Published online September 1, 2006
PEDIATRICS Vol. 118 No. 3 September 2006, pp. e890-e903 (doi:10.1542/peds.2005-0810)

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REVIEW ARTICLE

Youth Tobacco Use: A Global Perspective for Child Health Care Clinicians

Alexander V. Prokhorov, MD, PhD^a, Jonathan P. Winickoff, MD, MPH^b,c, Jasjit S. Ahluwalia, MD, MPH, MS^d, Deborah Ossip-Klein, PhD^e, Susanne Tanski, MD^f, Harry A. Lando, PhD^g, Eric T. Moolchan, MD^h, Myra Muramoto, MD, MPHⁱ, Jonathan D. Klein, MD, MPH^j, Michael Weitzman, MD^k, Kentya H. Ford, DrPH^a for the Tobacco Consortium, American Academy of Pediatrics Center for Child Health Research

^a Department of Behavioral Science, University of Texas M. D. Anderson Cancer Center, Houston, Texas
^b MGH Center for Child and Adolescent Health Policy, General Pediatrics Division, Mass General Hospital for Children
^c Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston, Massachusetts
^d Department of Preventative Medicine, University of Kansas School of Medicine, Kansas City, Kansas
^e Department of Community and Preventive Medicine, University of Rochester School of Medicine, Rochester New York
^f Center for Child Health Research, Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
^g Division of Epidemiology, University of Minnesota, Minneapolis, Minnesota
^h Teen Tobacco Addiction Treatment Research Center, National Institute on Drug Abuse, National Institutes of Health, Baltimore, Maryland
ⁱ Department of Family and Community Medicine, University of Arizona Health Sciences Center, Tucson, Arizona
^j Departments of Pediatrics and Community and Preventive Medicine
^k Center for Child Health Research, Department of Pediatrics, University of Rochester, Rochester, New York

	ABSTRACT

TOP ABSTRACT THE ETIOLOGY OF NICOTINE... FORMS OF YOUTH TOBACCO... GLOBAL TOBACCO-CONTROL EFFORTS MEDICAL EDUCATION IN SMOKING... CHILD HEALTH CARE CLINICIANS'... OTHER TOBACCO CONSORTIUM MEMBERS REFERENCES

 
Tobacco dependence, responsible for 4 million annual deaths worldwide, is considered to be a "pediatric disease." The smoking epidemic is spreading rapidly in developing countries. Factors contributing to youth smoking in developing countries include cultural traditions, tobacco's easy accessibility and moderate pricing, peer and family influences, and tobacco companies' advertisements and promotional activities. Secondhand tobacco smoke exposure is a substantial problem that causes increased rates of pneumonia, otitis media, asthma, and other short- and long-term pediatric conditions. Parental tobacco use results in children's deprivation of essential needs such as nutrition and education. In this article we review contemporary evidence with respect to the etiology of nicotine dependence among youth, the forms of youth tobacco products worldwide, global youth tobacco-control efforts to date, medical education efforts, and child health care clinicians' special role in youth tobacco-control strategies. In addition, we provide a review of currently available funding opportunities for development and implementation of youth tobacco-control programs.

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Key Words: youth • smoking • tobacco

Abbreviations: SIDS—sudden infant death syndrome • SHS—secondhand smoke • WHO—World Health Organization • FCTC—Framework Convention on Tobacco Control • HONC—Hooked on Nicotine Checklist • CDS-12—Cigarette Dependence Twelve Item Scale • CDS-5—Cigarette Dependence Five Item Scale

The adverse health effects of smoking have been documented since the 1950s,¹ yet, >1.1 billion people currently smoke tobacco. Four million deaths each year are attributed to smoking, and if current trends persist, the death toll from smoking will reach 10 million per year by 2030.² Smoking-related deaths include those resulting from cancers of the lung, esophagus, and pancreas, cardiovascular diseases, bronchitis, pneumonia, emphysema, sudden infant death syndrome (SIDS), prematurity, and low birth weight, as well as deaths resulting from smoking-related burns.³

The smoking epidemic is slowing in developed countries but spreading rapidly in developing countries. Tobacco dependence is a "pediatric disease,"^4,5 because most people begin smoking as adolescents and are likely to become dependent on nicotine.⁶ Around the world, between 82000 and 99000 young people start smoking daily.⁷ Among them, >80% come from countries in which citizens earn an average of less than $760 per year.^6,8 If this trend persists, >200 million young people under the age of 20 will die prematurely of smoking-related causes.⁹ Factors contributing to youth smoking in developing countries include cultural traditions, tobacco's easy accessibility and moderate pricing in comparison to pricing in developed countries, peer and family influences, and tobacco companies' advertisements and promotional activities.¹⁰

In addition, secondhand smoke (SHS) exposure is a substantial problem in developing countries. In 1999, the World Health Organization (WHO) reported that 700 million children were exposed to environmental tobacco smoke. This exposure has been associated with a multitude of health problems, summarized in detail in our consortium's article published elsewhere.¹¹ Short-term effects resulting from postnatal SHS exposure include increased rates of pneumonia, otitis media, asthma and asthma exacerbations, SIDS, and respiratory complications under anesthesia and may include higher rates of invasive meningitis and colic. Longer-term effects include reduction in pulmonary function, dental decay, increased progression of atherosclerosis, and higher rates of malignancies. Countries with the highest proportion of children exposed to SHS in 2000 were India, China, Indonesia, Pakistan, Nigeria, Philippines, Vietnam, and Russia (see www1.worldbank.org/tobacco/presentation.asp).

The economic burden of parental tobacco use includes the economic impact from expenditure of family resources on cigarettes instead of other essential needs such as nutrition.¹² The latter problem is particularly severe in developing countries, in which the majority of households face the aforementioned problems on a regular basis. In this article we explore the etiology of nicotine dependence among youth, the forms of youth tobacco products worldwide, global youth tobacco-control efforts to date, medical education efforts, and child health care clinicians' special role in youth tobacco-control strategies. Finally, we provide a review (Appendix 1) of the current available funding opportunities for development and implementation of youth tobacco-control programs. We understand that this article encompasses a spectrum of issues, some of which could have been presented in separate articles. However, we opted to compile these issues in one article, realizing that accessing multiple sources of information could be a challenge for many of our international readers, especially from developing countries. Warren et al¹³ reported that information on tobacco use among young people is not available for most developing countries; therefore, we strongly believe in using every opportunity to provide such information. Although many of the recommendations cited here are derived from research conducted in the United States and other developed countries, they may provide a starting point from which to proceed globally, because recent reports have highlighted the utmost importance of promoting tobacco-control research on the global scale.

	THE ETIOLOGY OF NICOTINE DEPENDENCE AMONG YOUTH

TOP ABSTRACT THE ETIOLOGY OF NICOTINE... FORMS OF YOUTH TOBACCO... GLOBAL TOBACCO-CONTROL EFFORTS MEDICAL EDUCATION IN SMOKING... CHILD HEALTH CARE CLINICIANS'... OTHER TOBACCO CONSORTIUM MEMBERS REFERENCES

 
Once youth start using tobacco, many of them become addicted to nicotine. In fact, studies indicate that 20% of teen smokers exhibit substantial nicotine dependence, and only a minority can be considered nondependent on nicotine.^14,15 After reaching the brain, nicotine binds to nicotinic receptors. Activated receptors then stimulate the release of dopamine, a neurotransmitter associated with addiction. Adolescents' developing brains may make them highly susceptible to nicotine addiction, and the duration of smoking and number of cigarettes required to establish nicotine addiction are lower in adolescents than in adults.^16,17 Recent research suggests that some adolescents begin to experience loss of control over their smoking within weeks of smoking the first cigarette.¹⁸

Smoking initiation among adolescents is a complex, multifaceted phenomenon that has been well studied in the United States and other countries. For example, the 1994 US Surgeon General's report "Preventing Tobacco Use Among Young People" described 4 categories of psychosocial risk factors associated with smoking initiation among adolescents: sociodemographic, behavioral, personal, and environmental.¹⁹ The specific sociodemographic risk factors for smoking initiation during adolescence in the United States were low socioeconomic status, being male, being white, low parental education level, and living in a single-parent household.^19–21 Among the behavioral and personal factors that may increase smoking initiation among adolescents are poor academic achievement, participation in risk-taking activities, low self-esteem, and more susceptibility to peer influences.^19–21 Environmental factors that might prompt adolescents to start using tobacco included smoking by parents, siblings, and peers, as well as not having a rule prohibiting smoking in the home.¹⁹ Generally speaking, parental smoking has a strong influence on smoking initiation among preadolescents in the United States, but as young people enter their teens, smoking initiation is more strongly associated with peer smoking.²² Although considerable work has been conducted in the United States to unveil the psychosocial risk factors related to adolescent smoking, more research is needed to understand the risk factors in developing countries, particularly in various ethnicities.

Environmental influences that may be acting on a pervasive global level are the messages adolescents receive from media advertising sources such as movies, television, and print. In a content analysis of 250 movies representing the top 25 box office hits for the years 1988–1997, 1 in 20 Hollywood movies favorably portrayed tobacco use.²³ US-released movies are distributed in theaters worldwide, and these movies have introduced global audiences to Western culture, including Western images of cigarette smoking. Images of smoking are not limited to US movies; some Indian movies of the so-called Bollywood genre use images of smoking to lure fans who want to imitate their movie idols. Most Hollywood and Bollywood movies glamorize (ie, portray as attractive and/or acceptable) smoking.²⁴

In a sample of 50 G-rated movies (ie, suitable for general audiences) reviewed for a 1990 study, approximately two thirds portrayed tobacco use, and none showed the negative consequences of using tobacco. One in 5 "endorsed" (displayed) a specific cigarette logo or brand name. Smoking, smoking paraphernalia, or both were portrayed during 28.4% of the time that leading Hollywood actors appeared on screen. Forty-two percent of female characters in these movies smoked to control emotions, express power, or express sexual appeal.²⁵

Television has been identified as one of the most influential media in terms of promoting tobacco use among youth.²⁶ In particular, a content analysis revealed that music videos portray tobacco use in a glamorous, favorable fashion.²⁷ In countries such as Japan, smoking is depicted in televised dramas at much higher levels than in the United States.²⁸ Images of smoking are also prevalent among prime-time television programs in the United States. One study showed that as hours of television viewing increased among youth, their likelihood of smoking initiation increased as well.²⁹ In addition to movie and television stars, sports figures and musicians often portray tobacco use in ways that are appealing to adolescents, who tend to imitate such figures.²⁵ Among the most effective efforts for reducing tobacco use in communities, Sargent and DiFranza indicate the limiting of children's exposure to R-rated ("restricted" according to the existing movie-rating system in the United States) movies.³⁰

	FORMS OF YOUTH TOBACCO PRODUCTS WORLDWIDE

TOP ABSTRACT THE ETIOLOGY OF NICOTINE... FORMS OF YOUTH TOBACCO... GLOBAL TOBACCO-CONTROL EFFORTS MEDICAL EDUCATION IN SMOKING... CHILD HEALTH CARE CLINICIANS'... OTHER TOBACCO CONSORTIUM MEMBERS REFERENCES

 
Youth use a diverse array of tobacco products. Besides conventional cigarettes, other forms of tobacco include bidis (tobacco in hand-rolled dry leaves), kreteks (clove cigarettes), chuttas (small, handmade, unfiltered cigars often smoked by placing the lit end inside the mouth), hookahs (long-necked water pipes), and smokeless tobacco. The wide variety of tobacco products must be taken into account when tobacco-prevention and -cessation measures are implemented in developed and developing countries. Gilpin and Pierce³¹ reported that public health surveillance of adolescent use of all forms of tobacco products is important to detect any changes in the patterns of adolescent use. Individual counseling for youth and adults should include messages specifically related to these products.

Although there are anecdotal reports of the high use of tobacco products other then cigarettes around the world, data on the use of these products (eg, bidis, smokeless tobacco) in developing countries are, unfortunately, rather sparse. Lately, more information became available because of the Global Youth Tobacco Survey, which has addressed tobacco use by youth in many countries around the world (see www.cdc.gov/tobacco/global/gyts/GYTS_countryreports.htm). In the following sections, we will briefly review and describe some of these tobacco products, discuss the harmful health effects, and recommend possible control measures.

Cigarettes
Cigarettes form the core of the mass production of tobacco products that are smoked globally, and no other tobacco product on the market today causes more harm to the world's children. Globally, most people start smoking before the age of 18, and one fifth of these individuals begin smoking cigarettes before the age of 10.¹³ Because of cigarettes' expense, they are often sold as single "sticks," which enables purchase by youth.³² Cigarettes are used as appetite suppressants in some areas in which children do not have adequate nutrition.³³ Even among the poorest of the poor (eg, street children), money is spent on cigarettes as well as other tobacco products in place of food.³⁴ The flavored cigarettes currently available in the US market (eg, Camel "winter mocha mint" and "warm winter toffee") seem to have been designed specifically to attract new smokers from youth.

Cheaper tobacco products that mimic cigarettes can be manufactured locally and may influence, to a degree, the enormous cigarette market in certain countries. Some of the other tobacco products that may have particular appeal to youth are listed below.

Bidis
Bidis are handmade cigarettes composed of tobacco hand-wrapped in a dried tendu or temburni leaf (Diospyros melanoxylon) and tied with a string. Bidis come in different flavors including strawberry, cinnamon, chocolate, mint, and wild cherry and along with manufactured cigarettes and other types of hand-rolled cigarettes account for up to 85% of the tobacco products consumed worldwide.⁶ The sweet smell, flavoring, and marketing make adolescents believe that bidis are "natural herbal cigarettes" and therefore better for one's health than conventional cigarettes. Because of their seemingly harmless characteristics and low price, bidis are gaining popularity among adolescents in developed countries as well.³⁵ However, bidis are anything but "herbal." They produce more carbon monoxide and tar than conventional cigarettes.^36,37 In addition, bidis' tendu wrapper has a low combustibility, so bidi smokers need to inhale frequently to keep the cigarette lit, in the process consuming more toxins than smokers of conventional cigarettes.^38,39

Bidis are extremely popular in South Asian countries such as India, Sri Lanka, Bangladesh, Pakistan, Afghanistan, Cambodia, and Nepal. Among these countries, India has the highest rates of bidi smoking and production.³⁵ Poverty, low education, scheduled castes, and scheduled tribes are found to be associated with higher prevalence of tobacco use.⁴⁰ Many children work (forced or voluntarily) in bidi-manufacturing factories, thus increasing their access to bidis as well as exposure to harmful working conditions.³⁴ In fact, some children start smoking bidis as early as the preteen years. In addition, these youth do not know of the harmful health effects of tobacco smoke.⁴¹

The control of bidi use should be focused on South Asian countries, especially India.⁴² One key first step is to educate parents and youth about the harmful health consequences of smoking bidis and passively breathing environmental tobacco smoke from bidis. The medical community could lead the way in bidi-smoking prevention and cessation. The existing literature on bidis mostly deals with the association between bidi use and disease incidence. More research should be devoted to designing, implementing, and evaluating bidi-smoking prevention and cessation programs.

Kreteks
Kreteks, also known as clove cigarettes, contain a mixture of Indonesian tobacco and shredded clove spice wrapped in either an ironed cornhusk or a slip of paper. They are often flavored and may have an anesthetizing effect, allowing deeper inhalation. The tobacco content of kreteks is 60% to 70%, similar to that of regular cigarettes.⁴³ Smoking-machine tests revealed that kreteks produced twice as much tar, nicotine, and carbon monoxide as conventional US cigarettes.⁴⁴ Moreover, the clove content may pose an additional health risk. Eugenol, an active ingredient in cloves, is an anesthetic that may contribute to the development of respiratory tract infections.⁴⁴ When one smokes a kretek, eugenol numbs the back of the throat and trachea and hides the harshness of the cigarette, which may encourage a beginning smoker to have additional puffs.

Little is known about the worldwide use of kreteks. Because kreteks are produced in Indonesia, they may be popular at least in this region. Recently, Internet sales have increased the popularity of kreteks in Western countries, especially among youth. A search for "kretek" on the Google search engine yields easily accessible Internet sellers of these cigarettes. Many sellers advertise kreteks as an exotic product filled with aromatic scents.⁴⁵ Other Web sites describe and "rate" the various brands of kreteks and their flavors in terms of "connoisseurs' preferences." Few Web sites discuss kreteks' harmful health effects. This type of positive advertisement might give young people the false impression that "it's okay to smoke kreteks" and encourage them to experiment with this product. Lack of regulation of Internet sales provides youth easy access to this product.

At present, few published studies are available on kreteks' health effects and epidemiology. No program seems to be available to address prevention and cessation of kretek smoking on a local or global scale. More research should be devoted to these issues. The control of kretek use should be focused in Indonesia and other regions in which kretek smoking is popular. Local medical communities should be informed of kreteks' harmful health effects and should work to protect citizens, especially children, from being exposed to environmental tobacco smoke from kreteks. Finally, pilot prevention and cessation programs should be designed, implemented, and evaluated in these regions. Results should be presented to political leaders so that community-wide prevention and cessation may take place.

Hookahs
A hookah is a long-necked water pipe. When smoke passes through the long tube and subsequently an urn of water, it makes a bubbling noise—hence the alternative name for a hookah, "hubble bubble." In India, the bulb used to hold the water is made of coconut shells. Nargil means coconut in Persian. Thus, hookahs are also called nargils. Some hookahs have become works of art. Instead of glass, the pipe can be made of porcelain, silver, or crystal and embellished with gold or silver. Some hookahs are even handcrafted with floral motifs. Although hookahs originated in India, they quickly spread to Arab countries.

Hookah smoking plummeted in the last century, but it recently regained immense popularity in Arab countries. In these regions, hookah smoking has become a favorite pastime in coffee houses and restaurants. Hookah cafes are proliferating on the streets of Amman, Jordan, Beirut, Lebanon, Damascus, Syria, and as far away as London, England, and Paris, France. They are also appearing in US cities. The revival of hookah smoking has been partly attributed to the belief that hookah smoking delivers less harmful substances to the smoker than do conventional cigarettes.⁴⁶ Research regarding this question is scarce, and it has produced conflicting evidence.^47–50 Nonetheless, hookah smokers inhale a significant amount of nicotine, and hookah smoke contains significant amounts of carbon monoxide.^47,48

Unlike cigarette smokers, hookah smokers are usually social smokers.⁵¹ Therefore, restricting hookah smoking in restaurants may yield significant results with respect to prevention and cessation.⁵² Iran has set an encouraging example: Health Ministry officials announced in 2004 that hookahs will soon be banned in public places.⁵³

Smokeless Tobacco
Smokeless tobacco is a very broad term that refers to >30 different types of products. These products are used around the world but are most common in northern Africa, Southeast Asia, and the Mediterranean region.⁵⁴ Smokeless tobaccos are consumed without burning the product, can be used orally or nasally, and include products that are placed in the mouth, cheek, or lip and sucked (dipped) or chewed. Smokeless tobacco also includes tobacco pastes or powders that are used in a similar manner and are placed on the gums or teeth. Fine tobacco powder mixtures are usually inhaled and absorbed in the nasal passages.⁵⁵

Southeast Asia is a major producer and net exporter of smokeless tobacco products known as "plug," "loose-leaf," or "twists."⁵⁶ One of these products, pan masala (or betel quid), consists of tobacco and areca nuts wrapped in a betel leaf. This product may be sweetened or otherwise flavored. Some of its varieties include kaddipudi, hogesoppu, gundi, kadapam, zarda, pattiwala, gutka, kaine, and mishri.

In countries such as India and Bangladesh, use of smokeless tobacco is more prevalent in areas with low education and low income. Most users seem to be unaware of the harmful health effects, and many use smokeless tobacco to "treat" toothache, headache, and stomachache. This false impression only promotes tobacco use among youth. Smokeless tobacco has been shown to increase the risks of oral cancers, oral submucous fibrosis, hypertension, and reproductive health problems.⁵⁶

	GLOBAL TOBACCO-CONTROL EFFORTS

TOP ABSTRACT THE ETIOLOGY OF NICOTINE... FORMS OF YOUTH TOBACCO... GLOBAL TOBACCO-CONTROL EFFORTS MEDICAL EDUCATION IN SMOKING... CHILD HEALTH CARE CLINICIANS'... OTHER TOBACCO CONSORTIUM MEMBERS REFERENCES

 
The WHO
The WHO's Tobacco Free Initiative aims to combat the global tobacco epidemic by combining efforts of research, policy, surveillance, capacity building, and global communications. Along with the United Nations Children's Fund, the World Bank, national ministries of health, and nongovernmental organizations, the WHO launched a project in 5 countries (Ukraine, China, Sri Lanka, Kenya, and Senegal) to control youth tobacco use.⁵⁷ In addition, the Tobacco Free Initiative monitors and evaluates the global surveillance program. Current projects include (1) designing a global database that stores standardized data on tobacco control from around the world and (2) joining efforts with the Centers for Disease Control and Prevention to conduct the Global Tobacco Youth Survey, which tracks tobacco use among 13- to 15-year-olds around the world and evaluates the effectiveness of tobacco-control programs.⁵⁸

Events such as the WHO's World No Tobacco Day have become increasingly popular and effective in illuminating the dangers of tobacco use. The World No Tobacco Day, May 31, was established in 1988 by the WHO and is supported by the United Nations Children's Fund. Its main objective is to draw global attention to the tobacco problem and the associated preventable deaths and disease. The day is celebrated internationally. Grants are available to help fund World No Tobacco Day activities and efforts to reduce tobacco use.

The WHO sponsors "Quit & Win," a popular annual smoking-cessation contest that challenges participants to abstain from smoking or using other tobacco products for 4 weeks. Participants able to abstain for the entire 4 weeks, as verified by a witness and a biochemical test, are eligible to win exciting gifts arranged for by their local contest coordinators. As of 2004, 100 countries participated in the Quit & Win contest. Although originally designed for adult smokers, a similar concept seems to be perfectly applicable to adolescent tobacco users.

The WHO has suggested a path toward improving global tobacco control by sponsoring the Framework Convention on Tobacco Control (FCTC). The FCTC is a legally binding treaty negotiated by WHO member states to reduce the devastating health and economic impacts of tobacco.

The FCTC
In the international war against smoking, the strongest and most important policy comes from the FCTC. The FCTC is an international treaty that was adopted by the World Health Assembly on May 21, 2003. The FCTC continues to be endorsed by countries, most recently by the countries of the European Union. To date, 168 countries have signed the FCTC, and 115 have ratified (ie, provided a statement of consent that is bound by previous signature) the treaty⁵⁹ (see www.who.int/tobacco/framework).

The treaty offers tools that countries can use to build tobacco-control legislation. The FCTC spelled out 6 primary goals: (1) enact comprehensive bans on tobacco advertising, promotion, and sponsorship; (2) obligate the placement of rotating health warnings on tobacco packaging that cover at least 30% (but ideally 50%) of the principal display areas and can include pictures or pictograms; (3) ban the use of misleading and deceptive terms such as "light" and "mild"; (4) protect citizens from exposure to tobacco smoke in workplaces, public transport, and indoor public places; (5) combat smuggling, including the placing of final destination markings on packs; and (6) increase tobacco taxes. The 6 goals will be fulfilled by following the policy process: identifying the problem; designing a course of action; mobilizing support; enforcing guidelines and rules of action; evaluating the policy; and reforming it on the basis of lessons learned.

The FCTC's guiding principles require a strong commitment to create strategies that are specific to gender risks and that protect all people from exposure to tobacco smoke. Although the treaty includes all ages, its principles are applicable to youth, although they are not explicitly stated that way. It obliges its signatories to adopt and implement legislation and policies that will reduce tobacco consumption and consequently reduce nicotine addiction and exposure to smoke. Article 6 specifically addresses the use of tobacco-product taxation, which has been shown to reduce the consumption of tobacco products by young persons. Article 8 requires smoke-exposure protection in indoor public places and arenas.

Article 13 of the FCTC prohibits advertising and promotional products for tobacco. A total ban on advertising, promotion, and sponsorship is mandated where possible, but countries are given the chance to govern their own actions within their own constitutional policies. At a minimum, Article 13 states that false and misleading impressions are banned, direct and indirect incentives are banned, and tobacco advertising, promotion, and sponsorship on media channels (including the Internet) should be reduced.

Article 16 is devoted to recommendations about sales to and by minors, which are defined according to the country's standard practice or as persons younger than 18 years. The FCTC calls for the elimination of tobacco products explicitly designed, because of their taste and "fun factor," to attract youth. It also calls for a stop to distributing promotional products to minors and for a stop to sales of small packets of cigarettes, which cost less.

Other Programs in Global Youth Tobacco Control
Several individual governments and international organizations have helped strengthen global tobacco-control efforts. The government of India's Uttar Pradesh state formally banned teachers from using chewing tobacco or keeping tobacco in the classroom. The government also attempted to require shops and stalls selling tobacco products to be at least 200 meters from educational institutions. Unfortunately, this ban received little support and was judged unsuccessful.⁶⁰

In another Indian state, Maharashtra, the government banned gutka, the sweet flavored tobacco product manufactured in the country and exported.⁶⁰ Banned were the production, distribution, sale, consumption, and possession of gutka.⁶¹ However, the industry quickly responded to the ban by legal challenges and by producing products that sold the tobacco content of gutka in a separate package from the other ingredients, which could then be combined into gutka by the user. Unfortunately, the manufacturers' legal challenge to the ban was recently upheld by the Supreme Court of India on the grounds that only the central government, not individual states, could enact such a ban.⁶² The government has asked national festival organizers to refuse advertisements from gutka producers.

The international Center for Communications, Health and the Environment, based in Washington, DC, is leading several international tobacco-control initiatives. Established in 1990, it is devoted to helping underserved communities in the United States and developing nations to design, implement, and support programs that eliminate negative health effects in the environment. The organization focuses on school- and community-based interventions, public policies, professional training, and education through mass media and information technology. It brings together scientists, journalists, educators, and policy makers from the United States, Central Europe, India, and other countries.⁶³ Its tobacco-control programs include A Global Coalition Against Tobacco, a mass-media tobacco-control program in Asia and Central Europe; Elixir of Life, a television series in the Czech Republic that emphasizes tobacco control; grassroots programs in Russia; a World Bank–supported Internet-based tobacco-control network in the Czech Republic; and community- and school-based media programs established in the United States, Poland, Russia, and India and broadcast to nearly 20 different countries to educate consumers about important economic, health, social, and environmental subjects.

The National Center for Chronic Disease Prevention and Health Promotion is part of the Centers for Disease Control and Prevention. By promoting healthy living, the center strives to prevent premature deaths and disabilities. Under their leadership, the Office on Smoking and Health aims to prevent youth smoking, promote smoking cessation among youth and adults, and protect the public from environmental tobacco smoke.⁶⁴ Home to the Tobacco Information and Prevention Source, the Office on Smoking and Health offers a wide range of resources for health professionals as well as the general public.

Other world organizations, such as the World Bank, have also contributed to tobacco control among youth. In 1999, the World Bank published "Curbing the Epidemic,"⁶ which reports on the economics of tobacco control on a global scale.

Yet another global program is the Global Partnerships for Tobacco Control, Essential Action. This program, which began in 2000, pairs groups in the United States and Canada with groups in Asia, Africa, Latin America, Central and Eastern Europe, and the former Soviet Union and helps them initiate shared activities.

	MEDICAL EDUCATION IN SMOKING CESSATION

TOP ABSTRACT THE ETIOLOGY OF NICOTINE... FORMS OF YOUTH TOBACCO... GLOBAL TOBACCO-CONTROL EFFORTS MEDICAL EDUCATION IN SMOKING... CHILD HEALTH CARE CLINICIANS'... OTHER TOBACCO CONSORTIUM MEMBERS REFERENCES

 
In the United States and United Kingdom, physicians were among the first members of society to quit smoking and commit themselves to the fight for elimination of tobacco use. Elsewhere, especially in developing countries, the picture is different. For example, the percentage of smoking among physicians in 2000 was 55% for males and 50% for females in Bosnia and 40% for males and 24% for females in Chile.¹⁰ In some developed countries with high smoking prevalence among the general population (eg, Japan), smoking among male physicians was reported at relatively high rates (27%).⁶⁵ The high smoking prevalences among physicians reflect these countries' lack of focus on smoking prevention and cessation in the medical community and in the medical education curriculum.

Physicians are not only health care providers but also role models for their patients. Their duties include not only treating patients' physical illnesses but also protecting citizens from potentially hazardous environments. When physicians smoke despite their knowledge of the harmful health consequences, it is difficult for them to convince patients to do otherwise.

To date, little is known about the smoking prevalence among physicians in many developing countries. To address this issue, the WHO designed a standardized survey, the Global Health Professional Survey, to gather information on health professionals' cigarette use, knowledge and attitudes toward smoking, and work-site practices. The survey also asks about providers' formal training in smoking-cessation approaches, an area in which improvement is needed in both developed and developing countries. This survey is part of the surveillance program of the WHO's Tobacco Free Initiative, which is designed to help developing countries prioritize smoking-cessation policies and interventions.⁵⁴ This survey is currently being conducted, and results will be forthcoming.

Medical education for students and continuing education for practicing physicians should be tailored to regional priorities. For example, in countries with strong tobacco-control activities, smoking prevalence among physicians is often low, and most primary care physicians are aware of the health consequences of smoking and environmental tobacco smoke. However, many physicians believe that they lack effective skills for smoking-cessation counseling.⁶⁶ Thus, education in these regions should focus on providing physicians with skills to help patients quit smoking. In contrast, physicians and medical students in developing countries and areas with weak tobacco-control activities may require a more comprehensive curriculum, addressing all aspects of tobacco control: causes of smoking, epidemiology of smoking, harmful health effects of smoking and environmental tobacco smoke, skills for counseling patients in smoking prevention and cessation, effective pharmaceutical treatments for nicotine addition, and techniques to cope with nicotine addiction for physicians who themselves are smokers.

In developing countries, methods used to deliver education to health care providers will differ from those used in developed countries because of scarce resources. However, effective educational efforts do not have to be expensive. Numerous hands-on curricula introduced in US medical schools could inspire low-cost and effective foreign training programs. For example, in 1998, Wake Forest University School of Medicine (Winston-Salem, NC) introduced a stepped curricular approach to the teaching of smoking-cessation strategies. In this program, preclinical students participated in weekly problem-based learning cases that included tobacco-related content such as epidemiology of smoking and nicotine addiction. Then they practiced tobacco-use history taking and counseling techniques on standardized patients. Finally, they incorporated available tools as well as mentors' feedback to counsel a real patient to quit smoking.⁶⁷ Michigan State University College of Human Medicine (East Lansing, MI) introduced a similar approach to teaching smoking-cessation strategies.⁶⁸ Before implementing any educational curriculum, it is important to have in place a performance assessment of clinical techniques for future evaluation.⁶⁹

	CHILD HEALTH CARE CLINICIANS' SPECIAL ROLE IN YOUTH TOBACCO-CONTROL STRATEGIES

TOP ABSTRACT THE ETIOLOGY OF NICOTINE... FORMS OF YOUTH TOBACCO... GLOBAL TOBACCO-CONTROL EFFORTS MEDICAL EDUCATION IN SMOKING... CHILD HEALTH CARE CLINICIANS'... OTHER TOBACCO CONSORTIUM MEMBERS REFERENCES

 
Diagnosis of Youth Tobacco Dependence
Child health care clinicians' role in youth tobacco control begins with diagnosis and treatment of youth who are already tobacco dependent. To guide diagnosis of nicotine dependence among adolescents, child health care clinicians may refer to the Diagnostic and Statistical Manual of Mental Disorders.⁷⁰ Child health care clinicians may also administer the Modified Fagerström Tolerance Questionnaire, which is very simple to use. The questionnaire has been validated psychometrically and biochemically.^14,71,72 It consists of 7 questions, and each response is preassigned a numeric value. Once the questionnaire is completed, the numbers for the responses to the 7 questions are totaled. Adolescents who score 0 to 2 have no nicotine dependence; those who score 3 to 5 have moderate nicotine dependence; and those who score 6 have substantial nicotine dependence.¹⁵

Several other instruments have recently been introduced to assess nicotine dependence in adolescents. Among them are the Hooked on Nicotine Checklist (HONC), Stanford Dependence Inventory, Cigarette Dependence Twelve Item Scale (CDS-12), and Cigarette Dependence Five Item Scale (CDS-5). The HONC is a 10-item instrument that assesses the onset and strength of nicotine dependence among youth aged 12 to 15 years.⁷³ Youth can self-administer the HONC with a minimal time requirement. For each item, they select either a positive or negative response. A positive response indicates the onset of nicotine dependence. As the number of positive responses increases, so does the strength of nicotine dependence.⁷³ The Stanford Dependence Inventory is a modified version of the Fagerström Tolerance Questionnaire, which also has been used among adolescents.⁷⁴ This 5-item instrument provides a continuous measure of nicotine dependence. Another measure worth considering is the CDS-12, which is a 12-item instrument that assesses nicotine dependence on the basis of its diagnostic definition⁷⁵; however, it does not measure degree of dependence. The CDS-5 is a shorter version of the CDS-12 that contains only 5 items.⁷⁵ Its content is similar to those covered in the CDS-12 but less comprehensive, providing a quick overview of nicotine dependence.⁷⁵

Treatment of Youth Tobacco Dependence
Once identified, nicotine dependence calls for prompt medical intervention. Counseling, nicotine-replacement therapies, and bupropion have been shown to increase cessation rates among adults.⁷⁶ However, little is known thus far about how adolescents respond to these treatments. Studies have reported that the nicotine patch is safe and well tolerated for use among adolescent smokers⁷⁷; however, more research is needed to determine the efficacy of the nicotine patch⁷⁸ as well as the safety and efficacy of bupropion. Because no evidence-based guidelines are currently available to guide the delivery of tobacco-cessation pharmacotherapies to youth by clinicians,⁷⁹ public health service experts recommend clinicians to adapt interventions found to be effective and Food and Drug Administration approved with adults to children and adolescents on the basis of their developmental needs.⁸⁰

Behavioral interventions including individual counseling (in-person, by telephone, or via the Internet) and group counseling may be provided in conjunction with pharmacotherapy to maximize the efficacy of treatment for nicotine dependence among adolescents.⁸¹ One intervention model that pediatricians may consider is the transtheoretical model of change. The transtheoretical model of change divides behavior change over time into 5 stages: precontemplation, contemplation, preparation, action, and maintenance. In the context of smoking cessation, individuals in the precontemplation stage do not plan to quit smoking within the next 6 months; individuals in the contemplation stage plan to quit smoking in the next 6 months and have not made a quit attempt in the past 12 months; individuals in the preparation stage plan to quit smoking in the next 30 days; individuals in the action stage have quit smoking for <6 months; individuals in the maintenance stage have abstained from smoking for 6 months. An additional stage, termination, describes the individuals who have been abstinent for at least 5 years and no longer have a desire to smoke and have total self-control over temptations.⁸² Among adolescent smokers and former smokers, in the United States, the majority (52.5%) are in the precontemplation stage; and 16%, 7.5%, 13.2%, and 10.8% are in the contemplation, preparation, action, and maintenance stages, respectively.⁸¹ Because most adolescent smokers are not planning to quit smoking in the near future, child health care clinicians' goals should include helping them move forward in the process of smoking cessation.

Child health care clinicians can play an active role in treating tobacco dependence among youth. The WHO has adopted guidelines recommending that child health care clinicians use the following tools to treat tobacco use and nicotine dependence among children and adolescents:

1. Clinicians should screen pediatric and adolescent patients and their parents for tobacco use and provide a strong message regarding the importance of totally abstaining from tobacco use.
   
2. Clinicians need to assess adolescent tobacco use and offer developmentally appropriate cessation counseling and behavioral interventions that have been shown to be effective with adults.
   
3. Clinicians should reinforce messages delivered in community- and school-based intervention activities.
   
4. Clinicians in a pediatric setting should offer smoking-cessation advice and interventions to parents to limit children's exposure to SHS.
   

In addition to treating youth who use tobacco, child health care clinicians as a group should recognize that tobacco use is a child health issue and lend their support for more stringent national and global restrictions on the advertising, sale, and use of tobacco products. Governments in the developed and developing world, with the help of child health care clinicians and tobacco-control advocates, should design and implement regulations to create an antismoking social atmosphere. Previous studies have investigated several methods for reducing tobacco use among youth, including establishing a minimum age at which individuals can purchase tobacco, limiting tobacco promotions, increasing the price of tobacco products, and encouraging tobacco control among parents. Again, different methods may have varying degrees of impact in different cultures. Additional research is necessary to establish the particular methods that are applicable and effective in particular countries and settings.

Age Restrictions
Restricting the age of legal purchase of tobacco is one method of reducing tobacco use among youth. The WHO recommends that countries make it illegal for people younger than 18 years to purchase tobacco products.⁸³ Methods to reinforce the implementation of age restrictions include licensing procedures for retailers who sell tobacco, enforcement of these procedures, and banning of sales to minors⁸⁴; compliance checks⁸⁵; and elimination of the sale of single cigarettes and "kiddie packs" (packs with <20 cigarettes).⁸⁶

Restricting Tobacco Promotion: "Countermarketing"
Tobacco advertising has changed dramatically over the past decade. In many countries, traditional cigarette advertisements in magazines, on billboards, and on television have been restricted. In response, tobacco companies are spending more money on point-of-purchase promotions. Retailers are receiving allowances to promote tobacco-related products⁸⁷ including shirts, hats, sunglasses, Frisbees, and other items adorned with tobacco-company logos. In addition, customers can "earn" promotional items by collecting "proofs of purchase" and mailing them in. In South Asia, the tobacco companies have sponsored concerts by Paula Abdul and Madonna, singers who epitomize the Western world's idea of sexiness and independence.⁸⁷ Another method of advertising tobacco products is to simply give the product away.⁸⁸

Tobacco advertising and marketing is banned in a growing number of countries. According to the Campaign for Tobacco-Free Kids, a total ban on tobacco marketing and advertisements exists in Botswana, Estonia, Finland, Lithuania, Mongolia, Niger, Norway, Singapore, South Africa, Sweden, Thailand, and Tonga.⁸⁸ Sports arenas and organizations have joined the battle to create smoke-free environments. In 1986, the Federation Internationale de Football Association stopped accepting advertisements from tobacco companies for the World Cup games. In 1988, the Olympics became smoke free, and open bidding for the games was offered only to cities that enacted tobacco-free policies.⁸⁹ These actions significantly reduced smoking rates wherever they were in force.^90,91

Increasing the Price of Tobacco Products
Increasing the price of cigarettes has been found to decrease rates of smoking and consumption of cigarettes among youth and adults.^92–105 Discrepancies in the literature on the presence or strength of this association in youth may be a result of the failure to control for key predictors of youth smoking such as peer and parental smoking and possession of tobacco promotional items.^106–108 Generally, young people are thought to have little disposable money; thus, their buying habits should be at least as sensitive to the price of cigarettes as adults.^100,109,110 Raising the price by taxation is one method that should be considered to decrease adolescent smoking initiation, consumption, and prevalence.^92,93,108

Parental Tobacco Control
Smoking by parents has 3 major harmful effects on children. The first is that exposure to tobacco smoke directly affects child health. When parents smoke at home, children are exposed to environmental tobacco smoke, which increases their risk of asthma, decreased lung function, lower respiratory tract infections, otitis media, and SIDS. These effects are particularly profound in children under the age of 7 years, because their lungs are undergoing rapid development.^111,112 The prenatal and postnatal effects of parental tobacco use are well summarized in Table 1. ¹¹ An additional health effect of parental smoking is in the increased numbers of burns resulting from house fires caused by parental smoking.¹¹³ The second harmful effect is that parental smoking increases the risk of smoking initiation among children.¹¹⁴ When parents use tobacco at home, they passively teach their children that "smoking is okay." Children growing up in an environment in which parents smoke are more susceptible to smoking in the future.^19,115 Parents' smoking habits grant children easy access to tobacco products in the household.³⁰ The third effect is that parental smoking has an economic impact on the family's ability to provide adequate nutrition, shelter, and education for the children.¹¹

View this table: [in this window] [in a new window]   TABLE 1 Specific Health Effects of Prenatal and Postnatal Exposure to Tobacco Smoke

 
When parents learn about tobacco-control issues from child health care clinicians, not only do they gain motivation to quit smoking, but they are better able to counteract other social influences that may increase their children's risk of smoking initiation, such as peer smoking behavior and exposure to tobacco advertisements, promotional products, and free samples.¹¹¹ Child health care clinicians should consider working with parents who smoke to protect children from environmental tobacco smoke exposure and to prevent them from starting to smoke. However, among child health care clinicians, the overall rate of screening parents for smoking behavior and intervening in parental smoking is low.¹¹⁶ Surprisingly, parents believe that child health care clinicians should intervene: both smoking and nonsmoking parents believe that child health care clinicians should address parental smoking during office visits.^66,117

Several barriers may keep child health care clinicians from intervening with parents who smoke. First, even in the United States, pediatricians do not perceive counseling parents to quit smoking to be a top priority.^{111,118–120} Second, current medical education programs do not teach pediatricians the skills necessary to help parents quit smoking successfully. As a result, many feel a low self-efficacy in parental counseling.¹²¹ Third, many pediatricians do not have enough time to provide counseling services.⁶⁶

Whether pediatricians counsel parents to quit smoking is closely related to the pediatrician's perception of the efficacy of such efforts. In other words, if a provider believes that his or her parental counseling efforts are effective, the provider will be more likely to intervene.¹²¹ Indeed, most pediatric health care providers are interested in learning brief and effective methods to help parents quit smoking.¹²² This goal can be achieved by providing pediatricians with training, literature, monetary reimbursement, and referral information.^123,124

Pediatricians' training on tobacco-control issues not only increases their rates of delivering counseling services but also increases their efficacy in changing parental behavior, especially maternal behavior.^{111,125–128} This is encouraging, because maternal smoking is the number one contributor to environmental tobacco smoke exposure among children.¹²⁹ In addition, there is evidence that maternal smoking specifically is strongly associated with the initiation and escalation of smoking and development of nicotine dependence among young smokers.^19,130,131 In many countries, the health care system is designed in such a way that child health care clinicians see patients and their parents a lot fewer times than, for example, in the United States. Therefore, it is even more important to educate child health care clinicians about the importance of youth smoking prevention and cessation as well as to advise parents on these issues so that no opportunities are missed.

Clinicians should realize that effective counseling for adults can be completed in a matter of 3 minutes.⁸⁰ Many parents who use tobacco in their children's presence may be ignorant of the full range of health consequences of environmental tobacco smoke. This may be especially true in developing countries, in which citizens are not educated about tobacco's harmful effects. Therefore, it is the child health care clinicians' duty to translate this knowledge to parents and advise them to quit using tobacco. Although most child health care clinicians will not follow through with parents through the day they quit using tobacco, the child health care clinicians' role in initiating the process of smoking cessation is critical. At the same time, physicians who use tobacco products should consider quitting to serve as role models in smoking cessation. This is especially true in developing countries, in which the prevalence of smoking among physicians remains high.

A good place to start for training in smoking-cessation counseling is the clinical practice guideline "Treating Tobacco Use and Dependence".¹³² "State-of-the-Art Interventions for Office-Based Parental Tobacco Control"¹¹ adapts the guideline for use by child health care office systems. The guideline recommends the "5 A's" approach to physician-based smoking cessation: ask about tobacco use; advise to quit; assess willingness to make a quit attempt; assist in quit attempts; and arrange follow-up.¹³²

	OTHER TOBACCO CONSORTIUM MEMBERS

TOP ABSTRACT THE ETIOLOGY OF NICOTINE... FORMS OF YOUTH TOBACCO... GLOBAL TOBACCO-CONTROL EFFORTS MEDICAL EDUCATION IN SMOKING... CHILD HEALTH CARE CLINICIANS'... OTHER TOBACCO CONSORTIUM MEMBERS REFERENCES

 
Other consortium members are Arthur Cosby, PhD, Susan Curry, PhD, Joseph DiFranza, MD, John P. Pierce, PhD, Julius Richmond, MD, James Sargent, MD, Robin Mermelstein, PhD, Lori Pbert, PhD, Robert McMillen, PhD, and Dana Best, MD, MPH.

View this table: [in this window] [in a new window]   APPENDIX 1 Some Government and University Funding Opportunities for Those Interested in Conducting Tobacco-Related Research in the United States, Canada, or Elsewhere in the World

 

	FOOTNOTES

 
Accepted Mar 8, 2006.

Address correspondence to Alexander V. Prokhorov, MD, PhD, Department of Behavioral Science, University of Texas M. D. Anderson Cancer Center, PO Box 301439, Houston, TX, 77230-1439. E-mail: aprokhor{at}mdanderson.org

Financial Disclosure: Dr Ahluwalia serves on a national advisory board and speaker’s bureau for Pfizer. All other authors have indicated they have no financial relationships relevant to this article to disclose.

The Center for Child Health Research is an independent operating branch of the American Academy of Pediatrics. The content of this article does not necessarily reflect the views of the Center for Child Health Research or the American Academy of Pediatrics.

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