Each day, 3000 teens and preteens across the country smoke their first cigarette. By the time they reach middle school, some are already regular smokers—even as young as ages 10 and 11.

In fact, statistics from the Surgeon General's Office reveal that: Children and teenagers constitute the majority of all new smokers. In 1998, tobacco companies spent nearly $7 billion — more than $18 million a day — to advertise and promote cigarettes. These marketing dollars promote many activities that appeal to young people. One tobacco company, the Liggett Group, Inc., has admitted that the entire tobacco industry conspired to market cigarettes to children. Money from the tobacco settlement has enabled states to produce anti-smoking ad campaigns — some of them with promising early results, such as Florida's and California's. Still, physician input is critical in preventing people from smoking and helping them to stop, according to Tammy Sims, MD. This is particularly true for teens. Sims is the newest member of the Center for Tobacco Research and Interven-tion at the University of Wisconsin Medical School, and has extensive experience in smoking cessation, especially with teenagers. "Kids will listen more to their doctor than other adults," Sims said, "so we have a great opportunity here to help kids make healthy choices." She acknowledges that peer pressure is sometimes too great to overcome, and some teens see themselves as rebels and nonconformists when they light up a cigarette. Furthermore, there is a tendency among some teens who are generally good students, involved in extracurricular activities and rarely get in trouble to be casual smokers. They want to try to avoid the "the goody two shoes" tag. So, occasionally they smoke a cigarette or two; it's considered "bad" but also appears less harmful than alcohol, marijuana, ecstasy, cocaine or other drugs. Often, this opinion is mirrored by parents and schools. "Just because cigarettes are legal, they are seen as a lesser evil," Sims said, "but, of course, tobacco remains a huge problem." That is where physicians can help. "Health care providers, educators and parents need to continually address the issue of smoking," said Sims. "Even casual smokers—the kids who only do it once in a while. We need to address this with prevention education in schools." The State Medical Society offers one way for physicians to deter young smokers. Targeted at middle school students, "Smoking: Truth or Dare?" brings SMS members into their local classrooms. Following a 50-minute video where real teens follow doctors and hospital patients as they learn about the terrible effects of smoking, physicians offer a local anti-smoking message and take part in a question-and- answer period. In the video two young women see computer simulations of the negative effects smoking will have on how they age. Young baseball players meet a former pro who had his jaw partially removed after contracting mouth cancer from chewing tobacco. Originally aired statewide by SMS, the video received tremendous acclaim, leading to a collaboration with WEAC, which produced the lesson plan. Educator, physician and student feedback to the program has been overwhelmingly positive. But physicians don't have to leave their offices to impact adolescent tobacco use. "Start informing kids about the dangers of tobacco at a young age, and keep it up," Sims said. "Let young kids know smoking is bad. It's never too early to start counseling against smoking. It should be part of every well-child visit." Unfortunately, too often that's not the case. Sims completed a study to determine whether health care providers addressed tobacco use with their young patients and found that the rate was low. "We are not doing a good job, though we think we are," she said. "We realize that it is due to time constraints, and also a lack of reimbursement for services. And, frankly, many are not convinced that it is going to make a difference. Some do not feel they are equipped to deal with it. In the past, tobacco cessation was not part of the curriculum in medical school. But now there are CME courses offered to do this." Sims says there are many resources available for physicians to help patients who want to stop smoking, including the Wisconsin Quit Line (1-877-270-STOP). "The Quit Line is up and running," she said. "Physicians can refer their patients to it. It's good for adolescents as well as adults. Adolescents can get counseling, and it's confidential. And, for physicians, it's a good resource to use to get information for their patients as well as themselves." Additionally, Sims said the staff at CTRI or at the Quit Line can give physicians pointers on how to address teen smoking. "Teens aren't interested in the long-term effects," she explained. "Telling them that they will get emphysema and cancer 20 years from now is not relevant. But stressing the short-term negative effects of tobacco use and smoking works. So emphasize that the cigarette smell gets into clothes, hair, in the car; the stained teeth and bad breath, especially from smokeless tobacco; the burn holes in the car seats and on clothing; and for those interested in athletics, the decreased physical performance that accompanies smoking." Another tip for physicians who counsel teen patients who see smoking as rebellious: point out that while they think they are flouting authority or announcing their autonomy by smoking, they are actually being used by the multi-billion-dollar tobacco companies. Let them know that you can't be any more dependent than someone addicted to nicotine.

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