Developing a successful smoking cessation program for
adolescents involves open discussion, family support, and
health care involvement.
The national
antitobacco media campaign is the latest step in trying to
prevent teen and preteen smoking. Designed to grab the
attention and play to the humor of adolescents, these
commercials have been reported to have positive effects on
teen and preteen understanding and attitudes about not
smoking.1,2 Despite the impact on teen perception of smoking,
most smoking prevention and cessation programs for adolescents
have not proven highly effective as is evidenced by the rise
in teen and preteen smoking rates. Consideration needs to be
given to the health impact of teen smoking, what respiratory
therapists and other medical professionals can do to
discourage teen smoking, and the development of teen-specific
smoking cessation programs and family involvement through
support.
Why is preteen and teen
smoking an issue? This is the section of the population where
new, lifelong smokers are recruited to replace those smokers
who have quit or died, sometimes due to smoking-related
deaths. Approximately 2 million adult smokers quit or die
annually and are replaced by nearly 3 million preteen and teen
smokers.2 Nearly 90% of people aged 30 to 39 who ever were or
still are daily smokers report having smoked their first
cigarette before the age of 18.3 In fact, it has been
estimated that more than 3,000 youths begin smoking each day,4
of which an estimated 1,000 will die from tobacco-related
illness.8 In addition, 70% of current smokers state that they
became dependent on nicotine before the age of 18.5 The rate
of current smokers who initiated tobacco use after reaching
age 18 is very low. Therefore, it seems wise to address the
preteen and teen population through prevention and cessation.
The majority of teens begin
experimenting with cigarettes between the sixth and eighth
grades.3 However, some smokers begin experimentation as young
as age 9.7 There is usually a 2-year period between smoking
experimentation and the act of smoking daily,7 so it seems
especially important to vigorously address teen and preteen
prevention and cessation to ensure healthier teens and young
adults. The younger people are when they begin to smoke, the
more likely they are to advance to being daily smokers or to
consume more cigarettes when they smoke. The earlier a person
begins smoking, the harder it is to quit.
In 1990,2 cigarette smoking
accounted for 400,000 deaths. This is not just a statistic;
this number represents 400,000 of yesterday’s teen smokers. It
has also been estimated that cigarette smoking is responsible
for $50 billion in annual lost work productivity and medical
care expense per year. It has been proposed that cigarette
smoking increases the risk of lung cancer by 2,000% and
coronary heart disease by 150%.7 Cigarette smoking has also
been identified as a cause for the development of asthma.
There is additional evidence7 suggesting that cigarette
smoking is involved in the development of respiratory disease,
osteoporosis, ulcers, and diabetes.
Given all of the negative
health effects associated with smoking, why would a preteen or
teen choose to become a smoker? John Wolfe, American Lung
Association (ALA) Not On Tobacco (N-O-T) Program Facilitator
and ALA of Colorado Board Member, has an answer. “The
overriding reason why teens begin smoking is to conform to
peer group activity. A lot of teen smokers began smoking
between the ages of 10 to 13 after being introduced to smoking
by a sibling or a friend.”
A seemingly common sense way
of preventing tobacco consumption by adolescents appears to be
to reduce and ideally eliminate youth access to tobacco
products. This, however, is not an easy task to accomplish.
Obstacles in banning youth access to tobacco include merchant
noncompliance with the law, lack of strong local ordinances
banning youth access and mandating merchant fining, and lack
of law enforcement manpower to enforce federal, state, and
local law. Woodridge, Ill, has developed and enforced
effective local legislation that has produced a sustained
reduction in cigarette sales to minors.8 Almost 2 years after
the passage of the Woodridge ordinance, the rate of regularly
smoking teens dropped from 16% to 5%.8 While the effect of
local legislation and enforcement is promising, there are not
a lot of subject communities for the investigation of this
topic. Further research is warranted.
In other areas of the nation,
merchant noncompliance with existing laws is a large problem.
Leonard Jason, PhD, professor of clinical and community
psychology at DePaul University, Chicago, comments, “Right
now, about 20% to 30% of merchants continue to sell cigarettes
to minors nationwide. That rate is very high. This means that
youth have access to tobacco. What’s needed is to drive these
rates down to 5% or less.”
Sources other than merchants
for teens to obtain cigarettes include fake identification,
theft, asking others to purchase tobacco,8 parents, and
peers.10 Parents may pose the largest problem in providing
cigarettes and encouraging smoking. Wolfe says, “A lot of
teens have parents who smoke and buy cigarettes for the
teens.”
Regardless of the source of
teens’ cigarettes, the question remains: what can be done to
keep the adolescent from using tobacco? One answer is quite
simple. The public should not condone public smoking by teens.
In addition, local government and law enforcement agencies may
want to consider fining a minor for possession of tobacco
products. While fining minors for possession of tobacco
products has not been methodically investigated, there is
expressed interest in this area among public health
officials.8
The media can also play an
important role in helping prevent minors from initiating
smoking and encouraging cessation in those adolescents who
already smoke. In the past, antismoking media campaigns have
been criticized for being too one-dimensional, resulting in a
poor atmosphere for open conversations to occur between
smokers and nonsmokers. An open environment would help support
the many stages of smoking cessation.2 It has also been
suggested that antismoking media campaigns may need to be more
carefully tailored to meet the needs and concerns of both
younger and older adolescents.1
The effectiveness of the
current national antismoking media campaign has yet to be
studied. At this point many believe that it is too new for a
comprehensive study of its impact to be made. Others believe
that it needs to be improved to more directly involve children
in every aspect of the message.10 Future studies of the
current media campaign are being demanded.
Physicians consulting on
tobacco use is another area of both intervention and cessation
encouragement that is not being fully utilized. A recent study
by Thorndike et al9 reviews the percentage of physicians that
spend time speaking with adolescents about not becoming a
smoker or quitting if they have already started. The low rates
gathered between 1991 and 1996 are alarming. On average, only
34.6% of routine physical examinations of teen smokers and
only 6.3% of routine physical examinations of teens,
regardless of smoking status, were coupled with counseling
about smoking. While physicians often did identify smoking
status, no further steps were usually taken to address the
issue of smoking or remaining smoke-free. When divided by
physician specialty, the rates were a little different.
Primary care physicians spend more time than specialists
discussing smoking with teens and pediatricians address
smoking more than family practitioners and internists.
However, the differences reported were small, with all types
of physicians doing little or no counseling.11
Many groups recommend that
physicians speak more to teens and preteens about smoking with
age-specific interventions. There are a number of sources
where physicians can receive more information about discussing
smoking with adolescent patients. The National Cancer
Institute and the American Academy of Pediatrics11 encourage
physicians to include the following items when meeting with
preteens and teens:
• ask the adolescent if they or
their friends use tobacco;
• advise users to stop using
tobacco;
• congratulate adolescents who do not use
tobacco; and
• advise tobacco abstinence.
Another source for physician
information about discussing smoking with teens is the Tar
Wars Program of the American Academy of Family Physicians.3
Finally, Thorndike et al advises the medical community to:
• provide training programs for residents and practicing
physicians to address smoking issues;
• alter office
practices and information to support addressing smoking;
•
provide reimbursement to physicians for providing adolescent
tobacco use counseling; and
• include smoking status
identification and tobacco counseling as quality indicators
for the treatment of preteen and teen patients.
If intervention activities
fail, cessation programs should be encouraged. In the past,
most teen cessation programs have been nothing more than an
adaptation of existing adult smoking cessation programs. This
approach is woefully inadequate as teens often face unique
obstacles in deciding to stop smoking and learning the tools
to do so. Many teens do want to become smoke-free. Wolfe
notes, “Health effects are concerns for teens who want to quit
smoking.” Effective teen smoking cessation programs should
include health effects.
A well-formed teen-specific
smoking cessation program should address topics that are
important to adolescents. Such issues would include exploring
reasons for smoking and not smoking; realizing the excuses to
not quit smoking and how to disregard those excuses;
understanding nicotine addiction and how cigarette smoking
affects the body; understanding both the physical and mental
benefits of quitting; discovering how to successfully deal
with urges and cravings; locating low fat alternative snacks;
involving relaxation and/or exercise to help deal with
withdrawal symptoms; being able to withstand peer and family
pressure to smoke; understanding how to be a nonsmoker in a
smoker-friendly environment, understanding how the tobacco
industry targets teens; rewards for every step of quitting;
and follow-up measures to provide ongoing support. While all
of these issues are important to any individual who is trying
to stop smoking, the concentration of the issues may be more
intense for adolescents. A successful teen-specific smoking
cessation program will also not use a lot of scare tactics,
opting instead for constructive goal formation and steps to
achieving goals.
Not On Tobacco or N-O-T is a
new teen-specific smoking cessation program that has been
developed by the ALA and includes all of the above listed
topics in a well-formed structure. This program is so new that
only pilot study results exist to assess its efficacy.
According to the pilot study, the quit rate of N-O-T
participants was greater than that of a brief intervention
group. Reduction rates were also higher for the N-O-T
participants. The majority of the N-O-T participants believed
the program was helpful in aiding their desire to quit smoking
and helpful in at least one other life area. The five most
commonly listed topics that teens felt were helpful were:
facts about smoking, stress management, nicotine and how it
affects the body, withdrawal symptoms, and dealing with peers
and family members who smoke.
Peer counseling has been
suggested as a good addition to any smoking intervention or
cessation program. Jason agrees by saying, “There’s not a lot
of data on teen smoking cessation programs. That’s only one of
the problems. Teens generally don’t listen well to adult
authority figures so it seems the best programs would involve
peers in the change process.” Peers can be utilized to set an
example of appropriate norms. As teachers, peers are many
times considered more credible and to have a better
understanding of youth issues.10 This makes youth more
receptive to their thoughts and suggestions. Although it is
more difficult to teach young people to be concerned about a
future preventable problem than it is to deal with an issue at
hand, Posavac and Kattapong10 report that peer intervention
programs do indeed work. While some educational facilities and
health organizations may be reluctant to include a peer
intervention program due to the cost of recruiting, training,
and transportation,10 they may want to consider the worth of
helping just one preteen or teen to remain or become
smoke-free.
The family, specifically the
parents of pre-teens and teens, may play the most important
part in preventing adolescent smoking or supporting successful
cessation. Many of the current teen smokers have a parent or
parents who are smokers. Farkas et al11 found that adolescents
who had parents who had quit smoking were almost a third less
likely to become smokers than teens whose parents had not quit
smoking. Youths aged 15 to 17 with parents who have quit
smoking are also twice as likely to have successful smoking
cessation than similar teens whose parents had not quit
smoking. The earlier in the child’s life that the parents
become smoke-free, the less likely it is that their children
will become smokers.11 In addition, if parents who smoke also
quit when their adolescent quits, a more supportive and
directly interactive system would be formed. Jason comments,
“Children, particularly preteenagers, learn many of their
values and adopt many of their healthy behaviors from what
they see in their families to the extent that families are
nurturant and clear in their expectations and positive role
models. These types of good parents, when they give
antismoking messages, will be most likely to have their
children adopt these positive behavioral
practices.”
It is the tobacco industry’s
desire to replace smokers who have quit or died with new
smokers. Unfortunately, the industry looks to the ranks of
America’s youth to do this through a series of advertisements
that target children. This target marketing was (and still is)
promoted by using cartoon tobacco industry mascots, by placing
inner city billboard advertisements near schools, and by
portraying smokers as healthy, active, popular, and common.
The tobacco industry portrayal of smokers is a fallacy and
teens and preteens need to be made aware of that fact. Open
discussion, health care involvement, and family support need
to be utilized and encouraged to curtail teen and preteen
smoking.
Jennifer Vavra is a
contributing writer for RT Magazine.
References
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