RE: "HEALTH PROBLEMS IN TEENAGE DAILY SMOKERS VERSUS NONSMOKERS, NORWAY, 19951997: THE NORD-TRØNDELAG HEALTH STUDY"
Esteve Fernandez,
Anna Schiaffino,
Luis Rajmil,
Montse García,
Michael Herdman and
Andreu Segura
Institut Universitari de Salut Pública de Catalunya Campus de Bellvitge Ctra. Feixa Llarga s/n 08907 L'Hospitalet (Barcelona) Catalonia, Spain
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INTRODUCTION
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We read with interest the article by Holmen et al. (1
) regarding the increased frequency of somatic and psychological health problems among Norwegian adolescents who smoke daily. Their study adds epidemiologic support to previous observations, mainly from the United States and northern European countries. This association has not been assessed in other developed countries where the tobacco epidemic presents certain differential characteristics (2
). The prevalence of smoking among young men and women in Catalonia, Spain, has increased in the last decade (3
, 4
). Smoking initiation rates were very low for women prior to the 1970s, and they have only recently begun to match those of men (5
). We assessed the association between daily smoking among adolescents and self-reported health, use of medication, and use of health services, using data from the Catalan Health Interview Survey.
The Catalan Health Interview Survey was conducted in 1994 in a randomly selected sample (n = 15,000) of the noninstitutionalized population of Catalonia. A two-step random sample strategy was used (5
, 6
). The survey included sociodemographic data and information on self-perceived health and morbidity, lifestyle habits (including daily, occasional, and past smoking), utilization of health services, and prevalence of chronic conditions. Face-to-face interviews were conducted in respondents' homes (JanuaryDecember 1994). For the present study, we included data from 564 boys and 524 girls aged 1518 years who responded directly. Younger children (aged
14 years) were excluded from analysis, since data on their tobacco consumption was not obtained (7
). The mean age at which smoking began, the mean number of cigarettes smoked per day, and the mean years of daily smoking, as well as their standard errors (SE), were calculated. The proportions of daily smokers and nonsmokers and the corresponding odds ratios (OR) (and 95 percent confidence intervals) among daily smokers versus never smokers for selected health conditions and use of health services were also derived.
In these data, 24.6 percent of boys and 20.8 percent of girls were daily smokers (
=1 cigarette/day). The mean age at starting smoking was 15.0 years (SE 0.1) for boys and 14.6 years (SE 0.1) for girls (t = 2.58, p = 0.01). No differences were found in the mean number of cigarettes smoked per day (11.3 (SE 0.6) in boys and 10.4 (SE 0.6) in girls) or in the mean number of years of smoking (1.9 years (SE 0.1) and 2.1 years (SE 0.1), respectively).
Boys and girls who smoked daily more frequently rated their health poor (OR = 2.5 in boys and OR = 4.3 in girls; p < 0.05 (table 1)). Asthma and bronchitis were significantly associated with daily smoking in boys but not in girls. Information on the use of selected medications was elicited for the 2 days before the interview; hence, the corresponding frequencies of use were low and are hardly comparable with those in the Norwegian study (table 1). In boys, there were no differences between the proportions of smokers and nonsmokers who visited a general practitioner, whereas daily smokers visited a specialist (OR = 1.6; p < 0.05) and were hospitalized (OR = 3.0; p < 0.05) more often. Girls who smoked daily were more likely to have visited a general practitioner, to have seen a specialist, and to have been hospitalized, although the associations were not statistically significant (table 1).
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TABLE 1. Association between daily smoking by teenagers aged 1518 years and selected health conditions and use of health services, Catalan Health Interview Survey, Catalonia, Spain, 1994
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The almost twofold higher prevalence of daily smoking among adolescents in Catalonia as compared with the corresponding figures in Norway (12.3 percent in boys and 15.8 percent in girls, computed from Holmen et al.'s table 2 (1
, p. 150)) is noteworthy. The patterns of association between daily smoking and the health variables examined were similar and were consistent with those in the Norwegian study. Smoking in adolescence is associated with health problems in adolescence itself, in addition to the relations of adolescent smoking with heavy smoking, lower cessation rates, longer duration of smoking, and higher nicotine dependence in adulthood (8
).
The main limitation of the present study is its cross-sectional design, which limits the causal interpretation of the associations observed. This means that it is not possible to discern whether poor health status and somatic symptoms are caused by smoking or vice versathat is, whether poor health promotes smoking or maintains smoking. Our sample was smaller than that of the Norwegian study, and hence the confidence intervals were wider. Nevertheless, the patterns of association were similar.
In summary, in terms of the association between daily smoking and health problems in adolescents, the results found in Catalonia mirror those reported from the United States and northern European countries (1
, 9

12
), despite differences in the patterns of smoking initiation and tobacco consumption in southern European countries. These short term tobacco-related conditions in adolescent smokers require prompt attention and should be considered alongside the well known long term health consequences of smoking.
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NOTES
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Editor's note: Holmen and colleagues were asked if they wished to respond to this letter but chose not to do so.
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References
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