Tobacco Use and Dependence in College Students:

1. Tobacco Use and Dependence in College Students:Using the USPHS Clinical PracticeGuideline in a College Setting Abigail Halperin MD MPH Campus Health Action on Tobacco CHAT Study Provider Training

2. Why Should I Treat College Students?They Don’t Want to Quit! • Smoking among college students has increased dramatically over the last 10 years • Tobacco is marketed aggressively to this population • Young adulthood is a time of transition in tobacco habits • Many students will die prematurely if they continueto smoke Almost all students who smoke say they want to quit before they graduate.

3. Case Studies

4. Robert Robert is a 23 year old freshman, who worked for several years as an auto mechanic before starting college. He presents in the clinic with a severe productive cough, shortness of breath and increased temperature x3 days. He has two previous diagnoses of acute bronchitis. Family history includes his mother with a recent diagnosis of emphysema and his father who died of lung cancer. Both of Robert’s siblings smoke. He is presently dating a smoker. On physical exam, he has a temperature 101.1 F. His RR is 22 and lungs have diffuse rhonchi. He has a severe cough which is productive of purulent sputum. His smoking history indicates that he has smoked 20-25 cigarettes/day for 6 years, more when he drinks. He has his first cigarette immediately after waking. He tried to quit last year using the patch but only remained abstinent for 2 days. His girlfriend smokes but may be willing to quit smoking with him.

5. What Steps Can You Take to Make the Greatest Impact on Robert’s Tobacco Use During This Visit? • ADVISE Robert to quit smoking, emphasizing personal risks and benefits • ASSESS if he is willing to make a quit attempt now • ASSIST him with a quit plan • Set a quit date • Provide counseling • Offer pharmacotherapy • ARRANGE a follow-up contact: clinic visit, call to/from the clinic and/or quit line or email support

6. Chelsea Chelsea is an 20 year old sophomore who presents to the clinic for a repeat pap smear, since her last one 3 months ago was atypical. She has never been hospitalized and has no other medical problems. Her mother smokes but is “fine”. Chelsea is concerned about her weight and exercises three to four times weekly. She is 5’3”, weighs 128 pounds, BP 126/70, pulse 66. Smoking history indicates that she started smoking 3-4 years ago and smokes about a pack per day since she’s been in college. She has her first cigarette one to two hours after waking. She tried to stop smoking a year ago but gained 7 pounds in two months, and relapsed. She thinks that being overweight is as bad for her as smoking. The residence halls at her college are all going smoke-free so she would consider trying to stop smoking, but doesn’t want to gain any weight. She is an art major and says quitting would be hard because “all of her friends smoke.”

7. What Strategies Would Be Most Appropriate in Assisting Chelsea to Quit Smoking? • Applaud Chelsea’s decision to consider quitting, and review previous quitting experience • Offer information on health risks of tobacco use, in light of her personal and family risk factors. • Discuss weight implications of tobacco cessation and review the facts about health effects of smoking vs. increased weight • Consider prescribing pharmacotherapies that have been shown to reduce weight gain.

8. George George is a 20 year old sophomore. He is visiting the clinic with a complaint of depression. Family history includes a father who smokes cigars. Both parents are alive and in good health. His physical exam is unremarkable. He recently broke up with his girlfriend and is in counseling. The onset of his depression coincides with his relationship breaking up. He states that he has been sleeping poorly and has difficulty concentrating. He feels “stressed out all the time.” Smoking history includes 1/2-1 pack per day cigarette use since age 16 although he quit “cold turkey” seven months ago when he started going out with his girlfriend, who was not a smoker. He states that he has started to smoke again as smoking helps him feel better, and he doesn’t care that much about his health anymore.

9. What Strategies Would You Use to Intervene with George’s Relapse? • Applaud George’s accomplishment in remaining abstinent for 7 months • Offer support • Encourage George to talk about the quitting process, including the benefits of being a non-smoker • Discuss pharmacotherapy options (i.e., buproprion as it is also an antidepressant) • Identify triggers to avoid

10. Stephanie Stephanie is a 19 year old freshman who comes to the clinic with a dry cough and sore throat for one week, and is also complaining of fatigue, with muscular aches and pains. She has an unremarkable past medical history. Neither of her parents smoke, but her grandmother did and recently died of lung cancer. She is close to her family, who live nearby, and she has three younger siblings. Findings on physical exam: temp 99.9, BP 120/70, pulse 70, respirations 18. Throat slightly erythematous, with moderately enlarged cervical lymph nodes. Smoking history: She didn’t start smoking until her last year in high school, and doesn’t really consider herself a smoker, since she mostly smokes socially, when she goes out and parties. She rarely smokes in the morning and smokes less than 1/2 pack per day. She has never tried to quit because she doesn’t think she smokes enough for it to be harmful and thinks she’ll be able to quit whenever she wants.

11. What Motivational Strategies Could Move Stephanie Towards Making a Quit Attempt? • Ask her about theRELEVANCEandbenefits of quitting for her. • What are the negative consequences or RISKS for her and others close to her? • What are the positive things or REWARDS she would gain from quitting? • What are the ROADBLOCKS in her way, and what strategies can she use to overcome these? • REPEATthe messages at each visit.

12. Leigh Leigh is a 21 year old junior who presents in the clinic for birth control consultation. She has no significant past medical history and has never used oral contraceptives before. Family history is positive for obesity and diabetes in her mother and hypertension in her father, both former smokers. Maternal GM died of a stroke at 60. Leigh is engaged to marry her boyfriend of two years, who is a non-smoker. On physical exam she is 5’6”, weighs 140 lbs, and has a BP of 128/80. Smoking history indicates that she smokes 10-15 cigarettes per day, has smoked for 4 years, has her first cigarette after breakfast, but mostly smokes during breaks and in the evening when she studies or socializes. She lives in a residence hall that allows smoking, but is planning to move into an apartment with her fiancée, who is encouraging her to quit. She has never made a serious quit attempt before and is concerned about how quitting might effect her weight and concentration when studying.

13. How Can You Best Assist Leighin Her Quit Attempt? • Applaud Leigh’s decision to make a quit attempt • Set a quit date • Discuss potential challenges to success and how to address them • Offer encouragement • Help Leigh to identify supportivefriends and relatives • Consider pharmacotherapy • Arrange follow-up

14. Eric Eric is a 21 year old junior who presents to the clinic for evaluation of “hay fever” with symptoms of a runny nose and itchy eyes. He is otherwise in good health and has no significant medical history. He’s a pitcher on the varsity baseball team. Although he only smokes occasionally when he drinks, he has used chewing tobacco since his sophomore year in high school. He currently dips an average of 4-5 times per day and goes through 1-2 cans per week. He has never tried to quit, because he doesn’t think he could play baseball as well without it, and believes that chewing is a safe alternative to smoking. On performing an ENT examination, you note that Eric has yellowish-brown teeth, some periodontal inflammation, a few pale plaques on his gums, plus the findings you expected to see with his allergic rhinitis. When you advise him to consider quitting, he says he has no interest.

15. What Can You Do to Help Motivate Eric to Consider Making a Quit Attempt? • Inform him of the RELEVANT findings on his exam • Personalize his RISK factors • Point out the potential REWARDS to his health of quitting now • Address the ROADBLOCKS of what Eric sees as the benefits of his tobacco use and fears about quitting • Send him home with educational materials and REPEAT message at every visit.