Perspective: Lighting up

Brad Breuer is what we like to call a "social smoker." He quit -- more or less -- in December. The combination of rising prices, concerns over physical well-being and a family history of heart problems provided a convincing argument. Yet the College freshman still lights up on the weekends. After all, why not? Herein lies the smoker's paradox -- though cigarette smoking is taking on an increasingly negative stereotype, smoking numbers among college students remain steadily on the rise. "If I'm out at a party and drinking, I'll definitely have a few cigarettes," Breuer says. "It's very image-based. At a party, there's so much loud music that you can't really talk so you drink or smoke." But Brad started smoking well before he started college partying -- at the age of 15. He was in Germany for the summer, away from his parents, with a group of friends. "We were on our own and experimenting with alcohol and smoking," he says. "Plus, the culture made them so accessible -- they sold cigarettes from vending machines or in singles." And while Breuer claims that German culture was the catalyst, the habit followed him all the way to boarding school in Wales. It was there, at the age of 16, that he became a full-fledged smoker. "It was a small international school, and everyone smoked," he says. "It was a very social thing, and it was glamorous to sneak away for a cigarette." Now at 20 years old, Breuer doesn't think he'll ever be able to quit completely. "I just really think there's something in them that makes it impossible for me to kick the habit forever," he says, possibly referring to the nicotine. "I'll always go back to smoking, and I think that holds true for all smokers." • Unfortunately, Breuer's situation is not unusual. He is just another one of the millions of Americans trying to quit. Because of this very epidemic, Penn and Georgetown University received funding in 1999 from the National Cancer Institute and the National Institute for Drug Abuse to start a Transdisciplinary Tobacco Use Research Center. TTURC is dedicated to the study of tobacco use and nicotine addiction, something in which students like Breuer would be very interested. TTURC Director Caryn Lerman was recruited from Georgetown and came to Penn in July 2001. Currently, two Penn TTURC studies led by Lerman are investigating whether smoking cessation therapies can be tailored to smokers' genotypes. TTURC is one of seven research centers across the United States studying different aspects of nicotine addiction and tobacco use. Each research center studies a different smoking-related theme. For instance, the Penn TTURC is focused on linking genetic factors with smoking behavior. "The mission of the Penn TTURC is to obtain a more complete understanding of the role of specific genetic factors and bio-behavioral mechanisms in tobacco addiction," Lerman explains, "and to apply this knowledge to tobacco use prevention and treatment." As the title explains, the TTURC centers use a transdisciplinary approach to research that the Penn center embraces as well. Drawing on Penn's School of Medicine, Annenberg School for Communication as well as the Department of Psychiatry, TTURC manages to incorporate a variety of disciplines to further its research. But the center is providing more than just data. Through Quit for Health, the Penn TTURC is offering a free smoking cessation program for people living in the Philadelphia area. Participants 18 and older attend professional smoking-cessation group counseling sessions and receive stop-smoking medications free of charge. Students who wish to participate can visit the TTURC Web site at http://www.med.upenn.edu/tturc/. • As part of the Penn TTURC, Psychiatry Professor Janet Audrain-McGovern is conducting an innovative treatment study -- to begin sometime this summer -- investigating approaches to reduce smoking among college students. "This summer's study is specifically focused on college students who smoke," Audrain-McGovern says. "And it's not just Penn students -- it's students around the Philadelphia area at a variety of universities." The study comes just in time -- as rates of college students who smoke continue to increase. In a 2001-2002 survey conducted by the Office of Health Education, results showed that 22 percent of Penn students smoke cigarettes regularly, with the numbers jumping to 36 percent when cigars were included. While the data is below the national average, further studies suggest a problem unique to Penn. In a 2000 study conducted by the Department of Earth and Environmental Science, results uncovered a disturbing trend -- of those students who now smoke regularly, 25 percent began as Penn freshmen. Audrain-McGovern hopes to study the behavioral basis for these smoking patterns in an effort to develop more effective smoking cessation programs. "The rates of college students smoking have increased, and that's of course always alarming," she says. "Our knowledge about it has not paralleled the increase in how many students are smoking." Jessica Hitt, a College senior, is a case in point. She had her first cigarette when she was in the eighth grade. "I was hanging out with an older group of people who all smoked, and they offered me a cigarette so I said, 'OK,'" she remembers. "I grew up with three heavy smokers, but I never had a desire to try one until a friend offered it to me." But over the next few years, Hitt gradually began smoking more and more. Like Breuer, her habit really took hold when she went to boarding school. "We were in the middle of nowhere, and it was a way to get out of the area to do something we weren't supposed to do," she says. "Plus, there were a lot of international students there, and they all smoked." Hitt has tried to "quit smoking" quite a few times, always to no avail. And the behavioral factors that contribute to Hitt's inability to fully quit provide the basis for Audrain-McGovern's study. This summer's study is specifically targeting factors unique to the college experience. "Older people don't understand the stressors behind getting a paper in or studying for exams or breaking up with your significant other,"Audrain-McGovern says, referring to some of the very factors that cause Hitt to light up. "The biggest part of smoking is behavioral," she continues. "Many people quit smoking meaning they can give up the nicotine, but the problem is that they relapse later, usually for the behavioral reasons. It's the over-learned habit that makes most people relapse." Behavioral factors that contribute to the addiction include alcohol consumption, stress, weight loss and social pressures. "I can't count how many times I've said, 'That's it, I'm quitting,'" Hitt says ruefully. "The biggest problem is when I'm drinking. Even when I have this rock solid desire not to smoke, when I start drinking, I feel weird not having a cigarette." And when she adds academics to alcohol, it's a mixture for disaster -- after all, she says another big factor that triggers her habit is the stress that plagues all college students. "If I'm pulling an all-nighter, writing a paper, alone at my computer all night, then I'll have a few to take a break and keep me awake," she says. Audrain-McGovern's study will not only investigate the factors that trigger smoking but will also offer help to students like Hitt who want to quit without being reduced to trying the local Student Health Service. "We want to help college students who want to quit," Audrain-McGovern says. "It's more appealing for college students to be in smoking programs with participants who are their own age." The study, funded by the National Cancer Institute, will yield results with more far-reaching consequences than just smoking cessation. "Smoking is a great contributor to cancer, so quitting smoking is one of the biggest things you can do to prevent many cancers and cardiovascular-related illnesses," she says. "It is probably the biggest premature cause of death in the U.S." Yet, in spite of these grim statistics, students like Hitt continue to smoke. However, there is hope. Despite the role of cigarettes as a stay-awake crutch -- not to mention the fact that previous attempts to quit have failed -- Hitt thinks that someday she will be able to kick the habit. "Once I get out of college is sort of the limit I've set for myself," she says. "I want to be a lawyer and have kids so I will quit for that." Still, not even a law school student yet, that future looms distant -- "Right now, the thought of never having another cigarette again in my life is completely ridiculous," she says. In fact, the 2000 study conducted by the Department of Earth and Environmental Science indicated that 80 percent of Penn smokers planned to quit after graduation. However, if national data are any indicator, only 25 percent of these attempts will be successful. • Environmental Science Professor Bob Giegengack is more interested in preventing people like Hitt from picking up a cigarette in the first place than in smoking cessation for those already addicted. As one of two professors for Environmental Studies 407 -- Prevention of Tobacco Addiction Among Pre-Adolescent Children in Philadelphia -- Giegengack is trying to stop the habit before it begins. "We know that it takes a lot of time and lot of money and a lot of attention trying to get people to quit, and the quit rate is extremely low and it's expensive," he says. "Then I realized if you had a certain amount of money to spend, it makes a lot more sense to keep people from starting smoking than it does to try to spend that same money to get them to stop after they've started because those efforts have been terribly unsuccessful." Giegengack's approach involves throwing out as many nasty facts about smoking as his students can stomach. He's hoping that guest speakers from the medical school will give students like Breuer -- a Giegengack protege -- the facts to turn down the glamorous offer of his first cigarette, and graphic pictures of blackened lungs to help someone like Hitt refuse the peer pressure of her older friends. Enter his class -- a mixture of Environmental Studies and community service. Students spend the first half of the semester learning about the evils of smoking. Then they take the knowledge they've accumulated out into the real world. This second half of the course involves, in addition to weekly lectures, a six-week teaching program that sends students to local Philadelphia middle schools to teach classes about smoking prevention. "When they know enough to be effective, we send them into the middle schools," he says. "This way, these teenage kids learn the real expression of independence is to tell the tobacco companies to buzz off." "You see," Giegengack says, "the tobacco companies have known a lot more about nicotine addiction than the medical community has for a long long time. They know the most vulnerable people to acquire the addiction are young teenagers, and they've designed their advertising accordingly." His class, then, is an attempt to level the playing field. And his students are enthusiastic, eagerly discussing various aspects of lesson plans and survey questions. Yesterday was their first day in the middle school classrooms. "Remember, they think you're cool," says Elaine Wright, the other teacher of the course, offering words of encouragement. "And you are cool. You know ample amounts, and hopefully they'll all get the picture. You'll be fine." • Times are changing along with what is considered socially acceptable. Smoking -- once the signature of the sophisticated socialite and James Dean movies -- is now turning into a societal stigma. "People at Penn now have a very negative connotation of smoking," Breuer says. "I get a lot of friends pressuring me and saying it's gross." Hitt, too, feels pressure to quit. "I think that even within the time span that I've been here, perceptions have changed," she says. "There is a stronger negative stereotype, fewer people smoke, fewer places allow smoking and fewer people have a tolerance for smokers now." Now that is one thing that TTURC, Audrain-McGovern and ENVS 407 would love to hear.

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