april 18, 2011 j. randy koch, ph.d. alison breland, ph.d. vcu institute for drug and alcohol studies
TRANSCRIPT
April 18, 2011J. Randy Koch, Ph.D.Alison Breland, Ph.D.VCU Institute for Drug and Alcohol Studies
EpidemiologyTobacco products/brief
history/Alternative tobacco productsCessation/Treatment
Prevention strategiesVirginia Youth Tobacco Projects
Research Coalition
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
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
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
Source: www.smokingcessationrounds.ca (Volume 2 #10)
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
CigarettesCigarsKreteks and bidisPipesSmokeless tobacco (“dip”, “chew” or
“snus” note: many new varieties)Waterpipe (hookah)
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
Source: Dr. Ken Warner.
“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).
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.
Newer cigarettes: Eclipse, Advance, Omni
Bold claims of reduced carcinogens
Breland, Kleykamp, Eissenberg, 2006
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)
http://www.smokefree.gov/tob-cigarillo.aspx
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.
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
dissolvable tobacco
snus
Slide courtesy of Bob Balster
LED
Rechargeable Battery2v – 6v
Smart ChipAir Flow Sensor
AtomizerHeater
Cartridge w/ Nicotine Solution/E-juice/ E-liquid
E-Juice/E-LiquidNicotine SolutionPropylene Glycol and/orVegetable GlycerinDistilled WaterFlavorings (Baking)
Electronic Cigarettes
Use MethodsPre-FilledDrippingFill your ownMake your own
Vaper Slide courtesy of Andrea Vansickel
Some lab studies show low nicotine delivery (significant after 4, 10-puff bouts), also large amounts with experienced users
May appeal to youthHealth effects unknown
Images courtesy of Bob Balster and Andrea Vansickel
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)
~70% of smokers say they want to quit
45% make quit attemptsRelapse rates are highNicotine produces dependence: very
difficult to quitNicotine is as addictive as heroin or
cocaine
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
Not recommended
Source: Treating Tobacco Use and Dependence: 2008 Update (Clinical Practice Guideline, Fiore et al., 2008)
Source: Treating Tobacco Use and Dependence: 2008 Update (Clinical Practice Guideline, Fiore et al., 2008)
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
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
Individual
Family
Peer
School
Community
Individual Risk Factors Psychiatric
disorders Novelty/sensation
seeking Positive attitudes
towards substance use
High antisocial behavior
Individual Protective Factors Ambitious life goals High religiosity
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
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
School-based programs
Family-based programs
Media campaigns
Reducing youth access
Excise Taxes
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
Skills Training Academic Competence Social Competence Social Resistance Skills
Norms EducationMedia LiteracyShould not be one-time efforts--
booster sessions
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
Adjusted Substance Use Means at One-Year Follow-up
LST Control Group
Mean SE Mean SE X2 df P
Smoking 1.79 .08 2.13 .09 6.4 1 .006
Drinking 1.82 .08 2.11 .08 5.8 1 .008
Marijuana 1.69 .10 1.87 .11 1.3 1 .126
N= 802Griffin et al., 2003
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
Strengthen family bonding and positive relationships
Improve parenting skillsHelping families to develop and
enforce rules about substance useProviding information about drugs
and their effects on development
Richard Spoth and colleagues, Iowa State University
Target Population: Youth 10 to 14 years old (also available for younger children)
Seven sessions Parents and youth meet separately for first hour
and then together for second hour Parent sessions
Skill-building focused on establishing rules, limits, and consequences while expressing love; communication with youth; handling stress; using community resources
Uses videos demonstrating parenting skills, with role playing, discussion and skill building activities
Youth sessions Youth skill-building focuses on following rules, peer
pressure resistance, handling stress, and problem-solving
Group discussions, group skill practice, and social bonding activities
Family sessions Games and projects to increase family bonding, build
positive communication skills, plan family activities, and facilitate learning to solve problems together
Booster program 3 to 12 months after completing initial program—Four sessions
Spoth et al., 2004
OutcomeInitiation Proportion
Estimated time in
months from pretest
SFP Control Difference
Lifetime alcohol use .40 38.2 25.3 12.9
Lifetime alcohol use without parental permission .40
46.8 34.4 12.4*
Lifetime drunkenness .35 58.6 45.3 13.3*
Lifetime cigarette use .30 54.9 30.8 24.1*
Lifetime marijuana use .10 63.7 48.6 15.1
Systematic review by Brinn et al., 2010 (Cochrane Collaboration) There is some evidence that mass media can
prevent the uptake of smoking in young people, however the evidence is not strong and contains a number of methodological flaws.
Effective media campaigns:▪ Based on good market research▪ Identify and tailor message to specific groups (market
segmentation)▪ Last longer and more intensive▪ Use multiple media (TV, radio, newspapers)
Primarily focus preventing illegal sales to minors Retailer education Active enforcement
Systematic review by Stead, 2008 (Cochrane Collaboration) Active enforcement more effective in reducing
sales to minors Little evidence of impact on perceived availability
of tobacco products or on prevalence of youth smoking (only three controlled trials)
Enacted in 1992Required States to enact laws
prohibiting the sale or distribution of tobacco products to those under 18 years old Required unannounced inspections of retail
outlets and reporting of results “False buys” Established targets for “violation rates” Failure to meet targets could result in loss
of funds—up to 40% of SAPT Block Grant
Synar Violation Rates by Year
0%
10%
20%
30%
40%
50%
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year
Viol
atio
n Ra
te
Create a financial disincentive to use tobacco
Based on known relationship between price and sales Elasticity of demand (Ed ) is percentage
change in sales as a result of percentage change in price
Ed = -1.5 (10% increase in prices results in 15% reduction in sales
Relationship between price and sales (demand) complicated by role of addiction
Adults Ed = -.40 (NCI, 1993)Less research on youth
Illegal product for youthGenerally believed that youth are more
price sensitive Less disposable income Less addicted
Youth Ed = -.9 to -1.5
“Policies that affect the price of tobacco products are the single most effective means of decreasing tobacco use, especially among youth and young adults.” (CDC, 1998)
Tobacco companies often respond by decreasing wholesale price
State Tobacco Excise Taxes
4.35
3.46
1.41
0.30 0.17
0.000.501.001.502.002.503.003.504.004.505.00
NY RI TX VA MO
State
Exci
se T
ax in
Dol
lars
Mission and Goals
History and Organization
Activities
Opportunity for Student Participation
The Virginia Youth Tobacco Projects (VYTP) Research Coalition was established to advance the prevention and treatment of youth tobacco use and nicotine dependence through a coordinated, multi-university program of basic and applied research.
Build a statewide program of research on the causes and prevention of youth tobacco use
Create active multi-university collaborations in carrying out the VYTP research program
Attract new faculty scholars to work on problems of youth smoking
Use VTSF funding as a base for attracting additional outside funding for youth tobacco research in Virginia
Translate research findings into improved prevention services and policies
The VYTP Research Coalition established in 2002 with funding from the Virginia Tobacco Settlement Foundation, now called the Virginia Foundation for Healthy Youth
The VFHY supports three types of activities related to youth tobacco use: Media campaign Community-based prevention programs Research
The VYTP Research Coalition includes over 40 faculty from seven of Virginia’s universities: The College of William and Mary George Mason University James Madison University University of Virginia Virginia Commonwealth University Virginia Tech Virginia State University
VCU-IDAS serves as coordinating center
Targeted grant funding to support research Small grant awards to fund preliminary/pilot
studies and encourage participation by new investigators
Research conference to disseminate findings to researchers, policy makers and practitioners
Coalition meetings to facilitate networking and the development of new research collaborations
Reports to facilitate research translation
Statewide survey assessing: Frequency and quantity of use Perceived availability of tobacco products Exposure to environmental smoke Attitudes towards tobacco use Exposure to tobacco advertisements
Conducted every other year beginning in 2001
Public school students in grades 6 through 12
Multi-stage sampling frame
Access is being provided to students and postdocs for the first time
Award ($500) for best student and best postdoc study
Opportunity to present at VYTP conference in spring 2012
And, thank you for not smoking!