Tobacco 101
Judith A. Groner MD
Clinical Professor of Pediatrics
The Ohio State University College of Medicine
Nationwide Children’s Hospital, Columbus, Ohio
…dedicated to eliminating
children’s exposure to secondhand
smoke and tobacco
www.aap.org/richmondcenter
o Audience-Specific Resources
o State-Specific Resources
o Cessation Information
o Funding Opportunities
o Reimbursement Information
o Tobacco Control E-mail List
o Pediatric Tobacco Control Guide
o Tobacco Prevention Policy Tool
Communities Putting Prevention to
Work (CPPW)
Seeks to implement evidence- and
practice-based strategies to:
o Reduce smoking
prevalence
o Decrease teen
smoking initiation
o Reduce exposure to
secondhand smoke
No conflict of interest to report
Learning Objectives
o Know the health effects of smoking and
secondhand smoke
o View smoking and exposure to tobacco as a
health disparity
o Understand why nicotine is so addictive
o Know basics principles of tobacco treatment
o Have an approach to adolescent smoking
o Be aware of new emerging tobacco products
48 Years After the 1st Surgeon
General’s Report –
People Still Smoke!
o 21% of US adults are smokers
o 18% of children ages 3-11 are regularly
exposed to secondhand tobacco smoke
(SHS) in the home
Smoking as a Health Disparity

Who smokes?
o About 20% of US population, slightly lower rates
among women
o In California, 12% (15% male, 9% female) current
daily smokers
o 54% exposed to SHS
o Geographical diversity
 (higher rates in Kentucky, West Virginia, lower in
California, Connecticut)
o Smoking rates inversely related to education &
income
o People who can least afford cigarettes & tobaccorelated disease
Smoking Affects Families
o Average cost of pack of cigarettes - $5.50
o In Santa Clara county – between $4.24 - $5.40
(not including .87 tax)
o State-state differences in price
o A ½ pack per day habit costs $1000 to $1500
a year
o Parental smoking related to food insecurity
Cost of Cigarettes
Local Data – Santa Clara County
o Prevalence of 1/10 adults
o Low income adults – 2/10
o Higher rates among subgroups
(25% Vietnamese men, 11% API and
Hispanic men, 21% Filipinos)
o At least $380 million/year spent on tobacco
related illness
o Twice the rate of asthma as non-smokers
The Life Cycle of Harm from
Tobacco Use
Asthma
Otitis Media
Fire-related Injuries
SIDS
Bronchiolitis
Meningitis
Influences
to Start
Smoking
Childhood
Infancy
In utero
Low Birth Weight
Stillbirth
Neurologic/Behavior/
Learning Problems
Decrease lung growth
Asthma
Adolescence
Adulthood
Nicotine Addiction
Cancer
Cardiovascular Disease
COPD
Attributable to Active Smoking
o
o
o
o
o
o
30% of cancer deaths
90% of all COPD cases
30% of cardiovascular disease
Overall the chief avoidable cause of death in US
Directly responsible for 1/5 of all deaths
$100 billion in health care costs, $97 billion
in lost productivity
o Per year, smokers incur, $1600 more in health
care costs
SHS - Cigarette Smoke Components
Carbon Monoxide
Tar
Gas from car exhausts
Road surfaces
Nicotine
Butane
Pesticide
Lighter fuel
Acetone
Ammonia
Nail varnish remover
Cleaning products
Arsenic
Methanol
Rat poison
Rocket fuel
Hydrogen Cyanide
Formaldehyde
Poison used on death row
Used to pickle dead bodies
Radon
Formaldehyde
Radioactive gas
Batteries
Sources of Exposure
o
o
o
o
o
o
o
o
Home
Car
Daycare
Outdoors – parks,
fairs, outdoor dining
Grandparents
Non-custodial parents
Friends
Multiunit housing
SHS, Heart Disease & Adults
o Relative risk: atherosclerotic heart disease
in SHS exposed non-smokers – 1.30
o Acute cardiac syndrome - 1.50
o Heart disease risk in smokers not much
greater – 1.78
o Impact of smoking bans (natural observational
experiments)
o Hospital admissions for MI ↓ almost 50% (Montana)
o Scotland – ACS admissions ↓ 17% after smoke-free
legislation
Cardiovascular Impact of SHS
Why Does this Happen?
o Exposure to tobacco smoke - < 1%
of active smoker (20 cigs/day)
o Negligible exposure to nicotine
and CO
o One likely contributor –
oxidant gas exposure
SHS Exposure
Population Attributable Risks
 Annually:
o 200,000 cases of
childhood asthma
o 150,000-300,000 cases of
lower respiratory illness
o 800,000 middle ear
infections
o 25,000-72,000 low birth
weight or preterm infants
o 430 cases of SIDS
Secondhand Smoke (SHS) Exposure
as a Health Disparity
 Who is exposed to SHS?
o Overall, about 25% of US children
o More than 2 in 5 households in Santa Clara
County that allow cigarette smoking inside
the house have kids 5 years of age
and younger
o Children in low-income homes –
as high as 79%
Secondhand Smoke (SHS) Exposure
as a Health Disparity
 Who is exposed to SHS?
o 12.3% in lowest income families ADMIT to
in-home SHS exposure/ compared to 2.3%
in highest income
o At least 50% of African American children
o More than 1/3 of children in
low SES homes
o Our data – Medicaid status independently
associated with hair nicotine level in
children (exposure measure)
SHS Exposure as a Health Disparity
 Why does this matter?
o Concentration of multiple exposures among low
SES children
 Lead, air pollution, SHS
 Obesity
o Exposure throughout the lifespan
o Modeling behavior – more likely to become
active smokers
o Teens are twice as likely to smoke if they have
one parent who smokes
What is Thirdhand Smoke?
o So what do we call the left-over
contamination to a room/car that
persists after the smoke is gone?
o The condensate on the glass from a
smoking chamber was used in one of the
first studies linking smoking & cancer
o Homes and cars in which people have
smoked may smell of cigarettes for
long periods
Thirdhand Smoke
Effect of Cigarette Smoke on
Indoor Air Quality
…it takes TWO
hours for the
air quality to
return to
normal for
levels of CO,
fine particles
and particulate
aromatic
hydrocarbons...
Thirdhand Smoke – the “R”s
o Residual tobacco smoke pollutants
o Remain on surfaces & in dust
o Re-emitted back into gas phase or
o React with oxidants & other compounds
to create secondary pollutants
So How Toxic is
Thirdhand Smoke (THS)?
o Good Question
o At this point not well known
o Potential for nicotine on surfaces to react
with nitrous acid
o Air pollutant found in vehicle exhaust,
improperly vented gas stoves, burning tobacco
o Form tobacco specific nitrosamines carcinogens
o Ozone reacts with 50 compounds in SHS
o Ultrafine particles deposit on surfaces &
then re-suspend in air
So How Toxic is Thirdhand Smoke
(THS)?
o California Tobacco-Related Disease
Research program (funded by California
tobacco tax) will fund research on
this topic
o Public aware of THS in terms of smell,
cleanliness, property values
So What Impact Does THS Have
on My Practice?
o The concept of THS resonates with
many parents
o Non-smoking parents are more likely to be
able to smell it, however…
o This can be used to focus a discussion
on protecting the family by making sure
areas are not contaminated
o 100% SMOKE FREE HOMES AND CARS
28
Why Do People Smoke?
o NICOTINE
o Nicotine is NOT a carcinogen
o Combustion products of cigarettes ARE
carcinogens & most likely responsible
for heart disease
Why Do People Smoke?
Tobacco is a substance of abuse/ Nicotine
is the addictive drug
o Appetite suppression
o Alert relaxation
o Increases metabolism
o Can be titrated via depth/frequency of puff
o And causes withdrawal after seven
cigarettes in a row
Distribution of Nicotine from
Cigarettes
o Enters body via pulmonary circulation
o Moves quickly (6-8 seconds) into brain
o Bind to nicotinic cholinergic receptors
o Rapid behavioral reinforcement
o Smoker can control concentration in
the brain
Nicotine – Tolerance & Relief of
Aversive States:
o Tolerance occurs with chronic smoking
o Proliferation of receptors and higher levels
of self administration
o Reduction of anxiety/stress from nicotine
deprivation
o Relief from hunger
o Nicotine’s “enhancement” of attention and
cognition - mainly reversal of withdrawal
effects
Pleasure and other subjective N
and cognitive benefits of smoking
Body weight control
N
Reduced discomfort from
tobacco abstinence
N
Cost
Social Pressures
Environmental Cues
(conditioning)
N
= motivation
factors that
are
determined by
pharmacologic
actions of
nicotine
Continued
Smoking
or
Relapse
Addiction
vs.
Free Will
Health Concerns
N
Social Pressures
Quitting
Smoking
Principles of Tobacco Dependence
Treatment
o Nicotine is addictive
o Tobacco dependence is a chronic
condition
o Effective treatments exist
o Every person who uses tobacco should
be offered treatment
Smokers Want to Quit
o 70% of tobacco users report wanting
to quit
o Most have made at least one quit attempt
o Cite physician/clinician/health expert
advice as important
o Previous quit attempts – most important
determinant of ultimate success
o So attempts, and relapse --- mean that
eventually smoker may succeed!
Tobacco Use in Different Groups
o Youth/Adolescents
o Pregnant Women
o Persons with psychiatric disorders
o African Americans – non-Hispanic
o Asian Americans
o Hispanic/Latino
o Native American/Alaskan
Adolescent Smoking
o Tobacco addiction begins in childhood &
adolescence
o 80-90% of adult smokers began during
adolescence
o 2/3 of those became daily smokers before
age 19
o 26.5% of high school seniors (2007) - current
smokers
o Disparities - Inverse relationship to SES &
education level – (same as adult smokers)
Youth Smoking in Santa Clara County
o 8% of middle & high school students
o Most common age to start smoking is
13 years
o 25% of middle school kids & 2/3 of high
school kids report it is easy to get
cigarettes
Adolescent Smoking - Prevention
 Public heath approaches
o Adolescents are cost sensitive
o Changing social norms
o Advertising
o Smoke-free movies
o Clean indoor air legislation
 Patient-level strategies
o Another A – “anticipate” – discuss tobacco
use early
Adolescent Smoking –
Nicotine Addiction
o Recent evidence - addiction in teens occurs
after short term use
o ‘Loss of autonomy’ - 10% within 2 days of
smoking; 25% within 1 month
o Physical and psychological withdrawal
symptoms even without daily use
o Adolescents underestimate addictive
nature of nicotine
Adolescent Smoking - Treatment
 Most teens want to quit
 But few do
 Motivation – need short term goals
o Decreased cough
o Increased exercise tolerance
o Nicotine staining
o Smell of cigarettes
Adolescent Smoking - Treatment
 Tobacco dependence treatment
o Evidence base strong in adults
o Evolving evidence in adolescents
o Cognitive-behavioral counseling approach –
shown to be effective
o Pharmacotherapy – approved for
18 yrs and older
o May be useful for clinician but off label use
o NRT has been shown to be safe in
adolescents
Smoking During Pregnancy Immediate Outcomes
o
o
o
o
o
o
Miscarriage
Fetal death
Pre-term deliveries
Low birth weight baby
Ectopic pregnancies
Placenta previa and placental
abruption
o SIDS
o Birth Defects (cleft lip/palate,
heart defects, webbing)
Smoking During Pregnancy –
Late Outcomes
o Decreased IQ in
offspring
o Behavior problems
(ADHD and other
externalizing problems)
o Decreased lung growth
o Increased prevalence
of asthma
Persons with
Psychiatric Disorders
o 2-4x more likely to be tobacco dependent
o Increased risk of tobacco-related illness
o 60% of current smokers report a history
of mental illness in their life
o Tobacco as a form of self-treatment
o It has been accepted that these persons
‘can’t quit’
o Psychiatric hospitals not yet smoke free!
Will Cessation Affect
Their Illness?
o Treatment is safe and is usually
well tolerated
o Evidence supports an association
between cessation and decreased
relapse to alcohol and/or drug use
o Little evidence that nicotine withdrawal
will escalate psychiatric symptoms
Special Considerations
o Be aware of increased tobacco use in
persons with psychiatric illnesses
o Users with psychiatric disorders will
require more than a brief intervention
o Refer to intensive programs
o Address tobacco use in all settings
o Including inpatient psychiatric facilities,
detention centers, etc.
Tobacco Use by
Black Non-Hispanic Populations
o 21.3% of Black non-Hispanic
adults smoke
o Males (24%) > females (19%)
o Black youth start smoking at older ages
o Making it out of high school without
starting doesn’t mean they’ll never start
o Menthol cigarettes popular
Menthol Cigarettes
o 83% of Black smokers use mentholated
brands; 24% of Caucasians
o Local anesthetic – relieves
throat irritation
o May increase absorption of toxins
o Cooling, numbing properties may permit
larger puffs, deeper, longer inhalations
Tobacco Use and
Asian-Americans
o 12% of adult Asian-Americans smoke
o Males (16.9%) > females (7.5%)
o Asian-Americans initiate smoking later
in life
o Among the most successful at quitting
permanently
Tobacco Use and Hispanics
o 14.5% of Hispanic adults smoke
o Males (19%) > females (9.8%)
o Hispanic smokers are more likely to
make a quit attempt than whites, though
less likely to receive counseling,
medications
o Hispanic households likely to have
smoking bans
Tobacco Use and American Indians
and Alaska Natives
o 23.2% of adult American
Indians/Alaska Natives smoke
o Males (29.7%) > females (no data)
o Teen estimated at 46%
o Tobacco plays an important cultural
role as a sacred gift of the earth
Emerging Products
o Snus
o Dissolvables
o Little Cigars and Cigarillos
o Hookah
o New / E-Cigarettes
o Roll Your Own
Snus
Snus. A spitless tobacco
packaged in small teabaglike pouches. Modeled after
a Swedish product
o Marlboro snus – tested
starting 2007 in plastic packs,
now in smaller foil packs
o Camel snus – Ads now appear
nationally in magazines
Images: Philip Morris, tobaccoproducts.org. socialbranding.org
Little Cigars
First asked in 2010 past
YEAR use, 12th graders: 23%
Males: 30%
Females: 16%
Hookah
First asked in 2010 past
YEAR use, 12th graders: 17%
Males: 19%
Females: 15%
Dissolvable Tobacco
Dissolvables Look a lot Like Candy
E-Cigarettes
(aka Electronic Nicotine Delivery Systems)
E-Cigarettes
o New evidence of acute pulmonary
effects
o Experimental use for 5 minutes:
o Increase in peripheral airway flow
resistance
o Increase in oxidative stress
o Long term risks are unknown
The FDA
o Current jurisdiction – cigarettes,
smokeless tobacco, and ‘roll your own’
o Currently has not asserted jurisdiction
cigars, dissolvable, electronic cigs,
and hookah
o However, law allows FDA to expand
jurisdiction if it benefits public health
The FDA
o Example – Menthol
o FDA advisory committee – recommended
to ban from cigarettes
o Nothing has happened yet
o FDA rule to require more graphic
tobacco packaging in appeals court
Local Resources
o Breathe California (manage Cessation
network throughout the county)
408-998-5865
o NO BUTTS helpline: 1-800-662-8887
Contact Us
o Contact the AAP Richmond Center:
o Website:
http://www.aap.org/richmondcenter/
o Email: [email protected]
o AAP Richmond Center-- Home
o Link at lower left corner to Richmond
Center email list
o Telephone:
• Elk Grove Village Office:
(847) 434-4264
Questions?
Jessica Liu- 1st Place winner Grades 6-8,
2009 AAP Richmond Center Art Contest