Discouraging Smoking: Interventions for Pediatric n Nurse Practitioners . Christina
Rasco, MN,
RN, PNP
Smoking is the most preventable cause of death in this country, and it often begins in adolescence. By discouraging the use of cigarettes, pediatric nurse practitioners and other health care professionals can significantly reduce this current and future threat to the health of the nation’s children and adolescents. This article describes factors associated with adolescent smoking and interventions to prevent the initiation of smoking. J PEDIATR HEALTH CARE (1992).
6, 200-207.
E
ach day approximately 3000 American teenagers start smoking (U. S. Department of Health and Human Services[USDHHS], 1989). Although smoking in adolescence is often viewed as a harmless experimental phase, typical of teenage curiosity and rebelliousness, the Surgeon General of the United Stateshas estimated that at least five million of the children now living will die of smoking-related diseases(USDHHS, 1989). The initiation of smoking rarely occurs atier high school, but teenagerswho are light smokers may progress to more frequent use after graduation. Teenagerswho become regular smokers rarely are able to quit (Johnston, O’Malley, & Bachman, 1987). Thus, the prevention of cigarette use by adolescentsis the key to decreasingthe morbidity and deaths related to smoking. Pediatric nurse practitioners (PNPs) who emphasizehealth promotion and prevention of illness for young children can have a great impact on this major public health problem. The purpose of this article is to review intervention techniques, that the PNP may use to discourage smoking by children and adolescents. n
EFFECTS OF SMOKING
ON HEALTH
The Surgeon General has stated that cigarette smoking is “the chief, single, avoidable cause of death in our society and the most important public health issue of our time” (USDHHS, 1984, p. xiii). Smoking affects every major organ system with both immediate and delayed effects. Health care providers across a variety of specialtieswitness the harmfLl side effects of smoking. However, pediatrics offers the optimal chance to prevent the onset of tobacco use. This article was written during the author’s studies at Emory University, Atlanta, Ca. Ms. Rasco was a recipient of an American Cancer Society graduate scholarship in cancer nursing. Reprint requests: Christina Rasco, MN, RN, PNP, Lucile Salter Packard Children’s Hospital at Stanford, Department of Hematology/Oncology, 725 Welch Road, Palo Alto, CA 94304. 25/l 132906
200
Smokers face many possible serious late effects. The relationship between smoking and lung cancer is well known, with an estimated 85% of lung cancer caused by cigarette smoking (USDHHS, 1989). Smoking contributes to chronic lung disease,cardiovasculardisease, peptic ulcers, and cancer of the larynx, esophagus, mouth, bladder, pancreas,kidney, stomach, uterus, and cervix (USDHHS, 1989). Smoking also contributes to numerous less serious, yet bothersome, complications. These respiratory symptoms include, but are not limited to, increasedcough and phlegm production, respiratory infections, and eye irritations. Passivesmoking also contributes to increased respiratory symptoms including infections and cancer and can lead to the birth of low birth-weight infants (USDHHS, 1989). n
PREVALENCE OF SMOKING
IN ADOLESCENTS
According to nationwide studies of high school seniors by the National Institute on Drug Abuse (NIDA) in 1987, 33% of the seniors had never smoked (USDHHS, 1989). Although from 1976 to 1980 smoking rates among high school seniors declined sharply, falling from 29% to 21% respectively, little change has been seen in smoking rates since that time, with the rate of 19% in 1987 (USDHHS, 1989). The rate of cigarette use by teenagershas stabilized despite a decline in the prevalence of smoking by adults (USDHHS, 1989) and a decline in the use of other illicit drugs by teenagers (Johnston et al, 1987). The age of initiation of the habit is occurring at younger ages in recent years. Experimenting with smoking occurs most frequently in grade 6, and the initiation of daily cigarette use occurs most often in grades 7 to 9 (Johnston et al., 1987). n SOCIODEMOCRAPHIC TEENAGE SMOKING
FACTORS RELATED TO
Gender plays an important role in predicting smoking. Although initially smoking was typically a male habit, JOURNAL
OF PEDIATRIC
HEALTH
CARE
Journal of Pediatric Health Care
Discouraging
daily smoking rates for high school seniors have been higher for girls than boys each year since 1977 (USDHHS, 1989). In 1987, 16% of male high school seniors smoked, compared to 20% of female high school seniors (USDHHS, 1989). Children in grades 6 and 10 described female smokers as more healthy, better looking, better at school, more obedient, and appearing older than the male smokers. The male smokers were viewed only as tougher than their female counterparts (Barton, Chassin, Presson, & Sherman, 1982). Considering that the girls were described with many positive qualities, not surprisingly young girls find smoking socially acceptable.
C hildren
feel that girls who smoke are more socially acceptable than are boys who smoke.
The prevalence of daily smoking among black adolescents has declined sharply. Smoking rates for black teenagers fell from 26% in 1976 to 8% in 1987; the decline for white teenagers in the same survey was from 29% to 20% (USDHHS, 1989). The reasons for the decreased prevalence of smoking for black adolescents are unclear. Further evaluating demographic differences among teenagers, blacks and Asians have the lowest rates of smoking, with females smoking less than males. The highest rates of teenage smoking was seen among Native Americans, followed by whites. In those groups, girls were smoking more often than boys. Intermediate smoking rates were noted for Hispanic teenagers (Bachman et al., 1991). Regional differences also were noted with smoking highest among teenagers in the Northeast and lowest in the West (Johnston et al., 1987). n
INTERVENTIONS
FOR THE PNP
The Surgeon General estimated that the 789,000 deaths avoided or postponed because of smoking cessation or prevention between 1964 and 1986 can be attributed to the nation’s antismoking campaign (USDHHS, 1989). School systems have adopted antismoking campaigns and are effective settings for reaching children and influencing attitudes toward smoking (Johnson, Hansen, Collins, & Graham, 1986; Murray, Luepker, Johnson, & Mittelmark, 1984). Health care professionals also play a major role in discouraging cigarette use. One program, consisting of six visits to the physician for smoking cessation advice over 6 months, had cessation rates of 33Y0, compared to rates of 3% in the control group (Richmond &Webster, 1985). However in one study, only 44% of the adult smokers reported being advised by their physician to quit smoking (Anda, Remington, Sienko, & Davis, 1987). Data are lacking for nurse practitioners’ effectiveness in preventing smoking initiation, because most of the reports of health care professionals influencing cigarette use focus on physician intervention and deal with smok-
Smoking
201
ing cessation. However, with the emphasis that nurse practitioners place on patient education and health promotion, one can assume that PNPs and other health care providers can effectively address the issues of adolescent cigarette use. Some interventions are described in the following section and are summarized in the Box. n
INTERVENTIONS
FOR PARENTS
To begin promoting a smoke-free environment, PNPs should first address parents, with children of any age. In a study of students ages 12 to 18 years, children of parents who smoke regularly smoked at a rate twice that of children with parents who do not smoke (Lauer, Akers, Massey, & Clarke, 1982). First graders with parents who smoke are more likely to rate smoking as an acceptable, positive habit than children with parents who do not smoke (Shute, St. Pierre, & Lube& 1981). Thus, parental smoking affects children’s attitudes toward smoking at a young age. Leventhal, Glynn, and Fleming (1987) found that young people with family members who smoked had lower ‘knowledge of addiction” scores than those from nonsmoking homes. Children may learn inaccurate information about the habit from smokers. Children growing up in a household of smokers may assume smoking is an appropriate way to handle stress and boredom or to end a meal. In addition, the children of parents who smoke may be tolerant of the unpleasant effects of smoking such as the odors and stale air. Influencing parents to quit smoking can have a great impact on adolescent smoking trends. PNPs should warn parents who smoke that their children will have positive attitudes about the habit and may become smokers. Practitioners also can present information about the increased rate of respiratory complications among children of smokers (USDHHS, 1989) and should always inquire about parental smoking when a child experiences respiratory problems. If the parents smoke, the possible correlation between parental smoking and the child’s symptoms should be discussed along with information that the symptoms may decrease if smoking is discontinued. If the parents do not smoke, this positive action should be reinforced.
Low self-esteem
often leads to smoking.
Children with low self-esteem have very high rates of smoking (Bonaguro & Bonaguro, 1987). Solely, PNPs would have little effect on a child’s self-esteem. However, PNPs can promote parenting skills that encourage nonsmoking and foster positive self-image in children, to lay the groundwork for a smoke-free future. Practitioners also should assist parents in developing close attachments between children and their parents. In one large study, teens who reported close attachments
Volume
202
Rasco
BOX PNP INTERVENTIONS TO DISCOURAGE SMOKING For Parents: Always determine parents’ smoking habits Urge parents who smoke to quit inform of the likelihood the child will follow the parents’ practices Inform of smoking’s hazardous effects on young children, such as increased respiratory Assist in the development of good parenting skills, particularly in fostering self-esteem For S&d-age C#d&-en: Point out smoking’s immediate effects on body systems and appearance Insure that children know that smoking is habit forming involve older siblings or peers who do not smoke to influence younger children Point out that smoking is not a universal habit Point out ostracism of smokers from public places Review cigarette advertisements and marketing strategies Encourage children to make antismoking posters Encourage involvement in extracurricular activities For Adoiescents: Interventions from school-age section Role play ways to diminish peer pressure Offer stress reduction classes Determine adolescent’s attitudes toward smoking Make an antismoking contract Send letters home commending teenagers who resist smoking in Ceneral: Have smoke-free office Display antismoking posters Always inquire about smoking status Subscribe to magazines that ban cigarette advertisements increase own knowledge of smoking’s effects and make public presentations Support antismoking legislation u
to their parents had low smoking rates (Reimers, Pomrehn, Becker, & Lauer, 1990). INTERVENTIONS GEARED SCHOOL-AGED CHILDREN
n
6, Number
July-August
TO
Smoking initiation occurs most frequently in grades 7 to 9 (Johnston et al., 1987). Thus, the school-age years can be a time to foster a strong antismoking attitude for children that will guide practices in the adolescent years. Many factors are related to smoking by children and adolescents, such as smoking by family members and by peers (Lauer et al., 1982). However for adolescents, a pre-formed attitude toward smoking may be an even stronger influence than family or peer smoking (Pederson, 1986). Adolescents need to view smoking as an unglamorous, expensive habit with immediate consequences. These attitudes must be formed in childhood. Although almost all young smokers are aware of the long-term effects of smoking (Leventhal et al., 1987), children and adolescentsmay feel invulnerable, making this knowledge seem irrelevant. Although 98% of the
4
1992
symptoms
teenagers in one study believed that smoking can injure the body, 47% of the smokers thought that they would be lesslikely to get sick from smoking than other people (Leventhal et al., 1987). Indeed, programs that focus on the short-term effects of smoking are more effective than those with emphasis on the long-term effects of the habit (Murray et al., 1984). Children are concerned with body integrity. The PNP can discuss changes in heart rate, blood pressure, and carbon monoxide levels that occur immediately after one cigarette. Cosmetic effects of smoking, such as tobacco-stained teeth and fingers, bad breath, smoke odors on clothes, and skin wrinkling, may also influence a child’s attitude toward smoking. PNPs also should emphasize that smoking is habitforming. Lever&al et al (1987) reported that the children had very low knowledge of addiction scores, with smokers having the lowest scores. In a longitudinal study, approximately 75% of the daily smokers in high school were still smoking 7 to 9 years later, although only 5% had predicted they would definitely be smoking (Johnston et al., 1987). In fact, 53% of the high school
Journal of Pediatric Health Care
seniors with half-pack-a-day smoking habits reported unsuccessfully trying to quit smoking (Johnston et al., 1987). The children studied by Latter et al. (1982) had rates of smoking that were ten times higher if they had a best friend who smoked, compared to the children with friends who did not smoke. Sibling smoking is also a predictor of smoking among children and adolescents. The association was strongest (63%) with a sibling of the same sex (Burchfiel, Higgins, Keller, Butler, & Donahue, 1989). Moreover, peer and parental smoking had a cumulative effect on smoking rates. Adolescent smoking rates may be as high as 74% if both parents and a friend smoked (Lauer et al., 1982). PNPs might take advantage of these influences. Older siblings who set a good example by refraining from smoking can be encouraged to counsel younger siblings. PNPs can give children the idea to organize “no-smoking clubs” among their peers. Children might even persuade parents who smoke to give up cigarettes. A misconception exists among adolescents that almost everyone in their age group smokes. Among students surveyed by Lever&al et al. (1987), estimates of peer smoking were approximately twice that of reported smoking, and the perceived prevalence of smoking was higher for smokers than nonsmokers. The PNP can point out the “everyone else is doing it” fallacy to young children by asking the child to notice how few children actually smoke at school or in play areas. Pointing out the increasing ostracism of smokers in the work setting and public places may also be helpful. Finally, the practitioner might add that 71% of high school seniors preferred to date individuals who do not smoke (USDHHS, 1989).
C hildren
often feel that smoking will make them a part of the group.
Although illegal in 43 states, the sale of tobacco to children is a big business. The estimated profit to the tobacco industry from the sale of cigarettes to minors nationwide was $221 million for 1988 (DiFranza & Tye, 1990). In 1984, the tobacco industry spent approximately $2.1 billion annually on advertising (Federal Trade Commission, 1986). Barring ethics, from a pure business sense, it seems logical for the tobacco industry to gear advertisements to minors, considering that most smokers adopt the habit in their teens (Johnston et al., 1987). Fortunately, ethics are important. However, cigarette advertisements use cartoon characters and advertise in magazines geared to young readers. Advertisers tend to target the groups who are most at risk for smoking. Advertising has targeted an audience of young women of lower socioeconomic status. The
Discouraging
Smoking
203
scenes in cigarette advertisements include beautiful young women, sports cars, and people involved in active, glamorous lifestyles. Children do pay attention to these pressures. Aitken and Eadie (1990) report that smokers recognized significantly more cigarette advertisements than nonsmokers did.
C hildren
should be aware of advertising techniques used to influence their decisions.
Children need help in critically analyzing the media to resist these strong pressures. Many successful antismoking programs have included sessions on analyzing media influences (Johnson et al., 1986). PNPs could easily discuss magazine advertisements during routine office visits, such as pointing out the discrepancy of appearing independent but being addicted to cigarettes. The PNP also could devise self-directed worksheets for children to do while in the waiting room. The children could describe the ads and how they feel about the influences. Richards (1983) suggests that practitioners could subscribe only to magazines that ban cigarette advertising. This fact could then be prominently displayed in the office waiting room. If magazines display cigarettes, the advertisement could be defaced with red markers. School-age children enjoy being industrious. The PNP can encourage children who are waiting for an appointment to make antismoking posters, to be displayed prominently in the waiting area of the office. A prize might go to the most impressive posters. Creative practitioners might also devise a board game for the children to use, to increase knowledge about smoking and to help develop a strong antismoking attitude. Children and adolescents who smoke have a lower self-esteem than their peers who do not smoke (Bonaguro & Bonaguro, 1987). Developing a positive selfimage must start at a young age. Thus, encouraging children to stay active in activities such as music or sports to improve self-esteem could later influence those children’s decision to smoke. These activities may also decrease children’s idle time or promote a healthy lifestyle that is inconsistent with smoking. Academic achievement and participation in extracurricular activities have been found to be negatively associated with smoking (Reimers et al., 1990). Academic goals are also related to cigarette use. Smoking rates for students who are not college bound tend to be twice that of college-bound students; smoking rates for high school drop outs exceeds either category (USDHHS, 1989). Children should be encouraged to keep up scholastic and extracurricular activities during their teen years. In fact, all the interventions listed in this section would be appro-
204
Volume 6. Number 4 July-August 1992
Rasco
TABLE 1 Educational materials available from the American Cancer Society*
n
TITLEj AND NUMBER
DESCKIPTWN
Unit for preschool age, to help them learn polite ways to express their feelings about smoking Unit includes: Facilitator’s guide Five story books Five activity sheets for care providers Three hand puppets Poster Coloring book “Smoke-free room” sticker “Smoke-free me” stickers For kindergarten to 3rd graders: wall chart, cassette, film strip Three teaching units following popular TV format to help 4th through 6th graders to understand their responsibility for good health Units contain: Sound filmstrips Teaching guide Wall poster/game Teaching curriculum for grades 7 to 9: science, language arts, and social studies Science unit looks at the medical facts on tobacco use, examines risks and myths to affect personal decisions, and includes filmstrip, “Because of What l Know...” Student-directed components geared to vocational education students, including: Discussion guide Comic book Poster Computer software Videotape Kit for health professionals, includes variety of professional education materials, resources for patients, and miscellaneous materials, such as labels for charts to identify smokers Geared to adolescent or young adult
Starting Free, Good Air for Me (#2419)
Early Start Kit (#2310.02) Health Network (R2316.02)
Health Myself (#2633-LE)
Breaking Free (#2418.06-LE)
Tobacco-Free Young America (#3702.05) Fifty most often asked ques; tions about smoking and health and the answers (#2023-LE) Most
materials
available
are geared
to school
systems,
but portions
of programs
priate to use with adolescents,with the possible exception of the poster-making contest or board game. n
INTERVENTIONS GEARED TO ADOLESCENTS
Adolescentsunequivocally face strong peer pressuresto smoke. Many successful antismoking programs have taught children and teenagerssocial skills to resist these pressures(Botvin, Eng, & Williams, 1980; Johnson et al., 1986). These programs have included topics such as communication and problem-solving skills, media influences,valuesclarification, improving self-image,anxiety reduction, and assertivenesstraining. A variety of methods are generally used, including role play, debates, peer testimonials, skits, and group discussions.Some of
would
apply
to health
care
settings
these studies compared such behavioral programs to health information alone, as well as to control groups. The health information groups had lower smoking rates than the control group, and the behavioral programs showed even better results (Johnson et al., 1986). Most of these studies have included follow-up for about 3 years, with sustained effects seen. Typically, behavioral antismoking programs are presented at schools. Nurse practitioners may not have the opportunity to provide programs on such a large scale. However, segments, such as role play, could be done during brief office visits. For example, when labeled “chicken” for not smoking, the child can learn to reply, “I would be chicken if I smoked just to impress you.”
Journalof Discouraging
Pediatric Health Care
n FIGURE American
Lung Association
poster #5013
Large pediatric practices or health maintenance organizations might benefit from offering behavioral skills classes,particularly during the summer months. Nurses involved in summer camps also may have the opportunity to devise similar programs. General stressreduction classesmay also affect smoking rates becauseadolescentsmokers have higher perceived stressthan their nonsmoking counterparts (Bonagm-o & Bonaguro, 1987). Practitioners in school settings would have the ideal conditions to affect a large number of teenagers. Many of the large antismoking programs have been successfulin preventing smoking initiation or progression to heavier cigarette use, with little effects on cessation rates (Botvin et al., 1980; Johnson et al., 1986). This gives support to providing skills programs early. The program by Botvin et al. (1980) was most effective for the youngest children in the group, eighth graders, and had only minimal effects on the tenth graders.
(printed
with
Smoking
205
permission).
The results of having peer-led discussion groups are unclear. Johnson et al. (1986) found no benefit in using either peer leadersor having videos with familiar media models to discourage smoking. However, other peerlead groups have had lower smoking rates than adultdirefted groups (Murray et al., 1984). If practitioners do offer antismoking classes,including an older adolescent to influence young students may be helpful.
P
NPs must find ways to gain the respect of adolescents.
Adolescents should be treated as responsibleindividuals for the health care providers to gain their respect. PNPs should discussattitudes and valuesabout smoking with adolescents,to understand eachteenager’spersonal motivation for using or ignoring cigarettes. Individualized interventions may then be made more effective.
Volume
206
n
TABLE
2 Educational
materials
available
from the American
~~~~~N
As You Live, You Breathe @061~ Lung Diagram Poster E&150) Octopuff in Kumquat (6224, video; 6022, sticker) Have Fun! Figure Out the Smoking Puzzle 0072) Let’s Solve the Smokeword Puzzle (0071) No Smoking Coloring Book (0043) No Smoking-Kid’s
Magazine
(0022) No Smoking-Lung’s at Work (0840) What’s Your Cigarette Smoking IQ? (1190)
Cameo Rock Group Poster (5195) Brooke Shields Poster f5 181) Teen no-smoking posters (5013; 5014)
Antismoking (6024) (6026) (6009)
Booklet to accompany “13reathing Easy” (school based program) describes breathing process, l$ pages,. for 5th to 8th graders From “Lungs are for Life” s&roof program, grade 3-4 moduie g-Minute videotape; sticker with sketch of Octopuff and “I’ll never Smoke” message, for 4 to 8 year olds Crossword puzzle, 1 page, for 7th to 9th graders Crossword puzzle, 1 page, for 5th graders Antismoking message in coloring book, 4 pages, preschool and primary grades Puzzles and stories, 8 pws, for 3 to 8-year-olds Describes how lungs work and how they are affected by smoking, 8 pages, for 5th and 6th graders Brief true or false quiz to test one’s knowledge of the effects of smoking “Break Lt. Don’t Take It!” with a picture of rock group breaking giant cigarette “Smoking Spoils Your Looks” “What Makes Smoking Such a Drag?“, depicts a fashionably dressed teenage boy, information points out how teens lose their a@ractivenessby smoking; “The Truth about Smoking Witl lust Kilt You,” similar to 5013, with a female
buttons “Yes, 1 Mind if You Smoke” “Your Smoking Hurts My Lungs” “Thanks for Not Smoking“
(0124)
Antismoking (5082)
4
1992
Lung Association
TITLE AND N
“No Smoking”
Stop Sign
stickers
(6061) (0119)
“Be A Friend . . . Please Don’t Smoke Here” “join the Smoke-Free Family” “No’ Smoking” Stop Sign
The adolescent may also recognize that some attitudes are based on ungrounded information. If teenagers view the negative social implications as stronger than the potential assets, they may choose not to smoke. The PNP might help an adolescent make a contract not to smoke. Letters may also be sent home commending the teenager for being smoke-free, which can help boost self-esteem. n
6, Number
July-August
Rasco
GENERAL INTERVENTIONS
Every PNP office should be smoke-free, and patients should receive a strong antismoking message. The PNP can display antismoking posters from organizations such as the American Cancer Society (ACS; Table 1) or the American Lung Association (ALA; Figure and Table 2), as well as antismoking buttons and pamphlets also from local chapters of the ACS or ALA. Smoking status should be recorded each visit, showing parents and patients the impact of smoking on health.
Smoking prevention should be included in the curricula of PNP programs. PNPs can also increase their own knowledge about the effects of smoking and make presentations to professional nursing organizations and to the lay public, especially to schools. Area merchants may even influence the nation’s smoking rates, by selling cigarettes to minors, against state laws. Nurse practitioners could offer guidance to the merchants who may not be aware of the consequences of their actions.
P
NPs should become politically area of smoking.
active in the
PNPs also should strongly support public policies that prohibit smoking at health care institutions and legislation banning the sale of cigarettes in vending machines. Practitioners might also support a tax on cigarettes to go toward antismoking education. Not only would the tax provide money for education, but it might
Journal of Pediatric Health Care
also financiallv deter individuals from smoking. California has recently increased the tax on cigarett; by 25 cents per pack, with the money allotted for health care expenses and prevention programs. No reports on the effectiveness of the tax program are available, but Warner (1986) estimated that a tax increase of 8 to 16 cents would deter one to two million young people from smoking. n
SUMMARY
Smoking by adolescents is a major obstacle to health promotion, with both immediate and long-term health consequences. Smoking is most often initiated during the teen years and becomes a life-long habit. The scare tactics used with adults, with the threat of lung cancer, may not be effective in the pediatric population. Strategies with young children should be to promote a strong antismoking attitude and to dispel myths associated with smoking. Older children and adolescents may need assistance in fighting off pressures to smoke. Practitioners may also have secondary influences on children, working through parents, legislators, and other methods to reduce the incidence of smoking. PNPs have many opportunities to help discourage adolescent smoking and thereby improve the health of the nation. REFERENCES Aitken, I’. P., & Eadie, D. R. (1990). Reinforcing effects of cigarette advertising on under-age smoking. British Jow& ofAddiction, 8.5, 399-412. Anda, R. F., Remington, I’. L., Sienko, D. G., &Davis, R. M. (1987). Are physicians advising smokers to quit? The patient’s perspective. Journal of the A merimn MedicalAssociutiun, 257, 1916-1919. Bachman, J. G., Wallace, J. M., O ’Malley, I?. M., Johnston, L. D., Kurth, C. L., & Neighbors, H. W. (1991). Racial/ethnic differences in smoking, drinking, and ilhcit drug use among American high school seniors, 1976-89. American Journal of Publh Health, 81, 372-377. Barton, J., Chassin, L., Presson, C. C., & Sherman, S. J. (1982). Social image factors as motivators of smoking initiation in early and middle adolescence. Child Devehpment, 53, 1499- 15 11. Bonaguro, J. A., & Bonaguro, E. W. (1987). Self-concept, stress .ss5p;matology, and tobacco use. Journal of School Health, 57, Botvin, G. J., Eng, A., & Williams, C. L. (1980). Preventing the onset of cigarette smoking through life skills training. Preventive Medicine, 9, 135-143. Burchtiel, C. M., Higgins, M. W., Keller, J. B., Butler, W. J., &
Discouraging
Smoking
207
Donahue, R. I’. (1989). Initiation of cigarette smoking in children and adolescents of Tecumseh, Michigk. Americun JM*mal of Epidemiology, 130,410-415. DiFranza, J. R., & Tye, J. B. (1990). Who profits from tobacco sales to children? Journal of the American MediculAssociution, 263,27842787. Federal Trade Commission. (1986). Report to Congrarpwsuant to the Federal Cgarette Labelin andAdve&tiingAct, 1984. Washington, DC: U. S. Government Printing Office. Johnson, C. A., Hansen, W. B., Collins, L. M., & Graham, J. W. (1986). High-school smoking prevention: Results of a three-year longitudinal study. Joumd of Bebaviural Medicine, 9, 439-452. Johnston, L. D., O ’MalIey, P. M., & Bachman, J. G. (1987). Nat&al trends in drug use and related f&on among American h&b school students and young adults, 1975-1986. (DHHS publication no. ADM 87-1535). Washington, DC: U. S. Government Printing Office. Lauer, R. M., Akers, R. L., Massey, J., & Clarke, W. R. (1982). Evaluation of cigarette smoking among adolescents: The Muscadine Study. Preventive Medicine, 11, 417-428. Leventhal, H., Glynn, K., & Fleming, R. (1987). Is the smoking decision an ‘informed choice’? Effect of smoking risk factors on smoking beliefs. Journal of the American Medical Association, 257, 3373-3376. Murray, D. M., Luepker, R. V., Johnson, C. A., & Mittelmark, M. B. (1984). The prevention of cigarette smoking in children: A comparison of four strategies. Journal ofApplied SociulPsycbolo~~~, 14, 274-288. Pederson, L. L. (1986). Change in variables related to smoking from childhood to late adolescence: An eight year longitudinal study of a cohort of elementary school students. Canadian Journal of Public Health, 77(suppl l), 33-39. Reimers, T. M., Pomrehn, I’. R., Becker, S. L., & Lauer, R. M. (1990). Risk factors for adolescent cigarette smoking. American Journal ofDtseaseSof Children, 144, 12651272. Richards, J. W. (1983). A positive health strategy for the office waiting room. New York State Journal OfMedicine, 83, 1358-1360. Richmond, R., & Webster, I. (1985). Evaluation of general practitioners use of a smoking intervention programme. International Journal of Ept&mMloJy, 14, 396-401. Shute, R. E., St. Pierre, R. W., & Lube& E. G. (1981). Smoking awareness and practices of urban preschool and first grade children. Journal of SchoolHealth, 51, 347-351. U. S. Department of Health and Human Services. (1984). The health consequences of smoking. Cbronit obstmetive lung diseace.A report of the Surgeon General (DHHS publication no. PHS 84-50205). Washington, DC: U. S. Government Printing Office. U. S. Department of Health and Human Services. (1989). Reducin. the health consequences of smoking. 25 years ofpropess. A report of the Surgerm General 1989 (DHHS publication no. CDC 89-8411). Washington, DC: U. S. Government Priming Office. Warner, K. E., (1986). Smoking and health implications of a change in the Federal Cigarette Excise Tax. Journal of theA&n Medical Associution, 255, 1028-1032.
Rasco, MN,
RN, PNP
Smoking is the most preventable cause of death in this country, and it often begins in adolescence. By discouraging the use of cigarettes, pediatric nurse practitioners and other health care professionals can significantly reduce this current and future threat to the health of the nation’s children and adolescents. This article describes factors associated with adolescent smoking and interventions to prevent the initiation of smoking. J PEDIATR HEALTH CARE (1992).
6, 200-207.
E
ach day approximately 3000 American teenagers start smoking (U. S. Department of Health and Human Services[USDHHS], 1989). Although smoking in adolescence is often viewed as a harmless experimental phase, typical of teenage curiosity and rebelliousness, the Surgeon General of the United Stateshas estimated that at least five million of the children now living will die of smoking-related diseases(USDHHS, 1989). The initiation of smoking rarely occurs atier high school, but teenagerswho are light smokers may progress to more frequent use after graduation. Teenagerswho become regular smokers rarely are able to quit (Johnston, O’Malley, & Bachman, 1987). Thus, the prevention of cigarette use by adolescentsis the key to decreasingthe morbidity and deaths related to smoking. Pediatric nurse practitioners (PNPs) who emphasizehealth promotion and prevention of illness for young children can have a great impact on this major public health problem. The purpose of this article is to review intervention techniques, that the PNP may use to discourage smoking by children and adolescents. n
EFFECTS OF SMOKING
ON HEALTH
The Surgeon General has stated that cigarette smoking is “the chief, single, avoidable cause of death in our society and the most important public health issue of our time” (USDHHS, 1984, p. xiii). Smoking affects every major organ system with both immediate and delayed effects. Health care providers across a variety of specialtieswitness the harmfLl side effects of smoking. However, pediatrics offers the optimal chance to prevent the onset of tobacco use. This article was written during the author’s studies at Emory University, Atlanta, Ca. Ms. Rasco was a recipient of an American Cancer Society graduate scholarship in cancer nursing. Reprint requests: Christina Rasco, MN, RN, PNP, Lucile Salter Packard Children’s Hospital at Stanford, Department of Hematology/Oncology, 725 Welch Road, Palo Alto, CA 94304. 25/l 132906
200
Smokers face many possible serious late effects. The relationship between smoking and lung cancer is well known, with an estimated 85% of lung cancer caused by cigarette smoking (USDHHS, 1989). Smoking contributes to chronic lung disease,cardiovasculardisease, peptic ulcers, and cancer of the larynx, esophagus, mouth, bladder, pancreas,kidney, stomach, uterus, and cervix (USDHHS, 1989). Smoking also contributes to numerous less serious, yet bothersome, complications. These respiratory symptoms include, but are not limited to, increasedcough and phlegm production, respiratory infections, and eye irritations. Passivesmoking also contributes to increased respiratory symptoms including infections and cancer and can lead to the birth of low birth-weight infants (USDHHS, 1989). n
PREVALENCE OF SMOKING
IN ADOLESCENTS
According to nationwide studies of high school seniors by the National Institute on Drug Abuse (NIDA) in 1987, 33% of the seniors had never smoked (USDHHS, 1989). Although from 1976 to 1980 smoking rates among high school seniors declined sharply, falling from 29% to 21% respectively, little change has been seen in smoking rates since that time, with the rate of 19% in 1987 (USDHHS, 1989). The rate of cigarette use by teenagershas stabilized despite a decline in the prevalence of smoking by adults (USDHHS, 1989) and a decline in the use of other illicit drugs by teenagers (Johnston et al, 1987). The age of initiation of the habit is occurring at younger ages in recent years. Experimenting with smoking occurs most frequently in grade 6, and the initiation of daily cigarette use occurs most often in grades 7 to 9 (Johnston et al., 1987). n SOCIODEMOCRAPHIC TEENAGE SMOKING
FACTORS RELATED TO
Gender plays an important role in predicting smoking. Although initially smoking was typically a male habit, JOURNAL
OF PEDIATRIC
HEALTH
CARE
Journal of Pediatric Health Care
Discouraging
daily smoking rates for high school seniors have been higher for girls than boys each year since 1977 (USDHHS, 1989). In 1987, 16% of male high school seniors smoked, compared to 20% of female high school seniors (USDHHS, 1989). Children in grades 6 and 10 described female smokers as more healthy, better looking, better at school, more obedient, and appearing older than the male smokers. The male smokers were viewed only as tougher than their female counterparts (Barton, Chassin, Presson, & Sherman, 1982). Considering that the girls were described with many positive qualities, not surprisingly young girls find smoking socially acceptable.
C hildren
feel that girls who smoke are more socially acceptable than are boys who smoke.
The prevalence of daily smoking among black adolescents has declined sharply. Smoking rates for black teenagers fell from 26% in 1976 to 8% in 1987; the decline for white teenagers in the same survey was from 29% to 20% (USDHHS, 1989). The reasons for the decreased prevalence of smoking for black adolescents are unclear. Further evaluating demographic differences among teenagers, blacks and Asians have the lowest rates of smoking, with females smoking less than males. The highest rates of teenage smoking was seen among Native Americans, followed by whites. In those groups, girls were smoking more often than boys. Intermediate smoking rates were noted for Hispanic teenagers (Bachman et al., 1991). Regional differences also were noted with smoking highest among teenagers in the Northeast and lowest in the West (Johnston et al., 1987). n
INTERVENTIONS
FOR THE PNP
The Surgeon General estimated that the 789,000 deaths avoided or postponed because of smoking cessation or prevention between 1964 and 1986 can be attributed to the nation’s antismoking campaign (USDHHS, 1989). School systems have adopted antismoking campaigns and are effective settings for reaching children and influencing attitudes toward smoking (Johnson, Hansen, Collins, & Graham, 1986; Murray, Luepker, Johnson, & Mittelmark, 1984). Health care professionals also play a major role in discouraging cigarette use. One program, consisting of six visits to the physician for smoking cessation advice over 6 months, had cessation rates of 33Y0, compared to rates of 3% in the control group (Richmond &Webster, 1985). However in one study, only 44% of the adult smokers reported being advised by their physician to quit smoking (Anda, Remington, Sienko, & Davis, 1987). Data are lacking for nurse practitioners’ effectiveness in preventing smoking initiation, because most of the reports of health care professionals influencing cigarette use focus on physician intervention and deal with smok-
Smoking
201
ing cessation. However, with the emphasis that nurse practitioners place on patient education and health promotion, one can assume that PNPs and other health care providers can effectively address the issues of adolescent cigarette use. Some interventions are described in the following section and are summarized in the Box. n
INTERVENTIONS
FOR PARENTS
To begin promoting a smoke-free environment, PNPs should first address parents, with children of any age. In a study of students ages 12 to 18 years, children of parents who smoke regularly smoked at a rate twice that of children with parents who do not smoke (Lauer, Akers, Massey, & Clarke, 1982). First graders with parents who smoke are more likely to rate smoking as an acceptable, positive habit than children with parents who do not smoke (Shute, St. Pierre, & Lube& 1981). Thus, parental smoking affects children’s attitudes toward smoking at a young age. Leventhal, Glynn, and Fleming (1987) found that young people with family members who smoked had lower ‘knowledge of addiction” scores than those from nonsmoking homes. Children may learn inaccurate information about the habit from smokers. Children growing up in a household of smokers may assume smoking is an appropriate way to handle stress and boredom or to end a meal. In addition, the children of parents who smoke may be tolerant of the unpleasant effects of smoking such as the odors and stale air. Influencing parents to quit smoking can have a great impact on adolescent smoking trends. PNPs should warn parents who smoke that their children will have positive attitudes about the habit and may become smokers. Practitioners also can present information about the increased rate of respiratory complications among children of smokers (USDHHS, 1989) and should always inquire about parental smoking when a child experiences respiratory problems. If the parents smoke, the possible correlation between parental smoking and the child’s symptoms should be discussed along with information that the symptoms may decrease if smoking is discontinued. If the parents do not smoke, this positive action should be reinforced.
Low self-esteem
often leads to smoking.
Children with low self-esteem have very high rates of smoking (Bonaguro & Bonaguro, 1987). Solely, PNPs would have little effect on a child’s self-esteem. However, PNPs can promote parenting skills that encourage nonsmoking and foster positive self-image in children, to lay the groundwork for a smoke-free future. Practitioners also should assist parents in developing close attachments between children and their parents. In one large study, teens who reported close attachments
Volume
202
Rasco
BOX PNP INTERVENTIONS TO DISCOURAGE SMOKING For Parents: Always determine parents’ smoking habits Urge parents who smoke to quit inform of the likelihood the child will follow the parents’ practices Inform of smoking’s hazardous effects on young children, such as increased respiratory Assist in the development of good parenting skills, particularly in fostering self-esteem For S&d-age C#d&-en: Point out smoking’s immediate effects on body systems and appearance Insure that children know that smoking is habit forming involve older siblings or peers who do not smoke to influence younger children Point out that smoking is not a universal habit Point out ostracism of smokers from public places Review cigarette advertisements and marketing strategies Encourage children to make antismoking posters Encourage involvement in extracurricular activities For Adoiescents: Interventions from school-age section Role play ways to diminish peer pressure Offer stress reduction classes Determine adolescent’s attitudes toward smoking Make an antismoking contract Send letters home commending teenagers who resist smoking in Ceneral: Have smoke-free office Display antismoking posters Always inquire about smoking status Subscribe to magazines that ban cigarette advertisements increase own knowledge of smoking’s effects and make public presentations Support antismoking legislation u
to their parents had low smoking rates (Reimers, Pomrehn, Becker, & Lauer, 1990). INTERVENTIONS GEARED SCHOOL-AGED CHILDREN
n
6, Number
July-August
TO
Smoking initiation occurs most frequently in grades 7 to 9 (Johnston et al., 1987). Thus, the school-age years can be a time to foster a strong antismoking attitude for children that will guide practices in the adolescent years. Many factors are related to smoking by children and adolescents, such as smoking by family members and by peers (Lauer et al., 1982). However for adolescents, a pre-formed attitude toward smoking may be an even stronger influence than family or peer smoking (Pederson, 1986). Adolescents need to view smoking as an unglamorous, expensive habit with immediate consequences. These attitudes must be formed in childhood. Although almost all young smokers are aware of the long-term effects of smoking (Leventhal et al., 1987), children and adolescentsmay feel invulnerable, making this knowledge seem irrelevant. Although 98% of the
4
1992
symptoms
teenagers in one study believed that smoking can injure the body, 47% of the smokers thought that they would be lesslikely to get sick from smoking than other people (Leventhal et al., 1987). Indeed, programs that focus on the short-term effects of smoking are more effective than those with emphasis on the long-term effects of the habit (Murray et al., 1984). Children are concerned with body integrity. The PNP can discuss changes in heart rate, blood pressure, and carbon monoxide levels that occur immediately after one cigarette. Cosmetic effects of smoking, such as tobacco-stained teeth and fingers, bad breath, smoke odors on clothes, and skin wrinkling, may also influence a child’s attitude toward smoking. PNPs also should emphasize that smoking is habitforming. Lever&al et al (1987) reported that the children had very low knowledge of addiction scores, with smokers having the lowest scores. In a longitudinal study, approximately 75% of the daily smokers in high school were still smoking 7 to 9 years later, although only 5% had predicted they would definitely be smoking (Johnston et al., 1987). In fact, 53% of the high school
Journal of Pediatric Health Care
seniors with half-pack-a-day smoking habits reported unsuccessfully trying to quit smoking (Johnston et al., 1987). The children studied by Latter et al. (1982) had rates of smoking that were ten times higher if they had a best friend who smoked, compared to the children with friends who did not smoke. Sibling smoking is also a predictor of smoking among children and adolescents. The association was strongest (63%) with a sibling of the same sex (Burchfiel, Higgins, Keller, Butler, & Donahue, 1989). Moreover, peer and parental smoking had a cumulative effect on smoking rates. Adolescent smoking rates may be as high as 74% if both parents and a friend smoked (Lauer et al., 1982). PNPs might take advantage of these influences. Older siblings who set a good example by refraining from smoking can be encouraged to counsel younger siblings. PNPs can give children the idea to organize “no-smoking clubs” among their peers. Children might even persuade parents who smoke to give up cigarettes. A misconception exists among adolescents that almost everyone in their age group smokes. Among students surveyed by Lever&al et al. (1987), estimates of peer smoking were approximately twice that of reported smoking, and the perceived prevalence of smoking was higher for smokers than nonsmokers. The PNP can point out the “everyone else is doing it” fallacy to young children by asking the child to notice how few children actually smoke at school or in play areas. Pointing out the increasing ostracism of smokers in the work setting and public places may also be helpful. Finally, the practitioner might add that 71% of high school seniors preferred to date individuals who do not smoke (USDHHS, 1989).
C hildren
often feel that smoking will make them a part of the group.
Although illegal in 43 states, the sale of tobacco to children is a big business. The estimated profit to the tobacco industry from the sale of cigarettes to minors nationwide was $221 million for 1988 (DiFranza & Tye, 1990). In 1984, the tobacco industry spent approximately $2.1 billion annually on advertising (Federal Trade Commission, 1986). Barring ethics, from a pure business sense, it seems logical for the tobacco industry to gear advertisements to minors, considering that most smokers adopt the habit in their teens (Johnston et al., 1987). Fortunately, ethics are important. However, cigarette advertisements use cartoon characters and advertise in magazines geared to young readers. Advertisers tend to target the groups who are most at risk for smoking. Advertising has targeted an audience of young women of lower socioeconomic status. The
Discouraging
Smoking
203
scenes in cigarette advertisements include beautiful young women, sports cars, and people involved in active, glamorous lifestyles. Children do pay attention to these pressures. Aitken and Eadie (1990) report that smokers recognized significantly more cigarette advertisements than nonsmokers did.
C hildren
should be aware of advertising techniques used to influence their decisions.
Children need help in critically analyzing the media to resist these strong pressures. Many successful antismoking programs have included sessions on analyzing media influences (Johnson et al., 1986). PNPs could easily discuss magazine advertisements during routine office visits, such as pointing out the discrepancy of appearing independent but being addicted to cigarettes. The PNP also could devise self-directed worksheets for children to do while in the waiting room. The children could describe the ads and how they feel about the influences. Richards (1983) suggests that practitioners could subscribe only to magazines that ban cigarette advertising. This fact could then be prominently displayed in the office waiting room. If magazines display cigarettes, the advertisement could be defaced with red markers. School-age children enjoy being industrious. The PNP can encourage children who are waiting for an appointment to make antismoking posters, to be displayed prominently in the waiting area of the office. A prize might go to the most impressive posters. Creative practitioners might also devise a board game for the children to use, to increase knowledge about smoking and to help develop a strong antismoking attitude. Children and adolescents who smoke have a lower self-esteem than their peers who do not smoke (Bonaguro & Bonaguro, 1987). Developing a positive selfimage must start at a young age. Thus, encouraging children to stay active in activities such as music or sports to improve self-esteem could later influence those children’s decision to smoke. These activities may also decrease children’s idle time or promote a healthy lifestyle that is inconsistent with smoking. Academic achievement and participation in extracurricular activities have been found to be negatively associated with smoking (Reimers et al., 1990). Academic goals are also related to cigarette use. Smoking rates for students who are not college bound tend to be twice that of college-bound students; smoking rates for high school drop outs exceeds either category (USDHHS, 1989). Children should be encouraged to keep up scholastic and extracurricular activities during their teen years. In fact, all the interventions listed in this section would be appro-
204
Volume 6. Number 4 July-August 1992
Rasco
TABLE 1 Educational materials available from the American Cancer Society*
n
TITLEj AND NUMBER
DESCKIPTWN
Unit for preschool age, to help them learn polite ways to express their feelings about smoking Unit includes: Facilitator’s guide Five story books Five activity sheets for care providers Three hand puppets Poster Coloring book “Smoke-free room” sticker “Smoke-free me” stickers For kindergarten to 3rd graders: wall chart, cassette, film strip Three teaching units following popular TV format to help 4th through 6th graders to understand their responsibility for good health Units contain: Sound filmstrips Teaching guide Wall poster/game Teaching curriculum for grades 7 to 9: science, language arts, and social studies Science unit looks at the medical facts on tobacco use, examines risks and myths to affect personal decisions, and includes filmstrip, “Because of What l Know...” Student-directed components geared to vocational education students, including: Discussion guide Comic book Poster Computer software Videotape Kit for health professionals, includes variety of professional education materials, resources for patients, and miscellaneous materials, such as labels for charts to identify smokers Geared to adolescent or young adult
Starting Free, Good Air for Me (#2419)
Early Start Kit (#2310.02) Health Network (R2316.02)
Health Myself (#2633-LE)
Breaking Free (#2418.06-LE)
Tobacco-Free Young America (#3702.05) Fifty most often asked ques; tions about smoking and health and the answers (#2023-LE) Most
materials
available
are geared
to school
systems,
but portions
of programs
priate to use with adolescents,with the possible exception of the poster-making contest or board game. n
INTERVENTIONS GEARED TO ADOLESCENTS
Adolescentsunequivocally face strong peer pressuresto smoke. Many successful antismoking programs have taught children and teenagerssocial skills to resist these pressures(Botvin, Eng, & Williams, 1980; Johnson et al., 1986). These programs have included topics such as communication and problem-solving skills, media influences,valuesclarification, improving self-image,anxiety reduction, and assertivenesstraining. A variety of methods are generally used, including role play, debates, peer testimonials, skits, and group discussions.Some of
would
apply
to health
care
settings
these studies compared such behavioral programs to health information alone, as well as to control groups. The health information groups had lower smoking rates than the control group, and the behavioral programs showed even better results (Johnson et al., 1986). Most of these studies have included follow-up for about 3 years, with sustained effects seen. Typically, behavioral antismoking programs are presented at schools. Nurse practitioners may not have the opportunity to provide programs on such a large scale. However, segments, such as role play, could be done during brief office visits. For example, when labeled “chicken” for not smoking, the child can learn to reply, “I would be chicken if I smoked just to impress you.”
Journalof Discouraging
Pediatric Health Care
n FIGURE American
Lung Association
poster #5013
Large pediatric practices or health maintenance organizations might benefit from offering behavioral skills classes,particularly during the summer months. Nurses involved in summer camps also may have the opportunity to devise similar programs. General stressreduction classesmay also affect smoking rates becauseadolescentsmokers have higher perceived stressthan their nonsmoking counterparts (Bonagm-o & Bonaguro, 1987). Practitioners in school settings would have the ideal conditions to affect a large number of teenagers. Many of the large antismoking programs have been successfulin preventing smoking initiation or progression to heavier cigarette use, with little effects on cessation rates (Botvin et al., 1980; Johnson et al., 1986). This gives support to providing skills programs early. The program by Botvin et al. (1980) was most effective for the youngest children in the group, eighth graders, and had only minimal effects on the tenth graders.
(printed
with
Smoking
205
permission).
The results of having peer-led discussion groups are unclear. Johnson et al. (1986) found no benefit in using either peer leadersor having videos with familiar media models to discourage smoking. However, other peerlead groups have had lower smoking rates than adultdirefted groups (Murray et al., 1984). If practitioners do offer antismoking classes,including an older adolescent to influence young students may be helpful.
P
NPs must find ways to gain the respect of adolescents.
Adolescents should be treated as responsibleindividuals for the health care providers to gain their respect. PNPs should discussattitudes and valuesabout smoking with adolescents,to understand eachteenager’spersonal motivation for using or ignoring cigarettes. Individualized interventions may then be made more effective.
Volume
206
n
TABLE
2 Educational
materials
available
from the American
~~~~~N
As You Live, You Breathe @061~ Lung Diagram Poster E&150) Octopuff in Kumquat (6224, video; 6022, sticker) Have Fun! Figure Out the Smoking Puzzle 0072) Let’s Solve the Smokeword Puzzle (0071) No Smoking Coloring Book (0043) No Smoking-Kid’s
Magazine
(0022) No Smoking-Lung’s at Work (0840) What’s Your Cigarette Smoking IQ? (1190)
Cameo Rock Group Poster (5195) Brooke Shields Poster f5 181) Teen no-smoking posters (5013; 5014)
Antismoking (6024) (6026) (6009)
Booklet to accompany “13reathing Easy” (school based program) describes breathing process, l$ pages,. for 5th to 8th graders From “Lungs are for Life” s&roof program, grade 3-4 moduie g-Minute videotape; sticker with sketch of Octopuff and “I’ll never Smoke” message, for 4 to 8 year olds Crossword puzzle, 1 page, for 7th to 9th graders Crossword puzzle, 1 page, for 5th graders Antismoking message in coloring book, 4 pages, preschool and primary grades Puzzles and stories, 8 pws, for 3 to 8-year-olds Describes how lungs work and how they are affected by smoking, 8 pages, for 5th and 6th graders Brief true or false quiz to test one’s knowledge of the effects of smoking “Break Lt. Don’t Take It!” with a picture of rock group breaking giant cigarette “Smoking Spoils Your Looks” “What Makes Smoking Such a Drag?“, depicts a fashionably dressed teenage boy, information points out how teens lose their a@ractivenessby smoking; “The Truth about Smoking Witl lust Kilt You,” similar to 5013, with a female
buttons “Yes, 1 Mind if You Smoke” “Your Smoking Hurts My Lungs” “Thanks for Not Smoking“
(0124)
Antismoking (5082)
4
1992
Lung Association
TITLE AND N
“No Smoking”
Stop Sign
stickers
(6061) (0119)
“Be A Friend . . . Please Don’t Smoke Here” “join the Smoke-Free Family” “No’ Smoking” Stop Sign
The adolescent may also recognize that some attitudes are based on ungrounded information. If teenagers view the negative social implications as stronger than the potential assets, they may choose not to smoke. The PNP might help an adolescent make a contract not to smoke. Letters may also be sent home commending the teenager for being smoke-free, which can help boost self-esteem. n
6, Number
July-August
Rasco
GENERAL INTERVENTIONS
Every PNP office should be smoke-free, and patients should receive a strong antismoking message. The PNP can display antismoking posters from organizations such as the American Cancer Society (ACS; Table 1) or the American Lung Association (ALA; Figure and Table 2), as well as antismoking buttons and pamphlets also from local chapters of the ACS or ALA. Smoking status should be recorded each visit, showing parents and patients the impact of smoking on health.
Smoking prevention should be included in the curricula of PNP programs. PNPs can also increase their own knowledge about the effects of smoking and make presentations to professional nursing organizations and to the lay public, especially to schools. Area merchants may even influence the nation’s smoking rates, by selling cigarettes to minors, against state laws. Nurse practitioners could offer guidance to the merchants who may not be aware of the consequences of their actions.
P
NPs should become politically area of smoking.
active in the
PNPs also should strongly support public policies that prohibit smoking at health care institutions and legislation banning the sale of cigarettes in vending machines. Practitioners might also support a tax on cigarettes to go toward antismoking education. Not only would the tax provide money for education, but it might
Journal of Pediatric Health Care
also financiallv deter individuals from smoking. California has recently increased the tax on cigarett; by 25 cents per pack, with the money allotted for health care expenses and prevention programs. No reports on the effectiveness of the tax program are available, but Warner (1986) estimated that a tax increase of 8 to 16 cents would deter one to two million young people from smoking. n
SUMMARY
Smoking by adolescents is a major obstacle to health promotion, with both immediate and long-term health consequences. Smoking is most often initiated during the teen years and becomes a life-long habit. The scare tactics used with adults, with the threat of lung cancer, may not be effective in the pediatric population. Strategies with young children should be to promote a strong antismoking attitude and to dispel myths associated with smoking. Older children and adolescents may need assistance in fighting off pressures to smoke. Practitioners may also have secondary influences on children, working through parents, legislators, and other methods to reduce the incidence of smoking. PNPs have many opportunities to help discourage adolescent smoking and thereby improve the health of the nation. REFERENCES Aitken, I’. P., & Eadie, D. R. (1990). Reinforcing effects of cigarette advertising on under-age smoking. British Jow& ofAddiction, 8.5, 399-412. Anda, R. F., Remington, I’. L., Sienko, D. G., &Davis, R. M. (1987). Are physicians advising smokers to quit? The patient’s perspective. Journal of the A merimn MedicalAssociutiun, 257, 1916-1919. Bachman, J. G., Wallace, J. M., O ’Malley, I?. M., Johnston, L. D., Kurth, C. L., & Neighbors, H. W. (1991). Racial/ethnic differences in smoking, drinking, and ilhcit drug use among American high school seniors, 1976-89. American Journal of Publh Health, 81, 372-377. Barton, J., Chassin, L., Presson, C. C., & Sherman, S. J. (1982). Social image factors as motivators of smoking initiation in early and middle adolescence. Child Devehpment, 53, 1499- 15 11. Bonaguro, J. A., & Bonaguro, E. W. (1987). Self-concept, stress .ss5p;matology, and tobacco use. Journal of School Health, 57, Botvin, G. J., Eng, A., & Williams, C. L. (1980). Preventing the onset of cigarette smoking through life skills training. Preventive Medicine, 9, 135-143. Burchtiel, C. M., Higgins, M. W., Keller, J. B., Butler, W. J., &
Discouraging
Smoking
207
Donahue, R. I’. (1989). Initiation of cigarette smoking in children and adolescents of Tecumseh, Michigk. Americun JM*mal of Epidemiology, 130,410-415. DiFranza, J. R., & Tye, J. B. (1990). Who profits from tobacco sales to children? Journal of the American MediculAssociution, 263,27842787. Federal Trade Commission. (1986). Report to Congrarpwsuant to the Federal Cgarette Labelin andAdve&tiingAct, 1984. Washington, DC: U. S. Government Printing Office. Johnson, C. A., Hansen, W. B., Collins, L. M., & Graham, J. W. (1986). High-school smoking prevention: Results of a three-year longitudinal study. Joumd of Bebaviural Medicine, 9, 439-452. Johnston, L. D., O ’MalIey, P. M., & Bachman, J. G. (1987). Nat&al trends in drug use and related f&on among American h&b school students and young adults, 1975-1986. (DHHS publication no. ADM 87-1535). Washington, DC: U. S. Government Printing Office. Lauer, R. M., Akers, R. L., Massey, J., & Clarke, W. R. (1982). Evaluation of cigarette smoking among adolescents: The Muscadine Study. Preventive Medicine, 11, 417-428. Leventhal, H., Glynn, K., & Fleming, R. (1987). Is the smoking decision an ‘informed choice’? Effect of smoking risk factors on smoking beliefs. Journal of the American Medical Association, 257, 3373-3376. Murray, D. M., Luepker, R. V., Johnson, C. A., & Mittelmark, M. B. (1984). The prevention of cigarette smoking in children: A comparison of four strategies. Journal ofApplied SociulPsycbolo~~~, 14, 274-288. Pederson, L. L. (1986). Change in variables related to smoking from childhood to late adolescence: An eight year longitudinal study of a cohort of elementary school students. Canadian Journal of Public Health, 77(suppl l), 33-39. Reimers, T. M., Pomrehn, I’. R., Becker, S. L., & Lauer, R. M. (1990). Risk factors for adolescent cigarette smoking. American Journal ofDtseaseSof Children, 144, 12651272. Richards, J. W. (1983). A positive health strategy for the office waiting room. New York State Journal OfMedicine, 83, 1358-1360. Richmond, R., & Webster, I. (1985). Evaluation of general practitioners use of a smoking intervention programme. International Journal of Ept&mMloJy, 14, 396-401. Shute, R. E., St. Pierre, R. W., & Lube& E. G. (1981). Smoking awareness and practices of urban preschool and first grade children. Journal of SchoolHealth, 51, 347-351. U. S. Department of Health and Human Services. (1984). The health consequences of smoking. Cbronit obstmetive lung diseace.A report of the Surgeon General (DHHS publication no. PHS 84-50205). Washington, DC: U. S. Government Printing Office. U. S. Department of Health and Human Services. (1989). Reducin. the health consequences of smoking. 25 years ofpropess. A report of the Surgerm General 1989 (DHHS publication no. CDC 89-8411). Washington, DC: U. S. Government Priming Office. Warner, K. E., (1986). Smoking and health implications of a change in the Federal Cigarette Excise Tax. Journal of theA&n Medical Associution, 255, 1028-1032.
