Transcript Tobacco*s New Connections - Society for Adolescent Health and

Tobacco’s New Connections
Nicholas Chadi, MDCM, FRCPC, FAAP
Trisha Tulloch, MD, MSc,FRCPC, FAAP
Karen Leslie, MD, MEd, FRCPC
The Hospital for Sick Children and
The Centre for Addiction and Mental Health
University of Toronto
March 11, 2017
SAHM Annual Meeting, New Orleans
Disclosures
No conflicts of interest
Learning Objectives
By the end of this session, participants will be able to:
1. Describe recent trends in tobacco and alternate tobacco product
use in youth
2. Summarize current evidence on the adverse health effects of
adolescent tobacco use
3. Compare and contrast current approaches and treatment of young
tobacco users
Outline
Tobacco’s emerging connections:
Tobacco and e-cigarettes
Alternate forms of tobacco
Tobacco and marijuana
Tobacco in at-risk groups
Approach to adolescent tobacco use: screening, counseling and
treatment
Resources for providers and families
Activity- application to practice
Discussion
Tobacco’s Emerging Connections
Cigars and
cigarillos
Cigarettes
E-cigarettes
Tobacco
Chewable
Dissolvable
Hookah and
waterpipe
NRT
Use of Conventional and Alternative Tobacco and Nicotine Products
Among a Sample of Canadian Youth (July 2015)
Christine D. Czoli, David Hammond, Ph.D., Jessica L. Reid, M.Sc., Adam G. Cole, M.Sc., Scott T. Leatherdale, Ph.D.
Purpose: The purpose of this study was to examine the use of conventional and alternative tobacco and nicotine
products among secondary school students.
Methods: Respondents were 44,163 grade 9–12 students who participated in Year 2 (2013–2014) of COMPASS, a
cohort study of 89 purposefully sampled secondary schools in Ontario and Alberta, Canada. Past-month use of
various tobacco and nicotine products was assessed, as well as correlates of use, using a generalized linear mixed
effects model.
Results: Overall, 21.2% of the sample reported past-month use of any tobacco or nicotine product, with 7.2%
reporting past-month use of e-cigarettes (11.4% cigarettes, 7.6% cigarillos). E-cigarette users reported significantly
greater prevalence of current use for all products. Students who were male, white, had more spending money, and
had a history of tobacco use were more likely to report past-month use of e-cigarettes.
Conclusions: Approximately one fifth of youth reported past-month use of a nicotine product, with e-cigarettes being
the third most common product. Overall, the findings suggest a rapidly evolving nicotine market.
Tobacco Use Among Middle and High School Students – United States (2011-2014)
Arrazola, 2015: National Youth Tobacco Survey: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6414a3.htm
Tobacco Use: International Data
Eriksen, M et al. The Tobacco Atlas, The American Cancer Society, Fifth Edition 2015
E-cigarettes
Pediatrics (Barrington-Trimis, 2016)
Higher prevalence of combined e-cigarette or cigarette use in 2014, compared
with historical smoking prevalence
E-cigarette use is not just substituting for cigarettes, but also occurring in
adolescents who would not otherwise have used tobacco
Pediatrics (Dutra, 2017)
E-cigarettes are increasing tobacco use overall and have not affected the
decline in traditional cigarette use in youth
E-cigarettes
Pediatrics (Wills, 2017) AND (Desmissie, 2017)
E-cigarettes increase risk of co-morbid substance use and high-risk behaviors
Those who smoke only e-cigs are potentially a new group of youth who would
not have smoked otherwise
Journal of Adolescent Health (Milicic, 2017)
Youth who binge drink or use marijuana have a greater increased risk for
using e-cigarettes compared to cigarette smokers
Efforts to prevent e-cigarette use should not only be discussed in the domain
of tobacco control
Current and ever use of e-cigarettes (1994-2014)
http://pediatrics.aappublications.org/content/early/2016/07/07/peds.2015-3983.figures-only
Alternate tobacco products - smoked
KRETEK
BIDI
HOOKAH
E-CIGARETTE
Alternate tobacco products - smoked
Product
Alternate names
Description
Cigar
Cigarillo, figurado
Large, tightly rolled bundle of tobacco
wrapped in leaf tobacco
Hookah
Pipes, waterpipe, hubble,
bubble, narghile, shisha
Lit tobacco bubbles through water,
inhaled through shared mouthpiece
Bidi
Kretek
Clove cigarette
Hand-rolled leaf-wrapped cigarette,
often with flavors
Rolled mixture of tobacco, cloves and
additives
Adapted from Sockrider M., Rosen JB ; Prevention of smoking initiation in children and adolescents In: UpToDate, Post
TW (Ed), UpToDate, Waltham, MA. and the AAP Julius B. Richmond Center of Excellence website
Alternate tobacco products - smokeless
Chewing/inhaled Tobacco
tobacco
Dissolvable
Alternate tobacco products - smokeless
Product
Alternate names
Description
Chewing tobacco
Chew, spit
tobacco
Consumed by holding between gum and cheek
(loos-leaf, « plug » or « rolls »)
Snuff
Pinch, dip
Finely ground tobacco (dry or moist) inhaled or
held in mouth
Snus
Form of moist snuff dispensed in packets, held
in mouth, no spitting
Dissolvable
tobacco
3 forms: strips, sticks or pellets/orbs
Adapted from Sockrider M., Rosen JB ; Prevention of smoking initiation in children and adolescents In: UpToDate, Post TW (Ed), UpToDate, Waltham,
MA. and the AAP Julius B. Richmond Center of Excellence website : ( both Accessed on June 9, 2015.)
Alternate tobacco products
What do you assess in your practice?
How do you ask about vaping or
other forms of tobacco?
Tobacco and cannabis
Drug and Alcohol Dependence (Hindocha, 2015):
298 tobacco and cannabis users ages 16-23
Cigarette smoking is related to concurrent cannabis dependence independently
of cannabis use frequency.
Cigarette smoking mediates the relationship between cannabis use and
cannabis dependence
Tobacco is a partial driver of cannabis dependence in young people who use
cannabis and tobacco
Tobacco, cannabis and the brain
Current Addiction Reports (Subramaniam, 2016)
Comorbid cannabis and tobacco use use has been shown to have a
differential effect on the structure and function of the brain
Reward circuitry, learning and memory.
Interaction mediated by the involvement of the endocannabinoid system and
alterations in dopamine signaling in regions associated with reward and
cognitive functioning
Implications on high-risk behaviors such as
Smoking (and drinking) and driving
High risk sexual behaviors
Past Month Use of Cigarettes and Marijuana
among 12th graders (1975-2014)
Source: University of Michigan, 2014 Monitoring the Future Study
Risk perception vs tobacco and marijuana use
2013 Monitoring the Future survey. University of Michigan, with funding from the National Institute on Drug Abuse.
Tobacco and cannabis - How teens do it
Mulling: Tobacco and cannabis rolled in paper
Chasing: Smoking a cigarette after a joint
Blunt smoking: Remove some of the tobacco from a cigar and add
cannabis
Ref: Belanger, RE. To What Extent Does Adding Tobacco to Cannabis Expose Young Users to Nicotine? Nicotine & Tobacco Research, 2013
Tobacco in at-risk groups
Cultural minorities:
African-American youth start smoking at an older age but adult smoking rates
similar between African-American and caucasian
Menthol cigarettes popular in young African-Americans
Asian-Americans and hispanics have the lowest smoking rates, but twice as
high in males vs females
Native Americans have the highest smoking rates
• Native American youth have smoking rates up to 2-3 times higher than populational
rates
Ref: Richmond Center, AAP Section on Tobacco Control. Special Populations: Tobacco Use And Cultural Considerations, 2011
Tobacco in at-risk groups
Mental illness: Journal of Behavioral Medicine (DeHay, 2011) “
More likely to smoke (up to 2-4 times)
Tobacco as a form of self-treatment
60% of current smokers report a history of mental illness in their life
Eating disorders: Journal of Eating Disorders (Sutter, 2016)
Cigarette and cigar smoking are associated with unhealthy dieting behaviors
Sexual minority groups: Richmond Center (AAP, 2011)
Smoking rates up to 2-3 times higher in LGBTQ teens 12-17 years
50% of LGBTQ youth initiated by age 13
Tobacco in at-risk groups
Home tobacco exposure
Parental smoking and parental nicotine dependence are the two
strongest predictors of tobacco use in youth
Chronic illness
Comparable rates as general teen population
Often a way to “fit-in” and feel “normal”
Disease-specific health risks
Harvey J, N Chadi. Preventing smoking in children and adolescents: Recommendations for practice and policy, Pediatrics and Child Health, 2016
Tobacco in at-risk groups
Chronic illness
Asthma
Cystic fibrosis
Juvenile idiopathic
arthritis
Cancer
Sickle cell disease
Diabetes mellitus
Potential disease-specific health consequences
Increased frequency and severity of exacerbations, medication use,
hospitalization and risk of respiratory arrest
Increased frequency and severity of bacterial lung infections and
hospitalization; accelerated decline in lung function and lower nutritional
status
Greater disease severity, higher risks for cardiovascular disease and
premature death, and exacerbation of osteopenia
Greater risks from several cancer treatments, for respiratory infections
when immunosuppressed, and exacerbated mucositis
Increased risk of acute chest syndrome and possible increased risk of
stroke
Accelerated cardiovascular and peripheral vascular disease, including
atherosclerosis, retinopathy and nephropathy. Smoking increases the
morbidity and mortality of type 1 diabetes by 50% to 75%.
Harvey J, N Chadi. Preventing smoking in children and adolescents: Recommendations for practice and policy, Pediatrics and Child Health, 2016
http://www.cps.ca/en/documents/position/preventing-smoking
Ask
Ask adolescents about their tobacco use during every clinic visit.
Asking about Tobacco Use
Tobacco Use in Canada: Patterns and Trends.(Reid JL et al 2015):
•Majority of adolescents considered quitting tobacco use.
•Many adolescents reported a quit attempt over the past 12
months.
Youth risk behaviour surveillance. MMWR. (Kann L et al, 2014):
• The proportion of past year attempts towards smoking cessation
among adolescents decreased from 57.4% (2001) to 48% (2013).
Asking about Tobacco Use
Tobacco induced diseases (Collins et al, 2017):
• 2013 data from the National Survey on Drug Use and Health (NSDUH)
• 74% of adolescents reported visiting a physician in the past
year
• 49% were screened for tobacco use or advised to quit tobacco
• The rates reported by adolescents were below previously
published clinician rates
The 5 As
Ask about tobacco use
Advise to quit
Assess readiness to quit
Assist in quit attempt
Arrange follow-up
U.S. Department of Health and Human Services. Treating tobacco use and dependence: 2008 update; Practice guideline executive summary:
http://www.ncbi.nlm.nih.gov/books/NBK63956 (Accessed January 23,2017).
Asking about Tobacco Use
• Adolescents may fail to mention other sources of nicotine when
asked about smoking.
•In addition to cigarettes use, adolescents should be asked specifically
about all forms of tobacco.
Asking about Tobacco Use
• Ask about other forms
•Tobacco and Cannabis
•Electronic Cigarettes
•Bidis
•Kreteks
•Snus
•Hookahs
•Smokeless Tobacco
•Chewing Tobacco
•Snuff
• Ask about sources of tobacco products (peers, siblings, parents)
Screening Tools
Drug and Alcohol Dependence. Frequent Marijuana Use is Associated with Greater
Nicotine Addiction in Adolescent Smokers (Rubenstein et al., 2015):
•
•
•
•
165 adolescents ages 13-17
Youth reported smoking at least 1 cigarette per day in the past 30d
80% reported past month cannabis use
Greater than 30% smoked cannabis daily
CRAFFT
Arch Pediatr Adolesc Med (Knight et al., 2002)
Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD)
Pediatrics (Kelly S et al., 2014)
The 5 As
Ask about tobacco use
Advise to quit
Assess readiness to quit
Assist in quit attempt
Arrange follow-up
U.S. Department of Health and Human Services. Treating tobacco use and dependence: 2008 update; Practice guideline executive summary:
http://www.ncbi.nlm.nih.gov/books/NBK63956 (Accessed January 23,2017).
The 5 As
Ask about tobacco use and SHS exposure
Advise to quit
Assess readiness to quit
Assist in quit attempt
Arrange follow-up
U.S. Department of Health and Human Services. Treating tobacco use and dependence: 2008 update; Practice guideline executive summary:
http://www.ncbi.nlm.nih.gov/books/NBK63956 (Accessed January 23,2017).
Assess
Determine degree of readiness and establish severity of use.
Determine readiness to quit
Ready or willing to quit?
•
•
•
Prepared (within 30 days)
Contemplation (within 6 months)
Pre-contemplation ( beyond 6 months)
Previous attempts?
•
•
•
Duration of abstinence/ reduced use
Barriers
Incentives
Barriers and Incentives
•There are a number of barriers which may deter adolescents from
reducing or abstaining from tobacco use
•Nicotine dependence
•Peer influence
•Asserting independence from parents or authority figures
•Concerns related to weight loss or body image
• Incentive to change should be
•Directed by the adolescent
•Explored with the adolescent using a nonjudgmental approach
Determine severity of use
Archives of Pediatric Adolescent Medicine (DiFranza et al., 2002)
•Hooked on Nicotine Checklist (HONC)
Psychology of Addictive Behaviors (DiFranza et al., 2009)
•Autonomy Over Smoking Scale (AUTOS)
Addict Behav.(Prokhorov et al., 1996)
•Fagerstrom Tolerance Questionnaire (mFTQ)
Nicotine & Tobacco Research (Nonnemaker et al., 2004)
•Nicotine Dependence Scale for Adolescents (NDSA)
Effects and Withdrawal Symptoms
Nicotine Effects
•
•
•
•
Alertness
Reduced the appetite
Palpitations
Increased BP and HR
Nicotine withdrawal
symptoms
•
•
•
•
•
•
•
•
Anxiety,
Irritability
Difficulty concentrating
Restlessness
Hunger
Tremor
Sweating
Dizziness
Assist
Incorporate appropriate and practical interventions
Interventions
• Studies involving adult data have established that both psychosocial
counseling and pharmacotherapy are effective, and that
combinations of the two methods achieve the best results.
• Although there is less information about outcomes of related
interventions for adolescents, existing data reveals effective shortterm cessation in youth.
Pbert L et al., State-of-the-Art Office-Based Interventions to Eliminate Youth Tobacco Use: The Past Decade. Pediatrics. 2015; 135 (4).
Eliciting Change
Motivational Interviewing/Enhancement
• Counselling method informed by level of
readiness based on stages of change
•(Pre-contemplation, Contemplation, Preparation,
Action, Maintenance)
• Assisting patients to resolve ambivalence.
• Aims to elicit the patient’s own reasons for
change and advantages favoring change.
Eliciting Change
• Motivational Interviewing/Enhancement
O - Open ended questions
A - Affirming
R - Reflecting
S - Summarizing
5Rs Motivational Enhancement
RELEVANCE
RISKS
REWARDS
Encourage the adolescent to talk about why quitting is important to him or her.
Ask the adolescent to identify potential negative consequences related to
tobacco use and most relevant to the patient.
Ask the adolescent to identify potential benefits of quitting tobacco use most
relevant to him or her.
ROADBLOCKS
Ask the adolescent to identify relevant barriers to quitting and discuss possible
and practical strategies to address the barriers.
REPETITION
Repeat process and messages during each clinical visit.
Provide reassurance, most tobacco users make repeated quit attempts prior to
experiencing success.
Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence Clinical Practice Guideline. Rockville, MD: Public Health Service; 2000.
Treatment
• For those adolescents who are interested in smoking cessation:
• Provide counselling options
• Assess severity and offer pharmacotherapy where indicated
• Provide advice
• Remove tobacco from environment
• Learn from previous quit attempts
• Review coping strategies
• Anticipate triggers
Nicotine Replacement Therapy (NRT)
• The treatment goal is to reduce nicotine withdrawal symptoms
•Assist with supressing urge to use
•Reducing, modifying habitual behaviour
•Delaying and deferring from smoking
Karpinski JP, Timpe EM, Lubsch L. Smoking cessation treatment foradolescents. J Pediatr Pharmacol Ther.2010;15(4):249–263
Pbert L et al., State-of-the-Art Office-Based Interventions to Eliminate Youth Tobacco Use: The Past Decade. Pediatrics. 2015; 135 (4).
Pharmacological Treatment Options
Medications
Nicotine patch
Nicotine lozenge
Nicotine gum
Nicotine inhaler
Nicotine nasal spray
Varenicline
Bupropion
Adverse Effects, Precautions, Warnings, and
Contraindications
Adverse effects:
local skin reaction, insomnia, and/or vivid dreams
Adverse effects:
nausea, hiccups, heartburn; acidic drinks interfere with absorption of nicotine
Adverse effects:
mouth soreness, hiccups, dyspepsia; acidic drinks interfere with absorption of nicotine
Acidic drinks interfere with absorption of nicotine
Adverse effects:
nasal irritation, nasal congestion; precaution: do not use in people with severe reactive
airways disease
Precaution: decrease dose if kidney disease ; warning: depressed mood, agitation,
behavior changes, suicidal ideation, and suicide have been reported; adverse effects:
nausea, trouble sleeping, abnormal/ vivid dreams
Adverse effects: insomnia, dry mouth; contraindications: monoamine oxidase (MAO)
inhibitor use in past 14 d, history of seizure or eating disorder
Tobacco as a Substance of Abuse. Pediatrics 2009;124;e1045
Other interventions
‘QuitSTART’
• Free app created for adolescents interested in smoking cessation
• App requests information about smoking history
• Provides recommendations to assist with reducing use
National Cancer Policy Forum; Board on Health Care Services; Institute of Medicine. National Academies Press (US); 2013 Apr 16
Arrange
Follow up, anticipatory guidance and resources
The 5 As
Ask about tobacco use and SHS exposure
Advise to quit
Assess readiness to quit
Assist in quit attempt
Arrange follow-up
U.S. Department of Health and Human Services. Treating tobacco use and dependence: 2008 update; Practice guideline executive summary:
http://www.ncbi.nlm.nih.gov/books/NBK63956 (Accessed January 23,2017).
Preventative and Protective Factors
Prevention
Asking about parent tobacco use
Asking about sources of tobacco/second hand smoke
Access to educational material
Individual, family, and environmental factors can guard against risky behaviors
Encouraging close communication with parents
Peer support
Self efficacy/self-esteem
“ROLL THE DICE”
Application Activity
Roll the dice 3 times
The number on the dice will correspond to the variables for the clinical
‘case’ that your group will discuss re: approach to assessment and
treatment
What additional information might you want?
What are the issues to consider in approaching the patient’s tobacco
use?
Discuss at your table and then we will share each scenario as a larger
group
Roll The Dice…
Dice roll
Age
Tobacco source
Presentation/context
1
12
e-cigarettes
Polysubstance abuse
2
13
Hookah
Suicide attempt requiring admission
to secure unit
3
14
‘Poppers’
Exacerbation of asthma
4
15
Chewing tobacco
Sports participation physical
5
16
15-20 cigarettes per day
Parental tobacco use
6
17
2-3 cigarettes per day
Anxiety with panic attacks
What additional information might you want?
What are the issues to consider in approaching the patient’s tobacco use?