Department of Community Medicine, The University of Hong Kong, 21 Sassoon Road, Pokfulam, Hong Kong, China. E-mail: hrmrlth{at}hkucc.hku.hk
The study on smoking among adolescents in China by Yang et al.1 is one of the largest youth smoking surveys in the world. The survey included 24 000 youths aged 1120 in 24 different urban and rural regions and covered youths in school and school leavers in rural areas. Note that the Global Youth Tobacco Survey (GYTS) only includes a narrow age band of 1315 years and excludes out-of-school youths.2 The latter are particularly important for developing countries and rural areas as the proportion of young school leavers can be very high (about 40% among youths aged 1519 years in this study). There is a lack of smoking data on school leavers in both urban (which is not covered by Yang et al.) and rural areas. As they usually have much higher smoking prevalence, any studies which have excluded school leavers, including the GYTS, will produce underestimates of youth smoking prevalence.
We suggest that a new Global Youth School Leaver Tobacco Survey is warranted. Yang et al. used convenience sampling to recruit school leavers in the villages, which is a major limitation. Whether convenience sampling would result in higher or lower overall youth smoking prevalence is uncertain. Better sampling methods are needed for future studies.
It is not clear how the high smoking prevalence in school leavers can influence the initiation and maintenance of smoking among youths who stay on in schools. Yang et al. and other authors have consistently shown that peer influence is the strongest factor associated with regular smoking. A key question is what are the predictors of peer smoking in the first place. Furthermore, there is a lack of information on the characteristics of the peers (such as gender, age, in or out of school) and the mechanism of peer influences. As school leavers are apparently more mature, independent, and rebellious, they are likely to be more susceptible to adult and peer influence into smoking and be influential as role models of smoking to their peers and juniors. Smoking among peers or older workers in the workplace of school leavers could have an important influence on their uptake of smoking. The influences of tobacco advertisements and sponsorships should also be examined in parallel with peer influences.
Tobacco use in Chinese youths is predominantly confined to cigarette smoking, and hence Yang et al. did not include other forms of tobacco use. The GYTS has shown that the overall median rate of current cigarette smoking was 13.9% and that current use of other tobacco products was 8.8%. If the latter is used, higher prevalence will be expected.
Although there is great variation in prevalence,2 tobacco use in youths is an expanding public health problem globally. Smoking prevalence in girls, particularly those in urban areas, is catching up with boys, whereas smoking prevalence in girls in rural areas remains low in China.1 With increasing urbanization and decreasing influences of traditional values, we would expect increasing smoking in girls in rural areas. As the majority of the Chinese population live in rural areas, the increasing smoking prevalence there will contribute huge numbers of new smokers in the near future. This is particularly serious as most tobacco control programmes fail to reach the villages and the most deprived regions.
Furthermore, there is increasing migration of rural youths to urban areas for employment. They are likely to be recruited into poorly paid jobs with the least desirable work conditions. Apart from being exploited in other ways, these young migrant workers from rural areas, especially young girls or women, are extremely vulnerable to smoking and other forms of drug addiction and abuse. There is a dearth of studies of these life course changes and their effects on smoking and other risk behaviours.
It is ironic that the tobacco industry appears to be a strong advocate for youth smoking prevention. Globally, there are more than 130 Youth Smoking Prevention (YSP) programmes in more than 70 countries funded by the tobacco industry (www.bat.com; accessed on 10 May 2004).
In 2001, a YSP project was set up in Hong Kong with funding (about US$2.3 million) from the tobacco industry. Despite strong objections from the Hong Kong Council on Smoking and Health and other tobacco control advocates, this first YSP in China has attracted the participation of some schools, and youth and parent organizations. It has succeeded in creating much confusion and distraction and can undermine strong and effective tobacco control measures such as increasing tobacco tax, banning of tobacco advertisements and sponsorships, and creation of totally smoke-free workplaces and restaurants. One year earlier, in 2000, the Hong Kong Special Administrative Region Government proposed more stringent tobacco measures. These include a total ban of smoking in restaurants, other public indoor premises, schools, universities, tertiary institutions, and indoor workplaces, further banning of advertisement and promotion of tobacco products, and introduction of pictorial and graphic contents in health warnings. The timing of the YSP in Hong Kong is not a coincidence.
Despite the majority support of the public as shown by Government consultation and population opinion surveys, objections and political lobbying from the tobacco industry and some legislators representing the catering and retailing businesses have been successful in obstructing and delaying the legislative process. The YSP in Hong Kong supports prohibition of sales of tobacco products to minors (already enshrined in law) and legislation to ban smoking in schools but is obviously silent with regard to other proposed tobacco control measures. Public health and tobacco control advocates need to be on the alert with regard to the YSP movement and be well prepared to fight back. Beware that what is most deceiving is what YSP purports to support and what is most revealing is what YSP does not explicitly support.
The WHO Western Pacific Region has published a booklet exposing the truth of the YSP that they don't work. (http://www.wpro.who.int/tfi/docs/PressReleases/Seeing_bneath_d_surface.pdf; accessed on 10 May 2004). Yang et al. rightly recommend a comprehensive programme against tobacco use and intervention should encourage communities to modify their social norms and enforce regulation.
In May 2003, the member countries of the WHO adopted an historic treaty, The Framework Convention on Tobacco Control (FCTC). The FCTC puts strong emphasis on comprehensive multisectional national tobacco control strategies, plans, and programmes. Although Yang et al. end their paper with the statement that a national tobacco control plan is not yet final, China signed (but has not yet ratified) the FCTC on 10 November 2003. By 4 May 2004, 107 countries have signed and 12 have ratified (www.fctc.org; accessed on 10 May 2004). The FCTC will become a legally binding document 90 days after the 40th ratification. Has your country ratified?
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2 The Global Youth Tobacco Survey Collaborative Group. Tobacco use among youth: a cross country comparison. Tob Control 2002;11:25270.
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