Monday, May 20, 2024

Pediatric Nicotine Abuse

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.

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.


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.


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.

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