AAP releases multiple policies to protect youths from tobacco, nicotine
Harold J.Farber, M.D., M.S.P.H., FAAP
For the first time, the Academy has released three linked, evidence-based statements
to help protect children from tobacco addiction and exposure. The policies call for
raising the minimum age to purchase tobacco to 21 years; urge pediatricians to screen
patients for use of tobacco and nicotine delivery devices; and address tobacco dependence
in parents as part of pediatric health care.
The policies and a technical report grading the evidence supporting the policies are
available online and appear in the November issue of Pediatrics. (See resources.)
A related policy statement Electronic Nicotine Delivery Systems also is available online and appears in the November Pediatrics. All of the documents are from the AAP Section on Tobacco Control.
Harms of tobacco use, exposure
Tobacco addiction and tobacco smoke exposure are among the most important, preventable
causes of sickness, disability and premature death in both the developed and developing
worlds. There is no safe level of tobacco smoke exposure.
Cigarette smoking has been causally linked to diseases of nearly all organs of the
body, to diminished health status and to harm to a fetus.
Exposure to tobacco smoke has been causally linked to adverse effects on the health
of infants and children.
The tobacco epidemic was initiated and has been sustained by the aggressive strategies
of the tobacco industry. Advertising and promotional activities by tobacco companies
cause the onset and continuation of smoking among adolescents and young adults.
Effective, evidence-based tobacco control interventions continue to be underutilized
and implemented at funding levels far below those recommended by the Centers for Disease
Control and Prevention.
The impacts on cardiovascular disease, cancer, emphysema and premature death are well-known.
Tobacco smoke exposure of children increases severity of bronchiolitis and asthma,
increases middle ear disease, leads to findings of preclinical atherosclerosis, and
increases risk for childhood cancers. Tobacco and nicotine exposure harms brain and
In addition to the well-documented impact on adverse fetal outcomes such as stillbirth
and sudden infant death syndrome, recent research demonstrates that in utero tobacco
and nicotine exposure increases risks for wheezing, asthma, obesity, learning disabilities
and neurobehavioral problems.
Treatments underused The adolescent’s developing brain is particularly susceptible to tobacco dependence.
Nicotine — a neurotoxin — changes brain structure and chemistry.
The Food and Drug Administration has approved prescription and over-the-counter medications
for tobacco dependence; however, these treatments are underutilized. Tobacco dependence
treatment medications include shorter-acting relievers such as nicotine gum and nasal
sprays and long-acting controllers such as nicotine patches, bupropion and varenicline.
Combination therapy is more effective than monotherapy. State-of-the-art approaches
initiate treatment intensity based on severity of the tobacco dependence and on treatments
the patient is ready to accept. Treatment intensity and duration are adjusted based
on control of nicotine withdrawal symptoms (http://tobaccodependence.chestnet.org).
Electronic nicotine delivery systems (such as e-cigarettes) should not be recommended because clinical trials have failed to demonstrate their effectiveness,
and there is evidence of harm from these devices.
Recommendations for pediatricians
Tobacco use prevention is an important — and effective — part of anticipatory guidance.
Pediatricians should inquire about tobacco use and tobacco smoke exposure as part
of health supervision visits and visits for conditions that may be caused or exacerbated
by such exposure. Be aware of the different tobacco products — not just cigarettes -— available to youths.
With fruit and candy flavors, hookah (water pipe) and electronic nicotine delivery
system use is rising rapidly among middle and high school students. Adolescents often
will use two or more different tobacco or nicotine products.
Parental tobacco dependence should be addressed as part of the child’s health care. Approaching tobacco dependence as a severe, chronic disease, pediatricians can acknowledge
the severity of the parent’s addiction and recommend treatment and/or treatment resources
to protect the health of the child. Recommendations can involve over-the-counter nicotine
replacement therapy, national or state help lines (such as 1-800-QUIT NOW) and/or
the parents seeing their own doctor or clinic for treatment. The motivated pediatrician
can, with appropriate documentation, prescribe for the parent to protect the health
of the child. If the parent is not ready to stop smoking, a smoke-free home and car
should be advised.
Tobacco dependence treatment or referral should be offered to adolescents who want
to stop smoking. There is very good evidence for effectiveness of behaviorally based approaches —
especially for those with mild levels of addiction. For those with moderate to severe
addiction, medications that are effective in adults are an option for use in adolescents,
although evidence is limited. Close follow-up is needed as non-adherence to regular
medication use and relapse of tobacco use after stopping therapy are common. Electronic
nicotine delivery systems (e-cigarettes, others) should not be recommended as their use is associated with reduced rates of stopping smoking in
Public policy guidance
Tobacco control programs need to be funded adequately. Programs should change the
image of tobacco by telling the truth about tobacco.
Increasing age of purchase decreases youth smoking rates. The age of purchase of tobacco
products should be increased to 21 years, and such regulations need to be enforced.
Tobacco taxes should be increased as this decreases tobacco use among youths.
In addition to comprehensive smoking bans in workplaces, recreation facilities, public
areas, and campuses of educational and health care institutions, smoking in multi-unit
housing should be prohibited. Smoking in or near one unit exposes and harms children
living in nearby units.
Advertising and promotion is a cause of tobacco use initiation in adolescents. Therefore,
tobacco advertising and promotion that is accessible to children should be prohibited,
including point-of-sale advertising, product placements in movies and other entertainment
media, and promotion in print or Internet-based media accessible to youths.
Flavoring agents, including fruit, candy and menthol flavors, should be prohibited
in all tobacco and nicotine products as flavored products encourage tobacco use initiation
Dr. Farber, a lead author of the tobacco reports, is policy chair of the AAP Section
on Tobacco Control Executive Committee.