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Paediatr Child Health. 1998 Mar-Apr; 3(2): 83–86.
PMCID: PMC2851274

Adolescents: Smoking and quitting How the physician can help

The prevalence of adolescent smoking is increasing despite the fact that adolescents claim to recognize the health risks associated with this addictive behaviour. Why youth begin to smoke seems to be different from why adult smokers smoke. As such, interventions tailored specifically to the adolescent profile are likely to be more successful.

This fact sheet discusses the stages in the development of smoking behaviour in adolescence, applies the stages of change model to adolescents, provides intervention tips for cessation counselling with adolescent smokers and outlines the profiles of adolescent smoking in Canada.

ESTIMATED RESULTS OF ADOLESCENT SMOKING

Most smokers and most users of smokeless tobacco become addicted while still in adolescence (1).

It is estimated that smoking will be resposnsible for the premature death (before age 70 years) or 55% of young men and 51% of young women smokers now age 15 years, if they continue to smoke (2).

SMOKING: THE STAGES OF ADDICTION

Young smokers go through a series of transitions and stages including preparation and anticipation, trying and experimenting, before they become regular, dependent smokers (3). While the movement through these stages is very individual, it can happen quite quickly. Many adolescents become addicted smokers in a just few years (4). Strategies aimed at any of these stages will reduce the number of young people who enter adulthood as regular, dependent smokers.

APPLYING THE STAGES OF CHANGE MODEL TO ADOLESCENTS

  • Pallonen et al (5) applied the stages of change model to a young adult population, and found that compared with older adults, distribution of the stages differed substantially. There were twice as many relapses and only half as many maintainers among young adults. Further, there was substantially more movement among stages in younger that older adults (5).
  • Many adolescent smokers are precontemplative – they perceive themselves to be immortal and are confident that they can quit at any time.
  • Relapses are likely to be highly discouraging for adolescents, taking them back to the precomtemplative stage.
  • The stages of change model (see the fact sheet in Guide Your Patients to a Smoke Free Future available from the Canadian Council on Tobacco Control, address below) is useful no matter where the smoker is in the development of smoking behaviour stages outlined above under stages of addiction.

INTERVENTION TIPS FOR DEALING WITH ADOLESCENT SMOKERS

Most of the research on adolescent tobacco use has focused on the prevention of onset of smoking in young adolescents rather than on intervention with active smokers (6). Despite the general recognition that adolescents consider themselves immortal, and as such don’t believe that smoking will kill them, many teenagers who smoke are motivated to quit (7). Given the high, and increasing, level of adolescent smoking in Canada, the following describes a mixture of preventive and cessation techniques geared to adolescents.

Anticipate and assess the addiction risk

Addiction risk increases with

  • age;
  • level of stress;
  • use of other illicit substances – tobacco use is a proven covariant (probably not a cause) for alcohol, marijuana and other drug use (8);
  • incidence of other risk-taking behaviour (9);
  • number of friends, family members and teachers who smoke (10).

Addiction risk decreases with

  • increasing level of self-esteem (11);
  • good marks at school (11);
  • family functionality and cohesiveness – if the family is dysfunctional, peer pressure is more important (11);
  • positive parental influence (12) – screen parents for smoking behaviour and ask parents about their advice and example to youth.

Ask

  • Begin screening patients for smoking behaviour at age 9 years and at each visit after that by asking, “Have you ever smoked or used alcohol or drugs?” Use follow-up questions on frequency, amount, etc, to gather any further information based on their original answer (13).
  • “What do you plan to do if a friend asks you to smoke?”
  • Ask about school and/or family friends to determine whether there are underlying problems or stresses for which smoking may be an outlet.
  • Assess the stage in the development of smoking behaviour – frequency of smoking, amount smoked and number of offers to smoke are keys to differentiating between tryers and experimenters.

Advise

  • Advise using stage-matched strategies (see the fact sheet on stages of change).
  • Provide anticipatory guidance – counselling for potential problems – and clearly state that you advise that they do not start or do try to quit. Research shows that physician opinion is valued and a predictor of change of adolescent behaviour.
  • Treat adolescents as adults; they have control over their smoking behaviour.

Assist

  • Assist using stage-matched strategies (see the fact sheet on stages of change).
  • Provide information about stages of change and the quitting process – this can be an important motivator.
  • Good listening skills are critical in creating the empathetic, trusting relationship needed to deal successfully with adolescents.
    • – Ask open-ended questions, and probe.
    • – Be nonjudgemental, and affirm their experiences.
    • – Summarize what you have heard to help them clearly distinguish between current behaviour and what they want.
  • In precontemplative, contemplative and preparation stages, it is important to accentuate the development of self-esteem and assertiveness, and that this means saying no to your friends.
  • Scare tactics are unlikely to motivate adolescents to change smoking behaviour (14), although youth often point to such tactics as what they believe would make them quit. It is important to provide the appropriate information about smoking in a forthright manner.
  • Provide information about nicotine addiction –this can be an important motivator.
  • Reinforce messages that smoking
    • – is not ‘cool’;
    • – gives you bad breath, yellow teeth;
    • – stains your fingers;
    • – increases wrinkles;
    • – decreases physcial endurance;
    • – is addictive – leads to a loss of freedom and control;
    • – is ‘ripping you off’ – tobacco manufacturers are taking your money and your freedom of choice by addicting you to something that is harmful to your health – you are being manipulated by the adults who run these companies.
  • Weight control is an issue for adolescents, particularly females, and it should be approached head-on. Smoking does help control weight, but it is an artificial control, as opposed to exercise and healthy eating. While smoking does control weight, it also causes many unhealthy and unattractive things to occur, thereby vastly outweighing any perceived benefits.
  • When planning a quit attempt with an adolescent, work specifically on identifying triggers and matching them with appropriate coping skills –particularly with adolescents; this includes effective self-assertion skills (strength to do what you know you must) (10).
  • Be prepared to answer questions about nicotine replacement therapy.
  • Have on hand information about community resources geared to adolescents (15).

Advocate

  • Lobby federal and provincial governments for
    • – increased taxes on tobacco products;
    • – plain packaging of tobacco products;
    • – clear and visible addiction warnings on and in tobacco packages;
    • – effective sales to minors legislation and enforcement;
    • – elimination of all forms of tobacco advertising and sponsorship;
    • – increased restrictions on smoking in public places; and
    • – the regulation of nicotine as the drug that it really is.
  • Lobby school boards to regulate school properties as no-smoking areas – inside buildings and outside.
  • Volunteer to train teachers in smoking prevention and cessation techniques to assist in their efforts.
  • Ensure that community drug education efforts include education about nicotine use and addiction, including the risks of experimentation.

PROFILE OF ADOLESCENT SMOKING IN CANADA

Prevalence

  • Health Canada’s Youth Smoking Survey (16) found that 24% of females and 23% of males between the ages of 15 and 19 years are current smokers.
  • In a recent “Study on youth smoking” by Rootman (17), 47% of Ontario grade 7 and 9 students report having had “at least one puff of a cigarette”. Forty per cent of these report that they had their first puff at 10 years of age of younger (17).
  • Eight per cent of grade 7 students in Ontario smoke, but the majority of them do not smoke on a daily basis. Twenty-eight per cent of grade 9 students in Ontario smoke: 9% smoke daily and 19% smoke less than daily (17).
  • Of the young men age 15 to 19 years who smoke, 31% began to smoke before age 13 years and 85% before age 16 years. Of the young women age 15 to 19 years who smoke, 26% began before age 13 years and 83% before age 18 years (18).

Amount smoked

  • The average number of cigarettes smoked daily by adolescent males and females is 12.9 and 9.9, respectively, for an overall average of 11.4 per day (19). For 21% of men and 20% of young women, their smoking increased between January and May 1994, after tobacco taxes were reduced significantly. For 28% of young men and 32% of young women, their smoking decreased between January and May 1994 (18).

Incidence of quitting

  • Seventy-four per cent of young men and 68% of young women who currently smoke have tried quitting for at least a week (18).

Reasons for quitting

  • Cost was the number one reason (27%) teens gave for quitting smoking (20).
  • Health Canada’s survey on smoking data shows that smoking prevalence among 15- to 19-year-olds is as much as 2% higher in the five provinces that did not cut tobacco taxes than in the five provinces that did cut taxes (21).
  • Future health concerns were also cited by teens (23%) as a reason for quitting (22).

Readiness to quit smoking

  • Fifty-five per cent of teen smokers are contemplating or preparing to quit. The survey was unable to differentiate between males and females. Interestingly, the 20 to 24 years age group is the most resistant to quitting, with 55% of each of male and female smokers not even contemplating quitting. These findings underline the urgency of preventing smoking among preteens and of encouraging cessation among those teens who have taken up smoking (23).

Awareness of health risks

  • Over 90% of smokers age 15 to 19 years believe smoking is harmful to both the smoker and the nonsmoker (24).
  • For both sexes, the 15 to 19 age group was most likely to believe that smoking is harmful (24).
  • The health problems most often cited, among each of the age groups, were lung cancer, heart disease, bronchitis and other respiratory disease. Virtually no one believed that smoking was risk-free (24). However, it is clear that the extent and magnitude of the health risks of tobacco use are not understood, or are denied, by youth.

Reasons for resuming smoking

  • Among those teens who tried quitting, the principal reason for resuming smoking was “family or friends smoke” (29%) (32% of males, 27% of females [18]) (25).
  • Sixteen per cent of females also cited “to relax” as another reason for resuming smoking (25).

Perceptions of tobacco company-sponsored activities

  • Generally, youth currently interpret advertising of tobacco company-sponsored events as advertising for tobacco products (ie, Player’s Racing Ltd, du Maurier Ltd Jazz Festival) (17).
  • Generally, youth associate tobacco company sponsorship activities with images, activities and events that are appealing and desirable (17).

Youth perceptions of plain packaging

  • Sixty-four per cent of Ontario grade 7 and 9 students like regular cigarette packaging better than plain packaging. Perceptions are that the plain package is ‘boring’, uglier’ and that ‘cool kids’ would be more likely to smoke cigarettes from regular packages (17).
  • One-quarter of Ontario grade 7 and 9 students said young smokers would smoke less if cigarettes were in plain packages and 35% said young nonsmokers would be less likely to start smoking if cigarettes were in plain packages (17).

TOWARD A SMOKE FREE FUTURE

Because most smokers begin smoking before age 20 years, smoking is an adolescent health problem which has long term consequences. Youth may be less likely to experiment with and continue to use tobacco if they are more aware of the immediate risks of tobacco use not only to their health, but to their attractiveness. Health care providers will be effective in promoting long term behaviour change among adolescents if they employ stage-matched interventions and focus on the things that matter to youth. Set up an office system that identifies the smoking status of each youth.

Footnotes

This fact sheet was originally published as part of Guide Your Patients to a Smoke Free Future. Reprinted with permission of the Canadian Council on Tobacco Control, 170 Laurier Avenue West, Suite 1000, Ottawa, Ontario K1P 5V5. Telephone 613-567-3050, fax 613-567-2730, website http://www.cctc.ca

The National Clearinghouse on Tobacco and Health (NCTH), operated by the Canadian Council on Tobacco Control, is Canada’s most comprehensive professional library on the issue of tobacco and health. The NCTH’s website is Canada’s best tobacco and health information web site and considered one of the best in the world by the World Health Organization. Call 1-800-267-5234 for more information or visit the clearinghouse web site http://cctc.ca/ncth

REFERENCES

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2. Villeneuve P, Morrison H. Health ‘consequences of smoking in Canada: An update’ Chron Dis Can. 1994;15:102–4.
3. Hitchcock J, et al. Questions and Answers about Adolescent Smoking Cessation Programs. New York: American Lung Association; 1990. p. 3.
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8. The Health Consequences of Smoking: Nicotine Addiction A Report of the Surgeon General. Rockville: United States Department of Health and Human Services; 1988.
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22. Health Canada. Fact sheet 5. Starting and quitting – November 1994. Survey on Smoking in Canada, Cycle 3. Ottawa: Health Canada; 1995.
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