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Workplace Strategies Are Needed to Protect Youth Across the Globe From Starting to Smoke
Journal of Adolescent Health 51 (2012) 205–206
www.jahonline.org Editorial
Workplace Strategies Are Needed to Protect Youth Across the Globe From Starting to Smoke
Although decreasing rates of cigarette use in the United States should be applauded by its champions, we cannot be complacent in our vigilance toward tobacco control. Tobacco use in many parts of the world is increasing and poses a significant threat to Asia. In Korea, the world’s eighth leading cigarette market [1], approximately one-quarter of the population above age 15 years smokes cigarettes, an estimate comparable with that of the United States [2]. However, differences in smoking behaviors in these nations are of concern. For example, more Koreans than Americans smoke daily (25% vs. 15%, respectively), and the smoking rate among Korean men is nearly double that of American men [2]. Although only 6% of Korean women smoke daily relative to 15% of American women, Western tobacco firms are specifically gearing their products to Asian countries and to women who live in these countries [2,3]. Ensuring that adolescents do not start smoking is a vital goal of any national tobacco control program; research that seeks to understand when and why youth begin smoking is therefore critical to developing effective antismoking strategies. In their article, Do and Finkelstein [4] make a highly relevant and important contribution to this effort by showing that in South Korea, when adolescents start working at part-time jobs, their risk of starting to smoke increases by 4%. These findings are similar to findings I obtained with my colleagues showing that among youth in Baltimore city, those who started to work had a 9-fold increased risk of starting to smoke relative to their peers who do not start working [5]. These studies join a substantial literature based primarily in the United States, but also with evidence from Egypt and Taiwan, that working, or working too much, may be bad for adolescents’ health. Although for some adverse health outcomes the link between working and adverse health behaviors may be endogenous [6], in the case of smoking, the evidence is mounting that something happens when youth start working that compels them to take up smoking. Restricting employment opportunities for youth is not a feasible response. Youth work to make money, and industries that employ youth both in Korea and the United States, like fast food restaurants, rely on an adolescent workforce. In both countries,
approximately one-quarter of all school-attending youth work in part-time jobs during the school year [7,8]. Instead of restricting young peoples’ opportunity to work, comprehensive prevention is needed that targets this important population of youth entering the workforce. Strategies to prevent youth smoking include increasing the price of cigarettes, ensuring smoke-free environments, restricting marketing of tobacco products and promoting antismoking messages, and implementing educational curricula [9]. The specific strategies used to target young workers will need to be based on research that examines the reasons why youth start smoking when they start working. Do and Finkelstein [4] make an exciting contribution that helps inform this question by testing the “income hypothesis” that youth who work have the means to purchase cigarettes. If the authors found evidence of an income effect, it suggests aggressive strategies to increase the price of cigarettes (which in Korea is on average $2.11 USD per pack) [2]. However, Do and Finkelstein did not find support for this hypothesis. Instead, their data show that having a job—not necessarily making money from that job—is associated with increased smoking. Their findings signal the importance of implementing other tobacco control strategies in the workplace setting that can help prevent young workers from initiating smoking. One area for which there is already significant evidence of effectiveness is ensuring that young people are working in smoke-free environments. Although designed to limit nonsmokers’ exposure to second-hand smoke, studies have found that such policies are correlated with increased rates of smoking cessation and reduced cigarette use among adult employees [10]; these policies, when specifically enacted in workplaces that employ youth, might similarly prevent youth from starting to smoke. As of 2010, Korean law only protects youth in schools with policies that enforce such institutions to be smoke free; such protections are notably absent in other settings like restaurants where youth are likely to work [2]. It is also important that we provide youth with information and tools that they need to choose not to smoke when the
See Related Article p. 226 1054-139X/$ - see front matter 䉷 2012 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2012.07.002
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R. Ramchand / Journal of Adolescent Health 51 (2012) 205–206
opportunity presents itself. Research has shown that providing youth with education about the harms associated with smoking, strategies to increase their ability to resist opportunities to use tobacco, and correcting their beliefs about social norms can all decrease smoking initiation [11]. For example, one intervention for seventh and eighth graders, Project ALERT, reduced smoking initiation by 19% [12]. But rather than developing another school-based intervention, it is time to move forward with recommendations I made in our original article (2007) and that are echoed by Do and Finkelstein [4], who write that “workplaces that hire youth may be an appropriate target for antismoking interventions.” In developing and implementing antismoking interventions geared specifically toward young workers, it is important to both test the strategies we know to be effective and to develop innovative approaches for this specific setting. We also need to consider what is developmentally relevant for this age-group and engage them in educational programs by specifically addressing their motivations for working in the first place, for example, by teaching them effective ways to use or save their earnings for delayed gratification rather than attaining the immediate rewards offered by smoking. For adults, Dr. Jody Sindelar and colleagues at Yale University (New Haven, CT) are developing and testing new approaches to encourage adult smokers in the United States to quit smoking by providing financial motivations, forcing them to think about how much of their earnings go toward buying cigarettes, and how these earnings could be otherwise spent. A program like theirs might be adapted for young workers and provides an important foundation on which new curricula could be developed for this population. However, the findings of Do and Finkelstein [4] also emphasize the importance of determining factors other than income that might increase smoking initiation among young workers. Some of the effect may be endogenous; youth more likely to take up part-time jobs might be independently more likely to start smoking. Other possible explanations are that youth who work may have increased opportunities to use cigarettes provided by older coworkers, or may turn to smoking as a way to cope with the increased stress brought about by having a job, or managing competing responsibilities at home, at school, and at work. Providing an intervention in the workplace for young workers is not without its challenges. Although smoking cessation programs for adults delivered in workplace settings are effective [13], the first feasibility study of an antismoking intervention for
young American workers showed that their irregular schedules and high rates of turnover resulted in relatively low levels of participation [14]. An additional challenge will be gaining the cooperation of employers, who are unlikely to experience large direct consequences to their businesses resulting from the smoking behaviors of their young employees [15]. However, these challenges are surmountable and, more importantly, are critical for Korea, the United States, and the rest of the world to overcome if we are to continue to curb tobacco use among our countries’ young population. Rajeev Ramchand, Ph.D. RAND Corporation Washington, DC
References [1] World Health Organization. Western Pacific region. Fact sheets smoking statistics. Geneva, Switzerland: World Health Organization. Available at: http://www.wpro.who.int/media_centre/fact_sheets/fs_20020528.htm. Accessed November 24, 2011. [2] World Health Organization. WHO report on the global tobacco epidemic, 2011: Warning about the dangers of tobacco. Geneva, Switzerland: World Health Organization, 2011. Available at: http://www.who.int/tobacco/ global_report/2011/en/index.html. [3] The last gasp: For big tobacco, South-East Asia is the final frontier. The Economist. March 31st, 2011. [4] Do YK, Finkelstein EA. Youth employment, income, and smoking initiation: results from Korean panel data. J Adolesc Health 2012;51:226 –32. [5] Ramchand R, Ialongo NS, Chilcoat HD. The effect of working for pay on adolescent tobacco use. Am J Public Health 2007;97:2056 – 62. [6] Paternoster R, Bushway S, Brame R, Apel R. The effect of teenage employment on delinquency and problem behaviors. Soc Forces 2003;82:297–335. [7] Ministry of Health Welfare and Family. The 2008 white paper of children and adolescents. Seoul, Korea: Ministry of Health Welfare and Family, 2008. [8] Morisi TL. Youth enrollment and employment during the school year. Mon Lab Rev 2008;131:51– 63. [9] Pierce JP, White VM, Emery SL. What public health strategies are needed to reduce smoking initiation? Tob Contr 2012;21:258 – 64. [10] Fichtenberg CM, Glantz SA. Effect of smoke-free workplaces on smoking behaviour: Systematic review. BMJ 2002;325:188. [11] Thomas R, Perera R. School-based programmes for preventing smoking. Cochrane Database Syst Rev 2006;3:CD001293. [12] Ellickson PL, McCaffrey DF, Ghosh-Dastidar B, Longshore DL. New inroads in preventing adolescent drug use: Results from a large-scale trial of project ALERT in middle schools. Am J Public Health 2003;93:1830 – 6. [13] Moher M, Hey K, Lancaster T. Workplace interventions for smoking cessation. Cochrane Database Syst Rev 2005;2:CD003440. [14] Hunt MK, Fagan P, Lederman R, et al. Feasibility of implementing intervention methods in an adolescent worksite tobacco control study. Tob Contr 2003;12(Suppl 4):IV40 –5. [15] Javitz HS, Zbikowski SM, Swan GE, Jack LM. Financial burden of tobacco use: An employer’s perspective. Clin Occup Environ Med 2006;5:9 –29, vii.
www.jahonline.org Editorial
Workplace Strategies Are Needed to Protect Youth Across the Globe From Starting to Smoke
Although decreasing rates of cigarette use in the United States should be applauded by its champions, we cannot be complacent in our vigilance toward tobacco control. Tobacco use in many parts of the world is increasing and poses a significant threat to Asia. In Korea, the world’s eighth leading cigarette market [1], approximately one-quarter of the population above age 15 years smokes cigarettes, an estimate comparable with that of the United States [2]. However, differences in smoking behaviors in these nations are of concern. For example, more Koreans than Americans smoke daily (25% vs. 15%, respectively), and the smoking rate among Korean men is nearly double that of American men [2]. Although only 6% of Korean women smoke daily relative to 15% of American women, Western tobacco firms are specifically gearing their products to Asian countries and to women who live in these countries [2,3]. Ensuring that adolescents do not start smoking is a vital goal of any national tobacco control program; research that seeks to understand when and why youth begin smoking is therefore critical to developing effective antismoking strategies. In their article, Do and Finkelstein [4] make a highly relevant and important contribution to this effort by showing that in South Korea, when adolescents start working at part-time jobs, their risk of starting to smoke increases by 4%. These findings are similar to findings I obtained with my colleagues showing that among youth in Baltimore city, those who started to work had a 9-fold increased risk of starting to smoke relative to their peers who do not start working [5]. These studies join a substantial literature based primarily in the United States, but also with evidence from Egypt and Taiwan, that working, or working too much, may be bad for adolescents’ health. Although for some adverse health outcomes the link between working and adverse health behaviors may be endogenous [6], in the case of smoking, the evidence is mounting that something happens when youth start working that compels them to take up smoking. Restricting employment opportunities for youth is not a feasible response. Youth work to make money, and industries that employ youth both in Korea and the United States, like fast food restaurants, rely on an adolescent workforce. In both countries,
approximately one-quarter of all school-attending youth work in part-time jobs during the school year [7,8]. Instead of restricting young peoples’ opportunity to work, comprehensive prevention is needed that targets this important population of youth entering the workforce. Strategies to prevent youth smoking include increasing the price of cigarettes, ensuring smoke-free environments, restricting marketing of tobacco products and promoting antismoking messages, and implementing educational curricula [9]. The specific strategies used to target young workers will need to be based on research that examines the reasons why youth start smoking when they start working. Do and Finkelstein [4] make an exciting contribution that helps inform this question by testing the “income hypothesis” that youth who work have the means to purchase cigarettes. If the authors found evidence of an income effect, it suggests aggressive strategies to increase the price of cigarettes (which in Korea is on average $2.11 USD per pack) [2]. However, Do and Finkelstein did not find support for this hypothesis. Instead, their data show that having a job—not necessarily making money from that job—is associated with increased smoking. Their findings signal the importance of implementing other tobacco control strategies in the workplace setting that can help prevent young workers from initiating smoking. One area for which there is already significant evidence of effectiveness is ensuring that young people are working in smoke-free environments. Although designed to limit nonsmokers’ exposure to second-hand smoke, studies have found that such policies are correlated with increased rates of smoking cessation and reduced cigarette use among adult employees [10]; these policies, when specifically enacted in workplaces that employ youth, might similarly prevent youth from starting to smoke. As of 2010, Korean law only protects youth in schools with policies that enforce such institutions to be smoke free; such protections are notably absent in other settings like restaurants where youth are likely to work [2]. It is also important that we provide youth with information and tools that they need to choose not to smoke when the
See Related Article p. 226 1054-139X/$ - see front matter 䉷 2012 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2012.07.002
206
R. Ramchand / Journal of Adolescent Health 51 (2012) 205–206
opportunity presents itself. Research has shown that providing youth with education about the harms associated with smoking, strategies to increase their ability to resist opportunities to use tobacco, and correcting their beliefs about social norms can all decrease smoking initiation [11]. For example, one intervention for seventh and eighth graders, Project ALERT, reduced smoking initiation by 19% [12]. But rather than developing another school-based intervention, it is time to move forward with recommendations I made in our original article (2007) and that are echoed by Do and Finkelstein [4], who write that “workplaces that hire youth may be an appropriate target for antismoking interventions.” In developing and implementing antismoking interventions geared specifically toward young workers, it is important to both test the strategies we know to be effective and to develop innovative approaches for this specific setting. We also need to consider what is developmentally relevant for this age-group and engage them in educational programs by specifically addressing their motivations for working in the first place, for example, by teaching them effective ways to use or save their earnings for delayed gratification rather than attaining the immediate rewards offered by smoking. For adults, Dr. Jody Sindelar and colleagues at Yale University (New Haven, CT) are developing and testing new approaches to encourage adult smokers in the United States to quit smoking by providing financial motivations, forcing them to think about how much of their earnings go toward buying cigarettes, and how these earnings could be otherwise spent. A program like theirs might be adapted for young workers and provides an important foundation on which new curricula could be developed for this population. However, the findings of Do and Finkelstein [4] also emphasize the importance of determining factors other than income that might increase smoking initiation among young workers. Some of the effect may be endogenous; youth more likely to take up part-time jobs might be independently more likely to start smoking. Other possible explanations are that youth who work may have increased opportunities to use cigarettes provided by older coworkers, or may turn to smoking as a way to cope with the increased stress brought about by having a job, or managing competing responsibilities at home, at school, and at work. Providing an intervention in the workplace for young workers is not without its challenges. Although smoking cessation programs for adults delivered in workplace settings are effective [13], the first feasibility study of an antismoking intervention for
young American workers showed that their irregular schedules and high rates of turnover resulted in relatively low levels of participation [14]. An additional challenge will be gaining the cooperation of employers, who are unlikely to experience large direct consequences to their businesses resulting from the smoking behaviors of their young employees [15]. However, these challenges are surmountable and, more importantly, are critical for Korea, the United States, and the rest of the world to overcome if we are to continue to curb tobacco use among our countries’ young population. Rajeev Ramchand, Ph.D. RAND Corporation Washington, DC
References [1] World Health Organization. Western Pacific region. Fact sheets smoking statistics. Geneva, Switzerland: World Health Organization. Available at: http://www.wpro.who.int/media_centre/fact_sheets/fs_20020528.htm. Accessed November 24, 2011. [2] World Health Organization. WHO report on the global tobacco epidemic, 2011: Warning about the dangers of tobacco. Geneva, Switzerland: World Health Organization, 2011. Available at: http://www.who.int/tobacco/ global_report/2011/en/index.html. [3] The last gasp: For big tobacco, South-East Asia is the final frontier. The Economist. March 31st, 2011. [4] Do YK, Finkelstein EA. Youth employment, income, and smoking initiation: results from Korean panel data. J Adolesc Health 2012;51:226 –32. [5] Ramchand R, Ialongo NS, Chilcoat HD. The effect of working for pay on adolescent tobacco use. Am J Public Health 2007;97:2056 – 62. [6] Paternoster R, Bushway S, Brame R, Apel R. The effect of teenage employment on delinquency and problem behaviors. Soc Forces 2003;82:297–335. [7] Ministry of Health Welfare and Family. The 2008 white paper of children and adolescents. Seoul, Korea: Ministry of Health Welfare and Family, 2008. [8] Morisi TL. Youth enrollment and employment during the school year. Mon Lab Rev 2008;131:51– 63. [9] Pierce JP, White VM, Emery SL. What public health strategies are needed to reduce smoking initiation? Tob Contr 2012;21:258 – 64. [10] Fichtenberg CM, Glantz SA. Effect of smoke-free workplaces on smoking behaviour: Systematic review. BMJ 2002;325:188. [11] Thomas R, Perera R. School-based programmes for preventing smoking. Cochrane Database Syst Rev 2006;3:CD001293. [12] Ellickson PL, McCaffrey DF, Ghosh-Dastidar B, Longshore DL. New inroads in preventing adolescent drug use: Results from a large-scale trial of project ALERT in middle schools. Am J Public Health 2003;93:1830 – 6. [13] Moher M, Hey K, Lancaster T. Workplace interventions for smoking cessation. Cochrane Database Syst Rev 2005;2:CD003440. [14] Hunt MK, Fagan P, Lederman R, et al. Feasibility of implementing intervention methods in an adolescent worksite tobacco control study. Tob Contr 2003;12(Suppl 4):IV40 –5. [15] Javitz HS, Zbikowski SM, Swan GE, Jack LM. Financial burden of tobacco use: An employer’s perspective. Clin Occup Environ Med 2006;5:9 –29, vii.