5.19 What is meant by prevention?

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5.1 Introduction

5.2 Stages in the uptake of smoking

5.3 Factors influencing uptake by young people—overview

5.4 Physiological aspects

5.5 Individual personality traits and psychiatric influences

5.6 Intentions, attitudes and beliefs

5.7 The home environment

5.8 The smoking behaviour of peers, and peer attitudes and norms

5.9 The educational environment: achievements, aspirations and 'school connectedness'

5.10 Other drug use

5.11 Accessibility of tobacco products to young smokers

5.12 Affordability of tobacco products

5.13 Opportunity to smoke

5.14 Cultural background

5.15 Tobacco advertising and promotion targeted at young people

5.16 Products and packaging created to appeal to new users

5.17 Factors influencing uptake of smoking later in life

5.18 Uptake—a concluding note

5.19 What is meant by prevention?

5.20 Approaches to youth smoking prevention

5.21 Mass media strategies/campaigns

5.22 Interactive technology and multimedia

5.23 School-based interventions

5.24 Peer influence and education

5.25 Parent/family/home targeted interventions

5.26 Reducing tobacco access and supply

5.27 Reducing product appeal

5.28 Promotion and visibility of tobacco

5.29 Denormalising smoking

5.30 Taxation and pricing of tobacco products

5.31 Harnessing predictors of uptake to prevent smoking

5.32 Preventing smoking in more 'at risk' groups

Acknowledgments

References

While the term prevention is generally used in tobacco control to refer to any interventions or efforts to deter smoking among young people, it includes within its spectrum the following:

Adolescents may be at any point along this prevention spectrum. It is important to recognise and understand these nuances in the youth smoking trajectory, as they have significant implications for the appropriateness and efficacy of programs and interventions. Moreover, the predictors that precipitate smoking initiation or 'first try' are not necessarily the exact same drivers that progress someone to more regular smoking.98 Thus some of the factors discussed in preceding sections of this chapter are highly predictive of a first try (such has having family members who smoke), while others play more of a role in facilitating continuation (like ease of access) or deterring it (for example an unpleasant first experience).

5.19.1 Preventing 'just trying it'

Traditionally, youth smoking strategies have concentrated on keeping young people from trying their first cigarette;196 yet some of the drivers of the 'first try' are difficult to prevent. Curiosity, for example, is a natural part of 'growing up' and a normal part of the teenage trajectory. Curiosity was one of the predominant reasons given for trying smoking (even among non-smokers) in two qualitative studies with young people in Australia.54, 98 'Seeing what it is like' is regarded by young people as part of making an 'informed choice'; hence even ardent non-smokers accept or even endorse 'just having a try' in the context of curiosity and life experiences.54 In Western Australian research, very few of the young people spoken to saw any perceived risks of trying (although risks of smoking are well known and accepted).54

5.19.2 Preventing progression to continuation

There is a relative research and intervention void in the published literature relating to experimental smoking and the progression to regular smoking.197 Figure 5.2 depicts some of the factors influencing whether young people who have tried cigarettes, continue to smoke, as identified in WA research with 13–15 year olds.54

A number of these factors present opportunities to 'intercept' young people between the points of trial and continuation. For instance, predisposing attitudes to smoking (whether for or against) are factors that also influence continuation, but which are amenable to intervention.54 Enjoyment of the initial smoking experience also influences continuation but is less amenable to intervention (other than through product taste regulation—see Chapter 12, Section 12.8). For some Indigenous and lower SES youth, stresses and troubles in life also appear to influence trial and continuation,54 mirroring barriers to cessation among Indigenous adults198 and disadvantaged population groups.199 While current generations of young people place a high value on individual choice,200 there may be opportunities to further challenge the sense and consequences (for self and others) of choosing to smoke tobacco.54

The standard adult dichotomy between smoker and non-smoker is somewhat less clear in the youth smoking area. Intermittent patterns of smoking and lower consumption are more typical in younger smokers.201 Moreover, qualitative research from WA found that young people who smoke 'socially' or intermittently often do not regard themselves as smokers or have any intention of becoming a regular smoker.54 Prevention messages need therefore to avoid simplistically cataloguing young people as either smokers or non-smokers.

5.19.3 Regular smoking and addiction

While youth smoking campaigns and programs have traditionally not focused on issues of addiction or cessation, there is a cohort of young people who smoke with some regularity, and a subset of these who are actually addicted. Addiction in young smokers has been poorly researched and understood until recently,202 but there is accumulating evidence of nicotine addiction in adolescent smokers203-205 and an emerging imperative to address this within a comprehensive approach to tobacco control. Qualitative studies with young people provide further experiential evidence of the validity of addiction experiences in young, regular and irregular smokers.54, 202

Research suggests that children's notions and expectations of addiction influence their predisposition and likelihood to smoke.202 There are marked differences between adolescents who have smoked or intend to smoke and those who are resolved not to try it, in regard to their perceptions of the addictive nature of smoking.206, 207 However, young people's understanding of addiction (including its likelihood, processes and consequences) is poor.202, 208 Notions of what it takes to become addicted seem primarily based on opinion or observation, rather than 'known facts'.54 Research with young smokers indicates that addiction is an unanticipated consequence,202, 203 and is not viewed as a danger associated with trialling smoking.202, 203, 208 Young people often believe that they can smoke during adolescence without becoming addicted58 and that they can easily give up at any time.207, 209, 210 Addiction and cessation tend to be viewed by teenagers as issues only for adult smokers.202

There are few effective or well-evaluated youth cessation interventions in the literature.211, 212 A recent Australian exception entails a whole-of-school approach that utilises school nurses in the delivery of cessation strategies.213, 214 While the presence of withdrawal symptoms among adolescents who are trying to quit smoking supports the appropriateness of using nicotine replacement therapy,215 some debate surrounds the acceptability of this, and ethical issues preclude controlled pharmacological trials with adolescent smokers.212

While addiction and cessation might be seen by some to sit at or outside the margins of smoking prevention per se, recent Australian studies with young people stress the importance of addressing understandings about addiction within primary prevention interventions.54, 98 Awareness and concerns about addiction may deter some young people from experimentation with smoking, and to a lesser extent, from continuing after trial. Issues of addiction can be incorporated into school-based programs, information on websites and youth resources and woven into mass media messages, as it has been in the 'Bus Stop' advertisement developed by the Western Australian campaign Smarter than Smoking[17] with the tag line 'wouldn't it better to quit before you started', which has been used in several states and territories.

For further information on young people and addiction, refer to Chapter 6, Section 6.7.