Pediatric Nicotine Abuse 

Updated: Apr 20, 2016
Author: Donna G Grigsby, MD; Chief Editor: Caroly Pataki, MD 

Overview

Practice Essentials

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]

Signs and symptoms

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.

Diagnosis

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.

Management

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.

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. 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]

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.

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]

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.[7]

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.

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]

Epidemiology

Race

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]

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.

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]

Age

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.

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%.

 

Presentation

History

The following are stages in the development of adolescent smoking:[10]

  • 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:[9, 11]

  • 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[12] :

  • 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[13] :

  • 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.[14]

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

 

Workup

Other Tests

The following are some of the diagnostic interview instruments used to assess nicotine dependence and/or use in adolescents:[15]

  • 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:[16]

  • 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:[6]

  • 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.[17]

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.[18]

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.[19]

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.[19] However, the US Public Health Service withdrew support for use of these medications in adolescents in their 2008 report.[18]

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:[18]

  • 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.

In August 2013, the US Preventive Services Task Force (USPSTF) issued updated guidelines on prevention of tobacco use in children and adolescents.[20, 21] A systematic review by the USPSTF indicates that primary care clinicians can make a difference in helping youth choose not to use tobacco, thereby improving their health and lifespan. Accordingly, the USPSTF recommends that healthcare professionals deliver behavioral counseling against tobacco use in person, by telephone, or via reading materials, computer applications, and videos.[21]

 

Medication

Medication Summary

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.[18]

Nicotine replacement therapies

Class Summary

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.

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.

Nicotine nasal spray (Nicotrol NS)

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

Nicotine transdermal system (Nicotrol, Nicoderm CQ)

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

Non-nicotine replacement therapy

Class Summary

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.