to advertisement influence, yet their perceived harm of e-cigarettes is notably lower than their peers with fewer internalizing problems. These disparities underscore the need for tailored prevention strategies: implementing anti-e-cigarette education programs for adolescents with low internalizing problems and providing mental health care for those facing internalizing challenges. Regulatory measures targeting e-cigarette advertising are also crucial.

The effect of smoking initiation in adolescence on the subsequent smoking trajectories of people who smoke, and the role of adverse childhood experiences: Results from the 1958 British cohort study

OBJECTIVE

To examine the association between smoking initiation in adolescence and subsequent different smoking trajectories of people who smoke, and to examine the combined effect of adverse childhood experiences (ACEs) and smoking initiation in adolescence on smoking trajectories of people who smoke.

DESIGN AND SAMPLE

Data are from 8757 individuals in Great Britain from the birth cohort National Child Development Study and who reported being smokers or former smokers by age 23.

MEASUREMENTS

Smoking initiation in adolescence was measured at 16 y and smoking trajectories were derived from smoking variables from ages 23 to 55. We modelled the relationship between smoking initiation in adolescence with or without ACEs and smoking trajectories.

RESULTS

Individuals who initiated smoking in adolescence were more likely to quit later than quitting in twenties (RRR quitting in thirties  = 3.43 [2.40; 4.89] p < .001; RRR quitting in forties  = 5.25 [3.38; 8.14] p < .001; RRR quitting in fifties  = 4.48 [2.95; 6.79] p < .001), to relapse (RRR Relapse  = 3.66 [2.82; 4.76] p < .001) and to be persistent smokers (RRR persistent  = 5.25 [3.81; 7.25] p < .001) compared to those who had initiated smoking in young adulthood. These effects were particularly pronounced in case of ACEs.

CONCLUSION

Smoking prevention programs aimed at reducing smoking initiation should be promoted to adolescents to limit the burden of smoking, especially for people who have suffered adversity during childhood.

Do tobacco 21 laws work?

Tobacco 21 (T-21) laws raise the minimum legal purchasing age for all tobacco products to 21. This study is the first to examine the impact of statewide T21 laws on teenage and young adult cigarette and electronic cigarette (e-cigarette) use. Using survey data from the Behavioral Risk Factor Surveillance System (BRFSS) and a difference-in-differences approach, we find that statewide adoption of a T-21 law is associated with a 2-to-4 percentage-point decline in smoking participation among 18-to-20-year-olds. Supplemental analyses using the State Youth Risk Behavior Surveys (YRBS) show that frequent e-cigarette use among 18-year-olds also fell following the adoption of T21 laws, though this effect was partially because teens turned to informal social sources to obtain e-cigarettes (i.e., borrowing or bumming). Finally, we find that T-21 laws generate spillover effects, including (2) reductions in cigarette use among 16-to-17-year-olds, a group that relies heavily on informal social markets in high school, and (2) reductions in marijuana use and days of alcohol use among some teens.

Trends and Demographic Differences in the Incidence and Mean Age of Starting to Smoke Cigarettes Regularly, National Health Interview Survey, 1997-2018

OBJECTIVES

Surveillance of cigarette smoking behavior provides evidence for evaluating the impact of current tobacco control measures. We examined temporal changes and demographic differences in the incidence and mean age of starting to smoke cigarettes regularly in the United States.

METHODS

We conducted retrospective birth-cohort and cross-sectional analyses using self-reported data from the 1997-2018 National Health Interview Survey to evaluate trends and demographic differences in the incidence and mean age of starting to smoke cigarettes regularly among participants aged 18-84 years. We estimated the incidence and mean age of starting to smoke cigarettes regularly by using Poisson and linear regression.

RESULTS

Among adults born during 1950-1999, the incidence of starting to smoke cigarettes regularly before age 35 years decreased by 18.8% (95% CI, 17.0%-20.7%) per 10 years, with a peak incidence at age about age 18 years. Male, non-Hispanic White, and US-born people had a higher incidence of starting to smoke cigarettes regularly than female, other racial and ethnic, and non-US-born people, respectively (P < .001 for all). From 1997 to 2018, the mean age of starting to smoke cigarettes regularly decreased by 0.4% (95% CI, 0.2%-0.6%) per 10 years among adults who ever smoked.

CONCLUSION

The incidence of starting to smoke cigarettes regularly decreased dramatically at all ages during the study period, which suggests a positive impact of current tobacco control measures. For evaluating trends in starting to smoke cigarettes regularly, incidence can be a more sensitive indicator of temporal change than mean age. Differences in smoking incidence by demographic subgroup suggest that additional opportunities exist to further reduce the incidence of starting to smoke cigarettes regularly.

Sex and macroeconomic differences and trends in early attempts at cigarette smoking among adolescents: findings from 147 countries

BACKGROUND

Most tobacco users initiate smoking during adolescence. Little is known about the global prevalence and trends in early cigarette smoking among adolescents. This study aimed to evaluate the prevalence of early attempts at cigarette smoking and its change trends among young adolescents.

METHODS

We used data from the Global Youth Tobacco Surveys on adolescents aged 12-16 years, comprising 456,634 participants from 147 countries between 2006 and 2018, to estimate the prevalence of early attempts at cigarette smoking and age distribution at attempt by sex, country income, purchasing power parity (PPP) per capita, and WHO region. We assessed the average annual rate of reduction (AARR) in the prevalence of attempts at cigarette smoking before 12 years of age in 70 countries that had data from three or more surveys completed between 1999 and 2018.

RESULTS

The average prevalence of early attempts at cigarette smoking was 12.2% (95% CI: 10.9-13.5) for boys and 6.7% (95% CI: 5.8-7.6) for girls, with the highest prevalence of 17.4% for boys and 10.7% for girls in the European region. Along with the growth of the national economy, the prevalence of early attempts at cigarette smoking gradually increased in both sexes. A total of 22.9% and 30% of countries had a negative change in AARR for boys and for girls, respectively. The countries with an upward prevalence were mainly located in the Eastern Mediterranean, Southeast Asia, and African regions. The age distribution at first cigarette smoked did not differ substantially between sexes. Notably, the age at first cigarette smoked of 10.7 years for girls was significantly earlier than that of 11.8 years for boys in low-income countries. Among cigarette-smoking adolescents, the average percentage of girls reporting smoking their first cigarette at an age <12 years was 55.7% in Q1 for PPP quintiles, 46.5% in Q2, 40.3% in Q3, 38.4% in Q4, and 34.6% in Q5, and the corresponding prevalence for boys was 46.0% in Q1, 42.8% in Q2, 42.9% in Q3, 43.5% in Q4, and 41.1% in Q5.

CONCLUSIONS

The global prevalence of early attempts at cigarette smoking among adolescents was substantial, with differences by sex and macroeconomic situation, and our findings stress that interventions and policies targeting the first smoking experience are required to prevent the initiation of tobacco use among early adolescents, especially girls in low-income countries.

Bidirectionality of smoking and depression in adolescents: a systematic review

INTRODUCTION

Recently, evidence has been accumulating that both smoking and mental health disorders are continuously increasing among adolescents. This systematic review elucidates the research into evidence of the direction of the association and risk factors influencing the relationship between smoking and depression. We also highlight recent studies on the effects of electronic cigarettes and developments on the association between depression and smoking.

METHODS

A literature search was conducted on databases including PubMed, Ovid Medline, EMBASE, and PsycINFO and in relevant neurology and psychiatry journals. Terms used for electronic searches included smoking, tobacco, cigarettes; depression; adolescent, youth; direction. Relevant information was then utilized to synthesize findings on the association between smoking and depression among adolescent population.

RESULTS

The initial database searches yielded 2,738 related articles. After screening and cross-referencing, duplicate articles, articles published in languages other than English, and studies on animals, social and lifestyle factors, mood disorders, and substance use were excluded. Of these, a total of 122 publications only focusing on smoking and depression in the adolescent population were selected for synthesis in this qualitative systemic review. These include 110 original research articles, eight meta-analyses and reviews, and four reports and websites.

CONCLUSION

The relationship between smoking and depression in the literature does not reflect the cause-effect relationship. The lack of evidence on the direction of the association may reflect futile study designs, confounding factors and/or use of indirect measures of depression and quantification of smoking. Future prospective randomized studies should target elucidation of the causal association.

What makes people quit tobacco and succeed at it? An exploratory analysis of smoked and smokeless tobacco from India

Tobacco cessation is a key component of WHO's Framework Convention on Tobacco Control. However, success rates decline significantly from intending to quit tobacco, through attempting and becoming a successful quitter. Among Indian adults, the prevalence of smoking and smokeless tobacco use was 10.7% and 21.4% respectively in 2016. Furthermore, 9% of all deaths were estimated to be attributable to tobacco. This study aims to explore associations of socio-demographic, environmental and behavioural dimensions of tobacco users with the process of successful quitting. Multivariable logistic regression analyses were conducted to study (i) attempting to quit and (ii) being a successful quitter for smoked and smokeless tobacco, using cross-sectional Global Adult Tobacco Survey (GATS) datasets for India (2009-10 and 2016-17), where data was pooled from the two surveys (n = 53,463). Advise to quit by health care provider was associated with quit attempts of smoking (1.82, 95% CI: [1.51; 2.20]), and smokeless tobacco (1.71, 95% CI: [1.45; 2.01]). Never being exposed to smoke at home was the strongest environmental factor for successful smoking cessation (4.04, 95% CI: [2.59; 6.31]). Noticing label warnings and advertisements was also associated with attempting to quit smoked and smokeless tobacco. Being a former smoker/smokeless tobacco user was positively connected with attempting to quit the current use of the other tobacco form. We recommend strategies to promote smoke-free homes, and incorporating 'tobacco cessation advocacy' into the curriculum of health care workers. Strengthening the tobacco control law and program promulgated in India since 2003 and its implementation would significantly promote tobacco cessation.

Effect of relative income price on smoking initiation among adolescents in Ghana: evidence from pseudo-longitudinal data

OBJECTIVE

Many smokers initiate smoking during adolescence. Making tobacco products less affordable is one of the best ways to control tobacco use. Studies on the effect of relative income price (RIP (ie, affordability)) of cigarettes on smoking initiation are scarce in low-income and middle-income countries, especially in Sub-Saharan Africa where data are limited. The goal of this study is to examine the effect of cigarette RIP on adolescent smoking initiation in Ghana.

SETTING

The study uses a pseudo-longitudinal data set constructed from the Global Youth Tobacco Surveys (GYTS (2000-2009 and 2017)) and RIP for the most sold cigarette brand in Ghana.

PARTICIPANTS

The GYTS is a national survey on adolescents.

PRIMARY AND SECONDARY OUTCOME

Effect of RIP on adolescent smoking initiation in Ghana.

RESULTS

Using the GYTS 2000-2009 data, we find that the probability of smoking initiation falls significantly in response to a higher RIP, with an elasticity of -0.372 (95% CI -0.701 to -0.042) for the unmatched sample and -0.490 (95% CI -0.818 to -0.161) for the matched sample. The RIP elasticity for women ((-0.888) (95% CI -1.384 to -0.392) and (-0.928) (95% CI -1.434 to -0.422)) is statistically significant at 1% in both the unmatched and the matched samples, respectively, while the RIP elasticity for men is statistically insignificant in the 2000-2009 surveys. Analysis of the 2017 GYTS shows a similar outcome: a negative relationship between RIP and smoking initiation, and the results are statistically significant for both men and women, and for both matched and unmatched samples.

CONCLUSION

The affordability (RIP) of cigarettes is negatively related to the probability of smoking initiation among adolescents in Ghana. Raising tobacco taxes in line with income growth would make cigarettes less affordable and dissuade adolescents from initiating smoking.

Initiation or cessation: what keeps the prevalence of smoking higher in Quebec than in the rest of Canada?

INTRODUCTION

We compared smoking initiation and cessation in Quebec versus the rest of Canada as possible underpinnings of the continued higher cigarette smoking prevalence in Quebec.

METHODS

Data were drawn from the Canadian Community Health Survey (CCHS). We compared average and sex-stratified prevalence estimates of (1) current cigarette smoking in persons aged 15 years and older; (2) past-year initiation of cigarette smoking in those aged 12 to 17 and 18 to 24 years; and (3) past-year cessation in adults aged 25 years and older in Quebec versus the other nine Canadian provinces in each two-year CCHS cycle from 2007/08 to 2017/18.

RESULTS

The prevalence of current smoking decreased from 25% to 18% among adults aged 15 years and older in Quebec from 2007/08 to 2017/18, and from 22% to 16% in the rest of Canada. Initiation among those aged 12 to 17 years decreased from 9% to 5% in Quebec, and from 7% to 3% in the rest of Canada. Neither initiation among people aged 18 to 24 (at 6% and 7%, respectively) nor cessation among adults aged 25 and older (approximately 8%) changed over time in Quebec or in the rest of Canada. In each two-year CCHS cycle, past-year initiation among those 12 to 17 years of age was consistently higher in Quebec than in the rest of Canada, but there were no substantial or sustained differences in initiation among people aged 18 to 24 or in past-year cessation. Findings were similar when stratified by sex.

CONCLUSION

Higher levels of smoking initiation among youth aged 12 to 17 years could be a proximal underpinning of the continuing higher prevalence of smoking in Quebec versus the rest of Canada.

Associations of childhood executive control with adolescent cigarette and E-cigarette use: Tests of moderation by poverty level

BACKGROUND

Adolescent cigarette smoking has continued to decline, whereas electronic cigarette (e-cigarette) use has increased dramatically among youth. Nicotine use in any form, even at low levels, during adolescence can have adverse consequences, particularly for low-income individuals. To elucidate potential early intervention targets, this study examined childhood executive control (EC), a set of cognitive processes for directing attention and behavior, in relation to adolescent cigarette and e-cigarette onset, testing for differential prediction by poverty level.

METHOD

Participants were 313 children (51% female, 64% European American) recruited in a small city in the Midwestern United States beginning in 2006 and then followed into adolescence between ages 14 and 16 years. EC was measured in the laboratory with performance-based tasks when children were age 5 years, 3 months. Self-reports of cigarette onset and e-cigarette onset were obtained in adolescence (M^age = 15.65 years). Overall, 24% of the sample was at or below the poverty line.

RESULTS

Cigarette onset was higher in the poverty group (17%) than in the non-poverty (8%) group, but e-cigarette onset did not differ by poverty level (36% poverty versus 38% non-poverty). Multiple group structural equation modeling revealed a statistically significant group difference such that EC ability was a significant negative predictor of e-cigarette onset for poverty but not for non-poverty youth. A similar group difference was evident as a trend for cigarette onset.

CONCLUSIONS

Because EC has been shown to be modifiable, early interventions to improve EC for children living in poverty might help prevent adolescent e-cigarette onset.

Smoking among High School Students in Iran: A Meta-Analysis Study

Objective: Cigarette smoking is an important and preventable risk factor, especially for adolescents and high school students. This issue has become one of the challenges for health system. Thus, the present study aimed to investigate the prevalence of smoking among Iranian high school students.

Method: This systematic review and meta-analysis study was done by searching PubMed, Scopus, Web Science (WOS), Science Direct, SID, and Google Scholar using the following keywords: “student” and “smoking” from 2000 to March 2018. After initial and critical appraisal, data were entered into a checklist and analyzed by a comprehensive meta-analysis software.

Results: The prevalence of smoking was 7.9% by combining the results of 49 articles. Males and females had 10.6% and 4.5% smoking prevalence, respectively. The overall prevalence of smoking was higher in northern areas in Iran (22.4%). Males in the northern (22.4%) and females in western regions (5.3%) were more smokers. There was a significant relationship between the prevalence of smoking with the year of publication, sample size, and age (P < 0.001).

Conclusion: In this study, Students' tendency to smoke was different in various regions of Iran, and had a high rate (7.9%). This figure indicates the necessity for planning some coherent educational programs for the public.

Behavioral and brain signatures of substance use vulnerability in childhood

The prevalence of risky behavior such as substance use increases during adolescence; however, the neurobiological precursors to adolescent substance use remain unclear. Predictive modeling may complement previous work observing associations with known risk factors or substance use outcomes by developing generalizable models that predict early susceptibility. The aims of the current study were to identify and characterize behavioral and brain models of vulnerability to future substance use. Principal components analysis (PCA) of behavioral risk factors were used together with connectome-based predictive modeling (CPM) during rest and task-based functional imaging to generate predictive models in a large cohort of nine- and ten-year-olds enrolled in the Adolescent Brain & Cognitive Development (ABCD) study (NDA release 2.0.1). Dimensionality reduction (n = 9,437) of behavioral measures associated with substance use identified two latent dimensions that explained the largest amount of variance: risk-seeking (PC1; e.g., curiosity to try substances) and familial factors (PC2; e.g., family history of substance use disorder). Using cross-validated regularized regression in a subset of data (Year 1 Fast Track data; n>1,500), functional connectivity during rest and task conditions (resting-state; monetary incentive delay task; stop signal task; emotional n-back task) significantly predicted individual differences in risk-seeking (PC1) in held-out participants (partial correlations between predicted and observed scores controlling for motion and number of frames [r_p]: 0.07-0.21). By contrast, functional connectivity was a weak predictor of familial risk factors associated with substance use (PC2) (r_p: 0.03-0.06). These results demonstrate a novel approach to understanding substance use vulnerability, which—together with mechanistic perspectives—may inform strategies aimed at early identification of risk for addiction.

Cigarette Smoking and Nicotine Dependence Trajectories Among Incident Adolescent Smokers

INTRODUCTION

Few interventions target adolescent cigarette smokers to prevent escalation in cigarette use or promote cessation, in part because little is known about co-developing smoking and nicotine dependence (ND). Our objectives were to: (1) estimate developmental trajectories of ND/cravings, withdrawal symptoms, the modified Fagerström Tolerance Questionnaire (mFTQ) and ICD-10 tobacco dependence in incident adolescent smokers; (2) describe concordance in number and shapes of trajectories across the four ND indicators; and (3) classify participants in each ND trajectory according to cigarette smoking trajectories.

METHODS

Data were drawn from an ongoing longitudinal investigation of 1294 grade 7 students recruited in 1999-2000 in 10 Montreal-area high schools. Group-based joint trajectory models were used to identify distinct subgroups defined by the four ND indicators, in 307 incident smokers.

RESULTS

The optimal trajectory model included five groups for ND/craving and four groups for each of withdrawal symptoms, the mFTQ and ICD-10 tobacco dependence. The four ND indicators showed similar developmental patterns and classification into smoking trajectory groups, although some discordance was observed. Smokers in the low-level decreaser group and stable low consumers who exhibited high ND were younger than those in the cigarette-low ND trajectory groups. Moderate or rapid escalators who exhibited no/low ND were less likely to have university-educated mothers and more likely to have parents who smoke.

CONCLUSIONS

Trajectories were similar across ND indicators, and generally reflected cigarette smoking trajectory shapes. Novice smokers may need education to become self-aware of developing ND symptoms, as well as to learn about alternative courses of action once ND symptoms manifest.

IMPLICATIONS

Trajectories of cigarette smoking and ND symptoms have rarely been investigated concurrently. This study provides evidence of high concordance across four distinct ND indicators in the proportion of participants with no/low-level dependence, and with high or increasing ND. Moreover, the development of cigarette smoking is concordant with ND symptom development. Interventions to prevent escalation and promote cessation should target adolescents before first puff to increase self-awareness of developing ND symptoms, as well as to learn about alternative courses of action once ND symptoms are experienced.

The First Cigarette Smoking Experience and Future Smoking Behaviors Among Adolescents with Different Parental Risk: a Longitudinal Analysis in an Urban Iranian Population

BACKGROUND

Longitudinal research among Iranian adolescent smoking is limited. The current study aimed to investigate (1) the first smoking experience (FSE) and future smoking behaviors of adolescents with different parental risk factors and (2) the association between age of the FSE and future smoking behaviors over a 12-year follow-up.

METHOD

Based on Tehran Lipid and Glucose Study (TLGS) database, 1487 adolescents (12-18 years) with complete baseline parental data were recruited. Using two-step cluster analysis, families were classified as either high or low risk; these were based on parental risk factors including age, education, employment, and smoking status. Participants were examined four times in 12 years and their data were used for survival analysis. After exclusion of 24 cases who were smokers at baseline, Cox proportional hazard modeling was used to evaluate the effect of parental clusters on the FSE in 1463 nonsmoking adolescents who completed all prospective follow-ups. Logistic regression analysis was used to examine the effect of the age of FSE on future smoking behaviors.

RESULTS

The mean age of adolescents was 14.63 ± 2.07 years at baseline. Adolescents in the high-risk cluster group were 49% more likely to try smoking for their first time, and 55% more likely to smoke in the future. Compared with girls, boys had 83% higher chance of trying their first cigarette. Moreover, 1-year delay in the FSE resulted in 25% reduction in the probability of smoking in the future.

CONCLUSION

The findings show that compared with adolescents living in low-risk families, teenagers living in high-risk families are at greater risk of smoking at an earlier age; therefore, this group could benefit from gender- and culture specific preventive interventions.

Longitudinal e-Cigarette and Cigarette Use Among US Youth in the PATH Study (2013-2015)

BACKGROUND

Evidence is accumulating that youth who try Electronic Nicotine Delivery Systems (ENDS, e-cigarettes) may go on to try cigarettes. This analysis examines the bidirectional patterns of ENDS and cigarette use among US youth over one year and uses propensity score matching (PSM) to examine frequency of ENDS use on changes in cigarette smoking.

METHODS

Our analysis included 11 996 participants who had two waves of available data (Wave 1 [W1] 2013-2014; Wave 2 [W2] 2014-2015) drawn from the longitudinal Population Assessment of Tobacco and Health Study. Cross-sectional weighted prevalence estimates are reported for cigarettes and ENDS. We used PSM to estimate the likelihood of ENDS use at W1 and to draw matched analytic samples, then used regression (logistic or linear) models to examine the effect of W1 ENDS use on W2 cigarette smoking. All statistical tests were two-sided.

RESULTS

In weighted analyses, 69.3% of W1 past-30-day cigarette smokers exhibited past-30-day smoking at W2; 42.2% of W1 past-30-day ENDS users were using ENDS at W2. W1 ever use of either product was similarly associated with W2 new use of the other product. Unweighted PSM models indicated W1 cigarette-naïve ENDS use was associated with W2 ever-cigarette smoking (n = 676; adjusted odds ratio = 3.21, 95% confidence interval [CI] = 1.95 to 5.45, P < .001); W1 ever-ENDS use did not affect change in cigarette frequency at W2 (n = 1020, beta = 0.31, 95% CI = -0.76 to 1.39, P = .57); 1-5 days ENDS use compared with ever, no past-30-day ENDS use was associated with a statistically significant decrease of W2 smoking days (n = 256, beta = -2.64, 95% CI = -4.96 to -0.32; P = .03); and W1 6+ day ENDS users did not show a decrease in frequency of cigarette smoking.

CONCLUSIONS

Ever-ENDS use predicts future cigarette smoking, and frequency of ENDS use has a differential impact on subsequent cigarette smoking uptake or reduction. These results suggest that both cigarettes and ENDS should be targeted in early tobacco prevention efforts with youth.

Religious Social Support Protects against Social Risks for Adolescent Substance Use

We used a social developmental perspective to identify how prominent social contexts influence substance use during adolescence. Longitudinal data were collected annually from 167 parent-adolescent dyads over four years. We investigated whether parent substance use was related to adolescent substance use directly and indirectly via peer substance use and whether these associations were moderated by religious social support. Structural equation modeling (SEM) analysis indicated significant moderated mediation: Greater parent substance use predicted increases in adolescent substance use indirectly via increased peer substance use when adolescent religious social support was low or average, but not high. These results suggest religious social support may protect adolescents against prominent social risks for intergenerational substance use.

Tobacco use and associated factors among Rwandan youth aged 15-34 years: Findings from a nationwide survey, 2013

Introduction

Use of tobacco and its products are the single most preventable cause of death in the world. The objective of this study was to determine the prevalence of current tobacco use and identify associated factors among Rwandans aged 15–34 years.

Methods

This study involved secondary analysis of existing data from the nationally representative WHO STEPwise approach to Surveillance of non-communicable diseases (STEPS) conducted in 2013 to explore the prevalence of tobacco use and its associated factors in Rwanda. Data of 3,900 youth participants (15–34 years old) who had been selected using multistage cluster sampling during the survey was analyzed. The prevalence of current smoking along with socio-demographic characteristics of the sample were determined and multivariable logistic regression was employed to identify independent factors associated with current tobacco use.

Results

The prevalence (weighted) of current tobacco use (all forms) was 8% (95%CI: 7.08–9.01). The prevalence was found to be significantly higher among males, young adults aged 24–34, youth with primary school education or less, those from Southern province, people with income (work in public, private organizations and self-employed) and young married adults. However, geographical location i.e. urban (7%) and rural (8%) settings did not affect prevalence of tobacco use. Factors that were found to be associated with current tobacco use through the multivariate analysis included being male, aged 25 years and above, having an income, and residing in Eastern, Kigali City and Southern Province compared to Western province.

Conclusion

The association between smoking and socio-demographic characteristics among Rwandan youth identified in this study provides an opportunity for policy makers to tailor future tobacco control policies, and implement coordinated, high-impact interventions to prevent initiation of tobacco use among the youth.

Cigarette Smoking Among Secondary School-Going Male Adolescents in Malaysia: Findings From the National Health and Morbidity Survey 2017

Smoking is a learned behavior during adolescence, and it is found predominantly among male adolescents in Malaysia. Our study aimed to investigate the prevalence and predictive factors of current cigarette smoking among school-going male adolescents in Malaysia. Data were derived from the National Health and Morbidity Survey: Adolescent Health Survey 2017, a cross-sectional study that utilized a 2-stage stratified cluster sampling to select a nationally representative sample of school-going adolescents in Malaysia (n = 27 497). Multiple logistic regression analysis was performed to identify factors associated with current cigarette smoking among male adolescents in Malaysia. Male adolescents aged 16 to 17 years (adjusted odds ratio [AOR] = 1.55; 95% confidence interval [CI] = 1.41-1.70), current illicit drug users (AOR = 8.14; 95% CI = 6.37-10.41), current alcohol users (AOR = 1.92; 95% CI = 1.65-2.23), those from rural schools (AOR = 1.60; 95% CI = 1.46-1.76), those whose parents were widowed/divorced/separated (AOR = 1.37; 95% CI = 1.21-1.55), and those whose parents/guardians were tobacco product users (AOR = 3.47; 95% CI = 2.33-5.16) were more likely to be current cigarette smokers. Tobacco control strategies should be aimed at both adolescents at risk and at promoting parental smoking cessation.

Sex Differences in Multilevel Factors of Smoking Experimentation and Age of Initiation in Korean Adolescents

This study purpose was to investigate sex differences in multilevel factors associated with smoking experimentation and age of initiation among Korean adolescents. Based on the ecological model, this cross-sectional study used data from the 2016 Korea Youth Risk Behavior Web-Based Survey (N = 65,528). Among 33,803 males (51.6%) and 31,725 females (48.4%), a greater proportion of males (21.9%) than females (7.1%) engaged in smoking experimentation. Males started smoking earlier than females (males: 12.7 years, females: 12.9 years, respectively, p < .05). In both sex groups, common factors associated with smoking were age, depression, suicidal ideation, academic achievement, household economic status, and having friends smoking and a specific person to talk with about their personal concern (all p values <.05). There were significant sex differences in psychological, family, and school factors of smoking initiation and experimentation. It is necessary to develop smoking interventions considering both individual and environmental factors with sex-specific strategies.

Initiation versus Cessation Control Policies: Deriving Optimal Resource Allocation Strategies to Decrease Smoking Prevalence Under a Fixed Budget

Background. Over several decades the tobacco control community has recommended and implemented smoking initiation and cessation interventions to reduce the smoking toll. It is necessary to study the combined effect of these interventions to allocate resources optimally. However, there is a paucity of studies that address the right combination of initiation and cessation policies over time to reduce smoking prevalence. Objective. To derive optimal trajectories of initiation and cessation interventions that minimize overall smoking prevalence over a specified period while satisfying a budget constraint. Methods. Using an established dynamic model of smoking prevalence, we employ an optimal control formulation to minimize overall smoking prevalence within a specified time period. The budget constraint is handled through an iterative application of a penalty function on above-budget expenditures. We further derive the optimal cost ratio of initiation versus cessation programs over time. To parameterize our model, we use results from two empirical interventions. The demographic data are from the National Health Interview Survey in the United States. Results. For our example, our results show that the optimal cost ratio (initiation over cessation) starts around 2.02 and gradually increases to 5.28 in 30 years. Smoking prevalence decreases significantly compared with the status quo, 8.54% in 30 years with no interventions versus the estimated 6.43% with interventions. In addition, the optimal units of initiation and cessation interventions increase over time. Conclusions. Our model provides a general framework to incorporate policy details in determining the optimal mix of smoking interventions.

Early vascular damage from smoking and alcohol in teenage years: the ALSPAC study

Aims

To determine the impact of smoking and alcohol exposure during adolescence on arterial stiffness at 17 years.

Methods and results

Smoking and alcohol use were assessed by questionnaires at 13, 15, and 17 years in 1266 participants (425 males and 841 females) from the ALSPAC study. Smoking status (smokers and non-smoker) and intensity ('high' ≥100, 'moderate' 20-99, and 'low or never' <20 cigarettes in lifetime) were ascertained. Participants were classified by frequency (low or high) and intensity of drinking [light (LI <2), medium (MI 3-9), and heavy (HI >10 drinks on a typical drinking day)]. Carotid to femoral pulse wave velocity (PWV) was assessed at 17 years [mean ± standard deviation and/or mean difference (95% confidence intervals)]. Current smokers had higher PWV compared with non-smokers (P = 0.003). Higher smoking exposure was associated with higher PWV compared with non-smokers [5.81 ± 0.725 vs. 5.71 ± 0.677 m/s, mean adjusted difference 0.211 (0.087-0.334) m/s, P = 0.001]. Participants who stopped smoking had similar PWV to never smokers (P = 0.160). High-intensity drinkers had increased PWV [HI 5.85 ± 0.8 vs. LI 5.67 ± 0.604 m/s, mean adjusted difference 0.266 (0.055-0.476) m/s, P = 0.013]. There was an additive effect of smoking intensity and alcohol intensity, so that 'high' smokers who were also HI drinkers had higher PWV compared with never-smokers and LI drinkers [mean adjusted increase 0.603 (0.229-0.978) m/s, P = 0.002].

Conclusion

Smoking exposure even at low levels and intensity of alcohol use were associated individually and together with increased arterial stiffness. Public health strategies need to prevent adoption of these habits in adolescence to preserve or restore arterial health.

Age of tobacco use initiation and association with current use and nicotine dependence among US middle and high school students, 2014-2016

INTRODUCTION

Tobacco use mostly begins in adolescence and young adulthood. Earlier age of initiation of cigarette smoking is associated with greater nicotine dependence and sustained tobacco use. However, data are limited on the age of initiation of non-cigarette tobacco products, and the association between using these products and nicotine dependence and progression to established use.

METHODS

Combined 2014-2016 National Youth Tobacco Survey data, a nationally representative cross-sectional survey of US students in grades 6-12 yielded 19 580 respondents who reported ever using any of five tobacco products: electronic cigarettes, cigarettes, cigars, smokeless tobacco and hookah. Analyses assessed age of reported first use of each product among ever-users, overall and by sex and race/ethnicity. Current daily use, past 30-day use, feelings of craving tobacco and time to first tobacco use after waking were assessed by age of first use.

RESULTS

Among ever-users, weighted median age for first use was 12.6 years for cigarettes, 13.8 years for cigars, 13.4 years for smokeless tobacco, 14.1 years for hookah and 14.1 years for e-cigarettes. First trying these tobacco products at age ≤13 years was associated with greater current use of the respective product and nicotine dependence compared with initiating use at age >13 years.

CONCLUSIONS

First tobacco use at age ≤13 years is associated with current daily and past 30-day use of non-cigarette tobacco products, and with the development of nicotine dependence among youth ever-users. Proven tobacco prevention interventions that reach early adolescents are important to reduce overall youth tobacco use.

Source of cigarettes among youth smokers in Malaysia: Findings from the tobacco and e-cigarette survey among Malaysian school adolescents (TECMA)

INTRODUCTION

Understanding how and where youth obtain tobacco products are major factors in the development of suitable intervention programs to reduce youth smoking. This study aimed to determine the source of cigarettes and the associated factors among Malaysian school adolescent smokers.

METHODS

Our sample consisted of 1348 youth aged 10-17 years who were current smokers (having smoked at least once in the last 30 days). The source of cigarettes (commercial, over-the-counter purchases; or social, borrowing or obtaining from someone else) was the dependent variable, and multivariable logistic regression was employed to determine its association with independent variables (i.e. sociodemographics, smoking behavior, and knowledge of laws prohibiting sales of cigarettes to youth).

RESULTS

Over half (54.3%) of current smokers obtained cigarettes from commercial sources, with a proportion nearly two times higher (84.2% vs 43.7%) among frequent smokers (i.e. those smoking more than 20 days per month) compared to less-frequent smokers, and among young males (56.5% vs 32.0%) compared young females. Multivariable logistic regression indicated that in urban areas, young females (AOR=12.5, 95% CI: 1.38-99.8) frequent smokers (AOR=4.41, 95% CI: 2.05-9.46), and those studying in lower (AOR=3.76, 95% CI: 1.41-10.02) and upper secondary (AOR=4.74, 95% CI: 1.72-13.06) school students were more likely to obtain cigarettes from a commercial source. On the other hand, in rural areas, only frequent smokers were more likely to get their cigarettes from commercial sources, whilst other variables were not significant.

CONCLUSIONS

The proportion of youth smokers who obtained cigarettes from commercial sources appeared to be high, suggesting that law enforcement and health promotion activities should be enhanced to reduce the rate of smoking among Malaysian youth.

Associations of perceived stress with the present and subsequent cortisol levels in fingernails among medical students: a prospective pilot study

Purpose

Cortisol in fingernails could retrospectively reflect cumulative stress over a long period. However, the association between fingernail cortisol and perceived stress needs to be validated. This exploratory study aimed to investigate the associations of perceived stress with the present and subsequent cortisol levels in fingernails of the subjective stress measurement among medical students.

Methods

Students were recruited from a medical university in Shenyang, China. The final sample consisted of 51 students (16 men, 35 women). On the Day 30 of our data and fingernail collection procedure, the 10-item Perceived Stress Scale was used to measure perceived stress. Fingernail samples were collected twice, on Days 15 (denoted as FD15) and 45 (denoted as FD45) of the procedure, and participants were asked to grow fingernails for 15 days in each collection. Cortisol was determined by an enzyme immunoassay method using the ELISA kit. Multiple linear regression was performed to examine the association between perceived stress and cortisol level. The Bonferroni correction was made for multiple comparisons.

Results

The level of cortisol was 5.65 pg/mg (SD =1.88) for FD15 and 5.41 pg/mg (SD =1.63) for FD45. Perceived stress was not associated with the cortisol level of FD15 (β=−0.014, P=0.924), but it was significantly and positively associated with the cortisol level of FD45 (β=0.436, P=0.003), which remained significant after Bonferroni correction. The associations between fingernail cortisol and demographic variables (gender, age, BMI, and physical activity) were not significant.

Conclusion

This study was the first to investigate fingernail cortisol in China. Perceived stress was positively associated with the subsequent cortisol levels in fingernails, but not the present. The findings suggested that fingernail cortisol could indicate stress exposure in the past. Furthermore, a simple and easy self-reported measure could reflect cumulative stress as measured by fingernail cortisol.

Never, non-daily, and daily smoking status and progression to daily cigarette smoking as correlates of major depressive episode in a national sample of youth: Results from the National Survey of Drug Use and Health 2013 to 2015

BACKGROUND

Cigarette smoking is associated with depression, and new initiates who progress more quickly to daily smoking may be at enhanced risk. In a nationally representative sample of youth, this study examined the association between daily, non-daily, and never smoking with past-year and lifetime major depressive episode (MDE) and, among daily smokers, whether faster progression to daily smoking was associated with increased MDE risk.

METHODS

Data were from n = 44,921 youth aged 12-17 in the 2013-2015 National Survey on Drug Use and Health. Weighted adjusted multivariable logistic regression models were used to examine the association of smoking status (daily, non-daily, never) with lifetime and past-year MDE, and the association between progression from cigarette trial to daily smoking with MDE outcomes among daily smokers.

RESULTS

Daily and non-daily smokers had similar rates of lifetime and past-year MDE; rates of MDE were approximately 50% lower among never smokers. Compared to never smokers, adjusted models showed that non-daily smokers had a higher risk of past-year and lifetime MDE, while daily smokers had a higher risk of past-year but not lifetime MDE. Daily smoking youth who progressed more quickly from cigarette trial to daily use had an increased risk of both lifetime and past-year MDE.

CONCLUSIONS

Prevention programs should target factors associated with the shift from cigarette experimentation to regular use to curb deleterious consequences of use.

Patterns in first and daily cigarette initiation among youth and young adults from 2002 to 2015

This study’s objective was to describe long-term trends and patterns in first cigarette use (cigarette initiation) and daily cigarette use (daily initiation) among youth and young adults in the U.S. We used cross-sectional survey data from the National Survey on Drug Use and Health, 2002–2015, to estimate annual incidence of first cigarette use (N = 270,556) and first daily cigarette use (N = 373,464) for each year by age groups, race/ethnicity and gender, examining trends over time and the average annual change in initiation for each group. Several clear patterns emerged: 1) cigarette initiation and daily initiation significantly decreased over time among those aged 12–14 and 15–17 and these trends were consistent among nearly all racial/ethnic and gender subgroups; 2) among 18–21 year olds, cigarette initiation sharply increased through 2009, surpassing rates among 15–17 year olds, and sharply declined through 2015 while remaining higher than rates among the younger group, and this trend was consistent for almost all racial/ethnic subgroups; 3) daily initiation for those aged 18–21 significantly declined, and this was significant among most subgroups 4) there was no change in cigarette initiation and daily initiation for 22–25 year olds overall and most subgroups; 5) there was a significant increase in cigarette initiation for 22–25 year old Hispanics males and daily initiation for 22–25 year old males. This study provides a comprehensive look at trends in cigarette and daily initiation among U.S. youth and young adults. Despite notable declines in smoking initiation among youth and young adult populations over the last two decades, targeted prevention and policy efforts are needed for subgroups at higher risk, including young adults and Hispanic males.

Responses to textual and pictorial cigarette pack health warnings: findings from an exploratory cross-sectional survey study in Austria

BACKGROUND

Packaging and labelling tobacco products has emerged as an effective policy to reduce the global health burden of tobacco use. The main purpose of this study was to explore Austrian smokers' and ex-smokers' responses to both the textual and pictorial cigarette pack health warnings (CPHWs) recently implemented.

METHODS

We analysed self-reported data (N=500) from an Austrian cross-sectional survey that was conducted after the implementation of the new pictorial CPHWs in 2016.

RESULTS

The results showed only weak effects of the CPHWs on the decision to quit or reduce smoking, and the level of impact of the CPHWs remained limited particularly because of smokers denying the ill-effects of tobacco use.

CONCLUSIONS

Although the CPHWs seem to have the potential to promote a change in smoking behaviour, the warnings reached only a rather small group of smokers, while the majority of smokers appeared to remain unaffected by this intervention. Public health policies are challenged to increase the salience of CPHWs and to overcome smokers' denial of detrimental health effects.

Tobacco smoking between immigrants and non-immigrants in Australia: A longitudinal investigation of the effect of nativity, duration of residence and age at arrival

ISSUE ADDRESSED

Earlier research evidence suggests that there is a difference and over time change in the prevalence of tobacco smoking between immigrants and native-born population. This study investigates the differences in smoking among immigrants from English speaking (ESC) and non-English speaking (NESC) countries relative to native-born (NB) Australians, and how those differences change with duration of residence (DoR) and age at arrival (AA).

METHODS

Information on 12 634 individuals from the first twelve waves (2001-2012) of Household, Income and Labour Dynamics in Australia (HILDA) longitudinal survey was analysed using multilevel group-mean-centred mixed logistic regression models. Smoking status as an outcome was dichotomized as current vs non-current smokers.

RESULTS

After adjusting for covariates, relative to native-born respondents, there was no difference in the odds of smoking for English speaking countries immigrants, while immigrants from non-English speaking countries had lower odds of smoking. The smoking prevalence of immigrants from non-English speaking countries converged towards the native-born after 20 years of residence in Australia. The association between duration of residence and smoking was modified by age at arrival, with immigrants (combined ESC and NESC) who arrived as children or adolescents and had lived 20 years or longer were significantly more likely to smoke than native-born Australians.

CONCLUSION

The results suggest that the initially lower smoking prevalence among non-English speaking countries immigrants converges with that of native-born Australians after twenty years of residence, and immigrants (combined ESC and NESC) who arrived as children or adolescents more than 20 years ago were more likely to be smokers. SO WHAT?: Current health promotion and anti-smoking programs should ensure that immigrants from non-English speaking background have access to education and information about the hazards of tobacco consumptions and are aware of the available smoking cessation services. Efforts to prevent smoking uptake among NESC immigrants and those who arrive as children or adolescents and live longer than 20 years is especially important for tobacco control interventions.

Trends in smoking initiation in Canada: Does non-inclusion of young adults in tobacco control strategies represent a missed opportunity?

OBJECTIVES

Young adults face high prevalence rates for smoking. Recent evidence suggests that many people initiate smoking during young adulthood, but little is currently known about trends in initiation rates for this age group.

METHODS

We examined rates of initiation to first cigarette (FC) and daily smoking (DS) during youth (5-17 years) and young adulthood (18-25 years) using nationally representative data from the 2001, 2003, 2005, 2007, 2009, 2011 and 2013 cycles of the Canadian Community Health Survey. We included all participants aged 25-26 to obtain seven mutually exclusive retrospective cohorts (n = 16 216). We used logistic regression to examine four correlates of smoking - sex, education, poverty status, and immigration status - and whether these factors modify time trends in smoking.

RESULTS

We found that initiation rates decreased during youth (p &lt; 0.001 for FC, p = 0.02 for DS) but not during young adulthood (p = 0.94 for FC, p = 0.28 for DS). We found that men and respondents with fewer educational credentials had relatively higher odds of initiating during young adulthood. Trends in young adulthood stayed constant across subgroups. Trends in youth were modified by education: participants who did not complete high school had no decrease in initiation to FC and DS while those with post-secondary education experienced a decrease in both outcomes.

CONCLUSION

Tobacco control has failed to address smoking initiation during young adulthood. Given the considerable amount of initiation that occurs during this period, practitioners and policy-makers should direct more of their planning toward young adults.

Association between Family and Friend Smoking Status and Adolescent Smoking Behavior and E-Cigarette Use in Korea

Smoking is harmful to the health of adolescents because their bodies are still growing. The aim of this study was to analyze the association between the smoking status of Korean adolescents' parents and friends and their own smoking behavior. The study assessed a nationwide sample of 72,060 middle and high students from the 10th Korea Youth Risk Behavior Web-based Survey (2014). Descriptive analysis, chi-square tests, and multiple logistic regression analysis were used to probe the association between family and friend smoking status and adolescent smoking behavior. The current cigarette smoking rates were 13.3% of boys and 4.1% of girls. The corresponding rates for electronic cigarette smoking were 4.1% and 1.5%, respectively. Higher exposure to secondhand smoke, smoking by any family member, more friends smoking, and witnessed smoking at school were associated with current smoking and electronic smoking. The smoking status of family and friends was significantly related to adolescent smoking behavior. These results should be considered in designing programs to control adolescent smoking.

Is vaping a gateway to smoking: a review of the longitudinal studies

BACKGROUND

The use of e-cigarettes (ECs) is rising globally. There is concern that e-cigarette may actually lead to smoking, especially amongst adolescents.

OBJECTIVE

To perform a comprehensive review of literature reporting the longitudinal effects of e-cigarette use on onset of smoking among adolescents and young adults.

METHODS

A search was conducted using PubMed, Google Scholar, Scopus, and Web of Science in February 2016 to identify the studies containing data on EC use among adolescents and young adults (age<30 years). We then narrowed our search to only include longitudinal studies with data on EC and conventional cigarette smoking among this population.

RESULTS

Four longitudinal studies were identified that analyzed the use of ECs and smoking at both baseline and follow-ups in the target population. These studies demonstrated that EC use is associated with an increase in combustible cigarette smoking, even amongst the adolescents who were not susceptible to smoking.

CONCLUSION

This review highlights the strong evidence that not only are ECs are not an effective tool for smoking cessation among adolescents, they actually are associated with higher incidence of combustible cigarette smoking. Policy makers need to recognize of the insidious nature of this campaign by the tobacco industry and design policies to regulate it.

School bullying and susceptibility to smoking among never-tried cigarette smoking students

INTRODUCTION

Bullying involvement has been linked with substance use; however, less is known about its relationship with pre-initiation stages of adolescent cigarette smoking behavior. This study examined the association between bullying involvement and smoking susceptibility among never tried or experimented with cigarette smoking students. Susceptibility to cigarette smoking in adolescence is a strong predictor of subsequent smoking initiation.

METHODS

A cross-sectional data on Canadian adolescent and youth were drawn from the 2012/2013 Youth Smoking Survey (n=28,843). Logistic regression analysis was used to examine the association between bullying and smoking susceptibility among never-smoking students.

RESULTS

About 21% self-reported involvement in bullying (as a bully, victim or both). Middle school students (grades 6-8) reported more involvement in bullying (24%) than those in grades 9-12 (16%). The multivariable analyses showed that the association between bullying and smoking susceptibility was significantly different by grade level. Middle school students involved in bullying had higher odds of smoking susceptibility compared to uninvolved students (bully, adjusted odds ratio [AOR]=2.54, 95% CI=1.73-3.74; victim, AOR=1.29, 95% CI=1.11-1.48; bully-victim, AOR=2.19, 95% CI=1.75-2.74). There were no significant associations between all subgroups of bullying and smoking susceptibility for grades 9-12 students.

CONCLUSIONS

Students involved in bullying were more susceptible to smoking, although patterns of association varied by grade level. In particular, the findings highlight that non-smoking middle school students involved in bullying were susceptible to future smoking.