Reducing Tobacco Use in Adolescents

Source from:  aafp.org February 15, 2008 02/15/2008

IRENE M. ROSEN, LTC, MC, USA, Madigan Army Medical Center, Fort Lewis, Washington DOUGLAS M. MAURER, MAJ, MC, USA, Carl R. Darnall Army Medical Center, Fort Hood, Texas After steadily decreasing since the late 1990s, adolescent smoking rates have stabilized at levels well above national goals. Experts recommend screening for tobacco use and exposure at every patient visit, although evidence of improved outcomes in adolescents is lacking. Counseling should be provided using the 5-A method (ask, advise, assess, assist, and arrange). All smokers should be offered smoking cessation assistance, including counseling, nicotine replacement therapy, bupropion therapy, or combination therapy. Pharmacotherapy of any kind doubles the likelihood of successful smoking cessation in adults; however, nicotine replacement therapy is the only pharmacologic intervention that has been extensively studied in children. Community interventions such as smoking bans and educational programs have been effective at reducing smoking rates in children and adolescents. Antismoking advertising and tobacco sales taxes also help deter new smokers and motivate current smokers to attempt to quit. (Am Fam Physician. 2008;77(4):483-490, 491-492. Copyright © 2008 American Academy of Family Physicians.) Tobacco is the leading cause of preventable death in the United States, causing more than 440,000 deaths annually.1 An additional 8 million Americans have smoking-related diseases such as cancers of the lungs, larynx, oral cavity, and esophagus, as well as pulmonary diseases such as chronic obstructive pulmonary disease (COPD).1 Tobacco is responsible for an estimated $157 billion in annual health care expenditures.1 Of greater concern is the large number of adolescents who start smoking early in life and continue throughout adulthood. Currently, 3 million U.S. adolescents younger than 18 years smoke cigarettes.2 Almost one fourth of adolescents smoke by the time they graduate from high school, and almost 90 percent of adults who smoke began at or before age 18.2 Each day about 4,400 teenagers try their first cigarette and contribute to the 1.5 million adolescents who begin to smoke each year.3 A significant number of adolescents who use illicit drugs smoked cigarettes first.4 Smoking rates among high school students peaked in 1976, when nearly 40 percent of graduating seniors classified themselves as current smokers. Rates tapered off in the 1980s but then steadily increased, peaking again in 1997.5 The Tobacco Master Settlement Agreement (MSA) was reached in 1998 between state attorneys general and the major tobacco manufacturers; the settlement banned certain types of tobacco advertising targeted at teenagers, and it launched a national antismoking campaign and several state-level campaigns. At the same time, cigarette prices increased substantially as a result of higher state taxes and the tobacco companies' efforts to recover money lost in the MSA. All of these factors have contributed to a significant decrease in adolescent smoking rates. Unfortunately, this downward trend has recently stalled and is showing signs of reversal, with current rates well above the Healthy People 2010 objective of 16 percent or less.2 Tobacco use among 10th and 12th graders has slightly increased, from 21.9 to 23.0 percent between 2003 and 2005.2,5 Risk Factors Many factors, internal and external, affect the risk for adolescent smoking. White adolescents consistently smoke much more than their Hispanic and black counterparts. Sex does not appear to exert an influence, with male and female smoking rates remaining equivalent over the past decade.2 Educational goals play a role, because students who plan to attend a four-year college have significantly lower smoking rates than those who do not.3 Finally, stress and psychiatric disorders such as attention-deficit/hyperactivity disorder and depression have been linked to increased adolescent smoking rates.6,7 External risk factors include peer pressure, parental smoking, media advertising, and beliefs about the positive and negative consequences of smoking.3 Assessment Although the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence to recommend for or against routine screening for tobacco use or interventions to prevent and treat tobacco use and dependence among adolescents,8 the U.S. Public Health Service and the Institute for Clinical Systems Improvement (ICSI) recommend that physicians determine and document tobacco use and exposure to secondhand smoke at every office visit.9,10 Tobacco cessation using the 5-A method (ask, advise, assess, assist, and arrange) should be offered on a regular basis to all adolescents who smoke (Table 1).9 After an adolescent has been identified as a smoker, the physician can assess the level of tobacco dependence using either qualitative or quantitative methods (Figure 1).11 Enditem