[Trends in educational inequalities in smoking among adolescents in Germany : Evidence from four population-based studies]

Persistent Social Inequality in Adolescent Health Indicators 1991-2022: Trend Study From Denmark

Objectives

To examine trends in socioeconomic inequality in adolescent health over three decades, across fifteen health indicators: overweight, underweight, headache, stomachache, backpain, emotional symptoms, difficulties falling asleep, loneliness, low life satisfaction, low self-rated heath, smoking, drunkenness, physical inactivity, low vegetable intake, and inadequate toothbrushing.

Methods

The Health Behaviour in School-aged Children (HBSC) study in Denmark included nine identical surveys of 11-15-year-olds from 1991 to 2022, n = 35,423. For each health indicator, we measured absolute and relative socioeconomic inequality by prevalence differences and odds ratios between low and high socioeconomic groups.

Results

There was socioeconomic inequality in thirteen health indicators, e.g., the OR (95% CI) for overweight in low vs. high socioeconomic groups was 2.22 (1.95-2.49). This social inequality persisted across health indicators throughout the study period with two deviations: Underweight was not associated with socioeconomic background and drunkenness was persistently most prevalent in higher socioeconomic groups.

Conclusion

The political efforts to reduce socioeconomic inequality in health seems to have failed. It is important to improve monitoring of adolescent health and implement improved policies to tackle socioeconomic inequality in adolescent health.

Evaluation of a medical student-delivered smoking prevention program utilizing a face-aging mobile app for secondary schools in Germany: The Education Against Tobacco cluster-randomized controlled trial

BACKGROUND

To reduce smoking uptake in adolescents, the medical students' network Education Against Tobacco (EAT) has developed a school-based intervention involving a face-aging mobile app (Smokerface).

METHODS

A two-arm cluster-randomized controlled trial was conducted, evaluating the 2016 EAT intervention, which employed the mobile app Smokerface and which was delivered by medical students. Schools were randomized to intervention or control group. Surveys were conducted at baseline (pre-intervention) and at 9, 16, and 24 months post-intervention via paper & pencil questionnaires. The primary outcome was the difference in within-group changes in smoking prevalence between intervention and control group at 24 months.

RESULTS

Overall, 144 German secondary schools comprising 11,286 pupils participated in the baseline survey, of which 100 schools participated in the baseline and at least one of the follow-up surveys, yielding 7437 pupils in the analysis sample. After 24 months, smoking prevalence was numerically lower in the intervention group compared to control group (12.9 % vs. 14.3 %); however, between-group differences in change in smoking prevalence between baseline and 24-months follow-up (OR=0.83, 95 %-CI: 0.64-1.09) were not statistically significant (p = 0.176). Intention to start smoking among baseline non-smokers declined non-significantly in the intervention group (p = 0.064), and remained essentially unchanged in the control group, but between-group differences in changes at the 24-months follow-up (OR=0.88, 0.64-1.21) were not statistically significant (p = 0.417).

CONCLUSION

While a trend towards beneficial effects of the intervention regarding smoking prevalence as well as intention to start smoking among baseline non-smokers was observed, our smoking prevention trial demonstrated no significant effect of the intervention.

Gender equality and smoking among 15 to 25 year olds-a time-based ecological analysis of developments in Germany from 1960 to 2005

Introduction

Smoking is a major risk factor for premature death and health problems in which there are significant gender differences in the prevalence of smoking. This ecological study examines the correlation between changes in gender equality and prevalence of smoking among young adults (15-25 years old) in Germany over a period of 45 years (1960-2005).

Methods

Gender inequality was measured using the United Nations Gender Inequality Index (GII), which is composed of three dimensions; health, empowerment and labour market. It was calculated for the entire registered German population in five-year intervals with values between 0 and 1 (1 = highest inequality). The smoking prevalence of young women and men in Germany was established using a reconstruction method. A gender smoking ratio (GSR) with values between 0 and 1 was determined (1 = identical smoking prevalence among men and women). The smoking behaviour was illustrated and stratified by education. The correlation between the GII and the GSR was analysed.

Results

The GII decreased from 0.98 to 0.56 between 1960 and 2005. The GSR increased from 0.34 to 0.93. There was a strong negative correlation between the GII and the GSR (r = -0.71). The strength of the correlation fell slightly as the level of education decreased. An increase in gender equality as measured by the GII came along with similarities of smoking prevalence between young women and young men.

Conclusion

Successful tobacco prevention among young women and men may benefit from involving experts in gender-specific public health research to develop counter-advertising and gender-specific information as needed.

Regional socioeconomic deprivation in Germany and nicotine use among children and adolescents

To assess the association of regional socioeconomic deprivation and nicotine use, survey data from 17,877 pupils aged 9-17 years were analysed. Lifetime use of combustible, e-cigarettes, and both products were the outcome variables. The German Index of Socioeconomic Deprivation was the exposure variable. Logistic regression models controlling for age, gender, school type, and sensation seeking were used to examine associations between regional socioeconomic deprivation and nicotine use. Ever use of combustible cigarettes was 17.8%, of e-cigarettes 19.6%, and of both products 13.4%. Compared to the most affluent area, the adjusted odds ratio of combustible cigarette use in the most deprived area was 2.24 (95% CI: 1.67-3.00), of e-cigarette use 1.56 (95% CI: 1.20-2.03), and of poly use 1.91 (95% CI: 1.36-2.69). Nicotine use among young people across ages and especially in socioeconomic-deprived areas was widespread. Nicotine control measures are urgently needed to reduce smoking and vaping in German adolescents.

Die Bedeutung schulischer Gesundheitsförderung für die Erhöhung gesundheitlicher Chancengleichheit

Sozioökonomisch bedingte Ungleichheiten in der Gesundheit sind ein wichtiges Public-Health-Handlungsfeld und deren Reduzierung eines ihrer wichtigsten Ziele. Bislang ist es jedoch kaum gelungen, gesundheitliche Ungleichheiten zu verringern, was zugleich auch auf ein großes Forschungsdefizit hinweist. Auch im Kindes- und Jugendalter lassen sich bereits Ungleichheiten in der Gesundheit und dem Gesundheitsverhalten feststellen, wobei jene mit einem niedrigen sozioökonomischen Status verglichen mit sozial privilegierteren Gleichaltrigen oftmals mehr Risikofaktoren und gleichzeitig weniger Ressourcen aufweisen. Obwohl Gesundheitsförderung auf gesundheitliche Chancengleichheit abzielt, berücksichtigen Interventionen nur selten den sozioökonomischen Status und können entsprechend wenig Evidenz über sozioökonomisch differenzierte Interventionseffekte liefern. Wie kann es daher gelingen, allen Heranwachsenden die gleichen Chancen auf ein gesundes Aufwachsen zu ermöglichen?

Um der Beantwortung dieser Frage näherzukommen, ist es zum einen das Ziel des Beitrags, einen Überblick über gesundheitliche Ungleichheiten im Kindes- und Jugendalter zu geben und die Rolle von Gesundheitsförderung sowie aktuelle Forschungsdefizite in diesem Zusammenhang aufzuzeigen. Zum anderen soll die Bedeutung der Schule und schulischer Gesundheitsförderungsmaßnahmen bei der Verringerung gesundheitlicher Ungleichheiten und der Erhöhung gesundheitlicher Chancengleichheit herausgestellt werden. Die Schule ist nicht nur ein Ort, an dem Heranwachsende unabhängig von ihrer sozialen Herkunft stets erreicht werden können, sondern hat das Potenzial, gesundheitliche Ungleichheiten sowohl zu verschärfen als auch zu reduzieren.

Socioeconomic inequalities in lung cancer - a time trend analysis with German health insurance data

BACKGROUND

Lung Cancer (LC) is one of the most prevalent cancer diseases. Due to the lack of databases which allow the combination of information on individual socioeconomic status (SES) and cancer incidence, research on social inequalities in LC among the German population is rare. The aim of the study is to analyse time trends in social inequalities in LC in Germany.

METHODS

The analyses are based on data of a large statutory health insurance provider. The data contain information on diagnoses, occupation and education (working age), and income (full age range) of the insurance population. Trends were analysed for two subpopulations (retirement age and working age) and stratified by sex. The analyses are based on incidence rates and proportional hazard models spanning the periods 2006-2009, 2010-2013 and 2014-2017.

RESULTS

Incidence rates declined in men but increased in women. For men, inequalities were strongest in terms of income and the decline in incidence was most pronounced in middle- and higher-income men. Among women at retirement age, a reversed income gradient was found which disappeared in the second period. The educational gradient among the working-age population decreased over time due to the trend towards increasing incidence among individuals with higher education. Declining gradients were also found for occupational position.

CONCLUSION

The findings reveal considerable inequalities in LC and that trends vary with respect to SES, sex and age. Widening income inequalities were found in the retired population, while educational and occupational inequalities tend to narrow among the working-age population.

[The association between school tobacco policies and the perceived smoking prevalence of adolescents]

BACKGROUND

In the German context, there is hardly any quantitative data about the implementation of school tobacco polices that include the perspective of both teachers and students. The aim of the study is to investigate the associations between implemented school tobacco policies and the perceived prevalence of smoking at the level of school staff and adolescents.

METHODS

The repeated cross-sectional study (2013 and 2017) is based on pooled responses of 13- to 17-year-old adolescents (N = 2393) and school staff (N = 85) from 25 schools located in the West German metropolitan region of Hanover. In linear regression models, average marginal effects (AMEs) with 95% confidence intervals (CI95%) and robust standard errors for perceived tobacco prevalence are reported separately for school tobacco policies assessed by teachers and students (scale 0-6). All models were controlled for sociodemographic, school-, and smoking-specific covariates.

RESULTS

On average, adolescents perceive a smoking prevalence of 30% ([Formula: see text]; s: 24.0) for their school. A comprehensive school tobacco policy is consistently associated with lower school smoking prevalence both from the point of view of teachers (AME: -3.54 CI95% -6.49 to -0.58) and students (AME: -1.69 CI95% -2.52 to -0.86). The number of smoking friends (e.g., "most of them are smokers" +14%: AME: 14.13 CI95% 10.46 to 17.80) and the type of school are the most relevant determinants of a high school smoking prevalence. School types with a nonacademic track report a 15% (AME: 15.03 CI95% 10.13 to 19.93) higher prevalence compared to grammar schools.

DISCUSSION

Progressive school tobacco control policies should focus more on school types with nonacademic tracks, certain groups at risk, and those schools that do not strictly enforce school tobacco policies.

Waterpipe Use among Adolescents in Germany: Prevalence, Associated Consumer Characteristics, and Trends (German Health Interview and Examination Survey for Children and Adolescents, KiGGS)

Waterpipe (WP) use is popular among youth worldwide, but epidemiological data from Germany are scarce. We aimed to describe prevalence rates of WP use (current, last 12 months, ever) and analysed correlates and trends among 11- to 17-year-olds in Germany. Analyses were based on data from the "German Health Interview and Examination Survey for Children and Adolescents" study during 2014-2017 (n = 6599). Changes in WP use prevalence compared with 2009-2012 were used to describe trends. Associations with sociodemographic characteristics and cigarette smoking were assessed with multivariable logistic regression models. Prevalence of current WP use among adolescents was 8.5% (95% confidence interval (CI) = 7.5-9.6), use in the last 12 months was 19.7% (95% CI = 18.3-21.2), and ever use was 25.8% (95% CI = 24.2-27.5). High prevalence rates were particularly found among 16-17-year-olds. During 2009-2012, these prevalence rates were 9.0%, 18.5%, and 26.1%, respectively. WP use was associated with older age, male sex, migration background, lower educational level, and current smoking status. Among current WP users, 66.2% (95% CI = 60.0-71.9) identified themselves as non-smokers, and 38.1% (95% CI = 32.5-44.0) had used WP ≥ three times in the last month. WP consumption is popular among German youth, and prevalence rates have not changed over time. Specific prevention strategies to reduce harmful WP consumption among youth should be implemented.

[Differences in subjective health, mental health, and health behavior among 11- to 17-year-olds at secondary schools in Germany : Results of the German health interview and examination survey for children and adolescents: first follow-up (KiGGS Wave 1)]

BACKGROUND

Social inequalities in health can already be found among children and adolescents to the disadvantage of socially deprived population groups. This paper aims to detect, whether differences in subjective health, mental health and health behavior among young people are due to the secondary school type attended and whether these associations exist independently of the family's socioeconomic position (SEP).

METHODS

The data basis was the German Health Interview and Examination Survey for Children and Adolescents (KiGGS Wave 1, 2009-2012). Data of 11- to 17-year-old girls and boys (n = 4665) who attend different types of secondary schools in Germany were analyzed. The dependent variables were self-rated health, findings of the Strengths and Difficulties Questionnaire (SDQ) for the detection of psychological abnormalities, as well as self-reported information regarding leisure sport, tobacco, and alcohol consumption. Prevalence and odds ratios (ORs) based on logistic regressions are shown.

RESULTS

For the majority of the examined indicators, it can be shown that adolescents in lower secondary schools are more likely to report worse self-rated health and mental problems and engage in unhealthy behavior than peers in grammar schools ("Gymnasium"). The differences decrease after controlling for family's SEP but mostly remain statistically significant. Adolescents who don't attend grammar schools are most strongly disadvantaged in terms of inattention/hyperactivity for both gender (OR: 2.29 [1.70-3.08]), smoking among girls (2.91 [1.85-4.57]) and physical inactivity (no leisure sport) among boys (OR: 2.71 [1.85-3.95]).

DISCUSSION

Unequal health opportunities should be viewed in relation to people's living conditions. For adolescents, school constitutes an important setting for learning, experience, and health. The results indicate divergent needs of school-based health promotion and prevention regarding differences among gender and type of school.

Intergenerational Educational Pathways and Self-Rated Health in Adolescence and Young Adulthood: Results of the German KiGGS Cohort

Health differences in social mobility are often analysed by income differences or different occupational positions. However, in early adulthood many young people still have very diffuse income situations and are not always fully integrated into the labour market despite many having finished school. This article focusses on the link between intergenerational educational pathways and self-rated health (SRH) among young adults considering their SRH in adolescence. The data source used is the German KiGGS cohort study. The analysis sample comprises 2175 young people at baseline (t0: 2003⁻2006 age 14⁻17) and first follow-up (t1: 2009⁻2012 age 19⁻24). Combining parent's and young people's highest school degree, the data can trace patterns of intergenerational educational pathways (constant high level of education, upward mobility, downward mobility, constant low level of education). Young people's SRH was recorded at t0 and t1. During adolescence and young adulthood, participants were less likely to report poor SRH if they had a constant high intergenerational education or if they were upwardly mobile. The differences were particularly striking among young adults: average marginal effects (AME) for poor SRH showed much higher risk among downwardly mobile compared to peers with an intergenerational constant high education (AME: 0.175 [0.099; 0.251]), while the upwardly mobile had a significantly lower risk for less than good SRH than peers with an intergenerational constant low level of education (AME: -0.058 [-0.113; -0.004]). In the context of great societal demands and personal developmental needs, educational differences in health tend to increase in young adulthood. Public Health should pay more attention to educational and health inequalities in young adulthood.

A Smoking Prevention Program Delivered by Medical Students to Secondary Schools in Brazil Called "Education Against Tobacco": Randomized Controlled Trial

Background

Smoking is the largest preventable cause of mortality in Brazil. Education Against Tobacco (EAT) is a network of more than 3500 medical students and physicians across 14 countries who volunteer for school-based smoking prevention programs. EAT educates 50,000 adolescents per year in the classroom setting. A recent quasi-experimental study conducted in Germany showed that EAT had significant short-term smoking cessation effects among adolescents aged 11 to 15 years.

Objective

The aim is to measure the long-term effectiveness of the most recent version of the EAT curriculum in Brazil.

Methods

A randomized controlled trial was conducted among 2348 adolescents aged 12 to 21 years (grades 7-11) at public secondary schools in Brazil. The prospective experimental design included measurements at baseline and at 6 and 12 months postintervention. The study groups comprised randomized classes receiving the standardized EAT intervention (90 minutes of mentoring in a classroom setting) and control classes in the same schools (no intervention). Data were collected on smoking status, gender, social aspects, and predictors of smoking. The primary endpoint was the difference in the change in smoking prevalence between the intervention group and the control group at 12-month follow-up.

Results

From baseline to 12 months, the smoking prevalence increased from 11.0% to 20.9% in the control group and from 14.1% to 15.6% in the intervention group. This difference was statistically significant (P<.01). The effects were smaller for females (control 12.4% to 18.8% vs intervention 13.1% to 14.6%) than for males (control 9.1% to 23.6% vs intervention 15.3% to 16.8%). Increased quitting rates and prevented onset were responsible for the intervention effects. The differences in change in smoking prevalence from baseline to 12 months between the intervention and control groups were increased in students with low school performance.

Conclusions

To our knowledge, this is the first randomized trial on school-based tobacco prevention in Brazil that shows significant long-term favorable effects. The EAT program encourages quitting and prevents smoking onset, especially among males and students with low educational background.

Trial Registration

ClinicalTrials.gov NCT02725021; https://clinicaltrials.gov/ct2/show/NCT02725021

International Registered Report Identifier (IRRID)

RR2-10.2196/resprot.7134

[The decline of cigarette smoking among adolescents and young adults in Germany and the rising relevance of waterpipes, e‑cigarettes and e‑hookahs]

BACKGROUND

National and international studies indicate that despite the decline in the consumption of traditional tobacco cigarettes, the consumption of other products, such as waterpipes (or hookahs), e‑cigarettes or e‑hookahs (a variant of e‑cigarettes), may be increasing. In addition to the long-term change in smoking behaviour, this article examines how the prevalence of smoking tobacco cigarettes, waterpipes, e‑cigarettes and e‑hookahs in adolescents and young adults in Germany has developed between 2007 and 2016.

METHODS

Data are based on representative surveys on substance use among adolescents and young adults between the ages of 12 and 25 conducted by the Federal Center for Health Education (BZgA) from 1973 to 2016. Age- and gender-specific trends of the proportion of those who describe themselves as smokers are shown. Additionally, trends of single and combined 30-day prevalence of consumption of tobacco cigarettes, waterpipes, e‑cigarettes and e‑hookahs are presented and tested for significance.

RESULTS

Between 2007 and 2016, the decline in the proportion of adolescents and young adults who call themselves smokers and the decline of 30-day prevalence of consumption of tobacco cigarettes continued. At the same time, the consumption of waterpipes is rising in young adults and the consumption of e‑cigarettes is rising in young men. Among adolescents, the exclusive use of waterpipes, e‑cigarettes or e‑hookahs was more widespread in 2016 than the exclusive consumption of tobacco cigarettes.

DISCUSSION

In comparison to tobacco cigarettes, the consumption of waterpipes, e‑cigarettes and e‑hookahs is becoming increasingly important among adolescents and young adults. Thus, these products must also be considered in the planning and design of preventive measures for the prevention of smoking.

[Tobacco-associated cancers in Germany-incidence and mortality trends since 1995]

BACKGROUND AND OBJECTIVES

Tobacco consumption is the most important cancer risk factor. In Germany, about 15% of all new cancer cases can be attributed to smoking. The aim of this paper is to analyze the incidence and mortality trends in tobacco-associated cancer cases in Germany for the last two decades.

MATERIALS AND METHODS

Age standardized incidence and mortality rates were calculated for tumors of the upper aerodigestive tract and lower urinary tract for the period from 1995 to 2014/2015. In addition, average annual percentage changes were calculated with joinpoint regression analysis. Regarding lung cancer, trends in incidence and mortality rates were also stratified by different age groups and trends in mortality rates were analyzed by birth cohorts.

RESULTS

The incidence and mortality rates among men are declining for all tobacco-associated cancers except esophageal cancer. Lung cancer mortality rates showed the greatest decrease with -1.9% on average per year. The incidence rates among women increased for all tobacco-associated cancers except lower urinary tract cancers. The increase in lung cancer incidence was greatest with 3.3% on average per year. Among men there was a continuous decline over all birth cohorts regarding the chance of dying of lung cancer at a certain age. Among women, the chance of dying of lung cancer increased for all birth cohorts until 1960.

CONCLUSIONS

The present analyses regarding tobacco-associated cancers in Germany reflect the changes in smoking prevalence with a deferment of multiple decades.

A Face-Aging Smoking Prevention/Cessation Intervention for Nursery School Students in Germany: An Appearance-Focused Interventional Study

The Education Against Tobacco (EAT) network delivers smoking prevention advice in secondary schools, typically using the mirroring approach (i.e., a “selfie” altered with a face-aging app and shared with a class). In November 2017, however, the German assembly of EAT opted to expand its remit to include nursing students. To assess the transferability of the existing approach, we implemented it with the self-developed face-aging app “Smokerface” (=mixed − methods approach) in six nursing schools. Anonymous questionnaires were used to assess the perceptions of 197 students (age 18–40 years; 83.8% female; 26.4% smokers; 23.3% daily smokers) collecting qualitative and quantitative data for our cross-sectional study. Most students perceived the intervention to be fun (73.3%), but a minority disagreed that their own animated selfie (25.9%) or the reaction of their peers (29.5%) had motivated them to stop smoking. The impact on motivation not to smoke was considerably lower than experienced with seventh graders (63.2% vs. 42.0%; notably, more smokers also disagreed (45.1%) than agreed (23.5%) with this statement. Agreement rates on the motivation not to smoke item were higher in females than in males and in year 2–3 than in year 1 students. Potential improvements included greater focus on pathology (29%) and discussing external factors (26%). Overall, the intervention seemed to be appealing for nursing students.