Why should nurses care about who smokes? Because the use of tobacco is the number one health problem and preventable cause of death in the U.S.¹ Every year, more than 400,000 Americans die from smoking-related diseases.² Smoking is associated with increased risk for at least 15 types of cancers, including cancer of the mouth, larynx, esophagus, pancreas, cervix, bladder, and other vital organs; and it’s a major cause of chronic lung diseases, heart disease, and stroke.¹ Smoking accounts for 30% of all cancer deaths and 87% of lung cancer deaths.¹ The effects of smoking do not end with the smoker: Environmental tobacco smoke ravages the health of nonsmokers as well. Lung cancer caused by tobacco users’ smoke wipes out about 3,000 nonsmokers every year.¹

More than ever before, today’s media informs adolescents about the hazards of smoking. However, the number of adolescents currently smoking is at least 4.5 million.³ The good news is that among U.S. high school students, the rate of current smokers declined in 2003 to 22% from a peak of 36% in 1997.¹ But the bad news is each day almost 6,000 adolescents (ages 11 to 17) smoke their first cigarette, and nearly 2000 become regular smokers, almost 800,000 per year.³ According to the American Lung Association (ALA), if the current U.S. tobacco use patterns persist, more than six million children are estimated to die prematurely from smoking-related disease.³

With the pervasiveness of smoking and the significant impact on health, nurses need to investigate the impact nursing can have on preventing smoking and facilitating smoking cessation in the next generation of smokers — the adolescent population.

The Pediatric Disease

Children and teenagers represent the majority of all new smokers.² Cigarette smoking during childhood and adolescence causes an increase in the number and severity of respiratory illnesses, decreases physical fitness, causes an unfavorable lipid profile, and potentially retards the rate of lung growth and level of maximum function of the lungs.³ 

Tobacco use is not limited to just cigarettes. In 2003, a nationwide study found that 11% of U.S. male high school students were using smokeless tobacco products, such as chewing tobacco, snuff, or dip.¹ Oral cancer occurs several times more frequently among snuff dippers compared with non-tobacco users.¹ In 2003, smoking cigars, cigarillos, or little cigars within the last three months was reported by 15% of U.S. high school males.¹ The other novel tobacco products used by high school and middle school youths include pipes, bidis (or beedies), and kreteks (also known as clove cigarettes).²

The reasons adolescents experiment or regularly use tobacco are diverse. It may be related to social and parental norms, advertising, peer influence, parental smoking, weight control, and curiosity.⁴ But once they start, most youth who smoke regularly report that the nicotine addiction keeps them hooked.³ Compounding the addiction is the fact that tobacco use in adolescence is associated with several health risk behaviors, such as being involved in fights, carrying weapons, engaging in unsafe sexual activity, and using alcohol and other drugs.³ The variety of causes and the risky behaviors associated with tobacco use require a multifaceted approach to preventing and stopping tobacco use in the pediatric population.

Developmental influences

Adolescence is a complex developmental period often associated with experimentation with illicit substances. Although many factors may be involved, the driving force to experiment with tobacco is social. Initiation of smoking is often socially mediated and is perceived by adolescents as attractive. The typical situation for experimentation is with a friend who already smokes. Prompted by peers, family influences, and societal factors, smoking often progresses from experimentation to addiction.

In a developmental model created by child developmental psychologist Erik Erikson, personality evolves from confrontations between the ego and the social milieu.⁵ Erikson believed that a person’s life cycle is characterized by eight psychosocial stages when specific conflicts become paramount. The adjustment to these conflicts channels a person toward one of two opposing positions. In Erikson’s model, adolescents strive for identity and need independent space. Adolescents’ search for independence leads them to many risk-taking behaviors, one of which is smoking; their quest for identity directs them to peers. Adolescents’ preferred support system is peers, making peer pressure an important influence on behavior. In fact, one research study found that the most important social influences in predicting smoking were peers and friends.⁶ An increased susceptibility to smoking was found among teenagers who had low self-esteem, feelings of hopelessness, and poor social skills.⁶ The correlation between smoking and low self-esteem has been substantiated by numerous studies over more than 30 years.

The manipulative media

The tobacco industry loses millions of smokers annually mostly because the individuals quit while the others die. The industry must recruit new smokers to replace those who leave, and their promotional campaigns often have a special appeal to young people.¹ There is nothing personal about who has been chosen; it’s just good business for an industry that needs to maintain a steady stream of new smokers to remain profitable.

Tobacco companies have long used the mass media to manipulate youth into using their products. In the past, tobacco companies have successfully employed the grim psychology of emotional control. They have tried to seduce youngsters with icons, such as Joe Camel, as role models for emerging adolescents. The tobacco companies have also manipulated teens by associating tobacco use with freedom, adventure, independence, and sexual conquest. Remember the Marlboro Man, a great outdoorsman, full of strength and endurance? The tobacco companies have tried to enter the world of teenage fashion by offering clothing and gifts for continued use of their products. They have attempted to manipulate emotions by targeting areas with which teenagers naturally struggle during normal growth and development — concerns such as independence, body image, peer relationships, and identity. The tobacco companies have tried to portray smoking as glamorous, with promises of acceptance and acceptability from using their products. Teenagers may believe that without cigarettes, they are incomplete or inadequate. The search for self-esteem overwhelms all the harmful information they have learned about smoking. The information becomes incidental as teens respond to the stronger pull of youthful feelings and desires.

Nurses can counter tobacco companies’ manipulation through the mass media. One way is to stay active in professional organizations and support lobbying efforts aimed at the entertainment industry. Public pressure can determine how media portray cigarette use in teen programming. Nurses can also direct teenagers to programs that can help them scrutinize messages they receive about tobacco use in movies and on television. One such program, sponsored by the Centers for Disease Control and Prevention (CDC), is “Smoke Screeners,” which uses a guide and a video to teach adolescents how to critically analyze media messages.⁷

Antitobacco messages communicated through the media have a significant impact on teenagers. Through its Media Campaign Resource Center and its interactive database, the CDC provides high-quality counter advertising materials and technical assistance to help state and local programs conduct media campaigns to prevent tobacco use.⁸ In 2005, the CDC joined together with a variety of government agencies, professional and voluntary organizations, and academic institutions to advance a comprehensive approach to reducing tobacco use, which involves —

• Preventing young people from starting to smoke
• Eliminating exposure to secondhand smoke
• Promoting quitting among young people and adults
• Identifying and eliminating disparities in tobacco use among different population groups.⁸

Before March of 2000, when the U.S. Supreme Court ruled that the Food and Drug Administration (FDA) lacked the authority to regulate tobacco, the FDA had also been instrumental in limiting the appeal of tobacco products to children. No billboards advertising tobacco products are now allowed within 1,000 feet of schools and playgrounds.⁹ In addition, print advertising is restricted to black-and-white to diminish its appeal. The tobacco companies are also prohibited from brand-name sponsorship of sporting or entertainment events. The attempt is to limit associations between enjoyable activities and smoking. It was also the FDA ruling in 1999, which mandated that tobacco companies launch a national mass media campaign to educate children and adolescents about the real dangers of smoking.¹⁰

Prevention strategies

Preventing initiation of smoking and promoting smoking cessation are a priority. In keeping with Erikson’s model of growth and development, the adolescent striving for independence must be an active participant in this prevention process. The adolescent needs to hold ownership of the prevention or cessation process and buy into the solutions so that success can be achieved.

The school setting offers many health programs for adolescents. The CDC has implemented a national framework to support coordinated school health programs.¹¹ These programs target high-risk behaviors among young people with an emphasis on tobacco use. The CDC also collaborates with professional and voluntary agencies to assist schools in developing policies that will aid in implementing effective school health programs.

The school is a natural environment in which to initiate peer-mediated smoking prevention programs. Adolescents spend the majority of time in school, and many of their peer relationships are formed there. The CDC’s Guidelines for School Health Programs to Prevent Tobacco Use and Addiction recommend that programs begin in kindergarten and run through 12^th grade.¹¹ Programs introduced in schools should be peer-controlled. Information about the hazards of smoking is better received from peers. The “cool” students, such as athletes and leaders from various social groups, can serve as role models and spokespersons and be involved in antismoking curriculum development. An adolescent’s strong desire for peer acceptance can be channeled toward the desired outcome: prevention of smoking initiation.

A successful peer-led program is Teens Against Tobacco Use (T.A.T.U.) managed by the ALA.¹⁵ T.A.T.U. was formed in 1996 in response to former U.S. Surgeon General C. Everett Koop’s call for a smoke-free society by the end of the 2000 school year. In this program, teens are responsible for creating and implementing their own tobacco prevention presentations after a training session. The program has already reached over 400,000 children and an estimated 40,000 more annually are educated about the dangers of tobacco use.¹²

Implementation of a school-based program should focus on accomplishing short-term goals, rather than long-term ones. Adolescents seek immediate gratification; they see the future as very far away. Teenagers are preoccupied with body image, and a strategy that takes this concern into consideration would be more effective. Focusing on how cigarettes pollute their breath, clothing, skin, and hair may have more relevance to them than warning about the risks of lung cancer and heart disease. Additionally, education curricula that address social influences (friends, family, and media) that encourage tobacco use have been consistently more effective than those based on other models.²

Life Skills Training (LST) is a program developed by the CDC that successfully addresses both individual and vulnerability issues, for example anxiety and self-esteem, and social risk factors, such as media influence and peer pressure.¹⁶ LST aims to reduce tobacco use by fostering skills and techniques that promote a positive self-image. LST also helps adolescents evaluate media messages regarding tobacco use. Students who completed at least 60% of the three-year Life Skills Training program were much less likely than other students to use tobacco, alcohol, and marijuana.¹³

Family involvement is always important. The family can best serve the adolescent by example. Parents who do not smoke send a strong, decisive antismoking message to their children. No amount of lecturing, preaching, or threatening will have as great an impact as the simple act of not smoking. Parents who do smoke send a conflicting message to their children.

The community is an important link in prevention. A community represents a specific population with similar goals, interests, and values.¹⁷ People within a community reflect the norms of the group. If the community promotes healthy behaviors, this belief is transmitted to its members.

Movements in the legislative arena

Significant legislative developments related to smoking and health have emerged over the last decade. During the Clinton administration, many legislative initiatives were enacted in an effort to reduce the onset of smoking among the adolescent population, such as limiting access to vending machines by restricting their location, and prohibiting the distribution of free samples and the sale of single cigarettes.² In 1998, The Master Settlement Agreement with the tobacco industry banned tobacco brand name sponsorship of events with a significant youth audience; the use of tobacco brand names in stadiums and arenas; and payments to promote products in movies, TV shows, videos, and video games, to name a few.²

Kicking the Addiction

Nurses also have a role to play in helping adolescents kick the habit. According to the newest clinical practice guideline issued by the U.S. Public Health Service, Treating Tobacco Use and Dependence, it is essential that clinicians and health care delivery systems establish in respective health care settings the consistent identification, documentation, and treatment of every tobacco user, including the pediatric population.⁴ Nurses have more contact with patients in most practice settings so it’s imperative that they familiarize themselves with the recommended strategies and the known effective therapies available for the patient who wants to quit as well as those who don’t. Even the strategy of “brief clinical intervention” for the tobacco user not ready to quit could produce a quit rate of 5% to 10% per year.² The guidelines address the needs of special populations, such as children and adolescents recommending community- and school-based interventions and the use of bupropion (Wellbutrin) when indicated.⁴

One successful school and community-based program is Not-on-Tobacco (N-O-T), which was launched by the ALA in 1999.³ This program is designed specifically for teens using a gender-sensitive approach by separating males and females during the sessions. The curriculum incorporates life management skills to help teens deal with stress, decision-making, and peer and family relationships, which influence the adolescent’s choice to smoke. The program also includes information and discussion about healthy lifestyle behaviors. These sessions are facilitated by teachers, nurses, counselors, etc., who have been trained by the ALA. Post-program evaluation has shown a 21% quit rate among adolescents and a reduction in cigarettes smoked by more than 70% of the participants who continue to use tobacco.

Ongoing research

Evaluation of methodologies to reduce adolescent smoking must be broad-based and comprehensive. Support from local, state, and federal agencies is needed to evaluate effectiveness of programs. Data must continue to be gathered and shared for analysis between the public and private sectors. For example, the law that requires picture identification to purchase tobacco was enacted after research showed that minors succeeded in buying cigarettes 70% of the time over the counter and almost 90% of the time from vending machines.⁹

Nurses can assess firsthand the effectiveness of federal limits on access to cigarettes. As community activists, nurses can challenge merchants who sell cigarettes to minors and can report them to local law enforcement.

Nurses are also in a unique position to conduct research to evaluate the effectiveness of antismoking programs. School nurses can have hands-on involvement in program creation, implementation, and evaluation and work one on one with adolescents. This interaction is pivotal in forming relationships necessary to accomplish an antismoking health initiative.

Ongoing support of struggling teenagers to encourage and promote positive choices is critical. The success of smoking prevention and cessation initiatives is inevitably linked to adolescents’ social environment. The antismoking message carries a powerful punch when it comes consistently and repeatedly from multiple sources. Nurses can be instrumental in ensuring that the message remains clear and strong by using their knowledge of adolescent development to utilize and implement effective smoking prevention programs and strategies. The antismoking battle is critical during the teenage years, since delaying the start of smoking and facilitating cessation reduces the likelihood of a lifelong habituation and addiction. It is time to make it history.