2002 Youth Smoking Survey - Technical Report

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Introduction

Steve R. Manske, EdD
Centre for Behavioural Research & Program Evaluation
University of Waterloo

Sarah J. Robinson, BKin
Department of Health Studies & Gerontology
University of Waterloo

Alan Diener, PhD
Tobacco Control Programme
Health Canada

Acknowledgements: The authors thank Scott Leatherdale (Cancer Care Ontario) and Susan Bondy (Ontario Tobacco Research Unit) who reviewed an earlier draft of this chapter and provided helpful commentary.

Survey Background and Objectives

Context of the 2002 Youth Smoking Survey

Tobacco use is Canada 's number one preventable cause of premature death. In the year 1998, it is estimated that the deaths of 47,581 Canadians were attributable to the use of tobacco industry products¹.

The 2002 Youth Smoking Survey (YSS) concerns youth in grades 5-9 (roughly ages 10-14), the population most likely to first try or experiment with smoking. Since the 1994 YSS, we have not had a representative, in-depth picture of smoking among these young Canadians. This report updates the groundbreaking findings of the 1994 report² and provides insights in additional areas of interest. It focuses exclusively on the youngest cohort reached through school-based surveillance to date. The 1994 YSS also included a phone-based survey of youth aged 15-19. This age group is now captured in the Canadian Tobacco Use Monitoring Survey (CTUMS), which has been conducted annually since 1999³. Thus, these youth were not included in the 2002 YSS.

While selected provinces (most notably Ontario) have studied tobacco use among youth in grades 5-9 over a number of years, and others have more recently added periodic surveys (e.g., Atlantic provinces, Alberta, British Columbia), no nationally representative sample of these youth has been surveyed since 1994 (Table1-1). Information about youth in higher grades is somewhat better (Table 1-2), since 15-19 year olds (approximately equivalent to grades 10-13) are sampled in CTUMS. Dramatic shifts in tobacco use have occurred in older adolescent groups³ and adults³. Such shifts may also have occurred among youth in grades 5-9. It is important that planning and evaluation processes are informed by up-to-date data for these youth as well.

Historically, smoking prevalence among grades 5-9 students has remained at low absolute levels in comparison to other ages. Figures 1-A and 1-B display findings for grades 7 and 9 respectively, starting with the 1994 YSS data. In 1994, 7% of the Canadian population in grades 7 and 9 self-reported as current smokers (using a definition of having smoked at least one cigarette in the past 7 days recalculated based on 1994 YSS Technical Report³ data). Note that provincial data reported in Figures 1-A and 1-B use less stringent definitions of smoking.

A comparison of the YSS 1994 rates shown in Figures 1-A and 1-B, reveals the dramatic jump in current smoking rates between students in grades 7 and 9. This jump is also consistently reflected in provincial data reported in Figures 1-A and 1-B. Similar findings hold for males and females. Since 1994, smoking rates in both grade 7 and 9 students declined as illustrated by the provincial rates reported in Figures 1-A and 1-B.

Figure 1-A - Smoking Prevalence* by Province, Grade 7, Canada, 1994-2002

*Note: Current smoking was defined as smoking greater than one cigarette in the past 12 months with two exceptions: (1) Canadian YSS 1994 data where current smoking included daily smokers and smoking in the past week; and, (2) BC data where current smoking was defined as smoking in the past 30 days.

Figure 1-B - Smoking Prevalence* by Province, Grade 9, Canada, 1994-2002

*Note: Current smoking was defined as smoking greater than one cigarette in the past 12 months with two exceptions: (1) Canadian YSS 1994 data where current smoking included daily smokers and smoking in the past week; and, (2) BC data where current smoking was defined as smoking in the past 30 days.

For the next oldest age grouping (approximately grades 10-12), the rapid rise in smoking continues. In 2003, national data indicate 13% of males and17% of females aged 15-17 years were current smokers (defined as answering "yes" to "At the present time do you smoke cigarettes every day or occasionally?")³. These rates increased further to 24% of males and 25% of females aged 18-19 years 3. Similar increases were observed in 2002 data from the United States, where smoking rates rose steadily in high school to peak in twelfth grade students at 26%⁴. The approximately quadrupling of smoking rates in the 10-year age span is a deep cause for concern. We need ongoing surveillance of smoking rates and related behaviours, attitudes and influences that may contribute to or stem these increases as the cohort ages. This information, in turn, may assist the development of policies and programs to help reduce the impact of smoking on the health of Canadians.

Age of smoking onset is another indicator of the need for surveillance in the youngest age group. The 2003 CTUMS data indicate that more than half (56%) of respondents age 15 and older had their first cigarette by age 15². Age of onset was consistent across genders. The 1994 YSS reported that the greatest relative increase (300%) in beginning smoking was between 10 and 12 years of age (with an increase in the prevalence rate from 2% to 8%)². Even modest increases in prevalence rates represent large numbers of youth nationally.

To fully understand the impact of youth smoking, we need to translate youth smoking rates into health and economic costs. The majority of these costs are delayed 20+ years from smoking onset, so looking only at the impact on youth is not fully informative. The most recent data suggest that the direct health care costs attributable to smoking among all ages in Canada amounted to $2.4 billion in 1996⁵. Table 1-A partials out these costs for the years 1991 and 1996 and reveals the need for up-to-date and projected costs. While taxes resulting from cigarette sales contributed about $2.1 billion in excise duties and excise taxes to the economy in 1996⁶, total direct (e.g., time in hospital) and indirect (e.g., lost productivity) costs attributable to tobacco smoke far exceeded this figure, amounting to $15.2 billion in that year. Using more stringent assumptions Single and colleagues estimated costs attributable to tobacco smoke were $9.6 billion in 1992⁷. As reported in the YSS Technical Report 1994, these smoking-attributable costs have continued to rise steadily since 1966. Due to the lag period of much smoking-attributable illness and mortality, these figures will remain high for several years and will not drop without significant and sustained efforts to reduce the number of smokers in Canada.

Table 1-A - Smoking Attributable Economic Costs, Canada, 1991 and 1996

Cost Item	Cost in 1991 (in $ Billion)7	Cost in 1996 (in $ Billion)8
Direct Costs
Health Care	2.5	2.4
Residential Care	1.5	(not available)
Workers' Absenteeism	2.0	2.2
Fires	0.8	(not available)
Indirect Costs
Lost Future Income Due to Premature Death	10.5	11.3
Adjustments for Future Costs (if Smokers Had Not Died)	-1.5	-0.7
Total Costs	$15.8	$15.2

The Canadian response to the health crisis posed by the use of tobacco products has grown with time. Built on both Canadian experience and successful interventions elsewhere, this response has incorporated a comprehensive approach. The technical report for the 1994 Youth Smoking Survey² indicated:

Prevention, cessation, and protection are the three pillars of Canada 's national anti-tobacco strategy. First articulated in the 1987 Directional Paper of the National Program to Reduce Tobacco Use in Canada⁸ these three objectives were reiterated in the update of the National Strategy to Reduce Tobacco Use in 1993⁹ and the Tobacco Demand Reduction Strategy of 1994¹⁰. Protection and cessation are the focus of Tobacco Control, A Blueprint to Protect the Health of Canadians, released by Health Canada in late 1995¹¹. The strategies and tactics outlined in these documents make it clear that prevention, protection, and cessation are mutually reinforcing. Prevention and cessation both serve to reduce smoking and thus environmental tobacco smoke, while protection measures promote cessation by removing opportunities to smoke. Protective measures also reinforce prevention efforts by reducing the modeling of smoking as a normal and desirable behaviour.

To the above objectives, for the new millennium, the federal strategy¹² added harm reduction. Harm reduction refers to efforts to regulate products in such a way as to reduce the risk from tobacco use. Further, the National Tobacco Control Strategy¹³ endorsed by the federal and provincial/territorial governments and non-governmental organizations, has identified tobacco industry denormalization, as an important objective.

Also complementary to the above strategies, 9 of 10 provinces and 2 of 3 territories have identified provincial / territorial strategies for tobacco control ¹. Despite these efforts, Table 1-B indicates that per capita expenditures fall far below those recommended by the Centers for Disease Control (CDC) in the United States to implement evidence-based best practices in state tobacco control. These estimates range from US$7 to $20 per capita [approximately $8.75-$25 Canadian) in states with population under 3 million, to US$5 to $16 per capita (approximately $6.25-$20 Canadian) in states with population over 7 million)¹⁴. Canada 's average expenditure (CAN$1.79) lags far behind the US average and even farther behind CDC's recommended per capita expenditures. On the other hand, jurisdictions like California have made substantive inroads into tobacco use reduction with funding that exceeds the Canadian average, but does not reach CDC's recommended level. Canadian jurisdictions should monitor costs and outcomes to assess the value they for resources invested.

Table 1-B - Per Capita Funding for Tobacco-Control (2002-2003) by Territories, Provinces in Canada and Selected US States¹⁵

Select Jurisdictions	Population	2002-2003 Funding (CDN$)	Per Capita Spending (CDN$)
CANADA	30,454,994	54,595,815	1.79
NT	41,186	317,815	7.72
NU	28,300	150,000	5.30
AB	3,086,034	11,700,000	3.79
QC	7,435,504	20,000,000	2.69
NS	943,756	1,600,000	1.70
ON	11,964,104	19,000,000	1.59
BC	4,120,891	4,400,000	1.07
PE	139,330	114,000	0.72
SK	1,014,403	584,000	0.58
MB	1,148,181	668,000	0.52
NL	533,305	250,000	0.47
NB	729,498	Unknown	Unknown
YK	28,674	Unknown	Unknown
United States (all)	284,796,887	1,190,707,200	4.18
Maine	1,286,670	21,333,504	16.58
Mississippi	2,858,029	31,008,000	10.85
Minnesota	4,972,294	44,806,560	9.01
California	34,501,130	208,590,816	6.05
Maryland	5,375,156	31,085,520	5.78

Objectives of the YSS

To pursue the multiple objectives of tobacco control effectively, comprehensive data are needed on behaviour, attitudes, beliefs, knowledge, and social influences. These data are needed not only for the population as a whole, but also for particular subsets, most notably youth. The YSS is the best source yet of such data at a national level, and this report of the 2002 YSS survey updates findings from the previous 1994 survey.

The 2002 YSS builds upon the objectives of the earlier YSS, and thus are largely consistent with those detailed in the 1994 YSS technical report: Specifically, the 2002 YSS was:

• to update the 1994 survey and provide a current national picture of youth smoking behaviour for students in grades 5-9;
• to provide insights into the regulatory, educational, and social influences² that youth face in deciding whether or not to experiment with or take up smoking, continue with the habit, or stop smoking;
• to establish a resource for making sound, evidence-based decisions on federal and provincial policies and programs to control tobacco use among Canada's youth; and,
• ultimately, to contribute to Canada 's tobacco control monitoring systems.

In addition, 2002 YSS objectives were enhanced to gain perspective in the following areas:

• students' experiences with alcohol and drug use in grades 7-9;
• the impact of health practitioners (doctors and dentists) on smoking behaviour;
• other potential correlates of smoking (e.g., physical activity, reading, recreation and self image).

Overview of the YSS Content

Table 1-C summarizes the topics covered in the 2002 YSS compared to those covered in the 1994 survey.

Table 1-C - 2002 & 1994 YSS Questionnaire Content

Questionnaire Content	YSS 2002	YSS 1994
Student Questionnaire
Smoking Prevalence	x	x
Smoking Behaviour, Other Forms of Tobacco Use, Attempts to Quit	x	x
Social and Demographic Factors (Influence of Family, Friends, Teachers)	x	x
Acquisition of Cigarettes	x	x
Impact Of Policies (In School and at Work)	x	x (School Only)
Education (At School, Pack Warnings)	x	x
Attitudes and Beliefs About Smoking	x	x
Awareness of Health Effects of Smoking	x	x
Youth Funds Available for Purchasing	x	x
Tobacco Marketing Influences	x	x
Experience with Alcohol and Other Drugs*	x
Influence of Health Practitioners	x
Physical Activity, Reading, Recreation, Self Image	x
Parent Interview
Household Composition	x	x
Demographics    Education    Occupation    Income	x x x	x
Child Access to Health Services (Family Doctor, Dentist)	x
Smoking Restrictions in The Home	x
Smoking Prevalence in The Home	x

* These items were surveyed in grades 7-9 only.
To protect the confidentiality of proprietary business information, brand preference was not included in the file provided by Statistics Canada. It was replaced by derived information on cigarette strength and tar levels.

Uses of the YSS Data

While the data collected for the YSS suit many purposes, they are primarily intended to facilitate the planning and monitoring of tobacco control policies and programs. Given the age group surveyed and national scope of the sample, the YSS is best suited to the prevention focus of the Federal Tobacco Control Strategy ¹² and the National Tobacco Control Strategy ¹³. To a lesser extent, analysis of questions in the survey also contributes to understanding of progress toward cessation, protection, harm reduction (Federal Strategy), and tobacco industry denormalization (National Strategy) objectives.

In general, surveillance needs for older age groups, including older youth, are well served by the Canadian Tobacco Use Monitoring Survey (CTUMS)³, the Canadian Community Health Survey (CCHS)¹⁶ and other data collection systems (e.g., School Smoking Profile¹⁷. However, Canada lacks current, nationally based trend data for tobacco use in youth in grades 5-9³, encompassing the age group marked by the onset of tobacco use². The 2002 YSS remedies this deficiency. The survey complements behavioural data with items tapping a variety of influences on smoking among students in grades 5-9. Analyses of these data will permit policy-relevant interpretation in the areas of education and health promotion, restrictions on public smoking, and denormalization of the tobacco industry. Finally, the addition of items tapping non-medical substance use in the 2002 YSS will facilitate the linkage of tobacco policy to policy in other areas of health protection and promotion. Chapters 3-12 are organised to improve understanding of this wide range of domains.

In addition to the policy driven uses of YSS data, the 2002 survey may facilitate further research in youth smoking. Unfortunately, this did not happen with the 1994 YSS data. A search of the Medline database from 1996-2004 did not find any reports analysing these data, in spite of their rich potential. The consistency of 2002 YSS items with those in the 1994 survey, and the comparable (large) sample size should make further research using these data more appealing to the research community. Large samples are required especially when behaviours are relatively infrequent, as is the case with many topics relevant to the grades surveyed with the YSS.

Overview of YSS Methods

The 2002 YSS was a two-stage stratified clustered design with schools as the primary sampling units and classes as the secondary units. Within each province, each school containing students in grades 5-9 was placed in one of two strata depending on whether the school was located in a Census Metropolitan Area⁴ or not, with an additional stratum in Quebec and Ontario for Montreal and Toronto. Within each stratum, for each of grades 5-9, schools were selected with probability proportional to their size. Then from the selected schools, field personnel selected one eligible class at random from those in the school at the designated grade.

The 2002 YSS was administered to students within selected classes and was supplemented by telephone interviews with parents. Although the basic function of the 2002 parent's questionnaire remained the same as it was in 1994 (i.e., the collection of socio-economic information about the child's family), the content was significantly augmented. Both the students' and parents' surveys were conducted under the voluntary provisions of the Statistics Act¹⁸.

Sufficient response rates were acquired for the targeted population. The student response rate was 82%, comprising 19,018 usable questionnaires. These questionnaires were used to provide estimates for the 2,027,506 students in the target population (grades 5-9). The number of responses was large enough to perform detailed analysis. This allows reliable provincial estimates to be available for many variables, an important consideration because the provinces have major responsibility for tobacco control in their populations and complete jurisdiction over activities in schools.

Statistics Canada was responsible for the sample design, data collection, and data processing. It collaborated with Health Canada on questionnaire design. The school questionnaire and the parent questionnaire were both developed through feasibility studies, pilot tests, and qualitative testing, including a series of in-depth interviews with children in grades 5-9.

Organization of the Report

Conceptual Framework of the Analysis

Figure 1-C displays a simplified model that guided development of the questionnaire and this report. Consistent with the 1994 survey, the principles used to guide efforts are consistent with a social-cognitive approach to explaining behaviour¹⁹ along with the policy context. Potential relationships between content areas are also suggested in Figure 1-C.

Foundational to the YSS is its assessment of past and current smoking behaviour, and expectations about future smoking behaviour, found at the bottom of Figure 1-C. The survey details current smoking behaviour, permitting distinctions at several levels of smoking behaviour appropriate to youth including youth with no smoking experience (Never Smoker who has Never Seriously Thought About Smoking, Never Smoker who has Seriously Thought About Smoking) and those with smoking experience (Puffer, Smoked Beyond Puffing, Not Daily Smoker, Daily Smoker). The survey also permits less-detailed descriptions of past behaviour (e.g., age of initiation for smokers and age of any attempts to stop) and future behaviour (e.g., expectations in one year, experimentation within a month for persons not currently smoking). The boxes surrounding the smoking behaviour box identify potential influences. These include items concerned with acquisition of cigarettes and restrictions on smoking in schools and the home, which could inform potential policy and program initiatives around the availability of cigarettes and the curtailment of where smoking is allowed. Added for 2002 are items that describe other behavioural influences (alcohol and non-medical drug use, recreational activities). The survey also explores selected psychosocial and educational influences that might influence decisions to experiment, start, continue, abstain, or stop smoking. These take the form of intra-personal factors, such as knowledge, beliefs, and attitudes about smoking. Inter-personal or social influences explored include the behaviours of parents and close friends and attitudes of parents. The influence of these social models surrounding youth may be moderated by educational influences. For instance, the survey explores the use of and support from health professionals (doctors and dentists). Respondents describe school lessons on tobacco use and awareness of cigarette pack warnings. Each of these topics may influence decisions to start, continue or stop smoking.

Figure 1-C - Smoking Behaviour and Social-Cognitive-Policy Influences Covered in YSS 2002

Format of the Report

The structure of this report is outlined in accordance with the conceptual framework, illustrated in Figure 1-C.

Chapter 2 provides details of survey methods including survey design, sample design, data collection, and analyses. Following this, smoking behaviour is described in Chapters 3 and 4. Chapter 3 provides prevalence data on types of smoking, as well as detail on such behaviours as inhaling, use of smokeless forms of tobacco, age of initiation, and expectations of future behaviour. Chapter 4 is devoted to the topic of stopping smoking, an important issue even among this young population.

Chapters 5 through 10 describe influences on smoking and the acquisition of cigarettes - factors that may either positively or negatively influence the development of smoking or lifelong abstinence.

Social influences originating from peers and parents are the topic of Chapter 5, while Chapter 6 looks at the perceived impact of heath practitioners, specifically doctors and dentists, on smoking behaviour (a topic that is novel to the 2002 YSS). Chapter 7 deals with more cognitive and value-laden influences - beliefs and attitudes about smoking, cigarette package health warning messages, health issues, and the reasons why smokers start. These three chapters are highly relevant to strategies focused on prevention.

Chapter 8 discusses knowledge of health problems and cigarette package health warning messages, the smoker's awareness of the contents of his or her own brand, and whether he or she learned in school about the dangers of smoking. The results of this chapter are important for those who design and deliver prevention-oriented programs, especially health education messages, as well as those whose focus is on protective legislation and regulation.

Chapter 9 examines many aspects of cigarette access that are relevant to tobacco control: usual source of cigarettes, attempts and strategies to purchase cigarettes, and usual brand. Most of these topics are directly relevant to objectives set out in the Federal and National Tobacco Control Strategies.

Regulatory restrictions on smoking are the subject of Chapter 10. This chapter describes the existence of restrictions on smoking in schools and whether these restrictions have had, or would have, the desired impact on youth smoking. Data are also presented on knowledge of the minimum age to purchase cigarettes. All of these topics are relevant to the Federal and National Tobacco Control Strategies and to the objectives of prevention, protection, cessation, harm reduction, and tobacco industry denormalization.

Insight into additional unhealthy behaviours of students is depicted in Chapter 11, including utilization rates of alcohol and drugs for non-medicinal purposes. The content of this chapter is another new component in the 2002 YSS, enabling the relationships among various risk behaviours to be better understood.

Chapter 12 deals with international comparisons of tobacco use and is a new chapter for the 2002 report. Comparison of the progress of Canada and other countries in youth tobacco control may facilitate identification of effective strategies.

Chapter 13 concludes the report with a synthesis of the findings reported in Chapters 3 through 12, and a discussion of the implications of findings, particularly with regard to tobacco control programs and policies.

Format of Chapters 3-12

The ten chapters that present the findings of the 2002 YSS share a common format. Each chapter begins with highlights of its findings, and a description of the methods specific to the chapter. Then, the findings are presented and described using text, tables and figures. Next, the findings are interpreted with reference to any methodological issues and data from other sources. Each chapter concludes with a discussion of policy and program implications of the findings and the identification of unanswered questions that should be addressed in further analysis.

Detailed tables follow each chapter, while summary figures and text tables appear within each chapter. As described in detail in Chapter 2, commonly accepted standards are used for qualifying the data appearing in tables and figures and for testing the significance of differences noted in the text.

Taken together, the chapters in this technical report issue a challenge to tobacco control stakeholders. The enhanced understanding of patterns of tobacco use and related behaviours and correlates offers an opportunity for evidence-based planning of policy and practice in tobacco control. The simple tabulations described suggest opportunities for more complex statistical controls in further research using the data. Difficulties accessing the 1994 data may account for the dearth of reports utilizing that survey. Statistics Canada has now made both the 1994 and 2002 datasets available through Regional Data Centres, thus markedly improving access. The authors of the current report trust that their efforts in this volume will signal the start of considerable activity to utilize the data effectively for further action to reduce the health burden caused by the use of tobacco industry products in Canada. We hope that the next Youth Smoking Survey will reflect further decreases in youth tobacco use as a result of these actions.

Footnotes

1. Provincial Tobacco Control Strategies: British Columbia Tobacco Strategy, Alberta Tobacco Reduction Strategy, Manitoba Provincial Tobacco Control Strategy, Ontario Tobacco Strategy, Plan Québécois de Lutte Contre le Tabagisme, New Brunswick Tobacco Strategy, Prince Edward Island Strategy for Healthy Living, Nova Scotia Comprehensive Tobacco Strategy, Newfoundland ACT Tobacco Reduction Strategy, Yukon Tobacco Reduction Strategy, Northwest Territories Action on Tobacco

2. While the 1994 YSS examined commercial influences [i.e., advertising and sponsorship] as part of social influences, the 2002 YSS did not.

3. This report will refer to the sample by the conventional grade system 5-9. Please note grades 5, 6, 7, 8, and 9 coincide with the Quebec grades Cycle 3-1, Cycle 3-2, Secondaire I, Secondaire II and Secondaire III respectively.

4. A Census Metropolitan Area is an area consisting of one or more adjacent municipalities situated around a major urban core that must have a population of at least 100,000.

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Table 1-1: Health Behaviour Surveys, Grades 5-9, Canada

Table 1-2: Health Behaviour Surveys, Grades 10-12, Canada