Helping youth to quit smoking: What does research suggest?

Helping youth to quit smoking: Helping youth to quit smoking: What does research suggest? What does research suggest?

Paul McDonald, PhDPaul McDonald, PhD

University of WaterlooUniversity of WaterlooOntario Tobacco Research UnitOntario Tobacco Research Unit

Why focus on youth?Why focus on youth?

15 to 19 year olds make up 8% of 15 to 19 year olds make up 8% of the NL population (age 15+) and the NL population (age 15+) and nearly 6% of tobacco users nearly 6% of tobacco users

20 to 24 year olds make up 8% of 20 to 24 year olds make up 8% of the NL population (age 15+) but the NL population (age 15+) but 12.2% of all tobacco users. 12.2% of all tobacco users.

Persons 45+ make up 51% of the Persons 45+ make up 51% of the NL population but less than 40% NL population but less than 40% of tobacco usersof tobacco users

Source: CTUMS, 2006

Reasons for optimismReasons for optimism

Unassisted quit rates for youth are higher Unassisted quit rates for youth are higher than with adultsthan with adults 12 month abstinence rates of up to 40% for 12 month abstinence rates of up to 40% for

adolescents compared to adults rate of 3% to adolescents compared to adults rate of 3% to 8% 8% (Driezen et al., submitted)(Driezen et al., submitted)

May be because more youth are occasional smokers; May be because more youth are occasional smokers; daily smokers consume fewer cigarettes; youth daily smokers consume fewer cigarettes; youth frequent more supportive environments; youth frequent more supportive environments; youth smoking patterns are less established.smoking patterns are less established.

Different puff topography than adults (lower puff Different puff topography than adults (lower puff volume) (Franken et al., 2006)volume) (Franken et al., 2006)

Reasons for optimismReasons for optimism

Youth have tried to quit in past yearYouth have tried to quit in past year 63% of 15-17 yr olds63% of 15-17 yr olds 69% of 18-19 yr olds69% of 18-19 yr olds 62% of 20-24 yrs olds62% of 20-24 yrs olds 45 % of 25+45 % of 25+

Trying to quit at least once in the previous Trying to quit at least once in the previous year doubles the likelihood of interest in year doubles the likelihood of interest in school-based programs (Leatherdale and school-based programs (Leatherdale and McDoinald, 2007)McDoinald, 2007)

CTUMS, 2006

How should we assess How should we assess interventions?interventions?

Should we only be concerned with Should we only be concerned with effectiveness and “reach”?effectiveness and “reach”?

A revised approach to tobacco controlA revised approach to tobacco control: : from prevalence to risk reductionfrom prevalence to risk reduction

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““Rosian” population approach to prevention:Rosian” population approach to prevention: Shift the risk of the majority.Shift the risk of the majority. Impact =Impact = ““Effect Effect x x

exposureexposure””

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Not all sub-populations have the same risk distribution; Not all sub-populations have the same risk distribution;

Not all people will yield the same benefit from interventionNot all people will yield the same benefit from intervention

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A new population paradigm:A new population paradigm:Effect of sustained program of interventionEffect of sustained program of intervention

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1. Shift risk continuum,2. especially for high risk (ie high burden)

Implications of the new paradigmImplications of the new paradigm

Population impact = Effect x Exposure x Benefit

Cost x

Equity variance

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Select intervention mix based on stakeholder acceptability, feasibility, stage of problem, and potential population impact where:

Exposure = % of population who receive or are exposed to intervention program;Effect = % of people exposed who benefit from an intervention or odds of success;Benefit = Average expected future benefit from “success” (ie reversible risk) Cost = Investment (dollars, opportunity etc.) required to achieve given impactEquity = Variance in impact across designated sub-populations of interest

Not all people Not all people benefitbenefit equally from equally from quitting: the case for youth cessationquitting: the case for youth cessation

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Average age of quitters

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SummarySummary

Evaluate programs in terms of:Evaluate programs in terms of: EffectivenessEffectiveness (odds of quitting) (odds of quitting) Reach or exposureReach or exposure (how many people) (how many people) Average expected Average expected benefit benefit (would addressing (would addressing

the needs of another group yield greater the needs of another group yield greater impact?)impact?)

Impact on Impact on sub populationssub populations of smokers (not of smokers (not just the majority)just the majority)

CostCost to benefit ratio (is it the best way to to benefit ratio (is it the best way to spend your money relative to alternatives) spend your money relative to alternatives)

How effective are individual How effective are individual treatments?treatments?

Recent reviews:Recent reviews: Mermelstein, 2003Mermelstein, 2003

• a narrative reviewa narrative review Garrison et al., 2003Garrison et al., 2003

• limited to 6 published, controlled trialslimited to 6 published, controlled trials Sussman, 2002; Sussman, Sun and Dent, 2006Sussman, 2002; Sussman, Sun and Dent, 2006

• Systematic review of 66 published and unpublished trials of various Systematic review of 66 published and unpublished trials of various designs and outcomesdesigns and outcomes

Grimshaw and Stanton, 2006 – Cochrane ReviewGrimshaw and Stanton, 2006 – Cochrane Review• Cochrane protocol applied to 15 eligible studies of published RCTsCochrane protocol applied to 15 eligible studies of published RCTs

McDonald et al., 2003McDonald et al., 2003• Refinement of Sussman, 2002Refinement of Sussman, 2002• Determined to be the most comprehensive and rigorousDetermined to be the most comprehensive and rigorous• Used a panel of experts instead of single reviewerUsed a panel of experts instead of single reviewer• Results based on 20 studies with high or moderate validity Results based on 20 studies with high or moderate validity

(emphasis put on high validity studies)(emphasis put on high validity studies)

Expert panel findingsExpert panel findings(McDonald et al., 2003)(McDonald et al., 2003)

Treatments for youth are promisingTreatments for youth are promising 9 of 20 were effective (incl. 2 of 5 high validity)9 of 20 were effective (incl. 2 of 5 high validity)

Treatments based on social cognitive Treatments based on social cognitive theory/cognitive-behavioural approaches are theory/cognitive-behavioural approaches are promisingpromising 8 of 14 were effective (incl. 2 of 5 high validity)8 of 14 were effective (incl. 2 of 5 high validity) SLT includes: goal setting, self monitoring, SLT includes: goal setting, self monitoring,

development of coping skills and self efficacy, cognitive development of coping skills and self efficacy, cognitive reframing, problem solving, positive reinforcement, reframing, problem solving, positive reinforcement, counter-conditioning, stimulus control, contingency counter-conditioning, stimulus control, contingency management, anger management, assertiveness management, anger management, assertiveness training, motivational enhancementtraining, motivational enhancement

Expert panel findings, cont…Expert panel findings, cont…

Insufficient evidence to support other theoretical Insufficient evidence to support other theoretical approaches approaches NO evidence to support stages of changeNO evidence to support stages of change

• Lawrance, McDonald et al. (unpublished) – 200+ high Lawrance, McDonald et al. (unpublished) – 200+ high schools studentsschools students

• Aveyard et al (1999) – 8,000 UK 13/14 yr oldsAveyard et al (1999) – 8,000 UK 13/14 yr olds• Quinlan & McCall – daily smokers in collegeQuinlan & McCall – daily smokers in college

• Efficacy with adults has also been questionedEfficacy with adults has also been questioned Riemssma et al, 2003 – BMJ review of matched treatmentsRiemssma et al, 2003 – BMJ review of matched treatments McDonald, in progress McDonald, in progress Whitelaw et al., 2000 - reviewWhitelaw et al., 2000 - review

Expert Panel Findings, cont…Expert Panel Findings, cont… Insufficient evidence to draw conclusions Insufficient evidence to draw conclusions

about:about: PharmacotherapyPharmacotherapy

• May not be effective for “light” adult smokers either May not be effective for “light” adult smokers either (Pierce & Gilpin, 2002; Niaura et al., 1994)(Pierce & Gilpin, 2002; Niaura et al., 1994)

Best delivery settingBest delivery setting• Most treatments delivered in school settings (class Most treatments delivered in school settings (class

or outside) and health clinicsor outside) and health clinics• Some school based and clinic programs were Some school based and clinic programs were

effective (just not enough to draw conclusions) effective (just not enough to draw conclusions) • Note: youth smokers less likely to be in school or Note: youth smokers less likely to be in school or

use clinicsuse clinics

Expert panel findings, cont…Expert panel findings, cont…

Insufficient evidence to draw conclusions about:Insufficient evidence to draw conclusions about:

Best type of providerBest type of provider• 4 of 6 teacher/school staff delivered programs were effective 4 of 6 teacher/school staff delivered programs were effective

(all mod. Validity)(all mod. Validity)• 2 of 4 using psychologists, health educators or counselors 2 of 4 using psychologists, health educators or counselors

were effectivewere effective• 1 of 3 using trained peers was effective1 of 3 using trained peers was effective

Voluntary vs. mandatory treatmentVoluntary vs. mandatory treatment• None of the 3 mandatory treatments were effectiveNone of the 3 mandatory treatments were effective

UpdateUpdate

Recent completed studies not available to McDonald et Recent completed studies not available to McDonald et al.al.

Zhu et al. – randomized trial of 1200 adolescents re proactive Zhu et al. – randomized trial of 1200 adolescents re proactive telephone counseling based on SCT. Modest short term effect telephone counseling based on SCT. Modest short term effect for 17 to 19 year olds; no effect for 14 to 16 year oldsfor 17 to 19 year olds; no effect for 14 to 16 year olds

Lipkus et al. Randomized trial of adolescents re proactive Lipkus et al. Randomized trial of adolescents re proactive telephone counseling based on SCT. Effective at 6 month telephone counseling based on SCT. Effective at 6 month follow-up. follow-up.

Adelman et al, 2001 – randomized trial of school-based group Adelman et al, 2001 – randomized trial of school-based group program. Effective at 4 week follow-up.program. Effective at 4 week follow-up.

Yiming et al. - randomized control study of laser acupuncture Yiming et al. - randomized control study of laser acupuncture with 200+ 12 – 18 yr olds in clinic. No effect. with 200+ 12 – 18 yr olds in clinic. No effect.

Roddy et al, 2006 – randomized trial of 98 teen smokers from Roddy et al, 2006 – randomized trial of 98 teen smokers from low SES backgrounds. Six weeks of NRT was not effective. low SES backgrounds. Six weeks of NRT was not effective. Adherence was very low (median duration of one week of use). Adherence was very low (median duration of one week of use).

UpdateUpdate Chen and Yeh, 2006 – 6 wk cessation program + Chen and Yeh, 2006 – 6 wk cessation program +

internet assisted instruction with 77 senior high school internet assisted instruction with 77 senior high school students. Relative to no treatment control, the treatment students. Relative to no treatment control, the treatment group had more positive attitudes toward quitting. Effect group had more positive attitudes toward quitting. Effect on quitting is unknown.on quitting is unknown.

Myers and Brown, 2005 – effect of intense counseling Myers and Brown, 2005 – effect of intense counseling with 54 adolescents being treated for substance abuse. with 54 adolescents being treated for substance abuse. Counseling increased # of quit attempts but not Counseling increased # of quit attempts but not likelihood of quitting at 3 mo. likelihood of quitting at 3 mo.

Moolchan et al., 2005 – RCT with 120 moderate to Moolchan et al., 2005 – RCT with 120 moderate to heavy teen smokers. Short term, but no long term heavy teen smokers. Short term, but no long term benefit for NRT. benefit for NRT.

Pbert et al (2006). Randomized trial with 577 smokers Pbert et al (2006). Randomized trial with 577 smokers receiving brief intervention from school nurses (5A model receiving brief intervention from school nurses (5A model using social cognitive theory). Relative to usual care using social cognitive theory). Relative to usual care control, intervention increased odds of quitting at 3 control, intervention increased odds of quitting at 3 month follow-up. month follow-up.

A few more words about pharmacotherapy A few more words about pharmacotherapy

and physician based interventionand physician based intervention Moolchan et al (2006) found that NRT was safe Moolchan et al (2006) found that NRT was safe

for adolescentsfor adolescents Recommended by most clinical guidelines for Recommended by most clinical guidelines for

both youth and adults, despite lack of efficacyboth youth and adults, despite lack of efficacy Youth have access to NRTYouth have access to NRT

Johnson et al (2004) found that 81% of those <18 Johnson et al (2004) found that 81% of those <18 who tried to purchase NRT from retailers were who tried to purchase NRT from retailers were successful successful

Wyman et (2006) found only 8% of parents Wyman et (2006) found only 8% of parents supported schools providing NRTsupported schools providing NRT

(Non-)impact of health professionals* (Non-)impact of health professionals* on adolescent smokers in Canadaon adolescent smokers in Canada

(Stevenson et al, 2007 – from CTUMS)(Stevenson et al, 2007 – from CTUMS)

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Received advice to reduce or quit

Provided with info on cessation aid*includes physician,

dentist, or pharmacist

US study done in US study done in 2000 with students in 2000 with students in grades 6 to 12 found grades 6 to 12 found that only 16% that only 16% received assistance to received assistance to quit from a physician quit from a physician and 12% received and 12% received assistance from a assistance from a dentistdentist

Source: Shelly et al., 2005

Additional observations regarding Additional observations regarding behavioural treatmentsbehavioural treatments

Virtually all effective treatments involved 8 to 24 Virtually all effective treatments involved 8 to 24 hours of contact with facilitatorhours of contact with facilitator

Few studies examine non-face to face Few studies examine non-face to face interactions (web-based, telephone)interactions (web-based, telephone) Emerging evidence suggests these may be promising Emerging evidence suggests these may be promising

Treatments more likely to be effective with older Treatments more likely to be effective with older youth (16+)youth (16+)

Few studies with special populations (despite Few studies with special populations (despite high prevalence and over-representation). high prevalence and over-representation). One study with psychiatric co-morbidity was not One study with psychiatric co-morbidity was not

successful successful

Additional observationsAdditional observations

No studies looked at interaction between No studies looked at interaction between intrapersonal and environmental factorsintrapersonal and environmental factors

Most studies had high loss to follow-up Most studies had high loss to follow-up which suggests:which suggests: Its difficult, even under ideal conditions, to Its difficult, even under ideal conditions, to

keep youth engagedkeep youth engaged It significantly undermines statistical power It significantly undermines statistical power

(increases likelihood of missing a true effect)(increases likelihood of missing a true effect)

Why have individual programs so Why have individual programs so ineffective?ineffective?

Nearly 30% of adolescent and young adult Nearly 30% of adolescent and young adult smokers do NOT smoke on a daily basissmokers do NOT smoke on a daily basis

Some young occasional smokers do not Some young occasional smokers do not think of themselves as “smokers” think of themselves as “smokers” Up to half of Ontario high school smokers do Up to half of Ontario high school smokers do

not consider themselves to be “smokers” not consider themselves to be “smokers” (Leatherdale and McDonald, 2006)(Leatherdale and McDonald, 2006)

Proportion of current Canadian smokers Proportion of current Canadian smokers who smoke less than daily, 1990 - 2005who smoke less than daily, 1990 - 2005

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Source: Various surveys


Most treatments don’t consider Most treatments don’t consider adolescent’s lack of experience adolescent’s lack of experience Little experience in changing any aspect of Little experience in changing any aspect of

behaviour. Not familiar with basic behavioural behaviour. Not familiar with basic behavioural principals such as re-enforcement, stimulus principals such as re-enforcement, stimulus control, etc. control, etc.

Little experience coping with stressLittle experience coping with stress


Many treatments don’t consider adolescent’s Many treatments don’t consider adolescent’s special circumstances – they simply offer special circumstances – they simply offer adult oriented programs (aimed at moderate adult oriented programs (aimed at moderate to heavy smokers) to heavy smokers) • Adolescents are more likely to smoke with friends, Adolescents are more likely to smoke with friends,

than alone or with family members (Oksuz et al., than alone or with family members (Oksuz et al., 2007)2007)

• More likely have to cope with friends who put them More likely have to cope with friends who put them down for not smoking (Falkin et al., 2007)down for not smoking (Falkin et al., 2007)

• More likely to feel they have to give up things More likely to feel they have to give up things important to them in order to quit (e.g., friends) important to them in order to quit (e.g., friends) (Falkin et al., 2007) (Falkin et al., 2007)

Tailored interventions may improve Tailored interventions may improve outcomesoutcomes

Does the adolescent think of themselves Does the adolescent think of themselves as a smoker? as a smoker?

Does an adolescent live with or social with Does an adolescent live with or social with other smokers (who are influential in their other smokers (who are influential in their lives)?lives)?

What is the adolescent’s natural history of What is the adolescent’s natural history of smoking? smoking?

Smoking predictors among early Smoking predictors among early vs. late initiatorsvs. late initiators(Robinson, et al, 2004)(Robinson, et al, 2004)

432 adolescents in a smoking cessation trial432 adolescents in a smoking cessation trial Based on self report of age of first whole Based on self report of age of first whole

cigarettecigarette Compared to late initiators, early initiators (<13) Compared to late initiators, early initiators (<13)

were more nicotine dependence, took longer to were more nicotine dependence, took longer to move from initiation to daily smoking (1.3 vs. .45 move from initiation to daily smoking (1.3 vs. .45 yrs.) and took longer to seek cessation treatment yrs.) and took longer to seek cessation treatment after becoming a daily smoker (2.9 vs. 1.6 yrs) after becoming a daily smoker (2.9 vs. 1.6 yrs)

The Montreal Natural History of The Montreal Natural History of Nicotine Dependence study (NDIT)Nicotine Dependence study (NDIT) A six year longitudinal study of 1,300 A six year longitudinal study of 1,300

students recruited in grade 7 from 10 students recruited in grade 7 from 10 schools in and around Montrealschools in and around Montreal

Self report survey and physiological Self report survey and physiological measures collected every 3 months measures collected every 3 months

Trajectory study included 369 students Trajectory study included 369 students who initiated smoking during the studywho initiated smoking during the study

Average age of smoking initiation was 13 Average age of smoking initiation was 13 yearsyears

Four trajectories of smoking among adolescents who become regular smokers

Karp, O’Loughlin, Paradis et al., 2006

3 6 9 12 15 18 21 24 27 30 33 36 39 42Months after smoking initiation

Class IV (6%)

Class I (72%)

Class III (11%)

Class II (11%)

Predictors of trajectoryPredictors of trajectory

Boys more likely to be rapid escalators (class IV)Boys more likely to be rapid escalators (class IV) Students with poor academic performance more Students with poor academic performance more

likely to become regular smokers (ie be in class likely to become regular smokers (ie be in class II, III and IV)II, III and IV)

Students with non-smoking parents and more Students with non-smoking parents and more than half of friends as non-smokers were less than half of friends as non-smokers were less likely to become regular smokers (ie become a likely to become regular smokers (ie become a class II, III and IV smoker) class II, III and IV smoker)

Attending a school with clear non smoking rules Attending a school with clear non smoking rules reduces likelihood of being in class II, III and IVreduces likelihood of being in class II, III and IV

ImplicationsImplications

Early escalators may require more Early escalators may require more intensive, longer treatmentintensive, longer treatment

Early interventions may be more effective Early interventions may be more effective with late escalators (before regular with late escalators (before regular patte5rns are established) patte5rns are established)

How can we improve utilization of How can we improve utilization of individual treatments?individual treatments?

• Review of literature (mostly based on surveys or Review of literature (mostly based on surveys or interviews with youth in school settings)interviews with youth in school settings)

• Factors that increase utilizationFactors that increase utilization• Program is free or incentive providedProgram is free or incentive provided• Friends are supportiveFriends are supportive• Friends are using itFriends are using it• Easy to use/low burdenEasy to use/low burden• Program is effectiveProgram is effective• Program is lead by adults from outside of schoolProgram is lead by adults from outside of school

• Factors that inhibit utilizationFactors that inhibit utilization• Potential breach of confidentiality/privacy (esp. to parents)Potential breach of confidentiality/privacy (esp. to parents)• Program or material cost moneyProgram or material cost money• Program offered after schoolProgram offered after school

Promoting cessation aidsPromoting cessation aids

McDonald et al completed meta-analysis McDonald et al completed meta-analysis of 48 promotion campaigns to youth of 48 promotion campaigns to youth smokers (12 to 24)smokers (12 to 24)

Median recruitment rate was 7.8% from a Median recruitment rate was 7.8% from a median audience size of 310median audience size of 310

Maximizing participation in Maximizing participation in cessation aidscessation aids

(McDonald et al meta-analysis)(McDonald et al meta-analysis)

Message characteristicsMessage characteristics Campaign should last one to three monthsCampaign should last one to three months Use credible adult spokesperson (not youth or Use credible adult spokesperson (not youth or

a combo)a combo) Channel characteristicsChannel characteristics

Use media in community rather than rely on Use media in community rather than rely on school or clinic-based promotion school or clinic-based promotion

Maximizing participation in Maximizing participation in cessation aidscessation aids

(McDonald et al meta-analysis)(McDonald et al meta-analysis) Source characteristicsSource characteristics

Health department or research organizations are Health department or research organizations are better than provincial or federal government sponsorsbetter than provincial or federal government sponsors

Destination characteristicsDestination characteristics Programs offered thru youth centres and workplaces Programs offered thru youth centres and workplaces

had higher recruitment than schools or clinicshad higher recruitment than schools or clinics Programs offered during winter are best; Programs offered during winter are best;

spring/summer the worstspring/summer the worst Programs offered before school, during lunch or Programs offered before school, during lunch or

during work are better than after schoolduring work are better than after school Programs that use a variety of cessation tools and Programs that use a variety of cessation tools and

formats are more attractive than programs that use formats are more attractive than programs that use one or two strategiesone or two strategies

If individual oriented quitting If individual oriented quitting treatments are only minimally treatments are only minimally

effective, what else should we do? effective, what else should we do?

Quitting: Its not just an individual Quitting: Its not just an individual enterpriseenterprise

Quit rates and quit ratios differ Quit rates and quit ratios differ substantially (up to 60%) substantially (up to 60%) across provinces, regions, across provinces, regions, cities, schools, neighborhoods cities, schools, neighborhoods (McDonald, et al., unpublished)(McDonald, et al., unpublished)

Youth prevalence has gone Youth prevalence has gone down faster than older adults, down faster than older adults, despite the lack of effective or despite the lack of effective or available individual cessation available individual cessation treatmentstreatments

This suggests the social and This suggests the social and economic environment, and economic environment, and policy measure profoundly policy measure profoundly influence youth quitting influence youth quitting

Interventions must not be Interventions must not be limited to individualslimited to individuals 15

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Proportion of current adults smokers in Canada who are 15 to 24 yrs old, 1995-2006

AA case for environmental interventions: case for environmental interventions: Gene-environment interactionsGene-environment interactions

Novak, Breslau & Kessler Novak, Breslau & Kessler 891 pairs of MZ and DZ twins aged 25-74891 pairs of MZ and DZ twins aged 25-74 Heritability index (for daily smoking) = .50, Heritability index (for daily smoking) = .50,

but…but…• H (low SES childhood) = .25H (low SES childhood) = .25• H (for high SES childhood) =.79H (for high SES childhood) =.79

The effect of population interventions The effect of population interventions on adult smoking prevalenceon adult smoking prevalence

Levy et al (2007) used data from California to simulate Levy et al (2007) used data from California to simulate the impact of various population interventions on adult the impact of various population interventions on adult smoking ratessmoking rates

Overall, tobacco control policies introduced between Overall, tobacco control policies introduced between 1988 and 2004 reduced smoking rates by 25% more 1988 and 2004 reduced smoking rates by 25% more than if policies had been kept at 1988 levels. 59% of the than if policies had been kept at 1988 levels. 59% of the excess reduction was due to price increasesexcess reduction was due to price increases

28% of the excess reduction was due to media campaigns28% of the excess reduction was due to media campaigns 11% of the reduction was due to smoke free places11% of the reduction was due to smoke free places 2% of the excess reduction was due to restrictions in youth 2% of the excess reduction was due to restrictions in youth

access access Studies from the UK suggest comprehensive individual Studies from the UK suggest comprehensive individual

cessation treatments only reduced prevalence by 1%cessation treatments only reduced prevalence by 1% Results suggest population interventions are profoundly Results suggest population interventions are profoundly

important important

The effect of price on cessation The effect of price on cessation among youthamong youth

Tauras (2004) used data from longitudinal Tauras (2004) used data from longitudinal surveys with young adults. surveys with young adults.

Found that restrictions on smoking in worksites Found that restrictions on smoking in worksites and public places marginally increases the odds and public places marginally increases the odds of quitting. of quitting.

Largest impact was taxation. Price has an Largest impact was taxation. Price has an elasticity of 0.35 on smoking cessation – each elasticity of 0.35 on smoking cessation – each 10% increase in the price will increase the 10% increase in the price will increase the likelihood young adults will quit smoking by 3.5%likelihood young adults will quit smoking by 3.5%

The tobacco industry and consumers are The tobacco industry and consumers are adapting: Discount cigarette useadapting: Discount cigarette use

Cigarettes Sold

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Speaking of taxes…Speaking of taxes…

Find out how much Find out how much your province collects your province collects in taxes from the sale in taxes from the sale or consumption of or consumption of tobacco by your more tobacco by your more than 5,000 underage than 5,000 underage tobacco users. How tobacco users. How does this compare to does this compare to expenditures on expenditures on tobacco control? tobacco control?

What are the effects of media on What are the effects of media on youth cessation?youth cessation?

Beiner et al (2006) survey 787 people who had Beiner et al (2006) survey 787 people who had quit smoking in the previous two yearsquit smoking in the previous two years

Media advertisements were the most frequently Media advertisements were the most frequently mentioned source of help mentioned source of help

Older smokers were more likely to find traditional Older smokers were more likely to find traditional quit aids to be helpfulquit aids to be helpful

Younger smokers were more likely to cite TV Younger smokers were more likely to cite TV ads as being helpful including those which depict ads as being helpful including those which depict smoking related illness and inspirational quit smoking related illness and inspirational quit tips. tips.

Effect of no-smoking policies on Effect of no-smoking policies on youth smokingyouth smoking

Wakefield et al (2000) surveyed 17,287 Wakefield et al (2000) surveyed 17,287 students in 202 US high schoolsstudents in 202 US high schools

Odds of 30 day smoking based on Odds of 30 day smoking based on locations with restrictions compared to no locations with restrictions compared to no restrictionsrestrictionsTotal home banTotal home ban .79 (.67 - .91).79 (.67 - .91)Partial home restrictionsPartial home restrictions .85 (.74 - .95).85 (.74 - .95)Public placesPublic places .91 (.83 - .99).91 (.83 - .99)Enforced school banEnforced school ban .86 (.77 - .94).86 (.77 - .94)School ban (no enforce)School ban (no enforce) .99 (.85, 1.13).99 (.85, 1.13)

Interaction of pharmacotherapy and Interaction of pharmacotherapy and smoke free homessmoke free homes

Effect of pharmacotherapy when the user’s home is not smoke free and there is another smoker in the house

Effect of pharmacotherapy whenthe user’s home is smoke freeand there is another smoker in the house

Gilpin, Messer & Pierce, 2006

Effect of number of close friends who Effect of number of close friends who smoke on the odds of moving from smoke on the odds of moving from

regular smoking to quittingregular smoking to quitting

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Number of close friends who smoke

Oddsratio

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Modeling mattersModeling matters

If having friends who smoke can inhibit If having friends who smoke can inhibit quitting, can having friends who quit with quitting, can having friends who quit with you enhance success? you enhance success?

Influence of Canadian smoking Influence of Canadian smoking bans on cessationbans on cessation

Shields (2007) used longitudinal data from the National Shields (2007) used longitudinal data from the National Population Health SurveyPopulation Health Survey

Smoke free homes significantly increases the odds a Smoke free homes significantly increases the odds a person will quit smoking in the next two years person will quit smoking in the next two years

Young smokers were more likely to quit due to smoke Young smokers were more likely to quit due to smoke free homes than any other age group. free homes than any other age group.

The effect of smoke free homes is particularly powerful The effect of smoke free homes is particularly powerful for men (OR = 1.3), those with high school education or for men (OR = 1.3), those with high school education or higher (OR>1.9), and those with children under age 15 in higher (OR>1.9), and those with children under age 15 in the home (OR=2.7) .the home (OR=2.7) .

Smoke free homes also significantly reduces the Smoke free homes also significantly reduces the average number of cigarettes people smoke on a daily average number of cigarettes people smoke on a daily basis. basis.

Influence of Canadian smoking Influence of Canadian smoking bans on cessationbans on cessation

Smoke free workplaces had the largest Smoke free workplaces had the largest effect on 35 to 44 year olds and the least effect on 35 to 44 year olds and the least impact on 15 to 24 year olds (likely impact on 15 to 24 year olds (likely because they spend less time at work). because they spend less time at work).

Do smoking bans have adverse Do smoking bans have adverse effects?effects?

No known reports of accidents caused by No known reports of accidents caused by school or institutional smoking bansschool or institutional smoking bans

Callahan et al (2007) studied effect of Callahan et al (2007) studied effect of institutional bans on the likelihood BC institutional bans on the likelihood BC youth would attend and stay for inpatient youth would attend and stay for inpatient substance abuse treatment substance abuse treatment Concluded that total smoking bans had no Concluded that total smoking bans had no

effect on recruitment or retention of youtheffect on recruitment or retention of youth

A few odds and ends…A few odds and ends…

Checking our assumptions Checking our assumptions against the evidenceagainst the evidence

Young women do not continue to smoke to Young women do not continue to smoke to avoid weight gainavoid weight gain Weight is seldom mentioned in qualitative Weight is seldom mentioned in qualitative

interviewsinterviews Weight was listed as primary barrier to quitting Weight was listed as primary barrier to quitting

by only .2% of current adolescent smokers by only .2% of current adolescent smokers (CTUMS, 2001)(CTUMS, 2001)

Coping with negative affect (depression, Coping with negative affect (depression, anger, stress, boredom) is a significant anger, stress, boredom) is a significant challengechallenge

Checking our assumptionsChecking our assumptions

Youth do not dismiss health warnings Youth do not dismiss health warnings because of feelings of immortalitybecause of feelings of immortality Henly and Donovan (2003) Australian youth Henly and Donovan (2003) Australian youth

responded as well or better to threat appealsresponded as well or better to threat appeals Threat campaigns should include efficacy Threat campaigns should include efficacy

information (re self and response)information (re self and response)

All the good ideas haven’t been All the good ideas haven’t been testedtested

Putting Putting warning on warning on cigarettes cigarettes increases increases salience. salience. Messages Messages could be used could be used to enhance the to enhance the immediacy of immediacy of health effects health effects


Any quit attempt is a good attemptAny quit attempt is a good attempt Zhu et al. (1999), Lawrance and McDonald (1996) Zhu et al. (1999), Lawrance and McDonald (1996)

and others have found that to be predictive of future and others have found that to be predictive of future abstinence a quit attempt needs to last at least 14 abstinence a quit attempt needs to last at least 14 days; short term quit attempts may actually reduce days; short term quit attempts may actually reduce future success (although studies need to adjust for future success (although studies need to adjust for self efficacy and other factors)self efficacy and other factors)

This suggests we need to do more to support youth This suggests we need to do more to support youth during at least the first two weeks of abstinence.during at least the first two weeks of abstinence.


Planning for a quit attempt may not be as Planning for a quit attempt may not be as important as many providers believe. important as many providers believe.

Checking assumptions: Is planning for a Checking assumptions: Is planning for a quit attempt necessary?quit attempt necessary?

Current counseling Current counseling models emphasize the models emphasize the importance of planning importance of planning and preparing for a quit and preparing for a quit attemptattempt

Nearly half of successful Nearly half of successful quitters did not plan their quitters did not plan their attempt (including 48% of attempt (including 48% of 16 to 34 year olds))16 to 34 year olds))

The odds of quitting for The odds of quitting for 6+ months were higher 6+ months were higher for unplanned quit for unplanned quit attempts relative to those attempts relative to those who planned (OR=2.5) who planned (OR=2.5)

0

10

20

30

40

50

60

Age16-34

Age35-54

Age55+

Unplanned

Planne

d fo

r sam

e

day o

r nex

t day

Planne

d a

few

days

ahe

ad

Source: West & Sohal, 2006

Thinking outside the boxThinking outside the box Helping parents helps their children.Helping parents helps their children.

Children with no smoking or former smoking parents Children with no smoking or former smoking parents are less likely to smoke or more likely to quit (Bricker are less likely to smoke or more likely to quit (Bricker et al., 2003)et al., 2003)

Children gain a stronger appreciation of the Children gain a stronger appreciation of the challenges of quitting when they were involved in their challenges of quitting when they were involved in their parent’s quit attempts (Tilson et al, 2005) parent’s quit attempts (Tilson et al, 2005)

88% of young smokers reported their parents were 88% of young smokers reported their parents were not in very good health – compared to 54% of not in very good health – compared to 54% of smokers whose parents did not smoke. Youth smokers whose parents did not smoke. Youth cessation programs could benefit from targeting cessation programs could benefit from targeting smokers who parents smoke and are likely showing smokers who parents smoke and are likely showing the long term effects of smoking related illness the long term effects of smoking related illness (Jamieson and Romer, 2006)(Jamieson and Romer, 2006)

Ontario smoking rates by level of Ontario smoking rates by level of belonging to the community, 2004belonging to the community, 2004

19

22

26

30

0

5

10

15

20

25

30

35%whosmoke

Verystrong

Somewhat strong

Somewhat weak

Very weak

Source: CCHS, 2004

*

*

**

*p< .0001 after adjusting for sex, age, and income

Smoking rates by sex and level of belonging Smoking rates by sex and level of belonging to the community, 2004to the community, 2004

21.724.6

29.3

34

15.7

2022.7

25.6

0

5

10

15

20

25

30

35

40

Very Strong Somewhatstrong

Somewhatweak

Very weak

Males

Females

Source: CCHS, 2004

Per cent P =<.001

The effect is strongest for those born The effect is strongest for those born most recentlymost recently

21

2527

42

2426

29

32

11 12

16 17

0

5

10

15

20

25

30

35

40

45

age 15-24

age 25-54

age 55+

% who smoke

Verystrong

Somewhat strong

Somewhat weak

VeryweakSource: CCHS, 2004

Interaction is significant (p< .0001)

Intentions to quit in next 6 months among Intentions to quit in next 6 months among Canadian smokers, by level of belonging to Canadian smokers, by level of belonging to

the community, 2004the community, 2004

68.962.8

48.4

0

10

20

30

40

50

60

70

80

Very or somewhatstrong

Somewhat weak Very weak

% who intend to quit

P < .0001 after controlling for sex, age, education

Source: CCHS, 2004

ImplicationsImplications

Join with other groups and agencies Join with other groups and agencies concerned with broader determinants of concerned with broader determinants of healthhealth Reduce marginalization and invest in social Reduce marginalization and invest in social

capitalcapital Reduce povertyReduce poverty Invest in education Invest in education

Consider the wisdom of dolphin feeding behaviour

Future Considerations for individual Future Considerations for individual treatment treatment

Study the interaction between individuals and Study the interaction between individuals and situations. Determine if individual treatments situations. Determine if individual treatments require certain predisposing situational conditionsrequire certain predisposing situational conditions

Identify and develop interventions for important Identify and develop interventions for important sub-populationssub-populations Separate 12 – 15, 16 to 18 and 19 – 24 year oldsSeparate 12 – 15, 16 to 18 and 19 – 24 year olds Consider aboriginal status, psychiatric co-morbidity and Consider aboriginal status, psychiatric co-morbidity and

low SES, those with and without social support, those low SES, those with and without social support, those with and without parents who smokewith and without parents who smoke

Future considerations for individual Future considerations for individual treatmenttreatment

Study new methods of treatment delivery Study new methods of treatment delivery Ubiquitous web-basedUbiquitous web-based Telephone-basedTelephone-based NRT (for “heavy” youth smokers only; in combo with NRT (for “heavy” youth smokers only; in combo with

other treatments)other treatments)

Enhance the rigor of evaluation and researchEnhance the rigor of evaluation and research More bad or quick and dirty studies won’t inform us.More bad or quick and dirty studies won’t inform us. Major investments are required (>$.5 million per Major investments are required (>$.5 million per

study) study)

Link research, practice and policy Link research, practice and policy

Future considerations for Future considerations for population interventions population interventions

Test and potential advocate for changes in Test and potential advocate for changes in cigarette design and testingcigarette design and testing Change the taste (quinine?); the appearance Change the taste (quinine?); the appearance

(fecal brown?); warnings on the cigarette? (fecal brown?); warnings on the cigarette? Reduce discounting by setting a minimum Reduce discounting by setting a minimum

price; outlaw the sale of used tobacco price; outlaw the sale of used tobacco manufacturing devicesmanufacturing devices

Provide greater enforcement to reduce Provide greater enforcement to reduce counterfeiting and smuggling counterfeiting and smuggling

Future considerations for Future considerations for population interventionspopulation interventions

Introduce smoking restrictions in youth Introduce smoking restrictions in youth workplaces, multi-unit dwellings, cars with workplaces, multi-unit dwellings, cars with children, etc.children, etc.

Encourage community action on smoke free Encourage community action on smoke free homeshomes

Restrict youth access to cigarettes (special Restrict youth access to cigarettes (special tobacco control outlets?)tobacco control outlets?)

Eliminate marketing and sales through the Eliminate marketing and sales through the internetinternet

Develop media campaigns to encourage youth Develop media campaigns to encourage youth to quit to quit

Summary Summary

Most individual approaches to cessation, Most individual approaches to cessation, including pharmatherapy, have not been including pharmatherapy, have not been successful with general populations of youth successful with general populations of youth tobacco users. Mtobacco users. Modestodest allocation of resources allocation of resources for behavioural counseling through websites, for behavioural counseling through websites, telephone quitlines, schools, health telephone quitlines, schools, health professionals, youth workplaces, community professionals, youth workplaces, community settings is warranted. However, much more settings is warranted. However, much more effort should be put into more population effort should be put into more population oriented strategies.oriented strategies.

The endThe end(and not a moment too soon) (and not a moment too soon)

Documents

Helping youth to quit smoking: What does research suggest?