2002 Youth Smoking Survey - Technical Report

International Comparisons

Alan Diener, PhD
Office of Research, Surveillance and Evaluation
Tobacco Control Programme
Health Canada

David Hammond, MSc
Department of Psychology
University of Waterloo

Acknowledgements: The authors thank Ed Adlaf (Centre for Addiction and Mental Health) and Neil Collishaw (Physicians for a Smoke Free Canada) who reviewed an earlier draft of this chapter and provided helpful commentary.

Highlights

• Rates of "ever tried" smoking were lower in Canada than they were in the four other countries for which data were reviewed. Twenty-six per cent of Canadian youth in grades 6-9 had ever tried smoking compared to rates of between 36% to 44% in Australia, England, Scotland, and the United States.
• There were no consistent differences in smoking behaviour amongst males and females in the countries reviewed.
• All five countries experienced falling prevalence rates of smoking among youth in recent years.
• Overall, 26% of Canadian youth in grades 6-9 who smoke purchased cigarettes from retail sources, while 12.5% of US youth who smoke purchased cigarettes from retail sources.
• Health practitioners in the US were more likely than Canadian health practitioners to talk to youth about the dangers of tobacco use.
• Common definitions of youth smoking behaviour and common questions should be encouraged across national surveys employed by different countries. This would permit similar analyses of data collected and better comparisons of tobacco use behaviours and their determinants across countries.

Introduction

This chapter compares smoking behaviour and related information among youth in Canada, Australia, England, Scotland, and the United States (US). These countries provide reasonable comparisons with Canada for several reasons. First, they share similar standards of living and cultures. Second, adult smoking rates in these countries are similar -between 21 and 26% in 2002--and the patterns of smoking are similar with respect to age and sex. ^a,1,2,3,4

Each of these countries also conducts a regular school based survey of youth smoking behaviour and related information. Direct comparisons between these surveys are difficult due to differences in methodologies and definitions. However, the surveys share enough core questions that it was possible to analyse and compare certain variables including the prevalence of tobacco use, sources of cigarettes, store refusals and asking for identification and whether health practitioners discussed smoking with youth, although all the information on each topic was not available for all of these countries.

Tobacco Control Policies and Programs

Prevention of tobacco use among youth is a primary objective of tobacco control policy, both within Canada and around the world. Although tobacco control regulations and legislation differ considerably among Canada, Australia, England, Scotland, and the United States, each has introduced leading-edge policies intended to reduce smoking among youth, including labelling policies, advertising restrictions, and taxation policies. The following provides a summary of tobacco control policies in these countries as of 2002, when the YSS was administered. It should be noted that there have been significant changes to several of these policies since 2002.

Health Warning Messages and Labelling Policy

Health warning messages on cigarettes are an important source of health information for youth. Health warning messages not only communicate the health risks of smoking, but can also provide cessation advice, and may encourage some smokers to quit. In 2002, there were substantial differences in the strength and size of health warning messages among the four countries. Canada had the most comprehensive health warning messages in the world, followed by Australia, the United Kingdom (UK), and the US . Canadian cigarette packages displayed one of 16 full colour graphic health warning messages, covering 50 percent of the cigarette package, with additional information inside the cigarette package. In contrast, Australian cigarette packages featured one of six black and white rotating health warning messages, covering 25 percent of the front of the cigarette package. The UK cigarette packages also had six text health warning messages, although these covered only 6% of the cigarette package, whereas US cigarette packages carried four small text-only health warning messages on the side of cigarette packages, introduced in 1984. As of 2002, there were no restrictions on the use of potentially misleading brand descriptors such as "light" or "mild" on cigarette packages in any of the countries examined.

Sales to Minors

Tobacco sales to individuals under the age of 18 were prohibited in all four countries. Compliance with this legislation varies within the four countries, yet remains generally high relative to international standards.

Tobacco Advertising, Sponsorship, and Promotion

Comprehensive restrictions on all forms of tobacco advertising are an essential component of youth smoking prevention strategies. In general, restrictions on tobacco advertising, in 2002, were strongest in Australia where all forms of advertising including print media have been banned since 1993 and Canada where most forms of advertising were banned.^b Print advertising was unrestricted by law in the UK and US and relatively widespread in 2002. Despite more comprehensive legislation in Canada and Australia, point-of-sale displays, sport and cultural sponsorships and promotional contests remained largely unrestricted, similar to the situation in the UK and US.^c

Note that it is difficult to compare national differences in tobacco advertising, sponsorship, and promotion given ongoing changes in policy and the fact that restrictions are often introduced regionally. Note also that several policies have been introduced since the 2002 YSS was administered. For example, in Canada, tobacco company sponsorship promotions were prohibited effective October 2003. In the UK, all tobacco advertising (with limited exceptions) has been banned since February 1993, and all sponsorship promotions will be banned as of July 31, 2005.^d Further changes are imminent in response to the Framework Convention on Tobacco Control (FCTC), which requires that signatories eliminate all tobacco advertising, promotion, and sponsorship within 5 years of ratification of the Convention.^e The FCTC was ratified by Canada, Australia and the United Kingdom in 2004.

Prices and Taxation Policies

Increases in the price of cigarettes leads to a decrease in cigarette use and overall smoking prevalence, particularly among youth smokers.⁶ As a consequence, cigarette taxes have become among the most widespread tobacco control policies. In 2002, cigarette taxes were lowest in the US and relatively equal among Canada, the UK, and Australia . However, because tobacco companies and retailers ultimately determine price, cigarettes were most expensive in the UK and roughly equal among the remaining three countries in 2002. Note, however, that these national averages obscure rather large differences between state and provincial taxes, within countries. Given the regional differences in price and taxation-- particularly within Canada and the US -- it is somewhat misleading to discuss national-level differences in taxation.^f

Smoke-Free Restrictions

Smoke-free policies have emerged as a critical strategy to protect the health of non-smokers. Workplace smoking restrictions have the added benefit in that they reduce tobacco use among employees who smoke. As of 2002, there were no national-level smoke-free policies in any of the four countries. Rather, smoke-free legislation has been introduced at the regional (province or state) and municipal level in all four countries. As a result, smoke-free policies vary considerably within each of the four countries and among the countries.

Anti-Smoking Media

Mass media campaigns are an important component of tobacco control strategies. Effective media campaigns help to communicate the health consequences of smoking and render tobacco use among both youth and adults less socially acceptable (see note below). Mass media campaigns are introduced at the national, regional, and even local levels in each of the four countries. In Canada, for example, 40% of the federal tobacco control budget was set aside for mass media campaigns, which is then divided between national and regional campaigns. Because media campaigns are conducted both nationally and regionally, it is difficult to compare the level of anti-smoking media between the countries.

Youth Prevention Programs

School-based programs remain the most common setting for youth prevention programs in each of the four countries. Yet, the scope and effectiveness of these programs vary considerably. In addition, although school-based programs may receive support from federal tobacco control agencies, they are rarely implemented on a national level and are typically local in scope. As a result, it is not possible to compare youth prevention programs between the countries in any systematic way.

Methods

Each of the countries included in this chapter conducts a regular school-based survey of smoking behaviour and related information. The most recently available published reports and data for the United States, England, Scotland, and Australia were employed.^{9,10,11,12,13} Comparing results across surveys is difficult due to differences in methodologies including what questions were asked and how they were asked, as well as the ages or grades of the target population. It is also common to find different definitions of smoking behaviour between youth and adults across countries. As discussed in Chapter 2, definitions of adult smoking behaviour are well established: a smoker is typically defined as an individual who has smoked over 100 cigarettes in their lifetime and smoked in the last 30 days, while a daily smoker is typically defined as an individual that has smoked every day of the last 30 days. However, the criteria used to define youth smoking, particularly for experimental tobacco use common to the age group surveyed in the YSS, is not as well established.

The surveys used in this chapter all employed different methodologies, and definitions of smoking behaviour. Hence, we were limited in what definitions we could use for comparison purposes. The prevalence of having ever tried smoking was reported for each country and was used in this analysis. Each country also surveyed different grades or age groups limiting comparisons between countries. The most comparable grade or age groups were used in all the analyses reported here. More detailed comparisons were possible between Canada and the United States due to our access to the 2000 National Youth Tobacco Survey (NYTS) data set.¹⁰ Comparable questions on the sources of cigarettes were available for Canada, United States, and Australia. It was also possible to analyse the prevalence of whether health practitioners advised their patients on tobacco use in Canada and the United States . (See the appendix for the questions employed in analyses for this chapter).

The Surveys

In the United States, the National Youth Tobacco Survey (NYTS) collects smoking related information from students in grades 6-12. The first NYTS was conducted in 1999, and it was repeated in 2000 and 2002. As of the writing of this chapter only a preliminary report was available for the 2002 NYTS, with very little comparable information to that available from the YSS.⁹ However, the data set for the 2000 NYTS was available from their web site and was used for this chapter.¹⁰ The 2000 NYTS obtained responses from a total of 35,828 youth in 324 schools. The overall response rate was 84% (the school response rate was 90% and the student response rate was 93%). A total of 21,950 youth in grades 6-9 -those comparable to the YSS sample--completed the NYTS.

England conducted its first Survey on Smoking, Drinking, and Drug Use Among Young People in England in 1982. The most recent survey was conducted in 2002 and sampled youth 11-15 years old in school years 7-11.¹¹ A total of 9,859 students from 321 schools completed both a survey and a 7-day smoking diary. The overall response rate to this survey was 63% (the school response rate was 72% and the student response rate was 88%). The main outcome measure of smoking behaviour employed was "regular smoker" defined as an individual that smokes at least once a week.

The Survey on Smoking, Drinking, and Drug Use Among Young People in Scotland, also started in 1982, employs a similar methodology to the English survey in terms of the questions included and the definitions of smoking behaviour used in the analysis. The most recently available published data were from the 2000 survey.¹² The sample in the Scottish survey included youth aged 12-15 years old, in school years S1 to S4 (comparable to grades 8-11 in Canada and the United States ). A total of 4,774 students from 150 schools completed the survey and 7-day smoking diary. The overall response rate for this survey was 64% (the school response rate was 79% and the student response rate was 90%).

The Australian Secondary School Alcohol and Drug (ASSAD) Survey was first conducted in 1984. The survey of 12 to 17 year old students is conducted every 3 years and was last conducted in 2002.¹³ A total of 23,417 students, between the ages of 12-17, from 363 schools completed the survey^g. Sixty-five per cent of the schools contacted agreed to participate in the survey. The response rate among students was 84%.^h Results were either broken down by age or by age-group. The age-groups employed were 12-15 and 16-17 years old. Hence, in this chapter we focused on the 12 to 14 year olds when results were presented for each age and 12-15 year olds when the results were only broken down by age group.

Definitions and Questions Compared

Data with respect to "ever tried smoking even just a puff" were analyzed for all of the countries. Due to methodological differences, it was not possible to compare any other smoking behaviour definitions except for Canada - Unites States comparisons. With direct access to the 2000 NYTS data set it was possible to analyse the U.S. data according to the 3-category definition of smoking status described in Chapter 2 (Table 2-C) and used elsewhere in this report - Never Smoker, Puffer, and Smoked Beyond Puffing. The NYTS and YSS samples were limited to grades 6-9 in order to be more comparable.

Information with respect to the sources of cigarettes (retail or social) was available from Canada, the United States, and Australia . Caution should be used when comparing the responses as the times frames employed in the question were different in each country's survey. In the YSS, respondents were asked where they usually obtained their cigarettes. In the NYTS respondents were asked where they usually obtained their cigarettes in the last 30 days . In the Australian survey, students were asked where they got their last cigarette.ⁱ Although the UK surveys included questions on sources of cigarettes, the respondents were not limited to just one response (i.e. they could have picked numerous retail and social sources). Hence, the responses from the UK surveys were not directly comparable to the YSS data and they were not analyzed.

The YSS and NYTS included questions regarding whether the respondents had been asked for identification or had been refused a cigarette sale. The UK surveys also included the latter question. These data were included in our analysis.

The YSS and NYTS included similar questions regarding whether a health practitioner had ever discussed the dangers of smoking or had asked if their patient had smoked. These data were not available for the UK or Australia.

The UK and Australian surveys only broke down their results by age (as opposed to grade). Hence, the YSS and NYTS results were also broken down by age for comparison purposes. Unfortunately, there were no comparable questions regarding exposure to environmental tobacco smoke or any attitude and belief questions. For Canada - United States comparisons all results were rounded off to one decimal place since the actual data sets were available and used in the analysis. When data from England, Scotland, or Australia were included in the comparisons the results shown were rounded to the nearest whole number as this is how results pertaining to those countries were published.

Sample and Response

The YSS was limited to grades 6-9 (or ages 11-14) for most comparisons as this was the minimum grade employed in all of the other surveys. In general, missing YSS data for items discussed in this chapter accounted for less than 10% of the total responses. As such, the data presented are based on those for whom complete data were available. According to Statistics Canada guidelines, data were deemed non-reportable if the sample size was too small (n<30). Statistical differences between countries were difficult to ascertain as confidence intervals were generally not reported.

Findings

Prevalence of Tobacco Use

It is important to reiterate that direct comparisons are difficult across surveys. While comparable questions were employed in this analysis, different age groups were sampled in each survey. For example, the UK surveys reported results for the age group 11-15 years old. Hence, the sample was slightly older than that of the YSS and this must be kept in mind when reviewing the results.

The Canada - United States results are most comparable as the same grades were analysed and more types of smoking behaviour could be examined. Rates of prevalence of tobacco use were higher for all products in the United States (Table 12-1). Almost 41% of U.S. youth reported that they had ever tried smoking, compared to 26% of Canadian youth in grades 6-9. U.S. students were four times more likely to have ever tried chewing tobacco (10.5% versus 2.5%).

Almost twice as many U.S. students had smoked beyond puffing compared to Canadian students (27% and 15%, respectively) (Table 12-2). This finding was also observed when examining males and females separately. The difference in prevalence of smoked beyond puffing was largest between the grade 6 students and the gap narrowed slightly across the higher grades (Table 12-3).

Rates of ever tried smoking were lower in Canada than they were in the other countries. Twenty-six percent of Canadian youth in grades 6-9 had ever tried smoking. The rates in the other countries were quite consistent and ranged from 36% to 44% (Table 12-4).^j Note that for the UK, 15 year olds were also included in the analysis (approximately grade 10 in Canada and the United States ), while in Australia and Scotland 11 year olds were not included in the sample.^k

There were no consistent gender differences between the countries. In Australia and Canada the prevalence of having ever tried smoking is similar amongst males and females. In the United States slightly more males had ever tried smoking than females and in England and Scotland slightly more males had ever tried smoking than females (Table 12-4). Rates of "ever tried smoking" among youth were lower in Canada than the other countries for each age amongst those who were between 11 through 14 years old (Table 12-5).

All countries had experienced similar trends with declining prevalence rates. The decline in proportion of youth who reported ever trying cigarettes between 1994 and 2002 was greater in Canada than in England, Scotland, and Australia . In 1994, 42%, 47%, and 53% of youth in Canada, England, and Scotland, respectively, had ever tried smoking cigarettes.^l,11,12,14 In 1993, 50% of Australian youth had ever tried smoking.^m,13 In 2002, the rates had fallen to 26%, 42%, 48%, and 36% in Canada, England, Scotland, and Australia, respectively. This finding is consistent with trends relating to adult prevalence in the countries reviewed.ⁿ

Sources of Cigarettes

In Canada, more youth reported buying cigarettes from retail sources than in the United States (Table 12-6). Overall, 26% of Canadian youth in grades 6-9, who had smoked in the last 30 days, purchased cigarettes from retail sources, while 12.5% of US youth who had smoked in the last 30 days purchased cigarettes from retail sources. In Australia, the respondents were asked for the source of their last cigarette and 14% of 12-15 year olds, who had smoked in the last 7 days, had purchased their last cigarette from retail sources. Both Canadian youth and US youth were asked for proof of age approximately the same amount of time (30% in Canada, 32% in US). With respect to having been refused a sale of cigarettes, the rates ranged from 37% in Canada to 45% in the United States (Table 12-7).

Practices of Health Practitioners

In the YSS about 20% of youth had had their doctor talk to them about the health effects of tobacco compared to 24% of comparable American youth (Table 12-8)Almost twice as many youth in the US than in Canada stated that their dentist had spoken to them about the dangers of tobacco use (16% and 9%, respectively).

Discussion

Prevalence of Tobacco Use

It is unclear why smoking rates were higher in the other countries than in Canada . The US and Scottish data are from 2000 so one explanation is that rates were higher due to the earlier sampling period. However, there was no statistically significant decrease in smoking between the 2000 and 2002 NYTS. Hence, the difference in time frames, with respect to the U.S. data, may not explain the difference.

The smoking prevalence among adults in each of the four countries was roughly similar in 2002: Canada -21% (23% male, 20% female), US -23% (25% male, 20% female), Australia - 23% (26% male, 21% female), and the UK - 26% (27% male, 25% female). Smoking remained more prevalent among males; however, gender differences in smoking prevalence continued to narrow in each of the four countries.

The lower smoking rates among Canadian youth may be attributable to Canada's comprehensive tobacco control policies, many of which are focussed upon preventing youth smoking. Many of these national policies have been implemented or strengthened since 1994 and have been supplemented by provincial, territorial, and municipal policies. These policies have included increases in taxation; school smoking bans and other school-based intervention programs, advertising bans, smoke-free legislation, and new health warning messages on cigarette packages. Groups such as the Youth Action Committee (YAC) on tobacco have provided valuable input on issues and ideas related to tobacco control. While YAC is a federal committee, there are also many youth tobacco groups in the provinces and territories, as well as in local communities and schools.

Sources of Cigarettes

While US youth were less reliant on retail sources of cigarettes than Canadian youth, the percentage of youth being asked for proof of age, or that were refused sales was similar in both countries. It should be noted that the Canadian questions asked about ever having been asked for proof of age or being refused a sale, whereas the US questions explicitly asked about the past 12 months only. One explanation for this apparent discrepancy is that youth in the United States made fewer attempts to purchase cigarettes from retail sources, perhaps due to having difficulties purchasing cigarettes in past experiences.

U.S. youth may be less likely to obtain cigarettes from retail sources than Canadian youth due to impact of the Synar Amendment. The Synar Amendment of the Federal Public Health Service Act, was passed in 1992, and requires states to limit tobacco sales to those 18 years of age and over and specifies requirements with respect to retailer compliance regarding sales of tobacco products to minors.¹⁶ Regulations with respect to inspections and other facets of tobacco sales are clearly specified in the Synar Amendment. Failure to comply with the Amendment, including achieving targeted compliance rates, results in a loss of federal funding for the states. Hence, the Synar Amendment has acted as an incentive for states to improve their compliance rates through increased enforcement. Compliance reached over 80% in 44 states by 2002.¹⁷ In comparison, in Canada, compliance rates were about 70% nationally, in 2002.

It should be noted that, although less youth are obtaining their cigarettes from retail sources in the U.S. than in Canada, this has not resulted in lower rates of tobacco use. Clearly, preventing retail access to cigarettes is just one aspect of tobacco policy. As social sources become more important for youth, it will become more vital for policies to target them as well.

Practices of Health Practitioners

It is not clear why health practitioners, particularly dentists, talked to youth about the dangers of tobacco use more often in the US than in Canada . One explanation may be that clinical practice guidelines have been promoted more widely in the US than in Canada.

Implications for Regulation and Legislation

The differences in how youth access cigarettes in the US and Canada may have implications with respect to regulation and legislation. It is clear that youth in the US are less likely to obtain their cigarettes from retail sources. The incentives created by the Synar Amendment has apparently been effective in increasing compliance and is likely the cause for the reduction in youth obtaining cigarettes from retail sources. It would be difficult, however, for Canada to implement similar incentives. The incentives in the U.S. work since individual states are responsible for enforcement and must follow federal regulation such as the Synar Amendment to be eligible for federal funds. In Canada the federal government is responsible for the regulations and enforcement of them. In addition, without any incentives from the federal government, several provinces have undertaken more stringent regulations than they are required to. For example, six provinces (Newfoundland and Labrador, Prince Edward Island, Nova Scotia New Brunswick Ontario, and British Columbia,) have a higher minimum age requirement for the sale of cigarettes - nineteen years of age - than the federal government minimum standards (eighteen years of age).

Implications for Future Monitoring and Further Research

One of the most important tasks that must be undertaken in the future is to develop a consensus with respect to definitions of youth smoking behaviour not only in Canada but also at the international level. Clearly, the biggest limitations of this chapter were due to difficulties in comparisons across surveys. While it was possible to compare those who have ever tried smoking, it was not possible to examine other smoking behaviours, which may have created learning opportunities. Not only is it important to develop consensus with respect to smoking behaviour definitions, it is potentially just as important to develop a series of common questions relating to knowledge and attitudes with respect to smoking and tobacco use. These data from individuals should also be matched systematically with program and policy data at local and state levels to potentially gain a better understanding of how different regulations, legislation, and the other aspects of tobacco control policy affect youth smoking behaviour and attitudes. Understanding of the association of individual behaviour with environmental influences could help establish leading edge interventions. However, it must be noted that the highest priority for all national surveys should be to meet local and national needs and that surveys must be adapted to the school systems in which they are undertaken. Any comparability should not be sought at the cost of reducing data quality or usefulness with respect to these needs.

Footnotes

a. Each country reports results for different age groups. In Canada the prevalence rate was 21% for ages 15 and up. In the Unites States the prevalence rate was 22.5% for ages 18 and up. In the UK the prevalence rate for those aged 16 and over was 26%, and in Australia the prevalence rate for those aged 14 and over was 23% (the most recent available data from Australia was from 2001).

b. In Canada, tobacco print advertising is restricted to publications with a minimum of 85% adult readership, or publications directly mailed to an adult.

c. Note that, in Canada, restrictions were phased in between 1998 and October 2003

d. Domestic tobacco sponsorships were banned in the UK in July, 2003. International sponsorships will be banned as July 31, 2005.⁵ A European Union directive, which covers the UK, banning tobacco advertising and sponsorship in all member countries by July 31, 2005 was agreed on in 2002.

e. Note that countries that cannot undertake a comprehensive ban due to constitutional requirements (including Canada ) shall apply restrictions on all tobacco advertising, sponsorship, and promotion.

f. For example, in Canada, federal excise taxes in 2002 were $1.59 per pack of 20 cigarettes, while provincial taxes ranged from $1.72 per pack in Ontario to 3.20 per pack in Manitoba and Saskatchewan⁷. Provincial and federal sales taxes may also be applicable. In the United States, in 2003, federal taxes were $0.39 per pack while state excise taxes on cigarettes ranged from $.03 in Kentucky to $2.40 in New Jersey⁸. Some counties and cities also impose cigarette taxes.

g. Nine-hundred and eighty-six students were outside of the age range and were excluded in all analyses.

h. The actual student response rate was not reported in White and Hayman (2004). However they noted that the aim was to survey 80 students from each participating school. Hence with 363 schools participating 29,040 students would have been asked to participate. Note that more students were likely asked to participate as in addition to the 80 students selected from each participating school, as replacement students were also selected although it is not clear how many were asked to participate. Hence the 84% response rate is likely over-stated.

i. Note that the responses in the YSS data set were limited to students who had smoked a whole cigarette in their lifetime and had smoked in the last 30 days. The NYTS analysis was similarly limited for comparison purposes. The Australian responses were limited to students that had smoked in the last 7 days.

j. Canada : Grades 6-9, approximate ages 11-14; U.S. : grades 6-9, approximate ages 11-14; England : ages 11-15; Scotland : ages 12-15; Australia : ages 12-14.

k. The Australian results for the 12-14 year old age group were estimated based on the published results in White and Hayman (2004) and are rough estimates. White and Hayman only presented results on prevalence of having ever tried cigarettes broken down by age and for the total population aged 12-17. In the latter age group, 46% of males had ever tried cigarette smoking, 47% of females had ever tried smoking, and 47% of both sexes combined had ever tried cigarette smoking.

l. Canada: ages 11-14; England: ages 11-15; Scotland: ages 12-15; Comparable data was not available for the United States; However, results from the Monitoring the Future Study have shown that prevalence rates of cigarette use among 8 th, 10 th and 12 th grade students have been falling since 1996¹⁵.

m. Ages 12-15. Australian data was not available for 1994. Note that the results for 12-14 year olds was estimated using the data presented in Hill et al (1995) and is an estimate.

n. Adult smoking rates have been falling or have stabilized in each country.

References

1. Canadian Tobacco Use Monitoring Survey 2002. Health Canada

2. Centers for Disease Control and Prevention. Cigarette Smoking Among Adults - United States, 2002. MMWR 2004;53: 427-430

3. Office for National Statistics. Social Survey Division, General Household Survey, 2001-2002 [computer file ]. 2nd Edition. Colchester, Essex: UK Data Archive [distributor], July 2003. SN: 4646.

4. AIHW 2002. 2001 National Drug Strategy Household Survey: detailed findings . AIHW cat. no. PHE 41. Canberra : AIHW (Drug Statistics Series No.11).

5. Action on Smoking and Health. ASH briefing: The UK ban on tobacco advertising, June 2004

6. U.S. Department of Health and Human Services Reducing Tobacco Use: A Report of the Surgeon General. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000

7. Treff Karen, Pe David B. Finances of the Nation 2002 A review of expenditures and revenues of the federal, provincial, and local governments of Canada . Canadian Tax Foundation: 2003

8. www.tobaccofreekids.org. State Cigarette Prices, Taxes, and Costs per Pack . Campaign for Tobacco-Free Kids, USA : 2003

9. Vilsaint, MC, Green M, Xiao J, Davis K, Vallone D, Allen J, Jessup A, Murchie S. Legacy First Look Report 13. Cigarette Smoking Among Youth: Results From the 2002 National Youth Tobacco Survey . American Legacy Foundation: June, 2004

10. www.americanlegacy.org

11. Boreham B, McManus S (editors). Smoking Drinking and drug use among young people in England in 2002 . The Stationary Office, UK Department of Health: 2003

12. Boreham B, Shaw A (editors). Smoking Drinking and drug use among young people in Scotland in 2000 . The Stationary Office, UK Department of Health: 2001

13. White V, Hayman J. Smoking behaviours of Australian secondary students in 2002. National Drug Strategy Monograph Series No. 54. Canberra : Australian Government Department of Health and Ageing. 2004

14. Hill D, White V, Segan C. Prevalence of cigarette smoking among Australian secondary students in 1993. Australian Journal of Public Health 1995, 19: 445-449

15. Johnson LD, O'Malley PM, Bachman JG, Schulenberg JE. Monitoring the Future national results on adolescent drug use: Overview of key findings 2004. Bethesda MD : National Institute on Drug Abuse. 2004

16. http://prevention.samhsa.gov/tobacco/

17. Substance Abuse and Mental Health Services Administration. Retailers Reduce Cigarette Sales to Youth. SAMSHA News 12(2): March/April 2004

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Table 12-1 - Tobacco Use, Canada and Unites States, Grades 6-9

Table 12-2 - Smoking Category* by Sex - Canada and United States, Grades 6-9 Percentages

Table 12-3 - Smoking Category, by Grade, Canada and United States, Grades 6-9 Percentages

Table 12-4 - Ever Tried Smoking, by Country and Sex

Table 12-5 - Ever Tried Smoking, by Country and Age (Percentages)

Table 12-6 - Source of Cigarettes, by Grade, Canada and U.S., Grades 6-9 (Percentages)

Table 12-7 - Sales Refusals And Proof Of Age

Table 12-8 - Practices of Health Practitioners, Canada and United States (Percentages)