Pediatric Nicotine Abuse

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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]

Adolescent smoking behavior develops in the following stages:

Precontemplation stage

Contemplation stage (preparatory)

Initiation into smoking

Experimentation with smoking

Regular (but still infrequent) smoking

Established/daily smoking

The following are signs and symptoms that constitute nicotine dependence:

Frequent unsuccessful attempts to quit smoking

Development of tolerance to nicotine 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 for tobacco

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:

Chronic lung disease

Cardiovascular diseases (coronary artery disease, peripheral vascular disease, stroke)

Cancers of the head and neck, lung, and gastrointestinal (GI) tract

See Presentation for more detail.

The following diagnostic interview instruments are used to assess nicotine use or dependence in adolescents:

World Health Organization (WHO)/Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) Composite International Diagnostic Interview-Substance Abuse Module (CIDI-SAM)

National Institute of Mental Health-Diagnostic Interview Schedule (NIMH-DIS)

NIMH Computerized DIS for children (aged 7-17 years)

National Household Survey on Drug Abuse (NHSDA)

Fagerstrom Tolerance Questionnaire (FTQ)

Fagerstrom Test for Nicotine Dependence (revised version of FTQ)

Nicotine Dependence Syndrome Scale

Perkins Adolescent Risk Screen (PARS)

See Workup for more detail.

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

Counseling of adolescents regarding smoking cessation may take a “5-A” approach as follows:

Ask about tobacco use

Advise to quit through personalized messages

Assess willingness to quit

Assist with quitting

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:

Nicotine replacement therapy (NRT)

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.

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]

According to the CDC, from 2011 to 2015, current cigarette smoking declined among middle and high school students. However, current use of electronic cigarettes increased among middle and high school students from 2011 to 2015. Increases in e-cigarette use in 2015 were largely driven by higher use among middle school students, a group in which use of the devices climbed to 5.3% in 2015 from 3.9% in 2014. There was no change in e-cigarette use among high school students between 2014 and 2015, following a dramatic 13.4% increase in 2014. [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]

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.

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. [6]

According to the WHO, by the early 1990s, 1.1 billion people used tobacco, representing one third of the global adult population. The 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. [7]

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]

In the United States, the prevalence of cigarette smoking among Hispanic, [8] 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. [9]

According to the CDC, among high school students in 2015, 26.2% of non-Hispanics whites used any tobacco product, followed by 25.4% of Hispanics, 25.3% of non-Hispanic other races, and 21.9% of non-Hispanic blacks. Among middle school students, 10.6% of Hispanics used any tobacco product, followed by 6.6% of non-Hispanic blacks, 6.3% of non-Hispanic whites, and 5.6% of non-Hispanic other races. [3]

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, 30.0% of males and 20.3% of females used any tobacco product in 2015. Among middle school students, 8.3% of males and 6.4% of females used any tobacco product. [3]

According to the CDC, about 2 of every 100 middle school students (2.3%) reported in 2015 that they smoked cigarettes in the past 30 days—a decrease from 4.3% in 2011. About 9 of every 100 high school students (9.3%) reported in 2015 that they smoked cigarettes in the past 30 days—a decrease from 15.8% in 2011. [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.

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.

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 the rate of those who still smoke after 5 years is actually close to 75%.

U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. 2014. Available at http://www.cdc.gov/tobacco/data_statistics/sgr/50th-anniversary/index.htm.

U.S. Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. 2012. Available at http://www.cdc.gov/tobacco/data_statistics/sgr/2012/index.htm.

Centers for Disease Control and Prevention. Tobacco Use Among Middle and High School Students—United States, 2011–2015. Morbidity and Mortality Weekly Report. Available at http://www.cdc.gov/mmwr/volumes/65/wr/mm6514a1.htm?s_cid=mm6514a1_w. 2016; Accessed: April 20, 2016.

Centers for Disease Control and Prevention. Tobacco Product Use Among Middle and High School Students—United States, 2011 and 2012. Morbidity and Mortality Weekly Report. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6245a2.htm?s_cid=mm6245a2_w. 2013; Accessed: April 20, 2016.

Wiencke JK, Kelsey KT. Teen smoking, field cancerization, and a “critical period” hypothesis for lung cancer susceptibility. Environ Health Perspect. 2002 Jun. 110(6):555-8. [Medline]. [Full Text].

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Shetgiri R, Kataoka S, Lin H, Flores G. A randomized, controlled trial of a school-based intervention to reduce violence and substance use in predominantly Latino high school students. J Natl Med Assoc. 2011 Sep-Oct. 103(9-10):932-40. [Medline].

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Donna G Grigsby, MD Associate Professor, Department of Pediatrics, University of Kentucky College of Medicine

Donna G Grigsby, MD is a member of the following medical societies: Kentucky Chapter of The American Academy of Pediatrics, Kentucky Pediatric Society, American Academy of Pediatrics

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Chet Johnson, MD Professor of Pediatrics, Associate Director and Developmental-Behavioral Pediatrician, KU Center for Child Health and Development, Shiefelbusch Institute for Life Span Studies; Assistant Dean, Faculty Affairs and Development, University of Kansas School of Medicine

Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Todd R Cheever, MD Consulting Staff, Department of Psychiatry, University of Kentucky College of Medicine

Todd R Cheever, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Kentucky Medical Association

Disclosure: Nothing to disclose.

Kristin M Rager, MD, MPH Assistant Professor of Pediatrics, Department of Pediatrics, Division of Adolescent Medicine, University of Kentucky College of Medicine

Kristin M Rager, MD, MPH is a member of the following medical societies: American Academy of Pediatrics, Kentucky Pediatric Society, North American Society for Pediatric and Adolescent Gynecology, and Society for Adolescent Medicine

Disclosure: Nothing to disclose.

Pediatric Nicotine Abuse

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