Teen Tobacco Use—Prevention and Treatment

1. Teen Tobacco Use—Prevention and Treatment This activity is made possible through a grant from the Illinois Department of Public Health, Illinois Tobacco-Free Communities Program.

2. Learning Objectives • Define the problem. • Identify the risk factors. • Understand readiness for change. • Develop and implement effective interventions. • Discuss role in implementing health policies.

3. The Scope of the Problem

4. An Epidemic Disease • Two-thirds of 12th graders have tried tobacco. • Each day more than 6,000 teens smoke their first cigarette, and 3,000 teens become daily smokers. • 4.5 million teens are now tobacco users. • 30% of 12th graders and 12% of 8th graders currently use tobacco products. • Most adult smokers developed a regular smoking habit by the age of 18.

5. Short-term Health Effects • Smoking • Greater susceptibility to colds and flu • Increased severity of respiratory infections • Decreased physical fitness • Precursors of peripheral artery disease • Chewing tobacco • Cracked lips, mouth sores, bleeding gums

6. Long-term Health Risks • Addiction to nicotine • Increased risk of cancer • Increased risk for developing: • Cardiovascular disease • COPD • Hypertension • Premature death

7. Trends in Current Cigarette Use* __12th Grade __10th Grade __ 8th Grade % *Smoked cigarettes within the last 30 days

8. 40 35.3 35 29.7 29.5 28.7 30 23.8 25 % 20 14.7 15 13.3 13.0 12.2 12.2 12.0 10 8.2 5 0 Total Male Female White Hispanic Black 8th Grade 12th Grade Current Cigarette Use* *Smoked cigarettes within the last 30 days

9. Addiction and Risk

10. Nicotine Nicotine Dopamine Dopamine Neuron Dopamine Neuron Nicotine Acetylcholine Addiction via the Brain’s Reward Center

11. Withdrawal Symptoms • Cravings for nicotine • Insomnia • Irritability and anxiety • Frustration • Anger • Depression • Difficulty concentrating • Restlessness • Increased appetite

12. Risk Factors • Association with friends who smoke • Parents who smoke • Comorbid psychiatric disorders • Weight concerns

13. Environmental Influences: Tobacco Use Seen in Films Age (years) ___14-15 ___13 ___12 ___9-11 % who Tried Smoking (# of Exposures) Sargent et al., 2001

14. Smoker Characteristics • Less attachment to parents • Poor school performance • Less involvement in extracurricular activities • More psychological stress

15. Cycle of Adolescent Tobacco Use Secondaryabstinence Abstinence Environmentalfactors Cessation Experimentaluse Relapse Personal and pharmacological factors Regularuse Dependentuse

16. Stages of Change Precontemplation Contemplation Preparation Action Maintenance Termination Relapse

17. Prevention and Treatment

18. Role of Primary Care • Ask about tobacco use at every visit. • Overcome barriers to treatment. • Establish an office system. • Use established interview tools and treatments.

19. Barriers Faced by Physicians • Lack of comfort • Lack of training • Lack of information • Lack of time

20. Establishing an Office System • Enforce a smoke-free office. • Remove tobacco ads from magazines. • Have routines to identify users. • Name an office “tobacco expert.” • Offer treatment to all tobacco users. • Make educational materials available. • Get everyone in the office involved. • Follow-up on quitters.

21. Vital Signs Stamp Vital Signs Blood Pressure: Pulse: Temperature: Respiration: Weight: Height: Tobacco Use: ____Current ____Former ____Never ____Mom ____Dad ____Inside ____Outside

22. Identifying the Users: Confidentiality • Interview teens separately from parents, and guarantee confidentiality. • Include parents in the interview, and enlist support.

23. Smoking Assessment Form • Name ______________________ Date ______________ • Have you ever smoked cigarettes • or used tobacco (cigars, chew)? Yes No • 2. Do you currently smoke cigarettes? Yes No • 3. Do you currently use other tobacco • products (cigars, chew)? Yes No • 4. Do any of your close friends smoke cigarettes • or use tobacco? Yes No • 5. How often do you smoke? • Every day 3-5 days/week 1 day/week Less then 1 day/week

24. Smoking Assessment Form • 6. How interested are you in stopping smoking or using tobacco? Not at all A little Very • 7. If you decided to quit smoking or using tobacco in the next 2 weeks, do you think you would succeed? Definitely Maybe I doubt it

25. Getting into their HEADS Home: Who lives with you? Education: How is school? Activities:What do you do for fun? Drugs:Do you ever use tobacco? Sex:Are you are having a sexual relationship?

26. Prevention Strategies • Counsel parents to quit. • Encourage parents to discourage tobacco use. • Adapt the message. • Reinforce tobacco-avoidance behaviors.

27. Glamorous! But the breath is too much! 3-Minute Smoking Facts • Lack of control when addicted. • The tobacco industry is manipulating you. • Tobacco use is expensive. • Smoking causes yellow teeth and bad breath. • Cigarettes are bad for your health. • Most kids do not use tobacco products. • Cigarettes contain toxic chemicals.

28. Common Chemicals • Acetone • Ammonia • Arsenic • Butane • Cyanide • DDT • Formaldehyde • Naphthalene • Tar If you wouldn’t put it on your pizza, why would you smoke it?

29. 866-QUIT YES Illinois Tobacco QuitLine 866-784-8937 Tobacco QuitLine

30. Tailoring the intervention

31. Treatment Strategies—the 5 A’s Ask Advise Assist Arrange Anticipatory Guidance

32. Treatment Strategies—the 5 A’s • Ask all patients about tobacco use. • Advise all tobacco users to quit. • Assist in the development of a plan for quitting.

33. Tobacco-Use Quit Date Agreement I,____________, agree to stop smoking/using tobacco on _____________. I understand that stopping smoking/using tobacco is the single best thing I can do for my health. My doctor has strongly encouraged me to quit and will assist me with quitting. _________________________________________ Patient’s Signature Physician’s Signature Quit Date Form Adapted from Ammerman, 1998

34. Treatment Strategies—the 5 A’s • Arrange follow up and provide support. • Anticipatory Guidance: Discuss obstacles to quitting and potential relapse.

35. Remember why you are quitting. Chew gum. Breath deeply. Call a friend. Change your. routine Exercise. Drink water. Reward yourself. Practical Suggestions Take one day at a time

36. Relapse Prevention • Critical timeframe—first 3 months. • Encourage continued abstinence. • Discuss benefits, milestones, problems. • Unsuccessful attempts: • Reinforce decision to quit. • Review benefits of quitting. • Resolve barriers to quitting.

37. Pharmacotherapy • 5 safe, FDA-approved, first-line therapies* • Approximately double the rate of cessation compared to placebo. • All help with symptoms of withdrawal. * Only approved by the FDA for tobacco-use cessation in patients aged 18 yearsand older.

38. Adverse Effects of Pharmacotherapy

39. Pharmacotherapy Research • Study 1 (n=22): • Nicotine patch for 8 weeks (22 mg/day for 1st 6 weeks; 11 mg/day for rest of study). • 3 (14%) quit by week 8; 1 was smoke-free at 3 and 6 months.1 • Study 2 (n=101): • Nicotine patch for 6 weeks (15 mg/16 hr). • 11% quit at end of study; 6% were smoke-free at 6 months.2 1 Smith, et al. 1996; 2 Hurt, et al. 2000

40. Pharmacotherapy Comparison

41. Pharmacotherapy Comparison

42. Estimated Cost Per Day

43. Health Policy

44. Tobacco Control Measures • Purchasing restrictions • Advertising restrictions • Increased tobacco excise taxes • Comprehensive state-wide programs

45. Need for Improvement • Build awareness of health risks. • Block availability of tobacco products. • Limit tobacco advertising. • Increase prices. • Restrict public smoking. • Increase funding for state programs.

46. Health Policy • Promote school-based programs. • In Florida, smoking rates  by 40%. • Tar Wars program Winning poster from the Tar Wars 2001 National Poster Contest, drawn by Leah Norsworthy from Oklahoma

47. Health Policy • Get involved in community programs. • Support the Great American Smokeout. • Join tobacco-control coalitions.

48. Health Policy • Change tobacco-use legislation. • Minors’ access to tobacco products • Environmental tobacco smoke • Preemptive legislation • Participate in counter-marketing campaigns.

49. Conclusions • Adolescent tobacco use is prevalent. • The key risk factor for teen smoking is friends who smoke. • Physicians must ask about tobacco use and assess readiness to change. • Tobacco-treatment intervention by physicians with teens is essential.

50. is a CME program co-sponsored by the IAFP, FPEN, ICAAP, AAP, and IDPH. Teen Tobacco Use—Prevention and Treatment