2002 Youth Smoking Survey - Technical Report

Overview and Conclusion

Murray Kaiserman, PhD
Tobacco Control Programmme
Health Canada

Paul McDonald, PhD
Department of Health Studies and Gerontology
Health Behaviour Research Group
University of Waterloo

Acknowledgements: The authors thank Mary Jane Ashley (Ontario Tobacco Research Unit) who reviewed an earlier draft of this chapter and provided helpful commentary.

Since the Youth Smoking Survey (YSS) of 1994 tobacco control activities in Canada targeted towards youth have reached unprecedented levels. While, on the legislative front, the Tobacco Products Control Act (TCPA, 1988) first identified the protection of youth within the purpose of the legislation, it was the Tobacco Sales to Young Persons Act (TSYP,1994) that restricted youth access. This was reaffirmed in the Tobacco Act of 1997. In addition, in 2000, the Tobacco Product Information Regulations introduced graphic health warning messages on tobacco products occupying 50% of the package.

Legislation and regulation were not the only activities occurring during this period. Beginning in 1994, the Federal government implemented three major tobacco control strategies, the Tobacco Demand Reduction Strategy (TDRS, 1994-1997), the Tobacco Control Initiative (TCI, 1997-2002) and the Federal Tobacco Control Strategy, (FTCS, 2001 - 2011) which provided a total of almost $800 M towards all federal tobacco control activities, with an emphasis on youth. Key to each of these strategies was the implementation at the federal level of a wide variety of programs aimed at either discouraging youth from taking up smoking or encouraging youth to quit smoking, and the provision of support for such interventions at all levels. Also, guided by the National Tobacco Control Strategy (1999), which was developed jointly by the federal, provincial and territorial governments and leading non-governmental organizations, legislation and programs implemented at the provincial, territorial, regional and municipal levels have contributed to tobacco control and to the reduction in the prevalence of tobacco product use.

As a result these activities, by 2002, as found in the second YSS, 69% of Canadian youth in grades 5-9 were classified as never smokers who had never seriously thought about smoking, i.e., they had never tried a cigarette, even a few puffs, and had never thought seriously about smoking, compared with 51% of youth in the 1994 YSS. Further, in 2002, only 23% of Canadian youth in grades 5-9 were classified as ever smokers, including 2% of Canadian youth who were daily smokers (Chapter 3). These rates were considerably lower than those found in the 1994 YSS, where 40% of youth were ever smokers and 4% were daily smokers. Among youth surveyed in the 2002 YSS, 10% had tried to smoke, even just a few puffs, but had never smoked a whole cigarette (classified as puffers) and another 10% had smoked more than a whole cigarette but were not current daily smokers (classified as smoked beyond puffing, not daily smokers). While all youth smoking rates were lower in 2002, self reported consumption by daily smokers increased to an average of 8.1 cigarettes per day in 2002 from 7.4 cigarettes per day in 1994.

In the 2002 YSS, ever smoking rates exhibited differences by province, sex, and grade. Across the provinces, ever smoking rates ranged from a high of 37% in Quebec to a low of 16% in British Columbia and Ontario . As found in the 1994 YSS, ever smoking rates increased progressively from grade 5 to grade 9 for both males and females. In contrast, for the most part, differences in the various smoking rates of boys and girls across the grades were minimal. By grade 9, there was no difference between the sexes with 58% of males and 58% of females reporting never having smoked.

In the 2002 YSS, there were more Anglophone never smokers who had never seriously thought about smoking (73%) as compared to Francophone never smokers who had never seriously thought about smoking (53%). There were more Francophone never smokers who had never seriously thought about smoking, residing outside of Quebec (73%) than Francophone never smokers who had never seriously thought about smoking, living in Quebec (52%). With respect to First Nations, there were less never smokers who had never seriously thought about smoking, among aboriginal students (51%) than smokers who had never seriously thought about smoking, among non-aboriginals (70%). In comparison to findings of surveys conducted about the same time among youth of similar age in Australia , England , Scotland , and the United States , Canadian youth in the 2002 YSS has the lowest rate of ever smokers, 26%, compared to 36%, 42%, 48%, and 41%, respectively. Compared to the 2000 US National Youth Tobacco Survey, tobacco use of all kinds among youth in Canada was less than that in the United States.

In keeping with the lower prevalence of all smoking rates among youth in the 2002 YSS, even fewer youth viewed smoking as a positive activity compared to youth in the 1994 YSS (Chapter 7). The percent of youth who considered smoking to be cool declined from 6% in 1994 to 3% in 2002. As in 1994, most of the youth who believed that smoking was cool were smokers. However, the 2002 finding that the percentage of youth who shared this belief remained unchanged across all grades was unexpected. In the 1994 YSS, there was an increase in this belief among youth in higher grades. While fewer youth in the 2002 YSS thought that smoking was cool compared to youth in the 1994 YSS, there was no difference in the perceived belief that youth start smoking because "smoking is cool" (45% vs 46%). However, in the 2002 YSS the perceived importance of each of peer pressure (64%) and curiosity (49%) was lower compared to the findings of the 1994 YSS (74% and 56%, respectively). Between 1994 and 2002, there was no change in the perceived influence of "popular kids" (45% and 46%, respectively), parent who smokes (31% and 32%, respectively) and sibling who smokes (27% and 26%, respectively). The stability in the importance of roles models as perceived reasons for smoking is an important finding for program planning.

One possible reason for the decline in smoking rates and changes in perception about smoking may be an increased awareness and understanding of the health risks associated with smoking (Chapter 8). While there was no difference in the proportions of youth in the 1994 and 2002 YSS who reported ever receiving education about smoking-related health problems (about three-quarters in both surveys), recall of specific diseases varied between the two surveys. While a smaller percentage of youth in 2002 than in 1994 reported lung cancer as a smoking-related health problem (49% and 56%. respectively), a greater percentage reported "other cancers" as an outcome (48% and 32%, respectively). The largest increase between 1994 and 2002 occurred with the reporting of "mouth problems" and "shortens lifespan", with both responses growing from about 3% to 18%.

Health warning messages which appear on cigarette packages play an important role in the education of youth, especially smokers. In the 2002 YSS, 73% of never smokers reported ever seeing health warning messages on cigarette packages, compared to 86% of puffers and 90% of those who smoked beyond puffing. Except for the last category, which remained stable between the two surveys, these percentages represent a growth from the 1994 YSS findings, when 65% of never smokers reported ever seeing health warning messages on cigarette packages, compared to 82% of puffers and 91% of those who smoked beyond puffing.

In addition to school-based programs and health warning messages health practitioners can play an important role in informing and advising youth about the consequences of tobacco use (Chapter 6). While nearly every respondent in the 2002 YSS had a regular family doctor (89%) and a regular family dentist (93%), only 17% of youth reported that their doctor ever asked them about tobacco product use and only 21% reported that their doctor ever talked about the health risks of using these products. Even fewer reported that their dentists had asked about tobacco product use and talked about the health risks (5% and 10%, respectively). Students of both sexes in the higher grades were more likely than students in the lower grades to report being asked about smoking by their doctor. For males, this percentage increased from 15% in grade 5 to 22% in grade 9, while for females, it increased from 8% to 30%. However, students of both sexes in the higher grades were less likely than students in the lower grades to report that they had been advised by their doctor about the health risks of using tobacco products. These findings indicate considerable potential for more involvement by these health professionals in preventing youth from starting to use tobacco products and promoting quitting among those who are already using these products.

In 2002, not only were fewer youth trying smoking, but fewer youth were purchasing cigarettes at retail. In addition, more youth reported being refused when trying to buy cigarettes (Chapter 9). In 2002, about 75% of Canadian youth reported that they usually obtained their cigarettes from social sources (family or friends), compared to 59% in 1994. Overall, a higher percentage of females relied upon social sources than males (80% and 68%, respectively). Older smokers and daily smokers, of both sexes, tended to be more reliant upon retail outlets than younger smokers. Of those who purchased cigarettes at retail, the corner store was the preferred venue. Of respondents who purchased cigarettes in a store about 53% reported ever being asked for their age, 44% reported ever being asked for identification, and 61% reported ever being refused the sale. This is compared to the 48% who were asked for identification and the 51% who were refused in 1994.

Despite the difficulty in purchasing cigarettes, 60% of youth in the 2002 YSS reported having a usual brand, down from 81% in the 1994 YSS. Of this group, 66% usually smoke a "regular" brand; 28% usually smoke a "light" or mild" brand and 6% usually smoke an "ultra" or "extra light" brand. The 2002 YSS also collected information on tar deliveries of the preferred brands. Almost 100% of youth reported that the tar delivery of their usual brand was 10 mg or greater. What this means is that youth are smoking cigarettes that are designed to deliver nicotine with little effort on the part of the smoker. In the 2002 YSS, data were not collected on the reasons given by youth for smoking other than "regular" brands.

While it is difficult to classify true quitting within this age group, the findings of the 2002 YSS indicate that 76% of daily smokers and 33% of smoked beyond puffing, not daily smokers have seriously thought about quitting at least once (Chapter 4). Of the youth within these two groups who had ever seriously thought about quitting and who made at least one quit attempt, 72% had actually tried to quit within the past six months. Overall, those youth who had ever seriously thought about quitting and who made at least one quit attempt had made an average of 3.2 lifetime quit attempts, with males making slightly more attempts than females (3.5 and 3.1, respectively). While, overall, 40% of youth reported quitting for longer than one month, only 17% of daily smokers who stopped smoking did so for longer than one month.

An important factor in encouraging and helping youth to quit and continue quitting should be school smoking restrictions, especially for the age group studied in the YSS (Chapter 10). The findings from the 2002 YSS indicate that 62% of students attended schools with a full ban on smoking, compared to 37% in the 1994 survey. In 2002, only 6% reported that there were no rules, compared to 25% in 1994. Reporting of restrictions is related to smoking status, with 66% of never smokers who had never seriously thought about smoking, reporting a full ban compared to 27% of daily smokers. The impact of these bans is seen on self-reported daily cigarette consumption. Those youth who reported a full ban and who smoked in last 30 days, reported smoking an average of 2.6 cigarettes per day compared to youth who reported a partial ban and who smoked in last 30 days, 5.2 cigarettes per day, and those who reported no rules and who smoked in last 30 days, 5.9 cigarettes per day. The impact of bans, both partial and full, was stronger in female than in male smokers.

While the 2002 YSS focussed mostly on cigarette use, the use of other forms of tobacco was also investigated (Chapter 3). Ever use of cigars or pipes was reported by 13% of the youth surveyed (11% for females and 15% for males); ever use of chewing tobacco was 2% (not reportable for females and 3% for males); ever use of snuff was reported by 2% (2% for females and 3% for males); and ever use of bidis was 3% (2% for females and 3% for males). Except for bidis, which were not reported in the 1994 YSS, the findings indicate significant declines in use of other tobacco products by Canadian youth.

Information on the prevalence of alcohol and other drug use was obtained for students in grades 7 through 9 (Chapter 11). The most commonly used substances were alcohol (54%), tobacco (31%) and marijuana (18%) (Chapter 11). However, 36% of males and 43% of females reported no lifetime use of alcohol, tobacco, cannabis, amphetamines, MDMA, hallucinogens, heroin, cocaine, steroids or inhalants. Of those who reported having used alcohol, 41% reported at least one heavy drinking episode. Smoking status was correlated with other substance use. For example, only 4% of never smokers reported marijuana use, compared to 67% of those who smoked beyond puffing.

The 2002 YSS provides considerable insight into the knowledge, attitudes and behaviour of Canadian youth with respect to tobacco product use and various factors that are related to such use. Each chapter provides extensive analyses of different aspects of youth smoking and its determinants. Such information is essential to policy makers, tobacco control program developers and researchers.

As with the findings of the 1994 YSS, the findings of the 2002 YSS are useful only if they are acted upon. The wealth of data collected in both surveys provides a basis for recommendations in a number of areas. Recommendations specific to various domains can be found in the findings chapters of this report. Priority recommendations for action that will affect future surveys, programs and policies are offered below.

The findings underline the importance of a comprehensive, ecological approach to smoking reduction among youth so that the public health gains of recent years can be sustained and further progress can be made. An ambitious research agenda is required to inform and support tobacco control initiatives in legislation, regulation, policy, education, programming, and monitoring and surveillance.

In general, the literature on the quit attempts, successful quitting, and the determinants of youth cessation is impeded by the lack of standardized measures of successful quitting. The development of valid and reliable questions to enable the identification of young smokers who are able to quit successfully is urgently needed.

The findings also suggest that there is a continuing need for comprehensive tobacco control interventions aimed at reducing youth exposure to smoking social models. Although youth reported being exposed to fewer friends and family members who smoke than was the case in the 1994 YSS, smoking social models continue to have a strong influence on youth smoking behaviour.

Both doctors and dentists need to be encouraged to speak to all youth about tobacco product use; youth-centered tools may need to be developed and disseminated to further assist health professionals in both prevention and cessation interventions.

The findings suggest that since 1994, youth beliefs and attitudes about the health risks associated with tobacco use have changed, and thus the education and message promotion provided to youth may need to be adapted accordingly. Many youth are successfully resisting smoking, having internalized messages from the past; however, in order to effectively communicate with the youth who now take up smoking, and overcome their resistance to current messages, we may have to alter messages and add new ones specific to changes in their beliefs that were identified.

The effectiveness of health warning messages may be enhanced if greater emphasis is placed on combining positive messages about the benefits of quitting smoking with current content relating to the negative impacts of tobacco use.

Banning point of sale displays, implementing product labelling legislation, increasing the number of smoke-free spaces, and further enforcement of restrictions on the sale of tobacco to minors will be important strategies for preventing tobacco product access and use among young people.

Schools should be viewed as one element in a young person's environment that potentially affects smoking behaviour. More information is needed on the interaction of school variables with a host of other community, provincial and national factors that influence youth smoking patterns.

An innovative feature of the 2002 YSS was the measurement of substance use other than tobacco, such as alcohol and other illicit drugs. Tobacco is indeed a drug, and the co-occurrence of the use of various psychoactive substances is an important aspect of understanding drug-taking behaviour, including tobacco use.

Common definitions of youth smoking behaviour should be encouraged in national surveys employed by different countries. This would entail the use of common questions on the different surveys allowing for similar analysis and better comparisons across countries. It would also provide a basis for more definitive comparative evaluations of the impacts of various tobacco control measures on youth smoking.