________________________________ (c)2013 UpToDate (R) Official Topic from UpToDate(R), the clinical information service on the web and mobile devices. To subscribe to UpToDate(R), visit us online at http://www.uptodate.com/store. Management of smoking cessation in adolescents Authors Joseph B Rosen, MD Marianna Sockrider, MD, DrPH Section Editors George B Mallory, MD Amy B Middleman, MD, MPH, MS Ed Deputy Editor Alison G Hoppin, MD All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Mar 2013. | This topic last updated: Jan 14, 2013. INTRODUCTION -- Long-term tobacco smoking can have adverse effects in nearly every organ of the body and cause a variety of diseases. In the United States, the adverse health effects from cigarette smoking account for more than 400,000 deaths among adults, or nearly one of every five deaths; more deaths are caused each year by tobacco use than by all deaths from human immunodeficiency virus (HIV), illegal drug use, alcohol use, motor vehicle injuries, suicides, and murders combined [1]. Cancer was among the first diseases causally linked to smoking. Smoking causes cancers of the bladder, oral cavity, pharynx, larynx, esophagus, cervix, kidney, lung, pancreas, and stomach, and acute myeloid leukemia (table 1). Smoking causes about 90 percent of lung cancer deaths in men and almost 80 percent of lung cancer deaths in women [1]. The epidemiology of smoking and the benefits of smoking cessation in adults are discussed in separate topic reviews. (See "Patterns of tobacco use" and "Cigarette smoking and other risk factors for lung cancer".) The prevalence of tobacco smoking among adolescents in the United States has gradually declined since the late 1990s. In 2011, 23 percent of 12th grade students reported smoking in the past 30 days, as compared with 37 percent in 1997 (figure 1) [2,3]. Regional variations, prevalence and trends in smoking among adolescents are discussed in a separate topic review. (See "Prevention of smoking initiation in children and adolescents".)
Smoking cessation is particularly important in the adolescent population, because intervention at this time may prevent nicotine dependence and severe health consequences later in life. Smoking in adulthood is closely associated with smoking during adolescence: 90 percent of adult smokers smoked their first cigarette before the age of 18 [4]. Smoking among adolescents is often clustered with other risk behaviors, including use of alcohol or drugs, earlier initiation of sexual activity, and unhealthy dieting techniques [5-8]. These associated behaviors pose additional health risks and may impede smoking cessation, so it is important that providers examine health behaviors in multiple domains, in concert with efforts to support smoking cessation. (See 'Smoking cessation in the setting of other risky behaviors' below and "Guidelines for adolescent preventive services".) Motivation to quit smoking, as well as methods to help adolescent patients stop smoking, including smoking bans, adolescent smoking cessation programs, and pharmacological interventions are reviewed here. Behavioral and pharmacological interventions to support smoking cessation in adults are presented separately. (See "Smoking cessation counseling strategies in primary care" and "Overview of smoking cessation management in adults".) PATTERNS OF SMOKING CESSATION -- A minority of adolescent smokers quit without intervention. In a national survey in the United States, 12.2 percent of adolescents who had ever smoked daily and tried to quit smoking were successful (defined as not smoking during the 30 days prior to the survey) [9]. In most populations, the overall prevalence of smoking increases from early to late adolescence, and is fairly stable thereafter, with approximately equal numbers of individuals initiating smoking and quitting [10]. As an example, a study prospectively followed regular and occasional smokers in Finland from early adolescence until age 28 years [11]. By age 21, 22 percent of daily smokers and 35 percent of occasional smokers had ceased smoking. This yields an annual quitting rate of 4.1 percent between ages 15 and 21. By the age of 28, 26 percent of those who were daily smokers and 46 percent of those who were occasional smokers at age 15 years had quit. The cessation rate was higher among those who were female, married, employed, and/or white collar workers.
However, this overall pattern is made up of several groups with independent trajectories (figure 2) [10]. The risk factors for those who remained stable high smokers (alcohol use, deviance from rules, peer smoking, and drug use) are remarkably similar to those who quit or remained stable light smokers after adolescence. Moreover, a distinct group initiates smoking during early adulthood ("late escalators"), and these individuals tend to have few of the risk factors that are associated with initiating smoking earlier in adolescence. A possible exception is that novice smokers who escalate rapidly during early adolescence are particularly likely to remain heavy smokers; it has been suggested that this pattern is a marker for nicotine dependence [12]. (See 'Nicotine dependence' below.) Thus, clinical risk factors do not reliably identify individual adolescent smokers who are most likely to quit independently, suggesting that intervention to support smoking cessation is appropriate for all adolescents who smoke, regardless of smoking frequency. READINESS TO QUIT -- Most adolescent smokers report that they want to quit smoking. In a study of adolescents caught smoking at school, 71 percent reported that they had attempted to quit in the last year, and two thirds intended to quit in the next six months [13]. Similar rates of attempts to quit smoking were found in a national survey study in the United States [9]. Thus, the majority of adolescents who smoke are interested in quitting, suggesting readiness for intervention. ESTABLISHED INTERVENTIONS FOR ADULTS -- Among adults, the long-term success rate of an unaided quit attempt is less than 7 percent, whereas the likelihood of success can be increased as much as four-fold with optimal treatment. A variety of studies and meta-analyses have established that both psychosocial counseling and pharmacotherapy are effective, and that combinations of the two methods achieve the best results. (See "Overview of smoking cessation management in adults".) There is considerably less information about the outcomes of related interventions in adolescent smokers, but existing data support the use of similar approaches, as discussed below. FOSTERING MOTIVATION -- Understanding the adolescent's motivations provides an important basis for an effective counseling interaction. Exploring the individual's incentives to smoke or to quit is the first
step in effective problem solving. Some of the most common motivations that prompt adolescents to smoke or to want to quit are discussed below. Incentives to quit -- In surveys of adolescents who smoke, concerns about future and current health, as well as physical appearance, cost of cigarettes, and athletic performance are the most common reasons given for making an attempt to quit smoking [14,15]. Adverse health effects -- Among adolescents who are considering quitting, the long term adverse health consequences are the most important motivating factor [14,15]. As an example, in a survey of adolescents who smoked, 75 percent said that future health was a motivation for quitting smoking, and 35 percent identified this concern as the most motivating factor [15]. Most of the respondents were older adolescents (average age 16 years); the frequency of this concern did not vary by age or gender. This may not be as strong a factor for those who are not already considering quitting. Monetary costs -- Many adolescents cite the cost of cigarettes as a reason to quit. The cost of regular smoking is considerable. In 2010, the average cost of a pack of cigarettes in the United States was $4.80, and was as high as $11.90 in some states [16]. Thus, the cost of buying one pack of cigarettes daily averages $1750 per year and can be as high as $4300 per year. Legislative and regulatory strategies that raise prices on tobacco products are effective in reducing smoking initiation and consumption levels, especially among youth and young adults [17]. Helping an adolescent calculate the costs of regular smoking may be motivating as they consider the current and future costs of their habit [15]. Adolescents may derive more motivation to quit if they realize this money could be put towards music, movies, clothes, or even a car. Athletic performance -- Concerns about athletic performance are commonly cited as reasons for attempting to quit. In one study, this was cited as the most important motivator by 16 percent of participants, and was only slightly more common among boys than girls [15]. Adolescents involved in sports may not be aware of the effects of smoking on current lung function and performance. A discussion of their goals for athletic performance and how smoking may limit their achievements in the future may boost their motivation to quit.
Barriers to quitting -- A variety of physiologic and psychosocial forces may impede smoking cessation in adolescents, including nicotine dependence, efforts to boost social standing among peers, or assertion of independence from parents or authority figures. Eliciting the adolescent's own reasons for starting or continuing smoking in a nonjudgmental way promotes insight and can help formulate a quitting strategy. Nicotine dependence -- Nicotine dependence is characterized by tolerance to nicotine, and psychobehavioral symptoms that are triggered by nicotine withdrawal [18]. These include: Craving for cigarettes Dysphoria or depressed mood Sleep disturbances Irritability and anger Anxiety Difficulty concentrating Restlessness Increased appetite Youth are particularly vulnerable to becoming dependent on nicotine, as compared to adults [17]. Nicotine dependence can develop after as few as 100 cigarettes. The first symptoms of nicotine dependence can appear within days to weeks of the onset of occasional cigarette use, and often appear before the onset of daily smoking [19]. With increasing nicotine exposure, smokers progress through a sequence of symptoms of addiction, characterized by "wanting," then "craving," then "needing" tobacco [20]. Adolescents who report early emergence of symptoms of nicotine dependence are significantly more likely to be smokers two years later, as compared to those who do not report early symptoms [21]. The likelihood of nicotine dependence increases with the quantity and duration of smoking: smokers who smoke more than 10 cigarettes per day report greater severity of withdrawal symptoms. One study found that 66 percent of adolescents who smoked daily for the past two to six months displayed symptoms of nicotine dependence [22]. Genetic factors also may influence an individual's predisposition to become dependent on nicotine [17,23]. In a survey of adolescent smokers, about 20 percent of adolescents were substantially dependent on nicotine, as assessed by a modified Fagerstrom Tolerance Questionnaire (a survey tool to measure symptoms of nicotine dependence), and 42 percent had moderate dependence [24]. Those with greater evidence of nicotine dependence were less likely to
be successful with a quit attempt. Thus, nicotine dependence and nicotine withdrawal can interfere with an adolescent's success in quitting smoking, suggesting a potential role for nicotine replacement therapy in the treatment of tobacco use and dependence among adolescents [25]. (See 'Nicotine replacement' below.) Weight control -- Many teens view smoking as a means of weight control. These concerns may be particularly relevant because of the increasing prevalence of obesity in youth. Contemplation of and experimentation with smoking have been found to be related to weight concerns [26]. A survey found that girls in sixth and seventh grade who reported dieting up to one time per week were almost twice as likely to be smokers as girls who had not dieted [27]. The odds ratio increased to 3.9 for girls who dieted more than once per week. They did not find such a relationship for boys. Among adults, smoking cessation is associated with a long-term average weight gain of about 7 kg [28]. Weight patterns after smoking cessation in adolescents are not well characterized, but the 2012 Surgeon General's report concludes that there is no evidence that young smokers weigh less or lose weight because of their smoking [17]. If concerns about weight gain present a barrier to smoking cessation, the clinician should offer advice about other ways to control weight, such as limiting high calorie foods and sodas, and increasing physical activity. Other strategies include identifying oral cravings and substituting them with healthy snacks, and finding new activities to occupy the hands after cessation [29]. Although there is little evidence that these strategies attenuate weight gain in adults [28], they have not been studied in adolescents. Adolescent patients who are motivated to quit smoking by an interest in improving athletic performance may be particularly willing to increase their physical activity. A separate topic review discusses eating habits and misconceptions that are commonly seen in adolescents, and counseling strategies to address these. (See "Adolescent eating habits".) Depression -- Depressed adolescents are significantly more likely to start smoking than those without depression. Symptoms of depression and anxiety increase the likelihood of smoking initiation during adolescence [10,30]. Therefore, treatment of depression may facilitate smoking cessation in this population. Although bupropion, an antidepressant, has been shown to assist with smoking cessation in adults, there is minimal data on the use of bupropion for smoking cessation in adolescents, so decisions about antidepressants should be based on considerations of efficacy and safety for depression rather
than for smoking cessation. (See "Psychopharmacological treatment for adolescent depression" and "Overview of smoking cessation management in adults" and 'Other drugs' below and "Pharmacotherapy for smoking cessation in adults", section on 'Bupropion'.) Stress and coping behavior -- Compared to adolescent smokers who had quit, current adolescent smokers have greater levels of perceived stress, and are less likely to use cognitive coping methods [31]. Therefore, it may be helpful to incorporate stress reduction techniques and training in problem solving skills into interventions to support cessation efforts. Recreational physical activity is associated with higher success rates of smoking cessation [11]. It is not clear if this effect is related to stress reduction, positive social influences, or other motivators [11]. OTHER INFLUENCES ON SMOKING BEHAVIOR Peer/social influences -- Peer habits have a powerful influence on smoking initiation and cessation [17]. In a report of teens caught smoking at school, half reported that all five of their five best friends smoked, and most were daily smokers [13]. Among individuals who started smoking by age 15 years, only 20 percent had quit by age 28 if their best friend was a smoker, whereas 52 percent had quit if their best friend was not a smoker [11]. The cross-sectional studies cited above could be explained by self-selection of friends with like habits, rather than causation. However, longitudinal studies suggest that peer smoking has a causal influence on smoking initiation and cessation. In a study of youth who smoked occasionally but not daily in eighth grade, progression to daily smoking was predicted by their parents' and peers' smoking habits [32]. Furthermore, smoking among parents was the most important influence on smoking initiation in younger adolescents, but smoking among peers became the more important influence in older adolescents [33]. Peers are often willing to support smoking cessation, particularly if they are a nonsmoker themselves. In a survey of college students, 54 percent reported that they "definitely would" be interested in helping an acquaintance quit smoking [34]. Characteristics significantly associated with willingness to help included being a nontobacco user, and whether they had a close relationship with the smoker (a boyfriend, girlfriend, or spouse). Similar degrees of altruism might not be expected in a sample of younger smokers. Parental smoking and cessation -- Parental smoking has a large
influence on adolescent smoking. Children whose parents smoke are more likely to smoke, particularly if both parents smoke. Conversely, smoking cessation efforts by parents can have an impact on their children's efforts [35]. In one study, adolescents whose parents quit smoking were almost one-third less likely to smoke than those whose parents still smoked [36]. The earlier in the child's life the parent quits, the less likely their children will become smokers. Furthermore, adolescents whose parents quit smoking were twice as likely to quit themselves, compared with those whose parents continued to smoke. Smoking bans -- Several studies have shown that household or workplace smoking bans are associated with reduced rates of smoking among adolescents [17,37-39]. Household smoking bans can be helpful even when parents are smokers. However, a no-smoking ban must be strictly enforced in order to be effective [37]. INTERVENTIONS -- There are a growing number of studies examining methods to promote and support adolescent smoking cessation. Some programs are school based, while others have been offered in community. Health care providers can provide support in quitting [40] through direct counseling, and/or by directing patients to cessation programs or to self-help resources [13,41-45]. One report used a survey to collect suggestions from smoking and nonsmoking teens for smoking cessation support [46]: Sixty percent of the teens surveyed supported having a friend as a quitting partner. Peer educators were considered a preferred source of information. Twenty-eight percent thought that medication would make quitting easier. Forty-two percent of nonsmoking respondents thought that seeing pictures of diseases causes by smoking would help encourage cessation. Health care provider interventions -- Pediatricians and other pediatric health care providers have an important role to play in helping teens with smoking cessation. Given the importance of adverse health effects teens cite in considering cessation, advice from a medical professional may be particularly effective. However, surveys in the United States suggest that only 30 to 50 percent of adolescent smokers are identified and counseled during visits to a physician [43,47-49]. It is important to talk with adolescents alone and explicitly outline a policy regarding confidentiality, including the issues that will be kept confidential and in which confidentiality is conditional. The provider can talk with the adolescent about how to share such
information with their parents, if appropriate, and be available to assist if needed [47]. (See "Confidentiality in adolescent health care".) Efforts at smoking cessation counseling can be successful in the medical care setting. According to a meta-analysis of counseling interventions in pediatric primary care settings, counseling doubles long-term abstinence rates as compared with no treatment, although overall abstinence rates with or without treatment are low [49]. A variety of techniques were used successfully, ranging from one session of individual counseling with follow-up phone calls, to six or eight sessions in a group format [49], or brief clinician counseling with a computer-based tobacco intervention [41]. There were too few studies to allow comparison of the efficacy of different counseling techniques. Six A's -- Health care providers should screen for health risk behaviors, including tobacco use, at every opportunity. A simple five-step algorithm called the 5 A's has been developed to guide clinician counseling about smoking cessation. This system encourages clinicians to ask patients about their smoking status, advise smokers to quit, assess their readiness to quit, assist them with their smoking cessation effort, and to arrange for follow-up visits or contact. Assistance includes helping the patient develop a quit plan, providing practical advice to avoid relapse, and follow up counseling and/or referrals to support the patient during the quit attempt (table 2). (See "Smoking cessation counseling strategies in primary care".) For pediatric patients a sixth A is added, encouraging clinicians to anticipate the risk of tobacco use by inquiring about parental smoking and discussing the possibility of smoking initiation in pre-adolescent and adolescent children (table 3) [50,51]. Clinicians should begin this anticipatory guidance during pediatric visits in mid-childhood. Stages of change -- Health care providers can be more effective by tailoring counseling to the adolescent's concerns and levels of readiness to quit smoking. The Transtheoretical Model of Change is a theoretical construct used to describe readiness for behavior change, and has been applied to smoking cessation in both adults and teens [52]. According to this model, smokers can be classified into one of four stages of smoking cessation: Precontemplation (not intending to quit in the foreseeable future) Contemplation (intending to quit in the foreseeable future) Preparation (intending to quit in the immediate future) Recent Action (cessation of smoking)
Using this model, an individual's stage of change is identified, and then counseling focuses on processes most likely to move him or her forward toward quitting. As an example, individuals in the precontemplation stage need messages to increase ambivalence about smoking and motivate them to consider quitting by shifting the pro/con balance. Those in the contemplation stage need messages to build confidence and a commitment to quit. Those in preparation need to set a quit date and discuss the actions that will be required to quit and to problem-solve about barriers to quitting. Lastly, those in Recent Action need to focus on maintenance of cessation and avoidance of relapse [52,53]. Adolescent smoking cessation programs -- There are few reports describing techniques and outcomes for smoking cessation interventions in adolescents. Successful programs emphasize immediate negative health and other consequences of tobacco use, and provide instruction in coping strategies [44]. A meta-analysis of 48 controlled smoking cessation studies in adolescents, most of which were in group format, found modest effects of smoking cessation programs overall [54]. Programs gave adolescent smokers a 2.9 percent (95% CI 1.47-4.35) advantage in quitting, increasing the probability of cessation by 46 percent as compared to a control condition [54]. The treatment effect was seen in programs with five or more sessions, and generally continued after the end of the program, although only a few studies included follow-up data for 12 months or more. Efforts to reach teens who smoke in the school setting have had mixed results [17]. Programs have been offered on a voluntary basis as well as an alternative to suspension for teens caught violating school no smoking policies [55]. One example is an educational program, the Tobacco Education Group (TEG): Intervening with Teen Tobacco Users, which is designed for adolescent smokers who were not yet thinking about quitting. The same company produced an adolescent cessation program, the Tobacco Awareness Program (TAP): Helping Teens Stop Using Tobacco, which is intended for adolescents who want to quit. Studies have shown that both programs significantly reduced tobacco use among intervention groups compared to a control group of adolescent smokers not assigned to programs [45]. The quit rate of voluntary participants in the program was 15 percent (using the conservative assumption that program drop-outs were still smoking); self-reported tobacco use was validated biochemically. Not On Tobacco (N-O-T) is another smoking cessation program for
adolescents, and is sponsored by the American Lung Association [55-58]. N-O-T uses a gender-sensitive, 10-session curriculum that includes booster sessions. The sessions are facilitated in schools and other community settings by teachers, school nurses, counselors, and other staff and volunteers specially trained by the American Lung Association. The program is designed as a voluntary, non-punitive program for teens. An Alternative-to-Suspension program is also included to address student violation of a school tobacco policy. Outcomes studies of N-O-T suggest that the program has modest effects on smoking cessation rates, but the analysis is hampered by high program attrition rates. One study reported a quit rate of 21 percent five months after completion of the program, as compared with 13 percent in a control group [56]. However, this was based on a liberal definition of quitting (not smoking in the previous 24 hours and breath CO levels
