Developing a successful smoking cessation program for adolescents involves open discussion, family support, and healthcare involvement.

By Jennifer Vavra

The national anti-tobacco media campaign is the latest step in trying to prevent teen and preteen smoking. Designed to grab the attention and play to the humor of adolescents, these commercials have been reported to have positive effects on teen and preteen understanding and attitudes about not smoking.1-2 Despite the impact on teen perception of smoking, most smoking prevention and cessation programs for adolescents have not proven highly effective as is evidenced by the rise in teen and preteen smoking rates. Consideration needs to be given to the health impact of teen smoking, what respiratory therapists and other medical professionals can do to discourage teen smoking, and the development of teen-specific smoking cessation programs and family involvement through support.

Why is preteen and teen smoking an issue? This is the section of the population where new, lifelong smokers are recruited to replace those smokers who have quit or died, sometimes due to smoking-related deaths. Approximately 2 million adult smokers quit or die annually and are replaced by nearly 3 million preteen and teen smokers.2 Nearly 90% of people aged 30 to 39 who ever were or still are daily smokers report having smoked their first cigarette before the age of 18.3 In fact, it has been estimated that more than 3,000 youths begin smoking each day,4 of which an estimated 1,000 will die from tobacco-related illness.8 In addition, 70% of current smokers state that they became dependent on nicotine before the age of 18.5 The rate of current smokers who initiated tobacco use after reaching age 18 is very low. Therefore, it seems wise to address the preteen and teen population through prevention and cessation.

The majority of teens begin experimenting with cigarettes between the sixth and eighth grades.3 However, some smokers begin experimentation as young as age 9.7 There is usually a 2-year period between smoking experimentation and the act of smoking daily,7 so it seems especially important to vigorously address teen and preteen prevention and cessation to ensure healthier teens and young adults. The younger people are when they begin to smoke, the more likely they are to advance to being daily smokers or to consume more cigarettes when they smoke. The earlier a person begins smoking, the harder it is to quit.

In 1990,2 cigarette smoking accounted for 400,000 deaths. This is not just a statistic; this number represents 400,000 of yesterday’s teen smokers. It has also been estimated that cigarette smoking is responsible for $50 billion in annual lost work productivity and medical care expense per year. It has been proposed that cigarette smoking increases the risk of lung cancer by 2,000% and coronary heart disease by 150%.7 Cigarette smoking has also been identified as a cause for the development of asthma. There is additional evidence7 suggesting that cigarette smoking is involved in the development of respiratory disease, osteoporosis, ulcers, and diabetes.

Given all of the negative health effects associated with smoking, why would a preteen or teen choose to become a smoker? John Wolfe, American Lung Association (ALA) Not On Tobacco (N-O-T) Program Facilitator and ALA of Colorado Board Member, has an answer. “The overriding reason why teens begin smoking is to conform to peer group activity. A lot of teen smokers began smoking between the ages of 10 to 13 after being introduced to smoking by a sibling or a friend.”

A seemingly common sense way of preventing tobacco consumption by adolescents appears to be to reduce and ideally eliminate youth access to tobacco products. This, however, is not an easy task to accomplish. Obstacles in banning youth access to tobacco include merchant noncompliance with the law, lack of strong local ordinances banning youth access and mandating merchant fining, and lack of law enforcement manpower to enforce federal, state, and local law. Woodridge, Ill, has developed and enforced effective local legislation that has produced a sustained reduction in cigarette sales to minors.8 Almost 2 years after the passage of the Woodridge ordinance, the rate of regularly smoking teens dropped from 16% to 5%.8 While the effect of local legislation and enforcement is promising, there are not a lot of subject communities for the investigation of this topic. Further research is warranted.

In other areas of the nation, merchant noncompliance with existing laws is a large problem. Leonard Jason, PhD, professor of clinical and community psychology at DePaul University, Chicago, comments, “Right now, about 20% to 30% of merchants continue to sell cigarettes to minors nationwide. That rate is very high. This means that youth have access to tobacco. What’s needed is to drive these rates down to 5% or less.”

Sources other than merchants for teens to obtain cigarettes include fake identification, theft, asking others to purchase tobacco,8 parents, and peers.10 Parents may pose the largest problem in providing cigarettes and encouraging smoking. Wolfe says, “A lot of teens have parents who smoke and buy cigarettes for the teens.”

Regardless of the source of teens’ cigarettes, the question remains: what can be done to keep the adolescent from using tobacco? One answer is quite simple. The public should not condone public smoking by teens. In addition, local government and law enforcement agencies may want to consider fining a minor for possession of tobacco products. While fining minors for possession of tobacco products has not been methodically investigated, there is expressed interest in this area among public health officials.8

The media can also play an important role in helping prevent minors from initiating smoking and encouraging cessation in those adolescents who already smoke. In the past, antismoking media campaigns have been criticized for being too one-dimensional, resulting in a poor atmosphere for open conversations to occur between smokers and nonsmokers. An open environment would help support the many stages of smoking cessation.2 It has also been suggested that antismoking media campaigns may need to be more carefully tailored to meet the needs and concerns of both younger and older adolescents.1

The effectiveness of the current national antismoking media campaign has yet to be studied. At this point many believe that it is too new for a comprehensive study of its impact to be made. Others believe that it needs to be improved to more directly involve children in every aspect of the message.10 Future studies of the current media campaign are being demanded.

Physicians consulting on tobacco use is another area of both intervention and cessation encouragement that is not being fully utilized. A recent study by Thorndike et al9 reviews the percentage of physicians that spend time speaking with adolescents about not becoming a smoker or quitting if they have already started. The low rates gathered between 1991 and 1996 are alarming. On average, only 34.6% of routine physical examinations of teen smokers and only 6.3% of routine physical examinations of teens, regardless of smoking status, were coupled with counseling about smoking. While physicians often did identify smoking status, no further steps were usually taken to address the issue of smoking or remaining smoke-free. When divided by physician specialty, the rates were a little different. Primary care physicians spend more time than specialists discussing smoking with teens and pediatricians address smoking more than family practitioners and internists. However, the differences reported were small, with all types of physicians doing little or no counseling.11

Many groups recommend that physicians speak more to teens and preteens about smoking with age-specific interventions. There are a number of sources where physicians can receive more information about discussing smoking with adolescent patients. The National Cancer Institute and the American Academy of Pediatrics11 encourage physicians to include the following items when meeting with preteens and teens:

  • ask the adolescent if they or their friends use tobacco;
  • advise users to stop using tobacco;
  • congratulate adolescents who do not use tobacco; and
  • advise tobacco abstinence.

Another source for physician information about discussing smoking with teens is the Tar Wars Program of the American Academy of Family Physicians.3 Finally, Thorndike et al advises the medical community to:

  • provide training programs for residents and practicing physicians to address smoking issues;
  • alter office practices and information to support addressing smoking;
  • provide reimbursement to physicians for providing adolescent tobacco use counseling; and
  • include smoking status identification and tobacco counseling as quality indicators for the treatment of preteen and teen patients.

If intervention activities fail, cessation programs should be encouraged. In the past, most teen cessation programs have been nothing more than an adaptation of existing adult smoking cessation programs. This approach is woefully inadequate as teens often face unique obstacles in deciding to stop smoking and learning the tools to do so. Many teens do want to become smoke-free. Wolfe notes, “Health effects are concerns for teens who want to quit smoking.” Effective teen smoking cessation programs should include health effects.

A well-formed teen-specific smoking cessation program should address topics that are important to adolescents. Such issues would include exploring reasons for smoking and not smoking; realizing the excuses to not quit smoking and how to disregard those excuses; understanding nicotine addiction and how cigarette smoking affects the body; understanding both the physical and mental benefits of quitting; discovering how to successfully deal with urges and cravings; locating low fat alternative snacks; involving relaxation and/or exercise to help deal with withdrawal symptoms; being able to withstand peer and family pressure to smoke; understanding how to be a nonsmoker in a smoker-friendly environment, understanding how the tobacco industry targets teens; rewards for every step of quitting; and follow-up measures to provide ongoing support. While all of these issues are important to any individual who is trying to stop smoking, the concentration of the issues may be more intense for adolescents. A successful teen-specific smoking cessation program will also not use a lot of scare tactics, opting instead for constructive goal formation and steps to achieving goals.

Not On Tobacco or N-O-T is a new teen-specific smoking cessation program that has been developed by the ALA and includes all of the above listed topics in a well-formed structure. This program is so new that only pilot study results exist to assess its efficacy. According to the pilot study, the quit rate of N-O-T participants was greater than that of a brief intervention group. Reduction rates were also higher for the N-O-T participants. The majority of the N-O-T participants believed the program was helpful in aiding their desire to quit smoking and helpful in at least one other life area. The five most commonly listed topics that teens felt were helpful were: facts about smoking, stress management, nicotine and how it affects the body, withdrawal symptoms, and dealing with peers and family members who smoke.

Peer counseling has been suggested as a good addition to any smoking intervention or cessation program. Jason agrees by saying, “There’s not a lot of data on teen smoking cessation programs. That’s only one of the problems. Teens generally don’t listen well to adult authority figures so it seems the best programs would involve peers in the change process.” Peers can be utilized to set an example of appropriate norms. As teachers, peers are many times considered more credible and to have a better understanding of youth issues.10 This makes youth more receptive to their thoughts and suggestions. Although it is more difficult to teach young people to be concerned about a future preventable problem than it is to deal with an issue at hand, Posavac and Kattapong10 report that peer intervention programs do indeed work. While some educational facilities and health organizations may be reluctant to include a peer intervention program due to the cost of recruiting, training, and transportation,10 they may want to consider the worth of helping just one preteen or teen to remain or become smoke-free.

The family, specifically the parents of pre-teens and teens, may play the most important part in preventing adolescent smoking or supporting successful cessation. Many of the current teen smokers have a parent or parents who are smokers. Farkas et al11 found that adolescents who had parents who had quit smoking were almost a third less likely to become smokers than teens whose parents had not quit smoking. Youths aged 15 to 17 with parents who have quit smoking are also twice as likely to have successful smoking cessation than similar teens whose parents had not quit smoking. The earlier in the child’s life that the parents become smoke-free, the less likely it is that their children will become smokers.11 In addition, if parents who smoke also quit when their adolescent quits, a more supportive and directly interactive system would be formed. Jason comments, “Children, particularly preteenagers, learn many of their values and adopt many of their healthy behaviors from what they see in their families to the extent that families are nurturant and clear in their expectations and positive role models. These types of good parents, when they give antismoking messages, will be most likely to have their children adopt these positive behavioral practices.”

It is the tobacco industry’s desire to replace smokers who have quit or died with new smokers. Unfortunately, the industry looks to the ranks of America’s youth to do this through a series of advertisements that target children. This target marketing was (and still is) promoted by using cartoon tobacco industry mascots, by placing inner city billboard advertisements near schools, and by portraying smokers as healthy, active, popular, and common. The tobacco industry portrayal of smokers is a fallacy and teens and preteens need to be made aware of that fact. Open discussion, health care involvement, and family support need to be utilized and encouraged to curtail teen and preteen smoking.


Jennifer Vavra is a contributing writer for RT Magazine. For more information, contact [email protected].


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