Perfect storm can spur nicotine addiction in youths
AlysonSulaski Wyckoff, Associate Editor
AAP Technical Report
Among the reasons to keep youths from starting to smoke: Each year, only about 4%
of 12- to 19-year-old smokers will successfully quit. While half of adult smokers
try to quit annually, less than 5% succeed. And the younger people are when they begin
smoking, the less likely they will kick the habit.
Tobacco exposure through personal use or second- or thirdhand smoke exposure remains
the most important preventable cause of illness, disability and death among adults
in the U.S. Internationally, tobacco use is the No. 1 cause of preventable death.
After a gradual decline in smoking, the rate of decline has begun to slow for cigarettes.
There also has been a significant rise in the use of nicotine products such as e-cigarettes,
hookahs and smokeless tobacco, according to a new AAP technical report.
Nicotine and Tobacco as Substances of Abuse in Children and Adolescents, from the Committee on Substance Use and Prevention, reviews the stages of use in
progression to dependence on nicotine-containing products, as well as the physiologic
characteristics, neurobiology, metabolism, pharmacogenetics and health effects of
nicotine. The report is available at http://dx.doi.org/10.1542/peds.2016-3436 and will be published in the January issue of Pediatrics.
Multiple contributing factors
While tobacco products contain more than 4,000 chemicals, nicotine is the major contributor
to the development of dependence and the primary pharmacologic component of tobacco.
Rapidly developing brains are especially susceptible to nicotine addiction, but behavioral,
social, environmental and psychological factors also influence the development and
maintenance of addiction.
The urge to smoke occurs early on after kids first try it, the report notes, and then
drives adolescents to smoke more often.
A predictable sequence of events often unfolds: wanting to smoke, having cravings
and then needing to smoke to avoid withdrawal symptoms. This “neurophysiologic dependence”
leads to tolerance, and a greater amount of nicotine is needed to maintain equilibrium.
Increasing the palatability of cigarettes are additives like menthol, with its candy-like
taste and cooling properties. The sensory effects may result in the perception that
cigarettes are less harmful than they really are and may drive up smoking frequency.
Similarly, the sweeteners and fruit flavors in hookahs and the more than 7,000 flavors
now available in electronic nicotine delivery systems including e-cigarettes also
add to the products’ appeal. E-cigarette experimentation and recent use among middle
and high school students in the U.S. doubled from 2011 to 2012, according to the report.
About 1.78 million students had used e-cigarettes as of 2012.
Although the delivery systems of products like e-cigarettes may reduce exposure to
some of the toxic chemicals in cigarettes, additional toxins are associated with electronic
“Exposure to nicotine and its high addiction potential remain major concerns,” the
Despite aggressive promotion of e-cigarettes as smoking cessation aids, research has
not documented their effectiveness in adults, according to the report. Recent studies
suggest that e-cigarette use “may encourage, rather than discourage, the use of conventional
cigarettes among U.S. adolescents,” according to the report.
Most of the adverse health consequences of tobacco use actually are the result of
damage caused by tar, carbon monoxide, oxidizing chemicals and other constituents
in the product rather than nicotine.
Adverse effects of nicotine
There are not enough data to conclude that nicotine causes cancer, but evidence shows
it may increase the risk for oral, esophageal and pancreatic cancer. Among other effects,
increases concentrations of dopamine, a neurotransmitter essential for boosting attention,
reward-seeking behaviors and the risk of various addictions, from gambling to drug
is at least partly responsible for the progression of chronic kidney disease in cigarette
increases risk of osteoporosis and bone fractures;
impacts body weight;
has a negative dose-related impact on both male and female fertility; and
significantly increases cortisol concentrations in daily smokers.
Tobacco or nicotine also can have major effects on early neurodevelopment. Infants
born to mothers who smoked during pregnancy had reduced weight, length and head circumference
and exhibited impulsivity, hyperactivity and significant impairments in cognitive
The report addresses cessation measures, suggesting pharmacotherapy to help moderately
to severely tobacco-dependent teens. However, there is concern that nicotine replacement
therapy use during adolescence may change the neurodevelopmental trajectory. Further
research is needed.
Most research to date has been on behaviorally based interventions, which are most
effective for youths with mild dependence. There are not enough data to support any
one clinical approach to adolescent cessation of nicotine use, the report concludes.