1. If Not Now, When? How to Influence Youth Use of Tobacco Products Your name, institution, etc. here YOUR LOGO HERE (can paste to each slide)

2. …dedicated to eliminating children’s exposure to tobacco and secondhand smoke

3. Objectives Understand social influences for teen tobacco use Develop strategies to increase teachable moments in patient encounters Learn how to incorporate Asking, Advising, and Referring into patient encounters

4. Teen Tobacco Use is a Big Problem Typically, tobacco use begins before age 18 years Every day, 3,450 people age 12 – 17 years initiate smoking in the US

5. Teen Tobacco Users- 2010

6. The Social Cycle of Tobacco Use Infancy In utero Influences to Start Smoking: Media, Household Members, Peers Adulthood Adolescence Childhood Alienation from peers who don’t use tobacco

7. Teen Tobacco Users Are… More likely to be psychologically distressed, abuse other substances Less likely to be attached to parents, do well in school, participate in extracurricular activities, know the adverse effects of smoking

8. Tobacco Use Progresses Faster Than Anyone Expected Experimentation Regular Use Nicotine dependence, as indicated by craving, starts BEFORE daily or regular use! Interventions may be delivered at any stage

9. Hooked on Nicotine Checklist  Nicotine dependence can be identified as soon as a smoker has developed any symptom that presents a barrier to quitting.  When quitting requires an effort, the smoker has lost some degree of autonomy over his or her tobacco use!  Symptoms of dependence can appear within days of the onset of use, when youths are smoking as little as one cigarette per week.  Many youths are hooked before they even think of themselves as smokers…

10. The Hooked on Nicotine Checklist 1.Have you ever tried to quit but couldn't? 2.Do you smoke now because it is really hard to quit? 3.Have you ever felt like you were addicted to tobacco? 4.Do you ever have strong cravings to smoke? 5.Have you ever felt like you really needed a cigarette? 6. Is it hard to keep from smoking in places where you are not supposed to, like school? In answering the last four questions, when you tried to stop smoking, or when you have not used tobacco for a while... 7.Did you find it hard to concentrate? 8.Did you feel more irritable? 9.Did you feel a strong need or urge to smoke? 10. Did you feel nervous, restless or anxious because you couldn't smoke?

11. Scoring/Discussion Have you ever tried to quit, but couldn’t? A failed cessation attempt is an obvious indication of diminished autonomy. If quitting was effortless, the patient would no longer be smoking. Do you smoke now because it is really hard to quit? This item is included to capture those who do not want to smoke, but have not made an “official” effort to quit, often out of a fear of failure. Since they are doing something they don’t want to, they have diminished autonomy. Have you ever felt like you were addicted to tobacco? A person with full autonomy over his or her tobacco use would not feel addicted. Do you ever have strong cravings to smoke? Strong cravings make quitting difficult and unpleasant. Have you ever felt like you really needed a cigarette? Smokers feel they really need a cigarette because of cravings, withdrawal symptoms, or psychological dependence. Whatever the reason, quitting is more difficult. Is it hard to keep from smoking in places where you are not supposed to? An autonomous smoker would have no difficulty refraining from smoking, especially where it is forbidden.

12. Teen Tobacco Addiction Dependence is more severe if use begins in adolescence Those who begin as teens are more likely to become dependent, use for more years, and user more heavily Increased vulnerability may be due to still- developing brain

13. Teen Cessation: What Works?

14. The 5 As Assess readiness to quit Ask about tobacco use and SHS exposure Advise to quit Assist in quit attempt Arrange follow-up

15. The 5 As Assess Ask Advise Assist Arrange Ask Advise Refer “2As and an R”

16. Treating Teens Ask about tobacco as part of psychosocial history Privacy and confidentiality a must Use the same techniques used for adults, tailored to the values of the teen

17. Counseling Teens Most teen smokers are interested in quitting Even occasional users may be addicted Provide education on nicotine addiction and quitting strategies No evidence that quitting is easier for teens than adults – It takes the average adolescent daily smoker 18 YEARS to successfully complete cessation!!!

18. Ask: The Concept Ask about tobacco use and SHS exposure at every visit – Include current tobacco use, SHS exposure – Teens who live with smokers are more likely to start smoking themselves… Make asking routine, consistent, and systematic Document as a “vital sign” – Use standardized documentation Just asking can double quit attempts

19. Advise: The Concept  Quitting smoking is the best thing you can do to help protect your health and the health of your child.  I can help you.  Have you thought about quitting (Assess)? No- exposure reduction Yes- exposure reduction and Assist/Arrange

20. Now What Do You Say? “Smoking isn’t good for you (or your child). I can help you quit. Are you ready?” 54% of high school smokers want to quit A smoker quits 5-7 times before it is for good…

21. Is the Tobacco User Ready to Quit? The Stages of Change model can help you figure out what to say and how to help Regardless of what stage the teen is in, provide information about cessation to all tobacco users

23. Your Goal: Help the Tobacco User Take the Next Step Help a precontemplator become a contemplator… …a contemplator start to make plans… …someone who relapsed become “ready for action”… And so on….

24. Be Specific Use clear, strong messages Use clear, strong messages Anticipate challenges Anticipate challenges – Ask about cues to use tobacco – There are fewer cues in smoke free homes and cars Practice problem-solving Practice problem-solving – enlisting help from friends or parents, quitting with a friend, getting parents to quit Prescribe or provide information about pharmacotherapy Prescribe or provide information about pharmacotherapy – Pharmacotherapy can be used, but has not been shown effective with teens (Mixed results…) Help the teen set a quit date Help the teen set a quit date Document your advice Document your advice

25. What Do You Say? Clear: “I’m really concerned about you, and I strongly advise you to quit smoking.” Personalized: Emphasize the impact on health, finances, family or the teen. – “Your lungs are still developing, and teens who smoke aren’t able to use their lungs as well. I think you’ll do better in basketball if you quit. I can help you… are you ready?”

26. An Intermediate Goal Cutting down Making a Smoke Free Home – “Secondhand smoke is bad for you and your family. Is it possible for you to make your home and car tobacco free now?” Smokers who live in tobacco free homes smoke fewer cigarettes, which can help the next quit attempt succeed

27. Pharmacotherapy and NRT Nicotine replacement therapy (NRT) is not currently FDA-approved under 18 PHS Clinical Practice Guideline: pharmacotherapy may be used in addicted teens interested in quitting Monitor those on Zyban closely for adverse effects related to antidepressants Varenicline (Chantix) – FDA-approved May 2006 but not approved under 18

28. Rationale for Pharmacological Treatment Nicotine addiction Mood and affect modulation Cognitive decrements during withdrawal Tobacco-free lifestyle coping skills take time to acquire

29. Tobacco Withdrawal Cigarette craving Anxiety Irritability Headache Insomnia Drowsiness Constipation Increased appetite Poor attention Impaired cognitive performance Decreased heart rate Symptoms occur within hours of stopping smoking, and may persist for weeks

30. Knowledge is a Good Thing… Even if you never prescribe NRT or cessation medications, familiarity with the medications typically used can be helpful – Comfort with talking to patients and their parents about what is “out there” But I encourage you to remove the barrier to pharmacotherapy and prescribe them!

31. Pharmacotherapy Types Nicotine replacement therapy (NRT) (many brands, some generics) – Many OTC – Some states reimburse, even for OTC (prescription may be required) Bupropion SR (Zyban, Wellbutrin) Varenicline (Chantix)

32. Using NRT: Treatment Goals Overall reduction of nicotine withdrawal symptoms – not to replace tobacco! Help with momentary urges Modify habitual behavior – Breaking the cigarette habit with use of NRT has been shown to increase likelihood of quitting Postponement of smoking – May be used to defer smoking when in environment in which smoking is not allowed

33. Nicotine Replacement Therapy All forms of NRT appear to be equally effective (increase quit rates by ~1.5-2 fold) – Heavier smokers should start with higher dosing Effectiveness of NRT increased with amount of behavioural support Choice of medication is based mainly on susceptibility to side effects, patient preference and availability

34. Nicotine Polacrilex Gum (OTC) Dosage – CPD < 25 use 2 mg, CPD  25 use 4 mg, Use enough, Use long enough (for full 12 weeks) Side Effects: taste, jaw pain, nausea, dyspepsia, constipation, headache,… Advantages – Flexible dosing – Rapid blood level Disadvantages – Poor compliance and Under-dosing – Dietary influence

35. Nicotine Lozenge (OTC) Dosage – 1mg, 2 mg and 4 mg (delivering 2 mg of nicotine if properly used) Side effects: oral irritation Advantages – Flexible dosing – Rapid blood level (4mg lozenge give 25% higher blood level than 4 mg gum) – No chewing (discrete) Disadvantages – Under-dosing – Oral pH

36. Nicotine Transdermal Patch (OTC) Dosage – 21mg, (16mg Day patch)- 14 mg, 7 mg, place the patch always at the beginning of the day Side effects: redness, itching, sleep disturbance Advantages – Good compliance – Sustained blood levels Disadvantages – Skin irritation

37. Nicotine Nasal Spray (Rx) Dosage – 1 dose yields 1 mg of nicotine (2 sprays, one/nostril) Side effects: cough, nasal /throat irritation Advantages – Flexible dosing – Rapid blood level (5-10 minutes) Disadvantages – Tolerance – Expensive

38. Nicotine Vapor Inhaler (Rx) Dosage – 10 mg/cartridge, 6-16 cartridges/day, MAX: 16/day, each puff yields about 13 μg, compared to 100μg per cigarette puff Side effects: throat irritation Advantages – Flexible dosing, “habit replacement” – Sensory cues (menthol, throat irritant) Disadvantages – ineffective if used alone

39. Minutes Increase in nicotine concentration (ng/ml Cigarette Gum 4 mg Gum 2 mg Inhaler Nasal spray Patch 510 15 20 25 30 0 2 4 6 8 10 12 14 Plasma nicotine concentrations for smoking and NRT

40. Bupropion (Rx) Non-nicotine aid to smoking cessation Chemically unrelated to nicotine Atypical antidepressant Pharmacodynamics: relatively weak inhibitor of the neuronal uptake of norepinephrine, serotonin, and dopamine – mechanism of action unknown, stimulant-like T1/2: 21 hours, peak plasma concentrations within 3 hours hydroxybupropion active metabolite

41. Bupropion (Rx) Dosage 150 mg QAM for 3 days, then increase to 150 mg BID Doses should be at least 8 hours apart Use for 7-12 weeks after quit date; longer use possible Side effects Dry mouth, headache, sleep disturbance, dizziness Advantages May be combined with NRT Disadvantages Need to pre-load: Start 2 weeks BEFORE quit date

42. The New Drug: Varenicline (Chantix®) Dosage Start 1 week BEFORE quit date 0.5 mg QD for 3 days, then 0.5 mg BID for 4 days, then 1 mg BID for 12 weeks or longer After a meal with a full glass of water Use for 12 weeks after quit date; longer use possible Side effects Nausea, sleep problems Advantages May be more effective than Bupropion Disadvantages Can not combine with NRT

43. African-Americans & Smoking 21.3% of African-American adults smoke Males (24%) > females (19%) HS students – 7.4% smoke; Middle School – 5.2% African-American youth are more likely to start smoking at a later age Menthol cigarettes are popular among African-Americans including HS and MS students

44. Menthol Cigarettes 83 % of African-American smokers use mentholated brands compared with 24% of white smokers Menthol is a local anesthetic – used to relieve minor throat irritation Menthol may help the absorption of toxins Cooling, numbing properties may permit larger puffs, deeper inhalation or allow smoke to stay in the lungs for a longer period of time

45. Following Up Plan to follow up on any behavioral commitments made Just asking at the next visit makes a big impression If they set a quit date Schedule follow-up in person or by telephone soon after the quit date Look for “teachable moments” in the future

46. Refer To quit line, 1-800-QUIT NOW To community and Internet resources Give every tobacco user something that contains information about quitting, the harms of tobacco use, etc.

47. What Do You Say? “I recommend that you call this number. It’s a free service – and the person on the other end of the telephone can help you get ready to quit.” “One thing that helps a lot is to learn as much as you can about quitting – the more you know, the more successful you’ll be. The quit line staff can help.”

48. Create a Tobacco-free Office and Waiting Room Replace tobacco ads in magazines with health promotion, tobacco free magazines Make cessation materials readily available in waiting room and exam room Provide risk awareness educational material and self help literature Posters and signage

49. You Can Advocate for Some Protective Factors Individual, family, and environmental factors can guard against risky behaviors – Close communication with parents – Parental support – High self-esteem – Regular church attendance

50. Counseling Their Parents Advise parents to Express disapproval of tobacco use Discourage friends who are smokers Keep the home smoke free – even if parents smoke Make tobacco products inaccessible Limit access to R-rated movies!

51. Home Smoking Bans Are More Effective with Teens than Smoking Bans in Public Places.03 0.83 - 0.99 0.91 Other Public Restrictions <.0010.77 - 0.94 0.86 Enforced School Ban.86 0.85 - 1.130.99School Ban <.01 0.74 - 0.95 0.85Some Home Restrictions <.0010.67 - 0.91 0.79Total Home Ban P value95%CI OR Odds Ratios for Association of Smoking Restrictions with 30-Day Smoking Prevalence, High School Students

52. www.aap.org/richmondcenter Need more information? The AAP Richmond Center Audience-Specific Resources State-Specific Resources Cessation Information Funding Opportunities Reimbursement Information Tobacco Control E-mail List Pediatric Tobacco Control Guide

53. Questions?