Lung cancer mortality patterns in selected Central, Eastern and Southern European countries
Article first published online: 22 JAN 2004
Copyright © 2004 Wiley-Liss, Inc.
International Journal of Cancer
Volume 109, Issue 4, pages 598–610, 20 April 2004
How to Cite
Tyczynski, J. E., Bray, F., Aareleid, T., Dalmas, M., Kurtinaitis, J., Plesko, I., Pompe-Kirn, V., Stengrevics, A. and Parkin, D. M. (2004), Lung cancer mortality patterns in selected Central, Eastern and Southern European countries. Int. J. Cancer, 109: 598–610. doi: 10.1002/ijc.20019
- Issue published online: 24 FEB 2004
- Article first published online: 22 JAN 2004
- Manuscript Accepted: 5 NOV 2003
- Manuscript Revised: 29 OCT 2003
- Manuscript Received: 8 SEP 2003
- lung cancer;
- European Union;
Significant changes in the prevalence of tobacco smoking have been observed in many European countries. EU candidate countries have also experienced major changes with respect to tobacco smoking, which have resulted in changes in the frequency of lung cancer. In men in the majority of these countries, a reduction of mortality rates has been observed recently, while in Hungary and Poland a deceleration of mortality increase was observed in the 1990s. The situation is much less favorable in females, where in the majority of countries a continuous increase of mortality rates has been observed, the only exceptions being Latvia, Lithuania and, to a lesser extent, Estonia. In Hungarian women, an acceleration of the increase rate was observed in the 1980s and 1990s (compared with the 1970s). Patterns of lung cancer mortality in analyzed countries are somewhat similar to those observed in EU member states. Recent analyses of time trends of lung cancer in EU countries showed, in general, a decreasing risk in the majority of male populations and an increase in several countries in women. If the decrease of mortality is to be achieved and maintained in the longer term, efforts have to be focused on young generations (entering adulthood now or in the near future). Despite all the difficulties present in reducing tobacco smoking in youth, it seems that one of the most important ways to reduce the future lung cancer burden in current and new EU member states is to strengthen efforts toward changing smoking attitudes in young generations. © 2004 Wiley-Liss, Inc.
Lung cancer has been a major public health issue in Europe for many years. This disease is the most frequent cause of cancer deaths in males in the majority of European countries and one of the most frequent in females. Although several studies have dealt with time trends of lung cancer in the European Union member states, relatively little has been published on lung cancer time trends in other parts of the continent.1, 2, 3, 4, 5, 6 This article aims to analyze and discuss recent changes in mortality trends in countries that are candidates for membership of the European Union.
It is well known that the major risk factor for lung cancer is tobacco smoking, and that there is a relationship between the magnitude of the risk and duration and intensity of smoking, age of initiation, type of cigarettes smoked and time since smoking cessation.7, 8, 9, 10, 11, 12 All these factors influence changes in the frequency and incidence of and mortality from lung cancer in the given population.
In many West European countries, decreasing trends in the prevalence of tobacco smoking in men observed since the 1960s and 1970s caused a decline in lung cancer mortality 1–2 decades later. In contrast, in many countries, increase of smoking prevalence in women caused an increase in mortality from lung cancer. Similar changes in smoking patterns were observed in the 1980s and 1990s in the majority of the EU accession countries. It implies that similar changes in lung cancer patterns should have been observed in these countries recently or will be in the near future.
The aim of this study was to analyze lung cancer patterns in new EU members, with special emphasis on changes in temporal trends, and to compare these patterns with those observed in other parts of Europe (mainly EU members). Since lung cancer rates in a given population depend strongly on former exposure to tobacco smoke, changes in mortality are being analyzed in relation to tobacco smoking as a major risk modifier.
MATERIAL AND METHODS
Mortality data from malignant neoplasms of the trachea, bronchus and lung (ICD-9 code 162) were extracted from the World Health Organization (WHO) Mortality Databank by 5-year age group and sex (www-depdb.iarc.fr/who/menu.htm). Data suitable for the analysis of time trends were available for 9 countries (the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Slovakia and Slovenia), although for Malta only an analysis for all ages combined was carried out due to the small number of deaths. Corresponding population data by age, sex and year were also extracted. Estimates of cancer mortality for the year 2000 for all 10 accession countries were derived from the Globocan 2000 software and database.13
Age-standardized mortality rates (ASRs) were calculated for all ages combined and for age groups 20–34, 35–44, 45–54, 55–64, 65–74 and 75 and over (the Czech Republic, Hungary and Poland) and for age groups 20–44, 45–64 and 65 and over (Estonia, Latvia, Lithuania, Slovakia and Slovenia) for each sex separately. The World Standard Population was used for age adjustment.14 A join-point regression was fitted to provide estimated annual percentage change (EAPC) and to detect points in time where significant changes in the trends occur.15, 16 For each EAPC estimate, we also calculated the corresponding 95% confidence interval (95% CI). Data on tobacco smoking were derived from different sources (WHO-EURO Web site: cisid.who.dk/tobacco).17, 18, 19, 20
Lung cancer has been a major cause of cancer in the countries of Europe for several decades now, and it is the most frequent cause of death due to cancer in men, with some 3 times more deaths from lung cancer (around 280,000 per year) than the second most frequent site, i.e., colorectal cancer (about 98,000 deaths).13 In females, only breast and colorectal cancers are more frequent than cancer of the lung. The situation is similar in the 15 member countries of the EU, where lung cancer (with approximately 150,000 deaths) is the most frequent cause of cancer deaths in males, while in females (around 67,000 deaths) it is the third most frequent cancer site.13
In EU candidate states (EUCSs), lung cancer is also the most common cancer in men and the third most important cause of cancer death in females (after breast and colorectum).13 In general, the average level of lung cancer mortality in all EUCSs is higher than in EU member states (EUMSs) in both males and females (Table I). The difference is especially large in males, where the average rate in EUCSs is nearly 50% higher compared with EUMSs. The proportion of deaths due to lung cancer among all cancer deaths in EUCSs is higher than in EUMSs and in Europe as a whole (Table I).
|ASRa||Number of deaths||% of all cancer deaths||ASRa||Number of deaths||% of all cancer deaths|
|The Czech Republic||65.3||4,651||29.3||11.5||1,088||8.7|
General description of lung cancer patterns in the candidate states
Table I shows ASRs, number of deaths and proportion of lung cancer deaths among all deaths from cancer in the 10 candidate countries individually, as well as average values for EU candidates, EU member states and the whole of Europe.
Lung cancer is the most frequent cause of deaths from cancer in males in all 10 candidate countries. Lung cancer was responsible for the largest proportion of deaths from cancer in Poland and Cyprus (34.6% and 33.2%, respectively), while the lowest proportion is observed in Slovakia (27.6%) and Slovenia (27.3%; Table I). The highest mortality rates are observed in Hungary (ASR = 86.2/105) and Poland (ASR = 71.5/105); the lowest mortality rates are noted in Malta (ASR 45.9/105) and in Cyprus (ASR = 50.0/105).
In females, lung cancer is the second most frequent cause of deaths from cancer in Cyprus (after breast cancer). In the Czech Republic, Hungary, Poland, Slovakia and Slovenia, lung cancer is the third most frequent cause of deaths from cancer (after breast and colorectal cancers), and in other countries it is fifth (Estonia and Malta) or sixth (Latvia and Lithuania). The highest proportion of deaths due to lung cancer is found in Hungary (12.8%) and in Poland (10.1%), and the lowest proportion is observed in Malta (4.6%) and in Lithuania (6.4%; Table I). The highest mortality rates from lung cancer in females were observed in Hungary (ASR = 20.0/105), the Czech Republic (ASR = 11.5/105) and Poland (ASR = 11.3/105). The lowest rates were noted in Malta (ASR = 4.8/105) and Lithuania (ASR = 5.5/105).
An analysis of trends in lung cancer mortality in EU applicant states showed different patterns in men and women. In males in 5 countries (Estonia, Latvia, Lithuania, Poland and Slovenia), a decrease of all-age mortality was observed in the 1990s following an increase in the 1980s. In Estonia, Latvia and Lithuania, the decrease began at the beginning of the 1990s and was of similar magnitude (EAPCs = −2.2%, −1.8% and −2.2%, respectively; Table II, Fig. 1). In Poland, the rate of increase in mortality began to slow down in the beginning of the 1990s, while in Slovenia, this began in the mid-1990s. In the Czech Republic, mortality from lung cancer was decreasing already in the 1980s (1.0% in the period 1986–1991), but an acceleration of the decrease was observed in the 1990s (−2.9% in the period 1992–1999). In Slovakia, a decrease of mortality began in the mid-1980s. In Hungary, no decrease in mortality was observed; however, the rate of increase has slowed down since 1993 (Table II, Fig. 1). In Malta, after a significant increase in the 1970s (2.6%), a nonsignificant decline in mortality was observed in the 1980s and 1990s (−1.2%).
|Country||Number of join points||Year of join point||Period||EAPC||95% CI|
|The Czech Republic||1||1986–1991||−1.0||−2.1||0.1|
|The Czech Republic||0||1986–1999||2.8||2.3||3.4|
In females, the pattern of lung cancer mortality is quite different from that in males. Only in one country has there been a decline in mortality since the middle of the 1980s: Latvia (significant decline at −1.1% per year). In Lithuania, a nonsignificant decrease of −0.1% was observed (Table II, Fig. 2). In other countries, an increase of mortality rates was observed (nonsignificant only in Estonia, 0.7%; Table II). The only country where a significant acceleration in the rate of increase was seen was Hungary (2.4% in the years 1970–1978 and 4.4% in the period 1979–1999; Table II, Fig. 2).
Description of patterns in individual countries
The number of lung cancer deaths in 2000 in Cyprus was estimated as 257 in males and 44 in females (Table I). Lung cancer is responsible for 33.2% of cancer deaths in men and 9.0% in women, and the ASR in the year 2000 was estimated as 50.0/105 in men and 7.4/105 in women (Table I). No data were available to evaluate time trends.
The Czech Republic.
Analysis of mortality rates over time (1986–1999) showed a decrease in men and an increase in women. In males, acceleration in the rate of decrease was observed: the EAPC was −1.0% before 1991 and −2.9% afterward. In females, no joinpoints were detected; mortality rates were increasing by 2.8% per year throughout the whole period (Table II). The trends are much the same in the different age groups: a steady decrease in men and an increase in women (with the exception of a nonsignificant decline in the youngest age category in females; Fig. 3). In males, the rate of decrease was higher in younger age groups, and in females the largest increase was observed in older women (over 65 years of age).
Join-point analysis of mortality time trends for the period 1985–1999 showed a significant increase of mortality in the late 1980s in men, followed by a decrease after the beginning of the 1990s (−2.2% per year). A nonsignificant increase in mortality was observed for women during the whole period (0.7%; Table II). Among males, a significant decline in mortality in the 1990s was noted in the middle-age range (45–64 years), with a nonsignificant decline in young adults (20–44 years). By contrast, mortality increased among elderly men (65+) during the entire period (1.7% per year; Fig. 4). In women, the only significant changes were observed for the oldest age group (65+), where mortality was increasing within the whole period by 2.0% per year (Fig. 4).
An analysis of all-age mortality time trends showed a significant reduction in the rate of increase of mortality in males in the 1980s, followed by a plateau in the 1990s (EAPC was 0.2% between 1993 and 1999; Table II). In contrast, acceleration in the rate of increase of mortality was observed in Hungarian women since the end of the 1970s and beginning of the 1980s (Table II). The deceleration in the mortality increase in males at all ages combined was also observed in some age groups and was especially evident at young ages (20–44 years) where a decline in mortality was present in the 1990s (Fig. 5). In women, a significant increase of mortality was observed in all age categories over 35 years (Fig. 5).
The trends in all-age lung cancer mortality in Latvia were favorable in both men and women in recent years. In males, after an increase of mortality in the 1980s (2.2% per year), mortality began to decline since the beginning of the 1990s (EAPC = −1.8%; Table II). Similarly, in females, after an increase in mortality in the first half of the 1980s, mortality started to decline after 1986 (Table II). The decrease in males affects young (20–44) and middle-age (45–64) men, while in older males an increase in mortality was observed throughout the period of analysis (Fig. 6). Conversely, the only age category in women where an increase of mortality was observed in the 1990s was the age group 20–44 (Fig. 6).
Mortality rates for all ages combined increased in males until the beginning of the 1990s, followed by a decrease since 1992 (Table II). In females, no significant changes were noted (Table II). Analysis of mortality trends by age showed a significant decline in the youngest age group of men throughout the whole period (−4.5%), a significant decrease in middle-aged men since the beginning of the 1990s and a significant increase for the whole period in the oldest individuals (65 years and older; Fig. 7). In females, the trends vary by age: a nonsignificant increase was found in the youngest women, while a significant decrease in mortality was observed in women in middle age (Fig. 7).
An estimated 120 lung cancer deaths occurred in men in the year 2000, and 15 in women (Table I). In males, Malta was the only country with a mortality rate lower than that estimated for all the EU member states combined (48.4/10;5 Table I). Due to the small number of cases, changes of mortality in time were assessed only for all ages combined. In men, after a significant increase of mortality in the 1970s, a decrease was observed after 1983 (nonsignificant, however). In women, despite the low mortality rates, a significant increase was observed (one of the largest among analyzed countries; Table II).
The increase in the ASR (all ages) has been significantly slowing down and there are first signs of a decline since 1991 (Table II). In women, mortality (all ages) has been increasing throughout the study period; the rate was 2.0% during the 1990s (Table II). An analysis of trends by age shows that, in men, there is a general tendency for the rates of increase to slow down at ages 35 and above (Fig. 8). At ages 35–44, mortality has been decreasing since 1980, while in the next 2 age categories (45–54 and 55–64), the decline of mortality began at the beginning of the 1990s. In women, there is no sign of any decrease in mortality, and in young women, the rates of increase are getting larger (Fig. 8).
Overall mortality rates from lung cancer in males were increasing until the mid-1980s, but have declined since 1985 (Table II, Fig. 1). In females, a constant increase of the overall mortality rates was observed (Table II, Fig. 2). An analysis of mortality trends by age shows that declines were greater in young males rather than at older ages (Fig. 9). In females, no increase of mortality has been observed in the oldest age group (over 65 years of age) since the mid-1980s, while in younger age groups a constant increase is observed (Fig. 9).
In males, overall mortality rates from lung cancer increased until 1994, then started to decline (Table II), while in females it increased throughout the whole period (1985–1999) by 2.7% per year (Table II). Examination of the trends by age in men showed a declining mortality in the young (20–44) and the middle-age (45-64) groups, while in older men (over 65 years of age) they are increasing by 1.6% per year (Fig. 10). In women, increasing mortality is observed in all age categories (Fig. 10).
Smoking patterns in candidate states
Past patterns of smoking were very different in the various countries. Table III shows estimates of smoking prevalence. Unfortunately, the number of data sources is limited, and for some countries only recent data are available.
|The Czech Republic||57||46||43||36|
|The Czech Republic||15||24||31||22|
There was a high prevalence of smoking in the 1960s and 1970s in men in Hungary, Poland, the Czech Republic and Slovakia (Table III). Since the 1970s, in the Czech Republic and, to a lesser extent, in Poland, a decline in smoking prevalence has been observed, so that prevalence in these 2 countries was among the lowest of all the countries by 2000. The lowest prevalence in the 1990s and 2000 was noted in Slovenia, Cyprus and Malta, while the highest was in Hungary and the Baltic countries (Estonia, Latvia and Lithuania). In women, a continuous increase in smoking prevalence was observed in Hungary, while in the Czech Republic, after an increase in the 1980s and 1990s, a decline has occurred (Table III). In Poland, the highest prevalence was observed in the 1980s, followed by a decline later on. Low prevalence was observed in Latvia and Lithuania, although in Lithuania a serious increase has been observed recently (Table III).
In young people, changes in tobacco smoking prevalence are not favorable. In boys, several countries have recorded a serious increase in prevalence, the greatest increase being observed in Slovenia, Lithuania, Slovakia and the Czech Republic (Table IV). The situation is even worse in girls; almost all countries have observed a notable increase in smoking prevalence (Table IV).
|Mid-1990s||Around 2000||Difference in %||Mid 1990s||Around 2000||Difference in %|
|The Czech Republic||30||39||30||20||34||70|
It has been shown many times in the past that the major risk factor for lung cancer is tobacco smoking.7, 8, 9, 10, 11, 12 It is also well known that there is a relationship between the magnitude of the risk and duration and intensity of smoking, age of initiation, type of cigarettes smoked and time since smoking cessation.8, 21, 22 All these factors influence changes in the incidence of and mortality from lung cancer in the given population.
The estimated tobacco smoking prevalence and consumption in the countries analyzed were derived from several different sources, and changes in the past consumption and prevalence of smoking were not available for all countries for the same period of time. An additional difficulty in assessing differences in exposure to tobacco smoke was created by the fact that different countries had applied different definitions of regular smokers and occasional smokers in the surveys they had carried out. Despite these difficulties, we tried to evaluate tendencies in the exposure to tobacco smoke and differences between particular populations, as well as to compare them with the situation within the European Union.
An analysis of the situation in men in EUCSs shows a similar pattern in the majority of countries. The major feature of this pattern is an increase of mortality in the past (in the 1970s and in some countries in the 1980s), followed by a decline in mortality in the 1990s (Fig. 1). There are, however, a few exceptions. The first one is Hungary, where no decrease of mortality has been observed so far, although there has been a slowing in the rate of increase. The second exception is Poland, where, since the beginning of 1990s, there has been no further increase in mortality. The only country for which a continuous decrease of mortality was observed since 1986 was the Czech Republic (Table II). However, a previous analyses using data from former Czechoslovakia showed an increase of lung cancer mortality in the 1960s, 1970s and the first half of the 1980s.23, 24, 25
Bray et al.3 describe how the decrease in tobacco smoking prevalence in men in many West European (EU members) countries has been reflected by a plateauing followed by a decline in lung cancer mortality 1–2 decades later (e.g., United Kingdom and Finland). In other Western countries, such as France, a modest drop in smoking prevalence led to a plateau in mortality (not decline). It is also interesting that the countries with the most notable decline of mortality had experienced the largest drop in average consumption of tobacco smoking earlier on.
It should be noted that the decline in smoking prevalence in men in the majority of candidate countries has led to a decline of mortality from lung cancer. This is in concordance with earlier observations, mainly from Western Europe.3, 4, 5
In women, the situation in EUCSs is similar in many aspects to that observed in Western Europe. The average mortality rates in EUCSs and EUMSs are similar (11.8 and 10.5, respectively), as are proportions of lung cancer deaths among all deaths due to cancer (Table I). The increasing trend in mortality is similar in member states and accession countries.3
Despite all the similarities, it is possible to distinguish 3 groups of countries with different patterns among women. The first group comprises the 3 Baltic countries (Estonia, Latvia and Lithuania), where the level of mortality is relatively low, and the increase of mortality over time is small or almost nil. Four other countries (the Czech Republic, Poland, Slovakia and Slovenia) form the second group, with a higher level of mortality (with the exception of Slovakia) and a rather constant increase in the rates. The third group includes just one country, Hungary, the only one in which there is an acceleration in the rate of increase and a level of mortality approximately twice that of any other country (Tables I and II). Smoking prevalence data follow a similar division: Hungary is the only country where a permanent increase in smoking prevalence in women has been noted since the 1960s, and by 2000 it was nearly 50% higher than that in any other country. On the other hand, countries such as the Czech Republic, Slovenia and Poland have not noted any increase in smoking prevalence recently. The phenomenon of increasing smoking prevalence followed by the increase in lung cancer mortality in women has been observed in some EU member states, such as Finland, Austria and Spain.3
In general, the study shows similar patterns of lung cancer mortality in EU member states and in EU candidate countries. These similarities concern the direction of mortality trends in both males and females and similarities in changes of smoking habits. There are, however, some differences, and these are important from the point of view of primary prevention activities and possible future scenarios.
The first difference, which has to be emphasized, is the much higher level of mortality in men in the EUCSs compared with the EUMSs. It is most probably the effect of the later start of smoking epidemic in these countries (compared with EU), and, in consequence, a later start of the decline in smoking in the majority of them. Another important feature is the increase of intensity of smoking in some of the EUCSs. In countries such as Hungary and Poland, an average number of cigarettes smoked per person per day is higher than in any member country of the EU. High lung cancer rates around the year 2000 may also be associated with smoking high-tar cigarettes in the 1980s (and before) in some EUCSs, particularly in the Baltic countries.26, 27
The second difference lies in the much earlier implementation of tobacco preventive measures in many of the EUMSs compared with a majority of candidate states. Activities focusing on the reduction of tobacco smoking prevalence had already been introduced in countries such as the United Kingdom and Finland by the 1970s, while in candidate states this type of action was taken in the late 1980s or even later (and not yet in some of them).28 It is, for example, reflected in the difference in recent smoking rates in Estonia and Lithuania compared with Finland.29 For example, the Tobacco Act came into force in Estonia on 1 January 2001. This act sets the rules about health warnings, tar and nicotine contents, product control, sales and smoking restrictions in workplaces and on certain premises or areas. According to the act, sale of tobacco is banned to persons under the age 18. Also, in Poland, the Tobacco Act was implemented in the second half of the 1990s.
The most important issue from the point of view of public health is the future direction of lung cancer trends. It is of course possible to predict future rates based on models taking into account recent trends in mortality rates. However, in the case of lung cancer (a disease with such a strong single risk factor), this type of approach is satisfactory only for short-term forecasts, but less so for a more distant horizon. It was, for instance, predicted by Kubik et al.30 using age-period-cohort models based on mortality data from 1960–1989 that lung cancer mortality in men would increase in the 1990s in the Czech Republic, Hungary and Slovakia. The observed data from the 1990s showed, however, a decrease (the Czech Republic and Slovakia) or stabilization (Hungary) in lung cancer rates. Hakulinen and Pukkala31 have showed that many different scenarios of the mortality development can take place as a result of changes in smoking habits, and that future trends of mortality do not necessarily have to follow mortality trends observed in the past. We can only foresee what can happen in the future, if recent trends in smoking prevalence and intensity remain the same. Based on the recent observation among adult populations, it is perhaps justified to predict that in the majority of EUCSs, lung cancer mortality will be declining in males and increasing in females in the near future (5–10 years). However, more long-term rates will be influenced to a major degree by the smoking habits of the young generations that are currently entering adulthood. Analysis of smoking prevalence in young people (adolescents) in the 1990s shows a rather unfavorable picture, with marked increases in smoking among girls in almost all countries, and among boys in many countries. Some countries that have observed a decrease in smoking prevalence in adult men as well as a decline in mortality rates have experienced a substantial increase in smoking prevalence among boys in the 1990s (e.g., the Czech Republic, Lithuania, Slovakia and Slovenia; Table IV). In girls, there is a huge increase in smoking prevalence in almost all countries (Table IV). If these unfavorable trends continue in these cohorts, we can face in the future a reversal of current declining mortality trends in the majority of the male populations and a further deterioration in the development of mortality in females.
Tobacco use among young people continues to rise as the industry aggressively promotes its products to potential new customers.32 In West European populations, around 2/3 of smokers begin smoking before the age of 18 and 1/3 before the age of 16, and few people initiate smoking or become regular smokers after adolescence.33, 34 An increase of tobacco smoking prevalence among youth has been observed not only in candidate states, but also in EU member states, e.g., in Germany and Spain.35, 36
There are several actions that can be taken to improve the situation. Undoubtedly, there is a need to continue (or, in some countries, implement) efforts to increase the proportion of ex-smokers. In the short term, this should result in a further decrease of mortality in males and a slowing of the increase (or a plateau) in women. A recent study of smoking patterns in Estonia demonstrated that the prevalence of smoking was associated with education among men but not among women.37 Also, in Latvia and Lithuania, less educated people tend to smoke more compared with highly educated groups.38 Thus, important targets of public health smoking cessation efforts are the less educated socioeconomic groups, particularly males. On the other hand, less educated women have been most frequently exposed to passive smoking in Estonia and Lithuania.29
However, if the decrease of mortality is to be achieved and maintained in the longer term, efforts have to be focused as well on young generations (entering adulthood now or in the near future). Perhaps this can be achieved by implementing coordinated smoking prevention and control strategies in youth, in particular educational programs in schools (at all levels of education: primary, secondary and high schools).39 These programs should focus not only on children (adolescents) but also on parents and teachers. Other measures that may be introduced are community intervention programs, mass media campaigns, appropriate fiscal policies (regulation of prices via tobacco excise taxes) and, last but not least, legislation to ban smoking in public places (schools), tobacco advertisement and the sale of cigarettes in vending machines.39
Programs for young people have to be designed differently from programs for adults. They must be focused on 2 different tasks: to prevent smoking among those who have not yet started, and to convince those who have already started smoking to quit. The aim is, however, difficult to achieve. Many randomized trials show no evidence of the effectiveness of the school-based social-influence approach in the long-term prevention of smoking among youth.39, 40, 41 The reason may lie in the fact that young people react to very different antismoking messages than adult long-term smokers. New smokers use cigarettes to help express their self-image and identity, to show solidarity with their peers and to make them feel adult and sociable by association with a product that is dangerous.33 Some studies show that community-based interventions may be more effective than school-based programs, and that different types of programs may strengthen each other.39, 42, 43, 44
It has also been shown that there is a dose-response relation at community level between the volume of tobacco promotional activities and the probability of experimental and established smoking.45 Based on knowledge of youth attitudes to smoking, the tobacco companies constantly develop more effective ways of selling tobacco products to young people.33, 46 There are also different opinions regarding the effectiveness of pricing policy among youth. Some authors tend to support a thesis that young smokers are not very price-sensitive, while other studies underline the relationship between level of cigarette prices and the prevalence and intensity of smoking among youth.33, 47
Despite all the difficulties present in reducing tobacco smoking in youth, it seems that one of the most important ways to reduce the future lung cancer burden in EU member states is to strengthen efforts toward changing smoking attitudes in young generations.
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- 41School-based programmes for preventing smoking. Cochrane Database Syst Rev 2002; 4: CD001293..
- 44Community interventions for preventing smoking in young people. Cochrane Database Syst Rev 2003; 1: CD001291., , .