Journal of Public Health Advance Access published online on August 4, 2007
Journal of Public Health, doi:10.1093/pubmed/fdm047
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Smoking in young people with asthma
A. Hublet, MA, Researcher1,
D. De Bacquer, PHD, Professor Epidemiology and Statistics1
W. Boyce, PHD, Director of Social Program Evaluation Group2
E. Godeau, PHD, Principal Investigator HBSC France3
H. Schmid, PHD, Director SIPA4
C. Vereecken, PhD, Researcher1
F. De Baets, PhD, Head of Pediatric Pulmonology5
L. Maes, PhD, Professor in Health Promotion and Medical Sociology1
1 Department of Public Health, Ghent University, 9000 Ghent, Belgium
2 Social Program Evaluation Group, Queen's University, Ontario, Canada, K7L 3N6
3 Service Médical du Rectorat de Toulouse, Inserm U558, Toulouse and Association pour le Développement d'HBSC, 31400 Toulouse, France
4 Swiss Institute for the Prevention of Alcohol and Drug Problems (SIPA), 1003 Lausanne, Switzerland
5 Department of Paediatrics and Medical Genetics, Ghent University, 9000 Ghent, Belgium
Address correspondence to Anne Hublet, E-mail: anne.hublet{at}ugent.be
Background Modern guidelines for the management of asthma state that asthmatic patients should be strongly advised not to smoke. However, it remains unclear to what extend young people with asthma actually behave like this. This study compares the prevalence of daily smoking between 15-year adolescents with diagnosed asthma and without asthma, and evaluates to what extent risk factors for smoking play a comparable role in the smoking behaviour of these two groups.
Methods The study is part of the 2001–2002 international HBSC study. Besides questions about health behaviour, individual and social resources, a set of asthma questions were included in six countries.
Results Adolescents with diagnosed asthma are more likely to be daily smokers than non-asthmatic adolescents. In asthmatic and non-asthmatic adolescents, similar associations with risk factors are found for daily smoking (drunkenness, cannabis use, low life satisfaction, spending evenings with friends, having smoking parents and peers). Diagnosed asthmatics are more prone to score high on these factors than non-asthmatics.
Conclusions Smoking in adolescents with asthma is a public health problem. Smoking prevention efforts directed towards young people should pay attention to young people with asthma and the curative sector should increase their efforts to motivate asthmatic adolescents not to smoke.
Keywords: adolescents, asthma, risk factors, smoking
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Introduction |
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Asthma is one of the most common chronic diseases among adolescents, especially in Western countries.1,2 The disease has consequences in most children in everyday life such as difficulties while playing with peers, doing sports and having contacts with pets; it leads to sleeping disturbances, negative emotions such as anxiety and missing school days.3–5 Recently, management of asthma has improved in the way that most people with asthma can have normal lives without significant symptoms.6
Adolescence is a period in which many youth engage in health risk behaviours such as regular smoking, alcohol abuse and illegal drug use.7 Risk behaviours can be seen as part of the adolescent process in which youths become more independent from parents and the peer group becomes more important. Youth participate in these risk behaviours, e.g. to enhance self-image, to fit into the peer group and to take part in ritual activities.8
One might expect that asthmatic adolescents would avoid certain risk behaviours, particularly smoking, as it can provoke or worsen asthmatic symptoms.9,10 Asthmatic adolescents who smoke are more symptomatic, have a more rapid decline in pulmonary function and have higher rates of hospitalization.8,9 Cigarette smoking may interfere with asthma treatment as it may reduce the anti-inflammatory action of glucocorticosteroids used in asthma management.11 Various guidelines for the management of asthma are clear in relation to smoking. They explicitly state that asthmatic patients should be strongly advised not to start smoking, to stop smoking and to avoid passive smoking.11,12 In adults, it is found that asthmatic patients are likely to stop smoking or continue to smoke, but at a moderate rate.10 However, in adolescence, asthma (like other chronic conditions) leads to negative social consequences that might limit popularity because of the need to take drugs and it limits certain activities. These social consequences may result in asthmatic youth feeling additional pressure to fit in with peers, including engaging in risk behaviours.8 There is a considerable body of empirical research that has identified adolescent–peer relationships as a primary factor involved in adolescent cigarette smoking.13
Few studies have addressed smoking in adolescents who have been diagnosed with asthma.14,15 The results show that asthmatic adolescents in Australia and the United States of America are as likely as, or even more likely to smoke than non-asthmatic adolescents. However, comparable data for other countries are missing. In addition, the role of risk factors for smoking in asthmatics is unclear.
A first objective of the international study presented in this paper is to compare the prevalence of daily smoking and other smoking characteristics between 15-year-old adolescents with diagnosed asthma and adolescents without asthma. Are asthmatic adolescents more likely to smoke and what is their smoking profile? A second objective is to evaluate to what extent a broad range of factors associated with daily smoking differ in asthmatic and non-asthmatic adolescents in order to identify fields for preventive action. The factors associated with smoking used in this paper were found in Beyers et al.16
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Methods |
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Study design and population
The present study is part of the 2001–02 Health Behaviour in School-aged Children (HBSC) study, a four-year cross-national research conducted in collaboration with the WHO Regional Office for Europe.17 The study aims at increasing the understanding of young people's health and well-being, their health behaviours and their social context. The target population of the HBSC study is young school-attending people, aged 11, 13 and 15 years. In this paper, only the 15-year-old students are analysed, as the prevalence of smoking risk behaviours is low in the younger age groups.
The survey is carried out on nationally representative samples and consists of more than 1200 students for each age group in each country. The study uses cluster sampling (schools or classes) as the sampling method. More details on methods can be found in Roberts et al.17 Besides the core HBSC questions, six countries included the HBSC-Asthma Scale (AS) in their national survey: Belgium (Flanders), Canada, Denmark, Finland, France and the Netherlands. The response rate at the school level ranged from 52% in the Netherlands to 86% in Denmark. At the student level, the response rate ranged from 74% in France and Canada to 95% in Belgium. The six countries and the large number of students within the countries raise the power for the analysis, especially when several subgroups are compared.
Questionnaire
The self-administered questionnaire is completed by students in the classroom and consists of a standard questions developed by the HBSC international research network. Topics in the questionnaire are socio-demographic variables, individual and social resources, health risk behaviours and health outcomes. The HBSC questionnaire covers several risk factors for smoking.17
Demographic variables
Information on age, gender and country is included, and parental occupation provides information about the adolescent's social background. Information on the profession of mother and father is gathered and recoded in six categories: from 1 (the highest category) to 5 (the lowest category) and category 6 the non-employed. The occupation of the parent with the highest status is retained and scored as low (category 4 + 5), medium (category 3) or high (category 1 + 2). The non-employed are included in the lowest category.
Asthma scale
An asthma scale (HBSC-AS) was developed and described previously.18 The first HBSC-AS question deals with asthma diagnosed by a doctor (‘Has the doctor ever told you that you have asthma?’). If the answer is positive, the student is categorized as ‘having diagnosed asthma’ (further called ‘asthmatic’). This group also includes former asthmatics for which smoking remains a risky behaviour in the development of lung diseases. The next three questions refer to the most common symptoms of asthma that occurred in the last 12 months: wheezing, wheezing after play or exercise and nocturnal cough. A final question asks whether the student has had a consultation for wheezing by a doctor or in an emergency room in the last 12 months. The weighted kappa for the scale was 0.64 (95% CI, 0.57–0.72) when compared with parents' self-reports.18
Smoking characteristics
The main outcome variable in this study is daily smoking (contrasted with non-smokers and smokers who do not smoke on a daily basis). Other smoking-related characteristics are age of smoking first cigarette, number of cigarettes smoked a week (question asked only in Belgium, Canada, Finland and France), smoking alone often and smoking with friends often. The two last variables were asked only in Belgium, Canada and France.
Factors associated with daily smoking
School variables include liking school (liking versus not liking school) and an estimation of academic achievement (above or below average).
Risk behaviours include lifetime prevalence of drunkenness (
4 times), cannabis use in last year (6 times) and being physically inactive (<2 days a week).
Psychosocial variables include communication with parents (highest score of the questions being able to talk to mother, father, stepmother and stepfather), evenings spent with friends (5 evenings a week), life satisfaction (from 10, best possible life, to 0, worst possible life).19 Low life satisfaction is defined as less than score 5.
A smoking environment is measured by parental smoking (none, one or both parents smoke) and smoking friends (more than half of their friends smoking). These questions are asked in three countries (Belgium, Canada and France).
Analysis
For the first objective, characteristics of asthmatic and non-asthmatic daily smoking adolescents are compared. Taking into account the hierarchical structure of the database (adolescents in schools or classes in different countries), multilevel modelling with three levels (countries, schools/classes and adolescents) was used, controlling for gender, age and socio-economic level of the parents.
For the second question, asthmatics and non-asthmatic adolescents are compared separately on several factors associated with smoking. Here also, multilevel modelling with three levels and controlling for gender, age and socio-economic level of the parents was used. To study whether the associations between smoking and these factors are the same in asthmatics and non-asthmatics, interaction between daily smoking and asthma status on the several risk factors was computed. No interactions proved significant at the 0.01 level and hence were omitted from the models (only main effects are presented). Data are analysed using SAS 9.1.
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Results |
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Population
In the six countries using the HBSC-AS, 9735 students aged 15 years participated in this study, of which 48.4% were boys and 51.6% were girls (Table 1). The mean age was 15.5 years. The number of respondents varied from 1143 in Canada to 2498 in France. The group of asthmatics included 1261 respondents in the six countries of which 51.5% were boys.
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Profile of asthmatic youth who smoke
The characteristics of the study population by asthma status can be observed in Table 2. The results of the multilevel analyses show that boys and adolescents of parents with a low socio-economic status are more likely to have asthma. Asthmatics are more likely to report their academic achievement to be below average and to dislike school than non-asthmatics. Also, asthmatics are more likely to indicate a low life satisfaction and to have been drunk more than four times. Finally, asthmatics are more likely to have smoking parents.
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Daily smoking prevalence in non-asthmatics is 17.9% when compared with 20.5% in asthmatic adolescents. In the multilevel model controlled for gender, age and socio-economic status of the parents, a significant odds ratio for daily smoking in asthmatics is found to be 1.26 (95% CI: 1.08–1.47; P = 0.003).
Smoking characteristics and breathing difficulty symptoms of daily smokers
Table 3 shows the profile of smoking students concerning smoking-related characteristics and breathing difficulty symptoms in both non-asthmatics and those diagnosed with asthma by a doctor. No significant differences are found between the smoking profile of non-asthmatic and asthmatic smokers. Obviously, asthmatics who smoke daily have significantly more breathing difficulty symptoms than smoking non-asthmatics, but surprising enough, non-asthmatic smokers also have some asthmatic symptoms, with up to a third of them having nocturnal cough. To study the impact of smoking on asthmatic symptoms, smoking asthmatics are compared with non-smoking asthmatics (results not shown). We have found that daily smoking asthmatics are more likely to have nocturnal cough (50.2 versus 36.9%; P < 0.001) and to go to the doctor more often (28.6 versus 22.5%; P < 0.001) than non-daily smoking asthmatics. There are no significant differences between non-daily smoking and daily smoking asthmatics regarding wheezing symptoms (55.5% wheezing in non-daily smokers compared with 60.2% in daily smokers; 63.3% wheezing after play or exercise in non-daily smokers compared with 64.9% in daily smokers).
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Factors associated with daily smoking and asthma status
In Table 4, asthmatic and non-asthmatic daily smoking and non-smoking adolescents are compared on several risk factors associated with smoking. Increased odds for all selected risk factors are associated with daily smoking in non-asthmatic as well as in asthmatic adolescents.
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Discussion |
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Main finding of this study
Despite the guidelines for asthma management about smoking and the negative influence that smoking can have on the asthmatic condition, asthmatic adolescents are more likely to be daily smokers compared with non-asthmatic adolescents. The consequences are that these daily smoking asthmatic adolescents are more likely to have nocturnal cough and have more medical visits than non-smoking asthmatics.
This study shows that the selected risk factors associated with daily smoking are the same in both asthmatics and non-asthmatics. Daily smokers are more likely to spend evenings with friends, to have a low life satisfaction and to engage in other risk behaviours like being drunk more often, using cannabis and being less likely to be physically active. Daily smokers are more likely to have smoking parents and smoking peers, and are less likely to have a good contact with their parents. Bad perceptions of school and of their own academic achievement are also related to daily smoking.
Although the factors associated with daily smoking are the same for asthmatics and non-asthmatics, asthmatics score worse on some of these risk factors than do the general student population. In general, asthmatics in this study are more likely to think they perform below average at school and are less inclined to like school. In this selected group, these factors are even more important, because evidence exists that school attachment is a protective factor for smoking.20 In addition, asthmatic adolescents report a lower life satisfaction compared with non-asthmatic adolescents. This may result in depressive feelings; another reported risk factor for smoking.14,20 We also found that asthmatic adolescents are more likely to have two smoking parents. Passive smoking in the direct environment of the child and adolescent can cause asthma, or at least trigger or worsen asthmatic symptoms.11 Smoking parents are role models for their children therefore a risk factor for smoking in adolescents. This was confirmed in these analyses.
What is already known on this topic
This study confirms and strengthens other studies stating that daily smoking in 15-year-olds with asthma is a real public health problem.14,21
What this study adds
Our study adds to the literature that the same risk factors of smoking are important for asthmatic patients, but that asthma patients score worse on school variables and life satisfaction. Besides, by using multilevel modelling, we do not find significant differences between countries regarding smoking and asthma, and hence, smoking in asthmatic adolescents can be seen as a universal health problem, independent of national health systems and health promotion strategies.
Our study also shows that the international guidelines of asthma management concerning smoking have failed regarding adolescents. Several explanations can be found for the gap between these asthma guidelines and practice. Patients may not be compliant with the advice of their physician, as with modern medication patients are almost symptom free and may think that smoking can not harm the evolution of their disease. Also, patients may want a normal life and smoking can be seen as part of this, especially for adolescents.22 From a medical point of view, one might expect that asthmatic adolescents would avoid certain risk behaviours, particularly smoking, as this can provoke or worsen asthmatic symptoms. However, this study shows that for young people, despite their asthmatic condition, the advantages of smoking must be more important than its physical consequences. On the other hand, physicians may not follow the guidelines and fail to give adequate smoking cessation advice. In the literature, several barriers in physicians were identified for not giving such advice, including perceptions of a lack of success, self-confidence, self-efficacy, resources and time.23–25
Moreover in this study, we observed that many asthmatic adolescents live in a ‘smoking environment’, which jeopardizes the efficacy of smoking cessation advices given by physicians. Therefore, physicians should also motivate parents of asthmatic children to stop smoking. They are role models for their children, increase the likelihood of their children's smoking and also increase the risk of problems with asthma due to passive smoking. General smoking prevention towards young people should give extra attention to young people with asthma. Smoking prevention in adolescents is mainly focused on strategies emphasizing social pressure, a negative aspect of their social environment.26 As non-asthmatic smoking adolescents also show breathing difficulty symptoms (24% wheezing and 33% nocturnal cough), more research must be done to investigate whether smoking prevention focusing on passive smoking, in addition to adolescents taking responsibility for their peers (with and without asthma), could be more effective.
Limitations of this study
One of the limitations in this cross-national research, and cross-national research in general, is the inability to demonstrate causal relations. In the HBSC study, it is not possible to claim that adolescents who are diagnosed with asthma are more likely to start smoking. It may also be that adolescents who smoke are more likely to develop asthma and do not change their behavioural pattern once the diagnosis is made. Although this assumption is less plausible as asthma is a disease of the young child, longitudinal research could address this question more adequately.
A second limitation of our research is that the questionnaire is self-reported. Although the questionnaire was anonymous, adolescents could be tempted to give socially desirable answers to some questions about risk behaviours and to deny asthma. However, although no clinical diagnosis is used to assess asthma, the value of the HBSC-AS was found in large-scale studies.18
A third limitation is the relatively small number of questions on our topic. As this study is part of a broader large-scale health behaviour study, the questionnaire could not cover all variables related to smoking and asthma.
In summary, adolescents with self-reported asthma are more likely to be daily smokers than adolescents without asthma. The same associated risk factors of daily smoking are important for both asthmatic and non-asthmatic adolescents, but adolescents with asthma score worse on the risk factors of daily smoking. Therefore, general smoking prevention in adolescents should have attention for young people with asthma and asthmatic symptoms. In asthma management programmes, more attention should be given to smoking prevention or cessation, and to possible risk factors for daily smoking such as poor life and school satisfaction.
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Acknowledgements |
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HBSC is an international study carried out in collaboration with WHO/EURO. International Coordinator of the 2001–2002 survey: Candace Currie, Child and Adolescent Health Research Unit, University of Edinburgh Scotland; Data Bank Manager: Oddrun Samdal, Research Centre for Health Promotion, University of Bergen, Norway. The HBSC Asthma Scale was used in the 2001–2002 survey by the Principal Investigators of six countries: Canada, W. Boyce; Denmark, P. Due: Finland, J. Tynjälä; Belgium (Flanders), L. Maes; France, E. Godeau and the Netherlands, W. Vollebergh. For details, see http://www.hbsc.org. This research project is approved by the Ethics Committee of the University Hospital of Ghent, project 2001/304.
Funding: In Flanders, Belgium, this project was financed by the Fund for Scientific Research, Flanders (Belgium), no. 7.0009.00.
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