Butt Out: A Report on the Issues of Teen Smoking. (Author: Candace Harvey)

_{05, November 2004}

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The first cigarette is a noxious experience to the novitiate.  To account for the fact that the beginning smoker will tolerate the unpleasantness, we must invoke a psychological motive.  Smoking a cigarette for the beginner is a symbolic act.  I am no longer my mother's child, I'm tough, I am an adventurer, I'm not a square's the force from the psychological symbolism subsides, the pharmacological effect takes over to sustain the habit. 

Philip Morris, 1969.

Scope

The primary objective of this Research Paper is to examine the issues that affect the uptake of tobacco smoking for adolescents under the age of 18.  Supply and demand side impacts will be analysed individually. 

Purpose of Research Paper

Acknowledgements

Abbreviations

Executive Summary

A system of positive licensing for retailers is needed.  This would provide health authorities with a database of tobacco sellers.

• A system of test purchases conducted by minors on retailers needs to be implemented.  The data gathered can be used for monitoring, prosecution and research purposes.
• Prosecutions need to be publicised to send a message to the community the government is serious about enforcing the law.
• Educational seminars should be conducted with key community figures like retailers and school and community groups.  The community needs to be educated about the necessity to halt the supply of cigarettes to children. 

The reasons why teens smoke vary as much as teenagers themselves.  However researchers generally agree that these factors increase the risk of smoking uptake:

• Poor self-esteem and poor refusal skills
• Poor academic performance
• From a low socio-economic background
• Parents and siblings who smoke
• Peers who smoke
• Adverse childhood events

Teens do not make decisions to smoke in a vacuum often the uptake is a combination of these factors.  The key findings to reduce the uptake of teen smoking are:

• Parents must be pro-active in communicating an anti-smoking message.  Which means, if they do smoke they need to quit. 
• Anti-smoking must start at around the age of 11 and continue throughout high school.
• Mentoring programs either involving older students or a community role model for younger students would have the ancillary benefit of reducing a wide range of risk taking behaviour whilst delivering an anti-smoking message.
• Increase the tobacco tax substantially.  This would not only reduce the number of teens able to smoke, but it may also reduce the number of adults who smoke which would have an indirect effect on the teen rate of smoking. 
• There is a need for quit programs targeted at teens.  Many teens want to quit and whilst they respond to the messages in adult targeted quit campaigns they lack the skills to go about it.

Introduction

Teen smoking is a much larger problem than the numbers indicate.  Australian teenagers spend $100 million on cigarettes each year.  The decision to experiment with cigarettes is usually made between eleven and sixteen years of age.  Girls smoke significantly more than boys in all but three jurisdictions, with Queensland girls having the second highest rate in Australia.  Between 1996 and 2002 the number of school children who smoked fell from 49 800 to 38 800.  These figures should be extrapolated to the general teen population with caution as smoking prevalence is generally higher among out-of-school youth (Fisher, Stanton et al, 1999).  Anti-smoking campaigns are best targeted at minors because ninety per cent of smokers take up the habit before their twentieth birthday.  In addition, the addictive nature of tobacco indicates that targeting the initial decision to start is most effective (Kidd & Hopkins, 2004). 

There are many problems to overcome.  Despite law prohibiting tobacco sales to persons under the age of 18, more than half of tobacco retailers still sell tobacco to minors (QCF, 2004).  Education programs have not successfully stopped large numbers of adolescents experimenting with cigarettes nor helped them quit.    Teen smoking does not happen in isolation and is often indicative of broader behavioural problems.  Therefore youth smoking issues must be addressed through a range of strategies on both the supply and demand side. 

PART A

Current Legislation

Background

3.  Prosecutions are necessary not only to fine those who ignore the law but also to serve as a warning to other retailers and the public that the government is serious about enforcing the legislation.  However, few retailers have been prosecuted because of the difficulty in trying to prove that they broke the law.  Publicising prosecutions has been shown by many studies to act as a deterrent to other retailers who may be breaking the law also. 

4. The 2002 Australian School Students' Alcohol and Drug (ASSAD) Survey found 25 per cent of regular teen smokers purchased their last cigarette themselves.  This is a marked reduction from the 1996 figure of 42 per cent.  Forty per cent of students aged 16-17 years purchased their last cigarette compared to 12 per cent of 12-15 year olds.  Of the regular smokers who did not purchase their last cigarette, 44 per cent had been given one by a friend and 23 per cent had someone else purchase it for them (Queensland Health, 2002).  The most common sources of cigarettes are friends, siblings, petrol stations, convenience stores and supermarkets (Stanton, Carmont, Ballard & Loew, 2000). 

5. Restricting the supply of tobacco products to young people as part of a comprehensive approach is a proven strategy to reduce the prevalence of youth smoking.  Access to cigarettes is a very important factor in the uptake of smoking by young people.  The aforementioned figures are evidence the current laws fail to act as a deterrent to selling to minors.  Legislation without the commitment to enforce it sends a message to the community and to teens that the government is not serious about tobacco prohibitions. 

Monitoring and Enforcement

7. Numerous health organisations have called for Queensland to introduce a system of test purchases conducted my minors, otherwise known as compliance monitoring.  This involves children usually around the age of 15 and 16 entering shops seeking to buy cigarettes whilst an adult supervisor waits outside.  Compliance monitoring, it has been agreed, is an important part of any strategy to halt teen smoking.  All states and territories have implemented compliance monitoring with the exception of Queensland and the Australian Capital Territory. 

8. A program on the New South Wales Central Coast region has been the most successful campaign in Australia to reduce teen smoking rates.  The comprehensive program which began in 1992 includes educational initiatives aimed at retailers and publicised prosecutions.  First they located all the tobacco sellers in the region and informed them by mail and media that it is an offence to sell tobacco to a minor.  They then ran seminars for key people from schools, police, local government and health, where the value of compliance monitoring was emphasised.  Teams of fourteen and fifteen year olds were then recruited and trained to make approaches to retailers to ascertain their behaviour in regard to sales to minors.  The retailers that were found to be in violation of the law were charged (Tutt et al., 2000: 20).

9. As a result compliance increased from 69 per cent to over 90 per cent.  Adolescent smoking dropped from 25.9 per cent to 17.1 per cent in the region (Tutt et al., 2000: 23).  When compliance initially increased, 12 to 13 year-olds showed the only significant reductions in smoking rates.  After three years all age groups from 12 to 17 years of age showed significant reductions.  The Central Coast researchers have also suggested tobacco licensing needs to be implemented because at present there is no record of how many retailers are selling tobacco (Tutt et al., 2000: 20). 

10. Resistance to compliance monitoring usually revolves around ethical issues.  With this in mind, both the New South Wales Central Coast Health Unit and the recent QCF sponsored test purchases in Queensland by minors adhered to strict ethical guidelines.  Participants must have parental permission, they must not look older than their age and they must not give a false age if asked by a retailer and must not show false identification.  These guidelines ensure the children are not being asked to commit an offence because it is not illegal for a minor to purchase or possess tobacco.  Parents of participants overwhelmingly reported their child found it a rewarding experience and made them feel they were doing something positive for their community (Heart Foundation, 2004; QCF, 2004). 
 
11. In 1999, the Federal government decided to draft a national approach to tobacco control.  In their key findings they endorse the nation wide implementation of compliance monitoring and state it is the most effective, least costly and practical means of monitoring illegal sales of tobacco.  Compliance monitoring is also endorsed by health authorities in the United Sates, United Kingdom and New Zealand (AIHW, 2002: viii).   

12. In Australia, compliance monitoring has proved not only to be a rewarding experience for the children involved, but a key way to effect prosecutions against rogue retailers.  Data gathered by compliance monitoring can be used for enforcement, prosecution and research purposes.  Policy and health authorities in Queensland continue to be sceptical about the advantages of compliance monitoring.  This is despite every other state implementing a system of test purchases by under 18s that meet national recommendations and international best practice.  Furthermore, all available evidence indicates it is an integral part of any strategy to restrict the supply of cigarettes to minors. 

13. Literature suggests the key to significantly reducing the supply of cigarettes is a rigourous education campaign encompassing retailers, the community and children in conjunction with comprehensive compliance testing and publicised prosecutions for those who do not comply with the law.  Rigourous enforcement can include sting operations, significant fines and licensure removal.  Publicising prosecutions, it has been agreed, is an essential component of increasing compliance.  This sends a clear message to the community that the health authorities are enforcing the law and deters other retailers from selling to minors. 

Penalising Adolescents

Licensing

16. Presently in Queensland, there is a system of negative licensing.  This system requires no license to sell tobacco, but if a business were to commit a serious breach of the law, they may be banned from continued activity.  It is a system which is not pro-active or preventative; the system responds after problems occur.  Negative licensing also fails to provide a comprehensive record of tobacco retailers, limiting the ability of health authorities to undertake targeted education campaigns. 

17. A system of positive licensing would be a beneficial step towards improving compliance with the law.  This system directly links compliance with tobacco control legislation to the right to sell tobacco products.  It would provide administrative enforcement options like license conditions and license withdrawal, which are less costly than legal action through the courts.  Furthermore it would ensure that tobacco sellers are aware of their legal responsibilities and would enable authorities to communicate directly to tobacco retailers and wholesalers.  Positive licensing of tobacco retailers and wholesalers is generally supported by retail organisations (Allen Consulting Group, 2002: 46-52). 

18. The proposed legislation is set to maintain the system of negative licensing.  Queensland Health is too under resourced and lacks the administrative capacity to manage a positive licensing system.  However they have recognized the need for a comprehensive database of tobacco sellers.  To overcome this they have recommended that all cigarette manufacturers provide lists of their buyers to the Queensland government. 

19. Most health advocacy organisations generally agree that banning the right to sell tobacco is a much greater threat and deterrent than fines alone.  Not only do retailers receive 17 per cent of the sale of a tobacco product, cigarettes are often the catalyst for the purchase of other products, like milk and bread for example.  While this is most true for convenience stores, banning the sale of tobacco for a period of time could seriously affect the profitability and viability of some small businesses; which is why licensure removal is a powerful incentive not to sell to minors.   Furthermore its implementation would match law enforcement sanctions for other serious offences such as alcohol sales to minors (Jacobson et al, 2001: 238).  While present public health resources do not permit the implementation of positive licensing, Queensland Health's recommendations are arguably the next best thing. 

Advertising and Display Restrictions

21. Advertising bans have not prevented tobacco companies communicating to potential and existing consumers.  It has caused them to become more innovative and creative; often exploiting ambiguities in the law.  The industry still spends $60 million per annum on cigarette promotion in Australia.  Based on pro-rata population share, this equates to about $12 million in Queensland (Scollo, 2001).  Cigarette cartons resemble mini billboards and when placed at eye-level with customers, essentially serve as an advertisement.  Yet, because it is a product 'usually for sale' it meets the requirements of the legislation.  Other tobacco companies went as far as devising a system where if all their cartons where stacked in correct order, would form a complete advertising picture (Cook & Edwards, 2000).  Duty-free shops are exempt from the Act and according to the QCF this 'helps glamorise smoking' (QCF, 2004).  These stores are often located in shopping centres and should be subject to the same restrictions as other tobacco sellers. 

22. To ensure the ongoing prominent display of cigarettes, tobacco companies have long nurtured their relationships with retailers by utilising loyalty programs, rebates and price supports (Queensland Health, 2004: 7).  The high impact displays are known as 'power walls' which are intended to 'seduce your customers to buy' (Heart Foundation, 2004: 15).  The fact that these 'power walls' are in view of any minor who walks into the store is exactly what the tobacco company intended.

23. Tobacco companies have proven over many decades that they are able to counter legislative initiatives restricting promotion.  Cigarettes are sold in many stores where children and teens frequent:  supermarkets, convenience stores, newsagents and petrol stations.  The ongoing display and promotion of tobacco products has provided tobacco companies with an opportunity to continue trying to entice young people to experiment with smoking.  Research has shown the visibility of cigarettes are one of the key environmental influences that first lead to social smoking, which in turn leads to addicted smoking (Young Women and Smoking Project, 2004).  A reasonable solution is for tobacco sellers to store all tobacco products out of customer view.  Furthermore, a total ban on display and promotion of tobacco products should be implemented to reduce the tobacco industry devising new ways to exploit loop holes in the legislation. 

PART B

Background

Education

26. Older high school students are also excellent candidates to become peer-educators for younger students.  Jacobson et al suggest that younger adolescents may be more responsive to anti-smoking messages delivered by older adolescents rather than adults (2001: 234).  Anecdotal evidence has also suggested students would be responsive to a role-model program, for example a local sports star coming to talk about the benefits of a healthy lifestyle.  Programs like these could also address the social pressure to use tobacco by educating teens with skill sessions on social interaction and equipping them with skills to refuse tobacco when offered it by peers.  

27. Better after-school programs have also been shown to reduce risky behaviours by adolescents.  Programs designed to improve academic performance, teach adolescents better refusal skills may have the ancillary benefit of reducing a wide range of risk taking behaviours.  Hence education programs that enhance teen self-image and self-esteem while simultaneously providing an anti-smoking message need to be considered.  Computer and Internet based education programs hold enormous potential for delivering anti-smoking messages to the younger computer-savvy generation. 

Prevention and Quit Programs

Tobacco Taxes

30. Kidd and Hopkins found that price plays a critical role in the decision to start smoking, but not to quit.  However more analysis needs to be done to clarify its role for different age groups and gender (2004, 191).  The increased price thesis is also supported by the New South Wales Central Coast Health Unit (Lygre, 2004: 12).  Raising the price would also have an indirect effect on the teen smoking rate because it would be expected that higher tobacco taxes would discourage adult smoking also (Jacobson, 2001: 236). 

31. There is a continuing debate in relation to tobacco tax and how the government is spending it.  Many tobacco researchers have cried foul at the Federal government for profiting from tobacco tax collected from sales to minors.  Less than a quarter of one per cent of the revenue raised from tobacco tax is spent on anti-smoking education (Scollo, 1998: 1).  The tax system has also provided an incentive to retailers to sell to minors as 17 per cent of tobacco sales go to the retailer, (Scollo, 1998).   

32. At present the evidence is unable to recommend a specific percentage increase that would decrease the teen smoking rate.  However, economic theory suggests that a substantial price rise may have a proportionately large impact on teen smoking rates versus smaller price increases (Jacobson et al, 2001: 236). 

Impact of Media Campaigns

34. While the States are responsible for most health and social services, in 1996 the Federal government decided for the first time there would be National Tobacco Control Campaign.  This involved a collaborative effort between State and Federal governments and non-government organizations like the Cancer Council.  Australian researchers tested the effectiveness of the National Tobacco Campaign aimed at 18 to 40 year-olds on adolescents.  They found that 85 per cent of teen smokers thought the campaign was relevant to them.  53 per cent indicated the campaign had led them to try and quit and 85 per cent thought the advertising made smoking less cool and desirable.  Overall, the campaign led 27 percent to cut down on the number of cigarettes they smoked (White et al, 2003: 23). 

35. The National Tobacco campaign was unique in that for the first time emphasis was placed on the immediate harmful consequences of tobacco.  Hence the motto of the campaign became, 'every cigarette is doing you damage'.  The graphic images of the health consequences were used so smokers would perceive their current behaviour as a severe threat to their health and well being while empowering them with the knowledge to reduce this threat.  The graphic images aimed to produce negative emotions about smoking and to motivate people to change their behaviour.   

36.  Anti-smoking campaigns aimed at adults should continue for a variety of reasons.  Adult targeted campaigns impact adolescents both indirectly and directly.  Firstly by reducing the number of parents who smoke it in turn reduces the number of teens exposed to smoking, which is a major risk factor for smoking uptake.  If smoking is a less desirable adult behaviour, teens' motivation to use tobacco as a signifier of adult hood is reduced.  Secondly because teens identify with adults and want to be treated like adults, they are more likely to listen to adult focused anti-smoking campaign (White, Tan & Wakefield, 2003: 23). 

Psychological Factors

38. The perceived health risks of smoking are another factor influencing teens' attitudes toward tobacco.  When adolescents value a healthy lifestyle, the risk of uptake of smoking decreases; conversely if a teen has a negative view of their health, their smoking risk increases.  Healthy lifestyle attitudes are indirectly and directly to participation in physical activity.  The more sport an adolescent plays, the less likely they are to ever smoke (Jacobson et al., 2001: 83). 

39. Peer influence is arguably one of the most significant factors in the decision to start smoking for adolescents.  The smoking status of friends is perhaps the biggest predictor of future smoking.  Best friends, boyfriends and girlfriends have the strongest impact on whether an adolescent takes up smoking (Jacobson et al, 2001:  85).  Peers who smoke are an integral part of an adolescent's progression from experimentation to regular smoking.  As the visibility of smoking in an adolescents group increases, they increasingly contemplate experimenting with tobacco.  The more often peers offer cigarettes to their non-smoking friends, the more likely they are to experiment with tobacco.  Furthermore, each time a smoker offers a cigarette; vulnerable teens are more likely to accept.  Cigarette offers from friends also send a powerful message that it is socially acceptable to smoke (Jacobson et al, 2001: 85).  Hence peer selection is important.  Adolescents tend to seek out friends that share similar smoking beliefs (Jacobson et al, 2001: 87).  Researchers are still unsure whether susceptible adolescents seek out smokers as friends or if smoking behaviour is transmitted once a friendship is formed. 

40. Peer pressure to smoke starts early at around 11 years of age.  Hence it is important that young adolescents develop social skills to refuse cigarettes early.  Friendships with non-smoking peers can produce a protective barrier against smoking initiation.  This is concurrent with studies that show more than 25 percent of 14 to 15 year olds have actively influenced their peers not to smoke (Stanton & McGee, 1996). 

41. Parental and familial influences also play a significant role in shaping teen attitudes towards smoking.  There is a general consensus in the literature of a significant association between parental smoking status and teen smoking status.  Parental attitudes toward smoking are also an important factor.  Adolescents are less likely to experiment with smoking if they know their parents will disapprove.  Parental influence tends to be strongest in younger adolescence, with peers becoming more influential as children progress through adolescence.  Older siblings who also smoke positively influence the uptake of smoking.  Having a family member who smokes also provides an easy supply for adolescents with 46% of children who have tried smoking citing they got their first cigarette from a family member (Greenlund et al, 1997).  Parents who foster a strong relationship with their children throughout their teen years decrease the likelihood they will smoke (Jacobson et al, 2001: 106). 

42. Social competence is another interrelated factor in the uptake of teen smoking.  Competence can be categorised as academic performance, physical appearance, social acceptance, behavioural conduct and athletic ability.  Low self esteem, low study motivation and low academic performance are associated with passing through the various stages of smoking intention, experimentation, and regular use.  Adolescents who believe in their decision-making capabilities have stronger refusal skills and are less likely to take up smoking (Jacobson et al, 2001: 102). 

43. Adolescents constantly cite stress as the reason for smoking; however, the influence of stress and depression is hard for researchers to assess.  Longitudinal studies have not found a strong relationship between depression and smoking initiation.  Smoking does not cause depression, but people suffering its symptoms gain some relief from smoking. 

44. Obviously, teens do not make decisions to smoke in a vacuum.  It is important to gain greater understanding of how the factors interact with one another to influence a teen's use of tobacco.  Psychosocial factors are dynamic and ongoing research is needed to illuminate historical patterns, identify target groups for prevention campaigns and to evaluate the effectiveness of anti-smoking campaigns. 

Social Context

46. Policy must start to address the broader social context of teen smoking and begin to marginalise its use in society.  Laws prohibiting smoking in public places are any easy avenue for governments to pursue and one which the Queensland government has considered.  Factors such as family structure and adverse childhood events are much more difficult for policy makers to address.  Programs that include teen mentoring and academic support are designed to improve self-efficacy, cognitive and social skills and may reduce teens' risk factor of taking up destructive habits like smoking (Jacobson et al, 2001: 243).  These programs are best aimed at 13 to 15 year old because this is usually the age of experimentation and progression to regular use.  To be pro-active about reducing teen uptake, adolescents in this age group who are experiencing risk factors like personal or social distress should be targeted by mentoring programs.  This would not only reduce smoking but may also address a wide range of developmental problems. 

47. Parental groups can play a significant role in changing the attitudes of adolescents and public attitudes surrounding drug use.  Community groups also serve to address adolescent smoking in the context of broader developmental issues and recognise that for some youth, smoking serves as a marker for adverse circumstances or problem behaviours (Jacobson et al, 2001: 236).  They can also play a role in a reward system for private retailers that do not sell tobacco to minors. 

 
PART C

Related Drug and Alcohol Abuse

PART D

Conclusions

50. Reducing the demand of cigarettes by minors is slightly more complicated and sometimes out of reach of public policy.  However there are still measures and improvements that can be undertaken.  The uptake of teen smoking is usually the result of many psychological and psychosocial factors.  This is why parental and peer smoking status is the biggest predictor of teen smoking.  In addition, teens that lack social skills, the ability to refuse cigarettes, have poor academic performance and poor physical fitness are more susceptible to smoking.  Education, media and policy responses need to marginalise the use of tobacco in society.  The expansion smoke free zones have been extremely beneficial in this regard.  Education and media campaigns need to be designed to target specific segments of adolescents to be most effective.  Teenagers are a diverse population and the reasons they take up smoking are as varied as they are.  Furthermore, it has been shown that smoking is often indicative of broader developmental problems and addressing these wider issues would have many positive far reaching effects. 

Recommendations

• A system of positive licensing for retailers is needed.  This would provide health authorities with a database of tobacco sellers.   In addition the threat of licensure removal is a much greater threat than a fine. 
• A system of test purchases conducted by minors on retailers needs to be implemented.  The data gathered can be used for monitoring, prosecution and research purposes. 
• Prosecutions need to be publicised to send a message to the community the government is serious about enforcing the law.
• Educational seminars should be conducted with key community figures like retailers and school and community groups.  The community needs to be educated about the necessity to halt the supply of cigarettes to children. 
• Increasing the tobacco tax substantially would be one of the most effective ways to reduce the demand of cigarettes by minors and adults. 
• Increasing the number of smoke-free areas would continue to marginalise cigarette use in society, which in turn would discourage teen uptake of smoking. 
• Mentoring programs either involving older students or a community role model would have the ancillary benefit of reducing a wide range of risk taking behaviours whilst delivering an anti-smoking message. 
• Anti-smoking education programs need to begin at age eleven and continue until the senior years of high school. 
• There is a need to develop quit programs specifically for teens.  While a large proportion of teens respond to adult focused quit campaigns, they are unable to translate their want to quit into action. 

Appendices

Table 1: Daily Smoking:  Percentage proportion of the population aged 14-19, by gender. 

Gender  NSW VIC  QLD WA    SA   TAS   ACT  NT    AUST
Male     11.2  17.3 14.1 13.7  17.4  9.4   12.7  20.3  14.1
Female 14.9  12.7 21.7 17.2  16.7  13.4  31.6 20.0  16.2

Source: 2001 National Drug Strategy Household Survey, AIHW.

Table 2: Recent cannabis use by 14-24 year olds by gender. 

Gender  NSW  VIC   QLD   WA   SA    TAS  ACT   NT    AUST
Male      29.1  33.5  31.9  34.2  32.6  24.3  34.5  41.0  31.6
Female  21.8  20.0  24.6  29.5  33.2  19.8  34.3  32.6  23.8

Source: 2001 National Drug Strategy Household Survey, AIHW.

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