Building the basis for primary prevention : factors related to cigarette smoking and alcohol use among adolescents

Background: Cigarette smoking and alcohol use influence morbidity and premature deathall over the world. Studies have shown that most life-time smokers andadult heavy drinkers began their use during their adolescent years andbetween 80-90% of them before the age of 18. Thus, early onset of smokingand alcohol use increases the risk of later dependence. Alcohol use andcigarette smoking among adolescents are also strongly correlatedbehaviors. Adolescents who initiate smoking are much more likely to beginusing alcohol at an early age than those who do not, and vice verse.Furthermore, both cigarette smoking and alcohol use among adolescents areknown to be gateways to the use of other substances, adding further tothe negative consequences of smoking and alcohol use. Hence, earlyidentification of key determinants for adolescent cigarette smoking andalcohol use may serve to decrease the likelihood of later substance usedevelopment and related health problems and delinquent behaviors.Aims and objectives: The aim of this project is to investigate several important factors inthe social environment of Icelandic adolescents that contribute to thelikelihood of cigarette smoking and alcohol use initiation andprogression. Senior public health scholars have highlighted the need foran increase in inter-disciplinary approaches for public health researchand practice. Consequently, the coverage builds on a literature from boththe social- and public health sciences.Material and method: The data for studies I-III is based on the population-basedcross-sectional survey, Youth in Iceland in 2006. The study was designedto monitor adolescent health risk behaviors and social circumstancesamong others. The study base includes all noninstitutionalized childrenwho were enrolled in the obligatory 9th and 10th grades, ages 14 to 15years, in all secondary schools in Iceland during March 2006. A total of7,430 students in 9th and 10th grade (49% males) completed thequestionnaire in 2006, yielding a response rate of 81% of the totalpopulation of these cohorts. The study base in study IV is pooled datafrom five cross-sectional studies in the Youth in Iceland series, fromthe years; 1997, 2000, 2003, 2006, and 2009. The emphasis is on changesin trends of substance use and associated risk and protective factors.Data collection was carried out using the same protocol as in the 2006study. The study base varied between 7,882 and 9,278 individuals, andrespondents numbered between 6,346 and 7,758 (81 to 90% of the totalpopulation).Results: The findings of study I suggest that multiple social factors are relatedto smoking behaviors among adolescents, including alcohol use. Of allfactors considered, peer smoking was by far the strongest predictor ofoccasional- and daily smoking. Perceived friends attitude to smoking wasalso found to be important and so was perceived parental reactions tosmoking. Study II shows that increase in probability of smoking and alcohol useamong adolescents that have experienced parental divorce or separationdoes not need to be a fact. Such increase in likelihood is largelyaccounted for by family conflicts. Study III further tests the relationship between parental- and peersocial support, parental and peer use, and smoking and alcohol use.Results suggest that perceived parental reactions and peer respect foruse are important variables in addition to peer use. Other factors, suchas parental use, were not found to be important. Study IV finds that smoking and alcohol use has decreased substantiallyin Iceland during the last 12 years and so has party lifestyle amongyouth. On the other hand, parental monitoring and participation inorganized sports have increased during the same time period.Study IV also finds that the relative decrease in substance use wasgreater in communities that have been using a specified community-basedprevention approach than in the comparison communities. Moreover, therelative increase in supportive mechanisms such as parental monitoringand sports participation was greater in intervention communities than inthe comparison communities, and so was the subsequent decrease inprevalence of party lifestyles.Discussion: These results challenge the current sphere of knowledge in several ways. First, study findings suggest that multiple social factors influencesmoking behaviors among adolescents, including alcohol use. Preventionapproaches and programs should account for such diversity while at thesame time considering contextual factors such as socio-economicbackground that are known to be important determinants for the likelihoodof adolescent smoking. Second, by avoiding family conflicts, includingdirect conflict between parents and their children, before and afterseparation, parents can prevent increase in likelihood of cigarettesmoking and alcohol use initiation by their children. Third, bydemonstrating to their children that adolescent cigarette smoking and/oralcohol use are not acceptable behaviors, parents can substantiallydecrease the likelihood of such use by their adolescent children.Likewise, through supportive mechanisms (e.g. healthy leisure timeactivities) and motivation around the peer group, prevention work shouldtarget peer respect for smoking and/or alcohol use as an important factorthat may increase the likelihood of such use. Finally, preventionactivities conducted in several municipalities in Iceland over the past12 years have shown that by stressing health promotion in the localcommunity setting and collaboration with local youth- and preventionworkers, cigarette smoking and alcohol use has decreased more than in thenon-participating communities. Likewise, the relative increase inprotective factors was greater in collaborative communities. This wastrue even though Iceland has a small and homogeneous population andcontamination and co-intervention effects are difficult to assess.