Confronting Tobacco Use Among Our Youth

Each day, approximately 3,800 youth in the United States try a cigarette for the first time. Of these youth, an estimated 1,000 will become daily smokers (Substance Abuse and Mental Health Services Administration, 2011). The peak age for trying cigarettes for the first time is between the ages of 11 and 13 years old (Johnston, O'Malley, Bachman, & Schulenberg, 2012b). Further, the U.S. Surgeon General reported that 88% of daily adult smokers used their first cigarette by the age of 18 and 99% before the age of 26 (U.S. Department of Health and Human Services, 2012). Based on these statistics, the Surgeon General concluded that an estimated 80% of youth who currently smoke will continue to smoke into adult hood due to the addicting effects of nicotine (U.S. Department of Health and Human Services, 2012). Overall, 15.7% of youth under the age of 18 are current smokers (Centers for Disease Control and Prevention, 2013).

An estimated 80% of youth who currently smoke will continue to smoke into adulthood due to the addicting effects of nicotine.

In 2013, the Youth Risk Behavior Survey reported that 41.1% of students had smoked a cigarette at some point in their lives (Centers for Disease Control and Prevention, 2013). Of those, 5.6% reported they had smoked for at least 20 consecutive days and 3.8% reported they had smoked on school property. The Centers for Disease Control and Prevention (2013) reported that 5.6% of high school students smoke frequently. When considering grade level, 7.6% of 11th-grade and 8.4% of 12th-grade students in high school are frequent smokers, while 2.9% of 9th-grade and 4% of 10th grade students are frequent smokers. In addition, when race/ethnicity is considered, 7.6% of Caucasian students, 2.9% of Hispanic students, and 2.7% of African-American high school students are frequent smokers. Approximately 6.1% of students graduating high school each year are current daily smokers (Centers for Disease Control and Prevention, 2013).

Overall, rates of tobacco use have been declining among youth over the past decade (Centers for Disease Control and Prevention, 2013). E-cigarettes however have become increasingly popular, and researchers have documented a significant rise in usage among students from 6th to 12th grades between 2011 and 2014 (Arrazola et al., 2015). According to a recent report, 14% of all middle and high school students across Texas currently use e-cigarettes, and 23.6% have tried it at some point in their lives (Cooper, Case, & Loukas, 2015). E-cigarettes currently are not regulated by the United States Food and Drug Administration, and it has not been determined that they are safe (Harrell, Simmons, Correa, Padhya, & Brandon, 2014).

Effects of Tobacco

The health risks associated with tobacco use are well researched and documented (American Lung Association, 2012; Centers for Disease Control and Prevention, 2012; Johnston et al., 2012a). Cigarette smoking not only causes bad breath, increased heartbeat, high blood pressure, and irritated eyes and throat, but also more serious health effects such as respiratory problems, gum disease, heart disease, stroke, various cancers, cardio vascular disease, and potentially death (Center for Disease Control, 2012). Cigarette smoking is considered the number one cause of preventable disease and mortality in the United States (Johnston et al., 2012a), and is responsible for more fatalities than alcohol, AIDS, motor vehicle accidents, drug use, violence, and suicide combined (Johnston et al., 2012a). Further, the health effects of smoking cigarettes are even more pronounced and severe when considering youth (U.S. Department of Health and Human Services, 2010).

In terms of youth, smoking causes an increased potential for airway obstruction, reduced lung function, and slowed growth of lung function. In addition, youth daily smokers are more likely to suffer from shortness of breath and have overall less endurance and performance in terms of physical fitness when compared to youth non-smokers (Centers for Disease Control and Prevention, 2012). Further, the Center for Disease Control (2012) reported that the resting heart rate of youth smokers is two to three heart beats per minute faster, indicating possible signs of heart disease and/or stroke. All of the potential negative health effects associated with smoking cigarettes are further enhanced due to the fact that one in five deaths each year can be attributed to smoking cigarettes (Center for Disease Control, 2012).

The long-term effects of e-cigarettes are not well known, but studies suggest that they may have harmful effects similar to those of traditional cigarettes, though generally less severe (Harrell et al., 2014).

Cigarette smoking not only causes bad breath, increased heartbeat, high blood pressure, and irritated eyes and throat, but also more serious health effects such as respiratory problems, gum disease, heart disease, stroke, various cancers, cardiovascular disease, and potentially death.

Even those that do not smoke cigarettes directly can be exposed to many of the negative health effects associated with tobacco use. Each year, secondhand smoke exposure kills an estimated 50,000 non- smokers (Centers for Disease Control and Prevention, 2012). In addition, secondhand smoke causes disease and respiratory problems in non-smokers. These adverse effects include lung cancer, heart disease, emphysema, coughing, respiratory discomfort, and reduced lung functioning (Centers for Disease Control and Prevention, 2012). These negative health effects are due to the more than 7,000 chemical compounds that have been identified in tobacco smoke. Of these compounds, at least 69 are known to cause cancer which result in secondhand smoke causing 30 times as many lung cancer deaths when compared to all regulated air pollutants combined (U.S. Department of Health and Human Services, 2012). In 2007-2008, approximately 88 million non- smokers were exposed to secondhand smoke. Over 53.6% of youth (age 3-11) in the United States are exposed to secondhand smoke on a daily basis (Centers for Disease Control and Prevention, 2012). Exposure to secondhand smoke increases the likelihood of ear infections, frequent and severe asthma attacks, and respiratory infections in youth (Center for Disease Control, 2012).

Addiction

In addition to adverse health effects, nicotine has been declared one of the most addicting substances by many leading public health organizations (Substance Abuse and Mental Health Services Administration, 2011; U.S. Department of Health and Human Services, 2012; U.S. Department of Health and Human Services, 1988). In a 1988 Surgeon General's report pertaining to the health consequences of tobacco, it was declared that tobacco use is addicting and nicotine is the drug that causes the addiction. Addiction to tobacco products was compared to that of such drugs as cocaine and heroin (U.S. Department of Health and Human Services, 1988). Nicotine addiction has since been recognized as the most common form of drug addiction and leads to more deaths and/or diseases than all other addictions combined. Smoking has a higher addiction rate than marijuana, alcohol, and cocaine (Johnston et al., 2012a). Furthermore, prolonged use of tobacco can be attributed to the powerfully addicting effects of tobacco products (U.S. Department of Health and Human Services, 2010). When an individual uses tobacco regularly, the nicotine accumulates in the body, resulting in the chemical effects of nicotine 24 hours a day (U.S. Department of Health and Human Services, 1998).
Many youth who become daily smokers before or during their high school years attempt to quit, but the reality is that a majority fail. The Centers for Disease Control and Prevention (2011) reported that over 60% of high school students who are daily smokers have tried to quit at least once, but less than one in eight were successful in quitting for more than 30 consecutive days. This can be attributed to the fact that users who start at an early age are more likely to develop a long-term nicotine addiction. Among all addictive behaviors (e.g. alcohol use, illicit drug use, etc.), cigarette smoking is the one most likely to be established during adolescence as evidence by the 88% of users that start before the age of 18 (U.S. Department of Health and Human Services, 2012). Overall, 80% of youth aged 12-18 who smoke at least one pack of cigarettes a day are dependent on nicotine (Substance Abuse and Mental Health Services Administration, 2011).

Addiction to tobacco products was compared to that of such drugs as cocaine and heroin.

Furthermore, nicotine has been labeled as a "gateway" drug (National Institute on Drug Abuse, 2012). Nicotine's addictive power "opens the door" for youth to experiment with other addictive substances such as alcohol and illicit drugs. For example, youth who smoke cigarettes daily are 11 times more likely to use illicit drugs and 16 times more likely to drink alcohol heavily when compared to youth non-smokers (National Institute on Drug Abuse, 2012). Youth who begin abusing substances at a young age are much more likely to grow up and become adult users, and tend to migrate toward other deviant behaviors (National Institute on Drug Abuse, 2012). Specifically, individuals that start smoking cigarettes at a young age are four times more likely to become a regular user of an illicit substance as an adult when compared to youth non-smokers.

E-cigarettes have been publicized as a means to quit traditional cigarettes, but the validity of this claim has not been firmly established (Harrell et al., 2014). E-cigarettes have been associated with use of other tobacco products (Cooper, Case, & Loukas, 2015).

Community Level Tobacco Prevention

With the adverse health effects to smokers and non-smokers and other social consequences (e.g. addiction, "gateway" drug, etc.) of smoking cigarettes, prevention at a community and/or school level is a vital step in reducing the toll tobacco has in the United States and in Texas. Subsequent to the legal settlements reached in 1998 between many states and large tobacco companies, comprehensive tobacco prevention programs were introduced. The Texas Department of State Health Services (2012) defines a comprehensive tobacco prevention and control program as "a coordinated effort to establish smoke-free policies and social norms, to promote and assist tobacco users to quit, and to prevent initiation of tobacco use". This approach to tobacco prevention and control focuses on educational, clinical, regulatory, economic, and social strategies with the goals of preventing tobacco use among youth, ensuring compliance with tobacco laws by utilizing adequate enforcement, increasing cessation among youth and adults, eliminating exposure to secondhand smoke, and reducing tobacco use among populations with the highest burden of tobacco-related health disparities (Centers for Disease Control and Prevention, 2007; Department of State Health Services, 2012).

Community level tobacco prevention and control programs are an important component of a statewide comprehensive program.

Community level tobacco prevention and control programs are an important component of a statewide comprehensive program. Such programs target families, peer groups, local organizations, businesses, and political systems with the overall goal of advancing health in the local community (Department of State Health Services, 2012). In addition, these programs build a community infrastructure that is needed to sustain efforts over time. The development and implementation of such programs requires that a broad range of community members and organization work together, rather than working individually. Building partnerships among youth, adults, schools, law enforcement officers, and community stakeholders reduces the impact of tobacco through prevention, training, and enforcement initiatives. The idea is to combine efforts and create one local program that is effective in meeting several goals and objectives relating to tobacco prevention and control (Department of State Health Services, 2012). Research has shown that tobacco prevention and control programs are more effective when schools, families, and youth work together rather than working separately (Department of State Health Services, 2012).

The Role of Schools

Youth spend almost one-third of their waking hours in school. Therefore, school administrators, teachers, law enforcement officers, and school staff play an important role in the health and safety of youth. There are several actions school staff members can take to reduce the toll of tobacco on youth. First, tobacco-free policies should be clearly communicated and consistently enforced among both staff and students (Centers for Disease Control and Prevention, 2007). This allows a clearer expectation to be set in the school environment as it pertains to tobacco, as well as enforce negative attitudes regarding tobacco use. Second, schools should develop and/or implement existing prevention curriculums that outline the long-term and short-term consequences of tobacco use (Centers for Disease Control and Prevention, 2007). Educating youth provides them with the knowledge needed to make well-informed decisions regarding tobacco use. Third, schools should make opportunities available for students to work on projects that promote smoke-free policies and social norms, assist tobacco users to quit, and prevent initiation of tobacco use (Centers for Disease Control and Prevention, 2010). It is important for schools to focus not only on prevention, but also on cessation efforts for those students who have already become daily smokers. School efforts should be regularly evaluated to ensure proper implementation and success in decreasing student tobacco use. As mentioned, schools should not address tobacco prevention independently, but rather in conjunction with families, youth, and other community members.

No Tobacco Sign

The Role of Families

Parents and other family members have the ability to influence the perceptions and attitudes of youth concerning tobacco. Therefore, family members must be involved in tobacco-free efforts. Research has shown that youth who have a smoking parent are more likely to be smokers, and at younger ages when compared to youth who do not have a parent that smokes (Centers for Disease Control and Prevention, 2010). Even parents and family members that smoke should communicate to youth that nicotine is an addictive drug and quitting is not easy. In addition, continuing efforts to quit will send a positive message to youth. Creating a smoke-free home can go a long way in shaping the perceptions and attitudes of youth as they pertain to tobacco use. A smoke-free home sends the message that smoking is undesirable. Parental and family attitudes and opinion of smoking can greatly influence those of youth (Centers for Disease Control and Prevention, 2007). Therefore, by communicating the harms, especially those that are immediate (e.g. bad breath, smelly clothes, yellow teeth, etc.), youth will develop negative perceptions and/or attitudes about smoking practices and the consequences associated. Research has shown that youth who develop negative attitudes and/or perceptions pertaining to the use of tobacco are less likely to use tobacco (Centers for Disease Control and Prevention, 2007; Centers for Disease Control and Prevention, 2010). Placing the burden only on parents will not reduce the use of tobacco by youth substantially. A comprehensive community approach calls for parents to work with schools, youth, and other community members.

The Role of Youth

Youth are arguably the most important group to have involved when developing tobacco prevention awareness efforts. Their importance stems from direct involvement and experience of the behavior to be prevented (e.g. tobacco use). Youth experience and witness the effects tobacco has on their peers first-hand. Essentially, they know what is "really happening" in their school/community and their perceptions of tobacco use are often reflective of other youth in the community. With such a strong base of knowledge, youth can effectively advocate for policy change, mobilize their peers, bring creativity and energy to the program, and evoke a genuine concern for their community (Centers for Disease Control and Prevention, 2010). A foundation in knowledge is crucial for creating social change and a structure that appeals to, and obtains buy in from, the targeted population (Kervin & Obinna, 2010). Therefore, youth should be included in the design, development, and delivery of tobacco prevention and control efforts to ensure accuracy, appropriateness, and acceptability of the strategies used. Tobacco prevention and control programs that incorporate youth develop an important advocacy component that alters social norms and perceptions of other youth in the community (Centers for Disease Control and Prevention, 2010). In addition, youth have shown to be more responsive to other youth. It is ultimately more effective to deliver a program to youth that is advocated for by other youth (Marko & Watt, 2011). Due to their direct involvement, first-hand knowledge of the situation, and potential impact on others, it is vital to involve youth in the development of community level tobacco prevention and control programs.

References

American Lung Association. (2012). Facts about secondhand smoke. American Lung Association: Fighting for Air. Retrieved March, 2013, from http://www.smokefreehousingvt.org.

Arrazola, R. A., Singh, T., Corey, C. G., Husten, C. G., Neff, L. J., Apelberg, B. J., Bunnell, R. E., Choiniere, C. J., King, B. A., Cox, S., McAfee, T., & Caraballo, R. S. (2015). Tobacco use among middle and high school students—United States, 2011-2014. Morbidity and Mortality Weekly Report, 64(14), 381-385.

Centers for Disease Control and Prevention. (2007). Best Practices for Comprehensive Tobacco Control Programs—2007. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

Centers for Disease Control and Prevention. (2010). Best Practices User Guide: Youth Engagement–State and Community Interventions. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

Centers for Disease Control and Prevention. (2011). Youth Risk Behavior Surveillance-United States. 61(4): 1-162.

Centers for Disease Control and Prevention. (2012). Smoking and tobacco use. Center for Disease Control and Prevention. Retrieved March, 2013, from http://www.cdc.gov/tobacco/basic_information/index.htm.

Cooper, M., Case, K. R., & Loukas, A. (2015). E-cigarette use among Texas youth: Results from the 2014 Texas Youth Tobacco Survey. Addictive Behaviors, 250, 173-177. doi: 10.1016/j.addbeh.2015.06.034

Harrell, P. T., Simmons, V. N., Correa, J. B., Padhya, T. A., & Brandon, T. H. (2014). Electronic nicotine delivery systems ("e-cigarettes"): Review of safety and smoking cessation efficacy. Official journal of American Academy of Otolaryngology—Head and Neck Surgery, 151(3), 381-393.

Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2012a). Monitoring the future national results on adolescent drug use: Overview of key findings, 2012. Ann Arbor: Institute for Social Research, The University of Michigan.

Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2012b). Monitoring the future national survey results on drug use, 1975–2011: Volume I, Secondary school students. Ann Arbor: Institute for Social Research, The University of Michigan.

Kervin D., & Obinna, J., (2010). Youth action strategies in the primary prevention of teen dating violence. Journal of Family and Social Work, 13: 362-374.

Marko, T., & Watt, T. (2011). Employing a youth-led adult-guided framework: Why drive high social marketing campaign, Family Community Health, 34(4): 319-330.

National Institute on Drug Abuse. (2012). NIDA examines nicotine as a gateway drug. National Institute on Drug Abuse: The Science of Drug Abuse and addiction. Retrieved March, 2013, from http://www.drugabuse.gov.

Substance Abuse and Mental Health Services Administration (SAMHSA) (2011), HHS, Results from the 2011 National Survey on Drug Use and Health, NSDUH: http://www.samhsa.gov.

Texas Department of State Health Services. (2012). Tobacco prevention and control. Texas Department of State Health Services. Retrieved March, 2013, from https://www.dshs.state.tx.us/tobacco/.

U.S. Department of Health and Human Services. (1998). The Health Consequences of Smoking; Nicotine Addiction. A Report of the Surgeon General. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

U.S. Department of Health and Human Services. (2010). How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

U.S. Department of Health and Human Services. (2012). Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.