Virginia Commonwealth Virginia Commonwealth UniversityUniversity

Pediatric Grand RoundsPediatric Grand Rounds 1 March 2005 1 March 2005

“Adolescent Tobacco Use:“Adolescent Tobacco Use:The Challenge for Public Health The Challenge for Public Health

and Clinical Practice”and Clinical Practice”Richard Brookman, MDRichard Brookman, MD

Earl Dowdy, PhDEarl Dowdy, PhD

Tobacco: A Public Health MenaceTobacco: A Public Health Menace

Tobacco use causes, according to the CDC, 440,000 Tobacco use causes, according to the CDC, 440,000 deaths per year deaths per year

– greater toll in human life than that exacted by car accidents, greater toll in human life than that exacted by car accidents, murders, suicides, fires, other drug and alcohol use, and HIVmurders, suicides, fires, other drug and alcohol use, and HIV//AIDS, AIDS, combined combined

– without improvements in use prevention, more than 6 million people without improvements in use prevention, more than 6 million people now 18 and under will die from tobacco’s effects now 18 and under will die from tobacco’s effects

Over $75 billion in public and private healthcare costs each Over $75 billion in public and private healthcare costs each year year

Reduces the productivity of Americans by more than $80 Reduces the productivity of Americans by more than $80 billion per year billion per year

Tobacco Use: Tobacco Use: A Pediatric DiseaseA Pediatric Disease

~80% of current adult smokers began tobacco use before age 18; ~80% of current adult smokers began tobacco use before age 18; ~90% began before age 21~90% began before age 21

Tobacco-industry internal documents show intent to manipulate Tobacco-industry internal documents show intent to manipulate adolescent psychology through advertisingadolescent psychology through advertising

– In a 1991 study published in JAMA (20 years after TV cigarette ads were In a 1991 study published in JAMA (20 years after TV cigarette ads were banned) it was reported that 91% of 6 year olds recognized the Joe banned) it was reported that 91% of 6 year olds recognized the Joe Camel logo and associated it with cigarettes; Joe Camel was as familiar Camel logo and associated it with cigarettes; Joe Camel was as familiar as Ronald McDonald or Mickey Mouseas Ronald McDonald or Mickey Mouse

– In 1996, ½ of adolescent smokers, and ¼ of adolescent non-smokers, In 1996, ½ of adolescent smokers, and ¼ of adolescent non-smokers, possessed some tobacco-promotion item (hats, t-shirts, etc.)possessed some tobacco-promotion item (hats, t-shirts, etc.)

– According to FTC filings, between 1996 and 2000 tobacco industry According to FTC filings, between 1996 and 2000 tobacco industry spending on advertising increased 86%, from $5.1B to $9.5Bspending on advertising increased 86%, from $5.1B to $9.5B

– Currently, 82% of adolescents (ages 12-17) prefer heavily advertised Currently, 82% of adolescents (ages 12-17) prefer heavily advertised brands (Marlboro, Camel, Newport)brands (Marlboro, Camel, Newport)

Tobacco Use: Tobacco Use: A Pediatric DiseaseA Pediatric Disease

2/3 of adolescent smokers say they want to 2/3 of adolescent smokers say they want to quit, but can’tquit, but can’t

Nicotine is addictive – cigarettes (and other Nicotine is addictive – cigarettes (and other tobacco products) aretobacco products) are

““nicotine delivery devices”nicotine delivery devices”

Tobacco Use: Tobacco Use: A Pediatric DiseaseA Pediatric Disease

Between 1/2 and 2/3 of Americans under age 19 try cigarettes at least Between 1/2 and 2/3 of Americans under age 19 try cigarettes at least onceonce

Adolescents who continue to smoke suffer mild airway obstruction and Adolescents who continue to smoke suffer mild airway obstruction and slowed growth of lung functionslowed growth of lung function

Adolescent smokers, on average, have 10% elevation in triglyceride Adolescent smokers, on average, have 10% elevation in triglyceride and low density lipoprotein levels, and 8% suppression in HDL levelsand low density lipoprotein levels, and 8% suppression in HDL levels

Laboratory studies have shown adolescent age mammals to be more Laboratory studies have shown adolescent age mammals to be more vulnerable than adults to neurological impairment from nicotine vulnerable than adults to neurological impairment from nicotine exposure, particularly in systems associated with learning and reward exposure, particularly in systems associated with learning and reward

~1/3 of people who become regular smokers as adolescents will die of ~1/3 of people who become regular smokers as adolescents will die of diseases caused by smokingdiseases caused by smoking– Lung CancerLung Cancer– Coronary Heart DiseaseCoronary Heart Disease– Chronic Obstructive Pulmonary DiseaseChronic Obstructive Pulmonary Disease

Tobacco Use: Tobacco Use: A Pediatric DiseaseA Pediatric Disease

Nicotine dependence develops in stagesNicotine dependence develops in stages

Stages-of-Change in Tobacco-UseStages-of-Change in Tobacco-UseInitiation and DependenceInitiation and Dependence

1)1) Preparation / contemplationPreparation / contemplation– knowledge, beliefs, attitudes, normative expectations are formedknowledge, beliefs, attitudes, normative expectations are formed

2) Initial trying – usually family or peer associated2) Initial trying – usually family or peer associated

3) Experimentation – irregular use over time3) Experimentation – irregular use over time

4) Regular use – often associated with alcohol use4) Regular use – often associated with alcohol use

5) Nicotine dependence/addiction5) Nicotine dependence/addiction– often associated with use of 10 or more cigarettes/dayoften associated with use of 10 or more cigarettes/day– dependence-producing dose varies considerably among individualsdependence-producing dose varies considerably among individuals– signs of dependence may occur at a smoking rate of as little as 2 signs of dependence may occur at a smoking rate of as little as 2

cigarettes/weekcigarettes/week– addiction typically develops within 2 years of first useaddiction typically develops within 2 years of first use– signs of dependence may appear within two months of first usesigns of dependence may appear within two months of first use

Stages-of-Change in Tobacco-UseStages-of-Change in Tobacco-Useand Nicotine Dependenceand Nicotine Dependence

CONTEMPLATINGCONTEMPLATINGCONTEMPLATINGCONTEMPLATINGTRYINGTRYINGTRYINGTRYING

USINGUSING

REGULARLYREGULARLY

USINGUSING

REGULARLYREGULARLY USINGUSINGHEAVILYHEAVILY

USINGUSINGHEAVILYHEAVILY

Stage 1Stage 1 Stage 2 Stage 2 Stage 3 Stage 3 Stage 4 Stage 5 Stage 4 Stage 5 Stage 1Stage 1 Stage 2 Stage 2 Stage 3 Stage 3 Stage 4 Stage 5 Stage 4 Stage 5

EXPERIMENTINGEXPERIMENTINGEXPERIMENTINGEXPERIMENTING

Increasing Risk of Nicotine DependenceIncreasing Risk of Nicotine Dependence

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* Estimates, based on CDC, “Trends in Cigarette Smoking Among High * Estimates, based on CDC, “Trends in Cigarette Smoking Among High School Students – United States, 1991-2001,” School Students – United States, 1991-2001,” MMRWMMRW 51(19). 51(19).

Stages-of-Change in Tobacco-Use and Stages-of-Change in Tobacco-Use and Nicotine DependenceNicotine Dependence

Different prevention approaches are appropriate at different Different prevention approaches are appropriate at different stages and ages of onsetstages and ages of onset

Empirical research is underway to understand the complex Empirical research is underway to understand the complex etiology of tobacco use, and to develop and evaluate prevention etiology of tobacco use, and to develop and evaluate prevention and cessation best practices in a range of situationsand cessation best practices in a range of situations

An array of variables affects probability of tobacco use and An array of variables affects probability of tobacco use and nicotine dependence in individual adolescents, includingnicotine dependence in individual adolescents, including

– genotypes, differential gene expression in various neural tissues, genotypes, differential gene expression in various neural tissues, and gene-environment interactionsand gene-environment interactions

– gender / body image

– ethnicity

– SES, education

Tobacco Use: Tobacco Use: Risk Factors in AdolescentsRisk Factors in Adolescents

Parents, siblings, peers who use tobaccoParents, siblings, peers who use tobacco

Favorable views of smokingFavorable views of smoking

Experimentation with tobacco Experimentation with tobacco

Poor academic achievementPoor academic achievement

Risk-taking, rebelliousnessRisk-taking, rebelliousness

Depression, anxiety, ADDDepression, anxiety, ADD

MaleMale

Age 10-18 yearsAge 10-18 years

Tobacco Use:Tobacco Use:Patterns of Incidence Among YouthPatterns of Incidence Among Youth

First use of tobacco usually occurs between the ages of 11 First use of tobacco usually occurs between the ages of 11 and 13 (6and 13 (6thth-8-8thth grade) grade)

By the end of high school, 1/2 - 2/3 have experimented with By the end of high school, 1/2 - 2/3 have experimented with tobaccotobacco

By the end of high school, about 1/3 of experimenters have By the end of high school, about 1/3 of experimenters have become regular, daily smokersbecome regular, daily smokers– higher ratio of regular tobacco users to experimenters than that higher ratio of regular tobacco users to experimenters than that

seen with alcohol, marijuana, or cocaineseen with alcohol, marijuana, or cocaine

– signs of nicotine dependence (craving, irritability or anxiety, signs of nicotine dependence (craving, irritability or anxiety, unsuccessful quit attempts) can appear within days or weeks of first unsuccessful quit attempts) can appear within days or weeks of first use, and before daily use is establisheduse, and before daily use is established

Youth Tobacco Use: Patterns of IncidenceYouth Tobacco Use: Patterns of Incidence(Monitoring the Future Study)(Monitoring the Future Study)

~3/4 of high-school grads who are regular, daily smokers ~3/4 of high-school grads who are regular, daily smokers have tried to quit and failedhave tried to quit and failed

Less than 1 in 7 high-school regular smokers have Less than 1 in 7 high-school regular smokers have successfully stopped smoking for 30 days or more successfully stopped smoking for 30 days or more

3% of high-school daily smokers say they will be smoking 3% of high-school daily smokers say they will be smoking in 5 yearsin 5 years

More than 60% of those who are regular smokers at high More than 60% of those who are regular smokers at high school graduation are still smokers 7-9 years laterschool graduation are still smokers 7-9 years later

Tobacco Use by High School StudentsTobacco Use by High School Students(2003 Youth Risk Behavior Survey)(2003 Youth Risk Behavior Survey)

58% have ever tried smoking58% have ever tried smoking

22% smoked at least once in past 30 days22% smoked at least once in past 30 days

10% smoked on 20 or more of past 30 days10% smoked on 20 or more of past 30 days

16% smoked every day for past 30 days16% smoked every day for past 30 days

3% smoke more than 10 cigarettes a day3% smoke more than 10 cigarettes a day

20% males, 16% females have smoked a whole 20% males, 16% females have smoked a whole cigarette before age 13cigarette before age 13

Tobacco Use by High School StudentsTobacco Use by High School Students(2003 Youth Risk Behavior Survey)(2003 Youth Risk Behavior Survey)

30% of males, 25% of females have engaged in some 30% of males, 25% of females have engaged in some form of tobacco use in the last 30 daysform of tobacco use in the last 30 days

11% males, 2% females used smokeless tobacco in past 11% males, 2% females used smokeless tobacco in past 30 days30 days

20% males, 2% females smoked cigars in past 30 days20% males, 2% females smoked cigars in past 30 days

21% have purchased cigarettes before turning 1821% have purchased cigarettes before turning 18

8% report smoking on school property8% report smoking on school property

6% report using smokeless tobacco on school property6% report using smokeless tobacco on school property

Incidence by Gender & Ethnicity Incidence by Gender & Ethnicity (2003 Youth Risk Behavior Survey)(2003 Youth Risk Behavior Survey)

25% of white, non-Hispanic high school students 25% of white, non-Hispanic high school students report current cigarette use (in the past 30 days)report current cigarette use (in the past 30 days)– 26.6% white females26.6% white females– 23.3% white males23.3% white males

15% of black, non-Hispanic high school students 15% of black, non-Hispanic high school students report current cigarette usereport current cigarette use– 10.8% black females10.8% black females– 19.3% black males19.3% black males

18.4% of Hispanic high school students report current 18.4% of Hispanic high school students report current cigarette usecigarette use– 17.7% Hispanic females17.7% Hispanic females– 19.1% Hispanic males19.1% Hispanic males

Tobacco Use by School GradeTobacco Use by School Grade(2004 Monitoring the Future Study %)(2004 Monitoring the Future Study %)

GradeGrade 8th8th 10th10th 12th12th

Any UseAny Use 2828 4141 5353

Past 30 DaysPast 30 Days 99 1616 2525

Daily UseDaily Use 44 88 1616

½ Pack / Day½ Pack / Day 22 33 88

Any SmokelessAny Smokeless 1111 1414 1717

Daily SmokelessDaily Smokeless 1.01.0 1.61.6 2.82.8

Cigarette Use by School Grade by YearCigarette Use by School Grade by Year(Monitoring the Future Study %)(Monitoring the Future Study %)

GradeGrade 8th8th 10th10th 12th12th

Any Use 1999Any Use 1999 4444 5858 6565

20012001 3737 5353 6161

20042004 2828 4141 5353

Daily Use 1999Daily Use 1999 88 1616 2323

20012001 66 1212 1919

20042004 44 88 1616

Reasons for Recent Decline in Tobacco Use Reasons for Recent Decline in Tobacco Use Among YouthAmong Youth

Intense adverse publicityIntense adverse publicity

Rise in prices and taxesRise in prices and taxes

Change in marketing due to Master SettlementChange in marketing due to Master Settlement

– End of Joe Camel logoEnd of Joe Camel logo

– Cessation of billboard advertisingCessation of billboard advertising

– Anti-smoking advertisingAnti-smoking advertising

Interviewing Adolescents Interviewing Adolescents About Tobacco UseAbout Tobacco Use

Have you ever smoked a cigarette?Have you ever smoked a cigarette? (If they say they do smoke or have smoked)(If they say they do smoke or have smoked)

– How many cigarettes do you smoke inHow many cigarettes do you smoke in A day? A week? A month? A year?A day? A week? A month? A year?

– When was the last time you smoked a cigarette?When was the last time you smoked a cigarette? Today? Yesterday? In the past week? Month? Year?Today? Yesterday? In the past week? Month? Year?

– Does your mom smoke?Does your mom smoke?– Does your dad smoke?Does your dad smoke?– Do you have any brothers or sisters who smoke?Do you have any brothers or sisters who smoke?– What percentage of your friends smoke?What percentage of your friends smoke?

None? Less than half? More that half? Almost all?None? Less than half? More that half? Almost all?

USPHS Smoking Cessation GuidelinesUSPHS Smoking Cessation Guidelines

ASK about tobacco useASK about tobacco use

ADVISE to quitADVISE to quit

ASSESS willingness to attempt quittingASSESS willingness to attempt quitting

ASSIST in quit attemptASSIST in quit attempt

ARRANGE for follow-upARRANGE for follow-up

The Hooked on Nicotine Checklist The Hooked on Nicotine Checklist (HONC)(HONC)

1.1. Have you ever tried to quit, but couldn’t?Have you ever tried to quit, but couldn’t?

2.2. Do you smoke now because it is really hard to Do you smoke now because it is really hard to quit?quit?

3.3. Have you ever felt like you were addicted to Have you ever felt like you were addicted to tobacco?tobacco?

4.4. Do you ever have strong cravings to smoke?Do you ever have strong cravings to smoke?

5.5. Have you ever felt like you really needed a Have you ever felt like you really needed a cigarette?cigarette?

6.6. Is it hard to keep from smoking in places where Is it hard to keep from smoking in places where you are not supposed to, like school?you are not supposed to, like school?

The Hooked on Nicotine Checklist The Hooked on Nicotine Checklist (HONC)(HONC)

When you have tried to stop smoking, or when When you have tried to stop smoking, or when you haven’t used tobacco for a whileyou haven’t used tobacco for a while

7.7. Did you find it hard to concentrate because you Did you find it hard to concentrate because you couldn’t smoke?couldn’t smoke?

8.8. Do you smoke now because it is really hard to Do you smoke now because it is really hard to quit?quit?

9.9. Did you feel more irritable because you couldn’t Did you feel more irritable because you couldn’t smoke?smoke?

10.10. Do you feel a strong need or urge to smoke?Do you feel a strong need or urge to smoke?

11.11. Did you feel nervous, restless, or anxious Did you feel nervous, restless, or anxious because you couldn’t smoke?because you couldn’t smoke?

Brief Intervention for Smoking CessationBrief Intervention for Smoking Cessation

RELEVANCE - determine personal reasonsRELEVANCE - determine personal reasons

RISKS - identify negative consequencesRISKS - identify negative consequences

REWARDS - identify potential benefitsREWARDS - identify potential benefits

ROADBLOCKS - identify barriers & solutionsROADBLOCKS - identify barriers & solutions

REPITITION - repeat motivational interventionREPITITION - repeat motivational intervention

Office Environment for Smoking CessationOffice Environment for Smoking Cessation

Smoke-free officeSmoke-free office

Affirmative pamphlets, postersAffirmative pamphlets, posters

Elimination of tobacco advertising (magazines)Elimination of tobacco advertising (magazines)

Reinforcement by other staffReinforcement by other staff

Chart promptsChart prompts

Trigger questionnairesTrigger questionnaires

Cessation education materialsCessation education materials

Resources for referralResources for referral

Guidelines for Adolescent Preventive Guidelines for Adolescent Preventive Services (GAPS)Services (GAPS)

Promulgated by the AMA’s Department of Adolescent HealthPromulgated by the AMA’s Department of Adolescent Health

Focus on 11 to 21 year oldsFocus on 11 to 21 year olds

Health risks for this age group are influenced by socialization Health risks for this age group are influenced by socialization and become engrained through habituation and become engrained through habituation

Risk assessment, prevention and early intervention are keys Risk assessment, prevention and early intervention are keys to successful adolescent health promotionto successful adolescent health promotion

Ask each adolescent, at least once a year, about their Ask each adolescent, at least once a year, about their tobacco use and other high-risk behaviorstobacco use and other high-risk behaviors

Become knowledgeable about intervention strategies and Become knowledgeable about intervention strategies and options, and become an advocate for access to evidence-options, and become an advocate for access to evidence-based approaches based approaches

Tobacco Use:Tobacco Use:Inadequate Healthcare System ResponseInadequate Healthcare System Response

~70% of adolescents see a physician yearly~70% of adolescents see a physician yearly

~30% of these are asked about their tobacco ~30% of these are asked about their tobacco useuse

<10% are asked about parent, sibling or peer <10% are asked about parent, sibling or peer tobacco usetobacco use

Inadequate rates of counseling for adolescents Inadequate rates of counseling for adolescents who present with tobacco use who present with tobacco use

Studies show inadequate charting of tobacco Studies show inadequate charting of tobacco use and other types of behavioral screening use and other types of behavioral screening

Tobacco Use: Entrée to Methods of Tobacco Use: Entrée to Methods of Evidence-Based Adolescent Clinical PracticeEvidence-Based Adolescent Clinical Practice

Adolescents 11-21 Years Old

High-Risk Behaviors• Injuries• Sex• Substance Use

• Stage of Behavior Devel.• School Failure• Incarceration

Vulnerable Populations

Clinical Screening& Intervention

System Performance

Measures

• SES • Co-occurring Disorders

• Age• Gender• Ethnicity

• Frequent & Reliable Observations?• Accurate & Available Clinical Records?• Available, Evidence-Based Interventions?

• Service-Provider Surveys• Medical Records Review• Indep. Observations of Clinical Interactions• Patient Post-Visit Surveys• Follow-Up Measures of Effectiveness

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Evidence-Based Adolescent Clinical PracticeEvidence-Based Adolescent Clinical Practice

Know your patients – know their history!Know your patients – know their history!

Modes of Policy Action and InfluenceModes of Policy Action and Influencefor Medical Clinical Practitionersfor Medical Clinical Practitioners

Govt. Govt. Advisory Advisory PanelsPanels

Professional Professional SocietiesSocieties

Business Business PartnershipsPartnerships

Community Community AdvocacyAdvocacy

Academic Academic CollaborationCollaboration

Clinical Trials &

Research

Clinical Clinical PracticePracticeHealth PolicyHealth PolicyPhysiciansPhysicians

Adolescent Tobacco Use: Adolescent Tobacco Use: Community-Based Action Community-Based Action by Medical Professionalsby Medical Professionals

Join with community-based adolescent risk-prevention effortsJoin with community-based adolescent risk-prevention efforts

Encourage local officials to adopt and strictly enforce bans onEncourage local officials to adopt and strictly enforce bans on

– the use of all tobacco products on school propertythe use of all tobacco products on school property

– the sale of tobacco products to minorsthe sale of tobacco products to minors

– smoking in public places and in places of employmentsmoking in public places and in places of employment

Encourage local merchants not to display tobacco advertisingEncourage local merchants not to display tobacco advertising

Support increases in local, state, and federal excise taxes on Support increases in local, state, and federal excise taxes on tobacco productstobacco products

Cigarette Excise Tax Increases and Cigarette Excise Tax Increases and Projected Effects on Demand in VirginiaProjected Effects on Demand in Virginia

CigaretteCigaretteExcise TaxExcise TaxIncrease (¢)Increase (¢)

CigaretteCigaretteRetail PriceRetail PriceIncrease (%)Increase (%)

Adult CigaretteAdult CigaretteTotal DemandTotal DemandDecrease (%)Decrease (%)

Youth Youth Cigarette Total Cigarette Total

Demand Demand Decrease (%)Decrease (%)

# of Youth# of YouthSmokersSmokersDecreaseDecrease

2020 6.86.8 2.72.7 8.28.2 3,5903,590

3030 10.210.2 4.14.1 12.212.2 5,3865,386

5050 17.017.0 6.86.8 20.420.4 8,9768,976

7575 25.425.4 10.210.2 30.530.5 13,41113,411

100100 33.933.9 13.613.6 40.740.7 17,89917,899

Tobacco Use and Clinical Practice:Tobacco Use and Clinical Practice:Resources on the World Wide WebResources on the World Wide Web

Campaign for Tobacco Free Kids Campaign for Tobacco Free Kids http://http://www.tobaccofreekids.orgwww.tobaccofreekids.org//

Doctors Ought to Care – DOCDoctors Ought to Care – DOChttp://www.bcm.edu/doc/http://www.bcm.edu/doc/

CDC – TIPS CDC – TIPS http://http://www.cdc.govwww.cdc.gov/tobacco//tobacco/

DHHS – SAMHSA DHHS – SAMHSA http://http://prevention.samhsa.govprevention.samhsa.gov//

Tobacco.org – Tobacco Control NewsTobacco.org – Tobacco Control Newshttp://www.tobacco.org/http://www.tobacco.org/

Society for Adolescent MedicineSociety for Adolescent Medicinehttp://http://www.adolescenthealth.orgwww.adolescenthealth.org//index.htmindex.htm

American Academy of Pediatrics – American Academy of Pediatrics – Pediatric Research in Office Pediatric Research in Office Settings (PROS) Settings (PROS)

http://http://www.aap.org/pros/abtpros.htmwww.aap.org/pros/abtpros.htm

American Academy of Family American Academy of Family PhysiciansPhysicians

http://http://www.aafp.orgwww.aafp.org//

American Medical Association – American Medical Association – Adolescent HealthAdolescent Health

http://www.ama-assn.org/ama/pub/http://www.ama-assn.org/ama/pub/category/1981.htmlcategory/1981.html

American Medical Association – American Medical Association – Clinical PracticeClinical Practice

http://www.ama-assn.org/ama/pub/http://www.ama-assn.org/ama/pub/category/6886.htmlcategory/6886.html

Science, for aScience, for a

Tobacco-Free VirginiaTobacco-Free Virginia

The Virginia Youth The Virginia Youth

Tobacco ProjectTobacco Project

The Virginia Youth Tobacco ProjectThe Virginia Youth Tobacco Project

www.vytp.vcu.eduwww.vytp.vcu.edu

Pharmacotherapies for Smoking CessationPharmacotherapies for Smoking Cessation

Nicotine gum - 2mg/4mg piecesNicotine gum - 2mg/4mg pieces Nicotine patch - 16/24 hoursNicotine patch - 16/24 hours Nicotine nasal spray - 0.5 mg/sprayNicotine nasal spray - 0.5 mg/spray Nicotine inhaler - 4 mg over 80 inhalationsNicotine inhaler - 4 mg over 80 inhalations

Buproprion SR tabletsBuproprion SR tablets

ClonidineClonidine NortriptylineNortriptyline