1.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Jonathan D. Klein, MD, MPH The AAP Julius B. Richmond Center of Excellence http://www.aap.org/richmondcenter/ Adolescents and Tobacco Prevention and Cessation

2.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Adolescent Tobacco Use Section A

3.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Learning Objectives Review evidence on adolescents and tobacco use Understand that addiction is rapid for many people, and that there is no “experimental” use or “safe” exposure Discuss prevention and cessation strategies that are effective with youth Understand the role of the media in promoting tobacco to young people 3

4.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Tobacco Declining rates in the U.S. (now leveling off) while rates are rising in much of the world Challenge of complacency Continued marketing/targeting of youth by industry Community and clinical interventions needed 4 Image source: iStockPhoto (top)

5.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Current Tobacco Use Almost one billion men smoke cigarettes  35% developed countries  50% developing countries 250 million women smoke cigarettes  22% developed countries  9% developing countries Every day, 80-100,000 young people around the world become addicted to tobacco One in three will die from a tobacco related disease 5 Source: http://tobaccofreecenter.org/global_tobacco_epidemic/key_facts

6.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Youth Tobacco Prevalence India  4.2% currently smoke Boys 5.9% Girls 1.8%  11.9% use other tobacco products Boys 14.3% Girls 8.5% U.S.  13% currently smoke Boys 12.1% Girls 13.9%  10.6% use other tobacco products Boys 14.0% Girls 7.4% 6 Source: Global Youth Tobacco Surveillance, 2000-2007 report. Retrieved 7/18/09 at http://www.cdc.gov/preview/mmwrhtml/ss5701a1.htm

7.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Why Do Youth Use Tobacco? Social influences  Friends  Parents Access to cigarettes Attitude toward smoking  Media Personality  Sensation seeking  Rebelliousness  Poor school performance 7 Source: Sargent, J.D., DiFranza, J.R. (2003). Tobacco Control for Clinicians Who Treat Adolescents. CA Cancer J Clin 53: 102-123.

8.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Why Do Youth Use Tobacco? Attitudinal factors  Intentions regarding future smoking  Susceptibility  Positive utilities—what might be gained by smoking Availability of cigarettes 8 Source: http://www.youthtobaccocessation.org/blueprint/index.html

9.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Tobacco Marketing Annual spending to promote tobacco use equals more than half of the NIH budget Advertising  Targeted to youth Non-advertising commercial speech  Product placement  Clothing, gear  Sponsorships, broadcast media  Candy look-alike products 9 Source: http://www.tobaccofreekids.org/research/factsheets/index.php?CategoryID=23

10.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Secondhand Tobacco Smoke India  26.6% exposed to secondhand smoke (SHS) at home  40.3% exposed to SHS in public places U.S.  41.1% exposed to SHS at home  54.9% exposed to SHS in public places 10 Source: Global Youth Tobacco Surveillance, 2000-2007; cdc.gov/preview/mmwrhtml/ss5701a1.htm

11.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Initiation and Addiction Exposure to tobacco promotion contributes to initiation of tobacco use Dose-response relationship  Greater exposure results in greater risk Nicotine addiction  Characterized by tolerance, craving, withdrawal symptoms, and loss of control  1st symptoms of dependence can appear with days or weeks of intermittent tobacco use 11 Source: Sargent, J., et al. (2007). Arch Dis Ch Adol.; DiFranza, J. (2008), Sci Am.

12.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Changing Evidence about Nicotine Dependence Signs of nicotine dependence often starts within two months after onset of smoking The median frequency of use at the onset of symptoms was two cigarettes, one-day-per-week 2/3 of teens report loss of autonomy over tobacco prior to the onset of daily smoking 12 Source: DiFranza, J.R., et al. (2002). Tobacco Control.

13.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Unsafe Alternatives Cigars: 14% past month use in the U.S. Hookahs: water pipes involving the burning of tobacco mixed with sweetened flavors Bidis: unfiltered flavored cigarettes  Higher levels of nicotine  Marketed as “herbal”; usually less expensive Kreteks: Clove cigarettes containing 60– 70% tobacco Smokeless tobacco: chewing tobacco, snuff, dip These are all tobacco products containing nicotine and carry similar risks to regular cigarettes 13

14.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Evidence Based Best Practices Increase price/taxation of tobacco Smoking bans and restrictions Counseling: reframe expectations of success  5As (Ask, Advise, Assess, Assist, and Arrange)  No smoking rules: smoke free homes and cars Availability of treatment for addiction  Reduced cost for pharmacotherapy treatment  Provider reminder systems  Telephone/web counseling and support Mass media counter-marketing campaigns 14 Source: http://www.thecommunityguide.org/tobacco/

15.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Summary Tobacco control for children and youth should be a public health priority This should include the following:  Both tobacco use and second hand smoke reduction  Age of sale restrictions  Advertising limitations and public smoke exposure reduction  Support for cessation and quitting services 15