Adolescent Tobacco Cessation

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Adolescent Tobacco Cessation

• Scott McIntosh, Ph.D.
• University of Rochester
• Department of Community and
  Preventive Medicine,
• and the James P. Wilmot Cancer Center

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Outline

• The problem of adolescent smoking
• Clinical, school and community approaches to
  smoking prevention and cessation for adolescents.
• Effective counseling for behavior change and
  effective office systems change strategies.
• To discuss the National Cancer Institutes (NCI)
  Adolescent Cessation Trial conducted in
  Rochester, NY and surrounding 5-county area
• 101 Pediatric and Family practices participated
  in the study from May 1, 2000 through September
  30, 2002
• Review study design, goals, progress, results,
  and future directions
• How evidence and politics influence social
  policies around tobacco use and tobacco marketing
  in the US.

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Annual U.S. Deaths Attributable to Smoking
(442,408 Deaths Total)
CDC, MMWR 2002.
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Tobacco Health/Cost Implications

• 440,000 deaths each year
• 50-70 billion in medical expenses/yr
• Poverty and education are strongest predictors of
  smoking status
• Nicotine is as addictive as cocaine or heroin
• Quitting Smoking is the number one preventable
  cause of death and disease in the U.S.
• Brief systematic cessation counseling is
  effective with 10-20 of adult smokers in the
  primary care setting

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Children and tobacco

• 3 million adolescents smoke
• 2,600 young people start smoking every day (2003)
• 33 will become addicted, smoke through adulthood
• 60 of smokers started before age 14
• Gateway risk behavior for other behaviors

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Youth Risk Behavior and Tobacco Surveys (2001)

• 28.5 report current smoking
• 64 had ever smoked
• 15 report cigars in past 30 days
• 8 report smokeless tobacco in past 30 days

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Prevalence of current cigarette use New York
State, 2000 and 2002
Youth Tobacco Survey, New York State Department
of Health, 2002.
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Why do Youth Use Tobacco?

• Social influences
• Friends
• Parents
• access to cigarettes
• attitude toward smoking
• Media
• Personality
• Sensation seeking
• Rebelliousness
• Poor school performance

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Why do Youth Use Tobacco?

• Attitudinal Factors
• Intentions regarding future smoking
• Susceptibility
• Positive utilities-what might be gained by
  smoking
• Availability of cigarettes

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Percentage of students who smoked one or more of
the past 30 days
27.5 30.5 34.8 36.4
34.8 28.5
Source Latest Youth Risk Behavior Survey (YRBS),
2001
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Past 30 Day Smoking, 1975-2002
Adapted from Johnston, et al., 2001
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Youth and Nicotine

• Adolescents more than adults
• become dependent
• progress to daily smoking
• smoke more heavily as adults
• have difficulty with quitting prior to smoking
  100 cigarettes

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Adolescent Smokers

• Know they are addicted
• Want to quit and expect primary health care
  providers to assist them with quitting
• Do not think there are resources to help them
  quit
• 75 of adolescents have thought about quitting
  (similar to adult smokers)
• 64 have made at least one quit attempt
• Clinicians feel unprepared to help (Not sure if
  effective interventions that take a small amount
  of time)

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Changing Evidence About Nicotine Dependence

• Signs of nicotine dependence often start within
  two months after onset of smoking
• The median frequency of use at the onset of
  symptoms was 2 cigarettes, one day per week
• 2/3 of teens report loss of autonomy over tobacco
  prior to the onset of daily smoking
• DiFranza JR. et al. Tobacco Control, 2002 .

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School-based

• An extensive body of research documented in the
  2000 Surgeon Generals Report, Reducing Tobacco
  Use, shows that comprehensive school-based
  programs, combined with community and media-based
  activities, can effectively prevent or postpone
  smoking onset in 20 to 40 percent of U.S.
  adolescents.

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School-based

• Existing data suggest that evidence-based
  curricula and national guidelines have not been
  widely adopted. In 1994, the most recent year of
  published data available, less than 5 percent of
  schools nationwide were implementing the major
  components of CDCs Guidelines for School Health
  Programs to Prevent Tobacco Use and Addiction,
  which recommends schools should
• Develop and enforce a school policy on tobacco
  use.
• Provide instruction about the short- and
  long-term effects of tobacco use, social
  influences on tobacco use, peer norms regarding
  tobacco use, and refusal skills.
• Provide tobacco-use prevention education in
  kindergarten through 12th grade, with especially
  intensive instruction in junior high or middle
  school.
• Provide program-specific training for teachers.
• Involve parents and families in support of
  school-based programs to prevent tobacco use.
• Support cessation efforts among students and
  school staff who use tobacco.
• Assess the tobacco-use prevention program at
  regular intervals.

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School-based

• Programs with the most educational contacts
  during the critical years for smoking adoption
  (age 11 to 15 years) are more likely to be
  effective, as are programs that address a broad
  range of educational needs. 
• Educational curricula that address social
  influences (of friends, family, and media) that
  encourage tobacco use among youth, have shown
  consistently more effectiveness than programs
  based on other models. 
• Two middle school programs that have demonstrated
  effectiveness
• Life Skills Training Program and
• Project Toward No Tobacco (TNT).
• These curricula use a social influences approach
  supplemented with training in life skills and
  refusal skills.

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School-based

• A major research trial funded by the National
  Cancer Institute, the Hutchinson Smoking
  Prevention Project, demonstrated that the
  implementation of a single-modality program (in
  this case, the delivery of a classroom
  curriculum) may be ineffective without attempting
  to change the social and policy environment in
  which the program is delivered. 
• Educational strategies to prevent tobacco use
  must become more consistent and comprehensive.
  This will require continuing efforts to build
  strong, multiyear prevention units into school
  health education curricula. It will also require
  expanded efforts to make use of school policies,
  the mass media, parents, and community resources.
  Schools cannot bear the sole responsibility for
  preventing tobacco use.

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School-based

• OREGON A randomized controlled trial of a
  community intervention to prevent adolescent
  tobacco use
• OBJECTIVE Experimental evaluation of
  comprehensive community wide program to prevent
  adolescent tobacco use.
• DESIGN Eight pairs of small Oregon communities
  (population 1700 to 13 500) were randomly
  assigned to receive a school based prevention
  program or the school based program plus a
  community program. Effects were assessed through
  five annual surveys (time 1-5) of seventh and
  ninth grade (ages 12-15 years) students.
• Tob Control 2000924-32
• Anthony Biglan, Dennis V Ary, Keith Smolkowski,
  Terry Duncan, Carol Black Center for Community
  Interventions on Childrearing, Oregon Research
  Institute, Oregon, USA

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School-based

• INTERVENTION The community program included (a)
  media advocacy, (b) youth anti-tobacco
  activities, (c) family communications about
  tobacco use, and (d) reduction of youth access to
  tobacco.
• MAIN OUTCOME MEASURE The prevalence of self
  reported smoking and smokeless tobacco use in the
  week before assessment.
• RESULTS The community program had significant
  effects on the prevalence of weekly cigarette use
  at several follow-up time points. The
  intervention affected the prevalence of smokeless
  tobacco among grade 9 boys at time 2. 
• CONCLUSION The results suggest that comprehensive
  community wide interventions can improve on the
  preventive effect of school based tobacco
  prevention programs and that effective tobacco
  prevention may prevent other substance use.

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Primary care interventions

• Health care provider smoking cessation counseling
  interventions are effective for adults
• Pediatric and adolescent guidelines recommend
  screening counseling for tobacco
• Several trails have established the efficacy of
  cessation counseling for adults
• Little data on adolescents

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Effective Counseling

• Confidential care
• Ask about smoking each time patient is seen
• Repeated brief prevention and cessation messages
• Assess motivation to change smoking behavior
• Reinforce abstinence and follow-up with patient

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Primary Care Interventions

• Most (gt90) clinicians report asking about
  tobacco
• Many report assessing motivation to quit, and
  discussing health risks
• Few provide handouts, set quit dates, or plan
  smoking-related follow-up
• lt 25 of adolescents report having received
  counseling

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Primary care

• Adolescents use preventive care
• 70 report well care visits
• Nationally, almost half did not have an
  opportunity to talk privately with their
  clinician
• gt70 for Rochester (2001 QI data)
• 39 girls/ 24 boys report having been too
  embarrassed to discuss a topic with their
  physician

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Clinician training is effective

• Training using NCI guidelines is effective at
  changing practices in adult and pediatric care
• Implementation of adolescent guidelines improves
  screening and counseling
• Does this work to help youth quit?

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NCI Study Overview

• 101 Pediatric and Family Medicine practices
  agreed to be randomized to
• - 5A intervention with adjuncts (QNow)
• or
• - Usual care (QLater)
• NOTE- All practices participated in the Teen
  Survey
• gt1000 adolescent smokers were recruited at well
  visits and followed for determination of smoking
  status
• - After well visits, and at 3 and 12 months

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Phase I - Formative Research

• 12 focus groups with 72 adolescent ex-smokers,
  smokers motivated to quit, and smokers not
  motivated to quit
• 4 focus groups with 30 Pediatricians and Family
  Medicine Physicians
• Strategies for recruiting offices
• Feedback on implementing office system changes

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Lessons from phase I

• Adolescents want to quit but do not think of
  getting assistance
• 75 of smokers have thought about quitting
• 64 of teens have made a quit attempt
• Self-help materials provide reinforcement and
  help smokers quit
• Adolescents use internet resources for health
  information
• Pharmacotherapy is safe for teens effectiveness
  studies are still underway

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Phase II - Intervention Study

• Contacted 185 Peds and FP practices
• Information sessions for 103 practices
• 101 practices agreed to participate and 49
  practices were randomized to Qnow (the treatment
  condition) and 52 to Qlater (the control/delayed
  condition)
• All practices participated in the Teen Survey

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Clinician training

• Intervention On site CME
• Effective counseling techniques
• NCI 5 As
• Stages of change based interventions
• Use of in-office adjunct materials
• Engagement of other adjunct resources
• Coordination with evaluation activities
• Usual Care
• Coordination with evaluation activities

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Office staff training

• Intervention
• Introduction to materials
• Evaluation enrollment procedures
• Release of Information forms
• Eligibility criteria
• Usual Care
• Evaluation enrollment procedures
• Release of Information forms
• Eligibility criteria
• Follow-up contact by office services team
• by telephone/on-site with goodies and supplies

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QNow Intervention

• Intervention ProjectQ
• Targeting adolescents ages 14-18 at well visits
• 5As training
• Chart checklist
• Tear-off to sign up for mailings
• Goody Pack
• Referral to Qline, Qweb/GottaQuit

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Office materials

• Goodie (Q) packs
• Chart (Q) stickers
• Self-help handouts
• Targeted to adolescents and to stages of
  change/motivation
• Trigger questionnaires (Green Checklists)
• Flow sheet/prompts for effective counseling and
  pharmacotherapy (Green Checklists)
• Internet, phone and mail adjunct resources

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Internet resource

• www.Qweb.com --gt GottaQuit.com
• Web site cessation and related information
• Email, chat room interactive cessation
  counseling and expert consultation
• Stage-based motivational counseling protocols
  (Based on Stages of Behavior Change Theory)

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GottaQuit.com

• A tobacco settlement funded Monroe County public
  health media campaign
• Promotes web-based assistance for adolescents
  seeking cessation aids
• cessation and related information
• Email quit calendar and chat with counselors
  for cessation counseling and expert consultation

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Project Believe GottaQuit.com

• Link public health and clinical adolescent
  smoking cessation resources
• Supported modifying existing NCI project office
  materials
• Flow sheet and prompts for effective counseling
• Tie-in handouts to help youth use GottaQuit.com
  website resources to promote better smoking
  cessation

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Adolescent Recruitment- The Teen Survey

• All adolescents at all well visits
• Given ROI referring them to an Adolescent Health
  Behavior Survey (Teen Survey)
• Adolescents marked yes or no on ROI
• Forms faxed to project office
• Called, consented and surveyed T0,3 12
• Evaluation is blinded to intervention status or
  delivery of smoking interventions

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Adolescent Recruitment- The Teen Survey

• Received approx 20,000 ROIs
• Approx 11,500 yes
• 9336 eligible/agreed to surveys
• 8385 completed baseline (t0) surveys
• Approx 60 were from Qnow practices
• 1000 smokers (11.9 of sampled teens)
• 631 (63) from QNow
• 369 (37) from QLater

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The Teen Survey

• Questions on the Teen Survey consisted of
• adolescent characteristics (age, gender,
  socio-economic status, etc.)
• well visit questions (what was discussed with
  clinician during well visit)
• - smoking behaviors and other health behaviors
  (nutrition exercise, etc.)

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Follow-up Rates

• Of about 1,000 smokers that completed the
  Baseline Questionnaire
• 81 captured at the 3-6 month follow- up
• 75 captured at the 12-15 month follow-up
• 67 completed all 3 surveys

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Did Practices Deliver Interventions?

• QLater QNow
• Did you and your doctor 88 92 plt.05
• discuss cigarettes/smoking?
• Did your doctor ask if you 87 93 plt.001
• smoked?
• If smoke, did your doctor 63 76 plt.0005
• ask if you want to quit?
• If smoke, did your doctor 18
  47 plt.0001
• hand you anything to help stop?

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Did Practices Deliver Interventions?

• Overall, QNow practices delivered more of the
  interventions in which they had been trained
• This would be expected to improve cessation
  outcomes in adults
• The QLater group did pretty well, too

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Did Intervention Practice Smokers Quit?

• abstinent 30days without tobacco
• QLater QNow
• baseline 27 24 ns
• 3 month 17 13 .058
• 12 month 16 13 ns

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More Comparison Practice Smokers Quit

• Is this a real finding?
• If so, important consequences re guidelines for
  treatment
• Or -- is this a result of methodological or
  other confounding?
• Recent analyses indicate that when controlling
  for extraneous variables, the trend disappears.

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But Why the trend??

• Was there a coding or algorithm error?
• Were smokers who participated in current study
  different from those who did not?
• Smoking rate in sample was only 11.9
• Heavier smokers were less likely to sign up for
  surveys
• Was baseline smoking status a valid measure?
• Did follow-up rates differ for QNow and QLater
  practices and/or subjects?

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Q-Now providers practiced differently than
Q-Later providers

• QLater (comparison) practices were more likely
  than QNow (intervention) practices to discuss
  more prevention topics

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QNow smokers also differed from QLater smokers

• QNow were heavier and more frequent smokers
• QNow were more addicted
• QNow Qlater
• African American 5.6 2.7 plt.05
• Ever smoked daily? 67 62 plt.10
• Want to stop completely 78 73 plt.05
• Smoke to relieve restless/irritab 59
  53 plt.05
• If no cig for a few hrs, craving 48
  40 plt.05
• I feel a sense of control, can 60
  68 plt.05
• take or leave it any time
• Household smokers 63 55 plt.01

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Variables related to abstinence

• In regression models - abstinence was associated
  with
• Pediatric practice
• Younger teens, those who smoked less, and those
  who dont think of self as smokers
• Controlled for practice type, demographics, and
  smoking variables -- QNow vs. Qlater were either
  not related to abstinence or abstinence rates
  were higher for QLater

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Study Summary

• QNow practices were more likely to implement the
  5A intervention. This would be expected to
  increase abstinence rates.
• Abstinence rates either did not differ between
  QNow and QLater, or where differences were found,
  abstinence rates were higher in Qlater,
  controlling for practice, demographics, and
  baseline smoking variables.

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Questions

• Did the QNow intervention not impact smoking?
• Did the QNow intervention suppress abstinence?
• What do we know from other current studies?
• What do we do now?

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Other studies?

• In a 2002 review, evidence for teen cessation
  programs is good,
• especially school-based, motivation enhancement
  programs.
• no successful brief intervention trials in
  primary care for adolescent cessation.
• One successful cessation study with adolescents
  referred to an intensive expert counseling
  system after brief primary care advice
  (OR2.43) (Hollis et al.)
• Policy interventions work

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GottaQuit Evaluation

• Ads have reached 94 of Monroe County teens
• Youth who smoke relate to the characters, the
  themes of addiction and wanting to quit
• 75 of adolescent smokers in Monroe County wanted
  to quit, and many tried in the past year
• Only 40 of smokers had ever been proofed
• 27 of smokers (vs 4 of non-smokers) had visited
  GottaQuit.com, mostly for help quitting

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What do we do now?

• Best practice recommendations
• Policy changes
• Clinical interventions
• Public health adjuncts
• More studies

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Best Practices in Tobacco Control

• Increase price of tobacco
• Smoking bans and restrictions
• Availability of treatment for addiction
• Reduce patient costs for treatment
• Provider reminder systems
• Telephone/web counseling and support
• Mass media campaigns

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Number of calls to NY Quit Line andmedia
campaigns, 2000 2002
NYC launches Quit Yet?
Western/Central media campaign
Western/Central Quit Win
DOH launches TV campaign
Erie Niagara NRT Give-away
Governor launches Quit Line
Roswell Park Cancer Institute New York State
Department of Health, 2002.
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Practice - Public Health Service 5 As

• Ask - If patient smokes
• Advise - Every patient to quit
• Assess - Readiness to quit
• Assist - In quitting and finding services
• Arrange - For cessation services and follow
  up

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Ask

• Ask every patient, each time
• Can be done in the context of routine screening
• During vital signs
• As part of a trigger questionnaire for teens

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Advise

• Advise all patients to stop smoking
• Dont assume knowledge about health effects
• Tie motivation to personal factors, risks

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Assess

• Readiness to quit
• Motivation
• during routine screening
• Prioritize the prevention message

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Assist

• Set a quit date for motivated smokers
• Short time frame (2-4 weeks)
• Not during high stress times
• Consider using behavioral contracts
• Provide self-help materials
• Discuss withdrawal and prior attempts
• Use other office staff
• Use community adjuncts
• Consider nicotine replacement or other
  pharmacotherapy

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Arrange

• Arrange follow-up visits
• Relapse prevention
• Not motivated?
• handouts and follow-up only

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Issues for Pediatric Practice

• Prenatal Smoking
• Environmental Smoke/Early Childhood
• School Age Intervention
• Adolescent Intervention

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Pre/Postpartum Messages

• Intervene with women and men during pregnancy and
  after delivery
• Postpartum health message should focus on
  secondhand smoke
• Parents should smoke outside

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Early Childhood (0-5)

• Goal Prevent smoke exposure (ETS)
• Ask About exposure
• Advise Parents to quit, limit exposure
• - Link to childs health
• Assess Motivation to change
• Assist
• - Provide self-help, set quit dates
• - Consider Rx, referral
• Arrange
• - Reinforcement at each visit

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School Age (5-12) Intervention

• Goal Prevent the onset of smoking
• Ask Experimentation and knowledge
• Advise Children and parents
• To quit if smoking
• Link to short term consequences
• Inoculate with awareness of smoking
  candy/toys/gear as socially acceptable
• Assess Motivation to change

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School Age Intervention

• Assist
• If experimenting - cessation
• Develop refusal skills
• Show how tobacco ads mislead
• Reinforce abstinence
• Arrange
• Frequent follow-up for experimenters

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Adolescent Intervention

• Goal
• Prevent onset and promote cessation
• Ask
• About friends use
• About patterns of use
• About school programs
• Reassure about confidentiality
• Assess
• Motivation and readiness

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Adolescent intervention

• Advise
• To quit for short term reasons
• Athletic capacity
• Cost, smell, etc.
• Reinforce non-use
• Assist
• Set quit dates
• Provide self-help materials, websites
• Encourage problem-solving, refusal skills
• Encourage activities incompatible with tobacco
• Consider pharmacotherapy

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Assessing Nicotine Dependence

• Have you ever tried to quit, but couldnt?
• Have you ever felt like you were addicted to
  tobacco?
• Do you ever have strong cravings to smoke?
• Is it hard to keep from smoking where you are not
  supposed to, like school?
• Do you
• find it hard to concentrate
• feel more irritable?
• feel nervous, restless, or anxious because you
  couldnt smoke?
• How soon after you wake up do you have your first
  cigarette?

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Nicotine Replacement Therapy

• Indications
• Able to stop smoking, plus
• Motivated to stop smoking, plus
• Nicotine addiction (gt10 cig/day)
• Patch for baseline
• Gum, lozenge, inhaler or nasal spray for cravings
• Not labeled for sale to lt18 year olds
• Alternatives Zyban (Wellbutrin), SSRIs

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Nicotine Replacement Therapy
Nicoderm
Nicotrol
50 / 14

• 16 hours/day

• tapered dose

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Nicotine Replacement Therapy
Spray
Inhaler
40 6 cartridges
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Nicotine Replacement Therapy
Gum
Lozenge
40/108 pieces
40/72 lozenges
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http//commitlozenge.quit.com/
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Pharmacotherapy

• Bupropion 150 SR bid
• Start 2 weeks before quit date
• Continued smoking will NOT cause more
  side-effects
• Treatment course 7-12 weeks

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Adolescent intervention

• Arrange follow-up
• 1-2 week follow-up after quit attempts

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Use Office materials

• Trigger questionnaires
• GottaQuit.com
• Project Believe, Monroe County, Metrix Marketing,
  Excellus/BCBS partnering
• Flow sheet/prompts for counseling and referral
• Qweb.org
• Currently being developed as centralized
  adjunctive treatment to office-referrals

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WATI Web Assisted Tobacco Intervention Workshops
  WATI-1 Toronto, Ontario January 18-20,
2004 WATI-2 March, 2005 Peter Selby, MD Scott
McIntosh, PhD (Co-Chairs) Funded by Health
Canada and the National Cancer Institute
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WATI

• Potentially Powerful interventions
• Static text and strategies transferred from
  effective programs
• Interactive features, always developing, capture
  attention, deliver messages, assess status,
  provide automated feedback, do things that are
  therapeutic
• Includes text, light, sound, memory, data
  processing
• Provide instant access to Professionals (chat,
  call,
• e-mail)
• Becoming the medium of choice for many
• Changes and improves rapidly
• Oh yea and its CHEAP!!

84
WATI

• WATI Talking Points
• The internet is a clinical tool
• The evidence base is just beginning
• Is the manual effect preserved, changed,
  enhanced?
• How can you measure something that is so fluid?
• Who, What, When, and Where - Will Work?
• What populations will be DISENFRANCHISED?
• How can this be overcome?

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WATI
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WATI
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Issues for future research

• AAP Center for Child Health Research goal - to
  improve the physical, mental, and social health
  of children
• One of first consortia was on tobacco -
  cross-disciplinary experts to identify key
  questions and develop plans for finding answers
• Developing PROs studies to build on current
  tobacco prevention research for children and
  cessation research for youth

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Implications

• If health care provider delivery of counseling
  can be improved and extended, we can have broad
  public health impact for reducing smoking among
  the 3 million adolescents who smoke
• Even a 3-5 effectiveness rate would result in
  45,000-75,000 new ex-smokers each year

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Pending in 2005 WATI-A Web Assisted Tobacco
Intervention for Adolescents Scott
McIntosh, PhD (PI) Deborah J. Ossip-Klein, PhD
(Co-Investigator) Jonathan Klein, MD, MPH
(Co-Investigator) Funding Sought National
Cancer Institute R01
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WATI-A Web Assisted Tobacco Intervention for
Adolescents

• Specific Aims
• Design
• Recruitment
• Hypotheses

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ADVOCACY How evidence and politics influence
social policies around tobacco use and tobacco
marketing in the US.
93
ADVOCACY How evidence and politics influence
social policies around tobacco use and tobacco
marketing in the US.
Tobaccos Deadly Secret The Impact of Tobacco
Marketing on Women and Girls On Tuesday, May 14,
2002, the Senate Subcommittee on Oversight of
Government Management, Restructuring, with the
help of the ACCP and The Chest Foundation, held a
hearing entitled "Tobaccos Deadly Secret The
Impact of Tobacco Marketing on Women and Girls".

94
ADVOCACY How evidence and politics influence
social policies around tobacco use and tobacco
marketing in the US.
Senator Richard Durbin (D-IL), Chair of the
Committee and friend of the ACCP, invited Dr.
Diane Stover, MD, FCCP, Chair of the Taskforce on
Women Girls, Tobacco Lung Cancer, and
Chicagoan Cassandra Coleman, a former smoker, to
testify at this hearing. The focus of the hearing
was to examine the impact of tobacco industry
marketing on smoking rates among women and girls
in the U.S. and overseas, and review the steps
that the U.S. Government is taking and should
take to address this epidemic of smoking-related
disease among women.
95
ADVOCACY How evidence and politics influence
social policies around tobacco use and tobacco
marketing in the US.
My name is Diane Stover and I am the Chief of the
Pulmonary Service and the Division Head of
General Medicine at Memorial Sloan-Kettering
Cancer Center in New York City. I appear before
you today on behalf the American College of Chest
Physicians and its philanthropic arm, The CHEST
Foundation. The ACCP is a 15,000 member
international multi-specialty medical society
comprised of pulmonologists, cardiologists,
critical care physicians, thoracic surgeons, and
other members of the health care team. We are the
physicians who treat people worldwide suffering
with various lung diseases the majority of
which are caused by tobacco use.
96
ADVOCACY How evidence and politics influence
social policies around tobacco use and tobacco
marketing in the US.
Smoking-related disease among women truly is a
"full blown epidemic." As cited by the Surgeon
General, smoking among high school age girls
increased to an alarming 30 during the 1990s. In
1999, nearly 35 of all high school girls were
smoking. And why should we care? Because along
life's continuum, smoking impairs the ability of
girls and women to fully realize their potential
in the classroom, as mothers, in the workforce,
and at life's end.
97
ADVOCACY How evidence and politics influence
social policies around tobacco use and tobacco
marketing in the US.
During pregnancy, women who smoke are more likely
to suffer from Excess bleeding Premature
rupture of membranes Abruptio placentae and
placenta previa Ectopic pregnancy
Spontaneous abortion Premature and difficult
labor During pregnancy, the fetus of a woman who
smokes or who is exposed to second hand smoke
is more likely to suffer from Growth
retardation Premature birth Low birth
rates Still birth Perinatal death and
Negative behavior as a toddler
98
ADVOCACY How evidence and politics influence
social policies around tobacco use and tobacco
marketing in the US.
We encourage your activism! We've provided
background information and a sample letter to
help you craft your own messages. Legislators on
state finance/budget/appropriations and health
committees are the key decision-makers in
allocating settlement dollars over the next 25
years. Let's flood their offices with letters,
emails, and phone calls! Please send a copy of
your letter(s) to us at info_at_alcase.org. Contact
your state legislators directly (Website
National Conference of State Legislatures) and in
particular let your home district representative
know your concerns. Tell them if you're a lung
cancer survivor, family member, or friend. Send
a copy of your letter to members of your U.S.
Congressional delegation, too. They need to know
that research dollars must be greatly increased
for lung cancer screening and effective
treatments.
99
The Honorable your Senators full name or
The Honorable your Representatives full
nameUnited States Senate U.S. House of
RepresentativesWashington, DC 20510
Washington, D.C. 20515 Dear Senator/Representativ
e last name, Nearly 30 of all cancer deaths
are due to lung cancer. About 157,200 American
women and men will die this year from lung
cancer more than breast cancer, colon cancer and
prostate cancer combined. Yet lung cancer
receives only fraction of the federal research
fundingjust 1/9 that for breast cancer. This
affects survival. Since Congress passed the War
on Cancer Act of 1971, the 5-year survival rate
for breast cancer has risen to 86, with colon
cancer survival reaching 62 and prostate cancer
97. By contrast, in 1971 the 5-year survival
rate for lung cancer was 12. Today it is only
15. This must change! We must devote more
federal funding to lung cancer research. Even if
all smoking stops tomorrow, lung cancer will be a
major health problem for decades. Right now, over
half of new cases are diagnosed in people who
have quit smoking or never smoked. Clearly,
research is urgently needed for effective early
detection, protection for people at risk for lung
cancer, and for better treatments. Please
speak out for me. Include your brief personal
reason, for example My mother just died of lung
cancer. Please let me know what you will do to
help address these lung cancer issues and save
more lives. Thank you. Your Name and
Contact Information
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ADVOCACY How evidence and politics influence
social policies around tobacco use and tobacco
marketing in the US.
Do you know these guys?
So do 6-year olds!
103
ADVOCACY How evidence and politics influence
social policies around tobacco use and tobacco
marketing in the US.
104
ADVOCACY How evidence and politics influence
social policies around tobacco use and tobacco
marketing in the US.
A very successful, but long-time-coming, campaign
finally got rid of Joe Camel. But hes not dead,
he just went to other countries, where the
markets are good and national laws are
non-existent.
105
ADVOCACY How evidence and politics influence
social policies around tobacco use and tobacco
marketing in the US.
106
ADVOCACY How evidence and politics influence
social policies around tobacco use and tobacco
marketing in the US.
http//www.cvhpinstitute.org/advocacy/advocacy02.h
tml
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THANK YOU!

• Scott McIntosh, PhD
• Department of Community and Preventive Medicine
• 585-273-3876
• scott_mcintosh_at_urmc.rochester.edu