SMOKE SIGNALS

 

Epidemiology detectives are searching for clues as to why tobacco use begins and how to stop it.

by Jon Nalick
 

Phrased as a riddle, the subject of this story could be described as:

A welcome companion to those it would kill,

A killer no jail can hold,

Hides in plain sight and will take a new life,

Before this minute is old.

The answer to this riddle is cigarette smoke-but for researchers at USC, the real riddle is how to stem the 400,000 American deaths each year that cigarette smoke is estimated to cause.

To answer that conundrum, researchers at a newly-established national center at USC are playing the role of detectives in a wide-ranging series of studies to determine why people start using tobacco, how addiction occurs and how it can be stopped before more lives are lost.

Funded by a $12.8 million, five-year grant from the National Cancer Institute (NCI), the Transdisciplinary Tobacco Use Research Center (TTURC) on the USC Health Sciences Campus will launch a series of studies aimed at reducing the prevalence and health risks of smoking. The studies include those that examine:

USC's Tobacco Use Research Center is one of only seven federally funded centers created nationwide, and the only one to look specifically at Asian, Pacific Islander and Latino issues-the first major, comprehensive and long-range project on such issues funded by the National Institutes of Health.

The seven academic institutions were awarded grants totaling $14.5 million in the first year by the NCI and the National Institute on Drug Abuse to study tobacco use and find new ways to combat it and its consequences. The centers plan to collectively spend $70 million over five years on the tobacco projects, and the Robert Wood Johnson Foundation committed an additional $14 million over five years to complement the centers' efforts.

"Tobacco-related diseases are a world-wide problem, affecting people from many cultures," says C. Anderson Johnson, Ph.D., the Sidney Garfield Professor of Preventive Medicine and director of the new Tobacco Use Research Center. "Chronic diseases of lifestyle-most of them originating largely from smoking-have replaced acute diseases as the leading causes of death, even in developing countries."

The Tobacco Use Research Center will operate through USC's Institute for Health Promotion and Disease Prevention Research, a unique unit celebrating its 20th year and drawing on faculty from varied disciplines including communication, education, film, psychology and medicine.

Johnson also directs that institute, which has a strong record of health promotion efforts related to tobacco, and is linked to other important campus resources such as the USC/Norris Comprehensive Cancer Center and the USC Neurogenetic Institute.

Johnson says because of the university's expertise in community-based alcohol, drug and tobacco prevention research, establishing a center of this kind at USC makes sense because the culture of Los Angeles is highly diverse.

Even so, it is hard enough to prevent smoking in a static environment-the changing demographics of Southern California make prevention a moving target. Latino, Pacific Islander and Asian populations in California are growing rapidly. Together, they are expected to make up more than 60 percent of the state's population by 2025-up from 40 percent in 1995. They will comprise 75 percent of the state's public school population.

California's school-based smoking prevention programs must start addressing the different cultures, lifestyles, issues and experiences of immigrant teenagers, Johnson says, noting that most current programs were developed for and tested in non-Pacific Rim populations. Those programs' messages may prove ineffective or irrelevant for populations for which they were not designed.

Researchers, from anthropologists and statisticians to physicians and public health specialists, will unite through the Tobacco Use Research Center to uncover the subtle and complex effects of mingling cultures, acculturation, advertising and media and social networks among teen-agers.

Issues may be different for Mexican immigrant youth than for second-generation Mexican-Americans, for example. Chinese-American youth living in multicultural areas may face different pressures than their peers in mostly Chinese neighborhoods.

Researchers have found that adolescent Vietnamese, Cambodians and Laotians, as well as South Americans, tend to smoke a lot when they arrive in the United States, but smoke less over time. Chinese and Mexican youth, meanwhile, tend to smoke more as they ease into American life.

The Tobacco Use Research Center will try to determine what accounts for such differences. Researchers will carry out trials to assess new ways to discourage tobacco use and track population characteristics and trends in California and the Pacific Rim. They will use the results to better tailor prevention trials to specific cultures within ethnic groups.

The researchers also will develop user-friendly databases on tobacco prevention and demographics for others to share. They will encourage tobacco programs outside USC to draw on research from the Tobacco Use Research Center and urge policymakers to use the center's findings to develop new tobacco laws, guidelines and programs.

Tobacco Use Research Center scientists are working with youths in 62 middle schools throughout California and Hawaii. Lourdes Baezconde-Garbanati, Ph.D., M.P.H., research assistant professor in preventive medicine, will lead community outreach efforts. She has worked in tobacco education among Latino groups since 1989.

Baezconde-Garbanati says she sees her role in the community outreach core as that of an "information broker," assessing what research the community would find most helpful to improve anti-smoking efforts, and disseminating the latest research findings to various audiences.

"The goal is to develop effective prevention programs that can reach these kids and their families in very particular ways, and not solely through the media," she says. Rather, the programs will use school-based education programs, family members and peer groups.

For example, the Tobacco Use Research Center uses focus groups of young Latinos and Asian/Pacific Islanders to help determine the factors that can predispose or prevent the acquisition of a smoking habit. Data from the focus groups and other sources help develop surveys that use the language, cultural expressions and values of the target audience members.

"Youth in various cultures may have different ways of defining smoking and they may smoke more than just cigarettes. They may call cigarettes something else, so when you ask 'How much do you smoke?' they may be thinking 'Smoke what?' because they could think you're asking about marijuana use instead of cigarettes or tobacco," she explains.

Using a variety of research methods and combining different disciplines, the Tobacco Use Research Center will focus on which messages youths respond to best and in what manner those messages are best conveyed.

"We know that kids like to be communicated with-not lectured to. We know that intuitively. Having research that underscores that is important and how to best communicate tobacco prevention information, especially in various cultural groups, will help us develop effective prevention programs and school-based curricula that can reach them to prevent tobacco use uptake or progression to addiction among those already smoking," says Baezconde-Garbanati.

Conversely, the Tobacco Use Research Center will look at what anti-smoking messages do not work and identify why not.

"In an effort to comply with the Tobacco Industry Master Settlement Agreement in various states, and to remake their corporate image, the tobacco industry itself disseminates anti-smoking messages. But these are not the most effective to prevent kids from smoking. One example is the 'We card' television campaign that refers to stickers at retailing outlets that warn those under 18 against trying to purchase cigarettes," Baezconde-Garbanati says.

"That message gives the impression that the tobacco industry companies are doing a good job about preventing youth access to tobacco products. But in California, the problem with underage smoking isn't as much that kids are buying cigarettes themselves from retailers, but they're getting them from friends and family members. So, the industry is focusing on anti-smoking messages in an area that for California is of less importance to curb youth access to cigarettes than other areas. Therefore, the message is ineffective as an anti-smoking message," she says.

She points out, "If new smokers are not recruited on a daily basis, it is not good business for an industry selling this product. They're savvy in how they do their work and they have some of the best minds in the business to get their message out. We can't match tobacco industry dollars, so for us to make a difference it takes more than money. It takes passion, commitment and interventions based on the most tailored, scientifically proven and effective strategies."

The research will address the health of people in other parts of the world as well. USC investigators at the Tobacco Use Research Center have formed a unique collaboration with health officials in the city of Wuhan in central China to uncover solutions to smoking problems among the Chinese, Johnson says.

About 70 percent of Chinese men smoke, and the nation has few governmental resources to combat the habit. Li Yan, chief physician and director of the Public Health and Anti-Epidemic Station in Wuhan, is working with USC researchers to coordinate projects involving smokers in China.

The goal of the study is to test a program that was found to be effective in reducing smoking among American youths to see if it also works in a culturally homogenous region that has few Western influences and a strong propensity for smoking. If so, it could help improve anti-smoking efforts elsewhere as well.

In addition, researcher Elahi Nezami, Ph.D., director for undergraduate studies for the Institute for Prevention Research, is examining a theory that suggests that people smoke as a way to avoid negative moods or feelings such as depression or anxiety-essentially using cigarettes as self-medication.

Because depressed adolescents often feel a greater need for acceptance, they may be more likely to smoke if their peers do. To test the theory, Nezami is studying the smoking behavior of seventh grade students in China, Iran and the U.S. and attempting to ascertain how psychological variables, acculturation levels and social norms can be used to predict smoking behavior.

Researcher Tess Boley-Cruz, Ph.D., also at the Institute for Prevention Research, is heading a study that examines the effects of both pro- and anti-tobacco advertising in California. Surveying more than 40,000 adolescents and 20,000 adults, her team will investigate how both affect their targets' attitudes about smoking and how to use that information to further bolster smoking prevention efforts.

Other researchers, including Johnson, hope to combine data from studies by their peers with medical data culled from 5,000 seventh grade students from a cross-sectional study of risk factors associated with respiratory illness. The study will examine the relationship between a child's exposure to tobacco smoke in the first three years of life and during later years and adolescence and also look at how genetic factors interact with environment to modify the risk of illness.

Johnson says these and other research programs now getting underway at the Transdisciplinary Tobacco Use Research Center have significant potential to improve our understanding of how tobacco use propagates and answer the riddle of how to stop it. Perhaps more importantly, he says, "Because of the real attention we're paying to community outreach, there's an opportunity for policy makers and individuals to benefit by reducing their own risks."

Alicia Di Rado contributed to this article.

 

For more information about the Transdisciplinary Tobacco Use Research Center, or to learn more about The Doctors of USC, call 1-800-USC-CARE (1-800-872-2273) or visit www.usc.edu/go/usc-care.

Products from patches to gum are available to help people quit smoking. But what if it is too hard to quit on your own?

Help can be found. The USC Smoking Cessation Program, a seven-week comprehensive course to kick the tobacco habit and prevent disease, opened to patients in September 1999.

"If you can quit on your own, that's great, but this type of course increases the chance you can quit, and stay quit," says Jonathan Weiner, M.D., assistant professor of clinical medicine and leader of the program. Few such programs are led by physicians, making the USC program unique.

Before starting the program at USC, Weiner was trained in the treatment of smoking addiction through a course designed by the American Lung Association, which emphasizes addressing both the emotional pull of cigarettes and the physical addiction of nicotine.

Smoking is a complicated addiction that requires expertise in a systematic approach to quitting, Weiner says. Participants in the program get personal attention and support. Smoking cessation programs using the Lung Association's techniques have helped 80 percent of their participants quit, he adds.

First, a program participant gets an office visit with Weiner, who takes a medical history and asks about a patient's smoking habits and family history of tobacco use to determine a path of treatment, including medications available to curb the addiction.

Next, program patients attend group therapy meetings once a week. Their first assignment: keep track of when they smoke and the circumstances under which they do it, such as during a coffee break or when driving to work.

Once patients find out the triggers for their smoking, Weiner employs behavior modification techniques, helping patients discover ways to avoid the triggers or replace the habit with other pastimes.

By the third week, participants reach their "quit day"-the day they stop smoking. Weiner follows up with them by phone to see how they are faring.

During the remainder of the program, patients talk about coping with being a non-smoker and get encouraging feedback for their accomplishments. Each has a buddy to turn to when temptations arise. Patients also get a relaxation tape and maintenance manual, as well as a package of materials including information on addiction, withdrawal, weight gain and stress management.

Cigarette and cigar smokers are eligible for the program, along with those who chew tobacco. Brochures and information are available through 1-800-USC-CARE (1-800-872-2273).

 

 

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