AUTHOR AND EDITOR INFORMATION

Section 1 of 8  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• References

INTRODUCTION

Section 2 of 8  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• References

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, with 75% of adult tobacco users reporting initial use when aged 11-17 years.

Although overall smoking rates are declining, smoking rates in American adolescents have shown a gradual increase since 1987, with an increase of almost one third from 1991-1997. Also, the rate of smokeless tobacco use has increased over the last 15 years. 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 lung cancer risk independent of smoking duration or intensity. This risk is accentuated in females because of earlier maximum lung growth compared with males (age 18 y in females vs 24 y in males).

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, which leads to the release of dopamine.

Frequency

United States

The daily use of tobacco in US schools has reached epidemic proportions. More than 3 million adolescents in the United States smoke; 6000 adolescents start smoking every day, and one half of these adolescents become daily smokers.

Studies reveal 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.

Other studies suggest that, by the year 2000, 15% of eighth graders, 24% of tenth graders, and 31% of high school seniors used tobacco daily. Tobacco use among individuals aged 18 years who are not in school has been estimated to be as high as 75%. Rates of tobacco use in adolescents are higher in rural areas than in urban areas.

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.

International

According to the WHO, by the early 1990s, 1.1 billion people used tobacco, which represents one third of the global adult population. Use of tobacco in developing countries is increasing, with 48% of men and 7% of women using tobacco regularly. In developed countries, where the use of tobacco by women has markedly increased, 42% of men and 24% of women use tobacco regularly.

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 human immunodeficiency virus (HIV), tuberculosis, maternal mortality, motor vehicle accidents, suicide, and homicide combined. A long-term tobacco user has a 50% chance of dying prematurely from a tobacco-related disease. Other studies suggest that one third of adolescents who become regular smokers will die from a smoking-related disease.

Race

In US adolescents, cigarette smoking is increasing in Hispanic, African American, and white adolescents, with the most dramatic increases occurring 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 differences include marketing strategies and African American attitudes toward smoking (eg, African American adolescents are less likely to perceive smoking as fun, African American parents have a more punitive approach to tobacco use, African American females are less likely to use smoking for weight control.)

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 for males and females.

Age

• 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.
• By 2000, studies suggested that adolescent smoking rates of high school seniors exceeded adult rates, with 15% of eighth graders, nearly 1 out of 4 tenth graders, and 31% of high school seniors using tobacco daily. Tobacco use by individuals aged 18 years who are not attending school has been estimated to be as high as 75%.
• The average age at initiation of tobacco use in adult smokers was 12.5 years. The average age at start of regular tobacco use in adult smokers was 14 years.

CLINICAL

Section 3 of 8  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• References

History

The following are stages in the development of adolescent smoking:

• Precontemplation stage
• • Never smoked
  • No desire to start smoking
• Contemplation stage (preparatory)
• • Begin to think about smoking
  • Develop attitudes and images of what smoking is like
  • Discover potential functions of smoking and develop an increasing awareness of social pressures to smoke (adolescents)
• Initiation
• • Try the first few cigarettes
  • Peer influences more important than family influences
  • Adolescent motivation to improve self-image
• Experimental
• • Gradual increase in frequency of smoking and increase in variety of situations in which cigarettes are used
  • See positive aspects and few negative aspects of smoking
  • Minimal pleasure from smoking
  • Still deciding if smoking is desirable
  • May develop self-image as a smoker
  • Learning how to handle a cigarette and how to inhale correctly
  • Physiological reactions may have greatest effect on whether or not smoking continues or progresses.
• Regularly smoking
• • Regular but still infrequent use of tobacco
  • Does not typically smoke every day or at high rates
• Established/daily smoking
• • Person may experience addiction/dependence.
  • Studies suggest adolescents become nicotine-dependent when smoking only one half the number of cigarettes smoked by adults who are nicotine-dependent.
  • Smoking regulates emotional responses elicited by environmentally induced stress.
  • Smoking regulates cravings conditioned to external cues.
  • Smoking regulates cravings due to internal cues caused by decreasing nicotine levels.

Physical

The following are signs and symptoms that constitute nicotine dependence:

• Frequent unsuccessful attempts to quit smoking
• Development of tolerance to nicotine effects manifested by decrease of characteristic symptoms despite continued use or the need to increase amounts of nicotine used to get the same effects
• Large amounts of time spent in obtaining or using tobacco
• Important events given up because of restrictions of tobacco use
• Continued tobacco use despite negative consequences
• Cravings of tobacco experienced by tobacco user
• Discontinuation of tobacco use produces a syndrome of withdrawal. Specific symptoms associated with withdrawal include the following:
• • Frustration or anger
  • Anxiety
  • Difficulty with concentration
  • Restlessness
  • Decreased heart rate
  • Increased appetite or weight gain
  • Irritability

Causes

• Possible factors involved in the increase in adolescent tobacco use include the following:
• • Decrease in age at initiation of smoking
  • Decrease in perceived risk of tobacco use
  • Fewer school-based substance avoidance programs
  • Pervasive media messages about tobacco use
  • Less punitive approach toward tobacco use by parents
  • Decrease in monitoring adolescents' behavior and decreased limit-setting by parents
  • Decrease in peer disapproval of smoking
• According to studies on parenting behavior, adolescent or parental risk factors predictive for becoming a smoker include the following:
• • Disruptive behavior
  • A friend who was a substance abuser
• According to studies on parenting behavior, adolescent or parental risk factors that appear to protect against becoming a smoker include the following:
• • Parental monitoring (parent keeping track of adolescent's whereabouts and setting curfews)
  • Spending time with parents
  • Living with both parents
  • Positive relationship with parents (less likely to choose a substance-abusing friend)
• According to studies of cross-sectional or prospective designs, the following are individual variables that influence progression of smoking in adolescents at different developmental stages of smoking:
• • Positive attitudes and beliefs about smoking
  • Minimization of risks of smoking
  • Concern about body weight
  • Affect regulation
  • Perception that smoking helps with relaxation
  • Perceptions of cigarette accessibility
  • Deviance and antisocial behavior
  • Other drug or alcohol use
  • Average to below average school performance
  • Mental illnesses such as depression and/or anxiety
• According to studies of cross-sectional or prospective designs, the following are family variables associated with progression of smoking in adolescents at different developmental stages of smoking:
• • Number of family members who smoke
  • Adolescents' perceptions of permissive attitudes toward smoking
  • Divorce or family conflict
• Another factor associated with progression of adolescent smoking is an increased number of smoking friends compared with nonsmoking peers.
• In a study of school children in Montreal, Becklake et al (2005) suggested that children with environmental tobacco exposure who have larger lung volumes are more likely to become smokers. The authors hypothesized that larger lung size enhances the uptake of tobacco smoke, maximizing the influence of passive smoking and inducing future smoking in children.

WORKUP

Section 4 of 8  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• References

Other Tests

• The following are some of the diagnostic interview instruments used to assess nicotine dependence and/or use in adolescents:
• • WHO/Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) Composite International Diagnostic Interview-Substance Abuse Module (CIDI-SAM) is administered by nonclinicians and is highly standardized.
  • National Institute of Mental Health-Diagnostic Interview Schedule (NIMH-DIS) contains the full DIS for psychiatric disorders, including substance abuse disorders, and has a section on tobacco dependence.
  • NIMH Computerized DIS for children, a structured diagnostic interview, can diagnose psychopathology in patients aged 7-17 years.
  • National Household Survey on Drug Abuse (NHSDA), a large-scale annual survey, assesses substance use prevalence across 12 classes of drugs and dependence symptoms across 4 drugs, which include alcohol, marijuana, cocaine, and nicotine.
  • Fagerstrom Tolerance Questionnaire (FTQ) includes self-report measures that relate to general nicotine dependence syndrome and may be a more direct measure of behavioral dependence rather than physiologic dependence.
  • Fagerstrom Test for Nicotine Dependence is a revised version of the FTQ that deleted items on the nicotine dose of cigarettes and the frequency of inhalation, items that were thought to contribute to psychometric problems with the FTQ.
  • Nicotine Dependence Syndrome Scale measures smoking drive, behavioral priority, tolerance, continuity, and stereotypy.
  • The Perkins Adolescent Risk Screen (PARS) includes questions on nicotine use. The PARS is a useful clinical tool, well-suited to a busy adolescent practice.

TREATMENT

Section 5 of 8  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• References

Medical Care

• Because of the widespread use of tobacco, the WHO encourages multiple approaches to decrease tobacco use worldwide and suggests the following:
• • Make treatment a priority.
  • Make treatment available.
  • Assess tobacco use at every opportunity and offer treatment.
  • Set an example, as health care workers, by avoiding tobacco use.
  • Motivate users to stop using tobacco.
  • Fund effective treatments and make them as accessible as tobacco products.
  • Governments should be responsible for monitoring and regulating tobacco.
• While prevention of smoking initiation should be the focus of treating nicotine dependence, behavioral and pharmacological treatments developed in recent years have proven to be effective.
• In 2000, clinical practice guidelines recommended offering nicotine replacement therapy (NRT) for nicotine-addicted adolescents.
• In 2001, The American Academy of Pediatrics (AAP) Subcommittee on Substance Abuse statement on tobacco use suggested that those who smoke more than 10 cigarettes per day may benefit from NRT. Nicotine substitutes, in the form of nicotine gum, patches, nasal sprays, and inhalers, are used to gradually reduce nicotine exposure, avoiding the symptoms of withdrawal while eliminating exposure to other toxic substances found in cigarette smoke.
• Recently, studies in adults have shown that medications previously used for the treatment of depression have also shown good results when used for smoking cessation. The AAP Subcommittee on Substance Use report recognized bupropion, clonidine, and nortriptyline as additional therapeutic modalities. Combination therapy with nicotine replacements and bupropion or other oral agents increase 1-year abstinence rates in adults, and early research suggests that these therapies may also be safe and effective in adolescents.

MEDICATION

Section 6 of 8  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• References

In adults with nicotine addiction, combination therapy with NRT and non-NRTs, particularly bupropion or other antidepressants, have been shown to double abstinence rates. Preliminary reports suggest that similar results may be possible with adolescents.

Drug Category: Nicotine replacement therapies

These agents help prevent nicotine withdrawal. They deliver nicotine systemically via oral or nasal mucosa or transdermal delivery systems. They are most effective for smoking cessation when used in conjunction with a support program, such as counseling, group therapy, or behavioral therapy.

Drug Category: Non-nicotine replacement therapy

These agents modulate noradrenergic neurotransmission and increase smoking cessation rates.

FOLLOW-UP

Section 7 of 8  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• References

Deterrence/Prevention

• Preventing initiation of smoking is crucial to decrease tobacco use and its health-related complications in adolescents and children for the following reasons:
• • Because of the highly addictive nature of nicotine, smoking cessation is not a matter of choice for most users.
  • Tobacco is addictive physiologically and psychologically and use is socially reinforced.
  • No amount of tobacco use has been proven to be safe.

Complications

• Smoking and tobacco use are associated with various health-related illnesses, including the following:
• • Chronic lung disease
  • Cardiovascular diseases, including coronary artery disease, peripheral vascular disease, and stroke
  • Cancers of the head and neck, lung, and GI tract

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 incidence of adult smoking.
• More than 50% of adolescents report trying to quit each year.
• • Of adolescents who smoke more than 10 cigarettes per day, fewer than 20% of those who quit will be successful for 1 month.
  • One study reported that only 5% of adolescent smokers expected to be smoking in 5 years, while incidence of those who still smoke after 5 years is actually close to 75%.

Patient Education

For excellent patient education resources, visit eMedicine's Public Health Center, Lung and Airway Center, and Substance Abuse Center. Also, see eMedicine's patient education articles Cigarette Smoking and Substance Abuse.

REFERENCES

Section 8 of 8

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• References

• American Academy of Pediatrics Committee on Substance Abuse. Tobacco''s toll: implications for the pediatrician. Pediatrics. Apr 2001;107(4):794-8. [Medline]. [Full Text].
• American Academy of Pediatrics. Committee on Substance Abuse. Tobacco, alcohol, and other drugs: the role of the pediatrician in prevention and management of substance abuse. Pediatrics. Jan 1998;101(1 Pt 1):125-8. [Medline]. [Full Text].
• Anczak JD, Nogler RA. Tobacco cessation in primary care: maximizing intervention strategies. Clin Med Res. Jul 2003;1(3):201-16. [Medline]. [Full Text].
• Becklake MR, Ghezzo H, Ernst P. Childhood predictors of smoking in adolescence: a follow-up study of Montreal schoolchildren. CMAJ. Aug 16 2005;173(4):377-9. [Medline]. [Full Text].
• CDC. The Health Consequences of Smoking: A report of the Surgeon General. 2004;[Full Text].
• Cohen DA, Richardson J, LaBree L. Parenting behaviors and the onset of smoking and alcohol use: a longitudinal study. Pediatrics. Sep 1994;94(3):368-75. [Medline].
• Colby SM, Tiffany ST, Shiffman S, Niaura RS. Are adolescent smokers dependent on nicotine? A review of the evidence. Drug Alcohol Depend. May 1 2000;59 Suppl 1:S83-95. [Medline].
• Colby SM, Tiffany ST, Shiffman S, Niaura RS. Measuring nicotine dependence among youth: a review of available approaches and instruments. Drug Alcohol Depend. May 1 2000;59 Suppl 1:S23-39. [Medline].
• Coleman T. Special groups of smokers. BMJ. Mar 6 2004;328(7439):575-7. [Medline].
• Eissenberg T, Balster RL. Initial tobacco use episodes in children and adolescents: current knowledge, future directions. Drug Alcohol Depend. May 1 2000;59 Suppl 1:S41-60. [Medline].
• Faulkner DL, Merritt RK. Race and cigarette smoking among United States adolescents: the role of lifestyle behaviors and demographic factors. Pediatrics. Feb 1998;101(2):E4. [Medline]. [Full Text].
• Jarvis MJ. Why people smoke. BMJ. Jan 31 2004;328(7434):277-9. [Medline].
• Klesges LM, Johnson KC, Somes G, et al. Use of nicotine replacement therapy in adolescent smokers and nonsmokers. Arch Pediatr Adolesc Med. Jun 2003;157(6):517-22. [Medline].
• Mayhew KP, Flay BR, Mott JA. Stages in the development of adolescent smoking. Drug Alcohol Depend. May 1 2000;59 Suppl 1:S61-81. [Medline].
• Shadel WG, Shiffman S, Niaura R, et al. Current models of nicotine dependence: what is known and what is needed to advance understanding of tobacco etiology among youth. Drug Alcohol Depend. May 1 2000;59 Suppl 1:S9-22. [Medline].
• Wiencke JK, Kelsey KT. Teen smoking, field cancerization, and a "critical period" hypothesis for lung cancer susceptibility. Environ Health Perspect. Jun 2002;110(6):555-8. [Medline]. [Full Text].
• Zapka JG, Fletcher K, Pbert L, et al. The perceptions and practices of pediatricians: tobacco intervention. Pediatrics. May 1999;103(5):e65. [Medline]. [Full Text].

Article Last Updated: Oct 18, 2006