Trends in smoking and smokeless tobacco use among Danish Adolescents, 1997-2014
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National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
Janne S. Tolstrup   

National Institute of Public Health, University of Southern Denmark, Studiestræde 6, Copenhagen 1455, Denmark
Publish date: 2018-03-20
Submission date: 2017-10-12
Final revision date: 2018-03-05
Acceptance date: 2018-03-06
Tob. Prev. Cessation 2018;4(March):10
High rates of smoking among adolescents remain a public health concern. This study investigates smoking behavior and use of smokeless tobacco among Danish high-school students and assesses how smoking and use of smokeless tobacco cluster in schools and school classes. We estimate the trend in cigarette smoking from 1997 to 2014.

We used data on 70 243 students, from 3 214 school classes in 119 high schools, who participated in the Danish National Youth Study from 2014. We had information on 87% of all Danish high schools and 85% of eligible students. We also used data from 1997 on 26 644 high-school students from a similar data set to assess the chronological trend in smoking. We calculated prevalences and intraclass correlation coefficients (ICCs) to estimate between-school and between-school class clustering in smoking and use of smokeless tobacco.

In all, 14% of boys and 11% of girls were daily smokers. A large fraction of the variation in smoking and the use of smokeless tobacco was attributable to the school and school-class level (ICC of 0.19, 0.12, 0.16 and 0.27, for daily smoking, waterpipe smoking, use of electronic cigarettes and snuff/chewing tobacco, respectively). Daily smoking decreased from 15% in 1997 to 12% in 2014, while more students were occasional smokers in 2014 than in 1997 (30% vs 18%).

The prevalence of smoking was high among Danish high-school students and had changed little since 1997. The school and class environment accounted for a large part of the variation in smoking behavior.

Smoking prevalence and attributable disease burden in 195 countries and territories, 1990-2015: a systematic analysis from the Global Burden of Disease Study 2015. Lancet (London, England). 2017;389:1885-906.
Lund I and Scheffels J. Adolescent tobacco use practices and user profiles in a mature Swedish moist snuff (snus) market: Results from a school-based cross-sectional study. Scandinavian journal of public health. 2016;44(7):646-53. doi:10.1177/1403494816656093
Maziak W. Rise of waterpipe smoking. BMJ (Clinical research ed). 2015;(apr17 5)350: h1991. doi: 10.1136/bmj.h1991
Maziak W, Taleb ZB, Bahelah R, Islam F, Jaber R, Auf R et al. The global epidemiology of waterpipe smoking. Tobacco control. 2014;24(Suppl 1): i3-i12. doi: 10.1136/tobaccocontrol-2014-051903
Salloum RG, Thrasher JF, Getz KR, Barnett TE, Asfar T and Maziak W. Patterns of Waterpipe Tobacco Smoking Among U.S. Young Adults, 2013-2014. American journal of preventive medicine. 2017;52(4):507-12. doi: 10.1016/j.amepre.2016.10.015
Pisinger C and Døssing M. A systematic review of health effects of electronic cigarettes. Preventive medicine. 2014;69:248-60. doi:10.1016/j.ypmed.2014.10.009
Hajek P, Etter JF, Benowitz N, Eissenberg T and McRobbie H. Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit. Addiction. 2014;109(11):1801-10. doi:10.1111/add.12659
Levy DT1, Mumford EA, Cummings KM, Gilpin EA, Giovino G, Hyland A, et al. The relative risks of a low-nitrosamine smokeless tobacco product compared with smoking cigarettes: estimates of a panel of experts. Cancer Epidemiol Biomarkers Prev. 2004 Dec;13(12):2035-42.
Soneji Samir, Barrington-Trimis Jessica L., Wills Thomas A., Leventhal Adam M., Unger Jennifer B., Gibson Laura A., et al. Association Between Initial Use of e-Cigarettes and Subsequent Cigarette Smoking Among Adolescents and Young Adults: A Systematic Review and Meta-analysis. JAMA pediatrics. 2017;171(8). doi: 10.1001/jamapediatrics.2017.1488
Jaber R, Madhivanan P, Veledar E, Khader Y, Mzayek F and Maziak W. Waterpipe a gateway to cigarette smoking initiation among adolescents in Irbid, Jordan: a longitudinal study. The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease. 2015;19(4):481-7. doi:10.5588/ijtld.14.0869
Sawyer SM, Afifi RA, Bearinger LH, Blakemore SJ, Dick B, Ezeh A C et al. Adolescence: a foundation for future health. Lancet. 2012;379 (9826):1630-40. doi:10.1016/s0140-6736(12)60072-5
Viner RM, Ozer EM, Denny S, Marmot M, Resnick M, Fatusi A et al. Adolescence and the social determinants of health. Lancet. 2012;379 (9826):1641-52. doi:10.1016/s0140-6736(12)60149-4
Crosnoe Robert, Johnson Monica Kirkpatrick. Research on adolescence in the twenty-first century. Annual Review of Sociology 2011;37(1): 439-60. doi: 10.1146/annurev-soc-081309-150008
Costello MJ, Leatherdale ST, Ahmed R, Church DL and Cunningham JA. Co-morbid substance use behaviors among youth: any impact of school environment? Global health promotion. 2012; 19:(1)50-9. doi:10.1177/1757975911429873
U.S. Department of Health and Human Services PHS, Office of the Surgeon General. The Health Consequences of Smoking—50 Years of Progress. A Report of the Surgeon General. 2014.
Sowell ER, Peterson BS, Thompson PM, Welcome SE, Henkenius AL and Toga AW. Mapping cortical change across the human life span. Nature neuroscience. 2003;6(3): 309-15. doi:10.1038/nn1008
Giedd JN. Structural magnetic resonance imaging of the adolescent brain. Annals of the New York Academy of Sciences. 2004;1021(1):77-85. doi:10.1196/annals.1308.009
Kendler KS, Myers J, Damaj MI and Chen X. Early smoking onset and risk for subsequent nicotine dependence: a monozygotic co-twin control study. The American journal of psychiatry. 2013;170(4):408-13. doi:10.1176/appi.ajp.2012.12030321
Pisinger VSC, Mikkelsen SS, Bendtsen P, Egan KK and Tolstrup JS. The Danish National Youth Study 2014: Study design, population characteristics and non-response analysis. Scandinavian journal of public health. 2017. doi:10.1177/1403494817729283
Nielsen GA. Gymnasie- & HF-elevers sundhedsvaner & livsstil 1996-97. Copenhagen: DIKE 1998.
Heatherton TF, Kozlowski LT, Frecker RC and Fagerström KO. The Fagerström test for nicotine dependence: a revision of the Fagerstrom Tolerance Questionnaire. Addiction. 1991;86(9):1119-27. doi:10.1111/j.1360-0443.1991.tb01879.x
Jensen VM and Rasmussen AW. Danish education registers. Scandinavian journal of public health. 2011;39(suppl 7):91-4. doi: 10.1177/1403494810394715
Merlo J, Chaix B, Ohlsson H, Beckman A, Johnell K, Hjerpe P et al. A brief conceptual tutorial of multilevel analysis in social epidemiology: using measures of clustering in multilevel logistic regression to investigate contextual phenomena. Journal of epidemiology and community health. 2006;60(40):290-7. doi:10.1136/jech.2004.029454
Joossens L and Raw M. The Tobacco Control Scale: a new scale to measure country activity. Tobacco control. 2006;15(3): 247-53. doi:10.1136/tc.2005.015347
Joossens LR, M. The Tobacco Control Scale 2016 in Europe. In: Leagues AoEC, (ed.). Belgium; 2017.
Guindon GE. The impact of tobacco prices on smoking onset: a methodological review. Tobacco control. 2014;23(2): e5. doi:10.1136/tobaccocontrol-2012-050496
Hughes N, Arora M and Grills N. Perceptions and impact of plain packaging of tobacco products in low and middle income countries, middle to upper income countries and low-income settings in high-income countries: a systematic review of the literature. BMJ open. 2016;6 (3): e010391. doi:10.1136/bmjopen-2015-010391
Christensen AI, Davidsen M, Ekholm O, Pedersen PV and Juel K. Danes health: The national health profil 2013. [Danskernes sundhed: Den nationale sundhedsprofil 2013]. 2014.
Andersen S, Rod MH, Ersbøll AK, Stock C, Johansen C, Holmberg T et al. Effects of a settings-based intervention to promote student wellbeing and reduce smoking in vocational schools: A non-randomized controlled study. Social Science & Medicine. 2016;161: 195-203. doi:10.1016/j.socscimed.2016.06.012
Inchley J and Currie D. Growing up unequal: gender and socioeconomic differences in young people’s health and well-being. Health Behaviour in School-aged Children (HBSC) study: international report from the. 2013; 2014.
Gorber SC, Schofield-Hurwitz S, Hardt J, Levasseur Gv and Tremblay M. The accuracy of self-reported smoking: A systematic review of the relationship between self-reported and cotinine-assessed smoking status. Nicotine & Tobacco Research. 2009;11(1):12-24. doi: 10.1093/ntr/ntn010
Vartiainen E, Seppälä T, Lillsunde P and Puska P. Validation of self reported smoking by serum cotinine measurement in a community-based study. Journal of Epidemiology & Community Health. 2002;56(3):167-70.doi: 10.1136/jech.56.3.167