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REVIEW ARTICLE |
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
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ABSTRACT |
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 TOP ABSTRACT ASTHMACFCANCERSCDDIABETESJRAMEDICAL, TREATMENT-RELATED, AND...PSYCHOSOCIAL RISK FACTORS...SMOKING INTERVENTIONS FOR...SMOKING INTERVENTIONS DELIVERED...IMPLICATIONS FOR CLINICIAN...SUMMARY AND FUTURE DIRECTIONSREFERENCES |
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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.
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ASTHMA |
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TOPABSTRACTASTHMACFCANCERSCDDIABETESJRAMEDICAL, TREATMENT-RELATED, AND...PSYCHOSOCIAL RISK FACTORS...SMOKING INTERVENTIONS FOR...SMOKING INTERVENTIONS DELIVERED...IMPLICATIONS FOR CLINICIAN...SUMMARY AND FUTURE DIRECTIONSREFERENCES |
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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 to23,31–33 or higher than34–38 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.
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CF |
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TOPABSTRACTASTHMACFCANCERSCDDIABETESJRAMEDICAL, TREATMENT-RELATED, AND...PSYCHOSOCIAL RISK FACTORS...SMOKING INTERVENTIONS FOR...SMOKING INTERVENTIONS DELIVERED...IMPLICATIONS FOR CLINICIAN...SUMMARY AND FUTURE DIRECTIONSREFERENCES |
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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.
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CANCER |
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TOPABSTRACTASTHMACFCANCERSCDDIABETESJRAMEDICAL, TREATMENT-RELATED, AND...PSYCHOSOCIAL RISK FACTORS...SMOKING INTERVENTIONS FOR...SMOKING INTERVENTIONS DELIVERED...IMPLICATIONS FOR CLINICIAN...SUMMARY AND FUTURE DIRECTIONSREFERENCES |
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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-induced56,57 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.
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SCD |
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TOPABSTRACTASTHMACFCANCERSCDDIABETESJRAMEDICAL, TREATMENT-RELATED, AND...PSYCHOSOCIAL RISK FACTORS...SMOKING INTERVENTIONS FOR...SMOKING INTERVENTIONS DELIVERED...IMPLICATIONS FOR CLINICIAN...SUMMARY AND FUTURE DIRECTIONSREFERENCES |
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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.
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DIABETES |
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TOPABSTRACTASTHMACFCANCERSCDDIABETESJRAMEDICAL, TREATMENT-RELATED, AND...PSYCHOSOCIAL RISK FACTORS...SMOKING INTERVENTIONS FOR...SMOKING INTERVENTIONS DELIVERED...IMPLICATIONS FOR CLINICIAN...SUMMARY AND FUTURE DIRECTIONSREFERENCES |
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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
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JRA |
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TOPABSTRACTASTHMACFCANCERSCDDIABETESJRAMEDICAL, TREATMENT-RELATED, AND...PSYCHOSOCIAL RISK FACTORS...SMOKING INTERVENTIONS FOR...SMOKING INTERVENTIONS DELIVERED...IMPLICATIONS FOR CLINICIAN...SUMMARY AND FUTURE DIRECTIONSREFERENCES |
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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 methotrexate102,108 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.
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MEDICAL, TREATMENT-RELATED, AND ENVIRONMENTAL FACTORS ASSOCIATED WITH SMOKING |
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TOPABSTRACTASTHMACFCANCERSCDDIABETESJRAMEDICAL, TREATMENT-RELATED, AND...PSYCHOSOCIAL RISK FACTORS...SMOKING INTERVENTIONS FOR...SMOKING INTERVENTIONS DELIVERED...IMPLICATIONS FOR CLINICIAN...SUMMARY AND FUTURE DIRECTIONSREFERENCES |
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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.
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PSYCHOSOCIAL RISK FACTORS ASSOCIATED WITH SMOKING |
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TOPABSTRACTASTHMACFCANCERSCDDIABETESJRAMEDICAL, TREATMENT-RELATED, AND...PSYCHOSOCIAL RISK FACTORS...SMOKING INTERVENTIONS FOR...SMOKING INTERVENTIONS DELIVERED...IMPLICATIONS FOR CLINICIAN...SUMMARY AND FUTURE DIRECTIONSREFERENCES |
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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 al62,124 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 adolescents128,129 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.
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SMOKING INTERVENTIONS FOR CHILDREN AND ADOLESCENTS WITH CHRONIC ILLNESS |
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TOPABSTRACTASTHMACFCANCERSCDDIABETESJRAMEDICAL, TREATMENT-RELATED, AND...PSYCHOSOCIAL RISK FACTORS...SMOKING INTERVENTIONS FOR...SMOKING INTERVENTIONS DELIVERED...IMPLICATIONS FOR CLINICIAN...SUMMARY AND FUTURE DIRECTIONSREFERENCES |
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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.
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SMOKING INTERVENTIONS DELIVERED WITHIN THE PRIMARY HEALTH CARE SETTING |
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TOPABSTRACTASTHMACFCANCERSCDDIABETESJRAMEDICAL, TREATMENT-RELATED, AND...PSYCHOSOCIAL RISK FACTORS...SMOKING INTERVENTIONS FOR...SMOKING INTERVENTIONS DELIVERED...IMPLICATIONS FOR CLINICIAN...SUMMARY AND FUTURE DIRECTIONSREFERENCES |
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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.
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IMPLICATIONS FOR CLINICIAN-DELIVERED SMOKING INTERVENTIONS |
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TOPABSTRACTASTHMACFCANCERSCDDIABETESJRAMEDICAL, TREATMENT-RELATED, AND...PSYCHOSOCIAL RISK FACTORS...SMOKING INTERVENTIONS FOR...SMOKING INTERVENTIONS DELIVERED...IMPLICATIONS FOR CLINICIAN...SUMMARY AND FUTURE DIRECTIONSREFERENCES |
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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 guidelines143–146 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.
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TOPABSTRACTASTHMACFCANCERSCDDIABETESJRAMEDICAL, TREATMENT-RELATED, AND...PSYCHOSOCIAL RISK FACTORS...SMOKING INTERVENTIONS FOR...SMOKING INTERVENTIONS DELIVERED...IMPLICATIONS FOR CLINICIAN...SUMMARY AND FUTURE DIRECTIONSREFERENCES |
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