Strategies to promote smoking cessation among adolescents
Posted: May 10 2016
The Canadian Paediatric Society gives permission to print single copies of this document from our website. For permission to reprint or reproduce multiple copies, please see our copyright policy.
Johanne Harvey, Nicholas Chadi; Canadian Paediatric Society, Adolescent Health Committee
Paediatr Child Health 2016;21(4):201-04.
In recent years, youth have been exposed to a broader spectrum of tobacco products including smokeless tobacco, hookah (water pipe) and e-cigarettes. Despite active local, provincial/territorial and national prevention strategies and legislated controls, thousands of teenagers develop an addiction to tobacco products each year. Current and available smoking cessation interventions for youth have the potential to help teens stop smoking and, as a result, greatly reduce Canada’s health burden in the future. Paediatricians and health care professionals can play a key role in helping teens make informed decisions related to tobacco consumption and cessation. This practice point presents the evidence and rationales for smoking cessation interventions which have been studied in youth specifically, such as individual counselling, psychological support, nicotine replacement therapy, bupropion and varenicline. Interventions for which limited or conflicting data exist are also discussed.
Key Words: Adolescents; CBT; Counselling; NRT; Smoking cessation; Tobacco
Tobacco use is the single most preventable cause of death and disease in North America. Every year in Canada, thousands of teenagers smoke their first cigarette. In fact, close to 90% percent of adult smokers smoked their first cigarette before the age of 18.
The present practice point complements the CPS position statement “Preventing smoking in children and adolescents: Recommendations for practice and policy”, also published in this issue.
Factors impacting smoking cessation
Studies have shown that most adolescent smokers would like to quit smoking. Many teenagers try to quit on their own, but most attempts are unsuccessful and relapse rates are high. There are many factors impacting the success of smoking cessation attempts in adolescents (Table 1). Multiple factors need to be taken into account when choosing the best strategy to help teenagers quit.-
Health care professionals (HCPs) need to be mindful of each adolescent’s personal needs and preferences related to smoking and smoking cessation. For example, smoking rates in Canada are significantly higher among sexual minority (LGBTQ) youth and Indigenous children and teenagers. For details, see the CPS position statement “Use and misuse of tobacco among Aboriginal peoples”. Other elements to be considered before recommending a cessation strategy include cultural background, knowledge, attitudes and beliefs involving tobacco, and readiness to quit.
Review of cessation interventions
According to a recent Cochrane review of smoking cessation in teenagers, the interventions with the strongest level of evidence to support them are individual counselling, motivational enhancement and cognitive behavioural therapy (CBT). Focused interventions from physicians, nurses and other HCPs could have significant impact on smoking cessation rates. For example, HCPs can use motivational enhancement therapy, a variation of motivational intervention, to help teenagers clarify their goals and beliefs related to smoking. The ‘5 A’s’ method (Ask-Advise-Assess-Assist-Arrange) is the most commonly used framework. It can be used to guide a brief counselling session and should take no more than 3 minutes to 5 minutes to perform. An overview of this method can be found in Table 2.
CBT, a structured one-on-one therapeutic approach that can be delivered by trained physicians, psychologists or other HCPs, has shown good effectiveness in adolescents. The therapy is usually ‘problem-focused’ and ‘action-based’, actively engaging youth in changing their own smoking habits and behaviours. Also, an increasing number of alternative, adapted or combined forms of counselling intervention (eg, contingency management – a type of substance abuse treatment using positive reinforcement or rewards) have shown promising results in different youth populations
The ‘5 A’s’ method for counselling smoking cessation
|5 A’s||Description||Suggested questions|
|Ask||Ask about tobacco use: For all teens, at every visit and without parents present|
|Advise||Strongly urge all tobacco users to quit|
Determine readiness to quit by assessing willingness to attempt to quit:
Provide help for teens attempting to quit (including pharmacotherapy, when indicated) by setting a date and directing the teen toward supportive materials or groups
Counsel on the risks associated with taking up replacement substances, such as marijuana or alternate forms of tobacco
|Arrange||Arrange follow-up to review progress and re-evaluate pharmacotherapy use and problems, as appropriate|
|Some sources also add a sixth “A” (Anticipate) before the five previous steps as a reminder to prepare to hold the interview in an appropriate setting (ie, with or without parents or peers present).|
First-line pharmaceutical therapy in adults includes nicotine replacement therapy (NRT), bupropion and varenicline. In the latest (2013) update of a Cochrane review summarizing the evidence for smoking cessation interventions in youth, the data were insufficient to recommend any type of pharmaceutical treatment in young smokers. Nevertheless, national guidelines encourage NRT use in regular teenage smokers, though not in occasional smokers, mostly based on adult data.
Several trials looking specifically at the efficacy of nicotine replacement products in teenagers have revealed promising results and acceptable safety profiles. Nicotine gums and transdermal patches are the most commonly prescribed products, with lozenges and nasal sprays lagging far behind. The most common reported side effects in youth are mouth and skin irritations, increased heart rates and higher blood pressure readings. Nicotine inhalers, which – unlike e-cigarettes – deliver slow and unheated nicotine vapour, are not recommended for adolescents due to lack of evidence of effectiveness.
A few trials have looked at the effects of bupropion and varenicline in adolescent smokers, with promising results. However, due to the small number of subjects being tested and conflicting or nonsignificant trial data, recommendations regarding the use of either medication are still mostly based on expert opinion. HCPs should be aware of contraindications to these medications (eg, an eating disorder or seizure disorder in the case of bupropion). Detailed information on dosages, relative and absolute contraindications, and the side effects of NRT, bupropion and varenicline can be found in the Selected resources, below (see especially the Winnipeg Regional Health Authority guideline for health professionals, pages 10-21). Data for other second-line pharmaceuticals used in adults, such as clonidine, nortriptyline and cytisine (a partial nicotine receptor antagonist), are lacking for youth.
Experimental interventions for adolescent smokers have been gaining popularity in the literature. Among the most studied interventions are school-based smoking cessation programs, smoking cessation interventions using text messaging, peer mentoring and digital or virtual self-help interventions. At the present time, data supporting the effectiveness of such interventions are limited; they should be used in combination with counselling.
Finally, mind-body interventions, such as mindfulness, yoga, hypnosis and biofeedback have been described as promising in the adult literature. However, data supporting their effectiveness in youth are lacking.
The topic of electronic cigarette use as a smoking cessation intervention strategy in youth is highly controversial. In fact, the study data around the safety and/or benefits of e-cigarette smoking in adults and youth are conflicting. At the present time, HCPs should not recommend e-cigarettes as smoking cessation aids, but rather educate young patients about their potential for harm. For details, see the CPS statement “E-cigarettes: Are we renormalizing public smoking?”.
Table 3 summarizes smoking cessation interventions in youth as well as the level of evidence supporting their recommendation. Readers can access the levels of evidence for individual recommendations using the Oxford Center for Evidence-based Medicine at: www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/.
Paediatricians and other HCPs can play a key role in helping teenagers to control tobacco consumption and cessation. To be most effective, however, they should be familiar with ongoing research into the rapidly increasing number of evidence-based interventions available for youth, including brief counselling techniques. Using the ‘5A’s’ method provides a practical framework for identifying and assisting adolescents who smoke. Important gaps in the research literature remain, however, and there are many questions still to answer around smoking cessation in youth. Paediatricians and other HCPs must stay informed about the latest advances in this area, particularly as more adolescent-specific data become available.
For health care professionals
1. The Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment (CAN ADAPT): www.nicotinedependenceclinic.com/English/CANADAPTT/Guideline/Introduction.aspx
2. Canadian Cancer Society, Smokers’ helpline (health care providers’ section): www.smokershelpline.ca/
3. Lung Association, Quit Now (health care providers’ section): www.quitnow.ca/helping-others-quit/healthcare-providers.php
4. Centers for Disease Control and Prevention (U.S.), Health care professionals: Help your patients quit smoking: www.cdc.gov/tobacco/campaign/tips/partners/health/hcp/
5. American Academy of Pediatrics Julius B. Richmond Center of Excellence for tobacco control: www2.aap.org/richmondcenter/Clinicians_ClinicalPractice.html
6. Winnipeg Regional Health Authority, August 2013. Clinical practice guideline: Management of tobacco use and dependence: www.wrha.mb.ca/Professionals/tobacco/cpg.php
1. Health Canada. Quit Smoking. On the road to quitting – guide for young adults: www.hc-sc.gc.ca/hc-ps/tobac-tabac/quit-cesser/index-eng.php
2. Health Canada. Quit4life website/Handbook for young smokers trying to quit: www.hc-sc.gc.ca/hc-ps/tobac-tabac/youth-jeunes/life-vie/index-eng.php
3. Government of Canada, Healthy Canadians, Smoking and tobacco: www.healthycanadians.gc.ca/healthy-living-vie-saine/tobacco-tabac/index-eng.php
4. iQuitnow (Quebec): http://www.iquitnow.qc.ca/
5. Canadian Cancer Society, Smokers’ helpline (online program, free phone help, text messaging [for Ontario residents only], self-help books, information for friends and family): www.smokershelpline.ca/
6. Department of Health and Human Services, National Institutes of Health, National Cancer Institute (U.S.). Teen self-help, online tools and information: http://teen.smokefree.gov/default.aspx#.VU5hiPlVhBc
This practice point has been reviewed by the Community Paediatrics, Drug Therapy and Hazardous Substances, and First Nations, Inuit and Métis Health Committees of the Canadian Paediatric Society.
CPS ADOLESCENT HEALTH COMMITTEE
Members: Giuseppina Di Meglio MD, Johanne Harvey MD (past member), Natasha Johnson MD, Margo Lane MD (Chair), Karen Leis MD (Board Representative), Mark Norris MD, Gillian Thompson NP-Paediatrics
Liaison: Christina Grant MD, CPS Adolescent Health Section
Principal authors: Johanne Harvey MD, Nicholas Chadi MD
- U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General, 2012. Preventing tobacco use among youth and young adults: A report of the Surgeon General: www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/ (Accessed March 11, 2016)
- Reid JL, Hammond D, Rynard VL, Burkhalter R. Tobacco use in Canada: Patterns and trends, 2015 edition. Waterloo, Ont.: Propel Centre for Population Health Impact, University of Waterloo: www.tobaccoreport.ca/2015/TobaccoUseinCanada_2015.pdf (Accessed March 11, 2016)
- Pbert L, Farber H, Horn K, et al. State-of-the-art office-based interventions to eliminate youth tobacco use: The past decade. Pediatrics 2015;135(4):734-47.
- O’Loughlin JL, Sylvestre MP, Dugas EN, Karp I. Predictors of the occurrence of smoking discontinuation in novice adolescent smokers. Cancer Epidemiol Biomarkers Prev 2014; 23(6):1090-101.
- Kollins SH, Adcock RA. ADHD, altered dopamine neurotransmission, and disrupted reinforcement processes: Implications for smoking and nicotine dependence. Prog Neuropsychoparmacol Biol Psychiatry 2014;52:70-8.
- Milton MH, Maule CO, Yee SL, Backinger C, Malarcher AM, Husten CG. Youth tobacco cessation: A guide for making informed decisions. Atlanta,GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2004: http://www.cdc.gov/tobacco/quit_smoking/cessation/pdfs/youth_tobacco.pdf (Accessed March 11, 2016).
- Moyer VA; U.S. Preventive Services Task Force. Primary care interventions to prevent tobacco use in children and adolescents: U.S. preventive services task force recommendation statement. Pediatrics 2013;132(3):560-5.
- U.S. Department of Health and Human Services. Treating tobacco use and dependence: 2008 update; Practice guideline executive summary: www.ncbi.nlm.nih.gov/books/NBK63956/ (Accessed March 11, 2016).
- American Congress of Obstetricians and Gynecologists.The First Method: The 5 A’s - For those ready to quit; Counselling your patients on smoking cessation: www.acog.org/About-ACOG/ACOG-Districts/District-II/Smoking-Cessation-The-5-As (Accessed March 11, 2016).
- Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: Toward an integrative model of change. J Consult Clin Psychol 1983;51(3):390-5.
- Stanton A, Grimshaw G. Tobacco cessation interventions for young people. Cochrane Database Syst Rev 2013;8:CD003289.
- Morean ME, Kong G, Camenga DR, et al. Contingency management improves smoking cessation treatment outcomes among highly impulsive adolescent smokers relative to cognitive behavioral therapy. Addict Behav 2015;42:86-90.
- Ministry of Health. New Zealand smoking cessation guidelines. 2007: Wellington: nihi.auckland.ac.nz/sites/nihi.auckland.ac.nz/files/pdf/addictions/nz-smoking-cessation-guidelines-v2-aug07.pdf (Accessed March 11, 2016).
- Steinberg MB, Zimmerman MH, Delnevo CD, et al. E-cigarette versus nicotine inhaler: Comparing the perceptions and experiences of inhaled nicotine devices. J Gen Intern Med 2014;29(11):1444-50.
- Aubin HJ, Luquiens A, Berlin I. Pharmacotherapy for smoking cessation: Pharmacological principles and clinical practice. Br J Clin Pharmacol 2014;77(2):324-36.
- Espada JP, Gonzálvez MT, Orgilés M, Guillén-Riquelme A, Soto D, Sussman S. Pilot clinic study of Project EX for smoking cessation with Spanish adolescents. Addict Behav 2015;45:226-31.
- Mason M, Ola B, Zaharakis N, Zhang J. Text messaging interventions for adolescent and young adult substance use: A meta-analysis. Prev Sci 2015;16(2):181-8.
- Hall AK, Cole-Lewis H, Bernhardt JM. Mobile text messaging for health: A systematic review of reviews. Annu Rev Public Health 2015;36:393-415.
- Thomas RE, Lorenzetti DL, Spragins W. Systematic review of mentoring to prevent or reduce tobacco use by adolescents. Acad Pediatr 2013;13(4):300-7.
- Haines-Saah RJ. Kelly MT, Oliffe JL, Bottorff JL. Picture Me Smokefree: A qualitative study using social media and digital photography to engage young adults in tobacco reduction and cessation. J Med Internet Res 2015;17(1):e27.
- Carim-Todd L, Mitchell SH, Oken BS. Mind-body practices: An alternative, drug-free treatment for smoking cessation? A systematic review of the literature. Drug Alcohol Depend 2013;132(3):399-410.
- Walker N, Howe C, Glover M, et al. Cytisine versus nicotine for smoking cessation. N Engl J Med 2014;371(25):2353-62.
- Brandon TH, Goniewicz ML, Hanna NH, et al. Electronic nicotine delivery systems: A policy statement from the American Association for Cancer Research and the American Society of Clinical Oncology. Clin Cancer Res 2015;21(3):514-25.
Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.