April 18, 2011
J. Randy Koch, Ph.D.
Alison Breland, Ph.D.
VCU Institute for Drug and Alcohol Studies





Epidemiology
Tobacco products/brief history/Alternative
tobacco products
Cessation/Treatment
Prevention strategies
Virginia Youth Tobacco Projects Research
Coalition




Tobacco use is the leading cause of preventable death in
the US: over 400,000 deaths each year
Morbidity and mortality caused by carbon monoxide
(CO) and carcinogens (e.g. tobacco-specific
nitrosamines)
Dependence caused by nicotine: reinforcing effects such
as euphoria, increased arousal, reduced stress, and
appetite suppression
Use of tobacco often leads to an aversive withdrawal
syndrome during periods of tobacco abstinence; this
can maintain tobacco use and thus, exposure to harmful
smoke constituents


Currently, about 21% of US adults smoke
cigarettes
Current use of cigarettes among youth:
 5.2% of middle school students
 17.2% of high school students


Rates higher if you include any tobacco
product
Most adult smokers (80%) began smoking
before age 18

Gender
 23.5% of men
 17.9% of women

Race





23.2% of American Indians/Alaska Natives
22.1% of whites (non-Hispanic)
21.3% of blacks (non-Hispanic)
14.5% of Hispanics
Socio-economic status
 31.1% of adults who live below the poverty level
 19.4% of adults who live at or above the poverty level
Source:
www.smok
ingcessatio
nrounds.ca
(Volume 2
#10)

Statewide: 16.4% of the adult population are
current cigarette smokers (BRFSS)

11-13% of youth aged 12-17 smoked 1 cigarette
in the past 30 days (NSDUH/VYTS)

Use of any tobacco in past 30 days: (cigarettes, cigars,
smokeless tobacco, pipes, bidis, hookahs, Black and Milds, and
SNUS)
 14% of middle-school students
 34% of high school students






Cigarettes
Cigars
Kreteks and bidis
Pipes
Smokeless tobacco (“dip”, “chew” or “snus”
note: many new varieties)
Waterpipe (hookah)

Cigarettes
 First developed 1800s
 US: 1930s – 1970s, start to see changes to
cigarettes
 Filters and “full flavor” vs “light” vs “ultra light”
 Start to see health claims, even after 1964
Surgeon General’s report on the dangers of
smoking
Source: Dr. Ken Warner.
 “Patients who are unable to stop cigarette smoking
should be assisted to reduce their smoke exposure
by smoking low-tar and low nicotine cigarettes . . .”
(Harrison’s Internal Medicine 9th Ed., 1980, p. 941).
 Smokers believe “light” and “ultra light” cigarettes
decrease health risks of smoking (Kozlowski,
Goldberg, et al., 1998; Giovino et al., 1996).
 Smokers switch to low yield cigarettes instead of
quitting (Giovino et al., 1996).
 Changes increased sales without harm reduction
 “The weight of the evidence indicates that lower-tar
and nicotine yield cigarettes have not reduced the
risk of disease proportional to their FTC yields”
(IOM, 2001).
 Past modifications did not alter exposure: changing
puff topography, covering vent holes
 New FDA regulation will eliminate use of “light” etc.
 Newer cigarettes: Eclipse, Advance, Omni
 Bold claims of reduced carcinogens
Breland,
Kleykamp,
Eissenberg,
2006

Cigars
 5.4% of US adults use (>1 in past 30 days)
 3.9% of middle school students
 10.8% of HS students

Kreteks (clove cigarettes) and Bidis

Pipes

Waterpipe, or hookah
 CO exposure is much higher than
cigarettes (Eissenberg et al., 2011)
http://www.smokefree.gov/tob-cigarillo.aspx

SOURCE: Adapted by CESAR from University of Michigan, “Smoking Stops Declining and Shows Signs of Increasing
Among Younger Teens,” Press Release, 12/14/2010. Available online at
http://www.monitoringthefuture.org/data/10data.html#2010data-cigs.

Smokeless tobacco
 “Dip”, “Chew” (e.g., Skoal,





Wintergreen)
Snus (Swedish)
Pressed tablets (Ariva)
Marlboro snus
Camel Snus, orbs, sticks, dissolvable strips
Health effects? In Sweden, low rates of lung
cancer, but effects in US not known
dissolvable tobacco
snus
Slide courtesy of Bob Balster
Electronic Cigarettes
Cartridge w/
Nicotine Solution/
E-juice/ E-liquid
Atomizer
Heater
E-Juice/E-Liquid
Nicotine Solution
Propylene Glycol and/or
Vegetable Glycerin
Distilled Water
Flavorings (Baking)
Smart Chip
Air Flow Sensor
Rechargeable Battery
2v – 6v
Use Methods
Pre-Filled
Dripping
Fill your own
Make your own
LED
Vaper
Slide courtesy of Andrea Vansickel



Some lab studies show low nicotine delivery
(significant after 4, 10-puff bouts), also large
amounts with experienced users
May appeal to youth
Health effects unknown
Images courtesy of Bob Balster
and Andrea Vansickel

Overall tobacco use has been going down
(although for cigarettes, is currently stalled)

Use of other products may be increasing

Hard to determine long-term impact of new
products (need to wait say, 20-30 years and
see what happens)





~70% of smokers say they want to quit
45% make quit attempts
Relapse rates are high
Nicotine produces dependence: very difficult
to quit
Nicotine is as addictive as heroin or cocaine

Medications to quit can increase likelihood of
success
 Nicotine replacement therapy (nicotine patch,
gum, inhaler, lozenge, nasal spray)
 Non-nicotine medications: buproprion
(Zyban/Wellbutrin), varenicline (Chantix)


1-800 QUIT-NOW (counseling)
Websites
Source:
Treating
Tobacco Use
and
Dependence:
2008 Update
(Clinical
Practice
Guideline,
Fiore et al.,
2008)
Not
recommended
Source:
Treating
Tobacco Use
and
Dependence:
2008 Update
(Clinical
Practice
Guideline,
Fiore et al.,
2008)




Current study: smoking cessation among
those in recovery from addiction to
alcohol/drugs
80-90% of individuals addicted to other
substances smoke
Tobacco use generally not addressed during
formal treatment
Currently testing brief computerized
motivational feedback in this population to
determine effectiveness

Effective prevention programs are based on
reducing risk factors and/or enhancing protective
factors

Related to age, gender, race, and environment
 A need for preventive interventions tailored to specific
populations and settings

Most risk and protective factors related to a broad
array of youth problems, but some are unique
 Additive effect—goal is to affect the balance of risk and
protective factors

Individual

Family

Peer

School

Community

Individual Risk Factors
 Psychiatric disorders
Individual Protective
Factors
 Novelty/sensation
 Ambitious life goals
seeking
 Positive attitudes
towards substance use
 High antisocial behavior
 High religiosity


Family Risk Factors
 Family conflict
Family Protective
Factors
 Family history of
 Parental nonsmoking
antisocial behavior
 Family attitudes
favorable to substance
use
 Parental advice not to

smoke
 Parental monitoring
 Strong family bonds


Peer Risk Factors

School Risk Factors
 Peer tobacco use
 Low school
Community risk
factors
connectedness
 Low academic
achievement
 School misbehavior
 Exposure to tobacco
advertising
 Perceived availability of
tobacco

School-based programs

Family-based programs

Media campaigns

Reducing youth access

Excise Taxes

Schools are most common setting for
tobacco use prevention programs
 Provide relatively easy access to youth
 Can address other concerns of interest to schools
 Can be integrated into school curriculum

Skills Training
 Academic Competence
 Social Competence
 Social Resistance Skills

Norms Education

Media Literacy

Should not be one-time efforts--booster
sessions
Gilbert Botvin and colleagues, Cornell University
 Target Population: Grades 6, 7 and 8 or Grades 7, 8
and 9
 Three year program (15, 10 and 5 session)
 Focus on:

 Drug resistance skills and information
 Self-management skills
 General social skills

Interactive program using facilitated discussion, role
playing, and small group activities
Adjusted Substance Use Means at One-Year Follow-up
LST
Control Group
Mean
SE
Mean
SE
X2
df
P
Smoking
1.79
.08
2.13
.09
6.4
1
.006
Drinking
1.82
.08
2.11
.08
5.8
1
.008
Marijuana
1.69
.10
1.87
.11
1.3
1
.126
N= 802
Griffin et al., 2003

Parents are a major influence on youth
behavior, especially on children

Most common approaches focus on
enhancing parenting skills
 Age appropriate expectations
 Consistent and appropriate discipline
 Monitoring of child activities/friends




Strengthen family bonding and positive
relationships
Improve parenting skills
Helping families to develop and enforce rules
about substance use
Providing information about drugs and their
effects on development





Richard Spoth and colleagues, Iowa State University
Target Population: Youth 10 to 14 years old (also available for
younger children)
Seven sessions
Parents and youth meet separately for first hour and then
together for second hour
Parent sessions
 Skill-building focused on establishing rules, limits, and consequences
while expressing love; communication with youth; handling stress;
using community resources
 Uses videos demonstrating parenting skills, with role playing,
discussion and skill building activities

Youth sessions
 Youth skill-building focuses on following rules, peer pressure
resistance, handling stress, and problem-solving
 Group discussions, group skill practice, and social bonding activities

Family sessions
 Games and projects to increase family bonding, build positive
communication skills, plan family activities, and facilitate learning to
solve problems together

Booster program 3 to 12 months after completing initial
program—Four sessions
Spoth et al., 2004
Outcome
Estimated time in
months from pretest
Initiation
Proportion
SFP
Control
Difference
38.2
25.3
12.9
46.8
34.4
12.4*
Lifetime alcohol use
.40
Lifetime alcohol use without
parental permission
.40
Lifetime drunkenness
.35
58.6
45.3
13.3*
Lifetime cigarette use
.30
54.9
30.8
24.1*
Lifetime marijuana use
.10
63.7
48.6
15.1

Systematic review by Brinn et al., 2010 (Cochrane
Collaboration)
 There is some evidence that mass media can prevent the
uptake of smoking in young people, however the evidence is
not strong and contains a number of methodological flaws.
 Effective media campaigns:
▪
▪
▪
▪
Based on good market research
Identify and tailor message to specific groups (market segmentation)
Last longer and more intensive
Use multiple media (TV, radio, newspapers)

Primarily focus preventing illegal sales to minors
 Retailer education
 Active enforcement

Systematic review by Stead, 2008 (Cochrane
Collaboration)
 Active enforcement more effective in reducing sales to
minors
 Little evidence of impact on perceived availability of
tobacco products or on prevalence of youth smoking (only
three controlled trials)


Enacted in 1992
Required States to enact laws prohibiting the
sale or distribution of tobacco products to
those under 18 years old
 Required unannounced inspections of retail
outlets and reporting of results
 “False buys”
 Established targets for “violation rates”
 Failure to meet targets could result in loss of
funds—up to 40% of SAPT Block Grant
Synar Violation Rates by Year
Violation Rate
50%
40%
30%
20%
10%
0%
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year

Create a financial disincentive to use tobacco

Based on known relationship between price
and sales
 Elasticity of demand (Ed ) is percentage change in
sales as a result of percentage change in price
 Ed = -1.5 (10% increase in prices results in 15%
reduction in sales



Relationship between price and sales
(demand) complicated by role of addiction
Adults Ed = -.40 (NCI, 1993)
Less research on youth
 Illegal product for youth

Generally believed that youth are more price
sensitive
 Less disposable income
 Less addicted

Youth Ed = -.9 to -1.5

“Policies that affect the price of tobacco
products are the single most effective means
of decreasing tobacco use, especially among
youth and young adults.” (CDC, 1998)

Tobacco companies often respond by
decreasing wholesale price
Excise Tax in Dollars
State Tobacco Excise Taxes
5.00
4.50
4.00
3.50
3.00
2.50
2.00
1.50
1.00
0.50
0.00
4.35
3.46
1.41
NY
RI
TX
State
0.30
0.17
VA
MO

Mission and Goals

History and Organization

Activities

Opportunity for Student Participation
The Virginia Youth Tobacco Projects (VYTP)
Research Coalition was established to
advance the prevention and treatment of
youth tobacco use and nicotine dependence
through a coordinated, multi-university
program of basic and applied research.





Build a statewide program of research on the causes
and prevention of youth tobacco use
Create active multi-university collaborations in
carrying out the VYTP research program
Attract new faculty scholars to work on problems of
youth smoking
Use VTSF funding as a base for attracting additional
outside funding for youth tobacco research in
Virginia
Translate research findings into improved
prevention services and policies

The VYTP Research Coalition established in 2002
with funding from the Virginia Tobacco Settlement
Foundation, now called the Virginia Foundation for
Healthy Youth

The VFHY supports three types of activities related
to youth tobacco use:
 Media campaign
 Community-based prevention programs
 Research

The VYTP Research Coalition includes over 40
faculty from seven of Virginia’s universities:
 The College of William and Mary
 George Mason University
 James Madison University
 University of Virginia
 Virginia Commonwealth University
 Virginia Tech
 Virginia State University

VCU-IDAS serves as coordinating center

Targeted grant funding to support research

Small grant awards to fund preliminary/pilot studies
and encourage participation by new investigators

Research conference to disseminate findings to
researchers, policy makers and practitioners

Coalition meetings to facilitate networking and the
development of new research collaborations

Reports to facilitate research translation

Statewide survey assessing:
 Frequency and quantity of use
 Perceived availability of tobacco products
 Exposure to environmental smoke
 Attitudes towards tobacco use
 Exposure to tobacco advertisements



Conducted every other year beginning in 2001
Public school students in grades 6 through 12
Multi-stage sampling frame

Access is being provided to students and
postdocs for the first time

Award ($500) for best student and best
postdoc study

Opportunity to present at VYTP conference in
spring 2012
And, thank you for not smoking!