Tobacco smoking is one of the major causes of preventable death and disease in the world. According to the World Health Organization, tobacco kills more than 8 million people each year, of which more than 7 million are due to direct tobacco use and around 1.2 million are due to exposure to second-hand smoke. Smoking also contributes to poverty, environmental degradation, and social inequalities. Therefore, reducing tobacco use is a key public health priority for many countries and regions.
One of the factors that influences tobacco use is education. Education can affect smoking behavior in various ways, such as increasing knowledge of the health risks of smoking, enhancing critical thinking and decision-making skills, influencing social norms and peer pressure, and providing opportunities for alternative activities and career aspirations. In this article, we will explore how education is related to current smokers in different parts of the world, based on the latest available data and research.
The Global Pattern of Smoking and Education
According to the Our World in Data, the global average share of adults who smoke tobacco was 22.3% in 2020, with a higher prevalence among men (36.7%) than women (7.8%). However, there is a wide variation across countries and regions, ranging from less than 5% in some African countries to more than 40% in some European and Asian countries.
There is also a clear pattern of inverse association between smoking and education level. In general, people with higher levels of education are less likely to smoke than those with lower levels of education. This pattern is consistent across most countries and regions, regardless of income level or cultural background. For example, the figure below shows the relationship between smoking prevalence and years of schooling for men and women in different regions of the world, based on data from 2016.
As we can see from the figure, smoking prevalence tends to decrease as years of schooling increase, for both men and women, in all regions except Sub-Saharan Africa. The slope of the line indicates the strength of the association: a steeper slope means a stronger association. We can observe that the association is stronger for men than for women, and stronger for high-income regions than for low- and middle-income regions.
The Mechanisms Behind the Association
How does education affect smoking behavior? There are several possible mechanisms that can explain this association, which can be broadly categorized into two types: direct and indirect effects.
Direct effects refer to the impact of education on smoking-related knowledge, attitudes, intentions, and behaviors. Education can increase awareness of the harmful effects of smoking on health, environment, and society, as well as the benefits of quitting or avoiding smoking. Education can also enhance cognitive skills such as critical thinking, problem-solving, self-regulation, and self-efficacy, which can help individuals resist peer pressure, cope with stress, and make informed choices about their health behaviors. Furthermore, education can influence social norms and values regarding smoking, such as perceived acceptability, desirability, and morality of smoking.
Indirect effects refer to the impact of education on other factors that are related to smoking behavior, such as income, occupation, social status, access to health care, and exposure to tobacco marketing. Education can improve economic opportunities and outcomes for individuals and households, which can reduce poverty and financial stress that may trigger or sustain smoking. Education can also increase occupational mobility and diversity, which can reduce exposure to occupational hazards or social environments that promote or facilitate smoking. Moreover, education can improve access to health care services and information that can support smoking cessation or prevention. Finally, education can reduce susceptibility to tobacco marketing strategies that target low-educated or vulnerable populations.
The Evidence from Intervention Studies
The association between education and smoking does not necessarily imply causation. It is possible that there are other factors that influence both education and smoking outcomes, such as genetic predisposition, personality traits, family background, or cultural context. To establish causality, we need evidence from intervention studies that manipulate or measure education as an independent variable and observe its effect on smoking as a dependent variable.
There are several types of intervention studies that aim to prevent or reduce tobacco use among young people through educational strategies. These include school-based programs that deliver smoking prevention curricula or activities in formal or informal settings; community-based programs that involve parents, peers, media, or other stakeholders in supporting smoking prevention efforts; and policy-based programs that implement laws or regulations that restrict or discourage tobacco use among minors.
A recent systematic review evaluated the impact of school-based interventions on smoking prevention among 11-14 year olds in Aceh, Indonesia. The review included three types of interventions: health-based programs that focused on increasing knowledge of the health consequences of smoking; Islamic-based programs that focused on increasing knowledge of the Islamic teachings against smoking; and combined programs that integrated both health and Islamic elements. The review found that all three types of interventions had positive effects on increasing health and Islamic knowledge, and improving smoking attitudes, compared to the control group. However, there were no significant effects on smoking intentions or behaviors.
Another systematic review assessed the effectiveness of school-based interventions for preventing tobacco smoking initiation among young people in low- and middle-income countries. The review included 16 studies that evaluated various types of interventions, such as life skills training, social influences, peer education, multimedia, and motivational interviewing. The review found that most of the interventions had positive effects on smoking knowledge, attitudes, and intentions, but only a few had positive effects on smoking behaviors. The review also identified several factors that influenced the effectiveness of the interventions, such as duration, intensity, fidelity, cultural adaptation, and evaluation methods.
The Implications for Policy and Practice
The evidence from the literature suggests that education is an important factor that influences tobacco use among young people in different parts of the world. However, the evidence also indicates that education alone is not sufficient to prevent or reduce smoking initiation or prevalence. There are many other factors that affect smoking behavior, such as biological, psychological, social, environmental, and economic factors. Therefore, a comprehensive and multi-sectoral approach is needed to address the tobacco epidemic effectively.
Some of the implications for policy and practice are:
- Strengthening the implementation and enforcement of the WHO Framework Convention on Tobacco Control (WHO FCTC), which is a global treaty that provides a set of evidence-based measures to reduce the demand and supply of tobacco products.
- Increasing the availability and accessibility of quality education for all children and adolescents, especially those from disadvantaged or marginalized groups, who are more likely to smoke or be exposed to second-hand smoke.
- Improving the content and delivery of school-based smoking prevention programs, by ensuring that they are based on sound theoretical frameworks, tailored to the local context and culture, and evaluated rigorously and regularly.
- Enhancing the involvement and collaboration of parents, families, communities, media, health professionals, and other stakeholders in supporting smoking prevention efforts among young people.
- Promoting a positive and supportive school climate and culture that fosters healthy behaviors and values among students and staff.
- Providing adequate resources and training for teachers and school staff to implement effective smoking prevention programs and policies in schools.
- Creating smoke-free environments in schools and other public places where young people spend their time.
- Providing accessible and affordable smoking cessation services and support for young people who want to quit or reduce their tobacco use.
Education is a key factor that influences tobacco use among young people in different parts of the world. Education can affect smoking behavior through direct and indirect mechanisms, such as increasing knowledge, enhancing skills, influencing norms, improving opportunities, and reducing exposure. However, education alone is not enough to prevent or reduce smoking initiation or prevalence. A comprehensive and multi-sectoral approach is needed to address the tobacco epidemic effectively. By investing in education and smoking prevention programs for young people, we can save millions of lives and improve the health and well-being of current and future generations.