Introduction:
Smoking is the leading cause of preventable mortality in industrialized countries. In France, it causes 66,000 premature deaths a year and forecasts estimate 135 to 165,000 deaths by 2020. Efforts to reduce these figures in recent years in France have been significant: information and awareness campaigns , The Evin law, changes to legislation, price increases, prohibition of sale to children under 16 years of age, professionalization of smoking cessation assistance, financial resources for the development of care facilities since circular d April 2000. All these measures had an undeniable effect on the smoking of the French which has been reduced and is no longer considered today as a habit. And yet every day new teenagers experience tobacco. Why is it adolescence that begins to smoke, the adolescence that “is probably one of the most difficult periods to live”: according to Philippe Jeammet? How to reduce this initiation? How can we help those who are already “addicted” to stop as soon as possible?
Epidemiology:
Many European and French surveys now make it possible to monitor the evolution of smoking among young people and help to understand the determinisms of smoking through national specificities: the Health Behavior in School-aged Children Study (HBSC) Pupils of 11, 13 and 15 years of age in 2002, attended by 30 European countries; The 2003 European School Survey on Alcohol and Other Drugs survey of a sample of 102,946 16-year-olds; The Escapad (2005 Health and Consumer Preparation for Defense Appeal) survey, which included 17-year-olds participating in the Defense Pre-Appeal Day (JAPD); The health barometer 2005 of the National Institute of Prevention and Health Education (INPES).
On average, 15% of young Europeans have already smoked at 11 years, reaching 62% at 15 years and 67% at 16 years. The French rank 20th in Europe with 12% to 11 years, 62% to 15 years and 68% to 16 years (17th European rank for this age): according to Choquet, if at 11 years girls are fewer (9.7% versus 14.4%), the ratio is reversed between 13 and 15 years. At age 16, 71% of girls smoked at least once in their lives, compared with 66% of boys. This female trend at this age is not confirmed in the INPES health barometer 2005. At age 17 in 2005, 7 out of 10 young people report having ever smoked at least one cigarette in their lifetime (74% of girls and 71% of boys).
Daily Smoking:
At 11 years of age, an average of 0.6% of young people report that they have smoked at least one cigarette per day for the last 30 days. They are 3% to 13 years, 8% to 15 years and 24% to 16 years. Again, if boys are more likely to smoke regularly at age 11, the trend is reversed (between 15 and 16 years of age); There are more regular smokers (24%) than regular smokers (21%) at 16 years.
Age of first cigarette:
In the European HBSC survey in 2002, 15-year-olds reported smoking their first cigarettes at the age of 12 years and 3 months (with a standard deviation of 6.5 months). On average, boys smoked their first cigarette 4 months before the girls. The 17-year-olds interviewed during the Defense Pre-Appeal Day (Escapad 2005) placed their first cigarettes in the middle of the thirteenth year (13.3 years for boys and 13.5 years for girls) . These figures confirm the rejuvenation of the first trial already described in the 2000 health barometer; Beginning at 16.5 years for men born between 1924 and 1934 versus 15.6 years for those born between 1965 and 1973; 18.6 years and 15.8 years for women born in the same years!
Youth smoking decreases in France:
The Espad 2003 survey showed a 20% reduction in the proportion of daily smokers in 4 years (2000-2003), regardless of sex. While France ranked first among European countries in terms of the number of tobacco users at age 16 in 1999, it was in 2003 in the average group of countries. The 2005 Escapad survey confirms a decline in the proportion of daily smokers and smokers of more than 10 cigarettes per day. This decline is confirmed in the 2005 Health barometer, among French youth aged 12 to 15, from 14.4% in 2000 to 8.6% in 2005.
Same for 16-19 year olds who go from 43.9% to 34.2%.
The decline in consumption observed in the 2000-2003 studies is confirmed in the 2005 Escapad study. The number of 17-year-old smokers who report smoking more than 10 cigarettes per day is reduced by 12 to 10%. This decline can be put into perspective when it is known that many of them inhale as much harmful products on a reduced number of cigarettes or even roll tobacco. On the other hand, which is certainly encouraging, the proportion of experimenters who declare not to have become smokers has increased from 26% in 2003 to 28% in 2005. The number of cigarettes smoked continues to increase with age, a sign of Addictions to tobacco.
Other uses of tobacco:
While cigarettes are still the most widely used mode of consumption by young people, other modes of consumption, which are still rarely used in France, tend to develop. For several years now, tobacco consumption has been increasing, especially among adolescents. Since rising cigarette prices in 2003 and 2004, 20% of 17-year-olds surveyed in 2005 reported turning to tobacco. The other modes of consumption are the bidis (small tobacco cigarettes manufactured in India and considered by the young as “natural” producing three times more carbon monoxide (CO) and nicotine and five times more tars than Industrial cigarettes), narghile, whose social use is on the increase, and smokeless tobacco (snus) from the Nordic countries where it competes with cigarettes.
Tobacco and other addictions in adolescence:
The consumption of tobacco in adolescence can not be studied without taking into account the use of other products.
The Espad 2003 study shows the joint development of other addictions, particularly alcohol and cannabis. In France, the use of cannabis is mainly in the form of a joint, cannabis resin associated with rolling tobacco. It is therefore systematically a polyconsumption.
Choquet, from the 1993 National Survey of Espad Studies 1999 and 2003, concluded that the risk of cannabis use increased if the adolescent smoked tobacco (odds ratio [OR] (adjusted for sex, age and cultural level of parents) ): Occasional smoking tobacco OR = 10.9) especially if this consumption was daily (OR = 43.5).
Factors of initiation to smoking:
The earlier the onset of smoking, the greater the number of cigarettes smoked per day in adolescence and adulthood, the greater the risk of developing tobacco-related illness. Early tobacco initiation is therefore a major public health concern.
Smoking is behavior reinforced by a physical dependence of which the nicotine is the main responsible. Some authors agree that the brain “addict” does not work according to the norm with altered cerebral mechanisms, pleasure, suffering and emotional management. The neurobiological alterations are mainly in the mesocortico-limbic dopaminergic system, also known as the “reward and punishment system”. This system is formatted from childhood onwards according to the early experiences of pleasure and physical and emotional displeasure related to the quality of mothering and the development of attachment bonds.
Taking the first cigarette is the result of the interaction between three factors:
• product risk factors;
• individual vulnerability factors;
• environmental risk factors.
Product Risk Factors:
Although the social norm evolves regularly, tobacco is still socially accepted. The first cigarettes are often smoked by imitation behavior resulting from patterns that can be real, symbolic or imaginary.
The attractive force of these patterns and also the individual’s reactions to cigarettes will depend on the continuation or cessation of smoking. Pomerleau hypothesized that the degree of sensitization and development of nicotine tolerance results in a shift towards high consumption smoking behavior if the reward effects are high and there is a strong tolerance to the aversive effects of First cigarettes. Conversely, if the tolerance remains low, these aversive effects will be very present, the adolescent will not benefit from this first experience and will remain non-smoker.
The development of irregular tobacco use to daily smoking will depend on the importance of these feelings (both psychological and physical), but also, it seems, the genetic possibilities of developing a physical dependence on Nicotine (and probably other products contained in tobacco smoke). Recent studies confirm the notion of a genetic predisposition for dependence: nicotine tolerance, genetic polymorphism of cytochrome P450 type 2A6 (CYP2A6), which inactivates the properties of nicotine by transforming it into cotinine.
Individual vulnerability factors:
Temperament:
It seems that certain temperament traits are particularly related to the taking of addictive substances. We can find a high level of sensation search (Zuckerman model), novelty search (Cloninger model) and a low risk avoidance. The search for sensation would be the main driver of risk behaviors in adolescents, including smoking. According to Pélissolo, on nicotine, the results of the research are more heterogeneous, showing globally the relation between the novelty search score and the risk of initiating consumption, whereas the risk avoidance score would be correlated with the level Addiction and difficulty in quitting smoking.
Psychiatric Comorbidity:
The association of psychopathological disorders with addictive behaviors, especially in the child and adolescent drug user, including tobacco, has been highlighted in numerous studies.
Anxiety:
The dimension of neuroticism (or neuroticism) appears to be increasingly correlated with the onset of smoking as well as with regular smoking. It is a dimension of personality designating a general vulnerability to living negative affects, anxiety. The depressive dimension within neuroticism seems to play the most important role here. In addition, several genetic studies have shown the link between neuroticism and depression.
A significant number of studies show that decreasing anxiety while smoking is one of the major motivations of smokers to explain their smoking. It is also one of the motivations mentioned by the youngest to start smoking! However, recent work shows that nicotine possesses anxiogenic powers and can induce breathing difficulties favoring the emergence of anxiety. In addition, DSM IV (Diagnostic and Statistical Manual) also raises anxiety as one of the sensations of lack of nicotine. Among anxiety disorders, Sonntag suggests in a prospective study of more than 3000 adolescents that social phobia is related to the development of tobacco use and nicotine addiction in adolescents.
Depression:
The links between depression and smoking have been widely described. But they remain complex: factors favoring, consequences, simple co-occurrences. Depression would precede smoking. For Patton, in a population of 2032 adolescents aged 14-15 years, there is a link between depression and initiation to smoking. Breslau found in a study of 4414 people aged 15 to 54 that pre-existing psychological disorders, including major depression, increased the risk of becoming a regular smoker and dependent smoker. In the same study, Breslau concludes that the existence of these psychiatric antecedents does not influence the arrest. This increased risk of becoming addicted to tobacco in the presence of depressive symptoms is confirmed in a follow-up study for 2 ½ years of 113 adolescents by Karp on the risk factors of dependence among adolescent smokers. Smoking leads to depression. This is what Steuber suggests in a 2006 study, showing that in a population of 14,634 adolescents whose smoking status was followed for 2 years, the prevalence of depression increases after initiation to smoking. Several studies have demonstrated the link between depression, serotonin and tobacco use. Audrain-McGovern and his team suggest an association between the dopamine DRD2 receptor (A1 allele) and the progression of smoking in adolescents, an association potentiated by the symptoms of depression. Overall, the most likely current hypothesis is that of common risk factors that predispose to both smoking and depression and that are genetic and / or psychological and environmental.
Many questions remain on the links between depression and smoking, requiring a thorough reading of the literature and certainly new studies. This is especially so since Dierker, in his search for genetic links with smoking, does not find a link between smoking and depression (OR 1.1) but finds it between tobacco and dysthymia (OR 7,6). Nevertheless, several studies have found the relationship between smoking and attempted suicide. In a survey of Britain’s DRASS, the odds-ratio of being a smoker when the individual made a suicide attempt is 2.8. Binder has made smoking a predictor of attempted suicide in adolescents to seek systematically by general practitioners.
Other disorders:
Links have been found between other disorders and smoking. This is the case of Attention Deficit Hyperactivity Disorder (ADHD) in, inter alia, a follow-up study of 15 197 adolescents between 1995 and 2002. The existence of symptoms of TDHA increases the likelihood of becoming a smoker regular. Bailly postulated that in some subjects, an anxiety disorder of childhood separation continues and becomes rich in adolescence of other anxiophobic disorders leading secondary to the addictive disorders.
Finally, according to Guilbaud et al. (Study involving 767 people), tobacco-dependent subjects are no more alexithymic (etymologically incapable of expressing their emotions in words) than non-dependent subjects; On the other hand, they find in this study in dependent men an elevation of the cognitive component of the alexithymic dimension.
In a psychological thesis, the prevalence of alexithymic smokers is lower than that found in other addictive and addictive behaviors but higher than that generally found in the general population.
Personality Disorders:
The underlying psychopathological elements associated with a personality disorder (antisocial, borderline, abandonment) facilitate access to the harmful abuse of psychoactive substances.
The antisocial personality (according to the DSM IV criteria) would be associated with the consumption of tobacco, alcohol and cannabis. This same antisocial personality would make it more difficult to stop smoking before 25 years.
Environmental factors:
Sociocultural factors intervene in the initiation and regulation of tobacco consumption as well as other products. There are several types of environmental factors.
Cultural and social factors:
Exposure to tobacco in a given society or micro-society: a training factor that can be found, for example, in certain classes of a school and not in others or in certain sports (collective rather than individual sports). The action of advertising for tobacco products must also be taken into account. There is evidence that young people exposed to these advertisements are more smokers than those who have not seen them.
Family Factors:
Tobacco use: smoking habits of the family, smoking by the mother (including maternal smoking during pregnancy), brothers and sisters but not the father, absence of prohibition on family and / or religious consumption, explanations given On parental behavior or not …. Similarly, cessation of smoking by parents seems to have an influence on children’s smoking if this stopped before the age of 10 years.
Family functioning: conflicts, vital events also play an important role in the consumption of psychoactive products.Sexual abuse in childhood is a very important risk factor for smoking.
Role of Peers:
Peers have a major role in initiating tobacco consumption. The teenagers questioned by Choquet in a survey of their behaviors and expectations report 82% smoking more than usual when they are with buddies. The risk is especially increased if the best friend (the best friend) smokes.
Critical review of the literature:
It was conducted in 1998 by Tyas and Pederson on the psychosocial factors related to adolescent smoking.
The authors recommended that new studies be conducted using common definitions of the variables and that multivariate analyzes be carried out to verify the different hypotheses.
Genetic factors:
They also appear to play an important role in smoking. Stallings et al. Conclude in a study of monozygotic twins that tobacco (as well as alcohol) initiation is influenced by environmental factors, whereas the shift from initiation to regular consumption is more dependent on genetic factors.
Development of smoking:
After the initiation phase, smoking will develop gradually. Several factors play a role in this development. Unlike alcohol and cannabis, young smokers do not look into intoxication into cigarettes.
Tobacco use is more social, 82% of teens say they smoke more than usual when they are with buddies, 31% when they attend a family celebration (more boys (36%) than girls %)). Adolescents are also looking for help. Confusion, cockroach or sadness and loneliness are, according to them, moments favorable to smoking, and more so for girls than for boys. Sometimes it is the effect of nicotine on attention and concentration that is sought.
Wahl finds smoking-smoking factors, weight control, boredom and negative affects as smoking factors. In addition to the anxiety cited above, help in managing conflict and anxiety and relaxation are the smoking motivations cited most often by adolescents.
Autotherapeutic consumption aimed at reducing feelings of malaise, curbing social phobias, calming a depressive experience has also been described for tobacco. Finally, smoking is part of the development of a self-image that must be given externally, but sometimes for the use of specific audiences. Constructing the adult self-image with cigarettes can explain some of the difficulties in smokers’ stopping: “I do not see myself without a cigarette.”
Tobacco addiction and the onset of withdrawal symptoms are, of course, responsible for maintaining smoking.
Assessment of smoking addiction in adolescence:
30% to 50% of experimenters become regular smokers. Dependence and consequent negative weaning symptoms are sometimes major barriers to quitting smoking. Several studies have shown that these symptoms exist in adolescents. Rojas et al. In a study of 249 adolescents who smoked in the last 30 days and tried to quit smoking found an intense need for smoking in 45% of them. About 30% described nervousness, an inability to remain calm or irritable. For 25% an increase in appetite, 22% an inability to concentrate, 15% a sadness and 13% of the sleep disorders.
The assessment of tobacco dependence is therefore often a necessity to help the young smoker to stop. Some questions in the Fagerström test, usually used in adults, are not applicable to adolescents. Experience shows that the young person, despite his or her addiction, is able to influence his consumption according to the elements of life such as deferring the time of the first cigarette of the day so as not to smoke it at home (question 1 of Test) or abstain in prohibited places (question 2). In addition, young people may be addicted and have withdrawal symptoms even with low consumption of cigarettes. The answers to some questions of the Fagerström test are distorted, leading to an error in the interpretation of dependency in this population. DiFranza et al. Have developed a questionnaire whose theoretical basis is based on the fact that dependence begins when the subject loses control of his or her consumption: HUNC (Hooked on nicotine checklist).
In the DANDY study using this questionnaire, DiFranza et al. Have shown that dependence would set in before the daily consumption of cigarettes. The urge to smoke would be present even before switching to a daily cigarette.
In a recent study of 1293 young people followed for 6 years and interviewed every 3-4 months, Karp et al. Have shown that the risk of becoming addicted to tobacco (according to the International Classification of Diseases, version 10) is associated with the intensity of consumption during this period of life. But also that the risk is greater in the slow metabolizers of nicotine and in those who have more depressive symptoms.
Primary prevention:
Prevention of risk factors:
Allowing young people not to start smoking is because of the rapid development of addiction a major issue. Many primary prevention programs have developed in the world as in France: as an example “Club Pataclop” of the League against Cancer, “Never the First” of the French Federation of Cardiology.
Interventions in schools are numerous. An assessment was made in 2006 by the Cochrane base. The authors reviewed all interventions in schools on the behavior of children (5 to 12 years of age) and adolescents (13 to 18 years of age) to discourage smoking and have a control group with Smoking status at entry into the study. Five types of school intervention were studied: simple information (on tobacco, risks, prevalence and incidence of smoking);Interventions on social skills (social skill, self-management, increased self-esteem, stress and anxiety, interaction with other sex …); Those on social influence (resistance training); Actions combining several methods (skills and social influences); And multiple programs (school, parents’ programs and legislative actions (price, prohibition …). The results were measured on the prevalence of non-smokers following the intervention among those who did not smoke at the start (biochemical validation of smoking status was not required); Some studies also yielded long-term results. A meta-analysis could not be performed because of the heterogeneity of the analyzes. Of the 209 control surveys studied, 94 randomized studies were selected and only 24 were of high methodological quality: one study on information alone, two on social skills, 13 on social influence, three on a combination of the two previous ones, One comparing work on social influence and information and finally four “multiple” programs. The only study on information alone gives positive results (OR = 0.61) but it is too unique to be able to conclude on the effectiveness of this method according to the authors. The two studies on social skills do not yield significant results.
In the large group of studies evaluating social influence programs, the largest and most rigorous study was the Hutchinson Smoking Prevention study, which, despite an intensive 8-year program, long-term. In the group including work on social skills and social influence, Life Skills Training reports a reduction in the prevalence of 25% of monthly, weekly and heavy smokers and the TNT project reduces initiation Tobacco use and tobacco use by 30%. Finally, three of the four multiple programs have positive results.
The authors of the Cochrane study conclude that rigorous evaluation of studies is necessary in order to resolve and initiate new research.
Prevention reinforcing protective factors:
Factors protecting tobacco use were much less studied than risk factors. In a recent review of the literature, Schepis finds as protective factors parents’ expectations of good behavior of their children, parental supervision and their participation in the lives of the youngest. Religion also seems to play a protective role.
Bricker studied the smoking status of adolescents at 17-18 years of age according to the smoking of the parents. He suggests that stopping smoking by one parent before the child reaches 8/9 years reduces the risk of 25% that the child becomes a smoker at the age of 18. This reduction is 39% if both parents stop.
The application of the ban on smoking in places frequented by young people plays a very important role in the “denormalization” of smoking and the decrease in the number of smokers.
Help with teen smoking cessation:
“It seems that the desire to quit smoking now appears earlier than before, even before the end of high school.
In fact, it often seems to settle down as soon as the new smoker recognizes that he is addicted. However, the desire to stop and the satisfaction of this desire are two quite different things as the candidate for weaning learns quickly. “(Kwechansky Marketing Research, Inc. for Imperial Tobacco Ltd [Canada], May 1982).
More than one in two teens want to quit smoking.
However, there are many difficulties in stopping, linked to the environmental risk factors, to the product factors and to the factors of psychological vulnerability already described, which lead to a lack of real motivation. Changing behavior such as smoking requires a maturing time and the passage of a number of steps outlined by Prochaska and Diclemente. From the stage of “smoker consonant” or “smoker satisfied” with that of ex-smoker, the tobacco subject according to the life events, his beliefs, his capacities and the information received will advance more or less quickly on this way. To help the adolescent to travel faster, motivational assistance seems necessary. Investigated in the management of adolescent cannabis users, a motivational approach inspired by the motivational interview of Miller and Rollnick was effective. It should be used for the adolescent tobacco smoker and evaluated as it is in adults [75] .Psychotherapeutic approaches of behavioral and cognitive type have been effective in helping to stop smoking.
They were recommended in the Consensus Conference on Stopping Tobacco Use. The most used approach consists of four phases: therapeutic alliance, self-observation phase, behavior modification phase, follow-up phase and recovery prevention. A randomized study of 261 16-year-olds on average in two groups, one group receiving four sessions of behavioral therapy and one without intervention did not find significant differences in smoking cessation numbers in 12 months The two groups.
Financial support for cessation of smoking cessation treatments may be attractive to adolescents. According to the National Institute of Public Health of Quebec (http://www.inspq.qc.ca/pdf/publications/468-ProgrammeRembAidesPharmacoArretTabac-PhaseI.pdf) studies in adults measuring the impact of ” A reimbursement of the aid or free of charge shows, for most of them, a positive effect on the rate of use of aid and the number of attempts to stop. They also show a positive effect on the abstinence rate of those who used them.
Treatments:
In France and in Europe, several medicinal treatments have been labeled ‘aid to stop smoking’. These are nicotinic substitution, Zyban ® (Bupropion) and varenicline.
There have been few studies of therapeutic assistance in adolescents.
Smith et al. Administered a 22 mg / d patch to 22 adolescents aged 13-17 years, smoking between 20 and 35 cigarettes per day: 19 finished the study, only one was absent at 6 months.
In another study using 15 mg / 16-hour patches for 101 adolescents smoking 10 to 40 cigarettes / d, 11% abstinent were found at the end of the 6-week treatment and only 5% at 6 months.
In a survey of the use of nicotine substitutes (NRT) in the United States, 17 to 20% of smokers under the age of 18 have used or use nicotine substitutes to stop smoking or reduce their consumption. But almost 30% of smokers in this study say they use cigarettes and TSN simultaneously. This raises the question: does the reduction achieved with the TSNs favor the development of dependency or on the contrary it helps to free oneself from it? Finally, 18% of TSN users say they have never smoked. This encourages the study of the reasons why these young people use nicotine substitutes.
Other tobacco cessation treatments, Zyban ® (Bupropion) and varenicline which have been marketed in the United States since 2006, are not indicated until 18 years of age.
Few good methodological studies have been done on the value of community programs in adolescents.
In adults, self-help programs, brochures, television programs, expert telephone advice systems (in France, Tobacco-Info-Service, 0 825 309 310 0.15 Q Minute), Internet, have shown their interests. They are all the more effective if they are associated.
The brief advice given by a health professional (minimal board) has also proved its effectiveness and is recommended in national consensus.
In all, we can conclude that it is necessary to inform the students about the possibilities of management and to develop several levels of management as in adults (motivation support, nicotine substitution and intake In psychotherapeutic charge). These actions will be reinforced by collective actions for individual help.
Conclusion:
Dependency behaviors are among the behaviors that refer to psychopathological disorders those that question the clinician the most about the boundaries between the normal and the pathological, a dimension that helps explain the enthusiasm that these disorders arouse both in the general public and in Researchers and therapists. Among these, smoking is the most important public health problem. Beginning most often in adolescence, major efforts must be made towards this population, in order to help it not to start or to get out of the tobacco as quickly as possible; Efforts to be made by all, the general public, researchers and therapists.
Published studies on adolescent smoking in recent years provide some insights. It seems useful to accompany a child and then a teenager in his reflection on smoking by helping him to build a non-smoker identity and by developing social skills and means of resistance to social influence. It is the role of the parents, the family but also of all the educators and actors who will accompany it in its construction. The denormalization of smoking in society is also a determining factor in the influence of adult smokers, parents and peers, but also the people to whom the youngest identify themselves, including singers and actors. The development of prevention, screening and treatment of personality disorders and psychiatric disorders arising in childhood or adolescence is also a major element of this prevention. But studies have yet to be done, in particular in order to better understand the actions of nicotine on the adolescent brain in training and on the mechanisms underlying the development of physical and psycho-behavioral dependencies. Finally, there is a need to improve or introduce new strategies to help stop adolescents, and then evaluate them.
