The Need to Prevent Nicotine Addiction and Diabetes in Our Youth
The Role of School Health Programs
By Mary Tobacco and Mark Butterbrodt, MD, FAAP
Print version (PDF* 52k)
Introduction
The Centers for Disease Control’s“Guidelines for School
Health Programs to Prevent
Tobacco Use and Addiction”
states the “challenge to provide
effective tobacco-use prevention
programs to all young
persons is an ethical imperative.
Schools are ideal settings
in which to provide such programs
to all children and adolescents”
(Centers for Disease
Control Morbidity and Mortality
Weekly Report, 1994).
Tobacco use continues to be the leading
cause of preventable premature
mortality in the United States. Nicotine
addiction combined with type 2 diabetes
is an especially lethal combination
because of increased risk of heart attack,
stroke, and peripheral vascular disease.
Smoking may increase the risk for type 2
diabetes. There is even some evidence that passive exposure to cigarette smoke may increase diabetes risk.
People with type 2 diabetes need to
stop smoking and most importantly,
school children at increased risk for type
2 diabetes need to avoid smoking. School
health programs to prevent tobacco use
have enormous potential to increase lifespan
and quality of life in populations
at increased risk for type 2 diabetes. As
CDC Guidelines suggest, “School-based
tobacco prevention education programs
that focus on skills training approaches
have proven effective in reducing the
onset of smoking.” The positive effect of
school-based programs is magnified in
settings such as ours, in Pine Ridge Indian
Reservation in southeastern South
Dakota, where smoking and smokeless
tobacco use are epidemic and the risk of
type 2 diabetes is high.
Tobacco Use And Diabetes Risk
The dire consequences of having type 2
diabetes and continuing to smoke have
been appreciated for decades. In recent
years, research suggests that smoking
may increase the risk of developing type
2 diabetes. For example, in a Harvard
School of Public Health study of 114,247
female nurses, the risk of diabetes was
nearly 50 percent higher among women
who smoked 25 or more cigarettes per day
compared with nonsmokers, after adjusting
for obesity and other risk factors. The
study suggested that the more women
smoked, the greater the risk of diabetes
(Rimm et al, 1993).
The role of smoking as an independent
risk factor for type 2 diabetes probably
has been underappreciated. Most research
on the causes of the diabetes epidemic
have focused on the contributions of poor
diet, lack of exercise, and genetic factors.
There are many well-known reasons to
discourage smoking in school children.
Decreasing future risk of diabetes may be
yet another.
Our Pine Ridge Experience
The Oglala Lakota people of Pine Ridge
Indian Reservation, in southeastern
South Dakota, have the lowest life expectancy
of any people in the western
hemisphere, outside of Haiti, according
to Dr. Christopher Murray at Harvard’s
Center for Population Studies. The
deadly partnership of smoking and type
2 diabetes is responsible for much of
the preventable premature mortality in
Pine Ridge.
The multi-site Strong Heart Study,
which includes Pine Ridge Reservation,
revealed that over half of Oglala Lakota
people who survive into their forties or
fifties have type 2 diabetes (U.S. Department
of Health and Human Services,
2001). There are no reliable estimates of
the number of people who smoke in Pine
Ridge but we know the number is high.
Indian Health Service chart audits suggest
that over one third of people with diabetes
continue to smoke. A survey of school
children conducted by the Oglala Sioux
Tribe’s Health Education Department in
the spring of 2005 showed over 80 percent
were exposed to cigarette smoke in
the home, a somewhat larger percentage
than is found nationally.
When the Oglala Lakota Nation Wellness
Team, a coalition of concerned individuals
representing the schools, health
organizations, and tribal organizations
across the reservation, embarked on the
dual task of reducing diabetes risk and
smoking in Oglala Lakota people over
ten years ago, the schools seemed a logical
place to begin the battle. If this important
work does not happen in the schools, it
will probably not happen at all, at least in
remote places like Pine Ridge Reservation
and in many inner-city populations at increased
risk for type 2 diabetes.
As with many groups of people nationally
who are at risk for type 2 diabetes,
Oglala Lakota people face a number of
formidable obstacles, including distance
and lack of transportation in getting to
a medical provider. Our survey of local
medical providers revealed a lack of enthusiasm
for either primary prevention
of smoking or identifying and treating
school children and their parents who
are already addicted to nicotine. Ethnic
groups most at risk for type 2 diabetes, including
Latinos, African Americans, and
American Indians, are often less likely
than other Americans to have ready access
to preventive medical services. Busy inner-city clinics and remote, often understaffed
rural health facilities are less than
ideal settings for encouraging positive
lifestyle changes in school children and
their families. Hurried athletic participation
physicals, often the only non-emergent
visit by many inner-city and remote
rural school children to a healthcare provider,
are unpromising venues to encourage
positive lifestyle decisions.
Our thirteen tribal schools, scattered
across the reservation, became enthusiastic
partners with the Oglala Lakota
Wellness Team in the combined effort
to prevent smoking and type 2 diabetes.
We have made good progress with
most of the Centers for Disease Control’s
seven recommendations for school
health programs to prevent tobacco use
and addiction. Those seven recommendations
are:
- Develop and enforce a school policy
on tobacco use.
- Provide instruction about the
negative physiologic and social
consequences of tobacco use.
- Provide tobacco-use prevention
education in kindergarten through
12th grade.
- Provide program-specific training
for all teachers.
- Involve parents of families in
support of school-based programs
to prevent tobacco use.
- Support cessation efforts among
students and all school staff who
use tobacco.
- Assess the tobacco-use prevention
program at regular intervals.
Our thirteen school campuses are
now smoke free, in contrast to none
10 years ago. Numerous presentations
about the negative consequences of tobacco
use have been made via health
fairs, invited speakers, the American
Lung Association’s “Not On Tobacco”
(N-O-T) program, and health walks
in all schools and communities on the
reservation. Every school child in every
grade is exposed to at least some tobacco
use prevention education.
Some program-specific training for
teachers has been provided, but staff turnover
in our schools is high. We have had
some successes, though, especially with
one of our school nurses, a former heavy
smoker, who is now skilled in tobacco cessation
counseling. We have embarked on
a school-based program, funded by the
Aberdeen Area Tribal Chairmen’s Health
Board, to encourage families to sign a
smoke-free home pledge.
The last two recommendations have
been the most difficult for us. Many of
our school children in Pine Ridge initiate
smoking at an early age, and we recognize
the need to offer treatment in the schools.
We are initiating school-based clinics that
will offer nicotine addiction treatment
to students and staff in the reservation
schools this fall.
We also need to develop better assessment
tools for gauging the success
or failure of our efforts. Our experience
with program assessment has been mixed.
As with most people nationally, Lakota
people are anxious to please by saying the
right thing. For example, a stock answer
among our people to questions about passive
cigarette smoke is “We all smoke outside.”
A drive through the housing projects
in Pine Ridge suggests otherwise.
Conclusion
School nurses and school health programs
are in a unique and enviable position to
salvage many years of preventable premature
mortality by helping school children
make good decisions about smoking. This
is especially true in populations at risk for
type 2 diabetes, a disease whose effects are
compounded by smoking.
REFERENCES
“Guidelines for School Health Programs to Prevent
Tobacco Use and Addiction.” Centers for Disease
Control Morbidity and Mortality Weekly Report.
1994;43:1-18.
Rimm EB, Manson JE, Stampfer MJ, Colditz GA, Willett
WC, Rosner B, Hennekens CH, Speizer FE. Cigarette smoking and the risk of diabetes in women. Am J Public Health. 1993 Feb;83(2):211-4.
Strong Heart Study Data Book: A Report of American
Indian Communities: US Department of Health and Human Services, Public Health Service, Public Health Service, 2001; NIH publication no. 01-3285.
ABOUT THE AUTHOR
Mary Tobacco has been the Health Educator for the
Oglala Sioux Tribe since l995 and was a founding
member of the Oglala Lakota Nation Wellness Team.
Mark Butterbrodt, MD has worked for 27 years in inner
city and remote rural settings. He is a member of
the National Diabetes Education Program’s Diabetes in
Children and Adolescents Work Group.
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