Published online August 1, 2006
PEDIATRICS Vol. 118 No. 2 August 2006, pp. e471-e487 (doi:10.1542/peds.2004-2413)

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REVIEW ARTICLE

Smoking Rates and the State of Smoking Interventions for Children and Adolescents With Chronic Illness

Vida L. Tyc, PhD^a,b and Leslee Throckmorton-Belzer, PhD^c

^a Division of Behavioral Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
^b Department of Pediatrics, University of Tennessee, College of Medicine, Memphis, Tennessee
^c Department of Psychology, University of Memphis, Memphis, Tennessee

	ABSTRACT

TOP ABSTRACT ASTHMA CF CANCER SCD DIABETES JRA MEDICAL, TREATMENT-RELATED, AND... PSYCHOSOCIAL RISK FACTORS... SMOKING INTERVENTIONS FOR... SMOKING INTERVENTIONS DELIVERED... IMPLICATIONS FOR CLINICIAN... SUMMARY AND FUTURE DIRECTIONS REFERENCES

 
Engaging in smoking is particularly risky for children and adolescents with chronic illness whose health status is already compromised because of disease- and treatment-related complications. Yet, some of these youngsters smoke at rates at least comparable to those of their healthy peers. To date, few randomized smoking-prevention and cessation trials have been conducted in children with chronic medical problems. In this review we report on the smoking rates among youngsters with chronic illness, identify specific disease- and treatment-related complications that can be exacerbated by smoking, examine risk factors associated with tobacco use among medically compromised youngsters, and review smoking interventions that have been conducted to date with pediatric populations in the health care setting. The following chronic illnesses are included in this review: asthma, cystic fibrosis, cancer, sickle cell disease, juvenile-onset diabetes, and juvenile rheumatoid arthritis. Objectives for a tobacco-control agenda and recommendations for future tobacco studies in chronically ill pediatric populations are provided. Finally, tobacco counseling strategies are suggested for clinicians who treat these youngsters in their practices.

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Key Words: smoking • tobacco • children and adolescents • interventions • clinicians

Abbreviations: CF—cystic fibrosis • SCD—sickle cell disease • IDDM—insulin-dependant diabetes mellitus • RA—rheumatoid arthritis • JRA—juvenile rheumatoid arthritis

The health effects of smoking are well documented; it is the leading preventable cause of illness and death in the United States.^1,2 This risky behavior is a serious pediatric health issue that is typically initiated during childhood and adolescence.³ Almost 90% of adult smokers report that they started smoking and 71% were daily smokers before age 18.^4,5 According to the most recent National Youth Tobacco Survey, 23% of high school–aged students reported current smoking, defined as having smoked on 1 of the past 30 days. Approximately 10% of middle school–aged children were current smokers.⁶ Studies have reported evidence of nicotine dependence among adolescents,⁷ and adolescents who want to quit are unable to do so because they experience withdrawal symptoms similar to those reported by adults.⁵ These and other statistics⁸ have prompted a national effort to prevent and treat tobacco use among youngsters. A major objective of the Healthy People 2010² agenda is a 50% reduction of the current rate of tobacco use among young people.

Although the more serious health consequences of smoking typically become apparent in adulthood, adolescent smokers experience slower rates of lung growth and reduced lung function, airway obstruction, increased phlegm production, increased shortness of breath, higher rates of cough, and other respiratory symptoms compared with nonsmokers.^9,10 In addition, the earlier an individual begins to smoke, the higher their risk for heart disease, stroke, cancer, and chronic obstructive lung disease.¹¹ Smoking is particularly risky for children and adolescents with chronic illness, whose health status is already compromised because of disease- and treatment-related complications.

The purpose of this article is threefold. Our first goal was to examine the prevalence of smoking among youngsters diagnosed with chronic illness who are at potential risk for adverse tobacco-related health outcomes. Included in this review are the following chronic illnesses in pediatric populations: asthma, cystic fibrosis (CF), cancer, sickle cell disease (SCD), insulin-dependant diabetes mellitus (IDDM), and juvenile rheumatoid arthritis (JRA). Related to this objective is the identification of specific disease- and treatment-related complications that could be exacerbated by tobacco use. Our second goal was to present a review of identified risk factors associated with tobacco use among medically compromised youngsters and to describe tobacco interventions that have been conducted with pediatric populations in health care settings to date. Our third goal was to provide suggestions for clinician-delivered tobacco counseling and recommendations for tobacco-control research in chronically ill children and adolescents.

	ASTHMA

TOP ABSTRACT ASTHMA CF CANCER SCD DIABETES JRA MEDICAL, TREATMENT-RELATED, AND... PSYCHOSOCIAL RISK FACTORS... SMOKING INTERVENTIONS FOR... SMOKING INTERVENTIONS DELIVERED... IMPLICATIONS FOR CLINICIAN... SUMMARY AND FUTURE DIRECTIONS REFERENCES

 
Illness- and Treatment-Related Complications
Asthma is a chronic inflammatory disorder of the airways that is typically characterized by increased airway responsiveness and variable, but often reversible, airflow obstruction resulting in frequent episodes of wheezing, breathlessness, chest tightening, and coughing.^12,13 In the United States, nearly 7% of children and adolescents under the age of 18 have asthma, making it one of the most common chronic illness conditions among this age group.¹⁴ Asthma rates are highest among members of racial/ethnic minorities who are poor and who live in urban environments.^14,15 Asthma is also the leading cause of hospitalization and school absenteeism among children and adolescents.¹⁴

In addition to medication, avoiding environmental irritants that trigger or exacerbate asthma symptoms is important in controlling this condition. Because tobacco smoke is a primary potential irritant, the National Asthma Education and Prevention Program Expert Panel,¹³ directed by the National Heart, Lung, and Blood Institute, recommends that persons with asthma refrain from smoking and avoid exposure to tobacco smoke in their environments. Passive smoke exposure in childhood has been reported to be associated with the early development of asthma¹⁶ and more severe asthma symptoms,^17,18 which lead to increased emergency department visits and hospitalization rates,¹⁷ as well as increased medication usage and longer recovery periods after hospitalization.¹⁹

Although the health effects associated with exposure to passive smoking have been widely studied, those associated with active smoking among asthmatic children and adolescents have received less attention. Smoking is known to increase the inflammatory burden of the lower respiratory tract through a number of related but separate mechanisms.²⁰ Therefore, it is not surprising that active smoking by asthmatic children and adolescents has been associated with increased pulmonary problems such as respiratory failure or arrest,^21,22 and the severity of complications is positively related to the number of cigarettes smoked.²³ Asthmatic youngsters who smoke are >4 times as likely to experience an asthma attack compared with nonsmoking asthmatic youngsters²⁴ and experience more acute difficulties with airway obstruction, airway inflammation, and an exaggerated bronchoconstrictor response than those who do not smoke.²⁵ A retrospective examination of 10 years of hospital admissions for asthmatic adolescents aged 13 to 19 years found that those requiring hospitalization for intubation were more likely to be active smokers or to be exposed to tobacco smoke.²²

In addition to acute health effects, asthmatic youngsters who smoke are also at risk for later medical complications in adulthood. Because smoking asthmatic teens may experience suboptimal lung growth and reduced lung function,¹⁶ they are at additional risk for lung-function deterioration as young adults.²⁶ However, the relationship between lung growth and later alteration in lung function is not clear from epidemiologic studies. Susceptibility to lung cancer among adult asthma patients who smoke may also be potentiated by smoking during adolescence.^26,27

In addition, the effectiveness of treatments for asthma may be impeded by smoking. Cigarette dose-dependent inflammatory responses and altered cytokine regulation in the airways of adult smokers have been associated with poor responsiveness to inhaled or oral steroid treatments.²⁸ Other mechanisms by which smoking may interfere with the antiinflammatory effects of steroids include differences in drug access or clearance from the lungs caused by increased mucus secretion or airway permeability.²⁹ In 1 double-blind placebo-controlled prospective study of smoking and nonsmoking asthmatic adults, Chalmers et al²⁹ found that smokers had significantly decreased peak expiratory flow readings after corticosteroid treatment as compared with nonsmokers. The authors concluded that active cigarette smoking impaired the efficacy of short-term inhaled corticosteroid treatment for mild asthma.

Smoking Rates
Collective results from several studies suggest that a diagnosis of asthma does not seem to be a motivating agent in preventing children and adolescents from smoking. Because the onset of asthma precedes smoking initiation in 90% of children and adolescents who smoke,^4,13,30 youngsters are likely to be aware of their health status before they begin to smoke. The prevalence of smoking among adolescents with asthma has been consistently demonstrated to be equivalent to^23,31–33 or higher than^34–38 rates among adolescents without asthma. In the most recent study of >2000 adolescents with asthma from the National Longitudinal Study of Adolescent Health (Add Health), Tercyak³⁷ reported that adolescents with asthma were just as likely to experiment with smoking in their lifetime and were significantly more likely to be current smokers than their peers without asthma. The prevalence of ever smoking among adolescents with and without asthma was 56%, whereas the rate of current smoking was 48% among adolescents with asthma and 42% among matched controls.

Zbikowski et al³⁸ examined the smoking status of 3234 adolescents who ranged in age from 15 to 18 years, 16% of whom had a positive asthma history. In their sample, the overall prevalence of current smoking was 20%. Adolescents with asthma (current or past) were nearly 1.5 times more likely to smoke than their peers without asthma. Another study found that 55% of asthmatic children and adolescents aged 11 through 15 years had used tobacco compared with 41% of nonasthmatic children and adolescents.³⁴ Asthmatic adolescents who were 15 years of age were 2.55 times more likely to smoke daily than were nonasthmatic adolescents of the same age. In addition, the average age of smoking initiation for those with asthma was 11.6 years, significantly younger than for those without asthma, who initiated smoking, on average, at 12.3 years.

	CF

TOP ABSTRACT ASTHMA CF CANCER SCD DIABETES JRA MEDICAL, TREATMENT-RELATED, AND... PSYCHOSOCIAL RISK FACTORS... SMOKING INTERVENTIONS FOR... SMOKING INTERVENTIONS DELIVERED... IMPLICATIONS FOR CLINICIAN... SUMMARY AND FUTURE DIRECTIONS REFERENCES

 
Illness- and Treatment-Related Complications
CF is a life-shortening autosomal recessive disease of the exocrine glands that primarily affects the gastrointestinal and respiratory systems. In the United States, nearly 30000 individuals are affected with CF, and 7 million are carriers of the disease. It is the most common lethal hereditary disease of white people.^39,40 Patients are usually diagnosed in childhood, with 80% being diagnosed before the age of 4 years.

Chronic respiratory disease causes 90% to 95% of the morbidity and mortality in patients with CF because of complications of abnormal mucus production.⁴¹ Risks for serious respiratory airway infections, commonly bacterial in nature, as well as airway obstruction, are drastically increased among children and adolescents with CF because of abnormally thick secretion of mucus. Upper respiratory tract involvement includes nasal polyposis and chronic or recurrent sinusitis.⁴⁰ Pulmonary manifestations are clinically apparent in 50% of patients and typically include chronic cough and wheezing associated with recurrent or chronic pulmonary infections.⁴⁰ Pulmonary damage may be caused, in part, by immune-mediated inflammation secondary to the release of proteases by neutrophils in the airways.⁴⁰ Eighty-five to 90% of patients with CF experience pancreatic insufficiency, which usually presents early in life and may be progressive. Adolescents with CF may have poor nutritional status, retarded growth, delayed onset of puberty, and a declining tolerance for exercise.⁴⁰

The disease processes that accompany CF are likely to be exacerbated by cigarette smoking. Smoking is known to irritate mucosal linings, increase coughing, and increase phlegm production in the respiratory tract, resulting in increased likelihood of bacterial infections, worsening of symptoms, and increased hospitalizations. An accelerated decline in pulmonary function is also associated with smoking.⁴² Verma et al⁴³ and Smyth et al⁴⁴ reported a dose-dependent relationship between the number of cigarettes smoked and the severity of disease among young patients with CF. Nasal ciliary beat frequency has also been found to be significantly reduced in tobacco smoke–exposed individuals (whether active or passive smokers), which might contribute to diminished nasal and sinus mucociliary clearance.⁴⁵ From a treatment perspective, relief of airway obstruction can be achieved by chest physiotherapy or vigorous physical exercise.⁴⁰ Because smoking is known to impair cardiopulmonary fitness and endurance during exercise, treatment efficacy may be compromised in patients who use cigarettes. Smoking may also result in appetite reduction and weight loss,⁴³ which can be problematic in the youngster with CF who has poor growth patterns and gastrointestinal complications.⁴⁰

Smoking Rates
In the only study conducted to date examining smoking rates among adolescents with CF, significantly fewer teens with CF reported ever smoking or regular tobacco use compared with their healthy peers.⁴² Specifically, 21.1% of adolescents with CF reported ever smoking relative to 53.3% of ever-smokers among adolescents without CF matched on age, race, and gender. Almost 3% reported smoking cigarettes for >2 days in the last month in comparison to 29.6% of regular smokers among adolescents in the healthy comparison group. The median age of onset of smoking (11–12 years) was comparable among adolescents with and without CF. The authors cautioned that the difference in reported smoking rates may have been impacted by the difference in questionnaire administration between the groups. The teens with CF completed the questionnaire in clinic after a face-to-face interview or on the telephone, whereas the healthy adolescents completed it in a more anonymous, school setting. Adolescents with CF who had more functional limitations reported the same frequency of smoking behavior and other risky health behaviors as those with fewer limitations, suggesting that health status did not affect how often they engaged in these behaviors.

	CANCER

TOP ABSTRACT ASTHMA CF CANCER SCD DIABETES JRA MEDICAL, TREATMENT-RELATED, AND... PSYCHOSOCIAL RISK FACTORS... SMOKING INTERVENTIONS FOR... SMOKING INTERVENTIONS DELIVERED... IMPLICATIONS FOR CLINICIAN... SUMMARY AND FUTURE DIRECTIONS REFERENCES

 
Illness- and Treatment-Related Complications
For children between 1 and 19 years of age, cancer ranks fourth as a cause of death behind unintentional injuries, homicides, and suicides.⁴⁶ Approximately 8000 children under the age of 15 developed cancer in 1999.⁴⁷ The most common type of cancer diagnosed in children is acute lymphoblastic leukemia, followed by malignant brain tumors, lymphomas, neuroblastomas, renal tumors, soft tissue sarcomas, osteosarcoma, and retinoblastoma.⁴⁷ The absolute incidence of various pediatric cancers varies greatly by age, gender, and race, but the peak incidence generally occurs in children <4 years of age. Treatment of children with cancer may include surgery, radiation therapy, chemotherapy, and amputation. The 5-year survival rate for all childhood cancers is currently 72%.⁴⁷

Tobacco use is a behavioral health problem that poses serious health risks for the young patient treated for cancer. Several antineoplastic therapies commonly used in the treatment of pediatric cancers are associated with cardiopulmonary toxicities and organ compromise that can be potentiated by tobacco use. For example, patients treated with carmustine and bleomycin⁴⁸ and/or pulmonary radiation therapy⁴⁹ may develop serious respiratory problems and restrictive lung disease if they smoke. Likewise, the long-term use of tobacco may also increase the risk of congestive heart failure and related cardiac problems in patients treated with anthracyclines.⁵⁰ More acute complications of tobacco use may include respiratory infections in the immunosuppressed patient secondary to damage to the patient's protective airway cilia, as well as aggravation of symptoms in patients with acute radiation mucositis.

Studies in adults have shown that cigarette smoking and radiation therapy have a multiplicative effect on the risk of subsequent lung cancer in survivors of Hodgkins disease.⁵¹ Similarly, increased rate and duration of symptoms,⁵² diminished efficacy of radiation therapy,⁵³ reduced survival time,⁵⁴ and greater risk of disease recurrence or a second primary tumor⁵⁵ have been reported in adult patients with head and neck cancer who continue to smoke when compared with patients who quit smoking after learning their diagnosis. Pediatric cancer patients are already at risk for developing second cancers because of treatment-induced^56,57 and genetic predispositions,⁵⁸ and tobacco use may exacerbate these vulnerabilities. The potential effect of tobacco use on treatment efficacy among pediatric patients with cancer remains largely unknown.

Smoking Rates
The bulk of published studies that have examined the smoking prevalence among youngsters treated for cancer have focused on adolescents and young adults who have survived cancer. Collectively, these studies show that smoking rates among survivors are somewhat lower than those reported for healthy adolescents. Estimates of smoking rates reported in individual studies, however, should be interpreted with caution, because they are based on small sample sizes and use varying definitions of current smoking/tobacco use. Mulhern et al⁵⁹ reported that <10% of survivors aged 11 to 17 years used tobacco, although this estimate was based on parents' report of their children's behavior. Other studies based on adolescent self-reports found that between 5% and 15% of teen survivors, aged 10 to 19 years, engaged in cigarette smoking.^60–62

Limited data are available regarding smoking rates among youngsters undergoing active treatment for cancer. In a study conducted at a large pediatric oncology institution, data from 104 children 10 to 19 years of age, who were consecutively admitted during a 1-year period, indicated that 6.7% of patients were current smokers according to their self-report.⁶³ However, these results were limited to families who provided information about tobacco use at the time of admission. Most recently, 2% of an adolescent population, aged 12 to 18 years, who were undergoing treatment for cancer and close in time to their diagnosis (median time since diagnosis: 2.4 months), reported current smoking compared with 22% of similarly aged adolescents without cancer. The lower smoking rates reported by young patients with cancer were attributed to the patient's medical status at the time of the study and the relative recency of their diagnosis. In this same study, adolescent patients with cancer were also one third as likely as their healthy peers to report some intention to smoke in the future.⁶⁴ Intention to use tobacco has consistently been found to be a strong predictor of future smoking behavior among healthy adolescents,^65–67 although this association has not been studied among young patients with cancer.

Estimates of smoking among young adults who have completed and survived their cancer treatment are generally higher than those obtained from younger survivors. Previous American and Canadian studies reported that between 17% and 20% of young adult survivors were current smokers, with higher percentages of survivors having experimented with tobacco in the past.^59,68,69 Results from the Childhood Cancer Study, the largest research cohort of cancer survivors ever assembled in the United States, demonstrated that 17% of 5-year survivors, at least 18 years of age, were identified as current smokers, with another 10% identified as former smokers.⁷⁰ Older age at diagnosis, lower household income, less education, and not having had pulmonary-related cancer treatment or brain irradiation were associated with a statistically significant relative risk of smoking initiation among survivors. Although these results showed that survivors smoke at rates below that of the general population, these rates are still alarming in that survivors are exposed to treatments that are known to compromise their cardiac, vascular, and pulmonary functioning. Moreover, the reported smoking-cessation rate among cancer survivors was only modestly greater than that in the general population,⁷⁰ demonstrating the persistence of their established smoking habits.

	SCD

TOP ABSTRACT ASTHMA CF CANCER SCD DIABETES JRA MEDICAL, TREATMENT-RELATED, AND... PSYCHOSOCIAL RISK FACTORS... SMOKING INTERVENTIONS FOR... SMOKING INTERVENTIONS DELIVERED... IMPLICATIONS FOR CLINICIAN... SUMMARY AND FUTURE DIRECTIONS REFERENCES

 
Illness- and Treatment-Related Complications
SCD refers to a group of autosomal recessive genetic disorders associated with the synthesis of an abnormal hemoglobin molecule, hemoglobin S, and characterized by chronic hemolytic anemia and vasculopathy.⁷¹ SCD is one of the most prevalent genetic diseases in the United States, with usual onset of symptoms in early childhood.^42,72–74 In the United States, SCD occurs predominantly in black populations; approximately 1 in 400 black newborns has SCD, whereas 8 in 100 are carriers of the genetic trait.⁷⁵ Individuals of Mediterranean, Middle Eastern, and Indian origin are also commonly affected.⁷³

Numerous clinical manifestations of SCD in childhood include painful vaso-occlusive episodes or "pain crises" that result from ischemia secondary to occlusion of blood vessels. Vascular occlusion occurs with the polymerization of hemoglobin S, resulting in the production of misshapen red blood cells that adhere abnormally to vascular endothelium.⁷⁶ Other complications include chronic anemia, stroke, splenic and renal dysfunction, and serious infections. Among children with SCD, the primary causes of morbidity are bacterial infections and stroke.⁷⁵

Acute chest syndrome is another common SCD-related pulmonary problem that is characterized by chest pain, fever, leukocytosis, cough, and pulmonary infiltrates on chest radiograph.^42,77 Young et al⁷⁷ reported that cigarette smoking is a causative factor for acute chest syndrome, although the exact mechanism by which smoking contributes to the development of this SCD-related complication is speculative at best. One plausible explanation is that the carbon monoxide in cigarette smoke displaces the oxygen from hemoglobin-binding sites resulting in decreased oxygen-carrying capacity of red blood cells and tissue hypoxia.^78,79 Adolescents with SCD are already at a disadvantage, because they have low oxygen saturations compared with healthy youngsters.⁸⁰ Other components of tobacco smoke are known to injure vascular endothelium, increase inflammation, and activate platelets, resulting in atherosclerosis and thrombus formation.^81,82 These collective effects could result in increased vascular occlusion by enhancing polymerization of hemoglobin S and abnormal adhesion of sickle red blood cells to damaged vascular endothelium. Because of its vaso-occlusive effects, cigarette smoking may also further compound the risk of stroke, which occurs in 5% to 10% of children with SCD.⁷¹

Smoking Rates
Only a single published study examining smoking rates among adolescents with SCD was identified. Britto et al⁴² found that 30.0% of adolescents with SCD reported ever smoking cigarettes, and 6.5% were regular smokers. These rates were significantly lower than those reported by a comparison group of adolescents demographically matched on age, race, and gender. Regular smoking was defined as smoking >2 cigarettes during the last month. Adolescents with SCD who smoked reported an older age of smoking initiation than their peers. The median age of smoking onset was 13 to 14 years compared with onset at 11 to 12 years for their peers.

	DIABETES

TOP ABSTRACT ASTHMA CF CANCER SCD DIABETES JRA MEDICAL, TREATMENT-RELATED, AND... PSYCHOSOCIAL RISK FACTORS... SMOKING INTERVENTIONS FOR... SMOKING INTERVENTIONS DELIVERED... IMPLICATIONS FOR CLINICIAN... SUMMARY AND FUTURE DIRECTIONS REFERENCES

 
Illness- and Treatment-Related Complications
IDDM or juvenile-onset diabetes is a chronic metabolic disorder that is typically diagnosed in childhood, with peak incidence occurring at puberty. It is characterized by complete pancreatic failure requiring daily exogenous insulin replacement by injection for survival, a propensity for accumulation of blood and urine ketones, and an association with immune markers.^83–85 Approximately 1 in every 600 US children has IDDM, and the risk of developing IDDM is equal to that of all childhood cancers combined and is much greater than other well-known diseases such as CF or rheumatoid arthritis (RA).⁸⁵ Females and males seem to be equally affected by IDDM, although white children are 1.5 times more likely to be diagnosed with this disease than are black children.

After 15 to 30 years with IDDM, most patients will develop 1 diabetes-related complications including retinopathy, renal failure (nephropathy), nerve damage, and heart (microvascular) disease.⁸⁶ Cigarette smoking is an independent risk factor for cardiovascular disease and has a synergistic effect with diabetes, thereby increasing the risk of coronary heart disease and peripheral vascular disease among diabetic patients.^87–89 Specifically, cigarette smoking is known to significantly increase the risk of atheroma and the accumulation of plaque of cholesterol and fatty deposits in the inner lining of the artery and may interact with diabetes to magnify its atherogenic effect.⁹⁰ Among diabetic patients, smoking has also been associated with the development and progression of late microvascular complications such as retinopathy and nephropathy.⁹¹ Children and adolescents with diabetes who smoke regularly are at 50% to 75% greater risk for morbidity and mortality in later life than youngsters with diabetes who do not smoke.^92–94

Smoking Rates
Gold and Gladstein⁹⁵ reported that more than half of a sample of 79 diabetic adolescents and young adults aged 11 to 25 years reported tobacco or alcohol use at least once, and 12% to 25% reported use >5 times in their lifetime. Within their sample, white adolescents were significantly more likely to be smokers than Hispanic or black adolescents. In a similarly aged sample of 155 predominantly white 10- to 20-year-olds with IDDM, 34% were reported to be ever-smokers and 27% had smoked in the past 12 months.⁹⁶ Eight percent of the sample reported using smokeless tobacco. Starkman et al⁹⁷ recently reported that 24% of a sample of 101 diabetic patients aged 17 to 29 years were current smokers. Others have reported lower smoking rates of 8% among 13- to 22-year-olds with IDDM.⁹⁸ Similarly low smoking-prevalence rates of 9% were reported among 11- to 18-year-olds with diabetes,⁹⁹ but unlike other studies, this sample did not include young adults. In another study that included objective measures of active smoking among diabetic patients aged 15 to 31 years, Masson et al¹⁰⁰ found that although 31% of the patients admitted to smoking on a questionnaire delivered by a nurse in the patient's clinic setting, urinary cotinine (nicotine metabolite) assays suggested that up to 48% were actively smoking. Fourteen percent of the sample were past smokers. The median age of smoking initiation for those who admitted to the habit was 16 years (range: 10–20 years). Interestingly, all diabetic smokers reported awareness of the deleterious effects of smoking, and 86% of them were aware that smoking could worsen diabetic complications.

The pattern of initiation and continued use of cigarettes in this adolescent population has not been clearly established, as evidenced by variable smoking rates. Because these studies included small samples composed of both adolescents and young adults and lacked adequate control groups, it is difficult to determine how smoking rates compare to national adolescent smoking rates.⁶ Smoking rates among diabetic adults have been found to be consistently comparable to those of the general population.^91,93,94,101

	JRA

TOP ABSTRACT ASTHMA CF CANCER SCD DIABETES JRA MEDICAL, TREATMENT-RELATED, AND... PSYCHOSOCIAL RISK FACTORS... SMOKING INTERVENTIONS FOR... SMOKING INTERVENTIONS DELIVERED... IMPLICATIONS FOR CLINICIAN... SUMMARY AND FUTURE DIRECTIONS REFERENCES

 
Illness- and Treatment-Related Complications
JRA is the most common type of childhood arthritis and is characterized by pain, swelling, stiffness, and potential deformity in 1 joints with onset usually before the age of 16.^102–104 It occurs in 50 to 100 per 100000 children in the United States.¹⁰⁴ The severity of JRA varies from mild to severe, and the disease course is characterized by periodic remissions and exacerbations.¹⁰³ Three subtypes of JRA can be diagnosed on the basis of clinical presentation. Systemic-onset disease (Still disease) occurs in 20% of patients and is manifested by high fever, rash, splenomegaly, and generalized adenopathy. The onset of the pauciarticular type occurs in 40% of patients, usually males, and involves <4 joints. Patients with this type of JRA may also experience chronic eye inflammation that causes scarring of the lens and permanent visual damage. Onset of the polyarticular type occurs in the remaining 40% of patients, is often similar to adult RA, and involves 4 joints. Complete remission occurs in 50% to 75% of patients with JRA, although patients with polyarticular onset have a less favorable prognosis, particularly if a positive rheumatoid factor (a measured antibody in the blood) is present.¹⁰²

Cardiovascular disease is the most common cause of premature death among adult patients with RA,^105,106 and smoking has been shown to be a risk factor for cardiovascular complications. Epidemiologic and case-controlled studies on adults have demonstrated that smoking is an important risk factor for both the incidence and severity of RA.^107,108 There is evidence that cigarette smoking may have direct biological effects on RA by increasing serum rheumatoid factor, the hallmark antibody and prognostic marker for RA severity, and other inflammatory elements,^109,110 as well as altering the immune function in the lungs and systemically.¹⁰⁹ Tobacco smoke may also directly cause endothelial/vessel wall damage, which may lay the groundwork for vasculitis and other features of RA.¹⁰⁷ Although no empirical evidence has been provided regarding the specific medical outcomes of young patients with JRA who smoke, adolescents whose symptoms do not remit and persist into adulthood will likely be at particular risk for adult cardiovascular problems if they engage in smoking. There is also an identified association between tobacco use during adolescence and osteopenia among adults with a history of JRA.¹¹¹ In addition, the risk for bone deterioration and depletion, growth retardation, bone marrow depression, and liver toxicity secondary to treatment of JRA with corticosteroids or methotrexate^102,108 may be exacerbated by tobacco use.

Smoking Rates
Only a single published study to date has examined the prevalence of tobacco use and other substance use among adolescents with JRA.¹¹² Nash et al¹¹² surveyed 52 adolescents aged 12 to 17 years by mail and found that 15.4% of the sample reported tobacco use within the past year. A comparison group was not included in this study, although these rates are generally lower than those reported for high school–aged adolescents.⁶ JRA was characterized as pauciarticular in 40.4%, polyarticular in 46.2%, and systemic onset in 13.5% of the adolescents. The mean age of disease onset was 5.9 years. Among ever tobacco users, the average age of smoking initiation was 12.7 years. This sample, however, was primarily composed of teens with minimal functional disability, suggesting that teens with the most severe disease may have been less likely to participate.

	MEDICAL, TREATMENT-RELATED, AND ENVIRONMENTAL FACTORS ASSOCIATED WITH SMOKING

TOP ABSTRACT ASTHMA CF CANCER SCD DIABETES JRA MEDICAL, TREATMENT-RELATED, AND... PSYCHOSOCIAL RISK FACTORS... SMOKING INTERVENTIONS FOR... SMOKING INTERVENTIONS DELIVERED... IMPLICATIONS FOR CLINICIAN... SUMMARY AND FUTURE DIRECTIONS REFERENCES

 
In addition to the methodologic differences inherent in these studies, medical, treatment-related, and environmental factors may also explain the differences in smoking rates and age of smoking onset between children with chronic illness and their healthy counterparts, as well as between children with different medical conditions. These factors, however, have received little empirical study. Poor medical status, presence of physical symptoms, and/or treatment-related adverse effects may account for the lower rates of smoking reported among some children and adolescents with chronic illness, particularly if the patient was hospitalized or ill during the intervals assessed by these studies.⁶⁴ Lower rates of smoking and older age of onset of smoking among some teens with chronic illness may be also be attributed partially to delayed physical and psychosocial maturation,¹¹³ although studies have not incorporated measures of pubertal or psychosocial development to adequately address this issue.

Smoking restrictions at the hospital and in the housing facilities in which many patients reside during their treatments may also explain more temporary lower rates of smoking. One cannot exclude the possibility that some adolescents with chronic illness may have underreported of misrepresented their smoking status, because the tobacco-use assessments for these studies was sometimes conducted by health care professionals in a medical setting. This was substantiated by the lack of correspondence between self-reported and objective measures of smoking reported among young diabetic patients who completed nurse-delivered questionnaires in a clinic setting.⁸⁸ It is possible also that the positive impact of supportive care services traditionally offered to pediatric patients as they undergo therapy may also serve to disrupt or delay their future tobacco use, as reflected in their lowered smoking rates.⁶⁸ These hypotheses certainly deserve further consideration.

The observed differences in smoking rates between chronically ill teens may also be explained, in part, by the different characteristics associated with a specific illness such as time of onset, course of the illness, visibility of the condition, degree of incapacitation,⁴² or demands of the disease. These distinct disease parameters, or some combination of these factors, may affect the adolescent's opportunity to smoke, their exposure to peers and social models who smoke, their smoking patterns, and/or their incentives to start smoking. For example, concerns about weight gain and dietary adherence have been suggested to play a role in smoking initiation among young diabetic patients because of the social and dietary constraints imposed by the disease.^114,115 Conversely, these same factors have been reported as barriers to smoking cessation for adolescents and young adults with diabetes who smoke.

	PSYCHOSOCIAL RISK FACTORS ASSOCIATED WITH SMOKING

TOP ABSTRACT ASTHMA CF CANCER SCD DIABETES JRA MEDICAL, TREATMENT-RELATED, AND... PSYCHOSOCIAL RISK FACTORS... SMOKING INTERVENTIONS FOR... SMOKING INTERVENTIONS DELIVERED... IMPLICATIONS FOR CLINICIAN... SUMMARY AND FUTURE DIRECTIONS REFERENCES

 
Despite the volume of research on the correlates of adolescent tobacco use, factors that influence tobacco use among youngsters with chronic illness have received little attention. The few studies that have examined tobacco-related psychosocial risk factors among youngsters with chronic illness have focused primarily on children and adolescents with asthma and cancer. In fact, no studies to date have assessed why youngsters with CF, diabetes, JRA, or SCD are motivated to begin or refrain from smoking. Although children with chronic illness experience social pressures similar to those experienced by their healthy peers, the way in which they perceive and respond to these challenges may be different as a function of their disease. The lack of empirical data regarding specific risk factors associated with tobacco use in these vulnerable pediatric populations underscores our limited knowledge regarding what motivates these youngsters to smoke. However, findings from the cancer and asthma populations may raise interesting questions about reasons for smoking that can be pursued with other pediatric groups.

As is the case with healthy adolescents,^116,117 adolescents with cancer who reported themselves as more rebellious and risk-taking were more likely to engage in past or current smoking.⁶⁴ Likewise, risk-taking and rebelliousness have been positively associated with current smoking among adolescents with asthma.³⁸ Other work has shown high rates of nonadherence to medication regimens among pediatric asthma patients, which may indicate an attempt to gain greater control over their illness.¹¹⁸ The findings regarding nonadherence, when combined with data on risk-taking and rebelliousness, may reflect a general tendency for adolescents with asthma to react against the self-management of their illness by engaging in health-compromising behaviors, such as smoking, known to negatively impact control of their illness.³⁷

Depression and anxiety have also been found to contribute to tobacco use among healthy adolescents.¹¹⁹ Perceived stress or psychological distress, often exacerbated by the experience of illness and treatment, may influence the youngsters' choice of smoking as a means of coping.⁴² When Forero et al³⁴ studied the health behaviors of a large community-based sample of Australian adolescents, they found that both tobacco and alcohol use were higher among adolescents with asthma compared with nonasthmatic adolescents. Asthmatic adolescents also reported elevated psychological distress. However, Tercyak's³⁷ findings did not support the relationship between distress and increased likelihood of current smoking among adolescents with asthma. Similarly, Zbikowski et al³⁸ failed to find that adolescents with asthma smoked to relieve distress. These variables have not been similarly examined in other pediatric populations.

Given the well-documented impact of social influences on adolescent smoking reported in the literature,^120,121 exposure to smoking models in the youngster's social environment has been explored as a risk factor among chronically ill adolescents. The lower smoking rates among young adult patients with cancer and survivors have been attributed to a less active social life and subsequently less exposure to smoking models because of the restrictions of their disease and/or treatment-related late effects.⁶⁸ However, results from studies conducted with pediatric patients with cancer and asthma found that adolescents with these conditions were just as likely as their healthy peers to be exposed to parents who have smoked and/or to have friends who smoke, despite their illness. Moreover, adolescents with greater exposure to smoking models in the social environment were more likely to be ever-smokers when compared with adolescents who had little or no exposure to these influences.^37,38,64

Because children and adolescents with chronic illness may be frequently isolated from their peer social networks for extended time periods during medical treatments, have increased absences from school, and be restricted from the activities or routines of their peers, they may engage in smoking as a vehicle to reconnect with their peers and seek peer approval.^38,64 This association is more likely if the adolescent perceives that smoking will improve their self-image. Similar to healthy adolescents,¹²² adolescents with cancer and asthma who reported a high social value of smoking were more likely to smoke or experiment with smoking.^38,64 This finding highlights the importance of educating youth about more appropriate alternatives to smoking when they are feeling pressured to "fit in."

Perceived vulnerability to health risks is a well-recognized component of current cognitive-motivational models of health behavior¹²³ that has recently been examined in relation to tobacco use among youngsters with IDDM as well as adolescent patients with cancer and survivors. One study⁹⁶ reported that youngsters aged 10 to 20 years with diabetes perceived themselves to be at less risk for adverse health effects associated with risky behaviors, including smoking, than their peers. Perception of risk was not related to self-reports of risky behaviors in this sample of adolescents. In contrast, Tyc et al^62,124 reported that preadolescent and adolescent cancer survivors have heightened perceptions of perceived vulnerability to tobacco-related health risks. Although an inverse relationship between perceived vulnerability and the practice of some risky behaviors has been noted among healthy adolescents,^116,125,126 perceived vulnerability has not been found to be a significant predictor of intentions to use tobacco among pediatric cancer patients and survivors.⁶² Perceived vulnerability, however, has been shown to predict readiness to quit smoking and confidence in one's ability to quit (eg, self-efficacy) among young adult childhood cancer survivors.¹²⁷

Having a cognitive predisposition or susceptibility to smoking, as defined by expectations of future smoking behavior, has also been found to predict smoking experimentation among nonsmoking adolescents^128,129 and established smoking among adolescents who experiment with cigarettes.¹³⁰ Other cognitive variables such as reduced problem-solving and poor decision-making skills has also been found to influence the likelihood of adolescent substance use.^131,132 For example, Hollen et al¹³² surveyed 52 adolescent cancer survivors and found that nonresiliency and poor decision-making were highly significant predictors of 1 risky health behaviors including tobacco use. Pediatric patients whose illness and/or therapies place them at risk for cognitive impairments (eg, patients with brain tumors who receive cranial radiation, those with cerebrovascular insults, and those with SCD) that can adversely impact their behavioral choices as well as their understanding of the consequences of their behavior may be at greater risk for smoking.

As evidenced from the findings presented above, psychosocial risk factors for smoking generally seem to be similar among children and adolescents with chronic illness and their healthy peers. The complexity of factors contributing to adolescent tobacco use is compounded by differences in age, gender, race, and socioeconomic status.^117,122 The few studies that compared risk factors between adolescents with asthma and cancer and a healthy control group found that adolescents with and without chronic illness seemed to smoke for similar reasons.^37,38,64 However, these studies were limited in that only traditional risk factors known to be predictive of smoking among youth in general were examined. Moreover, how these selected risk factors specifically impact observed smoking rates in the different pediatric groups reviewed has not been clearly established. Future research should identify whether there are unique risk factors for smoking, not yet studied, among adolescents with chronic illness.

	SMOKING INTERVENTIONS FOR CHILDREN AND ADOLESCENTS WITH CHRONIC ILLNESS

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Unlike studies in adults that have focused on cessation, much of the effort to reduce tobacco use in adolescents has focused primarily on preventing initiation of smoking. Our review of child and adolescent smoking-prevention and -cessation interventions conducted with chronically ill youngsters identified 3 clinical trials, only 2 of which used randomized, experimental designs. In addition, these smoking-prevention studies have been conducted exclusively with adolescents who have been treated for cancer. Although studies have demonstrated the efficacy of behavioral interventions to decrease parental tobacco smoke exposure among children with asthma,¹³³ no published empirical findings from intervention trials targeting active smoking among youngsters with asthma were identified.

In the only randomized smoking-prevention trial to date to be conducted with pediatric cancer survivors, Tyc et al¹²⁴ demonstrated the efficacy of a brief tobacco risk counseling intervention for youngsters aged 10 to 18 years. Compared with preadolescent and adolescent survivors who received advice about tobacco-related health risks, survivors who received the intervention including late-effects counseling, an educational video, goal-setting, written physician feedback, smoking literature, and follow-up telephone counseling obtained higher tobacco-knowledge scores and reported greater perceived vulnerability to tobacco-related health outcomes, as well as lower intentions to smoke 12 months post-intervention. This intervention was based on the health-belief model, which relates an increased likelihood of behavioral change to greater perceptions of vulnerability to health risks. Health care providers conducted the counseling in a single session within the patient's routine medical visits with periodic telephone follow-up. A greater intensity of intervention-based contact (eg, higher intervention dosage) and booster sessions may be necessary to promote more lasting effects on knowledge, health perceptions, and future smoking behaviors.

Using the same conceptual model as that used in the Tyc et al study,¹²⁴ Hudson et al¹³⁴ evaluated the efficacy of a late-effects counseling and behavioral intervention on survivor's health knowledge, health perceptions, and practice of health behaviors among 272 adolescent cancer survivors attending a long-term follow-up clinic. Unlike the Tyc et al study,¹²⁴ which focused only on tobacco use, this health-promotion trial addressed a variety of health behaviors. In this study, adolescents were randomly assigned to receive standard care or standard care plus a late-effects counseling/behavioral intervention at their annual medical visit. Standard care consisted of breast or testicular examination taught by a nurse using a breast/testicular model, late-effects screening based on clinical history and treatment exposures, a thorough clinical assessment by a clinician, and late-effects counseling. The intervention group received the standard care plus discussion of a written treatment and late-effects summary, health behavior training in 1 of 5 health goals selected by the survivor, commitment to practicing the selected health behavior, and telephone follow-up to reinforce the behavioral training. In addition to smoking cessation, targeted health behaviors included sun protection, dietary fat and weight reduction, and regular exercise. Of those patients assigned to the intervention group, only 6 patients (5%) selected smoking cessation as a health goal. With the exception of increased frequency of performing breast or testicular examination, there were no significant self-reported behavioral improvements at a 12-month follow-up for patients who selected other health goals, including smoking cessation. The intervention also failed to produce significant changes in knowledge and perceptions. A major limitation of this study, however, was that health goals were selected by survivors rather than assigned by the clinician using standardized objective risk criteria. According to the investigators, differences in the survivors' subjective biases and perceived salience of their selected health goals may have masked important intervention effects.

Working from the perspective that quality decision-making skills are critical for teens confronting risk behaviors such as smoking, Hollen et al¹³⁵ tested the effects of a tailored decision-making program aimed at reducing risk behaviors among a convenience sample of adolescents aged 13 to 21 years who survived cancer. This 1-day, 5-hour camp intervention, which focused on tobacco use in addition to alcohol and illicit drug use, was evaluated by using a quasi-experimental pretest/posttest design with repeated measures. Twelve months after the intervention, the effect of the intervention for improving decision-making was statistically significant, although risk motivation for smoking and self-reported smoking behavior were not affected. Despite the modest intervention effects, a clinician-delivered approach that teaches adolescents who have been treated for cancer to weigh the consequences of tobacco use within the context of their individual treatment histories and provides essential health content related to survivorship offers promise for adolescents making tobacco-related choices.

	SMOKING INTERVENTIONS DELIVERED WITHIN THE PRIMARY HEALTH CARE SETTING

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As is the case with adult patients,¹³⁶ visits for routine health services may provide an excellent opportunity for clinicians to deliver strong messages about tobacco abstinence and cessation to all adolescents. However, there have been limited efforts to use the availability of the health care visit, the impact of the provider-patient relationship, and the accessibility of the hospital setting to provide preventive tobacco counseling to children and adolescents. Overall, the few pediatric smoking interventions delivered by health care providers in their primary care practices have had limited success. Given that youngsters with chronic medical problems are often seen in specialty clinics, the impact of clinician-delivered interventions on medically compromised children encountered in the primary care setting has not been well established.

Fidler and Lambert¹³⁷ demonstrated that primary health care teams could play an important proactive role in maintaining the nonsmoking status of their young patients by implementing low-cost programs without increasing the demands on clinician's workloads. In their study, youngsters aged 10 to 15 years who were assigned to an intervention group that was sent informational materials, certificates, and posters intended to reinforce nonsmoking behavior at 3 monthly intervals from their health care provider demonstrated substantially lower smoking-uptake rates than the control group at a 1-year follow-up. The intervention effect was more pronounced among boys and among those who were firm in their decision not to smoke. Other office-based clinician-delivered studies have failed to produce desired smoking outcomes with their adolescent patients. In a prospective randomized trial, Stevens et al¹³⁸ failed to find significant intervention effects as assessed by the prevalence of tobacco use at a 36-month follow-up. Using an anticipatory guidance model, clinicians delivered the intervention during health supervision visits and other office encounters. The clinician messages encouraged family communication about adolescent health behaviors and rule setting, development of a family policy regarding tobacco use, joint child and parent discussions about health risks, and quarterly newsletters.

Similarly, Hovell and Slymen¹³⁹ failed to find significant differences in 2-year incidence rates for tobacco use between adolescents randomly assigned to an anti-tobacco intervention group or control group even when clinicians were trained and paid for delivering antitobacco messages to their patients. A lower rate of smoking initiation among adolescents, however, was obtained for the experimental group than the control group. A significant dose response was also reported such that patients who received 4 counseling episodes had substantially lower rates of smoking than those who received fewer episodes. However, poor clinician compliance with the proposed counseling procedures in this study suggest that the integrity of the intervention was compromised.

The few adolescent smoking-cessation interventions that have been incorporated into routine medical care have produced disappointing results. In 1 study, >500 adolescent females who were seen during Planned Parenthood visits for contraception were randomly assigned to receive either simple advice to quit smoking from their health care provider or a brief motivational counseling intervention from clinic staff, a short videotape, and 1- and 3-month follow-up telephone calls. Abstinence rates for the 2 groups were not significantly different at a 6-month follow-up.¹⁴⁰ In another randomized trial, no significant differences in smoking quit rates at a 3-month follow-up were reported by adolescent patients who were targeted for smoking cessation via brief advice or a motivational intervention at the time of their visit to the emergency department, outpatient clinic, or inpatient unit of an urban hospital.¹⁴¹ The intervention was delivered by trained research associates rather than the patient's health care provider.

	IMPLICATIONS FOR CLINICIAN-DELIVERED SMOKING INTERVENTIONS

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The implications of this review for tobacco control among adolescents with a medical illness are quite clear. Because youngsters with asthma are smoking at unacceptably high rates, it is evident that prevention and cessation efforts should be targeted at this population. The low rates of reported smoking among adolescents with cancer, CF, JRA, diabetes, and SCD should not be interpreted, however, to mean that smoking is not a significant problem in these vulnerable populations. Rates are higher among older adolescents and those who have completed treatment, and smoking rates among chronically ill adults are comparable to the general population in many instances. Therefore, it is important that smoking rates be minimized even further among these youngsters and that long-term abstinence and cessation be addressed with young smokers who may only temporarily decrease their smoking secondary to illness and treatment.

Given the serious health consequences associated with smoking, there is a surprising lack of controlled studies that have empirically evaluated interventions to prevent or stop tobacco use in youngsters with chronic illness. This is complicated by a lack of currently available evidence-based guidelines for clinician-delivered tobacco counseling in the primary care setting or subspecialty clinic.¹⁴² A question arises, however, as to whether a particular approach developed for children with a given medical condition may similarly apply to those with other conditions. Because there are several commonalities in potential risk factors for smoking between children with different chronic health problems, one approach would be to develop broad-based, noncategorical interventions that would reduce children's risk for smoking irrespective of their specific diagnosis. Until sufficient evidence is gathered to develop illness-specific guidelines, interventions found to be effective with the general adolescent population may be adapted to address the unique needs of youngsters with chronic illness. The challenge in the field is to design interventions that increase the understanding of the magnified health risks associated with smoking, provide an adequate dose of intervention, and are well accepted by young smokers.

At minimum, practice guidelines^143–146 suggest that health care providers should routinely incorporate the following activities, related to the 5 A’s model, into the adolescent patient's routine medical care: (1) anticipate tobacco use and risk factors for tobacco use; (2) ask all patients about their smoking status; (3) advise about tobacco-related health risks and encourage smokers to stop smoking and nonsmokers to continue to abstain from tobacco use; (4) assist patients who are ready to quit by providing self-help smoking-cessation materials and suggesting a quit date; and (5) arrange for routine follow-up and support. Although the majority of adolescent health care providers ask their adolescent patients about smoking and most assess the adolescent's motivation to stop smoking, fewer provide assistance or arrange follow-up.¹⁴⁷ Private, confidential interviewing techniques are crucial if young patients are to feel comfortable in discussing and seeking advice from their clinicians regarding their smoking behaviors.¹⁴⁸

Results from smoking interventions with healthy adolescents indicate that skill-building, counseling about the social influences of smoking, identifying healthier sources of reward, and provision of didactic materials have been effective in the prevention of adolescent tobacco use.^149,150 These intervention components may also be relevant for youngsters with chronic illness, particularly in light of the demonstrated similarities in selected psychosocial risk factors between healthy adolescents and those with cancer and asthma.^37,64 However, additional factors should be considered when delivering smoking interventions with medically compromised children and adolescents to enhance the impact of these more traditional approaches.

Although the behavioral goals of smoking interventions with chronically ill children and adolescents are similar to those established for their healthy peers, revisions to the content and the manner in which the intervention is delivered may be necessary. Reliance on the supportive and motivational aspects of the treatment setting and the unique patient-provider relationship may also be important in promoting behavioral change in the chronically ill youngster. Previous research with cancer survivors has demonstrated that although they may be aware of the general health risks associated with smoking, they may not be sufficiently aware of how these risks are impacted by previous treatment-related exposures.⁷⁰ Therefore, personalized risk information that is framed in the context of the patient's specific treatment history, current clinical condition, organ most vulnerable to treatment effects, and other psychosocial risk factors should be conveyed to patients to promote accurate perceptions of their disease risk as it relates to smoking.¹⁵¹ Additional issues that deserve consideration when counseling at-risk children and adolescents about tobacco use are outlined in Table 1.

View this table: [in this window] [in a new window]   TABLE 1 Clinician-Delivered Tobacco-Use–Counseling Strategies for Adolescents With Chronic Illness

 
Emphasizing the patient's risk for tobacco-related health problems as greater than their healthy peers without these conditions may be especially significant in motivating patients to take action in responsibly protecting their health. However, it is important to first frame the smoking behavior as a risk for any adolescent and then explain the additional risks of the synergistic effects of smoking and therapies for the young patient. This offers a more "normalizing" approach¹³¹ that recognizes the patients' need to identify with their peers without producing unnecessary anxiety and hypervigilance. Although provision of information may not be sufficient, by itself, in preventing smoking onset or impacting smoking cessation, it is critical to provide this risk information as a component of an effective counseling intervention.

	SUMMARY AND FUTURE DIRECTIONS

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With the exception of children and adolescents with asthma who reported smoking at rates comparable to or greater than youngsters without this condition, those with cancer, CF, SCD, and JRA are smoking at reduced rates relative to their healthy peers. Current smoking rates as high as 55% were reported among asthmatic adolescents,³⁴ whereas rates as low as 2% were reported among adolescents undergoing treatment for cancer.⁶⁴ A comparison of reported smoking rates across pediatric chronic illness groups is summarized in Table 2. Smoking rates are less clearly established among adolescents with diabetes, because most study samples have included both adolescent and young adults. In addition, the age of smoking initiation among youngsters varied across the different disease groups.

View this table: [in this window] [in a new window]   TABLE 2 Reported Smoking Rates For Pediatric Chronic Illness Groups

 
A primary finding from our review was that the presence of a diagnosis of a chronic illness by itself did not influence the acquisition of a smoking habit. Furthermore, age of onset of the disease as well as the age of smoking initiation for a particular illness did not necessarily affect the smoking incidence for that group. However, a direct comparison of smoking rates across different diagnostic groups is complicated because of differences in the demographic composition of the samples studied, as well as the differing definitions of smoking status that were used.

Understanding why children and adolescents with chronic illness smoke and identifying innovative ways to prevent smoking onset and stop patients from smoking is a daunting and challenging task for health care professionals. As our review suggests, these and other issues remain relatively unexplored and are outlined in Table 3. Studies of smoking-related variables among teens with chronic conditions have been marked by several limitations including small or nonrepresentative samples, lack of adequate control groups, cross-sectional studies, reliance on self-report measures, and lack of reliable, standardized instruments and measures of smoking status. Longitudinal research is needed to better understand the interrelated determinants of initiation, experimentation, and maintenance of smoking behaviors in these vulnerable populations and to resolve several outstanding research questions regarding the role of illness in tobacco control. Continued research efforts devoted to the evaluation of smoking-intervention approaches are clearly needed in light of the limited work that has been done in this area.

View this table: [in this window] [in a new window]   TABLE 3 Proposed Tobacco Control Objectives for Chronically Ill Pediatric Populations

 
Disease duration and severity, age of onset, the course of the disease (progressive, stable, or relapsing/episodic), the expected outcome, the degree of physical disability, and the visibility of the condition are just some of the variables yet to be investigated that may differentially impact the likelihood of smoking behaviors among youngsters with chronic illness. Different health care–delivery models and treatment settings that youngsters are exposed to as a function of their particular disease may also play a role. In addition, the optimal timing for implementing tobacco counseling with these patients has not been studied adequately. Patients may be more sensitized to their health at various stages of their disease and/or treatment and, therefore, more receptive to counseling at that time. Alternatively, the physical and emotional stressors associated with a particular disease or treatment phase may prevent the patient from focusing on less acute health concerns.

Preliminary data also suggest that pharmacotherapy and nicotine-replacement therapy can be safely provided to adolescent smokers¹⁵² but offer little improvement in terms of tobacco-cessation rates.^152–155 Assessment of nicotine dependence among adolescents has been difficult and controversial because of the varying subjective criteria used for defining dependence and the widely varying sample characteristics.^156,157 Unlike adults, adolescent smokers are also more likely to be influenced by behavioral and social factors than addiction to nicotine.¹⁵⁸ Therefore, pharmacotherapy may be most beneficial for the nicotine-addicted "adult-type" smoker who pursues tobacco to maintain a steady state of nicotine. Treatment regimens of adolescent smoking cessation may need to be determined on the basis of the adolescent's degree of nicotine dependence, within the context of a smoking-cessation program, and under the supervision of a physician.¹⁵⁸ Whether there are contraindications for administration of nicotine-replacement therapy or pharmacotherapy to chronically ill populations because of their disease-related complications and associated treatments has not been clearly established and has been largely ignored in the literature. In addition, the acceptability of pharmacotherapy for smoking cessation among adolescents who may already undergo multiple treatments and receive complex medication regimens, by nature of their disease, is an issue that deserves additional investigation.

The most likely avenues for interventions with chronically ill youngsters include health care provider screening and intervention as well as hospital-based education programs. Treatment fidelity, the actual delivery of the complete "dose" of the intervention, is a critical feature that is not adequately measured in most clinician-delivered interventions.^138,139 Future studies should include procedures to improve clinician compliance and ensure complete and standardized delivery of prevention programs in practice-based settings.

Consideration should also be given to expanding the network of national collaborative programs and consortia that prioritize tobacco-control initiatives among youth in the United States to encompass the agendas of investigators conducting tobacco-control research in pediatric populations. In light of the increasing complexity of youth tobacco research and the unique unanswered questions relevant to tobacco use among medically compromised children, it is critical that tobacco-control objectives with at-risk pediatric populations be included in the scope of activities addressed by this national effort. The ultimate goal of this concerted effort will be the translation of evidence-based findings to clinical practice and significant reduction of tobacco use by youth.

	ACKNOWLEDGMENTS

 
Dr Throckmorton-Belzer is currently a postdoctoral fellow at the Stanford Prevention Research Center (Stanford University School of Medicine, Stanford, CA) and is supported by Public Health Service grant 5 T32 HL 07034 from the National Heart, Lung, and Blood Institute.

	FOOTNOTES

 
Accepted Feb 6, 2006.

Address correspondence to Vida L. Tyc, PhD, Division of Behavioral Medicine, St Jude Children's Research Hospital, 332 N Lauderdale, Memphis, TN 38105-2794. E-mail: vida.tyc{at}stjude.org

The authors have indicated they have no financial relationships relevant to this article to disclose.

	REFERENCES

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1. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993;270 :2207 –2212[Abstract/Free Full Text]
2. US Department of Health and Human Services and Office of Disease Prevention and Health Promotion. Healthy People 2010: Understanding and Improving Health and Objectives for Improving Health. Washington, DC: US Department of Health and Human Services; 2000
3. Kessler DA, Witt AM, Barnett PS, et al. The Food and Drug Administration's regulation of tobacco products. N Engl J Med. 1996;335 :988 –994[Free Full Text]
4. Lynch BS, Bonnie RJ. Growing up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: National Academy Press; 1994
5. US Department of Health and Human Services. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1994
6. Centers for Disease Control and Prevention. Tobacco use among middle and high school students: United States, 2002. MMWR Morb Mortal Wkly Rep. 2003;52 :1096 –1098[Medline]
7. Schubiner H, Herrold A, Hurt R. Tobacco cessation and youth: the feasibility of brief office interventions for adolescents. Prev Med. 1998;27(5 pt 3) :A47 –A54
8. US Department of Health and Human Services. Youth tobacco surveillance: United States, 2000 [published correction appears in MMWR CDC Surveill Summ. 2001;50(46):1036]. MMWR CDC Surveill Summ. 2001;50(4) :1 –84
9. Gold DR, Wang X, Wypij D, Speizer FE, Ware JH, Dockery DW. Effects of cigarette smoking on lung function in adolescent boys and girls. N Engl J Med. 1996;335 :931 –937[Abstract/Free Full Text]
10. Prokhorov AV, Emmons KM, Pallonen UE, Tsoh JY. Respiratory response to cigarette smoking among adolescent smokers: a pilot study. Prev Med. 1996;25 :633 –640[CrossRef][Web of Science][Medline]
11. Davis JW, Shelton L, Watanabe IS, Arnold J. Passive smoking affects endothelium and platelets. Arch Intern Med. 1989;149 :386 –389[Abstract/Free Full Text]
12. Baldaia L. An educational approach to successful management of childhood asthma as a chronic illness. J Pediatr Nurs. 1996;11 :335 –336[CrossRef][Medline]
13. National Heart, Lung, and Blood Institute. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma—Clinical Practice Guidelines. Bethesda, MD: National Institutes of Health; 1997. NIH publication 97-4051
14. Centers for Disease Control and Prevention. Surveillance for asthma: United States, 1960–1995. MMWR CDC Surveill Summ. 1998;47(1) :1 –28
15. Evans R. Asthma among minority children: a growing problem. Chest. 1992;101 :368S –371S[Free Full Text]
16. Joad JP. Smoking and pediatric respiratory health. Clin Chest Med. 2000;21 :37 –46[CrossRef][Web of Science][Medline]
17. Beeber SJ. Parental smoking and childhood asthma. J Pediatr Health Care. 1996;10 :58 –62[CrossRef][Medline]
18. US Department of Health and Human Services. Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders. Washington, DC: US Department of Health and Human Services, Public Health Service, National Institutes of Health and US Environmental Protection Agency, Office of Research and Development, Office of Air and Radiation; 1993
19. Abulhosn RS, Morray BH, Llewllyn CE, Redding GJ. Passive smoke exposure impairs recovery after hospitalization for acute asthma. Arch Pediatr Adolesc Med. 1997;151 :135 –139[Abstract/Free Full Text]
20. Patel DR, Homnick DN. Pulmonary effects of smoking. Adolesc Med. 2000;11 :567 –576[Medline]
21. Larsson, L. Incidence of asthma in Swedish teenagers: relation to sex and smoking habits. Thorax. 1994;50 :260 –264[CrossRef][Web of Science]
22. LeSon, S, Gershwin ME. Risk factors for asthmatic patients requiring intubation II: observations in teenagers. J Asthma. 1995;32 :379 –389[Web of Science][Medline]
23. Martin AJ, Landau LI, Phelan PD. Asthma from childhood at age 21: the patient and his disease. Br Med J (Clin Res Ed). 1982;284 :380 –382
24. Leung R, Wong G, Lau J, et al. Prevalence of asthma and allergy in Hong Kong schoolchildren: an ISAAC study. Eur Respir J. 1997;10 :354 –360[Abstract]
25. Franceschinis R, Macciocchi A, Perruchoud D. Tobacco smoke: respiratory tract defense mechanisms and therapeutic implications. Eur J Respir Dis. 1985;139 (suppl):72 –79
26. Boffett P, Ye W, Boman G, Nyren O. Lung cancer risk in a population-based cohort of patients hospitalized for asthma in Sweden. Eur Respir J. 2002;19 :127 –133[Abstract/Free Full Text]
27. Wiencke JK, Kelsey KT. Teen smoking, field cancerization, and a "critical period" hypothesis for lung cancer susceptibility. Environ Health Perspect. 2002;110 :555 –558[Web of Science][Medline]
28. McCrea K, Ensor J, Nall K, Bleeker ER, Hasday JD. Altered cytokine regulation in the lungs of cigarette smokers. Am J Respir Crit Care Med. 1994;150 :696 –703[Abstract]
29. Chalmers GW, Macleod KJ, Little SA, Thomson LJ, McSharry CP, Thomson NC. Influence of cigarette smoking on inhaled corticosteroid treatment in mild asthma. Thorax. 2002;57 :226 –230[Abstract/Free Full Text]
30. Oechsli F, Seltzer CC, van den Berg BJ. Adolescents smoking and early respiratory disease: a longitudinal study. Ann Allergy. 1987;59 :135 –140[Web of Science][Medline]
31. Backer V, Nepper-Christensen S, Ulrik CS, von Linstow ML, Porsberg C. Factors associated with asthma in young Danish adults. Ann Allergy Asthma Immunol. 2002;89 :148 –154[Web of Science][Medline]
32. Brook U, Shiloh S. Attitudes of asthmatic and nonasthmatic adolescents toward cigarettes and smoking. Clin Pediatr (Phila). 1993;32 :642 –646[Abstract/Free Full Text]
33. Forero R, Bauman A, Young L, Booth M, Larkin P. Asthma prevalence and management in Australian adolescents: results from three community surveys. J Adolesc Health. 1992;13 :707 –712[CrossRef][Web of Science][Medline]
34. Forero R, Bauman A, Young L, Booth M, Nutbeam D. Asthma, health behaviors, social adjustment, and psychosomatic symptoms in adolescence. J Asthma. 1996;33 :157 –164[Web of Science][Medline]
35. Kaplan BA, Mascie-Taylor CG. Biosocial correlates of asthma in a national sample of young adults. J Biosoc Sci. 1989;21 :475 –482[Web of Science][Medline]
36. Sherman CB, Tosteson TD, Tager IB, Speizer FE, Weiss ST. Early childhood predictors of asthma. Am J Epidemiol. 1990;132 :83 –95[Abstract/Free Full Text]
37. Tercyak KP. Psychosocial risk factors for tobacco use among adolescents with asthma. J Pediatr Psychol. 2003;28 :495 –504[Abstract/Free Full Text]
38. Zbikowski SM, Klesges RC, Robinson LA, Alfano CM. Risk factors for smoking among adolescents with asthma. J Adolesc Health. 2002;30 :279 –287[CrossRef][Web of Science][Medline]
39. FitzSimmons SC. The changing epidemiology of cystic fibrosis. J Pediatr. 1993;122 :1 –9[Web of Science][Medline]
40. Beers MH, Berkow R. Cystic fibrosis. In: Merck Manual: Diagnosis & Therapy. 17th ed. Whitehouse Station, NJ: Merck & Co, Inc; 1999:2366 –2371
41. Wood RE, Boat TF, Doershuk CF. Cystic fibrosis. Am Rev Respir Dis. 1976;113 :833 –877[Web of Science][Medline]
42. Britto MT, Garrett JM, Dugliss MAJ, et al. Risky behavior in teens with cystic fibrosis or sickle cell disease: a multicenter study. Pediatrics. 1998;101 :250 –256[Abstract/Free Full Text]
43. Verma A, Clough D, McKenna D, Dodd M, Webb AK. Smoking and cystic fibrosis. J R Soc Med. 2001;94 (suppl 40):29 –34
44. Smyth A, O'Hea U, Williams G, Smyth R, Heaf D. Passive smoking and impaired lung function in cystic fibrosis. Arch Dis Child. 1994;71 :353 –354[Abstract/Free Full Text]
45. Agius AM, Smallman LA, Pahor AL. Age, smoking and nasal ciliary beat frequency. Clin Otolaryngol. 1998;23 :227 –230[CrossRef][Web of Science][Medline]
46. Ries LAG, Kosary CL, Hankey BF, Miller BA, Clegg L, Edwards BK. SEER cancer statistics review 1973–1995. Available at: http://seer.cancer.gov/csr/1973_1995. Accessed June 3, 2006
47. Landis MPH, Murray T, Bolden S, Wingo PA. Cancer statistics, 1998 [published corrections appear in CA Cancer J Clin. 1998;48:192; and CA Cancer J Clin. 1998;48:329]. CA Cancer J Clin. 1998;48 :6 –29[Abstract]
48. O'Driscoll BR, Hasleton PS, Taylor PM, Poulter LW, Gattamaneni HR, Woodcock AH. Active lung fibrosis up to 17 years after chemotherapy with carmustine (BCNU) in childhood. N Engl J Med. 1990;323 :378 –382[Abstract]
49. Benoist MR, Lemerle J, Jean R. Effects on pulmonary function of whole lung irradiation for Wilm's tumor in children. Thorax. 1982;37 :175 –180[Abstract/Free Full Text]
50. Lipshultz SE, Colan SD, Gelbar RD, Perez-Atayde AR, Sallan SE, Sanders SP. Late cardiac effects of doxorubicin therapy for acute lymphoblastic leukemia in childhood. N Engl J Med. 1991;324 :808 –815[Abstract]
51. Boivin J. Smoking, treatment for Hodgkin's Disease, and subsequent lung cancer risk. J Natl Cancer Inst. 1995;87 :1502 –1503[Free Full Text]
52. Des Rochers C, Dische S, Sanders MI. The problem of cigarette smoking in radiotherapy for cancer in the head and neck. Clin Oncol. 1992;4 :214 –216[CrossRef]
53. Cinciripini PM, Gritz ER, Tsoh JY, Skaar KL. Smoking cessation and cancer prevention. In: Holland JC, ed. Psycho-Oncology. New York, NY: Oxford University Press; 1998
54. Goodman MT, Kolonel LN, Wilkens LR, Yoshizawa CN, Le Marchand L. Smoking history and survival among lung cancer patients. Cancer Causes Control. 1990;1 :155 –163[CrossRef][Web of Science][Medline]
55. Day GL, Blot WJ, Shore RE, et al. Second cancers following oral and pharyngeal cancers: role of tobacco and alcohol. J Natl Cancer Inst. 1994;86 :131 –137[Abstract/Free Full Text]
56. Hawkins MM, Stevens MCG. The long-term survivors. Br Med Bull. 1996;52 :898 –923[Abstract/Free Full Text]
57. Marina N. Long-term survivors of childhood cancer. Pediatr Clin North Am. 1997;44 :1021 –1042[CrossRef][Web of Science][Medline]
58. Malkin D, Jolly KW, Barbier N, et al. Germline mutations of the p53 tumor-suppressor gene in children and young adults with second malignant neoplasms. N Engl J Med. 1992;326 :1309 –1315[Abstract]
59. Mulhern RK, Tyc VL, Phipps S, et al. Health-related behaviors of survivors of childhood cancer. Med Pediatr Oncol. 1995;25 :159 –165[Web of Science][Medline]
60. Hollen PJ, Hobbie WL. Risk taking and decision making of adolescent long-term survivors of cancer. Oncol Nurs Forum. 1993;20 :769 –776[Medline]
61. Hollen PJ, Hobbie WL, Finley SM. Testing the effects of a decision-making and risk-reduction program for cancer-surviving adolescents. Oncol Nurs Forum. 1999;26 :475 –1486
62. Tyc VL, Hadley W, Crockett G. Brief report: predictors of intentions to use tobacco among adolescent survivors of cancer. J Pediatr Psychol. 2001;26 :117 –121[Abstract/Free Full Text]
63. Tyc VL, Throckmorton-Belzer L, Klosky JL, et al. Smoking among parents of pediatric cancer patients and children's exposure to environmental tobacco smoke. J Child Health Care. 2004;8 :288 –300[Abstract/Free Full Text]
64. Tyc VL, Lensing S, Klosky JL, Rai SN, Robinson L. A comparison of tobacco-related risk factors between adolescents with and without cancer. J Pediatr Psychol. 2005;30 :359 –370[Abstract/Free Full Text]
65. Conrad KM, Flay BR, Hill D. Why children start smoking cigarettes: predictors of onset. Br J Addict. 1992;87 :1711 –1724[CrossRef][Web of Science][Medline]
66. Eckhardt L, Woodruff SI, Elder JP. A longitudinal analysis of adolescent smoking and its correlates. J Sch Health. 1994;64 :767 –772
67. Pierce JP, Choi WS, Gilpin EA, Farkas AJ, Merritt RK. Validation of susceptibility as a predictor of which adolescents take up smoking in the United States. Health Psychol. 1996;15 :355 –361[CrossRef][Web of Science][Medline]
68. Larcombe I, Mott M, Hunt L. Lifestyle behaviors of young adult survivors of childhood cancer. Br J Cancer. 2002;87 :1204 –1209[CrossRef][Web of Science][Medline]
69. Tao ML, Guo, MD, Weiss R, et al. Smoking in adult survivors of childhood acute lymphoblastic leukemia. J Natl Cancer Inst. 1998;90 :219 –225[Abstract/Free Full Text]
70. Emmons K, Li F, Whitton J, et al. Predictors of smoking initiation and cessation among childhood cancer survivors: a report from the Childhood Cancer Survivor Study. J Clin Oncol. 2002;20 :1608 –1616[Abstract/Free Full Text]
71. Lemanek KL, Buckloh LM, Woods G, Butler R. Diseases of the circulatory system: sickle cell disease and hemophilia. In: Roberts MC, ed. Handbook of Pediatric Psychology. 2nd ed. New York, NY: Guilford Press; 1995:286 –309
72. Beers MH, Berkow R. Anemias. In: Beers MH, Berkow E, eds. Merck Manual: Diagnosis & Therapy. 17th ed. Whitehouse Station, NJ: Merck & Co, Inc; 1999:878 –883
73. Ashley-Koch A, Yang Q, Olney RS. Sickle hemoglobin (HbS) allele and sickle cell disease: a HuGE review. Am J Epidemiol. 2000;151 :839 –845[Abstract/Free Full Text]
74. Platt OS, Brambilla DJ, Rosse WF, et al. Mortality in sickle cell disease: life expectancy and risk factors for early death. N Engl J Med. 1994;330 :1639 –1644[Abstract/Free Full Text]
75. Wethers D, Pearson H, Gaston M. Newborn screening for sickle cell disease and hemoglobinopathies. Pediatrics. 1987;259 :813 –814
76. West DC, Romano PS, Azari R, Rudominer A, Holman M, Sandhu S. Impact of environmental tobacco smoke on children with sickle cell disease. Arch Pediatr Adolesc Med. 2003;157 :1197 –1201[Abstract/Free Full Text]
77. Young RC Jr, Rachal RE, Hackney RL Jr, Uy CG, Scott RB. Smoking is a factor in causing acute chest syndrome in sickle cell anemia. J Natl Med Assoc. 1992;84 :267 –271[Medline]
78. Allred EN, Bleeker ER, Chaitman BR, et al. Short-term effects of carbon monoxide exposure on the exercise performance of subjects with coronary artery disease [published correction appears in N Engl J Med. 1990;322:1019]. N Engl J Med. 1989;321 :1426 –1432[Abstract]
79. Aranow WS. Effect of passive smoking on angina pectoris. N Engl J Med. 1978;299 :21 –24[Abstract]
80. Young RC, Rachel RE, Reindorf CA, et al. Lung function in sickle hemoglobinopathies: comparison with that in healthy subjects. J Natl Med Assoc. 1989;80 :509 –514
81. Celermajer DS, Adams MR, Clarkson P, et al. Passive smoking and impaired endothelium-dependent arterial dilatation in healthy young adults. N Engl J Med. 1996;334 :150 –154[Abstract/Free Full Text]
82. Kimura S, Nishinaga M, Ozawa T, Shimada K. Thrombin generation as an acute effect of cigarette smoking. Am Heart J. 1994;128 :7 –11[CrossRef][Web of Science][Medline]
83. Beers MH, Berkow R. Disorders of carbohydrate metabolism. In: Merck Manual: Diagnosis & Therapy. 17th ed. Whitehouse Station, NJ: Merck & Co, Inc; 1999:165 –177
84. Johnson SB. Insulin-dependent diabetes mellitus in childhood. In: Roberts MC, ed. Handbook of Pediatric Psychology. 2nd ed. New York, NY: Guilford Press; 1995
85. LaPorte R, Tajima N. Prevalence of insulin-dependent diabetes. In: Harris M, Harris, Hamman R, eds. Diabetes in America. Bethesda, MD: National Institutes of Health; 1985:V :1 –8. NIH publication 95-1468
86. Orchard T, Dorman J, Maser R, et al. Prevalence of complications in IDDM by sex and duration. Pittsburgh Epidemiology of Diabetes Complications Study II. Diabetes. 1990;39 :1116 –1124[Abstract]
87. Haire-Joshu D, Glasgow RE, Tibbs TL. Smoking and diabetes. Diabetes Care. 1999;22 :1887 –1898[Abstract/Free Full Text]
88. Stamler J, Vaccaro O, Neaton JD, Wentworth D. Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial. Diabetes Care. 1993;16 :434 –444[Abstract]
89. Palumbo PJ, O'Fallon WM, Osmundson PI, Zimmerman BR, Langworthy AL, Kazmier FJ. Progression of peripheral occlusive arterial disease in diabetes mellitus. What factors are predictive? Arch Intern Med. 1991;151 :717 –721
90. Suarez L, Barrett-Connor E. Interaction between cigarette smoking and diabetes in the prediction of death attributed to cardiovascular disease. Am J Epidemiol. 1984;120 :670 –675[Abstract/Free Full Text]
91. Mulhauser I. Smoking and diabetes. Diabet Med. 1990;7 :10 –15[Web of Science][Medline]
92. Ford ES, Newman J. Smoking and diabetes mellitus: findings from 1988 behavioral risk factor surveillance system. Diabetes Care. 1991;14 :871 –874[Abstract]
93. Gay EC, Cai Y, Gale SM, et al. Smokers with IDDM experience excess morbidity. Diabetes Care. 1992;15 :947 –952[Abstract]
94. Moy CS, LaPorte RE, Dorman JS, et al. Insulin-dependent diabetes mellitus mortality: the risk of cigarette smoking. Circulation. 1990;82 :37 –43[Abstract/Free Full Text]
95. Gold MA, Gladstein J. Substance use among adolescents with diabetes mellitus: preliminary findings. J Adolesc Health. 1993;14 :80 –84[CrossRef][Web of Science][Medline]
96. Frey MA, Guthrie B, Loveland-Cherry C, Park PS, Foster CM. Risky behavior and risk in adolescents with IDDM. J Adolesc Health. 1997;20 :38 –45[CrossRef][Web of Science][Medline]
97. Starkman HS, Cable G, Hala V, Hecht H, Donnelly CM. Delineation of prevalence and risk factors for early coronary artery disease by electron beam computed tomography in young adults with type I diabetes. Diabetes Care. 2003;26 :433 –436[Abstract/Free Full Text]
98. Cundiff DK. Diet and tobacco use: analysis of data from the Diabetic Control and Complications Trial, a randomized study. MedGenMed. 2002;4 :2[Medline]
99. Shaw NJ, McClure RJ, Kerr S, Lawton K, Smith CS. Smoking in diabetic teenagers. Diabet Med. 1993;10 :275 –277[Web of Science][Medline]
100. Masson EA, MacFarlane IA, Priestley CJ, Wallymahmed ME, Flavell HJ. Failure to prevent nicotine addiction in young people with diabetes. Arch Dis Child. 1992;67 :100 –102[Abstract/Free Full Text]
101. Jones JB, Hedley AJ. Prevalence of smoking in a diabetic population: the need for action. Diabet Med. 1987;4 :233 –236[Web of Science][Medline]
102. Beers MH, Berkow R. Musculoskeletal and connective tissue disorders. In: Merck Manual: Diagnosis & Therapy. 17th ed. Whitehouse Station, NJ: Merck & Co, Inc; 1999;2402 –2403
103. Rennebohm RM. Juvenile rheumatoid arthritis: medical issues. In: Olson RA, Mullins LL, Gillman JB, Chaney JM, eds. The Sourcebook of Pediatric Psychology. Boston, MA: Allyn & Bacon; 1994:70 –74
104. Medline Plus Medical Encyclopedia. Juvenile rheumatoid arthritis. Available at: www.nlm.nih.gov/medlineplus/ency/article/000451.htm. Accessed October 23, 2004
105. Gordon MM, Thomson EA, Madhok R, Capell HA. Can intervention modify adverse lifestyle variables in a rheumatoid population? Results of a pilot study. Ann Rheum Dis. 2003;61 :66 –69[CrossRef][Web of Science]
106. Wahlberg-Johnsson S, Ohman ML, Dahlquist SR. Cardiovascular morbidity and mortality in patients with seropositive rheumatoid arthritis in northern Sweden. J Rheumatol. 1999;26 :445 –451[CrossRef]
107. Albano SA, Santana-Sahagun E, Weisman MH. Cigarette smoking and rheumatoid arthritis. Semin Arthritis Rheum. 2001;31 :146 –159[CrossRef][Web of Science][Medline]
108. Saag KG, Cerhan JR, Kolluri S, Ohashi K, Hunninghake GW, Schwartz DA. Cigarette smoking and rheumatoid arthritis severity. Ann Rheum Dis. 1997;56 :463 –469[Abstract/Free Full Text]
109. Heliovaara M, Aho K, Aromaa A, Knekt P, Rernanen A, Daling JR. Smoking, obesity, alcohol consumption, and the risk of rheumatoid arthritis. J Rheumatol. 1993;20 :1830 –1835[Web of Science][Medline]
110. Spector TD, Blake DR. Effect of cigarette smoking on Langerhans' cells [letter]. Lancet. 1998;2(8618) :1028
111. French AR, Mason T, Nelson AM, et al. Osteopenia in adults with a history of juvenile rheumatoid arthritis: a population based study. J Rheumatol. 2002;29 :1065 –1070[Abstract/Free Full Text]
112. Nash AA, Britto MT, Lovell DJ, Passo MH, Rosenthal SL. Substance use among adolescents with juvenile rheumatoid arthritis. Arthritis Care Res. 1998;11 :391 –396[Web of Science][Medline]
113. Patton GC, McMorris BJ, Toumbourou JW, Hemphill SA, Donath S, Catalano RF. Puberty and the onset of substance use and abuse. Pediatrics. 2004;114 (3). Available at: www.pediatrics.org/cgi/content/full/114/3/e300
114. Haire-Joshu D. Smoking cessation and the diabetes health care team. Diabetes Educ. 1991;17 :54 –64[Free Full Text]
115. Haire-Joshu D, Heady S, Thomas L, Sclechtman K, Fisher EB Jr. Beliefs about smoking and diabetes care. Diabetes Educ. 1994;20 :410 –415[Free Full Text]
116. Burt RD, Dinh KT, Peterson AV, Sarason I. Predicting adolescent smoking: a prospective study of personality variables. Prev Med. 2000;30 :115 –125[CrossRef][Web of Science][Medline]
117. Tyas SL, Pederson LL. Psychosocial factors related to adolescent smoking: a critical review of the literature. Tob Control. 1998;7 :409 –420[Abstract/Free Full Text]
118. Creer TL, Bender BG. Pediatric asthma. In: Roberts MC, ed. Handbook of Pediatric Psychology. 2nd ed. New York, NY: Guilford Press; 1995:219 –240
119. Kovall JJ, Pederson LL, Mills CA, McGrady GA, Caravajal SC. Models of the relationship of stress, depression, and other psychosocial factors to smoking behavior: a comparison of a cohort of students in grades 6 and 8. Prev Med. 2000;30 :463 –477[CrossRef][Web of Science][Medline]
120. Biglan A, Ary DV, Smolkowski K, Duncan T, Black C. A randomised controlled trial of a community intervention to prevent adolescent tobacco use. Tob Control. 2000;9 :24 –32[Abstract/Free Full Text]
121. Johnson CC, Li D, Perry CL, et al. Fifth through eighth grade longitudinal predictors of tobacco use among a racially diverse cohort: CATCH. J Sch Health. 2002;72 :58 –64[Web of Science][Medline]
122. Robinson LA, Klesges RC, Zbikowski SM, Glaser R. Predictors of risk for different stages of adolescent smoking in a biracial sample. J Consult Clin Psychol. 1997;65 :653 –662[CrossRef][Web of Science][Medline]
123. Weinstein ND. Testing four competing theories of health-protective behavior. Health Psychol. 1993;12 :324 –333[CrossRef][Web of Science][Medline]
124. Tyc VL, Rai SN, Lensing S, Klosky JL, Stewart DB, Gattuso J. Intervention to reduce intentions to use tobacco among pediatric cancer survivors. J Clin Oncol. 2003;21 :1366 –1372[Abstract/Free Full Text]
125. Gerrard M, Gibbons FX, Benthin AC, Hessling RM. A longitudinal study of the reciprocal nature of risk behaviors and cognitions in adolescents: what you do shapes what you think, and vice versa. Health Psychol. 1996;15 :344 –354[CrossRef][Web of Science][Medline]
126. Gerrard M, Gibbons FX, Bushman BJ. Relation between perceived vulnerability to HIV and precautionary sexual behavior. Psychol Bull. 1996;119 :390 –409[CrossRef][Web of Science][Medline]
127. Emmons KM, Butterfield RM, Puleo E, et al. Smoking among participants in the childhood cancer survivors cohort: the Partnership for Health Study. J Clin Oncol. 2003;21 :189 –196[Abstract/Free Full Text]
128. Elder JP, de Moor C, Young RL, et al. Stages of adolescent tobacco use acquisition. Addict Behav. 1990;15 :449 –454[CrossRef][Web of Science][Medline]
129. Prokhorov AV, de Moor CA, Hudmon KS, Hu S, Keldor SH, Gritz ER. Predicting initiating of smoking in adolescents: evidence for integrating the stages of change and susceptibility to smoking constructs. Addict Behav. 2002;27 :697 –712[CrossRef][Web of Science][Medline]
130. Distefan JM, Gilpin EA, Coi WS, Pierce JP. Parental influences predict adolescent smoking in the United States, 1989–1993. J Adolesc Health. 1998;22 :466 –474[CrossRef][Web of Science][Medline]
131. Hollen PJ, Hobbie WL. Decision-making and risk behaviors of cancer-surviving adolescents and their peers. J Pediatr Oncol Nurs. 1996;13 :121 –134[CrossRef][Medline]
132. Hollen PJ, Hobbie WL, Finly SM, Hiebert SM. The relationship of resiliency to decision making and risk behaviors of cancer-surviving adolescents. J Pediatr Oncol Nurs. 2001;18 :188 –204[CrossRef][Medline]
133. Meltzer SB, Hovell MF, Meltzer EO, Atkins CJ, de Peyster A. Reduction of secondary smoke exposure to asthmatic children: parent counseling. J Asthma. 1993;30 :391 –400[Web of Science][Medline]
134. Hudson MM, Tyc VL, Srivastava DK, et al. Multi-component behavioral interventions to promote health protective behaviors in childhood cancer survivors: the Protect Study. Med Pediatr Oncol. 2002;39 :2 –11[CrossRef][Web of Science][Medline]
135. Hollen PJ, Hobbie WL, Finley SM. Testing the effects of a decision-making and risk-reduction program for cancer-surviving adolescents. Oncol Nurs Forum. 1999;26 :1475 –1486[Medline]
136. Orleans CT, Kristeller JL, Gritz ER. Helping hospitalized smokers quit: new directions for treatment and research. J Consult Clin Psychol. 1993;61 :778 –789[CrossRef][Web of Science][Medline]
137. Fidler W, Lambert TW. A prescription for health: a primary care based intervention to maintain the non-smoking status of young people. Tob Control. 2002;10 :23 –26[CrossRef][Web of Science]
138. Stevens MM, Olson AL, Gaffney CA, Tosteson TD, Mott LA, Starr P. A pediatric, practice-based, randomized trial of drinking and smoking prevention and bicycle helmet, gun, and seatbelt safety promotion. Pediatrics. 2002;109 :490 –497[Abstract/Free Full Text]
139. Hovell MF, Slymen DJ. An adolescent tobacco-use prevention trial in orthodontic offices. Am J Public Health. 1996;86 :1760 –1767[Abstract/Free Full Text]
140. Glasgow RE, Strycker LA, Eakin EG, Boles SM, Whitlock EP. Concern about weight gain associated with quitting smoking: prevalence and association with outcome in a sample of young female smokers. J Consult Clin Psychol. 1999;67 :1009 –1111[CrossRef][Web of Science][Medline]
141. Colby SM, Monti PM, Barnett NP, et al. Brief motivational interviewing in a hospital setting for adolescent smoking: a preliminary study. J Consult Clin Psychol. 1998;66 :574 –578[CrossRef][Web of Science][Medline]
142. Pbert L, Moolchan ET, Muramoto M, et al. The state of office-based interventions in youth tobacco use. Pediatrics. 2003;111 (6).Available at: www.pediatrics.org/cgi/content/full/111/6/e650
143. American Academy of Pediatrics, Committee on Substance Abuse. Tobacco, alcohol, and other drugs: the role of the pediatrician in prevention and management of substance abuse. Pediatrics. 1998;101 :125 –128[Abstract/Free Full Text]
144. Epps RP, Manley MW. Prevention of tobacco use during childhood and adolescence. Cancer. 1993;72 :1002 –1004[CrossRef][Web of Science][Medline]
145. Glynn TJ, Manley MW. How to Help Your Patients Stop Smoking: A National Cancer Institute Manual for Physicians. Bethesda, MD: Smoking and Tobacco Program, Division of Cancer Prevention and Control, National Institutes of Health; 1993:1 –77. DHHS publication 93-3064
146. Rosen DS, Elster A, Hedberg V, Paperny D. Clinical preventive services for adolescents: position paper of the Society for Adolescent Medicine. J Adolesc Health. 1997;21 :203 –214[CrossRef][Web of Science][Medline]
147. Klein JD, Levine LJ, Allen MJ. Delivery of smoking prevention and cessation services to adolescents. Arch Pediatr Adolesc Med. 2001;155 :597 –602[Abstract/Free Full Text]
148. Purcell JS, Hergenroeder AC, Kozinetz C, Smith EO, Hill RB. Interviewing techniques with adolescents in primary care. J Adolesc Health Care. 1997;20 :300 –305
149. Backinger CL, Fagan P, Matthews E, Grana R. Adolescent and young adult tobacco prevention and cessation: current status and future directions. Tob Control. 2003;12 :46 –53
150. Sussman S, Lichtman K, Ritt A, Pallonen UE. Effects of thirty-four adolescent tobacco use cessation and prevention trials on regular users of tobacco products. Subst Use Misuse. 1999;34 :1469 –1503[Web of Science][Medline]
151. Tyc VL, Hudson MM, Hinds P, Elliott V, Kibby MY. Tobacco use among pediatric cancer patients: recommendations for developing clinical smoking interventions. J Clin Oncol. 1997;15 :2194 –2204[Abstract/Free Full Text]
152. Smith TA, House RF Jr, Croghan IT, et al. Nicotine patch therapy in adolescent smokers. Pediatrics. 1996;98 :659 –667[Abstract/Free Full Text]
153. Hanson K, Allen S, Jensen S, Hatsukami D. Treatment of adolescent smokers with the nicotine patch. Nicotine Tob Res. 2003;5 :515 –526[CrossRef][Web of Science][Medline]
154. Killen JD, Robinson TN, Ammerman S, et al. Randomized trial of the efficacy of bupropion combined with nicotine patch in the treatment of adolescent smokers. J Consult Clin Psychol. 2004;72 :729 –735[CrossRef][Web of Science][Medline]
155. Stotts RC, Roberson PK, Hanna EY, Jones SK, Smith CK. A randomised clinical trial of nicotine patches for treatment of spit tobacco addiction among adolescents. Tob Control. 2003;12 (suppl 4):iv11 –iv15[Abstract/Free Full Text]
156. Stanton WR. DSM-III-R tobacco dependence and quitting during late adolescence. Addict Behav. 1995;20 :595 –603[CrossRef][Web of Science][Medline]
157. Prokhorov AV, Pallonen UE, Fava JL, Ding L, Niaura R. Measuring nicotine dependence among high-risk adolescent smokers. Addict Behav. 1996;21 :117 –127[CrossRef][Web of Science][Medline]
158. Adelman WP. Nicotine replacement therapy for teenagers. About time or a waste of time? Arch Pediatr Adolesc Med. 2004;158 :205 –206

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