Current trends in tobacco smoking among 15-year-old adolescents in Poland in the background of 30 countries

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1 prace oryginalne Joanna Mazur 1 Anna Dzielska 1 Anna Kowalewska 2 Anna Fijałkowska 3 1 Zakład Zdrowia Dzieci i Młodzieży, Instytut Matki i Dziecka Warszawa Dr hab. med. prof. IMiD Anna Oblacińska 2 Wydział Pedagogiczny, Uniwersytet Warszawski Prof. dr hab. Zbigniew Izdebski 3 Zakład Kardiologii, Instytut Matki i Dziecka Warszawa Dr hab. med. prof. IMiD Anna Fijałkowska Additional key words: tobacco smoking adolescents trends international comparisons Dodatkowe słowa kluczowe: palenie tytoniu młodzież trendy porównania międzynarodowe This work was supported by internal funding from Institute of Mother and Child, Poland ( /2016). Adres do korespondencji: Dr hab. n. o zdr. Joanna Mazur Zakład Zdrowia Dzieci i Młodzieży Instytut Matki i Dziecka Warszawa, ul. Kasprzaka 17a joanna.mazur@imid.med.pl Current trends in tobacco smoking among 15-year-old adolescents in Poland in the background of 30 countries Aktualne trendy palenia tytoniu przez młodzież 15-letnią w Polsce na tle 30 krajów The international HBSC (Health Behaviour in School-aged Children) survey has enabled the comparison of the patterns of changes with respect to a number of health indicators in adolescence. The aim of the study was to show international trends and how the position of Poland in international rankings of smoking prevalence has changed since Material and Methods: The study comprised 30 countries for which data was available from four rounds of HBSC survey ( ). In total, year-olds were surveyed, including 7289 in Poland. For each country a linear trend was estimated, separately for boys and girls, to describe changes in regular smoking (daily or at least once a week). Results: In the investigated period, the percentage of 15-year-old boys who smoke every week fell in Poland from 26.2% to 15.5%, and the respective percentage in girls decreased from 17.2% to 14.7%. This means annual decrease of 0.88% in boys and 0.24% in girls. In a combined international sample, exactly the same as in Poland rate of change was noted in boys; however, a definitely faster in girls (0.95% a year). The highest rate of change was observed in Ukraine, Germany and Norway, while the lowest in Greece, Croatia and Israel. Poland s position in the international ranking moved from 8th to 24th, providing that the countries are listed according to the growing percentage of 15-year-olds of both genders who smoke regularly. Conclusions: Decrease in the prevalence of smoking among Polish adolescents, observed from the beginning of this century, has been undoubtedly a success related to the implemented preventive measures. However, attention should be drawn to the strategies launched in countries which achieved better results than Poland, as well as to the reasons of less positive trends among Polish girls. Międzynarodowe badania HBSC (Health Behaviour in School-aged Children) pozwalają porównywać kierunki i tempo zmian szeregu wskaźników dotyczących zdrowia nastolatków. Celem pracy jest porównanie trendów międzynarodowych oraz przedstawienie, jak od 2002 roku zmieniała się pozycja Polski w rankingach dotyczących palenia tytoniu. Materiał i Metodyka: Badaniem objęto 30 krajów, dla których dostępne były dane z czterech rund badań HBSC ( ). Ogółem, zbadano w tych krajach 218,8 tysiąca 15-latków, w tym 7,3 tysiąca w Polsce. Dla każdego kraju oszacowano trendy liniowe regularnego palenia tytoniu (w każdym tygodniu lub codziennie), osobno dla obu płci. Wyniki: W badanym okresie odsetek 15-letnich chłopców regularnie palących tytoń zmniejszył się w Polsce z 26,2% do 15,5%, a odpowiedni odsetek dziewcząt z 17,2% do 14,7%. Oznacza to przeciętny roczny spadek o odpowiednio 0,88% u chłopców oraz o 0,24% u dziewcząt. W połączonej próbie międzynarodowej stwierdzono identyczne tempo zmian u chłopców, ale zdecydowanie szybsze niż w Polsce tempo spadku częstości regularnego palenia tytoniu przez dziewczęta (0,95% rocznie). Ogółem, najszybsze tempo zmian zanotowano na Ukrainie, w Niemczech i w Norwegii, a najwolniejsze w Grecji, Chorwacji i Izraelu. Pozycja Polski w rankingu międzynarodowym przesunęła się z 8 na 24 miejsce, jeśli uszeregujemy kraje według rosnącego odsetek 15-latków obojga płci palących regularnie tytoń. Wnioski: Obserwowany od początku tego wieku spadek częstości palenia tytoniu przez polską młodzież jest niewątpliwym sukcesem związanym z realizowanymi działaniami profilaktycznymi. Należy zwrócić jednak uwagę na strategie wdrażane w krajach, które osiągnęły szybsze niż Polska tempo spadku częstości palenia tytoniu oraz na przyczyny mniej korzystnych zmian u polskich dziewcząt. Przegląd Lekarski 2016 / 73 /

2 Introduction Reducing the frequency of tobacco smoking and its effects on health is currently a priority objective around the world [1]. As a result, numerous initiatives of a global reach are being launched and continued. One example might be the WHO Tobacco Free Initiative, followed by the Framework Convention on Tobacco Control (FCTC) and an implementation package (MPO- WER) [2]. One of the most recent documents published by the WHO in 2015, entitled Making tobacco the thing of the past, sets a realistic goal to completely eradicate the use of tobacco products [3]. The documents draws attention to the following areas of action: a stronger implementation of the FCTC; facing new challenges (presented by the appearance of alternative forms of tobacco use); and shaping social norms (including creating tobacco-free public space and further reducing the influence of the tobacco industry). Investigating the trends in tobacco smoking in various age groups and geographical areas is treated as an supporting measure. Regularly conducted epidemiological studies, which take into account biological, socio-economic and cultural determinants of tobacco smoking, have become the basis for planning, implementing and evaluating effectiveness at the international and national level. Apart from carrying out global surveys aimed at adults, the frequency of tobacco smoking in adolescents is also assessed. It is assumed that early tobacco initiation increases the risk of future addiction. An important source of information is provided by the HBSC (Health Behaviour in School-aged Children) - international studies conducted in Europe for the last 30 years in a growing number of countries [4]. Aside from many publications on the frequency and determinants of tobacco smoking [5,6], attempts have been made to evaluate the impact of introduced public health instruments in correlation with HBSC results [7,8]. To date, a series of studies on smoking trends have been published based on the HSBC data, which should be regularly updated [9,10]. From the perspective of a country, its changing position in international rankings should be observed. The rate of changes, slower than in other countries, may have cultural roots and may result from a less consistent implementation of preventive strategies. Poland s position in comparison with a greater number of countries, including the most recent HBSC 2014 data and long term changes in this position, has not been presented so far. The objective of the paper was to compare medium-term trends in tobacco smoking in adolescents from selected countries and to evaluate how Poland s position in international rankings had changed since Table I Changes in smoking prevalence in 15-year-old boys in Zmiany częstości palenia tytoniu przez chłopców 15-letnich w latach Material and Methods Anonymous surveys are conducted in schools during the same school year, according to the same protocol for all the countries [4]. It was decided that the end of a given school year would be the survey year. Thirty countries (European and Canada) were selected, those participated in all of the previous four rounds of the HBSC survey in The data relating to the United Kingdom includes England, Scotland and Wales, while data for Belgium comprise both the French- and the Flemish-speaking regions. In total, 218,759 people aged years (49% boys) including 7,289 from Poland, were surveyed during that period. The source of the data is the HBSC international data bank in Bergen (Norway). Minor differences (below 1%) among our own calculations and the graphs from international reports may result from rounding up and changing definitions of age groups [4,11-13]. The basic question about tobacco smoking is used in the HBSC survey in an unchanged form and reads: How often do you currently smoke tobacco? with the following response categories: every day, at least once a week but not every day, less frequently, I don t smoke. In compliance with the international reports, the indicator of weekly smoking was used as the basis, combining the first two categories of answers. Thus defined indicator takes into account adolescents who begin to move from the experimenting stage to more regular smoking [14]. In the statistical analysis for each country, the average annual rate of decrease in the frequency of weekly tobacco smoking was calculated separately for boys and girls. As a measure of that rate, a non- -standardized regression coefficient (β), was estimated based on the HBSC data from The significance of β and goodness of fit statistics (R-square) were presented. Results General frequency of tobacco smoking in 15-year-olds In the light of the data collected in the school year, the frequency of weekly tobacco smoking in 15-year-olds in the 30 analysed countries was between 3.9% in Norway to 51.7% in Greenland. The leading countries included Canada, Sweden and Denmark, while high indicators were noted in Croatia, Italy and Hungary (as well as Greenland). In Poland, tobacco was smoked regularly by 15.1% of the respondents, of which 9.8% smoked every day. In total, in a combined interna- Country Weekly smoking (%) Linear trend β* p R-sq Austria Belgium Canada Croatia Czechia Demark Estonia Finland France Germany Greece Greenland Hungary Ireland Israel Italy Latvia Lithuania Macedonia Netherlands Norway POLAND Portugal Russia Slovenia Spain Sweden Switzerland UK Ukraine Total * β unstandardized regression coefficient 686 J. Mazur et al.

3 tional sample, weekly tobacco smoking was admitted in this round of the HBSC survey by 12.0% respondents, of which 8.0% smoked every day. In the frequency of weekly smoking fell by 23.9% in the entire examined sample and by 21.5% in Poland. According to the international data, changes occurred in big steps; a significant decrease was noted twice: in and In Poland, the indicators began to reach a plateau around 2006, without a new drop in the last four years. As a result, Poland s position in the international ranking changed from 8th to 24th place (a lower position means greater intensity of regular smoking). The fact that Poland s position worsened in the last four years was influenced by an increase in the frequency of occasional (not every day) smoking. When analysing the international ranking according to the growing frequency of weekly tobacco smoking, two groups can be identified, in which the changes were significant: countries whose position moved in at least ten places up (deterioration): Greece, Poland, Italy, Croatia, Israel; Table II Changes in smoking prevalence in 15-year-old girls in Zmiany częstości palenia tytoniu przez dziewczęta 15-letnie w latach countries whose position moved in the same period at least ten placed down (improvement): Spain, Ukraine, Norway, Switzerland. A more in-depth analysis of the discussed trends requires taking into account the differences related to the gender of the respondents. It has to be emphasised that the frequency of smoking in boys and girls from 30 countries is identical as the average for the 42 countries included in the latest international report, which is proof that the analysed group is representative [4]. Changes in the frequency of smoking in boys Table I shows weekly smoking trends in 15-year-old boys from 30 countries. When comparing extreme time points (2002 and 2014) a drop can be noted in all the countries except for Croatia, Greece and Israel. Individual countries varied in terms of the rate of changes estimated by means of linear regression. In a combined international sample, the frequency of weekly smoking decreased annually by 0.88% on average. The biggest drop was noted in Ukraine, Germany and Estonia. In Poland, the rate of changes remained at an average level for the analysed group of countries. A linear fall Country Weekly smoking (%) Linear trend β* p R-sq Austria Belgium Canada Croatia Czechia Demark Estonia Finland France Germany Greece Greenland Hungary Ireland Israel Italy Latvia Lithuania Macedonia Netherlands Norway POLAND Portugal Russia Slovenia Spain Sweden Switzerland UK Ukraine Total * β unstandardized regression coefficient in rates (corroborated by the significance of the negative trend indicator) was found only in six countries, and in another seven countries was close to the significance level, with a very high trend adjustment (Tab. I). There are examples of countries in which the rate of the decrease in the frequency of tobacco smoking in boys was found to be much higher than in Poland despite similar indicators at the beginning of the analysed period (e.g. Czechia). Looking at the international rankings relating to boys, attention should be drawn to Poland s changing position. In Poland moved from the 19th to the 12th place, while its rank fell (to the 21st in 2014). Only in 2010 was the frequency of weekly smoking in boys in Poland lower than the global average. Changes in the frequency of smoking in girls Analogically, Table II shows weekly smoking trends in girls of the same age. A fall was noted in all the countries in the investigated period - the fastest occurred in Norway, Austria and Spain, while the slowest in Italy, Greece and Poland. In a combined international sample, the frequency of weekly smoking in girls fell on average by 0.95% year on year. In Poland, the rate of changes is significantly slower than the average for the analysed group of countries and from the one obtained in the national sample of male peers. The significance of a linear trend coefficient was identified in eight countries, while the result was close to the significance level in another four (Tab. II). Attention should be drawn also to countries starting from a position similar to that of Poland in 2002, which achieved a much faster decrease rate (e.g. Sweden). Poland s unfavourable position results not only from the low rate of decrease in the frequency of regular smoking in girls, but also from the change of its rank in the international ranking. In , Poland s position was favourable and stable (5th-6th place; countries ranked from the lowest to the biggest indicator). In 2014 there was a fall to the 23th position in that ranking. While in the first three research periods the Polish rates of smoking were significantly lower than the global average (by 4.2%-6.4%), in 2014 Poland exceeded this average value by 3.3%. In order to summarize the above, the rate of changes in weekly tobacco smoking in boys and girls from different countries (Fig. 1) could be compared. In the majority (two thirds) of countries, the rate of changes in boys is slower than in girls. Above the regression line there are countries in which the rate of changes in the frequency of smoking in girls is lower than expected based on analogical changes in boys. There are also countries with the most significant deviations from the estimated trend line. Poland and Norway can be found on two opposite ends. A slower rate of changes in girls is not just a Polish problem; it is noted also in Italy and in many countries of Eastern Europe. Przegląd Lekarski 2016 / 73 /

4 Figure 1 Correlation between average annual ( ) rate of change in weekly smoking among boys and girls. Korelacja średniego rocznego ( ) tempa zmian palenie tytoniu w każdym tygodniu przez chłopców i dziewczęta. Discussion it results from the conducted analyses that in (i.e. between the two most recent rounds of the HBsC survey) a significant fall in the frequency of smoking in 15-year-olds was identified in most countries. in Poland and in many countries of Eastern Europe a similar improvement was not found, which was related to the absence of the downward tendency in girls. according to Lopez s studies [15], this part of Europe is characterised by an earlier stage of epidemiological transformation and thus less positive trends in smoking among females. The presence of different patterns of changes was corroborated by previous studies by Hublet et al. based on the HBsC data obtained in 10 countries in already at that time Poland belonged to a group representing the least positive changes, along with Latvia, Hungary, austria and switzerland [9]. in the light of our analyses (Fig. 1) only the latter two countries managed to establish a permanent falling tendency also in girls. in interpreting the obtained results, attention should be drawn to the correlation between the trends and the public health measures. However, whether this kind of measures has an equal impact on young people and adults and whether they are equally effective for young people of both genders, remains a contentious issue [16]. The presented results prove that despite quite positive trends and a relatively low frequency of smoking, a country s position in comparison with the other countries may deteriorate. in the investigated period, Greece and Poland s position in the international ranking changed particularly negatively, while spain and Ukraine experienced the most positive change. in reports periodically published under the auspices of anti-cancer associations, the experts dealing with the legislative determinants of tobacco smoking draw attention to the extent to which individual countries implement recommendations regarding anti-tobacco preventive measures. according to the newest report, Poland has a stable but low (19th-20th) position in a ranking of 34 countries, with 42 points out of 100 possible [17]. The basis of the assessment was the Tobacco Control scale (TCs), which includes six key anti- -tobacco strategies: tobacco price, smoke- -free laws, mass-media campaigns, advertising bans, warning labels, and cessation support [18]. in the qualitative assessment, the main accusation towards Poland was that it protects the interests of the tobacco industry. attention was drawn to the impediments in implementing the new Directive of the European Parliament relating to tobacco products (2014/40/EU of 3 april 2014). one should, however, bear in mind that Poland was one of the initiators of the FCTC; the signs of progress include the currently implemented and regularly evaluated Programme for Reducing the Health Effects of Tobacco smoking [19]. Ukraine received a positive assessment (10th place) in the cited TCs. in the light of our analyses, it achieved a very fast rate of changes. in some countries which came top in the TCs ranking (e.g. in the United kingdom and Norway) we observed a very fast rate of decrease in the frequency of regular smoking in girls, who form the critical group from Poland s perspective. Earlier studies based on the HBsC data from 2006 suggest, however, that not all domains of anti-tobacco policy specified in the TCs are effective for adolescents, and even if they do have some effect, it is on boys [7]. For example, the impact was shown of increased cigarette prices on reducing the frequency of smoking in boys, regardless of their socioeconomic status. Moreover, in the light of Us studies, restricting smoking in public spaces also affects only boys, which is additionally more visible in affluent families [20]. From the perspective of preventive measures aimed at girls and young women, the design of packaging seems to be significant. Reducing the attractiveness of cigarette packaging should curtail the interest of girls in tobacco products, thus making marketing more difficult [21,22]. in interpreting the global trends discussed here, attention should be drawn (in compliance with the FCTC) also to the distortion caused by young people s increasingly frequent use of non-combustible tobacco products, including aerosolized products (electronic cigarettes) and smokeless tobacco (chew, dip, snuff, snus or other dissolvable products, which deliver nicotine via oral mucosal absorption). The fall in the frequency of tobacco smoking in young people observed in some countries could be somewhat caused by their use of substitute products which negatively affect health. Concurrent use of many tobacco products confer greater tobacco toxin exposure and risks [23]. The increasing popularity of such products is due to the absence of regulations prohibiting their use in public places [24]. Cultural patterns allowing their equally frequent use by girls may also influence the trends which are specific for both genders. in the light of our research, Poland and Norway reached a similar rate of changes in the frequency of smoking in boys, while experiencing extremely divergent results for the population of girls (Fig. 1). as emphasised by an independent study analysing long-term trends in those two countries, the significant drop in the frequency of smoking in Norwegian adolescents may have been influenced by a more frequent use of smokeless tobacco (snus), the sales of which is prohibited across the EU [25]. The literature review revealed that it is particularly popular in the Nordic countries [26]. Due to the increased interest in other tobacco products, attention should be drawn to the fact that it is possible that this problem might increase among young people in Poland, and that it is necessary to modify the questions asked in next surveys. Conclusions Having analysed the trends in regular smoking among 15-year-olds, it was found that in Poland s position in the ranking of 30 countries experienced a negative change from 8th to 24th place. it is a worrying that the prevalence of smoking as well as less positive tendencies of changes in adolescent girls reached a plateau after a slower (compared to boys) rate of changes in the frequency of tobacco smoking in 15-year-old girls is a problem occurring in the countries of Eastern Europe and in italy. attention should be drawn to the strategies implemented in countries which achieved a faster decrease in tobacco smoking. Furthermore, methods to influence the behaviour of girls should be searched for. Acknowledgements Professor Candace Currie, University of st. andrews (scotland), was the international Coordinator for the 2002, 2006, 2010, and 2014 surveys, and Professor 688 J. Mazur et al.

5 Oddrun Samdal, University of Bergen (Norway) was the International Data Bank Manager. The list of current and previous Principal Investigators in all member countries could be found in international reports and at the website ( References 1. Bilano V, Gilmour S, Moffiet T, d Espaignet ET, Stevens GA. et al: Global trends and projections for tobacco use, : an analysis of smoking indicators from the WHO Comprehensive Information Systems for Tobacco Control. Lancet. 2015; 385: Kaleta D, Kozieł A, Miśkiewicz P: MPOWER - strategia na rzecz walki ze światową epidemią używania tytoniu. Med Pr. 2009; 60: WHO. Making tobacco a thing of the past. Roadmap of actions to strengthen implementation of the WHO Framework Convention on Tobacco Control in the European Region WHO Regional Office for Europe. Copenhagen euro.who.int/ data/assets/pdf_file/0005/297563/ WHO-Roadmap-report-tobacco-control en. pdf. 4. Inchley J, Currie D, Young T, Samdal O, Torsheim T. et al: Growing up unequal: gender and socioeconomic differences in young people s health and well-being. Health Behaviour in School-aged Children (HBSC) study: international report from the 2013/2014 survey. Copenhagen, WHO Regional Office for Europe, 2016 (Health Policy for Children and Adolescents, No. 7). 5. Moor I, Rathmann K, Lenzi M, Pförtner TK, Nagelhout GE. et al: Socioeconomic inequalities in adolescent smoking across 35 countries: a multilevel analysis of the role of family, school and peers. Eur J Public Health. 2015; 25: Rasmussen M, Damsgaard MT, Holstein BE, Poulsen LH, Due P: School connectedness and daily smoking among boys and girls: the influence of parental smoking norms. Eur J Public Health. 2005; 15: Pförtner TK, Hublet A, Schnohr CW, Rathmann K, Moor I. et al: Socioeconomic inequalities in the impact of tobacco control policies on adolescent smoking. A multilevel study in 29 European countries. Addict Behav. 2016; 53: Schnohr CW, Kreiner S, Rasmussen M, Due P, Currie C. et al: The role of national policies intended to regulate adolescent smoking in explaining the prevalence of daily smoking: a study of adolescents from 27 European countries. Addiction. 2008; 103: Hublet A, De Bacquer D, Valimaa R, Godeau E, Schmid H. et al: Smoking trends among adolescents from 1990 to 2002 in ten European countries and Canada. BMC Public Health Nov 10; 6: Woynarowska B, Mazur J: Zmiany w używaniu substancji psychoaktywnych przez młodzież w wieku lat w Polsce w latach Probl Hig Epidemiol. 2007; 88: Currie C, Roberts C, Morgan A, Smith R, Settertobulte W. et al: Young People s Health in Context: international report from the HBSC 2001/02 survey, (Health Policy for Children and Adolescents, No.4). WHO Regional Office for Europe Copenhagen, Currie C, Nic Gabhainn S, Godeau E, Roberts C, Smith R. et al: Inequalities in young people s health: HBSC international report from the 2005/06 Survey. Health Policy for Children and Adolescents, No. 5, WHO Regional Office for Europe, Copenhagen, Denmark, Currie C. Zanotti C, Morgan A, Currie D, de Looze M. et al: Social determinants of health and well-being among young people. Health Behaviour in School-aged Children (HBSC) study: international report from the 2009/2010 survey. Copenhagen, WHO Regional Office for Europe, 2012 (Health Policy for Children and Adolescents, No. 6). 14. Charrier L, Berchialla P, Galeone D, Spizzichino L, Borraccino A. et al: Smoking habits among Italian adolescents: what has changed in the last decade? Biomed Res Int. 2014; 2014: Lopez AD, Collishaw NE, Piha T: A descriptive model of the cigarette epidemic in developed countries. Tob Control. 1994; 3: Amos A, Greaves L, Nichter M, Bloch M: Women and tobacco: a call for including gender in tobacco control research, policy and practice. Tob Control. 2012; 21: Joossens L, Raw M: The Tobacco Control Scale 2013 in Europe. Association of European Cancer Leagues. Brüssel, Bosdriesz JR, Willemsen MC, Stronks K, Kunst AE: Tobacco control policy and socio-economic inequalities in smoking in 27 European countries. Drug Alcohol Depend. 2016; 165: GIS Sprawozdanie z realizacji programu ograniczenia zdrowotnych następstw palenia tytoniu w Polsce w GIS, Warszawa, gov.pl/images/sprawozdanie_poznpt_2014.pdf. 20. Hawkins SS, Bach N, Baum CF: Impact of Tobacco Control Policies on Adolescent Smoking. J Adolesc Health. 2016; 58: Lund I, Scheffels J: Young smokers and non-smokers perceptions of typical users of plain vs. branded cigarette packs: a between-subjects experimental survey. BMC Public Health. 2013; 13: Balwicki Ł, Stokłosa M, Balwicka-Szczyrba M, Tomczak W: Tobacco industry interference with tobacco control policies in Poland: legal aspects and industry practices. Tob Control (online first), doi: /tobaccocontrol Hatsukami DK, Lemmonds C, Tomar SL: Smokeless tobacco use: harm reduction or induction approach? Prev Med. 2004; 38: Mejia AB, Ling PM: Tobacco industry consumer research on smokeless tobacco users and product development. Am J Publ Health. 2010; 100: Aarø LA, Mazur J, Zatonski W, Samdal O: Trends in smoking in Polish and Norwegian youth J Health Inequal 2016; 2: Øverland S, Hetland J, Aarø LA: Relative harm of snus and cigarettes: what do Norwegian adolescents say? Tob Control. 2008; 17: Przegląd Lekarski 2016 / 73 /

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