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TRC Research Update
Tobacco Control Research and Knowledge Management Center (TRC), Volume 6 Issue 2, 2014
Reduce Adolescent Access to Tobacco
Tobacco Control Research and Knowledge Management Center (TRC)
[www.trc.or.th]
www.thaicyberu.go.th/trc
Editor’s Assistant
» Haris Taweewatana
Editorial Team
» Dr. Stephen Hamann
» Asst. Prof., Dr. Sunida Preechawong
Artwork
» Adisak Neowarattanakorn
Content of this issue
Editor
Hot issue
Dr. Siriwan Pitayarangsarit
Director of Tobacco Control Research and » Equations of death: Access to
Knowledge Management Center cigarettes = new initial smokers =
cigarette addicts = life lost caused by 3
smoking..............................................
The purposes of the Research Update are to be a
medium in connecting and exchanging information » Driving tobacco control policies in
among tobacco control researchers, to build new schools to practice................. 8
knowledge and to drive changes in society based on
expertise. This TRC Research Update is the 16th » Global news........................................ 10
released.
The highlight of this Research Update is information » Global research.................................. 12
to reduce adolescent access to tobacco in various » Local research.................................... 14
forms by helping adolescents to know strategies of
tobacco control so they do not become victims of the » Interesting books................................ 26
tobacco industry. In this issue, we are honored with
contributions by Dr. Chakkraphan Phetphum, Asst. » TRC Community.................................. 27
Prof., Dr. Piyarat Nimpitakpong, Dr. Pichitpong
Soontornpipith, Asst. Prof., Dr. Srirat Leoisamut, Asst.
Prof. Dr. Pannyarat Larpwongwattana, Pharmacist
Natthinee Wattanwarasun, and Ajarn Supanyo
Jeenarong as core writers of this issue. Additionally,
this issue also presents interesting tobacco control
books and tobacco control news identified by TRC as
usual.
Tobacco Control Research and Knowledge Management Center (TRC)
420/1 Anekprasong Building 5th Floor, Ratchavithi, Ratchathewi, Bangkok 10400
Tel.: 02‐3545346 Fax: 02‐3545347
Website: www.trc.or.th / Email: webmaster@trc.or.th
Twitter: www.twitter.com/@trcorth
www.gotoknow.org/user/thebeattlecity38/profile
Facebook: TRCTobaccoControlResearch
The Equation of Death
Access to cigarettes = new initial smokers = cigarette addicts = life lost caused by smoking
Dr. Chakkraphan Phetphum and Asst. Prof., Dr. Piyarat Nimpitakpong
Tobacco access and availability is the most influential factor in youth smoking, being the first step that
provides adolescents the opportunity to try cigarettes, and it also affects the increasing number of cigarettes
smoked by adolescents each day. 1 Easy access to cigarettes also increases the opportunity for adolescents to
become addicted to cigarettes. Evidence shows that 90% of current cigarette smokers smoked their first
cigarette when they were teenagers and later became addicted to nicotine and then were not able to quit
smoking. 2 Finally, these smokers suffered and lost their lives caused by diseases from cigarette smoking. This
causes economic loss at the individual, family, and social level and also is a significant burden to the national
health system.
The Results of the Equation of death:
Smoking Situation of Thai Adolescents
The number of Thai adolescents who become new smokers each year is over 300,000 and this number
replaces adult smokers who die because of smoking‐related diseases. There is a steadily rising trend of both
daily smokers and occasional smokers. 3 This is consistent with findings from the Global Youth Tobacco
Survey (GYTS) indicating that 11.7% of school‐age adolescents smoke. The percent of Thai youth smoking is
higher than that in 140 countries worldwide, and i higher than the average percent smoking in Southeast Asia
where smoking is 9.5% and 5.9% respectively. 4
The Facts
These facts are a reflecting of the crisis of youth access to cigarettes in Thailand which is the
beginning of the Equation of death!
The beginning of the Equation of death: The situation of cigarette access of Thai adolescents
Study results worldwide confirm that commercial outlets are important places where youth access cigarettes,
including Thai adolescents. More than 90% of Thai adolescents indicate that they buy cigarettes from retail
shops around their homes. 5
Moreover, access to cigarettes from these direct
retail shops also extends cigarette access
opportunities through other social sources since
70 percent of adolescents who buy cigarettes
directly from shops serve as available cigarette
sources in transferring cigarettes to friends,
juniors in schools, and others who live in
communities that cannot buy cigarettes by
themselves. 6 This leads to the question: Why do
these cigarette retail shops in communities
become popular cigarette access sources for Thai
adolescents?
There were 570,000 retail shops registered to
distribute cigarettes with the Thai Excise
Department in 2011. These retail shops are in
various areas in Thailand. The factors of “density
and distance” of cigarette shops are part of a
strategy on providing an environment that helps
adolescents to buy cigarettes easily, it also clear
that these retail shop owners also intend to
respond to the needs of adolescents to buy
cigarettes in several ways, such as: making
cigarette purchasing simple because shop owners
never ask about age of cigarette buyers or check
their I.D. card before selling cigarettes to them.
Moreover, less than half of retail shop owners
refuse to sell cigarettes to adolescents. 7
Cigarette sales promotion is performed as both
direct and indirect sales. Research shows that
half of cigarette retail shops in communities show
cigarettes at point of sale which this is the most
common advertisement or promotion source in
the daily life of Thai adolescents 8 Besides,
cigarette retail shops also response to
Suggestions for participation in solving the
Equation
A research review based on previous problem
solving of cigarette access by adolescents
indicated a focus on making smoking
inconvenient and cigarettes difficult to access
for adolescents, as well as making cigarettes
more expensive. Accepted directions
considered effective in preventing access to
cigarettes by adolescents includes: (1) Increase
cigarette prices which will reduce both new
initial smokers and the number of cigarettes
smoked each day, and (2) Reducing the number
of cigarette retail shops. Current measures
which are regularly performed include providing
knowledge of cigarette dangers, and using law
enforcement to prevent access.
Distilled Lesson:
Limitations of using only measures providing
knowledge about cigarette dangers, and law
enforcement
Although a tax measure, providing knowledge of
cigarette dangers, and using law enforcement
can help to solve problems at a macro level,
these measures cannot help to sort out
sustained problems especially at a micro level.
Research results confirm that only providing
knowledge of cigarette dangers is a measure
with the lowest cost effectiveness.12 In addition,
using only law enforcement measures could lead
to conflict between law enforcers and cigarette
retail shop owners in communities. 13 These
measures are not consistent with existing
practices and social characteristics of the Thai
people which include, compromise and
patronage. Moreover, these measures do not
respond to problems, trends, and innovations of
the market strategies of cigarette companies
such as marketing by new cigarette companies,
and of new tobacco products such as electronic
cigarette, and Baraku.
Reference:
1. Ribinson, L.A., Robert, C., Susan, M. and Glaser, R. (1997).
Predictors of risk for different stages of adolescent smoking in a biracial sample. Renita Journal of
Consulting and Clinical Psychology, 65(4), 653‐662.
2. Chyke, A., Doubeni, W.L., Hassan, F., Joseph, R. and DiFranza, J.R. (2008). Perceived accessibility as a
predictorof youth smoking. Ann fam Med July, 6(4), 323‐330.
3. Benjakul, S., Kengkanphanit, M. and Termsirikulchai, (2008). The survey of cigarette smoking
behavior of Thai adolescents aged 15 and older during 1991 – 2007. Bangkok:
Charoenmungkongkranpim.
4. Warren, C.W., Jones, N.R., Peruga, A., Chauvin, J., Baptiste, J.P. and Costa de Silva, v., et al. (2008).
Global youth tobacco sureveillance, 2000 – 2007. MMWR Surveill sum, 57(1), 1 – 28.
5. Benjakul, S., Kengkanphanit, M. and Termsirikulchai, (2008). The survey of cigarette smoking
behavior of Thai adolescents aged 15 and older during 1991 – 2007. Bangkok:
Charoenmungkongkranpim.
6. Forster, J. L. and Wolfson, M. (1998). Youth access to tobacco: Policies and Politics. Annual Review of
Public Health, 19(1), 203 – 235.
7. Benjakul, S., Kengkanphanit, M. and Termsirikulchai, (2008). The survey of cigarette smoking
behavior of Thai adolescents aged 15 and older during 1991 – 2007. Bangkok:
Charoenmungkongkranpim.
8. Siriratsami, B., Siriratsami T., Holumyong, J., and et al. (2012). The national survey report: Impact of
tobacco control policy in Thailande (the 4th Adolescent group). (2009) under the project of the
International Tobacco Control Policy – Southeast Asia, Nakhornprathom: The Institute for Population
and Social Research, Mahidol University.
9. Kanroj, P., Siriratsami, B., Siriratsami, T. and e al. (2012). The trend to access to cigarette of Thai
adolescent smokers: the 4th Adolescent group survey of the project of monitoring impacts of tobacco
control in Thailand in the 11th National Control of Tobacco or Health (22 pages). Bangkok: Tobacco
Control Research and Knowledge Management (TRC.), Mahidol University.
10. Phetphumi, J., Noosorn, N., Nimpitakphong, T. and et al. (2014). The direction of behavior changing in
tobacco distribution to adolescents of retail shop owners in communities by knowledge preferment
community. Thesis. Naresuan University, phitsanulok.
11. Phetphumi, J., Noosorn, N., Nimpitakphong, . and et al. (2014). The direction of behavior changing in
tobacco distribution to adolescents of retail shop owners in communities by knowledge preferment
community. Thesis. Naresuan University, phitsanulok.
12. Stead, L.F. and Lancaster, T. (2005). Interventions for preventing tobacco sales to minors. Retrieved
August, 13, 2004, from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?c‐
md=Retrieveanddb=PubMedanddopt=Citationandilish_uids=11869 602
13. Altman, D. G., Wheelis, A. Y., McFarlane, M.L., Hye – Ryeon, F. and Stephen, P. (1999). The
relationship between tobacco access and use among adolescents: A four community study. Social
Science & Medicine, 48(6), 759 – 775.
1. Established a committee to drive a campaign 3. The Notification of the Ministry of Education
of non – smoking in educational places on 4 titled, “Practical directions according to the
May 2012. The cabinet agreed to the National tobacco control plan (2012 – 2014)” 3
resolution on 17 April 2012 and assigned in all levels of educational places and all
government sectors / offices to act according relevant sectors under the Ministry of
to the resolution of the 3rd National Health Education was released on 29 June 2012. The
Assembly titled, “Measures to control tobacco content of the Notification was consistent with
risk factors to health” in order to bring success the 3rd National Health Assembly (2010) as
on effective performance according to the detailed above.
National tobacco control strategy and the The Memorandum of understand (MOU) was
WHO Framework Convention on Tobacco a collaboration on smoke – free schools in
Control (WHO FCTC). The committee driving 2013 among the Department of Communicable
the campaign of non – smoking in educational Disease Control, the Ministry of Public Health,
places has authority to do the following: (1) the Office of the Basic Education Commission,
Consider directions and methods of situation the Ministry of Education, and the Action on
monitoring of legal drugs in educational places, Smoking and Health Foundation (ASH
(2) Define a standard of surveillance on legal Thailand). The purposes of the MOU were to:
drugs in educational places, (3) Consider (1) drive smoke – free schools, and (2) show
issuing a policy for notification of smoke – free intention to work for smoke – free schools. It
schools, under the Ministry of Education, and also requested cooperation among students
(4) Perform other duties as assigned. and school staff to participate in surveillance
2. Establish a working team to drive tobacco of cigarette use in schools. Moreover, distilled
control in educational places, under the lessons were used to expand smoke – free
Ministry of Education on 29 June 2012. The schools to 469 high schools under the Office of
purpose of the working team is to drive the Basic Education Commission. The MOU
sustained and effective policies and to monitor details are described as follow: (1) Encourage
and prevent the use of the legal drug tobacco the establishment of smoke – free school
in educational places. The working team has polices, (2) Support school environments to
authority to: (1) define measures in driving a have smoke – free schools according to
campaign of non – smoking in educational legislation, prohibit selling cigarettes in
places, (2) promote and encourage in planning schools, and surveillance of non – smoking by
to stop bringing cigarettes into educational students and school staff which will help to
places, (3) monitor and evaluate results of prevent new initial smokers among
actions conducted in educational places and adolescents, (3) Encourage creation of non –
also various relevant sectors to foster smoking trends among students and school
prevention and sorting out problems in staff, and also provide public relations for
educational places. Moreover, the working tobacco control in schools, (4) Encourage
team also establishes sub – committees provision of knowledge of cigarette dangers
working on assignment, and (4) perform other and tactics of cigarette companies in the
duties assigned by the Minister of the Ministry school curriculums, with various activities both
of Education. inside and outside the school curriculum, (5)
Support and help students and school staff
who want to quit smoking to access quit
smoking services, and (6) Prohibit participation
in activities supported by tobacco
entrepreneurs including activities labelled
“Corporate Social Responsibility” (CSR).
Global News
Preventing and reducing adolescents
access to tobacco products
Asst. Prof., Dr. Sunida Preechawong
Preventing and reducing adolescent access to
tobacco products is one measure to prevent new
initial smokers according to the National Strategic
Plan for Tobacco Control 2012 – 2014. In
Thailand, measures for preventing adolescent
access to tobacco products consist of main
activities which are to: (1) increase tobacco tax
and price, (2) prohibit selling through post and
internet, (3) prohibit selling single cigarettes and
ban display of tobacco products at points of sale,
and (4) prohibit selling tobacco products to
children younger than 18 years of age.
Raising the minimum legal sales age first happened
The report of medical authorities in the US in in 2005 in Needham, Massachusetts. It is
2012 indicates that 9 in 10 smokers started worthwhile to note that the smoking rate in high
smoking before age 21. Moreover, conclusion school students there significantly decreased (from
showed that if children and adolescents are able 12.9% to 6.7%) in the last eight years. This
to get away from cigarettes or do not smoke empirical evidence resulted in changes to the
before aged 21, they are likely to be non – minimum age that cigarette retail shops are able to
smokers. Last year, there was a movement at sell cigarettes in twenty other cities in
the local level in the US to modify legislation on Massachusetts, such as Brookline, Belmont Sharon,
“The minimum age to buy cigarettes and other Watertown, Westwood, Walpole, and Sudbury.
tobacco products” which increased the minimum
age of cigarette purchasers from 18 to 21. This Besides, in November 2013, New York state
issue is of interest to many people and it is a big governor, Mr. Michael Bloomberg, passed local
challenge to the tobacco industry. legislation, titled “Tobacco 21”. It banned the sale
of cigarettes and other tobacco products (such as
In late October 2014, the Wall Street journal 1 in cigars, small cigarettes, and smokeless cigarettes)
the US refereed to a case in the city of Evanston, including devices used for smoking (refills and
the first city in Illinois passing legislation on 27 cartridges) to purchasers younger than 21 in New
October 2014 to prohibit selling cigarettes / York City. This ban was considered the first in a big
tobacco products to purchasers younger than 21. city in the US that stipulates a minimum age of
This legislation was of interest to many people as purchasing of 21. This legislation has been in effect
Evanston is the location of North‐western since May 2014. At the same time, the Campaign
University, so this legislation affects smokers who for Tobacco – Free Kids released a fact sheet, titled
are students at this university. In addition, news “Increasing the Sale Age for Tobacco Products to
reports that the Health committee of Columbia, 21” 2 in order to propose that such local legislation
Missouri, which is the location of the University become state legislation. Utah and Colorado have
of Missouri is proposing similar legislation as well. proposed this legislation at the state level, but it
Legislative modifications are called: “The has not yet been approved by the state legislature.
minimum age to buy cigarettes and other tobacco
products” or “Minimum age that cigarette retail
shops are able to sell cigarettes according to
law”. In English, it often is referred to as the
“Minimum legal sale age for tobacco products”.
Of course, the law prohibiting selling cigarettes to The number of tobacco retail shops along with
purchasers under the age of 21 were opposed by clever strategies used to promote sales in retail
tobacco retail shop owners with claimed that this shops increases the opportunity for children and
law was not effective since children and adolescents to accept that cigarettes and tobacco
adolescents who smoke are able to easily find products are easy to access and available for
cigarettes in their own home. A report on them. In late October 2014, the Campaign for
accessibility of cigarettes in early adolescence Tobacco – Free Kids began a campaign that
indicates that friends, acquaintances, and family invited tobacco retail shops to give up selling
members were important sources of cigarette cigarettes, and encouraged people to spend
availability.3 For this reasons, policymakers money to buy goods in shops that do not sell
should consider measures to restrict access by cigarettes. 4 One is able to see a list of shops
children and adolescents to cigarettes aside from participating in this campaign through the
measures of tobacco tax and price. An website: www.shoptobaccofree.org. The
interesting measure that should be considered is measures mentioned above, whether to define a
the “Limitation of the number of tobacco retail minimum age to legally buy cigarettes, or to
shops (Retail stores)”. It is estimated that the control the number of tobacco retail shops are
number of tobacco retail shops in the United expected to make cigarettes more difficult for
States is 375,000 stores. Comparison to the adolescents to access and smoke. In addition, it
number of McDonald restaurants shows a ratio also helps to raise awareness of people that
of: 1 McDonalds versus 27 tobacco retail stops. smoking is not acceptable behaviour in society.
Reference:
1. Mickle, T. (2014) More cities raise tobacco age to 21. The Wall Street Journal, October 28, 2014.
2. Campaign for Tobacco ‐ Free Kids, (2014). Fact sheet: Increasing the Sale Age for Tobacco Products to 21.
http:// www. Tobaccofreekids.org/research/factsheets/pdf/0376.pdf
3. Gendall, P., Hoek, J., Marsh, L., Edwards, R., & Healey, B. (2014). Youth tobacco access: trends and policy
implications. BMJ Open 2014;4;e004631 doi:10.1136/bmjop‐en‐2013‐004631
4. Campaign for Tobacco – free kids. (2014). Press release: Tobacco – Free Kids launches National campaign that
calls on retailers to end tobacco sales, Make it easy for consumers to shop tobacco – free.
Global Research
First
International Research on Youth Access I have been quite alarmed by past preventive
to Tobacco Products medicine guidelines that neglect smoking by
By Stephen Hamann youth. These guidelines mention the detrimental
effects of smoking and secondhand smoke
exposure in other age groups, but not for children
and adolescents. For example, although the US
Preventive Service Task Force makes a
recommendation to screen for obesity among
children and adolescents in its 2012 guidelines, it
does not recommend screening for tobacco use
for 6 to 18 year olds. 1 In my opinion, this is
precisely the age group that needs screening and
counselling since it is the group forming attitudes
about harmful consumer products like tobacco
and alcohol. This is the group to which the
This report of research is somewhat different tobacco industry has and continues to invest their
from past reports since it emphasizes three attention. Their goal is to implant the aspirational
realities regarding youth access to tobacco. First, view that to become adult, youth must follow the
that there has been a lack of concern about minority of adults who use deadly tobacco
tobacco access by youth. This is described in products. In the past, adults smoked everywhere,
relation to clinicians’ missed preventive tobacco advertising and promotion was
interventions. Second, that the previous view of everywhere, and youth often accepted that
youth access measures was often driven by the smoking made them more adult. With public
notion that limiting youth access would simply places 100% smoke‐free, and restrictions on
make tobacco more desirable to youth. This was advertising, promotion and sponsorship of
an assumption based on an unwillingness to tobacco, many youth no longer accept smoking
confront the dangers and promoters of adult as normative and desirable. They increasingly feel
smoking. Third, research shows that restricting smoking is bad for them personally and as a
access to tobacco for a new generation of youth generation aspiring to take their place in the
has been and can be more and more successful if adult world. Unfortunately, many clinicians have
implemented based on circumstances trending not understood that change in perspective, don’t
against youth initiation. In short, it is not just present it to youth, and don’t advocate for its
advertising, sales or age to buy cigarettes that is acceptance and advantages. This is an
involved in access issues, it is the overall neglect opportunity lost, and slowly pediatricians and
of youth tobacco use issues that is of importance other youth advocates are making strides in
in this review. forwarding this ideal for youth. This is evident in
the recent “truth” campaign in the US where
youth urge other youth to “finish it”, that is,
finish the use of harmful tobacco in society. 2
Second
The ‘forbidden fruit’ idea is still with us, but is
more a remnant of the stereotype of rebellious
youth always wanting to act completely opposite
normative adult behaviour. Yes, it is true that
adolescence is a time of experimentation. But
experimentation has previously been thought
important for accepted adult behaviour among
all segments of the population. Youth have begun
to notice that smoking is mostly not normative
for successful adults. 3 Increasingly, only the less
educated and poorest segments of the As with many other tobacco control measures,
population are the smokers. The view that the success of youth access restrictions may
smoking adversely affects both health and depend on whether these restrictions occur as
productivity has become so accepted that even part of a set of comprehensive tobacco control
young adults embrace it. Even settings for young measures. Nonetheless, some results show the
adults like the military, discourage tobacco use as promise of such youth restrictions. 7
a misguided expression of adulthood. 4
Aspirations of youth in the past, fueled by the
Third
tobacco industry, have driven the use of tobacco
We come to the research that shows that limiting
to unparalleled levels. Now, youth aspirations
youth access can reduce tobacco use and that
based on a more informed understanding of
establishing a smoke‐free generation could be a
tobacco’s harm may help to end the exploitation
very important part of the end game to tobacco
of children and adolescents by the tobacco
use. 5, 6 It is important to be skeptical about
industry.8 Youth access restrictions as a positive
outcomes from limits on youth access since the
social movement to end child and youth abuse
positive results are not necessarily seen in all
have worked, and can contribute to
circumstances. The negative view of smoking in
comprehensive efforts against tobacco use.
Australia, the US or UK frames the success of
youth access restrictions there, and therefore
may not be present in low and middle income
countries.
References:
1. Recommendations of the U.S. Preventive Services Task Force: Guide to Clinical Preventive Services. September 2010.
Agency for Healthcare Research and Quality, Rockville, MD, http://archive.ahrq.gov/professionals/clinicians‐
providers/guidelines‐recommendations/guide2012/abstract.html
2. Truth, “Finish It” Campaign: http://www.youtube.com/watch?v=CNS0JaX9_X8&feature=player_embedded#t=55
3. Voigt K, “If you smoke, you stink” Denormalization strategies for the improvement of health‐related behaviors: the
case of tobacco. In Ethics in Public Health and Health Policy: Concepts, Methods, Case Studies. New York: Springer.
2013, pp 47‐61.
4. Smith EA, Jahnke SA, Poston WSC et al. Is It Time for a Tobacco‐free Military? N Engl J Med 2014; 371:589‐591.
http://www.nejm.org/doi/full/10.1056/NEJMp1405976
5. Grucza RA, Plunk AD, Hipp PR, Cavazos‐Rehg P, Krauss MJ, Brownson RC, Bierut LJ. Long‐term effects of laws
governing youth access to tobacco. Am J Public Health. 2013 Aug; 103(8):1493‐9.
6. Feldman R. (Commentary) Tobacco use: Options for an endgame strategy. The Star Press, October 4, 2014.
http://www.thestarpress.com/story/opinion/2014/10/04/tobacco‐use‐options‐endgame‐strategy/16682581/
7. Nagler RH, Viswanath K. Implementation and research priorities for FCTC Articles 13 and 16: tobacco advertising,
promotion, and sponsorship and sales to and by minors. Nicotine Tob Res. 2013 Apr; 15(4):832‐46
8. Farrelly MC, Arnold KY, Juster HR, Allen JA. Quantifying the effect of changes in state‐level adult smoking rates on
youth smoking. J Public Health Manag Pract. 2014 Mar‐Apr; 20(2):E1‐6.
Media used in activities to prevent
smoking
There are various media used in activities to
prevent smoking. These should include:
» Provide knowledge through media
(brochures, videos, manuals). Knowledge
provision is considered of basic importance
to build other activities, and its content
A Quit smoking program of students in should be concise and easy to understand.
educational places in Thailand » Role play is a group activity which permits
target groups to participate in shows.
For an effective smoking cessation program,
Researchers / leaders provide stories and
processes must be in place to provide individually‐
roles relevant to cigarette use through
centered counselling in groups, and to apply
various scenes.
concepts such as self‐ esteem in order to foster
behaviour change. A quit smoking program is » Exhibitions are activities showing beautiful
utilized to provide knowledge to adolescents pictures or pictures of harm caused by
studying in schools. cigarette smoking which generates emotion
in the audience so they would like to quit
The Effectiveness of smoking prevention
smoking.
programs
» Invite lecturers / patients with diseases
When considering smoking prevention programs,
caused by cigarette smoking to tell their
there are several principles that are important as
experience, knowledge as being an example
guidance about measures or methods to prevent
to those who are thinking to smoke to
students/adolescents from becoming initial
change their behaviour. This activity uses
cigarette smokers or can help to reduce new
knowledge and experience of the speakers to
adolescent smokers.
motivate target groups.
» Activities should focus on groups in terms of
» Group discussion where authors define
communication techniques to communicate
issues or scenarios related to cigarettes; then
with others.
members discuss and brainstorm on issues
» Activities should provide knowledge, trainings until reaching a conclusion. It is an activity to
and health education related to components stimulate thinking and assertiveness.
of cigarettes, diseases and severity of diseases
» Activities focused on building life skills. The
caused by cigarette smoking, benefits and
goal is to highlight skills that are
drawbacks of smoking avoiding, techniques to
necessary for life, especially various skills
refuse smoking, and how to release stress.
to prevent smoking such as refusal skills,
» Activities should focus on participating in release stress skills, decision-making
work, including problem finding, guideline skills, and problem solving skills.
setting, planning to sort out problems,
The results of this literature review will help to
implementation, and evaluation.
provide a clear and comprehensive overview of
» Activities should create power and enhance tobacco control in educational places. This will
social support to develop students' potential have the most benefit in applying knowledge to
in term of smoking prevention. appropriate management. So that, it can be used
to improve development and drive effective
» Activities should develop life skills in practice.
Cognitive, Affective, and Psychomotor
domains
Local Research
The Quit smoking project in adolescents
(Project EX)
By Asst. Prof. Dr. Pannyarat Larpwongwattana
After 3 month follow up, the number quitting
smoking confirmed using cotinine in saliva in the
Experimental group and Comparison group were
7.7% and 2.2%. However, self report indicated that
the number quitting smoking in the two groups
was 17.3% and 8.6% respectively. The number of
natural quitting for smokers who did not
participate in any quit smoking project was 3%,
which is close to the number who quit smoking in
the Comparison group in Project EX in Thailand.
For the numbers quitting smoking by self report in
an Experimental group and a Comparison group
(17.3% and 8.6%), these numbers were close to the
results of the Project EX in California, USA (17.0% A literature review found that there was a quit
and 8.0%), but higher than the Project EX in Russia smoking project in adolescents like Project EX in
(7.5% and 0.1%), and Project EX in China with the Thailand with research conducted using an
number quitting smoking in the Experimental Experimental group and Comparison group. This
group at 10.5%. However, the Experimental group similar project was a project to study the
was not able to quit smoking, and a report of the 3‐ effectiveness of curriculum to treat student
month follow up showed that the number of smokers in Chiang Rai province. This project used
cigarettes smoked decreased by 44.2% which was concepts, theories, and therapy to help smokers
close to the research findings in Project EX in quit smoking in Quit smoking Clinics and provided
Russia (46.0%), and a bit higher than the research treatments by treatment or health officers using a
findings in China (33.0%). curriculum from the health center for quit smoking
Comparison shows that groups obtaining knowledge in Chiang Mai. Practice guidelines for treatment of
from Project EX showed similar results although this addiction and a matrix‐based treatment were used
project was administered in different contexts. In to treat methamphetamine addicts for results in 6
addition, student smokers in the Experimental group weeks, with once a week sessions of 1‐2 hours
who learned the lessons from this project felt that including 20 activities. This was to study
this project was useful and able to help them to quit effectiveness of a curriculum of therapy in helping
smoking. This was consistent with Project EX in smokers quit. Since there was no comparison
California, USA. Favourite lessons of students were group, the assessment was performed on smokers
the Lesson 1 (Orientation), and Lesson 2 (cigarettes who participated in activities. Results of the study
affect students’ lives), as these lessons provided indicated that this project helped smokers reduce
activities after school time and students were able to smoking (56.6%), and quit smoking (24.6%) with
participate with other students who were smokers these numbers considered very high when
from other classes. Results of this study had compared with the study results of Project EX
different answers compared with the groups in used in several countries as indicated above. With
Project EX in California where the favourite lesson many differences in project design and concepts, it
was the last lesson (Promise to quit smoking and was not possible to make comparisons of the
avoid returning to smoking). Besides, the group also effectiveness of these projects.
answered that they liked classes and lecturers who
were enthusiastic with good understanding for the The project results of Project EX in Thailand
classes. These results necessitated that all lecturers indicates that the Quit smoking project in
receive training from the experts from the University adolescents that was developed in the US and
of Southern California who developed the program. expanded for use in several countries in Europe
and Asia can be adapted for use in the culture and
context of Thailand.
Reference
1. Punyarat Lapvongwatana. The quitting smoking project for students studying at a high school level in Bangkok
district. 2014. Research report. Bangkok. Tobacco Control Research and Knowledge Management Center, Mahidol
University.
After the end of the curriculum, follow up should
Local Research be performed regularly at least once a month
The effectiveness of a curriculum to aiming to provide advice to student smokers
who might return to smoking. Besides, the
address quitting smoking in student
techniques / approaches of those fighting
smokers in Chiang Rai province relapse / increased smoking were also important
By Female pharmacist, Natathinee Wattanavarangkul to show the intentions of student smokers to the
“The study project of the curriculum for smoking content of the Quit smoking curriculum. The
cessation of student smokers in Chiang Rai assignment / activity descriptions of the
province” 1 was operational research with the curriculum should be modified to be more
objective to study the effectiveness of this interesting. This modified description document
curriculum. The curriculum was developed from a enlivened by public staff, lecturers, and student
treatment program in helping students who have participants should be used in trainings with this
smoking behaviour to quit smoking in 2007. It was curriculum which lecturers who are interested in
developed by public health specialists in smoking it can use to change behaviour in student
cessation in a Quit smoking clinic in a hospital smokers.
according to the curriculum of the Quit smoking
clinic, Chiang Mai, and from other relevant Suggestions for practice
documents from medical practice. There were 20
activities over 6 months and 3 follow ups which For the content of the curriculum, important
were after 1 month, 3 months and 6 months. features that can help students to reduce and
Sample groups were selected from 20 interested quit cigarette smoking should be details of
schools with 325 students studying in Mattayom 1 cigarette dangers and awesome drawings. These
– 6. Information collection occurred before and would lead students to be concerned about
after treatment for quitting smoking. cigarette dangers so they would like to quit
Results indicated that the population studied was smoking by themselves. Moreover, the
male (97%) and 16 – 17 years in age, 15.7 on curriculum should enhance creative activities for
average. Most were Mattayom 3 students, student smokers so they participate in activities
started smoking at age 14 – 15 (41.3%), gave the such as a campaign to spotlight cigarette dangers
reason to smoke as would like to try smoking, and in schools, supporting activities in hospitals,
smoke 2 – 3 cigarettes per day. After following sport competitions, and music, and visiting
the curriculum, the number of smokers who were
friends in other schools. Besides, it should add
able to reduce smoking was 180 students (55.4%),
cigarette dangers to the orientation for parents.
78 students (24.0%) were able to quit smoking
and the remaining 59 students (18.2%) continued In terms of smoking cessation, study results
smoking. Follow up after 1 month, 3 months, and indicate that behaviour change in student
6 months, showed reported reduction of smoking populations studying at Mattayom 1 – 6 are in
of 52.3%, 56.6%, and 52.6%, and reported quit the beginning stage of smoking where a
smoking of 23.4%, 24.6%, and 30.5% respectively.
curriculum which addresses quitting smoking for
The conclusion is that the curriculum was able to student smokers in Chiang Rai can be used to
change smoking behaviour in student smokers assist adolescent smokers.
both to reduce and to quit smoking. Suggestions
were to conduct various activities for participating
students such as having observational activities
such as visiting patients sick with tobacco‐related
diseases, and to conduct campaign activities in
schools.
For prevention, findings from the study indicate
that most students start smoking at age 14 – 15 as
they feel they would like to try smoking along with
drinking behaviour. Prevention of smoking should
start in students at Primary school level (P.5 –
P.6). This can be driven by modifying the
curriculum and using that modified curriculum as
standard curriculum to provide knowledge of
cigarette dangers, how to keep oneself from
becoming an initial cigarette smoker, and skills to
refuse offers of smoking.
At follow up, research results showed that student
smokers had the greatest likelihood to return to
smoke in the first month after quitting as a result
of the school holiday (summer). Then students
have more free time and are spending time with
friends; this can lead them to return to smoking.
At 3 month and 6 month follow up, the number of
student smokers who were able to reduce or quit
smoking increases because of monitoring
stimulation by counsellors and lecturers
responsible for this project. Finally, this
curriculum can help student smokers to reduce
and quit smoking.
Suggestions to Public Health Agencies
For treatment, most student smokers are initial
smokers who have not yet become nicotine
addicts. Treatment in this group can utilize a
curriculum for smoking cessation with students
who exhibit smoking behaviour in schools, or
provide training to teachers, increase skills to
counter smoking through a focus on major
content such as cigarette dangers, direction to
quit smoking, prevention by proactive personal
actions, and skills to refuse cigarette smoking.
After implementing treatment, there should be
close follow up to stimulate students positively, so
they reduce or stop smoking as expected. Public
health staff should also follow up results of this
project in schools and help to provide advice
when student smokers have problems in quitting
smoking.
As to youth access legislation, collaboration
should be carried out with schools in monitoring
cigarette retail shops around schools so that the
prohibition to sell cigarettes to children who are
younger than 18 is enforced, and the school
environment becomes 100% smoke – free.
Reference:
Natathinee Wattanavarangkul. The study project for the effectiveness of a curriculum to address quitting smoking in
student smokers in Chiang Rai province. (2009). Research report. Bangkok: Tobacco Control Research and
Knowledge
Research results
2) Problems
There are several problems in tobacco control
which are: (1) Students have positive attitudes
toward cigarettes, (2) Schools lack
collaboration for tobacco control and other
dangerous drugs in terms of controlling the
environment surrounding schools, (3) There
are no clear policies from school owners /
administrators, (4) Committees to drive policy
to practice are missing so direct monitoring
and knowledge and skill development is at a
low level, (5) there is also a lack of
encouragement for collaboration among
students, the public, departments, and other
parties, and (6) working committees both at
the executive and operating levels for tobacco
control miss opportunities to have policies
developed, and lack funding support.
Moreover, there are only a few organizations
from the public and private sectors who
participate in the project.
3) Obstacles
4) Suggestion
Reference:
Subanyo Geenarong. The project, “Roles of school executives for tobacco control in Islamic private schools in the
South of Thailand”(2014). Research report, Bangkok: Tobacco Control Research and Knowledge Management Center.
Suggestion
Local Research
1. In term of closing illegal websites selling
tobacco products, the Ministry of
Surveillance system of illegal websites for Information and Communication Technology
tobacco product distribution (ICT) may have to modify its processes or
By Dr. Phichitpong Songthornpipit strategies for closing each web page. To do
this, the ICT needs to issue a letter informing
owners of these websites that their web
page will be closed or blocked on a page
directory of a website and also inform them
that they can contact the ICT if they have any
questions. It is necessary to take such action
so the ICT can prevent these illegal websites
in a timely manner because there are a lot of
new websites established each day. For
The name of this study project was, “Surveillance websites registered through domains abroad
system and website index of illegal tobacco such as online social networks, the Computer
product distribution in Thailand”. Results of this Act should be modified in order to give
study have been distributed to relevant strong punishment to owners of these illegal
departments as evidence of illegally selling websites.
tobacco products though internet websites. 2. Although the number of illegal websites or
URLs selling tobacco products has tended to
The number of illegal websites retrieved on 30
decrease, selling tobacco products though
April 2014 totalled 1,278 websites consisting of
online social network websites has
435 websites selling cigarettes and 843 websites
dramatically increased. Some tobacco sellers
selling e‐cigarettes. These illegal websites were
are concerned that it is dangerous to sell
blogs (161 blogs), web boards (421 websites),
their tobacco products though websites, so
social networks (110 websites), and online
they employ other selling systems where
shopping (276 websites).
they cannot easily be arrested such as
through the application of various systems
Conclusion
(iOS, Android, WM). These applications do
not contain information as websites do;
Although the number of illegal websites selling
however, it is still possible to have one’s own
tobacco products each month has tended to
groups and can produce public relations for
decrease, and the Ministry of Information and
their products selling them on Line,
Communication Technology (ICT) has closed many
whatsapp, Cubie, IG or Wechat. These
of these illegal websites, the number of markets
programs make it harder to find law
selling tobacco products through the internet has
breakers. Therefore, there really needs to be
rapidly increased. There are many reasons for
collaboration among program development
the expansion of selling tobacco products illegally
teams (who develop applications) in order to
through the internet: establishing web pages
monitor compliance along with the policies.
nowadays does not require high computer skills
as previously, fast growing online networks or 3. Many people, especially adolescents and
online selling with easy access to these websites, students, are not concerned about legislation
low charge of domain renting abroad, and the of the Excise Act, and the Tobacco Product
greater difficulty for the ICT to suppress tobacco Control Act, B.E. 2535 (1992) in terms of
product sales on the internet which have advertising and various tobacco distribution
continually expanded through online marketing. rules which make cigarette sales illegal as
also in the Computer Act. B.E 2550 (2007).
Therefore, relevant departments need to
inform people of this matter.
Local Research
Impacts of CSR of the Tobacco Industry
The most noticeable effect of the Corporate
Social Responsibility (CSR) of business is to change
the image of tobacco cigarettes to become less
negative. CSR activities turn a negative image of
tobacco as a drug of a drug business into a
positive business that has virtue and becomes a
business supporting children of tobacco farmers Another effect of the CSR in provinces having a
and an organization which helps to build the lot of CSR activities is that tobacco businesses
future of Thai adolescents. Therefore, farmers are able to overwhelm local organizations and
are turned into front groups to protest banning can use various provincial activities to promote
CSR of the tobacco industry with the argument their organizations and have more indirect sales;
that tobacco helps to build the future of for example, to overwhelm provincial activities
children’s activities; some poor adolescents will in sport activities (Thai Cup Sport Activity) which
miss good opportunities without these activities. provides opportunities to the tobacco business
Therefore, one should provide opportunities for for public relations to sell their cigarettes in
tobacco businesses to advertise as normal. sport stadiums, promote new cigarettes, invite
Moreover, when adolescent groups have a good beautiful pretties (women promoters), and
image of tobacco businesses, it is likely that they creating cigarette networks with schools by
view the government sector as “persecuting” persuading students to participate in activities.
tobacco businesses. A noticeable example is Thai Cup Sports in
Another impact of CSR is that it is able to Phichit province.
emphasize the belief that cigarettes are not a bad Tobacco business uses a partnership strategy
thing; However, smokers who smoke in the wrong along with other businesses. It can also be seen
place are wrong. So, the thinking is that being in the alcohol business that overwhelms other
wrong is due to smokers who smoke in wrong areas in the provinces with sport festivals. It is
places, not the bad effects of cigarettes. The provincial sports, but cigarettes and alcohol are
effects of doing CSR activities seem to be effective sold in front of sport stadiums and inside
in reducing the bad images of cigarettes and stadiums. Factors that can be used to fight with
turning cigarettes into a “Normal” product. It these partnerships is the collaboration among
creates a new belief that cigarettes are normal people, the willpower created in protesting, and
products, smoking as a personnel business, having support from senior government officials of the
no effect on society, and not wrong if smokers province, with Sukhothai having had success in
smoke in the right places. However, smokers are using these measures.
wrong if they smoke in the wrong places. These
beliefs expand to adolescents living in provinces The action of doing CSR activities with local
where they are common, and become a cause of media support is an action missing ethical
failed efforts with second hand and third hand consideration. Investigation found that money
smoke campaigns. (6,000 baht) was paid to each local media
through yearly provincial parties hosted by
Another effect of CSR on adolescents is that it tobacco businesses. These efforts provided
makes tobacco factories well known among money in order to get media to “Stop talking”,
adolescents, and tobacco interests can easily to limit local media in publishing negative news
access educational places to influence sport and requesting public relations about activities
provincial activities, and camp activities. This can of the tobacco industry. Moreover, tobacco
make tobacco production a part in all school industries try to buy local media which is
activities; for example, with children walking in considered unethical. It sounds like local media
parades wearing shirts screened with the name of are concerned about the benefits earned from
tobacco factories/companies. CSR activities; public relations are considered by
recipients as a major issue.
For CSR, in terms of being committed to the
Thailand Tobacco Monopoly, tobacco farmers
indicated that if there was legislation banning
CSR, they would accept it and be able to grow
other crops because tobacco growing is not their
Adolescents living upcountry (stakeholders) have major crop, but that the government needs to
positive attitudes to CSR because they earn provide assistance in this matter; for example, to
benefits from CSR and they become used to give advice about growing other crops for
receiving things, and also state agreement with replacement.
tobacco businesses that provide support to
schools or hospitals. They think that CSR
receivers have benefits and also believe that
cigarette smoking is a personal matter. The other
difference of these two groups is that Bangkok
adolescents agree with banning CSR of tobacco
businesses and support a total ban measure.
However, adolescents living upcountry
(stakeholders) have the opposite opinion on this
matter. The important variable in having
different attitudes by these two groups result
from CSR activities and benefits.
Interesting Book
PROJECT EX is a Quit smoking program for
adolescents (For teachers)
By: Steve Sussman and team
Translated by: Punyarat Lapvongwatana and team
Published year: 2014
Content:
Project EX is an effective quit smoking project for
adolescents studying at the high school level. This
project was considered by the US government as a
“Model”. This project has a manual (for teachers) that
contains details of strategies to help students quit
smoking through positive skills. In addition, it also
indicates major harmful substances in cigarettes and
other tobacco products.
PROJECT EX is a Quit smoking program for
adolescents (Student book)
By: Steve Sussman and team
Translated by: Punyarat Lapvongwatana and team
Published year: 2014
Content:
Project EX is an effective quit smoking project for
adolescents studying at the high school level. This
project has a manual (a student book) that contains 8
chapters. The purpose of this book is to help
adolescents to quit smoking through boosting 2
central factors: (1) Motivation, and (2) Skill. Methods
used for quitting smoking in school are various
activities such as various games, talk shows,
meditation and Yoga. These activities can create
motivation and build skills through cognitive
behavioral practice.
Tobacco Maya
By: Rasami Sangthong and team
Published year: 2010
Content:
This book lets adolescents know about tobacco and
new tactics and strategies of tobacco industries.
Moreover, this book is also a book for tobacco
surveillance for people providing knowledge of
tobacco dangers for smokers and others.
Readers who are interested to read these books at TRC library (Tobacco Control Information Center)
The 6th Floor, Anekprasong Building, Mahildol Library
or at www.trc.or.th.
TRC Community
6 May 2014
Tobacco Control Research and Knowledge
Management Center (TRC) held a meeting, titled
“A Muslim leader network to help people quit
smoking” supported by the Thai Health
Promotion Foundation (ThaiHealth). The
purposes of this meeting were to: (1) report
problems of tobacco use in the South of
Thailand, (2) to together find gaps and research
problems, and (3) to drive Muslim leaders to
help people quit smoking. Methods used in this
meeting were brainstorming, project
development, and management consulting.
Participants in this meeting were academic staff,
and tobacco control campaigners.
27 June and 22 August 2014
Tobacco Control Research and Knowledge
Management Center (TRC) held a meeting, titled
“The networking meeting on surveillance to
assess tobacco use among adolescents”
supported by the Thai Health Promotion
Foundation (ThaiHealth). The purposes of this
meeting were to: (1) establish core groups of
stakeholders, and (2) consult in development of
surveillance to assess tobacco use among
adolescents by finding missing parts and gaps,
and defining activity directions. Participants in
this meeting consisted of academic staff and
both public and private tobacco campaigners.
28 ‐ 30 July 2014
Tobacco Control Research and Knowledge
Management Center (TRC) along with the
tobacco control networks held a meeting, “The
13th National Conference on Tobacco or Health:
Raising Tobacco Taxes Reduces Smokers and
Deaths” with sessions of tobacco control poster
presentations at The Miracle Grand Convention
Hotel. This meeting was honoured to have Dr
Nopporn Cheanklin, Deputy Director General of
the Disease Control Department, Ministry of
Public Health, as president of the meeting.
Participants were from both public and private
sectors, and included academic staff and
reporters.
Important issues in the meeting were: (1) Using effective law enforcement, (2) Service models for quitting
smoking, (3) Setting smoke‐free environments, (4) Tobacco surveillance and controlling new tobacco
products, (5) Tobacco control using communities as the base, and (6) Tobacco tax collection in Thailand
and abroad. At the conclusion of this meeting a declaration by the National Alliance for Tobacco‐Free
Thailand announced its commitment to activities for a smoke – free Thailand.
Reasons for having a new Tobacco Product Control Act
The Tobacco Products Control Act and the Non‐Smokers' Health Protection Act have been in force for
over 22 years and have served to reduce the smoking rate from 32% (1991) to 19.94% (2013) and has also
reduced economic loss from death and disability caused by smoking. Now, it is important to update and
strengthen tobacco control legislation. The number of cigarette smokers has remained high at about 11
million people for the last 5 years. Moreover, current levels of smoking in adolescents and women are
likely to rise due to tobacco companies’ marketing strategies and new types of tobacco products.
Thailand has an obligation to improve tobacco control legislation consistent with its international
commitment as 1 of 179 member parties of the WHO Framework Convention on Tobacco Control. Data
from the National Statistics Office in 2013 shows the Thai population 15 years or older living inside
municipal areas was 24,535,755, of which 3,989,239 were cigarette smokers (16.26%). The number of
people 15 or older living outside municipal areas was 29,464,771, of which 6,779,566 were cigarette
smokers (23%). This information indicates that the number of cigarette smokers outside municipal areas
is 90% higher than in municipal areas of Bangkok. However, current tobacco control in Thailand is missing
a government structure to implement tobacco control at the provincial level. Therefore, it is necessary to
update tobacco control legislation to be consistent with the current situation and to establish provincial
committees to draft additional tobacco control legislation.
If the new Tobacco Product Control Act becomes effective, it is expected that it will reduce tobacco
demand among adolescents and also prevent the death of at least one hundred thousand smokers which
would reduce Thai economic losses by fifteen thousand eight hundred million baht per year (15,800
million baht). Moreover, it will not affect the Excise tax of the Ministry of Finance that adjusts yearly
according to inflation; the cigarette tax currently collects 60,000 million baht per year. This number is
based on a cigarette tax collected from international cigarettes imported to the country (38%), and
domestic cigarettes (62%).
Support
Tobacco Products Control Act
To Prevent Children and Adolescents from becoming Initial Smokers
Tobacco Control Research and Knowledge and Management Center (TRC)