MRC policy briefs to government

Children and tobacco in Southern Africa

Guthrie T*, ShungKing M*, Steyn K#, Mathambo V*.

*Child Health Policy Institute, University of Cape Town. Tel: +27 21 685-4103/4, Fax: +27 21 689-5403, e-mail: teresa@rmh.uct.ac.za
#Chronic Diseases of Lifestyle Programme, Medical Research Council. Tel: +27 21 938-0423, Fax: +27 21 933-5519, e-mail: krisela.steyn@mrc.ac.za

The Child Health Policy Institute (CHPI) of the University of Cape Town, and the Chronic Diseases of Lifestyle Programme of the Medical Research Council (MRC) were commissioned by the World Health Organisation (WHO) to undertake a review of the literature in the southern African region regarding the effects of environmental tobacco smoke (ETS) on the health of children, reports on youth smoking patterns and attitudes, as well as evaluations of tobacco-control interventions. General information was obtained regarding the production and sale of tobacco products in each of the SADC countries, as well as adult smoking rates. This was part of the WHO's Tobacco Free Initiative.

The review has provided a valuable database of all available literature from the region, for the period 1990 to 1999, and has supplied the evidence to inform international, regional and national policy and action.

Exposure of children to environmental tobacco smoke

During pregnancy
Maternal smoking during pregnancy rates could only be obtained from South Africa, where the rates varied between ethnic groups. An extremely high prevalence was found among coloured pregnant women, ranging from 75% in 1996 to 32,4% in 1999. Similar rates of 31,2% were found among white women. However, much lower rates were found among black and Indian women, of 4% and 3% respectively. An overall rate of 21% was found among pregnant women in South Africa. In addition, 50% of pregnant women were exposed to environmental tobacco smoke. Fig.1 indicates maternal smoking rates in South Africa, according to ethnicity.

Early childhood
Also cause for concern were the large numbers of children living in households with people who smoked, in particular, primary caregivers. The Birth-to-Ten Cohort study in Gauteng South Africa found that 64% of 5-year-old children were exposed to household ETS, with 40,6% of coloured children's primary caregivers smoking.

Effects of tobacco use on child health
The available studies from South Africa mainly examined tobacco and pregnancy, and birth outcomes, respiratory effects, childhood infections and the cardiovascular effects on adolescents. The literature confirmed a strong relationship between maternal smoking during pregnancy and low birth-weight, with increased risk of between 1,5 and 2,63. Decreases in weight of up to almost 250 g pose a major risk to the survival, health and development of children, especially in areas with poor antenatal services.

Respiratory studies found a statistically significant relationship between childhood asthma and maternal smoking patterns, as well as the number of persons smoking in the household. Various studies examined the combined effects of ETS and other environmental exposures, and confirmed that these other indoor and outdoor pollutants also contributed greatly to respiratory symptoms in children and adolescents.

Only one study examined the association between ETS and major non-respiratory infections. This study, which looked at the association between ETS and meningococcal meningitis. The risk increased dramatically when the child had an upper respiratory tract infection (URTI), and lived with two or more smokers in the home. (OR=3,6).

Smoking patterns of youth
The available data provide interesting information on consumption differences between races, gender, socio-economic groups and urban/rural locations. Swaziland and Tanzania reported very low rates of smoking among youth; 3,6% (1998) and 7,3% (1993) respectively, while Zimbabwe reports higher rates of 25.5% among Form 4 students (16/17 years) in 1996. Fig. 2 indicates some of the prevalence figures.

In South Africa, an overall prevalence of 19,6% was obtained for youth who smoke, with 8,9% being heavy smokers (1998). However, differences existed between the ethnic groups; 30,9% and 28,6% among Asian and Coloured males, compared with 22,2% and 21,8% among white and black males. Fig. 3 attempts to display the findings of various studies among the South African youth, indicating the differences between age groups.

With regard to gender differences, generally, very low rates were found among young women in Swaziland, Tanzania and Zambia (0,7%, 0,4% and 7,0% respectively). Low rates existed among rural Zimbabwean females (6%), while increasing to 17,3% among urban, private school girls. In South Africa differences again existed between racial groups, with low rates among Black (3,6%) and Asian (2,0%) females, but high among the Coloureds (16,0%) and Whites (18,4%). Obvious increases in prevalence were seen from rural to urban areas and with increasing socio-economic status.

The qualitative studies examine attitudes and knowledge, associated factor, and attempts to quit. These provide valuable insights into the world of the youth and what affects their vulnerability to tobacco and other drug use. The literature confirms the association between tobacco use and binge drinking (RR 2,19, 95% CI 1,53-3,14), dagga use (OR 3,6) and Mandrax and other drugs (PR: 5,82, 95% CI 3,35-10,11).

Effectiveness of tobacco-control interventions
There were very few evaluation studies of existing tobacco-control interventions targeting youth. Legislation controlling sales to minors, increasing excise taxes and banning of advertising and sponsorship by the tobacco industry were all found to decrease consumption among the youth. Of lesser impact were various health education efforts, with many youngsters reporting that they were sceptical of the overstated statistics given by the anti-tobacco lobby. Of concern was that they preferred and were susceptible to the alluring messages of the tobacco industry. Multi-media campaigns, with informative and appealing messages, were found to be highly effective in changing people's knowledge and attitudes. However, most of the evaluations of educational campaigns were unable to measure the actual impact on tobacco consumption. Similarly, with health warnings on the packaging of tobacco products - while an increase in knowledge was found due to these warnings, their effectiveness in reducing smoking rates was limited. This implies that they "need to be supported and reinforced by national and community smoking prevention initiatives".

Policy recommendations to reduce youth's exposure to tobacco for the SADC region

• The banning of all tobacco products advertising and sponsorship in South Africa should be followed by a similar ban in the whole SADC region.
• In South Africa, policies should be in place to ensure strict enforcement of the regulation banning sales to children younger than 16 years and offenders should be penalised.
• Continue with health warnings on all tobacco products.
• The distribution of free cigarettes is prohibited in South Africa. This policy should become policy throughout the SADC region and be strictly implemented
• Undertake public health education campaigns targeting youth.
• Develop effective, holistic, integrated school education programmes.
• Assistance to young people in giving up the habit is necessary, with subsidisation of Quit programmes and nicotine-replacement therapies.
• Consideration needs to be given to measures to protect children from tobacco smoke within their own homes.
• National Youth Commissions should be involved in all these processes.
• Provide specialised alcohol-, tobacco- and drug-related services for the youth. Tobacco programmes should not be dealt with in isolation, but as a component of a broader, holistic health programmes, facilitating the development of holistic, healthy lifestyle models.

The literature review showed that publications from the SADC region were scant. Further research is required on all the effects of environmental tobacco smoke on children, as well as on examining the possible synergistic effects of tobacco and other indoor and outdoor pollutants, which are major risk factors in the SADC region. Also required are national youth consumption surveys, and evaluations of the effectiveness of intervention techniques. It can be concluded that integrated and holistic legislation, policies and programmes are essential to protect children and youth from the influence of tobacco and the tobacco industry, and thus to create a generation of tobacco-free youth!

Acknowledgements
This project was funded by the Tobacco Free Initiative of the World Health Organisation.