Are adolescent smokers dependent on nicotine? A review of the evidence

Abstract

This paper reviews the empirical literature on adolescent nicotine dependence, withdrawal, and their associated features. Data documenting nicotine dependence scores, diagnoses, and individual features among adolescents are reviewed in detail and compared to observations based on adult smokers. These data are derived from a broad variety of sources, including national surveys, school-based surveys, and smoking cessation studies. Overall, results indicate that one to three out of five adolescent smokers is dependent on nicotine, with some adolescent groups clearly at higher risk for dependence (those who are incarcerated, in vocational schools, daily smokers, and/or heavy smokers). Across studies, data consistently indicate that a large majority (two-thirds or more) of adolescent smokers report experiencing withdrawal symptoms during attempts to quit or reduce their smoking. Craving or strong desire to smoke was the most commonly reported withdrawal symptom in every study reviewed. Although analyses of concurrent validity generally support the dependence and withdrawal findings among adolescents, data on the predictive validity of measures used are needed. Moreover, studies of adolescent tobacco withdrawal rely almost exclusively on retrospective self-report data. Recommendations for enhancing methodology and advancing our understanding of adolescent nicotine dependence and withdrawal are offered.

Introduction

More than 3 million adolescents in the US smoke, with ∼6000 starting every day (Pierce, 1991). Although the overall prevalence of cigarette smoking has been declining in the general adult population, the rate among American adolescents had held relatively steady for over a decade, but has been rising sharply since 1992 (Johnston et al., 1998). Over the past several years, increased smoking prevalence among adolescents has been accompanied by a decrease in the age of initiation for smoking, as well as a drop in adolescent perceptions of health risk and peer disapproval related to cigarette smoking (Johnston et al., 1998).

Early initiation of smoking is of particular concern because numerous studies have found that smoking in early adolescence is a strong predictor of smoking in adulthood (Chassin et al., 1990, Taoli and Wydner, 1991). Smoking just a few cigarettes during adolescence increases the probability of developing dependence on nicotine (Russell, 1990) and leads to a 16-fold increase in the risk of adult smoking (Chassin et al., 1990). Furthermore, the earlier one starts smoking, the more cigarettes per day one will smoke as an adult (Taoli and Wydner, 1991) and the more severe the tobacco-related health consequences one is likely to experience (USDHHS, 1989).

Nicotine dependence and withdrawal are implicated in the maintenance of tobacco use and difficulty quitting. Few adolescents anticipate difficulty quitting when they initiate smoking. However, more than half of smoking adolescents report attempting to quit each year, and among those who smoke ten or more cigarettes per day, fewer than 20% report being successful for even 1 month (Johnston et al., 1989). Among high school smokers, only 5% expect to be smoking 5 years after graduation; in actuality, 75% will still be smoking (Charlton et al., 1990). Ershler et al. (1989) found that more than 50% of adolescents experienced withdrawal symptoms as a result of a quit attempt. This figure compares with ∼85% of adults who experience withdrawal symptoms upon nicotine abstinence (Hughes and Hatsukami, 1986, Gritz et al., 1991). Like adult smokers, adolescents report frequent unsuccessful quit attempts and report urges to smoke and withdrawal symptoms among their reasons for difficulty quitting (Johnson, 1982, Biglan and Lichtenstein, 1984). Indeed, the Surgeon General of the US concluded in a 1994 report that most adolescents who are daily smokers are addicted to nicotine and want to quit smoking, but are unable to do so (USDHHS, 1994).

The primary objective of this paper is to provide a critical review of the empirical literature on adolescent nicotine dependence. The paper will evaluate the extent to which adolescent smokers display patterns of dependence and withdrawal that are comparable to those observed in more experienced smokers. The quality of the evidence will also be evaluated in terms of the methodology and instrumentation employed in the relevant studies.

The paper is divided into four sections. The first section reviews studies that estimate the prevalence of nicotine dependence in adolescent samples. The second section reviews studies that describe individual features of dependence and withdrawal and estimate their prevalence among adolescent smokers. In the third section the patterns of association between general and specific measures of dependence and other smoking-related variables will be summarized. Beyond the review of extant data, the final section will identify gaps in research and outline enhancements in methodology and measurement needed to advance our understanding of the etiology of nicotine dependence.

Do adolescent smokers share adult characteristics of nicotine dependence? What we know so far.