Prevalence and social environment of cigarette smoking in Cyprus youth

Tobacco smoking is a major public health problem worldwide and it is the single most preventable cause of morbidity and mortality in humans [1–3]. Approximately 5 million people die prematurely every year due to tobacco-related diseases, and this rate is projected to double by the year 2020 [4–8].

Adult smokers almost always initiate tobacco use before the age of 18 [9] when they are easily influenced by their peers, social norms, and tobacco advertising. Due to the highly addictive nature of tobacco often simple experimentation of young kids leads to regular smoking well before the age of 18 with more than a third of ever smokers (even one or two puffs) becoming daily smokers before graduating high school and nearly two-thirds becoming regular, daily smokers before they reach the age of 20 [10]. Most young people who smoke regularly during teenage years continue to smoke throughout adulthood with data in the USA suggesting that 80 percent of all adult smokers begin smoking regularly before the age of 18 whereas 90 percent begin smoking regularly before the age of 20 [11]. Initiating smoking at an early age also increases the risk of heavier smoking at a later age [12]. Therefore, tobacco research and prevention programs must focus on the early years of life and include education to prevent youth from initiating smoking. At the same time, smoking in youth (usually defined as at least one cigarette in the last month) is not equivalent to smoking in adults (usually defined as smoking at least one cigarette a day) and the body of evidence of how youth smoking can predict adult smoking is limited. Hence, further research is needed to address the issue of predicting adult smoking based on youth smoking.

The World Health Organization Framework Convention on Tobacco Control (WHO FCTC) reinforces the need for data on adolescent tobacco use by calling on countries to establish surveillance programs of "the magnitude, patterns, determinants, and consequences of tobacco consumption and exposure to tobacco smoke" [13]. Cyprus ratified the WHO FCTC in 2000, thus formally obligating the government of Cyprus to follow the Articles of the WHO FCTC.

In Cyprus limited data exist regarding smoking among youth. A survey conducted by the Ministry of Health in 1997 revealed that 6.5% of all youth 15–19 years old were daily smokers [14] whereas a study in 2003 showed that this number was 14.7% (22.6% for boys and 5.7% for girls) [15]. The European School Survey Project on Alcohol and Other Drugs (ESPAD) reported that 22% (30% for boys and 14% for girls) of 15–16 year-old students surveyed in Cyprus in 2003 had smoked at least once in the past 30 days [16]. In response to the need for additional data, the Cyprus International Institute for the Environment and Public Health in association with Harvard School of Public Health (CII) conducted the Global Youth Tobacco Survey (GYTS) in 2006. The GYTS was developed as a joint project by the WHO, the United States Center for Disease Control and Prevention (CDC), and the Canadian Public Health Association (CPHA). The GYTS collects data on youth smoking behavior, knowledge and attitudes, as well as factors affecting the youth initiation of smoking. It is designed to provide current and comparable data regarding tobacco use among youth around the world, and has already been conducted in more than 151 countries worldwide [5, 17–19].

The present study uses data from the 2006 Cyprus GYTS to assess cigarette smoking prevalence (the dominant form of tobacco use in Cyprus) among middle school students (with ages ranging from 12 to 15) and among high school students (with ages ranging from 15 to 18) and study the psychosocial, environmental, and behavioral factors associated with smoking among youth in these ages. The goal of the study is to provide scientific information and evidence in order to help create effective smoking prevention and cessation programs and reduce the smoking rate among youth in Cyprus. Results are reported on the prevalence and factors that influence youth smoking; exposure to second-hand smoke (SHS); access to and availability of tobacco products; exposure to media and advertising; cessation programs; and smoking-related education in Cyprus.

The GYTS was conducted in 2006 by the CII, in collaboration with the Harvard School of Public Health, the WHO, the CDC, and the Ministries of Health and Education and Culture of the Republic of Cyprus.

A number of findings from the 2006 Cyprus GYTS raise concerns for the future of tobacco control in Cyprus. First, the prevalence of cigarette smoking among high school boys, defined as smoking on at least one day in the last month, is 35.7%. Furthermore, 30.1% of all 17–18 year old boys and 20.4% of all 15-year or older boys smoke daily. Similar rates were observed in 2003 with the proportion of adult males (15 years old or older) that smoked daily in the last month reported to be 38.1% and the corresponding rate for boys 15–19 years old reported to be 22.6% [15].

Second, and even more concerning, are the smoking rates among high school girls; the prevalence of smoking is 23.2%, with 19.0% of all girls 17–18 years old and 11.8% of all 15-year old or older girls reporting being daily smokers. In 2003, among all adult females 15 years old or older 10.5% were daily smokers, with only 5.7% of girls ages 15–19 being daily smokers [15]. This may suggest a rise in the prevalence of smoking among adult females over the next few years. This is likely to be due to aggressive marketing efforts by tobacco companies that include advertising in fashion magazines targeting younger women as well as more general societal changes with women gaining more independence and smoking becoming more acceptable for them. The increase in the prevalence of smoking among girls and the narrowing of the gap in the corresponding rates between boys and girls is something that has been observed and reported frequently elsewhere [15, 21, 22].

Third, the susceptibility rates reported are high. Girls in both middle and high school that have never smoked and boys in middle school that have never smoked indicated that they are likely to initiate smoking within the next year at rates higher than the existing prevalence of current smokers. If that holds true then an increase in prevalence rates can be expected, especially among teenage girls in high school whose susceptibility rates are significantly higher than those of high school boys.

When compared with other countries that administered the GYTS, Cyprus has higher current cigarette smoking rates for both boys and girls aged 13–15 than the average of the Eastern Mediterranean region countries sampled (though it has lower rates for current use of other tobacco products) [5, 18]. On the other hand, Cyprus' rates are lower compared to the mean rates of the European countries sampled [5, 18]. For example, among children 13–15 years old, Cyprus current cigarette smoking rates are 12.3% for boys and 8.2% for girls and are higher compared to Egypt (5.9% and 1.4% for boys and girls, respectively), Lebanon (11.8% and 5.6%), and Saudi Arabia (10.2% and 2.6%) but lower than Bulgaria (26.0% and 39.4%), Czech Republic (29.8% and 32.7%), and Russian Federation (25.9% and 23.9%). [23]. In comparison, Greece, using the GYTS in 2005, reported prevalence rates among children 13–15 years old of 11% for boys and 9% for girls [20]. Furthermore, in 2003, based on the ESPAD, 22% of 15 to 16 year-old students surveyed in Cyprus had smoked in the past 30 days, compared with an average of 35% in the remaining 34 participating countries [16].

It is clear that smoking is an important problem in Cyprus. Conservative estimates suggest that between 600 and 700 people die every year in Cyprus because of smoking (about 12%–13% of about 5,000 deaths of individuals 35 years and older) [24]. In light of the present smoking rates and the increasing trend in smoking among young women, approximately 28,000 of the approximately 200,000 children under 20 years old alive today are projected to die prematurely as adults and many more will suffer from illnesses due to smoking. The government, school officials, health professionals and the society as a whole must intervene as rapidly as possible to counteract these predictions.

Several tobacco control measures exist in Cyprus including regulations regarding the manufacture and sale of tobacco products (e.g. cigarette levels of tar not exceeding 12 mg, no tobacco sales to anyone less than 18 years old), advertising bans and restrictions (e.g. banned in cinemas, regulated in print media), mandatory package warning labels (e.g. 'Smoking Kills' warning covering 32% of the area of one of the two largest surfaces of the outside of the packet), and policies on secondhand smoke (e.g. designated smoking areas, prohibition of smoking in public transportation). However, despite laws that prohibit the sale of tobacco to minors and ban smoking in public places, the present research suggests that these laws are not being observed. Exposure to SHS is extremely high both in the homes of students, where 84.5% report being exposed to smoke, and in other public spaces outside the home, where 91.2% report exposure. SHS is a serious danger even at low levels and is classified by the International Agency for Research on Cancer (IARC) as a known cause of cancer [25]. Measures must therefore be taken to eliminate the exposure of non-smokers (especially children) to passive smoking. The laws banning smoking in public spaces should be strictly enforced and should be tightened where necessary. Also, since tourism is a major industry in Cyprus, it should be made clear that numerous studies across a range of countries have shown that laws that ban smoking in public spaces have no detrimental effects on the businesses of restaurants and bars [26, 27]. Hence, the argument that banning smoking in public spaces affects tourism and the sales of restaurants, bars and other similar establishments is flawed. Finally, the laws banning sale of tobacco to minors must be enforced strictly; GYTS results suggest that 95.3% of current smokers that bought cigarettes in a store in the past month were not refused cigarettes because of their age.

The present study is limited by the subjectivity of self-administered questionnaires, introducing the possibility of information bias, as well as some non-response (mainly due to being absent on the day of the survey rather than refusal to participate in the study). Nevertheless, because of the high response rate, the anonymous administration of questionnaires, the good test-retest reliability of similar data, and the openness in Cyprus about the subject of smoking, biases introduced are likely to be minimal [28, 29]. The effect of non-response in GYTS was assessed previously and the smoking prevalence reported might in fact be underestimated (even when participation rates are higher than 90%) [30]. This could be the case because often the students that are absent from school on the day of the survey include a substantial number that behave differently than the average student and adopt unhealthy behaviors such as smoking and drinking [30].

Another limitation of the study is the fact that many students in technical schools were not surveyed. However, most of the students in Cyprus attend non-technical schools so we believe that the sample is representative of the whole population (if anything, including technical schools would raise the prevalence rates even higher).

Our recommendations include for the Cyprus government to ensure that the current laws regarding the sale of tobacco to minors and smoking in public spaces are enforced and to further strengthen the existing legislation. In addition, youth programs and anti-tobacco advertising campaigns need to be implemented, and increased professional help for cessation should be made available to persons who want to quit. (One of the few encouraging messages from the survey is that nearly half of the current smokers want to stop smoking.) Public awareness of the dangers of smoking should be promoted through public education campaigns and policy efforts need to be coordinated to address the problem. Further research is also needed in order to understand the complexity of the tobacco problem in Cyprus, the reasons for the high prevalence rates and the increase among females, as well as the specific measures that would effectively reduce tobacco use and its hazardous health effects. The Republic of Cyprus and the Ministry of Health have already adopted the 'Strategic Plan for Tobacco Control in Cyprus' prepared by the Tobacco Research Program of the CII [24]. This plan promises to be an important start towards curtailing the problem in the years to come.

Though further research is needed in Cyprus in relation to tobacco use and more scientific and updated data should be periodically collected, the GYTS indicates that the problem of cigarette smoking among youth in Cyprus is significant and that collective action needs to be taken immediately.