Preventing tobacco use in children and adolescents


The primary prevention of tobacco use among children and adolescents is both the cornerstone and the “Achilles heel” of tobacco control policy. For the tobacco industry, this age group is the territory where it can "effortlessly" hunt for new prey. Multinational tobacco companies are thus compensating for a decline in activity due to tobacco-related deaths (8 million per year worldwide) or people who have stopped smoking.

from Vincenzo Zagà


Unfortunately, the problem of tobacco is extremely complex, because many actors and factors intervene to shape, influence, and maintain the phenomenon. Added to this today is the diversification and complexity of new nicotine products.

Social variables play an important role in addition to the individual, personal, and psychological characteristics of people, regardless of whether they are at risk of smoking, smoke themselves, want to quit, or have already quit. Social variables notably include socio-demographic characteristics specific to smokers, their family and extra-familial environment, as well as the society in which they live. [1]

It is essential to consider these social variables in a global context. An effective battle against tobacco requires preventive and therapeutic measures, policy decisions and guidelines, and tobacco-control strategies. The system is very complex, involving measures at several levels, which must be used in a synergistic and convergent way.

Social factors – whether they are the socio-demographic characteristics of the smoker, the family and extra-familial environment, or societal – are important elements to take into consideration in the management of the smoking problem. They have a decisive influence on the start, continuation, and cessation of tobacco use. Social factors must also be taken into account in prevention, which is fundamental because tobacco use is the leading preventable cause of death and disease in most industrialised countries. The highest priority should be given to primary prevention campaigns, particularly those aimed at adolescents and preadolescents, as well as disadvantaged groups in general, such as people from an economically disadvantaged cultural or socio-economic background who are more likely to start smoking.

There are many interventions to control tobacco use by school-aged children, some of which are of particular interest because of their effectiveness. An Oxford study states that “school-based programmes have the advantage reaching all children, but must be accompanied by more comprehensive measures”. [2] Their impact would indeed be greater and more effective if "the teachers themselves were trained and were non-smokers, if the family circle also engaged actively in the fight against tobacco, and if the society as a whole took more initiatives to make smoking socially unacceptable. [1, 2]

On the other hand, countries should take effective measures to control tobacco use, such as:

(a) Preventing access to all types of nicotine-containing e-cigarettes and heated-tobacco products – a factor that strongly influences the initiation and continuation of tobacco use – by enacting strict prohibition laws for minors. In this context, it is worth mentioning a relatively new concept that is sometimes misunderstood by health professionals and especially by the general public, namely that nicotine acts as a gateway drug. Scientists Erik and Denise Kandel have demonstrated, with supporting biological and molecular evidence, what epidemiological and clinical studies had already suggested: when consumed regularly, nicotine in all its forms acts as a "Trojan horse" for all other drugs. [3] The criticism of the “gateway effect” has also been addressed. There is a growing body of evidence that e-cigarettes encourage the use of other tobacco and nicotine products. [4]

b) Increasing the price of cigarettes, which has proven to be an excellent measure for the primary prevention of tobacco use; [5, 6]

c) Complying fully with Article 13 of the FCTC (Framework Convention on Tobacco Control) [7], in particular countering the influence of Big Tobacco via social media (websites, Facebook, Instagram, Twitter, TikTok) through ad hoc regulations;

d) Applying and enforcing legislation on non-smoking areas in schools as well as in public and private places accessible to the public;

e) Extending to schools, on a national scale, programmes that have been shown to be effective in preventing tobacco use – while expressly specifying that the effectiveness is expected in the medium or long term, as is the case with the Smoke-free Class Competition. Students need sufficient time to mature and assimilate their experiences and knowledge about tobacco. [8, 9]

To ensure that primary prevention does not remain the “Achilles heel” of tobacco control, these interventions must be complemented by a series of measures aimed at making smoking “socially unacceptable”. This is the only way to ensure that primary prevention can have its full impact.


Dr. Vincenzo Zagà is a leading pulmonologist based in Bologna (ITA) with a long history of experience. In 1999, he co-founded the Italian Society of Tobaccologia (SITAB), which he chaired from 2017 to 2021. He is also co-founder of the scientific journal Tabaccologia, of which he has been editor-in-chief since its creation.

Dr. Zagà is not only committed to medicine and science, but also to communication and information, since he is also a journalist by training and has been working in this field for almost 20 years.



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2 Peterson AV, Kealey KA, Mann SL, et al. Hutchinson Smoking Prevention Project: long-term randomized trial in school-based tobacco use prevention--results on smoking. J Natl Cancer Inst 2000;92(24):1979–91.

3 Kandel ER, Kandel DB. Shattuck Lecture. A molecular basis for nicotine as a gateway drug. N Engl J Med 2014;371(10):932–43.

4 Chapman S, Bareham D, Maziak W. The Gateway Effect of E-cigarettes: Reflections on Main Criticisms. Nicotine Tob Res 2019;21(5):695–98.

5 Istituto Superiore di Sanità. World No Tobacco Day 2014: aumentare la tassazione sui prodotti del tabacco 2014. Available at:

6 Yeh C-Y, Schafferer C, Lee J-M, et al. The effects of a rise in cigarette price on cigarette consumption, tobacco taxation revenues, and of smoking-related deaths in 28 EU countries-- applying threshold regression modelling. BMC Public Health 2017;17(1):676. doi:10.1186/s12889-017-4685-x [published Online First: 21 September 2017].

7 WHO. WHO Framework Convention on Tobacco Control. Geneva: World Health Organization 2003.

8 Zagà V, Giordano F, Gremigni P, et al. Are the school prevention programmes - aimed at de-normalizing smoking among youths - beneficial in the long term? An example from the Smoke Free Class Competition in Italy. Ann Ig 2017;29(6):572–83.

9 Cosci F, Zagà V, Bertoli G, et al. Significant others, knowledge, and belief on smoking as factors associated with tobacco use in italian adolescents. ISRN Addict 2013;2013:968505. doi:10.1155/2013/968505 [published Online First: 27 November 2012].