Evidence-Based Reviews

Beating nicotine: Medication algorithm helps teens quit

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For motivated daily smokers, benefits of pharmacotherapy may outweigh the risks.


 

References

CASE: Depressed, irritable — and smoking

Michael, age 16, is admitted to a psychiatric unit for severe depressive symptoms and suicidal ideation. The next day, he is irritable and refuses to cooperate with the interview. During group therapy he is distractible and unable to focus. The treating psychiatrist learns that before admission Michael had been smoking 10 to 15 cigarettes per day and now feels a strong craving for cigarettes.

Unrecognized nicotine dependence can be problematic on inpatient psychiatric units, where adolescents such as Michael are not permitted to smoke and rarely are offered nicotine replacement therapy (NRT). Unfortunately, psychiatrists seldom diagnose and treat nicotine dependence—particularly in adolescents—whether in outpatient or inpatient settings.1,2

Do adolescent smokers need help quitting? Do they experience withdrawal symptoms when they stop smoking? Are pharmacologic interventions appropriate? For each question, the answer is a resounding yes.

To help you treat young smokers, this article offers:

  • tools for assessing adolescent tobacco use and dependence
  • evidence-based treatment options
  • an algorithm to guide treatment choice.

Not just a ‘phase’

Early smoking—especially among those younger than age 13—is associated with adolescent psychopathology, including depressive disorders and other substance use disorders.3 Compared with nonsmoking teens, those who smoke at least monthly are significantly more likely to smoke as adults.4 Among high school seniors:

  • >20% report smoking cigarettes in the past 30 days
  • 12% smoke daily
  • 6% smoke ≥10 cigarettes per day.5

Nicotine dependence can develop very rapidly: nearly 25% of adolescents have ≥1 symptom within 2 weeks of starting to smoke at least once a month.6

Role of parents. Early intervention for teen nicotine addiction is particularly important because of the long-term health risks associated with tobacco use.7 In our experience, however, teen smokers’ parents’ attitudes can make addressing adolescent nicotine dependence a therapeutic challenge.

Box 1

Self-report tools for assessing teen nicotine dependence

Modified Fagerstrom Tolerance Questionnaire8 (7 items)

Stanford Dependence Inventory (SDI)9 (5 items)

Hooked on Nicotine Checklist (HONC)10 (10 items)

Nicotine Dependence Scale for Adolescents11 (6 items)

Cigarette Dependence Scale (CDS-5 and CDS-12)12 (5 or 12 items)

Parents may be unaware of their teens’ smoking, and those who are aware may:

  • not know what help is available
  • dismiss teen smoking as “just a phase”
  • feel that smoking cigarettes is preferable to smoking marijuana or using other illicit drugs.

Other parents have no objections because they themselves smoke. Some permit their teens to smoke and may even give them cigarettes.

Parents who want their teens to stop smoking often believe erroneously that the best method is to quit “cold turkey.”

Assessing use and dependence

Teen smokers’ nicotine withdrawal symptoms—such as irritability, anxiety, and impaired concentration—can imitate or exacerbate other psychiatric symptoms, thus complicating diagnosis and treatment. Ask all adolescent patients about the quantity, frequency, pattern, and duration of use of all forms of tobacco, including:

  • cigarettes
  • cigars
  • cigarillos (short, narrow cigars)
  • bidis (thin, flavored South Asian cigarettes wrapped in leaf)
  • smokeless tobacco.

Dependence. Establishing nicotine dependence in young smokers is more complicated than in adults because of teen smokers’ variable smoking patterns. Several self-rating scales have been developed to assess nicotine dependence in adolescents (Box 1).8-12 Although some of these tools have been used primarily in research, outpatient psychiatrists may find these scales useful for evaluating adolescents’ smoking.

Some DSM-IV-TR criteria for substance dependence may not apply to nicotine dependence or correlate with other validated measures of nicotine dependence. For example, “significant time spent obtaining, using, or recovering from the effects of a substance” might not apply to all adolescent smokers.13 Based on our clinical experience, daily smoking for an extended period of time (several months) is a marker of dependence for almost all adolescents.

The Timeline Follow Back method can help you capture a more complete picture of adolescent tobacco use over time.14 This involves asking teens about tobacco use over the past 30 or 90 days, beginning with the assessment day and working backward. Record tobacco use on a calendar, using holidays, weekends, and events as anchor points to help teens recall their smoking.

Biomarker tests can be used to measure nicotine use. The 2 most common are:

  • expired carbon monoxide (CO) level (essentially a “breathalyzer” for smoking)
  • cotinine level—a metabolite of nicotine.

Expired CO testing is simple to conduct but requires specialized equipment that costs approximately $1,000. Marijuana use may affect CO results, but NRT will not. Measuring CO levels provides information about cigarette smoking over the past several hours, compared with the past several days with cotinine.15

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