PEDIATRICS Vol. 107 No. 4 April 2001, pp. 794-798
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ABSTRACT |
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The disease of tobacco addiction, which is pervasive in the United States, begins in childhood and adolescence. Twenty-five percent of the population regularly uses tobacco, despite evidence that such use is the leading preventable cause of death in the United States. Tobacco use reportedly kills 2.5 times as many people each year as alcohol and drug abuse combined. According to 1998 data from the World Health Organization, there were 1.1 billion smokers worldwide and 10 000 tobacco-related deaths per day. Furthermore, in the United States, 43% of children aged 2 to 11 years are exposed to environmental tobacco smoke, which has been implicated in sudden infant death syndrome, low birth weight, asthma, middle ear disease, pneumonia, cough, and upper respiratory infection. Pediatricians play a crucial role in reducing both tobacco use (by children, adolescents, and their parents) and exposure to tobacco smoke and should rank this among their highest health prevention priorities.
Every day in the United States, 6000 young people start
smoking, a 50% increase since 1988.1 Half of these youth
will become daily smokers. In 2000, some adolescent smoking rates
exceeded the 25% adult rate, with 31%, 24%, and 15% of 12th, 10th,
and 8th graders, respectively, reporting recent smoking (smoking in the
past 30 days) and 21%, 14%, and 8%, respectively, reporting daily
smoking.2 Smoking rates are higher among rural youth than
among their urban peers.3 Prevalence rates of cigarette
smoking among students do not include those youth who drop out of
school and are more likely to use tobacco than those who are in school.
One study conducted in North Carolina suggests that tobacco use among
elementary school children may be as high as 15% in the third through
fifth grades.4 These children, that is, those who start
tobacco use at an early age, are most likely to continue to smoke into
adult life.
Ethnic and cultural variations in tobacco use reflect multiple
interactions among income, tobacco price, availability, culture, stress, genetics, age, sex, and targeted advertising.5
Table 1 reveals that in 1994, cigarette
smoking was highest among American Indian and Alaska Natives (39%),
white (26%), and African American adults (26%), and lowest among
Hispanics (19%) and Asian American and Pacific Islanders
(15%).5 Youth rates were higher than adult rates in all
ethnic groups except African Americans. Girls of different ethnicities
smoked less than boys during the period studied except for white youth, in whom the rates were identical. Analysis of tobacco use data by
ethnic group can guide us in understanding smoking patterns of such
groups, developing culturally appropriate interventions, and evaluating
their efficacy. Data from the Youth Risk Behavior Survey demonstrate
that for the period 1991 to 1997, rates of smoking increased 28% for
white youth, 34% for Hispanic youth, and 80% for African American
youth.6
TABLE 1
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THE SCOPE OF THE PROBLEM
Smoking Rates by Age and
Ethnicity*
In the last several years, cigar smoking among youth has become more prevalent. In 1997, 22% of high school students reported smoking cigars in the past month (31% of boys and 11% of girls). Smokeless tobacco remains a problem as well, with 16% of male, though only 1.5% of female, students reporting use.6 Use of chewing tobacco and snuff tends to be greater among white youth who live in the South and Midwest regions, participate in organized sports, smoke cigarettes, and perceive friends to approve of or be indifferent to the use of smokeless tobacco.7 Although cigarette smoking is more prevalent among low-income, low socioeconomic populations, 10% to 15% of middle-income college-educated adults are smokers, and, according to a California study, cigar smoking is actually more common among those of middle and upper income as well as those with higher educational backgrounds.8
As with smoking, environmental tobacco smoke (ETS) exposure is a class-based epidemic with rates of about 40% for children who come from families of low socioeconomic status and 20% for children from wealthier, more educated families. Consequences of ETS increase as a function of the number of cigarettes smoked because more particulate matter is discharged into the air.
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NICOTINE AS A PSYCHOACTIVE DRUG |
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Addiction to nicotine is a common consequence of tobacco use. A puff on a cigarette results in peak brain nicotine levels within 10 seconds, activating the brain circuitry that regulates pleasure and increasing dopamine in the reward circuits.9 Ninety percent of those who will become regular smokers start smoking before age 19 years, and dependence is common after smoking as few as 100 cigarettes.10 Most daily smokers meet the diagnostic criteria for "nicotine/tobacco dependence," a pharmacologically based behavioral disorder described in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders.11 Nicotine dependence is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal because smoking causes coronary artery disease, chronic lung disease, and cancer. It is characterized by impaired control over tobacco use, preoccupation with the drug nicotine, use of tobacco despite adverse consequences, and distortion in thinking, including denial of addiction. Nicotine addiction in teenagers is as severe as that in adults, and they have similar difficulty in quitting tobacco use.12
Among adolescents and adults who abuse other substances, tobacco use is extremely high, with rates of 80% to 90%.13,14 Tobacco addiction has not been routinely addressed during drug treatment programs because of fear that nicotine abstinence will trigger relapse to other drugs or alcohol. However, there is evidence to suggest that offering help with tobacco cessation to recovering alcoholics is associated with prolonged abstinence from alcohol and some other drugs.15
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DANGERS OF TOBACCO USE AND EXPOSURE TO ETS |
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Consequences of smoking include increased incidence of upper respiratory infection, cough, asthma, sinusitis, cardiovascular disease, cancer, impaired fertility, premature aging, and death, as well as loss of time from work and school. Smoking in children and youth has been shown to interfere almost immediately with both growth and functioning of the lungs.16
In both adults and adolescents, smoking is statistically associated with depression, anxiety, attention deficit hyperactivity disorder, and other psychiatric disorders. Teens with these disorders are significantly more likely to initiate smoking than peers without these conditions.10,17-20 Conversely, teens who smoke are significantly more likely to develop depression than nonsmokers,18 suggesting either a common vulnerability or a causal link. More research is needed to clarify the relationships between smoking and psychiatric disorders so that appropriate preventive and cessation strategies can be developed.
Pregnant women who smoke should be aware of increased risks to their offspring, including spontaneous abortion, low birth weight, sudden infant death syndrome, and long-term cognitive and behavioral problems including lower intelligence and attention deficit disorder with or without hyperactivity.19 Recent research suggests that some children born to mothers who smoke during pregnancy have more brain nicotine receptors.21 Prospective fathers who smoke need to be aware of their increased risk for developing impotence and transmitting genetic abnormalities.22 Parents also need to be aware that ETS is classified by the US Environmental Protection Agency as a class A carcinogen and that exposing their children to ETS increases the risk of asthma, sudden infant death syndrome, middle ear disease, pneumonia, cough, upper respiratory infection, lower high-density lipoprotein cholesterol levels, and coronary artery disease.23 Exposure to ETS before age 10 years increases the risk of developing leukemia and lymphoma as an adult.24
Smokeless tobacco is associated with precancerous leukoplakia in 60% to 78% of regular users and with increased risk of mouth cancer. Cigar and pipe tobacco use is associated with increased rates of cardiovascular disease and emphysema as well as cancers of the lung, larynx, mouth, and esophagus.
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RISK FACTORS FOR INITIATION OF TOBACCO USE |
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As with other substances of abuse, early tobacco use is associated with a cluster of risk factors.25 Smoking is often associated with poor school performance, low aspirations, alcohol and other drug use, school absences, and anticipated dropping out. Nicotine is frequently the first substance of abuse used by children and youth. Those who use it are 15 times more likely to progress to other drug use than those who have never smoked. Environmental factors linked to tobacco use include parents, siblings, and peers who smoke, exposure to tobacco advertising, and the portrayal of tobacco in the media. Tobacco advertising appears to be a more potent influence than parents or peers, perhaps because it affects perceptions of the pervasiveness, image, and benefits of smoking.12 Personal characteristics correlated with child and teen cigarette smoking include low self-esteem, poor self-image, low perceived self-efficacy, susceptibility to peer pressure, novelty seeking and rebelliousness, ignorance of smoking-related adverse effects, depression, and anxiety.26 Genetic factors appear to influence the pharmacologic reaction to nicotine; some of these appear to be linked to genes that influence the expression of alcoholism.26
Initiation of tobacco use is more closely associated with environmental
factors, while progression from the first cigarette to additional
cigarettes appears more influenced by personal and pharmacologic
factors. The sociodemographic factors of low socioeconomic status, low
level of parent education, and being in the transition years between
elementary and high school (ages 11-16 years) correlate closely with
initiation.26 Protective factors in the individual,
family, and environment that can guard against risky behaviors such as
tobacco use include close communication with parents, positive parental
support, high self-esteem, assertiveness, social competence, school
success, regular church attendance, and a strong sense of right and
wrong
factors that can be encouraged in the context of a pediatric
office visit.27
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ADDRESSING TOBACCO USE IN THE OFFICE |
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A "no-smoking office" with appropriate signs, magazines without tobacco advertising, and tobacco-free posters, literature, and referral resources may help counter the omnipresent tobacco advertising.28 The National Institutes of Health (NIH) guidelines for pediatricians to address tobacco29,30 and the US Public Health Service Tobacco Use and Dependence Clinical Practice Guideline31,32 present 6 components that can guide pediatricians in addressing tobacco use by children and adolescents:
As alluded to earlier, the pediatrician's tobacco prevention activities should begin at the time of the prenatal visit with a discussion of the effects of smoking on the unborn infant. For infants and toddlers, tobacco prevention activities ideally begin at the very first visit. The pediatrician should assess tobacco use and ETS exposure in the extended family and environment, encourage smokers to smoke outside the home and to consider quitting, and provide relapse prevention for women who quit during pregnancy (50%-90% chance of relapse) and for other family members who have quit.
During health care visits for young children, the pediatrician can explore what the children have learned about tobacco and what they think about smoking. Children from families whose members smoke or use drugs are at high risk for starting tobacco use early. In these cases, the pediatrician can encourage tobacco, alcohol, or other drug treatment for parents and promote protective factors such as positive parenting skills and good communication. Children who are experimenting should be given a brief motivational interview to stop, and should be encouraged to find activities that will promote a smoke-free lifestyle.
It is critical to discuss the issue of tobacco, alcohol, and other drug use confidentially with every teen at virtually every visit. Parents can be encouraged to be role models for a tobacco-free lifestyle and establish a clear standard of no tobacco use because these behaviors are associated with a lower rate of initiating smoking.33 The pediatrician can explore the teen's knowledge of short-term risks of smoking (such as cough and shortness of breath) and chewing tobacco (such as gingivitis and bad breath), clarify misperceptions, and reinforce and rehearse refusal skills.34 Teens who use tobacco should also be advised to quit. Because they are at risk for other substance use, an appropriate assessment may be indicated.25 All these interventions will be most effective if done in culturally appropriate ways.
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ADDRESSING TOBACCO CESSATION IN THE OFFICE |
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The pediatrician should be prepared to discuss the issue of tobacco cessation at every opportunity. Whether identifying tobacco use during a routine health check or dealing with an illness precipitated by tobacco use or ETS exposure, cessation advice, treatment, and referral should be offered to parents or patients as appropriate. Although not every tobacco user is ready to quit, a personalized message and a brief motivational interview may be helpful in moving a tobacco user along the so-called "stages of change" from having no interest in quitting ("precontemplation") to interest ("contemplation") to making plans ("preparation") to actually doing something ("action").35 Success in quitting is facilitated by a patient, persevering, nonjudgmental, empathic approach on the part of the pediatrician. Supportive counseling and group interventions have been shown to be an effective part of a comprehensive nicotine treatment program for teenagers. However, all parties must recognize that relapses are common, and that they represent learning experiences on which the next quit attempt can be built.
Those who smoke 10 or more cigarettes a day may benefit from systemic nicotine replacement therapy supplied by patches, gum, spray, or inhaler. Bupropion, clonidine, and nortriptyline are additional therapeutic modalities. Various combinations of these products may increase abstinence rates at 1 year from the baseline of 5% (for self-help programs alone) to as high as 20% to 35% at 1 year in adults.36 Recent research suggests that pharmacotherapy can be useful and safe in adolescent tobacco users.37
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ROLE OF THE PEDIATRICIAN IN THE COMMUNITY |
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Recent political and legal strategies have shown clearly that lower rates of tobacco use, especially in young people, depend on a comprehensive, broad-based, and sustainable effort to restrict the desire for and availability of the product. Pediatricians can be strong advocates for such programs when these major components are included:
By extending their reach into the community to interface with schools, parent groups, civic and religious organizations, and other health professionals, pediatricians can be an instrumental force in decreasing tobacco use by youth.
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CONCLUSIONS |
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RECOMMENDATIONS |
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Committee on Substance Abuse, 2000-2001
Edward A. Jacobs, MD, Chairperson
Alain Joffe, MD, MPH
John R. Knight, MD
John Kulig, MD, MPH
Peter D. Rogers, MD, MPH
Liaisons
Gayle M. Boyd, PhD
National Institute of Alcohol Abuse and Alcoholism
Dorynne Czechowicz, MD
National Institute on Drug Abuse
Deborah Simkin, MD
American Academy of Child and Adolescent Psychiatry
Consultant
Richard B. Heyman, MD
Staff
Karen Smith
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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ABBREVIATIONS |
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ETS, environmental tobacco smoke; NIH, National Institutes of Health.
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REFERENCES |
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African Americans, American
Indians and Alaska Natives, Asian Americans and Pacific Islanders, and
Hispanics: A Report of the Surgeon General. Atlanta, GA: US
Department of Health and Human Services, Centers for Disease Control
and Prevention, National Center for Chronic Disease Prevention and
Health Promotion, Office on Smoking and Health; 1998
United States, 1997.
MMWR Morb Mortal Wkly
Rep
1998;
47:229-233 [Medline]Statement of reaffirmation:
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