Richard Brookman, MD Earl Dowdy, PhD

1. Virginia Commonwealth UniversityPediatric Grand Rounds 1 March 2005 “Adolescent Tobacco Use:The Challenge for Public Health and Clinical Practice” Richard Brookman, MD Earl Dowdy, PhD

2. Tobacco: A Public Health Menace • Tobacco use causes, according to the CDC, 440,000 deaths per year • greater toll in human life than that exacted by car accidents, murders, suicides, fires, other drug and alcohol use, and HIV/AIDS, combined • without improvements in use prevention, more than 6 million people now 18 and under will die from tobacco’s effects • Over $75 billion in public and private healthcare costs each year • Reduces the productivity of Americans by more than $80 billion per year

3. Tobacco Use: A Pediatric Disease • ~80% of current adult smokers began tobacco use before age 18; ~90% began before age 21 • Tobacco-industry internal documents show intent to manipulate adolescent psychology through advertising • 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 Camel logo and associated it with cigarettes; Joe Camel was as familiar as Ronald McDonald or Mickey Mouse • In 1996, ½ of adolescent smokers, and ¼ of adolescent non-smokers, possessed some tobacco-promotion item (hats, t-shirts, etc.) • According to FTC filings, between 1996 and 2000 tobacco industry spending on advertising increased 86%, from $5.1B to $9.5B • Currently, 82% of adolescents (ages 12-17) prefer heavily advertised brands (Marlboro, Camel, Newport)

4. Tobacco Use: A Pediatric Disease • 2/3 of adolescent smokers say they want to quit, but can’t • Nicotine is addictive – cigarettes (and other tobacco products) are “nicotine delivery devices”

5. Tobacco Use: A Pediatric Disease • Between 1/2 and 2/3 of Americans under age 19 try cigarettes at least once • Adolescents who continue to smoke suffer mild airway obstruction and slowed growth of lung function • Adolescent smokers, on average, have 10% elevation in triglyceride and low density lipoprotein levels, and 8% suppression in HDL levels • Laboratory studies have shown adolescent age mammals to be more vulnerable than adults to neurological impairment from nicotine exposure, particularly in systems associated with learning and reward • ~1/3 of people who become regular smokers as adolescents will die of diseases caused by smoking • Lung Cancer • Coronary Heart Disease • Chronic Obstructive Pulmonary Disease

6. Tobacco Use: A Pediatric Disease • Nicotine dependence develops in stages

7. Stages-of-Change in Tobacco-UseInitiation and Dependence • 1)Preparation / contemplation • knowledge, beliefs, attitudes, normative expectations are formed • 2) Initial trying – usually family or peer associated • 3) Experimentation – irregular use over time • 4) Regular use – often associated with alcohol use • 5) Nicotine dependence/addiction • often associated with use of 10 or more cigarettes/day • dependence-producing dose varies considerably among individuals • signs of dependence may occur at a smoking rate of as little as 2 cigarettes/week • addiction typically develops within 2 years of first use • signs of dependence may appear within two months of first use

8. Stages-of-Change in Tobacco-Useand Nicotine Dependence Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 CONTEMPLATING TRYING EXPERIMENTING Relative Numbers of Adolescents/Stage* USING REGULARLY USING HEAVILY Increasing Risk of Nicotine Dependence * Estimates, based on CDC, “Trends in Cigarette Smoking Among High School Students – United States, 1991-2001,” MMRW 51(19).

9. Stages-of-Change in Tobacco-Use and Nicotine Dependence • Different prevention approaches are appropriate at different stages and ages of onset • Empirical research is underway to understand the complex etiology of tobacco use, and to develop and evaluate prevention and cessation best practices in a range of situations • An array of variables affects probability of tobacco use and nicotine dependence in individual adolescents, including • genotypes, differential gene expression in various neural tissues, and gene-environment interactions • gender / body image • ethnicity • SES, education

10. Tobacco Use: Risk Factors in Adolescents • Parents, siblings, peers who use tobacco • Favorable views of smoking • Experimentation with tobacco • Poor academic achievement • Risk-taking, rebelliousness • Depression, anxiety, ADD • Male • Age 10-18 years

11. Tobacco Use:Patterns of Incidence Among Youth • First use of tobacco usually occurs between the ages of 11 and 13 (6th-8th grade) • By the end of high school, 1/2 - 2/3 have experimented with tobacco • By the end of high school, about 1/3 of experimenters have become regular, daily smokers • higher ratio of regular tobacco users to experimenters than that seen with alcohol, marijuana, or cocaine • signs of nicotine dependence (craving, irritability or anxiety, unsuccessful quit attempts) can appear within days or weeks of first use, and before daily use is established

12. Youth Tobacco Use: Patterns of Incidence(Monitoring the Future Study) • ~3/4 of high-school grads who are regular, daily smokers have tried to quit and failed • Less than 1 in 7 high-school regular smokers have successfully stopped smoking for 30 days or more • 3% of high-school daily smokers say they will be smoking in 5 years • More than 60% of those who are regular smokers at high school graduation are still smokers 7-9 years later

13. Tobacco Use by High School Students(2003 Youth Risk Behavior Survey) • 58% have ever tried smoking • 22% smoked at least once in past 30 days • 10% smoked on 20 or more of past 30 days • 16% smoked every day for past 30 days • 3% smoke more than 10 cigarettes a day • 20% males, 16% females have smoked a whole cigarette before age 13

14. Tobacco Use by High School Students(2003 Youth Risk Behavior Survey) • 30% of males, 25% of females have engaged in some form of tobacco use in the last 30 days • 11% males, 2% females used smokeless tobacco in past 30 days • 20% males, 2% females smoked cigars in past 30 days • 21% have purchased cigarettes before turning 18 • 8% report smoking on school property • 6% report using smokeless tobacco on school property

15. Incidence by Gender & Ethnicity (2003 Youth Risk Behavior Survey) • 25% of white, non-Hispanic high school students report current cigarette use (in the past 30 days) • 26.6% white females • 23.3% white males • 15% of black, non-Hispanic high school students report current cigarette use • 10.8% black females • 19.3% black males • 18.4% of Hispanic high school students report current cigarette use • 17.7% Hispanic females • 19.1% Hispanic males

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

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

18. Reasons for Recent Decline in Tobacco Use Among Youth • Intense adverse publicity • Rise in prices and taxes • Change in marketing due to Master Settlement • End of Joe Camel logo • Cessation of billboard advertising • Anti-smoking advertising

19. Interviewing Adolescents About Tobacco Use • Have you ever smoked a cigarette? • (If they say they do smoke or have smoked) • How many cigarettes do you smoke in • A day? A week? A month? A year? • When was the last time you smoked a cigarette? • Today? Yesterday? In the past week? Month? Year? • Does your mom smoke? • Does your dad smoke? • Do you have any brothers or sisters who smoke? • What percentage of your friends smoke? • None? Less than half? More that half? Almost all?

20. USPHS Smoking Cessation Guidelines • ASK about tobacco use • ADVISE to quit • ASSESS willingness to attempt quitting • ASSIST in quit attempt • ARRANGE for follow-up

21. The Hooked on Nicotine Checklist (HONC) • Have you ever tried to quit, but couldn’t? • Do you smoke now because it is really hard to quit? • Have you ever felt like you were addicted to tobacco? • Do you ever have strong cravings to smoke? • Have you ever felt like you really needed a cigarette? • Is it hard to keep from smoking in places where you are not supposed to, like school?

22. The Hooked on Nicotine Checklist (HONC) When you have tried to stop smoking, or when you haven’t used tobacco for a while • Did you find it hard to concentrate because you couldn’t smoke? • Do you smoke now because it is really hard to quit? • Did you feel more irritable because you couldn’t smoke? • Do you feel a strong need or urge to smoke? • Did you feel nervous, restless, or anxious because you couldn’t smoke?

23. Brief Intervention for Smoking Cessation • RELEVANCE - determine personal reasons • RISKS - identify negative consequences • REWARDS - identify potential benefits • ROADBLOCKS - identify barriers & solutions • REPITITION - repeat motivational intervention

24. Office Environment for Smoking Cessation • Smoke-free office • Affirmative pamphlets, posters • Elimination of tobacco advertising (magazines) • Reinforcement by other staff • Chart prompts • Trigger questionnaires • Cessation education materials • Resources for referral

25. Guidelines for Adolescent Preventive Services (GAPS) • Promulgated by the AMA’s Department of Adolescent Health • Focus on 11 to 21 year olds • Health risks for this age group are influenced by socialization and become engrained through habituation • Risk assessment, prevention and early intervention are keys to successful adolescent health promotion • Ask each adolescent, at least once a year, about their tobacco use and other high-risk behaviors • Become knowledgeable about intervention strategies and options, and become an advocate for access to evidence-based approaches

26. Tobacco Use:Inadequate Healthcare System Response • ~70% of adolescents see a physician yearly • ~30% of these are asked about their tobacco use • <10% are asked about parent, sibling or peer tobacco use • Inadequate rates of counseling for adolescents who present with tobacco use • Studies show inadequate charting of tobacco use and other types of behavioral screening

27. Tobacco Use: Entrée to Methods of Evidence-Based Adolescent Clinical Practice Adolescents 11-21 Years Old { • Age • Gender • Ethnicity • SES • Co-occurring Disorders Vulnerable Populations { • Injuries • Sex • Substance Use • Stage of Behavior Devel. • School Failure • Incarceration High-Risk Behaviors { • Frequent & Reliable Observations? • Accurate & Available Clinical Records? • Available, Evidence-Based Interventions? Clinical Screening & Intervention { • Service-Provider Surveys • Medical Records Review • Indep. Observations of Clinical Interactions • Patient Post-Visit Surveys • Follow-Up Measures of Effectiveness System Performance Measures

28. Evidence-Based Adolescent Clinical Practice • Know your patients – know their history!

29. Modes of Policy Action and Influencefor Medical Clinical Practitioners Academic Collaboration Community Advocacy Physicians Health Policy Clinical Trials & Research Govt. Advisory Panels Clinical Practice Professional Societies Business Partnerships

30. Adolescent Tobacco Use: Community-Based Action by Medical Professionals • Join with community-based adolescent risk-prevention efforts • Encourage local officials to adopt and strictly enforce bans on • the use of all tobacco products on school property • the sale of tobacco products to minors • smoking in public places and in places of employment • Encourage local merchants not to display tobacco advertising • Support increases in local, state, and federal excise taxes on tobacco products

31. Cigarette Excise Tax Increases and Projected Effects on Demand in Virginia

32. Campaign for Tobacco Free Kids http://www.tobaccofreekids.org/ Doctors Ought to Care – DOC http://www.bcm.edu/doc/ CDC – TIPS http://www.cdc.gov/tobacco/ DHHS – SAMHSA http://prevention.samhsa.gov/ Tobacco.org – Tobacco Control News http://www.tobacco.org/ Society for Adolescent Medicine http://www.adolescenthealth.org/ index.htm American Academy of Pediatrics – Pediatric Research in Office Settings (PROS) http://www.aap.org/pros/abtpros.htm American Academy of Family Physicians http://www.aafp.org/ American Medical Association – Adolescent Health http://www.ama-assn.org/ama/pub/ category/1981.html American Medical Association – Clinical Practice http://www.ama-assn.org/ama/pub/ category/6886.html Tobacco Use and Clinical Practice:Resources on the World Wide Web

33. Science, for a Tobacco-Free Virginia The Virginia Youth Tobacco Project

34. The Virginia Youth Tobacco Project www.vytp.vcu.edu

35. Pharmacotherapies for Smoking Cessation • Nicotine gum - 2mg/4mg pieces • Nicotine patch - 16/24 hours • Nicotine nasal spray - 0.5 mg/spray • Nicotine inhaler - 4 mg over 80 inhalations • Buproprion SR tablets • Clonidine • Nortriptyline