Practice Essentials
Tobacco is reportedly the single largest preventable cause of morbidity and premature death in the United States. Most people who smoke report initiation of tobacco use during childhood or adolescence. Nearly 9 out of 10 cigarette smokers first tried smoking by age 18, and 99% first tried smoking by age 26. [1, 2]
Signs and symptoms
Adolescent smoking behavior develops in the following stages:
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Precontemplation stage
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Contemplation stage (preparatory)
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Initiation into smoking
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Experimentation with smoking
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Regular (but still infrequent) smoking
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Established/daily smoking
The following are signs and symptoms that constitute nicotine dependence:
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Frequent unsuccessful attempts to quit smoking
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Development of tolerance to nicotine effects
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Large amounts of time spent in obtaining or using tobacco
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Important events given up because of restrictions of tobacco use
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Continued tobacco use despite negative consequences
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Cravings for tobacco
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Discontinuance of tobacco use produces a syndrome of withdrawal (frustration or anger, anxiety, difficulty with concentration, restlessness, decreased heart rate, increased appetite or weight gain, irritability)
Smoking and tobacco use are associated with various illnesses, including the following:
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Chronic lung disease
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Cardiovascular diseases (coronary artery disease, peripheral vascular disease, stroke)
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Cancers of the head and neck, lung, and gastrointestinal (GI) tract
See Presentation for more detail.
Diagnosis
The following diagnostic interview instruments are used to assess nicotine use or dependence in adolescents:
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World Health Organization (WHO)/Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) Composite International Diagnostic Interview-Substance Abuse Module (CIDI-SAM)
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National Institute of Mental Health-Diagnostic Interview Schedule (NIMH-DIS)
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NIMH Computerized DIS for children (aged 7-17 years)
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National Household Survey on Drug Abuse (NHSDA)
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Fagerstrom Tolerance Questionnaire (FTQ)
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Fagerstrom Test for Nicotine Dependence (revised version of FTQ)
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Nicotine Dependence Syndrome Scale
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Perkins Adolescent Risk Screen (PARS)
See Workup for more detail.
Management
Because of the widespread use of tobacco, the WHO encourages multiple approaches to decrease tobacco use worldwide and suggests the following:
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Make treatment a priority
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Make treatment available
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Assess tobacco use at every opportunity and offer treatment
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Set an example, as health care workers, by avoiding tobacco use
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Motivate users to stop using tobacco
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Fund effective treatments and make them as accessible as tobacco products
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Governments should be responsible for monitoring and regulating tobacco
Counseling of adolescents regarding smoking cessation may take a “5-A” approach as follows:
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Ask about tobacco use
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Advise to quit through personalized messages
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Assess willingness to quit
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Assist with quitting
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Arrange follow-up care and support
Whereas prevention of smoking initiation should be the focus of treating nicotine dependence, some behavioral and pharmacologic treatments are effective. Brief (< 10 minutes) behavioral counseling and pharmacotherapy are each effective alone, though they are most effective when used together.
Pharmacologic therapies have included the following:
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Nicotine replacement therapy (NRT)
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Antidepressants (eg, bupropion, clonidine, nortriptyline)
In adolescents, NRT is safe but has not been proved effective at promoting long-term smoking cessation.
See Treatment and Medication for more detail.
Background
According to the World Health Organization (WHO), tobacco use is widespread, affecting one third of the global adult population. Reportedly, tobacco is the single largest preventable cause of morbidity and premature death in the United States. Most people who smoke report initiation of tobacco use during childhood or adolescence. Nearly 9 out of 10 cigarette smokers first tried smoking by age 18, and 99% first tried smoking by age 26. [1, 2] Each day in the United States, more than 3,200 youth aged 18 years or younger smoke their first cigarette, and an additional 2,100 youth and young adults become daily cigarette smokers. [2]
In 2020, nearly 3 of every 100 middle school students (2.8%) and about 8 of every 100 high school students (8.2%) reported current use of two or more tobacco products in the past 30 days. During 2019-2020, current use of any tobacco product, any combustible tobacco product, multiple tobacco products, e-cigarettes, cigars, and smokeless tobacco among middle and high school students decreased. These declines resulted in an estimated 1.73 million fewer current youth tobacco product users in 2020 (4.47 million) compared to 2019 (6.20 million). [3, 4]
In addition to the immediate health impact of smoking and tobacco use, adolescent smokers are more likely to become adult smokers and to use alcohol and illicit substances. Studies also suggest that the earlier adolescents start to smoke, the more cigarettes they will smoke as an adult, which is associated with more severe tobacco-related health complications.
Additionally, molecular research now suggests that early smoking may lead to changes in lung cells, especially during a critical period of lung development in adolescence, increasing the lung cancer risk independent of smoking duration or intensity. This risk is accentuated in females because of earlier maximum lung growth compared with that in males (age 18 y in females vs 24 y in males). [5]
If cigarette smoking continues at the current rate among youth in this country, 5.6 million of today’s Americans younger than 18 will die early from a smoking-related illness. [6]
Pathophysiology
Absorption of nicotine from inhaled cigarette smoke is rapid, and a bolus of nicotine reaches the brain within 10-16 seconds. Once in the brain, nicotine activates nicotinic acetylcholine receptors, leading to the release of dopamine.
Frequency
The daily use of tobacco in US schools has reached epidemic proportions. More than 3 million adolescents in the United States smoke; 6,000 adolescents start smoking every day, and one half of these adolescents become daily smokers.
Studies show that 5 million people who smoke in the United States are aged 12-17 years; more than 500,000 people who smoke in the United States are aged 8-11 years.
Most adolescents who smoke daily are addicted to nicotine, and 50% report withdrawal symptoms when trying to stop smoking. More than one half of these smokers report wanting to stop smoking, and more than one half of them have tried to stop smoking in the last year. [7]
According to the WHO, more than 80% of the world's 1.3 billion tobacco users live in low- and middle-income countries. Globally, the number of youth aged 13–15 years who smoke is estimated to be around 24 million, and 13 million use smokeless tobacco products. [8]
Mortality/Morbidity
The WHO has estimated that, by the year 2030, tobacco will be the world's leading cause of morbidity and mortality, accounting for 10 million deaths per year. Worldwide, tobacco will cause more deaths than the deaths caused by HIV infection, tuberculosis, maternal mortality, motor vehicle collisions, suicide, and homicide combined. A long-term tobacco user has a 50% chance of dying prematurely of a tobacco-related disease. Other studies suggest that one third of adolescents who become regular smokers will die of a smoking-related disease.
If smoking continues at the current rate among youth in the United States, 5.6 million of today’s Americans younger than 18 will die early from a smoking-related illness. That’s about 1 of every 13 Americans aged 17 years or younger alive today. [1, 6]
Epidemiology
Race
In the United States, the prevalence of cigarette smoking among Hispanic, [9] African American, and white adolescents is increasing, with the most dramatic increases in African American teens, although smoking rates continue to be much higher in whites. These differences in tobacco use among whites remain when studies control for lifestyle and demographic factors.
While definitive studies have not been completed, factors suspected to play a role in these race-based differences include marketing strategies and attitudes toward smoking. As examples, African American adolescents are less likely to perceive smoking as fun, African American parents tend to have a more punitive approach to tobacco use, and African American females are less likely to use smoking for weight control. [10]
According to the CDC, among high school students in 2020, any tobacco product use was reported by 25.9% of non-Hispanic White, 23.3% of Hispanic, 18.4% of non-Hispanic Black, and 15.7% of non-Hispanic students of other races; and by 30.9% of those identifying as lesbian, gay, or bisexual, 22.0% of those identifying as heterosexual, and 20.4% of those reporting “not sure” about their sexual identity. Among middle school students, any tobacco product use was reported by 9.4% of Hispanic, 6.7% of non-Hispanic Black, and 5.7% of non-Hispanic White students; and by 16.5% of those identifying as lesbian, gay, or bisexual, 5.5% of those identifying as heterosexual, and 6.4% of those reporting “not sure” about their sexual identity. [3]
Sex
While the incidence of adolescent tobacco use is increasing overall, males are still more likely to smoke and use tobacco than are females, except in white adolescents, in whom rates are the same in males and females.
Among high school students, 24.7% of males and 22.5% of females used any tobacco product in 2020. Among middle school students, 6.8% of females and 6.6% of males used any tobacco product. [3]
Age
According to the CDC, in 2020, nearly 3 of every 100 middle school students (2.8%) and about 8 of every 100 high school students (8.2%) reported current use of two or more tobacco products in the past 30 days. [3, 4]
Studies report that 5 million people who smoke in the United States are aged 12–17 years and more than 500,000 people who smoke are aged 8–11 years.
Prognosis
Because of the highly addictive nature of nicotine, smoking a few cigarettes in adolescence increases the probability of nicotine dependence and is associated with a marked increase in the likelihood of adult smoking.
More than 50% of adolescents report trying to quit each year.
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Of adolescents who smoke more than 10 cigarettes per day, fewer than 20% of those who quit will be successful for 1 month.
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One study reported that only 5% of adolescent smokers expected to be smoking in 5 years, while the rate of those who still smoke after 5 years is actually close to 75%.
