Is Nicotine Addiction a Pediatric Disease?

[Gadarene]

David Kessler, FDA Commissioner under Bush I and Clinton, thinks so. In his excellent book A Question of Intent, he lays out his reasoning:

Only after reading the industry documents and talking to a number of informants did I fully understand that there exists a window, an opening into the world of addiction, during the adolescent years. While that window is open, nearly 90 percent of the people who will become addicted to nicotine begin to use tobacco. Once that window is closed, at the end of the teenage years, far fewer will ever begin to smoke.

(p. 281, emphasis added)

I opened by redefining smoking as a pediatric disease. I was armed with the statistical evidence to make three key points: most smokers begin to smoke as youngsters; young people become addicted as adults; and the prevalence of smoking among youth was on the rise, a marked contrast to trends of the recent past.

Our data were powerful and the implications were stark. We told [Donna Shalala, HHS Secretary] that 3 million young people were smoking, that an estimated 516 million packs of cigarettes were illegally purchased by young people every year, and that 93 percent of the young smokers who try to quit report withdrawal symptoms. To underscore the message, I read a line from Imperial Tobacco’s corporate marketing plan. “If the last ten years have taught us anything, it is that the industry is dominated by the companies who respond most effectively to the needs of younger smokers.”

(pp. 291-92)

I became focused on two reports–“Project 16” and a follow-up entitled “Project Plus/Minus.” Written by consultants for the Imperial Tobacco Company, the Canadian sister of Brown & Williamson, these were overt attempts on the part of the industry to understand why children start to smoke and why they want to quit. “However intriguing smoking was at eleven, twelve, or thirteen, by the age of sixteen or seventeen, many regretted their use of cigarettes for health reasons and because they felt unable to stop when they want to,” read one document.

Project 16 quoted from focus groups with preteen and adolescent smokers…

A single paragraph affected me more than anything else we had learned in our investigation. It noted how every young person was sure that he or she would not become addicted. “You never think you’ll do any damage to yourself,” said one of them. “You’ll know how to control it.”

(pp. 275-77)

…I did emphasize the need to prevent future generations of young people from becoming addicted to nicotine. Picking up on the industry’s refrain that the decision to smoke is freely made, I concluded, “Of course we all want freedom for our children. But not the freedom to make irreversible decisions in childhood that result in devastating health consequences for the future. Addiction is freedom denied. We owe it to our children to help them enter adulthood free from addiction. Our children are entitled to a lifetime of choices, not a lifelong addiction.”

(p. 320)

The last passage, being a speech, is a bit speechified, but the argument is cogent: Adolescents and pre-adolescents have less capacity for informed choice and consent than do adults. That’s why we have laws about statutory rape. This being the case, shouldn’t smoking habits that begin before the smoker is an adult be more appropriately framed as a pediatric disease? As Kessler says, by thinking of smoking as an adult problem, “*t is as if we [are entering] the theater in the third act–after the plot has been set in motion, after the stage has been set. For while the epidemic of disease and death from smoking is played out in adulthood, it begins in childhood.” (p. 320)

So two questions. First, is Kessler’s characterization a fair one? Second, if so, how does it/should it change the way we approach tobacco, tobacco regulation, and public health policy?

Or, alternatively, is this overblown? Is it easy enough to quit smoking as an adult that it doesn’t much matter what choices you make as a kid? Especially when balancing individual liberty against state regulation?

[trabi]

Do you smoke Gadarene?

Is it easy enough to quit smoking as an adult that it doesn’t much matter what choices you make as a kid?

I think not.

[Gadarene]

Was the “I think not” a rhetorical answer to your question, trabi, or a sincere one to mine? In any case, I’m not a smoker–I had a few cigarettes when I was a teenager, and I’ve smoked on and off at parties and bars since then. At its height, my intake amounted to perhaps one every two days. That’s cigarettes, not packs. I’ve stopped for good now, since it never held any particular appeal for me–mostly something to do with my hands while drinking. Plus I’ve got asthma, and I got tired of the slight chest constriction on the rare occasions I bummed a cigarette from a friend.

But I hope you don’t construe the comment of mine that you quoted above as anything more than an honest inquiry, rather than as a way to stack the debate. The thrust of the OP should make it clear where I stand on the question; I just wanted to offer one of the potential opposing views. The argument that people should be free to do what they want to do is a strong one, but if people truly are getting addicted as teens or preteens, it doesn’t leave a lot of room for future choice in the matter.

Oh, and anyone wanting to discuss whether or not nicotine is addictive generally is free to do so here as well. Personally, I don’t think there’s any question–and neither do the tobacco companies.

[trabi]

Both.

I don’t think it would have occurred to you to ask that question if you knew what it was like to be really addicted to the stuff.

There’s no doubt in my mind whatsoever that tobacco companies who encourage children to smoke (for which they have a variety of methods, depending on the local laws) know exactly what they are doing.

[Gadarene]

I don’t think it would have occurred to you to ask that question if you knew what it was like to be really addicted to the stuff.

But tobacco companies make that contention all the time, and many of them are smokers themselves. Some of them appear to actually believe it. Not to be argumentative.

And so what’s your response to the other questions I pose? Is nicotine addiction most appropriately viewed as a pediatric disease? How does that change our treatment or regulation of such?

[Gadarene]

To nit pick my own grammar, even though the thrust was clear: Some tobacco company executives make that contention all the time, and many of them are smokers themselves.

[trabi]

Sure, tobacco companies make all sorts of contentions, not all of them true.

Not to be picky, but how can a company smoke? Oh, okay then… Yes to be picky.

Some employees of tobacco companies smoke. So do some surgeons on cancer wards. Do you need any more proof of the addictive qualities of nicotine?

In the main, I agree with Kessler. Not being a medic, I’m not sure about the scientific aspect of how to classify a disease, but if you consider addiction a disease, then addiction in children is logically a pediatric disease.

What box you decide to put it into when that child grows up is another question.

As I see it, this is only relevent from the point of view of prevention - stop people from smoking at a young age and less people will take up smoking. Obviously, nearly all kids will try a cigarette at some time in their career, but it could be worth placing more emphasis on identifying what it is that turns a child into a regular smoker.

I started smoking regularly at 15. I’m 31 and smoke two packs a day. In my smoking career I have given up on four occasions. The longest I lasted was six weeks.

[plain_jane]

That was an interesting read, Gadarene.

I remember being 15 and 16 and dabbling with smoking and thinking, “gee, it’s no sweat for me to have one or two and then stop. I’m not going to get addicted like other people.” (And then, I didn’t recognize it when I was becoming dependent upon nicotine.) Of course, by the time you realize you are addicted… it’s been long enough it’s an ingrained habit that takes effort to unlearn (and the addiction, time and guts to ignore).

I wish someone had made me fully aware of just what “addicted” means. I had no idea my body and brain would rebel against me and torment me as I experienced lengthy withdrawl, or that I will always be like an alcoholic who can’t even have “just one”. I hid my smoking from the adults in my life so beyond the anti-smoking literature (which focused mostly on long term health issues), I didn’t really have any adult interaction about my smoking until years later when I was already firmly addicted.

I knew the dangers of hard drugs. I knew it was just too dangerous to tempt fate and try any of those things even once. We need to focus on teaching youth that cigarettes should be considered just as dangerous.

All smokers I’ve asked started before they left their teen years. Obviously, this is where we need to attack the problem.

Sorry for being so damned long-winded!

[trabi]

every young person was sure that he or she would not become addicted. “You never think you’ll do any damage to yourself,” said one of them. “You’ll know how to control it.”

This is the problem. plain_jane, how many people warned you that you wouldn’t be able to quit? Probably everyone who wasn’t actively encouraging you to smoke. But you felt indestructible.

The concept of an addiction is very difficult to grasp if you haven’t either had one or been exposed to other people who have.

The reason you didn’t touch ‘hard’ drugs is that you have been conditioned to associate them with all sorts of nasty scary things. In reality, nicotine is one of the worst of the lot, especially in terms of its addictiveness. The fact that a smoker is less likely to die suddenly of an overdose (or violently as a result of other factors) than, say, a heroin addict, does not alter the final outcome. In fact, dying of a heroin overdose has to be far more pleasant than dying of emphysema, for example (not sure if I spelled that right, should’ve chosen something simple like lung cancer…).

[DSeid]

Do people start smoking and become addicted in their teens or younger? Yes.

Is that a pediatric problem? Yes.

Has the tobacco industry successfully targeted teens? Yes.

Is Kessler’s characterzation fair? Yes.

Should this change any laws? No.

The laws are on the books. They need to be enforced. A small investment in enforcement of the laws about sales to minors would have a huge public health pay-out. Tobacco companies are not supposed to be marketing to kids but they still do, and get away with it.

[DSeid]

Oh, how much could enforcement save?

Prev Med 2001 Feb;32(2):168-74

What is the potential cost-effectiveness of enforcing a prohibition on the sale of tobacco to minors?

DiFranza JR, Peck RM, Radecki TE, Savageau JA.

Department of Family Medicine and Community Health, University of Massachusetts Medical Center, 55 Lake Avenue, Worcester, MA 01655, USA.

BACKGROUND. Enforcement programs to halt the sale of tobacco to youths have been implemented across the United States. The potential cost-effectiveness of enforcement was evaluated under a range of assumptions regarding cost and impact. METHODS. An enforcement model was constructed incorporating quarterly inspections of all tobacco vendors. The cost of discounted years of life saved was calculated using reported values regarding cost and a range of assumptions regarding the impact on youth tobacco use. RESULTS. Inspecting an estimated 543,000 tobacco outlets would cost up to $190 million annually. Costs range from $44 to $8,200 per year of life saved depending on the discount rate and assumptions regarding cost, and efficacy. To compete in cost-effectiveness with implementing smoking cessation guidelines, enforcement would have to produce a 5% reduction in adolescent smoking at a cost of no more than $250 per vendor. CONCLUSION. At this level of cost and effectiveness an enforcement program could save 10 times as many lives as the same amount spent on mammography or screening for colorectal carcinoma. A one-cent per pack cigarette tax could fully fund enforcement. Enforcement of tobacco sales laws deserves further study as one component of a multifaceted approach to tobacco use prevention.

[Gadarene]

Really interesting contributions from everyone so far. Unfortunately, although y’all make excellent points and speak from an experience that I don’t have, you still, y’know, pretty much agree with me. Which means this thread is less interesting than it might possibly be. Can we get any dissenters in here?