TECHNICAL REPORT Nicotine and Tobacco as Substances of Abuse in Children and Adolescents Lorena M. Siqueira, MD, MSPH, FAAP, FSAHM, COMMITTEE ON SUBSTANCE USE AND PREVENTION Nicotine is the primary pharmacologic component of tobacco, and users abstract of tobacco products seek out its effects. The highly addictive nature of nicotine is responsible for its widespread use and diffi culty with quitting. This technical report focuses on nicotine and discusses the stages of use in progression to dependence on nicotine-containing products; the physiologic characteristics, neurobiology, metabolism, pharmacogenetics, and health effects of nicotine; and acute nicotine toxicity. Finally, some newer approaches to cessation are noted. This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have fi led confl ict of interest statements with the American Academy of Pediatrics. Any confl icts have been resolved through a process approved by the Board of Directors. The American Academy of INTRODUCTION Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. Technical reports from the American Academy of Pediatrics benefi t Tobacco exposure, whether through personal use, second- or thirdhand from expertise and resources of liaisons and internal (AAP) and smoke exposure, or unintentional exposure, is the most important external reviewers. However, technical reports from the American Academy of Pediatrics may not refl ect the views of the liaisons or the preventable cause of illness, disability, and death among adults in the organizations or government agencies that they represent. 1 United States. Worldwide, tobacco use is also the leading cause of The guidance in this report does not indicate an exclusive course of preventable death. 2 Many preventive measures have increased the treatment or serve as a standard of medical care. Variations, taking perceived risk of smoking, which, along with the decreased access to into account individual circumstances, may be appropriate. cigarettes, has contributed to a gradual decline in use. However, the All technical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffi rmed, rate of decline has begun to slow for the use of cigarettes, and use revised, or retired at or before that time. has increased significantly for nicotine products such as hookahs and DOI: 10.1542/peds.2016-3436 electronic nicotine delivery systems as well as for smokeless tobacco. As PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). reported by the Centers for Disease Control and Prevention, 2 e-cigarette experimentation and recent use among US middle and high school Copyright © 2017 by the American Academy of Pediatrics students doubled from 2011 to 2012 and has increased significantly FINANCIAL DISCLOSURE: The author has indicated she does not have a fi nancial relationship relevant to this article to disclose. since then. It is now estimated that 1.78 million students have ever used e-cigarettes. Of these, 9% (an estimated 160 000 students) have FUNDING: No external funding. never used conventional cigarettes. The Monitoring the Future Study POTENTIAL CONFLICT OF INTEREST: The author has indicated she has has also found that more teenagers report using electronic nicotine no potential confl icts of interest to disclose. delivery systems in the past 30 days than any other tobacco product. 3 Although these delivery systems may reduce exposure to some of the To cite: Siqueira LM and AAP COMMITTEE ON SUBSTANCE toxic chemicals in cigarettes, there are additional toxins associated with USE AND PREVENTION. Nicotine and Tobacco as Substances electronic nicotine delivery systems, and exposure to nicotine and its of Abuse in Children and Adolescents. Pediatrics. 2017; 139(1):e20163436 high addiction potential remain major concerns.4 Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 139 , number 1 , January 2017 :e 20163436 FROM THE AMERICAN ACADEMY OF PEDIATRICS It is well known that tobacco 8% to 12% of the total alkaloid attitudes and beliefs about the utility products contain more than 4000 content of tobacco products. of tobacco and may then begin to different chemicals. 5 Their effects, experiment with a few cigarettes. A along with the sensory stimulation few will never use again, and some and the conditioning that develops CRITERIA FOR DEPENDENCE will smoke repeatedly but irregularly. with continued use, may contribute Both the World Health Organization, Traditional theoretical models to the addiction process, but nicotine in its International Classification explaining nicotine addiction is the major contributor to the 9 of Diseases, and the American maintain that, beyond the role development of dependence. It is the Psychiatric Association, in its of nicotine as a key component primary pharmacologic component Diagnostic and Statistical Manual of required for the development of of tobacco, and its effects are sought 10 Mental Disorders, Fifth Edition, have addiction, other behavioral, social, after by users. Its highly addictive issued diagnostic criteria to assess environmental, and psychological nature is responsible for the addiction. Currently, “substance use factors are also important for the widespread use and difficulty with disorder” is the preferred term and development and maintenance quitting. includes dependence and withdrawal of addiction. 15 These include the symptoms. Nicotine meets the attitude and behavior of friends established criteria for a drug that and family members toward HISTORICAL BACKGROUND produces the symptoms of addiction, smoking, an underestimation of the specifically, dependence, withdrawal, addictive potential of nicotine, and Nicotine was originally isolated and craving. an overestimation of the prevalence from the herbaceous plant Nicotiana First use of tobacco most often occurs of peer smoking. Users also report tabacum, a native of tropical and in young adolescents, and the earlier that smoking alleviates anxiety, subtropical America but now one begins, the less likely one is to be depression, and pain and that they, commercially cultivated worldwide. able to stop using tobacco products 11 therefore, use it as a stress reliever. The plant was named after the and the more likely use will continue Although some of these effects may diplomat Jean Nicot de Villemain, with greater quantities. 12 It has be related to the pharmacologic who, in 1556, brought tobacco seeds been estimated that two-thirds of response along with the relief of and leaves as a “wonder drug” to the children who smoke in sixth grade withdrawal symptoms at times of French court from Brazil. 6 Nicotine become regular adult smokers smoking cessation, the belief that is a potent parasympathomimetic and almost half (46%) of smokers they are coping better with stress is a alkaloid and is now known to occur in the 11th grade become regular psychological effect that may lead to in the nightshade family of plants adult smokers. 13 Even infrequent further use to control mood. Frequent (Solanaceae). It is also present experimentation with smoking dosing of nicotine is associated with in minimal quantities in tomato, cigarettes can increase the risk of hand-to-mouth movement that potato, eggplant (aubergine), becoming a regular adult smoker; often becomes a social crutch that is green pepper, and cocoa leaves. 7 regular (defined as smoking at least difficult to do without after quitting. Nicotine is produced in the roots monthly) smoking by an adolescent Other rituals associated with a and accumulates in the leaves of has been found to increase the risk of particular device used may contribute the tobacco plant, with the amount becoming an adult regular smoker by to continued use. Smoking also varying with position: that is, leaves 16 times compared with nonsmoking becomes connected to specific times, harvested from higher stalk positions adolescents. 13 Of tobacco-dependent experiences, and events, referred to contain more nicotine than those adults, 90% started smoking before as cues, and these become reinforcing from lower positions. Flue curing 18 years of age and 99% started of use over time. Light or intermittent of the leaves changes the pH so that smoking before 26 years of age.14 smokers may be more influenced by the smoke of the leaves is better these associated activities, such as inhaled and, as a result, both more A number of researchers have after eating or drinking alcohol, than addictive and more toxic. Leaves studied the development of nicotine the need to use tobacco to relieve are usually combined so that, on addiction in adolescents. Even before withdrawal symptoms. 16 average, cigarettes (in any of 15 any experimentation, adolescents’ different cigarette brands) contain exposure to advertising and the More recently, a newer model, the approximately 1.5% nicotine by marketing of the range of tobacco sensitization-homeostasis model, weight. 8 Burning tobacco releases the products available can influence their has been proposed as an alternative nicotine, which is carried proximally attitudes about the risks and benefits model, and a number of studies have on tar droplets and in the vapor when of tobacco use. This initial preparatory supported this model to explain the inhaled. Other alkaloids constitute stage is when individuals develop development of nicotine addiction in Downloaded