Smoking habit of children and adolescents: an overview

Introduction

Smoking is one of the largest public health problems since it is responsible for six million deaths annually worldwide (1). The leading causes of death are cancer (lung cancer being the most common), ischemic heart disease, chronic obstructive pulmonary disease (COPD) and stroke (2).

The majority of smokers start smoking at an early age. In the US 83% of smokers begin smoking before the age of 18 (3). Cigarette smoking in childhood and adolescence leads to short and long-term health problems. First of all, lungs are impaired and respiratory symptoms occur. Lung function and lung growth are reduced. Young people who smoke experience shortness of breath, lower physical endurance and sometimes wheezing. These patients are often mistreated for asthma. Moreover, smoking at a young age increases the risk for lung cancer and other smoking-related cancers such as oropharyngeal, esophageal and bladder’s. Smoking in adulthood is a known risk for heart disease and stroke. Early indications of these diseases, such as arteries’ atherosclerosis, have been detected at young smokers. Lastly, smoking among young has been shown to increase the risk for marijuana use or other drugs as well as the risk to be engaged in fighting and other risky behaviors (4).

Many children and adolescents initiate smoking annually making the existing smoking epidemic worse. Starting smoking at a young age bears great danger. Young people are more susceptible to risks associated with smoking. Growth has not been completed and the harmful components of tobacco impair the organs of the young. It has been indicated that the younger the age the stronger the addiction. Moreover, the longer the organs are been exposed to smoke the greater the danger for the appearance of smoking related diseases such as COPD or lung cancer (4). Purpose of this study was to present current data about the extent of tobacco use by children and adolescents, the situations facilitating the initiation of smoking at an early age and the available policies aiming to prevent early age smoking and to promote smoking cessation in non-adult individuals.

Methods

Data were collected from the international PubMed database as well as Google Scholar. PubMed and Google Scholar were searched for articles referred to smoking in childhood and adolescence and its effects, for causes of initiation and for interventions/programs that aim to prevention or cessation of smoking in young.

Results

Extent of tobacco use in childhood and adolescence

Smoking among children and adolescents constitutes an international concern because of the harmful consequences and the addiction that smoking causes (5). The majority of smokers start smoking at an early age. In the US 83% of smokers begin smoking before the age of 18. In middle class American families children start smoking at the mean age of 8.5 with a range between 6 and 11 years old (3). In the US, in 2006, 6.8% of students aged 11–14 were smokers (6). In 2011, among 13–15-year-old boys the smoking prevalence was 7–15.9% (2). In 2013, 22.9% of high school students reported the use of one product of smoke, while 12.6% reported the use of two or more products of smoke (7). In Canada during 2004–2005, 1.7% of students aged 10–15 were smokers, while in 2011, smokers constituted 7–15% at ages 13 to 15 (3,6). At the same year [2011] similar proportion of boys (7–15.9%) at the age of 13–15 were smokers in the US, Germany, Turkey, Greece and Serbia. However, in the UK in the last two decades a decline in the smoking rate was observed. In 2011 the smoking prevalence was about 7% for both sexes (2).

Among the countries of the world there are great differences in the smoking prevalence between men and women. Generally more boys start smoking than girls worldwide, although in many west European countries the numbers are about the same for both sexes (2,8). In at least 25 countries the percentage of girls who smoke is higher than that of boys. This may indicate that in the future the number of women that smoke may become even larger (9). On the other hand, the prevalence among girls and boys at the ages of 13–15 does not differ a lot. However, after the age of 18 the smoking prevalence begins to differ (2,10). Such an example is the difference in smoking prevalence among male and female college students; among female college students this smoking prevalence fluctuation is higher (11).

Smoking becomes more systematic as a child grows older. In the US they smoke less frequent at the ages 13–15 (6.8%) than 15–18 (19.8%) (6,12). During their college studies it is possible that college students will become systematic smokers (13,14). In 2000, 45.7% of American college students aged 18–24 smoked and one third of them reported to be regular smokers (15). During their college studies it is possible that students become dependent from nicotine for the rest of their life (15,16). However, during this time college students will also start their smoking cessation efforts (13). The highest smoking prevalence among college students has been detected in Greece, Italia, Portugal and Spain (11).

Situations facilitating smoking initiation at an early age

The reason why a child or an adolescent begins smoking varies and differs by gender, race and educational level (17). The exact age of beginning smoking also varies and is not the same in all populations (18). The risk of smoking initiation can be higher due to family and social causes in order to participate more easily in social groups; due to boredom or stress during their military service or during their stay in college; also, due to social beliefs that promote smoking (17).

Family and socioeconomic status (SES)

For students whose parents smoke is easier to start smoking (19,20). Until now it was believed that parents could do little to prevent their children from smoking initiation. If an adolescent’s parent smokes, the adolescent himself also may become a smoker but also if an adolescent’s parent has in the past quit smoking, himself won’t start smoking so easily. In the US, adolescents who knew that both their parents would be opposed to smoking would not initiate smoking; also, parents themselves with their acts can prevent their children from initiating smoking (21-23).

A big concern is how the SES can affect children and adolescents in starting smoking. Worldwide the results were controversial. However for a young adolescent “Low parental socioeconomic status” (LSES parental) is considered to be associated with high risk of initiating smoking (24-29). Teenagers that face problems in their social or family life are more likely to initiate smoking. This may be due to personal or psychological characteristics that lead them finally to initiate smoking. In the US from 2005 to 2007 adolescents between 18 and 23 years old had greater risk of initiating smoking. The smoking behaviour of children and adolescents from LSES families was the same in France and Holland (25,27). On the other hand, children and adolescents that came from a higher economical background had more chances to initiate use of drugs or cannabis (30). In addition, the effect that can have a smoker parent, brother, sister or friend on a child’s or an adolescent’s smoking initiation is higher in LSES families (26-28).

Substance abuse

Alcohol abuse and drugs have been related with smoking initiation. This relation can be bilateral; thus, a young smoker can easily become a social drinker (17,31,32).

Psychological problems

There is a true connection between anxiety, depression and smoking. Smoking exists in most people suffering from stress, anxiety and depression. People suffering from anxiety and depression have many possibilities of smoking initiation after suffering some stressful events. Moreover, smokers with depression and anxiety can easily become addicted to smoking. Tobacco use may also later lead to stressful actions (33-35).

However, it is a controversial issue whether the early initiation of smoking causes early stress or depression (36). Smoker college students have shown much more depressing symptoms than the non-smokers. Systematic college smokers can also show more frequently depression symptoms than non-smokers or non-systematic college smokers (37). In addition, adolescents who show depression signs and are regular or non-regular smokers have a higher chance of addiction in nicotine (38,39).

Social environment

Acceptance from friends and the other gender plays a significant role in smoking initiation in childhood and adolescence. A parent, brother, close relative or a friend who smoke will affect a child or an adolescent in his smoking initiation (40-42). A parent who smokes may affect his child in his smoking initiation, but in later adolescence he will not. As the young boy grows it will be more affected in initiating smoking by his close friends than his parents’ smoking habits. In American colleges both low income students and high income students were affected by their college friends in initiating smoking (43,44).

Army

The newly recruited soldiers are also more vulnerable in smoking initiation (45). Soldiers in active duty and in combat zones will smoke two to three times more and have greater chance to start smoking (45,46). Many newly recruited soldiers start smoking when they start cooperating with their older colleagues. This could be explained by the fact that smoke is an old part of the military culture as a measure of pleasure, comfort and as a mean of exchange (47-49). So, smoking may lead a soldier to feel equal with his older colleagues (50). However, in the armies of the UK, France and the US the smoking rate was equal to that of their society (45,51).

Cinema movies

Smoking initiation in children and adolescents is also influenced by the promotion of smoking products in cinema movies. Despite the existence of limitations on smoking products in cinema movies, the placement of smoking products in movies still exists and affects children and adolescents (52-55). Many movie stars smoke in popular movies and the star is often linked with a cigarette brand (56,57). Negative results of smoking are also never shown in the movies and young men see only a positive aspect of smoking. As a result, favourable conditions for smoking initiation are created (54); a young man smoking is presented as more masculine, so young people are intrigued to start smoking.

Internet

An aspect of how the internet can influence young people to initiate smoking has not been studied briefly. In 2001 internet’s effect raised smoking initiation about 6.9% and in 2005 that rate doubled. This influence of internet on smoking initiation is mostly seen through internet advertisements, e-mails and special web sites. There, children and adolescents can find cheap markets that sell cigarettes. Because the internet market and its effect on smoking initiation is not so clearly understood more research should be made to this direction (58-61).

Policies aiming to prevent early age smoking and to promote smoking cessation in non-adult individuals

Because of the seriousness of the smoking problem in children and adolescents many prevention and cessation programs have been proposed and implied. These efforts focus on interventions in school or in the community. Public education is also targeted through the mass media. Interventions are also based on restriction of cigarette advertisements, on raising cigarette taxes or even direct restriction of selling tobacco to children and adolescents. Moreover, many smoking cessation programs aim to individualized treatment to the young smoker (13,62,63).

Interventions based on school-education

School is a place where a great number of young smokers exist. For this reason, school is an ideal place where smoking prevention and cessation programs could be practised; children can be informed about the harmful habit of smoking in order to prevent them from initiating and proper smoking cessation protocols could be promoted. In the same direction, teachers could also assist by taking proper training with special programs in order to convince students to abstain from smoking (62-66). However, the success of these anti-smoking programs that are based on schools is questioned (67,68). These school programs in order to be more successful should be combined with anti-smoking initiatives based on the community and the society. The combination of these initiatives may have as a result the cessation of smoking in 35–40% of young people (69,70). Moreover, the prevention and smoking cessation programs can be more effective if they are focused on specific student subgroups; aiming to each gender separately and assessing the educational direction (71). Low educational level is associated with a higher risk of smoking initiation in children and adolescents in the US and in North Europe (27,72-74). Lately the same risk exists also in South Europe (74). In Germany and in India, students with low educational level are at risk of becoming systematic smokers and of quitting smoking with great difficulty (75). For this reason, health care specialists who are dealing with anti-smoking programs should give greater concern to this population group (74-76).

Interventions based on society

Many social antismoking efforts have been developed the last thirty years that aim to children and adolescents. These efforts have been made from the family, the community and the mass media. The support of each community to these programs is clearly understandable that is essential (62,64,69,77). However, the results have been controversial. It seems that in order to be effective these programs should be combined with school anti-smoking programs or at least to be based at the same time on school (77).

Interventions targeted on each person

The design of the smoking cessation efforts should also be based on the smoker himself, which is often forgotten by the antismoking policy designers. In this way, the treatment of each child or adolescent should be based on individualized social standards and needs as well as on the difficulties that he/she faces. In this procedure psychological support or pharmaceutical therapy from specialists should also be considered when it is needed. In all circumstances young smoker should be given all the attention needed by a specialist (64,78,79).

Interventions based on the mass media or the public education

Worldwide, the mass media have been used intensively for the public briefing about the dangers of smoking, because a great proportion of children and adolescents make an intense use of them. Despite the importance of the information these means of intervention provide, the results that they have had are not so enthusiastic (62,77). In the US, for example, the radio and the television have been used for the information of the children and adolescents, but their results did not satisfy the scientific community. It has been observed that these informative programs if they are not combined with anti-smoking programs in the school environment are not so effective (62,77,80). In addition, the effectiveness of the information campaigns that are associated with the traditional mass media has to be reconsidered. Many adolescents do not use any more television for their information and many also avoid commercial and informative messages when they do watch. For this reason, the designers of the anti-smoking programs should consider these aspects when they design these programs (80).

Interventions that restrict the access of young men to tobacco products

The promotion of cigarettes through advertisement and free disposal from smoking companies and generally the accessibility of cigarettes and smoking products by young men and children have been targeted from the anti-smoking programs because they can easily influence young people to initiate smoking (62,81-84). Harmfulness of smoking should always be reminded in every smoking commercial (84). However, the occasional young smokers usually become systematic smokers when they have access in buying cigarettes (85). For this reason, many anti-smoking programs have as a target to restrict access of children and adolescents to cigarettes and tobacco products. In addition, the controls in smoking selling places should be more strict and frequent. This may lead to further restriction on young people buying cigarettes and smoking products (62). The State of Massachusetts has taken additional measures for smoking products’ disposal in places where they are sold. As a result, control was also primed by the central government and became more intense and effective (85,86).

Increase cigarette taxes

The general view that exists in many states of the world is that the increase of taxes in cigarettes can decrease the rate of smoking at children and adolescents or the rate of their smoking initiation. The increase of cigarette taxes can also lead many smokers to reduce their smoking frequency. Many modern states have been undertaking these measures, having often some success. However, the effect of these measures can be controversial (62,87,88). In New Zealand, these measures had a positive effect on decreasing the smoking rate at young people (89). Positive were also the results in the US, where relatively to race the biggest decrease was observed at black smokers (88). However the increase of cigarette prices is usually small, about one dollar/euro rise, and its effectiveness is often questioned (62); regarding mainly the long-term smokers (90).

Conclusions

In summary, tobacco use by children and adolescents is a significant global health problem. The differences of smoking habit among children and adolescents can be based on the geographical, national, financial and social differences of each state; also on the family, school and state’s policy against smoking; as well as on the gender and the exact age (91-96). Since tobacco related diseases have a high health cost, antismoking cessation policies should be a priority in the health agenda. The constant briefing of young people about smoking’s harmful consequences in order to prevent them from starting as well as about the cessation programs is necessary. Many young people are not even aware of the existence of such programs while it has been observed that high school students show no interest in participating in them. Health professionals should act by informing thoroughly young students, parents and teachers in order to prevent smoking or help young people cease this harmful addiction (62).

Acknowledgements

None.

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

References

1. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2011. Geneva: World Health Organization, 2011.
2. Eriksen M, Mackay J, Ross H. The tobacco atlas. 4th ed. Atlanta, GA: American Cancer Society; New York, NY: World Lung Foundation; 2012. Available online: http://www.tobaccoatlas.org
3. Ahmed NU, Ahmed NS, Semenya KA, et al. Prevalence and correlates of initiation of smoking behavior among preteen black and white children. J Natl Med Assoc 2004;96:200-8. [PubMed]
4. CDC. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, 1994.
5. Jason LA, Berk M, Schnopp-Wyatt DL, et al. Effects of enforcement of youth access laws on smoking prevalence. Am J Community Psychol 1999;27:143-60. [Crossref] [PubMed]
6. Richardson L, Hemsing N, Greaves L, et al. Preventing smoking in young People: a systematic review of the impact of access interventions. Int J Environ Res Public Health 2009;6:1485-514. [Crossref] [PubMed]
7. Arrazola RA, Neff LJ, Kennedy SM, et al. Tobacco use among middle and high school students--United States, 2013. MMWR Morb Mortal Wkly Rep 2014;63:1021-6. [PubMed]
8. Zatoński W, Przewoźniak K, Sulkowska U, et al. Tobacco smoking in countries of the European Union. Ann Agric Environ Med 2012;19:181-92. [PubMed]
9. Pirie PL, Murray DM, Luepker RV. Gender differences in cigarette smoking and quitting in a cohort of young adults. Am J Public Health 1991;81:324-7. [Crossref] [PubMed]
10. Sinha DN, Palipudi KM, Rolle I, et al. Tobacco use among youth and adults in member countries of South-East Asia region: review of findings from surveys under the Global Tobacco Surveillance System. Indian J Public Health 2011;55:169-76. [Crossref] [PubMed]
11. Steptoe A, Wardle J, Cui W, et al. An international comparison of tobacco smoking, beliefs and risk awareness in university students from 23 countries. Addiction 2002;97:1561-71. [Crossref] [PubMed]
12. ONS. Statistics on smoking: England 2006. ONS; Pittsburgh, PA, USA, 2006.
13. Wechsler H, Rigotti NA, Gledhill-Hoyt J, et al. Increased levels of cigarette use among college students: a cause for National concern. JAMA 1998;280:1673-8. [Crossref] [PubMed]
14. Rigotti NA, Lee JE, Wechsler H. US college students' use of tobacco products: results of a National survey. JAMA 2000;284:699-705. [Crossref] [PubMed]
15. Rachiotis G, Muula AS, Rudatsikira E, et al. Factors associated with adolescent cigarette smoking in Greece: results from a cross sectional study (GYTS Study). BMC Public Health 2008;8:313. [Crossref] [PubMed]
16. Thompson B, Coronado G, Chen L, et al. Prevalence and characteristics of smokers at 30 Pacific Northwest colleges and universities. Nicotine Tob Res 2007;9:429-38. [Crossref] [PubMed]
17. Freedman KS, Nelson NM, Feldman LL. Smoking initiation among young adults in the United States and Canada, 1998-2010: a systematic review. Prev Chronic Dis 2012;9:E05. [PubMed]
18. Bernat DH, Klein EG, Forster JL. Smoking initiation during young adulthood: a longitudinal study of a population-based cohort. J Adolesc Health 2012;51:497-502. [Crossref] [PubMed]
19. Song AV, Glantz SA, Halpern-Felsher BL. Perceptions of second-hand smoke risks predict future adolescent smoking initiation. J Adolesc Health 2009;45:618-25. [Crossref] [PubMed]
20. Gilman SE, Rende R, Boergers J, et al. Parental smoking and adolescent smoking initiation: an intergenerational perspective on tobacco control. Pediatrics 2009;123:e274-81. [Crossref] [PubMed]
21. Sargent JD, Dalton M. Does parental disapproval of smoking prevent adolescents from becoming established smokers? Pediatrics 2001;108:1256-62. [Crossref] [PubMed]
22. Nilsson M, Weinehall L, Bergström E, et al. Adolescent's perceptions and expectations of parental action on children's smoking and snus use; national cross sectional data from three decades. BMC Public Health 2009;9:74. [Crossref] [PubMed]
23. den Exter Blokland EA, Engels RC, Hale WW 3rd, et al. Lifetime parental smoking history and cessation and early adolescent smoking behavior. Prev Med 2004;38:359-68. [Crossref] [PubMed]
24. Soteriades ES, Difranza JR. Parent's socioeconomic status, adolescents' disposable income, and adolescents' smoking status in Massachusetts. Am J Public Health 2003;93:1155-60. [Crossref] [PubMed]
25. Redonnet B, Chollet A, Fombonne E, et al. Tobacco, alcohol, cannabis and other illegal drug use among young adults: the socioeconomic context. Drug Alcohol Depend 2012;121:231-9. [Crossref] [PubMed]
26. Giesinger I, Goldblatt P, Howden-Chapman P, et al. Association of socioeconomic position with smoking and mortality: the contribution of early Life circumstances in the 1946 birth cohort. J Epidemiol Community Health 2014;68:275-9. [Crossref] [PubMed]
27. Cremers HP, Oenema A, Mercken L, et al. Explaining socio-economic differences in intention to smoke among primary school children. BMC Public Health 2014;14:191. [Crossref] [PubMed]
28. Green G, Macintyre S, West P, et al. Like parent like child? Associations between drinking and smoking behaviour of parents and their children. Br J Addict 1991;86:745-58. [Crossref] [PubMed]
29. Thorlindsson T, Vilhjalmsson R. Factors related to cigarette smoking and alcohol use among adolescents. Adolescence 1991;26:399-418. [PubMed]
30. Patrick ME, Wightman P, Schoeni RF, et al. Socioeconomic status and substance use among young adults: a comparison across constructs and drugs. J Stud Alcohol Drugs 2012;73:772-82. [Crossref] [PubMed]
31. Koopmans JR, Van Doornen LJ, Boomsma DI. Association between alcohol use and smoking in adolescent and young adult twins: a bivariate genetic analysis. Alcohol Clin Exp Res 1997;21:537-46. [PubMed]
32. Reed MB, Mccabe C, Lange JE, et al. The relationship between alcohol consumption and past-year smoking initiation in a sample of undergraduates. Am J Drug Alcohol Abuse 2010;36:202-7. [Crossref] [PubMed]
33. Patton GC, Hibbert M, Rosier MJ, et al. Is smoking associated with depression and anxiety in teenagers? Am J Public Health 1996;86:225-30. [Crossref] [PubMed]
34. Tobias M, Templeton R, Collings S. How much do mental disorders contribute to New Zealand's tobacco epidemic? Tob Control 2008;17:347-50. [Crossref] [PubMed]
35. Morissette SB, Tull MT, Gulliver SB, et al. Anxiety, anxiety disorders, tobacco use, and nicotine: a critical review of interrelationships. Psychol Bull 2007;133:245-72. [Crossref] [PubMed]
36. Johnson JG, Cohen P, Pine DS, et al. Association between cigarette smoking and anxiety disorders during adolescence and early adulthood. JAMA 2000;284:2348-51. [Crossref] [PubMed]
37. Dudas RB, Hans K, Barabas K. Anxiety, depression and smoking in schoolchildren--implications for smoking prevention. J R Soc Promot Health 2005;125:87-92. [Crossref] [PubMed]
38. McKenzie M, Olsson CA, Jorm AF, et al. Association of adolescent symptoms of depression and anxiety with daily smoking and nicotine dependence in young adulthood: findings from a 10-year longitudinal study. Addiction 2010;105:1652-9. [Crossref] [PubMed]
39. Patton GC, Carlin JB, Coffey C, et al. Depression, anxiety, and smoking initiation: a prospective study over 3 years. Am J Public Health 1998;88:1518-22. [Crossref] [PubMed]
40. Etcheverry PE, Agnew CR. Romantic partner and friend influences on young adult cigarette smoking: comparing close others' smoking and injunctive norms over time. Psychol Addict Behav 2008;22:313-25. [Crossref] [PubMed]
41. Etcheverry PE, Agnew CR. Similarity in cigarette smoking attracts: a prospective study of romantic partner selection by own smoking and smoker prototypes. Psychol Addict Behav 2009;23:632-43. [Crossref] [PubMed]
42. Bricker JB, Peterson AV, Robyn Andersen M, et al. Close friends', parents', and older siblings' smoking: reevaluating their influence on children's smoking. Nicotine Tob Res 2006;8:217-26. [Crossref] [PubMed]
43. Solberg LI, Asche SE, Boyle R, et al. Smoking and cessation behaviors among young adults of various educational backgrounds 2007;97:1421-6.
44. Almutairi KM. Smoking among Saudi students: a review of risk factors and early intentions of smoking. J Community Health 2014;39:901-7. [Crossref] [PubMed]
45. Mayet A, Marimoutou C, Esvan M, et al. Is serving in the armed forces associated with tobacco or cannabis initiation? A study of onset sequences before and after joining the French armed forces. Addict Behav 2013;38:2437-44. [Crossref] [PubMed]
46. Chisick MC, Poindexter FR, York AK. Comparing tobacco use among incoming recruits and military personnel on active duty in the United States. Tob Control 1998;7:236-40. [Crossref] [PubMed]
47. Hoffman KM, Haddock CK, Poston WS, et al. A formative examination of messages that discourage tobacco use among Junior enlisted members of the United States military. Nicotine Tob Res 2008;10:653-61. [Crossref] [PubMed]
48. Nelson JP, Pederson LL. Military tobacco use: a synthesis of the literature on prevalence, factors related to use, and cessation interventions. Nicotine Tob Res 2008;10:775-90. [Crossref] [PubMed]
49. de Silva VA, Jayasekera NE, Hanwella R. Smoking among troops deployed in combat areas and its association with combat exposure among navy personnel in Sri Lanka. Subst Abuse Treat Prev Policy 2012;7:27. [Crossref] [PubMed]
50. Green KJ, Hunter CM, Bray RM, et al. Peer and role model influences for cigarette smoking in a young adult military population. Nicotine Tob Res 2008;10:1533-41. [Crossref] [PubMed]
51. Bernard JG, Nauroy J, Bizeau JM, et al. Tobacco addiction of the young French male and his military service (author's transl). Rev Epidemiol Sante Publique 1980;28:413-21. [PubMed]
52. Sargent JD, Dalton MA, Beach ML, et al. Viewing tobacco use in movies: does it shape attitudes that mediate adolescent smoking? Am J Prev Med 2002;22:137-45. [Crossref] [PubMed]
53. Charlesworth A, Glantz SA. Tobacco and the movie industry. Clin Occup Environ Med 2006;5:73-84. ix. [PubMed]
54. Charlesworth A, Glantz SA. Smoking in the movies increases adolescent smoking: a review. Pediatrics 2005;116:1516-28. [Crossref] [PubMed]
55. Sargent JD. Smoking in movies: impact on adolescent smoking. Adolesc Med Clin 2005;16:345-70. ix. [Crossref] [PubMed]
56. Distefan JM, Pierce JP, Gilpin EA. Do Favorite Movie Stars Influence Adolescent Smoking Initiation? Am J Public Health 2004;94:1239-44. [Crossref] [PubMed]
57. Waylen AE, Leary SD, Ness AR, et al. Cross-sectional association between smoking depictions in films and adolescent tobacco use nested in a British cohort study. Thorax 2011;66:856-61. [Crossref] [PubMed]
58. Forsyth SR, Kennedy C, Malone RE. The effect of the Internet on teen and young adult tobacco use: a literature review. J Pediatr Health Care 2013;27:367-76. [Crossref] [PubMed]
59. Hrywna M, Delnevo CD, Lewis MJ. Adult recall of tobacco advertising on the Internet. Nicotine Tob Res 2007;9:1103-7. [Crossref] [PubMed]
60. Hrywna M, Delnevo CD, Staniewska D. Prevalence and correlates of internet cigarette purchasing among adult smokers in New Jersey. Tob Control 2004;13:296-300. [Crossref] [PubMed]
61. Unger JB, Rohrbach LA, Ribisl KM. Are adolescents attempting to buy cigarettes on the Internet? Tob Control 2001;10:360-3. [Crossref] [PubMed]
62. Lantz PM, Jacobson PD, Warner KE, et al. Investing in youth tobacco control: a review of smoking prevention and control strategies. Tob Control 2000;9:47-63. [Crossref] [PubMed]
63. Thomas R, Perera R. School-based programmes for preventing smoking. Cochrane Database Syst Rev 2006.CD001293. [PubMed]
64. Karpinski JP, Timpe EM, Lubsch L. Smoking cessation treatment for adolescents. J Pediatr Pharmacol Ther 2010;15:249-63. [PubMed]
65. Poulsen LH, Osler M, Roberts C, et al. Exposure to teachers smoking and adolescent smoking behaviour: analysis of cross sectional data from Denmark. Tob Control 2002;11:246-51. [Crossref] [PubMed]
66. Paek HJ, Hove T, Oh HJ. Multilevel analysis of the impact of school-level tobacco policies on adolescent smoking: the case of Michigan. J Sch Health 2013;83:679-89. [Crossref] [PubMed]
67. Wiehe SE, Garrison MM, Christakis DA, et al. A systematic review of school-based smoking prevention trials with long-term follow-up. J Adolesc Health 2005;36:162-9. [Crossref] [PubMed]
68. Thomas RE, McLellan J, Perera R. School-based programmes for preventing smoking. Cochrane Database Syst Rev 2013.CD001293. [PubMed]
69. Flay BR. School-based smoking prevention programs with the promise of long-term effects. Tob Induc Dis 2009;5:6. [Crossref] [PubMed]
70. Flay BR. The promise of long-term effectiveness of school-based smoking prevention programs: a critical review of reviews. Tob Induc Dis 2009;5:7. [Crossref] [PubMed]
71. Bosi S, Gorini G, Tamelli M, et al. A school-based peer-led smoking prevention intervention with extracurricular activities: the LILT-LdP cluster randomized controlled trial design and study population. Tumori 2013;99:572-7. [PubMed]
72. Widome R, Wall MM, Laska MN, et al. Adolescence to young adulthood: when socioeconomic disparities in substance use emerge. Subst Use Misuse 2013;48:1522-9. [Crossref] [PubMed]
73. Latvala A, Rose RJ, Pulkkinen L, et al. Drinking, smoking, and educational achievement: cross-lagged associations from adolescence to adulthood. Drug Alcohol Depend 2014;137:106-13. [Crossref] [PubMed]
74. Fernandez E, Garcia M, Schiaffino A, et al. Smoking initiation and cessation by gender and educational level in Catalonia, Spain. Prev Med 2001;32:218-23. [Crossref] [PubMed]
75. Setter C, Peter R, Siegrist J, et al. Impact of school and vocational education on smoking behaviour: results from a large-scale study on adolescents and young adults in Germany. Soz Praventivmed 1998;43:133-40. [Crossref] [PubMed]
76. Gupta R. Smoking, educational status and health inequity in India. Indian J Med Res 2006;124:15-22. [PubMed]
77. Backinger CL, Fagan P, Matthews E, et al. Adolescent and young adult tobacco prevention and cessation: current status and future directions. Tob Control 2003;12 Suppl 4:IV46-53. [Crossref] [PubMed]
78. Schwartz JL. Methods of smoking cessation. Med Clin North Am 1992;76:451-76. [Crossref] [PubMed]
79. Cummings KM, Mahoney MC. Strategies for smoking cessation: what is new and what works? Expert Rev Respir Med 2008;2:201-13. [Crossref] [PubMed]
80. Farrelly MC, Niederdeppe J, Yarsevich J. Youth tobacco prevention mass media campaigns: past, present, and future directions. Tob Control 2003;12:i35-47. [Crossref] [PubMed]
81. Altman DG, Schooler C, Basil MD. Alcohol and cigarette advertising on billboards. Health Educ Res 1991;6:487-90. [Crossref]
82. Evans N, Farkas A, Gilpin E, et al. Influence of tobacco marketing and exposure to smokers on adolescent susceptibility to smoking. J Natl Cancer Inst 1995;87:1538-45. [Crossref] [PubMed]
83. Lovato C, Watts A, Stead LF. Impact of tobacco advertising and promotion on increasing adolescent smoking behaviours. Cochrane Database Syst Rev 2011.CD003439. [PubMed]
84. Choi WS, Ahluwalia JS, Harris KJ, et al. Progression to established smoking: the influence of tobacco marketing. Am J Prev Med 2002;22:228-33. [Crossref] [PubMed]
85. Thomson CC, Hamilton WL, Siegel MB, et al. Effect of local youth-access regulations on progression to established smoking among youths in Massachusetts. Tob Control 2007;16:119-26. [Crossref] [PubMed]
86. Andersen BS, Begay ME, Lawson CB. Breaking the alliance: Defeating the tobacco industry's Allies and enacting youth access restrictions in Massachusetts. Am J Public Health 2003;93:1922-8. [Crossref] [PubMed]
87. Chaloupka FJ, Straif K, Leon ME, et al. Effectiveness of tax and price policies in tobacco control. Tob Control 2011;20:235-8. [Crossref] [PubMed]
88. Nonnemaker JM, Farrelly MC. Smoking initiation among youth: the role of cigarette excise taxes and prices by race/ethnicity and gender. J Health Econ 2011;30:560-7. [Crossref] [PubMed]
89. Wilson N, Thomson G. Tobacco tax as a health protecting policy: a brief review of the New Zealand evidence. N Z Med J 2005;118:U1403. [PubMed]
90. Bader P, Boisclair D, Ferrence R. Effects of tobacco taxation and pricing on smoking behavior in high risk populations: a knowledge synthesis. Int J Environ Res Public Health 2011;8:4118-39. [Crossref] [PubMed]
91. Shakib S, Zheng H, Johnson CA, et al. Family characteristics and smoking among urban and rural adolescents living in China. Prev Med 2005;40:83-91. [Crossref] [PubMed]
92. Ma H, Unger JB, Chou CP, et al. Risk factors for adolescent smoking in urban and rural China: findings from the China seven cities study. Addict Behav 2008;33:1081-5. [Crossref] [PubMed]
93. Levin KA, Dundas R, Miller M, et al. Socioeconomic and geographic inequalities in adolescent smoking: a multilevel cross-sectional study of 15 year olds in Scotland. Soc Sci Med 2014;107:162-70. [Crossref] [PubMed]
94. Yamamoto-Kimura L, Posadas-Romero C, Méndez-Ramírez I, et al. Tobacco smoking in urban and rural adolescents and its association with individual and familiar characteristics. Rev Med Inst Mex Seguro Soc 2008;46:511-8. [PubMed]
95. Sygit K, Kołłątaj W, Wojtyła A, et al. Engagement in risky behaviours by 15-19-year-olds from Polish urban and rural areas. Ann Agric Environ Med 2011;18:404-9. [PubMed]
96. Peer N, Bradshaw D, Laubscher R, et al. Urban-rural and gender differences in tobacco and alcohol use, diet and physical activity among young black South Africans between 1998 and 2003. Glob Health Action 2013;6:19216. [Crossref]