Tobacco Use Disorders

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Key points

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    Tobacco use is prevalent among adolescents, and alternative tobacco product (ie, electronic cigarettes and hookah) use rates are increasing.

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    Adolescents with psychiatric and/or substance use disorders are at particularly high risk of experiencing tobacco dependence and having difficulty with quitting.

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    Several practice guidelines recommend that clinicians ask adolescents about tobacco use and provide a strong messages regarding the importance of abstinence from all tobacco products.

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    Clinical

Introduction/Background

Tobacco use is a pervasive public health problem and the leading cause of preventable morbidity and mortality in the United States.1 The treatment of adolescent cigarette smoking and tobacco use disorders, in particular, continues to be a substantial public health priority. Adolescence is a critical period for neurodevelopment, and nicotine exposure during adolescence causes addiction, sustained tobacco use into adulthood, and may have lasting adverse consequences for brain development.1, 2, 3

Cigarette Use

Every day, approximately 3200 youths younger than 18 years old initiate cigarette smoking, and 700 youths begin daily smoking.1 There has been a decrease in cigarette smoking rates over the last 40 years. The decrease in cigarette smoking is likely owing to many factors, including restrictions on advertising, taxation of cigarettes, and smoke-free laws.10 In 2014, 9.8% of high school students and 2.5% of middle school students reported past month cigarette use. In 2013, 18.9% of 18- to

Clinical presentation

The general examination may reveal signs that increase the probability of tobacco use. For example, the presence of smoke-odored clothing, a bottle for chew/dip spit, or cigarette packs may clue the clinician to ask more detailed questions about tobacco use. Adolescents rarely present with clinical signs that are present in adults, such as stained teeth or fingernails, wrinkles, or a hoarse voice. Adolescents in nicotine withdrawal may present with irritability, anxiety, and agitation, and may

Diagnosis

The primary method of diagnosing tobacco use is through the confidential psychiatric or medical interview. The type of tobacco product used, and the frequency and intensity of use is gauged through adolescent self-report. The 2015 American Academy of Pediatrics’ (AAP) Clinical Practice Policy to Protect Children from Tobacco, Nicotine and Tobacco Smoke endorses several questions from the American College of Chest Physicians Tobacco Treatment Toolkit to screen for and characterize adolescent

Brief summary of clinical management

Many professional organizations endorse the importance of cigarette and tobacco cessation counseling. The 2006 American Psychiatric Association Substance Use Treatment Guidelines encourage mental health clinicians to assess smoking status with all patients and to assist smokers in quitting.47 Additionally, both the 2008 Public Health Service’s Guideline48 and the 2015 AAP policy statement on tobacco20 recommend that all clinicians ask adolescent and young adult patients about tobacco use and

Considerations with co-occuring psychiatric disease or substance use disorders

There are few published studies evaluating smoking cessation interventions in adolescents with co-occuring psychiatric or substance use disorders. A metaanalysis of smoking cessation trials in adults with depression, found that the addition of psychosocial mood management to standard smoking cessation treatment improved long term abstinence rates in adults with both current and past depression.55 However, there are no systematic evaluations of smoking cessation treatments in adolescents with

Summary

Despite great advances in tobacco control, tobacco use and secondhand smoke exposure continues to substantially impact youth. Rates of cigarette use are decreasing; however, use of e-cigarettes, hookah, and other alternative tobacco products are increasing. Youth with psychiatric or substance use disorders are particularly vulnerable to develop tobacco use disorders. All clinicians should screen adolescents for all forms of tobacco use, and provide behavioral and, when indicated, pharmacologic

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    Disclosures: The authors have nothing to disclose.

    Funding: Funded by NIH (K12DA033012).

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