Smoking and Adolescence: some issues on prevention and cessation

Transcription

1 Smoking and Adolescence: some issues on prevention and cessation by Diane Logan, BA Beatriz Carlini-Marlatt, PhD Tobacco use is one of the chief preventable causes of death in the world. The World Health Organization (WHO) attributes approximately 4.9 million deaths a year to tobacco use, a figure expected to double by Unless current trends are impacted, the vast majority of these deaths are projected to occur in the developing world. More often than not, smoking initiation starts early in life. An important challenge to those committed to the well-being of children around the world is to lessen the potentially deadly impact of tobacco by helping young people avoid smoking initiation and assisting them with cessation and remaining tobacco-free if they have already started. The present article reviews the literature on smoking prevention and cessation, using recent scientific articles published in English. The US reality was used as a reference in discussing policy issues and presenting prevalence curves. 1

2 The Tobacco Continuum Tobacco use has been declining in the last decades, from a record high of almost 40% in the midseventies to 22%, in 2003 (CDC, 2004 tobacco use defined as any cigarette use in the 30 days preceding the survey). However, despite decades of warnings, labels on cigarette packs, and prevention programs in the schools, the adolescent years still produce millions of smokers each year (Centers for Disease Control and Prevention [CDC], 2000). Boys who start smoking today can estimate two decades of smoking duration before successful cessation; girls can anticipate an average of 30 years (Pierce & Gilpin, 1996). If current patterns of smoking behaviors continue, an estimated 6.4 million of today s children can be expected to die prematurely from a smoking-related disease (CDC, 2002) The progression of smoking proceeds through five stages: preparation, onset, experimentation, regular smoking, and dependence ( Preventing tobacco use, 1994). Some of these stages will be discussed in this paper, including risk factors and antecedents, gender and racial differences, parental and environmental influences and smoking prevention and cessation issues. The section on prevention will emphasize promising approaches using anti-smoking advertising and briefly discuss school-based education and contemporary methods of prevention delivery. The discussion of cessation will include attempt rates, motivations for quitting, preferred methods, a review of current programs, and suggestions from adolescents on how programs can be improved in the schools. Onset and Experimentation: risk factors and prevention approaches Prevalence Studies report different ages at which children try their first cigarette. The Youth Risk Behavior study found that 18% of children had smoked a whole cigarette before age 13 (CDC, 2003). Jackson and Henriksen (1997) reported that 10% of third graders (generally ages 8-9) had already experimented with tobacco, and the rate rose to 21% by fifth grade (ages 10-11). Another study indicated that only 8% had initiated use before age 11 (CDC, 2000). Breslau and Peterson (1996) found that 34% of kids had their first cigarette at or below age 13, and another 43% initiated use between years old. Another report stated that the average trial age was 14.5 years (Elders, Perry, Eriksen, & Giovino, 1994). Risk Factors Environmental and societal factors From the perspective of social learning theory, the interplay between individual and environment is crucial in developing intentions, expectations and ultimately behavior (Bandura, 1986). The body of research on teen smoking experimentation is an excellent illustration of this theory. Longitudinal studies consistently suggest that exposure to tobacco advertising and promotion is associated with the likelihood that adolescents who report not considering to smoke will progress to considering to smoke, and those who say they are considering to smoke will actually start smoking (see Lovato, Linn, Stead & Best, 2003, for a review). One of these studies was conducted in California, and followed 1752 adolescents never smokers for 3 years (Pierce, Choi, Gilpin, Farkas & Berry, 1998). The authors found having a favorite cigarette ad at baseline had a significant association with becoming smokers or willing to consider smoking at the 3-year follow-up (OR=1.82); possessing or willingness to use a tobacco promotional item at baseline had an even stronger effect (OR=2.89). The paper concludes by estimating that 34% of all experimentation in California between 1993 and 1996 could be attributed to tobacco promotional activities. 2

3 Exposure to movies in which stars who are admired by adolescents are smokers and are portrayed as sexy, smart, attractive, rich, and courageous also considerably increases the chances of smoking initiation among teens. Subsequent to several cross sectional and experimental studies suggesting a link between smoking in movies and smoking initiation (Tickle, Sargent, Dalton, Beach M & Heatherton, 2001; Sargent, Dalton, Beach, Tickle, Ahrens & Heatherton, 2003; Distefan, Gilpin, Sargent & Pierce, 1999), a recent cohort study (Dalton, 2003) brought even more consistent evidence about this connection. Dalton and colleagues recorded the number of exposures to smoking scenes in movies among non-smoking kids and assessed their smoking status 13 to 26 months later. After controlling for a wide variety of other effects such as grade, sex, peers/parents/sibling smoking, self esteem, rebelliousness, and sensation-seeking 52.2% of smoking initiation in the year-olds that were studied was attributed to seeing smoking in movies. The tobacco industry is apparently aware of this dose-response relation, as it has historically worked to keep its relationship with Hollywood in very good terms (Mekemonson & Glantz, 2002). It should also be noted that the prevalence of smoking situations in movies has been higher than what can be found in the real world. An analysis of a random sample of major pictures from 1950 to 2002 found that movies in 2002 had as many smoking incidents as they used to have in 1950, when smoking prevalence was almost twice what it is now. In fact, smoking incidents declined from 10.7 incidents per hour in 1950 to a minimum of 4.9 in but increased back to the levels of 1950 s in the last few years (Glantz, Karcirk & McCulloch, 2004) Individual factors - There are also myriad individual activities and beliefs that have been related to smoking initiation. Some of the reported risk factors include: being White, intending to smoke at age 13, getting poor grades, being young for ones grade cohort, drinking by grade 7, early deviance, a nonnuclear family, higher parental education, lower expectancy of parents finding out, not anticipating negative consequences if caught, smoking allowed in the home, parents haven t discussed tobacco use, engaged in 6 or more fights in the last year, carried weapons within the last month, made at least one suicide attempt, had sex, had sex with four or more partners, didn t use a condom during last sexual encounter, have fewer skills to resist influences, have friends who smoke, have low self-image or low selfesteem, have accessibility to cigarettes, have normative perceptions of tobacco use, not engaged in organized sports, don t like school, left alone for 15 or more hours per week, have skipped school, have ridden a motorcycle, or have ridden with a driver who used alcohol or drugs (Ellickson, McGuigan, & Klein, 2001; Jackson & Henriksen, 1997; Elders et al., 1994; Preventing tobacco use, 1994, Moss, Allen, Giovino, & Mills, 1992). Clearly, with all these risk factors to choose from, it is extremely important to identify the ones with the highest correlation and inform parents of the warning signs (although some of these signs may signal a problem even more immediate than tobacco use, such as unprotected sex and carrying weapons). Parental Factors - Parents have a great deal of influence over their children s attitudes and beliefs about smoking, particularly through the initiation stage. It is imperative to teach parents how to communicate with their children about tobacco use. One study reported lowering children s susceptibility to smoking through parental education, increasing the adult s skill and comfort levels in discussing this issue with their children (Health & Medicine Week, 2003). Though children may have a substantially higher onset rate if both of their parents smoke (25%) compared to two nonsmoking parents (5%), antismoking socialization reduced the onset rate even if both of their parents were smokers (Jackson & Henriksen, 1997). 3

4 Another way parents can influence their children is by quitting tobacco if they currently use. One study showed that when parents choose to quit will affect the odds of their children initiating cigarette use, ranging from 6% risk if they quit at birth to 16% if they quit when the child is 17 years old (Farkas, Distefan, Choi, Gilpin, & Pierce, 1999). The risk rises approximately 0.6% each year after birth that the parent continues to smoke (Farkas et al., 1999). Another study, however, showed that children of exsmokers have odds of initiation similar to those of current smokers, with both groups being substantially higher than children of never smokers (Bauman, Foshee, Linzer, & Koch, 1990). Parental attitudes about discussing tobacco with their children may also have a relation to onset age. African American adolescents have a much later onset age compared to Whites (Moolchan, Berlin, Robinson, & Cadet, 2003; Breslau & Peterson, 1996). One study found that African American parents, compared to White parents, were more likely to set up rules about tobacco use, convey them clearly, and identify certain and effective consequences if those rules were broken (Clark, Searisbrick-Hauser, Gautam, & Wirk, 1999). They also found that African American parents were more likely to stress the importance of being involved and believed that schools should only reinforce parental teaching. White parents, conversely, had less assurance of the effectiveness of parents, believed that peer pressure was a greater force than parental intervention, thought discussing tobacco was not worth the possible conflict, and stated that tobacco prevention was the role of the schools. Also noteworthy was the age at which parents thought their children should be allowed to choose whether or not they wanted to smoke: White parents showed a mean of 16 years old, while African American parents stated either 18 years old or when they were out of the house. Prevention Programs Despite the variance in the estimates of initiation age, it is clear that many children experiment with smoking while in or before entering middle school. Although onset may have already occurred for 8%-21% of 11 year olds (CDC, 2003; Jackson & Henriksen, 1997; CDC, 2000; Breslau & Peterson, 1996; Elders et al., 1994), the majority of prevention programs target older children, generally later in middle school and in junior high. In a review of 25 published prevention programs, Skara and Sussman (2003) found that only four programs included children below the sixth grade, and that most interventions focused on students years old. Also to be noted, prevention efforts aimed at young adults (18-24 years) are rare, despite evidence of a sizeable proportion of smoking initiators in this age group (American Legacy Foundation, 2000). Perhaps beginning school interventions earlier in the education process and continuing the efforts later in life, both within and outside of the school setting could better help prevent or delay initiation. It is no surprise that prevention of smoking initiation a behavior so heavily shaped by environmental factors shows its most promising results through Tobacco Control regulations, such as price increase, marketing limitation and sales control (Siegel, 2002). Anti-smoking messages are also an important component of successful tobacco control programs (Siegel, 2002). Anti-smoking media campaigns seem to be more effective using two distinct approaches: portraying the tobacco industry as manipulative and emphasizing social norms against smoking (Wakefield, Flay, Nichter and Giovino, 2003). A third approach, that uses some scare tactics by graphically depicting the health effects of smoking, has also been gaining some credibility lately, due to its high popularity among young people (Wakefield, Flay, Nichter and Giovino, 2003) 4

5 One well evaluated example of the first approach is the Truth Campaign, funded by the American Legacy Foundation in the US. Centered on delivering stark facts about tobacco and tobacco industry marketing practices, Truth builds a tobacco-free identity, featuring youths confronting the tobacco industry in an attempt to channel youth s need to assert their independence and individuality (a good illustration is their website: ). A study comparing Truth Campaign with a more traditional just say no approach, used by Phillip Morris Company s Think, Don t Smoke, suggests that Truth was more effective on changing positive attitudes and beliefs on smoking, thought to be mediators of smoking initiation (Farrelly, Healton, Davis, Messeri, Hersey & Haviland, 2002). A good example of the potential of smoking prevention efforts that emphasize social norms comes from a 4-year longitudinal survey of youth in the US, Massachusetts (Siegel & Biener, 2000). The study examined the impact of a statewide antismoking campaign, in large part focused on correcting the misperception that the great majority of youth smoke by providing accurate information on smoking patterns among teens. The results show no effect on older adolescents (14-15 years old at baseline). Among younger adolescents (aged at baseline) recall of anti-smoking advertising in the past 30 days was significantly associated with lower rate of progression to established smoking, at four year follow-up. They were also 2.3 times more likely to report at follow up an accurate rather than inflated perception of youth smoking prevalence. The third prevention approach graphic depiction of smoking health related consequences has less empirical support but some data suggest exposure to them is associated with increased intention not to smoke (Hill, Chapman and Donovan, 1998). More research is needed on this, as some studies suggest that the strong emotional arousal elicited by these messages are beneficial only if combined with other components, such as self-efficacy promoting messages (Witte & Allen, 2000). Another natural venue for smoking prevention initiation is the school setting. However, despite some excellent conducted studies, there is no clear evidence that education in the schools is very effective in deterring kids from starting to smoke. (Peterson, Kealey, Mann, Marek and Sarason, 2000; Thomas, 2002). As its acceptability ranks high in public opinion, more research is needed to understand how to maximize the potential of school settings in helping adolescents not to smoke, including feedback and ideas from the students. Finally, some new initiatives are still under evaluation, such as the use of Internet (Skinner, Maley & Smith, 2001).) and work environment programs (Sorensen, Fagan, Hunt, Stoddard, Girod, Eisenberg and Frazier, 2004). These alternatives are being developed to be less identified with the approaches in the school setting, often perceived by youth as directive and judgmental. Regular Smokers: dependence and cessation issues Of adolescents who experiment with tobacco, 33%-50% become regular smokers (Elders et al., 1994). The most current data shows that over 58% of high school students had experimented with cigarettes, with percentages increasing each year from 52% of ninth graders to 65% of twelfth graders (CDC, 2003). Additionally, 22% of these students had smoked within the last thirty days, increasing from 17% of ninth graders to 26% of twelfth graders. These data are consistent with prior results from the CDC, which indicated over 28% of high school students were current smokers and over 63% of high school students had reported trying cigarettes (CDC, 2000). Since the 2000 CDC report found that only 9% of middle school students were regular smokers and 29% had previously experimented, the high school years still play an strong role in initiation and experimentation, and prevention programs must be continued through these formative years and beyond. 5

6 Elders et al. reported the average length from experimenting to regular smoking was a 2-3 year process (1994), and another study reported that this progression takes place in one or more years (Mowery et al., 2004). Conversely, a different study found that among year olds who smoked at least one time per month, 63% showed signs of nicotine dependence, and 22% reported the signs within four weeks (Blackinger, Fagan, Matthews, & Grana, 2003). According to the continuum, experimenters progress to regular smoking, and then regular smokers exhibit signs of dependence ( Preventing tobacco use, 1994; Elders et al., 1994). It appears that the long continuum is not always necessary for youth to become addicted to tobacco. Dependence Almost 20% of 18 year olds are dependent on tobacco, and over half of daily smokers in that age group meet the criteria for some level of dependence (Stanton, 1995). One study reported that 20% of adolescent smokers scored as significantly dependent (Robinson, Vander Weg, Riedel, Klesges, & McLain-Allen, 2003). Dependence is a strong impediment to successful cessation: adolescent smokers listed as non-dependent were 40% more likely to quit (Breslau & Peterson, 1996). A younger initiation age correlates with an increased chance of severe addiction ( Preventing tobacco use, 1994), emphasizing the importance of delaying onset. These addicted adolescents also have withdrawal symptoms similar to adults, which may impede their cessation attempts: 70% say they need to smoke or are dependent, 75% say they continue to smoke because it is hard to quit, and over 90% had at least one withdrawal symptom when they tried to quit (Elders et al., 1994; Preventing tobacco use, 1994; Reasons for tobacco use, 1994). Cessation Cessation Attempts - Higher dependence scores are associated with a greater number of quit attempts among teens (Prokhorov, Hudmon, de Moor, Kelder, Conroy, & Ordway, 2001). Estimates of smokers who had previously tried to quit range from 54% to 75% (CDC, 2003; Myers & MacPherson, 2004; Siqueria, Rolnitzky, & Rickert, 2001; Moss et al., 1992; Hu, Lin, & Keeler, 1998; Elders et al., 1994; Robinson et al., 2003; CDC, 2000). Ninety-two percent of smokers did not expect to be smoking in one year, though it is estimated that only 1.5% quit successfully (Moss et al., 1992). Another study found that half of daily smokers did not think they would be smoking five years after high school graduation, but a follow-up found that only 20% had quit, 13% cut down, 26% smoked the same amount, and 40% smoked more now then in high school (Elders et al., 1994). Gallogly (2004) suggests that teens underestimate how difficult it is to quit. Stone and Kristeller (1992) found that the most important reason for continuing to smoke was listed as, Because I like it. Additionally, they noted that boredom and anger precipitated the need to smoke. Similarly, Siqueria et al. (2001) found that nearly three-fourths of teens say they continue because it relaxes them, over half report it s from habit, 29% say they re addicted, 22% list boredom, and 17% say it s because everyone around them smokes. These reports are consistent with other studies: tobacco use by friends and family, perceived stress, and low success expectancies are shown to lessen the odds of cessation (Sussman, Dent, Severson, Burton, & Flay, 1998; Denham, Meyer, & Toborg, 2004). Race also seems to have a role in cessation rates. Minorities in general, and particularly African Americans and Latinos, have higher quit rates than non-hispanic Whites, doubling the quit rate in some studies (Ellickson et al., 2001; Farkas et al., 1999; Sussman et al., 1998). Interestingly, this may relate to an additional risk factor for Whites: although the levels of peer pressure were the same as among minorities, the peer influence seemed to have a stronger effect on Whites (Unger, Rohrbach, Cruz, Baezconde-Garbanati, Howard, Palmer, et al., 2001). 6

7 Gender did not appear to be a factor, though recent findings indicate a concerning trend. Although females are more likely to start smoking, their quit rates through junior high and high school are comparable to males (Ellickson et al., 2001). However, in examining quit attempts in the prior 12 months, the CDC found that attempts to quit decreased between 2001 and 2003 from 57% to 54% (CDC, 2003). Males only decreased from 53% in 2001 to 52% in 2003; females decreased from 61% to 55%. Clearly there is a need to examine these trends and develop gender specific interventions. Parental role models indicate a strong effect. Parental smoking cessation has a substantial effect on adolescents, potentially doubling their children s cessation rates (Farkas et al., 1999). Cessation Motivations - Multiple studies have found that the main reason cited by adolescents for wanting to quit is health, and in no article reviewed did it rank below third (Myers & MacPherson, 2004; Riedel, Robinson, Klesges, & McLain-Allen, 2002; Stanton, 1995; Jackson & Henriksen, 1997; Coleman- Wallace, Lee, Montgomery, Blix, & Wang, 1999; Hurt, Crogham, Beede, Wolter, Croghan, & Patten, 2000; Gillespie, Stanton, Lowe, & Hunter, 1995). It appears that health concerns may be more relevant in cessation than they are in prevention (Riedel et al., 2002). Most of the studies reviewed did not differentiate between current and future health concerns, so it is impossible to discern whether one is a greater motivator than the other. In the one study which did address the difference, 73% listed future health and 65% chose current health (Riedel et al., 2002). When asked to choose the most motivating factor, 35% chose future health while only 13% chose current health. Another study found that 36% of adolescent smokers said that smoking had caused a health problem in the last year (Stanton, 1995), which possibly explains the popularity of athletics (16%) as one of the strongest motivators (Riedel et al., 2002). Other motivations commonly reported in the above studies (and receiving at least 50% agreement) include: cost, nasty habit, appearance, and athletics. The high importance on cost is of particular interest, as Blackinger et al. reported that tax increases have a greater effect on youth cessation (5% decrease due to a 10% price increase) than adult cessation (1-2% reduction). While we may not be able to directly affect the importance of health or emphasize a negative appearance, we certainly have the ability to raise prices to make smoking less attractive. Cessation Methods - The most popular choice of cessation method among adolescents is stopping abruptly, independently, using willpower (Lawrance, 2001; Siqueria et al., 2001; Gillespie et al., 1995). This is also the most frequently attempted method (Myers & MacPherson, 2004; Stanton, 1995), yet one of the methods listed as least helpful (Stanton, 1995). In one study, out of the 69% of current smokers that had attempted to quit in the last six months, 58% thought they would be unsuccessful during their next quit attempt (Siqueria et al., 2001). Due to the prevalence yet low success of this method, ways to increase interest in other methods should be explored. Group Programs Most group cessation programs have occurred in school settings (Coleman-Wallace et al., 1999; Robinson et al., 2003). Unfortunately, these programs have had some problems with recruitment, reporting, and results. Studies have found that interest in group programs ranges from 10% to 19% (Siqueria et al., 2001; Gillespie et al., 1995; Lawrance, 2001). In order for adolescent smokers to take advantage of group programs, they first have to be willing to attend. Recruitment - Recruitment poses particular challenges. Some programs use methods where students who have already been caught smoking on school property are referred to the program in lieu of suspension or punishment (Coleman-Wallace et al., 1999). In these cases, some of the kids are not willing or ready to seriously pursue cessation, which may detract from the effectiveness for other participants. Other programs rely on volunteers recruited at school through conversations, posters, PA announcements, and the like (Massey, Dino, Horn, Lacey-McCracken, Goldcamp, & Kalsekar, 2003). In these programs, the recruiters face barriers such as uninterested students, lack of time to recruit, unsupportive parents, and particularly, the need for active parental consent (Massey et al., 2003). The 7

8 need for consent was the greatest barrier for myriad reasons: student s didn t want to tell their parents, were afraid of parental punishment, and didn t want the school administration or their friends to know (Massey et al., 2003). There appears to be a vicious cycle here: students will not actively seek assistance to stop smoking because they do not want anyone to know they started. Perhaps these concerns will not interfere with the contemporary efforts of web-based and alternative cessation assistance. Reporting - For the students who do attend and complete school-based programs, as well as those in the control groups when applicable, honesty in reporting seems rare. Robinson et al. (2003) began with a 20% cessation rate reported for the program Start to Stop (STS), and a 24% cessation rate for the control group. After implementing a bogus pipeline and biologically testing those who reported abstinence, the falsification rates were 40% for attendees and over 60% for the control. At a one-year follow-up, approximately 6% of both the program and control group participants were actually abstinent. Results were slightly more promising for TEG, the Tobacco Education Group and TAP, the Tobacco Awareness Program (Coleman-Wallace et al., 1999). These groups reported between 9% and 16% abstinence rates, but these were only verified at the termination of the programs. No data have been located indicating percentages at subsequent follow-ups. Results - Even with results such as those reported by the programs above, it is noteworthy that most successful quitters were already in the action stage of change, and the programs had no influence on moving precontemplators to any other stage of change (Robinson et al., 2003; Coleman-Wallace et al., 1999). Considering the accuracy of the stages of change model (Prochaska, 1991), on possible suggestion would be separate interventions designed for the particular stage that each student is in: motivation and education for precontemplators and contemplators, advice and action plans for those in preparation and action stages, and continual support for those students who have reached maintenance. The maintenance stage appears all but ignored for adolescents: though their relapse rates are similar to adults and we know the highest risk for relapse is within the first week (Choi, Ahluwalia, & Nazir, 2002), and 83% of former quitters reported they restarted due to stress (Siqueria et al., 2001), no literature was available specifically addressing adolescents and continued assistance after cessation. Student Suggestions - If interventions were designed to affect adolescents in particular stages, the overall effectiveness may improve. One suggestion made by students was that programs only include smokers who are serious about quitting (Lawrance, 2001). If the current groups include volunteers in the preparation stage and precontemplators who attend as an alternative to being suspended, clearly the peer influence and group support might suffer. Conversely, if there were separate groups for each of these stages, the curriculum could be tailored to meet the needs and interests of the specific students. Adolescents had many other suggestions to make school group programs more inviting. Some of these include: a more inclusive group, more student involvement in development and implementation of the program, addressing the broader concept of health rather than just focusing on tobacco cessation, gaining support in the community, grade specific or gender specific groups, student leaders or adults from outside the school running the program, knowing that they would be helping others, knowing how the program has helped and the success rates, if it was free, if lots of people were doing it, if the teachers supported it, if they got incentives for quitting, and not surprisingly, if they got released from class time (Stanton & Smith, 2002; Lawrance, 2001; Hurt et al., 2000; Massey et al., 2003; Gillespie et al., 1995). If we expect adolescents to utilize and benefit from these programs, we need to include their ideas throughout the planning stages and tailor the interventions to be more appealing. 8

9 Final Comments Prevention programs can reduce the number of kids who initiate tobacco use and proceed through the tobacco continuum. The combination of counter-advertising campaigns, taxation to increase price, advertisement control, and enforcement of sales-to-minors laws provide a strong assortment of measures that are closely associated to the decline observed in youth smoking initiation in the last decades. However, these methods are not 100% effective. This means that each year, millions of kids light their first cigarette, share with their friends, experiment, and in many cases, get addicted. Since prevention programs do not influence later cessation (Paavola, Vartiainen, & Puska, 2001), we also need to focus on interventions that will help kids get off tobacco. In order to be successful, these programs need to integrate the best research with student recommendations and present thorough, change-specific interventions appropriate to age, gender, and race. A key component might be a program that encompasses different stages to match the stages of change theory (Prochaska, 1991). Students would progress through each stage as was appropriate for the individual, and would receive specific assistance tailored to their current motivations. Another suggestion made by students that seems to have been overlooked is their motivation to help others. Perhaps programs can incorporate a way to allow students to mentor other students as an incentive for abstinence. Additionally, students could volunteer to present prevention programs to younger students. They would have an incentive to continue their abstinence along with developing a feeling of community involvement, both of which would be related to academia. Unfortunately, before any of these ideas could be researched let alone realized, a change of attitude would be required throughout our schools. We currently implement a punitive response to tobacco use, though there is no empirical evidence that this reduces its usage among our kids. When we realize that we are facing a health epidemic and start spending more time and money looking for vaccinations and antidotes rather than suspensions and public humiliation, we may reach a point where we can support and educate our youth rather than alienating them. References American Legacy Foundation (2000) First Look Report 3. Pathways to Established Smoking: Results from the 1999 National Youth Tobacco Survey. Washington, DC: American Legacy Foundation. Bauman, K. E., Foshee, V. A., Linzer, M. A., & Koch, G. G. (1990). Effect of parental smoking classification on the association between parental and adolescent smoking. Addictive Behaviors, 15(5), Bandura, A. (1986). Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall. Blackinger, C. L., Fagan, P., Matthews, E., & Grana, R. (2003). Adolescent and young adult tobacco prevention and cessation: current status and future directions. Tobacco Control, 12(Suppl IV), iv46-iv53. Breslau, N., & Peterson, E. L. (1996). Smoking cessation in young adults: Age at initiation of cigarette smoking and other suspected influences [Electronic version]. American Journal of Public Health, 86(2), Centers for Disease Control and Prevention (2004). Cigarette Smoking among high school students United States, MMWR Highlights, June 18 th, vol. 53, n. 23. Centers for Disease Control and Prevention. (2003). Youth Risk Behavior Survey. Retrieved September 15, 2004, from Centers for Disease Control and Prevention (2002). Office of Smoking and Health, calculations based upon: smoking attributable mortality and years of potential life loss United States, 1984, from retrieved September 22 nd,

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