Nicotine addiction: A pediatric disease

doi:10.1016/S0022-3476(97)70232-4

The Journal of Pediatrics

Volume 130, Issue 4, April 1997, Pages 518-524

https://doi.org/10.1016/S0022-3476(97)70232-4 Get rights and content

Abstract

Editor's note: It has been stated by Dr. David Kessler that “adolescents are the gateway through which tobacco addiction enters the population.” Multiple studies have indicated that, while setting the stage for health-related problems later in life, cigarette smoking itself does not leave the young habitué unaffected. The most recent study, by Gold et al.,*determined the sex-specific effects of cigarette smoking on the level and growth of lung function in adolescence, when the majority of the people in the United States who smoke tried their first cigarette. They found that cigarette smoking was associated with evidence of mild airway obstruction and slowed growth of lung function in adolescents. The data also suggested that adolescent girls may be more vulnerable than boys to the effects of smoking on lung function. This is of great concern because it is clear that the smoking rate among teenage girls has risen to the point where they are the major source of new smokers in the United States.

The concern regarding nicotine addiction has led Dr. Kessler to label it a “pediatric disease.” Dr. Kessler, himself a pediatrician, has been recognized for addressing the issue of cigarette smoking during his stewardship of the FDA and was the 1996 recipient of the American Academy of Pediatrics' Excellence in Public Service Award for his work. Dr. Kessler has stepped down as commissioner of the FDA. Despite his departure, his stated goal was to reduce the number of new tobacco users by 50% in 7 years. If this goal is to be achieved, it will require increased understanding and a major commitment by pediatric health care providers.

Given the special circumstances and the global importance of these issues, we have invited Dr. Kessler and his colleagues to comment on this pediatric disease. We invite your commentary.— W. F. Balistreri

Section snippets

ADOLESCENT ANGST

Researchers in at least one leading U.S. tobacco company have tried to understand the complex psychology of adolescence and how products like cigarettes can fit into the evolving development of personality. “The fragile, developing self-image of the young person needs all of the support and enhancement it can get,” wrote RJR's Teague ⁴ in 1973. “Smoking may appear to enhance that self-image in a variety of ways …. This self-image enhancement effect has traditionally been a strong promotional

EVERYWHERE THEY LOOK

In 1971, tobacco advertising was banned from television, a highly effective medium for reaching young people. ¹² As a replacement, the tobacco companies learned to use other venues to reach their many audiences with multiple messages. Almost all of these messages reach adolescents in one way or another; some are particularly effective with a young audience.

Colorful tobacco advertisements abound in the magazines read by adults and adolescents alike. They play on the adolescent themes of glamour,

APPEALING TO ADOLESCENTS

The tobacco companies strongly deny that their advertising is aimed at adolescents younger than 18 years of age. They say that if the advertising appeals to the nation's youth, that is beyond their control.

Yet the documents and statements from employees of at least one tobacco company indicate that young people are a target. RJR, for example, created a marketing strategy that seems to be aimed primarily at young smokers. Its Young Adult Smokers program features the extensive use of promotional

MARKETPLACE BASED ON ADDICTION

Once adolescents begin to light up, it does not take long for them to want to quit, as some tobacco companies quickly learned from their market research. “However intriguing smoking was at 11, 12, or 13, by the age of 16 or 17, many regretted their use of cigarettes for health reasons and because they feel unable to stop smoking when they want to,” concluded the report of “Project 16,” ⁸ a study conducted by Kwechansky Marketing Research in 1977 for Imperial Tobacco, Ltd., of Canada, an

MORE THAN JUST CIGARETTES

UST, the nation's leading producer of smokeless tobacco products such as snuff and chewing tobacco, developed marketing and product strategies that were intended to lead a smokeless-tobacco user from “starter” products with relatively low levels of nicotine to brands with higher levels of nicotine. Company documents show that lower nicotine starter brands of smokeless tobacco were created for new users who could not yet tolerate the higher nicotine products. One document showed that UST

PREVENTING PUBLIC HEALTH HAVOC

This article would be just an interesting review of a major industry's struggle for financial survival were it not for the impact that tobacco has on the public health. The fact is that tobacco products will kill more than 400,000 Americans this year. ⁵³ The annual number of deaths caused by smoking in the United States exceeds those of deaths caused by acquired immunodeficiency syndrome, car accidents, alcohol, homicides, illegal drugs, suicides, and fires— combined . ⁷⁴ Worse, these premature

A GENERATIONAL FIREBREAK

As a society—as government officials, public health experts, pediatricians, and parents—we have been slow to understand the dynamic of smoking initiation and addiction. In the past, we thought it was an issue of adults' quitting; now we know it is about children's starting. If the tragedy of tobacco use is ever to be stopped, we need to become more sophisticated and smarter in preventing our children from starting to use tobacco.

As physicians on the front lines of patient care, we must create a

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Previous studies have found that initiation of smoking tobacco use occurs predominantly among young people.9,13–15 Behavioural and biological studies suggest that young people are particularly susceptible to addiction, and that most adult smokers regret starting smoking.16–18 Despite this abundant motivating evidence, a study of tobacco use among adolescents aged 13–15 years across 143 countries found variable progress in reducing prevalence in this age group.19
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We modelled two indicators: prevalence of current smoking tobacco use among young adults aged 15–24 years, and the age at which current smokers aged 20–54 years in 2019 began smoking regularly. We synthesised data from 3625 nationally representative surveys on prevalence of smoking and 254 on age at initiation. We used spatiotemporal Gaussian process regression to produce estimates of the prevalence of smoking and age of initiation by sex, for 204 countries and territories for each year between 1990 and 2019.
Globally in 2019, an estimated 155 million (95% uncertainty interval 150–160) individuals aged 15–24 years were tobacco smokers, with a prevalence of 20·1% (19·4–20·8) among males and 4·95% (4·64–5·29) among females. We estimated that 82·6% (82·1–83·1) of current smokers initiated between ages 14 and 25 years, and that 18·5% (17·7–19·3) of smokers began smoking regularly by age 15 years. Although some countries have made substantial progress in reducing the prevalence of smoking tobacco use among young people, prevalence in 2019 still exceeds 20% among males aged 15–24 years in 120 countries and among females aged 15–24 years in 43 countries.
The fact that most smokers start smoking regularly before age 20 years highlights the unique window of opportunity to target prevention efforts among young people and save millions of lives and avert health-care costs in the future. Countries can substantially improve the health of their populations by implementing and enforcing evidence-based tobacco control policies that prevent the next generation from initiating smoking.
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An exploratory four-week, randomized controlled trial was conducted in Connecticut high schools to dismantle the independent and combined effects of CM and CBT; smokers received CM alone, CBT alone, or CM + CBT. Participants included 82 adolescent smokers seeking smoking cessation treatment. The primary outcome was seven-day end-of-treatment (EOT) point prevalence (PP) abstinence, determined using self-reports confirmed using urine cotinine levels. Secondary outcomes included one-day EOT PP abstinence and cigarette use during treatment and follow up.
Among participants who initiated treatment (n = 72), group differences in seven-day EOT-PP abstinence were observed (χ² = 10.48, p < 0.01) with higher abstinence in the CM + CBT (36.7%) and CM (36.3%) conditions when compared with CBT (0%). One-day EOT-PP abstinence evidenced similar effects (χ² = 10.39, p < 0.01; CM + CBT: 43%, CM: 43%, CBT: 4.3%). Survival analyses indicated differences in time to first cigarette during treatment (χ² = 8.73, p = 0.003; CBT: Day 3, CM: Day 9, CM + CBT: Day 20). At one- and three-month follow ups, while no differences were observed, the CM alone group had the slowest increase in cigarette use.
High-school, incentive-based smoking cessation interventions produce high rates of short-term abstinence among adolescent smokers; adding cognitive behavioral therapy does not appear to further enhance outcomes.
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^☆: J Pediatr 9/18/80198

^al.,*: Gold DR, Wang X, Wypij D, Speizer FE, Ware JH, Dockery DW. Effects of cigarette smoking on lung function in adolescent boys and girls. N Engl J Med 1996;335:931-7.

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Nicotine addiction: A pediatric disease☆

Abstract

Section snippets

ADOLESCENT ANGST

EVERYWHERE THEY LOOK

APPEALING TO ADOLESCENTS

MARKETPLACE BASED ON ADDICTION

MORE THAN JUST CIGARETTES

PREVENTING PUBLIC HEALTH HAVOC

A GENERATIONAL FIREBREAK

Growing up tobacco free: preventing nicotine addiction in children and youths

Preventing tobacco use among young people: a report of the Surgeon General

National Household Survey of Drug Abuse, 1994-B

Memorandum: research planning memorandum on some thoughts about new brands of cigarettes for the youth market

Memorandum: planning assumptions and forecast for the periods 1976–1986

Strategic Research Report, Marketing Development Department

Kwechansky Marketing Research. Project 16

Marketing tobacco to children

The Nation

Memorandum: the nature of the tobacco business and the crucial role of nicotine

Consumer behavior buying, having, and being

Trade regulation rule for the prevention of unfair or deceptive advertising and labeling of cigarettes in relation to the health hazards of smoking, and accompanying statement of basis and purpose of rule

Outdoor: it's not a medium, it's a large

Outdoors sets limits

Advertising Age

Advertising character and slogan survey

Cigarette advertising and promotion code

The Food and Drug Administration's regulation of tobacco products

N Engl J Med

Brand logo recognition by children aged 3 to 6 years: Mickey Mouse and Old Joe the Camel

JAMA

Changes in the cigarette brand preference of adolescent smokers—United States, 1989-93

MMWR Morb Mortal Wkly Rep

Add RJR to list of cigarette price cuts

Advertising Age

Never say die: how the cigarette companies keep on winning

ABC News, Peter Jennings Reporting

Memorandum: RJR sales company to sales reps

Tobacco critics see a subtle sell to kids

The Wall Street Journal

Memorandum: RJR sales company to all area sales representatives, sales representatives, and chain service representatives