Adolescents and teen smokers can be more susceptible to nicotine addiction and face unique developmental challenges in the initiation and cessation of cigarette smoking. They are an important group to target with regard to both prevention and cessation efforts.
The CDC reports that in 2015, 9.3% of high school students smoked cigarettes in the past 30 days. This number is down by over 6% from 2011, suggesting that progress is being made in youth tobacco prevention. While these statistics show positive change, cigarette smoking continues to be the leading cause of preventable morbidity and mortality worldwide.1,2 In the U.S., there are currently 30.7 million daily smokers. If current rates persist 5.6 million of today’s American youth, about 1 in every 13 Americans younger than 18, will die prematurely due to smoking-related illness.3,4,5 Every day, more than 3200 adolescents under the age of 18 experiment with their first cigarette and an additional 2100 go on to become daily smokers.4 In fact, over 95% of adults who are or were daily smokers tried their first cigarette before age 21.4
Recent studies have shown that reasons for youth cigarette use initiation vary widely, and are not universal to all youth smokers. Common reasons for initiation include:13,17,18
- Social norms
- Peer influence
- Parental smoking
- Weight control
These statistics illustrate why smoking needs to be prioritized as a major public health concern among today's youth.
Alternative Tobacco Products:
American youth have gradually been moving towards more non-cigarette forms of tobacco products, with hookah and e-cigarette usage particularly high.6 A recent study found that nearly 15% of youth use one or more tobacco products. Of this population, 2.8% use cigarettes exclusively, and 4% use one alternative tobacco product (e.g., cigars, cigarillos); 2.7% use both cigarettes and an alternative tobacco product, and 4.3% are poly-users (3 or more products).6 Furthermore 73% of high school and 56% of middle school students who currently smoke report using flavored tobacco products within the past 30 days.4 This suggests that certain tobacco products disproportionately target youth.
For more information on alternative tobacco products, please visit our webpage, or click here.
E-Cigarettes and Youth:
20.8% percent of all high school and 4.9% of all middle school students have used electronic cigarettes in the past 30 days. Among high school students, e-cigarette usage increased 78% from 2017 to 2018.20 A recent study reported that over 30% of all youth surveyed believed e-cigarettes to be less harmful than traditional cigarettes.7 This and other research suggests that lack of knowledge or misconceptions could promote electronic cigarette use.7,8 Although there are adolescent dual users, who use cigarettes and e-cigarettes, they are approximately half as prevalent as e-cigarettes users alone.6 This might indicate that e-cigarettes are more attractive to non-smokers. Several reasons for initiating e-cigarette use have also been shown to predict continued usage including: 7
- Lower cost
- Cessation from traditional cigarettes
- Exclusion from most smoke-free policies
These findings suggest that raising costs, including e-cigarettes in smoke-free policies, and targeting youth with tailored smoking cessation interventions could be crucial for preventing e-cigarette usage among youth.7 Particularly given that recent studies show that most adolescents (80%) who use e-cigarettes to quit smoking cigarettes are still smoking six months later.
Another recent study explained that adolescents may have motivations for initiating electronic cigarette usage unrelated to cigarette smoking cessation. Reported reasons included: 9
These results suggest that electronic cigarette use in American youth is mainly for pleasure or curiosity, rather than reasons like quitting regular cigarettes or substituting for regular cigarette smoking. 9
To learn more about electronic cigarettes and vaping, please visit our page on e-cigarettes or click here.
Social Influences and Adolescent Smoking
A number of studies have been dedicated to better understand and hopefully predict smoking initiation in young adults. These studies have found many potential predictors of young adult daily smoking; although parents' baseline smoking consistently emerged as the strongest long-term predictor followed closely by peer baseline smoking.1,10 It is well established that exposure to family members and peers who smoke significantly increases the likelihood of adolescent smoking.1,11,12,17 Additionally, other parenting practices have been found to be associated with current smoking in adolescents, including:10,13,14
- Lack of parental concern and social support
- Lack of parent-child closeness
- Parent-child conflict
- Weak or excessive controls
- Inconsistent discipline
- Ineffective parental monitoring
Studies have found that adolescents are less likely to smoke when parents:12, 13, 14
- Restrict exposure to smoking (e.g., not permitted indoors)
- Practice nonsmoking behaviors (e.g., sitting in nonsmoking sections)
- Engage in antismoking socialization
- Communicate openly with adolescents regarding smoking behavior
The quality and frequency of communication between child and parent plays a significant role in predicting youth smoking independent of adult smoking behavior. The literature suggests that parents and their children have different perceptions regarding each other’s feelings about smoking and any anti-smoking communication that may have occurred in the household15 This is significant as the research shows that even when a parent smokes, adolescents who expect negative consequences from parents for smoking have a lower rate of initiation than those who expect neutral or positive consequences.14,16 These findings suggest that many nonsmoking parents believe that the expectation of abstinence from cigarettes is understood¸ however explicit conversations and rules about the expectations of not smoking are imperative in the preventing of youth smoking initiation.14,17
Smoking Cessation Among Adolescents
Understanding why adolescents initiate smoking is simpler than understanding why they continue despite countless negative consequences. Adolescents are just as motivated as adults to quit yet are often faced with more difficult challenges when quitting. Over 82% of 11 to 19 year-olds who smoke contemplate quitting and over 70% have made a serious attempt within the first year.15,18 However, of those who quit, 34% relapse within the first week and up to 92% relapse within the first year; both higher rates of relapse than seen in adults.15,19 Research attributes these patterns to a number of factors facing adolescents including:18
- Underestimation of addictive potential of nicotine
- Overconfidence in ability to quit anytime desired
- Establishment of nicotine dependence more rapidly among adolescents
- Tendency to choose unassisted cessation methods (i.e. cold turkey), decreasing likelihood of success by 50%, compared to assisted methods
- Tendency to underestimate health-related consequences of tobacco use. A recent study found that adolescents are roughly three times more likely to smoke if they:16
- Believe smoking-related short-term and long-term risks are less likely to occur
- Believe smoking-related benefits are more likely to occur.
The culminating effect of these factors plays a major role in the struggle adolescents face when attempting to quit. In the United States, only 4% of smokers aged 12 to 19 successfully quit each year and less than 2% do so unassisted.18 Additionally, given adolescents’ misperceptions about the health consequences due to smoking, interventions may require greater and more targeted education to youth to help enhance their motivation to quit.
Nicotine is particularly problematic for adolescents because it can change the way the brain forms and can have lasting consequences.19 For more information about the effects of nicotine on adolescents and for tips on how to address the dangers of nicotine use with adolescents, please view our brochure on Nicotine and Adolescents.
Resources for Youth Smoking Cessation
- Maryland Quitline: smokingstopshere.com, 1-800-Quit-Now
- The Maryland Quitline provides web and phone services to individuals looking to quit smoking age 13 and up. Youth services begin with 5 coaching calls (compared to 4 for adults).
- Smokefree teen: teen.smokefree.gov
- Smokefree.gov provides texting services (SmokefreeTXT for teens) as well as other tools such as smartphone apps (quitSTART) for teens to aid them in their quit attempt .
Providers and Youth
Perception of health risks is evidently a crucial factor that can affect an adolescent’s decision to smoke. Initially forming in early childhood, these perceptions continuously develop in response to external influences from interactions with peers, educators, professionals, and advertisements.1,14,18 Medical professionals play increasingly important role in educating youth on the dangers of tobacco. Unfortunately, recent studies highlight a concerning trend in physicians’ efforts to initiate conversations around smoking with Adolescents. Several studies found that adolescent smokers were identified and counseled to quit in only:15,16,18
- 33% of physician visits
- 25% of otolaryngologist visits
- 20% of dental visits
- < 1% of other specialized visits (e.g. optometrist, gynecologists, etc.)
These trends are exacerbated when considering the discussion of e-cigarettes with youth during medical visits. Even though the majority of pediatricians expressed interest in talking with their patients, 65% of pediatricians had never discussed the topic. Over 90% of pediatricians expressed that they were uninformed about the health effects of electronic cigarettes. While trainings for how to address electronic cigarette usage exists, only 5% of pediatricians reported receiving training.20 Health care professionals have the unique opportunity to counsel youth on the benefits of tobacco cessation from the perspective of a certified health expert in order to help eliminate common misconceptions.
Increasing the rates of professional counseling during visits is a relatively easy task that involves patience and discipline. Please visit our page on brief interventions for more information.
1. Otten, R., Bricker, J. B., Liu, J., Comstock, B. A., & Peterson, A. V. (2011). Adolescent psychological and social predictors of young adult smoking acquisition and cessation: A 10-year longitudinal study. Health Psychology, 30(2), 163-170.
2. Sussman, S., Sun, P., & Dent, C. W. (2006). A meta-analysis of teen cigarette smoking cessation. Health Psychology, 25(5), 549-557.
3. Ahmed, J., et al (2015). Current Cigarette Smoking Among Adults – United States, 2005–2014. Center for Disease Control and Prevention’s Morbidity and Mortality Weekly Report, 64(44), 1233-1240. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6444a2.htm?s_cid=mm644 4a2_w
4. Center for Disease Control and Prevention (2016). Youth and Tobacco Use. Retrieved from: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm
5. US Department of Health and Human Services (2012). Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Retrieved from: http://www.surgeongeneral.gov/library/reports/preven
6. Lee, Y. O., et al (2015). Youth Tobacco Product Use in the United States. Pediatrics. Doi: 10.1542/peds.2014-3202.
7. Bold, K. W., Kong, G., Cavallo, D. A., Camenga, D. R., & Krishnan-Sarin, S. (2016). Reasons for trying e-cigarettes and risk of continued use. Pediatrics, 138(3), e20160895.
8. Bold, K. W., Kong, G., Cavallo, D. A., Camenga, D. R., & Krishnan-Sarin, S. (2016). Reasons for trying e-cigarettes and risk of continued use. Pediatrics, 138(3), e20160895.
9. Patrick, M. E., et al (2016). Self-reported reasons for vaping among 8th, 10th, and 12thgraders in the US: Nationally-representative results. Elsevier, 165, 275-278. Doi: http://dx.doi.org/10.1016/j.drugalcdep.2016.05.017
10. Otten, R., Engels, R. C., van de Ven, M. O., & Bricker, J. B. (2007). Parental smoking and adolescent smoking stages: The role of parents’ current and former smoking, and family structure. Journal of Behavioral Medicine, 30, 143–154.
11. Audrain-McGovern, J., Rodriguez, D., Tercyak, K. P., Neuner, G., & Moss, H. B. (2006). The impact of self-control indices on peer smoking and adolescent smoking progression. Journal of Pediatric Psychology, 31, 139–151.
12. Rodriguez, D., Tscherne, J., & Audrain-McGovern, J. (2007). Contextual consistency and adolescent smoking: Testing the indirect effect of home indoor smoking restrictions on adolescent smoking through peer smoking. Nicotine & Tobacco Research, 9(11), 1155-1161.
13. Mahabee-Gittens, E. M., Xiao, Y., Gordon, J. S., & Khoury, J. C. (2012). Continued importance of family factors in youth smoking behavior. Nicotine & Tobacco Research, 14(12), 1458-1466. doi:10.1093/ntr/nts078
14. Mahabee-Gittens, E., Ding, L., Gordon, J. S., & Huang, B. (2010). Agreement between parents and youths on measures of antismoking socialization. Journal Of Child & Adolescent Substance Abuse, 19(2), 158-170.
15. Van Zundert, R. M., Ferguson, S. G., Shiffman, S., & Engels, R. (2011). Dynamic effects of craving and negative affect on adolescent smoking relapse. Health Psychology, Advanced online publication. doi: 10.1037/a0025204.
16. Song, A. V., Morrell, H. R., Cornell, J. L., Ramos, M. E., Biehl, M., Kropp, R. Y., & Halpern-Felsher, B. L. (2009). Perceptions of smoking-related risks and benefits as predictors of adolescent smoking initiation. American Journal Of Public Health, 99(3), 487-492.
17. Bellatorre, A., Choi, K., Bernat, D. (2015) The influence of the social environment on youth smoking status. Elsevier, 81, 309-313. Doi: http://dx.doi.org/10.1016/j.ypmed.2015.09.017
18. Fiore, M. C., Jaen, C. R., Baker, T. B., & al., e. (2008). Treating Tobacco Use and Dependence 2008 Update. Clinical Practice Guideline. In U.S. Department of Health and Human Services (Ed.). Rockville, MD: U.S. Department of Health and Human Services. http://www.ahrq.gov/path/tobacco.htm
19. Yuan, M., Cross, S.J., Loughlin, S.E., & Leslie, F.M. (2015). Nicotine and the adolescent brain. The Journal of physiology, 593 (16), 3397 - 3412. doi:10.1113/JP270492
20. Gorzkowski, J. A., et al (2016). Pediatrician Knowledge, Attitudes, and Practice Related to Electronic Cigarettes. Elsevier, 59(1), 81-86. Doi: http://dx.doi.org/10.1016/j.jadohealth.2016.03.036
21. Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA. Notes from the Field: Use of Electronic Cigarettes and Any Tobacco Product Among Middle and High School Students — United States, 2011–2018. MMWR Morb Mortal Wkly Rep 2018; 67:1276–1277. DOI: http://dx.doi.org/10.15585/mmwr.mm6745a5