Pediatric Nicotine Abuse Clinical Presentation

Updated: Oct 14, 2021
  • Author: Donna G Grigsby, MD; Chief Editor: Caroly Pataki, MD  more...
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The following are stages in the development of adolescent smoking: [11]

  • 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.



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



Possible factors involved in the increase in adolescent tobacco use include the following: [10, 12]

  • 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 [13] :

  • 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 [14] :

  • 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.

A study of school children in Montreal 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. [15]



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