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Prevention of Adolescent Smoking and Drug Use
Prevention in Primary Care
0031-3955/86 $0.00
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Prevention of Adolescent Smoking and Drug Use Ddnald Ian Macdonald, M.D. *
The use of tobacco, alcohol, and other drugs has become a health problem of increasing concern. Its most dangerous impact is on young people, particularly teenagers. A sharp increase in adolescent drug use began in the 1970s, and by 1979 more teens were using drugs than ever before. In 1985, almost 20 per cent of twelfth graders were regular cigarette smokers and nearly 62 per cent had had some experience with illicit drugs. Twenty years ago, most Americans knew little about drugs and few were aware of or concerned with the adverse consequences of these substances. Only in the late 1970s did American society and the medical profession begin to recognize the health consequences of drugs such as marijuana and the importance of drug use patterns among teenagers. Pediatricians should have a major role and responsibility in tobacco and drug abuse prevention. The pediatrician has the advantage of a long- \ term relationship with families and enjoys their confidence. He or she understands the developmental stages of children, the changing relationships between parents and children, and the personality traits that can make a child particularly susceptible to drug use. The power of a physician to deliver health promotion messages should not be underestimated. Parents look to pediatricians for advice, so messsages to parents on tobacco and drugs should be part of a general health message and should be delivered on a routine basis. Advice and suggestions from a trusted physician can be influential in promoting smoking, alcohol, and drug abstinence. Many factors are involved with drug use, and several models are used to address the issue of prevention. The standard public health model considers many diseases to be caused by 1) interaction of a susceptible host, with 2) a harmful agent (drugs), in 3) a suitable environment. Prevention must address each of these three factors. Too often prevention efforts focus on just one, such as changing the environment or helping the child to build up resistance skills. Some omit consideration of the addictive
*Administrator, Alcohol,
Drug Abuse, and Mental Health Administration, Rockville, Maryland
Pediatric Clinics of North America-Vol. 33, No.3, August 1986
995
996
DONALD IAN MACDONALD
nature of the chemicals and forget that experimentation with substances like tobacco, even in the strongest-willed teenager, can lead to dependence. The prevention strategy proposed here addresses the three factors of the public health model and is based on what I call the five As for Action: awareness, age, attitudes and acceptance, aversion, and availability. The five As provide a structure around which primary prevention (avoiding the use of tobacco and other drugs) and secondary prevention (early recognition of symptoms and intervention before problems accelerate) can be practiced. AWARENESS Before pediatricians become involved in prevention, they must be aware that there is a problem and that they can and should help. Physicians who care for children should view drug use as common, progressive, dangerous, but treatable. They should understand that dependence on alcohol and other drugs is a primary disease process in which the use of psychoactive substances is the cause of problems. Preexisting risk factors and pathology may be important in treatment, but unless drug use is seen as primary and handled first, treatment is likely to fail. The pediatrician can be especially important in helping to increase awareness among parents, schools, and community groups about the prevalence of smoking and drug use among teenagers. Chemical dependency is an altered state, produced by prolonged exposure to a drug or drugs, that necessitates continued administration to prevent the appearance of abstinence symptoms such as depression, irritability, and loneliness. Intervention and treatment are much more difficult when a child has reached the dependent stage. The disease of chemical dependency has strong family and public health implications and should be viewed as chronic and contagious. Chemical dependency can be diagnosed and, more important, prevented. Diagnosis and treatment are discussed in more detail elsewhere. 3 Drug use often is unrecognized by physicians trained to associate only the later stages of use with problems, but a high index of suspicion may help. Pediatricians who are sensitive to the symptoms that signal early drug involvement will be better able to detect drug use before a child becomes dependent. There are more than 23 million American youngsters aged 12 to 17. With 20 per cent of high school seniors smoking daily and nearly 3 million teens of ages 14 to 17 estimated to be problem drinkers (National Council of Alcoholism), it is highly likely that all pediatricians are seeing patients suffering from the effects of smoking, alcohol, or other drugs. In the United States, the levels of drug use are higher than in any other industrialized country in the world. A nationwide survey of more than 16,000 high school seniors, sponsored each year by the National Institute on Drug Abuse, has reported prevalence of drug use among successive cohorts of twelfth graders since 1975. The survey tracks trends in use of various classes of drugs, intensity of drug use, and use at earlier grades, as well as related attitudes and beliefs about drug, alcohol, and
997
PREVENTION OF ADOLESCENT SMOKING AND DRUG USE
Table 1. Trends in Drug Use Among High School Seniors CLASS OF
CLASS OF
CLASS OF
1975
1979
1985
Marijuana Ever used Used in past month Use daily
47 27 6
60 36 10
54 25 5
Alcohol Used in past month
68
71
66
6
6
5
37 27
34 25
30 19
9 2
15 6
17 7
Perceive as harmful to health Marijuana (regular use) Tobacco (pack a day) Cocaine (regularly)
43 51 73
42 63 70
67* 64* 80
Friends disapprove of use Marijuana (occasional use) Tobacco (pack a day) Marijuana (regular use)
55 64 75
48 73 70
63* 74* 79*
Use daily Cigarettes Used in past month Use daily Cocaine Ever used U sed in past month (regular use)
*1984 data. Data source: Johnston, 1984 and 1985.
tobacco use. 1 Table 1 provides an overview of trends from 1975 to 1985. It is important to remember that this survey reports use in high school seniors only and omits an estimated 15 per cent of young people who drop out before senior year. There is good reason to suspect that these dropouts are even more heavily involved. Despite a decline in the use of most drugs since 1980, use among young people continues to be a Significant problem. The latest survey reports that about 5 per cent of the senior class of 1985 drank alcohol daily and 5 per cent used marijuana daily. Heavy drinking (5 or more drinks on one occasion in the past 2 weeks) occurs in 37 per cent of the 1985 cohort, a slight decline from previous years. Cocaine use is an exception to the general decline of the past few years, and there is real concern over what appear to be rising levels of use. Cocaine use among teenagers is at an all-time high. In 1985, 6.7 per cent reported using cocaine in the month preceding the survey. This proportion was significantly higher than the 5.8 per cent reported in 1984 and the 4.9 per cent reported in 1983. The increased use of cocaine has important implications for the long-term health of this generation because of its highly addictive nature. A small increase in the number of seniors who have tried phencyclidine
998
DONALD IAN MACDONALD
piperdine (PCP) is also disturbing. This drug can be highly unpredictable and lead to violent outbursts, making it one of the most dangerous drugs available to teenagers. In 1984, more than one third of those admitted to a large adolescent psychiatric unit and to detention centers in Washington, D.C., had PCP-positive urine tests. AGE
Despite the decline in use of most drugs by high school seniors from 1978 to 1984, there is disturbing evidence that the age of first use continues to drop. Surveys of high school seniors report that illicit drug use was initiated during earlier grades for the more recent senior classes than for earlier class cohorts. Of the class of 1984, 48 per cent had used some illicit drug by tenth grade, compared to 37 per cent of the class of 1975. 1 A longitudinal study that tracked drug use in a cohort of adolescents in grades 10 and 11 and later at ages 23 and 24 reported that almost 20 per cent of the cohort had used alcohol by age 10; more than 50 per cent had tried alcohol by age 14. Because of immaturity and the many developmental changes that occur during adolescence, youngsters are particularly at risk for yielding to various pressures to smoke, drink, and use drugs. Adolescence is a time for testing new behaviors (often with some degree of risk), establishing one's individuality, developing a sense of autonomy, building an adult value system, and growing to physical and emotional maturity. Drug use, however, interferes with the progress to mature adulthood and may prolong immaturity and dependence indefinitely. Children of this age group want to belong, to be accepted by their peers. They therefore frequently are influenced by those from whom they seek acceptance into participating in behaviors such as smoking and drinking. Although youngsters may be aware of the health risks associated with smoking and drug use, the perceived social benefits of belonging to a group may override this knowledge. Other nonusers may be drawn into use because of curiosity, discomfort in the presence of users, fear of being ridiculed by peers, or a perception that "everyone" is using drugs. Involvement in drugs most often follows a predictable sequence: individual use usually begins with alcohol, progresses to tobacco or marijuana, and eventually may include to other illicit drugs. Cigarettes, a major health problem in their own right, are often associated with other drug use and may indicate of greater involvement in drugs. For girls, for example, tobacco seems to be an especially important predictor of subsequent escalation of drug use. 2• 6 These three, namely alcohol, tobacco, and marijuana, are frequently called the "gateway" drugs because their use greatly increases the probability of later use of other substances. Physicians who view use of these "gateway" drugs as fairly normal for adolescents need to reexamine the data. Studies have shown that susceptibility to drug use and abuse is increased in children who have low self-esteem, a feeling of not belonging, greater need for social approval, inadequate bonding to family and society,
PREVENTION OF ADOLESCE:-.IT S~lOKIKG AKD DRUG USE
999
inadequate communication and coping skills, inability to defer gratification, and inability to accept the logical consequences of their actions. For successful drug treatment, consideration of these characteristics is essential, but there are no data proving that prevention based solely on social competency is effective. Families need specific help in handling issues related to child-rearing and with the parenting skills necessary to help children become strong, healthy, and able to function effectively in an adult world. A natural role for the pediatrician is to offer parents anticipatory guidance. Anticipatory guidance should aim at advising parents on how best to raise a child with a good self-image, able to cope with stressful situations, and capable of mature and independent function. Children should be guided in their natural search for value and belief systems and for goals commensurate with their abilities.
ATTITUDES AND ACCEPTANCE Prevention should focus on attaining appropriate attitudes and practices for the community, the physician, the parent, and the child. Evidence shows clearly that societal, parental, and peer attitudes are strong determinants of drug use by the child. Smoking, using drugs, and drinking alcohol are all widely accepted in American culture. The media, which are very important in shaping public attitudes, abound with messages that these substances will make people feel good, relieve anxiety, increase athletic ability, and enhance beauty. Sports and entertainment figures are used to glamorize tobacco, alcohol, and other drugs. Advertising techniques are designed to influence children's attitudes in their favor: a beer is depicted as a reward for a day's work, a cigarette will make you look sophisticated, grown up, and attractive to the opposite sex. Pediatricians often are unwilling to express opinions on smoking, drinking, and drugs to patients or their parents because they believe these are moral issues and inappropriate subjects for medical conversation. Moral issues may be involved, but the pediatrician should comment because of concern for the child's health. My opinion on this is unequivocal; young people should not smoke, drink, or take illegal drugs. Pediatricians have a right and a responsibility to transmit their opinions and the medical facts about the dangers of drug use to patients and parents. Pediatricians who view drinking and smoking marijuana as a normal part of adolescence will deliver different messages to families than those who, aware of the risks, prescribe abstinence. Enough documented evidence exists to preclude any ambivalence about discouraging young persons from even experimental use of these substances. To understand addiction is to understand that the effect of psychoactive chemicals on the brain may be so stong that even the most competent and the most moral person may be unable to withstand the compulsion or craving that develops and leads to further use. Immature teenagers are particularly at risk. Postponement of experimentation is associated with lower risk of every trying cigarettes and other addicting
lOOO
DONALD IAN MACDONALD
substances. No one can predict with certainty who will become hooked except that those who never begin, never will. Parental attitudes and practices concerning smoking, drinking, and drugs strongly affect teenagers' later use. Children are more likely to smoke or use drugs if one or both parents do or if siblings do. In families in which parents express mild disapproval of marijuana use, children are more likely to be involved than are children from families in which disapproval is stronger. Strong parental control appears to be protective; a large degree of autonomy granted to an adolescent seems to be related to increased drug use. Community attitudes, often shaped by parents, that are permissive toward "keg parties" for teenagers, smoking areas in schools, and the inevitability of drug use, also influence adolescent practices. Parental influence will have more negative import when one of the parents is alcoholic or drug dependent. One in every eight American children is the child of an alcoholic parent and those children are at great risk from genetic, attitudinal, and family milieu, factors that promote several distorted behaviors in addition to increased risk of alcohol and drug misuse. Pediatricians should explore and comment on parental attitudes and practices about alcohol and other drugs. It is helpful to ask older children and teenagers, in the presence of their parents, if smoking, alcohol, and other drug discussions occur at home. Parents should be encouraged to become knowledgeable about drugs and to discuss drug-related issues with children. Many parents believe that smoking or trying alcohol or drugs is a passing and inevitable, if not accepted, phase of adolescence. The parents may "enable" continued drug use with this belief. When parental attitudes delay or impede intervention, family cohesiveness and support, already strained because of the child's changing behavior, are likely to be weakened. Parents should be counseled on achieving the difficult and changing balance between overprotection and underprotection. They should be helped to gauge their practices and be willing to modifY them based on the child's demonstration of competence, choice of peer group, and feelings of parental comfort. Raising children to maturity is a difficult process. Children must experiment and make their own choices, and parents must give the child the opportunity to make decisions consistent with the child's ability and demonstrated responsibility. Strong family support helps children to develop the personal values and self-confidence they need to resist peer pressure to use drugs. Young children, however, need protection from environments and stimuli that may be too powerful for them. Pediatricians should advise parents to establish clear and consistent family guidelines for children regarding acceptability of smoking, drinking, and drug use. Parents should not be reluctant to tell their children that they are opposed to any drug use and that they intend to enforce that position. Children who are left to "figure it out on their own" are often confused and may turn to their friends for the kind of guidance that the parent should be giving. Parents need to re-evaluate constantly how much responsibility their children are capable of. Particularly relevant is the problem of safety for
PREVENTION OF ADOLESCENT SMOKING AND DRUG USE
1001
the teenager who drives. Parents should consider letting the teenager know that driving while under the influence of alcohol or drugs will mean the car keys being taken away and driving reconsidered when the child is more mature. Parents can be more effective if they join with other parents. Parent groups, organized to reduce or eliminate adolescent drug use, have grown throughout the country. They have been increasingly successful in changing attitudes about the acceptability of drugs. These groups have worked for better drug education programs in schools, legislation against drugs, and have been largely responsible for ridding communities of shops that openly sold drug paraphernalia. While educating themselves, their children, and their communities about drugs, they also have taken action to provide adequate supervision, protection, and guidance for their children. With role models such as Nancy Reagan to lend names and support to the parent movement, attention has been drawn to the problems of drugs and youngsters, and people made aware of its seriousness and involved in the fight against drug abuse. The single strongest predictor of drug use in a child is the drug use pattern of a child's peer group. If a youngster's friends use and approve of drugs, the child is much more likely to become involved. National surveys that study attitudes about drug use among high school seniors are interesting. The use of marijuana by high school seniors turned markedly down from 1978 to 1984 and was associated with a marked increase in the number of seniors who disapproved of marijuana use by their peers. The proportion of those who disapproved of regular marijuana use by their classmates rose from 68 per cent in 1978 to 85 per cent in 1984. During the same period daily use fell from 11 to 5 per cent. A majority of seniors (64 per cent) disapprove of even occasional use of marijuana. A similar relationship of attitudes and practice has been shown for other drugs.
AVERSION TO DRUGS Fear of negative consequences, whether legal or medical, can help to prevent drug use. Fully 40 per cent of adults who have not experimented with drugs give fear of being caught as a factor in the decision not to use. Similarly, higher ages oflegal drinking and enforcement oflaws prohibiting marijuana possession and use do lead to lower rates of use. Knowledge of medical consequences of tobacco and drug use also can be an effective deterrent to use. Early, frequent, and consistent messages are important. The importance of education is seen in the high correlation between perception of drug risk and drug use. The precipitous fall in daily use of marijuana from 11 per cent of seniors to 5 per cent was associated with an almost doubling of the number who perceived regular marijuana use as dangerous (from 35 per cent in 1978 to 67 per cent in 1984). Cocaine appears to be the exception to the rule that perceived harmfulness leads to less use. The rise in monthly use of cocaine noted in 1984 and 1985 was coupled with an increase in number of seniors who perceived regular use as dangerous. Although 80 per cent of the class of
1002
DONALD IAN MACDONALD
1985 did view regular cocaine use as harmful, only 34 per cent saw experimentation as risky. The 34 per cent represents a slight downturn and may reflect ignorance of the fact that cocaine use is so highly reinforcing. Even one exposure to this drug may provide a powerful stimulus to another trial experimentation. The health consequences .of drug use may be divided into acute and chronic effects. Acute effects are those related to intoxication and include accidents and homicide. Chroriic effects may be divided into physical and psychological. Of course, chrohic physical consequences, such as alcoholrelated cirrhosis or tobacco-related lung cancer, usually are not seen by pediatricians. Most frequently, chronic psychological effects are those associated with dependence. Accidents, homicides, and suicides are the leading causes of death among young Americans of ages 15 to 24.4 Many of these deaths are related to alcohol and drug use. For teenagers, the annual number of alcoholrelated highway fatalities is estimated to be about 8000. Approximately one half of all homicides-the second leading cause of death among the 15- to 24-year-old age group, and the leading cause among blacks in that age group--are related to the use of alcohol and drugs. The consequences of tobacco on morbidity and mortality are generally delayed, but its relationship to heart disease, lung diseases, and a variety of cancers is well established. An estimated 350,000 deaths per year can be attributed to tobacco smoking, Virtually all of which are preventable. The effects of alcohol and other drugs on young people go far beyond mortality statistics; they affect many more people than the child who drinks or is "hooked on" drugs. Disrupted relationships between parents and children, poor school performance, and crime often have drug and alcohol problems at their root. The Bureau of Justice Statistics reported that 54 per cent of prisoners convicted of violent crimes had been drinking alcohol before committing the offenses. In Florida, approximately 70 per cent of 28,000 people in the prison system are there on cocaine-related crimes. Furthermore, pediatricians are becoming increasingly aware that cases of child abuse and incest often involve drug-dependent parents. Although pediatricians should be aware of the physiologic effects of the various classes of drugs, the principal properties of psychoactive drugs are their ability to distort the sensory experience and produce a euphoria that is powerfully reinforcing. It is the ability of drugs to alter perception and response that causes accidental death and disability. The easy pleasure obtained from drugs induces behavior changes, inhibits psychosocial maturation, and leads the user to increasing levels and frequency of use. Most drug-dependent persons began their use as adolescents by experimenting with drinking or smoking. Although some youngsters discontinue use after a period of experimentation, many continue and some escalate their levels of drug consumption. Those who continue to smoke, drink, or use drugs progress through a series of recognizable stages from experimental to moderate use, to immoderate use, and finally to dependency. 3 Awareness of the widespread prevalence of drug use should force pediatricians to consider the extent to which drug use has either caused or
PREVENTION OF ADOLESCENT SMOKING AND DRUG USE
1003
contributed to the complaints or conditions of adolescent patients. Several symptoms should trigger suspicion of drug use. When a teenager comes to a physician's office with a cough, sore throat, red eyes, or other upper respiratory complaints, smoking tobacco or marijuana should be considered as a possible cause. The physician has a real diagnostic clue to drug use if a child admits to smoking or that his friends smoke. If the pediatrician has been perceived by the parents as someone interested in behavioral issues, they may consult the pediatrician. Behavioral problems, however, are rarely the stated cause of a visit. Instead, the child is brought in with physical symptoms such as abdominal pain, headache, or fatigue. The parent rarely is willing to correlate these symptoms with drug use. Lethargy, loss of appetite, mood changes and a look of sadness in the eyes, or avoidance of eye contact are other significant signs of possible drug involvement. If the pediatrician does not consider the possibility of a drug basis for these symptoms, the parent who worries about behavior may go elsewhere for help. Once the pediatrician suspects smoking or drug problems, intervention should begin. In the early stages, preventive intervention should focus on education and attitude change for both the parents and child. Although it would be desirable for the pediatrician to spend more time with a teenage patient, this often is unrealistic. Involvement of the parent or parental surrogate is essential. The pediatrician can provide appropriate information and reading material on tobacco and drugs, but positive attitudes and support provided by the family are more important. Parents should be encouraged to monitor the child's peer group and, if appropriate, assist in finding suitable, alternative, drug-free activities in which the child can participate. Newer drug prevention stategies combine cognitive information with psychosocial approaches. Until recently, most research about drug abuse concentrated on identifying and understanding the antecedents, risk factors, and situational correlates that contributed to the initiation to smoking and drug abuse. Research into prevention is relatively new. Most substance abuse programs are delivered in the school environment and are aimed at children and teenagers at transitional phases of adolescence, when they are most vulnerable to social pressures (e.g., entry into junior or senior high school). Many of them are modeled on smoking prevention programs, which are being adapted and tested for their effectiveness in preventing both alcohol and marijuana use. Educational programs usually focus on training adolescents to develop skills to feel more comfortable in social situations, on using specific skills for resisting peer or parental pressures to use substances, and on providing knowledge that might discourage drug use. Because the underlying factors that influence smoking and drug use in adolescents involve attitudes, beliefs, values, and personality factors, no single intervention approach will work for all children. Moreover, the effects of interventions seem to dissipate over relatively short periods so that a program's impact is unlikely to be sustained if delivered only once. Regardless of approach, it seems clear that for maximum effectiveness a range of intervention programs should be employed at appropriate intervals during the transition years, which are of highest risk for adolescents.
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DONALD IAN MACDONALD
The pediatrician should be prepared to monitor his patients who are in high-risk situations and to reinforce the school's prevention messages. He must be sensitive and cognizant of those times when children need more support to combat high-risk situations and use all means possible to protect those at high risk. Schools, parents, community groups, and even police may turn to physicians for assistance and information in combating drug use in a community. The pediatrician may be asked to give talks, serve on committees, or make statements about adolescent drug use. He or she should be prepared to help each of these groups in a manner appropriate to the audience. The pediatrician, as an authority figure and a creditable source of medical knowledge, should provide accurate information to his patients and their parents about health consequences of drug use. Discussing the violent behavior and possible psychosis related to PCP, the strongly addictive nature of cocaine and nicotine, or the extent to which tobacco causes chronic diseases (e.g., cancer, emphysema, or heart disease) are but a few examples. Such messages will be received more openly if they are presented in a nonthreatening, nonjudgmental manner suitable for the child. As important as education is, however, it is only part of prevention. School curricula that overly exaggerate the negative effects of drugs may be counterproductive. Attitudes about drug use are more important than is cognitive information. Children who are experimenters with drugs are, moreover, often the most interested in drug information and look for mistakes by the presenter or loopholes in the material to justify their continued use. Others may use what they do learn to devise strategies that they hope will help them to avoid the most serious consequences of use or discovery. Pediatricians also should point out that education, no matter how extensive, is likely to be insufficient in the face of sufficient temptation from peers or the natural curiosity and risk-taking behavior of normal adolescents. Schools are aware of these problems and feel burdened by others who, for a variety of reasons, believe that schools should carry the major or only responsibility for drug abuse prevention. AVAILABILITY OF DRUGS The easier it is to get drugs, the more drug~ will be used. The licit drugs, alcohol and tobacco, are used by far more people than the illicit drugs, for which the supply is restricted. Whereas nonusers of drugs usually will not seek out drugs, if cigarettes or beer are available to teenagers attending a gathering, they may be tempted or encouraged to try them. Parents must protect their children by knowing their whereabouts and by checking to see that alcohol and drugs are not used at parties attended by their children. The pediatrician's responsibilities include acting as the voice of awareness for the community and supporting local efforts related to decreasing the availability and attractiveness of drugs. Community parent groups
,I
PREVENTION OF ADOLESCENT SMOKING AND DRUG USE
1005
against adolescent drug use will welcome any support the pediatrician can give. CONCLUSION
The pediatrician can play a tremendously important role in reversing what has become an epidemic of adolescent alcohol and other drug use. He or she should be aware of the high prevalence of drug use and of the risks involved and must understand that patients are particularly at risk because of their immaturity. The attitudes and practice of the pediatrician can provide a positive influence on the community, families, and young people. Research evaluation of prevention strategies is not yet complete, but the time for action is now. REFERENCES 1. Johnston, L. D., O'Malley, P. M., and Bachman, J. G.: Use of Licit and Illicit Drugs by America's High School Students: 1975-1984. National Institute on Drug Ahuse. D.H.H.S. Publication No. (ADM) 85-1394 Washington, D.C., U.S. Government Printing Office, 1985. 2. Kandel, D. B., and Logan, J. A.: Patterns of drug use from adolescence to young adulthood: 1. Periods of risk for initiation, continued use, and discontinuation. Am. J. Public Health, 74:660, 1984. 3. Macdonald, D. I.: Drugs, Drinking, and Adolescents. Chicago, Year Book Medical Publishers, Inc., 1984. 4. National Center for Health Statistics: Health United States, 1984. D.H.H.S. Publication No. (PHS) 85-1232, Public Health Service. Washington, D.C., U.S. Government Printing Office, December, 1984. 5. National Institute on Drug Abuse; Prevention Research: Deterring Drug Abuse Among Children and Adolescents. Research Monogr. Series 63. Bell, C. S., and Battjes, R. (eds.): DHHS Publication No. (ADM) 85-1334. Washington, D.C., U.S. Government Printing Office, 1985. 6. Yamaguchi, K., and Kandel, D.B.: Patterns of drug use from adolescence to young adulthood: II. Sequences of progression. Am. J. Public Health, 74:668, 1984. United States Public Health Service Department of Health and Human Services 5600 Fishers Lane, Room 12-105 Rockville, Maryland 20857
0031-3955/86 $0.00
+ .20
Prevention of Adolescent Smoking and Drug Use Ddnald Ian Macdonald, M.D. *
The use of tobacco, alcohol, and other drugs has become a health problem of increasing concern. Its most dangerous impact is on young people, particularly teenagers. A sharp increase in adolescent drug use began in the 1970s, and by 1979 more teens were using drugs than ever before. In 1985, almost 20 per cent of twelfth graders were regular cigarette smokers and nearly 62 per cent had had some experience with illicit drugs. Twenty years ago, most Americans knew little about drugs and few were aware of or concerned with the adverse consequences of these substances. Only in the late 1970s did American society and the medical profession begin to recognize the health consequences of drugs such as marijuana and the importance of drug use patterns among teenagers. Pediatricians should have a major role and responsibility in tobacco and drug abuse prevention. The pediatrician has the advantage of a long- \ term relationship with families and enjoys their confidence. He or she understands the developmental stages of children, the changing relationships between parents and children, and the personality traits that can make a child particularly susceptible to drug use. The power of a physician to deliver health promotion messages should not be underestimated. Parents look to pediatricians for advice, so messsages to parents on tobacco and drugs should be part of a general health message and should be delivered on a routine basis. Advice and suggestions from a trusted physician can be influential in promoting smoking, alcohol, and drug abstinence. Many factors are involved with drug use, and several models are used to address the issue of prevention. The standard public health model considers many diseases to be caused by 1) interaction of a susceptible host, with 2) a harmful agent (drugs), in 3) a suitable environment. Prevention must address each of these three factors. Too often prevention efforts focus on just one, such as changing the environment or helping the child to build up resistance skills. Some omit consideration of the addictive
*Administrator, Alcohol,
Drug Abuse, and Mental Health Administration, Rockville, Maryland
Pediatric Clinics of North America-Vol. 33, No.3, August 1986
995
996
DONALD IAN MACDONALD
nature of the chemicals and forget that experimentation with substances like tobacco, even in the strongest-willed teenager, can lead to dependence. The prevention strategy proposed here addresses the three factors of the public health model and is based on what I call the five As for Action: awareness, age, attitudes and acceptance, aversion, and availability. The five As provide a structure around which primary prevention (avoiding the use of tobacco and other drugs) and secondary prevention (early recognition of symptoms and intervention before problems accelerate) can be practiced. AWARENESS Before pediatricians become involved in prevention, they must be aware that there is a problem and that they can and should help. Physicians who care for children should view drug use as common, progressive, dangerous, but treatable. They should understand that dependence on alcohol and other drugs is a primary disease process in which the use of psychoactive substances is the cause of problems. Preexisting risk factors and pathology may be important in treatment, but unless drug use is seen as primary and handled first, treatment is likely to fail. The pediatrician can be especially important in helping to increase awareness among parents, schools, and community groups about the prevalence of smoking and drug use among teenagers. Chemical dependency is an altered state, produced by prolonged exposure to a drug or drugs, that necessitates continued administration to prevent the appearance of abstinence symptoms such as depression, irritability, and loneliness. Intervention and treatment are much more difficult when a child has reached the dependent stage. The disease of chemical dependency has strong family and public health implications and should be viewed as chronic and contagious. Chemical dependency can be diagnosed and, more important, prevented. Diagnosis and treatment are discussed in more detail elsewhere. 3 Drug use often is unrecognized by physicians trained to associate only the later stages of use with problems, but a high index of suspicion may help. Pediatricians who are sensitive to the symptoms that signal early drug involvement will be better able to detect drug use before a child becomes dependent. There are more than 23 million American youngsters aged 12 to 17. With 20 per cent of high school seniors smoking daily and nearly 3 million teens of ages 14 to 17 estimated to be problem drinkers (National Council of Alcoholism), it is highly likely that all pediatricians are seeing patients suffering from the effects of smoking, alcohol, or other drugs. In the United States, the levels of drug use are higher than in any other industrialized country in the world. A nationwide survey of more than 16,000 high school seniors, sponsored each year by the National Institute on Drug Abuse, has reported prevalence of drug use among successive cohorts of twelfth graders since 1975. The survey tracks trends in use of various classes of drugs, intensity of drug use, and use at earlier grades, as well as related attitudes and beliefs about drug, alcohol, and
997
PREVENTION OF ADOLESCENT SMOKING AND DRUG USE
Table 1. Trends in Drug Use Among High School Seniors CLASS OF
CLASS OF
CLASS OF
1975
1979
1985
Marijuana Ever used Used in past month Use daily
47 27 6
60 36 10
54 25 5
Alcohol Used in past month
68
71
66
6
6
5
37 27
34 25
30 19
9 2
15 6
17 7
Perceive as harmful to health Marijuana (regular use) Tobacco (pack a day) Cocaine (regularly)
43 51 73
42 63 70
67* 64* 80
Friends disapprove of use Marijuana (occasional use) Tobacco (pack a day) Marijuana (regular use)
55 64 75
48 73 70
63* 74* 79*
Use daily Cigarettes Used in past month Use daily Cocaine Ever used U sed in past month (regular use)
*1984 data. Data source: Johnston, 1984 and 1985.
tobacco use. 1 Table 1 provides an overview of trends from 1975 to 1985. It is important to remember that this survey reports use in high school seniors only and omits an estimated 15 per cent of young people who drop out before senior year. There is good reason to suspect that these dropouts are even more heavily involved. Despite a decline in the use of most drugs since 1980, use among young people continues to be a Significant problem. The latest survey reports that about 5 per cent of the senior class of 1985 drank alcohol daily and 5 per cent used marijuana daily. Heavy drinking (5 or more drinks on one occasion in the past 2 weeks) occurs in 37 per cent of the 1985 cohort, a slight decline from previous years. Cocaine use is an exception to the general decline of the past few years, and there is real concern over what appear to be rising levels of use. Cocaine use among teenagers is at an all-time high. In 1985, 6.7 per cent reported using cocaine in the month preceding the survey. This proportion was significantly higher than the 5.8 per cent reported in 1984 and the 4.9 per cent reported in 1983. The increased use of cocaine has important implications for the long-term health of this generation because of its highly addictive nature. A small increase in the number of seniors who have tried phencyclidine
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piperdine (PCP) is also disturbing. This drug can be highly unpredictable and lead to violent outbursts, making it one of the most dangerous drugs available to teenagers. In 1984, more than one third of those admitted to a large adolescent psychiatric unit and to detention centers in Washington, D.C., had PCP-positive urine tests. AGE
Despite the decline in use of most drugs by high school seniors from 1978 to 1984, there is disturbing evidence that the age of first use continues to drop. Surveys of high school seniors report that illicit drug use was initiated during earlier grades for the more recent senior classes than for earlier class cohorts. Of the class of 1984, 48 per cent had used some illicit drug by tenth grade, compared to 37 per cent of the class of 1975. 1 A longitudinal study that tracked drug use in a cohort of adolescents in grades 10 and 11 and later at ages 23 and 24 reported that almost 20 per cent of the cohort had used alcohol by age 10; more than 50 per cent had tried alcohol by age 14. Because of immaturity and the many developmental changes that occur during adolescence, youngsters are particularly at risk for yielding to various pressures to smoke, drink, and use drugs. Adolescence is a time for testing new behaviors (often with some degree of risk), establishing one's individuality, developing a sense of autonomy, building an adult value system, and growing to physical and emotional maturity. Drug use, however, interferes with the progress to mature adulthood and may prolong immaturity and dependence indefinitely. Children of this age group want to belong, to be accepted by their peers. They therefore frequently are influenced by those from whom they seek acceptance into participating in behaviors such as smoking and drinking. Although youngsters may be aware of the health risks associated with smoking and drug use, the perceived social benefits of belonging to a group may override this knowledge. Other nonusers may be drawn into use because of curiosity, discomfort in the presence of users, fear of being ridiculed by peers, or a perception that "everyone" is using drugs. Involvement in drugs most often follows a predictable sequence: individual use usually begins with alcohol, progresses to tobacco or marijuana, and eventually may include to other illicit drugs. Cigarettes, a major health problem in their own right, are often associated with other drug use and may indicate of greater involvement in drugs. For girls, for example, tobacco seems to be an especially important predictor of subsequent escalation of drug use. 2• 6 These three, namely alcohol, tobacco, and marijuana, are frequently called the "gateway" drugs because their use greatly increases the probability of later use of other substances. Physicians who view use of these "gateway" drugs as fairly normal for adolescents need to reexamine the data. Studies have shown that susceptibility to drug use and abuse is increased in children who have low self-esteem, a feeling of not belonging, greater need for social approval, inadequate bonding to family and society,
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inadequate communication and coping skills, inability to defer gratification, and inability to accept the logical consequences of their actions. For successful drug treatment, consideration of these characteristics is essential, but there are no data proving that prevention based solely on social competency is effective. Families need specific help in handling issues related to child-rearing and with the parenting skills necessary to help children become strong, healthy, and able to function effectively in an adult world. A natural role for the pediatrician is to offer parents anticipatory guidance. Anticipatory guidance should aim at advising parents on how best to raise a child with a good self-image, able to cope with stressful situations, and capable of mature and independent function. Children should be guided in their natural search for value and belief systems and for goals commensurate with their abilities.
ATTITUDES AND ACCEPTANCE Prevention should focus on attaining appropriate attitudes and practices for the community, the physician, the parent, and the child. Evidence shows clearly that societal, parental, and peer attitudes are strong determinants of drug use by the child. Smoking, using drugs, and drinking alcohol are all widely accepted in American culture. The media, which are very important in shaping public attitudes, abound with messages that these substances will make people feel good, relieve anxiety, increase athletic ability, and enhance beauty. Sports and entertainment figures are used to glamorize tobacco, alcohol, and other drugs. Advertising techniques are designed to influence children's attitudes in their favor: a beer is depicted as a reward for a day's work, a cigarette will make you look sophisticated, grown up, and attractive to the opposite sex. Pediatricians often are unwilling to express opinions on smoking, drinking, and drugs to patients or their parents because they believe these are moral issues and inappropriate subjects for medical conversation. Moral issues may be involved, but the pediatrician should comment because of concern for the child's health. My opinion on this is unequivocal; young people should not smoke, drink, or take illegal drugs. Pediatricians have a right and a responsibility to transmit their opinions and the medical facts about the dangers of drug use to patients and parents. Pediatricians who view drinking and smoking marijuana as a normal part of adolescence will deliver different messages to families than those who, aware of the risks, prescribe abstinence. Enough documented evidence exists to preclude any ambivalence about discouraging young persons from even experimental use of these substances. To understand addiction is to understand that the effect of psychoactive chemicals on the brain may be so stong that even the most competent and the most moral person may be unable to withstand the compulsion or craving that develops and leads to further use. Immature teenagers are particularly at risk. Postponement of experimentation is associated with lower risk of every trying cigarettes and other addicting
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substances. No one can predict with certainty who will become hooked except that those who never begin, never will. Parental attitudes and practices concerning smoking, drinking, and drugs strongly affect teenagers' later use. Children are more likely to smoke or use drugs if one or both parents do or if siblings do. In families in which parents express mild disapproval of marijuana use, children are more likely to be involved than are children from families in which disapproval is stronger. Strong parental control appears to be protective; a large degree of autonomy granted to an adolescent seems to be related to increased drug use. Community attitudes, often shaped by parents, that are permissive toward "keg parties" for teenagers, smoking areas in schools, and the inevitability of drug use, also influence adolescent practices. Parental influence will have more negative import when one of the parents is alcoholic or drug dependent. One in every eight American children is the child of an alcoholic parent and those children are at great risk from genetic, attitudinal, and family milieu, factors that promote several distorted behaviors in addition to increased risk of alcohol and drug misuse. Pediatricians should explore and comment on parental attitudes and practices about alcohol and other drugs. It is helpful to ask older children and teenagers, in the presence of their parents, if smoking, alcohol, and other drug discussions occur at home. Parents should be encouraged to become knowledgeable about drugs and to discuss drug-related issues with children. Many parents believe that smoking or trying alcohol or drugs is a passing and inevitable, if not accepted, phase of adolescence. The parents may "enable" continued drug use with this belief. When parental attitudes delay or impede intervention, family cohesiveness and support, already strained because of the child's changing behavior, are likely to be weakened. Parents should be counseled on achieving the difficult and changing balance between overprotection and underprotection. They should be helped to gauge their practices and be willing to modifY them based on the child's demonstration of competence, choice of peer group, and feelings of parental comfort. Raising children to maturity is a difficult process. Children must experiment and make their own choices, and parents must give the child the opportunity to make decisions consistent with the child's ability and demonstrated responsibility. Strong family support helps children to develop the personal values and self-confidence they need to resist peer pressure to use drugs. Young children, however, need protection from environments and stimuli that may be too powerful for them. Pediatricians should advise parents to establish clear and consistent family guidelines for children regarding acceptability of smoking, drinking, and drug use. Parents should not be reluctant to tell their children that they are opposed to any drug use and that they intend to enforce that position. Children who are left to "figure it out on their own" are often confused and may turn to their friends for the kind of guidance that the parent should be giving. Parents need to re-evaluate constantly how much responsibility their children are capable of. Particularly relevant is the problem of safety for
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the teenager who drives. Parents should consider letting the teenager know that driving while under the influence of alcohol or drugs will mean the car keys being taken away and driving reconsidered when the child is more mature. Parents can be more effective if they join with other parents. Parent groups, organized to reduce or eliminate adolescent drug use, have grown throughout the country. They have been increasingly successful in changing attitudes about the acceptability of drugs. These groups have worked for better drug education programs in schools, legislation against drugs, and have been largely responsible for ridding communities of shops that openly sold drug paraphernalia. While educating themselves, their children, and their communities about drugs, they also have taken action to provide adequate supervision, protection, and guidance for their children. With role models such as Nancy Reagan to lend names and support to the parent movement, attention has been drawn to the problems of drugs and youngsters, and people made aware of its seriousness and involved in the fight against drug abuse. The single strongest predictor of drug use in a child is the drug use pattern of a child's peer group. If a youngster's friends use and approve of drugs, the child is much more likely to become involved. National surveys that study attitudes about drug use among high school seniors are interesting. The use of marijuana by high school seniors turned markedly down from 1978 to 1984 and was associated with a marked increase in the number of seniors who disapproved of marijuana use by their peers. The proportion of those who disapproved of regular marijuana use by their classmates rose from 68 per cent in 1978 to 85 per cent in 1984. During the same period daily use fell from 11 to 5 per cent. A majority of seniors (64 per cent) disapprove of even occasional use of marijuana. A similar relationship of attitudes and practice has been shown for other drugs.
AVERSION TO DRUGS Fear of negative consequences, whether legal or medical, can help to prevent drug use. Fully 40 per cent of adults who have not experimented with drugs give fear of being caught as a factor in the decision not to use. Similarly, higher ages oflegal drinking and enforcement oflaws prohibiting marijuana possession and use do lead to lower rates of use. Knowledge of medical consequences of tobacco and drug use also can be an effective deterrent to use. Early, frequent, and consistent messages are important. The importance of education is seen in the high correlation between perception of drug risk and drug use. The precipitous fall in daily use of marijuana from 11 per cent of seniors to 5 per cent was associated with an almost doubling of the number who perceived regular marijuana use as dangerous (from 35 per cent in 1978 to 67 per cent in 1984). Cocaine appears to be the exception to the rule that perceived harmfulness leads to less use. The rise in monthly use of cocaine noted in 1984 and 1985 was coupled with an increase in number of seniors who perceived regular use as dangerous. Although 80 per cent of the class of
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1985 did view regular cocaine use as harmful, only 34 per cent saw experimentation as risky. The 34 per cent represents a slight downturn and may reflect ignorance of the fact that cocaine use is so highly reinforcing. Even one exposure to this drug may provide a powerful stimulus to another trial experimentation. The health consequences .of drug use may be divided into acute and chronic effects. Acute effects are those related to intoxication and include accidents and homicide. Chroriic effects may be divided into physical and psychological. Of course, chrohic physical consequences, such as alcoholrelated cirrhosis or tobacco-related lung cancer, usually are not seen by pediatricians. Most frequently, chronic psychological effects are those associated with dependence. Accidents, homicides, and suicides are the leading causes of death among young Americans of ages 15 to 24.4 Many of these deaths are related to alcohol and drug use. For teenagers, the annual number of alcoholrelated highway fatalities is estimated to be about 8000. Approximately one half of all homicides-the second leading cause of death among the 15- to 24-year-old age group, and the leading cause among blacks in that age group--are related to the use of alcohol and drugs. The consequences of tobacco on morbidity and mortality are generally delayed, but its relationship to heart disease, lung diseases, and a variety of cancers is well established. An estimated 350,000 deaths per year can be attributed to tobacco smoking, Virtually all of which are preventable. The effects of alcohol and other drugs on young people go far beyond mortality statistics; they affect many more people than the child who drinks or is "hooked on" drugs. Disrupted relationships between parents and children, poor school performance, and crime often have drug and alcohol problems at their root. The Bureau of Justice Statistics reported that 54 per cent of prisoners convicted of violent crimes had been drinking alcohol before committing the offenses. In Florida, approximately 70 per cent of 28,000 people in the prison system are there on cocaine-related crimes. Furthermore, pediatricians are becoming increasingly aware that cases of child abuse and incest often involve drug-dependent parents. Although pediatricians should be aware of the physiologic effects of the various classes of drugs, the principal properties of psychoactive drugs are their ability to distort the sensory experience and produce a euphoria that is powerfully reinforcing. It is the ability of drugs to alter perception and response that causes accidental death and disability. The easy pleasure obtained from drugs induces behavior changes, inhibits psychosocial maturation, and leads the user to increasing levels and frequency of use. Most drug-dependent persons began their use as adolescents by experimenting with drinking or smoking. Although some youngsters discontinue use after a period of experimentation, many continue and some escalate their levels of drug consumption. Those who continue to smoke, drink, or use drugs progress through a series of recognizable stages from experimental to moderate use, to immoderate use, and finally to dependency. 3 Awareness of the widespread prevalence of drug use should force pediatricians to consider the extent to which drug use has either caused or
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contributed to the complaints or conditions of adolescent patients. Several symptoms should trigger suspicion of drug use. When a teenager comes to a physician's office with a cough, sore throat, red eyes, or other upper respiratory complaints, smoking tobacco or marijuana should be considered as a possible cause. The physician has a real diagnostic clue to drug use if a child admits to smoking or that his friends smoke. If the pediatrician has been perceived by the parents as someone interested in behavioral issues, they may consult the pediatrician. Behavioral problems, however, are rarely the stated cause of a visit. Instead, the child is brought in with physical symptoms such as abdominal pain, headache, or fatigue. The parent rarely is willing to correlate these symptoms with drug use. Lethargy, loss of appetite, mood changes and a look of sadness in the eyes, or avoidance of eye contact are other significant signs of possible drug involvement. If the pediatrician does not consider the possibility of a drug basis for these symptoms, the parent who worries about behavior may go elsewhere for help. Once the pediatrician suspects smoking or drug problems, intervention should begin. In the early stages, preventive intervention should focus on education and attitude change for both the parents and child. Although it would be desirable for the pediatrician to spend more time with a teenage patient, this often is unrealistic. Involvement of the parent or parental surrogate is essential. The pediatrician can provide appropriate information and reading material on tobacco and drugs, but positive attitudes and support provided by the family are more important. Parents should be encouraged to monitor the child's peer group and, if appropriate, assist in finding suitable, alternative, drug-free activities in which the child can participate. Newer drug prevention stategies combine cognitive information with psychosocial approaches. Until recently, most research about drug abuse concentrated on identifying and understanding the antecedents, risk factors, and situational correlates that contributed to the initiation to smoking and drug abuse. Research into prevention is relatively new. Most substance abuse programs are delivered in the school environment and are aimed at children and teenagers at transitional phases of adolescence, when they are most vulnerable to social pressures (e.g., entry into junior or senior high school). Many of them are modeled on smoking prevention programs, which are being adapted and tested for their effectiveness in preventing both alcohol and marijuana use. Educational programs usually focus on training adolescents to develop skills to feel more comfortable in social situations, on using specific skills for resisting peer or parental pressures to use substances, and on providing knowledge that might discourage drug use. Because the underlying factors that influence smoking and drug use in adolescents involve attitudes, beliefs, values, and personality factors, no single intervention approach will work for all children. Moreover, the effects of interventions seem to dissipate over relatively short periods so that a program's impact is unlikely to be sustained if delivered only once. Regardless of approach, it seems clear that for maximum effectiveness a range of intervention programs should be employed at appropriate intervals during the transition years, which are of highest risk for adolescents.
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The pediatrician should be prepared to monitor his patients who are in high-risk situations and to reinforce the school's prevention messages. He must be sensitive and cognizant of those times when children need more support to combat high-risk situations and use all means possible to protect those at high risk. Schools, parents, community groups, and even police may turn to physicians for assistance and information in combating drug use in a community. The pediatrician may be asked to give talks, serve on committees, or make statements about adolescent drug use. He or she should be prepared to help each of these groups in a manner appropriate to the audience. The pediatrician, as an authority figure and a creditable source of medical knowledge, should provide accurate information to his patients and their parents about health consequences of drug use. Discussing the violent behavior and possible psychosis related to PCP, the strongly addictive nature of cocaine and nicotine, or the extent to which tobacco causes chronic diseases (e.g., cancer, emphysema, or heart disease) are but a few examples. Such messages will be received more openly if they are presented in a nonthreatening, nonjudgmental manner suitable for the child. As important as education is, however, it is only part of prevention. School curricula that overly exaggerate the negative effects of drugs may be counterproductive. Attitudes about drug use are more important than is cognitive information. Children who are experimenters with drugs are, moreover, often the most interested in drug information and look for mistakes by the presenter or loopholes in the material to justify their continued use. Others may use what they do learn to devise strategies that they hope will help them to avoid the most serious consequences of use or discovery. Pediatricians also should point out that education, no matter how extensive, is likely to be insufficient in the face of sufficient temptation from peers or the natural curiosity and risk-taking behavior of normal adolescents. Schools are aware of these problems and feel burdened by others who, for a variety of reasons, believe that schools should carry the major or only responsibility for drug abuse prevention. AVAILABILITY OF DRUGS The easier it is to get drugs, the more drug~ will be used. The licit drugs, alcohol and tobacco, are used by far more people than the illicit drugs, for which the supply is restricted. Whereas nonusers of drugs usually will not seek out drugs, if cigarettes or beer are available to teenagers attending a gathering, they may be tempted or encouraged to try them. Parents must protect their children by knowing their whereabouts and by checking to see that alcohol and drugs are not used at parties attended by their children. The pediatrician's responsibilities include acting as the voice of awareness for the community and supporting local efforts related to decreasing the availability and attractiveness of drugs. Community parent groups
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against adolescent drug use will welcome any support the pediatrician can give. CONCLUSION
The pediatrician can play a tremendously important role in reversing what has become an epidemic of adolescent alcohol and other drug use. He or she should be aware of the high prevalence of drug use and of the risks involved and must understand that patients are particularly at risk because of their immaturity. The attitudes and practice of the pediatrician can provide a positive influence on the community, families, and young people. Research evaluation of prevention strategies is not yet complete, but the time for action is now. REFERENCES 1. Johnston, L. D., O'Malley, P. M., and Bachman, J. G.: Use of Licit and Illicit Drugs by America's High School Students: 1975-1984. National Institute on Drug Ahuse. D.H.H.S. Publication No. (ADM) 85-1394 Washington, D.C., U.S. Government Printing Office, 1985. 2. Kandel, D. B., and Logan, J. A.: Patterns of drug use from adolescence to young adulthood: 1. Periods of risk for initiation, continued use, and discontinuation. Am. J. Public Health, 74:660, 1984. 3. Macdonald, D. I.: Drugs, Drinking, and Adolescents. Chicago, Year Book Medical Publishers, Inc., 1984. 4. National Center for Health Statistics: Health United States, 1984. D.H.H.S. Publication No. (PHS) 85-1232, Public Health Service. Washington, D.C., U.S. Government Printing Office, December, 1984. 5. National Institute on Drug Abuse; Prevention Research: Deterring Drug Abuse Among Children and Adolescents. Research Monogr. Series 63. Bell, C. S., and Battjes, R. (eds.): DHHS Publication No. (ADM) 85-1334. Washington, D.C., U.S. Government Printing Office, 1985. 6. Yamaguchi, K., and Kandel, D.B.: Patterns of drug use from adolescence to young adulthood: II. Sequences of progression. Am. J. Public Health, 74:668, 1984. United States Public Health Service Department of Health and Human Services 5600 Fishers Lane, Room 12-105 Rockville, Maryland 20857