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Adolescent Smoking:
A Lethal Addiction
Laurie Anne Ferguson

ABSTRACT
According to the Centers for Disease Control and Prevention, cigarette smoking is the
leading preventable cause of death in the United States. It is estimated that in 2006,
2.6 million adolescents were current cigarette smokers. A critical objective for Healthy
People 2010 is to reduce the prevalence of cigarette smoking among high school students.
Because most adults who are regular smokers began smoking in adolescence, a focus
on the prevention of teen smoking is critical. As the leading cause of preventable
death, smoking is a lethal addiction.

Keywords: adolescent smoking, smoking cessation, teen smoking, tobacco addiction

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INTRODUCTION Psychosocial and behavioral risk factors relevant to smok-

According to the Centers for Disease Control and ing include the lack of strong social bonds (families,
Prevention (CDC), cigarette smoking is the leading pre- school, and religion); exposure to pro-smoking social
ventable cause of death in the United States. It is estimated
influences; and engagement in other problem behaviors.
that in 2006, 2.6 million adolescents were current cigarette Several studies have identified a need to positively
smokers.1 A critical objective for Healthy People 2010 is toinfluence adolescent social skills to positively impact smok-
reduce the prevalence of cigarette smoking among high ing prevention and cessation interventions.7-9 An assess-
school students. While the rate of adult smoking continues ment of 1694 adolescent smokers7 found that this type of
to decline, there has been an increase in adolescent smok- intervention strategy positively influenced outcomes. The
ing.2 If adolescent smoking rates persist, it is estimated that
interventions included a health-oriented, a fitness-ori-
6.4 million youth will die prematurely from tobacco- ented, and a social skills/stress management-oriented strat-
related illnesses.1 Because most adults who are regular egy, and revealed that while the health-oriented strategy
smokers began smoking in adolescence, a focus on the pre- was superior immediately after the intervention, interven-
vention of teen smoking is critical.4 Yet adolescents are not
tions that emphasized social skills and stress management
“little adults” when it comes to smoking. Their patterns of was the most effective at the 12-month follow-up. Another
use and addiction vary from adults, and strategies to prevent
study examined 1021 non-Hispanic black and white ado-
smoking and encouraging smoking cessation are unique. lescents.8 Their findings concluded that, stress and lower
Early research on adolescent smoking viewed the problem socioeconomic status increased the risk of adolescent
as “teen rebellion,” rather than the addiction that it is.5 This
smoking, and therefore interventions to decrease stress
article will discuss special strategies for preventing adoles-
aimed at younger children in elementary school might
cent smoking and encouraging smoking cessation. prove effective at smoking prevention. Programs that focus
on stress management and strategies for dealing with peer
RISK FACTORS pressure, which include improving social and coping skills
Adolescence is a time when teenagers begin to separate as part of the intervention, are some of the most effective
from the family and develop their own sense of self-worth. strategies in controlling smoking behavior.7,8 Providers
Along with rapid physical changes, emotionally, adolescents who are comfortable screening adolescents for high-risk
are developing their own set of values. They seek approval behaviors are better able to deliver preventative services.9
from their peers which, in turn, can induce conflict or Health care providers who demonstrate an increased com-
risk-taking behaviors such as fort level are more likely to
smoking. Caucasian and Hispanic screen and provide health pro-
adolescents are more likely than motion in daily practice.9
African Americans to be daily Providers who are In adolescence, interventions
smokers. Asians have the lowest need to focus on decreasing
smoking rates. On average, Asians
comfortable screening risk-taking behaviors to prevent
demonstrate the highest commit- adolescents for high-risk the initiation of smoking.
ment to academics while behaviors are better able to Because risk-taking behavior
Caucasians and Hispanics have deliver preventive services. may be perceived as “cool,” ado-
more powerful family ties, and lescents may be more receptive
African Americans have stronger to tobacco advertising.
religious ties. African Americans Adolescents who own smoking
also have stronger parental disapproval, which appears promotional items are at increased risk for smoking pro-
to have a positive influence on lower use of tobacco gression. “Novelty seeking” is behavior that seeks out new
products.6 As early as 13 years of age, nearly 60% of and stimulating activity and has been associated with
African Americans, 70% of Hispanic, 50% Caucasian, and increased odds of smoking. Adolescents who are impulsive
36% of Asian youth have initiated smoking. This increases risk takers are at increased risk of using tobacco.10
to 90% for Hispanics, 80% for Caucasians and African Entire books have been written in recent years that
Americans, and 65% for Asian youths at age 18.6 discuss the power of a few influencers or salesmen in

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Table 1. Information for Parents
• Have a direct discussion about tobacco risks with your
children
• Avoid smoking in your child’s presence
• Start talking with your children about tobacco use at
age 5 or 6 and continue through high school
• Discuss with your children ways to refuse tobacco
• Point out the false allure of tobacco in the media
• Remember that close parental-adolescent relationships
have been shown to decrease risk-taking activities in teens
Adapted from Youth and Tobacco Information Sheets.17
shaping the behavior of groups.11,12 Specifically,
Gladwell discusses that it isn’t smoking that is cool but
rather the smokers who are “cool.”11 Gladwell main-
tains that programs which emphasize the health risks of
smoking miss opportunities to really positively affect
adolescent behavior. This is because adolescents are
often drawn to risk-taking activities. Extroverted, defi-
ant, sensational individuals wield great influence, espe-
cially during adolescence. This reinforces other research
that has found that interventions which increase social
skills, stress management, and strategies to resist peer
pressure may be most effective with adolescents.
A discussion of adolescent smoking would not be
complete without including the risks of other tobacco
products. Adolescents who dip or chew may not consider
themselves smokers and should be educated about the
risks of nicotine in all forms. An increasingly popular form
of tobacco use includes waterpipe smoking or the use of
Hookahs. A (hookah shisha, nargile, or hubble bubble) is a
waterpipe filled with sweetened, flavored, and heated
tobacco and is smoked through a pipe or hose.3 The
tobacco smoked via a hookah is often at higher levels than
conventional cigarette smoking and represents a new and
stronger health threat.
PARENTAL INFLUENCE
A finding consistently seen in the literature is that
adolescents whose parents are nonsmokers are less
likely to smoke.14-16 Parents, even if they themselves
are smokers, can have a powerful influence on reduc-
ing teen smoking. Parents should be encouraged to
begin talking about not smoking with their children as
early as 4 to 5 years17 (Table 1). Motivating parents to
594 The Journal for Nurse Practitioners - JNP
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engage in home smoking bans, promoting nonsmoking
areas in public establishments, and asking others not to
smoke in your presence effectively reduces adolescent
smoking.14
Because adolescence is often a volatile time, parents
who have a close relationship with their children can
have a positive influence on adolescents’ choices.
Parental expectations may prohibit adolescents from
smoking even if the teen’s social environment encour-
ages smoking.15 Good parent-child connectedness may
also be protect against youth smoking.18 Clearly,
strategies that encourage strong parent-child commu-
nication throughout childhood may positively impact
adolescent smoking.
There is some evidence in the literature that genetics
plays a strong role in influencing tobacco smoking, par-
ticularly with those adolescents who move from casual
smoking to addiction.19 It is unclear how this influences
intervention strategies except to educate parents to be
alert to the genetic risks of tobacco addiction, just as
providers routinely address other health risks such as
heart disease and diabetes.
LEGISLATION
While legislation has decreed how tobacco usage may be
advertised, tobacco advertising still plays a role in influ-
encing adolescents’ smoking habits. Although television
advertising of smoking has been banned, smoking pro-
motional items and print advertisements of tobacco
products are commonly available. Henriksen et al20 stud-
ied the effect of tobacco advertising on teen smoking in
local convenience stores. These researchers20 found that a
weekly visit to a convenience store increased the odds of
smoking by 50%. On the other hand, the cost of tobacco
products consistently decreases tobacco initiation and
increases tobacco cessation.21,22
Several states have enacted laws that encourage
smoking cessation and support treatment strategies.
The Council of State Governments passed a collective
resolution in 2007 supporting states’ efforts to promote
smoking cessation and coverage for treatment.23 A U.S.
congressional bill, H.R. 1108, titled the Family
Smoking and Tobacco Control Act, failed to pass the
110th Congress in 2007. H.R. 6393, titled the Quit
Smoking for Life Act of 2008, was referred to the
house subcommittee in July 2008. This bill would
amend Medicare to cover diagnostic and counseling
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services and to cover tobacco cessation drugs under
Medicare part D. In addition, this bill would amend
Medicaid coverage to cover counseling and tobacco-
cessation medications.24
WHAT WORKS, WHAT DOESN’T
Strategies that work for adults may not be effective with
teens. Programs focused on impacting adolescent smoking
need to be tailored to teens to be effective in reducing
smoking initiation and increasing smoking cessation.
Web-based strategies and computer interactive pro-
grams have been shown to be effective in this popula-
Table 2. Health Provider’s Role
• Screen all parents and patients at well-child visits for
tobacco use
• Encourage smoking cessation
• Encourage household smoking bans
• Support legislative efforts to decrease tobacco
advertising and access
• Support smoking cessation programs in local school
and community
• Support tobacco-free environments
Adapted from Youth and Tobacco Information Sheets.17

tion.2,25 It has also been found that increasing the length of

the visit with the primary care provider to address smoking
cessation is a positive intervention.25 However, this is often
non-judgmental atmosphere for children and adolescents
difficult to implement in busy office practices where and assess risk-taking behaviors at all visits17 (Table 2).
patient education is not reimbursed. Interventions aimed at Counseling remains critical to smoking cessation and
reducing adolescent smoking must provide two-way inter- abstinence. The Public Health Service Clinical Practice
action and ongoing support to be effective. Information- Guideline and the American Academy of Pediatrics endorse
only interventions, no matter what type of format, have not the use of the 5A intervention model4,28,29 (Table 3).
been very effective with teens. Programs that teach prob- Telephone counseling is available at 1-800-QUIT-NOW.
lem-solving, decision-making, goal setting, and self- Table 4 provides several excellent resources for providers
improvement strategies are the most effective in developing that can be incorporated in busy practice settings.
tobacco refusal skills.26 The Food and Drug Administration has not approved
pharmacological therapies for the use of smoking addiction
IMPLICATIONS FOR PRACTICE in adolescents even though some providers use the medica-
Providers who are comfortable tions off-label.1 A 2006
with their knowledge regarding Cochrane summary on tobacco
risk-taking behaviors are more cessation interventions for young
likely to screen their patients people did not provide enough
Interventions aimed
for these behaviors.9 While evidence to support the use of
both parents and children see at reducing adolescent nicotine replacement therapies
the pediatric primary provider smoking must provide (NRT) in adolescents due to
most often during childhood, two-way interaction and insufficient evidence.30 This may
often, pediatric providers do be due to the fact that not all
ongoing support.
not take the opportunity to dis- adolescents who smoke or chew
cuss parental smoking during are physically addicted to
well visits.9,27 Increasing tobacco. Many adolescents do
emphasis on the risks of tobacco use and encouraging not smoke or chew daily but may increase their use of
smoking cessation during routine office visits are tobacco products on the weekends or at parties. Typical ado-
needed. Smoking cessation programs need to be inter- lescent tobacco use is strongly influenced by relationships,
active and employ a variety of strategies. Emphasis activities, and social attitudes.31,32 A careful history of
must be placed on stress reduction and strategies to tobacco use may provide the clinician with insight as to
develop self-esteem and tobacco refusal skills. whether the use of NRT may augment cessation strategies.
Health care providers need to be proactive at all well- Depression and cigarette smoking are highly corre-
child visits to encourage smoking cessation of parents. In lated in the literature. Adolescents may not seek treat-
addition, health care providers need to provide an open, ment for symptoms of depression and may be at

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Table 3. Five A Intervention Strategy Table 4. Resources for Health Providers

• Ask the adolescent about his/her smoking status • Clinical Practice Guideline, Treating Tobacco Use and
Dependence: 2008 Update
• Advise the adolescent to stop smoking with a statement
that quitting smoking is the single best thing he/she can http://www.surgeongeneral.gov/tobacco/treating_tobacco_
do for his/her health use08.pdf
• Assess motivation to stop smoking • Help for Smokers and Other Tobacco Users
• Assist the adolescent to quit http://www.ahrq.gov/consumer/tobacco/lowlit.htm
By assessing the following: • Healthy Hearts Guide
• Pros/cons for smoking http://www.healthfinder.gov/scripts/SearchContext.asp?
topic5801&basic5123
• Personal reasons for quitting
• Smoking Cessation
• Anticipated problems in quitting
http://www.nlm.nih.gov/medlineplus/smokingcessation.
• Previous quit attempts
html
• Nicotine addiction
• Helping Young Smokers Quit
• Quit methods
http://www.helpingyoungsmokersquit.org/home
• Set a quit date
• Youth Tobacco Cessation Collaborative
• Triggers and strategies
http://www.youthtobaccocessation.org/publications/
By addressing the following: factsheets.asp
• Managing triggers
• Handling social situations
• Managing withdrawal symptoms with high quit rates.1 Improving clinician training and
• 4 Ds for managing cravings documentation for tobacco addiction treatment are
Delay important goals for affecting better outcomes.
Deep breath
CONCLUSION
Drink water
The majority of today’s smokers became addicted to
Do something else
tobacco during adolescence. As smoking is a public health
• Managing stress problem, providers need to be vigilant in identifying
• Minimizing weight gain smokers and promoting cessation. Public health policies
• Gaining support and laws need to be strengthened to encourage smoking
• Taking control of one’s environment cessation. Treatment of tobacco dependence requires a
• Rewarding oneself
multipronged approach. Health care providers need to
assess smoking behavior and willingness to quit. There
• Arrange for follow-up
must be open dialog between the provider and adolescent
Table adapted from Anderson et al.28,29 in providing support and resources. The implications for
providers are clear: encouraging parental smoking cessation
during childhood and addressing smoking behavior in
increased risk of tobacco addiction.33-35 Munafo et al35 adolescence are necessary to screen and intervene for
found that depressed mood made individuals particularly health promotion.
susceptible to peer smoking and other social influences.
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Laurie Anne Ferguson, MSN, APRN, ANP-BC, FNP-C, CPNP, is
a family nurse practitioner at Varnado Family Practice in Greensburg,
LA. She can be reached at larjpark@gmail.com. In compliance with
national ethical guidelines, the author reports no relationships with
business or industry that would pose a conflict of interest.
1555-4155/09/$ see front matter
© 2009 American College of Nurse Practitioners
doi:10.1016/j.nurpra.2009.01.006

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