Tobacco Prevention

Over the past 50 years America has increased its level of knowledge towards the use of tobacco as well as enhanced its cessation techniques through the use of medication and researched programs. Despite these advancements smoking has continued to be a detrimental problem to the American public. According to the CDC, “about 1,000 persons younger than 18 years of age begin smoking on a daily basis.” 1 Many of the cessation programs directed at youths are still young and creating names for themselves. As a result of all the research that has been done regarding the cessation programs for youths, three effective steps have been found. First, screen for tobacco dependency within families; second, educate parents about the dangers of smoking and second hand smoke and third, counsel and the use of prescription medication. While these three techniques have been proven to be effective they are not a 100% guarantee and they don’t address the major issue of actually getting the youths themselves to the programs. Research has extensively documented the harms of tobacco to people, specifically youths but none of it has stopped the tobacco industry from creating advertisements intended for youths. According to the World Health Organization “Tobacco companies must attract a new generation of tobacco users to survive. The industry constantly loses customers because many current smokers quit smoking or die from tobacco-related diseases. As a result, tobacco companies develop massive marketing campaigns to entice youth to smoke and become long-term smokers.”2 To parents, teacher and politicians the youth are the future of our country, to tobacco companies; the youth are the future of their business and their needs for survival. The problem of youth smoking is one that we cannot ignore and must continue to attack. As a whole Healthcare professionals, government lobbyist groups, insurance companies and most important the youth themselves all must re-commit themselves to exterminate this persistent problem at hand. Out of the 4,000 chemicals found in cigarettes, nicotine is often referred to as the most dangerous one. It is not regarded as being incredible dangerous to someone’s health but is feared by many people because extremely addictive. When smoke is inhaled that contains nicotine, the nicotine reaches the brain in a mere six seconds. When used in small doses nicotine acts as a stimulant to the brain or a substance that raises the levels of physiological activity in the body. In large doses it acts as a depressant and hinders the current of signals in the nervous system. “Those substances which we call drugs cause their effects by mimicking some substance that naturally occurs in the body or by interfering with some process which naturally goes on. Nicotine acts in the former manner, by mimicking a naturally occurring substance in the body.”3 The substance that nicotine imitates is the chemical neurotransmitter acetylcholine. Each neuron has a protein, which is called a receptor, when nicotine is inhaled they attach on to these receptors in the place of acetylcholine. When nicotine binds to these receptors, like any other drugs they cause changes in the body. The primary changes that occur in the body due to nicotine inhalation are increases in the blood pressure and heart rate. Nicotine also has psychoactive effects or mood-altering effect upon use. The release of dopamine during the use of nicotine is a major contributor to the drugs highly addictive qualities. Dopamine is a chemical neurotransmitter that is naturally released in the body during a pleasurable experience. The nicotine released when smoking cigarettes release dopamine leaving the smoker with the feeling of extreme pleasure, resulting in the desire to feel that way often. The evil genius of this drug is that while it produces dopamine it impedes the production of monoamine oxidase, which is responsible for the natural process of breaking down dopamine. The ability for nicotine to block the production of monoamine oxidase wears off short after the end of use, this fact causes the smokers to continue to get the urge to smoke and feel heightened levels of dopamine.4 Nicotine dependence is defined as an addiction to tobacco products caused by the drug nicotine, meaning you can’t stop using the substance despite the knowledge that is causing you harm. The united States Department of Health and Human Services have concluded that for most youths its takes 2-3 years to become nicotine dependent but as few as 100 cigarettes to become addicted. 5 “In 2010 about 2.6 American adolescents (aged 12-17) reported using a tobacco product in the month prior to the survey. In that same year it was found that nearly 60 percent of new smokers were under the age of 18 when they first smoked a cigarette. Of smokers under the age of 18 more then 6 million will likely die prematurely from a smoking-related disease. ”6 There are two primary influences that cause adolescents to susceptible to developing nicotine dependence, the first being peer pressure. Peer pressure is a fact of life and inevitable in your childhood and adolescence. Wheatear a person is conscious or not towards the pressure the choices and behaviors peers make affect the surrounding peers. According to Phillip Morris USA youths with at least three friends who smoke are 10 times more likely pick up the habit than youths who have friends that do not smoke. 7 The other influence that causes adolescents to be more susceptible to nicotine dependence than adults is not a psychosocial factor but a biological one. There are biological differences in adults and adolescents that leave adolescents more vulnerable to nicotine addition. Much of the research done in this sector has been executed with the use of adolescent rats and adult rats for safety reasons. “Adolescent rats are more susceptible to reinforcing effects of nicotine that adult rats, and take more nicotine when it is available than do adult animals.”8 An animal study done by the National Institute on Drug Abuse has reported the negative affects that acetaldehyde has on smokers, specifically adolescents. The study found that acetaldehyde, an organic chemical compound found in cigarettes “dramatically increases the reinforcing properties of nicotine and may also contribute to tobacco addiction.” It was also found that acetaldehyde has an age- related effect and was far more drastic in the adolescent animals brains than the adult animals. 9 In 2009 the Philadelphia Department of Health conducted a study that found the high school smoking rate was higher in Philadelphia then any other large city. The smoking rate for high school students was 3.6%, the racial breakdown of those statistics were 1.2% of African Americans, 3.1% of Hispanics and 15.6% of Caucasians. 10 There are two main contributors that lead Philadelphia to have the highest high school smoking rate; cigarettes are cheaper in Philadelphia then any other major city and the prevalence of tobacco retailers in Philadelphia, there are 27 retailers for every 1,000 youth between the ages 10-17.11 Pennsylvania ranked 19th in the country for price of cigarettes with an average of 5.85 per pack, about 5$ behind New York which was ranked 1st. 12 To formulate national statistics the CDC uses the data from the National Youth Tobacco Survey. The National Youth Tobacco Survey is our countries most effective way of measuring youth tobacco use. It is a school- based, self- administered questionnaire given to middle school students (6th to 8th grade) and high school students (9th- 12th grade). It has been given every 2 years since 2000 and is used by the Healthy People Foundation to keep track of the 2020 goal it has set. In 2011 the use of all types of tobacco for middle school and high school 7.1% and 23.2% respectively and the prevalence of specific cigarette use was 4.3% for middle school students and 18.1% for high school students. 13 The Healthy People goals for 2020 were set in 2009 when the cigarette use rate for high school students was at 19.5%, the overall goal is to get it down to 16% by 2020.14 In order to reach the goals set for 2020 it is crucial that the countries cessation programs are doing their part. Research has shown that the most effective method for youths to quit smoking is a binary method, both behavioral techniques and medication use. In terms of medication use there are two types of medicinal categories, first- line and second- line. First-line medications are the ones that tend to be used first by smokers trying to quit and second-line medications are used if the first- line medications prove inadequate. The most simplistic first-line medications are over-the-counter and come in the form of nicotine gum, patches and lozenges. The gums, patches and lozenges all offers doses of nicotine, starting with the highest dose the smoker is supposed to reduce dose over-time with the hopes of eventual nicotine independence. Nicotine Inhalers and Nicotine nasal spray are also first- line medications that work in the same way as the gum, lozenge and patch but are prescription rather then over-the-counter. Bupropion and Varenicline are two other forms of first-line medications that are also prescription. Bupropion also known as Zyban and Varenicline also known as Chantix both work to reduce the symptoms of nicotine withdrawal and reduce the urges smokers feel. The two second-line medications are Nortriptyline known as Aventyl and Clonidine known as Catapres. Aventyl is traditionally used to teat depression but has also proved successful with tobacco cessation efforts and Catapres is generally used to treat high blood pressue, but like Aventyl has shown effective in tobacco cessation.15 The behavioral techniques that are used in tobacco cessation come in two forms, an intervention style and a program style. The current research efforts that have been done regarding the intervention methods of cessation are deficient. There is simply a lack of evidence- based interventions, which makes it very difficult to judge the success as well as improve the programs. This issue was addressed with the Canadian Tobacco Control Research Initiative, which came up with the “better practices” model. “The better practices model is based on the idea that successful solutions to complex problems must draw from both science and experience.”16 The Canadian Tobacco Control Research Initiative came out with guidelines on what issues should be used while developing cessation interventions. As time passes with these new guidelines and more evidence based interventions occur it shouldn’t take long to specify what are the best methods for success. 16
Programs can be more accurately researched because their data is much more accessible. A cessation program can mean many different things, ranging from face to face counseling, telephone counseling, Internet counseling and group counseling. The most effective forms of counseling have been face-to-face counseling as well as group counseling. Telephone counseling is relatively new but has showed success in its short life. Regardless of how the counseling has been delivered the technique that has been proved to be the most effective is the problem-solving approach. The problem-solving approach asks smokers to think of times they are likely to smoke and then planning what to do to distract themselves from the urge to smoke.17 Social support such as encouragement and caring has not surprisingly been proven effective ways to help cessation.
N-O-T, Not on Tobacco is the American Lung Associations voluntary program for teens that want to quit smoking has proven to be successful in the past. “It is the most researched, most widely used and most successful program in the United States.” (YTC) N-O-T has 7 major characteristics that have made it to successful: 18
1. Allows teens to volunteer to participate
2. Includes group activities
3. Has separate activities for boys and girls
4. Uses a total health approach
5. Consists of 10 session and can be used in school and community settings
6. Is based on more then 10 years of research
7. Is proven effective, has a 21% quit rate, higher then any other program
N-O-T develops skills, confidence and support system that teenagers need in order to quit. They understand that one of the keys to quitting smoking is to have the ability to keep your life the same without the use of cigarettes. By doing this and aiding the teens in other problems other then the smoking such as controlling weight after quitting and managing stress they have been successful. While there has been success in the cessation programs there is clearly an incredible amount of room for improvement. The most effective way to drastically improve success is creating a more accessible environment to programs. “Although many youth think about and attempt to quit tobacco many are unaware of or unable to access cessation services. Also, many youth do not think quitting tobacco is difficult enough to warrant professional assistance.”19 The most important thing we can do moving forward is to better recruit youth who smoke and use tobacco. Recruiting for programs such as these should be very specific and focus are the target audience. Using the data from the National Youth Tobacco Survey it can be figured out which ethnicity has the most smokers and recruitment techniques should be in accordance with those number. An effective way to do this would be to tap in to previous existing social networks in a community, such as a club or a sports team. While your peers can be the reason you start smoking as a result of negative pressure they can also be the reason you quit as a result of positive pressure. Offering incentives can also be a useful technique for recruitment, offering something like pizza at meetings could raise the attendance and access. Even if the child goes into the meeting with the sole intent of getting the incentive they are still exposed to cessation efforts. One last recruitment technique can be to use other teens as recruiters. It will give a more personalized appearance and give you the feeling that you will not be alone. It is also on the shoulders of the health insurance companies and the health care system to provide access to these youths. All health insurance policies should cover any cessation program or method used by teens to quit smoking, the high prices of some medications and some counseling practices can deter youths from making an attempt to quit. It should be the standard that all health care services monitor and care for nicotine dependency. It falls on a combination of the government, healthcare systems and public health agencies to formulate a system that can effectively treat youth nicotine dependence. It is also extremely important that high schools are smoke free; the majority of youth’s time is spent, as schools and creating a smoke-free environment will deter smoking amongst youth. Another way to improve the current youth cessation programs in to apply adult programs to youth specifically for interventions, the most lacking in research of all methods. Due to this lack of research on youth interventions we can use what has been proven effective with adults. The United States Public Health System has provided the public specifically adults with recommendations that have proved successful. These recommendations include: “It is essential that clinicians and health care delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a health care setting”, “Telephone quitline counseling is effective with diverse populations and has broad reach. Therefore, clinicians and health care delivery systems should both ensure patient access to quitlines and promote quitline use” along with eight other proven effective recommendations. 20 As spoken about previously there are biological differences are one of the many things that vary between youth and adults. These differences could lead to a lack of success and should encourage counselors to use adult recommendations carefully. As a country we should be encouraged by the amount of success youth cessations programs have had but also motivated to continue to improve them. While it is unrealistic to think there will be a time when there are no smokers on this earth that should be our goal. We should aim for a 0% high school smoking rate because that will drive people to continue to find successful methods. If we live with the goal of a 0% smoking rate five or ten years down the road when we look at what the youth smoking is and look at its decline, it will be drastic. If you think about it in terms of a professional baseball pitcher, he goes into each game with the mindset of pitching a perfect game and works each day towards that goal. In hindsight with a more realistic mindset he can look back on his performance and see that getting 24 out of 27 men out rather then 27 out of 27 is still a success. Cessation is not an easy process and the only thing that can make it easier is a more committed effort by all parties involved.