1. SMOKING and TEENAGERS
For questions regarding this presentation, please contact:
Karen Hudmon, DrPH, MS, RPh
Yale University School of Medicine
Department of Epidemiology & Public Health
60 College Street, 4th Floor
New Haven, CT 06473
Telephone:
Materials prepared by Karen Hudmon for the San Mateo County Pharmacists Association. Copyright All rights reserved.

2. SMOKING AMONG TEENS in the UNITED STATES
4.5 million kids aged smoke.
Each day, more than 3,000 kids become daily smokers.
Most teen regular smokers report some level of addiction and withdrawal.
Approximately 4.5 million adolescents (between the ages of 12 and 17) smoke.
Each day, more than 3,000 adolescents under the age of 18 become daily smokers.
Most teens who smoke regularly report some level of addiction and withdrawal. Of daily smokers who think that they will not smoke in five years, nearly 75% are still smoking five to six years later.
Source:
Centers for Disease Prevention and Control. Available:

3. WHAT IS THE LEGAL AGE FOR SMOKING?18
What is the legal age for smoking?
18.
In the United States, experimentation with cigarettes and the development of regular smoking typically occur during adolescence, with 89% of adult smokers having tried their first cigarette by 18 years of age (USDHHS, 1994; Gilpin et al., 1994) and 71% of adult daily smokers becoming regular smokers by age 18 (Gilpin et al., 1994).
Should the smoking age be increased?
Sources:
United States Department of Health and Human Services. Preventing tobacco use among young people: A Report of The Surgeon General. Atlanta, GA: United States Department of Health and Human Service, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1994.
Gilpin EA, Lee L, Evans N, Pierce JP. Smoking initiation rates in adults and minors: United States, Am J Epidemiol 1994; 140(6):

4. HOW MANY TEENAGERS SMOKE?
Cigarette smoking: 12th graders
Students who smoked one or more cigarettes in the past month
White
Percent of students
Hispanic
Cigarette smoking among adolescents is a public health concern of utmost importance. In the U.S., experimentation with cigarettes and the development of regular smoking typically occur during adolescence, with 89% of adult smokers having tried their first cigarette by 18 years of age (Gilpin et al., 1999; USDHHS, 1994), and 71% of adult daily smokers having become regular smokers by age 18 (Gilpin et al., 1999). Each day, an estimated 3,000 additional children and adolescents become established smokers (Gilpin et al., 1999). Because most youth who smoke at least monthly continue to smoke in adulthood, tobacco use trends among youth are a key indicator of the overall health trends for the U.S. (USDHHS, 2000).
During 1991–1997, the smoking prevalence (defined as one or more cigarettes in the 30 days before survey completion) among high school seniors increased to 36.5%. At that time, the prevalence was highest among whites (40.7%) and lowest among blacks (14.3%). This worrisome increasing trend highlighted a need for tobacco prevention and cessation programs focused on this age group.
In 2004, an estimated 25.0% of 12th graders had smoked one or more cigarettes in the past 30 days. Among 8th- and 10th-grade students in 2004, the overall 30-day point prevalence for cigarette smoking was 9.2% and 16.0%, respectively (Johnston et al., 2005). As can be seen in the graph, smoking among adolescents has declined over the past decade; however, the downward trend has largely diminished in recent years.
♪ Note to instructor(s): Monitoring the Future data, publications, and press releases are available at
Gilpin EA, Choi WS, Berry C, Pierce JP. (1999). How many adolescents start smoking each day in the United States? J Adolesc Health 25:248–255.
Johnston LD, O'Malley PM, Bachman JG, Schulenberg, JE. (2005). Monitoring the Future National Results on Adolescent Drug Use: Overview of Key Findings, 2004 (NIH Publication No ). Bethesda, MD: National Institute on Drug Abuse. Data retrieved December 19, 2005, from
U.S. Department of Health and Human Services (USDHHS). (1994). Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking Health.
U.S. Department of Health and Human Services. (2000). Healthy People Washington, DC: U.S. Department of Health and Human Services.
Black

5. CONSEQUENCES of SMOKING
Nearly 440,000 people die each year because of smoking.
Smoking kills more Americans every year than car accidents, alcohol, cocaine, crack, heroin, homicide, suicide, fire, and AIDS combined.
Each year, approximately 434,000 smokers and 53,000 nonsmokers die because of tobacco smoke. That is equivalent to having two to three jumbo jets, filled to capacity, collide mid-air every day of the year, with no survivors.
Tobacco kills more Americans each year than car accidents alcohol, cocaine, crack, heroin, homicide, suicide, fire and AIDS combined. This is shown in the next slide.

6. CAUSES of DEATH in the U.S.
Tobacco
Poor diet and exercise
Alcohol
Smoking can harm YOU and OTHERS.
Infections
1 in 5 DEATHS
are caused by
TOBACCO
Pollutants/toxins
Firearms
In fact, tobacco causes nearly 1 in every 5 deaths in the U.S. (McGinnis & Foege, 1993).
Smoking no only harms the smoker, but also those who breathe second-hand smoke. Approximately 53,000 nonsmokers die each year in the United States because of second-hand smoke (National Cancer Institute, 1999).
*The percentages used in this figure are composite approximations derived from published scientific studies that attributed deaths to these causes.
Source:
McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:
National Cancer Institute. Health Effects of Exposure to Environmental Tobacco Smoke: The Report of the California Environmental Protection Agency. Smoking and Tobacco Control Monograph No. 10. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute, NIH Publication No , 1999, pp. 185–264.
Sexual behavior
Motor vehicles
Illicit drug use
Percentage of all deaths

7. WHAT’S in TOBACCO SMOKE?
4,800 chemicals in tobacco smoke
Harmful gases
Tar
Lead
Nicotine
Tobacco smoke, which is inhaled either directly or as second-hand smoke, contains an estimated 4,800 compounds. The majority of the compounds are present in the particulate phase, suspended in tobacco smoke. Based on a classification system by the International Agency for Research on Cancer, there currently are 11 known human carcinogens (Group I), 7 probable human carcinogens (Group 2A), and 49 animal carcinogens that possibly also are carcinogens in humans (Group 2B) (NCI, 2001).
Examples of detrimental compounds (some of which are carcinogens) in tobacco smoke include the following:
Carbon monoxide: automobile exhaust; binds to hemoglobin, inhibits respiration
Hydrogen cyanide: gas chamber poison; highly ciliotoxic, inhibits lung clearance
Ammonia: floor/toilet cleaning agent; irritation of respiratory tract
Nicotine : addictive substance; toxic alkaloid
Benzene: solvent, banned substance in organic chemistry labs; Group I carcinogen
Nitrosamines: carcinogenic in animals and probably in humans; Group 2A and 2B carcinogens
Lead: heavy metal, toxic to central nervous system; Group 2B carcinogen
Cadmium: heavy metal found in rechargeable batteries; Group I carcinogen
Hexavalent chromium: highlighted in the movie Erin Brockovich; Group I carcinogen
Arsenic: pesticide; Group I carcinogen
Polonium-210: radioactive agent; Group I carcinogen
Formaldehyde: embalming fluid; Group 2B carcinogen
Other substances in tobacco smoke (not listed above) that have sufficient evidence to be classified as Group I carcinogens in humans include 2-naphthylamine, 4-aminobiphenyl, vinyl chloride, ethylene oxide, beryllium, nickel, and cadmium.
Source:
National Cancer Institute. Risks Associated with Low Machine-Measured Yields of Tar and Nicotine. Smoking and Tobacco Control Monograph No. 13. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute, NIH Publication No , October 2001.
Many are PROVEN to cause cancer

8. A diseased lung showing emphysema, characteristic of smoking
This picture shows a lung with emphysema, one of many diseases that is characteristic of smoking.
About 87% of lung cancers are caused by smoking.
Men who smoke have a 22-fold increased risk of developing lung cancer, compared to men who don’t smoke (American Cancer Society, 2000).
Women who smoke have a 12-fold increased risk of developing lung cancer, compared to women who don’t smoke (American Cancer Society, 2000).
Source:
American Cancer Society. Available online at:
A diseased lung showing emphysema,
characteristic of smoking

9. FORMS OF TOBACCO Cigarettes Smokeless tobacco: snuff, chewing tobacco
Pipes
Cigars
Clove cigarettes
Bidis
Although cigarettes are, by far, the most commonly used form of tobacco in the U.S., there are other forms available. Several of these, such as clove cigarettes and bidis, have attained increased popularity in recent years:
Cigarettes
Smokeless tobacco (oral snuff and chewing tobacco)
Pipes
Cigars
Clove cigarettes: Originated in Indonesia in the 1800s, are made from tobacco in combination with 30-40% minced cloves.
Bidis: Manufactured primarily in India and in other southeast Asian countries, these products come in chocolate, vanilla, strawberry, licorice, orange and other flavors and are becoming increasingly popular among young smokers.
ALL forms of tobacco are HARMFUL and highly addictive.

10. SMOKING AND QUITTING What does this mean?
7 of every 10 smokers want to quit!
About 3 in 100 quit for good
What does this mean?
Tobacco is VERY addictive,
and it’s hard to quit,
even if you want to quit.
Approximately 4.5 million adolescents (between the ages of 12 and 17) smoke. Each day, more than 3,000 adolescents under the age of 18 become daily smokers.
Most teens who smoke regularly report some level of addiction and withdrawal. Of daily smokers who think that they will not smoke in five years, nearly 75% are still smoking five to six years later.
An estimated 70% of all smokers want to quit (CDC, 1994). Fewer than 3% successfully stop smoking each year.
♪ Note to instructor(s): Cessation statistics vary depending on factors such as the duration of follow-up, definitions of abstinence, and whether reports of cessation were biologically confirmed. The Centers for Disease Control (1993) reports that 5.7% of daily smokers are able to maintain abstinence for 1 month, and an estimated 2.5% of smokers successfully stop smoking each year.
Source:
Centers for Disease Prevention and Control. Available:
Centers for Disease Control and Prevention. Cigarette smoking among adults—United States, MMWR 1994;43:925–930.
NICOTINE, in tobacco,
makes people become addicted to smoking

11. Release of “pleasure” chemicals
Nicotine addiction is a disease that begins in the brain. This picture shows the area of the brain where nicotine addiction occurs, the dopamine reward pathway. This area of the brain also is where other additions develop, including heroin and cocaine addiction.
This slide is made available to the public through the National Institute on Drug Abuse Web page, at Adapted with permission by Dr. Rochelle D. Schwartz-Bloom, Duke University.
Leshner Al. Drug abuse and addiction are biomedical problems. Hosp Pract (special report) April 1997:2–4.
Stimulates brain receptors
Nicotine enters brain

12. GETTING HOOKED on TOBACCO
A YEAR
or MORE LATER:
Hooked and can’t quit
MONTHS LATER:
Smoking
more
regularly, start craving it
NEXT FEW USES:
Not as bad, getting used to it
FIRST USE:
Tastes bad;
dizzy,
nausea
The process of developing nicotine addiction is shown in this slide. For most folks, the first use of tobacco is not a positive experience. The tobacco tastes bad, irritates the back of the throat, and causes coughing; the nicotine often causes a person to feel dizzy and nauseous. Over time, with repeated use, the negative effects wear off, and the positive effects take over (such as enhanced concentration and feelings of pleasure). The person begins smoking more regularly. Soon, they become hooked, and can’t quit—or would have a lot of difficulty doing so.
The time that it takes to progress to routine smoking and the development of tobacco dependence will vary between individuals. Some researchers believe that it can develop very early, within a few weeks or months, for some.

13. TOBACCO and PERSONAL APPEARANCE
Bad breath
Hair and clothes stink
Stains teeth
There are several negative “cosmetic” effects of smoking… smokers have bad breath, their clothes and hair smell like smoke, and their teeth become stained.

14. TOBACCO and ATHLETIC PERFORMANCE
NICOTINE/SMOKING:
Narrows blood vessels, puts extra strain on your heart
Harms lungs, reducing oxygen availability during exercise
Causes shortness of breath
Can’t run as fast or as far
Nicotine and smoking can significantly reduce your athletic performance.
It will narrow the blood vessels in the body, putting added strain on the heart—which leads to cardiovascular and heart disease.
Smoking harms the lungs, and will reduce the amount of oxygen that is available to the body’s cells during exercise.
Smoking also causes shortness of breath, and if you smoke, you won’t be able to run as fast or as far.

15. HOOKED on TOBACCO? Coughing Difficulty breathing Lung infections
Increased resting heart rates
Increased likelihood of stronger addiction, the younger they start
NEW SMOKERS SUFFER:
When compared to nonsmoking youth, young smokers suffer more from coughing (the lungs trying to clear the tobacco-related particulates), they have increased difficulty breathing, a greater incidence of lung infections, increased resting heart rates, and a higher likelihood of developing a strong dependence on nicotine (the younger they start).

16. HOOKED on TOBACCO? YOU SMOKE: As soon as you wake up When stressed
With friends
Automatically
To concentrate, for energy
WHEN YOU CAN’T SMOKE:
Irritable, restless
Impatient, nervous
Tired, can’t sleep well
Can’t concentrate well
Crave a cigarette above all else
HOOKED AND CAN’T QUIT
After a year or more of regular smoking, when you’re hooked and can’t quit, your smoking becomes a habit driven by a need for nicotine. You smoke:
As soon as you wake up
When you are stressed, you reach for a cigarette
You often smoke with friends
Sometimes you light up without even realizing it
And you need to smoke in order to be able to concentrate, and to give you energy.
When you can’t smoke, you:
Become easily irritable and restless
You’re very impatient and nervous
You’re tired, because you can’t sleep well
You have difficult time concentrating
And when you’ve gone without a cigarette for awhile, you begin craving it above all else.

17. HOOKED on TOBACCO? AFTER SEVERAL YEARS of SMOKING Cancers
Heart diseases
Lung diseases
Stroke
Slower healing & recovery after surgery
Eye diseases
Sexual dysfunction
Bone loss
Lipid profile changes
Difficulty getting pregnant
AFTER SEVERAL YEARS of SMOKING
This slide shows a long list of negative health effects of tobacco use.

18. WHY DO TEENS START SMOKING?
Advertisements
Their friends smoke
People in their family smoke
Rebel against parents, others
Commonly, teens begin smoking because they are manipulated by appealing advertising. Sometimes they smoke because their friends or their family members smoke. Some youth decide to smoke as a way of expressing themselves as an “individual”—as being “cool” or part of an “in crowd.”

19. TOBACCO ADVERTISEMENTS
Cigarette companies claim they do not advertise to kids
Recently, Phillip Morris claimed it is a changed company and that its goal is “to responsibly market our products to adults who choose to smoke”
Cigarette companies cannot stay in business unless kids smoke
Cigarette companies claim that they don’t advertise directly to kids, and recently a major U.S. tobacco company declared that they changed their goals to responsibly market [their]products to adults who choose to smoke.
What kinds of advertisements have you seen FOR smoking? AGAINST smoking?
TV shows, movies
billboards (no longer legal in California)
Magazines, etc.
At sporting events
TV commercials AGAINST smoking: The TRUTH campaign
Yet, given that about 90% of all adult smokers begin smoking by the age of 18, tobacco advertising clearly “works” in getting teens to smoke—whether it is intentionally targeted to teens or not. The fact is clear: cigarette companies cannot stay in business if kids don’t smoke.

20. HELPING TEENS STOP SMOKING
Difficult to do—teens get addicted, too
Can’t use nicotine patches or gum
Teen stop-smoking programs
Best way is prevention…
DON’T START!
Teens who attempt to quit smoking have a difficult time—because they have developed an addiction to nicotine.
Although several stop-smoking programs have been developed for teens, none of the medications for quitting smoking are approved for use in persons under age 18.
The best way to be tobacco-free as an adult is to not start smoking as a teen. Did you know that 90% of all adult smokers started smoking by the age of 18?
And also…(next slide)

21. HELPING TEENS STOP SMOKING
70% of all teen smokers
wish they had never
started
Nearly three fourths (70%) of all teen smokers WISH THAT THEY HAD NEVER STARTED SMOKING.
What can YOU do, to be sure that you do not become addicted to tobacco?
Source:
Centers for Disease Control and Prevention. Available at:

22. WHAT CAN YOU DO to AVOID TOBACCO ADDICTION?
Make a commitment.
Commit to NOT using tobacco, EVER.
Decide that you do not want your life to be ruled by an addiction.
Know the truth.
Despite all the tobacco used on TV and in the movies … most teens, adults, and athletes don’t use tobacco.
Don’t let the tobacco industry fool you.
There are several tactics that you can use to stay tobacco free.
First, and perhaps most importantly, is to make a commitment, to yourself and/or to others. Commit to NOT using tobacco, ever. Do not assume that you can experiment with tobacco or smoke “just a few, every now and then” and be able to quit later. It doesn’t work that way—just ask any adult smoker that you know. Nicotine is highly addictive. A full 25% of the adult population currently uses tobacco. That’s one in every four persons whose life is ruled by a substance that takes years off of their life (the average pack-a-day or more smoker dies 7 years earlier than a person who has never smoked).
Know the truth about tobacco advertising. It is specifically designed to make cigarettes appealing to you. Don’t be fooled. Although 1 of every 4 adults smoke, 3 of every 4 don’t. And of the ones who DO smoke, 70% want to quit— yet only about 3% of those who try to quit are successful in doing so.

23. WHAT CAN YOU DO to AVOID TOBACCO ADDICTION?
Do any of your friends or family members smoke or use tobacco?
YES: Encourage them to quit
NO: Encourage them to stay tobacco-free.
Get involved in sports and other activities.
Students who are involved in extracurricular activities are less likely to use drugs or tobacco.
Encourage your nonsmoking friends and family members to stay tobacco-free, and if they DO use tobacco, encourage them to quit.
Get involved in sports and other activities. This “structured” time helps students to stay away from drugs and tobacco.

24. WHAT CAN YOU DO to AVOID TOBACCO ADDICTION?
Spend your money on things other than tobacco.
Get involved:
Spread the word about the dangers of tobacco use
Start or join an activist group against smoking
Finally, make a decision to spend your money on something other than tobacco. Because, as the next slide shows, it can be VERY costly to be a smoker.

25. Hundreds of thousands of dollars lost
IT COSTS A LOT TO SMOKE
Buying cigarettes every day for 50 $4.12 per pack
Money banked monthly, earning 1.5% interest
$331,467
$220,978
In addition to the many health benefits of quitting, there are financial benefits associated with quitting.
The financial costs of tobacco use can be substantial to a smoker, particularly when costs are accrued over a lifetime.
What three levels of smokers who buy cigarettes every day for 50 years at $4.12 per pack will have if they instead bank their cigarette money each month:1
1 pack a day: $110,489
2 packs a day: $220,978
3 packs a day: $331,467
Even if you don’t invest the money, the savings associated with not smoking is more than $1,500 a year for a pack-a-day smoker.
1 Assumes constant price per pack, an annual interest rate of 1.5% (not adjusted for inflation), and that the money was banked monthly.
Savings calculator tool available at
Source:
CDC. Medical-care expenditures attributable to cigarette smoking—United States, MMWR 1994;43:
Packs
per
day
$110,489
100
200
300
400
Hundreds of thousands of dollars lost