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					  Prevention of Tobacco
   Use: Doing the right
things, Doing them right!
                   Richard R. Clayton
  The Good Samaritan Foundation Chair in Health Behavior, Kentucky School of
                                Public Health,
  Chair, Robert Wood Johnson Foundation’s Research Network on the Etiology of
                        Tobacco Dependence (TERN)
                                24 March 2004
      The Virginia Forum on Youth Tobacco Use: From Research to Practice
               Five Themes
   Formidable Challenges
   Incredible Opportunities
   Capturing, measuring, and understanding
    the complexity youth tobacco use in real
    time
   Translating the science into practice
   Transdisciplinary collaborations
      Virginia Tobacco Settlement
    Foundation: Goals and Objectives
   Educate youth, adverse health, economic, and social effects
   Educate parents/guardians, adverse health, economic and social
    effects on children in context of strategies to educate their children.
   Promote school/community-based programs targeting youth tobacco
    use reduction.
   Serve as advocate/resource to Virginia lawmakers on legislative
    initiatives to reduce youth tobacco use.
   Promote research to study ways to reduce the deleterious effects of
    tobacco and to reduce the social, economic, environmental effects of
    tobacco use by youth.
   Develop marketing strategies to promote the efforts of the Foundation.
   Serve as hub of youth tobacco use reduction efforts in Commonwealth
    by creating a comprehensive approach to the issue.
   Leverage the resources of the Foundation to encourage private sector
    investments in order to develop public/private partnerships to address
    this issue.
    VYTP
 Virginia Youth
Tobacco Project

 Securing the health
 of Virginia’s youth
  through science
    Historical Context: We are nearer the
    beginning than the end of the journey
   1953 – Double helix structure of DNA
   1969 – “One small step for a man, one giant leap for
    mankind.”
   1971 – Declaration of War on Cancer
   1990s – Decade of the Brain
   1991/94 – Society for Prevention Research/SRNT
   1998 – Master Settlement Agreement
   2000-03 – Mapping of Human Genome

   Let’s celebrate the progress, apply what we know at this
    point in time, be humble about how much we don’t know,
    and do something about creating new knowledge and more
    effective applications.
Change is pervasive and the pace of
  change seems to be increasing
   From radio to television to HDTV
   From Ozzie and Harriett and Leave it to
    Beaver to the Simpsons and South Park
   From American Bandstand to MTV
   From typewriters to large desktop
    computers to laptops to PDAs
   From wired to wireless communication
   From snail mail to email and the web
        Formidable Challenges
   Adolescence – it’s not one period, it’s an
    incredibly complicated number of periods of
    time
   Adolescents – they may look the same but
    they are all different
   Adolescent Brain Development
   In this first decade of the 21st century there
    will be more children/youth per adult than
    at any other time in American history.
        The Research Questions:
         Formidable Challenges
   What differentiates those who use and those who
    don’t use tobacco?
   Among those who use, what factors explain why
    some become dependent, others continue to use
    but don’t become dependent?
   How is dependence different for youth and adults?
   Why is it seemingly easy for some to quit and
    seeming impossible for others?
The Prevention Research Questions:
      Formidable Challenges
   Are we asking the wrong question: “What
    works?”

   Should we be asking: “What works, for
    whom, under what circumstances, why and
    how?”
    The Complexity: Effective Prevention
         Requires Rigorous Research
   What are the individual differences in
    trajectories of tobacco use (that may or may
    not involve the emergence of dependence)?

   How do these differences in trajectories
    interact with individual development and the
    environmental contexts in which individuals
    are embedded?
Cigarettes as drug delivery device
   Tobacco Delivered Nicotine
       Most toxic
       Most addictive
       Explosively fast delivery
       Optimal particle size
       pH controlled
       Sensory optimization
       Chemical cocktail (ammonia increases dose,
        acetaldehyde synergy, MAO inhibiting effects, additives
        reduce barriers)
Our measurement and understanding of
 what we want to prevent is imprecise
   Ever, past year, past 30 days
   Days smoked within past 30 days
   Cigarettes smoked per day
        Self-reported cigarette use:
               12-17 year olds
   Among 1,000 youth 12-17 years old in U.S. (2001)
      629 have not smoked
      371 have ever smoked. Of those:
         222 did not smoke in the past 30 days
         149 smoked at least once in past 30 days
              1-2 days                    38
              3-10 days                   32
              11-20 days                  17
              More than 20 days           62
         62 are current daily smokers
              5 or fewer a day             6
              6-15 a day                  57
              Pack or more a day           3
              Daily Smoking Pattern: #57
                  % smk days = 63%
        12                                                        “cpd” = 11
Max cpd 11
        10
         9
         8                                               M cig/smk day = 7.7
 Range = 11




         7
         6
         5
         4                           M cpd = 4.9
         3
         2
         1
Min cpd 0
              M T W T F S S M T W T F S S M T W T F S S M T W T F S S M T


                                       30-Day Baseline     Longest Abs = 3
Percent Who Self-Identify as a Smoker by
Number of Cigarettes Consumed a Day on
       Average: Current Smokers
0.9
0.8                         1-6 cigs per day
0.7
                            7-12 cigs per day
0.6
0.5                         13-18 cigs per day
0.4
0.3                         19-24 cigs per day

0.2                         More than 24 cigs per
0.1                         day
 0
Adolescent Smokers Differ from Adult
             Smokers
  • Nicotine is more reinforcing during early
    adolescence than at later ages
  • There is greater nicotine-induced adaptive
    plasticity during late adolescence than in
    adults
  • There are synergistic interactions between
    nicotine and other tobacco components


                                        Leslie and Belluzzi
 Key Neurochemical Systems
Comprising Brain Drug Reward
          Circuitry
Genes and Jeans: Candidate
          genes

Dopamine       Dopamine transporter (DAT)
               Dopamine D2 receptor (DRD2)
               Dopamine D4 receptor (DRD4)
               Tyrosine Hydroxylase
Serotonin      Serotonin transporter (5HTTLPR)
               Serotonin receptors
               Tryptophan Hydroxylase (TPH)
Drug           CYP 2A6, 2B6, 2D6, ALDH2, nAChR,
               OPRM1
metabolism &
response
Prevention, Intervention, Treatment
 UPSTREAM Public Health Interventions
  Purchase, Use, Possession Laws
  Mass media campaigns

  Excise Taxes and other policy approaches

 MID-DOWNSTREAM Interventions
  School Based, Curriculum Driven Programs
  Community Coalitions

  Smoking Cessation
     PUP (Purchase, Use, Possession
               Laws)
   PUP Laws – essentially universal thanks to the Synar
    Amendment
   Low likelihood of detection and uncertain punishment,
    relatively long delay between offense and punishment,
    great potential for avoidance of detection, relatively
    distant and impersonal relationship between punisher
    and recipient.
   Bottom Line: scant evidence of efficacy
   What should we do? Figure out how to make them more
    effective!
        Mass Media Campaigns:
        Incredible Opportunities
   Novelty seeking stimulates the mesolimbic
    dopaminergic system in ways similar to
    amphetamine/nicotine
   Sensation seeking can be used effectively as a
    psychographic technique for segmenting
    audiences
   Youth are bombarded with media messages – how
    do they encode, decode, and apply them?
   How does the need for cognition interact with the
    need for affect? (“hot” and “cold” cognition)
School-based, Curriculum-driven
   Prevention Programming
   Catch them where they are
   Get to them early enough
   Get to them often enough
   Prevent onset or initiation
   Prevent progression

   Incredible progress has been made in prevention
    science. We now have available effective science
    based programs.
     Challenges and Opportunities
   How do we integrate prevention with the academic
    responsibilities of school?
   How do we insure implementation fidelity? Some teachers
    are great – others have difficulty.
   What do we do with students exposed to only part of the
    program? They may be the ones most at risk
   How do we handle different reading levels?
   The prefrontal cortex, site of executive functions is still
    developing
   Let’s remember: the classroom/school is just one setting.
   Schools vary – how do we take the environmental context
    into consideration and intervene at that level as well?
         Youth Smoking Treatment:
            Significant Potential
   Intermittent use is normative and self-identity as a
    smoker may not have developed.
   Selling cessation to youth, lack of social norms for
    youth to “stop” smoking
   Dependence in adolescents may not be same as in
    adults
   Maintenance of abstinence in context of the many
    life transitions youth are experiencing make
    cessation difficult

				
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