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Title: Reducing Tobacco Use Among Youth: Effective Prevention and Cessation Strategies


1
Reducing Tobacco Use Among Youth Effective
Prevention and Cessation Strategies
  • Paul McDonald, PhD
  • University of Waterloo
  • Centre for Behavioural Research and Program
    Evaluation
  • Ontario Tobacco Research Unit

2
Whats on your mind?
  • Are their reasons to be optimistic about youth
    smoking?
  • What you should know about claims for best
    practice
  • How to help youth smokers to quit smoking?
  • Best treatments
  • Improving participation in cessation programs?
  • How to prevent smoking? Impact of
  • Community wide strategies
  • Taxes
  • Sales to minors/access restrictions
  • Youth possession laws
  • School policies and characteristics
  • School based education
  • Interventions thru primary care providers
  • Parental factors
  • Individual characteristics of youth
  • Future trends/frontiers

3
Why focus on youth?
  • 15 to 24 years olds make up 16 of population in
    Nova Scotia but 18 of tobacco users (CTUMS,
    2003)
  • across Canada, 15-24 yr olds make up 16 of pop
    but 25 of smokers
  • Compared to never smokers, a 15 year old smoker
    is twice as likely to die before their 70th
    birthday
  • The earlier an individual starts to smoke, the
    greater the threat to their health
  • starting to smoke before age 15 doubles the risk
    of lung cancer compared to starting after age 15
  • The sooner a smoker quits smoking, the lower the
    risk to their health
  • Quitting before age 40 eliminates 90 of the
    health risks associated with tobacco use

4
There are reasons for optimism!
5
Estimated prevalence of current smokers by age
and sex in Nova Scotia, 1999-2003
Percentof Current Smokers
Year
Source Health Canada, Canadian Tobacco Use
Monitoring Survey (CTUMS)
6
Reasons for optimism
  • Youth have tried to quit in past year
  • 67 of 15-17 yr olds
  • 61 of 18-19 yr olds
  • 60 of 20-22 yrs olds
  • 52 of 21-22 yr olds
  • 40 of 25

CTUMS, 2002
7
Helping youth to quit smoking
There no need to throw your hands in the air
the problem isnt completely unbearable
8
How should we define best practice?
  • Best depends on who is asking the question
  • Smoker or clinical provider approach that
    maximizes my/smokers odds of remaining abstinent
    or cutting down
  • Public health approach that maximally reduces
    health related burden of smoking
  • Voluntary agency approach that maximally
    reduces CVD, cancer, psychiatric illness, etc.
  • Government or pharmaceutical company approach
    that produces largest return on investment

9
How should we define best practice?
  • In general, you need to balance
  • Odds of reaching your goal (e.g., effectiveness)
  • Number of youth who use and/or are exposed to
    effective interventions
  • The cost per success (this ensures you are using
    fixed resources to help as many people as
    possible)
  • Outcomes may be different for different subgroups
    (based on sex, age, culture, SES)

10
Important Distinctions
  • Proven (recommended) practice A practice or
    approach that has directly, repeatedly, and
    consistently demonstrated a desirable outcomes
    (effectiveness, cost efficiency, etc.)
  • Note the term best depends on the outcome of
    interest and the audience receiving the
    intervention
  • Whats best for one program provider or intended
    user may not be whats best for another
  • Promising practice An approach that, based on
    consistent indirect evidence, consistent
    incomplete evidence, and/or preliminary direct
    evidence, will likely be proven to be effective,
  • E.g., only one or two studies with only modest
    effect

11
Important Distinctions
  • Insufficient evidence/not recommended at present
    An approach that has resulted in inconsistent
    findings, or for which there are too few highly
    valid studies.
  • Worst practice An approach that consistently
    fails to produce a desired outcome or is deemed
    to be potentially and un-necessarily harmful
    (e.g., deprivation tanks),

12
Effectiveness of individual treatments
  • McDonald et al., (2003 Am. J. Hlth Beh. Vol 27,
    suppl. 2)
  • Refinement of Sussman, 2002
  • Determined to be the most comprehensive and
    rigorous
  • Used a panel of experts instead of single
    reviewer
  • Results based on 5 studies with high validity
    plus 15 studies with at least moderate validity
    (emphasis put on high validity studies)

13
What is a valid study?
  • Studies were reviewed with respect to
  • Whether they had a clear definition of abstinence
  • Whether they used biochemical validation
    (cotinene is best)
  • Whether the study included a suitable control
    group (RCT was best)
  • Sample size and low loss to follow-up
  • If the intervention was theory based and properly
    described
  • A measure of implementation compliance
  • The length of the follow-up period (gt 6 months
    was preferred)
  • The analysis included all people in the
    denominator of the quit rate, not just those who
    could be followed up.

14
Expert panel findings(McDonald et al., 2003)
  • There are no proven practices at the present
    time
  • There are some promising treatments to help youth
    quit smoking
  • 9 of 20 were effective (incl. 2 of 5 high
    validity)
  • Treatments based on social cognitive
    theory/cognitive-behavioural approaches are
    promising
  • 8 of 9 promising treatments utilized SCT
  • 8 of 14 that used SCT were effective (incl. 2 of
    5 high validity)

15
Sample of Cognitive-Behavioural
Techniques/Components
  • Develop positive expectancies (values) and
    expectations re quitting
  • Belief that quitting will get you something of
    value confidence that it is possible to quit
    confidence in a quit aid
  • Goal setting
  • Making a private and public commitment for a quit
    date
  • Behavioural contract specifying goal (quit or
    reduce) and consequences of obtaining the goal
  • Self monitoring
  • Keeping a diary of behaviour, thoughts, feelings,
    environment before and after quitting
  • Develop self-efficacy (confidence that you can
    quit and remain abstinence)
  • thru modeling, practice/mastery, management and
    reinterpretation of physical symptoms

16
Sample of Cognitive-Behavioural
Techniques/Components
  • Problem solving, develop coping and relapse
    prevention skills
  • Anticipate challenges and develop alternate
    strategies for dealing with them
  • Counter conditioning
  • replace negative feelings, thoughts, physical
    sensations with positive thoughts, feelings,
    sensations thru self talk, relaxation, systematic
    desensitization
  • Reinforcement and punishment
  • Apply a positive reinforcer (praise)
  • Remove a negative reinforcer (stop nagging)
  • Punish by removal (pay a fine for smoking)
  • Punish by application (e.g., rapaid smoking not
    recommended)

17
Sample of Cognitive-Behavioural
Techniques/Components
  • Removing social, physical, cognitive and
    emotional cues for smoking
  • Breaking behavioural chains
  • Anger management and/or assertiveness training
  • Motivational enhancement
  • Develop insight into problem)
  • Enlisting the help and support of others

18
Expert panel findings, cont
  • Insufficient evidence to support other
    theoretical approaches
  • NO evidence to support stages of change with
    adolescents
  • Lawrance, McDonald et al. (unpublished) 200
    high schools students
  • Aveyard et al (1999) 8,000 UK 13/14 yr olds
  • Quinlan McCall daily smokers in college
  • Efficacy with adults has also been questioned
  • Riemssma et al, 2003 BMJ review of matched
    treatments
  • McDonald, in progress
  • Whitelaw et al., 2000 - review

19
Expert Panel Findings, cont
  • Insufficient evidence to draw conclusions about
  • Pharmacotherapy (NRT, Zyban)
  • NRT wont harm youth smokers
  • May not be effective for light adult smokers
    either (Pierce Gilpin, 2002 Niaura et al.,
    1994)
  • Youth have less experience modifying their
    behaviour hence, non-physiological factors may
    figure more prominently
  • Best delivery setting
  • Most treatments delivered in school settings
    (class or outside) and health clinics
  • Some school based and clinic programs were
    effective (just not enough to draw conclusions)
  • Note youth smokers less likely to be in school
    or use clinics

20
Expert panel findings, cont
  • Insufficient evidence to draw conclusions about
  • Best type of provider
  • 4 of 6 teacher/school staff delivered programs
    were effective (all mod. Validity)
  • 2 of 4 using psychologists, health educators or
    counselors were effective
  • 1 of 3 using trained peers was effective
  • Voluntary vs. mandatory treatment
  • None of the 3 mandatory treatments were effective

21
Additional observations and speculations
  • Virtually all effective treatments involved 8 to
    24 hours of contact with trained facilitator
    (observation)
  • In the absence of strong environmental supports,
    it is unlikely that low contact programs will be
    effective with youth (speculation)
  • Few studies examine non-face to face interactions
    such as web-based or telephone counseling
    (observation). These may have high appeal for
    youth (speculation).
  • Treatments more likely to be effective with youth
    age16 (observation).

22
Additional observations and speculations
  • Few studies with special populations, despite
    high prevalence and over-representation
    (observation).
  • One study with psychiatric co-morbidity was not
    successful
  • Specially designed programs will likely be
    required to help youth deal with special and
    substantive challenges associated with
    psychiatric illness, poverty, acculturation, etc.

23
Additional observations and speculations
  • Few studies have looked at the impact of policy
    on cessation or consumption (observation)
  • No studies looked at interaction between
    intrapersonal and environmental factors
    (observation)
  • Based on emerging literature with adults, it is
    highly likely that social, economic, and physical
    environmental factors will have a profound effect
    on cessation rates (speculation)
  • Programs must make youth aware of environmental
    conditions and alter perceptions and develop
    coping strategies (speculation)

24
Additional observations and speculations
  • Few studies look at combination of formats,
    delivery methods, providers, settings, etc.
    (observation)
  • Most studies had high loss to follow-up
    (observation) which suggests (speculation)
  • Its difficult, even under ideal conditions, to
    keep youth engaged
  • It significantly undermines statistical power
    (increases likelihood of missing a true effect)

25
Best practices for promoting cessation aids to
youth
  • Review of literature (mostly based on surveys or
    interviews with youth in school settings)
  • Factors that increase utilization
  • Program is free or incentive provided
  • Friends are supportive
  • Friends are using it
  • Easy to use/low burden
  • Program is effective
  • Program is lead by adults from outside of school
  • Factors that inhibit utilization
  • Potential breach of confidentiality/privacy (esp.
    to parents)
  • Program or material cost money
  • Program offered after school

26
Promoting cessation aids
  • Meta-analysis of 48 promotion campaigns to youth
    smokers (12 to 24)
  • Median recruitment rate was 7.8 from a median
    audience size of 310

27
Maximizing participation in cessation
aids(McDonald et al meta-analysis)
  • Message characteristics
  • Campaign should last gt 3 months
  • Use credible adult spokesperson (not youth or a
    combo)
  • Channel characteristics
  • Use media in community rather than rely on school
    or clinic-based promotion

28
Maximizing participation in cessation aids
  • Source characteristics
  • Local health department, non-profit agency or
    research organizations are better than provincial
    or federal government sponsors
  • Destination characteristics
  • Programs offered thru youth centres and
    workplaces had higher recruitment than schools or
    clinics
  • Programs offered during winter are best
    spring/summer the worst
  • Programs offered before school, during lunch or
    during work are better than after school

29
Checking our assumptions
  • Although intentions predict cessation, cessation
    also predicts changes in intentions
  • Any quit attempt is a good attempt
  • Zhu et al. (1999), Lawrance and McDonald (1996)
    and others have found that to be predictive of
    future abstinence a quit attempt needs to last at
    least 14 days short term quit attempts may
    actually reduce future success (although studies
    need to adjust for self efficacy and other
    factors)

30
What does it mean?
  • Providers dont have to passively wait for the
    research to be done
  • Just dont repeat the mistakes of the past (e.g.,
    simple brief interventions are not effective)
  • Dont declare success based on pen-ultimate
    measures (quit attempts, intention to change)
  • You can try new approaches, provided you
    rigorously evaluate them and share your results
    (good or bad)
  • If you dont have the expertise or resources,
    find a research group to work with

31
Promising interventions focused on individual
change
  • Not on Tobacco (NOT) American Lung Association
  • No More Butts! Nova Scotia Public Health
  • Quit 4 Life Health Canada
  • Kick the Nic BC Ministry of Health

32
Promising comprehensive interventions
  • Leave the Pack Behind Brock University
  • Individual self help materials and website
  • Referrals to quit line and health professionals
  • Appoint student coordinators
  • Eliminate campus sales of tobacco
  • NRT widely available on campus
  • Train campus health service staff to deliver
    brief interventions
  • Smoke free campuses
  • Eliminate tobacco advertising and sponsorships
    (e.g., students newspapers)

33
Preventing adolescents from using tobacco
Whats the right recipe?
34
Some important background
  • Two thirds of adolescents will try using tobacco
    at least once before the end of grade 12
  • Experimentation can occur anytime between age 5
    and 25
  • Its no longer true that 95 start before age 18

Driezen et al, submitted
35
When do youth start to experiment? Cumulative
Per cent of Youth Who Try Smoking, by the End of
Each Grade
Cumulative who have tried smoking
Grade
Driezen et al, submitted
36
Transition from experimentation to regular
tobacco use
of regular grade 12 smokers
Grade
Driezen et al, submitted
37
Community wide interventions
  • Taxes
  • Reducing access to tobacco
  • Youth possession laws
  • Banning point of purchase tobacco displays
  • No smoking restrictions
  • Public places
  • Schools
  • Homes

38
Do tax increases work?
  • Yes. Most studies suggest a price elasticity of
    about -1.0.
  • A 10 price increase will decrease youth
    consumption by about 10
  • Impact on initiation may be more modest a 10
    price increase reduces initiation by about 3
  • Effects may be greatest on regular smokers under
    age 16 and those in low SES groups

39
Speaking of taxes
  • Ask your Premier and Ministers of Health why Nova
    Scotia likely make more than 2.5 million/yr from
    cigarettes illegally consumed by youth under 18,
    but will spend only 2.1 million on tobacco
    control this year?

40
Does reducing access to tobacco reduce youth
smoking?
  • Review of studies suggest retail laws probably
    have a modest effect on youth smoking
  • Most effective with older youth who purchase own
    cigarettes
  • Less likely to effect young smokers who use
    social sources (friends, family, strangers,
    theft)
  • Trials are more likely to significantly reduce
    youth prevalence if
  • There is regular and sustained enforcement (e.g.,
    min. of 2 checks per vendor per year)
  • There is broad community support for restrictions
  • There is a simultaneous campaign to reduce
    distribution of cigarettes through social
    channels (adults, peers)
  • Adjacent communities also have similar
    restrictions that are enforced

41
Perceptions about access are important
  • Never smokers who thought getting tobacco would
    be easy were 41 more likely to try smoking
    and/or become regular smokers compared to those
    who believed it would be hard to get cigarettes

Source Gilpin et al. (2004) Prev. Med., 38,
485-491
42
Do youth possession laws work?
  • No evidence of effectiveness
  • Woodbridge IL reported effect but study was
    flawed
  • May strengthen attitudes toward tobacco as the
    forbidden fruit

43
Does banning point of purchase advertising
(Powerwalls) work?
  • Indirect support through studies which show usage
    is linked with advertising
  • Youth most likely to smoke brands that advertise
    the most
  • Odds of smoking increase if youth own merchandise
    with tobacco logo (e.g., hat, bag, backpack)
  • Direct mail campaigns circumvent bans on mass
    media
  • US Youth more likely to identify Marborough man
    than Olympic rings
  • Reductions of in-store advertising reduces sales
    to high school students (Wakefield et al, 2001).

44
Effect of no-smoking policies on youth smoking
  • Wakefield et al (2000) surveyed 17,287 students
    in 202 US high schools
  • Odds of 30 day smoking based on locations with
    restrictions compared to no restrictions
  • Total home ban .79 (.67 - .91)
  • Partial home restrictions .85 (.74 - .95)
  • Public places .91 (.83 - .99)
  • Enforced school ban .86 (.77 - .94)
  • School ban (no enforce) .99 (.85, 1.13)

45
Prevalence of smoking, by level of school smoking
policy
of grade 11 students who smoked daily
Rates of occasional smoking also differed, but
not as much as with daily smokers
Moore et al, 2001
46
Effects of perceived enforcement
  • Leatherdale et al. (in prep.) studied 4800
    Ontario students from 29 high schools who had
    tried smoking at least once
  • One time smokers who did not believe smoking
    restrictions at school were enforced were 30
    more likely to become regular smokers, compared
    to those who believed bans were enforced.

47
Perceived barriers to school policy
  • Teachers and admin staff have more pressing
    issues
  • Policing students will be time consuming
  • Moving students off school property increases
    school liability and reduces control over
    students
  • Greater risk of auto accidents, sex trade and
    illicit drug use increased student conflict
    unhappy neighbours and store keepers
  • The belief policies wont work
  • Policies may increase drop out rates among most
    vulnerable students
  • Resistance among staff who smoke

48
Are there other unintended effects of tobacco
free policies?
  • Ontario has had policy for 10 years no reports
    of auto accidents, increased sex trade, drugs,
    etc.
  • No significant increase in drop out rates because
    smokers are much more likely to drop out even
    when there is no smoking policy

49
Suggestions for success
  • Make the consequences of policy violation clear
    and enforce them consistently and early
  • Require policy violators to perform community
    service (clean up the butts) rather than suspend
    them
  • Suspension In school or out of school) may only
    increase rebelliousness
  • NO evidence that mandatory cessation is effective
  • Take pride in being a smoke free school dont
    apologize for it
  • Make neighbours part of the solution smoking
    wont go away by hiding it
  • Get as many people involved as possible (admin,
    teachers, staff, students, parents, neighbours,
    etc.)
  • Implement smoking cessation programs for staff

50
Other school factors that influence smoking
  • Great variation in smoking rates across schools,
    even after accounting for differences in SES,
    tobacco policies and education
  • The question is why?

51
Effect of smoking on school periphery on
  • Leatherdale et al., in preparation
  • Multi-level analysis with 6,679 non smokers at 29
    Ontario high schools
  • After controlling for other characteristics,
    non-smokers who saw students smoking at the
    periphery of the school were 24 more likely to
    indicate an interest in smoking

52
Influence of school ethos
  • gt23,000 students from 166 secondary schools in
    the UK
  • Smoking rates did not differ by academic
    performance (after controlling for SES)
  • Schools with lower smoking rates tended to offer
    more extra academic assistance, were more
    responsive to special needs, and had more
    behavioural control procedures

Aveyard et al. (2004) Soc. Sci. Med. 58,
1767-1780
53
Effect of worksite smoking restrictions
  • Leatherdale et al students from 29 Ontario high
    schools.
  • Never smokers exposed to smoking at work were 43
    more likely to try smoking
  • One time tobacco users exposed to smoking at work
    were 52 more likely to become regular tobacco
    users

54
School-based educationYou dont have to lose
your mind
55
What kind of school-based education doesnt work?
  • Approaches based on information deficit
  • Info on health risks (without other components)
  • Enhancing self esteem
  • Stress management

56
Peer pressure revisited
  • Equivocal evidence that peer groups put pressure
    on kids to smoke
  • Kids may be more likely to smoke if they have
    smoking peers because tobacco is more accessible
  • Direction of the influence may be backwards,
    especially in high school
  • Different identifiable groups have different
    smoking rates (skaters, jocks, arties, nerds,
    misfits, metal heads, etc.)
  • Kids may smoke to be accepted in a desired group
    that has a perceived norm around smoking

57
Its about social influences, not peer pressure
  • Positive reinforcers to smoke
  • Adult and peer role models
  • Smoking cues (e.g., smell of smoke)
  • Misplaced social attributions (re peer attitudes)
  • Tobacco advertising (better lifestyle,
    independence, etc.)
  • Negative reinforcers to smoke
  • Difficulty getting access to tobacco
  • Limitations where you can smoke (with penalties
    for violation)
  • Clear anti-smoking norms
  • Messages about the costs of smoking (health,
    social, economic)

Find ways to allow youth to make their mark in
positive ways way
58
What works?
  • Social influences approach involves understanding
    and developing skills to counter social
    influences such as family, friends, media,
    tobacco companies.
  • Social influences approaches can reduce smoking
    by 5 to 30 for up to 25 years, especially when
    they employ booster sessions (Skara and
    Sussman, 2003, Prev. Med. 37, 451-474)
  • Education approaches may be particularly
    effective with some schools
  • This may explain why the Hutchinson study failed
    to find significant effects

59
Interaction of education and school environment
Odds that a grade 6 never smoker will become a
smoker by the End of grade 8
Prevalence of grade 8 smoking
Cameron et al, 1999
60
What is best practice for tobacco control
education?
  • Intensity at least 10 lessons with tobacco use
    as the focus delivered over at least two years
  • Content info on health consequences social
    consequences social influences (peers, family,
    media) demonstrate that smoking is not the norm
    includes methods for students to make decisions
    about smoking develops skills to identify and
    resist temptations.

61
What is best practice for tobacco control
education?
  • Delivery interactive (brainstorming,
    discussion, research) includes modeling of
    tobacco use resistance behaviours includes
    rehearsal of resistance skills includes verbal
    or written commitment not to smoke or to quit
    includes discussions with parents includes
    discussion about public policy
  • Implementation includes training of
    facilitators (including what can be adapted and
    what is core) includes references to national,
    provincial and local events linked with policy
    and other comprehensive school elements
  • Doesnt matter if adult leader is a teacher or a
    nurse or how training is provided

62
Can health professionals help?
  • Systematic review by Christakis et al, 2003 (Am.
    J. Prev. Med.) of prevention interventions
    associated with physicians and dentists
  • 4 randomized trials with gt21,000 youth aged 10 to
    18 in UK, US, Finland
  • Only 1 of 4 studies found a significant effect
  • UK study no face to face contact age related
    materials discussing advantages of being smoke
    free mailed under cover of family doctor
  • Conclusion insufficient evidence

63
Parental influences on smoking
  • Many, but not all studies have found that youth
    are more likely to smoke if their parents smoke
  • Inconsistency likely due to failure to consider
    the nature of the parent-child relationship

64
Parental and household influences
  • Children that have daily dialogues with their
    parents about what they did that day reduce the
    probability they will smoke by 7
  • Effect is greatest on girls
  • Largest effect on 1213 yr olds (12) and no
    effect on 17 yr olds
  • Teen girls who live in households where limits
    are set on how they spend their free time are 3
    less likely to smoke
  • No significant effect on boys
  • Effective for 16 yr olds but not other age groups

Source Powel Chaloupka, 2003 Impact Teen
65
Parental and household influences
  • Youth who value their parents opinions are 18
    less likely to smoke compared to those who dont
    value their parents opinion
  • Impact is largest on 13 to 15 yr olds (29) with
    no effect by age 17
  • Teens that live in households where no one is
    allowed to smoke are 5 less likely to smoke
    compared to youth who live in houses with no
    restrictions on smoking

Source Powel Chaloupka, 2003 Impact Teen
66
Parental and household influences
  • Children of parents who never marry, or are
    separated or divorced are 4 to 6 more likely to
    smoke
  • Having a parent die has no impact on probability
    of smoking
  • Conclusions Being a good parent means more than
    just quitting. It also means being engaged with
    your children and setting reasonable limits on
    behaviour
  • Family friendly policies are good for everyone

Source Powel Chaloupka, 2003 Impact Teen
67
Other factors that increase the risk of youth
smoking
  • Having peers that smoke
  • Psychiatric or behavioural problems
  • Rebelliousness
  • Low SES
  • Problems in school/attachment to school
  • Living on your own
  • Disposable income

68
What can communities do?
  • Implement and support school education in high
    risk schools using social influence model
  • Adopt and enforce smoke free homes, work places
    and public places

69
What can communities do?
  • Provide adequate cessation programs for adults
    who want to be good role models
  • Provide intensive cognitive behaviorual
    couselling for youth who want to quit
  • Advocate for and enforce youth access laws (dont
    just leave it to enforcement officers)
  • Create public support for limiting distribution
    of tobacco through social channels

70
What can communities do?
  • Advocate for complete advertising restrictions
    (e.g., point of purchase displays)
  • Advocate for tax increases and for tax revenue
    from sales to minors to be re-invested for youth
    prevention
  • Support and recognize parents, schools,
    workplaces and youth who are trying to be
    constructive
  • Its time to turn the media tide lets accentuate
    the positive

71
What can communities do?
  • Advocate for policies which reduce
    marginalization of our youth and create
    empowerment

72
What can communities do?
  • Closely monitor local youth smoking rates in
    schools and communities and provide timely,
    constructive feedback to all stakeholders
  • Develop partnerships with researchers to shape
    the research agenda, collect and share
    standardized data, and enhance evaluation

73
Some final thoughts on prevention
  • Interventions should not be restricted to certain
    grades or ages
  • Adults are significant role models you cant
    eliminate youth tobacco use by only focusing on
    youth

74
Emerging trends and ideas
  • The nature of (youth) smoking is changing
  • The characteristics of youth who smoke are
    changing
  • Simple and inexpensive assessment and evaluation
    tools (SSP) are becoming available
  • Countering the tobacco industry
  • Reducing prevalence vs. changing trajectories.

75
Estimated Prevalence of Occasional Smokers in
Canada
Percentage of Occasional Smokers
Year
Sources Statistics Canada, Report on Smoking
in Canada 1985-2001 Health Canada, Canadian
Tobacco Use Monitoring Survey (CTUMS),
76
Percent of current smokers in N.S. who are
non-daily smokers
of Current Smokers who are Non-Daily Smokers
Data Year
Sources Statistics Canada, Report on Smoking
in Canada 1985-2001 Health Canada, Canadian
Tobacco Use Monitoring Survey (CTUMS),
77
Average number of cigarettes smoked per day,
Canada, 1999-2003 (among
daily smokers, ages 15 to 19)
Ave. Number of Cigarettes Smoked/Day
Year
Sources Health Canada, Canadian Tobacco Use
Monitoring Survey (CTUMS),
78
Average number of cigarettes smoked per day,
Canada, 1999-2003 (Daily
smokers aged 20 to 24)
Ave. Number of Cigarettes Smoked/Day
Year
Sources Health Canada, Canadian Tobacco Use
Monitoring Survey (CTUMS),
79
The characteristics of youth smokers are changing
  • More likely to have psychiatric problems
  • Especially conduct disorders, attention deficit
    hyperactivity disorder, anxiety disorder,
    depression
  • More likely to come from low income families
  • More likely to be aboriginal

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A new tool for assessment and evaluation The
University of Waterloo School Smoking Profile
  • A tool to assess smoking rates, patterns and
    determinants
  • Provides individualized reports to schools that
    can be used for planning actions
  • Repeating the survey provides an evaluation of
    progress
  • Separate versions for elementary and secondary
    school
  • Tested with gt120,000 students so far

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Front cover of the School Feedback Report
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The tobacco industry has changed their tactics
  • Greater focus on young adults (age 18 to 24)
  • Promotion (direct or indirect) of alternative
    products and imply they are healthier and less
    intrusive

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Ready or not, the tobacco industry is promoting
some new death traps
  • Cigarettes that use modified tobacco with lower
    nitrosomines, nicotine, etc. (Omni SCoR)
  • Smokeless tobacco (Snus)
  • New delivery systems that vaporize rather than
    burn tobacco (Eclipse Premier revisited
    Accord)

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Eclipse vs conventional cigarettes
  • Glass fibers from the mouthpiece may be inhaled
    (Kents microfilter revisited)
  • Eclipse users inhale more CO
  • Eclipse users must puff longer and harder to
    obtain similar amounts of nicotine as regular
    cigarettes meaning the respiratory tract is
    exposed to quantities of aerosol (light and mild
    revisited?)

Sources Lee et al, 2004 Fagerstrom et al, 2000
Stapleton, 1998 Pauly et al., 1998
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Is it déjà vu all over again?
  • The US Surgeon Generals report focused concerns
    on tar and nicotine
  • 1970s the tobacco industry introduced machine
    measured low tar cigarettes (ie light
    cigarettes)
  • Industry explicitly portrays light cigarettes as
    an option to quitting (e.g., True)
  • Within 10 years, light cigarettes become dominate
    product
  • Some health care professionals advise smokers to
    switch to light and mild
  • 1990s research shows light and mild do reduce
    health risk
  • Deeper inhalation patterns lead to rise of lung
    cancer deeper in the lung
  • Giovino et al., 1996) project that consumption
    may have fallen faster if not for low tar and
    nicotine cigarettes.

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Lets not let the tobacco industry gallop away
(again). Lets close the barn gate
  • We all do harm reduction. Therefore, the issue is
    not whether to do it, but how to do it.
  • Unless we take action NOW, the tobacco industry
    will set the agenda based on sales and marketing
    instead of science
  • We need an aggressive policy agenda that ensures
    individual level harm reductions are likely to
    produce population benefits
  • Regulatory and education frameworks must be based
    on sound science, not wishful thinking

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New frontiers in prevention
  • Not all students have similar trajectories
  • gt60 of youth try smoking at least once, but
    about one third become regular smokers
  • About 6 of youth appear to rapidly develop
    nicotine dependency (may have genetic
    pre-dispositions re metabolism of nicotine
    prevalence of nicotine receptors, etc.),
  • gt30 of regular smokers never become dependent
  • If we could predict which trajectory a young
    person is on, we could determine if they are
    candidates for more risky interventions (e.g.,
    harm reduction, pharmacotherapy).

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What about nicotine vaccines?
  • Appear to be several years away from receiving
    approval
  • Will only help those for whom the biology of
    nicotine plays a significant role it cant help
    the large portion that are driven by social
    rather than biological factors.

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Suggested Reading
  • Canadian Tobacco Use Monitoring Survey
    www.hc.gc.ca/necs-sesc/tobacco/research/stums/inde
    x.html
  • Youth Tobacco Survey (technical report due in
    late fall, 2004)
  • Am. J. Health Behavior Special Issue on Youth
    Tobacco Cessation, volume 27 supl. 2, 2003.
  • National Cancer Institute - US (2001). Changing
    Adolescent Smoking Prevalence. Where Is It and
    Why. Smoking and Tobacco Control Monograph 14,
    Bethesda, MD US DHHS, National Institutes of
    Health, National Cancer Institute. NIH Pub. NO.
    02-5086.
  • Lantz PM, et al. Investing in youth tobacco
    control A review of smoking prevention and
    control strategies. Tobacco Control, 9, 47-63.
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