By Joseph Kays
Tobacco kills more Americans than AIDS, accidents, fires, illegal drugs and suicides combined," says University of Florida Dr. Mark Gold. "If we could get people to stop using tobacco, we could put many of our treatment centers out of business."
Gold and a host of University of Florida colleagues have been working for years to reduce tobacco use, particularly among children. Last August, their efforts got a dramatic boost when Florida Gov. Lawton Chiles and Attorney General Bob Butterworth announced that the tobacco industry had settled a lawsuit brought by the state for $11.3 billion. Shortly after that settlement was announced, UF administrators compiled a list of more than 60 current or proposed projects that could benefit from funding through the tobacco settlement.
"No amount of money will ever replace the lives and repair the families destroyed by tobacco illness," Chiles said upon accepting the first $750 million payment from the settlement. "These dollars are important because they'll provide us with the resources to break tobacco's deadly cycle and reach out to kids to ensure they'll never light up."
Gold couldn't agree more.
"For the first time, we have the resources to approach tobacco addiction from the causative point of view," Gold says. "We have an abundance of treatment centers for the outcomes of smoking - cancer, emphysema, heart disease - but a dearth of health centers committed to preventing smoking."
Addicted to Addictions
Mark Gold has been studying other people's addictions for 25 years.
The man the Journal of the American Medical Association called "the most prolific and brilliant of the addiction experts writing today," has served as an adviser to the Reagan, Bush and Clinton administrations. He has a badge from the Drug Enforcement Administration for a decade of service. He was the first person to write that people were actually smoking cocaine, what we now know as "crack."
Gold - a professor at the UF Brain Institute who holds joint appointments in the departments of psychiatry, neuroscience, and community health and family medicine - says nicotine has addictive properties that are strikingly similar to heroin, cocaine and marijuana, but tobacco is treated differently.
"Tobacco smoking is a social issue, a cultural issue, a political issue, an economic issue and a medical issue with no easy solutions," Gold writes in his 1995 book Tobacco. "Tobacco use is entrenched in our national psyche. It is viewed as a habit - a bad habit - but generally not an addiction."
The author of more than 700 professional articles and nearly 20 books, Gold spends much of his week conducting scientific research, writing and lecturing about addictions to health-care professionals at hospitals throughout the United States. He also has developed clinical and basic science training programs for UF medical students.
"Better training of current and future health-care professionals is a 'missing link' to any effective tobacco prevention effort," says Gold, who emphasizes smoking prevention as he works to develop new treatments for smokers.
"Most health-care providers have only minimal knowledge or skill in the prevention and treatment of addiction to tobacco products," Gold says. "Continuing medical education is the most effective way to provide doctors and nurses with a basic understanding so they can help their patients avoid developing or kick a tobacco habit."
Gold also has a long history of fighting addictions through the media. He was the medical consultant for the Media Partnership's classic "This is your brain on drugs" advertising campaign, and he serves on the boards of six of the nation's largest and most respected adolescent drug prevention groups.
"Every day, 3,000 children light up cigarettes for the first time, beginning a life-long road to poor health that will cause 25 percent of them to die prematurely," Gold writes in Tobacco. "Given the data that show smoking increasing in the adolescent population, it's not surprising that the tobacco industry has cynically targeted those under 21 for its marketing efforts."
Partners in Prevention
Venita Sposetti knows how adolescents think. She was once a ninth-grade science teacher.
"Middle school students are a group both vulnerable to the charms of substance abuse and suspicious of adults," Sposetti says. "The critical eye of youth requires you to be up to the nanosecond in terms of fashion. If you don't look and speak their language, they won't accept your message. They don't want to hear from us old and hopelessly out-of-date adults."
So Sposetti, an associate professor of dentistry, is using students from UF's six health-related colleges to provide a "hipper" message about substance abuse, including tobacco.
With a $240,000 grant from the Josiah Macy Jr. Foundation and additional funding from the Ounce of Prevention Fund of Florida and the North Florida Area Health Education Centers, Sposetti has arranged two days of special training on substance abuse for more than 600 students in medicine, dentistry, veterinary medicine, pharmacy, health professions and nursing. One day will focus exclusively on tobacco.
Those students then will translate that message to students at area middle schools.
"Health professions students have the potential to serve as appealing and positive role models for middle school students," Sposetti says. "They are still young enough to speak the middle school students' language, and they are living, breathing examples of what the middle school students can aspire to."
The program has the added benefit of "developing a culture of service and volunteerism" among future doctors and other health professionals "from the beginning of their formal instruction," Sposetti says.
"Health professions students have not yet had their attitudes and practice habits fully shaped and are more receptive to new information," Sposetti says. "We think this approach will cause them to learn the material in ways that will affect their personal and professional behavior."
With the assistance of specialists from throughout UF's Health Science Center, Sposetti and her colleagues are developing sets of educational materials on substance abuse. The materials for the health professions students are called POPS (Patient Oriented Problem Solving) and the materials for the middle-school students are called Team Packs.
Team Packs are designed to promote roll-playing among students. Similar team packs on such subjects as teen pregnancy and sexually transmitted diseases developed by Dr. Parker Small, a professor of pediatrics and pathology at UF who is a co-investigator on this project, have won national awards for their effectiveness and are now being used throughout the country.
The program will employ a "trigger video" to facilitate the UF students' presentations in the middle schools.
"The tape will show three to five short vignettes, such as an oral cancer patient talking about smokeless tobacco or someone talking about how bad breath from smoking is a turn-off for kissing," Sposetti says.
The program also hopes to link the younger students with the professional students via electronic mail.
"We hope to create some electronic pen pals," Sposetti says. "This would allow middle school students to ask questions and seek information from older mentors while allowing health professions students to reinforce their own knowledge base and continue volunteer service activity."
Just a Pinch
Smokeless tobacco is cool, right? It's safe, right?
Smokeless tobacco can cause mouth and throat cancer and is considered to be a "gateway" to cigarette smoking and other substance abuse.
But research indicates that message isn't getting through to kids, or to their parents.
Between 1970 and 1985, the number of American males between the ages of 12 and 24 who used smokeless tobacco increased from 1 percent to 26 percent, and 50 percent of the nation's smokeless tobacco users are in the South. In Florida, smokeless tobacco use among sixth- and eighth-grade students rose 13 percent between 1990 and 1992.
In contrast to cigarette smoking, more than one third of smokeless tobacco users report that an older relative first introduced them to the habit.
"Many family members encourage adolescents to try smokeless tobacco because they believe it is a safer alternative to cigarette smoking," say UF clinical psychology Professor James Rodrigue.
For her dissertation, University of Florida doctoral student Susannah P. Kury wanted to find out just what adolescents think about cigarette and smokeless tobacco use. Working with Rodrigue and clinical psychology Professor Michael Perri, Kury developed a series of videotapes that introduced a new student to more than 500 sixth-, seventh- and eighth-grade students in Florida's rural Bradford and Levy counties.
Kury recruited from a local theater group three actors judged "attractive" by a separate group of adolescents. She then videotaped six two-minute vignettes of the actors portraying a new student in the school. In one clip, the actor held a cigarette, and a pack of cigarettes was very apparent; in another, the actor appeared to be using smokeless tobacco, and a can of smokeless tobacco was very apparent; in the third clip, no tobacco products were present.
"The experimental conditions varied only in the actor's gender and the presence of a tobacco product," Kury says. "The script, surrounding environment, clothing and facial expressions of the actors remained constant for each videotape clip."
Using several established survey techniques, including a checklist of positive and negative adjectives about the person in the videotape, Kury sought to measure the students' attitudes toward the hypothetical peer. The students also filled out a separate questionnaire about their own tobacco use.
While the results were encouraging in that the students rated the actor without tobacco most favorably, they also showed that students had a more favorable attitude toward the actor using smokeless tobacco than toward the actor with a cigarette.
"This finding supports previous research indicating that smokeless tobacco carries fewer negative associations than cigarette smoking," Kury says.
Another interesting finding of Kury's research was that girls were more positive than boys about the male actor using smokeless tobacco.
"This finding is inconsistent with recent research that smokeless tobacco use is more accepted by males than by females," Kury says, and may explain why some boys who don't use smokeless tobacco report putting an empty can in their jeans pocket so they get a ring on the fabric.
"Positive perceptions by girls may serve as a primary motivation for boys to begin or continue using smokeless tobacco," Kury says.
Mary Wells, principal of Chiefland Middle School, where some of Kury's research was conducted, says the study's findings do not surprise her.
"Image is very important to children this age," Wells says, "and smokeless tobacco is very big in a rural community like ours, where the cowboy culture is strong."
Based on the results of Kury's research, Rodrigue would like to expand the research to other school districts and to implement an educational program to reduce smokeless tobacco use among young adolescents.
Chiles and the Florida Legislature already have earmarked $200 million from the tobacco settlement for the first phase of the Florida Kids Campaign Against Tobacco pilot program, and the Governor's budget being acted on by the Legislature this spring provides an additional $143 million to implement the next phase of the program. The budget also includes $175 million for preventive health grants and $20 million for research and facilities grants.
Based on their proposals, the many scientists conducting tobacco-related research at the University of Florida hope Florida's historic settlement with the tobacco industry will help them change the attitudes of children and adults about tobacco, and advance Gold's dream of rendering many of America's health-care facilities obsolete.
Dr. Mark Gold, Professor, Department of Psychiatry, (352) 392-0490, email@example.com
Dr. James Rodrigue, Department of Clinical and Health Psychology, (352) 395-0680, firstname.lastname@example.org
Dr. Venita Sposetti, Department of Prosthodontics, (352) 392-4231, email@example.com
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While many UF researchers concentrate on ways to deter people from smoking or chewing tobacco, some also focus on positive uses for the plant, which is farmed on about 7,700 acres in northern Florida.
Tobacco has been called the "white mouse of agricultural genetics research" because it accepts genetic changes faster and more easily than other plants. In an ironic scientific twist, molecular biologist Rob Ferl of UF's Institute of Food and Agricultural Sciences has genetically altered tobacco plants so that they produce ricin, a compound that destroys cells and provides exciting possibilities for cancer and HIV treatments.
IFAS plant pathology Professor Ernest Hiebert used genetics research on tobacco plants to make tomato plants naturally resistant to the tomato mottle geminivirus, which causes millions of dollars in damage annually to Florida's tomato industry. UF addiction expert Mark Gold also is studying some of the positive medicinal benefits of nicotine, such as a nicotine enema to treat colitis and the use of nicotine in appetite- suppression therapies.