Role of Government and Community in Primary Prevention

cards,฀and฀strong฀rules฀on฀the฀siting฀of฀cigarette฀vending฀machines.฀“We฀want฀children฀to฀ be฀able฀go฀into฀shops฀without฀being฀faced฀with฀tobacco฀adverts฀or฀promotional฀materials”฀ [106] .฀To฀ensure฀the฀achievement฀of฀these฀goals,฀the฀White฀Paper฀describes฀detailed฀mea- sures฀that฀are฀to฀be฀implemented฀by฀central฀and฀local฀governments. Since฀tobacco฀consumption฀is฀a฀socially฀determined฀phenomenon,฀changes฀in฀the฀social฀ environment฀and฀social฀norms฀could฀become฀important฀ [107] .฀It฀is฀entirely฀conceivable฀ that฀ a฀ change฀ in฀ norms,฀ values฀ and฀ behavioural฀ patterns฀ would฀ increasingly฀ discredit฀ tobacco฀consumption,฀and฀that฀this฀would฀then฀be฀further฀mirrored฀in฀the฀social฀environ- ment.฀This฀objective฀can฀be฀assisted฀by฀charitable฀organisations฀in฀many฀countries฀dedi- cated฀to฀the฀struggle฀for฀a฀smoke-free฀environment฀–฀a฀goal฀that฀would฀also฀include฀schools.฀ School฀฀curriculum-based฀smoking฀prevention฀programmes฀might฀well฀prove฀highly฀effec- tive฀ [108] ฀and฀local฀communities฀should฀help฀to฀create฀a฀positive฀non-smoker฀image฀ [109] .฀ A฀combined฀school-฀and฀community-based฀tobacco-use฀prevention฀programme฀clearly฀has฀ the฀potential฀to฀reduce฀smoking฀initiation฀rates,฀as฀demonstrated฀by฀studies฀in฀28-year-old฀ non-smokers฀ [72] .฀Analysis฀of฀the฀data฀by฀the฀Cochrane฀Group฀also฀indicates฀a฀positive฀ result฀ [110] . A฀restriction฀on฀the฀sale฀of฀tobacco฀products฀to฀minors฀is฀an฀important฀aspect฀of฀preven- tion.฀Sales฀to฀minors฀must฀be฀reduced฀in฀accordance฀with฀the฀following฀stipulated฀recom- mendations฀ of฀ the฀ WHO:฀ a฀ minimum฀ age฀ 18฀ years,฀ b฀ licence฀ system฀ for฀ tobacco฀ retailers,฀c฀threat฀of฀penalties฀for฀illegal฀sale฀of฀tobacco฀goods,฀through฀to฀revocation฀of฀ licence,฀d฀statutory฀prohibition฀on฀sales฀to฀minors,฀e฀no฀sales฀in฀health฀service฀buildings,฀ schools฀or฀sports฀facilities฀and฀f฀no฀sales฀from฀cigarette฀vending฀machines฀or฀self-service฀ stores฀ [34,฀111] .

12.12 Concluding Remarks

The฀issues฀surrounding฀primary฀tobacco-use฀prevention฀programmes฀designed฀to฀deter฀ •฀ students฀from฀smoking฀in฀their฀youth฀need฀to฀be฀revisited.฀Children฀try฀tobacco฀just฀as฀ they฀try฀alcohol฀or฀illicit฀drugs.฀Even฀though฀it฀may฀sound฀surprising,฀these฀facts฀cannot฀ be฀altered฀overnight฀because฀adolescents฀typically฀want฀to฀discover฀what฀the฀world฀has฀ to฀offer.฀Consequently,฀this฀experimentation฀phase฀can฀only฀be฀suppressed. Attempts฀to฀limit฀tobacco฀consumption฀by฀using฀school-based฀programmes,฀mass฀media฀ •฀ campaigns฀or฀restrictions฀on฀tobacco฀sales฀to฀minors฀have฀been฀effective฀principally฀in฀ the฀context฀of฀research฀studies.฀However,฀some฀of฀the฀studies฀conducted฀to฀date฀are฀ highly฀complex฀and฀would฀be฀impractical฀in฀a฀real-life฀setting.฀The฀ease฀with฀which฀ minors฀can฀obtain฀illicit฀drugs฀demonstrates฀the฀futility฀of฀seeking฀to฀prevent฀the฀supply฀ of฀these฀substances.฀The฀only฀possible฀guarantee฀of฀success฀might฀be฀through฀the฀world- wide฀coordination฀of฀such฀efforts฀ [97] . Advertising฀ encourages฀ smoking฀ initiation฀ and฀ sustains฀ smoking฀ see฀ •฀ Chap.฀ 13 ,฀ whereas฀advertising฀bans฀reduce฀the฀number฀of฀smokers,฀although฀the฀factors฀involved฀ in฀smoking฀behaviour฀are฀very฀dificult฀to฀identify฀individually.฀The฀burden฀of฀proof฀for฀ the฀effectiveness฀of฀advertising฀bans,฀however,฀lies฀with฀public฀health฀authorities. Moreover,฀in฀view฀of฀the฀hazardous฀nature฀of฀tobacco,฀society฀should฀accept฀no฀adver- •฀ tising฀or฀promotion฀by฀the฀tobacco฀industry฀until฀the฀absolute฀safety฀of฀tobacco฀has฀been฀ conirmed฀beyond฀doubt฀–฀something฀that฀is฀inherently฀impossible.฀Since฀comprehen- sive฀advertising฀bans฀cannot฀currently฀be฀implemented,฀price฀increases฀and฀media฀cam- paigns฀ should฀ be฀ launched฀ to฀ further฀ publicise฀ the฀ harmful฀ effects฀ of฀ smoking.฀ In฀ particular,฀heavy฀price฀rises฀for฀cigarettes฀in฀conjunction฀with฀other฀inancial฀disincen- tives฀could฀be฀a฀key฀to฀prevention. The฀tobacco-use฀prevention฀programmes฀presented฀in฀this฀chapter฀are฀useful฀and฀effec- •฀ tive฀in฀small฀groups฀or฀settings฀but,฀because฀they฀are฀costly฀in฀terms฀of฀time฀and฀person- nel,฀ they฀ would฀ be฀ dificult฀ to฀ implement฀ in฀ a฀ large฀ country฀ such฀ as฀ Germany,฀ for฀ example.฀Moreover,฀cigarette฀smuggling฀should฀be฀mentioned฀in฀this฀context฀because฀ the฀cigarette฀companies฀can฀also฀earn฀revenue฀by฀this฀route.฀Harsh฀penalties฀should฀be฀ imposed฀on฀the฀tobacco฀industry฀when฀these฀illegal฀transactions฀are฀detected.฀The฀rev- enue฀ thus฀ earned฀ could฀ also฀ be฀ funnelled฀ back฀ into฀ prevention฀ programmes,฀ as฀ has฀ happened฀in฀the฀UK฀ [112] .฀Overall,฀effective฀primary฀prevention฀will฀only฀result:฀1฀if฀ a฀general฀ban฀is฀placed฀on฀advertising฀for฀tobacco฀products;฀2฀if฀tobacco฀products฀can฀ only฀be฀obtained฀in฀specialist฀tobacco฀retail฀outlets;฀and฀3฀if฀sales฀are฀only฀made฀to฀ persons฀ over฀ the฀ age฀ of฀ 18฀ years,฀ backed฀ up฀ by฀ tough฀ legislation฀ to฀ protect฀ young฀ people. With฀any฀tobacco-use฀prevention฀programme,฀it฀should฀always฀be฀remembered฀that฀it฀ •฀ will฀take฀decades฀before฀success฀becomes฀effective฀and฀apparent฀in฀terms฀of฀a฀dramatic฀ reduction฀in฀the฀number฀of฀smokers฀Fig.฀ 12.6 . References ฀ 1.฀Kessler฀DA,฀Natanblut฀SL,฀Wilkenfeld฀JP,฀Lorraine฀CC,฀Mayl฀SL,฀Bernstein฀IB,฀et฀al฀1997฀ Nicotine฀addiction:฀a฀pediatric฀disease.฀J฀Pediatr฀1304:518–524 ฀ 2.฀Delener฀ N฀ 1995฀ Assessing฀ cigarette฀ smoking฀ motives฀ of฀ young฀ adolescents฀ in฀ the฀ US:฀ research฀and฀health฀perspectives.฀J฀Smoking฀Relat฀Disord฀6:81–88 ฀ 3.฀Walters฀R,฀Whent฀H,฀Sayers฀M,฀Morgan฀A,฀Sinkler฀P฀1996฀Health฀update.฀Smoking.฀Health฀ Education฀Authority,฀London ฀ 4.฀Health฀Education฀Authority฀1997฀Tobacco฀control฀in฀England:฀communication฀strategies฀of฀ the฀Health฀Education฀Authority.฀The฀Health฀Education฀Authority,฀London ฀ 5.฀Oei฀TP,฀Fae฀A,฀Silva฀P฀1990฀Smoking฀behavior฀in฀nine฀year฀old฀children:฀a฀replication฀and฀ extension฀study.฀Adv฀Alcohol฀Subst฀Abuse฀83–4:85–96 ฀ 6.฀Reed฀DO฀1993฀Preventing฀adolescent฀nicotine฀addiction:฀what฀can฀one฀do?฀J฀Amer฀Acad฀ Phys฀Assist฀6:703–710 ฀ 7.฀Pierce฀JP,฀Gilpin฀EA฀1995฀A฀historical฀analysis฀of฀tobacco฀marketing฀and฀the฀uptake฀of฀smok- ing฀by฀youth฀in฀the฀United฀States:฀1890–1977.฀Health฀Psychol฀146:500–508 ฀ 8.฀Pierce฀JP,฀Lee฀L,฀Gilpin฀EA฀1994฀Smoking฀initiation฀by฀adolescent฀girls,฀1944฀through฀1988.฀ An฀association฀with฀targeted฀advertising.฀JAMA฀2718:608–611 ฀ 9.฀Gilpin฀EA,฀Pierce฀JP฀1997฀Trends฀in฀adolescent฀smoking฀initiation฀in฀the฀United฀States:฀is฀ tobacco฀marketing฀an฀inluence?฀Tob฀Control฀62:122–127