Promoting health in adolescents : preventing the use of tobacco

Abstract: There is a robust evidence base for the negative health effects from smoking. Smoking is linked to severe morbidity and to mortality, and kills up to half of its regular users. Tobacco use and production also bring other negative consequences such as economic loss for countries, poverty for individuals, child labour, deforestation and other environmental problems in tobacco growing countries.  A combination of comprehensive interventions at different levels is needed to curb the tobacco epidemic. Tobacco control strategies at national levels in the western world often include components of information/education, taxation, legislative measures and influencing public opinion. Two approaches have dominated at the meso and micro levels: cessation support for tobacco users and prevention activities to support young people refraining from tobacco use. Smoking uptake is a complex process that includes factors at the societal level as well as social and individual characteristics.  At national level, taxation and legislation can contribute to a societal norm opposing tobacco and creating a context for primary prevention aimed at tobacco free youth.  There is no magic bullet in primary prevention.  At the meso and micro levels, a continued development of knowledge on the underlying mechanisms and primary prevention methods is essential to prevent young people from starting to use tobacco.  The overall aim of this thesis was to gain knowledge about factors that influence young people’s use of tobacco and of preventive mechanisms.  The specific aims included to study the relation between Tobacco Free Duo, an intervention program targeting youth in Västerbotten County, and tobacco use prevalence.  A specific interest was to explore the role adults can play in supporting young people to refrain from tobacco use.  The thesis is based on four studies with three separate sets of data, two were quantitative and one was qualitative. The studies were conducted among adolescents (aged 13-15 yr) in Västerbotten County and on national level in Sweden (aged 13, 15 and 17 yr).  Tobacco Free Duo is a school-based community intervention that started in 1993. An essential component of the intervention was to involve adults in supporting adolescents to stay tobacco free. Results showed decreased smoking in adolescents among both boys and girls in the intervention area during the study period of seven years.  There was no change in a national reference group during the same time period. A bonus effect was a decrease in adult tobacco use in the intervention area. One out of four adults who supported a young person taking part in the intervention stopped using tobacco. In a qualitative assessment of young smokers, starting to smoke was described as a means of gaining control of their feelings and their situation during early adolescence. They expected adults to intervene against their smoking and claimed that close relations with caring adults could be a reason for smoking less or trying to quit smoking.  In a quantitative study that used three decades of national data, over time adolescents became more positive toward parental action on children’s smoking. The adolescents strongly supported the idea of parental action, regardless of whether or not they themselves smoked. Adolescents preferred that actions from parents were dissuading their children from smoking, not smoking themselves, and not allowing their children to smoke at home.  These results suggest that the Tobacco Free Duo program contributed to a reduction in adolescent smoking among both boys and girls.  Using a multi-faceted intervention that includes an adolescent-adult partnership can decrease adolescent smoking uptake.  Engaging adults as partners in tobacco prevention interventions that target adolescents has an important tobacco reducing bonus effect in the adults. The intervention has proven sustainable within communities.  A growing majority of adolescents support parental interventions to help them refrain from tobacco.  The findings dismiss the notion that adolescents ignore or even disdain parental practices concerning tobacco. A common and consequent norm against tobacco from both schools and parents using a supportive attitude can prevent tobacco use in young people.