ReviewInitial tobacco use episodes in children and adolescents: current knowledge, future directions
Introduction
Approximately three-quarters of adult tobacco users (i.e. cigarette and cigar smokers and users of smokeless tobacco, or SLT) report that their first tobacco use occurred during childhood or adolescence (11–17 years; United States Department of Health and Human Services, 1994a, United States Department of Health and Human Services, 1994b, Riley et al., 1996). Similarly, many adults who do not regularly use tobacco report that they have experimented with it, usually as adolescents (McNeill, 1991). There are no definitive data on how important these initial use episodes are in determining who becomes a regular tobacco user and who does not, though one estimate suggests that 94% of individuals who smoke four or more cigarettes go on to use them regularly (Russell, 1990). Nonetheless, there are suggestions that the effects of the first tobacco use episode may play a role in initiating or preventing a regular pattern of tobacco use by producing positive effects in the eventual regular user, but producing aversive effects in the eventual non-regular user (Kozlowski and Harford, 1976, Silverstein et al., 1980, Silverstein et al., 1982, Pomerleau et al., 1993). Knowing the role that nicotine plays in the effects of these early tobacco use experiences may be important in understanding the development of nicotine dependence. For adult tobacco users, nicotine is delivered in pharmacologically active doses either through the lungs (cigarette smokers) or oral mucosa (cigar smokers; smokeless tobacco users, SLT). In adults, nicotine’s direct pharmacologic activity, as well as the withdrawal produced by tobacco/nicotine abstinence are thought to play an important part in maintaining tobacco use behavior in adults. Whether an adolescent’s initial tobacco use episode results in delivery of pharmacologically active doses of nicotine has not been addressed directly. However, this issue may be central to understanding the role that nicotine plays in continued tobacco use in the adolescent population.
Unfortunately, controlled examination of the effects of tobacco use in children or adolescents can be difficult for at least two reasons. First, experiments involving self-administration of an addictive drug in this vulnerable population present ethical and practical challenges, including maintaining confidentiality while obtaining parental consent, and potentially furthering the addictive process. Second, identifying adolescent tobacco users early in their history of use can be problematic because traditional methods of detection (e.g. salivary cotinine, carbon monoxide levels) may be unreliable when tobacco use is intermittent (McNeill et al., 1987a). Nonetheless, the fact that tobacco use is implicated in the premature deaths of over 400 000 Americans and costs over $50 billion in health care expenses annually drives the need to understand what causes some individuals who use tobacco to become nicotine-dependent while others do not. Additionally, reports indicating that experimental smoking during adolescence doubles the risk of adult smoking (Chassin et al., 1990) and that over 42% of high school students use tobacco (United States Department of Health and Human Services, 1998a), highlight the need to understand the effects of initial tobacco use episodes in young people.
The purpose of this review is to examine existing data on initial tobacco use episodes in adolescents, with particular attention to:
- 1.
the effects adolescents experience after their initial tobacco use episode;
- 2.
nicotine exposure during initial use episodes; and
- 3.
how adolescents use tobacco (i.e. topography of use).
Where possible, this review will focus on data collected from children or adolescents regarding their initial tobacco use episodes. Where data from children or adolescents are not available, information gained from adult smokers will be used, with the understanding that information from adult smokers might be helpful in guiding future research into adolescent smoking. The review will conclude with a summary of what information would be most helpful in furthering the understanding of initial tobacco use episodes in adolescents and some methods that might be used to obtain that information.
Section snippets
The effects of initial tobacco use episodes in children and adolescents
A potential method of investigating initial tobacco use episodes might be to identify adolescents before their first tobacco use and then to observe them during their first use — perhaps by collecting subjective and physiological response data immediately before and after the first use episode. This idealized experiment presents several potential ethical concerns, however, as well as obvious difficulties in identifying subjects. Less ideally, but more practically, potentially valuable data can
Tobacco smoke and nicotine exposure during initial use episodes
Many of the effects of initial tobacco use episodes that have been reported by adolescents are consistent with the effects of nicotine, CO, and/or other constituents of tobacco smoke. However, the actual dose of these constituents delivered during an initial use episode are unknown. For nicotine, dose is directly related to tobacco nicotine content and other tobacco-specific factors (Henningfield and Nemeth-Coslett, 1988). Also, for smokers, the dose of virtually any smoke constituent is
What research is needed next?
The preceding review has made clear that much remains to be known about initial tobacco use episodes and the acquisition of tobacco use behavior among children and adolescents. Ideally, learning about the acquisition of tobacco use would include observing the details of this behavior as it emerges among different groups of young people. Such observation would be very informative, especially if it entailed cigarette-by-cigarette, dip-by-dip, or puff-by-puff records of tobacco use in real time.
Potential methods for tobacco-related research that includes adolescents and children
One of the reasons why so much remains to be known about tobacco use in children and adolescents is that they are a challenging population to study. For example, most data collection efforts using non-adult populations are limited, and rightly so, by the need for informed parental consent. However, many young tobacco users may not want parents informed about their tobacco use. Also, studying tobacco use behavior in a relatively naı̈ve user (e.g. <10 episodes of use, lifetime) may be seen as
Conclusion
Tobacco abuse is a disease with a pediatric age of onset (Kessler et al., 1997, Najem et al., 1997). As with any disease, researchers interested in treating tobacco abuse must understand each stage of this disease’s progression, from first exposure to final outcome. Over the previous several decades much research effort and resources have been focused on tobacco abuse and dependence in those who suffer from its later stages: adult tobacco users with well-developed tobacco use patterns and
Acknowledgements
This research was supported by the Robert Wood Johnson Foundation Research Network on the Etiology of Tobacco Dependence and the National Institute on Drug Abuse (R29 DA-11082).
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