Nicotine withdrawal symptoms in an adolescent psychiatric patient
Beth, age 15, was admitted overnight to an inpatient psychiatric unit after running away from home and being taken into police custody. Her primary diagnosis was conduct disorder.
At morning rounds, the nurse reported that Beth was very irritable, had threatened the staff, and had been moved to seclusion. During routine examination, the psychiatrist discovered that Beth was a half-pack/day smoker and “really” wanted a cigarette. The psychiatrist told her hospital policy did not allow smoking, but she could try a transdermal nicotine patch (TNP) to help reduce her nicotine withdrawal symptoms. She agreed and received a 14 mg/d nicotine patch.
Beth’s irritability improved substantially with TNP, and she moved back to her regular room within 2 hours without incident.
We have found daily smoking to be a good indicator of nicotine dependence, and anyone who smokes daily would receive significant health benefits from quitting. Hence, any daily smoker who wants to quit, regardless of DSM-IV nicotine dependence status, is a candidate for treatment.
BEHAVIORAL THERAPY
Unlike adults, adolescents usually lack smoking-related medical consequences, such as heart or lung disease. Even so, most adolescent smokers report that they would like to quit but face barriers such as:
- having to inform parents they smoke
- not knowing how to get help for smoking cessation
- lack of transportation for treatment
- lack of third-party reimbursement for smoking cessation treatment.
To help adolescents, we recommend following the U.S. Public Health Service guideline for smoking cessation.14 At least provide and discuss smoking cessation brochures developed specifically for adolescents. For example, one Centers for Disease Control and Prevention brochure describes what symptoms to expect when quitting, how to cope with craving, and other topics (see Related resources).
To manage peer pressure, we counsel teens to let their friends know they are trying to quit so that friends do not smoke in front of them. If that does not work, we ask patients to avoid being around friends who smoke at least for the first 2 weeks and preferably 2 months.
Many states have free telephone quit lines that provide support and advice on how to stop smoking. Several Web sites also are available for smokers (including adolescents) wanting to quit (see Related resources).
PHARMACOLOGIC TREATMENT
For adults, first-line FDA-approved medications for smoking cessation include nicotine replacement therapies (NRT)in transdermal, gum, inhaler, and lozenge forms and sustained-release bupropion. Nortriptyline, doxapine, and clonidine have shown effectiveness for smoking cessation but are not FDA-approved for this indication.15 Selegiline and mecamylamine have shown initial efficacy and are being examined in larger clinical trials.
For adolescents, little is known about what medications might help them stop smoking. Nicotine replacement therapies and bupropion SR have been most explored in adolescent smokers. The effect of psychiatric comorbidity on the quit rate is not well-studied in adolescents.
The transdermal nicotine patch (TNP) has shown modest results in preliminary trials among adolescents. One study found 11% abstinence at 6 weeks,16 and another found a <5% quit rate.17 A third study reported an 18% abstinence rate with a combination of TNP and contingency management therapy.18 Discussion of contingency management and other behavioral therapies is beyond the scope of this article.
A recent study comparing TNP, nicotine gum, and placebo in adolescent smokers found the lowest drop-out rate and highest compliance among the TNP group. Three-month abstinence rates were 17.6% for TNP, 6.5% for nicotine gum, and 2.5% for placebo. The difference between the TNP and placebo groups’ abstinence rates was statistically significant.19
Bupropion SR. In an open-label pilot study, our group treated 16 adolescent smokers weighing >90 lbs with bupropion SR, 150 mg bid. Average age was 18, and two-thirds of patients had ADHD. The endpoint abstinence rate—as measured by self-report and CO levels—was 31%, which is similar to rates reported in adult smokers treated with this dosage of bupropion SR.20
The adolescents did not gain weight during the study, which may be important to this age group. Reported side effects were similar to those in adults, with one adolescent reporting an allergic reaction (urticaria). We are conducting a larger follow-up study using bupropion SR with and without behavioral therapy.
A PRACTICAL CLINICAL APPROACH
Smoking behavior. For treatment, we propose two categories of adolescent smokers: regular (daily) and nonregular (nondaily) (see Algorithm). We recognize that many nondaily smokers smoke frequently and may benefit from aggressive treatment. However, we propose this two-track approach as a starting point because of limited data and medication risks, such as possible seizures with bupropion SR. We suggest: