eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Substance Abuse, Nicotine

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

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

Workup

Other Tests

The following are some of the diagnostic interview instruments used to assess nicotine dependence and/or use in adolescents:⁶
- 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, is used to 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 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

Medical Care

According to the US Preventive Services Task Force (USPSTF) guidelines, clinicians should ask adolescents about use of tobacco products and provide cessation interventions to current users. The guideline engages a “5-A” approach to counseling that includes the following:⁷

Ask about tobacco use.
Advise to quit through personalized messages.
Assess willingness to quit.
Assist with quitting.
Arrange follow-up care and support.

Brief (<10 min) behavioral counseling and pharmacotherapy are each effective alone, although they are most effective when used together. The task force also advises clinicians to ask all pregnant women, regardless of age, about tobacco use. Those who currently smoke should receive pregnancy-tailored counseling supplemented with self-help materials.

Because of the widespread use of tobacco, the WHO encourages multiple approaches to decrease tobacco use worldwide and suggests the following:²
- 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.
Despite these recommendations, studies suggest that the rates of tobacco counseling at well child visits and illness visits for conditions affected by tobacco use remain low.⁸
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) to adolescents addicted to nicotine. However, after studies failed to show significant efficacy of these medications in adolescents, the 2008 update no longer recommends their use.⁹
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.¹⁰
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.¹⁰ However, the US Public Health Service withdrew support for use of these medications in adolescents in their 2008 report.⁹

Medication

In adults with nicotine addiction, combination therapy with NRT and non-NRTs, particularly bupropion or other antidepressants, have been shown to double abstinence rates.

Nicotine replacement in adolescents has been shown to be safe, but studies have not demonstrated that these medications are effective in promoting long-term cessation in adolescents. As a result, the use of these medications is not recommended by the US Public Health Service in their most recently updated clinical practice guideline on treating tobacco use and dependence.⁹

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.

Nicotine polacrilex gum/lozenge (Nicorette Gum, Commit Lozenge)

Nicotine is quickly absorbed through the oral mucosa. Closely approximates time course of plasma nicotine levels observed after cigarette smoking. Available as gum or lozenge.

Dosing

Adult

Gum: Chew 1 piece of gum PO q1-2h while awake for 6 wk, then reduce dose to 1 piece of gum q2-4h during weeks 7-9, then reduce dose to 1 piece of gum q4-8h during weeks 10-12
Note: Initiate with 4-mg gum if 25 or more cigarettes smoked/d, initiate with 2-mg gum if <25 cigarettes smoked/d
Lozenge: Dissolve 1 lozenge PO q1-2h while awake for 6 wk, then reduce dose to 1 lozenge q2-4h during weeks 7-9, then reduce dose to 1 lozenge q4-8h during weeks 10-12
Note: Initiate with 4-mg lozenge if first cigarette smoked within 30 min of waking; if first smoked is >30 min after waking, initiate with 2-mg lozenge

Pediatric

<18 years: Not established; use only with physician supervision

Interactions

May decrease diuretic effects of furosemide and decrease cardiac output; may decrease absorption of glutethimide; may increase circulating cortisol and catecholamines; do not use if patient continues to smoke, use snuff, chew tobacco, or use other nicotine products, as it may increase toxicity of nicotine

Contraindications

Documented hypersensitivity; nonsmokers; children; pregnancy; life-threatening arrhythmias; severe or worsening angina pectoris

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Do not smoke cigarettes in addition to nicotine replacement; caution in peptic ulcer, coronary artery disease, angina, hypertension, peripheral arterial disease, diabetes, severe renal dysfunction, and hepatic dysfunction; chew gum 4-6 times or until tingling sensation or peppery taste appears, then place between cheek and teeth until tingling dissipates, repeat this chewing process for about 30 min

Nicotine inhaler (Nicotrol Inhaler)

Quickly absorbed and closely approximates time course of plasma nicotine levels observed after cigarette smoking. Each inhaler cartridge delivers 4 mg of nicotine. Once activated, may be used over several min to simulate smoking, although the drug is generally absorbed from oral mucosa.

Dosing

Adult

Individualize dose by self-titration to the level of nicotine required; most successful use demonstrated 6-16 cartridges/d
Most effective with continuous puffing over 20 min
Recommended duration of treatment is 3 mo, then gradually reduce daily dose over 6-12 wk

Pediatric

Not established

Interactions

May decrease diuretic effects of furosemide and decrease cardiac output; may decrease absorption of glutethimide; may increase circulating cortisol and catecholamines; do not use if patient continues to smoke, uses snuff, chews tobacco, or uses other nicotine products, as it may increase toxicity of nicotine

Contraindications

Documented hypersensitivity; nonsmokers; children; pregnancy; life-threatening arrhythmias; severe or worsening angina pectoris

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Nicotine nasal spray (Nicotrol NS)

Intranasal nicotine may closely approximate the time course of plasma nicotine levels observed after cigarette smoking.

Dosing

Adult

1-2 sprays/h intranasally, each spray contains 0.5 mg of nicotine, not to exceed more than 10 sprays (5 mg) per h or 40 sprays/24 h

Pediatric

Not established

Interactions

Contraindications

Documented hypersensitivity; nonsmokers; children; pregnancy; life-threatening arrhythmias; severe or worsening angina pectoris

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Do not smoke cigarettes in addition to nicotine replacement; caution in peptic ulcer, coronary artery disease, angina, hypertension, peripheral arterial disease, diabetes, severe renal dysfunction, and hepatic dysfunction; may cause coughing or exacerbation of asthma; may also cause burning or irritation upon administration

Nicotine transdermal system (Nicotrol, Nicoderm CQ)

Transdermal patches are most appropriate for individuals who smoke more than 10 cigarettes each day.

Dosing

Adult

Nicotrol: Apply one 15-mg transdermal patch qd for 6 wk; remove at bedtime; decrease to 10 mg/d for weeks 7-8, then 5 mg/d for weeks 9-10, then discontinue
Habitrol or Nicoderm CQ: Apply one 21-mg patch qd for 6wk, then one 14-mg patch qd for 2 wk, followed by one 7-mg patch qd for 2 wk for a total of 10 wk

Pediatric

Not established

Interactions

Contraindications

Documented hypersensitivity; nonsmokers; children; pregnancy; life-threatening arrhythmias; severe or worsening angina pectoris

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Do not smoke cigarettes in addition to nicotine replacement; caution in peptic ulcer, coronary artery disease, angina, hypertension, peripheral arterial disease, diabetes, severe renal dysfunction, and hepatic dysfunction; may cause skin irritation; if persistent insomnia occurs, remove patch at bedtime

Non-nicotine replacement therapy

These agents modulate noradrenergic neurotransmission and increase smoking cessation rates.

Bupropion (Zyban)

Used in conjunction with a support group and/or behavioral counseling. Inhibits neuronal dopamine reuptake in addition to being a weak blocker of serotonin and norepinephrine reuptake.

Dosing

Adult

150-mg tab PO qd for 3 d, then increase to 150 mg bid with at least 8 h between each dose for 7-12 wk

Pediatric

Not established

Interactions

Carbamazepine, cimetidine, phenytoin, and phenobarbital may decrease effects; toxicity increases with concurrent administration of levodopa and MAOIs

Contraindications

Documented hypersensitivity; seizure disorder, anorexia nervosa, concurrent use with MAOIs; concurrent use with other bupropion products (eg, Wellbutrin)

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in renal or hepatic insufficiency; doses >450 mg/d significantly decrease seizure threshold; may cause hypertension; may increase risk of suicidal ideation or worsening depression

Follow-up

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.
The US Public Health Service made 3 specific recommendations regarding children and adolescents in their 2008 clinical practice update on treating tobacco use and dependence, as follows:⁹
- Clinicians caring for children and adolescents should ask about tobacco use and should strongly discourage tobacco use in this population.
- Because of the effectiveness of counseling programs, adolescent smokers should be provided with counseling interventions to help in smoking cessation.
- Because of the harmful affects of secondhand smoke and the effectiveness of cessation counseling in increasing abstinence in parents who smoke, clinicians should ask parents about smoking and offer cessation advice and assistance.

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 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%.

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.

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Keywords

nicotine abuse, nicotine dependence, tobacco use, cigarette use, smoking, tobacco-related disease, smoking-related disease

Contributor Information and Disclosures

Author

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: American Academy of Pediatrics and Kentucky Pediatric Society
Disclosure: Nothing to disclose.

Coauthor(s)

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.

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.

Medical Editor

Chet Johnson, MD, Medical Director, Child Development Unit, Department of Pediatrics, Professor, University of Kansas Medical Center
Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck 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, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

Further Reading