# Presentation: 075715

## Tobacco Use Prevention and Education: How to Strengthen Your Center’s Tobacco Use Prevention Program (TUPP)

- Teresa Lowery, MD, MPH
- Regional Medical Consultant

## TUPP PRH Requirements

- Implement a program to prevent the onset of tobacco use and to promote tobacco free environments and individuals. To support this program, a TUPP coordinator shall be appointed (he or she need not be a health service staff member). At minimum, this program shall include:
- a) Educational materials and activities that support delay and/or cessation of tobacco use
- b) A smoke free tobacco free environment that prohibits the use of all tobacco products in center buildings and center operated vehicles
- c) Designated outdoor smoking areas located away from the building entrance
- d) Prohibition of the sale of tobacco on center
- e) Adherence to federal and state laws regarding the use of tobacco products by minors

## The Importance of TUPP

- Cigarette smoking is the greatest cause of preventable death and disability in the US
- Tobacco use kills more Americans each year than alcohol, illicit drugs, suicide, AIDS, and accidents combined
- More than 3,000 children in the US begin smoking each day
- 90% of adult smokers initiated smoking before the age of 18 and 70% were daily smokers before this age

## The Importance of TUPP

- Evidence indicates the period of nicotine addiction is greater during adolescence
- Cigarette smoking during adolescence reduces the rate of lung growth, maximum lung function, increases the risk of respiratory problems and reduces the overall fitness levels
- Cotinine, a by product of nicotine, has been found at harmful levels in infants and children who live with smokers

## Who’s Smoking???

- According to 1999 Youth Risk Behavior Survey, 70.4% of high school students have attempted to smoke one occasion, and 25.3% have smoked at least one cigarette per day for the previous 30 days
- Among 8th graders, 18% report smoking in the past month; (26% of 10th graders and 35% of 12th graders)
- Higher numbers from students from alternative high schools

## Who’s Smoking???What are they smoking???

- Despite the recent decline in adolescent smoking, in 2002, 10-15% of middle school students and 23-35% of high school students report current cigarette smoking in the past 30 days
- Unfortunately, the majority of these adolescents will maintain their smoking into adulthood.
- In 2000, US high school students reported current use: cigarettes 28%, smokeless tobacco 6.6%, cigars 14.8%, pipes 3.3%, bidis 4.1%, and kreteks 4.2%.

## What We’re Up Against

- The tobacco industry spends $6.2 billion a year to advertise and promote their product
- This is equal to $17 million a day, $708,000 an hour, $12,000 per minute or $197 a second
- Television advertisements banned, but youth-oriented magazines, and industry-sponsored sporting events continue to result in logo exposure to young viewers
- 30% of 12-17 year old smokers and nonsmokers own at least one tobacco promotional item

## What We’re Up Against: Adolescent Attitudes and Behaviors

- 85% of adolescents who smoke think about quitting and 80% of current smokers made a quit attempt during the past year
- Youth may not grasp the long-term consequences of cigarette use, focus may have to include and emphasize the short term rewards of cessation
- A series of focus groups with high school students found the motivation to quit stemmed from disliking the smell of cigarettes, cost, and a decline in artistic/athletic performance

## What We’re Up Against: Adolescent Attitudes and Behaviors

- Teens who had never tried to quit were likely to state that quitting was difficult and to believe that quitting would promote weight gain, increase stress, and force a change in their social groups
- The bad news is that most attempts to quit are unsuccessful.

## What We’re Up Against: Adolescent Attitudes and Behaviors

- Risk Factors for Adolescent Smokers
- Low educational aspirations
- Poor or uneducated families
- **Friends and/or Family members who smoke
- Other health-risk behaviors
- Low self esteem or poor self image
- Low perception of self-efficacy
- Depression
- Acceptance by peers
- Desire to seem more adult or mature

## Federal Policy Initiatives: How effective have they been??

- Legislative initiative alone may not be sufficient to produce significant impact on tobacco use prevalence
- Synar amendment: requires that states receiving federal funding for substance abuse and treatment adopt and enforce tobacco age-of-sale laws, have been put into place
- Studies on youth access show that young people continue to obtain cigarettes from both non-commercial sources and commercial sources, although sales are prohibited for  individuals under the age of 18

## Federal Policy Initiatives:How effective have they been??

- Strict enforcement of merchants reduces youth prevalence
- Youth are more responsive to cigarette price increases than adults, with a 10% increase in the price of cigarettes estimated to reduce youth smoking by about 5% (as compared to 1-2% among adults)
- Tobacco products are reported by retailers to be one of the most frequently shoplifted items; yet many stores continue to place cigarettes in unobserved areas of easy access

## Why Try??

- The main goal of Healthy People 2010 in regards to tobacco use is to “reduce illness, disability, and death related to tobacco use and exposure to second hand smoke.”
- Plans include:
-  decreasing tobacco accessibility to minors
- decreasing targeting advertising of tobacco products toward children
- Increase insurance programs for tobacco cessation products and programs

## Why Try??

- Cigarette use and its consequences impacts employability
- The most common form of drug addiction is nicotine dependency, which causes more death and disease than all other addictions combined
- Many adolescents lack the skills and  knowledge to quit on their own
- Because the PRH says so !

## What Can We Do??

- Once adolescents are motivated to stop smoking, we need to have developmentally appropriate interventions available and accessible to them
- Various programs and interventional models have been studied
- Most have low rates of success, anticipate several attempts at quitting
- Relapse must be addressed
- Nicotine withdrawal symptoms should be anticipated and addressed in daily users

## Where Do We Begin?: Assessing Readiness

- The 5A brief intervention
- USPHS uses mnemonic
- involving 5 A’s:
- Ask, Advise, Assess,
- Assist, Arrange
- (Requires less than 3 minutes of counseling and studies in adults have shown that brief physician intervention promotes cessation)

- 	6 Cessation Stages
- Recent acquisition
- Pre-contemplation
- Contemplation
- Preparation
- Action
- Maintenance

## Basic Elements of a Cognitive-Behavioral Intervention

- Establish Self-Awareness of Tobacco Use
- Record tobacco use behaviors
- Discuss thoughts, beliefs, and reasons for using and not using tobacco
- Learn about the physical and psychological effects of tobacco use

## Basic Elements of aCognitive-Behavioral Intervention

- Prepare to Quit
- Set a specific and reasonable quit date
- Choose a quit method (eg, cold turkey, gradual reduction), and set short- and long-term goals appropriate to quit method
- Learn about the physical and psychological symptoms of withdrawal

## Basic Elements of aCognitive-Behavioral Intervention

- Provide Strategies to Maintain Abstinence
- Use problem-solving techniques to minimize effects of situational triggers
- Develop coping skills (thoughts and actions)
- Seek social support from family and peers
- Develop strategies to monitor and reinforce progress

## Pharmacological Interventions: Considerations

- 	The following are important considerations regarding the use of medications with youths:
- No over-the-counter or prescription products have been approved by the FDA for use by individuals under the age of 18
- None of the youth clinical trials that used pharmacotherapy for cessation have shown effectiveness (not true for adults)
- Risks associated with the use of medications should outweigh the determined risks of continuing use of the tobacco product.

## Pharmacological Interventions:Considerations

- The average cigarette contains approximately
- 	9 mg of nicotine
- Smoking one pack per day yields about 180 mg of nicotine accompanied by 4,000 compounds with 43 known carcinogens
- Nicotine is the addictive component in cigarettes, and smokers experience cravings similar to those experienced by heroin and cocaine addicts
- The primary pharmacological efforts involve either replacing nicotine or reducing the craving for nicotine through receptor site interactions

## Pharmacological Interventions:Considerations

- Remember to educate students on what to expect:
- Quitting is difficult since the nicotine addict will experience withdrawal symptoms
- These symptoms peak by day 3 and gradually diminish thereafter.
- Symptoms include: increase cravings, hunger, irritability, restlessness, difficulty concentrating, mood disturbance and urge to smoke

## Pharmacological Interventions

- Bupropion (*Wellbutrin, Zyban*) by prescription only
- MOA: still unknown, but postulated to  reduce craving for nicotine and may be combined with replacement products
- Dosage: (immediate release) 150mg Qam for 3 days, then 150 mg bid (begin treatment 1-2 weeks prequit)
- Duration: 12 weeks, may be extended
- Cost: 150 mg, 60 each, $97.00
- Side effects: nausea, seizures, tremors, agitation, dry mouth, and insomnia.
- Caution: drug interactions have been reported with other antidepressants and psychotropic compounds

## Pharmacological Interventions

- Nicotine Gum (*Nicorette*) available over the counter
- MOA: releases nicotine buccally, (not to be chewed like a gum)
- Each piece of gum last between 20-30 minutes
- Dosage: one to two pieces per hour, with the 2mg dose used for those who smoke less than one pack per day; 4mg dose for those who smoke more than one pack per day
- Cost: 2mg, 48 each, $29; 4mg, 48 each, $33
- Side Effects: headache, indigestion, mouth irritation or sores, and nausea
- Initially use one piece of gum q1-2 hrs, rather than treating emergent cravings

## Pharmacological Interventions

- Nicotine inhaler (*Nicotrol*)* *by prescription only
- MOA: a 10 mg cartridge delivers 4mg of vaporized nicotine to the oral mucosa
- Dosage: Each smoker should individualize the dose to between 6 and 16 cartridges daily to minimize withdrawal symptoms
- Cost:10mg cartridge, 42 each, $41
- Side Effects: local irritation, coughing, rhinitis, dyspepsia and headache.
- An advantage to the inhaler is that it substitutes some of the behavior effects of smoking by the administration of puffing

## Pharmacological Interventions

- Nicotine Nasal Spray (*Nicotrol NS*)* *by prescription
- MOA: delivers 0.5mg of nicotine per dose to the nasal mucosa via an aqueous solution
- Dosage: one to two doses intranasally per hour for a total of 8-40 inhalations per day
- Cost: 10ml, $41
- Side Effects: nasal and throat irritation, sneezing, runny nose, and watery eyes
- An advantage of this system is that it delivers nicotine more rapidly to the systemic circulation than other nicotine replacement products

## Pharmacological Interventions

- Nicotine Patch (*Habritrol, Nicoderm, and Nicotrol*) by prescription,
- MOA: useful in reducing nicotine withdrawal symptoms and are intended as a temporary aid in the early stages of smoking cessation
- Provides nicotine through the skin and require 1-2 hours from the time of administration to reach peak levels in the bloodstream.
- Dosages: 21mg, 14mg, 7mg (all per 24 hrs)
- 	The recommended starting dose is 21 mg patch applied QD for 4-8wks; followed by a 14mg patch QD for 2-4wks, and a 7mg patch QD for 2-4wks.

## Pharmacological Interventions

- Students who smoke less than 1ppd (packs per day) may receive a patch delivering between 15-22mg of nicotine replacement daily
- Those smoking between 1-2 ppd may start with  21-35mg patches
- Those smoking more than 2 ppd should receive a patch or patches delivering between 42-44mg daily
- The student should commit to stop smoking on initiation of therapy; however, relapses do not warrant discontinuation of the patch
- Cost: 30 each, range between $112-125 depending on  dosage

## Pharmacological Interventions

- Nicotine Patch (cont’d)
- Side effects: erythematic, pruritis, local irritation, diarrhea, dyspepsia, arthralgias, myalgias, sweating, somnolence, and abnormal dreams
- Sleep disturbances can be minimized by using a16-hour patch or by removing the patch before bedtime
- There is an OTC Nicotine patch; 15mg dosage/ 24 hour
- Cutaneous reactions can be minimized by rotating application sites and using a specific site no more than once a week
- Local reactions may be caused by the adhesive in the patch rather than the nicotine, and can be symptomatically treated with hydrocortisone cream.

## Teen Smoking Cessation Studies: What’s worked, What hasn’t

- Nicotine replacement therapy (NRT)
-  Success rates overall low
- Long term cessation rates around 5-10%
- Overall found to be safe and well tolerated
- Usually high relapse rate
- **Many  adolescents continued to smoke while on the patch!!
- Of note, some non-smokers or “light” smokers (less than one cigarette per week) also use the patch (usually bought over the counter)

## Teen Smoking Cessation Studies:What’s worked, What hasn’t

- School Based Health Programs
- Generally ineffective for long term in terms of *prevention (*when used alone)*,* but are more effective when combined with other approaches such as media and smoke-free policies
- For cessation: may be very helpful for support if includes cognitive-behavioral approaches, with emphasis on coping skills training, and alternative ways of handing situations or negative moods without smoking (programs should be fun and enjoyable)
*More effective for volunteer students, but not  for those for whom  program is mandated (i.e., in lieu of school suspension)*

## Teen Smoking Cessation Studies:What’s worked, What hasn’t

- Peer leadership
- Peer led group vs. adult-led group
- Both were equally effective when compared with control group with 18.1% quit rate at one month reported by participants
- Focused on immediate consequences of smoking
- Bad smelling breath and hands, stained fingernails, shortness of breath in sports and recreation, and cost
- What students found most helpful
- Learning the negative consequences of smoking, tips for quitting, learning coping behaviors, encouragement from leaders to quit, spending more time with nonsmoking friends, and learning the reasons for smoking

## Teen Smoking Cessation StudiesWhat’s worked, What hasn’t

- Peer Support Programs
- 	“Buddy System” for pregnant adolescents
- Buddy had to be a nonsmoking female friend in the same age range
- Buddy to provide encouragement and support, as well attend all sessions
- Used materials from the *Teen Fresh Start Program*  developed by the American Cancer Society
- 30% reported quitting smoking completely

## Teen Smoking Cessation Studies:What’s worked, What hasn’t

- Computer Intervention Programs
- Several models exist
- i.e. *Action Oriented* based on a program developed by the American Lung Association
- Capitalize on student’s interest in working with computers
- Students usually respond to questions on the computer screen regarding smoking cessation and receive immediate feedback on the screen
- Students reported quit attempts after session, but long term outcome has been disappointing
- **May be better used as an adjunct to other smoking cessation programs

## Conclusion of Teen Smoking Cessation Studies

- No one program experienced great success
- May give insight into the development of future cessation programs
- Variety may be the key to success
- Using peer leaders and buddies may reduce the cost of programs while providing intensive support
- Teens with a higher level of nicotine addiction may need NRT incorporated into their program
- Incorporating computer programs may increase students’ interest and participation in programs

## Other Suggestions

**Components of A Comprehensive Tobacco Control Program**
- 	(from Centers for Disease Control and Prevention. Best Practices
- 	for Comprehensive Tobacco Control Programs. Atlanta, GA: CDC 1999)
- Tobacco use prevention efforts involving education and counter marketing
- Legislative and policy efforts to limit tobacco use, stop tobacco advertising and promotions, promote clean indoor air, restrict youth access to tobacco, and increase the cost of tobacco through taxation
- Enforcement of existing laws and policies

## Other Suggestions (cont’d)

- CDC recommendations Cont’d
- Cessation interventions, for adults and youth
- Intervention to prevent and/or reduce the burden of chronic diseases related to tobacco use
- Surveillance and evaluation to improve knowledge about best practices in tobacco control
- Administration and management activities that can coordinate tobacco control efforts at both the community level and at the level of the state, province, or other larger jurisdiction
- Tobacco control efforts that operate at multiple levels (ie state, or province, community, and school)

## Ideas From Job Corps Centers

- Incentive Programs from Oral Health and Wellness Programs
- Tooth whitening
- Oral Health Care Product Give-a-ways
- ???Other Prizes???
-  Essay Contests
- Frequent Cleanings

## Ideas from Job Corps Programs

- Potomac JCC (Region 2, Washington, DC)
- Cigarette butt pick-up contest
- Suggested by RA’s in dorms
- Students collect and clean up as many cigarette butts as possible from campus (hopefully their not smoking the cigarettes)
- Winning dorm wins a pizza party
- May not truly be geared toward cessation, but cleaning up the campus may serve as a reminder to not smoke in non designated areas
- Innovative and interesting, but will students do this?
- Update: How is it going (Mrs. Karen Marcelle, HWM)

## Ideas from Job Corps Programs

- Penobscot JCC *Butt Out Program* (Region 1, Bangor, Maine)
- Grant sponsored by the Healthy Maine Partnership under the Bureau of Health by funds obtained through the state tobacco settlement
- Geared toward female population because tobacco companies are targeting young females
- 8 week program designed by student interests
- Goal of stopping use of tobacco products
- Includes focusing on body image, nutrition and exercise, anxiety, and prevention of weight gain from quitting, coping skills and other topics
- Part of the completion requirement is for each woman to bring one friend
- At the conclusion of the program, successful participants will be taken on a field trip off center as a reward

## Issues/Ideas Specific to Job Corps

- 	How do they fare??
- 	Staff adherence
- 	Long term success rates for smoking cessation

## Issues/Ideas Specific to JCC

- Enforcement of Smoking in Non-designated smoking areas
- Do we expect previous marijuana users to not smoke as well (once THC use is abandoned)?
- Enforcement of Minors on Center Who Smoke
- Encourage and Convince Staff To Not Smoke with students and only in non-designated areas
- ??Fine Students who do not comply
- ??Require Violators to clean an area of campus that has excessive cigarette butts
- All money collected in fines should go to TUPP for future programs and funding

## Conclusion

- 	Strengthening  your center’s TUPP is a comprehensive task that will involve health and wellness staff, oral health providers, TUPP specialists, as well as center staff. Recruitment and use of nonsmoking peers for support and leadership may also prove to be invaluable. The most effective programs offer a variety of models which grab and maintain the students’ interests.
- 	Whatever it takes, WE CAN DO IT!!