Adolescent Health Care: A Practical Guide

Chapter 70

Tobacco

Seth D. Ammerman

“Cigarette smoking is the chief, single avoidable cause of death in our society and the most important public health issue of our time.”

—C. EVERETT KOOP, M.D.

This statement made by Dr. Koop when he was United States Surgeon General from 1981 to 1989 remains equally true in the early part of the twenty-first century. The World Health Organization (WHO) estimates that if current smoking patterns continue, tobacco use will cause 10 million deaths each year by 2020. In the United States, approximately 438,000 deaths each year—the equivalent of three 747 fatal airline crashes/day—can be attributed to cigarette smoking. This figure is almost triple the annual number of deaths due to illegal drugs, homicide, alcohol, acquired immunodeficiency syndrome, suicide, and motor vehicle accidents combined (Fig. 70.1). The financial cost for smoking-related health care/year in the United States is approximately $75 billion, or approximately 10% of total medical expenditures, plus an additional $92 billion in productivity losses. Additionally, cigarettes are the leading cause of the approximately 1,000 fire-related deaths and many thousands of fire-related injuries in this country each year, costing approximately $0.5 billion annually just in direct property losses. More than 80% of all cigarette smokers start before the age of 18 years; almost 5% of youth first began smoking by 8 years of age, and another approximately 15% before their 13th birthday. Estimates derived from current smoking rates indicate that approximately 250 million youth worldwide will die prematurely from a tobacco-related disease. Many youth who are daily smokers report that they want to quit smoking. At the same time, a significant number of middle and high school students who have never smoked cigarettes stated that they might try smoking in the next year. Exposure to environmental tobacco smoke (ETS or second-hand smoke) is also a serious problem: In one study >50% of youth were exposed to ETS in the previous week and one third of the youth were exposed to >3 hours of ETS in the previous week. Therefore, tobacco use should also be considered a pediatric disease. Clinicians can play an important role in preventing cigarette use by their patients and in helping their patients who are already smoking to stop.

Prevalence

Use among Adolescents

Tobacco use by adolescents remains a serious problem, with >2,000 American teenagers becoming regular smokers each day. The good news is that usage rates for youth younger than 18 years have been declining in the last decade. The bad news is that the decline in cigarette smoking in young adults (age 18–24 years) has been minimal. The tobacco industry is overtly and heavily targeting the young adult smoker, often sponsoring events in bars and clubs that are popular with young adults. The tobacco industry, to maintain profits, needs ongoing replacement of smokers who have died using their products. Youth are exposed to significant amounts of tobacco advertising on the Internet, and more importantly to tobacco use in movies (see subsequent text on Smoke-Free Movies campaign). Lack of compliance with status laws (i.e., asking for proof of age for those <18 years) also leads to increased smoking among youth.

Prevalence data are gathered from a number of sources; three major sources are the following:

  1. National Youth Tobacco Survey (sponsored by the American Legacy Foundation, www.americanlegacy.org, and the Centers for Disease Control and Prevention [CDC] Foundation, www.cdc.gov/tobacco).

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  1. Youth Risk Behavior Survey (YRBS) (sponsored by the CDC, http://www.cdc.gov/tobacco; YRBS 2005 and updated data are available at: http://www.cdc.gov/HealthyYouth/yrbs/index.htm).
  2. Monitoring the Future (sponsored by the University of Michigan Institute for Social Research, www.monitoringthefuture.org, and the National Institute of Drug Abuse, www.nida.nih.gov).
 

FIGURE 70.1 Deaths in the United States of America, 2004. Tobacco, 438,000; MVA, 43,947; Suicide, 31,647; Drugs, 29,036; Alcohol, 20,398; Homicides, 16,611; AIDS, 12,995. MVA, motor vehicle accident; AIDS, acquired immunodeficiency syndrome. (Adapted from the National Center for Health Statistics, fastats. www.cdc.gov/nchs/fastats/acc_inj.htm; and the National Vital Statistics Report, Vol. 54, No.19, June 28, 2006.)

All three use school-based samples, and the rates of tobacco use shown would likely be greater if high school dropouts had been included in the study samples. A fourth source, which is a home-based survey on alcohol and other drugs, is the National Survey on Drug Use and Health (formerly the National Household Survey on Drug Abuse; sponsored by the Substance Abuse and Mental Health Sciences Administration), and is available at http://oas.samhsa.gov/nsduh.htm.

The 2006 Monitoring the Future data revealed that approximately 8.7% of 8th graders, 14.5% of 10th graders, and 21.6% of 12th graders reported current smoking (i.e., smoking one or more cigarettes during the previous 30 days). Twenty-one percent of 12th grade females and 25% of 12th grade males were current smokers. Furthermore, 4% of 8th graders, 8% of 10th graders, and 12.2% of 12th graders were daily smokers in 2006. Whites have the highest smoking rates, followed by Hispanics, and then African-Americans. Table 70.1 is adapted from the Monitoring the Future study, showing trends in current and daily smoking from 1990 to 2005. For current smokers in both middle and high school, cigarettes are the most commonly used tobacco product, followed by cigars, smokeless tobacco, pipes, bidis, and kreteks. Bidis are small, brown, hand-rolled cigarettes that are made primarily in India and other South Asian countries. They consist of tobacco wrapped in a tendu or temburni leaf (plants native to Asia), and may be secured with a colorful string at one or both ends. They are available in many flavors, such as chocolate, raspberry, and strawberry, making them appealing to adolescent smokers. Kreteks are imported from Indonesia, and typically contain a mixture consisting of tobacco, cloves, and other additives. Both bidis and kreteks deliver more nicotine, carbon monoxide, and tar than conventional cigarettes.

The 2005 YRBS also shows mixed results in high school seniors (Morbidity and Mortality Weekly Report, 2006). Current use of tobacco declined from a high (since 1991) of 36.4% in 1997 to 21.9% in 2003 and increased back to 23% in 2005. Current frequent use (>20 of 30 days in last month) declined from 16.8% in 1999 to 9.7% in 2003 and to 9.4% in 2005. Smoking>10 cigarettes/day declined in high school seniors from 18% in 1991 to 13.7% in 2003 and to 10.7% in 2005.

Table 70.2A and B shows current use of tobacco products from the 2002 and 2004 National Youth Tobacco Survey. Note that a variety of tobacco products used by adolescents was studied.

Use among College Students and Young Adults

Smoking continues to be a problem for college students and young adults. In 2004, 36% of college students reported having used a tobacco product. There was an equal distribution of use between men and women. Of those who used cigarettes, two third were current smokers and approximately 7% were daily smokers. For both male and female college students, cigarettes are the most commonly used tobacco product, followed by cigars, smokeless tobacco, and pipes. Whites have the highest use of tobacco products, followed by Hispanics, Asians, and African-Americans. College students who use tobacco are more likely to be single, white, and engaged in other risky behaviors involving substance use and sexual activity. They are also more likely to value social life over educational achievement, athletic participation, or religion. Among young adults aged 18 to 24, 26.3% of men and 21.5% of women are current smokers. For more details on tobacco use in college students see Chapter 84.

Why do Adolescents Use Tobacco?

Adolescent Development

Tobacco use in adolescence can be understood in terms of biopsychosocial development during adolescence. Major developmental tasks during adolescence include establishing independence and autonomy, developing meaningful peer relations, negotiating the changes associated with physical development and puberty, and establishing a coherent self-identity. Cigarette smoking may, for example,

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be viewed as a means of attaining maturity and autonomy, as smoking is a legal adult behavior. Smoking may also be viewed as a social event and a means of fitting in with a peer group. Research has shown that peer influence (e.g., smoking status of best friends) is the most significant and consistent predictor of adolescent smoking. On the other hand, protective factors leading to less smoking among youth include giving clear messages against smoking, involvement in healthy activities such as sports and religious institutions, and limiting exposure to tobacco advertising (including magazines, movies, sporting events, etc.). The price of tobacco products also correlates with adolescent tobacco use: A significant price increase leads to a decrease in adolescent tobacco use.

TABLE 70.1
Trends in Prevalence of Use of Cigarettes, for 8th, 10th, and 12th Graders, 1991–2005

 

1975

1976

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

 

Level of significance of difference between the two most recent classes: s = 0.05, ss = 0.01, sss = 0.001.
‘—’ indicates data not available.
Any apparent inconsistency between the change estimate and the prevalence of use estimates for the two most recent classes is due to rounding error.
(Johnston LD, O'Malley PM, Bachman JG, et al. Monitoring the future: decline in teen smoking seems to be nearing its end. www.monitoringthefuture.org. December 19, 2005.)

Lifetime

                                 

 8th Grade

 

 10th Grade

 

 12th Grade

73.6

75.4

75.7

75.3

74.0

71.0

71.0

70.1

70.6

69.7

68.8

67.6

67.2

66.4

65.7

64.4

 

Thirty-day

                                 

 8th Grade

 

 10th Grade

 

 12th Grade

36.7

38.8

38.4

36.7

34.4

30.5

29.4

30.0

30.3

29.3

30.1

29.6

29.4

28.7

28.6

29.4

 

Daily

                                 

 8th Grade

 

 10th Grade

 

 12th Grade

26.9

28.8

28.8

27.5

25.4

21.3

20.3

21.1

21.2

18.7

19.5

18.7

18.7

18.1

18.9

19.1

 

1/2 Pack + per day

                                 

 8th Grade

 

 10th Grade

 

 12th Grade

17.9

19.2

19.4

18.8

16.5

14.3

13.5

14.2

13.8

12.3

12.5

11.4

11.4

10.6

11.2

11.3

 

Approx, Ns:

                                 

 8th Grade

 

 10th Grade

 

 12th Grade

9,400

15,400

17,100

17,800

15,500

15,900

17,500

17,700

16,300

15,900

16,000

15,200

16,300

16,300

16,700

15,200

 
 

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2005–2006 Change

Lifetime

                                 

 8th Grade

44.0

45.2

45.3

46.1

46.4

49.2

47.3

45.7

44.1

40.5

36.6

31.4

28.4

27.9

25.9

24.6

-1.3

 10th Grade

55.1

53.5

56.3

56.9

57.6

61.2

60.2

57.7

57.6

55.1

52.8

47.4

43.0

40.7

38.9

36.1

-2.8

 12th Grade

63.1

61.8

61.9

62.0

64.2

63.5

65.4

65.3

64.6

62.5

61.0

57.2

53.7

52.8

50.0

47.1

-2.9

Thirty-day

                                 

 8thGrade

14.3

15.5

16.7

18.6

19.1

21.0

19.4

19.1

17.5

14.6

12.2

10.7

10.2

9.2

9.3

8.7

-0.6

 10th Grade

20.8

21.5

24.7

25.4

27.9

30.4

29.8

27.6

25.7

23.9

21.3

17.7

16.7

16.0

14.9

14.5

-0.4

 12th Grade

28.3

27.8

29.9

31.2

33.5

34.0

36.5

35.1

34.6

31.4

29.5

26.7

24.4

25.0

23.2

21.6

-1.6

Daily

                                 

 8th Grade

7.2

7.0

8.3

8.8

9.3

10.4

9.0

8.8

8.1

7.4

5.5

5.1

4.5

4.4

4.0

4.0

-0.1

 10th Grade

12.6

12.3

14.2

14.6

16.3

18.3

18.0

15.8

15.9

14.0

12.2

10.1

8.9

8.3

7.5

7.6

+0

 12th Grade

18.5

17.2

19.0

19.4

21.6

22.2

24.6

22.4

23.1

20.6

19.0

16.9

15.8

15.6

13.6

12.2

-1.4

1/2 Pack + per day

                                 

 8th Grade

3.1

2.9

3.5

3.6

3.4

4.3

3.5

3.6

3.3

2.8

2.3

2.1

1.8

1.7

1.7

1.5

-0.1

 10th Grade

6.5

6.0

7.0

7.6

8.3

9.4

8.6

7.9

7.6

6.2

5.5

4.4

4.1

3.3

3.1

3.3

+0.2

 12th Grade

10.7

10.0

10.9

11.2

12.4

13.0

14.3

12.6

13.2

11.3

10.3

9.1

8.4

8.0

6.9

5.9

-1.0

Approx, Ns:

                                 

 8th Grade

17,500

18,600

18,300

17,300

17,500

17,800

18,600

18,100

16,700

16,700

16,200

15,100

16,500

17,000

16,800

16,500

 

 10th Grade

14,800

14,800

15,300

15,800

17,000

15,600

15,500

15,000

13,600

14,300

14,000

14,300

15,800

16,400

16,200

16,200

 

 12th Grade

15,000

15,800

16,300

15,400

15,400

14,300

15,400

15,200

13,600

12,800

12,800

12,900

14,600

14,600

14,700

14,200

 

TABLE 70.2A
Percentage of Students in Middle School (grades 6–8) Who Were Current Users
a of Any Tobacco Product, By Product Type, Sex, and Race/Ethnicity—National Youth Tobacco Survey, United States, 2002 and 2004

 

Any Tobaccob

Cigarettes

Cigars

Smokeless Tobacco

Pipes

Bidis

Kreteks

Characteristic

%

(95% CIc)

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

aUsed tobacco on at least 1 day during the 30 days preceding the survey.

b Cigarettes, cigars, smokeless tobacco, pipes, bidis (leaf-wrapped, flavored cigarettes from India), or kreteks (clove cigarettes).
c Confidence interval.
d Significant difference (p < 0.05), 2004 versus 2002.
MMWR Morb Mortal Wkly Rep April 1, 2005;54(12):297.

Middle school, 2004

                           

 Sex

                           

  Male

12.7

(±1.7)

7.7d

(±1.3)

6.6

(±1.1)

3.9

(±1.0)

3.3d

(±0.8)

2.8

(±0.7)

1.9d

(±0.4)

  Female

10.7

(±1.8)

8.5

(±1.9)

3.9

(±0.5)

1.9

(±0.5)

1.8

(±0.5)

1.7

(±0.4)

1.2

(±0.4)

 Race/Ethnicity

                           

  White, non-Hispanic

11.2

(±1.9)

8.3

(±1.8)

4.4

(±0.8)

3.1

(±0.9)

2.2

(±0.6)

1.8

(±0.5)

1.2

(±0.4)

  Black, non-Hispanic

12.3

(±2.5)

7.5

(±1.9)

6.9

(±1.8)

1.8

(±0.8)

2.0d

(±0.8)

2.7

(±0.9)

1.6

(±0.6)

  Hispanic

14.8

(±1.9)

9.4

(±1.5)

8.0d

(±1.2)

3.7

(±0.9)

5.3

(±1.2)

4.3d

(±0.8)

3.0

(±0.7)

  Asian

3.4d

(±1.8)

2.2d

(±1.5)

0.7d

(±0.6)

1.0

(±0.7)

0.7d

(±0.7)

0.5d

(±0.6)

0.7d

(±0.7)

Total

11.7

(±1.6)

8.1

(±1.5)

5.2

(±0.7)

2.9

(±0.6)

2.6d

(±0.6)

2.3

(±0.5)

1.5

(±0.3)

Middle school, 2002

                           

 Sex

                           

  Male

14.7

(±1.6)

9.8

(±1.3)

7.9

(±1.1)

5.3

(±1.3)

5.1

(±0.8)

3.1

(±0.6)

2.7

(±0.6)

  Female

11.7

(±1.4)

9.7

(±1.4)

4.1

(±0.7)

1.6

(±0.5)

1.9

(±0.4)

1.7

(±0.4)

1.1

(±0.3)

 Race/Ethnicity

                           

  White, non-Hispanic

13.2

(±1.9)

10.1

(±1.6)

5.5

(±1.0)

3.8

(±1.1)

2.8

(±0.6)

1.8

(±0.4)

1.5

(±0.4)

  Black, non-Hispanic

13.5

(±2.4)

9.0

(±2.3)

7.3

(±1.7)

2.3

(±0.9)

3.9

(±1.4)

3.1

(±1.0)

2.3

(±0.9)

  Hispanic

12.5

(±1.9)

8.7

(±1.5)

6.3

(±1.1)

2.7

(±0.7)

4.3

(±0.9)

2.9

(±0.7)

2.6

(±0.7)

  Asian

8.6

(±3.3)

7.4

(±3.3)

5.0

(±2.8)

3.5

(±2.7)

4.6

(±2.7)

3.1

(±2.2)

3.8

(±2.9)

Total

13.3

(±1.4)

9.8

(±1.2)

6.0

(±0.7)

3.5

(±0.7)

3.5

(±0.5)

2.4

(±0.3)

2.0

(±0.4)

TABLE 70.2B
Percentage of Students in High School (grades 9–12) Who Were Current Users
a of Any Tobacco Product, By Product Type, Sex, and Race/Ethnicity

 

Any Tobaccob

Cigarettes

Cigars

Smokeless Tobacco

Pipes

Bidis

Kreteks

Characteristic

%

(95% CIc)

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

aUsed tobacco on at least 1 day during the 30 days preceding the survey.

b Cigarettes, cigars, smokeless tobacco, pipes, bidis (leaf-wrapped, flavored cigarettes from India), or kreteks (clove cigarettes).
c Confidence interval.
d Significant difference (p < 0.05), 2004 versus 2002.
National Youth Tobacco Survey, United States, 2002 and 2004.

High school, 2004

                           

 Sex

                           

  Male

31.5

(±3.0)

22.1

(±2.7)

18.4

(±1.8)

10.8

(±2.2)

4.6

(±0.9)

3.6

(±0.7)

3.2

(±0.8)

  Female

24.7

(±3.1)

22.4

(±3.1)

7.5

(±1.4)

1.4

(±0.6)

1.6

(±0.6)

1.6

(±0.5)

1.5

(±0.5)

 Race/Ethnicity

                           

  White, non-Hispanic

31.5

(±4.1)

25.4

(±3.8)

13.6

(±2.1)

7.5

(±1.6)

2.9

(±0.8)

2.2

(±0.5)

2.3

(±0.7)

  Black, non-Hispanic

17.1d

(±3.3)

11.4

(±3.1)

10.5

(±2.1)

1.7

(±1.2)

1.8d

(±0.8)

2.1

(±0.8)

1.3

(±0.5)

  Hispanic

26.2

(±2.9)

21.6

(±3.1)

13.3d

(±1.7)

3.5

(±1.1)

5.0

(±1.0)

4.6

(±0.9)

3.3

(±0.7)

  Asian

13.1

(±3.3)

11.2

(±2.6)

5.7

(±2.4)

2.1

(±1.7)

2.0

(±1.1)

2.1

(±1.2)

1.4

(±1.0)

Total

28.0

(±2.9)

22.3

(±2.7)

12.8

(±1.5)

6.0

(±1.2)

3.1

(±0.6)

2.6

(±0.5)

2.3

(±0.5)

High school, 2002

                           

 Sex

                           

  Male

32.6

(±2.3)

23.9

(±2.1)

16.9

(±1.4)

10.5

(±2.0)

5.0

(±0.9)

3.7

(±0.8)

3.5

(±0.7)

  Female

23.7

(±1.8)

21.0

(±1.9)

6.2

(±0.9)

1.2

(±0.3)

1.4

(±0.4)

1.5

(±0.4)

1.8

(±0.5)

 Race/Ethnicity

                           

  White, non-Hispanic

30.9

(±2.0)

25.2

(±1.8)

11.8

(±1.0)

7.3

(±1.4)

2.8

(±0.6)

2.2

(±0.5)

2.7

(±0.6)

  Black, non-Hispanic

21.7

(±2.9)

13.8

(±2.8)

12.0

(±1.9)

1.8

(±0.8)

3.7

(±1.2)

3.4

(±1.1)

1.9

(±0.8)

  Hispanic

24.1

(±2.7)

19.8

(±2.5)

10.8

(±1.5)

3.3

(±1.1)

4.6

(±1.1)

3.5

(±0.9)

3.0

(±0.8)

  Asian

14.6

(±3.8)

12.2

(±3.4)

5.4

(±2.3)

2.1

(±1.5)

2.7

(±1.5)

2.9

(±1.6)

2.1

(±1.7)

Total

28.2

(±1.7)

22.5

(±1.6)

11.6

(±0.9)

5.9

(±1.1)

3.2

(±0.6)

2.6

(±0.5)

2.7

(±0.4)

Psychosocial Factors

Psychosocial factors related to smoking initiation for both genders include low educational aspirations or attainment; low self-esteem or low self-image, or ongoing stress or depression; risk-taking; minimizing perceived hazards of smoking; and favorable attitudes toward smoking or smokers. Other variables associated with adolescent smoking include parental or sibling smoking, perceived support for smoking by parents or peers, having lower socioeconomic status or parental educational attainment, or a history of abuse. There are also gender-specific factors associated with smoking. For example, adolescent girl smokers are more likely to be socially skilled, outgoing, and self-confident. In contrast, adolescent boy smokers may be more insecure in social settings. Teenage girls may use cigarette smoking as a method of weight control and maintenance of a thin appearance. Teenage boys may smoke for a sense of adventure and recreation as well as daring. Youth who identify themselves as gay, lesbian, or bisexual smoke at rates >50% of those of their straight counterparts, and they are four times more likely to use smokeless tobacco products. Preteens and early adolescents may in particular underestimate the addictive nature of cigarettes and may believe that there are many benefits to smoking.

Advertising

Tobacco industry advertising plays an important role in inducing adolescents to smoke. One study found that 86% of 10th graders and 88% of 12th graders who purchase their own cigarettes bought one of the three most heavily advertised brands—Marlboro, Camel, and Newport. In comparison, <50% of adults buy these three brands. Until 1999, when parts of the Master Settlement Agreement between the tobacco companies and the states' attorneys general went into effect, cigarettes were the most heavily advertised product in the outdoor (billboard) media, including the newest and growing form of outdoor advertising—the neighborhood-based bus-stop shelter illuminated billboard. The tobacco industry is now focusing on print media such as magazines with a youth or young-adult focus, electronic media, and movies, so adolescents are constantly exposed to the messages promoted by these advertisers. Studies have shown that >50% of the onset of tobacco use among youth is due to smoking portrayed in the movies. The Smoke-Free Movies campaign has proposed four measures to make sure the U.S. film industry does not act as a marketing arm for the tobacco industry. The American Academy of Pediatrics, the Society for Adolescent Medicine, the WHO, the American Heart Association, the American Medical Association, and the U.S. Public Interest Research Group have endorsed all four measures. They are as follows:

  1. Certify no pay-offs: Every new smoking movie should run the following affidavit in the closing credits: “No person or entity involved in this motion picture accepted anything from a tobacco company, its agents, or fronts.”
  2. Require antismoking ads: Exhibitors should run effective antitobacco spots before all feature films. Spots should also be added to newly released videos and DVDs of smoking films, regardless of rating; many teens view R-rated movies through these media.
  3. Stop displaying brands: Use of specific brands gives the appearance of violating agreements against brand placement.
  4. Rate new smoking movies “R”: All new movies with smoking and tobacco use should receive an R rating from the Motion Picture Association of America (MPAA). Doing so will reduce the amount of smoking in the movies teens see, by >60%. And, because the effect of smoking in the movies depends on the “dose” kids get, an R rating will prevent 535 kids from starting to smoke every day.

Tobacco industry advertisements virtually ignore all health concerns and use themes that appeal to young people. In the messages, use of cigarettes is associated with healthy activities involving adventure and recreation, independence, sexual attractiveness, professional success, confidence in social settings, and weight control and physical appearance. Advertising tobacco in the context of other businesses and services (e.g., household detergents, movies, clothing) helps legitimize tobacco use. The internal documents of tobacco companies demonstrate targeting of youth, women, and minorities. Promotional offerings and “contests,” as well as offers of “free” items (e.g., hats, jackets) that are usually redeemable after sending in a specified number of empty cigarette packs, are also inducements to youth to start and continue smoking. Although the Liggett Tobacco Company, in a precedent-setting legal case in March 1997, submitted documents to the Arizona Attorney General admitting that (a) nicotine is addictive, (b) cigarettes cause cancer, and (c) the tobacco industry targets children and teenagers, the tobacco industry continues to promote its deadly products extensively, spending >15 billion/year in the United States alone.

Nicotine Addiction and Health Consequences

Addiction

In addition to being a potent pesticide, nicotine is one of the most addictive substances known. Tobacco use by adolescents, which may have started primarily for psychosocial reasons, may over time become a serious drug addiction. Initial symptoms of nicotine dependence occur, in some teens, within days to weeks of onset of use.

Modes of Action

Nicotine seems to function as a positive reinforcer through its actions on nicotinic acetylcholine receptors in the mesocorticolimbic dopamine pathway. Stimulation of brain dopamine systems is of great

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importance for the rewarding and dependence-producing properties of nicotine. Abstinence from nicotine is associated with depletion of dopamine and other neurotransmitters, which may cause numerous withdrawal symptoms including anxiety, irritability, and cravings (Fig. 70.2). Relapse rates for persons attempting to quit use of nicotine are comparable to those for quitting heroin (Fig. 70.3). There are likely genetic factors (e.g., genetic variants in the dopamine D2 receptor [DRD2] gene) in an individual's susceptibility to tobacco addiction as well as to response to the various pharmacological treatments. This is an active area of ongoing research.

 

FIGURE 70.2 Nicotine withdrawal symptoms. GI, gastrointestinal. (Adapted from National Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health. The health consequences of smoking: nicotine addiction. A report of the surgeon general. Washington, DC: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, 1988.)

Pharmacology

  • Each cigarette contains 6 to 11 mg of nicotine, and smokers absorb 1 to 3 mg of nicotine/cigarette.
  • Each cigarette contains 10 to 12 doses (puffs) of nicotine; one who smokes half a pack/day therefore inhales approximately 200 doses of the drug daily.
  • One pack/day equals 20 to 40 mg of nicotine absorbed/day.
  • Each dose of the drug acts on the user within seconds of being inhaled.

Plasma concentrations of nicotine decline in a biphasic manner. Typically the initial half-life is 2 to 3 minutes, and the terminal half-life is 30 to 120 minutes. Most nicotine is metabolized in the liver to cotinine and nicotine-1'-oxide. Cotinine has a plasma half-life that varies from approximately 10 to 40 hours. Nicotine and its metabolites are excreted by the kidneys; approximately 10% to 20% of the nicotine is eliminated unchanged in the urine.

Effects of Other Compounds in Cigarettes

In addition to nicotine, cigarettes contain tar—a toxic compound. Cigarettes usually contain thousands of other chemicals, many poisonous and cancer causing, including ammonia, cadmium, carbon monoxide, cyanide, formaldehyde, nitrosamines, and polynuclear aromatic hydrocarbons. The tobacco industry is actively fighting disclosure of the chemical ingredients in cigarettes, including pesticides and flavor additives, arguing that they are “trade secrets.” However, the province of British Columbia, Canada, has mandated the release of all tobacco ingredients, including tobacco, paper, filter, and filter paper (www.healthservices.gov.bc.ca/ttdr).

Systemic Effects of Tobacco

The U.S. Surgeon General's report in 2004 updated the list of diseases related to tobacco use. Use of tobacco products can adversely affect virtually every organ system in the body (www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/index.htm). Some of these adverse effects include the following:

  • Heart and lung disease—ischemic heart disease, and cerebrovascular and peripheral vascular diseases
  • Cancers—lung, head and neck, esophageal, gastric, colorectal, bladder, renal, prostate, and cervical cancers
  • Diminished bone density
  • Pulmonary effects—chronic obstructive pulmonary disease and small airway disease
  • Gastrointestinal effects—gastroesophageal reflux and peptic ulcer disease
  • Cataracts
  • Premature wrinkling of the skin
  • Potential adverse effects on immune system
  • Pregnancy-related problems including low–birth weight babies and higher rates of spontaneous abortions
  • Erectile dysfunction (impotence)

Smokeless Tobacco

Smokeless tobacco users, in addition to suffering from many of the same systemic adverse effects as smokers

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due to nicotine, have higher rates of various cancers, including oral, prostate, pancreas, and cervical cancers. Smokeless tobacco use is associated with numerous dental, periodontal, and oral soft tissue problems, including gingival recession, periodontal attachment loss, tooth staining, halitosis, and leukoplakia. Inflammatory bowel disease is more common in smokeless tobacco users.

 

FIGURE 70.3 Relapse over time for heroin use, smoking, and alcohol abuse. (From National Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health. The health consequences of smoking: nicotine addiction. A report of the surgeon general. Washington, DC: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, 1988.)

Environmental Tobacco Smoke

ETS or second-hand smoke has numerous serious adverse health effects. A report by the California Environmental Protection Agency, Air Resources Board, is an excellent resource: “Proposed Identification of Environmental Tobacco Smoke as a Toxic Air Contaminant—June 24, 2005.” www. arb.ca.gov/toxics/ets/finalreport/finalreport.htm. Children exposed to ETS may have development of and/or worsening of asthma, higher rates of lower respiratory tract infections (e.g., bronchitis, pneumonia), and higher rates of otitis media. Heart disease, lung cancer, and nasal sinus cancer are also more common with exposure to ETS, as are pulmonary hypertension of the newborn, sudden infant death syndrome (SIDS), and postanesthesia pulmonary complications.

Prevention and Treatment

Brief Practitioner Interventions

Research has demonstrated that 3-minute discussions of tobacco use (brief interventions) can have a significant impact on smoking prevention or smoking cessation. Busy practitioners can still address the smoking issue in a meaningful way in a short period of time. Dentists and dental hygienists have also been shown to have a positive impact on cessation counseling. There are two types of 3-minute interventions—those directed toward patients (Fig. 70.4) and those directed toward parents (Fig. 70.5). Strong and direct language is purposefully used, and these kinds of messages have been found to be very helpful. Given the medical problems associated with second-hand smoke, and given that parents are one of the most important role models for adolescents, pediatricians must also provide smoking cessation referrals and/or interventions for the parents. It is much more likely for an adolescent to start smoking, and much more difficult for an adolescent to successfully quit smoking if he or she is living with siblings or parents who smoke. Therefore, siblings and parents need to be encouraged to quit too. Parents should be encouraged to maintain smoke-free homes.

Intensive Smoking Cessation Interventions

More intensive smoking cessation interventions may be more effective in helping addicted smokers quit. These more intensive interventions may involve a medical clinician to discuss health issues and prescribe pharmacotherapy, and a health educator to focus on additional psychosocial or behavioral issues.

Antismoking Messages

The antismoking message should be varied according to the smoking status, age, and developmental stage of the patient. Prevention starts with the prenatal visit and continues throughout childhood (as noted earlier, children may start smoking by the age of 8 years) and during the preteen, teen, young adult, and adult years. Anticipatory guidance should always include tobacco-use counseling.

  1. Nonsmokers: Nonsmoking should be praised and the behavior normalized. Urge continuation of nonsmoking: “Keep making smart choices.”
  2. Individuals who are considering starting: For someone who is considering smoking and who lives in an environment with exposure to smokers (e.g., parents, siblings, friends who smoke), offer praise for nonsmoking to date, healthy alternatives to smoking, and role-playing of methods to gracefully bow out of smoking among peers. For example, the teen may refuse opportunities to smoke by saying, “No thanks, I'm not in the mood right now” or “I feel like I'm getting a sore throat and smoking will make it worse” or “I don't want to expose my body to all those nasty chemicals.”
  3. Patients who smoke: For patients who are smoking, the sooner treatmentis begun, the more likely successful quitting will occur. The estimates of quitting rates for teen smokers, quitting on their own without help, range from 0% to 11%. For someone who is experimenting with tobacco use, immediate quitting should be encouraged

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and a quit date set. For someone who is regularly using tobacco, quitting should be encouraged. If the patient wants to quit, the clinician can be more assertive and set a quit date. If the patient does not want to quit, the physician must be less assertive but should raise quitting as an important issue, provide motivational literature, and follow-up at subsequent visits.

 

FIGURE 70.4 Patient 3-minute pointers. (Adapted from Ammerman SD. Helping kids kick butts. Contemp Pediatr 1998;15(2):64.)

 

FIGURE 70.5 Parent 3-minute pointers. (Adapted from Ammerman SD. Helping kids kick butts. Contemp Pediatr 1998;15(2):64.)

United States Public Health Service Clinical Guidelines

The U.S. Public Health Service originally published guidelines that stressed the five “R's” for enhancing motivation to quit tobacco use: (a) indicating why quitting is personallyRelevant; (b) identifying the Risks of tobacco use; (c) identifying the medical and psychosocial Rewards of quitting; (d) identifying Roadblocks to quitting and how to overcome them; and (e) Repeating the motivational intervention at every clinic visit.

In 2000, the clinical practice guideline for treating tobacco use and dependence was revised. The five “A's”Ask, Advise, Assess, Assist, and Arrange—are used for smoking cessation counseling. There are very few published (and even fewer methodologically sound) studies concerning smoking cessation in teens. Therefore, these treatment guidelines are based primarily on the adult literature.

 

FIGURE 70.6 Tobacco as a vital sign: Teen and parent forms

  1. Asksystematically about smoking at each visit. A simple and effective way to operationalize this is to add a yes/no question about tobacco exposure and use to the vital sign portion of the chart note (Fig. 70.6A and B). Therefore, when vital signs are taken at every visit, the use of tobacco will be brought up. Using tobacco as a vital sign gives a simple and effective antitobacco use message at the beginning of the visit, helps the health care provider remember to discuss the issue, and helps increase quitting. Smoking status can change quickly in teenagers, and a previous nonsmoker may be smoking by the time of the next visit—or a regular smoker who did not wish to quit in the past may now wish to quit smoking. Because teens often come in only sporadically for health care, the tobacco issue should be raised at every office visit, no matter what the chief complaint. In addition to cigarette use, it is important to inquire about the use of other tobacco products. Teens may use cigars, chewing tobacco, snuff, bidis, or kreteks, and they may not realize that these products are harmful. Additionally, adolescents who use tobacco products may also be using alcohol and other drugs. Therefore, an alcohol and other drug use history should be obtained. Concomitant use of tobacco with alcohol or other drugs may make it more difficult for the teen to stop tobacco use without also stopping alcohol or other drug use; this needs to be addressed directly during smoking cessation counseling.
  2. Strongly Adviseall smokers to quit. Advice that is clear and personally relevant is most effective. Physicians are looked on as authoritative figures, even by teens, and giving a consistent cessation message is important. Additionally, be sure that smokers understand that cigarettes labeled “light” or “ultralight” are not safer cigarettes. These cigarettes contain the same amount of nicotine, tar, and many other ingredients as regular cigarettes, but have been used as a marketing ploy by the tobacco industry to encourage smokers to continue smoking.
  3. Assesspatient willingness to make a quit attempt (as noted earlier). A quick and easy method to assess potential success in quitting is to ask the patient two questions, both using a 1 to 10 scale. First, how much confidence does the patient have in being able to quit, and second, how much importance does the patient attribute to the behavior change. A patient with high self-confidence who feels that this is a highly important behavior change will likely do well, whereas a patient with low self-confidence and not feeling that quitting is very important will likely do poorly. It is usual for patients to be somewhere in the middle on both scales, so both the patient and physician can strategize about doing better on both.

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  1. Assistthe patient in stopping smoking.
  2. Motivational steps: Setting a quit datehas been shown to be an important and effective first step in smoking cessation. An actual calendar date should be chosen and agreed upon by the patient and physician. See Figure 70.7 for an example of a “quit date” form. Once the quit date has been selected (usually 2–4 weeks away), the patient can prepare to become a nonsmoker. Preparation to quit smoking has physical, psychological, and emotional components. For example, in getting ready to quit (before the quit date), the patient should keep a journal noting when and why and how much he or she smokes, as well as any routine activities in which smoking plays a part, such as drinking coffee or alcohol. The patient can attempt to change smoking routines by keeping cigarettes in a different place, smoking with the other hand, or smoking only in self-designated areas. The patient should occasionally chew gum or drink a glass of water instead of smoking a cigarette; he or she will notice that the smoking craving usually subsides within a few minutes. Gum, hard candy, sunflower seeds, or toothpicks can be carried around and used as cigarette substitutes. By the quit date, the patient'senvironment should be rid of cigarette cues. For example, clothes, the living space, and the inside of the car should all be cleaned to get rid of the tobacco smell. Ashtrays and all cigarettes should be got rid of. The patient should make it a point to find nonsmoking spaces to be in and to stay away from places where smoking is permitted (e.g., bars). Patients need to think of themselves as nonsmokers, and they should literally say to themselves that being a nonsmoker is important. Patients should try to remember the benefits of nonsmoking! Writing down the benefits on a 3 × 5 card that the patient can carry around and look at in tempting situations may be helpful. To maintain the quit effort, patients need to know that withdrawal symptoms are common but transient and that pharmacotherapy is available if necessary. Mild-to-moderate exercise, such as walking or riding a bicycle, can help attenuate withdrawal symptoms. Suggest that the patient start a money jar with the money saved from not buying cigarettes. This will add up quickly, and the patient can reward himself or herself by buying new music, going to the movies, and so on. Psychosocial support has been shown to lead to more successful quit attempts. The patient should actively elicit support from friends and family. Going through the process with a “buddy” who is also willing to quit simultaneously can make the whole cessation process easier and should be encouraged. The clinician should provide self-help materials, such as the “quit tips” listed in Table 70.3.
  3. Pharmacotherapy: Pharmacotherapy includes nicotine replacement products (patch, gum, lozenge, inhaler, or nasal spray), and bupropion (Zyban) and varenicline (Chantix). These modalities may be very helpful for addicted smokers. Addiction is usually defined as smoking half a pack of cigarettes or more/day, smoking the first cigarette of the day within 1 hour of awakening, or having had withdrawal symptoms during a previous quit attempt. Nicotine dependence criteria are listed in the American Psychiatric Association'sDiagnostic and Statistical Manual of Mental Disorders, Fourth Edition(DSM-IV). Withdrawal symptoms and cravings can make quitting very difficult and may be mitigated in large part with use of pharmacotherapy. Prescribing instructions for these medications can be found in Table 70.4. Note that nicotine patches, gum, and lozenges are now over-the-counter medications. Distraction and relaxation techniques should also be encouraged to help patients deal with withdrawal and craving symptoms.
  4. Arrange follow-up. Cessation rates have been shown to significantly improve with regular follow-up. For example, we usually call the patient on the quit date to congratulate him or her on the effort, and then talk with or see the patient every 1 or 2 weeks during the first 3 months of the quit attempt—the time of greatest relapse. If a patient is able to quit for 3 straight months, he or she is more likely to successfully quit for good. It is rare for a patient to have a relapse after abstaining from smoking for an entire year.
 

FIGURE 70.7 A firm quit date is an important step in quitting smoking. (Adapted from Ammerman SD. Helping kids kick butts. Contemp Pediatr 1998;15(2):64.)

It is very important for both the pediatrician and the patient to remember that tobacco is an addictive drug and

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that the cessation process is usually difficult. The average number of quit attempts before successful cessation is approximately seven! Therefore, neither the pediatrician nor the patient should get discouraged if the first few quit attempts are unsuccessful. Rather than looking at these unsuccessful quit attempts as failures, the patient should view them as learning experiences. The pediatrician and the patient should discuss what worked and why, and what did not work and why. This helps make the next quit attempt work better. Depression may occur during a quit attempt and the patient should be asked about mood changes. For smokers with numerous unsuccessful quit attempts, referral to a support group such as Nicotine Anonymous may be helpful.

TABLE 70.3
Guide for Patients: How to Stop Smoking

From Ammerman S. Helping kids kick butts. Contemp Pediatr 1998;15:71.

Quitting smoking is not easy but millions of people have done it and so can you. These tips will help.

Getting ready to quit

·   Set a date for quitting. Try to convince a friend to quit with you, so you will have mutual support. Let your family and friends know that you are trying to quit; they can help you through the harder times and give you ongoing encouragement.

·   Notice when, where, and how you smoke—list the times when you usually light up—with morning coffee, after a meal, while driving, or whatever your usual smoking occasions are.

·   Change your smoking routines. Keep your cigarettes in a different place, do not hold your cigarette in the hand you are used to using, switch brands, and do not carry on any other activity—such as reading, driving, talking on the phone, or watching television—while you smoke.

·   Designate one place to smoke—such as the back porch—and do not smoke anywhere else.

·   When you want a cigarette, wait a few minutes before you light up. Try doing something else, such as chewing gum or drinking a glass of water, and see if the urge passes.

·   Buy only one pack of cigarettes at a time.

·   Ask your doctor about medications that ease withdrawal symptoms and reduce cigarette cravings. You may want to have nicotine patches or gum on hand, ready for quit day.

On quitting day

·   Get rid of all your cigarettes and put away your ashtrays.

·   Change your morning routines, especially where and when you eat breakfast. Try sitting somewhere else, or going out to eat.

·   When you get the urge to smoke, do something else instead.

·   Carry substitutes to put in your mouth, such as chewing gum, hard candy, or toothpicks.

·   Reward yourself at the end of the day. See a movie, or eat a favorite treat.

Staying smoke free

·   Do not be upset if you feel sleepy or short tempered. These are symptoms of nicotine withdrawal and they will go away in a few days.

·   Exercise regularly. Go for walks, ride a bike, or take part in sports you enjoy.

·   Think about the positive aspects of not smoking: Your self-image as someone who has kicked the habit, the health benefit you and your family get from living in a smoke-free environment, and the example you set for others.

·   When you feel tense, think about the problem that causes those feelings and try to solve it. Tell yourself that smoking will not make it better.

·   Eat regular meals, so you do not have times when you feel hungry and confuse that feeling with the desire to smoke.

·   Put the money you would have spent on cigarettes in a money jar every day, and watch it mount up. Plan to buy something special for yourself.

·   Let other people know you have stopped smoking. Your friends who still smoke may want to know how you did it.

·   If you break down and smoke a cigarette, do not give up. Many former smokers made several attempts to stop before they succeeded. Quit again.

Office Changes

It is important to express a consistent antismoking message to parents and patients throughout the entire medical office. Listed are some simple ways to do this.

  1. Select a smoking cessation coordinator: This person is in charge of all antismoking efforts and may be anyone who

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is interested in the project (e.g., receptionist, nurse, aide, doctor). The immediate goal is to create a smoke-free office.

  1. Select a date to make the office smoke free: This is the office employees' equivalent of the individual patient's quit date.
  2. Post “no smoking” signs in all office areas: Prominently display smoking cessation materials and information in your waiting and examination rooms.
  3. Eliminate all tobacco advertising from your waiting room,either by not subscribing to magazines that carry tobacco advertisements and thereby support the tobacco industry (the Maryland Medicine Society, www.smokefreemd.org, has a list of magazines that do not carry any tobacco ads) or by having the office smoking coordinator write over cigarette ads or place stickers with slogans such as, “Don't fall for this” or “This is a rip-off.”
  4. Have prominent office campaigns to publicize theGreat American Smoke-out,” which is always the Thursday before Thanksgiving, and “World No-Tobacco Day,” which is always May 31. These are particularly high-profile public events to encourage smoking cessation.

TABLE 70.4
Pharmacotherapeutic Aids

Type

Indications

Warnings

Adverse Effects

Dosage

Prescribing Instructions

How to Obtain

NRT, nicotine replacement therapy

Patch

Indicated for the relief of nicotine withdrawal symptoms, as part of a comprehensive smoking cessation program

Potential for fetal harm; cardiovascular effects may occur

Local skin reaction, usually mild

Nicoderm CQ and Habitrol: 21 mg (if smoke >10 cigarettes/d; otherwise start with 14 mg) × 6 wk, then 14 mg × 2 wk, then 7 mg × 2 wk; worn 24 hr/d
Nicotrol: 15 mg × 6 wk, then 10 mg × 2 wk, then 5 mg × 2 wk, worn either 16 hr while awake, or 24 hr/d

Start the first patch on awakening on quit day
Do not smoke while using the patch; if you must smoke, take off the patch Each morning, place a new patch on a relatively hairless spot between the neck and waist Use a different spot each day, to reduce skin irritation

Over the counter

Gum

Appropriate for patients who prefer it, or who have had skin reactions, or failure with the patch

Potential for fetal harm; cardiovascular effects may occur

Mouth soreness, hiccups, dyspepsia, and aching jaws are common, mild, and usually transient

2 mg and 4 mg Use 4 mg if smoking >25 cigarettes/d, use 2 mg if smoking <25 cigarettes/d Preferable to chew at least one piece every 1–2 hr; may chew up to 30 pieces of the 2 mg, or 20 pieces of 4 mg gum/d

Do not smoke while using the gum
Chew gum slowly until it tastes minty, peppery, or orange, then park it between the cheek and gum to enhance nicotine absorption Chew slowly and park intermittently for approximately 30 min Reduce number of pieces chewed gradually over time

Over the counter
Mint, pepper, or orange flavors

Nasal spray

Same as gum

Not recommended for patients with chronic nasal disorders; keep out of the reach of children

Nasal irritation

1–2 sprays in each nostril/hr, at least 8 times/d, to a maximum of 80 sprays/d; maximum recommended duration of treatment is 3 mo

Use as frequently as needed to counter withdrawal symptoms for approximately 8 wk, then reduce use over the next 4–6 wk

Prescription only

Inhaler

Same as gum

Same as gum

Use with caution in asthma

Up to 20 cartridges/d, up to 6 mo

Insert cartridge into mouthpiece; cartridge lasts approximately 20 min

Prescription only

Nicotine lozenge

Same as gum

Same as gum

Same as gum

2 mg or 4 mg
Use 4 mg if smoke first cigarette of day within half hr of awakening
Otherwise use 2 mg

Do not chew or swallow the lozenge
Allow the lozenge to slowly dissolve over 20 or 30 min
There may be a warm or tingly sensation in the mouth
Intermittently shift the lozenge around in the mouth
Reduce number of lozenges used gradually over time

Over the counter

Bupropion

For smokers who have failed to quit using nicotine medications alone

Should not be used in patients already on bupropion, or in patients with anorexia, bulimia, or seizure disorders

Dry mouth, insomnia, headache, rhinitis

150 mg once or twice a d, for up to 6 mo

Start with 150 mg q.o.d for 3 d, increase as needed to a maximum of 300 mg/d
Initiate 1 wk q.o.d before quit date, to allow time for blood levels to build up
May use in conjunction with nicotine replacement products

Prescription only

Varenicline

For smokers who prefer non-NRT or oral therapy

No studies in patients younger than 18 years, or pregnant women

Nausea, sleep disturbance, constipation, flatulence, vomiting

0.5 mg days 1–3 0.5 mg b.i.d. days 4–7, 1.0 mg b.i.d. day 8—end of treatment
May use for up to 6 mo

Initiate 1 wk before quit date, to allow time for blood levels to build up

Prescription only

HEDIS (Health Plan Employer Data and Information Set) Standards and Billing Issues

Smoking prevention and cessation counseling is considered a standard of care, and formal ratings of health plans and individual physicians commonly include these efforts. The National Committee on Quality Assurance (NCQA: www.ncqa.org) issues annual reports on the state of health care quality. Concerning billing issues for follow-up, if smoking cessation per se is not covered, there is almost always a related medical issue that may be billed, such as asthma, bronchitis, cough, pharyngitis, or an upper respiratory infection.

Educational Materials

Educational materials for teens, parents, and physicians are available from a variety of sources either free or for nominal fees. The Web sites listed in this section and at end of the chapter all offer educational materials and provide hypertext links to many other tobacco control groups. These include local chapters of the American Cancer Society (www.cancer.org) and the American Lung Association (www.lungusa.org/tobacco); the American Academy of Pediatrics (www.aap.org); the U.S. Department of Health and Human Services (www.hhs.gov/diseases/index.shtml#smoking); the National Cancer Institute (www. nci.nih.gov); and the Agency for Health Care Policy and Research, now called the Agency for Health Care Research and Quality (www.ahcpr.gov), which also provides free smoking cessation guidelines for physicians, and guides for patients. Finally, the federal government's CDC, in conjunction with the Office on Smoking and Health and the National Center for Chronic Disease Prevention and Health Promotion (www.cdc.gov/tobacco), offers educational materials, posters, hypertext links, and other information.

Advocacy Issues

The most successful tobacco control efforts involve a number of concerted actions. These include the following:

  • Increasing the cost of tobacco products through higher taxes on the products
  • Litigation against the tobacco industry to hold corporations financially responsible for the disease and death caused by their products
  • Ending government subsidies to the tobacco industry (which currently exceed $100 million dollars/year)
  • Banning advertising of tobacco products in youth-oriented media (see preceding text concerning the Smoke-Free Movies campaign) and youth-frequented activities such as sporting events
  • Enforcing laws that ban minors from buying tobacco products
  • Banning cigarette-vending machines
  • Promoting adoption of clean indoor air laws and smoke-free facilities such as schools, day care centers, office buildings, restaurants, and bars
  • Getting pharmacies to stop selling tobacco products
  • Advocating for divestment of tobacco industry stocks by state and local government investment agencies
  • Shareholder efforts to change tobacco industry behavior
  • Giving the federal government the regulatory oversight of tobacco as a drug

Advocacy organizations such as Action on Smoking and Health (http://www.ash.org), Americans for Nonsmokers' Rights (www.no-smoke.org), and the Campaign for Tobacco-Free Kids (www.tobaccofreekids.org) have many useful fact sheets, educational materials, and up-to-date information on various aspects of the tobacco wars. The American College Health Association published a position statement on tobacco use on college and university campuses; this is available at www.acha.org/info_resources/tobacco_statement.pdf.Smokefree.net (http://www.smokefree.net) is another excellent tobacco advocacy site. It offers daily e-mail updates on a wide variety of tobacco issues, from the latest science to the latest legal battles. In addition, information received from this site can be personalized to one's own areas of interest. Features include tobacco-related news from individual states and a daily document from the tobacco industry files, which were long suppressed by the tobacco industry until 1999. A companion site, www.tobacco.org, features daily updates of “tobacco in the news,” as well as related documents and health information. The American Legacy Foundation (www.americanlegacy.org) was founded as part of the master settlement agreement, and particularly involves youth in its tobacco control activities e.g., the Truth counter-advertising campaign. The University of California, San Francisco (www.library.ucsf.edu/tobacco) provides online access to the Tobacco Control Archives Print Collection, tobacco industry Web sites and documents, state-by-state reports on tobacco industry activities, and the “Cigarette Papers.”

Internationally, the tobacco industry has not changed its tactics. It has shifted its efforts elsewhere around the globe, and particularly increased them in developing countries, where tobacco control efforts may not be as well established. The tobacco industry continues to

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aggressively market its damaging and deadly products. To fight this global epidemic of tobacco-related disease, the WHO (http://tobacco.who.int) has developed a treaty on tobacco control, the International Framework Convention on Tobacco Control. The United States has refused to ratify this treaty to date, although >90 other countries have formally adopted the treaty. For more information on this important development, contact the Web site at http://tobacco.who.int.

Research Issues

A number of questions concerning tobacco use prevention and cessation in adolescents are being actively investigated in the research setting, including the following:

  1. What are the best methods, and in which settings are programs and clinicians best able to help prevent or delay onset of tobacco use in the pediatric population?
  2. How is tobacco addiction in youth similar to, or different from, that of adults?
  3. How should successful treatment be defined—for example, is significant decrease in use, as opposed to total quitting, a reasonable treatment outcome for adolescents?
  4. How valid is self-reporting of tobacco use, including self-report measures in adolescents?
  5. Does biochemical verification (e.g., breath carbon monoxide, salivary or urinary cotinine) significantly increase the validity of self-reporting?
  6. How should relapse be defined for adolescents?
  7. What are the best methods for recruitment and retention of participants in prevention and cessation studies?
  8. What are the reasons for ethnic differences in smoking rates, and what methods are best to prevent smoking as well as target smokers in an ethnically and culturally appropriate manner?

The Society for Research on Nicotine and Tobacco (www.srnt.org) publishes its own research journal Nicotine and Tobacco Research. The journal Tobacco Control(http://tc.bmjjournals.com) has comprehensive articles on issues related to health, advocacy, and research.

Summary

Tobacco prevention and cessation counseling is one of the most important steps pediatricians can take to improve the short-term and long-term health of patients and their parents. Smoking is a very serious disease with potentially lifelong and life-shortening consequences. Practitioners are in a unique position to help prevent smoking onset or intervene early to stop smoking by adolescents.

WEB SITES

For Teenagers

http://www.thetruth.com. American Legacy Foundation site for adolescents.

http://www.tobaccofreekids.org/youthaction. The Campaign for Tobacco-Free Kids youth component.

http://www.cdc.gov/tobacco/tips4youth.htm. CDC Web site for teens.

For Parents

http://www.cdc.gov/tobacco/smokescreen.htm. CDC education and advocacy sites.

http://www.smokefree.gov. National Cancer Institute Web site for smoking cessation.

http://www.tobaccofreekids.org/. Campaign for Tobacco-Free Kids Web site.

For Clinicians

http://www.americanlegacy.org. American Legacy Foundation Web site.

http://www.tobaccofreekids.org. Campaign for Tobacco-Free Kids Web site.

http://www.cdc.gov/tobacco. CDC Web site on tobacco.

http://www.smokefree.net. A national advocacy Web site.

http://www.surgeongeneral.gov/tobacco/. Surgeon General's Web site for smoking cessation.

http://www.hhs.gov/safety/index.shtml#smoking. Department of Health and Human Services tobacco Web site.

http://www.treatobacco.net/home/home.cfm. A Society for Research on Nicotine and Tobacco related site.

http://www.smokefreemovies.ucsf.edu. Home page for the Smoke-Free Movies campaign.

http://www.tobaccofreeperiodicals.org. Lists magazines that do not accept tobacco advertising.

References and Additional Readings

Abroms L, Simons-Morton B, Haynie DL, et al. Psychosocial predictors of smoking trajectories during middle and high school. Addiction 2005;100(6):733.

American Cancer Society. Cancer prevention and early detection facts and figures. American Cancer Society, www.cancer.org/docroot/STT/stt/_0.asp. 2006.

American College Health Association. American College Health Association—National College Health Assessment (ACHA-NCHA) Web Summary. www.acha.org/projects_programs/ncha_sampledata.cfm. 2005.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994.

American Psychiatric Association. Nicotine-related disorders. In: Diagnostic and statistical manual, 4th ed. Washington, DC: American Psychiatric Association, 1994.

Ammerman SD. Helping kids kick butts. Contemp Pediatr 1998; 15(2):64.

Ammerman SD. Tobacco and pediatrics in the 21st century. Calif Pediatrician 1999;Fall/Winter:31.

Ammerman SD, Nolden M. Neighborhood-based tobacco advertising targeting adolescents. West J Med 1995;162:514.

Austin SB, Ziyadeh N, Fisher LB, et al. Sexual orientation and tobacco use in a study of US adolescent boys and girls. Arch Pediatr Adolesc Med 2004;158:317.

Backinger CL, McDonal P, Ossip-Klein DJ, et al. Improving the future of youth smoking cessation. Am J Health Behav 2003; (27 Suppl 2):S170.

Balch GI, Tworek C, Barker DC, et al. Opportunities for youth smoking cessation: findings from a national focus group study. Nicotine Tob Res 2004;6(1):9.

P.905

 

Becklake MR, Ghezzo H, Ernst P. Childhood predictors of smoking in adolescence: a follow-up study of Montreal Children. Can Med Assoc J 2005;173(4):377.

Biener L, Harris JE, Hamilton W. Impact of the Massachusetts tobacco control program: population-based trend analysis. BMJ 2000;321:351.

Biglan A, Ary DV, Smolkwski K, et al. A randomized controlled trial of a community intervention to prevent adolescent tobacco use. Tob Control 2000;9:24.

Blum RW, Beuhring T, Rinehart PM. Protecting teens: beyond race, income, and family structure [Monograph]. Minneapolis, MN: Center for Adolescent Health, University of Minnesota, 2000.

Bolliger CT, Zellweger JP, Danielsson T, et al. Smoking reduction with oral nicotine inhalers: double-blind, randomized clinical trial of efficacy and safety. BMJ 2000;321:329.

Braverman MT. Research on resilience and its implication for tobacco prevention. Nicotine Tob Res 1999;1:S67.

Bryn Austin S, Ziyadeh N, Fisher LB, et al. Sexual orientation and tobacco use in a cohort study of US adolescent boys and girls. Arch Pediatr Adolesc Med 2004;158:317.

Bush T. Preteen attitudes about smoking and parental factors associated with favorable attitudes. Am J Health Promot 2005; 19:410.

California Department of Health Services, Cancer Prevention Program. Does tobacco advertising influence teens to start smoking? Chapter 10: tobacco use in California: a focus on preventing uptake in adolescents. San Diego: University of California, San Diego, 1993:109.

California Medical Association Foundation. Pharmacy partnership: prescription for change. (221 Main Street, 3rd floor, P.O. Box 7690, San Francisco, CA 94120-7690). San Francisco, CA: California Medical Association Foundation, Available at www.RxforChange.org.2002.

Centers for Disease Control and Prevention. Comparison of the cigarette brand preferences of adult and teenaged smokers—United States, 1989, and 10 U.S. communities, 1988 and 1990. Morb Mortal Wkly Rep CDC Surveill Summ 1992;41: 169.

Centers for Disease Control and Prevention. Changes in the cigarette brand preferences of adolescent smokers—United States, 1989–1993. Morb Mortal Wkly Rep CDC Surveill Summ 1994;43:577.

Centers for Disease Control and Prevention. Strategies for reducing exposure to environmental tobacco smoke, increasing tobacco use cessation, and reducing initiation in communities and health cares systems: a report on recommendations of the Task Force on Community Preventive Services. MMWR Morb Mortal Wkly Rep 2000;49(Suppl):RR–12.

Centers for Disease Control and Prevention. Tobacco use among middle and high school students—United States, 1999. Morb Mortal Wkly Rep CDC Surveill Summ 2000;49:49.

Centers for Disease Control and Prevention. Youth tobacco surveillance—United States, 1998–1999. Morb Mortal Wkly Rep CDC Surveill Summ 2000;49:10.

Centers for Disease Control and Prevention. Cigarette use among high school students—United States, m1991-2003. Morb Mortal Wkly Rep CDC Surveill Summ 2004;53:499.

Centers for Disease Control and Prevention. Prevalence of tobacco use among 14 racial/ethnic populations. Morb Mortal Wkly Rep CDC Surveill Summ 2004;53:49.

Centers for Disease Control and Prevention. Annual smoking-attributable mortality, years of potential life lost, and productivity losses—United States, 1997–2001. Morb Mortal Wkly Rep 2005;54(25):655.

Centers for Disease Control and Prevention. Current smoking among adults—United States, 2003. Morb Mortal Wkly Rep 2005;54(20):509.

Centers for Disease Control and Prevention. Use of cigarettes and other tobacco products among students aged 13–15 years–worldwide, 1999–2005. Morb Mortal Wkly Rep 2005; 55:553.

Centers for Disease Control and Prevention. Youth risk behavior surveillance—United States, 2005. Morb Mortal Wkly Rep CDC Surveill Summ 2006;55(SS05):1.

Colby SM, Monti PM, O'Leary TT, et al. Brief motivational intervention for adolescents in medical settings. Addict Behav 2005;30(5):865.

Crosby MH. Religious challenge by shareholder actions: changing the behavior of tobacco companies and their allies. BMJ 2000;321:373; Lancet 2003;362(9380):281.

Dalton MA, Sargent JD, Beach ML, et al. Effect of viewing smoking in movies on adolescent smoking initiation: a cohort study. Lancet 2003;362(9380):281.

Danard RA. The Engle verdicts and tobacco litigation. BMJ 2000;321:312.

Davis RM. Moving tobacco control beyond “the tipping point.” BMJ 2000;321:309.

DiFranza JR, Rigotti NA, McNeill AD, et al. Initial symptoms of nicotine dependence in adolescents. Tob Control 2000;9:313.

DiFranza JR, Savageau JA, Rigotti NA, et al. Development of symptoms of tobacco dependence in youths: 30 month follow up data from the DANDY study. Tob Control2002;11:228.

Ellickson PL, Orlando M, Tucker JS, et al. From adolescence to young adulthood: racial/ethnic disparities in smoking. Am J Public Health 2004;94:293.

Everett SA, Warren CW, Sharp D, et al. Initiation of cigarette smoking and subsequent smoking behavior among U.S. high school students. Prev Med 1999;29:327.

Farkas AJ, Gilpin EA, White MM, et al. Association between household and workplace smoking restrictions and adolescent smoking. JAMA 2000;284:717.

Farrelly MC, Davis KC, Haviland ML, et al. Evidence of a dose–response relationship between “truth” antismoking ads and youth smoking prevalence. Am J Public Health2005;95(3):425.

Farrelly MC, Niederdeppe J, Yarsevich J. Youth tobacco prevention mass media campaigns: past, present, and future directions. Tob Control 2003;12(suppl 1):i35.

Federal Trade Commission. Annual report on cigarette sales. www.ftc.gov/opa/2005/08/cigreport.htm.2003.

Ferrence R, Ashley MJ. Protecting children from passive smoking. BMJ 2000;321:310.

Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: a clinical practice guideline. AHRQ Publication No. 00–0032. Rockville, MD: U.S. Department of Health and Human Services, 2000.

Francey N, Chapman S. “Operation Berkshire”: the international tobacco companies' conspiracy. BMJ 2000;321:371.

French SA, Perry CL. Smoking among adolescent girls: prevalence and etiology. J Am Med Womens Assoc 1996;51:25.

French SA, Perry CL, Leon GR, et al. Weight concerns, dieting behavior, and smoking initiation among adolescents: aprospectivestudy. Am J Public Health 1994;84:1818.

Frieden TR, Blakeman DE. The dirty dozen: 12 myths that undermine tobacco control. Am J Public Health 2005;95:1500.

Gansky SA, Ellison JA, Kavanaugh C, et al. Oral screening and brief spit tobacco cessation counseling: a review and findings. J Dent Educ 2002;66(9):1088.

Gilpin EA, Pierce JP. Trends in adolescent smoking initiation in the United States: is tobacco marketing an influence? Tob Control 1997;6:122.

P.906

 

Gilpin EA, White MM, Farkas AJ, et al. Home smoking restrictions: which smokers have them and how they are associated with smoking behavior. Nicotine Tob Res 1999;1: 153.

Glantz S. The truth about big tobacco in its own words. BMJ 2000;321:313.

Glantz G, Kacirk K, McCulloch C. Back to the future: smoking in movies in 2002 compared with 1950 levels. Am J Public Health 2004;94(2):261.

Glantz SA, Slade J, Bero LA, et al. The cigarette papers. Berkeley: University of California Press, 1996.

Godlee F. WHO faces up to its tobacco links. BMJ 2000;321:314.

Goodman E, Capitman J. Depressive symptoms and cigarette smoking among teens. Pediatrics 2000;106:748.

Gritz ER. Cigarette smoking by adolescent females: implications for health and behavior. Women Health 1984;9:103.

Hampl JS, Betts MB. Cigarette use during adolescence: effects on nutritional status. Nutr Rev 1999;57:215.

Hastings G, MacFadyen L. A day in the life of an advertising man: review of internal documents from the UK tobacco industry's principal advertising agencies. BMJ 2000;321:366.

Heyes E Tobacco U.S.A.: the industry behind the smoke curtain. Brookfield, CT: Twenty First Century Books, 1999.

Hoffman D, Hoffman I. The changing cigarette, 1950–1995. J Toxicol Environ Health 1997;50:307.

Houston T, Kaufman NJ. Tobacco control in the 21st century: searching for answers in a sea of change. JAMA 2000;284:752.

Howell MF, Zakarian JM, Matt GE, et al. Effect of counseling mothers on their children's exposure to environmental tobacco smoke: randomized controlled trial. BMJ2000;321:337.

Hurt RD, Croghan GA, Beede SD, et al. Nicotine patch therapy in 101 adolescent smokers: efficacy, withdrawal symptom relief, and carbon monoxide and plasma cotinine levels.Arch Pediatr Adolesc Med 2000;154:31.

Jha P, Chaloupka FJ. Tobacco control in developing countries. Oxford: Oxford University Press, 2000.

Johnson JG, Cohen P, Pine DS, et al. Association between cigarette smoking and anxiety disorders during adolescence and early adulthood. JAMA 2000;284:2348.

Johnston LD, O'Malley PM, Bachman JG, et al. Monitoring the future: decline in teen smoking seems to be nearing its end. www.monitoringthefuture.org. December 19, 2005.

Jordan TR, Price JH, Dake JA, et al. Adolescent exposure to and perceptions of environmental tobacco smoke. J Sch Health 2005;75(5):178.

Karp I, O'Loughlin J, Paradis G, et al. Smoking trajectories of adolescent novice smokers in a longitudinal study of tobacco use. Ann Epidemiol 2005;15(6):445.

Kessler DA. Nicotine addiction in young people. N Engl J Med 1995;333:186.

Killen J, Ammerman S, Rojas N, et al. Do adolescent smokers experience withdrawal when deprived of nicotine? Exp Clin Psychopharmacol 2001;9(2):176.

Killen JD, Robinson TN, Ammerman S, et al. Major depression among adolescent smokers undergoing treatment for nicotine dependence. Addict Behav 2004;29:1517.

Killen JD, Robinson TN, Ammerman S, et al. Randomized clinical trial of the efficacy of bupropion combined with nicotine patch in the treatment of adolescent smokers. J Consult Clin Psychol 2004;72(4):729.

Killen J, Robinson TN, Haydel KF, et al. Prospective study of risk factors for the initiation of cigarette smoking. J Consult Clin Psychol 1997;65:1011.

Klein JD, St Clair S. Do candy cigarettes encourage young people to smoke? BMJ 2000;321:362.

Klein JD, Graff Havens C, Carlson EJ. Evaluation of an adolescent smoking-cessation media campaign: gottaquit.com. Pediatr 2005;116:950.

Klitzner M, Gruenewald PF, Bamberger E. Cigarette advertising and adolescent experimentation with smoking. Br J Addict 1991;86:287.

Koop CE. The tobacco scandal: where is the outrage? Tob Control 1998;7:393.

Lancaster T, Stead L, Silagy C, et al. Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library. BMJ 2000;321:355.

Landrine H, Klonoff EA, Reina-Patton A. Minors' access to tobacco before and after the California STAKE Act. Tob Control 2000;9(Suppl II):ii15.

Lasser K, Boyd JW, Woolhandler S, et al. Smoking and mental illness: a population-based prevalence study. JAMA 2000;284:2606.

Leatherdale ST, McDonald PW. What smoking cessation approaches will young smokers use? Addict Behav 2005;30(8): 1614.

Leistikow BN, Martin DC, Milano CE. Fire injuries, disasters, and costs from cigarettes and cigarette lights: a global overview. Prev Med 2000;31:91.

Lerman C, Jepson C, Wileyto EP, et al. Role of functional genetic variation in the dopamine D2 receptor (DRD2) in response to bupropion and nicotine replacement therapy for tobacco dependence: results of two randomized clinical trials. Neuropsychopharmacoy 2006;31(1):231.

Levy DT, Cummings KM, Hyland A. A simulation of the effects of youth initiation policies on overall cigarette use. Am J Public Health 2000;90:1311.

Levy DT, Cummings KM, Hyland A. Increasing taxes as a strategy to reduce cigarette use and deaths: results of a simulation model. Prev Med 2000;31:279.

Luke DA, Stamatakis KA, Brownson RC. State youth-access tobacco control policies and youth smoking behavior in the United States. Am J Prev Med 2000;19:180.

McVey D, Stapleton J. Can anti-smoking television advertising affect smoking behavior? Controlled trial of the Health Education Authority for England's anti-smoking TV campaign.Tob Control 2000;9:273.

Mermelstein R. Teen smoking cessation. Tob Control 2003;12: i25.

Mermelstein R, Colby SM, Patten C, et al. Methodological issues in measuring treatment outcome in adolescent smoking cessation studies. Nicotine Tob Res 2002;4:395.

Miller WR, Rollnick S. Motivational interviewing. Preparing people for change. New York, NY: The Guilford Press, 2002.

Milton MH, Maule CO, Yee Sl, et al. Youth tobacco cessation: a guide for making informed decisions. U.S. Department of Health and Human Services. Centers for Disease Control and Prevention, 2004.

Mitchell P, Chapman S, Smith W. Smoking is a major cause of blindness. Med J Aust 1999;171:173.

National Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health. Reports of the Surgeon General. The health consequences of smoking for women, 1980. The health consequences of smoking: nicotine addiction, 1988. Reducing the health consequences of smoking, 1989. Preventing tobacco use among young people, 1994. Tobacco use among U.S. racial/ethnic minority groups, 1998. Reducing tobacco use, 2000. The health consequences of smoking. Washington, DC: U.S. Dept. of Health and Human Services, Public Health Service, Centers for Disease Control, Available at http://www.cdc.gov/tobacco/sgr/index.htm.2004.

P.907

 

National Center for Health Statistics. Health United States, 2000: adolescent health chartbook. Washington, DC: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2000.

Nichols HB, Harlow BL. Childhood abuse and risk of smoking onset. J Epidemiol Community Health 2004;58:402.

Nides M, Oncken C, Gonzales D, et al. Smoking cessation with varenicline, a selective alpha4beta2 nicotinic receptor agonist: results from a 7-week, randomized, placebo and bupropion-controlled trial with 1-year follow-up. Arch Intern Med 2006;166(15):1561.

Oncken C, Gonzales D, Nides M, et al. Efficacy and safety of the novel selective nicotinic acetylcholine receptor partial agonist, varenicline, for smoking cessation. Arch Intern Med 2006;166(15):1571.

O'Neill HK, Glasgow RE, McCaul KD. Component analysis in smoking prevention research: effects of social consequences information. Addict Behav 1983;8:419.

Pechman C, Reibling ET. Anti-smoking advertising campaigns targeting youth: case studies from USA and Canada. Tob Control 2000;9(Suppl II):ii–18.

Piasecki M, Newhouse PA, eds. Nicotine in psychiatry: psychopathology and emerging therapeutics. Washington, DC: American Psychiatric Press, 2000.

Prabhat J, Chaloupka FJ. The economics of global tobacco control. BMJ 2000;321:358.

Pucci LG, Siegel M. Features of sales promotion in cigarette magazine advertisements, 1980–1993: an analysis of youth exposure in the United States. Tob Control 1999;8:29.

Quinlan KB, McCaul KD. Matched and mismatched interventions with young adult smokers: testing a stage theory. Health Psychol 2000;19:165.

Remafedi G, Carol H. Preventing tobacco use among lesbian, gay, bisexual, and transgender youth. Nicotine Tob Res 2005; 7(2):249.

Rigotti NA, Lee JE, Wechsler H. U.S. college students' use of tobacco products: results of a national survey. JAMA 2000;284:699.

Rojas N, Killen JD, Haydel KF, et al. Nicotine dependence and withdrawal symptoms in adolescent smokers. Arch Pediatr Adolesc Med 1998;152:151.

Sargent JD, Dalton M, Beach M. Exposure to cigarette promotions and smoking uptake in adolescents: evidence of a dose-response relation. Tob Control 2000;9:163.

Schroeder SA. What to do with a patient who smokes. JAMA 2005;294(4):482.

Simons-Morton B, Haynie DL, Crump AD, et al. Peer and parent influences on smoking and drinking among early adolescents. Health Educ Behav 2001;28:95.

Smith TA, House RF, Croghan IT, et al. Nicotine patch therapy in adolescent smokers. Pediatrics 1996;98:659.

Sopori ML, Kozak W. Immunomodulatory effects of cigarette smoke. J Neuroimmunol 1998;83:148.

Spangler JG. Smoking and hormone-related disorders. Prim Care 1999;26:499.

Sussman S, Dent C, Severson H, et al. Self-initiated quitting among adolescent smokers. Prev Med 1998;33:2703.

Sussman S, Lichtman K, Ritt A, et al. Effects of thirty-four adolescent tobacco use cessation and prevention trials on regular users of tobacco products. Subst Use Misuse 1999;34: 1469.

Sutton CD. A hard road: finding ways to reduce teen tobacco use. Tob Control 2000;9:1.

Symm B, Morgan MV, Blackshear Y, et al. Cigar smoking: an ignored public health threat. JPrimPrev 2005;26(4):363.

Thun M, Glynn TJ. Improving the treatment of tobacco dependence. BMJ 2000;321:311.

Tickle JJ, Sargent JD, Dalton MA, et al. Favourite movie stars, their tobacco use in contemporary movies, and its association with adolescent smoking. Tob Control 2001; 10:16.

Tobacco Control Archives. Library and center for knowledge management. San Francisco: University of California, Available at www.library.ucsf.edu/tobacco.2007.

Tuckson RV. Race, sex, economics, and tobacco advertising. J Natl Med Assoc 1989;81:1119.

Tyas SL, Pederson LL. Psychosocial factors related to adolescent smoking: a critical review of the literature. Tob Control 1998;7:409.

Unger JB, Palmer PH, Dent CW, et al. Ethnic differences in adolescent smoking prevalence in California: are multiethnic youth at higher risk? Tob Control 2000;9(Suppl II): ii–i9.

Van den bree MB, Whitmer MD, Pickworth WB. Predictors of smoking development in a population-based sample of adolescents: a prospective study. J Adolesc Health2004;35:172.

Wakefield MA, Chaloupka FJ, Kaufman NJ, et al. Effects of restrictions on smoking at home, at school, and in public places on teenage smoking: cross sectional study. BMJ2000;321: 333–337.

Wang MQ, Fitzhugh EC, Westerfield RC, et al. Family and peer influences on smoking behavior among American adolescents: an age trend. J Adolesc Health 1995;10:200–203.

Warner KE, Hodgson TA, Carroll CE. Medical costs of smoking in the United States: estimates, their validity, and their implications. Tob Control 1999;8:290–300.

Weitzman M, Cook S, Auinger P, et al. Tobacco smoke exposure is associated with the metabolic syndrome in adolescents. Circulation 2005;112(6):862.

Wernakulasuriya S. Effectiveness of tobacco counseling in the dental office. J Dent Educ 2002;66(9):1079.

World Health Organization. Why is tobacco a public health priority? www.who.int/tobacco/health_priority/en/index.html.2007.

Zhu SH, Anderson CM, Johnson CE, et al. A centralized telephone service for tobacco cessation: the California experience. Tob Control 2000;9(Suppl II):ii–48.

Zhu SH, Sun J, Billings SC, et al. Predictors of smoking cessation in US adolescents. Am J Prev Med 1999;16(3):202.