Towards a smoke-free future for children in the Netherlands.

Tobacco use is a serious and challenging public health burden. It is estimated that more than 8 million die due to tobacco use and 1.2 million die due to exposure to second-hand smoke[1]. Tobacco use is the single biggest preventable cause of premature deaths and 90% of adult smokers begin smoking in their adolescence.

Nicotine is an addictive substance and its use in adolescence can lead to tobacco dependency throughout adulthood. Adolescents have ego-centric thinking wherein they erroneously believe that they are in control of their unhealthy or risky behaviours such as smoking and that, they would be able to stop when they want to[2]. Further, adolescents are more prone to risk-taking behaviours to be perceived as more independent, emancipated and “cool” and also feel the pressure to conform to peers. However, the adolescent brain is unable to fully understand the long-term negative consequences of picking up the first cigarette.

The tobacco industry views children as “replacement smokers” and lobbies extensively to push tobacco products into the market and use enticing tobacco products targeting children and adolescents[3]. The tobacco industry in recent times, has brought out flavoured electronic nicotine delivery systems (ENDS), because flavours, such as mango, and candy are more appealing to youth[4].

In the Netherlands, 20.2% of adults smoked in the year 2020, of which 14.1 % smoked daily[5]. 21% of adolescents between 18 and 19 years of age smoked in the year 2020 of which 10.4% smoked daily. Exposure to cigarette smoke or second-hand smoke during childhood and adolescence is linked to increased incidence and severity of respiratory diseases such as asthma, ear infections, long-term adverse effects on the lungs and cardiovascular system, cancer and premature death [5].

Another tobacco-related health hazard is thirdhand smoke. Thirdhand smoke exposure happens when cancer-causing residue in tobacco smoke settles indoors on several surfaces such as bedding, carpets, furniture and clothing or in closed spaces such as cars [6]. Thirdhand smoke is difficult to remove and remains on surfaces for a long time. Thirdhand smoke is a health hazard, especially to young children and infants who stay indoors most of the time and are exposed to tobacco toxins via inhalation, ingestion or skin contact.

In the Netherlands, the burden of smoking costs 2.4 billion euros in healthcare every year [7].

In WHO’s International Framework Convention for Tobacco Control (FCTC) treaty, there are six tobacco control measures, known as the acronym MPOWER [8]. MPOWER stands for M: monitor tobacco use and prevention policies, P: protect people from tobacco smoke (e.g., smoke-free legislation), O: offer help to quit tobacco use, W: warn about the dangers of tobacco, E: enforce bans on tobacco advertising, promotion and sponsorship, R: raise taxes on tobacco.

Today’s conversation around tobacco control has taken a human rights angle i.e., children and adolescents have a right to live in a smoke-free environment [3]. Therefore, public health interventions need to begin before children feel enticed to try any form of tobacco. Health promotion strategies are vital in smoking prevention and cessation. Finally, smoking is not an individual problem but a complex social problem that needs multi-level interventions, therefore, not only at an individual level but at the population and community level.

1.???? Population-level change: The government’s role is paramount in decreasing tobacco use. Tobacco use is a complex problem and involves the cooperation of multiple stakeholders to participate in introducing policies to reduce tobacco use. In the Netherlands, the government has initiated a National Prevention Agreement that allows for an integrated approach to the problem of tobacco use along with several other stakeholders such as civil society organizations, healthcare organizations, business entities and associations [7]. Its goal is to achieve a smoke-free generation by 2040 which translates to 0% of children and pregnant women and less than 5% of Dutch people aged 18 and over smoke. It recognizes that the goals of the tobacco industry are polar opposite of the goal of public health. According to the WHO Framework Convention of Tobacco Control Article 5.3, the Dutch government does not do business with the tobacco industry[7]. The following are key features of population-level intervention under the National Prevention Agreement.

a.???? Increasing taxation for tobacco products- Tobacco taxes are seen as one of the most effective population-based interventions for reducing smoking [8,9]. Increasing the price of cigarettes is effective in deterring people, especially youngsters, from buying them. It also encourages smokers to quit and decreases exposure to second-hand smoke in non-smokers. The revenue from taxation can be used to fund anti-tobacco efforts. In the Netherlands, the price of cigarettes, cigars and tobacco products has steadily increased aligning with the efforts to deter people from buying them.

b.???? Using large explicit photos and health warnings on tobacco products along with plain packaging- Studies have shown that graphic warning messages are more effective in eliciting negative impressions about smoking, compared to text-only warning messages [8,10]. Tobacco products also will have plain, neutral packaging so that it is not seen as attractive to youngsters. Plain packaging has been shown to increase negative perceptions of smoking such as it being “uncool” and “unfashionable” compared to brand packaging [11]. Studies have also shown that graphic health warnings on plain packaging are seen as more serious and credible compared to flashy brand graphics which tend to diminish health warnings [11]. Adolescents are less likely to desire smoking with such measures.

c.???? Banning tobacco advertisement, promotion and sponsorship (TAPS) and point-of-sales displays of tobacco products in shops- Many tobacco companies previously sponsored youth sporting events to attract young players into trying smoking [12]. It was one of the tactics employed to periodically gain youth as their new customers. A meta-analysis report mentioned in the WHO Evidence Brief on TAPS shows that adolescents who are exposed to tobacco advertising, have 1.6 times higher odds of having tried smoking [13]. Following the WHO FCTC, tobacco sponsorship is banned for any type of event [1].

Point-of-sale displays also increase tobacco sales and make it harder for smokers who are trying to quit. A Global Youth Tobacco Survey of 130 countries found that banning point-of-sales displays of tobacco products was “significantly associated with a reduction of experimental smoking in young people of both genders” [13]. It also creates a supportive environment for smokers who are trying to quit.

d.???? Banning flavoured ENDS products: Most adolescents try flavoured e-cigarettes as their entry into the smoking world [4]. The argument for the sale of flavoured e-cigarettes is that it aids adult smokers in quitting combustible tobacco products and is perceived to be less harmful than cigarettes. However, evidence suggests that the highest prevalence of e-cigarette use in the US and European countries is among youth, 18 to 24 years and not among adult smokers [4,5,14]. This suggests that e-cigarettes, especially the flavoured kinds, entice youth to initiate smoking and does not justify their presence in the market for harm reduction in established adult smokers [5,14,15]. Sales of flavoured cigarettes, such as mango, strawberry, and menthol cigarettes are banned in the Netherlands.

2.???? Community level change:

Schools, playgrounds and sports schools to implement smoke-free policies: One of the strategies to prevent second-hand smoking exposure is to create healthy, smoke-free environments[15,16,17]. Smoke-free policies (SFP) reduce the chance of second-hand smoke exposure and send a strong message to children and adolescents that smoking is not socially acceptable or “cool”[3,15,16,17]. The key feature of SFPs is that they need to be implemented and enforced both indoors and outdoors. Not allowing smoking outdoors decreases the visibility of smoking and also restricts opportunities to smoke.

A majority of children and adolescents play sports and second-hand smoke exposure in sports fields and sports clubs is detrimental to their health[18]. Seeing members of their sports clubs smoking, whom they may see as role models, may also increase the likelihood of adolescents trying smoking in the future. Sports clubs promote being healthy and smoking is the opposite of being healthy.

Similarly, all organizations that involve the participation of children or take care of children, such as daycare centres, petting zoos, playgrounds, zoos and aquariums will be required to implement smoke-free policies [7,19]. The Dutch Union of Playground Organizations (NUSO) and the petting zoo association are investing strongly in promoting, raising awareness and providing smoke-free playgrounds and petting zoos[7,19]. Further funding of petting zoos will rest on the condition of providing a smoke-free environment to children[7]. All childcare centres will be required to provide a smoke-free environment to children in their facilities.

3.???? Individual-level change: Smoking is an individual behaviour decision largely influenced by social behaviour norms [16]. School-based anti-tobacco programs can effectively help with individual-level interventions for smoking prevention in adolescents [20]. Adolescents often use various cognitive rationalizations for their smoking behaviour, such as that they have control over their smoking habits and would be able to quit easily or not turn into adult smokers [21]. The US general surgeon reports suggest that if adolescents remain non-smokers throughout their adolescent years, there is a high likelihood that they will not use tobacco products later in life [22]. However, knowledge about tobacco harm alone is not effective enough to influence healthy behaviours and attitudes [17]. Therefore, children and adolescents must be empowered to resist peer pressure of smoking, by educating them and equipping them with skills to say no. The social influence resistance model is effective in reducing smoking initiation in adolescents [17,23]. In this model, adolescents are taught skills to resist negative influences from peers or media advertisements, build healthy self-esteem and learn stress management techniques.

The interventions at the population level and community level mainly focus on keeping tobacco products and the act of smoking out of sight. Keeping smoking out of sight for children in areas they mostly participate in, means smoking is seen as not normal. It also reduces demand for tobacco products because of increased taxation and “out-of-sight” policy. At the individual level, children and adolescents are educated and empowered to choose wisely, to recognize tactics and manipulation by the tobacco industry and to work on their skills of refusal to conform with peers who smoke. These three interventions have a shared goal of changing the environment in which tobacco is consumed into a supportive ecosystem to reduce the burden of youth taking up smoking. There is evidence to suggest that national, community and individual interventions when implemented together have the greatest impact than stand-alone interventions[17].

Conclusion:

For long, in the Netherlands and worldwide, the tobacco industry has used manipulation and connections with powerful people in the political circle to keep their harmful products visible and lure youth into initiating smoking [15,24]. For tobacco control programs to succeed, they need agreement from involved stakeholders on tobacco control solutions and they need the political willingness to create positive change [4,15]. ?However, over the past 20 years, momentum against the tobacco industry has picked up and there is more evidence and political support to dismount the tobacco industry [15,24].

With rigorous implementation of WHO’s FCTC and focused public health efforts, we can envision every municipality in the Netherlands, free of tobacco. After all, it is a fundamental right of children to live and grow up in a smoke-free world.

References:

1.????? WHO Framework Convention on Tobacco control. Reprint 2005. Available from https://fctc.who.int/ Accessed 13 February 2023

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