A literature review on effects of smoking on the success of dental

implants

Abstract

The use of dental implants has revolutionized the treatment procedure for over last 25 years. Implants now have been
widely accepted by patients as their treatment plan and have become a routine procedure by dental surgeons. Owing
to the remarkable success, there have been various researches going on to find out factors responsible for the failure
of implants. With the growing use of tobacco among patients, its ill effects on bone quality and quantity it arises a keen
interest to associate effect on the success of implants. To establish a relationship between smoking and implant
success and its long term survival and compare the result with non-smokers based on the literature. Relevant clinical
studies and reviews published in English literature published between 1990 and 2012 were reviewed. The articles were
located through EBSCO host and manually through the references of peer reviewed literature. Most of the literatures
supported the fact that smoking is a prominent risk factor affecting the success of implants. Studies reported that implant
failure and its complications associated are twice in smokers as compared to non-smokers. Literatures also revealed
that maxillary implant are more affected than mandibular in smokers. Studies suggested that effects of smoking were
reversible in smokers who followed the smoking cessation protocol prior to the procedure. Smokers have a greater
chances of implant failure and more prone to the complications following implants and related procedures. Surgeons
should stress on counseling of patient willing for implant for smoking cessations protocols.

Introduction

Nowadays, dental implants are the best permanent and secure solution in the replacement of one or more missing
teeth giving you a natural appearance. They are made of biocompatible materials, just the same as hip implants or
similar orthopedic devices, and function as anchors or support for traditional forms of dentistry, such as crowns,
bridges, or dentures. Implants are artificial tooth that are anchored in the gums or jaw bone to replace a missing
tooth. Dental implant success is related to operator skill, quality, and quantity of bone available at the site and
patient's oral hygiene. In practice, the number of patients coming with the habit of smoking cannot be neglected so
this article gives a review of the studies done on the effect of smoking on dental implants.

According to World Health Organization (WHO) Global burden disease report, 2004, The WHO estimates that
tobacco caused 5.4 million deaths in 2004 and 100 million deaths over the course of the 20 th century. Similarly, the
United States Centers for Disease Control and Prevention describes tobacco use as "the single most important
preventable risk to human health in developed countries and an important cause of premature death worldwide".

Studies [1] suggest that smokers have an increased prevalence of periodontal diseases, tooth loss, and oral cancer.
There are several studies associating implant failures with smoking. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10] Moy, et al. suggested that
smoking caused both systemic and local injury to the tissues and is a common contributor to decrease tissue
oxygenation, which negatively affects wound healing. [11]

Nicotine presents as a main element of cigarette reduces proliferation of RBC, macrophages, and fibroblast which are
the main element of healing. [11],[12] It also increases platelet adhesiveness which can lead to poor perfusion due to
microclots. [12] It also acts as sympathomimetics by increasing the release of epinephrine and nor epinephrine and
causes increased vasoconstriction which limits over all tissue perfusion. [11],[12] These all
studies [11],[13],[14],[15],[16],[17],[18],[19],[20] hypothesized that smoking compromises wound healing.

There are many studies [12] showing smoking impairs bone wound healing and cause clear detriment to the skeletal
tissues. Smoking is also found to be associated with osteoporosis [12] as well as with reduced bone density in femur,
vertebra and jaw bone, [12] and decreases in the bone mineral content found in the smokers than compared to
nonsmokers (Raiken, et al.,1998 [21] ). Smoking effect on bone regeneration is established by studies [22] that found
success of bone regeneration in nonsmokers may reach 95%, whereas 65% in smokers. Currently, lifetime tobacco
smoking has been associated with deterioration in bone quality. [1]

A higher incidence of marginal bone loss has been found in smoking group and this was more pronounced in
maxilla. [23]

The commonly accepted criteria for assessment of implant success were proposed by (Albrektsson and colleague,
1986) to identify clinical evidence of successful osseointegration and survival of implant. [24],[25] Over past three
decades, implant success has been assessed by survival rate, continuous prosthesis, stability, radiographic bone
loss, and absence of infection in pre-implant soft tissues [25] (Albrektsson, et al.,1986; [24] Smith and Zerb,
1989; [24] Buser, et al., 1990; [26] Albrektsson and Zerb, 1988; [24] Misch, et al. 2008; [27] Annibali, et al., 2009 [28] ).

On the basis of the past literature, smoking may be associated with compromised wound healing, effect on bone
architecture, width, length, density, and effect on peri-implant tissues. Hence, it becomes a matter of interest to
establish the effect of smoking on implant and its success. It is also necessary to study the different outcomes of
implant success among smokers and non smokers.

This review of the literature will give a brief outline to all dental health professional regarding the management of
patient with habit of smoking and would guide to formulate treatment plan accordingly.

http://www.jdionline.org/article.asp?issn=0974-
6781;year=2013;volume=3;issue=1;spage=46;epage=51;aulast=Goutam
A Systematic Literature Review of Self-Reported
Smoking Cessation Counseling by Primary Care
Physicians

Abstract
Tobacco consumption is a risk factor for chronic diseases and worldwide around six million
people die from long-term exposure to first- or second-hand smoke annually. One effective
approach to tobacco control is smoking cessation counseling by primary care physicians.
However, research suggests that smoking cessation counseling is not sufficiently implemented in
primary care. In order to understand and address the discrepancy between evidence and practice,
an overview of counseling practices is needed. Therefore, the aim of this systematic literature
review is to assess the frequency of smoking cessation counseling in primary care. Self-reported
counseling behavior by physicians is categorized according to the 5A’s strategy (ask, advise,
assess, assist, arrange). An electronic database search was performed in Embase, Medline,
PsycINFO, CINAHL and the Cochrane Library and overall, 3491 records were identified. After
duplicates were removed, the title and abstracts of 2468 articles were screened for eligibility
according to inclusion/exclusion criteria. The remaining 97 full-text articles reporting smoking
cessation counseling by primary care physicians were assessed for eligibility. Eligible studies
were those that measured physicians’ self-reported smoking cessation counseling activities via
questionnaire. Thirty-five articles were included in the final review (1 intervention and 34 cross-
sectional studies). On average, behavior corresponding to the 5A’s was reported by 65% of
physicians for “Ask”, 63% for “Advise”, 36% for “Assess”, 44% for “Assist”, and 22% of
physicians for “Arrange”, although the measurement and reporting of each of these counseling
practices varied across studies. Overall, the results indicate that the first strategies (ask, advise)
were more frequently reported than the subsequent strategies (assess, assist, arrange). Moreover,
there was considerable variation in the items used to assess counseling behaviour and developing
a standardized instrument to assess the counseling strategies implemented in primary care would
help to identify and address current gaps in practice.

Introduction
Tobacco consumption is a preventable risk factor for non-communicable diseases such as
chronic obstructive pulmonary disease (COPD) and cardiovascular disease. Each year, around
six million people die from long-term exposure to first- or second-hand smoke worldwide [1].
Globally, one of the guiding instruments for tobacco control is the World Health Organization
Framework Convention on Tobacco Control (WHO FCTC) [2]. The convention gives specific
recommendations for a number of different tobacco control strategies that should be
implemented, such as developing comprehensive smoking cessation guidelines and introducing
warning labels on cigarette packages [2]. One approach to reduce tobacco consumption that is
recommended in guidelines for the treatment of tobacco dependence is to offer smoking
cessation counseling in the primary care setting [3–5]. Smoking cessation counseling by general
practitioners (GP’s) has been shown to increase quit rates [6]. The general practice is an
appropriate setting for smoking cessation counseling for a number of reasons [7]. First, GP’s
have suitable access to the target group because around 80% of the German population visit their
GP at least once per year [8]. Second, regular personal contact builds trust between GP’s and
patients and facilitates the provision of quit advice [9]. Third, face-to-face contact allows for the
delivery of individual smoking cessation advice [10].
The clinical practice guideline of the US Public Health Service contains a comprehensive
approach to smoking cessation counseling in primary care settings, which specifies individual
counseling steps such as asking about tobacco consumption and recommending the use of
pharmacological aids; the 5A’s strategy [5]. The 5A’s refer to a sequence of 5 different
counseling strategies: “Ask” (ask all patients about tobacco use), “Advise” (advise all tobacco
users to quit), “Assess” (assess the willingness to quit), “Assist” (assist with quitting) and
“Arrange” (arrange follow-up) [5]. Examples of other approaches are the ABC model (Ask about
and document smoking status, give brief advice and encourage the use of cessation support) and
the recommendation of the American Association of Family Physicians (AAFP; Ask about
tobacco use, advise to stop using tobacco products and provide behavioral interventions). We
focus on the 5 A’s strategy because it distinguishes between 5 counseling steps and is therefore
more inclusive than the ABC model and AAFP recommendation which describe 3 counseling
steps [4, 5, 11].
Although smoking cessation counseling is effective and recommended in clinical guidelines, it is
not fully implemented in primary care [10, 12]. In order to further understand and address the
discrepancy between evidence and practice, an overview of current counseling practices is
needed. A systematic literature review has examined the frequency of behavioral counseling by
physicians for multiple behaviors (tobacco consumption, physical activity and nutrition) and
found that the use of educational materials and referral to smoking cessation courses were
frequently reported counseling strategies [13]. For example, educational materials were
recommended by 58% of Scottish physicians and 61% of Canadian physicians [14, 15].
However, comparability of quantitative information on smoking cessation counseling practices
was limited and it is not clear which counseling steps are implemented in practice. Therefore, the
aim of this literature review is to systematically assess physician-reported smoking cessation
counseling in primary care by classifying counseling practices according to the 5A’s strategy.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5176294/
Nurses and cigarette smoking: a literature review.

Abstract
This brief literature review covers forty-eight references from the English-speaking world and is
concerned with three subject areas or questions, which are: In what way are nurses heavy smokers?
What particular aspects of nursing may cause nurses to smoke? What influence does a nurse's
smoking behaviour have on the effectiveness of the use of nurses in health-education campaigns
specifically designed to decrease smoking? The first part of the article critically examines the
assumptions underlying some of the evidence which has already been collected on the question of
nurses' supposed heavy cigarette-smoking consumption. The general point which is made is that
few of the social-research studies concerned with nurses' smoking behaviour seem to be correctly
focused. The second part of this review is concerned with some of the issues which may need to be
clarified. For example, it is proposed that a distinction should be made between the starting,
continuing and stopping of cigarette smoking. Similarly, it is argued that nursing cannot account for
the cigarette-smoking behaviour of nurses who begin nursing as smokers, nor (obviously) for those
who never smoke. It is therefore suggested that the emphasis of research could initially be on those
who become cigarette smokers while they are becoming nurses. Finally, having accepted Farrell's
definition of health education as only including information-giving, and not behavioural changes, it is
argued that any ideas of the use of nurses as health educators in smoking-cessation work in
hospitals will need to be clarified and translated into practical and sensible options which take
account of the limitations within the nurse training process, and also the heavy work load of nurses.

https://www.ncbi.nlm.nih.gov/pubmed/6348116
Cigarette Smoking
Andrew W. Bergen, Neil Caporaso

Cigarette smoking is the largest preventable risk factor for morbidity and mortality in developed
countries. Dramatic changes in the prevalence of cigarette smoking in the second half of this
century in the United States (i.e., a reduction among men and an increase among women) have
reduced current smoking levels to approximately one quarter of the adult population and have
reduced differences in smoking prevalence and smoking-attributable diseases between the sexes.
Current smoking in the United States is positively associated with younger age, lower income,
reduced educational achievement, and disadvantaged neighborhood environment. Daily smokers
smoke cigarettes to maintain nicotine levels in the brain, primarily to avoid the negative effects
of nicotine withdrawal, but also to modulate mood. Regular smokers exhibit higher and lower
levels of stress and arousal, respectively, than nonsmokers, as well as higher impulsivity and
neuroticism trait values. Nicotine dependence is the single most common psychiatric diagnosis in
the United States, and substance abuse, major depression, and anxiety disorders are the most
prevalent psychiatric comorbid conditions associated with nicotine dependence. Studies in twins
have implicated genetic factors that explain most of the variability in vulnerability to smoking
and in persistence of the smoking phenotype. Future research into the causes of smoking must
take into account these associated demographics, social factors, comorbid psychiatric conditions,
and genetic factors to understand this complex human behavior. [J Natl Cancer Inst
1999;91:1365–75]

Cigarette smoking, hereafter referred to as “smoking,” is the largest single risk factor for
premature death in developed countries. Approximately one fifth of the deaths in the United
States are attributable to smoking, and 28% of the smoking-attributable deaths involve lung
cancer, 37% involve vascular disease, and 26% involve other respiratory diseases (1). More than
400 000 deaths per year and 30% of all cancers in the United States are attributable to smoking
(2). Lung cancer is the largest single cause of cancer-associated mortality (3) and is the most
common cause of smoking-related mortality in the United States (4). The attributable risk from
smoking for oral, pharyngeal, and esophageal cancers is substantial, although less than that for
lung cancer (5,6). The attributable risk from both smoking and alcohol consumption accounts for
the majority of both oral and pharyngeal cancers (5) and of esophageal cancer (7). Morbidity and
mortality attributable to smoking would decline in the future if reductions in smoking prevalence
were to be observed. However, despite dramatic declines in adult male smoking prevalence in
the United States observed from the 1960s through the 1990s (8), the decline in current adult
smoking prevalence slowed by about 1990 (9), and recent surveys of current smoking in youth,
defined as cigarette use on at least one of the last 30 days preceding the survey, show a
statistically significant increase (from 27.5% in 1991 to 36.4% in 1997) (10). The prevalence of
current smoking among adults in the United States, defined as smoking daily or smoking on
some days (11), is now about 23% in women and 27% in men and is statistically significantly
higher in those less than 65 years of age; in those with 9–11 years of education; in those below
the poverty threshold; in whites, blacks, and American Indians/Alaskan Natives; and in military
veterans (9,12–15). Projected demographic and smoking prevalence trends suggest that the
absolute number of current smokers in the United States, about 47 million individuals in 1995,
will continue to increase, especially in those below the poverty threshold, in those with less than
13 years of education, and in those greater than or equal to 65 years of age (9,15–18). Smoking
prevalence in men worldwide is higher than it is in the United States, while smoking prevalence
among women worldwide is usually less than the prevalence in men, although it has equaled or
exceeded that in men in some northern European countries (19,20). While annual per capita
cigarette consumption has dropped in developed countries from a high of more than 3000 in the
1970s to about 2600 in 1990, it is increasing in developing countries (260% increase in China
between 1970 and 1990), so that worldwide annual per capita cigarette consumption has not
changed substantially over the last 25 years (20). Because of the delayed health effects of
smoking, morbidity and mortality in developing countries attributable to smoking have not yet
surpassed those in developed countries but are likely to do so in the next century (20,21). The
study of biomarkers in smoking-attributable cancer has concentrated on measures of exposure
(i.e., cotinine, NNALGluc1 ), dose (i.e., carcinogen–macromolecular adducts, such as 4-amino
biphenyl hemoglobin adducts), micronutrients (i.e., b-carotene), and genetic factors that may
modify these factors or their effects (22). The investigation of such biomarkers is predicated on
the assumption that an enhanced understanding of metabolic mechanisms will help to identify
susceptible groups or individuals and direct future research or prevention efforts. Another group
of risk factors for lung cancer and other smokingrelated cancers are those that are associated with
smoking, its initiation, and its persistence. We will review factors associated with current and
persistent smoking that have been studied by use of pharmacologic, epidemiologic, behavior
genetic, psychologic, and psychiatric perspectives. The identification of those factors
consistently and statistically significantly associated with smoking will provide biologic and
social variables with which to investigate mechanisms that contribute to the persistence of this
behavioral phenotype. Improved understanding of these mechanisms may enable improved
cancer prevention and control efforts.

https://watermark.silverchair.com/1365.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3
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Smoking, Mental Health and Addiction: A Review of the Literature

Abstract

Patients with mental health and addiction disorders are the only core cigarette smokers left in the
Western world as the number of smokers in the general population has declined dramatically over the
last decades. Simultaneously there is a gap in life expectancy of more than 20 years between patients
who have been in treatment for mental disorders and the rest of the population and this gap has not
declined in the last two decades. Adding to this are new research findings that show that cigarette
smoking has a detrimental effect also on mental health being a risk factor for depressive symptoms.
There is therefore a need for concentrated action to curb the smoking epidemic among people with
mental health and addiction disorders. There is limited research and guidelines on how to both prevent
and cease smoking in this group. The aim of this paper is to give an overview of the current literature
of the size of the problem, how to handle smoking cessation both individually and at system level and
on the prevention of smoking.
The review confirms that the rate of smokers among patients with mental health and addiction
disorders is huge with some figures pointing up to 80 % in specific groups. It also confirms that
cigarette smoking is a strongly addictive making the success rates low, especially without aides like
snooze and e-cigarettes. It also shows, however, that it is safe to create a smoking free environment
in all mental health and addiction units which also might be beneficial to the patients in the long run.

Introduction

Historically, smoking has been very common among mental health patients and mental healthcare
workers, and only recently has smoking declined among healthcare professionals [1,2]. Smoking by
mental health patients while receiving treatment for their mental health problems has been used to
reduce feelings of aggression and anxiety [1]. The ability to smoke while in treatment has been used
as a tool by healthcare providers to exact punishment or reward to influence the behavior of mental
health patients. For many mental health professionals, smoking was seen as a way to break down
barriers between themselves and their patients. Moreover, many mental health professionals had
longstanding belief that mental health disorders lessened the detrimental effects of smoking [1].
Smoking remains very common among people with mental health problems, particularly those with
substance abuse disorders [2]. When people with mental health disorders are receiving treatment,
smoking poses a health risk to their fellow patients and the mental health professionals providing their
care. Countries worldwide have prohibited smoking in the workplace in an effort to curb smoking and
thereby protect the health of both the smokers and those in the vicinity of the smoker. Mental health
treatment centers in many countries remain an important exception to this trend [1]. Given the high
prevalence of smoking among patients receiving treatment, the clientele, staff, and healthcare
providers at these treatment facilities are commonly exposed to second-hand smoke [2]. The aim of
this narrative review is to present an overview of the prevalence of smoking among people with mental
health disorders and the impact of smoking on mental health morbidities and life expectancy, and to
describe efforts to curb smoking among people with mental health disorders, both in and out of
treatment, and barriers to the enactment of prohibiting smoking at treatment sites. We conclude with
proposals for future research and smoking policy updates.
Smoking among People with Mental Health Disorders

Tobacco use is still one of the leading preventable causes of death in the world killing up to half of its
users [3]. The tobacco epidemic is one of the biggest public health threats, killing around six million
people a year [3]. More than five million of those deaths are the result of direct tobacco use while more
than 600,000 are the result of non-smokers being exposed to second-hand smoke [3]. The number of
smokers in the general population is rapidly decreasing in the Western world. For example, in 1973 in
Norway almost 45 % of the populations were daily smokers, in 2004 this was reduced to 26 %, and
last year only 13 % of populations were daily smokers [4].
The severely mentally ill comprise a large proportion of the heavy smokers of today in the western
world [2]. A third of all cigarettes smoked in England are the people with a mental disorder, and in
contrast to the marked decline in smoking prevalence in the general population, smoking among those
with mental disorders has changed little, if at all, over the past 20 years [5]. A study from the US based
on the National Comorbidity Survey conducted from 1991 to 1992 reported that 44.3 percent of all
cigarettes in America were consumed by individuals who live with mental illness and/or substance
abuse disorders [6]. This means that persons with mental illness were about twice as likely to smoke
as other persons, even at times when the general population smoking rate was higher [6].

Impact of Smoking on Life Expectancy and Mental Health

Life expectancy
Life expectancy among mental health patients has recently become a pressing issue. Studies from
the Nordic countries of Sweden, Finland, and Denmark show that men and women who have been in
hospital with a psychiatric diagnosis, except for mental retardation and dementia, have a shortened
life expectancy of 20 years and 15 years, respectively, compared to the rest of the population. Despite
major changes in the health services available to people with mental illnesses, the life expectancy gap
between people with a psychiatric hospitalization and the rest of the population has not changed
significantly over the last 20 years [7].
The higher death rate is present in all psychiatric diagnostic groups, where it is highest for those with
drug addiction and lowest for those with mood disorders [8]. About 40% of the total excess mortality
among patients with schizophrenia is caused by external causes, primarily suicides, while
approximately 60% can be attributed to somatic disease. For people with bipolar disorder or
schizophrenia, the mortality rate when cardiovascular disease is present is 2-3 times higher than for
the rest of the population [9].
Figures from Australia in the period between 1985 and 2005 show that the gap in life expectancy
between those who have contact with mental health services and the rest of the population increased
by 2.4 years for men and 1.6 years for women. The study showed further that 77.7% of the excess
mortality was related to medical conditions, where cardiovascular diseases accounted for 29.9% and
cancer for 13.5% excess mortality. Suicide was linked to only 13.9% of the reduction in life expectancy
[10].
Mental health
In 2000, the US National Comorbidity Study found evidence that smoking preceded and was a risk
factor for mental health problems [6]. Later studies confirmed this finding, such as Lineberry’s
observation that smoking is a risk factor for suicidality [11]. Similarly, a longitudinal study among
teenagers showed that daily smokers at 15 years of age were more likely to be depressed 3 years
later. This same study did not show that depressive symptoms increased smoking [12]. A large birth
cohort study from Australia also identified an association between age at first tobacco use and
subsequent psychosis-related outcomes in young adulthood [13]. All the studies mentioned are
general-population based which exclude inpatient populations and thus make it impossible to study
the impact of smoking among inpatients on their own health and on those around them.
In contrast to the evidence showing negative effects of smoking on mental health outcomes, a report
by the Royal College of Psychiatrists summarizes the potential positive effects of cigarette smoking
[5]. The investigators found that there is experimental evidence to suggest that nicotine can relieve
symptoms of anxiety, depression, schizophrenia and attention deficit hyper activity disorder (ADHD).
The authors also note, however, that nicotine withdrawal symptoms may then exacerbate symptoms
of mental disorders. The evidence supporting a positive impact of smoking on mental health outcomes
suggests that some people with mental disorders may self-medicate with nicotine to ameliorate mental
health symptoms such as depression or anxiety. It is important to acknowledge these apparent positive
effects when motivating patients for smoking cessation. On the other hand, it is important to state that
the symptoms of mental disorders can be confused with or exacerbated by those of nicotine
withdrawal, resulting in false attribution of cessation to the relief of symptoms of mental disorders [5].
Other studies have examined other relevant dimensions between smoking and mental health. One
such study found that there was an association between smoking severity and poor self-reported
quality of life connected to leisure activities, social relationships, and finances [14]. Another study
showed that mental health patients who smoked had a poorer prognosis, more problems with
medication, and more hospitalizations than non-smokers [15]. A recent meta-analysis of smoking and
psychosis included 61 studies up to 2014 and involved 14,555 tobacco smokers and 273,162 non-
smokers [16]. The investigators hypothesized that if the high rate of smoking among people with
psychosis was related to self-medication, then smoking rates could be expected to be normal at the
time of the first psychotic episode and subsequently increase in reaction to the symptoms. Instead,
the analysis of case-control studies found that 57% of people with a first episode of schizophrenia
were already smokers, for an overall odds ratio for smoking of 3.22 among people with an episode of
schizophrenia (95% confidence interval [CI], 1.63 - 6.33) [16]. The authors noted some evidence of
publication bias. An additional sub-analysis of five longitudinal, prospective studies showed a more
modest association, but daily smokers were still approximately twice as likely to develop new psychotic
disorders as nonsmokers (relative risk, 2.18; 95% CI, 1.23 - 3.85). In addition, those who smoked daily
were found to develop psychotic illness approximately one year earlier than non-smokers. There was
no significant difference in age of smoking debut between those who did and did not develop psychosis
[16].
There have also been a few studies investigating the possible biological underpinnings of the
association between psychosis and smoking. One study showed that nicotine could cause a change
in the dopaminergic system through induction of super sensitivity of D2 receptors, which has been
proposed as an explanatory mechanism for several risk factors for schizophrenia and as a common
pathway for psychotic symptoms [17]. Finally, a key cluster of genes — CHRNA5, CHRNA3, and
CHRNB5— on chromosome 15, which have been linked to schizophrenia in the largest genome-wide
association study of the disease to date, are also associated with nicotine dependence and smoking
behavior [18].

Efforts Towards Smoking Cessation Among People With Mental Health Disorders

Barriers to smoking cessation

The US National Comorbidity Survey observed that more than a third of patients with a history of
mental illness had quit smoking by the time of the survey [6]. Furthermore, they found that persons
abstinent from alcohol had quit rates equal to those of persons without mental illness [6]. The Smoking
and Mental health report states that smokers with mental disorders are just as likely to want to quit as
those without, but are more likely to be heavily addicted to smoking [5].
So why then is it so difficult to reduce smoking among patients with mental health problems and
especially those with severe problems? First, mental health care workers do not always view smoking
as an addiction comparable to addiction to alcohol and other drugs. Rather, smoking is seen as one
of few pleasures in an otherwise tumultuous life. Second, there is the belief among mental healthcare
workers that pressure to quit might lead to feelings of shame and guilt among patients, of which they
typically already have plenty. Moreover, the expectations of success with smoking cessation are
extremely low [1].
Other obstacles to smoking cessation among patients with mental health problems come from
experience-based knowledge among health workers. For example, the increased emotional stress
they observe among patients abstinent from cigarettes. A strongly held belief is that to abandon
smoking might lead to increased violent behavior. These are some of the reasons that health workers
and managers may justify violating smoking laws. A third and more theoretical reason for allowing
smoking is that cigarettes or smoking privileges are seen as a stable object while working on other
addiction treatments [1].
Quitting Measures
There is increasing pressure from health workers to reduce smoking among patients to ensure a
smoke free work environment. As discussed above, however, there are many barriers to attempts to
“denormalize” smoking in treatment facilities. One important question is how to motivate people with
mental health problems to reduce or quit smoking. General public information campaigns don’t seem
to work as smoking has not been reduced among people with mental health problems compared with
the general population. An important measure that works especially well among youth is price control
on cigarettes. While youth are sensitive to marked increases in the price of smoking, this measure
seems to only increase the financial burden for those with mental health problems. Studies report
some patients with mental health disorders spend up to 30 % of their income on cigarettes. Since
restrictions seem difficult to impose and public health measures are insufficient, innovative methods
to reach people with mental health problems should be developed [5].
One approach may be to increase the impact of existing approaches, such as media campaigns, by
tailoring them to the specific needs of the mental health patient populations. Also, given the
opportunities presented by contacts with mental health services, these visits may be points at which
to intervene to support smoking cessation and harm reduction. Smoke-free policies are more likely to
be successful and effective if they are comprehensive, and can be implemented successfully in mental
health settings with appropriate leadership and support strategies for patients and staff. Training and
support to overcome prevailing misconceptions and negative or indifferent attitudes towards treating
smoking among mental health staff is needed [3].
Psycho education for chronic psychiatric patients indicates that patients are willing to learn more about
the effects of smoking, although most find it difficult to quit [19]. A review article mentioned that people
with mental health disorders are as motivated to quit smoking as the general population, although
those with psychotic disorders may be less motivated as individuals with depression [20]. A common
experience however, is that health care providers are less motivated than their patients, which may
be due to lacking of experience and tools to work with patients to reduce smoking. Moreover, health
care workers at mental health treatment facilities are often working at capacity and introducing more
interventions may be overwhelming and thus not implemented [1].
So, are there effective smoking cessation interventions? The combination of cognitive behavioral
smoking cessation counseling session with cessation pharmacotherapy is effective in the general
population, and has also been shown to be effective in people with mental disorders. Nicotine
replacement therapy (NRT) {nicotine patches, gums, sprays or lozenges} is effective in people with
mental disorders, but may require high doses, for longer durations, and include more intensive
behavioral support compared to the general population of smokers [21]. In addition to their
effectiveness at reducing smoking among people with mental health problems, smoking cessation
programs have also been shown to be highly cost-effective. A randomized controlled trail of a stage-
based smoking cessation service at a psychiatric hospital found the intervention did not result in higher
mental health care costs in the short-term and were highly cost-effective over the projected lifetime of
patients [21].
First line drugs like bupropion, varenicline and second line drugs nortriptyline and clonidine are
effective in people with mental disorders, but should be used with appropriate supervision and
monitoring [22]. Smoking cessation reduces the metabolism of some drugs, such as clozapine,
necessitating prompt reduction in doses of affected drugs at the time of quitting, and increases in the
event of relapse. Naltrexone hydrochloride is another drug that can be used for smoking cessation
which reduces desire of smoking if combined with CBT (cognitive behavior therapy).Smokers who do
not want to quit smoking, or else feel unable to make a quit attempt, should be encouraged to cut
down on smoking, and to use snooze or e-cigarettes in line with the tobacco harm reduction guidance
of the National Institute for Health and Clinical Excellence [23].
Prevention
There is a need for increased focus on the prevention of lifestyle diseases in people with mental illness
based on the known recommendations on diet, smoking, alcohol, and exercise. Risk factors should
be followed closely and interventions should be planned based on the individual patient's everyday life
while aiming to create change with 'small steps'. There is good evidence that the prevention
intervention of lifestyle diseases is effective among patients with mental disorders. Studies evaluating
efforts to increase physical activity in people with schizophrenia are consistently positive [24]. Positive
effects have also been observed among depressed patients, and these physical activity prevention
interventions were also noted to be very cost effective [25].
Achieving cessation in 25%, 50%, and 100% of people with mental disorders would, respectively,
result in a gain of 5.5 million, 11 million, and 22 million undiscounted life-years in the UK [5]. At 3.5%
discounting, the corresponding figures are 1.4, 2.7, and 5.4 million life-years gained [5]. Harm
reduction through lifelong substitution with medicinal nicotine is highly cost-effective when compared
with continuing smoking, at around £8,000 per quality-adjusted life-year (QALY) gained for lifetime
nicotine patch use and £3,600 per QALY for inhalators. Addressing the high prevalence of smoking in
people with mental disorders offers the potential to realize substantial cost savings as well as benefits
in quantity and quality of life [5].
Child and adolescent mental health services, and local authority foster care and smoking policies,
should explicitly protect children from passive smoke, and promote smoke-free foster homes.
Professionals working with or caring for young people should provide positive non-smoking role
models and be trained to deliver cessation advice and provide or arrange further support for those
who want help to quit. In settings where young people are most vulnerable, such as adolescent in
patient units, there should be a broad program of health promotion aimed at preventing initiation of
smoking as well as smoking cessation [5].

Conclusion

People with mental health disorders smoke at higher rates, and they are more nicotine-dependent,
and suffer greater morbidity and mortality from smoking-related illnesses than the general population.
Helping people with mental health disorders to quit smoking is a public health priority; however, some
mental health professionals assume that those with mental illness are not motivated to quit.
On the contrary, studies suggest that people with mental health disorders are indeed motivated to quit
smoking, although more research is needed studying in-patient populations in particular [1]. The
commonly held false belief that people with mental health disorders are not motivated to cease
smoking means that opportunities to encourage smoking cessation among this disenfranchised group
are being missed. It is likely that the persistent acceptance of smoking as normal behavior in primary
and secondary care, and failure by health professionals to address smoking prevention as a health
priority, drives and perpetuates the high prevalence of smoking among people with mental disorders.
This persistent high prevalence of smoking reflects a major failure of public health and clinical services
to address the needs of a highly disadvantaged sector of society. There is a moral duty to address this
problem in the future, and to prioritize the rights of people with mental disorders to the same protection
and health interventions as the general population. Smoke-free policy is crucial to promoting smoking
cessation in mental health settings. All healthcare settings used by people with mental disorders
should be completely smoke free.

http://www.elynsgroup.com/journal/article/smoking-mental-health-and-addiction-a-review-of-
the-literature
Smoking among school-going adolescents in
selected secondary schools in Peninsular
Malaysia- findings from the Malaysian Adolescent
Health Risk Behaviour (MyaHRB) study

ABSTRACT
Background:
A multitude of studies have revealed that smoking is a learned behaviour during
adolescence and efforts to reduce the incidence of smoking has been identified as
long-term measures to curb the smoking menace. The objective of this study was
to determine the prevalence as well as the intra and inter-personal factors
associated with smoking among upper secondary school students in selected
schools in Peninsular Malaysia.

Methods:
A study was carried out in 2013, which involved a total of 40 secondary schools.
They were randomly selected using a two-stage clustering sampling method.
Subsequently, all upper secondary school students (aged 16 to 17 years) from
each selected school were recruited into the study. Data was collected using a
validated standardised questionnaire.

Results:
This study revealed that the prevalence of smoking was 14.6% (95% CI:13.3–
15.9), and it was significantly higher among males compared to females (27.9%
vs 2.4%, p < 0.001). Majority of smokers initiated smoking during their early
adolescent years (60%) and almost half of the respondents bought cigarettes
themselves from the store. Multivariable analysis revealed that the following
factors increased the likelihood of being a current smoker: being male (aOR 21.
51, 95% CI:13.1–35), perceived poor academic achievement (aOR 3.42, 95%
CI:1.50–7.37) had one or both parents who smoked (aOR 1.80, 95% CI:1.32–2.45;
aOR 6.50, 95 CI%:1.65–25.65), and always feeling lonely (aOR 2.23, 95%
CI:1.21–4.43). In contrast, respondents with a higher religiosity score and
protection score were less likely to smoke (aOR 0.51, 95% CI:0.15–0.92; aOR
0.71, 95% CI 0.55–0.92).

Conclusions:
This study demonstrated that the prevalence of smoking among Malaysian
adolescents of school-going age was high, despite implementation of several anti-
smoking measures in Malaysia. More robust measures integrating the factors
identified in this study are strongly recommended to curb the smoking epidemic
among adolescents in Malaysia.

http://www.tobaccoinduceddiseases.org/Smoking-among-school-going-adolescents-in-selected-
secondary-schools-in-Peninsular,69718,0,2.html
Factors associated with Cigarette Smoking
among Filipinos in the Philippines
Abstract
BACKGROUND & PURPOSE: Philippines has one of the highest cigarette
smoking rates in Southeast Asia, yet few studies have been published on
the smoking patterns and behaviors of Filipinos. The purpose of this study
is to identify environmental, demographic, cognitive, lifestyle, and personal
health factors associated with smoking cigarettes among Filipinos in the
Philippines. METHODS: This study analyzed the 2000 Adult Philippine
Behavioral Risk Factor Survey. Both bivariate and multivariate analyses
were conducted to identify factors associated with being a never smoker,
current smoker, and former smoker for both Filipino men and women.
Using STATA, data were weighted and results were adjusted to reflect the
general Philippine adult population. RESULTS: Approximately 53% of men
and 9% of women are current smokers. Factors independently associated
with smoking among men include being married and employed in
agriculture or blue-collar industry, while factors associated with smoking
among women include having less than a college degree and being older.
Drinking alcohol and the interaction effect of living in an urban community
and having negative attitude toward anti-smoking policies were associated
with smoking for both men and women. CONCLUSION: Findings suggest
that the factors associated with smoking cigarettes among Filipinos are
gender specific. They also show that there is a significant interaction
between one's type of community and one's attitudes toward anti-smoking
policies. Tobacco prevention and control efforts should not be a one-size-
fits-all approach. Program planners should develop interventions within the
context of the male and female perspective and the type of community they
live.

https://www.researchgate.net/publication/266900954_Factors_associated_with_Cigarette_Smoking_a
mong_Filipinos_in_the_Philippines
Addressing the tobacco epidemic in the Philippines:
progress since ratification of the WHO FCTC

Abstract
Tobacco use is the leading cause of preventable death, and is estimated to kill more than 5
million persons each year worldwide. Tobacco use and exposure to second-hand smoke pose a
major public health problem in the Philippines. Effective tobacco control policies are enshrined
in the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC),
a legally binding international treaty that was ratified by the Philippines in 2005. Since 2007,
Bloomberg Philanthropies has supported the accelerated reduction of tobacco use in many
countries, including the Philippines. Progress in the Philippines is discussed with particular
emphasis on the period since ratification of the WHO FCTC, and with particular focus on the
grants programme funded by the Bloomberg Initiative. Despite considerable progress, significant
challenges are identified that must be addressed in future if the social, health and economic
burden from the tobacco epidemic is to be alleviated. Non-communicable diseases (NCDs) pose
one of the main health challenges of the twenty-first century; of the estimated 57 million global
deaths in 2008, 36 million (63%) were due to NCDs.1 From the Global Burden of Disease
projections, an estimated 2.6 million people died from NCDs in the 10 Association of South-East
Asian Nations (ASEAN) countries, and the mortality rate adjusted to age per 100 000 population
is high in low-income countries.2,3 The largest proportion of NCD deaths is caused by
cardiovascular disease (48%), followed by cancers (21%) and chronic respiratory diseases
(12%).
Tobacco use is an important behavioural risk factor that is responsible for 12% of male deaths
and 6% of female deaths in the world.4 Exposure to second-hand smoke (SHS) is estimated to
cause more than 600 000 premature deaths annually. These include 166 000 deaths from lower
respiratory infections, 35 800 from asthma (1100 from asthma in children), 21 000 from lung
cancer and 379 000 from ischaemic heart disease in adults. This disease burden amounts in total
to about 10.9 million disability-adjusted life years. Of all deaths attributable to SHS, 28% occur
in children and 47% in women.5 Tobacco use is the leading cause of preventable death, and is
estimated to kill more than 5 million people each year worldwide; if current trends persist,
tobacco will kill more than 8 million people worldwide each year by the year 2030, with 80% of
these premature deaths in low- and middle-income countries.6,7 In the Philippines, tobacco kills at
least 87 600 Filipinos per year (240 deaths every day); one third of these are men in the most
productive age of their lives.8
The most effective tobacco control policies are contained in the World Health Organization
(WHO) Framework Convention on Tobacco Control (FCTC),9 which is the first global health
treaty, and encapsulated in the corresponding MPOWER policy package.10 In the Philippines, the
FCTC was ratified in 2005 by the Senate and signed by the President, i.e., the ratification itself
went through a legislative process. Parties to this legally binding international treaty must enact
new laws or amend existing ones so that they are consistent with the FCTC. Progress in
implementation of the FCTC is monitored and reported by the WHO.6,7,11 The South-East Asia
Tobacco Control Alliance also publishes reports on FCTC implementation
(http://www.seatca.org/). Since 2007, Bloomberg Philanthropies has supported the
implementation of proven policies to accelerate the reduction of tobacco use worldwide; as of
2012, the total commitment confirmed under this initiative is more than US$600 million;12 the
Philippines has received some US$5 million through grants to government and civil society
under this initiative.13 Discussion in the peer-reviewed literature of tobacco control and related
issues specifically with respect to the Philippines has been limited to date, with some noteworthy
exceptions.14–23 This article provides an overview of progress in the country since the 2005
ratification of the WHO FCTC to the end of 2012, and provides a particular focus on the grants
programme funded under the Bloomberg Initiative.

TOBACCO USE IN THE PHILIPPINES

The Philippines is the world’s twelfth most popu-lous country, with projected population
estimates of 101.8 million by 2015 and over 132.5 million by 2040.24 Total health expenditure
per capita is estimated at US$66.1 The tobacco industry in the country has been described as ‘the
strongest tobacco lobby in Asia’.20 The Philippines has one of the highest per capita levels of
cigarette consumption among the ASEAN countries, well above the ASEAN average (873
cigarettes).25 Tobacco use, exposure to SHS and pervasive marketing of tobacco products pose a
major public health problem in the country, according to recent data:26,27
 28.3% (17.3 million Filipinos) of the adult population currently smoke (males 47.6%,
females 9.0%);
 48.8% (29.8 million Filipinos) allow smoking in their homes;
 36.9% of adult workers report exposure to tobacco smoke in enclosed areas at their
workplace in the past month;
 exposure to SHS was 55.3% in public transport, 33.6% in restaurants, 25.5% in
government buildings and 7.6% in health care facilities; and
 96.2% of smokers bought their last cigarettes in a store and 53.7% of adults said they had
noticed cigarette marketing in stores where cigarettes are sold.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4463107/
A Study on the Effects of NCR Male High School Students’
Exposure to and Recall of Anti-Smoking Advertisements to Their
Perceptions of and Attitudes toward Smoking

ABSTRACT
Aguillon, J. &Romano, P(2012). SMOKECHECK: A study on the effects of NCR male
high school students’ exposure to and recall of anti-smoking advertisements to
their perceptions of and attitudes towards smoking, Unpublished Thesis,
University of the Philippines College of Mass Communication. The study aims to
determine the effects of the extent of exposure to anti-smoking advertisements
and the recall of National Capital Region (NCR) male high school students to their
perceptions of and attitudes toward smoking. Male students were chosen
because The Health Belief Model (HBM), Mere Exposure Theory, and Availability
Heuristics Principle were used for the theoretical framework of the study. A
survey was conducted randomly among 400 NCR male high school students. The
researchers also conducted two Focus Group Discussions divided to smokers and
nonsmokers. the 2007 Global Youth Tobacco Survey estimates that there are 17%
or 4 million Filipino youths with ages 13-15 years who are smoking. Of these early
starters, 2.8 million are boys and 1.2 million are girls, thus majority are male in
the high school level. Results found out that three in ten NCR male high school
students had tried smoking at ages 12 to 14 years. There was a high general
perceived susceptibility and severity of having smoking-related diseases among
the NCR male high school students. The general attitude of the students toward
smoking was either positive or negative (neutral). The study also found out that
there was a weak correlation between the NCR male high school students’
exposure to and recall of anti-smoking advertisements and their perceptions of
and attitudes towards smoking.

https://iskwiki.upd.edu.ph/images/c/c7/Aguillon,Joyce_Mendoza&Romano,Precious_Barredo;April_201
2;A_Study_on_the_Effects_Anti-Smoking_Ads.pdf
Smoking-Related Research in the Asian-Pacific Countries
Malcolm A Moore, Hiroyuki Tsuda

Abstract
In addition to the obvious link between tobacco consumption and cancer of the lung and oral
cavity, there is increasing evidence that carcinogens in smoke many also have an impact in
many other organ sites. The potential damage of second hand smoke, especially to children,
also requires stress. While studies of gene polymorphisms for enzymes involved in carcinogen
metabolism have pointed to a genetic background to smoking likelihood and clearly increased
risk of cancer development in many organs for smokers with decreased detoxification potential,
the question of how to make best use of this information for practical prevention remains
largely unexplored. Similarly, the fact of peer group and family influence in determining
initiation of adolescent smoking has yet to be translated into a concrete strategy based on
psychological understanding. Cessation programs for adult smokers on the other hand could
make use of positive results from interventions in hospital settings, possibly married to
screening programs for early cancers. Political and socioeconomic questions are clearly very
important and putting into action principles of tobacco control efforts with collaboration
between all of the interested parties must now be stressed. Government can play a very
positive role by control of sales and marketing, heavy taxation and smoking bans, and provision
of funding for research and community interventions, while education and awareness are
natural targets of NGOs. The academic research community can perhaps best contribute by
further clarifying mechanisms underlying tobaccorelated disease, possibly with an emphasis on
chemoprevention in association with epidemiological assessment of confounding factors, and
also very importantly the psychosociology of the tobacco habit.

http://journal.waocp.org/article_25247_8c76452c9843e189cc60740169556c14.pdf
Cigarette-Smoking Behavior Correlates with
High Anxiety among University Students
Helena B. Florendo

Abstract:
Cigarette smoking is always harmful since it is one of the primary reasons for human death, however,

smoking can be prevented. In the Philippines, there are dearth of studies conducted that deal with

cigarette smoking and anxiety among college students. The main purpose of the study is to find out

the cigarette-smoking behavior among college students and its correlates to anxiety. The researcher

used of questionnaires, standardized test and interviews to gather data. Likewise, descriptive-

correlational method, purposive sampling and SPSS were utilized. Out of 1,866 freshman students

surveyed in Isabela State University Main Campus, Philippines, 286 were current smokers. Findings

revealed that most of the participants are in their adolescence stage, male dominated, received

minimal allowance, have parents with high educational attainment, and their parents’ jobs require

physical labor. Results showed that peer, familial, mass media, environmental factors respectively

except for the teacher factor had considerable impact on the smoking behavior of the participants.

Findings indicated that most of the smokers have a high level of anxiety. Anxiety is significantly related

to the developmental stage when one started smoking and sticks he/she consumed per day. An

intervention program aimed at reducing anxiety and cigarette smoking among students need further

research.

https://ejournals.ph/article.php?id=2662
Smoking and Tobacco Consumption in
the Philippines
In 2009, the Department of Health (DOH) launched Unang Yakap, a newborn care campaign.
"Yakap" is the Filipino term for embrace or hug, a nurturing motion that people do towards
someone who is loved or who is in distress. Figuratively, "yakap" also means protecting
something valuable like spirituality, social activism, education, the environment, or other
interests that bring a positive influence or offer benefits to oneself, to others, or to society as a
whole.

Though health (or kalusugan in Filipino) is a basic human need that should be embraced, not
everyone takes good care of it. Not all Filipinos see their "kalusugan" as worthy of a "yakap".
Such disregard for health often leads to poor healthy choices and behaviors like smoking and
addiction to tobacco use. It is the same disregard that results in non-communicable illnesses
that could have been prevented with appropriate information on healthy lifestyles and sound
public health care policies that provide accessible, affordable, and efficient services and
programs.

When the health of Filipinos is at stake, their "kinabukasan" or future is equally compromised,
and so is the future of the Philippines in general.

Commitment to Public Health Care: The WHO and The Philippines

The World Health Organization (WHO) defines health as "a state of complete physical and
social well being, and not merely the absence of disease or infirmity." As a key unit of the United
Nations (UN), it assists member states by providing good health policies, standards, and
protocols. This also includes helping governments achieve Millennium Development Goals
(MDGs), particularly those that focus on "the continuum of care from pregnancy through to
adolescence". It likewise supports other UN conventions that deal with gender discrimination
and child's rights protection, and prescribes the institutionalization of "regulatory, economic,
educational, organization-based, and community-based programs" that support healthy
lifestyles and safe environments.

Among many global health problems, the WHO seeks to address the wide-ranging impact of
tobacco consumption, including its effect on maternal, neonatal, infant, child, and adolescent
health. Through the efforts of its Tobacco Free Initiative (TFA), more than 160 countries,
including the Philippines, signed the Framework Convention on Tobacco Control (FCTC) in
2003. The FCTC limits the promotion, marketing, and smuggling of tobacco and tobacco
products. Using them, as WHO Director-General Dr. Margaret Chan Fung Fu-chun says, "...is a
risk factor for six of the eight leading causes of death in the world." Unless forestalled by
effective smoking cessation measures, the WHO warns that current annual tobacco-related
deaths of over five million could figure around 10 million in succeeding decades. It further notes
that many of these deaths are likely to happen in developing countries where "smokers spend
disproportionate sums of money relative to their incomes that could otherwise be spent on food,
healthcare, and other necessities" (Tobacco Atlas 2009).

Indeed, the Philippines is not immune from tobacco-related diseases (e.g., lung and oral cavity
cancers, hypertension, tuberculosis, etc.), causing about 35,000 Filipinos to die yearly (Panesa
2011). The Framework Convention on Tobacco Control Alliance Philippines (FCAP) reveals that
the country "has the second highest number of smokers" in Southeast Asia, with smokers
composing "Over a third of the country's 90 million population" (Santos 2010).

As a party to a number of WHO conventions and as stipulated in the Philippine Constitution,

having good health then is a fundamental right of every Filipino. The government bears the
responsibility to pass and enforce laws meant to deliver good health services and programs,
especially for vulnerable groups (i.e., women, infants, children, and the youth) and marginalized
communities. With tobacco as one of the preventable causes of health ailments, the country
needs to strengthen its drive to curb smoking and improve the state of maternal and child health
in the process.

Smoking and Public Health in The Philippines: Current Conditions, Policy Measures,
and Related Studies
The Philippines passed the Tobacco Regulation Act (RA 9211) in 2003. In line with this and
WHO's FCTC, the DOH later launched the "No to Sigarilyo" (NoSi; No to Cigarette) sticker
project in collaboration with the Land Transportation and Franchising Regulatory Board
(LTFRB). This measure required public utility vehicles to display the stickers, reminding
passengers of the law against smoking in public.

The DOH also piloted the Red Orchid Program to recognize localities, government offices,
health centers, and public hospitals with effective anti-smoking initiatives by adopting WHO's
MPOWER tobacco control strategies: (1) Monitor tobacco use and prevention policies; (2)
Protect people from tobacco smoke; (3) Offer help to quit tobacco use; (4) Warn against the
dangers of tobacco; (5) Enforce bans on tobacco advertising; and (6) Raise taxes on tobacco.
Awardees receive a grant of Php 100,000 to purchase drugs and medicines and are cited as
"Best Practices" in the country's National Tobacco Control Program. Prior to this campaign, the
government funded the Lung Cancer Control Program (LCCP) that supported anti-tobacco
legislative efforts and used "Yosi Kadiri" (Smoking Sucks) and "'No Sa 'Yo" (It Isn't Cool to
Smoke) campaigns.

Smoking and The Filipino - Young and Old, Men and Women
However, in spite of these efforts, the Global Youth Tobacco Survey (GYTS) show that
"smoking prevalence among Filipino youth had jumped from 15 percent in 2003 to 21.6 percent
in 2007." FCAP deplores the ineffective execution of the law that "sets both the guidelines for
and regulation of the packaging, sale, distribution and advertisements of tobacco products"
(Chapin 2009).

Moreover, based on the 2005-2006 Tobacco and Poverty Study in the Philippines, around 250
Filipinos everyday or 90,000 annually die due to smoking. Many of whom suffer from
"cardiovascular, pulmonary, metabolic diseases, and cancers, especially lung cancers" (Chua
2009). Furthermore, according to the 2009 Global Adult Tobacco Survey (GATS), there are 17
million Filipino smokers aged 15 years old and over, as well as about 23 million inhale cigarette
smoke at home everyday. Out of this population, men comprise 47.7 % (14.6 million), while 9%
(2.8 million) are women. Many consume manufactured cigarettes and 80% of current nicotine
addicts smoke on a daily basis.

The WHO reveals that Filipina smokers have reached 33%. The Philippine League of
Government and Private Midwives, Inc. (PLGPMI) notes that the country has claimed the 16th
spot in the list of Top Female Smoking Population in the World for 2009. The PLGPMI laments
how tobacco firms lure women through "false images of vitality, slimness, emancipation,
sophistication, and sexual allure. But in reality, smoking causes reproductive damage, disease
and death..." Women smokers or recipients of second-hand smoke (synonymous with
passive/involuntary smoking, environmental tobacco smoke (ETS), and environmental smoke
pollution or ESP) often experience fertility problems, high-risk pregnancies, and increase their
chances of having: "babies born prematurely, babies born too small, babies who die before they
can be born at all" and "may cause a reduction in breast milk" (Penner 2010, American Cancer
Society 2010, Woolston 2009, WHO 2010).

In addition, the Health Justice Philippines (HJP)and the Department of Social Welfare and
Development (DSWD) note that secondhand smoke "is a form of violence against women" and
that "smoking is the least explored among other forms of violence against women" (Balane
2008). FCAP opines that not wanting to fight with their smoking partners is what drives Filipino
women to tolerate them. In another light, a study in the United States identifies childhood abuse
"as a stressor that increases a woman's risk for smoking" among college students (Figueroa-
Moseley, Abramson, and Williams 2010).

According to the International Pediatric Association or IPA (2010), "Tobacco use is a pediatric
disease." FCAP avers that "The younger a child starts to smoke, the greater the chances of
becoming a regular smoker." The IPA notes "... a low awareness of the importance of
integrating tobacco control measures in child and adolescent health programmes and services
among health professionals in general." It further views that "Child health and tobacco control is
a strategic entry point for building capacity within the health sector." Health practitioners then
have an essential role in helping individuals quit smoking successfully, as well as in guiding
"communities adopt policies that promote smoke-free environments, and help families ensure
that children are protected from second-hand smoke."

The WHO approximates that 250 million children worldwide could die because of tobacco use.
The 2007 GYTS reveals that the Philippines has one of the highest figures of young smokers in
Asia. Around 30% live in cities and over 70% aged 13-15 years old "use tobacco products,
smoke cigarettes, chew tobacco and use 'shisha' (a water pipe for smoking)..." Aside from this
and ETS, children and adolescents can also get sick of third-hand smoke or "the residue left in a
room after someone smokes, which often sticks to furniture and clothes. Infants and young
children who play with items that have been exposed to cigarette smoke can eventually develop
asthma and other smoking-related diseases" (Santos 2010).
The Role of Cigarette Manufacturing Companies and the Food and Drug Administration
One possible factor for these alarming rate of young smokers was the concerted effort of major
cigarette manufacturing firms (i.e., Mighty Corporation and Fortune Tobacco) to block the
implementation of DOH Administrative Order (AO) 2010-0013 in adherence to FCTC guidelines.
Said AO requires these companies to avoid using "misleading words on cigarette packs like
'mild', 'light', 'ultra-light', and 'low tar'. It also pushes for graphic warnings in lieu of textual
messages to discourage children and young people from smoking. A Regional Trial Court (RTC)
issued an injunction order in favor of the tobacco companies. Consequently, a group of former
DOH secretaries (i.e., Drs. Esperanza Cabral, Francisco Duque III, Alberto Romualdez Jr.,
Jaime Galvez-Tan, and Alfredo Bengzon) have asked the Supreme Court to decide on the case
(Panesa 2011).

A recent development however shows that the newly approved Implementing Rules and
Regulations (IRR) of the Food and Drug Administration (FDA) have given the DOH more "power
to regulate tobacco products in the country, among other supplementary mandates" (Uy 2011).
The IRR allows the FDA to "examine the nicotine levels or any substance in cigarettes", as well
as to "reinforce its partnership with other agencies, including the US-FDA to regulate tobacco
use." It also provides the FDA the power to: (1) confiscate non-compliant items without the need
for a court order, and (2) "... hold in contempt any person who ignores orders and writs issued
by the agency." This then involves the strict implementation of AO 2010-0013 (Uy 2011).

The International Tobacco Control (ITC) Policy Evaluation Project affirms that the use of
pictorial warnings on how smoking affects the body have a considerable deterrent effect on
young smokers, including children. These images can inspire them to consider quitting, as well
as reinforce the decision of others not to smoke. Moreover, these help people to protect
themselves from ETS.

Challenges to Smoking Cessation and Improving Public Health in the Philippines

Though the Philippines has achieved some legislative and institutional success in support of
WHO's FCTC and MPOWER policy strategies against smoking and tobacco use, the Tobacco
Atlas - a joint venture of the World Lung Foundation (WLF) and the American Cancer Society
(ACS) - identifies that "the lack of standardized data and inadequate communication networks,
tobacco-control research capacity, and human and financial resources" hinders developing
countries to fully participate in international tobacco control research initiatives.

The Philippine Legislators' Committee on Population and Development (PLCPD) reports that
budgetary allocation for health has been dismal at 1.6% or only 3% of the country's GNP (gross
national product) compared to WHO's 5% GNP standard (Tulali, 2010). Using the results of the
2006 Tobacco and Poverty Survey, the HJP and the Southeast Asia Tobacco Control Alliance
(SEATCA) note the high health care costs and productivity losses related to tobacco
consumption at 148.47 to 314.38 billion pesos compared to over than $6 billion in 2003. This
echoes the WHO's position:
"The economic costs of tobacco use are equally devastating. In addition to the high public
health costs of treating tobacco-caused diseases, tobacco kills people at the height of their
productivity, depriving families of breadwinners and nations of a healthy workforce. Tobacco
users are also less productive while they are alive due to increased sickness. A 1994 report
estimated that the use of tobacco resulted in an annual global net loss of $200 billion, a third of
this loss being in developing countries."

Another economic consideration in the tobacco-free programs is the impact these will have on
the tobacco industry whose production reached Php 4.7 billion in 2010. Moreover, as the
National Tobacco Administration (NTA) reports, the industry contributes "... an average of P30
billion annually to the national coffers from the excise tax payments of cigarette manufacturers."
The NTA is a regulatory body under the Department of Agriculture (DA) which is tasked to
advance and protect those whose livelihoods depend on the tobacco industry.

Tobacco and the Philippine Economy - Government Efforts and Increased Taxes
Tobacco has played a crucial role in Philippine history and in the country's economic
development. Plantations of this crop can be found "in 27 provinces, covering approximately
40,297 hectares" (NTA 2008). Presently, the industry benefits almost two million Filipinos. This
includes over 62,000 tobacco farmers and their families, as well as technicians and workers in
cure barn, trading center re-drying plants, and cigarette factories.

The Philippine government, through the DA-NTA, invested in the establishment of a "Quality
Assurance Laboratory". The facility has "state-of-the-art analytical equipment, capable of
detecting the presence and level of toxins and carcinogenic substances on tobacco leaf and
tobacco products, which are the burning issues oft-repeatedly raised by some government and
non-government health advocates."

Edgardo Zaragoza, current NTA administrator, conducted a series of dialogues with tobacco
farmers to "advocate the massive production of high-quality tobacco" as the world market
continues to demand for the product "despite the presence of smear campaign against tobacco
smoking by various health groups..." He is committed "to earn more income for our government
coffers and help our farmers to raise their standard of living." This goal is aligned with President
Benigno Aquino III's vision of improving the lives of Filipinos. Thus, it opposes increasing
cigarette taxes, for it will raise cigarette prices and negatively affect the economic conditions of
tobacco industry workers and their families.

Likewise, the International Tax and Investment Center (ITIC) claims that such tax hike would
only be counterproductive, for it will "encourage consumers to switch from legitimate - meaning
tax paid - sources to contraband tobacco... higher taxes would undermine the quality of
products entering the market, encourage a culture of tax evasion and crime, deter investment in
developing markets by international companies and weaken the tax base."

However, Frank J. Chaloupka (2009), an economics professor, notes that though raising
tobacco taxes could result in smuggling, pricey cigarettes can "induce current users to try to
quit, keep former users from restarting, prevent potential users from starting, reduce
consumption among those who continue to use, and lead to other changes in tobacco use
behavior." Also, with the shift towards a less moneyed market targets, the price increase will
deter less-educated and/or lower-income smokers from sustaining such unhealthy lifestyle.
Raising tobacco tax then becomes an effective anti-smoking policy.

In response to tax increases and other efforts to reduce tobacco use, major industry players like
Phillip Morris-Fortune Tobacco, whose "Marlboro" brand is the top-selling cigarette product in
the Philippines, resort to "predatory marketing" by aggressively promoting ads that cater to
women and the youth. The cheap price of single cigarette stick and its availability in many
neighborhood sari-sari stores or retail/convenience shops have also contributed in the increased
number of tobacco users among youngsters and women. Add to this the exposure to more
media-produced images of famous personalities smoking in movies, music videos, reality
shows, and teleseryes (TV series).

An Alternative Approach to Curb Smoking and Tobacco Use

The PLGPMI strongly advises the adoption of "new and creative approaches" to lessen,
if not eradicate, the "the inequity of health services and the maldistribution of health
workers in the provinces..." It likewise recommends that the government "build on the
strengths and capacities of the existing workforce by developing the needed
competencies to effectively provide services in hospitals and even in remote
communities." PLGPMI further asserts that "The people, too, have a right and duty to
participate individually and collectively in the planning and implementation of their health
care. The public would not be given false hopes of free health care for all but instead will
inform them that the poor will be taken care of by the government while those who can
pay must do so according to their financial capacity."

Undoubtedly, pursuing an effective drive towards smoking-free, healthy living to address

these issues involves a comprehensive approach that would allow a strategic partnership
between health advocates and agencies and those who benefit from the tobacco industry,
as well as the cooperation of the academic and research institutions, media companies,
civil society organizations (CSOs), and community-based groups. The NTA has already
started exploring alternatives to tobacco use. These include the production of: (1) tobacco
dust as molluscicide cum fertilizer for fishponds; (2) tobacco hand-made paper; (3)
tobacco "virgin" pulp for the manufacture of various types of paper, packaging materials
and specialty papers, among others; (4)tobacco extracts as organic pesticides for fruits
(mango), vegetables, and ornamentals; and (5) ethanol from tobacco stalks.

Further support to develop these other options could definitely serve as a means to
lessen, if not eliminate, the clashing goals and interests. After all, the tobacco industry
and the Philippine economy as a whole would also suffer if its workers' productivity and
those of its consumers get afflicted with tobacco-related diseases caused by smoking.

https://researchedworks.com/smoking-tobacco-consumption-philippines
Cigarette smoke and adverse health effects: An overview
of research trends and future needs

Abstract
A large volume of data has accumulated on the issues of tobacco and health worldwide. The
relationship between tobacco use and health stems initially from clinical observations about lung
cancer, the first disease definitively linked to tobacco use. Almost 35 years ago, the Office of the
Surgeon General of the United States Health Service reviewed over 7000 research papers on the
topic of smoking and health, and publicly recognized the role of smoking in various diseases,
including lung cancer. Since then, numerous studies have been published that substantiate the
strong association of tobacco use with a variety of adverse human health effects, most
prominently with cancer and cardiovascular diseases. Cigarette smoking is regarded as a major
risk factor in the development of lung cancer, which is the main cause of cancer deaths in men
and women in the United States and the world. Major advances have been made by applying
modern genetic technologies to examine the relationship between exposure to tobacco smoke and
the development of diseases in human populations. The present review summarizes the major
research areas of the past decade, important advances, future research needs and federal funding
trends. A repository for the collection, analysis, validation and dissemination of all smoking and
health-related data was established by the World Health Organization. The data received from
various member countries were compiled into a book entitled Tobacco or Health: A Global
Status Report, 1997 (1). This report showed smoking prevalence and other tobacco use-related
data from various countries and presented an analysis. It is estimated that there are
approximately 1.1 billion smokers worldwide, of which 900 million are men and 200 million are
women. The sex ratio of men to women is 2:1 for developed nations and 7:1 for developing
nations. Smoking prevalence in men and women averages 42% and 24%, respectively, for
developed countries, and 48% and 7%, respectively, for less developed countries. In comparison,
approximately 47 million people smoke cigarettes in the United States (2), and smoking
prevalence in the United States is estimated at 28% and 23% for men and women, respectively.
The Surgeon General’s report in 2004 concluded that in the United States, cigarette smoking has
caused 12 million deaths since 1964, at a cost to the nation of approximately US$157.7 billion
each year (3). There has been a significant decline in the consumption of cigarettes in the United
States since 1964. The production of cigarettes continues at a steady pace mainly to meet export
demands, which continue to rise due to increasing tobacco use in the rest of the world, especially
in far eastern and southeastern Asia. On the basis of consumption and disease incidence trends, it
is predicted that there will be an epidemic of tobacco-related diseases in various countries of the
world in the next 20 to 30 years.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2733016/
Depression and cigarette smoking behavior: a critical review of population-based studies

Andrea H. Weinberger PhD, Rachel S. Kashan MA, Danielle M. Shpigel MA, Hannah Esan, Farah Taha,
Christine J. Lee MA, Allison P. Funk & Renee D.

ABSTRACT Background: Smoking and depression are both leading causes of disability, mortality and
morbidity around the world. Using epidemiologic data to study the association between depression and
the severity, course, and persistence of smoking in the general population is important for
understanding the scope of the problem of smoking among people with depression. Objectives: The
current paper aims to critically review existing epidemiologic research on the smoking behaviors of
persons with depressive symptoms and disorders and to identify gaps in the literature that warrant
further study. Methods: Literature searches of Medline and EMBASE were used to identify articles that
analyzed epidemiologic data and examined an aspect of smoking behavior in persons with depressive
symptoms or disorders. Six hundred ninety-three abstracts were reviewed and 45 studies met all of the
inclusion criteria to be included in the review. Results: Persons with depression, compared to those
without depression, are more likely to smoke, and meet criteria for nicotine dependence, are less likely
to quit smoking, and are more likely to relapse. Little is known about the association between
depression and smoking behavior by age, socioeconomic status, or race/ethnicity or with regard to the
use of tobacco products other than cigarettes. Conclusion: Persons with depression are more likely to
smoke cigarettes and have greater difficulty quitting smoking. Community-based and public health
approaches may need to begin considering the links between depression and smoking in order to best
target the current smokers in the population and develop more effective tobacco control campaigns.

Introduction

Cigarette smoking is the leading preventable cause of mortality and morbidity in developed countries.
Smoking is related to a wide range of health consequences including a large number of cancers as well
as cardiovascular and respiratory diseases (1). The number of deaths attributable to smoking-related
causes has increased to approximately half a million every year in the United States (US) alone (1,2);
smoking is associated with millions of deaths every year around the world (3). Reducing the costly
effects of smoking, especially among groups who are disproportionally impacted by smoking, is a critical
global public health objective. Adults with psychiatric disorders report higher rates of current and
lifetime smoking (4,5), higher rates of nicotine dependence (6), and lower rates of smoking cessation
(4,5), relative to those without psychiatric disorders. Data from the US suggest that adults with a lifetime
history of at least one psychiatric disorder are three times more likely to be current smokers and 20%
less likely to quit smoking over a 3-year period, compared with those without a history of a psychiatric
disorder (5). While comprising only a small minority of the US population, it has been estimated that
adults with current (past-month) psychiatric disorders consume 44% of all cigarettes in the US each year
(4). Depression is the most common psychiatric disorder in the US (6–8) with 7–9% of US persons aged
12 and older reporting current (past 12-months) depression (9,10) and approximately 16% reporting
lifetime depression (10). Depression is also a significant cause of global disability, impacting
approximately 350 million people around the world (11). Major depressive disorder (MDD) is defined as
the presence of depressed mood or loss of interest in activities for at least 2 weeks and the report of
action) (12). In addition to causing significant impairment and distress (12), MDD is associated with
premature mortality, including mortality from smoking-related causes such as cardiovascular disease
and cancer, even after adjusting for smoking as these relations do not appear to be entirely attributable
to smoking (13–15). Dysthymia, or persistent depressive disorder, is another mood disorder that is
marked by an extended period (≥2 years) of depressed mood and additional symptoms (e.g., change in
appetite, change in sleep, low energy, low selfesteem, poor concentration or decision making, feelings
of helplessness) (12). Dysthymia is less prevalent than MDD; however, those with dysthymia experience
significant impairment and a more severe course of subsequent MDD compared with those without
dysthymia (16,17). The prevalence of depression differs by demographics. With regard to age, current
depression prevalences range from 5.7% for persons aged 12–17 to 9.8% for persons aged 40–59 (9).
With regard to race, recent CDC data suggest that persons who identify as nonHispanic Black and
Hispanic experience higher levels of depression symptoms than persons who identify as non-Hispanic
White (9) although the data from other studies differ (e.g., (18–20)) Most notably, there is a significant
gender difference with depression being significantly more common among women than men in all age
groups (9). Beyond being more likely to meet criteria for depression, a stronger relationship between
depression and smoking (21) has been observed among women; depression also appears to have a
greater impact on smoking treatment outcomes for women than men (22). As a result, it may be
important to examine differences by demographics when trying to understand the relationship between
smoking and depression. Recent reviews of smoking and depression have focused on clinical study data
examining the association of depression with smoking cessation treatment outcomes (22–24), as well as
understanding the genetics of smoking and depression (25). The current paper provides the first review
of epidemiologic studies of the smoking and quit behavior of persons with depressive disorders. Only a
small minority (approximately 30%) of those with depression are seen in psychiatric treatment settings
(26). By reviewing epidemiologic studies, we can develop our understanding of the smoking behavior of
persons with depressive disorders from a public health perspective via studies that include large,
diverse, unselected samples, collect detailed assessments of behaviors, and provide greater
generalizability at the population level. The primary aim of this paper is to review the epidemiologic
literature on smoking behavior among persons with depressive symptoms and disorders in order to
synthesize currently available knowledge, quantify the scope of the problem of smoking for people with
depression, and identify areas in need of further inquiry. In addition, this review sought to summarize
the findings of analyses that examined demographic differences in the relationship between depression
and smoking additional symptoms (e.g., change in appetite, change in sleep, low energy, low self-
esteem, poor concentration or decision making, feelings of helplessness, suicidal thoughts, plan, or
action) (12). In addition to causing significant impairment and distress (12), MDD is associated with
premature mortality, including mortality from smoking-related causes such as cardiovascular disease
and cancer, even after adjusting for smoking as these relations do not appear to be entirely attributable
to smoking (13–15). Dysthymia, or persistent depressive disorder, is another mood disorder that is
marked by an extended period (≥2 years) of depressed mood and additional symptoms (e.g., change in
appetite, change in sleep, low energy, low selfesteem, poor concentration or decision making, feelings
of helplessness) (12). Dysthymia is less prevalent than MDD; however, those with dysthymia experience
significant impairment and a more severe course of subsequent MDD compared with those without
dysthymia (16,17). The prevalence of depression differs by demographics. With regard to age, current
depression prevalences range from 5.7% for persons aged 12–17 to 9.8% for persons aged 40–59 (9).
With regard to race, recent CDC data suggest that persons who identify as nonHispanic Black and
Hispanic experience higher levels of depression symptoms than persons who identify as non-Hispanic
White (9) although the data from other studies differ (e.g., (18–20)) Most notably, there is a significant
gender difference with depression being significantly more common among women than men in all age
groups (9). Beyond being more likely to meet criteria for depression, a stronger relationship between
depression and smoking (21) has been observed among women; depression also appears to have a
greater impact on smoking treatment outcomes for women than men (22). As a result, it may be
important to examine differences by demographics when trying to understand the relationship between
smoking and depression. Recent reviews of smoking and depression have focused on clinical study data
examining the association of depression with smoking cessation treatment outcomes (22–24), as well as
understanding the genetics of smoking and depression (25). The current paper provides the first review
of epidemiologic studies of the smoking and quit behavior of persons with depressive disorders. Only a
small minority (approximately 30%) of those with depression are seen in psychiatric treatment settings
(26). By reviewing epidemiologic studies, we can develop our understanding of the smoking behavior of
persons with depressive disorders from a public health perspective via studies that include large,
diverse, unselected samples, collect detailed assessments of behaviors, and provide greater
generalizability at the population level. The primary aim of this paper is to review the epidemiologic
literature on smoking behavior among persons with depressive symptoms and disorders in order to
synthesize currently available knowledge, quantify the scope of the problem of smoking for people with
depression, and identify areas in need of further inquiry. In addition, this review sought to summarize
the findings of analyses that examined demographic differences in the relationship between depression
and smoking. http://midus.wisc.edu/findings/pdfs/1560.pdf
CIGARETTE SMOKING AMONG HIGH SCHOOL STUDENTS RELATED TO SOCIAL CLASS AND PARENTAL
SMOKING HABITS

Eva J. Salber, M.D., and Brian MacMahon, M.D., F.A.P.H.A.

N NOVEMBER, 1959, a questionnaire on tobacco smoking patterns was administered to the students of
the public high schools (grades 7 through 12) in Newton, Mass. Among other things, information was
sought on students' smoking patterns, parental smoking habits, and parental occupation. The present
report presents data on smoking patterns in relation to social class, as measured by parental occupation,
and on the relationship between parental and student smoking. These relationships are examined using
information from the single comprehensive senior high school, which houses grades 10, 11, and 12,
corresponding approximately to ages 15, 16, and 17. The student body of this high school has
approximately 80 per cent of the Newton population of appropriate age. Details of this survey will be
reported elsewhere, but it should be pointed out that the questionnaires were completed in school time
under supervision of the school teachers. The questionnaires were signed by the students but were
sealed by them and not opened until they reached the study staff. The studentswere assured that their
answers would not become known to teachers or parents. The questionnaires were completed by 92
per cent (2,891) of the school's student body. The missing students included those absent from school
or excused by the housemaster because of duties elsewhere. One questionnaire had to be excluded
because of unstated sex, and five because of unstated smoking habits. In the present analysis an
additional 62 questionnaires had to be excluded because of lack of information on parental occupation.
The basis of this report is the 2,823 completed questionnaires that remained.

https://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.51.12.1780
Factors Related to Cigarette Smoking
Initiation and Use among College
Students

Abstract
The purpose of this cross-sectional study was to examine the impact of
personality factors (neuroticism, extraversion, openness, agreeableness, and
conscientiousness), cognitive factors (sense of coherence and self-efficacy),
coping resources (family and friend social support) and demographic factors
(gender and ethnicity) on cigarette smoking behaviors (initiation, frequency,
and amount of cigarette smoking) among college students. A total of 161 U.S.
college students, aged 18–26, who enrolled in an introductory psychology
course completed self-report questionnaires. The majority of the students had
tried smoking (55%); among those who had tried, 42% were current smokers.
The majority (77%) who had smoked a whole cigarette did so at age 16 years or
younger. Students who reported lower levels of conscientiousness and self-
efficacy had a greater likelihood to had tried cigarette smoking. Also, students
who had lower levels of self-efficacy reported smoking more frequently and
greater quantities of cigarettes than students with higher levels of self-efficacy.
Self-efficacy was the most significant predictor of smoking behaviors. Health
promotion programs focused on self-efficacy may be an effective tool for
reducing the initiation, frequency, and amount of cigarette smoking among
college students.

Introduction
Cigarette smoking is the leading cause of preventable death in the United
States (U.S.)[1]. Although cigarette smoking among adults has steadily
declined over the past decade, smoking among college students has risen
sharply [2]. In the U.S, it is estimated that approximately 29% of those, 18 to
24 years of age, smoke [3]. Similarly, Steptoe & Wardle (2001) reported that
22.9% and 19.8% of Western and Eastern European university students were
regular smokers [4]. Coupled with this increase in smoking is the concern that
younger smokers, such as college students, do not heed smoking-associated
health warnings. Kvis and colleagues (1995) found that younger smokers (18–
29 years of age) are less concerned about health outcomes associated with
smoking than older adults [5]. Other researchers have reported that smoking
prevalence in college students is complicated by the fact that these young
adults believe that they can easily quit smoking [6], ignoring its addictive
properties, and ultimately believe they can be spared from the long-term
effects of smoking [7]. Elucidating determinants of cigarette smoking
behaviors among college students, thus, would aid healthcare professionals to
target intervention programs to those most in need.

Background
Individual personality factors, cognitive factors, and coping resources may
play a key role in determining which college students will have a propensity to
initiate and continue to smoke. Personality factors as stable and distinctive
traits of an individual may account for variability in health perceptions [8].
The proposition of the Five Factor Model of Personality is that people have
consistent and enduring individual differences based on their personality.
Personality factors include neuroticism (e.g., nervous or high-strung),
extraversion (e.g., energetic or outgoing), openness (e.g., original or creative),
agreeableness (e.g., accommodating or obliging), and conscientiousness (e.g.,
careful or incorruptible) [9, 10]. Researchers have shown that neuroticism is
associated with smoking onset in young people [11–13] and continued
cigarette smoking in adults [14]. Individuals with high neuroticism tend to be
impulsive and anxious, and are less likely to adhere to positive health
behaviors even when the benefits are known [15]. Smokers and regular alcohol
drinkers scored higher on extraversion than nonsmokers and nondrinkers
[16]. Higher conscientiousness, on the other hand, was associated with
protective health behaviors, such as regular exercise [15]. Although personality
factors have been examined individually on health behaviors, few studies have
comprehensively examined the associations between personality factors and
cigarette smoking. All five major personality factors, thus, were examined in
association with smoking behaviors among college students.

Cognitive factors, such as sense of coherence and self-efficacy, may also play
an important role in determining smoking behaviors. Sense of coherence is a
global orientation to life that reflects the degree to which a person feels
confident that life is understandable, manageable, and meaningful [17, 18].
Individuals with a high sense of coherence are believed to be better equipped
at mobilizing the necessary resources to meet life demands. Individuals with
high levels of sense of coherence are more likely to engage in positive health
behaviors, such as regular exercise [19]. Conversely, Van Loon et al. (2001)
found that women who smoked reported lower levels of sense of coherence
than those who had never smoked[20]. These findings suggest that sense of
coherence may play a significant role in smoking behaviors. However, this
relationship has not been examined among college students.
Self-efficacy is well known to influence health behaviors [21]. Bandura's
Theory of Self-Efficacy (1977) suggests that behavior is best predicted by an
individual's confidence in their ability to accomplish a given task. Self-efficacy
may impact health by influencing the adoption of health promoting behaviors,
cessation of unhealthy behaviors, and/or the maintenance of behavioral
changes when faced with difficult situations [22]. Kear (2002) found that self-
efficacy to resist cigarette smoking was a significant determinant of smoking
behavior. Similarly, Kvis and colleagues (1995) found that increased smoking
self-efficacy is an important predictor for quitting smoking among 18–29 year
olds. The role of self-efficacy on smoking, however, needs to be further
examined along with other personality and cognitive factors among college
students.

Social support, a coping resource, has been shown to positively influence

health [23, 24]. Previous research has generally indicated that adults with high
levels of social support are less likely to engage in substance use [25–27].
Conversely, students with a negative social support network are especially at
risk to develop poor health behaviors. College students with low levels of
overall social support engaged in risky health behaviors including substance
use of cigarettes and alcohol, clearly suggesting a potentially important role of
social support on choosing healthy lifestyles [28]. Empirical findings,
however, have been mixed. In general, parental emotional social support is
believed to act as a protective factor and lower the likelihood of substance use
[29, 30]. Teenagers are less likely to smoke when parents are involved in their
children's activities [31] and are supportive [32]. Similarly, parental emotional
support was inversely related to tobacco, alcohol, and marijuana use among
adolescents. Lack of family support, on the other hand, was a significant
barrier to smoking cessation among Australian teenagers [33]. These findings
suggest that family social support has a positive influence on health promoting
behaviors. In comparison, friend or peer social support has been linked as a
primary factor for adolescents to initiate cigarette smoking [34, 35] and
reduce their attempts to quit smoking [36].

Adolescents with friends who smoke are more likely to initiate smoking than
those with friends who do not smoke [34]. Further research is needed to
examine the varying role of social support from family and friends on smoking
behaviors in college students many of who are away from home for the first
time.

Demographic factors, such as gender and ethnicity, may also impact health
behaviors [37]. Females are more likely than males to practice protective
health behaviors [38], whereas male gender is a significant predictor of
smoking initiation among adolescents [39, 40]. Although ethnicity may also be
an important factor in smoking behaviors, the majority of studies have been
conducted with White subjects [37]. Kann (1993) found that White
adolescents were more likely to smoke cigarettes than Non-white adolescents
[41]. In general, however, little is known about the impact of gender and
ethnicity on smoking behaviors, particularly among college-aged students
[42].

In summary, empirical research has been limited in that it has failed to

simultaneously address the aforementioned determinants on smoking
behaviors among college-age students. The purpose of this study, therefore,
was to examine the impact of the five major personality factors, sense of
coherence, smoking self-efficacy, family and friend emotional social support,
gender and ethnicity on smoking behaviors among college students.

https://tobaccoinduceddiseases.biomedcentral.com/articles/10.1186/1617-9625-3-1-27