Tobacco Control

1. April 7, 2014 J. Randy Koch, Ph.D. Alison Breland, Ph.D. VCU Center for the Study of Tobacco Products Tobacco Control

2. Overview of Topics to Cover Today • Health effects of tobacco • Tobacco dependence • Epidemiology • Types of tobacco products • Cessation/Treatment • Prevention strategies • Virginia Youth Tobacco Projects Research Coalition • Family Smoking Prevention and Tobacco Control Act

3. Health Consequences • In the US: over 480,000 people die from tobacco related diseases each year • Globally, nearly 6 million annually • What’s in tobacco that is so harmful? • Nicotine • Carbon monoxide or CO (when burned) • Carcinogens (e.g., tobacco-specific nitrosamines, PAHs) • Morbidity and mortality caused by CO and carcinogens • Smoked tobacco use increases risk of: • coronary heart disease by 2 to 4 times • stroke by 2 times • Lung cancer by 15-30 times • chronic obstructive lung diseases (such as emphysema) by 10 times

4. Tobacco Dependence/Withdrawal • Effects of tobacco: mild euphoria, reduced stress, increased energy, and appetite suppression • Dependence likely caused by nicotine • Symptoms of withdrawal generally start within 2 - 3 hours after the last tobacco use, and peaks about 2 - 3 days later • Intense craving for tobacco • Anxiety, restlessness, impatience • Difficulty concentrating • Drowsiness or trouble sleeping, as well as bad dreams and nightmares • Headaches • Increased appetite and weight gain • Irritability or depression

5. Global Sources of Epidemiological Data • Lack of standardized data on a global level • Global Tobacco Surveillance System—1999+ • Collaborative effort among WHO, United States Centers for Disease Control and Prevention, and the Canadian Public Health Association • Surveys • Global Youth Tobacco Survey (GYTS) • Global School Personnel Survey (GSPS) • Global Health Professions Student Survey (GHPSS) • Global Adult Tobacco Survey (GATS)

6. GYTS: Current Cigarette Smokers

7. Epidemiology: US rates • Currently, about 18% of US adults smoke cigarettes • Rates higher if you include any tobacco product

8. Adult smoking prevalence by state SOURCE: Behavioral Risk Factor Surveillance System, 2010; http://www.cdc.gov/VitalSigns/AdultSmoking/index.html#StateInfo

9. Epidemiology: US rates (adults, cigarettes only) • Gender • 20.5% of men • 15.8% of women • Race • 21.8% of American Indians/Alaska Natives • 19.7% of whites (non-Hispanic) • 18.1% of blacks (non-Hispanic) • 12.5% of Hispanics • Socio-economic status • 27.9% of adults who live below the poverty level • 17.0% of adults who live at or above the poverty level

10. Epidemiology: US rates (adults, cigarettes only) • Adults with mental illness • 36% of adults with mental illness are smokers • Adults with substance use disorders: ~80% • Adults with MH or SUD account for 40% of all cigarette smoked in the US

11. Epidemiology: US rates for youth • Current use of cigarettes among youth: • 3.5% of middle school students • 14% of high school students • Rates higher if you include any tobacco product • Most adult smokers (80%) began smoking before age 18

12. Past Month Tobacco Use among Youths Aged 12 to 17: 2002-2012 From: http://www.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/NationalFindings/NSDUHresults2012.htm#fig4.1

13. Types of Tobacco Products (US) • Cigarettes • Cigars • Pipes • Smokeless tobacco (“dip”, “chew” or “snus” note: many new varieties) • Waterpipe (hookah) • E-cigarettes (not actually tobacco, although will likely be regulated as tobacco)

14. Cigarettes • Modern cigarette developed in the early 1800s • At the start of the 20th century, less than 0.5% of the population smoked • Consumption peaked in the US in 1965: ~50% of men and 33% of women smoked • Smoking and Health: Report of the Advisory Committee to the Surgeon General (1964) • Start to see changes to cigarettes: “light”“filtered”; health claims

15. FDA Regulation of tobacco products Source: United States Department of Agriculture; Centers for Disease Control and Prevention; Alcohol and Tobacco Tax and Trade Bureau

16. Cigarettes

17. Cigarettes • Changes increased sales without harm reduction • “The weight of the evidence indicates that lower-tar and nicotine yield cigarettes have not reduced the risk of disease proportional to their FTC yields” (IOM, 2001). • Past modifications did not alter exposure: changing puff topography, covering vent holes • New FDA regulation has eliminated the use of “light,”“low” and “mild”

18. Types of Tobacco Products • Cigars • 5.4% of US adults use (>1 in past 30 days) • 12.6% of high school students • 2.8% of middle school students http://www.smokefree.gov/tob-cigarillo.aspx

19. FIGURE 2. Consumption of cigarettes and other combustible tobacco products — United States, 2001–2011 Alternate Text: The figure above shows consumption of cigarettes and other combustible tobacco products in the United States during 2001-2011. Annual cigarette consumption declined each year during 2000-2011, including a 2.6% decrease from 2010 to 2011, but total consumption of combustible tobacco decreased only 0.8% from 2010 to 2011, in part, because of the effect of continued increases in the consumption of noncigarette combustible tobacco products. From 2000 to 2011, the percentage of total combustible tobacco consumption composed of loose tobacco and cigars increased from 3.4% (15.2 billion cigarette equivalents out of 450.7 billion) to 10.4% (33.8 billion of 326.6 billion).

20. Types of Tobacco Products • Pipes • Waterpipe, or hookah • CO exposure is much higher than cigarettes (Eissenberg et al., 2011)

21. Types of Tobacco Products • Smokeless tobacco • “Dip”, “Chew” (e.g., Skoal, Wintergreen) • Snus (Swedish) • Marlboro snus, Camel snus • Camel orbs, sticks, dissolvable strips • Verve disc • Health effects? In Sweden, low rates of lung cancer, but effects in US not known

22. dissolvable tobacco snus

23. Ploom loose-leaf vaporizer

24. Electronic Cigarettes Cartridge w/ Nicotine Solution/ E-juice/ E-liquid Atomizer Heater E-Juice/E-Liquid Nicotine Solution Propylene Glycol and/or Vegetable Glycerin Distilled Water Flavorings (Baking) Smart Chip Air Flow Sensor Rechargeable Battery 2v – 6v Use Methods Pre-Filled Dripping Fill your own Make your own LED Vaper Slide courtesy of Andrea Vansickel

25. Different ECIGS with varying power supplies. A is a V4L model (3.7 v) powered by a USB port. B is a V4L model (3.7 v) powered by internal rechargeable battery. C is a Silver Bullet powered by a 3.7 v replaceable/rechargeable battery. D is a ProVari powered by a 3.7 v replaceable/rechargeable battery and the user controls power settings ranging from 3.3 to 6.0 volts. A B C D

26. Types of Tobacco Products • Health effects of e-cigarettes unknown • 2-6% of US adults have ever used • Youth: 3% to nearly 7% between 2011 - 2012 • $18 million grant to VCU awarded September 2013 (5 years) Images courtesy of Bob Balster and Andrea Vansickel

27. Summary • Overall, tobacco use has been going down in the US (by small amounts in recent years) • Use of other products may be increasing • Hard to determine long-term impact of new products • Major concern—Will people switch to new “safer” products rather than quit? • Will youth start using new products?

28. Smoking cessation • ~70% of smokers say they want to quit • 45% make quit attempts • Relapse rates are high • Tobacco produces dependence: very difficult to quit • Tobacco is as addictive as heroin or cocaine

29. Smoking cessation • Medications to quit can increase likelihood of success • Nicotine replacement therapy (nicotine patch, gum, inhaler, lozenge, nasal spray) • Non-nicotine medications: • buproprion (Zyban/Wellbutrin) • varenicline (Chantix) • 1-800 QUIT-NOW (counseling) • Websites

30. Estimated abstinence rates—Behavioral therapies Source: Treating Tobacco Use and Dependence: 2008 Update (Clinical Practice Guideline, Fiore et al., 2008)

31. Estimated abstinence rates—Medications

32. Questions?

33. Prevention

34. Risk and Protective Factors Effective prevention programs are based on reducing risk factors and/or enhancing protective factors Related to age, gender, race, and environment A need for preventive interventions tailored to specific populations and settings Most risk and protective factors related to a broad array of youth problems, but some are unique Additive effect—goal is to affect the balance of risk and protective factors

35. Risk and Protective Factors Domains Individual Family Peer School Community

36. Risk and Protective Factors Individual Risk Factors Psychiatric disorders Novelty/sensation seeking Positive attitudes towards substance use High antisocial behavior Individual Protective Factors Ambitious life goals High religiosity

37. Risk and Protective Factors Family Risk Factors Family conflict Family history of antisocial behavior Family attitudes favorable to substance use Family Protective Factors Parental nonsmoking Parental advice not to smoke Parental monitoring Strong family bonds

38. Risk and Protective Factors Peer Risk Factors Peer tobacco use Community risk factors Exposure to tobacco advertising Perceived availability of tobacco School Risk Factors Low school connectedness Low academic achievement School misbehavior

39. Types of Prevention Strategies School-based programs Family-based programs Media campaigns Reducing youth access Excise Taxes

40. School-Based Prevention Programs Schools are most common setting for tobacco use prevention programs Provide relatively easy access to youth Can address other concerns of interest to schools Can be integrated into school curriculum

41. School-Based Prevention—What Works? Skills Training Academic Competence Social Competence Social Resistance Skills Norms Education Media Literacy Should not be one-time efforts--booster sessions

42. Life Skills Training Gilbert Botvin and colleagues, Cornell University Target Population: Grades 6, 7 and 8 or Grades 7, 8 and 9 Three year program (15, 10 and 5 session) Focus on: Drug resistance skills and information Self-management skills General social skills Interactive program using facilitated discussion, role playing, and small group activities

44. Family-Based Prevention Programs Parents are a major influence on youth behavior, especially on children Most common approaches focus on enhancing parenting skills Age appropriate expectations Consistent and appropriate discipline Monitoring of child activities/friends

45. Family-Based Prevention—What Works? Strengthen family bonding and positive relationships Improve parenting skills Helping families to develop and enforce rules about substance use Providing information about drugs and their effects on development

46. Strengthening Families Program Richard Spoth and colleagues, Iowa State University Target Population: Youth 10 to 14 years old (also available for younger children) Seven sessions Parents and youth meet separately for first hour and then together for second hour Parent sessions Skill-building focused on establishing rules, limits, and consequences while expressing love; communication with youth; handling stress; using community resources Uses videos demonstrating parenting skills, with role playing, discussion and skill building activities

47. SFP (cont’d) Youth sessions Youth skill-building focuses on following rules, peer pressure resistance, handling stress, and problem-solving Group discussions, group skill practice, and social bonding activities Family sessions Games and projects to increase family bonding, build positive communication skills, plan family activities, and facilitate learning to solve problems together Booster program 3 to 12 months after completing initial program—Four sessions

48. Intervention–Control Differences in Time to Initiation Rates: 6 Year Follow-up

49. Mass Media Interventions • Systematic review by Brinn et al., 2010 (Cochrane Collaboration) • There is some evidence that mass media can prevent the uptake of smoking in young people, however the evidence is not strong and contains a number of methodological flaws. • Effective media campaigns: • Based on good market research • Identify and tailor message to specific groups (market segmentation) • Last longer and more intensive • Use multiple media (TV, radio, newspapers)

50. Virginia “Y Campaign”