Editorial Releases: 2002A A

Following is a report back from research that has been compiled from the Birth to Twenty study. IF you would like further information or would like to interview the researchers, please contact Stella Fleetwood on 011 4883246.

Childrenand Smoking - a South African Report

South Africa, as a "third world" country, has been the target of aggressive marketing campaigns by tobacco companies. Driven by a steady decline in cigarette consumption among European, Scandinavian and North American countries, this strategic marketing focus on the developing world has lead to a dramatic increase in tobacco sales. Legislation has now been passed in South Africa that bans cigarette advertising, but there is still much research and implementation to be done. There has been little attention to children and smoking in developing countries, despite the fact that children from these countries will make up the majority of the world s smokers in the future.

What does international research indicate?

Research that focuses on the impact of tobacco use among young children is of fundamental importance because it helps to assess the long-term effects of tobacco use and helps to identify factors that influence induction into smoking. Most of our current knowledge on children and smoking is from Western countries, where studies indicate that most smokers start during adolescence and early adulthood. However, there are already indications from China and India that children in the developing world start smoking at an increasingly younger age.

South African research - Birth to Twenty

In 1995 Birth to Twenty (BTT) began a follow-up study of a group of five-year-old BTT children s experiences with smoking and tobacco. This study, which is part of the larger BTT longitudinal project, plans to conduct two-yearly surveys of the same BTT children until they are 20 years old.

Birth to Twenty (BTT) is a longitudinal birth cohort study of 3275 children born in Soweto-Johannesburg within a seven-week period in 1990 to mothers who gave a permanent address in the area. The collaborative project between the Medical Research Council, Human Sciences Research Council, University of the Witwatersrand, Health Departments of the Greater Johannesburg Metro Council and individuals from local and international universities, provides researchers with a unique opportunity to follow the health and development of a diverse group of urban children.

In addition to annual interviews with BTT families, the study began to gradually incorporate the views of BTT children into the study. In 1995, individual interviews were conducted with 1350 of the BTT children (age five) on their knowledge and experience of smoking and tobacco. During 1997/98, when they were seven or eight years old, this was repeated and the base expanded to 1400 children.

The aims of the research

The specific aim of the longitudinal tobacco study with the children was to investigate:
(i) their knowledge of tobacco use (at five and seven/eight years of age);
(ii) their perceptions of, and attitudes towards smoking (at five and seven/eight years of age);
(iii) their decision to experiment with cigarettes and to smoke when grown-up (at five and seven/eight years of age);
iv) their recognition of brand names and logos (at five and seven/eight years of age); and
vii) their recognition of health warnings (at seven/eight years of age).

The Findings
Preliminary findings of these five-year-old and seven/eight-year-old BTT children s experience with cigarette purchasing, perceptions of the danger of tobacco use, intentions to smoke in future and brand name recognition are reported.

1. Children have well-developed beliefs about tobacco and smoking
BTT children seem to have well-developed beliefs about tobacco and smoking long before having any personal experience thereof. It is clear from our studies that the smoking behaviours of people around them and cigarette advertising, have a substantial impact on very young children.

2. Parents and significant family members exert an important influence
Parents and other family members have an important influence in shaping and influencing children s knowledge and experience with tobacco and smoking. Sixty percent of five-year-old BTT children were buying cigarettes for adults in 1995. In 1997/98, when the question was repeated, 56% were buying cigarettes for adults. This happens regardless of the fact that it is illegal to sell cigarettes to children younger than 16 years old. Most of the children were buying the cigarettes for their male relatives.

3. Since the change in the tobacco control laws, there has been a significant increase in the number of children that perceive the danger of tobacco use
Seventy-seven percent of the five-year-old children thought smoking was bad for you , while two years later, when the question was repeated 98% of them thought smoking was not good for you . The reasons why smoking was bad included health-related reasons, antisocial behaviour of smokers and the personal hygiene. In their own words children said:
* "You ll be sick and you ll die from cancer if you smoke"
* "People who smoke drink liquor and get drunk. When they get home they curse their grandmothers"
* "When you smoke your mouth smells bad and people won t sit next to you"

In 1995, 7% of the five-year-olds told us that they tried to smoke, but in 1997/98 only 1.3% of the seven/eight -year-olds tried to smoke. They said, for example:
* "I tried to smoke. I took the cigarettes from my mother s bedroom. Nobody saw me. Afterwards I felt sick."
* "I did not know what I was doing. I coughed a lot!"

4. There has been a decrease in the number of children that believe they will smoke in the future
When they were five years old, 19% of the children thought they would smoke when grown-up, but only 2% of them thought so when they were seven or eight years old. Eighty-one percent thought that they would not smoke when grown-up and supported their decisions with statements like this:
* "Don t want to smoke because when I smoke, I ll make people sick and I ll lose "I m not going to smoke because I m going to be a teacher-teachers don t smoke."
* "Because when I m a doctor and smoke cigarettes the people I treat will get more sick."
* "Smokers are not permitted to play soccer. Stars don t smoke!"
* "You can t smoke in church when you are a nun."

5. Children have a high level of brand recognition
An interesting finding of the study was the high level of brand name recognition among very young children. Twenty-nine percent of the BTT five-year-olds identified South African cigarette brands when shown a variety of cigarette packages. Brand name recognition was much higher for the seven/eight-year-old BTT children - when shown a variety of commonly advertised SA products, including cigarettes and snuff.

We know that children are very receptive to advertising campaigns and are particularly susceptible to campaigns directed at adolescents and young adults. Although it is difficult to say what exactly the influence of cigarette advertising is on small children, there seems to be a high rate of recognition of commonly displayed and advertised products, including beer and cigarette names and logos. Almost all the BTT children recognised (98%) the new South African flag in 1997/98 when it was only a few years old.

The BTT data show how quickly young South African children can incorporate new significant images, indicate brand consciousness, as well as the potential impact of cigarette advertising on children. This information, in particular, was developed into a policy brief and formed part of the information briefing that resulted in a change of legislation regarding cigarette advertising.

There was a strong indication from the qualitative interviews around these questions that the seven/eight-year-old children were positively exposed to South Africa s tobacco control campaigns. Their reasons for not wanting to smoke clearly reflect the key health warnings for using cigarettes, for example, "smoking will damage your lungs" and "smoking can cause cancer". South Africa s tobacco control campaigns only began the year after interviewing the children at five years of age.

Conclusion

* Preliminary results from the BTT study suggest that attitudes towards smoking are formed early in childhood, although the decision to smoke or experiment with cigarettes occurs at various ages in different children.
* Families need to be informed that their actions impact upon their children, that allowing children to buy cigarettes is implicitly stating that cigarette smoking is acceptable.
* The public also needs to be made aware that children are brand conscious and, although legislation has been changed, cigarette branding still occurs, for example using clothing.

If we can understand how children s perceptions change over time we might be able to understand why some children decide to experiment with cigarettes, and why some children take up smoking while others do not. It is crucial to prevent tobacco use among young people as part of the development and implementation of effective smoking control measures. The findings from the follow-up study also suggest that the promotion of a healthy lifestyle should start in early childhood.

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Birth to Twenty supports World Health Day, on Sunday 7th April 2002,
in their global message focusing on the importance of physical activity in promoting health.
www.who.int.world-health-day

SouthAfricans CAN protect themselves against chronic diseases

Research increasingly suggests that physical activity is essential if you want to protect yourself against chronic diseases in adulthood. It s known is that physical inactivity and unhealthy eating contribute to obesity, cancer, cardiovascular disease, diabetes and hypertension. (Being overweight is, in fact, the most common health problem facing American children. Europe and South Africa seem to be following a similar trend.) Much of this chronic disease burden is preventable through increased physical activity and healthy eating. What does this mean in real-life terms? Get out those running shoes, because the benefits of a daily run around far outweigh the inconvenience!

What will regular physical activity do for you?

Regular physical activity substantially reduces the risk of dying of coronary heart disease, as well as decreases the risk for colon cancer, diabetes, and high blood pressure. It also helps to control weight; contributes to healthy bones, muscles, and joints; reduces falls among the elderly; helps to relieve the pain of arthritis; reduces symptoms of anxiety and depression; and is associated with fewer hospitalisations, doctors visits, and medications.

Furthermore, physical activity doesn?t have to be strenuous to be beneficial; people of all ages benefit from moderate physical activity, such as 30 minutes of brisk walking five or more times a week.

The Birth to Twenty study at Wits has been examining the effects of physical activity on bone health for the last four years in an ongoing study that will continue for the next 10 years. Research has already known that ?loading? sports, such as netball, hockey, soccer, rugby, have excellent benefits for bone mineral density in later life. This, in turn, reduces the risk of developing osteoporosis in later life. (That is not to say that ?non-loading? sport, such as swimming and cycling, aren?t beneficial - they are great for keeping toned and fit.)

Are South African children active enough?

It appears that South African children are not doing nearly enough physical activity, despite its proven benefits. Unpublished findings from the Birth to Twenty study have found that insufficient physical activity is not limited to adults. More than a 40% of young people in South Africa (in grades 4-5) do not regularly engage in vigorous physical activity. Birth to Twenty has found that physical activity is less common among girls than boys and among those with lower income and less education.

What should South Africa do?

South Africa has a long way to go with regards to educating its youth about the benefits of sport participation and physical activity. Much of the weight of the chronic disease burden can be prevented if effective programs to increase physical activity and decrease sedentary behaviour in youth are put in place. Culturally competent strategies, as well as other policy interventions, are required to increase physical activity and encourage healthy eating patterns in children.

The Birth to Twenty Sports Day

As an acknowledgement of BTT s contribution with regards to the importance of physical activity, BTT has been approached by the World Health Organisation (WHO) to hold an event celebrating World Health Day on the 7th April 2002. BTT will be hosting a Heroes Sports Day for families of the study at the Johannesburg College of Education sport grounds. The programme will involve children having fun and participating in a series of team sports ? netball, cricket, soccer, and touch rugby. BTT is just one of two groups that will be representing Africa in this campaign to communicate the value of physical activity in promoting health.

Sponsors of the BTT Heroes Sports Day

BTT would like to thank the following companies for their support:
Standard Bank
Albany Bakery
Bic
Coke
Bromor Foods
Glaxo-Smith Kline

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Birth to Twenty (BTT) is the largest and longest running study of child health and development in Africa, and it is also one of the few large-scale longitudinal studies in the world. For further detailed information on BTT, please go to www.wits.ac.za/Academic/health/research/birthto20.

Birth to Twenty supports World Health Day, on 7th April 2002, in their global message focusing on the importance of physical activity in promoting health: MARCH 2002

BirthtoTwenty &World Health Day

Over the past 5 years the Birth to Twenty (BTT) study at Wits has been investigating the impact of physical activity on bone health in childhood and now adolescence. Preliminary study findings suggest that 70% of black children in Soweto-Johannesburg attend schools where physical education classes are not offered, 55% do not participate in any after-school team sport, and 85% are not participating in any private extramural sport. What is more alarming is that 42% of black children are not participating in any formal physical activity.

As an acknowledgement of BTT s contribution with regards to the importance of physical activity, BTT has been approached by the World Health Organisation (WHO) to hold an event celebrating World Health Day on the 7th April 2002. BTT will be hosting a Heroes Sports Day for families of the study at the Johannesburg College of Education sport grounds. The programme will involve children having fun and participating in a series of team sports ? netball, cricket, soccer, and touch rugby. BTT is just one of two groups that will be representing Africa in this campaign to communicate the value of physical activity in promoting health.

TheWorldHealthOrganisationDebate

WHO is seeking to stimulate a global health debate on the epidemiological shift in the global burden of disease and the factors that are fuelling this process of change. In most parts of the world, non-communicable diseases have become a major epidemic. This is due, in part, to a rapid transition in lifestyles leading to reduced physical activity, changing diets and increased tobacco use. This trend is present in all societies, rich and poor, developed and developing.

WHO estimates that lack of activity leads to more than 2 million deaths per year. It is likely that one-third of cancers can be prevented by maintaining a healthy diet, normal weight and physical activity throughout one?s life. A combination of improper diet, lack of physical activity and tobacco use are estimated to be the cause of up to 80% of premature coronary heart disease. In countries as diverse as China, Finland and the US, studies have shown that even relatively modest lifestyle changes are sufficient to prevent the development of almost 60% of type 2 diabetes cases.

For more information on World Health Day, go to http://www.who.int/world-health-day/eng.shtml.

SponsorsoftheBTTHeroesSportsDay
BTT would like to thank the following companies for their support:
Standard Bank
Albany Bakery
Bic
Coke

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Physicalactivity&SAchildren - someshockingfindings: MARCH 2002

Unpublished data concerning physical activity patterns of nine-year old South African children has revealed shocking findings. Here are some of the results:

Physical Education: Children were asked if their schools offered physical education (PE) classes that they could take part in. 91.5% of the white children in the study took part in PE, while less than a third (30.6%) of the black children were offered PE lessons at school.

Commuting to and from school: White children spent shorter times travelling to and from school in an active manner ie walking or riding (2 minutes per day), while black children spent an average of 19 minutes per day actively commuting to and from school. White and black children spent similar amounts of time (between 22 and 26 minutes per day) getting to and from school in a passive manner, such as a car, bus or taxi.

Sleep: Children reported that they slept for an average of nine to 10 hours per night.

Organised Sport: The biggest discrepancy between racial groups however was seen when children were asked how much sport they did either at school or as a private extra-mural activity. White children spent an average of 2 hours and 10 minutes per week playing sport (over a whole year), while black children spent an average of 29 minutes per week playing sport. 55% of black children participated in no school sport, 85% in no private/club sport and 42% in no formal sport at all. These figures contrast the 17% of white children that are not participating in school sport; 52% that are not participating in private sport and only 2% that participate in no formal physical activity whatsoever.

Television: White children spent an average of 4 hours and 31 minutes per week (including weekends) watching TV, while black children spent almost double this with an average of 7 hours and 37 minutes of TV watching per week.

Height and Weight: Height and weights of the children were also recorded. When children were split up into activity levels (low to high) according to how much physical activity they actually did, it was found that the children who were most active were almost 3cm taller than children who were in the lowest activity group. The highly active children also weighed about 2kg more than the inactive children.

Although further analysis still needs to be completed, the above research raises many questions - from the present-day lack of sportsman from previously disadvantaged backgrounds to focusing on how far South Africa has come since 1994 in closing the gaps.

Birth to Twenty supports World Health Day, on 7th April 2002, in their global message focusing on the importance of physical activity in promoting health.
http://www.who.int/world-health-day/eng.shtml

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Mandela s children: FEBRUARY 2002

What are they up to right now?

The ten year mark for Birth to Twenty (BTT), the largest and longest running study of child health and development in Africa, was critical. Not only was it decided to extend the project a further 10 years, but the comprehensive research data that had been gathered over the decade can now be compiled in an even more meaningful manner.

But investigations did not end with the ten year mark. Current research has been brought under two umbrellas - Bone Health and the Youth Maturity Study. Together both of these encompass the following areas but have been streamlined to focus the research.

• Growth
• Nutrition
• Health and Illness
• Bone Health Study
• Psychosocial Development
• Child Care and Education
• Social Context, Environment and Health
• Sexual Maturity & Teen Parenthood
• Methodological Issues

The streamlined approach has seen a specific emphasis on sexual debut and the associated risks and factors influencing bone development during adolescence.

Some of the questions that these umbrella projects will be answering are:

• Post-apartheid, are the conditions for all children optimal? Are South Africa s children developing properly.
• Aids statistics are all around us. Will these become facts? How many of the BTT children will actually become infected? According to current thinking the infection rate is between 21% to 25%.
• Are children becoming sexually mature at a younger age?
• Is our population moving to a more Western lifestyle of less physical activity and more fast food? Will this translate into more lifestyle diseases - obesity, hypertension and diabetes, to name a few

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The impact of the study: FEBRUARY 2002

Birth to Twenty (BTT) is the largest and longest running study of child health and development in Africa, and it is also one of the few large-scale longitudinal studies in the world. For further detailed information on BTT, please go to www.wits.ac.za/birthto20.

Birth to Twenty (BTT) study results have had a major impact on a number of areas of children?s health, well-being and education, both locally and nationally.

• Over 100 scientific documents have been presented and published at national and international conferences and in journals.
• Improvements to the way routine data about children s births are collected in hospitals and clinics, so that accurate and complete information are collected on children at risk.
• Children s perceptions and experiences of smoking at 5 and 7 years of age were presented to the Minister and the Parliamentary Standing Committee on Health, and contributed to the tobacco control legislation passed in 2000.
• Birth to Twenty researchers developed a policy brief on the consequences of high rates of lead in the blood of children living in Johannesburg linked to fuel emissions and other sources.
• A report addressing schools as social environments for learning and health promotion has been circulated to all the schools in the Soweto-Johannesburg area.
• In 2001, a book on the first seven years of the children s lives by Oscar Barbarin and Linda Richter, entitled Mandela s Children: Growing up in post-Apartheid South Africa was published in New York by Routledge.
• Information on the early age at which some children were being admitted to school (15% of BTT went to school before they were five years old) contributed to the introduction of a mandatory school enrolment age being introduced by the minister of education in 2000.
• Before 2001, BTT engaged in a bilateral meeting in JHB with researchers from Germany funding by the Goethe foundation to consider the issues involved in children?s preparation and adjustment to school under rapidly changing social conditions. Similarities and diff between Germany and SA? s unification and transition to democracy were debated in relation to school achievement, afterschool-care, family life, prejudice and racism.

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Mandela schildren Your national heritage: FEBRUARY 2002

For seven weeks between March and April, following Nelson Mandela s release from prison in 1990, 5500 children were born in the metropolitan area of Soweto-Johannesburg. They were all enrolled into a long-term birth cohort study in which it was planned to follow them (and their families) for at least the first decade of their lives.
With this auspicious beginning, Birth to Twenty is now the largest and longest running study of child health and development in Africa. It also holds a prestigious position as one of the few large-scale longitudinal studies in the world. This complex study continually impacts on current thinking about South Africa and its youth.

Whoarethefamilies?

Birth to Twenty families come from the full spectrum of residential areas in the city, and represent White, African, Indian and Coloured families from Chiawelo to Blairgowrie. Birth to Twenty incorporates children that grow up in homes of clapboard and zinc, a curtained area in an inner city high rise, a newly acquired home in Eldorado Park, and an elite townhouse in Hyde Park. The Birth to Twenty children are representative of children living in Johannesburg over time.

The families involved in Birth to Twenty are extraordinary as they continually give up their time to help researchers understand what factors influence child development in an urban South African environment. These families are an example of South African pride and the sacrifice that people are prepared to make for the greater good of their country.

Mandela?s children

What makes the study special is not only its research credentials and the fact that the same 3 275 families from the Johannesburg-Soweto catchment are being investigated for twenty years, but that it began in 1990 ? the year of Mandela?s release. As a result, the informal name for Birth to Twenty is ?Mandela?s Children?. (A recently published book on the study, released in New York last year, bears the title ?Mandela?s Children?.)

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Contact person: Carmen Basson
Phone: 011 4883246
e-mail: bassoncd@medicine.wits.ac.za