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Social Smokers Are in Danger, Too

College students require help and intervention.

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Many terms are used to identify smokers who don't smoke daily: intermittent smokers, social smokers, or light and occasional smokers. Social smokers are usually young, nondaily smokers who smoke in the presence of other people rather than alone. Light and occasional smokers fall in between intermittent and social smokers. For this article, occasional, intermittent, light and social smokers will be included under the umbrella term "social smoker," since cessation efforts should be directed toward all categories.

Health Consequences of Social Smoking

According to the Centers for Disease Control1 and other research, smoking causes a multitude of health problems: coronary heart disease leading to stroke and heart attack; peripheral vascular disease; abdominal aortic aneurysm; emphysema; bronchitis; and chronic airway obstruction. Smoking also causes decreased bone mass in postmenopausal women, complications in pregnant women, and multiple types of cancer.1 In the past, attention to tobacco-related disease focused mainly on regular smokers. But there is growing evidence that even social smokers experience greater health risks compared to nonsmokers.2,3 Okuyemi et al4 found that the risks of coronary heart disease among light smokers are similar to those among regular smokers. Other behavioral and health risk factors for young adult social smokers include high alcohol use, unsafe driving practices, less exercise, depression and utilization of emergency mental services.3

Quitting Difficulty

Young adults can become as dependent on nicotine as adults.5 Addiction to tobacco is clear after 100 cigarettes1 or within a month of initiation, even after smoking only a few cigarettes.3 Levinson et al6 state that symptoms of tobacco abuse develop rapidly and no minimum nicotine dose or duration has been linked to an addiction level.7

The challenge in treating college students and social smokers is that they are more resistant to antismoking efforts and they do not see themselves as smokers. College students who use tobacco intermittently tend to believe they will not become addicted and that no health risks are associated with smoking.3

Nicotine addiction involves factors other than physical dependence.8 Barriers to cessation mentioned by college students include emotional triggers for smoking, social aspects and the habit of smoking.9 Women in college tend to smoke in more emotional situations whereas men in college smoke in peer situations. Regardless of gender, 75% of college smokers mentioned emotional situations as reasons for tobacco use and that tobacco use was a learned habit for coping with stressful situations.10

Motivations associated with tobacco use often hinder cessation efforts. Research by Rasmussen-Cruz et al10 found that students at Mexican universities believed that tobacco use could help them form friendships. Students also report that peers often downplay the health risks associated with tobacco use. Beginner smokers see healthy smokers and dismiss the notion that cigarettes are harmful.

Most college-age smokers do not seek cessation help and therefore don't formulate a plan to quit. Research shows that many students view presenting to a health clinic for cessation help as a personal failure.11

Identifying Social Smokers

Screening for tobacco use should occur at every office visit. The provider should ask about daily use of tobacco as well as social smoking. A form that asks only whether the patient is a smoker may fail to identify 50% or more of college students who are currently smoking.6 A better question to identify social smokers is, "In the last 3 months, have you smoked cigarettes at all, even a puff?"3 To identify social smokers, researchers have determined that Internet and phone screening tools are also effective.12

Cessation Efforts

Tobacco intervention should be addressed early in students' college careers. Students who decrease the amount they smoke while in college are more likely to quit prior to graduation. Those who do not decrease the amount they smoke while in college are less likely to have a desire to quit with each passing year.13 Public Health Service (PHS) guidelines14 recommend brief interventions at every office visit. This includes the 5 A's, a strategy that identifies cessation desires. The mnemonic refers to: Ask, Advise, Assess, Assist and Arrange for follow-up.15

Murphy-Hoefer et al16 found that young adult college students respond more positively when advertisements focus on the health consequences of tobacco use. This was supported by Wolburg,11 with the exception that health consequences should not focus on death since young students are not able to relate to something thought to be far in the future.

Using screening tools enables the clinician to link smoking behaviors to cessation tools. The Reasons for Smoking Scale (RSS) was developed based on Silvan Tomkin's affect management model for smoking.17 According this model, people smoke for emotional motives - either to enhance positive affect or to decrease negative affect. The RSS did not address social smoking.

The RSS has been modified to include the subscale of social smoking. This subscale was derived from Russell et al18 in addition to traditional subscales developed by Ikard et al.19 The category focuses on handling, pleasure, habit/automatism, stimulation, and tension reduction/relaxation associated with smoking.20 The revised scale is called the Modified Reasons for Smoking Scale (MRSS), and it was first used with French smokers. The MRSS scale with the subsets allows the clinician to determine addiction plus behavioral reasons for smoking. The MRSS has demonstrated validity and reliability when used with patients in France, Brazil and the Netherlands.8,21

Identifying the motives of a college-aged tobacco user requires the establishment of a therapeutic relationship, and counseling should be a component of this.10 Berg et al9 identified four motivators for the college smoker to quit: cost of smoking, health concerns, improving fitness level and the stigma of being a smoker.

In the adolescent population, nicotine replacement has been essentially ineffective.15 Instead of nicotine replacement, Abroms and colleagues22 tried a different approach to enhance tobacco cessation rates. They issued the X-Pack Smoking Cessation Kit and provided counseling. The kit included a quitting booklet, X-Pack quit cards (explained reasons to quit smoking), Success-O-meter/Ick-U-Lator (explained risks and costs associated with smoking), Wrigley's Orbit chewing gum, Hotlix cinnamon toothpicks and preoccupation putty (to help with cravings). At 6 months, the quit rate based on self-report was about twice as high in the X-Pack group compared to the natural quit rate.

A smoke-free policy for college campuses has been advocated to discourage tobacco use. In a national sample of college students, less tobacco use was documented among students living in smoke-free residences.23 Smoke-free policies can reinforce positive social networks and preferences.6 Restricting smoking in places where students socialize is important to help reduce social smokers.24 These statements are supported by the American College Health Association,25 which states that all college campuses should be smoke-free.                                                 

Time to Intervene

Tobacco use by people who are not chronic smokers has been difficult to define. Social smoking has been identified in various studies and identifies someone who usually smokes in a social setting. Haleprin et al3 found that more than 28% of college students smoke cigarettes and despite intentions to quit, they smoke throughout college and beyond. Social smoking has been linked to increased health risks.2 Social smokers have difficulty with smoking cessation. Studies suggest that social smokers do not see themselves as smokers, deny health risks associated with social smoking, believe they can quit anytime they want, and do not believe they can become addicted to cigarettes with occasional use.3 Tobacco industries often target the college-age population, linking smoking with positive social peer encounters with smoking and decreased anxiety.24

Social smokers tend to get missed during routine tobacco screening because they do not perceive themselves as smokers. Questions that ask only if they are smokers miss this population. Questions targeting "any" smoking in the last 3 months will help identify the social smoker. Once identified, finding proper cessation techniques poses the next challenge. Targeting the reason and triggers for smoking and linking this to education will help with cessation.

Patients are more successful at quitting when they are included in their cessation plan. The MRSS helps find the core reasons a social smoker is smoking.20 Nicotine replacement has not been as successful within this unique population.15 The utilization of the X-Pack improved cessation rates in at least one study.22 Studies examining anti-tobacco education found that health risks where a motivator for quitting,17 except when targeting death as a risk.11 Nonsmoking campuses also reduce the amount social smokers are able to smoke, taking away that peer-smoking link.

References

1. Centers for Disease Control and Prevention. Health effects of cigarette smoking. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/

2. Okuyemi K, et al. Relationship between smoking reduction and cessation among light smokers. Nicotine Tob Res. 2010;12(10):1005-1010.

3. Halperin AC, et al. Cigarette smoking and associated health risks among students at five universities. Nicotine Tob Res. 2010;12(2):96-104.

4. Okuyemi K, et al. Light smokers: issues and recommendations. Nicotine Tobacco Res. 2002;4(Suppl 2):S103-S107.

5. Orleans CT. Preventing tobacco-caused cancer: A call to action. Environ Health Perspect. 1995;103(Suppl 8):149-152.

6. Levinson AH, et al. Smoking, but not smokers: identity among college smokers who smoke cigarettes. Nicotine Tob Res. 2007;9(8):845-852.

7. DiFranza JR, et al. The development sequence of tobacco withdrawal symptoms of wanting, craving and needing. Pharmacol Biochem Behav. 2012;100(3):494-497.

8. Souza ES, et al. University of Sao Paula reasons for smoking scale: a new tool for the evaluation of smoking motivation. J Bras Pneumol. 2010;36(6):768-778.

9. Berg CJ, et al. Defining "smoker": College student attitudes and related smoking characteristics. Nicotine Tob Res. 2010;12(9):963-969.

10. Rasmussen-Cruz B, et al. Tobacco consumption and motives for use in Mexican university students. Adolescence. 2006;41(162):355-368.

11. Wolburg J. Misguided optimism among college student smokers: Leveraging their quit-smoking strategies for smoking cessation campaigns. J Cons Aff. 2009;43(2):305-331.

12. An LC, et al. Feasibility of Internet health screening to recruit college students to an online smoking cessation intervention. Nicotine Tob Res. 2007;9(Suppl 1):S11-S18.

13. Harris JB, et al. Characteristics associated with self-identification as a regular smoker and desire to quit among college students who smoke cigarettes. Nicotine Tob Res. 2008;10(1):69-76.

14. Torrijos RM, Glantz SA. The US public health service "treating tobacco use and dependence clinical practice guidelines" as a legal standard of care. Tob Control. 2006;15(6):447-451.

15. Friend K, Colby S. Healthcare providers' use of brief clinical interventions for adolescent smokers. Drugs: Education, Prevention and Policy. 2006;13(3):263-280.

16. Murphy-Hoefer R, et al. The influence of tobacco countermarketing ads on college students' knowledge, attitudes, and beliefs. J Am College Health. 2010;58(4):373-381.

17. Fiala KA, et al. Construct validity and reliability of college students' responses to the reasons for smoking scale. J Am College Health. 2010;58(6):571-577.

18. Russell MA, et al. The classification of smoking by factorial structure of motives. J Royal Stat Soc. 1974;137(3):313-346.

19. Ikard FF, et al. A scale to differentiate between types of smoking as related to the management of affect. Int J Addictions. 1969;4(4):649-659.

20. Berlin I, et al. The modified reasons for smoking scale: factorial structure, gender effects and relationship with nicotine dependence and smoking cessation in French smokers. Addiction. 2003;98(11):1575-1583.

21. Bourdrez H, De Bacquer D. A Dutch version of the modified reasons for smoking scale: factorial structure, reliability and validity. J Eval Clin Pract. 2011;18(4):799-806.

22. Abroms LC, et al. Getting young adults to quit smoking: a formative evaluation of the X-Pack program. Nicotine and Tob Res. 2008;10(1):27-33.

23. Rigotti NA, et al. Tobacco use by Massachusetts public college students: long term effect of the Massachusetts Tobacco Control Program. Tobacco Control. 2002;11(Suppl 2):20-24.

24. Waters K, et al. Characteristics of social smoking among college students. J Amer Coll Health. 2006;55(3):133-139.

25. American College Health Association. Position statement of tobacco on college and university campuses. American College Health Association. http://www.acha.org/Publications/docs/Position_Statement_on_Tobacco_Nov2011.pdf    

Carol Sternberger is the associate vice chancellor for faculty development at Indiana Unversity-Purdue University in Fort Wayne, Ind. Heather Krull is an assistant professor and family nurse practitioner at the same university. Diana Bantz is an associate professor of nursing at Ball State University in Muncie, Ind.




     

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