Initiation of Smoking and Other Addictive Behaviors: Understanding the Process

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1 Initiation of Smoking and Other Addictive Behaviors: Understanding the Process Carlo C. DiClemente, Ph.D. Director of MDQuit UMBC Presidential Research Professor Department of Psychology, UMBC

2 What are Addictions? Habitual patterns of intentional, appetitive behaviors Become excessive and produce serious consequences Stability of problematic behavior patterns over time Interrelated physiological and psychological components Addicted individuals have difficulty modifying and stopping them

3 Becoming Addicted Happens over a Period of Time Has a Variable Course Involves a Variety of Predictors that can be both Risk and Protective Factors Involves a Process of Change

4 THE COURSE OF ADDICTION: A Behavioral Perspective DEPENDENCE ABUSE REGULAR USE REGULAR USE CASUAL USE EXPERIMENTATION EXPERIMENTATION

5 Change the Integrating Principle No single developmental model or singular historical path can explain acquisition of and recovery from addictions A Focus on the Process of Change and how individuals change can bring together different perspectives and help us to understand the pathway into addictions

6 Initiation of Smoking: Personal Pathways to Change Are influenced by personal decisional considerations and choices Personal choices are influenced by and influence genetic, psychological, and social forces (risk and protective factors) There is an interaction between the individual and the internal and external risk and protective factors

7 How Do People Change? People change voluntarily only when They Become interested in or concerned about the need for change They Become convinced that the change is in their best interests or will benefit them more than cost them They Organize a plan of action that they are committed to implementing They take the actions that are necessary to make the change and sustain the change

8 Stage of Change Tasks Precontemplation Not interested Contemplation considering Preparation Preparing Action Initial change Interested and Concerned Risk-Reward Analysis & Decision making Commitment & Creating an Effective/Acceptable Plan Implementation of Plan and Revising as Needed Maintenance Sustained change Consolidating Change into Lifestyle

9 The Transtheoretical Model of Intentional Behavior Change STAGES OF CHANGE PRECONTEMPLATION CONTEMPLATION PREPARATION ACTION MAINTENANCE COGNITIVE/EXPERIENTIAL PROCESSES OF CHANGE BEHAVIORAL Consciousness Raising Self-Revaluation Environmental Reevaluation Emotional Arousal/Dramatic Relief Social Liberation Self-Liberation Counter-conditioning Stimulus Control Reinforcement Management Helping Relationships CONTEXT OF CHANGE (Risk and Protective factors) 1. Current Life Situation 2. Beliefs and Attitudes 3. Interpersonal Relationships 4. Social Systems 5. Enduring Personal Characteristics Decisional Balance MARKERS OF CHANGE Self-Efficacy/Temptation

10 THE STAGES OF CHANGE FOR ADDICTION AND RECOVERY ADDICTION Dependence PC C PA A M PROCESSES, CONTEXT AND MARKERS OF CHANGE PC C PA A M Dependence RECOVERY Sustained Cessation

11 Theoretical and practical considerations related to Prevention and Stages of Initiation Expectancies/Beliefs Decision-Making Self-efficacy Precontemplation Contemplation Preparation Action Maintenance Personal Environmental Decisional Cognitive/ Behavioral Concerns Pressure Balance Experiential Processes (Pros & Cons) Processes Experimentation Casual use Regular Use Dependence Genetic & Biological Risk Brain & Physiology Changes

12 Differences between Epidemiological, Behavioral, Attitudinal, and Process Perspectives Epidemiology seeks prevalence number of individuals who used past 30 days Behavioral seeks to use quantity and frequency of behavior as indicators Attitudinal focuses on acceptability, risk perception, peer approval Process perspectives combine attitudes, intentions, behavioral and temporal indicators

13 Maryland Youth Tobacco Surveys (MYTS)

14 MYTS Surveys 2000 Classroom-based survey, conducted in public schools throughout the state of Maryland between October 2 nd and November 15 th, ,967 Maryland students enrolled in grades 6 through 12 participated in the survey. 89.5% of eligible middle school students and 84.8% eligible high school students chose to participate. Classroom-based survey, conducted in public schools throughout the state of Maryland between October 30 th and December 15 th, ,500 Maryland students enrolled in grades 6 through 12 participated in the survey. 85.7% of eligible middle school students and 89.2% eligible high school students chose to participate.

15 Stages of Smoking Initiation Precontemplation: Youth who are not currently smoking and expressed a firm commitment to not start in the next year Contemplation: Youth who are not currently smoking and did not express a firm commitment to not smoke in the next year Preparation: Youth who have minimally tried cigarettes (< 100 in their lifetime) who may be currently smoking (less than 6 days in past 30) and definitely plan on smoking within the next year Action: Youth who have smoked on 6 or more days during the past 30 day and for < 6 months Maintenance: Youth who have smoked on 6+ days during the past 30 days and for at least 6 months DiClemente, 2003

16 Staging Methodology in questions were used to stage smoking initiation: Lifetime Prevalence: About how many cigarettes have you smoked in your entire life? Future Intention: Do you think you will smoke a cigarette in the next year? Current Smoking: During the past 30 days, on how many days did you smoke? Key Staging question of Duration of Smoking (i.e., how long have you smoked at your current rate) included in 2000 but not included in 2002 & 2006 MYTS

17 Action & Maintenance without Duration of Rate of Current Smoking Future Intention of Smoking: Probably Not, Probably Will or Definitely Will Smoke a cigarette in next year # of days smoked during past days 20+ days Action Maintenance

18 About how many cigarettes have you smoked in your entire life? None 1 or more puffs, but less than 6 cigarettes Do you think you will smoke a cigarette in next year? Do you think you will smoke a cigarette in next year? Definitely Not Probably Not, Probably Yes or Definitely Not Probably Not Definitely Yes Definitely Yes or Probably Yes PC (Inexperienced) C (Inexperienced) PC (Exposed) C (Exposed) P (Exposed) 2000: 24,118 (50.2%) 2000: 5,641 (11.7%) 2000: 4,109 (8.6%) 2000: 3,502 (7.3%) 2000: 589 (1.2%) 2002: 31,794 (56.0%) 2002: 7,211 (12.7%) 2002: 4,572 (8.0%) 2002: 3,861 (6.8%) 2002: 687 (1.2%) 2006: 43,028 (63.0%) 2006: 7,321 (10.7%) 2006: 4,813 (7.0%) 2006: 3,345 (4.9%) 2002: 531 (.8%) Posted on mdquit.org/documents/algorithm2.pdf

19 About how many cigarettes have you smoked in your entire life? 6-99 Cigarettes cigarettes (Ever-smokers) Do you think you will smoke a cigarette in next year? Do you think you will smoke a cigarette in next year? Definitely Not Probably Not, Probably Yes or Definitely Yes Probably Not, Probably Yes or Definitely Yes During the past 30 days, on how many days did you smoke? During the past 30 days, on how many days did you smoke? None PC (Experienced) 2000: 859 (1.8%) 2002: 636 (1.1%) 2006: 619 (.9%) None 5 days or less 6 or more days C (Experienced) P (Experienced) A (Experienced) 2000: 1,690 (3.5%) 2000: 1,737 (3.6%) 2000: 1,209 (2.5%) 2002: 1,501 (2.6%) 2002: 1,593 (2.8%) 2002: 1,269 (2.2%) 2006: 1,109 (1.4%) 2006: 1,885 (2.8%) 2006: 1,284 (1.9%) 6-19 days A (Experienced) 2000: 881 (1.8%) 2002: 737 (1.3%) 2006: 817 (1.2%) 20 or more days M (Experienced) 2000: 3,688 (7.7%) 2002: 2,959 (5.2%) 2006: 3,525 (5.2%) Posted on mdquit.org/documents/algorithm2.pdf

20 Cross-sectional Analyses Stage of Smoking Initiation by Key Risk Factors

21 Table 1. Distributions of Stage of Smoking Initiation (2000 & 2006) Stages of Smoking Initiation n * % n * % Precontemplation Contemplation Preparation Action Maintenance 29, , , , , , , , , , * Unweighted data 48,023 68,277

22 Distributions of SOI by School Status 2000* 2006* MS HS MS HS Stages of Smoking Initiation % % % % Precontemplation Contemplation Preparation Action Maintenance * Unweighted data

23 Logistic Regressions Using 2006 MYTS data, logistic regressions were estimated for the Stages of Smoking Initiation 3 Key Risk Factors from 3 Domains of Influence were selected Behavioral Attitudinal Intention Would you ever use or wear something that has a tobacco company name or picture on it such as a lighter, t-shirt, hat, or sunglasses? Do you think smoking cigarettes makes young people look cool or fit in? If one of your best friends offered you a cigarette, would you smoke it?

24 Table 2. Odds-Ratios of Stage of Smoking Initiation for Behavioral Risk Factor: Wearing or Using Tobacco-Related Merchandise ORs for Precontemplation vs. Each Other Stage of Initiation Middle School High School Stage of Initiation OR CI OR CI Precontemplation Contemplation 5.2 *** *** Preparation 15.6 *** *** Action 18.6 *** *** Maintenance 25.2 *** *** *** p <.001

25 Table 3. Odds-Ratios of Stages of Smoking Initiation for Attitudinal Risk Factor Smoking Cigarettes Makes Young People Look Cool or Fit In ORs for Precontemplation vs. Each Other Stage of Initiation Middle School High School Stage of Initiation OR CI OR CI Precontemplation Contemplation 4.3 *** *** Preparation 10.1 *** *** Action 12.3 *** *** Maintenance 11.4 *** *** *** p <.001

26 *** p <.001 Table 4. Odds-Ratios of Stages of Smoking Initiation for Intention Risk Factor: Accept Cigarette Offer from Best Friend ORs for Precontemplation vs. Each Other Stage of Initiation Middle School High School Stage of Initiation OR CI OR CI Precontemplation Contemplation 21.1 *** *** Preparation *** *** Action *** *** Maintenance *** ***

27 STAGES OF INITIATION FOR SMOKING, ALCOHOL, AND MARIJUANA TRACKING VULNERABILITY AND THE JOURNEY INTO USE

28 A DECADE OF MARYLAND DATA 2000 to 2010

29 Data from DHMH Legislative Report (2011):

30 Middle School SOSI over time by School Status PC C P A M % 20.4% 2.7% 1.9% 1.3% % 19.0% 2.3% 1.6% 1.2% % 15.6% 1.6%.9%.9% % 14.3% 1.4%.8% 1.0% % 13.3% 1.2%.8%.6% High School % 24.1% 6.3% 6.1% 12.2% % 24.4% 5.3% 5.0% 8.3% % 20.7% 4.7% 4.0% 6.5% % 20.4% 4.1% 3.4% 5.9% % 20.5% 4.0% 3.6% 4.7%

31 Percent who would smoke cigarette if best friend offered by SOSI & school status over time 100% 80% 60% 40% 20% 0% PC C P A M Middle School High School

32 4.00 Number of 4 closest friends who smoke by SOSI and school status over time Middle School PC C P A M High School

33 80% Percent who believe smoking makes young people look cool by SOSI & school status over time 60% 40% 20% 0% Middle School PC C P A M High School

34 Figure from DHMH Legislative Report (2011):

35 Youth Substance Use: Alarming Trend of Cigar Use Prevalence Figure from DHMH Legislative Report (2011):

36 Current Underage MD High School Tobacco Users: Tobacco Products Used in 2010 Figure from DHMH Legislative Report (2011):

37 SMOKING, ALCOHOL & MARIJUANA USE AMONG UNDERAGE YOUTH UNDERAGE SMOKERS DO NOT JUST SMOKE TOBACCO

38 Figure from DHMH Legislative Report (2011):

39

40 Current Underage MD High School Substance Users: Use of Cigarettes, Alcohol, and/or Marijuana in 2010

41 100% Percent who used alcohol in the past month by SOSI & school status over time 80% 60% 40% 20% 0% Middle School PC C P A M High School

42 100% Percent who binge drank (5+ drinks on one occasion) in the past month by SOSI & school status over time 80% 60% 40% 20% 0% Middle School PC C P A M High School

43 Stages of Initiation for Cigarettes, Alcohol & Marijuana by School Level in 2010 Stages of Substance Initiation by School Level Substance Precontemplation Contemplation Preparation Action Maintenance Middle School Cigarettes Alcohol Marijuana High School Cigarettes Alcohol Marijuana

44 Percentages of Stages of Smoking Initiation by Stages of Alcohol Initiation Stages of Alcohol Initiation Stage of Smoking Initiation Precontemplation Contemplation Preparation Action Maintenance Total Precontemplation Contemplation Preparation Action Maintenance Total

45 Percentages of Stages of Smoking Initiation by Stages of Marijuana Initiation Stages of Marijuana Initiation Stage of Smoking Initiation Precontemplation Contemplation Preparation Action Maintenance Total Precontemplation Contemplation Preparation Action Maintenance Total

46 SEQUENCE AND PATTERNS OF SMOKING, ALCOHOL AND MARIJUANA INITIATION IN A STATEWIDE SURVEY OF ADOLESCENTS Society for Research on Nicotine & Tobacco Poster Presentation, March 2012

47 Initiation of Alcohol, Cigarettes & Marijuana A subsample of youth (N=4,381) who reported using all 3 substances (cigarettes, alcohol and marijuana) in the past month (5% of the 83,357 respondents) This subsample had more boys (56%) than girls (44%), p <.001 Looked at age of onset and classified them into 12 different patterns of initiation based on year they reported starting each substance Only 4% had typical gateway pattern: cigarettes alcohol marijuana

48 4 Most common Patterns of Initiation Most Common Patterns of Initiation Percent Initiated Cigarettes First 12.7 Initiated Alcohol First 51.1 Initiated Marijuana First 10.1 Initiated All 3 at Same Age 26.1

49 Demographic Differences by Patterns of Initiation No demographic differences for youth who initiated cigarettes first compared to others Youth who initiated alcohol first more likely to be female and White Youth who initiated marijuana first more likely to be male, African American & older (i.e., in High School) Youth who initiated all 3 at same age more likely to be younger (i.e., in MS) and either Hispanic or from an other minority group

50 A STAGE BY ADDICTIVE BEHAVIOR PERSPECTIVE ON ALLEN TYPE OF BEHAVIOR ALCOHOL NICOTINE MARIJUANA HEROIN COCAINE AMPHETAMINES LSD GAMBLING EATING DISORDER STAGE OF INITIATION PC C PA A M X X X X X X X X X

51 PREVENTION OF INITIATION OF ADDICTION PC - C C - PA PA - A A - M POPULATION PREVENTION AT- RISK PREVENTION ALREADY AFFLICTED

52 Implications for Acquisition and Prevention If there is a common but unique pathway, we can better understand where individuals are in this process of change for each addictive behavior We can make better distinctions between prevention and treatment We can understand how risk and protective factors interact with the process of change We can target prevention interventions more to address the tasks and issues identified in movement through the process of change

53 Prevention Need a broad approach to use of substances Focus on benefits of wellness and managing any consumption of substances and medications Identify and message to high risk youth differently form general prevention programming Need environmental as well as personal and group strategies (policies, enforcement, modeling, etc.)

54 Maryland Tobacco Control Program State and Local Resources Maryland Tobacco Quitline Services Local Health Department Resources Statewide Resource Centers MDQuit - Provider trainings and Fax To Assist Legal Resource Center Smoke-free environments activities Media campaign materials and activities Prevention and Health Promotion Administration December 3,

55 Maryland Tobacco Quitline QUIT-NOW FREE evidenced based counseling program to assist Marylanders ages 13 years and older in quitting tobacco use Operational seven days a week, 24 hours/day Services available in English, Spanish, and other languages via translation Clinical intervention Confidential Effective 7x higher quit rate than quitting on your own 97% satisfaction rate Prevention and Health Promotion Administration December 3,

56 Maryland Tobacco Quitline Tailored programs QUIT-NOW Counseling Pregnant Women Youth ages Free quit guides and information on the effects of tobacco use Includes tailored materials for pregnant women, youth, and chronic diseases Referrals to free smoking cessation programs in the caller s local jurisdiction/local health department Prevention and Health Promotion Administration December 3,

57 Youth Support Program Counseling specifically tailored to youth needs Five counseling calls delivered by highlyskilled Youth Quit Coaches Discussion of triggers, stressors, peer influences, and exposure to second-hand smoke Relapse prevention addressed through planning and preparation Prevention and Health Promotion Administration December 3,

58 Web Coach Personalized to your overall health Comorbidities, medication use, lifestyle Unlimited Tailored messages, counseling, and feedback from Quit Coaches Interactive progress tracking, videos, discussion forums, community groups Enroll (or access through Prevention and Health Promotion Administration December 3,

59 Text2Quit Text messaging has been shown to be an effective tobacco intervention More intimate and less effort required by the participant (vs. making a phone call or logging into a website) Participants are able to receive mobile support, when they are potentially more at risk of smoking Enroll by calling QUIT-NOW ( ) Prevention and Health Promotion Administration December 3,

60 Local Health Department Cessation Resources Cessation Classes and Referrals Cessation Aids: Nicotine Replacement (patch, gum) Some offer medications Services free to residents of the jurisdiction Prevention and Health Promotion Administration December 3,

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