From the American Academy of Pediatrics: Technical report--Tobacco as a substance of abuse

A multilevel intervention in pediatric primary care for youth tobacco control: Outcomes of implementing an Ask, Advise, and Connect model

Multilevel interventions in healthcare settings (e.g. Ask, Advise, and Connect; AAC) can reduce tobacco product use among adult patients: their effectiveness in pediatric practice is largely unknown. We implemented an AAC model in pediatric primary care to deter children's tobacco use, and evaluated its effectiveness in a single-arm trial. At wellness visits, young patients (ages 12-17) completed a tablet-based assessment (Ask) of lifetime and current tobacco use. These data were made available within the electronic health record to pediatric primary care providers for preventive counseling (Advise). Providers then referred patients to an e-health evidence-based tobacco control intervention (Connect). Tobacco control outcomes were examined in the clinic population (N = 2219) and in a sample of patients (N = 388, 62% female, 39% non-White, M age = 15) over time, along with intervention engagement. Population use of tobacco products decreased following introduction of AAC (more than 2-fold). At the patient level, most children (80.9%) engaged with the intervention: those who were Black or African American, who never used tobacco products/were not susceptible to use, and who used fewer non-cigarette tobacco products were more likely to engage, but only after multiple prompts versus a single prompt. Engagement was positively associated with lowering children's susceptibility to using tobacco at follow-up. A pediatric AAC model holds promise in deterring youth tobacco use, including among historically marginalized populations who may require additional support.

Substance use and abuse in pediatric transplant recipients: What the transplant provider needs to know

Substance abuse is infrequently addressed during pre- and post-transplant care. However, the significant increase in the use of nicotine- and marijuana-containing products in the general and transplant adolescent population is concerning. In addition, alcohol use/abuse remains prevalent in the US population as it is highly accessible. Pediatric transplant providers should be prepared to screen for the use of any of these substances (eg, alcohol, nicotine, marijuana, cocaine, opiates, amphetamines) and to counsel them about the dangers of substance use and abuse including the unique dangers of the substances as a transplant recipient. Formal screening tools (in children as young as 9 years) should always be used as casual assessment of substance abuse has a high failure rate. This review summarizes the substances most commonly used in adolescent transplant recipients and the approach that transplant providers should take in order to prevent, decrease, or halt use in this patient population.

The TOBg Tobacco Treatment Guidelines for Adolescents: A real-world pilot study

INTRODUCTION

We conducted a pilot study to: 1) obtain feedback from prevention practitioners in terms of their satisfaction, knowledge, and self-efficacy following exposure to the Tobacco Treatment Guidelines for Adolescents (TOBg Guidelines); and 2) examine the effectiveness of a school-based intervention based on the TOBg Guidelines on quit rates among a sample of adolescent tobacco users.

METHODS

Two parallel studies were conducted. In Study 1, prevention practitioners were exposed to a 1-day training in the TOBg Guidelines with assessment occurring before, immediately after, and at 6 months following the training. In Study 2, participating adolescent smokers were exposed to a 3-session group-based smoking cessation intervention that drew on the TOBg Guidelines and was delivered by practitioners trained in Study 1. The primary outcome measure was self-reported smoking status assessed at 1 month and at 6 months following baseline.

RESULTS

A total of 18 prevention practitioners and 65 adolescent tobacco users participated in the pilot study. The majority of practitioners reported high rates of satisfaction with the TOBg Guidelines and indicated that the guidelines positively influenced the manner in which they addressed tobacco use with adolescents. Prevention practitioners’ self-efficacy for intervening with adolescent smokers was also significantly increased following exposure to the TOBg Guidelines and training. Among adolescents exposed to the school-based intervention, 62.5% and 23.1% had reduced smoking by 50% or more at 1 month and at 6 months follow-up, respectively. No significant change in smoking abstinence was documented.

CONCLUSIONS

The TOBg Guidelines for adolescent smokers were well received by prevention practitioners and were feasible to implement in a real-world school setting.

[Tobacco use in Brazilian school adolescents: association with mental health and family context]

OBJECTIVE

To study the association between aspects of mental health and the family context with tobacco experimentation and consumption among Brazilian schoolchildren.

METHOD

A cross-sectional study using data from the National Survey of Schoolchildren's Health in Brazil conducted on 109,104 schoolchildren from the ninth year of elementary school, day scholars in public and private schools in all Brazilian state capitals and the Federal District. Descriptive analysis of variables, bivariate and multivariate analyses were performed with logistic regression estimates, adjusted for socioeconomic variables, obtaining the odds ratio (OR) and 95% confidence interval (95%CI).

RESULTS

Among the participants, 52.2% were female. Twenty point nine percent of the students reported having experimented with cigarettes at least once. Adolescents who experienced more often feelings of loneliness (OR: 2.07; 95%CI: 1.98-2.16), difficulty sleeping (OR: 2.37; 95%CI: 2.52-2.48) and lower social interaction (OR: 1.27; 95%CI: 1.26-1.32), were more likely to smoke, regardless of socioeconomic status. The schoolchildren of parents or caregivers (OR: 2.39; 95%CI: 2.29-2.49) who did not know what their children did in their free time (OR: 1.52; 95%CI: 1.46-1.59) were associated with more frequent cigarette smoking.

CONCLUSION

An association was seen between aspects of mental health and the family context with the experimentation and consumption of tobacco in adolescents enrolled in the study in Brazil. These associations are independent of school type, sex and skin colour. It is important that programmes for the prevention of tobacco use in adolescence emphasise these findings.

Smoking among adolescents is associated with their own characteristics and with parental smoking: cross-sectional study

BACKGROUND

This study aimed to analyze the association between smoking during adolescence and the characteristics of smoking and alcohol consumption among their parents.

DESIGN AND SETTING

Cross-sectional study in Londrina (PR), Brazil.

METHODS

The subjects comprised 1,231 adolescents aged 14-17 years. The adolescents and their parents answered a self-report questionnaire that asked for sociodemographic information and data on smoking and alcohol consumption. Multiple logistic regression models were used to analyze associations between smoking among adolescents and their characteristics (age, sex, period of the day for attending school, alcohol consumption and socioeconomic level) and their parents' characteristics (smoking, alcohol consumption, age and education level), adjusted according to the adolescents' characteristics (sex, age and socioeconomic level).

RESULTS

The prevalence of smoking among adolescents was 3.4% (95% confidence interval, CI: 2.4-4.4). Adolescents whose mothers or fathers were smokers were 2.0 and 2.5 times more likely to be smokers, respectively. The prevalence of smoking among adolescents with a smoking mother was 7.1% (95% CI: 2.6-10.7) and a smoking father, 5.4% (95% CI: 1.6-8.5). There were significant associations between smoking adolescents and age [5.2% (95% CI: 3.3-6.6)], studying at night [9.6% (95% CI: 4.0-15.5)] and alcohol consumption [69.0% (95% CI: 55.0-83.0)]. It was observed that the number of alcoholic beverage doses consumed was higher among smoking adolescents (P = 0.001).

CONCLUSION

Adolescent smoking was associated with smoking by their parents, regardless of the gender of the parents or adolescents. Age, alcohol consumption and studying at night are characteristics of adolescents that can contribute towards smoking.

Exposure to smoking in soap operas and movies: smoking cessation and attempts to quit

The objectives of this research were to evaluate whether there was an association between seeing an actor smoke in telenovelas, Brazilian films, or international films, and trying to quit and quitting among adult Brazilian smokers. Data from 39,425 participants in the Global Adult Tobacco Survey were used. Quit ratio (former smoker/former smoker + ever smoker) and proportions of current, former, and never smokers were calculated. Multivariable weighted regression was used to determine significant associations between quitting smoking and exposure to telenovelas and films. For current smokers, the odds of trying to quit were significantly higher among those who saw an actor smoking in a Brazilian film. Those who believed smoking caused serious illness and had rules in the home prohibiting smoking were significantly more likely to have tried to quit or had quit smoking. Exposure to smoking in the media may be different in adults than adolescents. Influential factors for trying to quit and quitting are rules prohibiting smoking at home, belief that smoking causes serious illness, and hearing about dangers of smoking in media.

Smoking Cessation in Adolescents: targeted approaches that work

Smoking Cessation in adolescents can be considered in a developmental context to enable the clinician to individualise the appropriate assessment and management of the young person they are seeing whether it is in a primary or tertiary care setting. Adolescence is a time of rapid neurocognitive and hormonal change with these factors affected by personality and behavioural factors as well as family, cultural and psychosocial context. Adolescents are uniquely vulnerable to smoking initiation and nicotine addiction throughout these years. Increased awareness of the risks of smoking and using opportunities to assess and intervene regarding smoking cessation are integral to clinical practice for all clinicians seeing young people. This review will discuss the demographics of adolescent smoking, risk factors, assessing smoking and nicotine addiction, the importance of brief interventions, the evidence base for appropriate interventions, particularly in high risk groups and will emphasise innovative training for health professionals in adolescent smoking cessation.

Nicotine and Tobacco Use Prevention among Youth and Families

OBJECTIVE

To review the importance of and evidence-based strategies to prevent tobacco use and promote tobacco cessation in the pediatric setting.

DATA SOURCES

Literature review of evidence-based resources on tobacco use and prevention/cessation interventions in the pediatric/adolescent population.

CONCLUSION

Knowledge of the impact of tobacco use on cancer risk, second- and third-hand smoke carcinogenesis, and newer methods of tobacco delivery is necessary to select appropriate and effective prevention and cessation strategies.

IMPLICATIONS FOR NURSING PRACTICE

Systematic evaluation of both parents and children for tobacco use can identify patients that will benefit from tobacco cessation interventions. Patients and families need education and support so they can make good decisions and adhere to recommendations for prevention and cessation of tobacco use.

Pediatricians' Confidence and Behaviors in Smoking Cessation Promotion and Knowledge of the Smoking Cessation Trust

BACKGROUND

Secondhand smoke exposure increases morbidity and mortality in children. Thirty-one percent of caregivers who accompany their children to the Ochsner Health Center for Children smoke, and none uses the services of the Smoking Cessation Trust (SCT), a free smoking cessation program for eligible Louisiana residents who began smoking before 1988. The objective of this study was 2-fold: first, to assess and compare pediatricians' confidence and behaviors in regard to smoking cessation promotion with caregivers, and second, to determine pediatricians' knowledge and comfort level with the SCT.

METHODS

Pediatricians were given a questionnaire to assess 12 parameters regarding their confidence and practice when screening, counseling, and referring caregivers to smoking cessation programs.

RESULTS

Thirty-six questionnaires were administered, of which 27 were completed (75%). Only 7.41% of respondents had formal training in smoking cessation, 18.52% had never heard of the SCT, and 92.59% do not refer to the SCT. All the pediatrician respondents stated that they were confident in their ability to screen for secondhand smoke exposure, 62.96% were confident in providing counseling, and 44.44% were confident in offering referrals. Most pediatricians very often or always screened for secondhand smoke exposure (77.78%); however, only 25.93% counseled smoking caregivers to quit, and only 11.11% provided a smoking cessation referral. Pediatricians stated that they were confident to screen, counsel, and refer caregivers; however, they were significantly less likely to report actually screening for secondhand smoke exposure (P<0.05), counseling (P<0.05), and referring caregivers (P<0.05).

CONCLUSION

Efforts should be made to increase the rate by which pediatricians provide smoking cessation, counseling, and referrals to the SCT through education and training.

Estilos parentais como fator de proteção ao consumo de tabaco entre adolescentes brasileiros

Resumo O objetivo foi analisar a associação entre o uso de tabaco (no mês e frequente) com os estilos parentais e o comportamento de fumar dos pais, em uma amostra de estudantes do Ensino Médio. Foram avaliados 17.246 estudantes do Ensino Médio de escolas públicas e privadas das 27 capitais brasileiras. A prevalência do uso de tabaco na vida foi de 25,2%, 15,3% no ano, 8,6% no mês, e 3,2% para uso frequente. Em relação aos estilos parentais, 39,2% dos pais foram classificados como negligentes, 33,3% autoritativos, 15,6% como indulgentes e 11,9% autoritários. Comparados a estudantes com pais autoritativos, filhos de pais negligentes ou indulgentes tiveram maior chance de relatar o uso no último mês ou frequente de tabaco. Observou-se uma associação entre o estilo parental e uso de cigarros por estudantes do Ensino Médio. O estilo parental autoritativo foi associado à proteção ao uso de tabaco no mês e frequente entre os adolescentes.

Determinants of cigarette smoking initiation in Jordanian schoolchildren: longitudinal analysis

OBJECTIVE

To identify determinants of cigarette smoking initiation, by gender, among schoolchildren in Irbid, Jordan.

METHODS

Between 2008 and 2011, data were collected annually using self-reported questionnaires over 4-years in a prospective cohort of 1,781 students recruited from all 7th grade classes in 19 secondary schools, selected out of a total 60, using probability-proportionate-to-size method. Independent predictors of smoking initiation were identified among the cigarette naïve participants (N = 1,454) with mixed-effect multivariable logistic regression.

RESULTS

Participants were 12.6 years of age on average at baseline. 29.8% of the 1,454 students (37.2% of boys and 23.7% of girls) initiated cigarette smoking by 10th grade. Of those who initiated (n = 498), 47.2% of boys and 37.2% of girls initiated smoking in the 8th grade. Determinants of cigarette smoking initiation included ever smoking a waterpipe, low cigarette refusal self-efficacy, intention to start smoking cigarettes, and having friends who smoked. For girls, familial smoking was also predictive of cigarette initiation.

CONCLUSION

This study shows that many Jordanian youth have an intention to initiate cigarette smoking and are susceptible to cigarette smoking modeled by peers and that girls are influenced as well by familial cigarette smoking. Prevention efforts should be tailored to address culturally relevant gender norms, help strengthen adolescents' self-efficacy to refuse cigarettes, and foster strong non-smoking social norms.

Insights into smoking and its cessation among current smokers in India

BACKGROUND

Initiation, perpetuation and cessation of smoking are all multifactorial. It is essential to explore interactions among various parameters influencing smoking and its cessation for effective smoking cessation interventions.

OBJECTIVES

To obtain insights into smoking and its cessation among current smokers in India.

MATERIALS AND METHODS

The present study was conducted among current smokers visiting the Department of Oral Medicine and Radiology, Manipal College of Dental Sciences (MCODS), Manipal University, Mangalore. Knowledge, attitudes, behavior, worksite practices towards smoking and its cessation, barriers to smoking cessation and socio-demographic variables were explored using a structured, pretested, self-administered questionnaire.

RESULTS

A total of 175 current smokers participated in the study. Mean knowledge, attitude, worksite practice and barrier scores were 15.2±5.67 (66.1%), 57.5±7.67(82.1%), 4.18±2.02 (41.8%) and 57.4±12.37 (63.7%) respectively. Correlation analysis revealed: association of knowledge with education, occupation and religion; attitude with education and occupation; worksite practices with occupation; knowledge with attitude; and barriers negatively with worksite practices. The majority (85.7%) of respondents intended to quit smoking and this was associated with higher attitude scores, whereas actual quit attempts were associated with high knowledge, attitudes, worksite practices and low barrier scores.

CONCLUSIONS

Various socio-demographic factors associated with smoking and its cessation were identified. The present study highlights the importance of identifying and targeting these interactions while framing guidelines and interventions for effective tobacco cessation in a developing country like India.

Health care provider advice for adolescent tobacco use: results from the 2011 National Youth Tobacco Survey

BACKGROUND

Health care providers play an important role in promoting tobacco use abstinence among adolescents. This study aimed to provide nationally representative data on the prevalence of provider tobacco use screening and advice delivered to adolescents. Cessation behaviors and correlates of past year quit attempts among current smokers are also explored.

METHODS

Data came from the 2011 National Youth Tobacco Survey, a nationally representative school-based survey of adolescents in grades 6 through 12 (n = 18385). Provider screening and advice were assessed by smoking status and demographic characteristics. Logistic regression was used to assess the association between advice and past year quit attempt.

RESULTS

The overall prevalence of current tobacco use was 16.6%; 10.8% were current cigarette smokers (3.6% were established smokers, 7.2% were nonestablished smokers); 17.3% were former smokers; and 71.9% were never smokers (22.6% high susceptibility, 77.4% low susceptibility). Among all respondents, the prevalence of being asked about tobacco use by a health care provider was 32.2%; the prevalence of being advised to quit or avoid tobacco was 31.4%. Established smokers were more likely than other groups to report provider assessment of tobacco use and advice. Receipt of advice was associated with a higher adjusted odds of having made a past year quit attempt (odds ratio: 1.47, 95% confidence interval: 1.18-1.82).

CONCLUSIONS

Less than one-third of adolescents report being asked about tobacco use or being advised not to use tobacco. Increased tobacco use intervention by health care providers is needed to prevent initiation and increase cessation.

The adolescent with asthma

The adolescent with asthma experiences a period of physical and psychosocial changes that affect their health and well-being. Overall, adolescents with asthma are at increased risk for asthma morbidity and death. Increased rates of depression and anxiety, for the adolescent and their caregivers, can lead to non-adherence to their medical regimens, poor symptom control, and poor treatment outcomes. Contextual factors, such as race, ethnicity, and living situation, affect the prevalence, morbidity, and mortality for the adolescent with asthma. These factors also affect the transition process for adolescents entering adult medical care. An overview is presented of how the adolescent with asthma differs and how healthcare providers can promote effective asthma management and better asthma control.

Parental smoking exposure and adolescent smoking trajectories

OBJECTIVE

In a multigenerational study of smoking risk, the objective was to investigate the intergenerational transmission of smoking by examining if exposure to parental smoking and nicotine dependence predicts prospective smoking trajectories among adolescent offspring.

METHODS

Adolescents (n = 406) ages 12 to 17 and a parent completed baseline interviews (2001-2004), and adolescents completed up to 2 follow-up interviews 1 and 5 years later. Baseline interviews gathered detailed information on parental smoking history, including timing and duration, current smoking, and nicotine dependence. Adolescent smoking and nicotine dependence were assessed at each time point. Latent Class Growth Analysis identified prospective smoking trajectory classes from adolescence into young adulthood. Logistic regression was used to examine relationships between parental smoking and adolescent smoking trajectories.

RESULTS

Four adolescent smoking trajectory classes were identified: early regular smokers (6%), early experimenters (23%), late experimenters (41%), and nonsmokers (30%). Adolescents with parents who were nicotine-dependent smokers at baseline were more likely to be early regular smokers (odds ratio 1.18, 95% confidence interval 1.05-1.33) and early experimenters (odds ratio 1.04, 95% confidence interval 1.04-1.25) with each additional year of previous exposure to parental smoking. Parents' current non-nicotine-dependent and former smoking were not associated with adolescent smoking trajectories.

CONCLUSIONS

Exposure to parental nicotine dependence is a critical factor influencing intergenerational transmission of smoking. Adolescents with nicotine-dependent parents are susceptible to more intense smoking patterns and this risk increases with longer duration of exposure. Research is needed to optimize interventions to help nicotine-dependent parents quit smoking early in their children's lifetime to reduce these risks.

The effects of cigarette smoke extract on ovulation, oocyte morphology and ovarian gene expression in mice

Cigarette smoking can harm fertility, but the existing research has targeted primarily on ovarian follicles, embryos or sex hormone. In this study, we tested cigarette smoke extract on ovulation, oocyte morphology and ovarian gene expression associated with inhibition of oxidative stress using C57BL/6 mice. Mice in the experimental group were administered a cigarette smoke extract (CSE) solution (2 mg/ml) orally daily, while the blank control group was given dimethylsulfoxide (DMSO). A positive control group (menadione) was used that received an intraperitoneal injection of 15 mg/kg menadione in oil solution daily. We found that the CSE group manifested a reduced diameter of zona pellucida-free oocyte (ZP-free OD) and a morphologically misshapen first polar body (PB). Our results suggest that CSE exposure is associated with a shrink size and poor quality of oocytes. Quitting smoking is a wise choice to ensure good fertility.

Changes in Attitudes, Intentions, and Behaviors toward Tobacco and Marijuana during U.S. Students' First Year of College

Tobacco and marijuana are commonly used by college students and have negative health effects. The purpose of this study was to understand how students’ attitudes, intentions, and behaviors toward tobacco and marijuana change during freshman year and to examine how attitude and intention predict use of these substances. 275 college students completed phone interviews before and after their freshman year. The identical interviews assessed students’ attitudes, intentions, and behaviors toward both substances. Attitudes and intentions increased significantly. 12.2% of participants initiated tobacco use and 13.5% initiated marijuana use. Only intention predicted tobacco initiation, while both attitude and intention predicted marijuana initiation. Overall, attitudes, intentions, and behaviors changed significantly toward favored use. Predictors of use varied by substance, suggesting that different prevention approaches may be beneficial.

Examining the nature of the association between attention-deficit hyperactivity disorder and nicotine dependence: a familial risk analysis

OBJECTIVE

To use familial risk analysis to examine the association between attention-deficit hyperactivity disorder (ADHD) and nicotine dependence (ND).

METHOD

Subjects were children with (n = 257) and without (n = 229) ADHD of both sexes ascertained from pediatric and psychiatric referral sources and their first-degree relatives (N = 1627).

RESULTS

ND in probands increased the risk for ND in relatives irrespective of ADHD status. There was no evidence of cosegregation or assortative mating between these disorders. Patterns of familial risk analysis suggest that the association between ADHD and ND is most consistent with the hypothesis of independent transmission of these disorders.

CONCLUSIONS

These findings may have important implications for the identification of a subgroup of children with ADHD at high risk for ND based on parental history of ND.

US prevalence and trends in tobacco smoke exposure among children and adolescents with asthma

OBJECTIVE

To examine exposure to tobacco smoke products (TSPs), environmental tobacco smoke (ETS), and in-home smoke among youth with asthma in the United States.

METHODS

Nationally representative, cross-sectional data from 2250 youth aged 4 to 19 years with current asthma in the 1988-1994, 1999-2004, and 2005-2010 National Health and Nutrition Examination Survey (NHANES) were analyzed. Outcomes were use of TSPs (serum cotinine level >10 ng/mL or self-reported recent use of cigarettes, cigars, or pipes) and, among non-TSP users, ETS exposure (serum cotinine ≥0.05 ng/mL) and in-home smoke exposure (reported). Multiple logistic regression analyses assessed the associations between the outcomes and age, gender, race/ethnicity, and family income.

RESULTS

Among adolescents (aged 12-19 years) with asthma in 2005-2010, 17.3% reported TSP use. Among youth (aged 4-19 years) with asthma who did not use TSPs, 53.2% were exposed to ETS and 17.6% had in-home smoke exposure. Among low-income youth, 70.1% and 28.1% had exposure to ETS and in-home smoke, respectively. After controlling for sociodemographic factors, higher prevalence of exposure to ETS and in-home smoke persisted among low-income youth. Between 1988-1994 and 2005-2010, there was a decline in ETS and in-home smoke exposure (both P < .001).

CONCLUSIONS

ETS exposure among youth with asthma declined between 1988-1994 and 2005-2010, but a majority remained exposed in 2005-2010, with higher exposure among low-income youth. More than 1 in 6 youth with asthma in 2005-2010 were exposed to in-home smoke and a similar portion of adolescents used TSPs.

Do stimulants reduce the risk for cigarette smoking in youth with attention-deficit hyperactivity disorder? A prospective, long-term, open-label study of extended-release methylphenidate

OBJECTIVE

Although attention-deficit hyperactivity disorder (ADHD) is a well-known risk factor for cigarette smoking, prospective studies aimed at reducing smoking risk in this population are critically needed.

STUDY DESIGN

This was a 2-year, prospective, open-label clinical trial of extended-release methylphenidate for smoking prevention in adolescents with ADHD (n = 154). Smoking outcomes were assessed with the Fagerstrom Tolerance Questionnaire. Comparisons were made using data from a historical, naturalistic sample of ADHD (n = 103) and non-ADHD comparators (n = 188) of similar age and sex assessed with the same assessment battery as that used in subjects participating in the clinical trial.

RESULTS

The smoking rate at endpoint (mean, 10 months of methylphenidate treatment) was low in the clinical trial subjects and not significantly different from that in the non-ADHD comparators or the ADHD comparators receiving stimulants naturalistically (7.1% vs 8.0% vs 10.9%; P > .20). In contrast, the smoking rate was significantly lower in the clinical trial subjects than in the naturalistic sample of ADHD comparators who were not receiving stimulant treatment (7.1% vs 19.6%; P = .009 [not significant], adjusting for comorbid conduct disorder and alcohol and drug abuse).

CONCLUSION

Although considered preliminary until replicated in future randomized clinical trials, the findings from this single-site, open-label study suggest that stimulant treatment may contribute to a decreased risk for smoking in adolescents with ADHD. If confirmed, this finding would have significant clinical and public health impacts.

Pediatric residency training director tobacco survey II

OBJECTIVE

To assess the current status of pediatric residency training on tobacco use and smoke exposure.

METHODS

A nationwide survey of all pediatric residency training directors in the United States was conducted from November 2010 to May 2011 via use of surveymonkey.com. The survey assessed training director characteristics, attitudes and beliefs about pediatricians' role in addressing tobacco control in patients and parents, past training in tobacco use and smoke exposure, inclusion of tobacco control in their training curriculum, and barriers to inclusion. Data are presented as percentages, with χ(2) tests of significance.

RESULTS

Sixty-five percent of programs included tobacco control in the curriculum, and training directors who received past training in tobacco prevention and control were significantly more likely to include tobacco use and smoke exposure than those without training. The vast majority of training programs focused on health effects as opposed to intervention, failed to employ active learning to teach tobacco intervention skills, did not evaluate resident tobacco knowledge and skills, and did not encourage use of medications to help parents quit smoking.

CONCLUSIONS

Pediatric residency training programs must do more to prepare residents to address tobacco use and smoke exposure. Given the many competing priorities of residency training, there is a need to explore new ways of integrating tobacco control into the 3-year curriculum.

Cigarette smoke impairs granulosa cell proliferation and oocyte growth after exposure cessation in young Swiss mice: an experimental study

Background

Cigarette smoke is associated with decreased female fertility, causing damage to ovarian function and disturbing follicle development. However, the effects of cigarette toxicants on ovarian function depend on duration and intensity of exposure. The aim of this study was to assess the effects of brief, intense exposure to tobacco smoke on granulosa cell number, oocyte growth, and follicle size during puberty in female Swiss mice.

Methods

Ten female Swiss mice aged 35 days were exposed to tobacco smoke from 3R4F reference research cigarettes. They were exposed to an automatic smoking machine 8 h/day, 7 days/week for 15 days. Ten age-matched controls were kept in a different room and exposed to ambient air. At the end of 15 days, five mice in each group were euthanized and the ovaries were analyzed for follicular morphometry and granulosa cell count. The remaining animals were kept for an additional 30 days for further analysis as an ex-smoker group and control group. Comparison between the two groups was evaluated by the Student’s t-test or a two-way ANOVA followed by Bonferroni post-test was applied for multiple comparisons.

Results

We found that cigarette smoke impaired antral follicular growth even after exposure cessation (p < 0.001). Both smoking and ex-smoking groups exhibited similar follicle diameter. However, at the same follicular stage, the number of granulosa cells was smaller in the ex-smoking group compared to smoking animals (p < 0.001). This was associated with increased oocyte diameter in ex-smoking animals compared to smoking animals (p < 0.01).

Conclusions

The negative effects of cigarette smoking seem to last even after exposure has been interrupted. Moreover, brief exposure during puberty may induce silent oocyte disruption, which could in turn lead to decreased fecundity rates.

Smoking and health-related quality of life among U.S. Adolescents

OBJECTIVE

Smoking continues to be a public health problem among youth. Developmentally, adolescence is a period marked by the vulnerability to initiate risk behaviors such as smoking. While studies have documented associations between smoking and poor health related quality of life (HRQOL) among adults, little is known about the association among adolescents.

METHODS

Data on smoking and HRQOL from a sample of 4,848 adolescents aged 12-17 years from the 2001-2008 National Health and Nutrition Examination Surveys were analyzed. Smoking status (current, not current, and never) was determined using self-report data and serum cotinine levels. HRQOL was assessed based on self-reported physical and mental health in the last 30 days, activity limitations in the last 30 days, and general self-rated health.

RESULTS

Compared with never smokers, adolescents who ever smoked reported more recent physically unhealthy days (p < .001), mentally unhealthy days (p < .0001), and activity limitation days (p < .01). Compared with never smokers, adolescents who ever smoked or who were current smokers were more likely to report ≥ 14 physically unhealthy days, ≥ 14 mentally unhealthy, ≥ 14 activity limitation days, and fair or poor health; not current smokers were also more likely than never smokers to report ≥ 14 days for being both physically unhealthy and mentally unhealthy.

CONCLUSIONS

Among a nationally representative sample of adolescents, this study found strong associations between smoking and HRQOL measures. The relationship of smoking to self-reported activity limitations warrants attention and further research. The findings underscore the importance of addressing smoking and subjective well-being early in the lifespan.

Cigarette smoking as a risk factor for other substance misuse: 10-year study of individuals with and without attention-deficit hyperactivity disorder

BACKGROUND

We previously documented that cigarette smoking is a risk factor for subsequent alcohol and drug misuse and dependence in adolescent girls with attention-deficit hyperactivity disorder (ADHD).

AIMS

To revisit this hypothesis with a large longitudinal sample of both genders followed up for 10 years into young adulthood.

METHOD

We used data from two identically designed, longitudinal, case-control family studies of boys and girls with and without ADHD ascertained from psychiatric and paediatric sources. We studied 165 individuals with ADHD and 374 controls followed up longitudinally and masked for 10 years. We assessed ADHD, smoking and substance use status using structured diagnostic interviews. We tested the association between cigarette smoking and subsequent substance use outcomes using Cox proportional hazard regression models.

RESULTS

Youth with ADHD who smoked cigarettes (n = 27) were significantly more likely to subsequently develop drug misuse and dependence compared with youth with ADHD who did not smoke (n = 138, P<0.05).

CONCLUSIONS

These results confirm that cigarette smoking increases the risk for subsequent drug and alcohol use disorders among individuals with ADHD. These findings have important public health implications, and underscore the already pressing need to prevent smoking in children with ADHD.

Substance use screening, brief intervention, and referral to treatment for pediatricians

As a component of comprehensive pediatric care, adolescents should receive appropriate guidance regarding substance use during routine clinical care. This statement addresses practitioner challenges posed by the spectrum of pediatric substance use and presents an algorithm-based approach to augment the pediatrician's confidence and abilities related to substance use screening, brief intervention, and referral to treatment in the primary care setting. Adolescents with addictions should be managed collaboratively (or comanaged) with child and adolescent mental health or addiction specialists. This statement reviews recommended referral guidelines that are based on established patient-treatment-matching criteria and the risk level for substance abuse.

Effectiveness of a school nurse-delivered smoking-cessation intervention for adolescents

OBJECTIVE

To evaluate the effectiveness of a school nurse-delivered smoking-cessation intervention in increasing abstinence among adolescent smokers.

METHODS

Thirty-five high schools were pair-matched and randomly assigned to 1 of 2 conditions, each of which consisted of 4 visits with the school nurse: (1) counseling intervention using the 5 A's model and cognitive-behavioral techniques; or (2) an information-attention control condition. Adolescents (n = 1068) who reported past 30-day smoking and interest in quitting completed surveys at baseline and at 3 and 12 months and provided saliva samples for biochemical validation of reported smoking abstinence.

RESULTS

Intervention condition participants were almost twice as likely to be abstinent per self-report at 3 months (odds ratio: 1.90 [95% confidence interval: 1.12-3.24]; P = .017) compared with control participants; at 12 months there were no differences. The difference at 3 months was driven by quit rates in male students (15.0% [intervention] vs 4.9% [control]; odds ratio: 3.23 [95% confidence interval: 1.63-6.43]; P = .001); there was no intervention effect in female students at either time point (6.6% vs 7.0% at 3 months and 16.6% vs 15.5% at 12 months) and no intervention effect in male students at 12 months (13.9% vs 13.2%). Smoking amount and frequency decreased significantly in intervention compared with control schools at 3 but not at 12 months.

CONCLUSIONS

A school nurse-delivered smoking-cessation intervention proved feasible and effective in improving short-term abstinence among adolescent boys and short-term reductions in smoking amount and frequency in both genders. Additional research is needed to enhance both cessation and maintained abstinence.

Adolescent alcohol and tobacco use and early socioeconomic position: the ALSPAC birth cohort

OBJECTIVE

To examine the association between use of alcohol and cigarettes among adolescents and their early socioeconomic background.

METHODS

Members of a longitudinal birth cohort (Avon Longitudinal Study of Parents and Children [ALSPAC], United Kingdom) were invited to attend a personal interview. A total of 5837 children aged 13 years were asked about previous consumption of alcohol and tobacco. Information on parental socioeconomic position, collected from questionnaires from the mother, included both social class and education of the expectant mother and her partner and average household disposable income in early preschool childhood. The impact of missing data was assessed by multiple imputation.

RESULTS

Consuming a drink of alcohol in the previous 6 months was linearly associated with higher income levels even when adjusting for other socioeconomic indicators. In contrast, both the risk of binge drinking and recent drinking was lower for children whose mothers had a higher educational level. Smoking tobacco was associated with lower socioeconomic position irrespective of the indicator used. Analyses after imputation of missing data confirmed these associations.

CONCLUSIONS

Alcohol drinking was more common in young people from higher-income households but less common with higher levels of maternal education. A consistent inverse socioeconomic gradient with tobacco smoking was apparent. These results may reflect how different aspects of socioeconomic position can influence health behavior in opposing directions. Higher income may increase the availability of alcohol in the family, whereas mothers with higher educational attainment might encourage more healthy behaviors in their children, including reduced alcohol use.

Adolescent gender differences in the determinants of tobacco smoking: a cross sectional survey among high school students in São Paulo

BACKGROUND

Diverse psychosocial factors have been associated with the use of cigarettes by adolescents. We investigated gender differences in tobacco smoking, and factors correlated with smoking among boys and girls.

METHODS

Data was collected on recent cigarette smoking (CS) and related factors, with a focus on religious beliefs, leisure activities, family structure, relationships and parental monitoring from 2,691 private school-attending youths from 28 schools in São Paulo, Brazil, selected via probability sampling. Estimates were derived via weighted hierarchical logistic regression models.

RESULTS

There was no difference in the prevalence of recent cigarette smoking between boys and girls (14.2%). Older age (aORboys = 1.71[1.33-2.21]; aORgirls = 1.73[1.35-2.23]), second-hand smoke exposure at home (aORboys = 1.52[1.00-2.29]; aORgirls = 1.74[1.13-2.68]) and not having a religion (aORboys = 1.99[1.41-2.81]; aORgirls = 1.78[1.14-2.78]) were associated with CS in boys and girls. Adolescents who went out often at night were more likely to be tobacco smokers (aORboys = 8.82[3.96-19.67]; aORgirls = 14.20[6.64-30.37]). For girls, data suggest that CS was also associated with a lack of parental attention and care (aORgirls = 4.37[1.19-16.04]) and no participation in youth religious activities (aORgirls = 2.76[1.49-5.12]). For boys, CS was additionally associated with the loss of one or both parents (aORboys = 3.75[1.78-7.85]).

CONCLUSIONS

Although older age, living with smokers at home and lack of religion were common contributing factors to cigarette smoking among all adolescents, girls were influenced to a greater degree by family relationships and religiosity than boys. The study results may be materially important to the development of prevention programs that influence determinants connected to gender and the implementation of single-core models of prevention; gender differences must be considered in order to reduce adolescent CS.

Smoking Cessation Treatment for Adolescents

Cigarette smoking in the adolescent population remains a public health concern. A significant portion of the adolescent population currently uses tobacco. Nicotine is particularly addicting in adolescents, and quitting is difficult. The goals for adolescent cigarette smoking efforts must include both primary prevention and smoking cessation. Bupropion and nicotine replacement therapies—including nicotine patches, gum, and nasal spray—have been studied to a limited extent in the adolescent population. Varenicline has not been evaluated as a treatment modality in adolescents. Long-term quit rates in the pharmacotherapy trials have not been optimal; however, decreases in cigarettes smoked per day have been observed. Several evidencebased guidelines include recommendations for smoking cessation in adolescents that include counseling and pharmacotherapy. Pharmacotherapy may be instituted for some adolescents in addition to counseling and behavioral interventions. Therapy should be individualized, based on smoking patterns, patient preferences, and concomitant disease states. Smoking cessation support for parents should be instituted as well. The pharmacist can play a large role in helping the adolescent quit smoking. Further studies evaluating pharmacotherapy options for smoking cessation in adolescents are necessary. If pharmacotherapy is used, it should be individualized and combined with psychosocial and behavioral interventions.

From the American Academy of Pediatrics: Policy statement--Tobacco use: a pediatric disease

Tobacco use and secondhand tobacco-smoke (SHS) exposure are major national and international health concerns. Pediatricians and other clinicians who care for children are uniquely positioned to assist patients and families with tobacco-use prevention and treatment. Understanding the nature and extent of tobacco use and SHS exposure is an essential first step toward the goal of eliminating tobacco use and its consequences in the pediatric population. The next steps include counseling patients and family members to avoid SHS exposures or cease tobacco use; advocacy for policies that protect children from SHS exposure; and elimination of tobacco use in the media, public places, and homes. Three overarching principles of this policy can be identified: (1) there is no safe way to use tobacco; (2) there is no safe level or duration of exposure to SHS; and (3) the financial and political power of individuals, organizations, and government should be used to support tobacco control. Pediatricians are advised not to smoke or use tobacco; to make their homes, cars, and workplaces tobacco free; to consider tobacco control when making personal and professional decisions; to support and advocate for comprehensive tobacco control; and to advise parents and patients not to start using tobacco or to quit if they are already using tobacco. Prohibiting both tobacco advertising and the use of tobacco products in the media is recommended. Recommendations for eliminating SHS exposure and reducing tobacco use include attaining universal (1) smoke-free home, car, school, work, and play environments, both inside and outside, (2) treatment of tobacco use and dependence through employer, insurance, state, and federal supports, (3) implementation and enforcement of evidence-based tobacco-control measures in local, state, national, and international jurisdictions, and (4) financial and systems support for training in and research of effective ways to prevent and treat tobacco use and SHS exposure. Pediatricians, their staff and colleagues, and the American Academy of Pediatrics have key responsibilities in tobacco control to promote the health of children, adolescents, and young adults.