By Erik J. MacLaren, PhD
Tobacco smoking is a well-known risk factor for developing lung cancers, and the US Centers for Disease Control and Prevention has reported that nine out of 10 cigarette smokers began smoking by age 18.1 Michael Kulik, MS, a lecturer at the University of Pennsylvania in Philadelphia, Pennsylvania, teaches an academically based community service course called Preventing Tobacco Addiction in Urban Pre-adolescents. IASLC Lung Cancer News recently spoke with Mr. Kulik about current trends in adolescent smoking and what can be done to prevent it.
Q: What predisposes teens to smoke?
A: Physically, the brains of adolescents are hyperplastic and, because of this, they are susceptible to making decisions that lead to smoking. Tobacco is more addictive than coffee, alcohol, or cocaine, but adolescents do not understand what addiction is all about until after they get addicted themselves. Peer pressure is also important, as it is for all adolescents concerning many behaviors. Teenagers want to fit in and do not want to be left out, so if their friends smoke, it is more likely that they are going to smoke as well. Kids all want to act cool; they all want to be grown-up. Smoking is an adult decision, so that alone is something that tempts kids to smoke.
Globally, cigarette smoking is common among youth.2 Most regular smokers initiate smoking before 20 years of age. Youth may have several reasons for starting tobacco use, including looking ‘cool,’ ‘mature,’ or ‘sociable,’ or believing that tobacco use is good for coping with stress and weight control. The factors increasing youth tobacco initiation may vary across countries, but some common factors are: tobacco use by parents or peers; exposure to tobacco advertising; acceptability of tobacco use among peers or in social norms advertised in movies or tobacco commercials; having depression, anxiety, or stress; and higher accessibility and lower prices of tobacco products. Tobacco is also easy to get worldwide. Many urban convenience stores, especially in lower-income communities, sell what are sometimes called “loosies,” even though in the US it is illegal to sell single cigarettes. For adolescents, store signage that says personnel will check the identification of people buying tobacco often functions as a kind of challenge, daring teenagers to try to buy tobacco products.
Q: To what extent do genetics factor into nicotine addiction?
A: There are basically three categories of people: those who have never smoked, those who try it and don’t like it, and those who try it and keep going. There are genetic factors that have been shown to influence the uptake, continuing, or quitting of smoking. People with certain genotypes can metabolize nicotine faster, and they get more emotional and physiological pleasure from smoking, making it more likely that they will become addicted.
Q: Are alternative forms of tobacco a “gateway drug” that can lead to teen smoking?
A: Teenagers have a lot of alternatives to choose from, including smokeless tobacco, little flavored cigars, and e-cigarettes. These are products that have become more popular as the taboo against combustion-type cigarettes has become stronger. Teens tend to think e-cigarettes are safe; I do not think they realize that a lot of the substances that are used in these devices have nicotine and can prove addictive.
One alternative I learned about while teaching 12th graders several years ago is the hookah pen. Hookah pens are a form of e-cigarettes that look like pens, and they come in different flavors and colors. Teenagers can have a backpack full of them and their parents would never know. Kids use hookah pens to inhale nicotine; it is a very common thing that is well known among adolescents. Many teens also smoke the little cigars that are flavored, which is attractive to kids; these cigars are also inexpensive and not regulated in the same way that cigarettes are. Hookah smoking is huge among college students and on the rise. The last estimate I have seen indicates that 40%–50% of college students have engaged in hookah smoking in the last year, and my experience with students in the classroom has borne this out.
A number of manufacturers offer hookah pens for sale, but there does not seem to be any connection as yet to Big Tobacco. As of August 8, in the US Hookah pens are regulated by the US FDA, which has regulatory authority under a rule that is referred to as Electronic Nicotine Delivery Systems (ENDS).3
In a typical hookah session, the smoker takes 200 puffs of tobacco smoke and inhales about 150 times as much tobacco smoke as when smoking a cigarette. However, many young adults do not even realize that there is nicotine involved; plus, it is considered to be a fun social experience. There are hookah bars all around US college campuses, but they are fairly invisible to people who are not looking for them. The invisibility of some of these things is the most troubling aspect of these phenomena. They are out there, but most of us are unaware unless looking for them.
Q: Smoking rates among teens in the US have declined over the past 50 to 60 years. Why is that?
A: The primary reason is because the norms have changed, and, for the most part, kids no longer grow up in households with smokers. But when they do, they perceive smoking as a normal adult behavior, and those kids are more likely to smoke. In addition, smoking bans are more prevalent, and cigarette prices have gotten much higher. Teens are also switching to other alternatives, as we discussed earlier. Another reason cigarette smoking is becoming less popular is that the tobacco industry in the US has pretty much given up on trying to replace as many smokers as they did previously; it is now concentrating on other countries instead.
Q: What interventions work in preventing smoking in preadolescents and adolescents?
A: The most successful interventions, which require a holistic approach, stem from an overall goal of having a healthy lifestyle involving a lot of physical activity. It is pretty true of all negative behaviors that if you want teens to avoid them, you have to keep teens busy. Team sports are very good at keeping kids from smoking, in part because nicotine releases dopamine in the brain as does physical activity. So, in many cases, kids get the same kind of rush from playing sports. Now, on the other end of that, smokeless tobacco is kind of a rite of passage for some kids involved in sports.
The education we provide to teenagers seems to be most successful by showing kids that the tobacco industry is manipulating them. Teens are not persuaded by the fact that they might get cancer in 30 or 40 years. A lot of the teenagers we work with in disadvantaged neighborhoods have experienced death up close, so they are not worried about getting cancer. However, they do resent the tobacco industry trying to manipulate them, take advantage of them, and fool them. So, the most effective way we have found to keep kids from taking up smoking is to persuade them that the industry is only there to take their money. ✦
1. Centers for Disease Control and Prevention. Youth and Tobacco Use. Fact Sheets 2016; http:// www.cdc.gov/tobacco/data_statistics/fact_sheets/ youth_data/tobacco_use/. Accessed July 2, 2016.
2. The Tobacco Atlas. World Lung Foundation. http:// www.tobaccoatlas.org/topic/smoking-amongyouth/ . Accessed July 13, 2016.
3. Extending Authorities to All Tobacco Products, Including E-Cigarettes, Cigars, and Hookah. US FDA website. http://www.fda.gov/TobaccoProducts/ Labeling/RulesRegulationsGuidance/ucm388395. htm. Accessed July 13, 2016.