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

IndividualFamilyPeerSchoolCommunity

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 programsFamily-based programsMedia campaignsReducing youth accessExcise 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 1992 Required 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 0.170.000.501.001.502.002.503.003.504.004.505.00

NY RI TX VA MO

State

Exci

se T

ax in

Dol

lars

Mission and GoalsHistory and OrganizationActivitiesOpportunity 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!