Struggle to Quit

Dr. Richard Hurt didn’t hold out much hope the day he launched a drive to recruit volunteers for a Mayo Clinic study on smoking.

Hurt was looking for teenagers.

Teenagers who wanted to quit smoking.

Teens who would have to have parental consent, visit a clinic weekly and wear a nicotine patch for six weeks.

So Hurt was pleasantly surprised when more than 100 volunteers--13- to 17-year-olds who smoked at least 10 cigarettes a day--signed up. There were so many volunteers that he had to turn away dozens.

“There is a mythology out there that teen smokers don’t want to stop,” says Hurt, of the Mayo Clinic’s Nicotine Dependence Center in Rochester, Minn. “That is not true. We just don’t know how to help them very well.”

But a burgeoning movement focused on efforts to stop teenagers from smoking is gaining momentum in this country, targeting a group of smokers who have been largely ignored for years.

“It’s been a very strange area of research,” says Steve Sussman, an associate professor of preventive medicine at USC and an authority on youth smoking cessation. “Back in 1982, the surgeon general report encouraged teen cessation. But there also has been kind of a folk wisdom among lay people and researchers that teens won’t quit smoking, so you need to wait until they’re young adults.”

About a year ago, the U.S. Centers for Disease Control and Prevention organized a conference on teen smoking cessation that amounted to “a call to begin doing research in this area,” he says.

Efforts to help teenage smokers quit are also a response to a series of revelations about tobacco use, experts say. These insights include:

* Most smokers start as teens.

* The younger people start to smoke, the harder it is to quit.

* Health problems resulting from smoking begin to accrue quickly in young smokers.

Aimee Garten was a poster child for youth smoking. Garten, of Julian, Calif., began smoking at 12. By the time she entered USC last year, she was a two-pack-a-day smoker.

“When I started smoking, it was the cool thing to do,” Garten says. Cigarettes were “easy to get and fairly cheap. Most of the people in liquor stores would sell to us without hassling us.”

Many of those conditions have changed, thanks to a major state anti-tobacco initiative that began with passage of the Proposition 99 cigarette tax in 1988. Proposition 10, which took effect last year, boosted the tax on cigarettes by 50 cents a pack.

That caught Garten’s attention.

“I sat down and calculated it,” she says, “and realized I was spending $50 a month on cigarettes. When you’re in college, money becomes a major issue.

“I also realized my health was being affected. I had asthma as a child, and it started up again. I was coughing up disgusting things every morning.”

After several unsuccessful efforts to quit and four months of trying to simply cut back on the number of cigarettes she smoked daily, she was able to quit. Her asthma symptoms have eased dramatically.

“I have an elderly relative who is sick and refuses to quit smoking,” Garten says. “I’m glad I’m not going to be like that.”

Teens Do Try to Quit--Often

Garten isn’t exceptional in her desire to quit. A landmark 1992 study from the University of Massachusetts Medical Center in Worcester found that 52% of 10th-grade smokers had already tried to quit two or more times.

The study also found that one-quarter of the teens thought they were addicted. And nearly half were concerned about their health.

While many teenagers apparently want to quit, they have an especially difficult time doing so. The few teen smoking cessation programs that have been scientifically evaluated show poor results.

Hurt’s work is a case in point. In his recent study, published last month in the Archives of Pediatric & Adolescent Medicine, only 11 of 101 smokers had stopped at the end of six-week patch therapy. Six months later, only five remained abstinent.

He attributes the poor results to the fact that the patch study did not include much behavior intervention, which teaches things like what to do when a craving strikes. But others note that such intervention programs have fared poorly among adolescents.

Sussman examined 17 teen cessation programs using behavioral approaches (not including nicotine aids, like the patch) and found an average quit rate of 6% to 7%. In programs where kids seemed highly motivated, the quit rate was closer to 10%.

The typical adult quit rate after a cessation program is 50%.

“I think one of the problems with the programs developed early on is they were based on an adult model of cessation,” Sussman says.

Research shows that in some ways, teen smokers are similar to their adult counterparts: They tend to smoke out of addiction or habit, to fit in socially, or to improve mood or relieve stress. According to a federal government study, most kids who smoke daily do so within two years of first trying a cigarette.

But kids differ on how they are persuaded to stop using nicotine.

“If you want kids to go to a clinic, you need to round them up,” Sussman says. “If you want to keep them, you have to make it kind of fun. These are the things people hadn’t been doing.”

Most teen smoking cessation programs are funded through the state or county and are offered at high schools. Some are voluntary classes, while others target students who are caught smoking. These students are punished with a suspension, a fine or community service, Sussman says. Community service can include a cessation program.

Schools need to deal with student smokers in a helpful manner, Sussman says.

“While smoking is illegal, if a teen wants to quit, there needs to be a lot of support at that point,” he says.

Support may be the most vital component of teen programs. Like adult smokers, adolescents experience withdrawal symptoms. But adolescents appear less able or willing to put up with the irritability, headaches or fatigue, and need more moral support during this phase.

“These kids need support,” says Rita Moncrief, a teacher who oversees smoking cessation programs at El Camino Real High School in Woodland Hills. Moncrief keeps a supply of chewing gum and plastic straws in her classroom for ex-smokers to gnaw on if a craving strikes.

“It’s amazing--their addiction. They find it very hard to quit. You would think that these are young kids and they haven’t been smoking that long. But many have. I had one girl start when she was 8.”

For teen girls, who often begin smoking as a way to control their weight, quitting poses the additional problem of weight gain.

Quitting can also be hampered if teens use other addictive substances, says Dr. Gary Wong, a preventive medicine expert at Kaiser Permanente Medical Center in Fontana.

“It’s been shown that [some adolescents] start smoking and move to the illegal drugs,” Wong says. For these kids, he says, therapy should address all addictive behavior.

Smoking, Socializing Seem to Go Together

Helping adolescents deal with the people around them who smoke--family and friends--is also a huge issue, Hurt says. Surveys show that 30% of adult smokers have another smoker at home. But among teen smokers, 75% have another smoker in the home. The presence of another smoker often deters those trying to quit.

“We asked the kids in our study if there was someone at home to help you, what would you want them to do?” Hurt says. “They said things like: Tell them not to smoke around me. Not to offer me cigarettes. Not to buy me cigarettes.

“The environmental factor is not a trivial one. As many teens wanted to bring a person in their household who is smoking into the study as wanted to stop smoking themselves.”

Perhaps especially for teenagers, the social aspect of smoking complicates quitting. Garten, who met many of her college friends in areas where smokers congregate, found she had to drop those friends in order to quit.

“The reason I failed initially was because all my friends smoked,” she said. “Finally my best friend decided to quit too, and he was really good at it. He really encouraged me. I’m not really friends with [the smokers] anymore.”

James Chanthapak, a senior at Marshall High School in Los Angeles, tried to quit smoking in November on the American Cancer Society’s Great American Smokeout Day. During the last few years, the cancer group has stepped up its campaign to target teens during the Smokeout with a “Teens Kick Ash” motto. Chanthapak was enthusiastic enough to quit for two or three weeks. But he couldn’t sustain the effort.

“It’s such a social thing,” he says. “I would have had to change friends. Smoking is just what we do.”

In the meantime, his habit has grown from one pack a week to three packs.

“I used to tell people that if you wanted to quit smoking, you could quit,” he says, softly. “Now I think you need help. I didn’t know it was as hard as it is.”

The Push Is on to Establish Programs

Should Chanthapak decide to try to quit again, there are a range of options. And within the next year, cessation experts will have a better idea of what works with kids, Sussman says.

The enthusiasm to help teens is so great that some experts worry that programs may be implemented before they’ve been shown to work.

“People are trying the Internet, CD-ROMs, school programs, patches, all kinds of ways to approach the topic,” Sussman says. “But there is a push toward getting programs out there quickly, before they are evaluated.”

Sussman hopes to publish results soon from his program at a continuation high school that shows a quit rate of 17%, compared with 10% in a similar group that received no services.

At UC San Diego, the results of a telephone counseling study involving 1,400 adolescents--which program directors say will be favorable--will be released in May. In that program, teens who call in ([800] 7-NO-BUTTS) are assigned a telephone counselor who regularly contacts them.

Studies will also continue on nicotine aids, like the patch, gum or the antidepressant medication Zyban. Those aids shouldn’t be ruled out for teens despite poor early results, Hurt says. Although few kids in his study quit smoking, the teens cooperated with wearing the patch and many dramatically cut back on the number of cigarettes they smoked.

And then there was that most hopeful sign: They wanted to quit.

“When we got the final results, we said, ‘Oh, no,’ ” says Hurt. “But when we started peeling away the layers, there are some positive things happening.”

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

Young Smokers

Smoking rates among adolescents are significantly higher than for adults. While roughly one in four adults smokes daily, slightly more than one in three high school students does so.

% of high school students who smoke daily

Male 34.7%

Female 37.1

White 41.7%

Black 14.9%

Hispanic 24.5%

Grade 9 35.7%

Grade 10 34.9%

Grade 11 37.1%

Grade 12 35.5%

*

Source: U.S. Centers for Disease Control and Prevention; Youth Risk Behavior Survey, 1997.

Dangers of Smoking

The consequences of smoking are not limited to such illnesses as heart disease or lung cancer, which develop over many years. Smoking can result in serious health damage to young smokers, too, medical experts say.

Smoking during adolescence:

* Lowers lung function.

* Causes permanent, genetic changes in the lung.

* Reduces the rate of lung growth.

* Reduces physical endurance and fitness.

* Increases resting heart rate.

* Causes shortness of breath and phlegm.

* Raises the risk of succumbing to other unhealthy behaviors, such as drug and alcohol use.

*

Source: U.S. Centers for Disease Control and Prevention; Journal of the National Cancer Institute.