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Research paper

How adolescents view the tobacco endgame and tobacco control measures: trends and associations in support among 14–15 year olds Richard Jaine,1 Benjamin Healey,2 Richard Edwards,1 Janet Hoek3 ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ tobaccocontrol-2013-051440) 1

Department of Public Health, University of Otago, Wellington, New Zealand 2 Department of Marketing, University of Otago, Wellington, New Zealand 3 Department of Marketing, University of Otago, Dunedin, New Zealand Correspondence to Dr Richard Jaine, Department of Public Health, University of Otago, PO Box 7343, Wellington 6242, New Zealand; [email protected] Received 14 November 2013 Accepted 4 April 2014 Published Online First 2 May 2014

ABSTRACT Background and aims Adolescents represent the next generation and have the greatest amount to gain from the tobacco endgame. They will provide the future momentum to achieve the tobacco endgame, thus it is important that their views on interventions are monitored. We examined support among 14–15-year-old New Zealanders for tobacco endgame goals and measures, and trends in this support from 2009 to 2012. Methods This study used data from an annual survey of over 25 000 Year 10 students (14–15 year olds) undertaken by Action on Smoking and Health New Zealand. We assessed support for five tobacco control goals and measures: living in a smoke-free country; having fewer tobacco retail outlets; not selling tobacco in 10 years’ time; implementing outdoor smoking bans; and raising the price of tobacco. Results Support for living in a smoke-free country was 59%, while support for a ban on all tobacco sales in 10 years’ time was 57% in the most recent survey year. Most respondents supported each of the tobacco control measures and gave strongest support to having fewer places where tobacco could be sold (71% in 2012). Support for the other two tobacco control measures in the most recent year ranged from 59% to 64% and had increased over time, in most cases significantly. Support was strongest among non-smokers and declined as participants’ smoking frequency increased. Conclusions Young people support New Zealand’s smoke-free goal and interventions that could help achieve it; this evidence should galvanise policy action, which remains out of step with public opinion.

INTRODUCTION

To cite: Jaine R, Healey B, Edwards R, et al. Tob Control 2015;24:449–454.

The New Zealand government has committed to the goal of making New Zealand smoke-free by 2025, defined as reducing smoking prevalence and tobacco availability to minimal levels.1 Measures already in place include pictorial health warnings, the removal of tobacco retail displays, purchase age restrictions and regular excise tax increases; plain packaging, removal of duty free tobacco sales and designating cars carrying children as smoke-free spaces are currently under consideration. However, while each of these measures has contributed to reductions in smoking prevalence, additional policies are required to change current smoking trajectories and achieve the endgame goal. In order to achieve this objective, researchers and advocates have suggested varied tobacco control measures.2 Studies have examined New Zealand adults’ support for these measures;3–7 however, few international or domestic studies have examined

support for tobacco control measures among children and adolescents. Because New Zealand’s goal of becoming smokefree by 2025 is a medium-term objective, it will have a significant impact on young people, whose opinions will influence policy as they reach voting age (18 years). If young people do not engage with, and actively support, the endgame goal, there is a risk it could lose momentum. Assessing young people’s support for the 2025 goal and how it might be achieved is thus crucial to informing policy priorities and advocacy strategies. Furthermore, as citizens of a society, children have a right for their opinions and attitudes to be heard. The United Nations Convention on the Rights of the Child (UNCROC) (which New Zealand ratified in 1993) makes this right explicit; article 12 states that children should ‘be provided the opportunity to be heard’.8 Shier has outlined the levels of participation required to align with article 12 of the convention.9 The five levels of participation range from ‘children are listened to’ at the low level through to ‘children share power and responsibility for decision making’. Shier states that level 3 (ie, ‘children’s views are taken into account’) is the minimum level required for any country that has adopted the UNCROC. Our study represents a small step to achieving this participation and ensuring that children’s views are taken into account in policymaking. As well as being important from a human rights perspective, studying adolescents’ attitudes to tobacco endgames is also important conceptually, as attitudes are likely to align strongly with current behaviour and may predict adolescents’ future actions.10 Research examining specific attitudes to smoking and adolescents’ own smoking behaviour has found antismoking attitudes are negatively correlated with smoking frequency, and adolescent non-smokers consistently hold more negative views of smoking than their smoker counterparts.11 12 Similar findings emerge in evaluations of large-scale attitude inoculation programmes, such as the Truth campaign, which exposed the tobacco industry’s duplicitous practices, thus stimulating the development of antismoking attitudes and reinforcing intentions not to smoke.13 Overall, studies examining adolescents’ attitudes to smoking suggest antismoking attitudes are strongly associated with increased intentions not to smoke. This evidence has two important implications: first, encouraging positive attitudes towards the tobacco endgame goal is likely to reinforce nonsmoking intentions, which in turn will support

Jaine R, et al. Tob Control 2015;24:449–454. doi:10.1136/tobaccocontrol-2013-051440

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Research paper realisation of the 2025 goal. Second, attitudes towards the endgame are likely to be strongly associated with adolescents’ own smoking status. Although New Zealand was the first country to announce an endgame goal, the relative recency of this announcement means few studies have examined young people’s views on potential tobacco control measures or endgame strategies. While Smith et al14—who used data from the 2009 Action on Smoking and Health (ASH) Year 10 snapshot survey—found a majority of young people supported reducing access to tobacco products such as reducing the number of places selling tobacco and increasing tobacco prices, no studies have examined more recent trends. The 2009 ASH Year 10 snapshot survey was the first to include questions assessing support for potential tobacco control policy measures such as banning smoking in outdoor places where young people go and reducing the number of outlets allowed to sell tobacco . We updated Smith et al’s analysis by examining up-to-date data, exploring trends and examining data from questions included since 2009 that assess support for an additional tobacco control policy (raising the price of tobacco), a tobacco control endgame aspiration (wanting to live in a smoke-free country) and a scenario (a ban on all tobacco sales in 10 years’ time). The aims of this research were 1. to examine and describe 14–15-year-olds’ support for tobacco control goals and measures in New Zealand 2. to examine the trends in support for tobacco control goals and measures from 2009 to 2012.

METHODS We analysed data from an annual survey for the years 2009– 2012 of Year 10 students (14–15 year olds) undertaken by ASH New Zealand and funded by the Ministry of Health. This longrunning survey was first fielded in 1999, and all New Zealand schools teaching Year 10 students face-to-face (ie, not by correspondence) are invited to participate each year. Schools administer the survey to their Year 10 students during supervised class time and individual students may decline to participate. In order to maintain confidentiality, students do not provide any identifying information and teachers are instructed not to check the questionnaires returned to them.15 The Ministry of Health Multiregional Ethics Committee approved the survey in 2007 for the 2008–2012 surveys. Significant changes to the survey are notified to the ethics committee through a yearly progress report. The ASH questionnaire incorporates and extends some key measures from the international Global Youth Tobacco Survey (GYTS) relating to smoking and cessation behaviour, susceptibility, and exposure to secondhand smoke, as well as assessing the smoking status of family and friends. Since 2009 it has included questions investigating attitudes towards a range of tobacco control issues. The statements examined in this study are part of the larger survey conducted by ASH. The overall survey is developed and administered by ASH and includes some modifications each year (we note some statements were not included in the survey every year). Between 2009 and 2012, school-level participation rates have ranged between 44% and 58%. Over 25 500 students have responded to the survey in each year, with 48% of the target population (28 447) responding in 2012 (see online supplementary table S4). The characteristics of the returned sample remained fairly stable over time (table 1), with one exception being the age 450

Table 1 Characteristics of the ‘Year 10’ sample by year (percentages) Year Variable

2009

2010

2011

2012

n (count) Age (years) 14 15 Sex Male Female Ethnicity (prioritised) NZ European Maori Pasifika Asian Other SES, based on school decile* Low (1–3) Medium (4–7) High (8–10) Smoking status Never smoker, not susceptible Never smoker, susceptible Experimented in past Less than monthly Monthly Weekly Daily

25 762

32 605

26 645

28 447

65 35

62 38

82 18

83 17

47 53

53 48

48 52

48 52

61 18 9 11 1

58 20 10 11 1

59 20 9 11 1

57 20 9 12 2

14 45 42

16 45 39

15 42 43

16 41 43

44 18 21 5 3 3 6

48 16 21 6 2 2 6

52 17 18 5 2 2 5

52 16 19 5 2 2 5

*A school’s decile rating indicates the extent to which it draws its students from low socioeconomic communities. A low decile represents a school with a high proportion of students from disadvantaged communities. Deciles are used to allocate differential funding in New Zealand’s public education system. SES, socioeconomic status.

profile for the 2011 and 2012 surveys. These two surveys were fielded earlier during the school year than previous surveys. As such, fewer students had turned 15 prior to completing the questionnaire. Overall, sample characteristics show a close correspondence to population figures for Year 10 students available from the New Zealand Ministry of Education16 with respect to sex, prioritised ethnicity17 and school-based socioeconomic status (SES). In most cases, the sample characteristics were within 3% of the population parameters, although there was some systematic over-response by New Zealand Europeans and under-response by the low SES group. All analyses in the study are weighted by ethnicity and SES. Weights are also used to standardise the age distribution in each year (65% 14 year olds and 35% 15 year olds), to adjust for differences in age due to variation in the timing of the survey fieldwork. Between 2009 and 2012, students were asked to indicate their level of agreement with five statements relating to tobacco control goals and measures (table 2). The statements included in the survey varied from year to year, but the wording for the statements remained consistent except for the fewer outlets selling tobacco products statement. Responses to these statements were divided into ‘agree’, ‘disagree’ or ‘don’t know’. For the most recent survey results (either 2012 or 2011 depending on the statement), we used logistic regression analysis to calculate adjusted ORs for the association between agreement with each statement and age, gender, ethnicity, SES, parental smoking status, friend smoking status, sibling smoking status Jaine R, et al. Tob Control 2015;24:449–454. doi:10.1136/tobaccocontrol-2013-051440

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Research paper Table 2 Five tobacco control statements from the ASH Year 10 survey Year statement included Statement name

2009

2010

2011

2012

Statement wording

Smoke-free country Fewer outlets selling tobacco products





✓ ✓

✓ ✓







I want to live in a country where no one smokes In 2009 and 2010: The number of places allowed to sell cigarettes and tobacco should be reduced to make them less easily available; In 2011 and 2012: There should be fewer places where cigarettes and tobacco can be sold Cigarettes and tobacco should not be sold in New Zealand in 10 years’ time

✓ ✓

✓ ✓

No tobacco sales in 10 years’ time Outdoor smoking ban Raise price of tobacco products



Smoking should be banned in all outdoor places where young people go Cigarettes and tobacco should be made more expensive so that children and young people can’t afford to buy them

ASH, Action on Smoking and Health.

and participant smoking status. Changes in responses to the five statements for the total study population were compared across years. A dichotomous indicator of smoking susceptibility was also created using questions from the GYTS and originally adapted from a measure developed by Pierce et al.18 This analysis was restricted to never smokers only. Respondents were defined as being not susceptible if they answered ‘definitely not’ to both of the following questions: “If one of your best friends offered you a cigarette, would you smoke it?” and “At any time during the next year do you think you will smoke a cigarette?” All other respondents were defined as being susceptible. All analyses were performed using SAS V.9.3 software. Significance tests were two-sided, with p

How adolescents view the tobacco endgame and tobacco control measures: trends and associations in support among 14-15 year olds.

Adolescents represent the next generation and have the greatest amount to gain from the tobacco endgame. They will provide the future momentum to achi...
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