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Cigarettes and other tobacco products are among the most commonly consumed recreational chemicals used in Canada. Use of cigarettes has been associated with an increased risk of heart disease, lung cancer, emphysema and other chronic lung diseases, and with low birth weight (1). Reduction in the rate of cigarette smoking is one of the few proven interventions to reduce the rate of heart disease and lung cancer (2). The potential impact of reducing smoking can be quite profound; it has been estimated that a decrease in smoking frequency in Canada to 10% of adults (from 52% in 1989) would result in an annual decrease of 21,000 smoking-attributable deaths (3). Although the smoking frequency in Canada among adults has declined since 1989, it appears to have levelled out at a stable rate of 30% (4).
The vast majority of adults who smoke cigarettes began smoking as teens, with 80% of adult smokers having started regular tobacco consumption before their 18th birthday (5). Adolescent smokers usually follow a common pattern, in which the first several years of smoking experience are marked by exploratory behaviour, but in the majority of adolescent smokers addiction is established after three years of smoking. Efforts to reduce smoking once addiction is established are difficult and frequently fail. It is important to note that 80% of adult smokers express the wish that they had not started smoking as adolescents. Equally significant is that approximately half of all adolescents who smoke on a regular basis will have their lives shortened by a tobacco-associated illness (6). An alarming fact is that adolescents appear to begin smoking earlier; currently 85% of smokers start smoking before age 16 years and almost 30% start before age 13 years (4). It has been demonstrated that adolescents who smoke have increased rates of respiratory illness, including asthma, than nonsmokers (7,8).
A key element of public policy aimed at reducing the impact of tobacco-related illness, therefore, should be directed at preventing adolescents from smoking. Several approaches to prevent smoking have been attempted. Educational programs have been used, with variable success rates. Limiting access to tobacco products by legislation limiting sale of these products to those above a defined minimal age has been attempted, with little evidence that these policies actually reduce use or access. Public awareness programs and restriction of advertising may have some effect on rates of cigarette smoking, although this requires considerable initial and on-going effort (7). Increasing the price of tobacco products through taxation has been associated with a decline in the use of tobacco products, primarily cigarettes, by adolescents (9–12).
This decline has occurred over a time when, in addition to price impact, other societal changes are likely to have influenced the rate of adolescent smoking. In this respect, Canada has historically taken a leadership role internationally in restricting tobacco advertising and requiring warning labels on tobacco products (5). However, recent reductions in cigarette taxation have demonstrated that price of cigarettes is a prime determinant of smoking rates among women and adolescents. It appears that smoking rates among women of all ages, including adolescents, respond more to increases in price of cigarettes than to educational campaigns (12).
In 1994 the Canadian federal government, under considerable pressure related to widespread crossborder smuggling of cigarettes, substantially reduced cigarette taxes, with a consequent substantial decline in the retail price of cigarettes. The decline in cigarette prices in Canada has been accompanied by an increase in the rate of cigarette smoking among Canadian adolescents and a relative increase in smoking rates among women in Canada, notably among adolescent women (Table 1).
Smoking has been and remains a major public health problem. The greatest opportunity available to reduce the severity and rate of tobacco-related illness is to decrease the number of people who start smoking, which most commonly occurs during adolescence (13). Government and society must consider approaches that will reduce the incidence of cigarette smoking among adolescents if a meaningful reduction in the burden of tobacco-related illness is to be achieved.
DRUG THERAPY AND HAZARDOUS SUBSTANCES COMMITTEE
Members: Drs Stuart M MacLeod, Father Sean O’Sullivan Research Centre, St Joseph’s Hospital, Hamilton, Ontario (Chair); Benoit Bailey, Montreal, Quebec; Prashant Joshi, Fort Erie, Ontario; John C LeBlanc, IWK-Grace Health Centre, Halifax, Nova Scotia; Doreen M Matsui, Children’s Hospital of Western Ontario, London, Ontario; Margaret Jane Stockwell, Medical Services Branch, Health Canada, Ottawa, Ontario; Milton Tenenbein, Children’s Hospital, Winnipeg, Manitoba (director responsible)
Consultant: Dr Natalie Dayneka, Children’s Hospital of Eastern Ontario, Ottawa, Ontario
Liaison: Dr Gideon Koren, The Hospital for Sick Children, Toronto, Ontario (Canadian Society for Clinical Pharmacology)
Principal author: Dr Michael J Rieder, Children’s Hospital of Western Ontario, London, Ontario
The recommendations in this Clinical Practice Guideline do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate.