Tobacco use is a serious pediatric health issue, as dependence begins during childhood or adolescence in the majority of tobacco users. In short, nicotine dependence is a pediatric disease that manifests most of its symptoms later in life.
More than 3 million adolescents in the United States smoke; 6,000 adolescents start smoking every day. Studies reveal 5 million people who smoke in the United States are 12 to 17 years old and more than 500,000 people who smoke in the United States are 8 to 11 years old. Other studies suggest that nationwide 10 percent of eighth graders, one out of 6 tenth graders and 25 percent of high school seniors use tobacco daily. In Anne Arundel County, smoking rates among teens peaked in 2000, and now about 19 percent of teens are current smokers. Tobacco use among individuals aged 18 years who are not in school has been estimated to be as high as 75 percent. Forty-four percent of all County children live in a household where at least one person smokes. Most adolescents who smoke daily are addicted to nicotine and 50 percent report withdrawal symptoms when trying to stop smoking. A long-term tobacco user has a 50 percent chance of dying prematurely from a tobacco-related disease. Tobacco use remains the largest contributor not only to deaths, but also to years of potential life lost in the County. Almost 75 percent of adolescent daily smokers who believe that they will not be smoking in five years find that they are unable to quit. The American Academy of Pediatrics (AAP) has issued a number of policy statements relevant to the problem of adolescent smoking and nicotine dependence in the past five years, focusing on the fact that pediatricians as a group are well positioned to take an active role in addressing this issue.
While many of the more serious impacts of smoking appear later in life, adolescent smokers show evidence of airway obstruction, slowed growth in lung function, and higher rates of cough and other respiratory symptoms, compared with nonsmokers. In addition, the earlier individuals begin to smoke, the higher their risk for cancer, heart disease, stroke and chronic obstructive lung disease; nicotine addiction; and possibly their risk of developing anxiety disorders and depression. Similar to adults, nearly three fourths of adolescent smokers have seriously thought about quitting, 64 percent report having made an attempt to quit, and 40 percent of daily smokers report having tried to quit at least once and failed. Cessation and successful abstinence are more common in smokers who began smoking at or after 17 years of age. Among 17-year-old smokers, 40 percent report that they would be interested in cessation treatment.
Asking the right questions, including simple ones like “Have you ever smoked? How frequently? Does your mother or father smoke?” This can effectively sort the teen smokers from the nonsmokers. Teens tend to be honest about their smoking status when asked, especially in private.
Primary care settings provide tremendous opportunities for delivering tobacco treatment to young tobacco users. Many organizations, including the AAP, the Surgeon General and others have listed general guidelines for youth smoking cessation. The current clinical practice guidelines for adults also provide recommendations based on expert opinions. Pediatricians and other clinicians can and should play an important role in treating tobacco dependence in youths.
Between 63 and 85 percent of adolescents are seen for preventive care visits each year. Among those with at least one visit, 60 percent had two or more visits during the year. Because of their authority, credibility and long-term relationship with patients, clinicians are afforded many clinical opportunities and teachable moments to deliver smoking prevention messages and reinforce cessation interventions during routine care.
There is strong evidence that brief counseling by physicians, dentists and other health care providers increases smoking cessation rates in adult patients. While there is less accumulated evidence regarding the efficacy of brief clinician interventions in treating tobacco use in adolescence, expert opinion rather than empirical data is used to guide clinical interventions for young smokers. Current guidelines recommend that clinicians deliver strong messages regarding abstaining from tobacco and cessation of use to children and adolescents.
Guidelines from DHHS include the following recommendations for adolescents:
- Clinicians should screen pediatric and adolescent patients, and their parents, for all forms of tobacco use and provide a strong message regarding the importance of totally abstaining from tobacco use.
- Counseling and behavioral interventions shown to be effective with adults should be considered for use with children and adolescents. The content of these interventions should be modified to be developmentally appropriate; adult group settings might not be appropriate.
- When treating adolescents, clinicians may consider prescriptions for bupropion SR or NRT when there is evidence of nicotine dependence and a desire to quit tobacco use.
- Clinicians in a pediatric setting should offer smoking cessation advice and interventions to parents to limit children’s exposure to secondhand smoke.
A recent report from the U.S. Surgeon General claims that nationwide use of available anti-smoking programs could cut in half the rates of teen and adult smoking within 10 years.
The report backs a series of plans based on a community approach to the problem that include:
- School-based educational programs. Combined with community and media-based anti-tobacco messages, fewer than 5 percent of the nation’s schools are using government-recommended guidelines to set up programs.
- State and local passage and enforcement of tough clean indoor air standards and “secondhand smoke” protections.
- Higher taxes on tobacco products. The government backs increasing federal and state taxes by $2 per pack by 2010. A 10 percent price increase will cut tobacco product consumption by 3 – 5 percent, with an even higher reduction in youth use.
- Expanded use of behavioral counseling and pharmacological treatments to help individuals quit smoking.
While community-based programs are making progress against the new initiation of smoking, the clinician’s office is significant in helping smoking teens quit. Advertising research shows that most messages to quit smoking are rejected by smokers, except when they are delivered in the context of the physician/patient relationship.
- Tobacco Counseling at Well-Child and Tobacco-Influenced Illness Visits: Opportunities for Improvement