Role of Teachers in Primary Prevention

does฀ not฀ inluence฀ their฀ students’฀ behaviour.฀ Inconsistency฀ such฀ as฀ this฀ in฀ any฀ single฀ institution฀can฀only฀have฀a฀negative฀effect฀on฀the฀credibility฀of฀tobacco-use฀prevention฀in฀ the฀ school฀ and฀ may฀ even฀ condemn฀ such฀ programmes฀ to฀ failure฀ [74,฀ 77] .฀ Ultimately,฀ teachers฀should฀act฀as฀role฀฀models฀for฀their฀students,฀and฀therefore฀tobacco฀consumption฀ by฀teachers฀inevitably฀becomes฀a฀key฀determinant฀of฀student฀behaviour฀ [78] .฀Many฀stu- dents฀report฀that฀their฀teachers฀smoke฀and฀this฀provides฀them฀with฀an฀alibi฀for฀their฀own฀ smoking฀behaviour.

12.9 Prevention by Restricting Sales of Tobacco Products to Minors

In฀addition฀to฀health฀education฀for฀students,฀another฀possibility฀of฀delaying฀smoking฀initia- tion฀among฀minors฀is฀the฀statutory฀regulation฀of฀cigarette฀sales฀to฀young฀people฀below฀the฀ age฀of฀16฀years฀by฀the฀enforcement฀of฀youth-protection฀legislation.฀Campaigns฀using฀post- ers฀such฀as฀those฀depicted฀in฀Figs.฀ 12.4 ฀and฀ 12.5 ฀can฀also฀be฀effective฀in฀a฀school฀setting.฀ At฀the฀same฀time,฀the฀numerous฀cigarette฀vending฀machines฀sited฀close฀to฀schools฀should฀ be฀removed฀and,฀in฀conjunction฀with฀new฀legislation,฀retailers฀should฀be฀“educated”฀to฀ recognise฀that฀the฀sale฀of฀cigarettes฀to฀children฀and฀adolescents฀16฀years฀of฀age฀is฀both฀ illegal฀and฀immoral.฀Such฀action฀could฀ultimately฀bring฀about฀changes฀in฀adolescent฀smok- ing฀behaviour.฀Studies฀examining฀this฀issue฀have฀been฀reviewed฀in฀the฀USA฀ [79] .฀In฀con- nection฀with฀the฀sale฀of฀tobacco฀products,฀the฀US฀studies฀showed฀that฀three฀questions฀were฀ important:฀1฀whether,฀in฀response฀to฀appropriate฀interventions,฀retailers฀comply฀with฀the฀ request฀no฀longer฀to฀sell฀cigarettes฀to฀adolescents;฀2฀whether฀adolescents฀quit฀cigarette฀ smoking฀or฀at฀least฀cut฀down฀to฀some฀extent;฀and฀3฀whether฀such฀interventions฀produce฀a฀ decline฀in฀smoking฀prevalence฀among฀adolescents. Overall,฀attempts฀to฀inluence฀retailers฀by฀verbally฀advising฀them฀of฀the฀legal฀situation฀ have฀been฀minimally฀effective฀ [80,฀81] .฀Availability฀from฀other฀sources฀may฀be฀a฀deci- sive฀factor,฀as฀demonstrated฀by฀a฀study฀in฀700฀communities฀in฀Massachusetts฀ [81] .฀More฀ favourable฀results฀were฀only฀achieved฀when฀the฀interventions฀included฀personal฀visits฀to฀ the฀retailers฀and฀mobilisation฀of฀assistance฀from฀the฀community฀ [82] .฀Only฀a฀permanent฀ warning฀to฀retailers฀was฀found฀to฀be฀effective,฀and฀eficacy฀was฀reduced฀when฀4–6฀checks year฀were฀made฀ [83] .฀Penalties฀have฀an฀important฀part฀to฀play฀where฀violations฀are฀found฀ but฀ these฀ must฀ be฀ set฀ at฀ the฀ right฀ level฀ because฀ excessive฀ leniency฀ merely฀ serves฀ to฀ harden฀retailers฀to฀the฀issue.฀The฀threatened฀withdrawal฀of฀tobacco฀sales฀licences฀would฀ carry฀more฀weight฀if฀retailer฀compliance฀were฀to฀be฀monitored฀continually฀ [84] .฀Where฀ legal฀circumstances฀permit,฀a฀graduated฀system฀of฀warnings฀and฀ines฀through฀to฀licence฀ withdrawal฀would฀be฀effective.฀Similarly,฀a฀warning฀system฀with฀graduated฀ines฀targeted฀ at฀smoking฀adolescents฀in฀Woodridge฀was฀highly฀effective฀but฀did฀not฀meet฀with฀very฀ wide฀acceptance฀ [85] .฀The฀sanctions฀directed฀at฀offending฀tobacco฀retailers฀only฀hit฀home฀ where฀a฀uniform฀policy฀existed฀in฀the฀states฀surrounding฀Woodridge฀ [86] .฀Likewise,฀ado- lescent฀lockout฀devices฀on฀cigarette฀vending฀machines,฀such฀as฀are฀currently฀also฀being฀ tested฀in฀Germany,฀have฀been฀less฀effective฀than฀removal฀of฀the฀vending฀machines฀alto- gether฀ [87] . One฀ major฀ methodological฀ problem฀ is฀ that฀ retailers’฀ attitudes฀ to฀ selling฀ cigarettes฀ to฀ minors฀cannot฀be฀revealed฀even฀by฀undercover฀checks.฀Retailers฀recognise฀undercover฀pur- chasers฀because฀they฀behave฀unusually฀and฀tend฀to฀be฀are฀slightly฀older.฀In฀cases฀of฀doubt,฀ they฀claim฀to฀sell฀cigarettes฀only฀to฀children฀who฀are฀known฀to฀them;฀alternatively,฀they฀argue฀ that฀children฀ask฀grown-ups฀to฀buy฀the฀cigarettes฀for฀them฀ [88] .฀The฀campaigns฀conducted฀to฀ date฀reduce฀smoking฀behaviour฀among฀children฀by฀restricting฀youth฀access฀to฀cigarettes. A฀fall฀in฀the฀sales฀of฀tobacco฀products฀to฀minors฀must฀necessarily฀also฀be฀relected฀in฀a฀ fall฀in฀sales฀igures.฀Trends฀such฀as฀these฀have฀been฀demonstrated฀in฀some฀communities.฀ The฀study฀conducted฀in฀Woodridge฀conirms฀this฀trend฀when฀the฀policy฀is฀applied฀consis- tently.฀Also,฀according฀to฀data฀from฀Massachusetts,฀it฀is฀clear฀that฀a฀high฀inhibitory฀thresh- old฀has฀to฀be฀established฀in฀order฀to฀achieve฀a฀measurable฀reduction฀in฀tobacco฀consumption฀ among฀children.฀The฀density฀of฀the฀retail฀network฀is฀also฀an฀important฀factor฀in฀these฀con- siderations.฀In฀the฀USA,฀despite฀the฀enactment฀of฀the฀Synar฀Amendment฀by฀Congress฀in฀ 1992,฀not฀all฀individual฀states฀90฀so฀far฀have฀yet฀passed฀appropriate฀legislation฀prohib- iting฀the฀sale฀of฀tobacco฀products฀to฀minors฀ [89] .฀Similar฀problems฀exist฀in฀the฀developing฀ countries฀because,฀over฀and฀beyond฀the฀differently฀structured฀social฀situations,฀it฀is฀essen- tial฀to฀protect฀children฀from฀the฀sale฀of฀tobacco฀products. If฀the฀youth฀initiation฀rate฀could฀be฀reduced฀or฀completely฀eliminated,฀smoker฀numbers฀ would฀be฀clearly฀reduced฀after฀20–40฀years฀ [90] .฀According฀to฀one฀simulation฀model,฀if฀ initiation฀among฀18-year-olds฀had฀been฀reduced฀by฀50฀starting฀in฀1993,฀the฀smoking฀rate฀ would฀ have฀ fallen฀ from฀ 19฀ 48.1฀ million฀ smokers฀ to฀ 16.4฀ 44.1฀ million฀ smokers฀ 10฀years฀later฀in฀2003฀Fig.฀ 12.6 ,฀and฀this฀would฀have฀been฀only฀3.7฀million฀smokers฀fewer฀ Fig. 12.4 ฀฀฀Anti-smoking฀ poster:฀“That’s฀real฀strength”฀ DHM฀1995-668