Farida Agha  ( PMRC Central Research Centre, National Institute of Health, Islamabad. )
Agha Sadaruddin  ( PMRC Central Research Centre, National Institute of Health, Islamabad. )

The onset of tobacco use occurs primarily in early adolescence. The most vulnerable ages are 10 through 18 years, when most users start smoking and become addicted to tobacco^1-3 Very few people begin to use tobacco as adults; almost all first use has occurred before the age of 18³. The addictive nature of tobacco is well known, but it is perhaps less appreciated that early addiction is the chief mechanism for renewing the pool of smokers. The earlier young people begin usmg tobacco, the more heavily they are likely to use it as adults and the longer potential time they have to be users. Both the duration (years) and the intensity (amount) of tobacco use are i-elated to eventual chronic health problems like lung cancer, other fatal malignancies, atherosclerosis and coronary heart disease, chronic obstructive pulmonary disease and other conditions that _constitute a wide of array of serious health consequences^4,5. Cigarette smoking during childhood and adolescence produces significant health problems among young people, including cough and phlegm production, an increased number and severity of respiratory illnesses, decreased physical fitness, an unfavourable lipid profile and potential retardation in the rate of lung growth and the level of maximum lung^3-6.
Function. The processes of nicotine addiction further ensure that many of today’s adolescent smokers will regularly use tobacco when they are adults^3,7. Tobacco use is associated with alcohol and illicit drug use and is generally the first substance used by young people who enter a sequence of tobacco, alcohol, marijuana and harder drugs^8-11 - Tobacco use in adolescence is associated with a range of health-compromising behaviours, including being involved in fights, carrying weapons, attempting suicide and engaging in high risk sexual behaviours^12-15.
The initiation and development of tobacco use among children and adolescent progresses in five stages:
From forming attitudes and beliefs about tobacco, to trying, experimenting with and regularly using tobacco, to being addicted^1,2-5,14. This process generally takes about three years.
2. Socio-demographic factors associated with the onset of tobacco use include, being an adolescent from a family with 3,16 low socio- economic status^1,3,16.
3. Environmental risk factors include accessibility and availability of tobacco products, perceptions by adolescents that tobacco use is normative, ‘peers’ and siblings’ use and approval of tobacco use and lack of parental support and involvement as adolescents face the challenges of growing^1,17-19.
4. Behavioural risk factors for tobacco use include low levels of academic achievement and school involvement, lack of skills required to resist influences to use tobacco and experimentation with any tobacco product^3,12,14.
5. Personal risk factors for tobacco use include a lower self- image and lower self-esteem than peers, the belief that tobacco use in ‘functional and lack of self-efficacy in the ability to refuse offers to use tobacco^14,20.
Fobacco advertising and promotional activities are also playing important influences as young people are currently exposed to cigarette messages through print and electronic media and through promotional activities, such as, sponsorship of sporting events and public entertainment. point-of-sale displays and distribution of speciality items^21,22. Human models in cigarette advertising convey independence, healthfulness. adventure seeking and youthful activities -themes correlated with psychosocial factors that appeal to young people. In presenting attractive images of smokers,
cigarette advertisements appear to stimulate some adolescents who have relatively low self-images to adopt smoking as away to improve their own self image^23,24.
A current report documents that smoking kills 434,000 Americans each year¹. Adolescent smoking is the first step in this totally preventable public health tragedy. The facts are simple: one out of three adolescents in the United States is using tobacco by age 18, adolescent users become adult users and few people begin to use tobacco after age 18. This report points out the overwhelming need in public health for efforts directed toward stopping young people before they start using tobacco.
In Pakistan, some studies have reported the smoking habits and its adverse effects on health parameters in different population groups^25-32. Among the younger age group, 21 .3% of’ male medical students were found to be smokers in Karachi²⁷ and 22.4% ofmale students in Peshawar colleges³¹. The average age at start of smoking was 17 years amongst smokers in Karachi students²⁷; whereas, in another study²⁵ in general population of Karachi, it was reported that smoking was the commonest habit in the male (30.3 1%) and most ofthe smokers had started before the age of 1 0 years.
Amongst medical students of Karachi²⁷, most of the smokers smoked for pleasurable relaxation (49.9%) and tension reduction (38.2%). In Peshawar³¹, 43% of the student smokers, aged 15 to 23 years, expressed their views that they smoked to i-educe personal tension. Other psychological motivating factors for smoking were craving psychological addiction, handling, stimulation and habit. It was also reported that in 72% of the smokers, the reasons for smoking were such that they could easily give it up27.
Family has a strong influence to take up smoking27,31. Fathers and brothers of most of the smokers were also smokers” 1. Amongst the various family members, the intluence of brothers was more important in preventing or encouraging to take up smoking27. There were 3% ex-smokers in Karachi students and 2.1% in Peshawar31. Most of the ex-smokers had given up smoking due to its advance effects on health.                                               -
Although, these studies^25-27,31 provide useful data on smoking habits, the factors that influence the onset of tobacco use in our youth, the reasons that young men begin using tobacco, the extentto which they use it and also the reasons for leaving smoking, the efforts to provide effective tobacco-use programmes to all young persons have not yet been made. Schools arew ideal settings in which to provide such programmes to all children and adolescents³³, because many children and adolescents do not understand the nature o’f tobacco addiction and are unaware of, or under-estimate, the important health consequences oftobacco use⁶. As most ofthe young persons begin using tobacco at or after age 1 5, tobacco prevention education must be continued throughout high school and colleges. Particularly, important is the yea!- ofentry into middle or high school when new students are exposed to older students who use tobacco at higher rates. To be most effective, school based programmes must target young persons before they initiate tobacco use or drop Out of schools³³. Further, nicotine addiction in young people follows the same process as in adults, resulting in withdrawal symptoms and failed attempts to quit^1,33.  Thus, cessation programmes are needed to help the young persons who already use tobacco and who find it hard to stop using it. despite knowledge about the health hazards of tobacco use. These programmes should enable and encourage them to immediately stop all use and should help them seek additional assistance to successfully give up the use of tobacco. As our studies^25-27,31 indicate that family has strong influence to take up smoking, parents or families can play an important role in providing social and environmental support or not smoking. Schools can capitalize on this influence by involving parents or families in programme planning, in soliciting community support for programmes and in re-inforcing educational messages at home. Homework assignments involving families increase the likelihood that smoking is discussçd at home and motivate adult smokers to consider cessation³³. Teachers should be trained to recognize the importance of carefully and completely implementing the selected programme. Some programmes ma\\\\ elect to include peer leaders, who can help counteract social pressures on youth to use tobacco. Effective cessation programmes for adolescents should provide social support and leach avoidance, stress nianagementanci refusal skills. Further. young persons need opportunities to practice skills and strategies that will help them remain non—users. The public health movement against tobacco use will be successful when young people no longer want to smoke, which will l kill the epidemic. To prevent smoking among young people, policies should he made which include tobacco education in the schools. restrictions on tobacco advertising and promotions, a complete ban on smoking by anyone on school grounds, prohibition of the sale of tobacco products to minors and earmarked lax increase on tobacco products. Preventing young people from starting to use tobacco is the key to reducing the death and disease caused by tobacco use. A great opportunity lies before us to prevent millions of premature deaths and improve the quality of lives.

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