Interview #1:

'Youth Tobacco Use'

Gary Giovino, PhD, is a senior research scientist at Roswell Park Cancer Research Institute in Buffalo, New York. His primary interest is the study of patterns, determinants, consequences, and control of tobacco use. Before working at Roswell Park Cancer Research Institute, he was chief of the Epidemiology Branch in the Office of Smoking and Health at the Centers for Disease Control and Prevention (CDC). He has a doctorate in experimental pathology/epidemiology from the State University of New York at Buffalo. A former smoker himself, Dr. Giovino is also the son of two smokers, one of whom died of lung cancer.

Q: How prevalent is tobacco use among young people?

A: More than one out of three of high school students say they use tobacco. The National Youth Tobacco Survey data from the fall of 1999 indicate that nearly 35 percent of high school students and nearly 13 percent of middle school students had used some form of tobacco in the previous 30 days. Twenty-eight percent of high school students and 9 percent of middle school students used cigarettes. Cigars were the next most commonly used tobacco product, followed by smokeless tobacco.[5]

Q: Are more young people smoking now?

A: Yes. Monitoring the Future provides the most comprehensive long-term trend data.[8] The data, confirmed by the Youth Risk Behavior Survey, show an increase in youth tobacco use during the 1990s. The prevalence of smoking dropped in the late 1970s, plateaued in the 1980s, and increased in the 1990s. However, since 1997, it appears that tobacco use among young people has leveled off and may be turning back.

Q: Among young people, who is most likely to smoke or use tobacco products?

A: In the 1980s, girls were more likely than boys to smoke, but today boys are as likely as girls to smoke. Boys are more likely to be heavy smokers, and that is true for adult males as well. In terms of racial and ethnic groups, the highest prevalence of tobacco use among adolescents and young adults is in Native Americans, followed by whites and then Hispanics. The lowest prevalence is in Asians and African-Americans. However, we now have some evidence suggesting that the prevalence in African-American middle school students is increasing. Overall, people who drop out of school or who are not doing well in school are most likely to become cigarette smokers.

Q: What types of tobacco are being used?

A: Cigarette use among young people increased in the 1990s. We do not have a lot of long-term data on cigar use. However, there is some anecdotal and survey evidence showing that cigars have emerged as a common tobacco product used by adolescents and young adults, especially among urban, male college graduates. Smokeless tobacco use by young people appears to be declining slightly, but the evidence is not definitive.

Q: What about kreteks and bidis? What are they and how common are they?

A: Kreteks are clove cigarettes from Indonesia. They contain clove extract and tobacco, and they produce a chemical that apparently can induce respiratory distress. Bidis are tobacco wrapped in a tendu or temburni leaf tied with a string. They come from India and other southeast Asian countries, and their tar and nicotine levels are very high. Bidis are inexpensive and come in different flavors, which is part of the allure. The National Youth Tobacco Survey data show that 5.8 percent of high school students used kreteks and 5.0 percent of high school students used bidis during the 30 days preceding the survey. We do not have trend data, but anecdotally they seem to be an emerging phenomenon and should be monitored.

Q: What are the health consequences of tobacco use among young people?

A: The 1994 Surgeon General's report, Preventing Tobacco Use Among Young People, spells out the health consequences of tobacco use.[12] Even by age 18 or 19 years, smokers clearly experience adverse health effects, including reduced physical fitness, shortness of breath, increased productive cough, greater susceptibility to and severity of respiratory illness, early development of artery disease, and slower rate of lung growth. The long-term consequences include cancer, heart disease, stroke, peripheral vascular disease, chronic bronchitis, emphysema, pregnancy complications, slower healing, facial wrinkling, possibly eye disorders such as macular degeneration and glaucoma, and compromised immune function.

Q: Is tobacco use associated with other problems, such as using other drugs?

A: Without question. There is clear evidence that tobacco is associated with alcohol, marijuana, and cocaine use, and there is some evidence that tobacco use actually may contribute to the use of other substances. People who use tobacco are reinforced by the drug nicotine. Animal studies indicate that this reinforcement may generalize to other substances. Environmental and/or genetic factors that contribute to tobacco use may also contribute to substance abuse, alcohol abuse, and other risk behaviors.

Q: How many young people quit smoking once they begin?

A: We find that many adolescents try to quit, with multiple quit attempts, but few -- even fewer than in the adult population -- are successful. Two separate surveys in 1997 showed that about 13 percent of the participants who had previously smoked on a daily basis had not smoked in the past month. Another study found that among high school seniors who had ever been established smokers, only 3 percent had not smoked in the 12 months before the survey. This suggests that the quitting process for young people may differ in some ways to the process for adults and that researchers need to be aware of the fine distinctions between the two.

Interview #2:

'Can We Help Young Tobacco Users Quit?'

C. Tracy Orleans, PhD, senior scientist at The Robert Wood Johnson Foundation, is responsible for research-based programs in health and behavior, tobacco control, and chronic disease management and for initiatives that translate behavioral science research into programs and policies that benefit the public. Much of her work has focused on developing and evaluating model tobacco control and treatment programs for community and health care settings. A clinical psychologist, she is an adjunct member of the behavioral science program at the Fox Chase Cancer Center in Philadelphia and an adjunct professor in the Department of Psychiatry at the University of Medicine and Dentistry of New Jersey.

Q: What are the options for quitting smoking or using other forms of tobacco -- for all ages?

A: Fortunately, we know more about how to help people quit smoking than we know about how to help people make any other lifestyle changes. We are also fortunate to have a clinical practice guideline for smoking cessation sponsored by the Public Health Service, Treating Tobacco Use and Dependence, that describes a number of effective treatments: brief counseling and intervention in primary care settings, more intensive counseling in primary care or specialty settings, telephone counseling, and effective pharmacotherapies that include nicotine replacement therapy (gum, patches, inhalers, nasal spray) and the anti-depressant bupropion.[6] However, we know less about smoking cessation in some populations, including youth.

Q: Do we know which cessation methods work best for youth?

A: Actually, we know very little about how youth try to quit, how they think about quitting or the quitting process, why they try to quit, and which treatment options might or might not work for them. The limited research conducted with teen smokers indicates that adult smoking cessation programs are not as appealing or as effective for youth as they are with adults. Therefore, we need to gain a better understanding of how kids become addicted and what the process of addiction recovery looks like in kids, and we need to understand what youth want and value in a cessation program. The Guideline recommends that, until we know that anything works better for youth, we use the same basic approaches that have worked for adults. But the huge health benefits that will result from finding new ways to help young smokers quit make it urgent that we fund more research in this area.

Q: Do any new methods look promising for young people?

A: One of the things we know from adults who smoke and quit is that most of them do not go to clinics. They prefer to quit on their own and with support such as brief treatments, including telephone counseling, and pharmacotherapeutic agents. With further research, we are likely to find that young people prefer the same minimal contact treatments that adults prefer. Internet-based programs, computer-based programs, and telephone counseling programs look promising and might appeal to kids. This does not mean that there is no place for clinics or more extended face-to-face counseling, but it is extremely unlikely that clinics will have the highest reach.

Q: What are "mandatory cessation programs" for youth? Are these programs effective?

A: Increasingly, schools are banning tobacco use on school grounds and communities are banning tobacco use in public places, and they are penalizing youth for violating smoking restrictions. The penalties include fines and, sometimes, mandatory participation in cessation programs that discuss the harms of smoking and the harms of secondhand smoke exposure as well as quit smoking methods. These mandatory cessation programs face some challenges. For example, participants may want to quit, but the fact that they have been "sentenced" to such a program constitutes a serious threat to the therapeutic alliance. We do not know how well these programs work to deter smoking or promote quitting.

Q: Are school-based programs and policies effective in helping young people to quit or to resist using tobacco products?

A: We know more about prevention programs than we do about cessation programs in schools. Programs that teach refusal skills and counter some of the attitudes that support youth smoking have been found to be effective for preventing tobacco as well as other drug use. These skills-based programs often use peer-counseling methods, and they focus on changing perceptions about the prevalence, harms, and peer views of tobacco use. Among the aims of these programs are to convey that most kids do not like to be around smokers and do not find smoking to be cool and that tobacco use hinders sports performance and attractiveness to the opposite sex. Unfortunately, in the face of pervasive tobacco advertising and promotion, these programs have proven more effective in delaying the onset of youth smoking than in preventing smoking.

Q: What impact do broader strategies have on encouraging young people to resist or quit using tobacco products?

A: During the past 20 years, we have learned some things about adults and tobacco use that we can apply to youth. As with adults, helping teen smokers to resist or quit will require a combination of individually focused interventions; organizationally-focused interventions offered through schools, communities, and health plans; and macro-level societal interventions that change norms and policies governing youth access to tobacco products and susceptibility to addiction. All of these components are critically important and most successful when combined. We have to expand our focus beyond treatment methods.

Q: Do population-based approaches have a greater impact than interventions focused on individuals?

A: Absolutely. Treatment is important, but we need to pay more attention to changing the macro-level social environment in which kids initiate smoking and go on to addiction. For example, we know that raising the price of cigarettes is the single most effective change we can make not only to prevent youth tobacco use but also to motivate them to quit. We have seen stunning results from Florida, California, and Massachusetts showing that multi-component, comprehensive tobacco control programs can dramatically reduce the number of kids who become addicted to tobacco products. These programs include restrictions on smoking in the schools, effective counter-advertising campaigns, enforcement of youth access laws, and limitations on advertising and marketing.

QuitNet: Click Here to Quit:

Log on and quit smoking.

Although it's not quite that simple, that's the idea behind QuitNet (www.quitnet.org), an online smoking cessation service. Since its 1996 launch, over one million people have visited QuitNet. The original QuitNet application was created by Nathan Cobb, a former smoking cessation counselor with a background in computerized health intervention systems. QuitNet was further developed by Join Together, a substance abuse resource center at Boston University with funding from the Robert Wood Johnson Foundation and the National Cancer Institute.

In keeping with evidence that both adults and youth prefer to go it alone, QuitNet offers users the benefits of around-the-clock service, anonymity, and a variety of resources and self-directed behavior modification tools. At the click of a mouse, registered users can set a quit date, receive automated e-mail quit tips tailored to their stage in the quitting process, track personal progress toward quitting, locate local smoking cessation programs, and access bulletin boards to exchange information and support one another in the quest to quit.

"One of the things that is unusual about QuitNet and one of the advantages of the Internet is that we can reach people where they are, without the obstacles inherent in (traditional) cessation programs," says Chris Cartter, Join Together's director of online services. "A lot of people who come to the site do not see themselves as people who would go talk to a counselor or even pick up a telephone and call an 800 number."

In addition, Cartter notes, "A lot of support programs require that you're ready to quit next week. We work with people where they're at in the quitting process."

A recent survey of QuitNet users indicates that the site's informational and peer support components are most valued by users. According to Cartter, visitors post as many as 1,500 messages daily on the site's bulletin boards, testifying to users' high level of interaction and the site's "very strong sense of community."

Although QuitNet's impact has not yet been evaluated formally, the site appears to be meeting a need and, according to Cartter, complies with the latest U.S. Surgeon General's Guidelines on treating tobacco use. Currently, 80,000 people from more than 130 countries are registered with the site, and they represent only 15 percent of the site's total visitors, reports Cartter. In March 2000, 47,000 people made 160,000 visits to QuitNet, with each visit averaging 18 minutes. "The high intensity and frequency of support smokers get on QuitNet is exactly what the Surgeon General recommends," says Cartter.

Two-thirds of the site's registered visitors are women, and 80 percent live in the United States. Two percent of users are under age 18, 10 percent between 18 and 24 years old -- an age group in which tobacco use has been on the rise.

QuitNet has also garnered the interest of the medical community. "We're hearing from an increasing number of physicians and health plans who want a comprehensive support program to refer their patients to," Cartter says.

Youth Perceptions about Smoking Vary by Gender, Ethnicity:

Research has shown that two of the most important predictors of adolescent cigarette smoking are gender and ethnicity.[11] For example, results of the 1999 Youth Risk Behavior Survey indicate that white and Hispanic high school students are much more likely than black high school students to smoke more than 10 cigarettes a day, and that white male students are significantly more likely than white female students to smoke more than 10 cigarettes a day.[5]

To better understand the role of gender and ethnicity in adolescent smoking, researchers at 11 university-based, CDC-funded Prevention Centers conducted 178 focus groups with 1,175 adolescents ages 11 to 19. Seventy-one percent of the sample had smoked at some point, 45 percent within the past 30 days. The sample included African Americans, whites, Native Americans, Hispanics, and Asian/Pacific Islanders.[11]

"Rates and patterns of (tobacco) use vary tremendously by ethnicity and gender," says investigator Robin Mermelstein, PhD, who is associate professor in the Department of Psychology and deputy director of the Health Research and Policy Centers, University of Illinois at Chicago. "Because there are different patterns of use, there likely are different reasons for use. From both a prevention and a cessation standpoint, those differences very likely have intervention implications."

According to the focus group study results, unlike white students, ethnic minority students believed that smoking is inappropriate for girls. Notably, Hispanic and African-American females felt that smoking causes one to lose respect and reputation. African-American girls also emphasized the negative effect of smoking on appearance and smell, and felt that smoking interferes with one's life chances, social acceptance, and self-concept.

The focus group participants reported that messages about smoking come from movies, television, music, friends, family, and billboards. For all of the groups, family was the most frequently cited source of pro-smoking and anti-smoking messages, both explicit and implicit. African Americans, Hispanics, and Native Americans said that messages come from broad family groups and significant community others, while white students reported that messages come more often from their nuclear families.

Also in contrast to whites, ethnic minorities believed that youth smoking was disrespectful to parents or seen as a bad reflection on parents, and African-Americans, Hispanics, and Asian-Pacific Islanders reported harsher consequences from parents for smoking. Some ethnic students, particularly Native Americans and Hispanics, reported contradictory messages in that family members "recruited" youth into smoking or facilitated their smoking.

Dr. Mermelstein notes that further research into gender and ethnic differences as they relate to youth smoking behavior is needed.

"The questions we addressed relate to how youth get into smoking," she says. "What we don't know is how they get out of it -- what are the gender and ethnic differences in pathways to quitting, and what are the reasons for quitting. There may not be a universal intervention that works equally well for boys and girls and across ethnicities."

Helping Kids to Quit: What Works Best?:

Much is known about smoking cessation in adults, but far less is known about what young people need to quit smoking and which types of interventions work best for youth. This lack of research defies development of "best practices," or evidence-based guidelines, that are specific to youth tobacco-use cessation, experts say.

"Best practices guidelines for youth smoking cessation would include criteria or evidence-based guidelines to help identify the characteristics of effective and appropriate cessation policies and programs," says Geri Dino, PhD, director of the Prevention Research Center at West Virginia University. "Best practice guidelines would also offer recommendations about the type of intervention that would be 'best' under certain circumstances, such as in a particular setting or with a certain group of teens. For instance, a program that might work well in a high school might not work well in a hospital setting."

"Best practice guidelines would also provide guidance about what programs or interventions should not be recommended," continued Dino.

According to Dino, the field of adolescent smoking cessation is still relatively new, so there is minimal research evidence to develop the criteria needed for best practices, and many studies have not used rigorous, experimental research design.

Furthermore, past studies of youth smoking cessation programs have involved varied study populations and used varied outcome measures and definitions of quitting. These differences making it difficult to compare studies and to lay the foundation for best practices.

"We have a balancing act," Dino explains. "On the one hand, we don't yet have the research needed to fully determine best practice guidelines. On the other hand, researchers and state departments of education and public health continually get calls from people in the schools or the community saying, 'We need an effective cessation program. Tell us what we should do.' It's hard because we want to be responsive to the need, yet we don't want to recommend a program before it has been adequately researched."

Many youth tobacco-use cessation experts believe that increased research funding and collaborative, informed decision making are keys to advancing the field to a point where best practices can be developed. Researchers must work together to develop agreed-upon measures of program effectiveness, and must tackle important questions about the nature of tobacco use and nicotine dependence in young people.

Dino is optimistic not only about increased funding, but also about collaboration. "I've found the field of youth tobacco to be very collaborative," she says. "People share a similar goal, which is to make a difference in the lives of youth."

Teen Smoking? N-O-T!:

The American Lung Association (ALA) now offers a comprehensive, gender-sensitive program designed to help teens quit smoking or reduce the amount they smoke. Called Not on Tobacco, the program teaches healthy lifestyle behaviors and life skills, such as stress management and decision-making.

Developed in collaboration with West Virginia University's Prevention Research Center, N-O-T was launched in 1998 as a pilot project in Florida and West Virginia. Since then, the program has been implemented in schools and communities in 43 states.

N-O-T involves a 10-session curriculum and offers four optional booster sessions. All sessions are led by ALA-trained facilitators who include teachers, counselors, nurses, and health educators. The program takes teens through the stages of quitting, provides social support, and increases self-efficacy.

One of the distinctive aspects of the program is that it was developed for teens and was based on available research on smoking patterns in teens, says Ruth Newlin, MPH, ALA's assistant director for public education and outreach. "Many programs have been adapted from adult programs, but N-O-T was based on research with youth. We think this makes it unique," she says.

According to Newlin, the program is voluntary and the groups are separated by gender. "Research has shown that boys and girls start to smoke, continue to smoke, and relapse for different reasons. It is important that the teens be separated by gender because they need to address such different issues," explains Newlin. "It's the only gender sensitive smoking cessation program I am aware of that was developed specifically for youth."

Although evaluations of the program's effectiveness are only preliminary, N-O-T does appear to be yielding some positive results. Preliminary findings from a 1998-99 evaluation conducted in 67 Florida schools show that N-O-T is effective in helping participants quit smoking, reduce smoking, and maintain or improve their smoking cessation efforts over time. The overall self-reported quit rate was 22 percent after six months -- nearly double the rate reported after a brief self-help intervention with a comparison group of Florida students. Chemically validated results showed a quit rate of nearly 20 percent in the N-O-T students.

Among Florida N-O-T students who participated in the evaluation but did not quit, 65 percent reduced their smoking by more than 50 percent on weekdays and 75 percent cut back by 60 percent on weekends. Furthermore, 85 percent of the participants believed that the program had helped them alter their smoking behavior.

"It looks like this is a very promising program," says Geri Dino, PhD, director of West Virginia University's Prevention Research Center. "Kids are either quitting or reducing, the program facilitators like it, and the schools like it."

Dino, who helped design the N-O-T program has been involved in its evaluation, says that the program also makes a difference in their lives beyond smoking cessation. "They say that they feel better about themselves, that they are exercising more, and that they are going to school more often."

This issue of the Facts of Life was prepared with assistance from the Youth Tobacco Cessation Collaborative. The Youth Tobacco Cessation Collaborative is a group of representatives of major organizations that fund research, program, and policy initiatives related to controlling youth tobacco use. Founded in 1998, the Collaborative works to establish and sustain cross-sharing between researchers and cessation service providers, to sustain team building and coordination across involved agencies and organizations, and to track progress and build toward youth cessation goals. Funding to support the Collaborative is provided by the Robert Wood Johnson Foundation.

The Collaborative includes:

• American Cancer Society
• American Legacy Foundation
• American Lung Association
• Canadian Tobacco Research Initiative
• Centers for Disease Control
• National Cancer Institute
• National Cancer Institute of Canada
• National Heart, Lung and Blood Institute
• National Institute on Drug Abuse
• Robert Wood Johnson Foundation

1. Centers for Disease Control and Prevention. (November 1996). Projected smoking-related deaths among youth -- United States. Morbidity and Mortality Weekly Report, 45(44):971-4.

2. Centers for Disease Control and Prevention. (April 1998). Tobacco use among high school students -- United States, 1997. Morbidity and Mortality Weekly Report, 47(12):229-233.

3. Centers for Disease Control and Prevention. (1999). Best Practices for Comprehensive Tobacco Control Programs -- August 1999. 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.

4. Centers for Disease Control and Prevention. (January 2000). Tobacco use among middle and high school students -- United States, 1999. Morbidity and Mortality Weekly Report, 49(3):49-53.

5. Centers for Disease Control and Prevention. (2000). Youth risk behavior surveillance -- United States, 1999. CDC Surveillance Summaries, June 9, 2000. Morbidity and Mortality Weekly Report, 49(SS05):1-96.

6. Fiore MC, Bailey WC, Cohen SJ, et al. (June 2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service.

7. Heyman RB. (2000). Turning the tide: Tobacco and the 21st century. Adolescent Medicine: State of the Art Reviews, 11(1):69-78.

8. Johnston LD, O'Malley PM, Bachman JG. (December 1999). Cigarette smoking among American teens continues gradual decline. University of Michigan News and Information Services: Ann Arbor, MI. http://www.monitoringthefuture.org; accessed 6/5/00.

9. Johnston LD, O'Malley PM, Bachman JG, Schulenberg JE. (April 1999). Cigarette brands smoked by American teens: One brand predominates; three account for nearly all of teen smoking. University of Michigan News and Information Services: Ann Arbor, MI. http://www.isr.umich.edu/src/mtf; accessed 6/5/00.

10. Lantz PM, et al. (2000). Investing in youth tobacco control: A review of smoking prevention and control strategies. Tobacco Control, 9:47-63.

11. Mermelstein R, et al. (1999). Explanations of ethnic and gender differences in youth smoking: A multi-site, qualitative investigation. Nicotine & Tobacco Research, 1;S91-S98.

12. U.S. Department of Health and Human Services. (1994). Preventing Tobacco Use among Young People: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health.

13. U.S. Department of Health and Human Services. (August 1996). 1995 National Household Survey on Drug Abuse, Tobacco Related Statistics. Substance Abuse and Mental Health Services Administration. http://www.cdc.gov/tobacco/samhsa.htm; accessed 7/14/00.

14. U.S. Department of Health and Human Services. (1996). Clinical Practice Guideline Number 18: Smoking Cessation. Agency for Health Care Policy and Research Publication No. 96-0692.

15. U.S. Department of Health and Human Services. (1998). Summary findings from the 1998 National Household Survey on Drug Abuse. Substance Abuse and Mental Health Services Administration.

16. U.S. Department of Health and Human Services. (2000). Healthy People 2010, Conference Edition. http://www.health.gov/healthypeople/Document/default.htm; accessed 6/5/00.

17. Wechsler H, Rigotti NA, Gledhill-Hoyt J, et al. (1998). Increased levels of cigarette use among college students: A cause for national concern. The Journal of the American Medical Association, 280:1673-1678.

The Center for the Advancement of Health, a nonprofit organization, promotes the science underlying the relationship between mental and physical states that influence health and illness, and works to turn that knowledge into practical health care solutions. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding. Funding for this series was provided by the Robert Wood Johnson Foundation.

For Information Contact:
Ira R. Allen
Director of Public Affairs
Center for the Advancement of Health
2000 Florida Ave., NW, Suite 210
Washington, DC 20009
p. 202.387.2829 / f. 202.387-2857
bmoore@cfah.org