Adolescents and Tobacco

Adolescents use all forms of tobacco including cigarettes, cigars, pipe tobacco, snuff, chewing tobacco, and hookahs as well as new tobacco products including snus, electronic cigarettes, dissolvable tobacco strips.  According to the 2009 Youth Risk Behavior Surveillance (Centers for Disease Control and Prevention), among high school students, 46% of females and males report ever smoking at least one cigarette, 19% of females and 20% of males have smoked in the past month, and 6% of females and 8% of males have smoked on at least 20 of the past 30 days. Of those who are current smokers (use in the past month), 54% of females and 48% or males have tried to quit one or more times. While 15% of males reported use of smokeless tobacco, only 2% of females did so. Of concern is that 9% of females and 12% of males smoked their first cigarette before age 13 years. While the majority of adolescents are nonusers, they often are exposed to second-hand smoke from their peers or family members.

Adolescents may initiate use of tobacco to express independence, to “feel” and “act” like adults, and to be socially accepted. Some smoke to try to control their weight, some smoke to reduce stress. Risk factors for regular tobacco use include having parents, siblings, or peers who use tobacco, poor school performance and limited goals, tendency to risk-taking behaviors, and use of alcohol and/or other drugs. Despite debate about the roles of media portrayals of tobacco use as normal, natural, and safe and  marketing that appears targeted to the young, many researchers suggest a strong influence of these on underage smoking.

Nicotine, the major active ingredient in all tobacco products, is highly addictive. Research has shown that addiction to nicotine develops more quickly and at lower doses in adolescents than in adults. The younger one becomes a regular user of tobacco, the more difficult it is to discontinue use.  There are no safe tobacco products and casual or social tobacco use is strongly associated with subsequent tobacco addiction.  The long-term health hazards of tobacco use and of exposure to secondhand tobacco (e.g. cardiovascular diseases, hypertension, numerous cancers, pulmonary diseases, dental diseases) are well known to adolescents but often discounted as too remote for current concern. Tobacco use can affect performance in sports, increase respiratory symptoms in those who have asthma, seasonal allergies, or even upper respiratory infections, stain teeth, and lead to foul breath and smoky smell in hair and clothing. Tobacco use poses risk to the fetus, especially in the pregnant adolescent who is not yet diagnosed or in denial. Adolescent tobacco users can incur legal penalties – in most states, it is illegal to purchase cigarettes  under age 18 or to purchase cigarettes for someone who is under 18.

ACOG recommends that Obstetrician/Gynecologists and other providers of health care for adolescents should ask about use of tobacco and other forms of nicotine and exposure to second-hand smoke as part of the routine medical history at every preventive health visit  and when there are clinical indications, such as counseling about hormonal contraceptives or treatment of chronic respiratory problems such as asthma. Pregnant adolescents should be asked about use of tobacco as well as alcohol or other drugs. Adolescents who report current use of tobacco in any amount or any form should be encouraged to discontinue use and offered assistance with cessation.  The National Smoker’s Quitline has counselors trained to assist adolescents with smoking cessation and to provide the adolescent or his/her family with local smoking cessation resources (1-800-STOP NOW). At this time, tobacco cessation aids including nicotine replacement therapy, bupropion and varenicline are not approved for adolescent use. 

The following resources provide information for the interested health professional, parent, or adolescent about tobacco use, associated health hazards, and strategies for cessation of use and for prevention. Many of the organizations listed have available pamphlets, posters, and other materials to promote and assist tobacco cessation efforts in the office setting. Additional related references can be found in the ACOG Resource Guide: Adolescents and Substance Use.

The following resources are available from ACOG:

American College of Obstetricians and Gynecologists. Alcohol, tobacco, and other substance use and abuse. In: Guidelines for adolescent health care. 2nd ed. Washington, DC: American College of Obstetricians and Gynecologists; 2011. p. 97-110.

American College of Obstetricians and Gynecologists. Smoking and women's health. In: Special issues in women's health. Washington, DC: ACOG; 2005. p. 151-67.

American College of Obstetricians and Gynecologists. Fact sheet: tobacco use. In: Tool kit for teen care. 2nd ed. Washington, DC: ACOG; 2009.

American College of Obstetricians and Gynecologists. Tobacco use: a fact sheet for parents. In: Tool kit for teen care. 2nd ed. Washington, DC: ACOG; 2009.

American College of Obstetricians and Gynecologists. Tobacco, alcohol, drugs, and pregnancy. ACOG Patient Education Pamphlet AP170. Washington, DC: ACOG; 2008.

The resources listed below are for information purposes only. Referral to these sources and sites does not imply the endorsement of ACOG. Further, ACOG does not endorse any commercial products that may be advertised or available from these organizations or on these web sites. These lists are not meant to be comprehensive. The exclusion of a source or site does not reflect the quality of that source or site. Please note that sites and URLs are subject to change without notice.

References for Professionals

General

Tobacco use: a pediatric disease. Policy statement. American Academy of Pediatrics [published erratum appears in Pediatrics 2010;125:861]. Pediatrics 2009;124:1474-87.

Baler RD, Volkow ND. Addiction as a systems failure: focus on adolescence and smoking. J Am Acad Child Adolesc Psychiatry 2011;50:329-39.

Botvin GJ, Epstein JA, Botvin EM. Adolescent cigarette smoking: prevalence, causes, and intervention approaches. Adolesc Med 1998;9:299-313, vi.

Heyman RB. Turning the tide: tobacco and the 21st century. Adolesc Med 2000;11:69-78.

Martinasek MP, McDermott RJ, Martini L. Waterpipe (hookah) tobacco smoking among youth. Curr Probl Pediatr Adolesc Health Care 2011;41:34-57.

Moolchan ET, Ernst M, Henningfield JE. A review of tobacco smoking in adolescents: treatment implications. J Am Acad Child Adolesc Psychiatry 2000;39:682-93.

Patel DR, Homnick DN. Pulmonary effects of smoking. Adolesc Med 2000;11:567-76.

Sunday SR, Folan P. Smoking in adolescence: what a clinician can do to help. Med Clin North Am 2004;88:1495-515, xi.

Epidemiology

Charlesworth A, Glantz SA. Smoking in the movies increases adolescent smoking: a review. Pediatrics 2005;116:1516-28.

Cortese DK, Lewis MJ, Ling PM. Tobacco industry lifestyle magazines targeted to young adults. J Adolesc Health 2009;45:268-80.

Eaton DK, Kann L, Kinchen S, Shanklin S, Ross J, Hawkins J, et al. Youth risk behavior surveillance - United States, 2009. Centers for Disease Control and Prevention (CDC). MMWR Surveill Summ 2010;59(SS-5):1-142. Available at: http://www.cdc.gov/mmwr/pdf/ss/ss5905.pdf. Retrieved December 7, 2011.

Hipple B, Lando H, Klein J, Winickoff J. Global teens and tobacco: a review of the globalization of the tobacco epidemic. Curr Probl Pediatr Adolesc Health Care 2011;41:216-30.

Jackson C, Brown JD, L'Engle KL. R-rated movies, bedroom televisions, and initiation of smoking by white and black adolescents. Arch Pediatr Adolesc Med 2007;161:260-8.

Johnston LD, O'Malley PM, Bachman JG, Schulenberg JE. Monitoring the Future national results on adolescent drug use: overview of key findings, 2010. Ann Arbor (MI): Institute for Social Research, University of Michigan; 2010. Available at: http://monitoringthefuture.org/pubs/monographs/mtf-overview2010.pdf. Retrieved December 7, 2011.

Lakon CM, Hipp JR, Timberlake DS. The social context of adolescent smoking: a systems perspective. Am J Public Health 2010;100:1218-28.

Lessov-Schlaggar CN, Wahlgren DR, Liles S, Ji M, Hughes SC, Winickoff JP, et al. Sensitivity to secondhand smoke exposure predicts future smoking susceptibility. Pediatrics 2011;128:254-62.

Marano C, Schober SE, Brody DJ, Zhang C. Secondhand tobacco smoke exposure among children and adolescents: United States, 2003-2006. Pediatrics 2009;124:1299-305.

Nelson DE, Mowery P, Asman K, Pederson LL, O'Malley PM, Malarcher A, et al. Long-term trends in adolescent and young adult smoking in the United States: metapatterns and implications. Am J Public Health 2008;98:905-15.

Sargent JD. Smoking in movies: impact on adolescent smoking [published erratum appears in Adolesc Med Clin 2006;17:809]. Adolesc Med Clin 2005;16:345-70, ix.

Sargent JD, Stoolmiller M, Worth KA, Dal Cin S, Wills TA, Gibbons FX, et al. Exposure to smoking depictions in movies: its association with established adolescent smoking. Arch Pediatr Adolesc Med 2007;161:849-56.

Wellman RJ, Sugarman DB, DiFranza JR, Winickoff JP. The extent to which tobacco marketing and tobacco use in films contribute to children's use of tobacco: a meta-analysis. Arch Pediatr Adolesc Med 2006;160:1285-96.

Intervention/Cessation

Adelman WP. Tobacco use cessation for adolescents. Adolesc Med Clin 2006;17:697-717; abstract xii.

Curry SJ, Emery S, Sporer AK, Mermelstein R, Flay BR, Berbaum M, et al. A national survey of tobacco cessation programs for youths. Am J Public Health 2007;97:171-7.

Dino GA, Pignataro R, Breland A, Murray PJ, Horn K. Adolescent smoking cessation: promising strategies and evidence-based recommendations. Adolesc Med State Art Rev 2011;22:614-30, xiii-iv.

DuRant RH, Smith JA. Adolescent tobacco use and cessation. Prim Care 1999;26:553-75.

Garrison MM, Christakis DA, Ebel BE, Wiehe SE, Rivara FP. Smoking cessation interventions for adolescents: a systematic review. Am J Prev Med 2003;25:363-7.

Lamkin LP, Houston TP. Nicotine dependency and adolescents: preventing and treating. Prim Care 1998;25:123-35.

National Cancer Institute. Smokefree smartphone applications. Available at: http://smokefree.gov/apps. Retrieved February 1, 2012.

Orleans CT, editor. Young adult tobacco cessation [special issue]. Am J Public Health 2007;97(8).

Patel DR, Greydanus DE. Office interventions for adolescent smokers. Adolesc Med 2000;11:577-88.

Spigarelli MG, Heyman RB. The A-R-T of tobacco use counseling: a new office approach. Contemp Pediatr 2005;22(9):77, 80-2, 84, passim.

Upadhyaya H, Deas D, Brady K. A practical clinical approach to the treatment of nicotine dependence in adolescents. J Am Acad Child Adolesc Psychiatry 2005;44:942-6.

Ziedonis D, Haberstroh S, Hanos Zimmermann M, Miceli M, Foulds J. Adolescent tobacco use and dependence: assessment and treatment strategies. Adolesc Med Clin 2006;17:381-410.

Prevention

Klein JD, Camenga DR. Tobacco prevention and cessation in pediatric patients. Pediatr Rev 2004;25:17-26.

Rosen IM, Maurer DM. Reducing tobacco use in adolescents. Am Fam Physician 2008;77:483-90.

Sherman EJ, Primack BA. What works to prevent adolescent smoking? A systematic review of the National Cancer Institute's Research-Tested Intervention Programs. J Sch Health 2009;79:391-9.

Winickoff JP, Berkowitz AB, Brooks K, Tanski SE, Geller A, Thomson C, et al. State-of-the-art interventions for office-based parental tobacco control. Tobacco Consortium, Center for Child Health Research of the American Academy of Pediatrics. Pediatrics 2005;115:750-60.

Books for Professionals, Parents

American Academy of Pediatrics Julius B. Richmond Center for Excellence. Solving the puzzle: a guide to pediatric tobacco control. Elk Grove Village (IL): AAP; 2011. Available at: http://www.aap.org/richmondcenter/SolvingThePuzzle.html. Retrieved December 7, 2011.

Hunnicutt SC, editor. Tobacco and smoking: opposing viewpoints. Detroit (MI): Greenhaven Press; 2009.

Jacobson PD, Lantz PM, Warner KE, Wasserman J, Pollack HA, Ahlstrom AK. Combating teen smoking: research and policy strategies. Ann Arbor (MI): University of Michigan Press; 2001.

Kiesbye S. Contemporary issues companion: teen smoking. Detroit (MI): Greenhaven Press; 2007.

Books for Adolescents

Egendorf LK. Issues that concern you: smoking. Detroit (MI): Greenhaven Press; 2007.

Hyde MO, Setaro JF. Smoking 101: an overview for teens. New York (NY): Twenty-First Century Books; 2006.

Keyishian E. Everything you need to know about smoking. Rev ed. New York (NY): Rosen; 2003.

McCay W, Dingwell H. The truth about smoking. 2nd ed. New York (NY): Facts on File; 2009.

Williams R. At issue: teen smoking. Detroit (MI): Greenhaven Press; 2009.

Organizations/Websites

American Academy of Family Physicians
www.aafp.org/online/en/home.html

http://familydoctor.org/familydoctor/en/diseases-conditions/tobacco-addiction.html

American Academy of Pediatrics
www.aap.org

Pamphlets: Dangers of Secondhand Smoke
                  The Risks of Tobacco Use
                  Tobacco: Straight Talk for Teens

American Cancer Society
www.cancer.org

American Heart Association
www.heart.org/HEARTORG

American Lung Association
www.lungusa.org

Campaign for Tobacco-Free Kids
www.tobaccofreekids.org

Channing Bete Company
www.channing-bete.com

 Numerous booklets, pamphlets especially on smoking cessation

ETR Associates
www.etr.org

Pamphlets: Smoking: Talking With Your Teen
      Teens and Butts
      Teens and Chew
      Tobacco: Incredible Facts

Krames
www.krames.com
Numerous booklets, pamphlets on smoking and health, secondhand smoke, smoking cessation
 
National Cancer Institute
www.cancer.gov

SmokeFree.gov
www.smokefree.gov

Surgeon General’s office
www.surgeongeneral.gov

Office of the Surgeon General. The health consequences of smoking: a report of the Surgeon General. Rockville (MD):OSG;2004. Available at: http://www.surgeongeneral.gov/library/smokingconsequences. Retrieved December 6. 2011.
Office of the Surgeon General. Tobacco cessation – you can quit smoking now! Rockville (MD):OSG;2008. Available at: http://www.surgeongeneral.gov/tobacco. Retrieved December 6, 2011.

Contact:

Caitlin Phelps, MA
Director of Gynecology
cphelps@acog.org

Lyndona Charles
Special Assistant, Gynecology and Ethics
lcharles@acog.org