1.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Susanne E. Tanski, MD, FAAP The AAP Julius B. Richmond Center of Excellence http://www.aap.org/richmondcenter/ Tobacco Use Prevention for Children and Youth

2.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Objectives Learn prevalence of youth tobacco use worldwide Understand the influences for youth tobacco use Review some prevention/treatment for youth tobacco use 2

3.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Section A Impact and Use of Tobacco

4.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Worldwide Tobacco Impact Global use of tobacco products is increasing  Epidemic shifting to the developing world, 84% of smokers decreasing in high-income countries Almost half the world’s children breathe air polluted by tobacco smoke  700 million children 4 http://www.who.int/topics/tobacco/facts/en/ Source: http://www.who.int/topics/tobacco/facts/en/

5.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Youth Tobacco Use Worldwide Among young smokers, 25% smoked their first cigarette before the age of 10 The highest youth smoking rates can be found in Central and Eastern Europe, sections of India, and West Pacific Islands 5 Image source: Adapted from http://www.who.int/tobacco/en/atlas7.pdf

6.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Youth Tobacco Use 6 Image source: Adapted from http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5701a1.htm

7.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Tobacco Use Trends in Europe 7 http://www.euro.who.int/Document/EHI/ENHIS_Factsheet_3_4.pdf

8.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Gender Gap in Tobacco Use Initiation 8 Image source: http://www.searo.who.int/EN/Section1174/Section2469/Section2481.htm

9.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Youth Tobacco Use: U.S. In 2007, 50.3% of students surveyed in the U.S. Youth Risk Behavior Surveillance System (YRBSS) had smoked a cigarette  12.4% of students had at some point smoked daily  20% reported current smoking (within the last 30 days) Of U.S. youth smokers, 49.7% had tried to quit  Overall current tobacco use was reported at 25.7% 29.9% of White youth, 16% of Black youth, and 20.1% of Hispanic youth 9 Source: www.cdc.gov/mmwr/preview/mmwrhtml/ss5701a1.htm

10.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Percentage of Tobacco Use in the Past 30 Days 10 Image source: Adapted from http://monitoringthefuture.org/pubs/monographs/overview2005.pdf

11.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Smoking Effects on Youth Addiction Lower lung function Decreased rate of lung growth Cumulative effects over time increase risk of heart disease in adulthood Tobacco use is associated with other risky behaviors:  Among U.S. youth, tobacco users are three times more likely to use alcohol, eight times more likely to use marijuana, twenty-two times more likely to use cocaine  Tobacco use is also associated with fighting and unprotected sex 11

12.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Smoking Initiation: Social and Individual Influences Parents/siblings/family: modeling, access Peers: social culture Comorbid psychiatric disorders  Anxiety, ADHD, substance abuse Media  Modeling behavior: the “SuperPeer”  Social normalization “Everybody” smokes Image identification and branding 12

13.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Attitudes and Beliefs 28% of youth say boys who smoke have more friends; 16.8% say girls who smoke have more friends 13.5% say smoking makes boys look more attractive: 10% say this for girls 68% of youth want to stop smoking now and almost ¾ say they have tried to quit in the past year 13 Source: http://tobaccocontrol.bmj.com/cgi/content/full/11/3/252/

14.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Why Do Youth Start Smoking? Social Learning Theory People can learn by observing others  This can be real-life observation or symbolic observation through movies and TV  Can learn how to do things (smoke/drink)  Can form expectations Why people do things (stressed, upset, need to relax) How you are supposed to respond to things (craving) Consequences of behavior (reinforcing/punishing) 14

15.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Why Do Youth Start Smoking? Marketing  Roughly seven cents per pack to make, $4.50+ sold  $70 billion a year industry  Most profitable crop in the U.S.  $12 billion a year in advertising  $500 million a year in sales to children  Number one sold product in the world: Marlboro cigarettes 15 Image source: http://mrg.bz/dIZOXT

16.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Advertising Influences Youth 16 Image source: http://www.tobaccofreekids.org/reports/products/ U.S.GermanyKenya

17.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Youth 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 17 Source: American Academy of Pediatrics. (2001).

18.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Source: Monitoring the future project, U.S., 1976-1986 senior classes. Youth Who Start Smoking, Continue Smoking 18 Smoking status 5-6 years later Senior-year smoking status (use in past 30 days) Quit Less use Same level More use None 85.614.4 < 1 cigarette per day 57.814.427.8 1-5 cigarettes/day 29.68.817.244.4 About 1/2 pack/day 18.813.621.746.0 > 1 pack a day 13.217.740.229.0

19.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Youth Are Especially Susceptible to Addiction For some youth, symptoms of dependence develop  Before daily use begins  Within days after inhalation There is no minimum requirement of number smoked, frequency, or duration of use! 19

20.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Youth 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 use more heavily Increased vulnerability to addiction may be due to still-developing brain 20 Source: Sargent. (2003).

21.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence That First Puff... The nicotine in one to two puffs occupies 50% of nicotinic receptors in the brain A single dose increases the following:  Noradrenaline synthesis in the hippocampus  Neuronal potentiation can last for weeks Meaning that neurons discharge action potentials at lower threshold 21

22.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Progress of Tobacco Use 22 Image source: DiFranza. (2007).