The European Journal of Public Health Advance Access published online on September 27, 2008
The European Journal of Public Health, doi:10.1093/eurpub/ckn083
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Smoking and related factors of the social environment among adolescents in the Republic of Karelia, Russia in 1995 and 2004
Anastasiya Rogacheva1, Tiina Laatikainen1, Kristiina Patja1, Meri Paavola1, Kerttu Tossavainen2 and Erkki Vartiainen1
1 Department of Health Promotion and Chronic Disease Prevention, National Public Health Institute, Finland
2 Department of Nursing Science, University of Kuopio, Finland
Correspondence: Anastasiya Rogacheva, Department of Health Promotion and Chronic Disease Prevention, Chronic Disease Prevention Unit, National Public Health Institute, Mannerheimintie 166, 00300 Helsinki, Finland, tel: +358 (09 4744 8807), fax: +358 (09) 47448338, e-mail: anastasiya.rogacheva{at}ktl.fi
Received January 9, 2008, accepted July 18, 2008
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Abstract |
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Background: To investigate changes in smoking prevalence associated with social factors and existing health policies among adolescents in Russia from 1995 to 2004. Methods: In 1995 and 2004 a confidential questionnaire was distributed to every 9th grade student of all 10 comprehensive schools of the Pitkäranta in Republic of Karelia, Russia. In 1995, 385 children participated in the survey (response rate 95%) and 395 children (response rate 85%) in 2004. Results: Twenty-nine percent of boys smoked daily in 1995 and 31% in 2004. Daily smoking doubled from 7% to 15% for girls. Smoking in the schoolyard increased among girls. The proportion of girls who reported smoking at home with their parents’ knowledge increased. Both genders cited the ease of purchasing tobacco as a minor. Knowledge about the fast development of tobacco addiction increased statistically significantly among boys. Fewer numbers of respondents of either gender thought that young smokers look ‘cool’ and more grown up. Having a best friend who smoked was the strongest predictor for smoking for both genders. Conclusion: Smoking has increased among girls. Social environment is a predisposing factor. Anti-smoking legislation was implemented weakly. Minors purchase tobacco relatively easily. Knowledge about tobacco's harmfulness has somewhat increased but is not sufficient to deter starting smoking, especially among non-smoking girls. Adequate education of adolescents on the hazards of tobacco consumption is needed, accompanied by a more determined enforcement of health policies. The potent influence of peers should be considered when planning preventive interventions.
Keywords: adolescents, Russia, smoking, social enironment, survey
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Introduction |
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Tobacco consumption is well recognized as a preventable risk factor for early morbidity and mortality.1,2 In Russia, smoking is highest in the European region and one of the main causes of high mortality.3,4 Smoking prevalence among Russian men has remained quite stable during the past decade but recently a slightly decreasing trend has been observed in some urban areas. Smoking among Russian women shows steady growth.5,6 In general, smokers usually start the habit before the age of 18 years.7 In Russia, smokers of both genders start to smoke between the years of 16 and 20.8
Besides genetic, individual and socio-cultural interactions, smoking is also shaped by environment either promoting or preventing smoking in youth. The main predictors for smoking initiation is usually smoking of other family members and friends.9 Exposure to environmental tobacco smoke during childhood is associated with subsequent smoking in adolescence.10 Moreover, marketing is a powerful factor, providing models to emulate.11
Initiation into smoking at an early age may have far-reaching consequences later in life. Adolescents who started smoking at an early age are more likely to continue when they are older12,13 and are less likely to quit smoking.14 Consequently, every third smoking adolescent transits into a regular adult smoker.15 Tobacco usage in adolescence predicts a range of early adult social and health problems, as this period of life is prone to the acceptance of behaviours that influence health status in adulthood.15,16 Along with an increased likelihood of early adult tobacco use, tobacco smoking in adolescents is associated with alcohol consumption. There is also a link between tobacco use by youths and subsequent behavioural and mental health problems in adults.17
Little is known about changes in smoking prevalence in connection with social and environmental factors among Russian youth in the past decade. The present study aims to investigate changes in smoking behaviour in the Pitkäranta region of the Republic of Karelia in Russia between 1995 and 2004. The study particularly focuses on: existing health policies, the availability of tobacco and places for its consumption, opinions and attitudes regarding smoking as a means of enhancing self-image; together with the influences of the close environment such as relatives and friends upon prevalence of smoking among adolescents.
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Methods and participants |
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The Republic of Karelia is located in Northwest Russia, bordered by Finland and has a population of 703 100 inhabitants. Pitkäranta is a typical region of the Republic of Karelia and is characterized by a high prevalence of chronic disease risk factors among the adult population.18 Total and CVD mortality are high in Pitkäranta. Life expectancy in 2004 was 54 years among men and 69 years among women. The mortality, associated with diseases of the circulatory system was 1004 and that of neoplasm was 199/100 000 inhabitants.19 The region of Pitkäranta consists of urban and rural districts without precise demarcation between them.
The present study is a part of a health survey, conducted among school children in all 10 secondary schools of the Pitkäranta region in 1995 and in 2004. The study group for both years comprised every 9th grade (15-year old) students. The sample size was 385 students (response rate 95%) for 1995 and 395 students (response rate 85%) for 2004. The final data included 176 boys and 192 girls for 1995, and 171 boys and 169 girls for 2004. Each student filled in a confidential questionnaire with mainly pre-coded answers for the assessment of their smoking status. A detailed methodology was published earlier.20
The smoking status of each participant was sought by asking: ‘Are you currently a smoker?’ (I do not smoke; 1–2 times a month or less; 1–2 times a week; I smoke daily). Exposure to smoking was assessed by the questions: ‘Does your father, mother, brother or sister (who is older than you by 10 years), or friend smoke?’ Smoking occasions, places and related were assessed using questions/statements: ‘Do you smoke during breaks at school?; Smoking on the school premises is easy; I smoke at home and my parents do know; I smoke at home and my parents do not know’. Answers were categorical: never; seldom; sometimes; often. Information about sources of tobacco acquisition was gathered through the statements: ‘I buy cigarettes myself from kiosks; older friends buy cigarettes for me; I get cigarettes from somewhere else’. The degree of difficulty associated with tobacco acquisition for minors was assessed by a question about the relative ease of purchasing tobacco when under age of 16 years old and under the legal age of 18 years. Opinions and attitudes on the development of smoking addiction were sought through the extent of agreement with the following statements: ‘Dependence on tobacco develops fast; Tobacco should be sold to children under 16 years old; Nobody should smoke at home; Young smokers are "cool" and look more grown up; Youth smokers have more friends; Young people can easily stop smoking.’ Categorical responses were: agree, partly agree, do not agree. Agreement or disagreement with these statements indicated to what extent smoking was perceived by the young as being a means of enhancing self-image and a facilitator for meeting and socializing with new friends. They also indicated attitudes towards existing smoking policies.
Informed consent was obtained from participants and their parents. The main reason for the non-response was the pupil's absence from school on the day of the survey.
Data analysis
Data were analysed separately for boys and girls according to the status of being either: a smoker or non-smoker. In all analyses the smoker category included daily and occasional smokers. Places of tobacco acquisition, smoking occasions and venues were analysed only for smokers. Analyses conducted using SPSS 14 software. The Chi-square test used to assess changes in smoking prevalence, places of tobacco acquisition and general attitudes toward smoking. Logistic regression for binominal variables applied to predict the association between best friends or close relatives smoking with adolescents smoking, using combined data for the years 1995 and 2004.
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Results |
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Smoking prevalence
Prevalence of daily smoking increased among girls from 7% to 15% between 1995 and 2004, (P = 0.015). Among boys the daily smoking prevalence was 29% for 1995 and 31% for 2004, and did not change statistically significantly. The mean number of cigarettes consumed daily among girls was 5.1 (median 4.5). Among boys the mean number of cigarettes smoked daily was 6.8 (median 5.0).
Smoking among family and friends
Boys reported similar levels of smoking prevalence among best friends, fathers, mothers and older siblings for 1995 and 2004. Girls reported an increase in smoking prevalence among older sisters from 23% for 1995 to 39% for 2004 (P = 0.012), smoking prevalence of best friends, mother, father or brother(s) remained unchanged (table 1).
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Places and occasions of tobacco-smoking occurrence
About 80% of smokers smoked during the breaks at school. No changes occurred for boys regarding smoking venues, occasions and parents being informed about their smoking between the survey years.
Among girls, smoking at school increased from 39% for 1995 to 76% for 2004 (P = 0.003). The number of girls reporting smoking at home with their parents’ knowledge was 11% for 1995 and 33% for 2004, (P = 0.047). Among smokers, 67% of girls and 62% of boys reported ‘smoking within the school premises is easy’ for 2004. Fifty percent of girls reported smoking at home without their parents’ knowledge whereas the corresponding result for boys was 42% (table 2).
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Places of tobacco acquisition
The main outlet of tobacco acquisition for self-consumption among young smokers in Pitkäranta remained kiosks: 84% of the boy-smokers reported for 1995 and 83% for 2004. Among the girl-smokers, tobacco purchasing from kiosks increased from 54% for 1995 to 94% for 2004, (P < 0.001). Older friends were a source of tobacco supply for 32% girls for 1995, which decreased to 6% for 2004, (P < 0.001). Among boys-smokers the respective value was 7% for both years.
The ease of purchasing tobacco when under age
Tobacco purchasing became slightly more difficult for minors in Pitkäranta in 2004. However, 30% of boys and 20% of girls in 2004 reported being able to buy tobacco when under 16-years old. In contrast, 48% of boys and 35% of girls reported purchasing tobacco when under 18-years old (table 3).
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Smoking-related opinions
Opinions related to smoking and sociological perceptions of smokers differed between the genders and also between smokers and non-smokers.
Dependence on tobacco is developing fast
The proportion of boys who supported the opinion that tobacco dependency develops fast increased from 53% for 1995 to 75% for 2004, (P = 0.001). This increase was from 47% for 1995 to 70% for 2004 among non-smokers (P < 0.001) compared with 62% for 1995 to 81% for 2004 among smokers (P = 0.015).
Among girls, the increase was significant (P = 0.052) only among smokers, from 56% in 1995 to 78% in 2004 (table 4).
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Young smokers are ‘cool’
The proportion of the boys who think that young smokers are ‘cool’ decreased from 38% for 1995 to 9% for 2004 (P < 0.001) among non-smokers. However, there was no corresponding statistically significant change among smokers. The proportion of girls who think that young smokers are ‘cool’ decreased among smokers (P < 0.001) and non-smokers (P = 0.029) by 2004 (table 4).
‘Young smokers look more grown up’
The proportion of boys who agreed with the opinion that ‘young smokers look more grown up’ decreased (P = 0.001). The decrease was greater among boy-smokers, from 30% for 1995 to 10% for 2004 (P = 0.002) (table 4).
’Young people can easily stop smoking’
The proportion of girl non-smokers who believe that quitting smoking is easy for young people increased from 29% for 1995 to 46% for 2004, (P = 0.002). Among boys there was no statistically significant change in this opinion (table 4).
In Pitkäranta, a best friend who smoked was the strongest predictor for both boys and girls to smoke (P < 0.001). The univariate model revealed that smoking among close relatives was also significantly associated with an adolescent smoking. However, in the multivariative model analyses only the best friend's smoking remained associated with the respondents’ smoking (P < 0.001) (table 5).
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Discussion |
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Daily smoking prevalence doubled among the girls between 1995 and 2004. However, there was no change among the boys over the same period, though their smoking prevalence was twice that of the girls. The prevalence of smoking among youths in Pitkäranta is among the highest in Russia, after those reported for Moscow and Tomsk (about 30%).21 Smoking prevalence in adolescents (smoking at least once a week) varies across regions in Russia from 3% up to 40%.21,22 In the Moscow region, every third adolescent boy and every fifth girl smoke daily.23
The change in the prevalence of smoking in youths in Pitkäranta correlated with that among adults from the same area. Since 1992, the prevalence of smoking among men remained steady (about 65%), whereas among women, it increased from 11% to 22% by 2004.20,24 However the gender gap in the prevalence of smoking among adolescents in Pitkäranta is narrower than among adults.
Tobacco use among adolescents is becoming a serious problem for developed and developing countries.25 Smoking trends among European youth develop differently. In Andorra and Slovakia a growth in smoking prevalence is reported among both genders, whereas in Denmark, Latvia, Ireland, Sweden and Switzerland decreasing trends have been observed. In Finland, the Czech Republic and Germany smoking prevalence among girls is growing and also exceeds the prevalence among boys.26 In Russia, a general growth in smoking is reported among girls and a decrease in smoking among boys. Similarly, increases in smoking among girls in: Estonia, Lithuania, Malta and Portugal have been reported.27
Other indicators reflecting an increase in smoking among girls are: easier to smoke during the breaks at school, increased number of girls smoking at home with their parents’ knowledge together with the an increase in the number of girls buying cigarettes for themselves. The increases in smoking rates among pupils in school reflects on the existing smoking policy and its implementation.28 Strict non-smoking rules and strict compliance with the school authority rules are protective factors against smoking among schoolchildren.29 Nevertheless, prevailing school culture may provide either risk factors, or a protective environment for smoking and adolescents’ health in general.30 Increased opportunities for girls to smoke at school and also at home with their parents’ knowledge indicate less control on girls smoking at schools and increased societal acceptance of female smoking.
Tobacco legislation in Russia bans tobacco sales to youths <18 years of age.31 Tobacco acquisition by youths under 16 or under the legal age of 18 years in Pitkäranta became somewhat difficult. However, sufficient access to tobacco products was still reported by both genders. Tight implementation of legislation on tobacco sales to minors decreases the contribution of commercial sources for tobacco supply to youth and increases that of social sources as friends and other outlets.32 Friends were a less important source of tobacco supply for adolescents in Pitkäranta. This should be taken into account when enforcing the tobacco sales ban. Simultaneous health-promotion measures should also be applied to decrease the influence of youth's social channels of tobacco supply.
Despite widespread smoking in the USSR,33 several initiatives had been implemented to assist the anti-tobacco campaigns. These aimed at intensifying anti-smoking information and establish a negative image of smoking within the population.5 In 1980, the age limit for tobacco sales were set at 16-years old.34 Since then tobacco legislation in Russia has undergone subsequent changes (table A1).
Partial prohibition of tobacco advertising, by date,35,36 increased indoor promotions, especially in the city metros. In bigger cities, smoking rates are highest in Russia and the metro is the most visited public place by different age groups. Tobacco advertising to children in the media is actually forbidden. However, tobacco is widely advertised in women's magazines, with unrestricted access to girls. As a whole, people are unaware of the hazards of smoking and the popularity of non-smoking environments is low. The equipment and facilities of smoke-free areas in public places with adequate ventilation are mostly poor and the implementation of smoke-free public policy is rather weak. Russia has recently ratified the Framework Convention on Tobacco Control.37 Due to the difficulties experienced in Russia with policy implementation, it is unlikely that the harmful influence of tobacco will be reduced significantly in the near future. Therefore, urgent measures must be actively taken in accordance with regulations of the FCTC to counter the tobacco epidemic.
In our study, smoking in close environments such as the family and among friends was found to be an influential factor for smoking initiation among adolescents. Having a best friend who smokes was the strongest predictor for both genders. Smoking among peers and within the family predisposes children towards initiation and the subsequent maintenance of the smoking habit.11 A mother who smokes was the second strongest predictor for girls. These findings correlated with earlier studies from Russia and other countries.38,39 An acceptance of smoking by adults at home, at school or early access to tobacco products is ideal for furthering the smoking habit among minors in Pitkäranta.
General knowledge on the effects tobacco somehow increased and smoking was perceived less as an image enhancing activity by adolescents in Pitkäranta. However, the underestimation of the power of tobacco addiction increased among non-smoker girls while the opposite trend was observed among girls who smoke. Another study from Russia reported that among Russian youth the attitude toward smoking as a ‘harmful habit’ decreased between 5th and 7th grade. In that study 90% of respondents of these grades agreed, compared with only 30% of respondents in the 8–11th grades.20
In spite of growth in the negative attitudes towards the smoking habit, smoking prevalence has risen among girls in Pitkäranta. Girl non-smokers are not fully aware of the addictive effect of tobacco consumption. This indicates an insufficiency of delivered information and a deficiency in public health education. It also reflects existing norms related to smoking. It would be interesting to study whether such a phenomenon exists in other parts of Russia and CIS countries with similar developmental patterns of smoking among teenage girls. Better understanding of the factors related to the initiation of smoking among Russian children and youth would be needed.
The study samples included 95% for 1995 and 85% for 2004 of all secondary school students, from one age category (15-year olds), from the same area. High response rates ensured the study's credibility. The confidential personal questionnaire and the maintained anonymity of respondents predispose towards honesty in their answers. It is most likely this ensured that any underreporting of smoking was kept low. The Pitkäranta region is a typical area in the Republic of Karelia. Our findings could therefore be easily extrapolated to the whole of the republic. Questions on the exposure to environmental tobacco smoke, consumption of smokeless tobacco or the frequency of exposure to smoking advertisements and smoking as depicted in the movies were not included in our survey. Despite the lack of these data on children, the smoking prevalence among men is very high in Pitkäranta.24
Recent significant social, political and economic changes in Russia, the aggressive influence of transnational tobacco companies combined with the weakness of the implementation of health policies have contributed to an increase in smoking among women.40,41 Tobacco companies in the Russian market use recognizable strategies as linking tobacco consumption to liberation, friendship and independence, deliberately targeting both genders. The price of tobacco in Russia is lower than in Europe and affordable for children. The promotion of smokeless tobacco and the increasing popularity of nasvai/nass (a homemade type of smokeless tobacco product, famous in Central Asia) is becoming more prevalent in different parts of Russia. The production of nasvai is not officially regulated. It is prepared privately in homes, sold in local markets and is purchased by youths.
The characteristics of smoking patterns and predisposing factors in Russia and the Republic of Karelia may reflect one another. The narrowing of the gender gap in smoking among adolescents suggests westernization of the smoking pattern. Further increase in smoking prevalence may be expected among females in Pitkäranta and in the Republic of Karelia. Increased societal tolerance to female smoking is a likely feature all over Russia. The liberalization towards females smoking, an increasing smoking rate among female adolescents, tobacco marketing and a lack of sufficient knowledge may lead to a gender switch in the smoking epidemic there.
Policy implications
Surveillance of smoking prevalence in association with the contributing factors of the social environment among adolescents is important. It allows detecting changes in health behaviour of youth early enough to respond adequately considering long-term outcomes of early smoking prevention.
There is a strong need for the enforcement of existing non-smoking health policies in Russia. Revision and further development of anti-smoking policies are required with the main emphasis on minors and women. All types of tobacco promotion including smoking scenes depicted in movies should be prohibited. The ban on smoking in public places should be implemented. Increasing prices and taxes on tobacco products would make them less affordable. It is essential that implementing preventive programmes aimed at reducing the prevalence of smoking and preventing its onset and uptake by the whole population in Russia is adopted as part of a national health strategy. Activities against smoking should not be implemented incidentally, but consistently included in governmental and political routines.
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National Public Health Institute, Finland; European Union Interreg III A Karjala project (partial).
Conflicts of interest: None declared.
Key points
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Table A1 Development of existing anti-smoking legislation in Russia
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The study was supported by Ministry of Health and Social Development of the Republic of Karelia and was implemented in co-operation with Pitkäranta central hospital and the North Karelia Center for Public Health, Finland.
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