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.
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.