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Assessment smoking among teenagers is on the rise. Statistics have shown that smoking trends were decreasing between 1976 and 1985 by approximately 10%, but have started to climb since the early 1990’s (Lawrence 1999). Over the last decade, there has been more than a seventy- percent increase in youth smoking. The average age of onset of smoking is fourteen years old. Ninety percent of those who smoke began before the age of eighteen. (www.healthierohio.org.).

Not all adolescents are at the same risk level to smoke. Studies have been done that demonstrate who is at more risk to smoke than others are, but adolescents of every race, socioeconomic, and sex are affected. Smoking rates are more than doubled among white adolescents than African American adolescents are. “Children who are more committed to education, religion, and family are, in general, at lower risk for cigarette use” (Lawrence, 1999, p699).

Smoking is not a disease, but it is an addiction that usually begins among high school students. An addiction is a compulsive psychological need for a habit-forming substance such as nicotine. There are eight major risk factors that contribute to adolescent smoking. The first one is the social influences (an environmental factor) in a teen’s life. There are two types of social influences, direct and indirect. The direct social influences are all of the effects that peers and family have on a youth smoking. Peers demonstrate to each other the ease of obtaining cigarettes and the message that smoking is a normal and necessary aspect of the peer group. (Lamkin 1998). Parental influences regarding smoking has shown to “be a significant, general factor promoting youth smoking, even greater than peer smoking and socioeconomic status.” (Males, 1995, p228).

The indirect social influences include the effects of the media and tobacco advertisers. They create a positive attitude related to smoking in adolescent’s minds. “Adolescents are more likely to believe information presented by sources when less certain about their own opinions.” (Lamkin, 1998, p129). Tobacco-industry documents show that they have been targeting youth as young as nine years old through their advertisements. The top three brands that are advertised the most to target youth are Marlboro, Camel, and Newport. (www.healthierohio.org.)

The next risk factor, psychological factors (environmental factor), consists of two parts. The first is depression or negative affect in adolescents. Depression is a risk factor because smoking helps an adolescent to deal with their emotions and feeling of stress. (Adolescents and Smoking 5) The second is self-efficacy. An adolescent’s level of self-efficacy determines whether coping behaviors will be used successfully in the face of obstacles. Therefore, by ensuring that an adolescent feels confident about himself to abstain from smoking would eliminate this risk factor. (Lamkin 1998).

The race (host) of an adolescent as a predictor of smoking is more prevalent in some races more than others are. In the MMWR (April 1998), it states that Caucasian high school students have a higher rate of use and risk versus Hispanic and Black students. Substantial increases in smoking have occurred over the last decade in all races, but especially among White students. (Lawrence 1999). “In a recent study, 80% of African-American parents said they have a “no smoking” rule in the home as compared to 48% of white parents” (www.healthierohio.org).

The fourth risk factor of youth smoking is the sex (host) of the adolescent. Overall, females have greater risk of onset of smoking than males. This stays true throughout the races studied. There is a particular vulnerability to smoking especially among white female students, who consistently hold the highest rates among all of the groups studied. (Lawrence 1999). For example, 39.9% of White females smoke and 39.6% of White males smoke. (MMWR 1998).

Social bonding (environmental factor) is a predictor of smoking that includes the adolescent’s family and peer bonding, school influences, and religiosity. Conrad (1992) found that 71% of the subjects studied, there was a correlation between social bonding and a risk of smoking. (Adolescents and Smoking 6) Interpersonal, personality, and self-image (environmental factor) of adolescents are predictors of smoking. Students who exhibited rebellious, risk taking, shyness, submissive, and aggressive behaviors were all found to be positive predictors to the onset of smoking. (Conrad 1992). Intentions (environmental factor) to smoke predicted the onset of smoking 89% of the time. Intentions to smoke means that the adolescent intended to smoke when they got older. This is a higher risk factor for high school students than any other grade level. (Conrad 1992).

The final risk factor of adolescent smoking is previous exposure (agent). Other exposure to alcohol use and other substance use such as marijuana consistently predicts the onset of smoking in adolescents. (Conrad 1992) With these risk factors, this will explain how the natural history of disease affects adolescents and smoking.

The natural history of smoking involves the prepathogenesis, early, middle, and advanced pathogenesis period. Only the prepathogenesis and the early pathogenesis stages involve the high school adolescent. The prepathogenesis period takes into account the interrelations between the agent, host, and environmental factors. This period is the pre-exposure or susceptibility that the host has. The definition of the host is a person or organism that is capable of being infected by the agent. In this case, it is the high school student. The agent is the primary cause of a health-related condition, or the cigarette. The environment is all of the external conditions and influences that affect life and the host’s development. This includes the host’s influence that is from peers and parents, their lifestyle and school performance, sociodemographic characteristics (such as poor home environments), and the positive portrayal of cigarette smoking within the media, movies, magazines, etc. The previous factors are all prepathogenesis, before the high school students begins to smoke.

Early pathogenesis is in the preclinical stage. The agent, a cigarette, is introduced to the host at this time. In other words, the adolescent takes his first smoke on a cigarette. During the middle pathogenesis, tissue and physiologic changes occur. For example, the inhalation of cigarette smoke increases airway resistance, reduces ciliary action, increases mucus production, causes thickening of the alveolar-capillary membrane, and causes bronchial walls to thicken and lose their elasticity. (Taylor 1997) Signs and symptoms of addiction or withdraw also begin to occur now. “Nicotine addiction develops over the course of five stages in adolescents, with a progression starting with initial trying and ending with nicotine addiction.” (Lamkin, 1998, p 130) There is typically a two or three year interval from the initiation of smoking to addiction of nicotine.

Over one half of adolescents who try to quit smoking suffer from withdrawal symptoms. Illness and disability occur in the final stage, advanced pathogenesis. Some example of illness and disease that are caused by smoking include lung cancer, cardiovascular disease, and hypertension. Short-term effects include cough, dyspnea on exertion, decreased overall fitness, phlegm production and respiratory illnesses. Middle and advanced pathogenesis have to do with the long term effects of smoking, therefore, is not an immediate effect of high school students. (Adolescents and Smoking 8)

The progression from pre-exposure to resolution of adolescent smoking begins during the prepathogenesis period. During this period, the host, environment, and agent all come into play. The host, or adolescent and their environment interact. The more environmental factors that influence the host, the more their risk for smoking increases. The agent or cigarette is then introduced. When all 3 factors of the epi triad are introduced to each other, what is left is a high school student with a high probability of smoking. Once we identify the risks of smoking, we now have an adolescent who has begun to smoke cigarettes. This is the first step in the process of becoming a smoker, initiation (trying the first cigarette). Next, experimental smoking occurs (less than weekly). The end result, or step three of the process, is a regular smoker (at least weekly). (Whaley and Wong 1999)

The nicotine from the cigarette produces a feeling of “well-being, increases mental acuity and ability to concentrate, and heightens one’s sense of purpose. Nicotine may also exert a calming effect on the smoker” (Clark, 1999, p 864). Unfortunately, it is an abusive substance. There are two possibilities for the resolution of smoking. The adolescent can either continue smoking throughout his or her lifetime, resulting in a chronic disease or illness, or quit smoking before any severely damaging effects occur.

The Tobacco Coalition provides a four-step program to quit smoking. Step one involves writing down your reasons you want to quit smoking and reading it daily. Then wrap the pack of cigarettes with paper and rubber bands. When you smoke, (Adolescents and Smoking 20) write down the time of day and how important the cigarette is to you on a scale of one to five. Rewrap the cigarettes. During step two, continue reading the list of reasons and add to it when possible. Do not carry matches or a lighter with you and keep the pack of cigarettes out of reach. Each day, try to smoke less often. Continue with the second step during step three. Do not buy a new pack until the old one is completely finished. Change brands throughout the week, decreasing the amount of tar and nicotine with each pack bought. Try to stop smoking for forty-eight hours at one time. The final step is when you quit smoking completely. Doing deep breathing exercises when the urge to smoke hits helps make it through the desire to smoke. (www.healthierohio.org). This plan needs to be accessible to school officials and adolescents.

Early detection of smoking is the key to the resolution of smoking. If a student is caught smoking anywhere on school grounds or at a school activity, not only should they be reprimanded through the school for disobeying rules, but also a letter should be sent home to the parents to inform them of the illegal activity that their child is doing. Part of the punishment that should be included through the school is a mandatory health education class about the effects of smoking. The school can set up a class like this themselves, or possibly through the local hospital or health department. An example of early detection and casefinding can include a lecture during their health education class about assessing their level of self-esteem and their vulnerability to peer pressure. When students are found to have low self-esteem or vulnerable to their peer pressure, they can be directed to perhaps the school nurse or guidance counselor to help them with this. (Adolescents and Smoking 21) Hopefully, through some guidance, the teen will be able to quit smoking.

This plan will need cooperation from everyone. Within the school district, members will have to come together to create programs for self-esteem and peer pressure classes, health education classes about the effects of smoking, and enforcing the faculty to address parents of their child’s behavior. Law enforcement will play a major role in the plan to prevent adolescent smoking. Officers will have to patrol stores as often as possible and during sensible times of day. The media needs to be encouraged to send messages to teens about the negative aspects of smoking and to ban tobacco advertisements that are aimed at young readers. This plan would be simple to evaluate. Surveys would need to be conducted to compare the percentage of high school students who smoke prior to the plan and compare it with the amount of students who smoke each year to see if the plan is having an effect on the number of smokers. The surveys would need to be anonymous in order to avoid students lying about their habits due to fear of being caught. If there is a substantial decrease each year, and then continue on with the designated plan. If the number of students who smoke is not decreasing, the interventions mentioned need to either be enforced more or adjusted. (Adolescents and Smoking 22) The key is to continue educating the students about the effects of smoking before they begin to smoke.

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