1. Adolescents and Tobacco Prevention and Cessation Jonathan D. Klein, MD, MPH

2. 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

3. Healthy People 2010 Ten 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. Tobacco and Children 25 - 40% (~15 million) US children live with one or more smokers25 - 40% (~15 million) US children live with one or more smokers Movie imagery, social marketing, and causal use leads to addiction of many youthMovie imagery, social marketing, and causal use leads to addiction of many youth http://www.cdc.gov/tobacco/data_statistics/

11. 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

12. 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 –1 st 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

13. 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.

14. 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

15. Evidence based best practices Increase price/taxation of tobacco Smoking bans and restrictions Counseling – reframe expectations of successCounseling – reframe expectations of success –5A’s - Ask, Advise, Assess, Assist and Arrage –No 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/

16. Adolescent and Adult Smokers Know they are addicted and want to quitKnow they are addicted and want to quit Many have tried to quit without successMany have tried to quit without success Younger smokers less likely to think there are resources to helpYounger smokers less likely to think there 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

17. Counseling 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

18. 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

19. Adolescents Goal:Goal: –Prevent onset and promote cessation Anticipate:Anticipate: –School performance –Overestimating prevalence –Poor coping resources –Peer influence –Smokeless tobacco

20. Adolescent intervention AskAsk –About friend’s use –About patterns of use –About school programs –Reassure about confidentiality Assess - motivation & readinessAssess - motivation & readiness AdviseAdvise –To quit for short term reasons Athletic capacityAthletic capacity Cost, smell, etc.Cost, smell, etc. –Reinforce non-use

21. Adolescent intervention AssistAssist –Set quit dates –Provide self-help materials –Encourage problem-solving, refusal skills –Encourage activities incompatible with tobacco –Consider pharmacology Arrange:Arrange: –1-2 week follow-up after quit attempts

22. Public Health Service Guideline AnticipateAnticipate Ask - if smokesAsk - if smokes Assess - readiness to quitAssess - readiness to quit Advise - to quitAdvise - to quit Assist - in quitting & finding servicesAssist - in quitting & finding services Arrange - for cessation servicesArrange - for cessation services

23. Adolescent oriented office materials Self-help handouts Targeted to adolescents and to stages of change/motivation Trigger questionnaires Internet resources

24. 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. 2006 Hollis et al.Pediatrics, 2005

25. Changing Evidence: Youth and Nicotine Adolescents are more likely to become addicted than adultsAdolescents are more likely to become addicted than adults Signs of nicotine dependence often start within two months after onset of smoking and before adolescent are daily usersSigns of nicotine dependence often start within two months after onset of smoking and before adolescent are daily users Quitting is harder for teens but still possible; adolescents more likely to choose less effective methods for quittingQuitting is harder for teens but still possible; adolescents more likely to choose less effective methods for quitting DiFranza, J, Sci Am. 2008 MMWR Morb Mortal Wkly Rep. 2006

26. What Can Pediatricians and Other Child 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

27. Best available evidence - Responses to Patient Who Smokes Unacceptable: “I don’t have time.”Unacceptable: “I don’t have time.” AcceptableAcceptable –Refer to a quitline –Establish systems in office and hospital –Become a cessation expert Ask, Advise, ReferAsk, Advise, Refer

28. 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

29. 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

30. 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

31. AAP Bright Futures Guidelines Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 3 rd Edition

32. 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

33. 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

34. 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

35. 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/

36. Exposure to Tobacco Use in Movies and Smoking Among 5th-8th grader Adapted from Sargent, DiFranza, 2003 8 th Grade 7 th Grade 6 th Grade 5 th Grade

37. 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/

38. 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

39. www.aap.org/RichmondCenter