A Practical Clinical Approach to the Treatment of Nicotine Dependence in Adolescents

Abstract

Even with the recent reduction in rates of cigarette smoking among adolescents, it remains a major public health problem in the United States, with almost 16% of 12th graders using cigarettes daily (Johnston et al., 2004). Most smokers initiate smoking before age 18, and by one estimate, approximately 3,000 adolescents initiate smoking every day in the United States (Fiore et al., 2000). Cigarette smoking, at least in the United States, is predominantly a pediatric disorder and causes significant morbidity and mortality; tobacco is related to more than 400,000 deaths in the United States annually (U.S. Department of Health and Human Services, 2000). Cigarette smoking in adolescence affects lung function and bone growth (Gold et al., 1996) and may cause increased risk of depressive disorder (Goodman and Capitman, 2000). Cigarette smoking during pregnancy can cause low birth weight, hyperactivity, conduct disorder, and increased nicotine receptors in the children (Kinney, 1998). In addition, environmental tobacco smoke exposure before age 10 may increase the risk of leukemia and lymphoma in adulthood (Sandler et al., 1985). Psychiatric comorbidity is associated with smoking, and early-onset smoking (before age 13) is robustly associated with psychopathology later in adolescence (Upadhyaya et al., 2002). Child and adolescent psychiatrists are in a position to prevent and treat nicotine dependence because many of our patients smoke cigarettes. Unfortunately, nicotine dependence is frequently underdiagnosed and undertreated among adolescents in psychiatric settings. In a systematic assessment of 120 adolescents admitted to an inpatient psychiatric unit, only six of the 47 current smokers had a chart diagnosis of nicotine dependence (Upadhyaya et al., 2003). Nicotine withdrawal can become a significant issue among adolescents admitted to locked inpatient psychiatric units because they are not allowed to smoke. Common nicotine withdrawal symptoms include irritability, anxiety, decreased concentration, increased appetite, and craving for cigarettes (American Psychiatric Association, 2000). These symptoms can mimic symptoms of other psychiatric disorders as well as make patients more difficult to manage on the unit. Hence, in this clinical perspective article, we offer practical advice for addressing nicotine dependence by child and adolescent psychiatrists.