Post on 23-Jan-2023
SMOKING 1
Smoking Cessation Strategies Among Adolescents:
Critique and Recommendations
Laurie Rogers Trlak
L25958143
May 9, 2014
HLTH 505.D07
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Abstract
Fifty years after the U.S. Surgeon General released a report
showing the dangers of cigarette smoking, tobacco use continues
to be the single most preventable cause of illness and death in
the United States1. In spite of a reduction in the overall rate
of smoking, smoking among adolescents continues to be a major
concern for health practitioners. This paper examines various
smoking cessation methods as well as issues surrounding
adolescent smoking.
Introduction
In 1964 the U.S. Surgeon General released a report about the
dangers of cigarette smoking, yet despite legislation to end
television advertising of tobacco products, and taxes to raise
the price of tobacco, smoking continues to be the single most
preventable cause of death in the U.S.1 While overall smoking
rates have declined, smoking among adolescents continues to be a
major concern for health practitioners. According to the Centers
for Disease Control and Prevention, nine out of ten smokers begin
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smoking before the age of 18, with another 9% starting to smoke
by the age of 261. While smoking has declined significantly since
19642, a high prevalence persists among those under age 18. At
current levels, some 5.6 million young people currently under the
age of 18 will die prematurely due to cancer, emphysema, heart
disease, and other tobacco-related illnesses2.
Background
Since the Surgeon General’s report was released in 1964, massive
efforts at tobacco control have been launched at federal, state,
and local levels. Efforts at tobacco control have included
banning cigarette advertisements on television and radio (1970);
taxing cigarettes and other tobacco products (1988); and banning
smoking on commercial airliners (1990); and bans on smoking in
bars and restaurants. The result has been that cigarette smoking
among adults has declined significantly; however, tobacco use,
including cigarettes, cigars, smokeless tobacco, and electronic
cigarettes, remains at a troubling level among adolescents3.
The report noted that those who smoke are much more likely to die
from smoking-related diseases than those who don’t smoke4. In the
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50 years since the report was released, 20 million people have
died because of illnesses caused by tobacco smoke4. Most of the
deaths have been among smokers, but a significant number, 2.5
million, were among those who inhaled tobacco smoke from the
cigarettes of others, also known as second-hand smoke4. In order
to combat teenaged smoking, a number of smoking cessation efforts
have been tried with varying results. Advertising campaigns in
mass media such as radio and television, heavily patronized by
adolescents, have attempted to deliver targeted messages about
the dangers of smoking. Schools have also used mass media in the
classroom in smoking cessation interventions3. While compulsory
enrollment in mass media programs in lieu of disciplinary action
has not resulted in smoking cessation, voluntary enrollment has
failed to attract students. Adolescents are reluctant to enroll
in such programs voluntarily, possibly due to fears of parental
disapproval and sanctions once their smoking behavior becomes
known. Consequently, 80% of adolescents say they prefer to quit
on their own rather than be enrolled in a smoking cessation
program1. Since teens may be more sensitive to the addictive
effects of nicotine, relapse is more problematic for this age
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group, and this presents unique challenges to public health
officials when designing smoking cessation interventions targeted
for adolescents1. Nevertheless, smoking prevention and cessation
efforts utilizing mass media messaging are considered to be a
viable means of tobacco control. Indeed, in a study by Flynn et
al, significant differences in daily smoking habits were observed
in adolescents who had undergone a mass media intervention
compared with a control group who had not1.
A study by Erol and Erdogan (2008) evaluated the use of
motivational interviewing (MI) based on the five stages of change
outlined in the Transtheoretical Model (TTM)5: precontemplation
(those not yet ready to quit); contemplation (those planning to
quit within six months); preparation (those planning to quit
within 30 days; action (those who quit within the previous six
months); and maintenance, (those who quit more than six months
ago). 60 students from one high school were recruited for an MI
intervention. Prior to its start, smoking status, perceptions of
the pros and cons of tobacco use, and temptations were measured.
At follow-up at three and six months 40% and 55% respectively had
made progress in stage, and 18.3% and 33% respectively had quit5.
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During the MI phase of the intervention the students participated
in five 45 minute sessions during which they were guided in
imagining what their future lives would be like if they continued
to smoke, and what they would be like if they quit. In follow-ups
at three and six months, the students’ progress was assessed, and
the authors concluded that the gains in smoking cessation were
modest at best; however they also concluded that use of
motivational interviewing in conjunction with the five stages of
change in the Transtheoretical Model could be useful for teachers
and health care providers in guiding young people to quit
smoking.
Another smoking cessation strategy that has been studied is the
use of nicotine replacement therapy (NRT), consisting of patches
and gum. Nicotine dependence is a primary cause of the failure of
smoking cessation efforts6, characterized by withdrawal symptoms
and cravings. As noted previously, adolescents may be
particularly susceptible to the addictive effects of nicotine;
however, NRT has not been particularly successful, although the
study in question did not factor in variables such as compliance,
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making it impossible to determine the effectiveness of the
therapy.
In another study on the use of bupropion in adolescent smoking
cessation, 134 adolescents were randomized into four groups:
placebo; placebo plus contingency management; bupropion alone;
and bupropion plus contingency management7. Although combined
treatment for bupropion showed some benefit during the first four
weeks, no benefit was apparent in the final two weeks, or at the
12 week follow-up. The author suggested that study into longer
courses of treatment might provide health care providers greater
insight into the use of bupropion in smoking cessation
interventions.
Most studies of adolescent smoking have focused on smoking
prevention. Ideally preventing the start of smoking is preferable
to cessation, as tobacco addiction is particularly difficult for
many adolescents to overcome1, 8. A study which focused on the
underlying environmental characteristics surrounding the
adolescent emphasized prevention, as opposed to smoking
cessation, showed that students attending schools that enforced
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strong rules against smoking were less likely to smoke than those
attending schools without such restrictions9.
A study by Prokhorov, Hudmon, and Stancic takes an
epidemiological approach to smoking cessation treatment based on
the definition of addiction in the Diagnostic and Statistical
Manual of Mental Disorders: “a maladaptive pattern of substance
use, leading to clinically significant impairment or distress, as
evidenced by the following manifestations, occurring at any time
in the same 12-month period: tolerance, withdrawal, and
persistent desire or unsuccessful efforts to quit10.” The authors
used a modified Fagerstrom Tolerance Questionnaire (FTQ),
developed in 1978 and used for determining tobacco and nicotine
dependence for adult smokers. Consisting of only seven simple
questions, the modified questionnaire found that adolescents
experience the same degree of cravings and withdrawal symptoms as
adults. Based on the results of the study, the authors
recommended that the same behavioral and counseling interventions
shown to be effective with adults be used with adolescents who
want to quit smoking. Specifically, they suggested the
Transtheoretical Model (TTM) of Change could be effective if used
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in adolescent smoking interventions. They also urge health care
providers to prioritize identification of adolescent smokers, and
to incorporate smoking cessation counseling into their treatment
of adolescent smokers, as this has been shown to be effective
with adults.
Another area of study involves disparities in rates of smoking
among adolescents in lower socioeconomic groups. Disparities in
smoking behavior in low socioeconomic groups are difficult to
quantify because the causes of smoking are multi-faceted and
complex. According to Pampel, Krueger, and Justin, et al, unlike
other health behaviors, smoking inception and cessation
disparities are culturally and socially determined, rather than
being dependent on access to information and cessation
programs10. Access to health services such as smoking cessation
programs depends in part on the ability to pay for them, yet
smoking costs an average $1638 per year for a pack-a-day
smoker10.
While factors such as socioeconomic status cannot by themselves
explain the high prevalence of smoking among disadvantaged
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groups, education level appears to be directly connected to
smoking prevalence. When controlled for other socioeconomic
variables, high school dropouts are nearly three times as likely
as college graduates to smoke10. But the high cost of cigarettes
in relation to the lower wages of those without a high school
diploma still does not account for the higher rates of smoking in
the lowest socioeconomic groups. The authors of the study suggest
that stressors such as high unemployment, low wages, and racial
discrimination associated with lower socioeconomic status
contribute to unhealthy behaviors such as smoking, overeating,
and lack of exercise, because they bring pleasure and are a means
of coping with those stresses; however, they acknowledge that the
relationship between smoking and dealing with high-stress
situations needs further study10.
Differences in tobacco prevalence among racial groups are another
source of disparity. According to the Surgeon General’s report,
American Indians and Alaskan Natives have the highest prevalence
of tobacco use, followed by African Americans. As is the case
with socioeconomic status, no single factor is responsible for
the rate of smoking among these groups. Cultural factors, stress
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related to socioeconomic status, and targeted advertising all
contribute to smoking10.
Current Research Efforts
While preventing smoking initiation may be ideal, as opposed to
smoking cessation, some researchers believe that current
strategies aimed at smoking prevention among adolescents are
ineffective when those young people reach their twenties9.
Additionally, the United States Centers for Disease Control and
Prevention reports that despite tobacco control programs aimed at
smoking prevention, nearly one fourth of teenagers smoke10.
An initiative by the West Virginia University Centers for Public
Health Research and Training, partnering with the West Virginia
state health and education departments, the Coalition for a
Tobacco-Free West Virginia, and the American Lung Association,
developed an innovative program specifically targeting adolescent
smokers, the Not On Tobacco (NOT) program. Gender-specific, and
consisting of 10 50-minute group sessions, topics focus on such
issues as stress management, preparation for cessation, and the
health effects of smoking, as well as coping with cravings. Six
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studies between 1997 and 2002 evaluated the effectiveness of the
NOT program, with a more recent follow-up evaluation. A follow-
up study showed that teenagers who participated in NOT were
nearly twice as likely to quit smoking as those who received more
traditional smoking intervention methods, such as a 15 minute
smoking prevention presentation10. Because of the success of the
program, the American Lung Association has approved of it as a
best practice model.
In other research, in 2008 the Tobacco Use and Dependence
Guideline Panel updated its 2000 clinical practice guidelines to
reflect recent scientific literature into smoking cessation
interventions. Sponsored by a number of government and non-
governmental organizations, including the Agency for Healthcare
Quality and Research, the Centers for Disease Control and
Prevention, and the National Cancer Institute, among others, the
guideline identified recent research into effective,
scientifically verified and tested tobacco control interventions.
The Guideline makes 10 recommendations for smoking cessation
interventions:
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1. Tobacco dependence is a chronic disease that often
requires repeated
intervention and multiple attempts to quit. Effective
treatments exist,
however, that can significantly increase rates of long-term
abstinence.
2. It is essential that clinicians and health care delivery
systems consistently
identify and document tobacco use status and treat every
tobacco user
seen in a health care setting.
3. Tobacco dependence treatments are effective across a
broad range of
populations. Clinicians should encourage every patient
willing to make
a quit attempt to use the counseling treatments and
medications recommended
in this Guideline.
4. Brief tobacco dependence treatment is effective.
Clinicians should offer
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every patient who uses tobacco at least the brief treatments
shown to be
effective in this Guideline.
5. Individual, group, and telephone counseling are
effective, and their
effectiveness increases with treatment intensity. Two
components of
counseling are especially effective, and clinicians should
use these when
counseling patients making a quit attempt:
• Practical counseling (problemsolving/skills training)
• Social support delivered as part of treatment
6. Numerous effective medications are available for tobacco
dependence,
and clinicians should encourage their use by all patients
attempting to
quit smoking—except when medically contraindicated or with
specific
populations for which there is insufficient evidence of
effectiveness (i.e.,
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pregnant women, smokeless tobacco users, light smokers, and
some adolescents).
• Seven first-line medications (5 nicotine and 2 non-
nicotine) reliably
increase long-term smoking abstinence rates:
– Bupropion SR
– Nicotine gum
– Nicotine inhaler
– Nicotine lozenge
– Nicotine nasal spray
– Nicotine patch
– Varenicline
• Clinicians also should consider the use of certain
combinations of
medications identified as effective in this Guideline.
7. Counseling and medication are effective when used by
themselves
for treating tobacco dependence. The combination of
counseling and
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medication, however, is more effective than either alone.
Thus, clinicians
should encourage all individuals making a quit attempt to
use both
counseling and medication.
8. Telephone quitline counseling is effective with diverse
populations and
has broad reach. Therefore, both clinicians and health care
delivery
systems should ensure patient access to quitlines and
promote quitline use.
9. If a tobacco user currently is unwilling to make a quit
attempt, clinicians
should use the motivational treatments shown in this
Guideline
to be effective in increasing future quit attempts.
10. Tobacco dependence treatments are both clinically
effective and highly
cost-effective relative to interventions for other clinical
disorders. Providing
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coverage for these treatments increases quit rates. Insurers
and
purchasers should ensure that all insurance plans include
the counseling
and medication identified as effective in this Guideline as
covered benefits.
The guideline notes the increase in available pharmaceuticals for
the treatment of smoking cessation, such as varenicline and
bupropion, among others, and recommends their use to treat
nicotine dependence16.
Discussion
Until recently, tobacco control programs have focused on
preventing smoking initiation among adolescents rather than
cessation; however, given that 23% of adolescents still smoke,
these programs have failed to be efficacious for a variety of
reasons: peer pressure, fear of parental disapproval if the
behavior becomes known, and relapses due to nicotine addiction
have all contributed to high failure rates in tobacco prevention
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programs3. Smoking cessation programs have produced mixed
results, but given that almost a quarter of high school students
still smoke in spite of tobacco prevention programs, more
emphasis is needed on cessation programs. This is especially
important, as adolescents are believed to be more susceptible to
the effects of nicotine addiction8.
The use of mass media – television, radio, and more recently the
Internet - holds promise for influencing young people to quit
smoking. Young people tend to be heavy consumers of mass media,
especially social networking: according to the Centers for
Disease Control and Prevention (CDC), 93% of teens spend time
online, and 55% have a blog or use social networks such as
Facebook and My Space12. More adolescents have cell phones
capable of accessing the Internet than computers, and they use
their phones to communicate with one another via text message; to
play games; download music; to do research for school
assignments; and to obtain health information12. Results from a
study by Solomon, Bunn, and Flynn et al showed that media
messages utilizing social constructs common among adolescents,
such as self-image and the perception of peer norms were
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effective at preventing the start of smoking. Further study
involving the use of media messages based on social cognitive
theory and their effect on teen smokers showed significantly high
rates of smoking cessation3. Clearly, mass media offers a
promising venue for reaching adolescents with smoking cessation
messages.
A study by Scherphof et al involving the use of nicotine
replacement therapy (NRT), and small group class room
interventions did not result in significant cessation numbers;
however, the results are inconclusive, since the studies suffered
from problems such as small sample size and selection bias3. The
study also did not control for compliance, rendering any
conclusions regarding the efficacy of NRT in adolescents invalid.
Further study into these methods is required in order to make a
determination about their efficacy.
Recommendations
An area of concern surrounds funding for state smoking cessation
programs. Funding is often inadequate, in spite of the fact that
such programs have resulted in a marked decrease in the number of
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adults who smoke11. A reduction in smoking related illness would
ease the strain on state Medicaid budgets by reducing the number
of Medicaid patients with chronic illnesses due to smoking.
Additionally, smoking cessation programs accompanied by higher
taxes on cigarettes and legal restrictions on permitted smoking
venues may also play a role in reducing smoking rates, although
the relationship between taxes and legal restrictions, and
reduction in smoking rates is unclear9. Studies into the
effectiveness of higher taxes have found a positive impact on
teenaged smoking, but it had a negligible effect once they
reached adulthood and were earning their own money9, suggesting
that cessation and prevention programs should be available beyond
high school. Once again, further study is required in order to
determine whether higher taxes and anti-smoking ordinances are
effective in promoting smoking cessation.
Despite an overall reduction in the rate of smoking in the United
States, adolescent smoking remains worrisome. Warnings about the
dangers of smoking notwithstanding, a significant number of young
people continue to start smoking3. Emphasis on smoking prevention
has largely failed to reduce the numbers of adolescents who start
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smoking. Furthermore, while smoking cessation efforts have been
successful among adults, teen smoking cessation is more
problematic; however, since nearly one in ten smokers starts
smoking after the age of 18, efforts at tobacco control should
not end at age 18, but should continue into young adulthood.
Regarding racial and socioeconomic disparities, the Surgeon
General recommends heightened surveillance of smoking behaviors,
along with further study to increase understanding of the role
played by ethnic, racial, and cultural norms, and socioeconomic
status in the high prevalence of smoking among ethnic and racial
groups15. Community involvement is extremely important. In order
to reduce smoking rates among both adolescents and adults,
community norms and attitudes towards smoking must be changed15.
Further study is needed to determine the reasons for higher rates
of smoking among lower socioeconomic groups.
It is recommended that increased funding be made available at the
state and federal level to underwrite smoking cessation
programs12, as these programs require infrastructure, to include
administrative staff and sufficient capacity to serve all those
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in need of smoking cessation services. The CDC report Best
Practices for Comprehensive Tobacco Control Programs recommends a
multi-tiered strategy for reducing the numbers of Americans who
smoke, thereby reducing costs associated with damage to health
caused by smoking. Among the recommendations are12:
State and community interventions to include:
Preventing initiation among youth and young adults
Promoting cessation among adults and youth
Eliminating exposure to secondhand smoke
Identifying and eliminating tobacco-related disparities
among population groups
Use of mass media and community wide health interventions
Increase the price of tobacco products via increased
tobacco taxes
Community-wide educational programs
Enlist community involvement in the enforcement of
statutory laws regulating the sale of tobacco products
to minors
State cessation programs with the following goals
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Educating health organizations and providers on the
benefits of screening patients for tobacco use and
including cessation treatment
Provision of technical expertise for health care
organizations and providers to effect changes to health
systems in order to facilitate the inclusion of tobacco
cessation screening and treatment into clinical
treatment protocols.
Provision of assistance to health care organizations
and providers to incorporate the use of electronic
health records for the purpose of tracking tobacco use
and cessation effectiveness
Development of staff and funding to support statewide
smoking cessation efforts.
Sufficient staff numbers to support increased screening
responsibilities
Collaboration between program leaders and leaders in
other departments
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Flexibility within leadership to adjust to changes in
scientific knowledge and funding, especially reduction
of funds.
The funding levels recommended by the CDC report are $3,306
billion in total program costs. This massive outlay of funds is
justified by the fact that savings will be realized in the
reduction of costs due to tobacco-related illness, disability,
and death12. In addition to funding for comprehensive tobacco
control programs, a need exists for further research into the
factors which contribute to higher levels of smoking in the
lowest socioeconomic groups, since the relationship between
socioeconomic status and risky health behaviors is not entirely
clear12.
The Comprehensive Guide also recommends a National Prevention
Strategy to include:
1. Support comprehensive tobacco-free and other evidence-based
tobacco control policies.
2. Support full implementation of the 2009 Family Smoking
Prevention and Tobacco Control Act.
3. Expand use of tobacco cessation services.
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4. Use media to educate and encourage people to live tobacco-
free13.
These recommendations include a commitment by the Department of
Health and Human Services (HHS) to support states, communities,
and tribes in their efforts at smoking cessation. Toward that
end, HHS will launch a website providing information and links to
resources for those desiring to quit smoking13.
Additionally, the Department of Defense is expected to implement
tobacco control initiatives with a view toward unit cohesiveness,
unit readiness, and leadership by example13. In an era when many
young people see military men and women as heroes, the importance
of setting a good example cannot be understated.
Finally, further research into the effectiveness of
pharmaceuticals in treating adolescent smoking should be
conducted to determine whether they are appropriate.
Conclusion
Ultimately, the costs of smoking cessation programs and media
campaigns will be offset by the savings realized in health costs
and lost work days due to smoking-induced health problems. While
smoking cessation in adolescents is a complicated, multi-tiered
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process, the cost of doing nothing in terms of lost work days,
increased health care costs, and millions of premature deaths is
a price we as a nation cannot afford to pay. We should do all we
can to help adolescents stop smoking, for their good and the good
of the nation.
“If anyone causes one of these little ones—those who believe in
me—to stumble, it would be better for them to have a large
millstone hung around their neck and to be drowned in the depths
of the sea17.”
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