Tobacco Control

1. April 18, 2011 J. Randy Koch, Ph.D. Alison Breland, Ph.D. VCU Institute for Drug and Alcohol Studies Tobacco Control

2. Overview of Topics to Cover Today • Epidemiology • Tobacco products/brief history/Alternative tobacco products • Cessation/Treatment • Prevention strategies • Virginia Youth Tobacco Projects Research Coalition

3. Epidemiology • Tobacco use is the leading cause of preventable death in the US: over 400,000 deaths each year • Morbidity and mortality caused by carbon monoxide (CO) and carcinogens (e.g. tobacco-specific nitrosamines) • Dependence caused by nicotine: reinforcing effects such as euphoria, increased arousal, reduced stress, and appetite suppression • Use of tobacco often leads to an aversive withdrawal syndrome during periods of tobacco abstinence; this can maintain tobacco use and thus, exposure to harmful smoke constituents

4. Epidemiology: US rates • Currently, about 21% of US adults smoke cigarettes • Current use of cigarettes among youth: • 5.2% of middle school students • 17.2% of high school students • Rates higher if you include any tobacco product • Most adult smokers (80%) began smoking before age 18

5. Epidemiology: US rates (adults, cigarettes only) • Gender • 23.5% of men • 17.9% of women • Race • 23.2% of American Indians/Alaska Natives • 22.1% of whites (non-Hispanic) • 21.3% of blacks (non-Hispanic) • 14.5% of Hispanics • Socio-economic status • 31.1% of adults who live below the poverty level • 19.4% of adults who live at or above the poverty level

6. Source: www.smokingcessationrounds.ca (Volume 2 #10)

7. Tobacco use in Virginia • Statewide: 16.4% of the adult population are current cigarette smokers(BRFSS) • 11-13% of youth aged 12-17 smoked 1 cigarette in the past 30 days (NSDUH/VYTS) • Use of any tobacco in past 30 days: (cigarettes, cigars, smokeless tobacco, pipes, bidis, hookahs, Black and Milds, and SNUS) • 14% of middle-school students • 34% of high school students

8. Types of Tobacco Products (US) • Cigarettes • Cigars • Kreteks and bidis • Pipes • Smokeless tobacco (“dip”, “chew” or “snus” note: many new varieties) • Waterpipe (hookah)

9. Types of Tobacco Products • Cigarettes • First developed 1800s • US: 1930s – 1970s, start to see changes to cigarettes • Filters and “full flavor” vs “light” vs “ultra light” • Start to see health claims, even after 1964 Surgeon General’s report on the dangers of smoking

10. Cigarettes

11. Cigarettes

12. Cigarettes

13. Cigarettes

14. Types of Tobacco Products Source: Dr. Ken Warner.

15. Cigarettes

16. Cigarettes • “Patients who are unable to stop cigarette smoking should be assisted to reduce their smoke exposure by smoking low-tar and low nicotine cigarettes . . .” (Harrison’s Internal Medicine 9th Ed., 1980, p. 941). • Smokers believe “light” and “ultra light” cigarettes decrease health risks of smoking (Kozlowski, Goldberg, et al., 1998; Giovino et al., 1996). • Smokers switch to low yield cigarettes instead of quitting (Giovino et al., 1996).

17. Cigarettes • Changes increased sales without harm reduction • “The weight of the evidence indicates that lower-tar and nicotine yield cigarettes have not reduced the risk of disease proportional to their FTC yields” (IOM, 2001). • Past modifications did not alter exposure: changing puff topography, covering vent holes • New FDA regulation will eliminate use of “light” etc.

18. Cigarettes • Newer cigarettes: Eclipse, Advance, Omni • Bold claims of reduced carcinogens

19. Cigarettes

20. Breland, Kleykamp, Eissenberg, 2006

21. Types of Tobacco Products • Cigars • 5.4% of US adults use (>1 in past 30 days) • 3.9% of middle school students • 10.8% of HS students • Kreteks (clove cigarettes) and Bidis • Pipes • Waterpipe, or hookah • CO exposure is much higher than cigarettes (Eissenberg et al., 2011)

22. Types of Tobacco Products http://www.smokefree.gov/tob-cigarillo.aspx

23. Trends • SOURCE: Adapted by CESAR from University of Michigan, “Smoking Stops Declining and Shows Signs of Increasing Among Younger Teens,” Press Release, 12/14/2010. Available online at http://www.monitoringthefuture.org/data/10data.html#2010data-cigs.

24. Types of Tobacco Products • Smokeless tobacco • “Dip”, “Chew” (e.g., Skoal, Wintergreen) • Snus (Swedish) • Pressed tablets (Ariva) • Marlboro snus • Camel Snus, orbs, sticks, dissolvable strips • Health effects? In Sweden, low rates of lung cancer, but effects in US not known

25. dissolvable tobacco snus Slide courtesy of Bob Balster

26. Electronic Cigarettes Cartridge w/ Nicotine Solution/ E-juice/ E-liquid Atomizer Heater E-Juice/E-Liquid Nicotine Solution Propylene Glycol and/or Vegetable Glycerin Distilled Water Flavorings (Baking) Smart Chip Air Flow Sensor Rechargeable Battery 2v – 6v Use Methods Pre-Filled Dripping Fill your own Make your own LED Vaper Slide courtesy of Andrea Vansickel

27. Types of Tobacco Products • Some lab studies show low nicotine delivery (significant after 4, 10-puff bouts), also large amounts with experienced users • May appeal to youth • Health effects unknown Images courtesy of Bob Balster and Andrea Vansickel

28. Trends • Overall tobacco use has been going down (although for cigarettes, is currently stalled) • Use of other products may be increasing • Hard to determine long-term impact of new products (need to wait say, 20-30 years and see what happens)

29. Smoking cessation • ~70% of smokers say they want to quit • 45% make quit attempts • Relapse rates are high • Nicotine produces dependence: very difficult to quit • Nicotine is as addictive as heroin or cocaine

30. Smoking cessation • Medications to quit can increase likelihood of success • Nicotine replacement therapy (nicotine patch, gum, inhaler, lozenge, nasal spray) • Non-nicotine medications: buproprion (Zyban/Wellbutrin), varenicline (Chantix) • 1-800 QUIT-NOW (counseling) • Websites

31. Source: Treating Tobacco Use and Dependence: 2008 Update (Clinical Practice Guideline, Fiore et al., 2008) Not recommended

32. Source: Treating Tobacco Use and Dependence: 2008 Update (Clinical Practice Guideline, Fiore et al., 2008)

33. Smoking cessation • Current study: smoking cessation among those in recovery from addiction to alcohol/drugs • 80-90% of individuals addicted to other substances smoke • Tobacco use generally not addressed during formal treatment • Currently testing brief computerized motivational feedback in this population to determine effectiveness

34. Computerized Feedback Program

37. Questions?

38. Prevention

39. Risk and Protective Factors • Effective prevention programs are based on reducing risk factors and/or enhancing protective factors • Related to age, gender, race, and environment • A need for preventive interventions tailored to specific populations and settings • Most risk and protective factors related to a broad array of youth problems, but some are unique • Additive effect—goal is to affect the balance of risk and protective factors

40. Risk and Protective Factors Domains • Individual • Family • Peer • School • Community

41. Individual Risk Factors Psychiatric disorders Novelty/sensation seeking Positive attitudes towards substance use High antisocial behavior Individual Protective Factors Ambitious life goals High religiosity Risk and Protective Factors

42. Family Risk Factors Family conflict Family history of antisocial behavior Family attitudes favorable to substance use Family Protective Factors Parental nonsmoking Parental advice not to smoke Parental monitoring Strong family bonds Risk and Protective Factors

43. Peer Risk Factors Peer tobacco use Community risk factors Exposure to tobacco advertising Perceived availability of tobacco School Risk Factors Low school connectedness Low academic achievement School misbehavior Risk and Protective Factors

44. Types of Prevention Strategies • School-based programs • Family-based programs • Media campaigns • Reducing youth access • Excise Taxes

45. School-Based Prevention Programs • Schools are most common setting for tobacco use prevention programs • Provide relatively easy access to youth • Can address other concerns of interest to schools • Can be integrated into school curriculum

46. School-Based Prevention—What Works? • Skills Training • Academic Competence • Social Competence • Social Resistance Skills • Norms Education • Media Literacy • Should not be one-time efforts--booster sessions

47. Life Skills Training • Gilbert Botvin and colleagues, Cornell University • Target Population: Grades 6, 7 and 8 or Grades 7, 8 and 9 • Three year program (15, 10 and 5 session) • Focus on: • Drug resistance skills and information • Self-management skills • General social skills • Interactive program using facilitated discussion, role playing, and small group activities

49. Family-Based Prevention Programs • Parents are a major influence on youth behavior, especially on children • Most common approaches focus on enhancing parenting skills • Age appropriate expectations • Consistent and appropriate discipline • Monitoring of child activities/friends

50. Family-Based Prevention—What Works? • Strengthen family bonding and positive relationships • Improve parenting skills • Helping families to develop and enforce rules about substance use • Providing information about drugs and their effects on development