Tobacco Use Disorder in Children and Adolescents

ICD-10 code: F17.200

Tobacco use disorder is grouped within the cluster of diagnoses called the substance-related and addictive disorders. Substance-related addictive disorders are characterized by a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the use of substances. These problems are persistent and occur repeatedly within the same 12-month period.

The term substance can refer to a drug, a medication, or a toxin. In addition to alcohol, types of substances to which individuals may become addicted include:

Tobacco
Caffeine
Cannabis
Hallucinogens
Inhalants
Opioids
Sedatives
Stimulants

Substance-related disorders are divided into two groups:

Substance use disorders (SUD)
Substance-induced disorders—intoxication, withdrawal, and other substance/medication-induced metal disorders (psychotic disorders, bipolar and related disorders, depressive disorders, anxiety disorders, obsessive-compulsive and related disorders, sleep disorders, sexual dysfunction, delirium, and neurocognitive disorders).

The essential feature of a substance use disorder is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems. An important characteristic of this disorder is an underlying change in brain circuits that may persist beyond detoxification, particularly in individuals with severe disorders. The behavioral effects of these brain changes may be exhibited in the repeated relapses and intense drug craving when the individuals are exposed to drug-related stimuli.

What is tobacco use disorder?

The diagnosis of tobacco use disorder is assigned to children and adolescents who are dependent on the drug nicotine, due to use of tobacco products.

Learn More

Tobacco use disorder is a problematic pattern of tobacco use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

Tobacco is often taken in larger amounts or over a longer period than was intended
There is persistent desire or unsuccessful efforts to cut down or control tobacco use
A great deal of time is spent in activities necessary to obtain or use tobacco
Craving, or a strong desire to use tobacco
Recurrent tobacco use resulting in failure to fulfill major role obligations
Continued tobacco use despite persistent social or interpersonal problems
Important social or recreational activities are reduced or ceased because of the use
Recurrent tobacco use in hazardous situations
Tobacco use is continued despite knowledge of having a problem
Tolerance and/or withdrawal symptoms

When we consider substance use disorder, we often think of substance dependence. Individuals are considered dependent on a substance when symptoms of tolerance and withdrawal are present:

Tolerance is a need for markedly increased amounts of a substance to achieve its desire effect.

Withdrawal is the development of substance-specific maladaptive behavioral changes, with physiological and cognitive concomitants, that is due to the cessation or reduction of substance use.

Understanding Tobacco Use Disorder

According to the National Survey on Drug Use and Health, more than 80 percent of smokers begin smoking before age 18, and more than 90 percent do so before leaving their teens. The DSM-5 notes that many people in the United States experiment with cigarettes in their teens, and the American Psychiatric Association estimates that about 20 percent of individuals will use tobacco at least monthly by age 18.

Cigarettes are the most commonly used tobacco product in the United States. The rewarding properties of cigarettes (e.g. behavioral reinforcement of the hand- to -to mouth habit) and societal approval of tobacco products (as featured in the media) enhance the addictive properties of nicotine. Additionally, lack of social support to cease smoking (i.e. due to cultural acceptance), and ease of access of tobacco products, make smoking cessation especially difficult for adolescents and teens.

The American Psychiatric Association has found there is a genetic component to substance related disorders.

Learn More

The American Psychiatric Association has found there is a genetic component to substance related disorders.

Counseling, using one of the following approaches:
- Cognitive-behavioral therapy consists of gradually exposing the person to the substance (tobacco) while simultaneously refraining from compulsive behavior (using the substance).
- Motivational counseling focuses on decreasing ambivalence toward change
- Social influence strategies address social influences that maintain tobacco use
Pharmacological Interventions may be used with adolescents, but are not recommended for use with children. They include antidepressant medications and nicotine antagonist drugs. The drug most widely prescribed for Tobacco Use Disorder in adolescents is Zyban.
Nicotine Replacement Therapy (NRT) may also be used with adolescents, but is not recommended for use with children. NRT gives the smoker a dose of nicotine to alleviate cravings, rather than obtaining through the more hazardous method of administration. NRT may include use of the following:
- Electronic cigarettes ( currently not FDA approved devices) which vaporize nicotine
- Chewing nicotine gum
- Transdermal nicotine ("the patch")

Research additionally suggests that the following treatments are promising:

Short term tangible reinforcement for not smoking (e.g. collecting money that would normally be used to purchase cigarettes or other tobacco products, and saving it to purchase a reward for quitting).
Hypnosis
Social support through smoking cessations self-help groups
Exercise as an adjunct to relieve nicotine cravings