Title: Reducing Tobacco Use Among Youth: Effective Prevention and Cessation Strategies
1Reducing 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
2Whats 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
3Why 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
4There are reasons for optimism!
5Estimated 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)
6Reasons 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
7Helping youth to quit smoking
There no need to throw your hands in the air
the problem isnt completely unbearable
8How 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
9How 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)
10Important 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
11Important 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),
12Effectiveness 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)
13What 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.
14Expert 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)
15Sample 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
16Sample 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)
17Sample 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
18Expert 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
19Expert 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
20Expert 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
21Additional 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).
22Additional 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.
23Additional 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)
24Additional 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)
25Best 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
26Promoting 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
27Maximizing 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
28Maximizing 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
29Checking 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)
30What 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
31Promising 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
32Promising 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)
33Preventing adolescents from using tobacco
Whats the right recipe?
34Some 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
35When 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
36Transition from experimentation to regular
tobacco use
of regular grade 12 smokers
Grade
Driezen et al, submitted
37Community wide interventions
- Taxes
- Reducing access to tobacco
- Youth possession laws
- Banning point of purchase tobacco displays
- No smoking restrictions
- Public places
- Schools
- Homes
38Do 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
39Speaking 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?
40Does 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
41Perceptions 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
42Do 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
43Does 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).
44Effect 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)
45Prevalence 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
46Effects 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.
47Perceived 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
48Are 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
49Suggestions 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
50Other 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?
51Effect 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
52Influence 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
53Effect 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
54School-based educationYou dont have to lose
your mind
55What kind of school-based education doesnt work?
- Approaches based on information deficit
- Info on health risks (without other components)
- Enhancing self esteem
- Stress management
56Peer 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
57Its 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
58What 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
59Interaction 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
60What 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.
61What 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
62Can 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
63Parental 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
64Parental 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
65Parental 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
66Parental 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
67Other 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
68What 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
69What 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
70What 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
71What can communities do?
- Advocate for policies which reduce
marginalization of our youth and create
empowerment
72What 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
73Some 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
74Emerging 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.
75Estimated 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),
76Percent 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),
77Average 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),
78Average 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),
79The 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
80A 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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83Front cover of the School Feedback Report
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86The 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
87Ready 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)
88Eclipse 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
89Is 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.
90Lets 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
91New 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).
92What 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.
93Suggested 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.