Tobacco addiction and smoke exposure are among the leading causes of preventable and premature death and disability in the United States and elsewhere in the world. The landmark 2012 Surgeon General’s report, Preventing Tobacco Use Among Youth and Young Adults, stated, “The vast majority of Americans who begin daily smoking during adolescence are addicted to nicotine by young adulthood.” All youth are at risk for experimenting and using “standard” tobacco products, as well as relatively new merchandise such as e-cigarettes, hookas, bidis (small, hand-rolled cigarettes), and little cigars (Pediatrics. 2013 Aug 5;132:e578-86). In a 2015 article, data show more than twice as many youth use two or more types of tobacco products than use cigarettes alone (Pediatrics. 2015 March;135:409-15).
In a 2015 American Academy of Pediatrics policy statement, the academy stated that all children, adolescents, and young adults must be safeguarded from using all of the various tobacco products (Pediatrics. 2015 Oct 26. doi: 10.1542/peds.2015-3108). Therefore, a working knowledge of the various types of products is essential when speaking with youth on this subject.
The AAP recommended that all children and youth, without exception, must be considered to be at risk for using tobacco products. Therefore, all youth should be counseled, as the AAP made no exceptions with regard to race, national origin, ethnic group, socioeconomic status, or membership in the LGBT community.
Tobacco use by sexual identity
Much more needs to be known with regard to tobacco use for all children, youth, and young adults. National surveillance data are needed for the LGBT community, whose members have unique health care needs. A 2013 article demonstrated disparities in the use of tobacco products in young adults in the LGBT community (Nicotine Tob Res. 2013;15:1822-31).
This study used data from the American Legacy Foundation’s Young Adult Study. The survey compared the use of tobacco by the LGBT community versus the heterosexual community during the previous 30-day period. The prevalence of use of tobacco products for young adults who self-identified as sexual minorities was statistically higher than for their heterosexual counterparts. For example, current use of tobacco products was 22% in heterosexual young adults, compared with 35% in young adults who identified as homosexual and 31% in young adults who identified as bisexual.
However, this same publication stated that there are very few studies on this subject, including why there are these disparities. This information is important to know so better approaches can be developed to address these issues. In addition, health care providers must address the issue of tobacco use by youth and young adults, and develop specific approaches that can specifically target at-risk populations that are culturally competent. The authors concluded that it remains unclear why the tobacco use rate among the LGBT community is significantly higher than in their peers who are heterosexual. Risk factors that have been posited include social stigma, the role of bars in this community, and alcohol and drug use. Also, social acceptance issues, inclusion issues, alienation and depression, and marketing by tobacco manufacturers may be risk factors.
Much work remains to be done to address these risk factors and, therefore, the use of tobacco and similar drugs. The 2012 surgeon general’s report emphasized that health care providers of young people must address these issues directly and consistently with their patients.
Practical next steps for your practice
One approach to addressing tobacco use with your patients is to implement the “5 A’s”:
1. Anticipate/Ask. Ask young people if they or their friends are interested in tobacco products and/or if they use tobacco products of any type. Do this at every visit.
2. Advise. In clear, strong, personalized language, urge the tobacco user to quit.
3. Assess. Assess the willingness of the tobacco user to quit, and urge the youth to quit smoking.
4. Assist. For the youth willing to quit, use counseling yourself and/or refer for counseling to individuals with expertise in tobacco cessation or support groups, and consider pharmacotherapy if necessary.
5. Arrange. Schedule a follow-up contact in person within the first week and then on a regularly scheduled basis.
The 5 A’s have been recognized by the Agency for Healthcare Research and Quality as an evidence-based practice for both adult and pediatric patients. In a 2014 article, Dr. Jonathan Klein reported on a study of youth who had seen a clinician for a preventive visit within the past year. However, the youth also reported that the rate of their receiving counseling on tobacco use was relatively low (Pediatrics. 2014 Sep;134:600-1) Most recently, Howard University completed a project funded by the District of Columbia Department of Health to develop and teach a curriculum for medical and nursing students, residents, and physician and nursing staff on this important issue. The youth whom we interviewed in developing the curriculum reported that they had never received counseling by health professionals during their preventive health care visits. This important issue needs to be addressed because it truly is a key to future health for our children and youth.