Adolescents and Tobacco Prevention

and Cessation

Jonathan D. Klein, MD, MPH

Learning Objectives

Review evidence on adolescents and tobacco use

Understand that addiction is rapid for many people, and that there is no “experimental” use of “safe” exposure

Discuss prevention and cessation strategies that are effective with youth

Understand role of media in promoting tobacco to young people

Healthy People 2010Ten Leading Health Indicators

1. Physical Activity

2. Overweight & Obesity

3. Tobacco Use

4. Substance Abuse

5. Responsible Sexual Behavior

6. Mental Health

7. Injury and Violence

8. Environmental Quality

9. Immunization

10. Access to Health Care

www.healthypeople.gov

Tobacco

• Declining rates in US - now leveling off – rates rising in much of the world

• Challenge of complacency

• Continued marketing/targeting of youth by industry

• Community and clinical interventions needed

Current Tobacco Use• Almost 1 billion men smoke cigarettes

– 35% developed countries– 50% developing countries

• 250 million women smoke cigarettes – 22% developed countries – 9% developing countries

• Every day, 80-100,000 young people around the world become addicted to tobacco

• 1 in 3 will die from a tobacco related disease

http://tobaccofreecenter.org/global_tobacco_epidemic/key_facts

Youth Tobacco Prevelance

India• 4.2% currently

smoke– Boys 5.9% – Girls 1.8%

• 11.9% use other tobacco products– Boys 14.3% – Girls 8.5%

USA• 13% currently

smoke– Boys 12.1% – Girls 13.9%

• 10.6% use other tobacco products– Boys 14.0% – Girls 7.4%

Global Youth Tobacco Surveillance, 2000—2007

cdc.gov/preview/mmwrhtml/ss5701a1.htm

Why do Youth Use Tobacco?• Social influences

– Friends– Parents

• access to cigarettes• attitude toward smoking

– Media

• Personality– Sensation seeking– Rebelliousness– Poor school performance

http://www.youthtobaccocessation.org/blueprint/index.html

Why do Youth Use Tobacco?

• Attitudinal Factors– Intentions regarding future smoking – Susceptibility– Positive utilities-what might be gained by

smoking

• Availability of cigarettes

http://www.youthtobaccocessation.org/blueprint/index.html

Tobacco Marketing• Annual spending to promote tobacco use =

more than half the NIH budget

• Advertising – Targeted to youth

• Non-advertising commercial speech– Product placement– Clothing, gear– Sponsorships, broadcast media– Candy look-alike products

http://www.tobaccofreekids.org/research/factsheets/index.php?CategoryID=23

Tobacco and Children Tobacco and Children

• 25 - 40% (~15 million) 25 - 40% (~15 million) US children live US children live with one or more with one or more smokerssmokers

• Movie imagery, Movie imagery, social marketing, social marketing, and causal use and causal use leads to addictionleads to addictionof many youthof many youth

http://www.cdc.gov/tobacco/data_statistics/

Secondhand Tobacco Smoke

India• 26.6% exposed to

SHS at home • 40.3% exposed to

SHS in public places

USA• 41.1% exposed to

SHS at home • 54.9% exposed to

SHS in public places

Global Youth Tobacco Surveillance, 2000—2007

cdc.gov/preview/mmwrhtml/ss5701a1.htm

Initiation and Addiction

• Exposure to tobacco promotion contributes to initiation of tobacco use

• Dose-response relationship– Greater exposure results in greater risk

• Nicotine addiction– Characterized by tolerance, craving, withdrawal

symptoms, & loss of control– 1st symptoms of dependence can appear with days

or weeks of intermittent tobacco use

Sargent, J, et al. Arch Dis Ch Adol. 2007

DiFranza, J, Sci Am. 2008

Changing Evidence About Nicotine Dependence

• Signs of nicotine dependence often start within two months after onset of smoking

• The median frequency of use at the onset of symptoms was 2 cigarettes, one day per week

• 2/3 of teens report loss of autonomy over tobacco prior to the onset of daily smoking

DiFranza JR. et al. Tobacco Control, 2002 .

Unsafe Alternatives• Cigars: 14% past month use in US

• Hookahs: water pipes involving the burning of tobacco mixed with sweetened flavors

•Bidis: unfiltered flavored cigarettes– higher levels of nicotine– Marketed as “herbal”; usually less expensive

•Kreteks: Clove cigarettes containing 60 – 70% tobacco

• Smokeless tobacco: chewing tobacco, snuff, dip

These are all tobacco products containing nicotine and carry similar risks to regular cigarettes

Evidence based best practices• Increase price/taxation of tobacco• Smoking bans and restrictions• Counseling – reframe expectations of Counseling – reframe expectations of

successsuccess– 5A’s - Ask, Advise, Assess, Assist and Arrage5A’s - Ask, Advise, Assess, Assist and Arrage– No Smoking Rules - smokefree homes and carsNo Smoking Rules - smokefree homes and cars

• Availability of treatment for addiction– Reduced cost for pharmacotherapy treatment – Provider reminder systems– Telephone/web counseling and support

• Mass media counter-marketing campaigns

http://www.thecommunityguide.org/tobacco/

Adolescent and Adult SmokersAdolescent and Adult Smokers

• Know they are addicted and want to quitKnow they are addicted and want to quit

• Many have tried to quit without success Many have tried to quit without success

• Younger smokers less likely to think Younger smokers less likely to think there are resources to helpthere are resources to help

• Many clinicians feel unprepared to helpMany clinicians feel unprepared to help

• With advice, most parents say they would be able to set strict smoking policies

Camenga, D. J Adol Health, 2006

CounselingCounseling

• ConfidentialityConfidentiality

• Ask each timeAsk each time

• Repeated brief messagesRepeated brief messages

• Assess motivation to changeAssess motivation to change

• Reinforce and follow-upReinforce and follow-up

5 A’s Counseling

• Ask - If patient smokes

- About Secondhand smoke

• Advise - Every smoker to quit- Strict no smoking rules in all places children spend time

• Assess - Readiness to quit

• Assist - In quitting and finding services

• Arrange - For cessation services and follow up

www.surgeongeneral.gov/tobacco/

www.aap.org/richmondcenter/resourcesclinicians

AdolescentsAdolescents

• Goal:Goal:– Prevent onset and promote cessationPrevent onset and promote cessation

• Anticipate:Anticipate:– School performanceSchool performance– Overestimating prevalenceOverestimating prevalence– Poor coping resourcesPoor coping resources– Peer influencePeer influence– Smokeless tobaccoSmokeless tobacco

Adolescent interventionAdolescent intervention• AskAsk

– About friend’s useAbout friend’s use– About patterns of useAbout patterns of use– About school programsAbout school programs– Reassure about confidentialityReassure about confidentiality

• Assess - motivation & readiness Assess - motivation & readiness • AdviseAdvise

– To quit for short term reasonsTo quit for short term reasons• Athletic capacityAthletic capacity• Cost, smell, etc.Cost, smell, etc.

– Reinforce non-useReinforce non-use

Adolescent interventionAdolescent intervention• AssistAssist

– Set quit datesSet quit dates– Provide self-help materialsProvide self-help materials– Encourage problem-solving, refusal skillsEncourage problem-solving, refusal skills– Encourage activities incompatible with tobaccoEncourage activities incompatible with tobacco– Consider pharmacologyConsider pharmacology

• Arrange: Arrange: – 1-2 week follow-up after quit attempts1-2 week follow-up after quit attempts

Public Health Service GuidelinePublic Health Service Guideline

• AnticipateAnticipate

• Ask Ask - if smokes- if smokes

• Assess Assess - readiness to quit- readiness to quit

• AdviseAdvise - to quit- to quit

• AssistAssist - in quitting & finding services- in quitting & finding services

• Arrange Arrange - for cessation services- for cessation services

Adolescent oriented office materials

• Self-help handouts• Targeted to adolescents and to stages of

change/motivation

• Trigger questionnaires

• Internet resources

Interventions and quitting?

• Cessation among adolescent smokers is half of the adult rate (approx. 4%/yr)

• Smokers aged 16 – 24 yrs rely more on unassisted methods rather than on effective methods recommended by PHS guidelines

• 2 year success with adolescents referred to an intensive expert counseling ‘system’ after brief primary care advice (OR=2.43)

MMWR Morb Mortal Wkly Rep. 2006Hollis et al.Pediatrics, 2005

Changing Evidence: Changing Evidence: Youth and NicotineYouth and Nicotine

• Adolescents are more likely to become addicted than Adolescents are more likely to become addicted than adultsadults

• Signs of nicotine dependence often start within two Signs of nicotine dependence often start within two months after onset of smoking and before adolescent months after onset of smoking and before adolescent are daily usersare daily users

• Quitting is harder for teens but still possible; adolescents Quitting is harder for teens but still possible; adolescents more likely to choose less effective methods for quittingmore likely to choose less effective methods for quitting

DiFranza, J, Sci Am. 2008

MMWR Morb Mortal Wkly Rep. 2006

What Can Pediatricians and OtherChild Health Advocates Do?

• Ask all parents about smoking

• Educate parents about SHTS

• Offer treatment or referral (quitline or local system)

• Advocate for smoke free areas

• Advocate for tobacco control

Best available evidence - Best available evidence - Responses to Patient Who SmokesResponses to Patient Who Smokes

• Unacceptable: “I don’t have time.”Unacceptable: “I don’t have time.”

• AcceptableAcceptable– Refer to a quitlineRefer to a quitline– Establish systems in office and hospitalEstablish systems in office and hospital– Become a cessation expertBecome a cessation expert

• Ask, Advise, ReferAsk, Advise, Refer

International tobacco issues

• MPOWER Initiative (WHO) goals– Raise taxes– Outlaw public smoking– Outlaw advertising to children– Fund antismoking advertising campaigns– Offer NRT and cessation assistance

www.who.int/tobacco/mpower/en

Adolescent health care utilization

• Access to care - requires systems and services that meet adolescents’ needs– Confidentiality– Reproductive health, mental health services

• “Medical Home” = a regular source of care

• Content of care available or delivered is not always best practice

AAP Committee on Adolescence. Pediatrics, 2008

Missed opportunities for adolescent prevention

• Most have source of care and have made visits

• Nearly half had not spoken with MD privately• Many had missed needed care• Many were too embarrassed to discuss topics

with MDs• Fear of disclosure is reason for 35% of

missed care• Much of desired content is not discussed

Klein, JD. J Adol Health, 1999

AAP Bright Futures Guidelines

Bright Futures: Guidelines for Health

Supervision of Infants, Children, and

Adolescents, 3rd Edition

Systematic approaches improve preventive service practices

– Decision tools • Trigger questionnaires

• Chart forms

– Information systems

– Patient self-care• Effective counseling techniques

• Patient education resources

– Community resources

http://www.centerforhealthstudies.org:80/research/areas/chronic.aspx

Policy - School curriculum• At least 5 session/year over 2 years

• Should include– Social influences– Short term health effects– Refusal skills

• NOT self-esteem or delay based

• Be aware of dilution and confusion strategies by tobacco interests

• School policies should reinforce goals

http://www.cdc.gov/HealthyYouth/tobacco/guidelines/index.htm

Community and public health

• Make tobacco control for children and youth a priority – Include secondhand smoke

• Age of sale restrictions and enforcement

• Advertising limitations

• Smokefree Movies

• Public smoke exposure reduction

• Do not allow preemptive efforts by tobacco industry

• Reduce social acceptability of smoking

AAP Tobacco Policy, forthcoming, 2009

Movies & Adolescents• Adolescents whose favorite movie stars smoke

on-screen are more likely to become smokers

• Smoking seen in > 75% of youth rated films

• Non-smoking teens are 16 times more likely to develop positive feelings towards smoking if they see their favorite stars smoking on screen

http://smokefreemovies.ucsf.edu/

Exposure to Tobacco Use in Movies Exposure to Tobacco Use in Movies and Smoking Among 5th-8th graderand Smoking Among 5th-8th grader

Adapted from Sargent, DiFranza, 2003

8th Grade

7th Grade

6th Grade

5th Grade

Smoke Free Movies Smoke Free Movies

• Rate new smoking movies "R"

• Certify no pay-offs

• Require strong anti-smoking ads

• Stop identifying tobacco brands

Guidelines are endorsed by AAP and many other organizations

http://smokefreemovies.ucsf.edu/

Conclusions• Many missed opportunities for SHTS prevention in primary care

• With advice, many parents would set smoking rules

• There is no safe “experimental” smoking

• Policies are needed to protect adolescents

• Tobacco control efforts should include interventions in child health care for secondhand smoke and tobacco control for all household members

www.aap.org/RichmondCenter