SMOKING and TEENAGERS For questions regarding this presentation, please contact: Karen Hudmon, DrPH, MS, RPh Yale University School of Medicine Department of Epidemiology & Public Health 60 College Street, 4th Floor New Haven, CT 06473 Telephone: 203-785-7367 E-mail: karen.hudmon@yale.edu Materials prepared by Karen Hudmon for the San Mateo County Pharmacists Association. Copyright 1999-2006. All rights reserved.

SMOKING AMONG TEENS in the UNITED STATES 4.5 million kids aged 12-17 smoke. Each day, more than 3,000 kids become daily smokers. Most teen regular smokers report some level of addiction and withdrawal. Approximately 4.5 million adolescents (between the ages of 12 and 17) smoke. Each day, more than 3,000 adolescents under the age of 18 become daily smokers. Most teens who smoke regularly report some level of addiction and withdrawal. Of daily smokers who think that they will not smoke in five years, nearly 75% are still smoking five to six years later. Source: Centers for Disease Prevention and Control. Available: http://www.cdc.gov/tobacco/research_data/youth/initfact.htm

WHAT IS THE LEGAL AGE FOR SMOKING? 18 What is the legal age for smoking? 18. In the United States, experimentation with cigarettes and the development of regular smoking typically occur during adolescence, with 89% of adult smokers having tried their first cigarette by 18 years of age (USDHHS, 1994; Gilpin et al., 1994) and 71% of adult daily smokers becoming regular smokers by age 18 (Gilpin et al., 1994). Should the smoking age be increased? Sources: United States Department of Health and Human Services. Preventing tobacco use among young people: A Report of The Surgeon General. Atlanta, GA: United States Department of Health and Human Service, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1994. Gilpin EA, Lee L, Evans N, Pierce JP. Smoking initiation rates in adults and minors: United States, 1984-1988. Am J Epidemiol 1994; 140(6):535-543.

HOW MANY TEENAGERS SMOKE? Cigarette smoking: 12th graders Students who smoked one or more cigarettes in the past month White Percent of students Hispanic Cigarette smoking among adolescents is a public health concern of utmost importance. In the U.S., experimentation with cigarettes and the development of regular smoking typically occur during adolescence, with 89% of adult smokers having tried their first cigarette by 18 years of age (Gilpin et al., 1999; USDHHS, 1994), and 71% of adult daily smokers having become regular smokers by age 18 (Gilpin et al., 1999). Each day, an estimated 3,000 additional children and adolescents become established smokers (Gilpin et al., 1999). Because most youth who smoke at least monthly continue to smoke in adulthood, tobacco use trends among youth are a key indicator of the overall health trends for the U.S. (USDHHS, 2000). During 1991–1997, the smoking prevalence (defined as one or more cigarettes in the 30 days before survey completion) among high school seniors increased to 36.5%. At that time, the prevalence was highest among whites (40.7%) and lowest among blacks (14.3%). This worrisome increasing trend highlighted a need for tobacco prevention and cessation programs focused on this age group. In 2004, an estimated 25.0% of 12th graders had smoked one or more cigarettes in the past 30 days. Among 8th- and 10th-grade students in 2004, the overall 30-day point prevalence for cigarette smoking was 9.2% and 16.0%, respectively (Johnston et al., 2005). As can be seen in the graph, smoking among adolescents has declined over the past decade; however, the downward trend has largely diminished in recent years. ♪ Note to instructor(s): Monitoring the Future data, publications, and press releases are available at www.monitoringthefuture.org. Gilpin EA, Choi WS, Berry C, Pierce JP. (1999). How many adolescents start smoking each day in the United States? J Adolesc Health 25:248–255. Johnston LD, O'Malley PM, Bachman JG, Schulenberg, JE. (2005). Monitoring the Future National Results on Adolescent Drug Use: Overview of Key Findings, 2004 (NIH Publication No. 05-5726). Bethesda, MD: National Institute on Drug Abuse. Data retrieved December 19, 2005, from www.monitoringthefuture.org/data/04data.html#2004data-cigs. U.S. Department of Health and Human Services (USDHHS). (1994). Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking Health. U.S. Department of Health and Human Services. (2000). Healthy People 2010. Washington, DC: U.S. Department of Health and Human Services. Black

CONSEQUENCES of SMOKING Nearly 440,000 people die each year because of smoking. Smoking kills more Americans every year than car accidents, alcohol, cocaine, crack, heroin, homicide, suicide, fire, and AIDS combined. Each year, approximately 434,000 smokers and 53,000 nonsmokers die because of tobacco smoke. That is equivalent to having two to three jumbo jets, filled to capacity, collide mid-air every day of the year, with no survivors. Tobacco kills more Americans each year than car accidents alcohol, cocaine, crack, heroin, homicide, suicide, fire and AIDS combined. This is shown in the next slide.

CAUSES of DEATH in the U.S. Tobacco Poor diet and exercise Alcohol Smoking can harm YOU and OTHERS. Infections 1 in 5 DEATHS are caused by TOBACCO Pollutants/toxins Firearms In fact, tobacco causes nearly 1 in every 5 deaths in the U.S. (McGinnis & Foege, 1993). Smoking no only harms the smoker, but also those who breathe second-hand smoke. Approximately 53,000 nonsmokers die each year in the United States because of second-hand smoke (National Cancer Institute, 1999). *The percentages used in this figure are composite approximations derived from published scientific studies that attributed deaths to these causes. Source: McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207-12. National Cancer Institute. Health Effects of Exposure to Environmental Tobacco Smoke: The Report of the California Environmental Protection Agency. Smoking and Tobacco Control Monograph No. 10. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute, NIH Publication No. 99-4645, 1999, pp. 185–264. Sexual behavior Motor vehicles Illicit drug use Percentage of all deaths

WHAT’S in TOBACCO SMOKE? 4,800 chemicals in tobacco smoke Harmful gases Tar Lead Nicotine Tobacco smoke, which is inhaled either directly or as second-hand smoke, contains an estimated 4,800 compounds. The majority of the compounds are present in the particulate phase, suspended in tobacco smoke. Based on a classification system by the International Agency for Research on Cancer, there currently are 11 known human carcinogens (Group I), 7 probable human carcinogens (Group 2A), and 49 animal carcinogens that possibly also are carcinogens in humans (Group 2B) (NCI, 2001). Examples of detrimental compounds (some of which are carcinogens) in tobacco smoke include the following: Carbon monoxide: automobile exhaust; binds to hemoglobin, inhibits respiration Hydrogen cyanide: gas chamber poison; highly ciliotoxic, inhibits lung clearance Ammonia: floor/toilet cleaning agent; irritation of respiratory tract Nicotine : addictive substance; toxic alkaloid Benzene: solvent, banned substance in organic chemistry labs; Group I carcinogen Nitrosamines: carcinogenic in animals and probably in humans; Group 2A and 2B carcinogens Lead: heavy metal, toxic to central nervous system; Group 2B carcinogen Cadmium: heavy metal found in rechargeable batteries; Group I carcinogen Hexavalent chromium: highlighted in the movie Erin Brockovich; Group I carcinogen Arsenic: pesticide; Group I carcinogen Polonium-210: radioactive agent; Group I carcinogen Formaldehyde: embalming fluid; Group 2B carcinogen Other substances in tobacco smoke (not listed above) that have sufficient evidence to be classified as Group I carcinogens in humans include 2-naphthylamine, 4-aminobiphenyl, vinyl chloride, ethylene oxide, beryllium, nickel, and cadmium. Source: National Cancer Institute. Risks Associated with Low Machine-Measured Yields of Tar and Nicotine. Smoking and Tobacco Control Monograph No. 13. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute, NIH Publication No. 02-5074, October 2001. Many are PROVEN to cause cancer

A diseased lung showing emphysema, characteristic of smoking This picture shows a lung with emphysema, one of many diseases that is characteristic of smoking. About 87% of lung cancers are caused by smoking. Men who smoke have a 22-fold increased risk of developing lung cancer, compared to men who don’t smoke (American Cancer Society, 2000). Women who smoke have a 12-fold increased risk of developing lung cancer, compared to women who don’t smoke (American Cancer Society, 2000). Source: American Cancer Society. Available online at: www.cancer.org. A diseased lung showing emphysema, characteristic of smoking

FORMS OF TOBACCO Cigarettes Smokeless tobacco: snuff, chewing tobacco Pipes Cigars Clove cigarettes Bidis Although cigarettes are, by far, the most commonly used form of tobacco in the U.S., there are other forms available. Several of these, such as clove cigarettes and bidis, have attained increased popularity in recent years: Cigarettes Smokeless tobacco (oral snuff and chewing tobacco) Pipes Cigars Clove cigarettes: Originated in Indonesia in the 1800s, are made from tobacco in combination with 30-40% minced cloves. Bidis: Manufactured primarily in India and in other southeast Asian countries, these products come in chocolate, vanilla, strawberry, licorice, orange and other flavors and are becoming increasingly popular among young smokers. ALL forms of tobacco are HARMFUL and highly addictive.

SMOKING AND QUITTING What does this mean? 7 of every 10 smokers want to quit! About 3 in 100 quit for good What does this mean? Tobacco is VERY addictive, and it’s hard to quit, even if you want to quit. Approximately 4.5 million adolescents (between the ages of 12 and 17) smoke. Each day, more than 3,000 adolescents under the age of 18 become daily smokers. Most teens who smoke regularly report some level of addiction and withdrawal. Of daily smokers who think that they will not smoke in five years, nearly 75% are still smoking five to six years later. An estimated 70% of all smokers want to quit (CDC, 1994). Fewer than 3% successfully stop smoking each year. ♪ Note to instructor(s): Cessation statistics vary depending on factors such as the duration of follow-up, definitions of abstinence, and whether reports of cessation were biologically confirmed. The Centers for Disease Control (1993) reports that 5.7% of daily smokers are able to maintain abstinence for 1 month, and an estimated 2.5% of smokers successfully stop smoking each year. Source: Centers for Disease Prevention and Control. Available: http://www.cdc.gov/tobacco/research_data/youth/initfact.htm Centers for Disease Control and Prevention. Cigarette smoking among adults—United States, 1993. MMWR 1994;43:925–930. NICOTINE, in tobacco, makes people become addicted to smoking

Release of “pleasure” chemicals Nicotine addiction is a disease that begins in the brain. This picture shows the area of the brain where nicotine addiction occurs, the dopamine reward pathway. This area of the brain also is where other additions develop, including heroin and cocaine addiction. This slide is made available to the public through the National Institute on Drug Abuse Web page, at http://www.nida.nih.gov/Teaching/largegifs/slide-9.gif. Adapted with permission by Dr. Rochelle D. Schwartz-Bloom, Duke University. Leshner Al. Drug abuse and addiction are biomedical problems. Hosp Pract (special report) April 1997:2–4. Stimulates brain receptors Nicotine enters brain

GETTING HOOKED on TOBACCO A YEAR or MORE LATER: Hooked and can’t quit MONTHS LATER: Smoking more regularly, start craving it NEXT FEW USES: Not as bad, getting used to it FIRST USE: Tastes bad; dizzy, nausea The process of developing nicotine addiction is shown in this slide. For most folks, the first use of tobacco is not a positive experience. The tobacco tastes bad, irritates the back of the throat, and causes coughing; the nicotine often causes a person to feel dizzy and nauseous. Over time, with repeated use, the negative effects wear off, and the positive effects take over (such as enhanced concentration and feelings of pleasure). The person begins smoking more regularly. Soon, they become hooked, and can’t quit—or would have a lot of difficulty doing so. The time that it takes to progress to routine smoking and the development of tobacco dependence will vary between individuals. Some researchers believe that it can develop very early, within a few weeks or months, for some.

TOBACCO and PERSONAL APPEARANCE Bad breath Hair and clothes stink Stains teeth There are several negative “cosmetic” effects of smoking… smokers have bad breath, their clothes and hair smell like smoke, and their teeth become stained.

TOBACCO and ATHLETIC PERFORMANCE NICOTINE/SMOKING: Narrows blood vessels, puts extra strain on your heart Harms lungs, reducing oxygen availability during exercise Causes shortness of breath Can’t run as fast or as far Nicotine and smoking can significantly reduce your athletic performance. It will narrow the blood vessels in the body, putting added strain on the heart—which leads to cardiovascular and heart disease. Smoking harms the lungs, and will reduce the amount of oxygen that is available to the body’s cells during exercise. Smoking also causes shortness of breath, and if you smoke, you won’t be able to run as fast or as far.

HOOKED on TOBACCO? Coughing Difficulty breathing Lung infections Increased resting heart rates Increased likelihood of stronger addiction, the younger they start NEW SMOKERS SUFFER: When compared to nonsmoking youth, young smokers suffer more from coughing (the lungs trying to clear the tobacco-related particulates), they have increased difficulty breathing, a greater incidence of lung infections, increased resting heart rates, and a higher likelihood of developing a strong dependence on nicotine (the younger they start).

HOOKED on TOBACCO? YOU SMOKE: As soon as you wake up When stressed With friends Automatically To concentrate, for energy WHEN YOU CAN’T SMOKE: Irritable, restless Impatient, nervous Tired, can’t sleep well Can’t concentrate well Crave a cigarette above all else HOOKED AND CAN’T QUIT After a year or more of regular smoking, when you’re hooked and can’t quit, your smoking becomes a habit driven by a need for nicotine. You smoke: As soon as you wake up When you are stressed, you reach for a cigarette You often smoke with friends Sometimes you light up without even realizing it And you need to smoke in order to be able to concentrate, and to give you energy. When you can’t smoke, you: Become easily irritable and restless You’re very impatient and nervous You’re tired, because you can’t sleep well You have difficult time concentrating And when you’ve gone without a cigarette for awhile, you begin craving it above all else.

HOOKED on TOBACCO? AFTER SEVERAL YEARS of SMOKING Cancers Heart diseases Lung diseases Stroke Slower healing & recovery after surgery Eye diseases Sexual dysfunction Bone loss Lipid profile changes Difficulty getting pregnant AFTER SEVERAL YEARS of SMOKING This slide shows a long list of negative health effects of tobacco use.

WHY DO TEENS START SMOKING? Advertisements Their friends smoke People in their family smoke Rebel against parents, others Commonly, teens begin smoking because they are manipulated by appealing advertising. Sometimes they smoke because their friends or their family members smoke. Some youth decide to smoke as a way of expressing themselves as an “individual”—as being “cool” or part of an “in crowd.”

TOBACCO ADVERTISEMENTS Cigarette companies claim they do not advertise to kids Recently, Phillip Morris claimed it is a changed company and that its goal is “to responsibly market our products to adults who choose to smoke” Cigarette companies cannot stay in business unless kids smoke Cigarette companies claim that they don’t advertise directly to kids, and recently a major U.S. tobacco company declared that they changed their goals to responsibly market [their]products to adults who choose to smoke. What kinds of advertisements have you seen FOR smoking? AGAINST smoking? TV shows, movies billboards (no longer legal in California) Magazines, etc. At sporting events TV commercials AGAINST smoking: The TRUTH campaign Yet, given that about 90% of all adult smokers begin smoking by the age of 18, tobacco advertising clearly “works” in getting teens to smoke—whether it is intentionally targeted to teens or not. The fact is clear: cigarette companies cannot stay in business if kids don’t smoke.

HELPING TEENS STOP SMOKING Difficult to do—teens get addicted, too Can’t use nicotine patches or gum Teen stop-smoking programs Best way is prevention… DON’T START! Teens who attempt to quit smoking have a difficult time—because they have developed an addiction to nicotine. Although several stop-smoking programs have been developed for teens, none of the medications for quitting smoking are approved for use in persons under age 18. The best way to be tobacco-free as an adult is to not start smoking as a teen. Did you know that 90% of all adult smokers started smoking by the age of 18? And also…(next slide)

HELPING TEENS STOP SMOKING 70% of all teen smokers wish they had never started Nearly three fourths (70%) of all teen smokers WISH THAT THEY HAD NEVER STARTED SMOKING. What can YOU do, to be sure that you do not become addicted to tobacco? Source: Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/tobacco/research_data/youth/initfact.htm

WHAT CAN YOU DO to AVOID TOBACCO ADDICTION? Make a commitment. Commit to NOT using tobacco, EVER. Decide that you do not want your life to be ruled by an addiction. Know the truth. Despite all the tobacco used on TV and in the movies … most teens, adults, and athletes don’t use tobacco. Don’t let the tobacco industry fool you. There are several tactics that you can use to stay tobacco free. First, and perhaps most importantly, is to make a commitment, to yourself and/or to others. Commit to NOT using tobacco, ever. Do not assume that you can experiment with tobacco or smoke “just a few, every now and then” and be able to quit later. It doesn’t work that way—just ask any adult smoker that you know. Nicotine is highly addictive. A full 25% of the adult population currently uses tobacco. That’s one in every four persons whose life is ruled by a substance that takes years off of their life (the average pack-a-day or more smoker dies 7 years earlier than a person who has never smoked). Know the truth about tobacco advertising. It is specifically designed to make cigarettes appealing to you. Don’t be fooled. Although 1 of every 4 adults smoke, 3 of every 4 don’t. And of the ones who DO smoke, 70% want to quit— yet only about 3% of those who try to quit are successful in doing so.

WHAT CAN YOU DO to AVOID TOBACCO ADDICTION? Do any of your friends or family members smoke or use tobacco? YES: Encourage them to quit NO: Encourage them to stay tobacco-free. Get involved in sports and other activities. Students who are involved in extracurricular activities are less likely to use drugs or tobacco. Encourage your nonsmoking friends and family members to stay tobacco-free, and if they DO use tobacco, encourage them to quit. Get involved in sports and other activities. This “structured” time helps students to stay away from drugs and tobacco.

WHAT CAN YOU DO to AVOID TOBACCO ADDICTION? Spend your money on things other than tobacco. Get involved: Spread the word about the dangers of tobacco use Start or join an activist group against smoking Finally, make a decision to spend your money on something other than tobacco. Because, as the next slide shows, it can be VERY costly to be a smoker.

Hundreds of thousands of dollars lost IT COSTS A LOT TO SMOKE Buying cigarettes every day for 50 years @ $4.12 per pack Money banked monthly, earning 1.5% interest $331,467 $220,978 In addition to the many health benefits of quitting, there are financial benefits associated with quitting. The financial costs of tobacco use can be substantial to a smoker, particularly when costs are accrued over a lifetime. What three levels of smokers who buy cigarettes every day for 50 years at $4.12 per pack will have if they instead bank their cigarette money each month:1 1 pack a day: $110,489 2 packs a day: $220,978 3 packs a day: $331,467 Even if you don’t invest the money, the savings associated with not smoking is more than $1,500 a year for a pack-a-day smoker. 1 Assumes constant price per pack, an annual interest rate of 1.5% (not adjusted for inflation), and that the money was banked monthly. Savings calculator tool available at www.calculatorweb.com. Source: CDC. Medical-care expenditures attributable to cigarette smoking—United States, 1993. MMWR 1994;43:469-472. Packs per day $110,489 100 200 300 400 Hundreds of thousands of dollars lost