Preventing and Treating Tobacco Dependence
Harold J. Farber, MD, MSPH, FAAP, and Marianna M. Sockrider, MD, DrPH, FAAP
Introduction/Etiology/Epidemiology
•Tobacco dependence is a severe chronic illness. Nicotine changes brain structure and chemistry.
•Tobacco causes disease and premature death when used exactly as intended.
•In addition to conventional cigarettes, oral tobacco (also called dip, chew, and snuff), hookahs (nargiles, water pipes), cigars (often inexpensive and candy flavored), and electronic nicotine delivery systems (ENDS) are popular among youth. Many young people regularly use more than 1 type of tobacco product. Table 27-1 shows the different tobacco products currently available in the United States.
•Tobacco promotion is an important cause of tobacco use initiation and escalation. Flavoring agents, including menthol, increase the appeal of tobacco products to youth.
•In the United States, close to 90% of current adult smokers started their tobacco use prior to 18 years of age, and 99% started prior to 26 years of age. Earlier age at tobacco use initiation is associated with more severe addiction and lower rates of stopping tobacco use.
•Sexual minority (lesbian, gay, bisexual, and transgender) youth and Native American youth have higher rates of tobacco use and are therefore at substantially increased risk for developing tobacco dependence. This may be due in part to the stresses and social discrimination they face; however, another contributing factor is marketing efforts by the tobacco industry that directly target these communities.
Electronic Nicotine Delivery Systems
•ENDS (eg, e-cigarettes, e-hookahs, vape pens) are rapidly rising in popularity among youth.
•Toxic and carcinogenic chemicals, including acrolein and benzene, as well as metallic nanoparticles, have been found in ENDS emissions.
•Flavoring agents can have clinically significant pulmonary toxicity, the full extent of which is not yet known.
| Table 27-1. Tobacco Products | |
| Product | Description |
| Cigarette | A small roll of paper that is filled with cut tobacco and smoked |
| Cigar, little cigar | A tightly rolled bundle of dried and fermented tobacco, wrapped in a tobacco leaf; cigars marketed to youth come in a variety of flavors, including “cherry,” “peach,” and “grape” |
| Pipe | A tube with a small bowl at one end, used for smoking tobacco that is marketed in different flavors |
| Hookah or narghile | A single-stemmed or multistemmed instrument in which the smoke is cooled by passing through water; flavors are commonly added to the tobacco. Charcoal is used to keep the tobacco burning. |
| Bidi or beedi | A thin, South Asian cigarette filled with tobacco flake and wrapped in a tendu leaf, tied with a string at 1 end |
| Kretek | Cigarettes made with a blend of tobacco, cloves, and other flavors |
| Chewing tobacco | Loose leaves, plugs, or twists of tobacco that are placed between the cheek and gum and are commonly sweetened |
| Snuff | Finely ground tobacco packaged in cans or pouches, which can be sold dry (a powdered form that is sniffed) or moist (placed between the lower lip or cheek and gum) and is commonly flavored |
| Snus | A moist powder tobacco product originating from a variant of dry snuff, usually not fermented and commonly flavored |
| Dissolvable tobacco | Dissolves in the mouth, unlike ordinary chewing tobacco; orbs or pellets resemble a small breath mint; sticks similar to toothpicks are inserted between the upper lip and gum; strips administer nicotine through thin-film drug delivery technology and look similar to breath-freshening strips |
| Electronic nicotine delivery system: e-cigarette, hookah stick, e-hookah, vape pen, other | Battery-powered devices that heat a solution to create an aerosol that can be inhaled; content is not regulated; devices usually contain nicotine from tobacco, propylene glycol, and flavoring agents; heating the mixture creates other toxins |
•Youth who would not otherwise be at risk for smoking are initiating their nicotine addictions with these devices.
•Youth who use ENDS are more likely to become combustible tobacco users and are less likely to stop smoking.
Nicotine Withdrawal Symptoms
•Cravings
•Irritability, frustration, anger
•Anxiety, restlessness
•Difficulty concentrating, slowed cognitive performance
•Insomnia
•Increased appetite
•Constipation
•Tremors
•Dysphoric or depressed mood
•Anhedonia—inability to feel pleasure
Usual Clinical Course
•Tobacco dependence almost always starts in the pediatric years.
•Symptoms of dependence can develop rapidly—even after just 1 cigarette and with smoking occuring less than monthly.
•Symptoms of nicotine dependence can be used to predict progression from intermittent to daily smoking.
•Early symptoms of tobacco use include coughing, bad breath, yellow stains on the fingers and teeth, and impaired sports performance.
•Tobacco smoking and exposure to tobacco smoke exacerbate asthma and decrease the effectiveness of inhaled and oral corticosteroid medications for asthma control.
Diagnostic Considerations
•The best way to establish the diagnosis is to ask the patient and the parents about their own tobacco and nicotine product use. When possible, talk with the teen separately from his or her parents (or alone) about tobacco and nicotine use.
•The tobacco product used may not be cigarettes and may not be smoked. A person may not consider him- or herself a “smoker,” even if he or she smokes.
•After establishing the diagnosis, the next step is to assess the severity of tobacco dependence, readiness to change, and treatments the patient would be willing to accept.
•Questions to screen for tobacco and nicotine use include
—“Do any of your friends use tobacco?”
—“Have you ever tried (name of tobacco product)?”
—“How often do you use (name of tobacco product)?”
—“Do your friends use hookahs, cigars, e-cigarettes, e-hookahs, or vapes?”
—“Have you tried hookahs, cigars, e-cigarettes, e-hookahs, or vapes?”
•An algorithm for assessing severity of tobacco dependence appears in Table 27-2.
The presence of 1 feature of severity is sufficient to place the patient in that category. If chronic medical or psychiatric disease is present in the smoker, escalate severity assessment—more intensive treatment is needed. Adapted with permission from Sachs DPL, Leone FT, Farber HJ, et al. American College of Chest Physicians Tobacco-Dependence Treatment Tool Kit. 3rd ed. Northbrook, IL: American College of Chest Physicians; 2010. http://tobaccodependence.chestnet.org.
•Simple questions to screen for nicotine dependence that can easily be used in the office setting include
—“How long is it between when you wake up in the morning and your first (tobacco product use)?”
—“How much (tobacco product) do you use a day?”
—“If you go long enough without using (tobacco product), how bad does your withdrawal get?”
•If the patient first uses tobacco within 1 hour of waking and/or smokes half a pack per day of cigarettes, then addiction is at least moderately severe.
•If withdrawal is so bad that without tobacco or nicotine the patient can’t focus, gets very irritable, and can’t get tobacco out of his or her mind, then dependence is very severe.
Prevention
•Counseling from a health care provider reduces the risk for tobacco product initiation. The U.S. Preventive Services Task Force recommends that primary care physicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use in children and adolescents.
•Messages should be clear, personally relevant, and age appropriate.
Messages for Tobacco and Nicotine Use Prevention
•Smoking causes bad breath.
•Smoking hurts sports performance.
•Tobacco addiction costs a lot of money.
•Nicotine addiction can develop very quickly.
•Nicotine is one of the most difficult addictions to kick.
•The tobacco industry deceives youth into thinking their products are attractive.
•E-cigarettes, e-hookahs, vapes, and other ENDS are not safe. A number of toxins are added, are generated by heating the liquid, or come off of the solder or casing (such as metalic nanoparticles) when using these products. To date, there are no manufacturing, quality, or safety standards for ENDS. Just because a flavoring agent is safe to eat does not mean it is safe to inhale.
•Ask children and adolescents to make a commitment to be tobacco and nicotine free.
•Ask the child to identify his or her own reasons for being tobacco and nicotine free.
Evidence-Based Public Policy Recommendations
•Pediatricians can be powerful advocates for effective public policy to control the tobacco epidemic.
•Recommendations for effective public policy include the following. — Tobacco control should be adequately funded.
—The minimum age to purchase tobacco should be increased to 21 years.
—Tobacco product prices should be increased to reduce youth tobacco use initiation.
—Tobacco product advertising and promotion in forms that are accessible to children and youth (including point of service advertising) should be prohibited.
—Depictions of tobacco products in movies and other media that can be viewed by youth should be restricted.
—Flavoring agents, including menthol, should be prohibited in all tobacco products.
Treatment
Pediatricians may be in the best position to counsel, recommend treatment, and/or treat patients and parents who wish to stop smoking. The pediatrician may be the health care provider that the parents see the most, as the physician for their child.
•Behaviorally based treatments are most effective for those with mild levels of addiction.
•Effective behaviorally based strategies focus on problem-solving skills and providing support and encouragement.
•ASK NOW (Box 27-1) is an approach to negotiating behavioral change.
Box 27-1. ASK NOW for Behavioral Change
A:Assess the health behavior of concern .
S:Determine the patient’s Stage of change.
K:Keep in mind Key facts, such as previous experience with making the change, social stresses, barriers, areas of resistance, etc .
N:Jointly Negotiate an action plan .
O:Observe outcomes in follow-up . Does the action plan need to be updated or modified? Learn from slips and lapses .
W:Work toward the next stage . Acknowledge and reinforce any progress . Jointly negotiate a plan to consolidate gains and move forward .
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