Building the basis for primary prevention : Factors related to cigarette smoking and alcohol use among adolescents

Abstract: Background Cigarette smoking and alcohol use influence morbidity and premature death all over the world. Studies have shown that most life-time smokers and adult heavy drinkers began their use during their adolescent years and between 80-90% of them before the age of 18. Thus, early onset of smoking and alcohol use increases the risk of later dependence. Alcohol use and cigarette smoking among adolescents are also strongly correlated behaviors. Adolescents who initiate smoking are much more likely to begin using alcohol at an early age than those who do not, and vice verse. Furthermore, both cigarette smoking and alcohol use among adolescents are known to be gateways to the use of other substances, adding further to the negative consequences of smoking and alcohol use. Hence, early identification of key determinants for adolescent cigarette smoking and alcohol use may serve to decrease the likelihood of later substance use development and related health problems and delinquent behaviors. Aims and objectives The aim of this project is to investigate several important factors in the social environment of Icelandic adolescents that contribute to the likelihood of cigarette smoking and alcohol use initiation and progression. Senior public health scholars have highlighted the need for an increase in inter-disciplinary approaches for public health research and practice. Consequently, the coverage builds on a literature from both the social- and public health sciences. Material and method The data for studies I-III is based on the population-based cross-sectional survey, Youth in Iceland in 2006. The study was designed to monitor adolescent health risk behaviors and social circumstances among others. The study base includes all noninstitutionalized children who were enrolled in the obligatory 9th and 10th grades, ages 14 to 15 years, in all secondary schools in Iceland during March 2006. A total of 7,430 students in 9th and 10th grade (49% males) completed the questionnaire in 2006, yielding a response rate of 81% of the total population of these cohorts. The study base in study IV is pooled data from five cross-sectional studies in the Youth in Iceland series, from the years; 1997, 2000, 2003, 2006, and 2009. The emphasis is on changes in trends of substance use and associated risk and protective factors. Data collection was carried out using the same protocol as in the 2006 study. The study base varied between 7,882 and 9,278 individuals, and respondents numbered between 6,346 and 7,758 (81 to 90% of the total population). Results The findings of study I suggest that multiple social factors are related to smoking behaviors among adolescents, including alcohol use. Of all factors considered, peer smoking was by far the strongest predictor of occasional- and daily smoking. Perceived friends attitude to smoking was also found to be important and so was perceived parental reactions to smoking. Study II shows that increase in probability of smoking and alcohol use among adolescents that have experienced parental divorce or separation does not need to be a fact. Such increase in likelihood is largely accounted for by family conflicts. Study III further tests the relationship between parental- and peer social support, parental and peer use, and smoking and alcohol use. Results suggest that perceived parental reactions and peer respect for use are important variables in addition to peer use. Other factors, such as parental use, were not found to be important. Study IV finds that smoking and alcohol use has decreased substantially in Iceland during the last 12 years and so has party lifestyle among youth. On the other hand, parental monitoring and participation in organized sports have increased during the same time period. Study IV also finds that the relative decrease in substance use was greater in communities that have been using a specified community-based prevention approach than in the comparison communities. Moreover, the relative increase in supportive mechanisms such as parental monitoring and sports participation was greater in intervention communities than in the comparison communities, and so was the subsequent decrease in prevalence of party lifestyles. Discussion These results challenge the current sphere of knowledge in several ways. First, study findings suggest that multiple social factors influence smoking behaviors among adolescents, including alcohol use. Prevention approaches and programs should account for such diversity while at the same time considering contextual factors such as socio-economic background that are known to be important determinants for the likelihood of adolescent smoking. Second, by avoiding family conflicts, including direct conflict between parents and their children, before and after separation, parents can prevent increase in likelihood of cigarette smoking and alcohol use initiation by their children. Third, by demonstrating to their children that adolescent cigarette smoking and/or alcohol use are not acceptable behaviors, parents can substantially decrease the likelihood of such use by their adolescent children. Likewise, through supportive mechanisms (e.g. healthy leisure time activities) and motivation around the peer group, prevention work should target peer respect for smoking and/or alcohol use as an important factor that may increase the likelihood of such use. Finally, prevention activities conducted in several municipalities in Iceland over the past 12 years have shown that by stressing health promotion in the local community setting and collaboration with local youth- and prevention workers, cigarette smoking and alcohol use has decreased more than in the non-participating communities. Likewise, the relative increase in protective factors was greater in collaborative communities. This was true even though Iceland has a small and homogeneous population and contamination and co-intervention effects are difficult to assess.