How to help nicotine-dependent adolescents quit smoking
Teens, like adults, may benefit from ‘patches’ and other therapies
Many adolescent psychiatric patients who smoke are not getting the help they need to quit. When we asked 120 teen inpatients if they smoked and then checked their charts, we found only 6 of 47 smokers had been diagnosed as nicotine-dependent.1
Adolescents who cannot quit on their own may benefit from smoking cessation therapies. Based on evidence and our experience, we offer a practical approach to treating nicotine dependence in adolescents, using drug and behavioral therapies.
Psychiatric comorbidity is highly associated with cigarette smoking in adults and adolescents. In the United States:
- 44% of cigarettes smoked are sold to someone with a mental illness.2
- Persons with mental illness are 2.7 times more likely to smoke than are those without mental illness.2
- Most smokers start before age 18,3 and starting before age 13 is linked to psychopathology in later adolescence.4
Smoking likelihood by age and comorbidity among adolescent psychiatric inpatients
Logistic regression odds ratio
95% confidence interval
Significance (P value)
Cannabis use disorder
Source: Data from 120 patients admitted to an inpatient child and adolescent psychiatry program.
Adapted with permission from reference 1.
Disruptive behavior disorders in adolescent smokers include oppositional defiant disorder, conduct disorder, and attention-deficit/hyperactivity disorder (ADHD). Among psychiatric disorders, conduct disorder has the strongest association with smoking in adolescents.1 ADHD is associated with smoking and perhaps with increased difficulty in quitting.5,6
Mood disorders. Major depressive disorders have a strong, consistent, bidirectional association with smoking in the young. Depression may lead to smoking, and smoking to depression.7
Substance use disorders. Alcohol use disorders are strongly associated with smoking among adolescents, and the association is both bidirectional and dosedependent.8 Cannabis use disorder is also associated with cigarette smoking among adolescents (Table).9
Anxiety disorders. Evidence is emerging that anxiety disorders—especially social phobia—may be linked to smoking among adolescents.10
Nicotine withdrawal symptoms—irritability, anxiety, decreased concentration, increased appetite, craving for cigarettes—can mimic those of other psychiatric disorders. Adolescent smokers admitted to locked psychiatric units may experience withdrawal symptoms that require nicotine replacement treatment (Box).
Effect on quit rates. Psychiatric comorbidity may reduce quit rates during smoking cessation treatment.6 When smokers are trying to quit, watch for remission, worsening, or emergence of psychiatric conditions.
ASSESSING ADOLESCENT SMOKING
Adolescents with psychiatric diagnoses can be assessed for nicotine dependence—and vice versa—although accurately gauging their smoking habits is more difficult than in adults. For example:
- Rating scales for nicotine dependence severity—such as the modified Fagerstrom Tolerance Questionnaire11—lack standard cutoff scores for adolescents.
- Unlike adults, many adolescents cannot reliably report use in “packs per day” because the number of cigarettes they smoke varies widely from day to day.
Biological markers commonly used to assess smoking in adults include expired-air carbon monoxide (CO), cotinine (nicotine metabolite), and thiocynate levels. Preliminary evidence indicates that cotinine may be a more sensitive and specific biological marker for smoking among adolescents than CO levels.12 Thiocynate has not been evaluated as a marker for smoking in adolescents.
CO levels typically reflect smoking in the previous few hours, whereas the half-life of cotinine is longer (1 day or more). Also, factors such as environmental pollution or marijuana use can inflate CO levels. Thus, cotinine levels have greater accuracy and specificity, reflecting only the amount of nicotine consumed.
Unfortunately, most laboratories do not measure cotinine levels, and the expired-air CO test (CO Breathalyzer) is relatively expensive for most clinicians. Commercially available single-use cotinine test kits are modestly priced and provide semi-quantitative (a range instead of an exact number) urine cotinine levels. These tests, however, might not be covered by third-party insurers.
Until cotinine testing becomes widely available, we recommend a combination of self-report and expired-air CO level to monitor abstinence.
Self-report monitoring. Most clinicians rely on self-report rate of smoking among adolescents, as no screening assessment has been validated in this age group. As initial prompts, we recommend asking all adolescents if they smoke cigarettes, if they smoke regularly, and if they smoke daily.
We recommend using the “time line follow-back” method13 to monitor the self-reported smoking rate. Begin by providing the patient with a 30-day calendar, starting backwards from the day of assessment. Cite anchor points, such as special holidays and school or family events, to help the patient recall his or her cigarette use. Then have the patient fill in the number of cigarettes smoked each day for 30 days.
This assessment method appears more reliable than asking an adolescent “how many cigarettes do you smoke per day?”. After the initial time line follow-back assessment, encourage adolescent smokers to keep a daily diary of how many cigarettes they smoke, and monitor the diary at each visit.
Nicotine withdrawal symptoms in an adolescent psychiatric patient
Beth, age 15, was admitted overnight to an inpatient psychiatric unit after running away from home and being taken into police custody. Her primary diagnosis was conduct disorder.
At morning rounds, the nurse reported that Beth was very irritable, had threatened the staff, and had been moved to seclusion. During routine examination, the psychiatrist discovered that Beth was a half-pack/day smoker and “really” wanted a cigarette. The psychiatrist told her hospital policy did not allow smoking, but she could try a transdermal nicotine patch (TNP) to help reduce her nicotine withdrawal symptoms. She agreed and received a 14 mg/d nicotine patch.
Beth’s irritability improved substantially with TNP, and she moved back to her regular room within 2 hours without incident.
We have found daily smoking to be a good indicator of nicotine dependence, and anyone who smokes daily would receive significant health benefits from quitting. Hence, any daily smoker who wants to quit, regardless of DSM-IV nicotine dependence status, is a candidate for treatment.
Unlike adults, adolescents usually lack smoking-related medical consequences, such as heart or lung disease. Even so, most adolescent smokers report that they would like to quit but face barriers such as:
- having to inform parents they smoke
- not knowing how to get help for smoking cessation
- lack of transportation for treatment
- lack of third-party reimbursement for smoking cessation treatment.
To help adolescents, we recommend following the U.S. Public Health Service guideline for smoking cessation.14 At least provide and discuss smoking cessation brochures developed specifically for adolescents. For example, one Centers for Disease Control and Prevention brochure describes what symptoms to expect when quitting, how to cope with craving, and other topics (see Related resources).
To manage peer pressure, we counsel teens to let their friends know they are trying to quit so that friends do not smoke in front of them. If that does not work, we ask patients to avoid being around friends who smoke at least for the first 2 weeks and preferably 2 months.
Many states have free telephone quit lines that provide support and advice on how to stop smoking. Several Web sites also are available for smokers (including adolescents) wanting to quit (see Related resources).
For adults, first-line FDA-approved medications for smoking cessation include nicotine replacement therapies (NRT)in transdermal, gum, inhaler, and lozenge forms and sustained-release bupropion. Nortriptyline, doxapine, and clonidine have shown effectiveness for smoking cessation but are not FDA-approved for this indication.15 Selegiline and mecamylamine have shown initial efficacy and are being examined in larger clinical trials.
For adolescents, little is known about what medications might help them stop smoking. Nicotine replacement therapies and bupropion SR have been most explored in adolescent smokers. The effect of psychiatric comorbidity on the quit rate is not well-studied in adolescents.
The transdermal nicotine patch (TNP) has shown modest results in preliminary trials among adolescents. One study found 11% abstinence at 6 weeks, 16 and another found a <5% quit rate. 17 A third study reported an 18% abstinence rate with a combination of TNP and contingency management therapy. 18 Discussion of contingency management and other behavioral therapies is beyond the scope of this article.
A recent study comparing TNP, nicotine gum, and placebo in adolescent smokers found the lowest drop-out rate and highest compliance among the TNP group. Three-month abstinence rates were 17.6% for TNP, 6.5% for nicotine gum, and 2.5% for placebo. The difference between the TNP and placebo groups’ abstinence rates was statistically significant.19
Bupropion SR. In an open-label pilot study, our group treated 16 adolescent smokers weighing >90 lbs with bupropion SR, 150 mg bid. Average age was 18, and two-thirds of patients had ADHD. The endpoint abstinence rate—as measured by self-report and CO levels—was 31%, which is similar to rates reported in adult smokers treated with this dosage of bupropion SR.20
The adolescents did not gain weight during the study, which may be important to this age group. Reported side effects were similar to those in adults, with one adolescent reporting an allergic reaction (urticaria). We are conducting a larger follow-up study using bupropion SR with and without behavioral therapy.
A PRACTICAL CLINICAL APPROACH
Smoking behavior. For treatment, we propose two categories of adolescent smokers: regular (daily) and nonregular (nondaily) (see Algorithm). We recognize that many nondaily smokers smoke frequently and may benefit from aggressive treatment. However, we propose this two-track approach as a starting point because of limited data and medication risks, such as possible seizures with bupropion SR. We suggest:
- using behavioral therapy and patient education as first-line treatment for nonregular adolescent smokers
- using medication and behavioral therapy as first-line treatment for regular smokers and medication as second-line treatment for nonregular smokers who do not respond to behavior therapy/patient education.
Algorithm Suggested smoking cessation approaches for adolescents
Offer a treatment for at least 6 to 8 weeks before considering a change in therapy. One definition of initial success is no tobacco use in a 7-day period by self-report and biological verification (such as CO levels).
Behavioral therapy is relatively low-risk and helps many adult smokers. Despite a lack of evidence, some sort of behavioral therapy in combination with pharmacologic therapy might also help adolescent smokers.
When adolescents get disheartened by a slip or relapse to smoking, be patient and encourage them to try again. Inform them that smokers often require multiple attempts before they can quit completely.
Medication. Based on the limited published evidence, we consider TNP and bupropion SR first-line medications for adolescent smokers who want to quit.
For adult smokers, clinicians often combine medication and NRT to increase success rates.15 No data suggest that combining TNP and bupropion SR may be more effective than monotherapy in adolescents, but the combination might help those who do not respond to either agent alone.
We recommend starting bupropion SR treatment at least 1 week before the patient’s quit date. Titrate the dosage based on the package insert and patient tolerance.
Start NRT according to package instructions, and titrate dosages based on response:
- increase if the patient reports substantial craving and withdrawal symptoms, such as irritability and anxiety.
- decrease in case of toxicity (such as nausea).
In our experience, adolescent smokers require slightly lower NRT dosages than adults, although this varies among individuals.
- Centers for Disease Control and Prevention. Tobacco Information and Prevention Source (TIPS). www.cdc.gov/tobacco/quit/iquit.htm
- National Institute of Drug Abuse. NIDA for Teens. The Science Behind Drug Abuse. teens.drugabuse.gov/index.asp
- Society for Research on Nicotine and Tobacco. www.srnt.org
Drug brand names
- Bupropion SR • Zyban
- Clonidine • Catapres
- Doxapine • Sinequan
- Mecamylamine • Inversine
- Nortriptyline • Pamelor
- Selegiline • Eldepryl
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Upadhyaya HP, Brady KT, Wharton M, Liao J. Psychiatric disorders and cigarette smoking among child and adolescent psychiatry inpatients. Am J Addict 2003;12:144-52.
2. Lasser K, Boyd JW, Woolhandler S, et al. Smoking and mental illness. A population-based prevalence study. JAMA 2000;284(20):2606-10.
3. Johnston LD, O’Malley PM, Bachman JG. Teen smoking continues to decline in 2003, but declines are slowing. Ann Arbor, MI: University of Michigan News and Information Services, Dec. 19, 2003. Available at: www.monitoringthefuture.org/press.html. Accessed 08/13/04.
4. Upadhyaya HP, Deas D, Brady KT, Kruesi M. Cigarette smoking and psychiatric comorbidity in children and adolescents. J Am Acad Child Adolesc Psychiatry 2002;41(11):1294-1305.
5. Molina BS, Pelham WE. Childhood predictors of adolescent substance use in a longitudinal study of children with ADHD. J Abnorm Psychol 2003;112(3):497-507.
6. Pomerleau OF, Downey KK, Stelson FW, Pomerleau CS. Cigarette smoking in adult patients diagnosed with attention-deficit/hyperactivity disorder. J Subst Abuse 1995;7:373-8.
7. Dierker LC, Avenevoli S, Merikangas KR, et al. Association between psychiatric disorders and the progression of tobacco use behaviors. J Am Acad Child Adolesc Psychiatry 2001;40(10):1159-67.
8. Zacny J. Behavioral aspects of alcohol-tobacco interactions. Recent Dev Alcohol 1990;8:205-19.
9. Rohde P, Lewinsohn P, Kahler C, et al. Natural course of alcohol use disorders from adolescence to young adulthood. J Am Acad Child Adolesc Psychiatry 2001;40(1):83-90.
10. Sonntag H, Wittchen HU, Hofler M, et al. Are social fears and DSM-IV social anxiety disorder associated with smoking and nicotine dependence in adolescents and young adults? Eur Psychiatry 2000;15:67-74.
11. Prokhorov AV, Pallonen UE, Fava JL, et al. Measuring nicotine dependence among high-risk adolescent smokers. Addict Behav 1996;21:117-27.
12. McDonald P, Colwell B, Backinger CL, et al. Better practices for youth tobacco cessation: evidence of review panel. Am J Health Behav 2003;27(suppl 2):S144-S158.
13. Sobell LC, Sobell MB, Leo GI, Cancilla A. Reliability of a timeline method: assessing normal drinkers’ reports of recent drinking and a comparative evaluation across several populations. Br J Addict 1988;83(4):393-402.
14. Fiore M, Bailey W, Cohen S. Treating tobacco use and dependence: Clinical practice guideline. Rockville, MD: US Public Health Service, 2000.
15. George TP, O’Malley SS. Current pharmacological treatments for nicotine dependence. Trends Pharmacol Sci 2004;25(1):42-8.
16. Hurt RD, Croghan GA, Beede SD, et al. Nicotine patch therapy in 101 adolescent smokers. Efficacy, withdrawal symptom relief, and carbon monoxide and plasma cotinine levels. Arch Pediatr Adolesc Med 2000;154:31-7.
17. Smith TA, House RF, Jr, Croghan IT, et al. Nicotine patch therapy in adolescent smokers. Pediatrics 1996;98:659-67.
18. Hanson K, Allen S, Jensen S, Hatsukami D. Treatment of adolescent smokers with the nicotine patch. Nicotine Tob Res 2003;5(4):515-26.
19. Moolchan ET. Efficacy of the nicotine patch and gum for the treatment of adolescent tobacco dependence. Scottsdale, AZ: Society for Research on Nicotine and Tobacco Research annual meeting, 2004.
20. Upadhyaya HP, Brady KT, Wang W. Bupropion SR in adolescents with comorbid ADHD and nicotine dependence: a pilot study. J Am Acad Child Adolesc Psychiatry 2004;43(2):199-205.