Smoking prevalence and tobacco exposure among ... - Oxford Academic

European Journal of Public Health, Vol. 19, No. 6, 655–661 ß The Author 2009. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/ckp064 Advance Access published on 27 May 2009

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Smoking prevalence and tobacco exposure among adolescents in Cyprus Maria Karekla1,2, Anastasia Symeou2, Haritini Tsangari3, Margarita Kapsou4, Marios Constantinou1,2 Background: Smoking has been internationally recognized as an epidemic contributing to major health problems. Smoking contributes to most of the preventable deaths worldwide. Although Cyprus is considered among developed countries with high smoking prevalence (estimates of 25–35% of the population), not much has been done for the systematic scientific study of this problem, especially in adolescence. The present study aimed to investigate smoking prevalence and related factors among Cypriot adolescents. Methods: Participants were selected through stratified random sampling. The final sample included two subpopulations: middle (n = 1085) and high (n = 767) school students. Results: Six percent of middle school students reported being regular smokers. This climbed to 24% among high school students. Smoking prevalence increases with age, and appears higher in boys than in girls. Smoking is quite common in the participant’s families, particularly among fathers. Cigarette and smoke exposure in the home was high, as only a fifth of the students reported smoking never being allowed in the home. Exposure to actors smoking on television was the norm (62–67%) with low reported exposure to anti-smoking messages. Having friends who smoke, exposure to others smoking and low educational aspirations were significant predictors of smoking for both groups. Additional predictors, which were different for middle and high school students, were identified. Conclusion: Further research to investigate the nature of these effects is required and to provide further insight into the psychosocial parameters affecting smoking. These results can guide possible prevention and intervention programs for adolescents, and suggest the importance of following a systemic approach. Keywords: smoking, adolescents, smoking prevalence, tobacco exposure, Cyprus.

................................................................................................ Introduction dolescent smoking rates appear to have decreased among Westernized countries where efforts to combat smoking have been systematic.1 Despite such decreases, smoking still remains a serious health problem among youth worldwide.2 In the United States alone, it is estimated that 734 000 adolescents start smoking each year.3 Many of these adolescents continue smoking throughout adulthood (80% of smokers initiating use before 18 years of age4). Prolonged smoking could contribute to numerous health problems including but not limited to cancer, emphysema, heart disease and diabetes.5,6 Indeed, smoking is considered as one of the major preventable contributors to premature death.7,8 In Cyprus little is known regarding smoking rates among the population and especially among adolescents. Most existing knowledge is based on mass media anecdotal evidence and news reports and it suggests that Cypriot adolescents’ smoking rates are among the highest worldwide. Until recently, smoking prevalence was only studied as part of research conducted for other purposes, and only consisted of questions asking whether somebody smokes or not.9,10 Such findings suggest prevalence rates of 25–35% in the adult population. The Cyprus Institute for Environmental and Public Health11 recently conducted the Global Youth Tobacco Survey, however final published data are not yet

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1 Center for Cognitive Behavioral Psychology, Stavrou 18, Strovolos, Nicosia, Cyprus 2 University of Nicosia, Department of Psychology, Nicosia, Cyprus 3 University of Nicosia, Department of Economics & Finance, Nicosia, Cyprus 4 University of Cyprus, Department of Psychology, Nicosia, Cyprus Correspondence: Maria Karekla, Center for Cognitive Behavioral Psychology, Stavrou 18, Strovolos, Nicosia, Cyprus, tel: +357 99378676, fax: +357 22428029, e-mail: karekla.m@unic.ac.cy

available. Preliminary reports suggest that 10.7% (13.6% of boys; 7.3% of girls) of middle school (MS) students and 29.3% (36.8% of boys; 23.1% of girls) of high school (HS) students use tobacco products. The purpose of the present study was to systematically examine the prevalence and rates of smoking in Cypriot adolescents. Additionally, it aimed to investigate their family smoking history and their exposure to tobacco products and smoke, as well as potential demographic and environmental factors predicting smoking in the adolescents.

Method Participants Participants were 1085 MS students (564 females; mean age = 13.5; SD = 0.93) and 767 HS students (388 females; mean age = 16.3; SD = 0.97) selected using stratified random sampling. The sample size meets pre-study estimates.

Procedure The strata utilized were the major districts (nine) of the government-controlled area of Cyprus, namely the rural and urban areas of Nicosia, Limassol, Larnaca, Pafos districts and the free part of Famagusta (considered rural). Schools were proportionally and randomly selected from each stratum, based on lists of all schools obtained from the Ministry of Education. In each school, classes were proportionally and randomly selected from each grade and all students in each class were given the questionnaire (Average number of students in classes = 21.52; SD = 4.38). Questionnaires were anonymously completed during class time, and supervised by study experimenters (teachers were asked to wait outside). Ninety-nine students had either declined participation or were absent on testing day.

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Measures A questionnaire compiled by the authors (researchers with clinical and research experience on the topic) was used to obtain demographic- and smoking-related information. Adolescent’s smoking status was assessed based on responses to the question ‘Do you smoke?’ Possible answers were ‘No’, ‘Yes, regularly’, and ‘I used to smoke but quit’. Adolescents who responded ‘Yes, regularly’ were classified as smokers. A series of questions were asked to examine additional variables hypothesized to relate to smoking status. Some of the questions included were drawn from existing international surveys, such as the Global Tobacco Youth Survey (GYTS)12 and The National Youth Tobacco Survey Questionnaire (NYTS).13 The original English questions used were translated and back-translated by senior students bilingual in Greek and English. The questionnaire was then administered to a pilot sample, and the wording was readjusted following comments to ensure the validity of the instrument. The questionnaire is available from the authors upon request.

Statistical procedure Relations between smoking prevalence and environmental and demographic parameters were examined. Since most variables of interest were measured at the ordinal or nominal level, chi-square (2) tests of independence were employed and odds ratios calculated when appropriate. Independent samples t-tests were used for continuous variables. Unless otherwise reported, all analyses were carried out separately for the MS and HS samples. For a simultaneous testing of significance, two multivariate logistic regression (MVLR) analyses using the forward entry method were performed (one for each group) to identify potential smoking predictors as a function of more than one independent variable. The dichotomous variable ‘smoker/nonsmoker’ was used as the dependent variable. The following 18 independent demographic and environmental variables were tested for significance: sex; place of residence (village, small town, city); district of residence; age; weekly allowance; rules regarding smoking in the home; ease of cigarette access in their home; maternal, paternal and sibling smoking status; being aware of a family member or close friend who suffered from a disease as a result of smoking; frequency of contact with friends who smoke, frequency of being in the same room with a smoker, frequency of exposure to anti-smoking advertisements on television or radio, to actors smoking on television, to promotions of cigarettes or other smoking products in newspapers or magazines, and at kiosks, supermarkets or gas stations; and the adolescent’s educational aspirations. Logistic regression coefficients (B) were used to estimate odds ratios for each of the independent variables in the model. Adult supervision after school was not entered as a predictor, due to the high number of missing data, and was assessed instead through 2.

Results Demographic results Demographic results concerning place of residence, participants’ reported educational aspirations and weekly allowance are summarized in table 1.

Table 1 Participants’ demographic characteristics

Place of residence [n (%)] City Small town Village Educational aspirations [n (%)] Had enough education already Do not care if I do not complete high school Up to high school education Would like to go to university Would like to receive post-graduate education Weekly allowance [n (%)] No allowance 51 CYP

Middle school (n = 1085)

High school (n = 767)

593 (55) 349 (32) 143 (13)

516 (67) 182 (24) 69 (9)

14 (1) 32 (3)

4 (1) 3 (0)

137 (13) 434 (40) 465 (43)

60 (8) 334 (44) 366 (48)

48 (4) 37 (3) 281 (26) 349 (32) 225 (21) 76 (7) 38 (4) 31 (3)

12 (2) 6 (1) 80 (10) 220 (29) 266 (35) 122 (16) 45 (6) 15 (2)

1CYP = 1.71 Euros

Table 2 Smoking prevalence and smoking parameters in middle and high school Middle school, n = 1085 Have tried smoking 19 (15a) Current smoker 6 (5) Where did you find your first cigarette? (%) From a friend 47 Stole it from a parent/relative 13 Given by a parent/relative 11 Bought it from a store 8 Other 18 How do you obtain your cigarettes? (%) From a store 61 Borrowed the cigarettes from 15 someone else Gave money to someone else 9 to buy them Stole them 8 Mean SD Average age first cigarette 12 (12) 2.3 is smoked Average number of cigarettes 9 (4a) 10.9 per day

High school, n = 767 53 (48a) 24 (18a) 64 9 7 10 10 83 6 4 2 Mean SD 14 (14a) 2.0 10 (10) 7.2

Number in parenthesis designates females (percentage or mean accordingly) a: Sex difference at the P < 0.05 level

offered them a cigarette at least once. Most commonly, the person who offered them a cigarette was ‘a friend’ (MS: 81%; HS: 82%), but for a small percentage it was a parent, uncle or aunt (3%) or sibling (3%). A large percentage of the students reported not having (MS: 43%; HS: 40%) or not being aware of having (MS: 30%; HS: 24%) a family member or close relative who suffered serious health problems due to smoking.

Smoking prevalence and parameters Table 2 presents the results for smoking prevalence rates and parameters for MS and HS students. Twenty-two percent of MS and 55% of HS students reported that someone

Predictors of smoking Table 3 presents the MVLR for MS and HS students. Five predictors of smoking status were identified for MS students,

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Table 3 MVLR for MS and HS students (n = 1085) MS students Independent Variables

OR

HS students P

95% CI Lower

Sex Place of residence District of residence Grade Weekly allowance Smoking allowed inside house Easy access to cigarettes Father smokes Mother smokes Siblings smoke Relative with health problem Often with friends who smoke Same room with smokers See antismoking ads See actors smoke Newspapers/Magazines ads Kiosks/Supermarkets ads Educational aspirations

1.42 1.09 1.5 1.43 0.94 1.01 1.04 1.04 1.79 1.49 0.96 8.75 1.47 1.02 0.43 1.1 1.39 0.37

0.37 0.61 0.11 0.14 0.67 0.95 0.89 0.87 0.01 0.32 0.86 0.00 0.01 0.94 0.00 0.52 0.1 0.00

0.66 0.79 0.91 0.89 0.72 0.69 0.58 0.65 1.16 0.68 0.60 4.79 1.09 0.67 0.27 0.83 0.94 0.24

OR

P

95% CI

Upper 3.06 1.49 2.46 2.30 1.24 1.48 1.86 1.66 2.75 3.27 1.53 15.98 1.99 1.45 0.69 1.46 2.04 0.57

0.60 0.67 1.02 1.68 1.24 0.76 0.86 1.16 1.18 2.52 0.86 8.48 1.64 1.48 0.82 0.9 0.91 0.40

0.05 0.01 0.93 0.00 0.04 0.04 0.43 0.40 0.28 0.00 0.34 0.00 0.00 0.02 0.22 0.31 0.52 0.00

Lower

Upper

0.36 0.5 0.69 1.26 1.01 0.58 0.59 0.82 0.87 1.49 0.64 4.49 1.31 1.08 0.60 0.73 0.69 0.27

1.00 0.88 1.51 2.24 1.53 0.99 1.25 1.64 1.6 4.26 1.17 16.03 2.05 2.02 1.13 1.10 1.20 0.58

MS students: R2 = 0.56, 2(18) statistics for goodness-of-fit = 231.91, P < 0.001; HS students: R2 = 0.55, 2(18) statistic for goodnessof-fit = 314.18, P < 0.001, *p < 0.05.

correctly classifying 94% of cases and 10 predictors were identified for HS students, correctly classifying 75% of cases.

Smoking by age and sex As expected, examination of all age groups together, showed that students in higher grades reported increased smoking experimentation and prevalence, 2(10) = 194.72, P < 0.001. MVLR results for HS students showed that students in higher grades are significantly more likely to smoke. (OR = 1.68, P < 0.001). In HS, boys were more likely than girls to smoke (30% boys vs. 17% girls, OR = 0.60, P = 0.05), and reported starting to smoke at a younger age (mean age = 13.61; SD = 2.23) than girls (mean age = 14.65; SD = 1.54), t(340) = 4.75, P < 0.001. No such differences were found in MS. Boys smoke significantly more cigarettes per day compared with girls in MS, t(64) = 3.34, P < 0.01; boys: mean age = 11.99, SD = 13.08; girls: mean age = 4.24, SD = 4.72, but not in HS, t(150) = 1.11, P > 0.05.

lower allowance (OR = 1.24, P = 0.04). For example out of HS students with weekly allowance between 1 and 5 CYP, 13% smoke compared with 60% of students receiving between 31 and 50 CYP.

Exposure to tobacco products and smoke Family Table 4 shows reported exposure to tobacco products and smoke from family, friends and the media. Maternal smoking was a significant predictor of smoking for MS (OR = 1.79, P = 0.01), while sibling smoking was a significant predictor of smoking in HS students (OR = 2.52, P < 0.001). HS students who reported smoking being allowed without any rules inside their home were more likely to smoke compared with those for whom smoking is not allowed (OR = 0.76, P = 0.04).

Smoking and demographic variables No differences were found in smoking rates in relation to place (village, small town or city) or district of residence for MS students. Urban HS students were more likely to smoke, (OR = 0.67, P = 0.01), compared with rural HS students. A significantly higher percentage of smokers was found in technical/vocational schools (39%) compared with public (23%) and private high schools (16%), 2(4) = 14.75, P < 0.01.

Smoking and educational aspirations Results indicate that MS and HS students with higher educational aspirations are less likely to smoke (MS: OR = 0.37, P < 0.001; HS: OR = 0.40, P < 0.001). Specifically, 4% of MS and 22% of HS students who would like to go to university or graduate school smoke, compared with students who think they had enough education already (79% smokers in MS and 100% smokers in HS) or who only want to finish HS (16% smokers in MS and 57% smokers in HS). In HS, students receiving higher weekly allowance appeared more likely to smoke compared with their peers receiving

Friends Frequent contact with friends who smoke also predicted smoking (MS: OR = 9.75, P < 0.001; HS: OR = 8.48, P < 0.001). There were no smokers among students who reported never being around friends while their friends smoke. On the contrary, students who reported being around friends often while their friends smoke were more likely to report smoking themselves (MS: 61% smokers; HS: 48% smokers). More frequent presence in the same room with someone who smoked during the previous week (in number of days) was also associated with greater likelihood of smoking (MS: OR = 1.47, P = 0.01; HS: OR = 1.64, P < 0.001). For MS, 1% of the students who have not been in the same room with a smoker smoke, compared with 20% of those who have been everyday of the past week in the same room with a smoker. For HS, 2% of the students who have not been in the same room with a smoker smoke, compared with 45% of those who have been everyday of the past week in the same room with a smoker.

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Table 4 Reported exposure to tobacco products and smoke through family, friends and media MS students, n = 1085 % Smokers in the family Father smoker 47 Mother smoker 17 Sibling smoker 18 Is smoking allowed inside your home? Not allowed 23 Only if have guests who smoke 35 Only in some rooms 13 Allowed anywhere (no rules) 30 How easy is it to find a cigarette inside your home? Impossible 36 Difficult but not impossible 26 Quite easy 38 How many days over the past week have you been around somebody who was smoking? No exposure at all during the past week 38 In the same room 1–2 days 27 In the same room 3–4 days 11 In the same room 5–6 days 7 All 7 days 19 Do you have friends who smoke? No 48 Yes 52 How often are you around friends who smoke? Never 57 Sometimes 28 Often 14 How often do you see actors smoking in the television or movies? Most of the time 62 Sometimes 29 Almost never 3 Never 2 How often do you see tobacco advertisements in newspapers and magazines?a n = 818 Most of the time 21 Sometimes 45 Almost never 21 Never 13 b How often do you see tobacco advertisements in kiosks, supermarkets or gas stations? n = 977 Most of the time 34 Sometimes 39 Almost never 17 Never 11

HS students, n = 767 %

50 19 26 18 31 15 36 30 22 48 15 26 15 12 31 10 90 12 39 50 67 25 2 1 n = 629 27 48 18 8 n = 697 43 43 11 1

Percentages may not add up to 100 due to some missing data on behalf of participants a: Percentage reported corresponds to percentage of students who read newspapers and magazines b: Percentage reported corresponds to percentage of students who go to places like kiosks, supermarkets and gas stations

Media

Smoking and adult supervision after school

Girls were significantly more likely than boys to report seeing actors on television smoking [MS: 2(4) = 17.45, P < 0.01; 57% girls; HS: 2(4) = 19.52, P < 0.001; 56% girls], to report seeing tobacco advertisements on television [MS: 2(4) = 47.80, P < 0.001, 57% girls; HS: 2(4) = 62.61, P < 0.001, 59% girls], and in kiosks, supermarket or gas stations [MS: 2(4) = 17.19, P < 0.005; 58% girls; HS: 2(4) = 22.76, P < 0.001, 55% girls]. In MS, students who see actors smoke most of the time were more likely to smoke themselves, compared with those who almost never see actors smoke (OR = 0.43, P < 0.001). No other media exposure variable predicted smoking status. Girls were more likely than boys to report frequently seeing anti-smoking advertisements [MS: 2(3) = 8.47, P < 0.05, 20% of girls vs. 19% of boys; HS: 2(3) = 9.29, P < 0.05, 15% of females vs. 8% of males]. In HS, smokers were more likely to report never coming across anti-smoking advertisements on TV or radio (33%) compared with students who come across such advertisements very often [6%; 2(3) = 21.32, P < 0.001]. No such relation was identified for MS students [2(3) = 2.03, P > 0.05].

In both MS and HS, adult supervision after school was significantly associated with reduced smoking rates [MS: 2(8) = 31.40, P < 0.00; HS: 2(6) = 14.09, P < 0.05]. Specifically, 5% of MS and 23% of HS students who reported never being home alone were smokers compared with 12% of MS and 32% of HS students who reported being home alone during 3 days/week.

Smoking and awareness of legislation Most MS (85%) and HS students (92%) reported being informed regarding the law prohibiting cigarette sales to minors. In MS, awareness of the law did not differentiate between smokers and non-smokers, 2(1) = 1.23, P > 0.05, or between the way students obtained their cigarettes (i.e. whether they bought them illegally from a store), 2(4) = 5.52, P > 0.05. In HS, students who reported being aware of the law smoke more compared with those who are not, 2(1) = 4.55, P < 0.05, OR = 2.26. Smokers who were aware

Smoking prevalence in Cypriot adolescents

of the law were more likely to report buying their cigarettes illegally from a store, 2(4) = 22.27, P < 0.00, OR = 3.50.

Discussion Adolescent smoking rates in Cyprus, as reported in this study are high compared with other European countries.14 Already in MS, 6% of students smoke, and 19% have tried smoking. The equivalent values for HS are 24 and 53%. As expected, smoking rates increased with age. Results indicate smoking prevalence among MS and HS students at similar or slightly lower levels than what is indicated from the 2005 Cyprus Global Youth Tobacco Survey (CGYTS), which reports smoking rates of 29% for HS and 11% of MS students, and at 17% overall.11,15 A similar, disconcertingly young age of smoking onset appears in both studies (12 years for MS and 14 years for HS in this study, and 12–13 years in the CGYTS study). The slight discrepancy in smoking prevalence in the two studies may be accounted for by the stricter criterion for classifying a student as a smoker in our study (reported smoking on a regular basis rather than occasionally). The number of students absent during the days of data collection for this study was small, therefore it was not considered necessary to recruit absent students at later points. The possibility that illness-related absences are actually linked to smoking or exposure to second hand smoke, should be taken into account before generalizing findings to all adolescents. The data available so far for Cyprus indicate noticeably higher adolescent smoking prevalence than the culturally similar country of Greece (14% smoking prevalence among students), and present comparable or higher levels of ETS exposure at home and outside the home. If we take into account the looser definition of current smokers in the GYTS study, prevalence rates appear comparable to Eastern European and Balkan countries.16 Further direct comparison of the situation in Cyprus with the situation in other Western countries is somewhat limited since Cyprus has not participated in the Health Behaviour of School Children Project (HBSC). Longitudinal data from the HBSC and elsewhere indicate that many Western countries are at Stage III of the smoking epidemic, which means that smoking rates are predicted to decrease in the next few years.17,18 In the case of Cyprus, longitudinal data are lacking, but trends in the data, such as the persisting high male smoking prevalence, suggest that Cyprus is still at Stage II.18 We assume that the higher average age for smoking the first cigarette reported in HS (14 years) compared with MS students (12 years), is due to the inclusion of students who started smoking at later periods, during their high school years. This may suggest that MS and HS students start smoking throughout most of their school years, rather than having a critical period in HS or MS, and perhaps for different reasons. Peer pressure and perceptions of tobacco use as socially normative may be crucial in younger ages, whereas stress and high academic pressure in the final years of HS along with inadequate coping skills, may lead older adolescents to start smoking as a coping strategy.19,20 These results suggest that, to reach students before they start experimenting with smoking, prevention programmes need to start early and be ongoing throughout their secondary education. It is also possible that given the lack of public awareness campaigns and low levels of sensitization regarding the harmful effects of smoking in Cyprus, smoking is becoming increasingly popular and age of onset is becoming lower among adolescents in Cyprus. However, the cross-sectional design of both the present study, and the CGYTS, do not allow for definitive conclusions regarding the reason for the

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observed discrepancy in smoking age between MS and HS students. Further longitudinal and cross-sequential studies are necessary to investigate potential changes in smoking trajectories over the years, and differences in reasons for smoking among students who start smoking at different ages. According to de Vries and Kok,21 smoking rates were higher among adolescents attending technical/vocational school compared with those who attend public or private HS. Further comparisons may be needed to determine more precisely how these three HS populations differ, and how prevention and intervention programmes can be tailored to achieve maximum impact for each population. Interesting findings included the higher prevalence of smoking among students who received higher weekly allowance, lower parental supervision after school and loweducational aspirations. However, no causal link can yet be inferred for any of these observations and the precise mechanism accounting for these effects needs to be investigated further. Prevention programmes might consider addressing parenting and supervision styles, student’s long-term goals, including educational aspirations. Differentially targeting adolescents with lower aspirations as a vulnerable target group should be considered, as lower educational aspirations are often associated with other risk factors for deviant or harmful behaviours. Despite high awareness of the 2002 legislation, which prohibits sales of tobacco products to minors (individuals younger than 18 years), adolescents do not appear discouraged from purchasing cigarettes or from smoking. It is obvious from the present study that this law is not currently being enforced, and adolescents are aware of this. This should alert authorities to immediately enforce existing legislation as a strategy to discourage some adolescents from picking up the habit.22 The large proportion of smokers among parents may represent the smoking prevalence within the adult population in Cyprus, which has not so far been systematically investigated.9,10 This, along with the alarming reported absence of rules regarding smoking in adolescents’ homes, and the frequency of adolescents having friends who smoke and being present in the same room with smokers, are reasons for worry. Our findings are consistent with previous studies documenting the importance of family and social parameters, especially friends, in most models representing factors influencing smoking initiation.23 As expected, adolescents were more likely to report smoking if their parents smoked, especially if their mother smokes (MS students) or if their siblings smoke (HS students). Once more, although a causal relation cannot be established based on the data reported in this study, given available evidence for the effectiveness of implementing smoke-free legislations,24 we suggest that strict enforcement of legislation requiring public places to be smoke free could also decrease levels of exposure to friends who smoke. As in previous studies, associations between macro level, societal factors, including exposure to tobacco products and smoking advertisements with adolescent smoking were identified.25 Adolescents’ reports of actors smoking on television, and of advertisements promoting tobacco products in newspapers, magazines, supermarkets, gasoline stations, etc., suggest that these are frequent phenomena, whereas almost 50% of adolescents reported that they never see anti-smoking advertisements. Although, the reported findings may not be representative of how often anti-smoking advertisements are presented via the media in Cyprus, they are representative of the adolescents’ perception of these advertisements. This perception alone should alert and motivate the appropriate governmental and non-governmental agencies to

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examine their anti-smoking campaigns since their messages do not appear to reach, or have sufficient impact on adolescents. More research could contribute to the investigation and evaluation of alternative means of presenting non-smoking messages and reaching the youth. It is integral for any prevention programme to tackle smoking from a systemic perspective, which will simultaneously deal with the influences of smoking on a variety of levels that appear to be important (macro-societal, meso-social and micro-intrapersonal levels26). This study examined several such factors. Still, numerous individual differences that have been associated with adolescent smoking, including, personality, temperament, coping styles, anxiety sensitivity and negative affectivity27,28 need to be further explored, and considered in the design, adaptation and implementation of any prevention and intervention programmes. Indeed, the imperativeness of effective prevention of adolescent smoking, to achieve decreases in incidence rates of serious health problems associated with smoking,2,29 cannot be overstated.

4

Marshall L, Schooley M, Ryan H, et al. Youth tobacco surveillance – United States, 2001–2002. MMWR CDC Surveillance Summer 2006;55:1–56.

5

Everett SA, Warren CW, Sharp D, et al. Initiation of cigarette smoking and subsequent smoking behavior among U.S. high school students. Prev Med 1999;29:327–33.

6

Lando HA, Thai DT, Murray DM, et al. Age of initiation, smoking patterns, and risk in a population of working adults. Prev Med 1999;29:590–8.

7

ENSP: European Network for Smoking Prevention. European News Bulletin. Brussels: ENSP Office, 2004.

8

Davis RM, Smith R. Addressing the most important preventable cause of death. Br Med J 1991;303:732–3.

9

Loizou T, Pouloukas S, Tountas C, et al. An epidemiologic study on the prevalence of diabetes, glucose intolerance and metabolic syndrome in the adult population of the republic of Cyprus. Diabetes Care 2006;29:1714–5.

Acknowledgements

12 Center of Disease Control: Global Youth Tobacco Survey (GYTS) English core questionnaire, 2001. Available at http://www.cdc.gov/ tobacco/global/gyts/english_questionnaire.htm (1 December 2008, date accessed).

The authors thank the Cyprus Anticancer Association and Cyprus Smoke-Free Coalition (KESAK) for their help and support for this study, and the anonymous reviewers for their helpful suggestions.

Funding Cyprus Research Promotion Foundation (to M.K. and A.S., partial). Conflicts of interest: None declared.

Key points This article constitutes a first systematic, nationwide study of smoking prevalence and parameters in adolescents in Cyprus. It demonstrates the strong relations between the adolescents’ toxic environment, with frequent exposure to smoking by parents and friends, and smoking prevalence in adolescence. It documents the gaps and inadequacies in present legislation and law implementation and enforcement, especially regarding the prohibition of tobacco sales to minors and legal requirements for smoke-free public places. It provides suggestions for the more effective design of prevention and intervention programmes for adolescents, including suggestions for government officials in dealing with the smoking problem.

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Received 21 August 2008, accepted 21 April 2009