Looking Ahead to a Tobacco-Free Generation

Maternal cigarette smoking and environmental tobacco smoke exposure have been shown to have a myriad of adverse effects on pregnancy and the newborn, including increased risk of admission to a neonatal intensive care unit because of higher rates of prematurity and intrauterine growth restriction,1 longer stays in the neonatal intensive care unit after admission,1 increased risk of sudden infant death syndrome,2, 3 increased wheezing and asthma,4 and increased risk for persistent pulmonary hypertension.5 In this issue of The Journal, 2 articles further support the relationship between maternal tobacco use/exposure and effects on the fetus/neonate. Shaw et al6 substantiate the association of orofacial clefts and maternal tobacco exposure with a biomarker to estimate exposure. Stroud et al7 provide further support for the neurocognitive effects of maternal smoking by measuring changes on the NICU Network Neurobehavioral Scale between infants of smoking mothers and control infants.

Although investigations defining the phenotype of tobacco-exposed neonates and children continue, the pressing need is to stop this harmful exposure from occurring. Tobacco is highly addictive. Regular tobacco use causes tolerance and withdrawal. Tobacco remains the leading cause of preventable premature death in adults, from cancer, chronic respiratory illnesses, and cardiovascular disease. With cotinine as a biomarker of tobacco exposure, environmental tobacco smoke is harmful to pregnant women, as in the article by Shaw et al.6 Several trials of interventions for smoking cessation during pregnancy have been conducted8 and found to be successful, but with an absolute difference of 6 in 100 women continuing to smoke. Reductions were also found with reduced low birthweight (relative risk [RR], 0.81; 95% CI, 0.70-0.94) and preterm birth (RR, 0.84; 95% CI, 0.72-0.98). One intervention strategy resulted in significantly greater smoking reduction than other strategies (RR, 0.77; 95% CI, 0.72-0.82). However, 5 trials of smoking relapse prevention showed no statistically significant reduction in relapse.

Primary prevention, or preventing the start of tobacco use, would be a more effective way of reducing tobacco-related morbidities. Interventions aimed at the pediatric population are needed. Approximately 4 million American teenagers have used a tobacco product in the past month.9 Approximately 80% of smokers start smoking by age 18 years, and of smokers <18 years of age, >5 million will die prematurely from a smoking-related disease.10 Prevention of tobacco addiction is a major pediatric problem and needs a pediatric solution. Teens begin smoking for numerous reasons. One recent article describes the perception of accessibility to cigarettes as a risk factor for smoking. Perceived physical development and self-esteem were associated with regular smoking in female adolescents.11 There are even data to suggest that teens smoke in a manner based on parental smoking habits.12 Teens also do not smoke for numerous reasons. One recent article supports parental disapproval of smoking as a strong deterrent force.13 Female adolescents are less likely to smoke when family meals occur regularly.14

Interventions should target the initiation of smoking—“taking a puff.” There are 5 stages to nicotine dependence. The first is a trial of smoking. In 1 prospective study, sixth graders who tried smoking rapidly proceeded to inhalation, then regular smoking. Teenagers become addicted more rapidly after initiation of smoking than adults. Genetic studies suggest that adolescents with certain genotypes are more likely to become addicted. Thus the prevention of the first puff is a critical step to prevent teen smoking and, subsequently, adult smoking.

Several innovative interventions come to mind. First, tobacco should be unavailable and therefore perceived to be inaccessible. Adopting 100% tobacco-free school policies in all school districts is essential. Teachers, like hospital employees, should be prescreened for smoking habits and offered cessation programs. All tobacco vending machines should be banned. Strict enforcement of age restrictions on tobacco sales will make cigarettes and other tobacco products more difficult to obtain. Second, teen role models should not smoke or use tobacco products. Movie stars and athletic figures should not use or promote tobacco products. The adverse effects of tobacco on physical attractiveness should be advertised. Public health service advertisements should graphically portray the damaging efforts of tobacco use on physical characteristics such as stained teeth, halitosis, and withdrawal symptoms. Parents should be educated and supported in behaviors that reduce the risk of smoking in their children. Parents should be encouraged to have family meals regularly and vocally disapprove of tobacco use. Children themselves can be taught to be proactive against the tobacco-using culture. Preschool children should be taught to actively protect themselves from passive smoking by either removing themselves from the environment or by asking that the smoking behavior be stopped.

What about all those tobacco farmers who depend on tobacco production for a living? A revolution is occurring among tobacco farmers. New uses for tobacco plants are being developed. For example, tobacco plants can be genetically engineered to produce proteins for potential human immunodeficiency virus vaccines,15 to clean up environmental pollutants,16 and to produce human collagen in large scale for drug delivery systems.17 Thus, we can eradicate the recreational and addictive use of tobacco and tobacco products from our population without guilt.