Many adolescent psychiatric patients who smoke are not getting the help they need to quit. When we asked 120 teen inpatients if they smoked and then checked their charts, we found only 6 of 47 smokers had been diagnosed as nicotine-dependent.1
Adolescents who cannot quit on their own may benefit from smoking cessation therapies. Based on evidence and our experience, we offer a practical approach to treating nicotine dependence in adolescents, using drug and behavioral therapies.
PSYCHIATRIC COMORBIDITY
Psychiatric comorbidity is highly associated with cigarette smoking in adults and adolescents. In the United States:
- 44% of cigarettes smoked are sold to someone with a mental illness.2
- Persons with mental illness are 2.7 times more likely to smoke than are those without mental illness.2
- Most smokers start before age 18,3 and starting before age 13 is linked to psychopathology in later adolescence.4
Table
Smoking likelihood by age and comorbidity among adolescent psychiatric inpatients
| Significant variable | Logistic regression odds ratio | 95% confidence interval | Significance (P value) |
|---|---|---|---|
| Age | 1.30 | 1.03, 1.64 | 0.03 |
| Depressive disorders | 4.02 | 1.267, 12.734 | 0.018 |
| Conduct disorder | 12.96 | 1.678, 100.07 | 0.014 |
| Cannabis use disorder | 24.60 | 3.7, 163.42 | 0.0009 |
| Source: Data from 120 patients admitted to an inpatient child and adolescent psychiatry program. | |||
| Adapted with permission from reference 1. | |||
Disruptive behavior disorders in adolescent smokers include oppositional defiant disorder, conduct disorder, and attention-deficit/hyperactivity disorder (ADHD). Among psychiatric disorders, conduct disorder has the strongest association with smoking in adolescents.1 ADHD is associated with smoking and perhaps with increased difficulty in quitting.5,6
Mood disorders. Major depressive disorders have a strong, consistent, bidirectional association with smoking in the young. Depression may lead to smoking, and smoking to depression.7
Substance use disorders. Alcohol use disorders are strongly associated with smoking among adolescents, and the association is both bidirectional and dosedependent.8 Cannabis use disorder is also associated with cigarette smoking among adolescents (Table).9
Anxiety disorders. Evidence is emerging that anxiety disorders—especially social phobia—may be linked to smoking among adolescents.10
Nicotine withdrawal symptoms—irritability, anxiety, decreased concentration, increased appetite, craving for cigarettes—can mimic those of other psychiatric disorders. Adolescent smokers admitted to locked psychiatric units may experience withdrawal symptoms that require nicotine replacement treatment (Box).
Effect on quit rates. Psychiatric comorbidity may reduce quit rates during smoking cessation treatment.6 When smokers are trying to quit, watch for remission, worsening, or emergence of psychiatric conditions.
ASSESSING ADOLESCENT SMOKING
Adolescents with psychiatric diagnoses can be assessed for nicotine dependence—and vice versa—although accurately gauging their smoking habits is more difficult than in adults. For example:
- Rating scales for nicotine dependence severity—such as the modified Fagerstrom Tolerance Questionnaire11—lack standard cutoff scores for adolescents.
- Unlike adults, many adolescents cannot reliably report use in “packs per day” because the number of cigarettes they smoke varies widely from day to day.
Biological markers commonly used to assess smoking in adults include expired-air carbon monoxide (CO), cotinine (nicotine metabolite), and thiocynate levels. Preliminary evidence indicates that cotinine may be a more sensitive and specific biological marker for smoking among adolescents than CO levels.12 Thiocynate has not been evaluated as a marker for smoking in adolescents.
CO levels typically reflect smoking in the previous few hours, whereas the half-life of cotinine is longer (1 day or more). Also, factors such as environmental pollution or marijuana use can inflate CO levels. Thus, cotinine levels have greater accuracy and specificity, reflecting only the amount of nicotine consumed.
Unfortunately, most laboratories do not measure cotinine levels, and the expired-air CO test (CO Breathalyzer) is relatively expensive for most clinicians. Commercially available single-use cotinine test kits are modestly priced and provide semi-quantitative (a range instead of an exact number) urine cotinine levels. These tests, however, might not be covered by third-party insurers.
Until cotinine testing becomes widely available, we recommend a combination of self-report and expired-air CO level to monitor abstinence.
Self-report monitoring. Most clinicians rely on self-report rate of smoking among adolescents, as no screening assessment has been validated in this age group. As initial prompts, we recommend asking all adolescents if they smoke cigarettes, if they smoke regularly, and if they smoke daily.
We recommend using the “time line follow-back” method13 to monitor the self-reported smoking rate. Begin by providing the patient with a 30-day calendar, starting backwards from the day of assessment. Cite anchor points, such as special holidays and school or family events, to help the patient recall his or her cigarette use. Then have the patient fill in the number of cigarettes smoked each day for 30 days.
This assessment method appears more reliable than asking an adolescent “how many cigarettes do you smoke per day?”. After the initial time line follow-back assessment, encourage adolescent smokers to keep a daily diary of how many cigarettes they smoke, and monitor the diary at each visit.