Although overall teen smoking rates have dropped,
tobacco use continues to increase among girls, less-educated
teens, and other adolescent groups.
First the good news: teen
smoking rates have recently hit a 10-year low. The Centers for
Disease Control and Prevention’s Youth Risk Behavior Survey
reports that teen cigarette smoking has dropped to 28% in
2001. That is down from 36% in 1997 as measured by the same
survey. Now the bad news: teenage girls are still the
fastest-growing demographic of new smokers, and lung cancer
has surpassed breast cancer as the number one cancer killer of
women. Both the tobacco industry and public health advocates
have long recognized teens as a crucial factor in the smoking
equation. The tobacco industry has consistently discussed the
importance of teen smokers in internal documents while denying
that it in any way targets children and teens.
In the Beginning
The seeds of teenage
smoking and the effects of smoking on children are often sown
before birth. Smoking during pregnancy continues to be one of
health care’s most significant challenges. The children of
women who continued to smoke during pregnancy may have serious
outcomes. These can include miscarriage, low birth weight (a
predictor of frequent illness in the first year of life),
perinatal death, asthma, otitis, sudden infant death syndrome
(SIDS), childhood leukemia, cancer of the brain or lungs later
in life, conduct disorder, and emotional as well as
intellectual deficits. Recent research also indicates
increased risks resulting from second-hand smoke. Nicotine,
carbon monoxide, and carcinogens all pass through the
placenta. In many cases, they can be detected in blood samples
from newborns.
Virtually every parent has observed a pre-school-age child
mimicking smoking rituals observed on TV and in restaurants.
In communities where smoking is still allowed in restaurants,
it is common to hear a hostess ask parents to choose “smoking
or nonsmoking” as they enter a restaurant. Even when seated in
a nonsmoking section, children observe adults smoking
cigarettes and begin to associate it with adult behavior.
Parental smoking is an additional aggravating factor,
fostering an increased incidence of smoking among teens whose
parents smoke. Several teens I interviewed for this article
stated that their parents buy them cigarettes, and one teenage
girl mentioned that her father had “taught” her how to
inhale.
Addicted Teens
Cigarette smoking is the most
prevalent form of nicotine addiction in the United
States of America. Each cigarette contains 10 mg or more
of nicotine, but the average smoker inhales 1-2 mg of
nicotine per cigarette.1
Nicotine is absorbed through
the skin and mucosal lining of the mouth and nose, and
through inhalation directly into the lungs. Depending on
how tobacco is taken, nicotine can reach peak levels in
the bloodstream and brain rapidly. Cigarette smoking,
for example, results in rapid distribution of nicotine
throughout the body, reaching the brain within 10
seconds of inhalation. Cigar and pipe smokers do not
inhale the smoke, so nicotine is absorbed more slowly
through the mucous membrane in the
mouth.2
When inhaled nicotine reaches
the brain, it accelerates the release of dopamine, a
neurotransmitter that carries information across the
synaptic clefts. This circuit, known as the pleasure
center, is associated with emotions. Dopamine-releasing
pathways extend from the midbrain to the hypothalamus
and trigger activities that increase the likelihood of
survival, such as procreating and eating. The increase
of dopamine takes place in the nucleus accumbens, a
small part of the brain associated with substance
addictions in rats. In a new study, precise measurements
were used to track nicotine-stimulated dopamine release
to the shell of the nucleus accumbens. The shell is
wired to the forebrain, where emotional and motivational
processing occurs. The forebrain includes the amygdala,
which is active in many emotional states and is
associated with addictive behavior. The study also
measured an increase in metabolism in the shell of the
nucleus accumbens. Nicotine did not raise the
concentration of sugar anywhere else in the
brain.3
The stimulation of the fibers
originating in the nucleus accumbens is interpreted by
the brain as the neurotransmitter equivalent of
“Good—let’s have it again.” High levels of dopamine
result in a desire for repeated increases in dopamine.
Activation of this pleasure-reward circuit also creates
a memory of the event and the motivation to do it again.
An addiction is formed.
The development of
psychological dependence in cigarette smokers is
abundantly evident in nicotine dependency. Nicotine can
act as both a sedative and a stimulant. Immediately
after nicotine is inhaled, it stimulates the adrenal
glands, resulting in the discharge of epinephrine
(adrenaline). The rush of adrenaline stimulates the body
and causes a sudden release of glucose and an increase
in blood pressure, respiratory rate, and heart rate.
Nicotine also suppresses insulin output from the
pancreas, causing hyperglycemia, which suppresses
appetite.4
Nicotine combines with other
neurotransmitters in the brain and may contribute to the
following effects: • Acetylcholine: Arousal,
cognitive enhancement • Serotonin: Mood changes,
appetite suppressant • Norepinephrine: Arousal,
appetite suppressant • Vasopressin: Memory
improvement • Beta-endorphin: Anxiety/tension
reducer • As a mood- and behavior-altering agent,
tobacco is as addictive as heroin.
Nicotine is: • 1,000 times
more potent than alcohol • 10-100 times more potent
than barbiturates • 5-10 times more potent than
cocaine or morphine
A person who smokes one to
two packs per day takes 200 to 400 hits daily, a
constant intake of a fast-acting drug that affects mood,
concentration, and performance and will produce
dependence in a very short time.5 Nicotine
withdrawal symptoms, which can include sweating and
rapid pulse, increased hand tremors, insomnia, nausea or
vomiting, physical agitation and anxiety, or transient
visual, tactile, or auditory hallucinations or
illusions, can last from weeks to months. After
withdrawal subsides, urges for nicotine return in
response to cues to smoke, including social gatherings
and consumption of alcohol or
coffee.6
—Carol Mihailuk,
RRT |
The Target: Young Lungs
Internal
tobacco industry documents clearly demonstrate a focus on
youth as essential to replacing the estimated 450,000 people
who die each year from smoking-related disease. And no
wonder—90% of all smokers started before the age of 18. If
individuals do not begin smoking in their teen years, chances
are they never will.
The Colorado Society for Respiratory Care recently honored
Anne Landmann, RRT, as clinician of the year for her research
into tobacco industry documents on behalf of the American Lung
Association of Colorado. “A host of internal tobacco industry
documents show that the tobacco companies are fully aware that
children must start to smoke or they will go out of business,”
she says. “Adults simply don’t enter into nicotine addiction
in adequate numbers to sustain growth in the industry, but
hordes of children can be made to ‘follow the leader’ into
smoking when they receive the right cues to do so. Young
people are far less educated, less aware, less sophisticated,
and less media-literate than any other market. As such, young
people are a fertile target for exploitation by the tobacco
industry.”
Although the ubiquitous Joe Camel cartoon character was
retired as a condition of the tobacco settlement, opponents
charge that the industry continues to target teens while
covertly promoting their products to young lungs. Several
companies, including Camel, are now marketing orange, vanilla,
cherry, and chocolate flavored cigarettes. These are not to be
confused with the candy products available to children who
want to play “grown-up” by pretending to smoke candy
cigarettes and chewing bubble-gum chaw. These are real
cigarettes, loaded with tar and nicotine.
Following an aggressive, in-your-face antismoking campaign,
the Florida Youth Tobacco Survey reported an unprecedented 54%
decline in middle school tobacco use over 2 years and a 24%
drop among high school students. Meanwhile, the tobacco
industry has jumped in with its own ads, which seem to
discourage teen smoking but may have a more subversive
purpose.
Lorillard Tobacco Company is not overtly promoting its
product by sponsoring the ESPN Winter X Games. Its
advertisements declare “Tobacco is whacko if you’re a teen.”
But industry opponents point out that the hidden message is
“smoking is for grown-ups” and perpetuates the image of
tobacco as a forbidden fruit.
Tobacco industry internal documents suggest that the
purpose of their antitobacco campaigns, including the
ubiquitous “We Card” campaign, is to demonstrate to
legislators they are addressing the problem, thus preempting
more restrictive measures, and promoting a positive image for
the industry. Effectively discouraging teens from lighting up
is not even mentioned as a goal in their advertising
campaign.
What American Teenagers
Believe
Females: • American
Indians are less likely to agree with the negative
health consequences. • Asian Americans are more
likely to endorse strong social disapproval of
smoking. • African Americans see smoking as “risky”
and incompatible with the promise of a successful
future. • White American girls have expectations
about smoking reinforced by mainstream culture. Among
them: Smoking controls weight (an important
reinforcement because thinness is highly desired in
white culture); smoking helps increase a mellower mood;
smoking enhances the image of sophistication and
independence. • Among nonwhite groups, smoking is
seen as inappropriate for women.
Males: •
African Americans with less education and living in
poverty smoke more than those with higher education and
economic success. • Among American Indians, 40% of
all males smoke and do not acknowledge the negative
aspects of smoking. • Among Asian Americans, 34% to
43% of males smoke. A factor believed to be significant
in this figure is the growing presence of new immigrants
who lack proficient English language skills, are not
aware of the hazards of smoking, and who seek to adopt
the norms of American life and culture. • American
males smoke due to role models, gathering with friends
for happy hour, and easing
tension.7
A study on teen smoking found
that teenagers got hooked within weeks of starting,
following the use of only a few cigarettes per
day.8 The study pointed to alcohol as the
number-one reinforcement factor for teen smoking. It
also indicated that current antismoking campaigns, which
drive smokers together into clusters in segregated
smoking areas, might be reinforcing rather than
deterring smoking.9
(Survey of teenagers
including a cross section of American Indian, Asian
American, African American, and white
youth)
Carol Mihailuk, RRT, RCP, is
a critical care therapist at UCSD Medical Center, San
Diego. |
Fighting Back
RTs can provide
leadership in their individual states and communities by
supporting local smoke-free community ordinances and opposing
moves to raid tobacco settlement funds to shore up sagging tax
revenues. Since the November 1998 state tobacco
settlement—expected to total $246 billion over 25 years—states
have continually collected more money, but are increasingly
spending less of it to adequately fund tobacco prevention and
cessation programs. Overwhelming evidence demonstrates that
such programs not only reduce smoking and save lives, but also
save up to three dollars for every dollar spent by reducing
smoking-related health care costs.
RTs interested in learning about tobacco control issues can
find state-by-state information on smoke-free air, youth
access, tobacco use prevention, control spending, and
cigarette tax at: http://lungaction.org/reports/tobacco-control.html.
By becoming active in their communities, RTs can
contribute to the considerable momentum toward the fundamental
cultural change currently taking place.
John A. Wolfe, RRT, is the Northern Region Program
Coordinator for the American Lung Association of
Colorado.
References
1. Martin WR, Van Loon GR,
Iwamoto ET, Davos L, eds. Tobacco Smoking and Nicotine. New
York: Plenum Press; 1987.
2. Bartecch CE, MacKenzie TD,
Schrier RW. Human cost of tobacco use. N Engl J Med. 1996;330:
907-980.
3. Pontieri FE, Tanda G, Orzi F, Di Chiara G.
Effects of nicotine on the nucleus accumbens and similarity to
those of addictive drugs. Nature. July 18,
1996;382(6588):255-7.
4. Giovino GA, Henningfield JE, Tomar
SL, Escobedo LG, Slade J. Epidemiology of tobacco use and
dependence. Epidemiol Rev. 1995;17(1):48-65.
5. University
of Minnesota School of Dentistry, Division of Periodontology.
Nicotine addiction, Available at:
http://www.umn,edu/peril/tobacco/nicoaddct.html.
6. Long
PW. Nicotine dependence, Internet Mental Health. Available at:
www.mentalhealth.com. Accessed December 10, 2002.
7. Action
on Smoking and Health (ASH), 2013 H Street, NW, Washington, DC
20006. Available at:
http://ash.org.surgeongeneralsreportat-a-glance.
8.
Monitoring the Future, National Results on Adolescent Drug
Use, Overview 2000-2001. Bethesda, Md: National Institute on
Drug Abuse; 2001. NIH publication No. 01-4923.
9. Huffman
K. Psychology in Action. 6th ed. New York: John Wiley and
Sons; 2002:89-91.