eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics
Substance Abuse, Nicotine: Treatment & Medication
Updated: Jun 12, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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.
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
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
Documented hypersensitivity; nonsmokers; children; pregnancy; life-threatening arrhythmias; severe or worsening angina pectoris
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.
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
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
Documented hypersensitivity; nonsmokers; children; pregnancy; life-threatening arrhythmias; severe or worsening angina pectoris
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 rhinitis, and throat and mouth irritation
Nicotine nasal spray (Nicotrol NS)
Intranasal nicotine may closely approximate the time course of plasma nicotine levels observed after cigarette smoking.
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
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
Documented hypersensitivity; nonsmokers; children; pregnancy; life-threatening arrhythmias; severe or worsening angina pectoris
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.
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
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
Documented hypersensitivity; nonsmokers; children; pregnancy; life-threatening arrhythmias; severe or worsening angina pectoris
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.
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
Carbamazepine, cimetidine, phenytoin, and phenobarbital may decrease effects; toxicity increases with concurrent administration of levodopa and MAOIs
Documented hypersensitivity; seizure disorder, anorexia nervosa, concurrent use with MAOIs; concurrent use with other bupropion products (eg, Wellbutrin)
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
More on Substance Abuse, Nicotine |
| Overview: Substance Abuse, Nicotine |
| Differential Diagnoses & Workup: Substance Abuse, Nicotine |
 Treatment & Medication: Substance Abuse, Nicotine |
| Follow-up: Substance Abuse, Nicotine |
| References |
| « Previous Page | Next Page » |
References
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].
CDC. The Health Consequences of Smoking: A report of the Surgeon General. 2004;[Full Text].
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].
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].
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].
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].
U.S. Preventive Services Task Force. Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women: U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med. Apr 21 2009;150(8):551-5. [Medline]. [Full Text].
Tanski SE, Klein JD, Winickoff JP, Auinger P, Weitzman M. Tobacco counseling at well-child and tobacco-influenced illness visits: opportunities for improvement. Pediatrics. Feb 2003;111(2):E162-7. [Medline].
Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services. Public Health Service; May 2008. [Full Text].
American Academy of Pediatrics. American Academy of Pediatrics: Tobacco's toll: implications for the pediatrician. Pediatrics. Apr 2001;107(4):794-8. [Medline].
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].
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].
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].
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].
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].
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].
Further Reading
Keywords
nicotine abuse, nicotine dependence, tobacco use, cigarette use, smoking, tobacco-related disease, smoking-related disease
