eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Substance Abuse, Nicotine

Author: Donna G Grigsby, MD, Associate Professor, Department of Pediatrics, University of Kentucky College of Medicine
Coauthor(s): Kristin M Rager, MD, MPH, Assistant Professor of Pediatrics, Department of Pediatrics, Division of Adolescent Medicine, University of Kentucky College of Medicine; Todd R Cheever, MD, Consulting Staff, Department of Psychiatry, University of Kentucky College of Medicine
Contributor Information and Disclosures

Updated: Jun 12, 2009

Introduction

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. In addition, 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 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).¹

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

United States

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.

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.²

International

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.

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.

Race

In the United States, the prevalence of cigarette smoking among Hispanic, 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.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.

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 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 of initial tobacco use in adult smokers was 12.5 years. The average age at the start of regular tobacco use in adult smokers was 14 years.

Clinical

History

The following are stages in the development of adolescent smoking:⁴

• 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 but 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
  • May experience addiction or dependence
  • Studies suggest that 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:³
  • Younger 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/image
  • 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.⁵

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