Journal of Adolescent Health
Volume 40, Issue 2 , Pages 144-150, February 2007

Nicotine Dependence and Withdrawal Symptoms among Occasional Smokers

  • Saadhna Panday, Ph.D.

      Affiliations

    • Department of Health Education and Health Promotion, Maastricht University, Maastricht, The Netherlands
    • Corresponding Author InformationAddress correspondence to: Dr. Saadhna Panday, Child, Youth, Family and Social Development, Human Sciences Research Council, Private Bag X07, Dalbridge 4014, South Africa.
    • ,
  • S. Priscilla Reddy, Ph.D.

      Affiliations

    • National Health Promotion Research and Development Group, Medical Research Council, Cape Town, South Africa
    • ,
  • Robert A.C. Ruiter, Ph.D.

      Affiliations

    • Department of Experimental Psychology, Maastricht University, Maastricht, The Netherlands
    • ,
  • Erik Bergström, Ph.D.

      Affiliations

    • Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences, Umeå University, Umeå, Sweden
    • Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
    • ,
  • Hein de Vries, Ph.D.

      Affiliations

    • Department of Health Education and Health Promotion, Maastricht University, Maastricht, The Netherlands

Received 27 March 2006; accepted 5 September 2006. published online 30 November 2006.

Article Outline

Abstract 

Purpose

This study describes the levels of nicotine dependence, withdrawal symptoms, depressive mood, and risk behavior reported by male and female weekly and monthly adolescent smokers in South Africa.

Methods

A cross-sectional survey was conducted among 554 grade 9–11 weekly and monthly smokers in the Southern Cape-Karoo Region. Differences between the gender groups and smoking status were analyzed while controlling for demographic characteristics.

Results

Weekly and monthly smokers were classified as light smokers having smoked 6–10 cigarettes and 0–1 cigarettes a week, respectively. However, they displayed substantial levels of dependence, with 11.6% of weekly smokers classified as highly dependent. Furthermore, 55.9% of weekly smokers and 47.1% of the overall sample experienced more than two withdrawal symptoms. Although dependency levels and withdrawal symptoms were higher among weekly smokers, the levels were not negligible among monthly smokers. Weekly smokers reported higher levels of depressive mood and risk behavior than monthly smokers. Females reported higher levels of dependence, withdrawal symptoms, depressive mood, and lower levels of risk behavior than males. Gender differences were not found on the number of cigarettes smoked in a week.

Conclusions

This study demonstrates multiple symptoms of dependence among a large sample of adolescent occasional smokers in a multi-ethnic cultural setting. Smoking cessation programs may, therefore, be required to help adolescents quit smoking and possibly consider pharmacotherapy for highly dependent smokers. Prevention programs should also consider providing occasional smokers skills to identify and cope with withdrawal symptoms.

Keywords: Adolescence, Occasional smokers, Nicotine dependence, Withdrawal symptoms

 

Despite concerted efforts to prevent smoking uptake and promote cessation, smoking rates among adolescents remain high and have led to smoking being labeled a pediatric disease or epidemic [1]. In the United States, past-month smoking rates among adolescents rose from 27.5% in 1991 to 36.4% in 1997, but declined to 21.9% by 2003 [2]. In South Africa (SA), past-month smoking decreased from 23.0% in 1999 to 18.5% in 2002 [3]. The SA Global Youth Tobacco Survey, consistent with international trends [4], demonstrated in 1999 and 2002 that over two-thirds of monthly smokers expressed a desire to stop smoking and actually made quit attempts [3]. However, success rates are limited. A review of 66 youth smoking cessation programs reported a mean overall cessation rate of 12% across active treatment groups, compared with 7% in the control groups [5].

Although a growing number of studies focus on cognitive-behavioral models to facilitate smoking cessation among adolescents, the notion that prolonged use of nicotine is required before signs of dependence emerge [6] has perhaps delayed the availability of theoretical literature on nicotine dependence. However, recent studies have reported signs of dependence earlier in the trajectory of tobacco use and that adolescent smokers do experience withdrawal symptoms outside of formal quit attempts [7].

While attempts are being made to clarify the dimensions of nicotine dependence for youth [8], parallels have been drawn between the standard features of substance dependence and nicotine dependence. Nicotine dependence consists primarily of positive reinforcement through the compulsive use of nicotine and negative reinforcement to avoid nicotine withdrawal symptoms [8]. Nicotine withdrawal is characterized by craving, depressed mood, insomnia, irritability, frustration, anger, anxiety, difficulty concentrating, restlessness, decreased heart rate, and weight gain [9].

At the time this study was designed, the field lacked theoretically based and psychometrically validated indices to measure dependence among adolescents [10]. Instead, tools for psychometric analysis and clinical diagnosis among adults were used to measure dependence and withdrawal. The Fagerström Tolerance Questionnaire was adapted for adolescents and demonstrated satisfactory internal consistency and agreement with biochemical markers [11]. The Diagnostic and Statistical Manual of Mental Disorders (DSMIV) [9] provides criteria for diagnosing nicotine withdrawal and has been used to measure withdrawal symptoms among adolescents [12].

The literature is also ambiguous with regards to gender differences in nicotine dependence and withdrawal symptoms prompting recommendations for further studies in this field [10]. Current smoking rates (past 30-day smoking) differ between South African male (26.7%) and female (11.5%) adolescents [3] and to our knowledge, data are not available on nicotine dependence or withdrawal symptoms among adolescents. In fact, the large number of occasional smokers in SA [3] provides a useful setting to investigate whether occasional smokers from a different cultural setting experience dependence and withdrawal symptoms. Given the difficulty associated with quitting, the lack of support for the effectiveness of nicotine replacement therapy among adolescents, and the fact that the public health system can ill afford to treat nicotine dependence, particularly among its youth, this article aims to provide insight into earlier intervention points along the smoking trajectory. This information is necessary for the development of comprehensive smoking cessation programs that consider both the behavioral and physiological processes of smoking.

This study describes the levels of nicotine dependence, withdrawal symptoms, depressive mood, and risk behaviors reported by a sample of male and female weekly and monthly smokers. The latter two outcome variables were included as a result of the body of evidence that shows co-variation of smoking with psychological factors such as depression [13], [14] and deviance-prone behavior such as alcohol and marijuana use [6], [15].

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Methods 

Participants and sampling 

In 2002, a cross-sectional survey was administered to grade 9–11 students (14–16 years of age) in the Southern Cape-Karoo Region, Western Cape Province. Forty-two public schools were eligible to participate in the study. Based on previous research [16], school selection was stratified by ethnicity, in accordance with the previous race classification of schools, namely Black African (six schools), Coloured (17 schools) or White (19 schools). (During the Apartheid years, all South Africans were classified into race groups in accordance with the Population Registration Act of 1950 namely, Black African [people of African descent], Coloured [people of mixed African and European descent], Indian [people of Indian descent], and White [people of European descent]. The authors in no way subscribe to this classification.) Previous research [17] was also used to estimate the sample of 100 smokers required for each ethnic by gender group. A total of 23 schools were selected to participate in the study, consisting of all six Black African schools, eight randomly selected Coloured schools, and nine randomly selected White schools.

The number of classes selected was proportional to the number of grade 9–11 classes in the school, based on an estimated class size of 40 students. All students in the selected classes were eligible to participate in the study. A total of 121 classes representing 4768 students were selected to participate in the study.

The Research Ethics Committees of the South African Medical Association and the Medical Faculty of Umeå University granted ethical approval for the study. Active consent was also obtained from the education department, principals of selected schools, and from parents and students in the selected classes. Parents and students were informed both verbally and in writing that all answers would be treated confidentially and viewed only by the researchers.

Questionnaire 

The questionnaire, based on the European Smoking Framework Approach study, consisted of 137 questions and assessed, among others, smoking behavior, nicotine dependence, withdrawal symptoms, depressive mood, risk behaviour, and several demographic items. The questionnaire was adapted to the South African context using the findings of prior qualitative research [16], through focus group discussions conducted during questionnaire development, and a pilot study among 292 grade 9 students in the study area. To guarantee confidentiality, trained research assistants administered the survey in the classroom. Teachers were asked to leave the classroom during survey administration. Additionally, students were requested not to write their names on the questionnaires as a means to protect their anonymity.

The questionnaire was administered in English, Afrikaans, and Xhosa during two regular classroom periods either to individual classes or to groups of classes. The questionnaire was prepared in English and translated from English to Afrikaans and to Xhosa. To ensure the accuracy of the translations, the Afrikaans and Xhosa versions of the questionnaire were back-translated to English.

Measures 

Smoking behavior 

Adolescents were asked to pick a statement that best described them out of a set of specific smoking-related questions. Adolescents were then categorized as never smokers (never smoked not even one puff), triers (tried smoking once in a while but not monthly), nonsmoking deciders (tried smoking less than once a week but not smoking anymore), monthly smokers (smoking at least once a month, but not weekly), weekly smokers (currently smoking cigarettes weekly or more), and quitters (quit smoking after having smoked at least once a week) [18]. Self-reports of smoking could not be biologically validated due to logistical and financial constraints. However, when anonymity is assured, self-reports have been shown to be reliable and in agreement with biochemical markers [19]. Self-reported smoking was cross-validated using an algorithm consisting of four additional concepts measuring current smoking and lifetime smoking. When incongruent answers were found, participants were given the most unfavorable response, that is, classified at the higher level of smoking [20].

Nicotine dependence 

The adapted version of the Fagerström Tolerance Questionnaire (FTQ) for adolescents [11], [21] was used to measure nicotine dependence. Eight items on a continuous scale (except for “smoking more during the first two hours of the day”) assessed “inhaling when smoking,” “time to first cigarette,” “cigarette they would hate to give up,” “difficulty in refraining from smoking in forbidden places,” “smoking when ill,” “smoke more in the morning,” and “number of cigarettes smoked each day.” The items were summed to produce an index of nicotine dependence with a range of 0–9 (Cronbach alpha (α) = .60). Those smokers who displayed an FTQ score of 6 or higher were classified as highly dependent [22].

Withdrawal symptoms 

DSM-IV criteria [9] were used to assess withdrawal symptoms (WSI). Eight items assessed how students “feel when you tried to stop smoking or when you have not smoked for a while,” namely “miserable and sad,” “trouble sleeping,” “irritable,” “nervous and tense,” “unable to concentrate,” “restless,” “hungry,” and “craving.” Yes/No alternatives were given for each of the items and summed to produce an index with a range of 0–8 (α = .86). Prior research in SA [16], as well as other studies [12], [13], have reported craving as an important withdrawal symptom. Hence, craving was included in the index.

Number of cigarettes smoked 

The number of cigarettes smoked in a week was assessed with one item on a continuous scale. Scores were combined to produce a five-point scale (1 = <1 cigarette, 2 = 1–5 cigarettes, 3 = 6–10 cigarettes, 4 = 11–20 cigarettes, 5 = >20 cigarettes).

Depressive mood 

Kandel and Davies’ scale [23] was used to measure depressive mood. Six items using a four-point scale (0 = never, 4 = always) assessed “How often adolescents were bothered or troubled by the following states,” namely “feeling too tired to do things,” “having trouble going to sleep or staying asleep,” “feeling unhappy, sad or depressed,” “feeling hopeless about the future,” “feeling nervous or tense” and “worrying too much about things.” The scores were summed to produce an index of depressive mood with a range of 0–24 (α = .86).

Risk behavior 

Risk behavior was measured with eight items on a five-point scale (0 = never, 1 = sometimes, 2 = less than once a month, 3 = not weekly but at least once a month, 4 = at least once a week) that were identified using factor analyses (alpha factoring and direct oblimin rotation). The scale assessed use of alcohol, marijuana, methaqualone, other drugs, sniffing substances, gambling, playing the Lotto (lottery in SA), and playing truant from school. The scores were summed to produce an index of risk behavior with a range of 0–32 (α = .77).

Demographic variables 

Characteristics of the participants were provided by asking for ethnicity (1 = Black African, 2 = Coloured, 3 = White), age (continuous scores), and school performance (0 = lowest, 1 = average, 2 = best).

Statistical analyses 

Weekly smokers (coded as 0) were compared with monthly smokers (coded as 1). Male and female weekly and monthly smokers were compared on demographic variables using logistic regression for dichotomous variables and F-tests for continuous variables. Significant differences (p < .05) were found for age, school performance, and ethnicity. These variables were included as covariates in the analyses only if they contributed significantly to the prediction of the dependent variables. Subsequently, age and ethnicity were included as covariates for the measurement of nicotine dependence, withdrawal symptoms, and number of cigarettes smoked, whereas age and school performance were included as covariates for the measurement of depressive mood and risk behavior.

Differences between gender groups and smoking categories for nicotine dependence, withdrawal symptoms, number of cigarettes smoked in a week, depressive mood, and risk behaviors were analyzed using 2 (gender: male vs. female) ×2 (smoking category: weekly smokers vs. monthly smokers) covariance analyses (ANCOVAs). Interaction effects between smoking categories and gender were explored using simple effect analyses, as we were interested in investigating whether the expected co-variation between smoking categories and the identified outcome variables differed for male and female adolescent smokers. Except for depressive mood, interaction effects were not found to be significant. (Simple effect analyses showed that for both weekly smokers and monthly smokers, females reported higher levels of depressive mood than males. Male weekly smokers also reported significantly higher levels of depressive mood than male monthly smokers.) Hence the findings are not reflected in the results. The significance level was set at p < .05.

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Results 

Characteristics of the sample 

Of the 4768 students selected to participate in the study, 3869 completed the questionnaire. Due to incomplete data on key variables, 257 cases were excluded from the analyses. Among the remaining cases (n = 3612), the prevalence of weekly smoking was 11.2% (n = 404), whereas the prevalence of monthly smoking was 6.8% (n = 246). Data on the FTQ and WSI scales that were inconsistent with the smoking behavior measure led to the exclusion of 7 weekly smokers and 89 monthly smokers to produce a total of 554 participants (397 weekly smokers and 157 monthly smokers) eligible for the present study (Table 1). The mean age of the participants was 16.3 years (SD = 1.56) and the overall distribution of males and females was 59.4% for males and 40.6% for females. Most students were classified as Coloured (56.1%), followed by Black African (28.3%) and White (15.6%) students. Most students reported an average school performance (66.2%).

Table 1. Demographic characteristics of the sample
Total genderTotal smoking statusTotal
Male 59.4a(n = 329)Female 40.6a(n = 225)Weekly smokers 71.7a(n = 397)Monthly smokers 28.3a(n = 157)(n = 554)
Mean age (years) (SD) (n = 547)16.62a(1.62)15.82a(1.32)16.40a(1.53)16.04a(1.60)16.30(1.56)
Ethnicity (%)
Black (n = 154)40.7a10.4a27.630.128.3
Coloured(n = 305)44.4a73.0a57.253.256.1
White(n = 85)14.916.715.216.715.6
School performance(%)
Lowest(n = 33)4.78.16.9a3.9a6.1
Average(n = 361)64.668.666.9a64.5a66.2
Best(n = 151)30.723.326.2a31.6a27.7

aSignificant differences between groups for gender and smoking status (p < .05).

As can be seen from Table 1, weekly smokers were significantly older than monthly smokers; males were also significantly older than females. Significantly more Black students were male, and significantly more Coloured students were female. In addition, significantly more weekly smokers reported an average school performance than monthly smokers.

Levels of nicotine dependence and withdrawal symptoms experienced 

The mean level of nicotine dependence for weekly and monthly smokers was 2.83 (SD = 1.84), whereas just over 9.5% (n = 53) of the sample met the criteria for a high level of nicotine dependence (FTQ ≥ 6) (Table 2). The mean level of withdrawal symptoms reported for the sample was 2.84 (SD = 2.68). Craving was the most frequently reported withdrawal symptom and hunger the least reported withdrawal symptom (Table 3). Whereas 30.0% (n = 167) of the sample reported experiencing no withdrawal symptoms at all, 47.1% (n = 262) of the sample reported experiencing more than two withdrawal symptoms.

Table 2. Sum scores (SD) of male and female weekly and monthly smokers on nicotine dependence (FTQ), withdrawal symptoms (WSI), number of cigarettes smoked, depressive mood and risk behavior
Total genderTotal smoking statusTotal
MaleFemaleWeekly smokersMonthly smokers
FTQ, WSI(n = 318)(n = 219)(n = 382)(n = 155)(n = 537)
FTQa(range 0–9)2.76d(1.90)2.94d(1.76)3.25d(1.77)1.80d(1.61)2.83(1.84)
WSIa(range 0–8)2.61d(2.60)3.18d(2.77)3.37d(2.71)1.54d(2.11)2.84(2.68)
No. of cigarettes smokedab(range 1–5)3.01(1.41)2.70(1.36)3.35d(1.27)1.70d(0.94)2.88(1.40)
Depressive mood, risk behavior(n = 325)(n = 222)(n = 391)(n = 156)(n = 547)
Depressive moodc(range 0–24)6.67d(5.54)9.42d(5.15)8.24d(5.54)6.65d(5.42)7.79(5.55)
Risk behaviorc(range 0–32)6.24d(6.08)4.38d(3.78)5.90d(5.48)4.44d(4.85)5.48(5.34)

FTQ = Fagerström Tolerance Questionnaire; WSI = Withdrawal Symptom Index.

aCovariates: age, ethnicity.

bNumber of cigarettes smoked in a week (1 = < 1 cigarette, 2 = 1–5 cigarettes, 3 = 6–10 cigarettes, 4 = 11–20 cigarettes).

cCovariates: age, school performance.

dSignificant differences between males and females and between weekly and monthly smokers (p < .05).

Table 3. Prevalence (%) of withdrawal symptoms by smoking status
Withdrawal symptomWeekly smokersaMonthly smokersbTotalc
Craving64.528.554.2
Irritable45.722.839.2
Restless44.618.437.1
Nervous and tense42.022.636.5
Miserable and sad41.417.034.4
Unable to concentrate35.518.930.7
Trouble sleeping34.315.428.9
Hunger30.012.024.9

Note: Sample sizes varied due to missing data.

aRange 392–397.

bRange 156–159.

cRange 550–554.

Differences between weekly and monthly smokers on levels of dependence and withdrawal symptoms experienced as well as number of cigarettes smoked 

Whereas weekly smokers smoked 6–10 cigarettes in a week, monthly smokers smoked 0–1 cigarettes in a week. Independent of gender, weekly smokers reported higher levels of nicotine dependence, withdrawal symptoms, number of cigarettes smoked, depressive mood, and risk behavior than monthly smokers (Table 2). A substantial percentage of weekly smokers (11.6%, n = 46) reported a high level of nicotine dependence (FTQ ≥ 6). More weekly smokers (64.5%; n = 254) than monthly smokers (28.5%; n = 45) reported craving, χ2 (1) = 58.83, p < .001, as was the pattern for all of the other withdrawal symptoms (ps < .001) with 55.9% (n = 222) of weekly smokers reporting more than two withdrawal symptoms.

Gender differences in dependence and withdrawal symptoms 

Independent of smoking categories, females reported higher levels of nicotine dependence, withdrawal symptoms, and depressive mood, as well as lower levels of risk behavior than males (Table 2). Although males reported smoking more cigarettes in a week than females, this was not a significant difference. In-depth analysis showed that the only FTQ item on which females (47.2%, n = 126) differed substantially from males (39.7%, n = 149), though not significantly, was that they experienced more difficulty in refraining from smoking in forbidden places, χ2 (1) = 16.41, p = .06.

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Discussion 

This study describes the prevalence of and differences in nicotine dependence, withdrawal symptoms, depressive mood, and risk behavior among a sample of male and female weekly and monthly smokers. Our results showed that weekly smokers, who were, in fact, light smokers (smoked 6–10 cigarettes a week), displayed substantial levels of nicotine dependence, with 11.6% classified as highly dependent. Prokhorov et al [21] and Riedel et al [24] reported that 20% and 17% of their adolescent samples, respectively, were highly dependent, using samples that were comparable in age but who were heavier smokers. What is more, almost half of our sample of occasional smokers (47.1%) also reported experiencing more than two withdrawal symptoms.

Our findings concur with other studies that substantial numbers of adolescent light smokers do in fact experience nicotine dependence and withdrawal symptoms [12], [13], [21], [25]. Smoking cessation programs may, therefore, be required to assist adolescents to stop smoking. Pharmacotherapy may also be required to assist those adolescents who are highly dependent on nicotine. The effectiveness of nicotine replacement therapy (NRT) and bupropion to quit smoking has been demonstrated among adults [26], [27]. However, the limited research in this field among adolescents suggests that both NRT and bupropion are ineffective [28], [29], [30], [31], although they may have helped decrease the number of cigarettes smoked. It has been suggested that cognitive-behavioral therapy may be better suited to the behavioral and social nature of smoking among adolescents and that NRT, whose safety has been demonstrated among adolescents in existing studies [28], [29], should be reserved for highly dependent adolescent smokers, preferably administered in the clinical setting [32], [33].

Although occasional smokers may be the target for prevention programs, our results suggest that addiction levels, with the concurrent withdrawal symptoms experienced, may perpetuate smoking. As adolescents progress along the stages of the smoking continuum, the balance of program content may need to be shifted to reflect both prevention and cessation strategies. Our results also suggest that occasional smokers may benefit from skills to identify and cope with withdrawal symptoms. To facilitate early intervention, however, much more empirical research is needed on the progressive onset of nicotine dependence and withdrawal symptoms. In fact, Colby and colleagues [10] recommended that nicotine dependence, like smoking onset or smoking cessation, should be viewed as a “dynamic, unfolding process” rather than a singular event. Certainly in a developing country like SA, the existing levels of nicotine dependence and withdrawal symptoms among occasional smokers, the lack of empirical support for the effectiveness of pharmacotherapy among adolescents, and the challenge to the public health system to deliver treatment even to highly dependent smokers amidst several competing health priorities, provides a compelling argument for earlier interventions to prevent or delay smoking onset and to promote cessation before adolescents reach nicotine dependence.

Females in this study reported higher levels of nicotine dependence and withdrawal symptoms, although they did not differ significantly from males in the number of cigarettes smoked. Similarly, O’Loughlin and colleagues [34] and DiFranza et al [35], [36], [37] also found higher rates of nicotine dependence symptoms among females even though levels of cigarette consumption were similar between the gender groups. A similar pattern of higher nicotine dependence has been reported among adult females [38]. It has been suggested that females report higher levels of nicotine dependence because of biological differences in the metabolism of nicotine, differences in the topography of smoking [10], or that they simply report more symptoms [10], [34]. However, the lower levels of risk behavior reported among females in our study militate against the latter argument.

Weekly smokers reported higher levels of depressive mood and risk behavior than monthly smokers; females also reported higher levels of depressive mood, whereas males reported higher levels of risk behavior. Other studies have also shown higher levels of depression among female monthly smokers than male monthly smokers [13]. The co-variation of risk behavior among adolescents is well documented [6], [15], [39]. Further studies are required to analyze the impact of psychological factors and deviance-prone behavior on nicotine dependence and the ability to stop smoking.

Our findings are subject to some limitations. First, retrospective self-reports are vulnerable to recall bias. Second, the FTQ has been criticized for not measuring physiological dependence but behavioral dependence, and may be less suitable for measuring the early onset of dependence [10]. Third, the low internal consistency of the FTQ in our study, as reported elsewhere [40], suggests a need for adolescent measures of nicotine dependence. Fourth, the self-reports of nicotine intake were not validated using biochemical measures due to financial and logistic constraints as well as the difficulty of current biochemical measures to detect low levels of infrequent intake. However, studies have shown agreement between self-reports of smoking and biochemical measures [11], [13]. Fifth, the cross-sectional nature of the study does not lend itself to an estimation of the manifestation of dependency symptoms at lower levels of nicotine intake. Due to small cell sizes in the study, ethnic differences could not be elaborated. Further studies will be required in SA to investigate the cultural specificity of dependence and withdrawal symptoms.

To conclude, our study demonstrates multiple symptoms of nicotine dependence among adolescent occasional smokers in a multi-ethnic cultural setting that should be addressed in comprehensive tobacco control programs.

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Acknowledgments 

The authors would like to thank the participating schools and students as well as the research assistants for assisting with data collection. We are grateful to the Medical Research Council, South Africa for funding this study.

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References 

  1. Perry CL, Eriksen MP, Giovino G. Tobacco use: a pediatric epidemic. Tob Control. 1994;3:97–98
  2. Centers for Disease Control and Prevention. Cigarette use among high school students—United States, 1991–2003. MMWR. 2004;53(23):499–502
  3. Swart D, Reddy P, Panday S, et al. The 2002 Global Youth Tobacco Survey (GYTS): The 2nd GYTS in South Africa (SA)—A Comparison between GYTS (SA) 1999 and GYTS (SA) 2002. Cape Town, South Africa: South African Medical Research Council; 2004;
  4. Warren CW, Riley L, Asma S, et al. Tobacco use by youth: a surveillance report from the Global Youth Tobacco Survey project. Bull World Health Organ. 2000;78(7):868–876
  5. Sussman S. Effects of sixty six adolescent tobacco use cessation trials and seventeen prospective studies of self-initiated quitting. Tob Induced Dis. 2002;1(1):35–81
  6. U.S. Department of Health and Human Services. Preventing Tobacco Use among Young People: A Report of the Surgeon General. Washington, DC: US Department of Health and Human Services, Public Health Services; 1994;
  7. Stanton WR. DSM-III-R tobacco dependence and quitting during late adolescence. Addict Behav. 1995;20(5):595–603
  8. Shadel WG, Shiffman S, Niaura R, et al. Current models of nicotine dependence: what is known and what is needed to advance understanding of tobacco etiology among youth. Drug Alcohol Depend. 2000;59(suppl 1):S9–S22
  9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition. Washington, DC: American Psychiatric Association; 1994;
  10. Colby SM, Tiffany ST, Shiffman S, et al. Are adolescent smokers dependent on nicotine? (A review of the evidence). Drug Alcohol Depend. 2000;59(suppl 1):S83–S95
  11. Prokhorov AV, De Moor C, Pallonen UE, et al. Validation of the modified Fagerstrom tolerance questionnaire with salivary cotinine among adolescents. Addict Behav. 2000;25(3):429–433
  12. Prokhorov AV, Hudmon KS, de Moor CA, et al. Nicotine dependence, withdrawal symptoms, and adolescents’ readiness to quit smoking. Nicotine Tob Res. 2001;3(2):151–155
  13. Rojas NL, Killen JD, Haydel KF, et al. Nicotine dependence among adolescent smokers. Arch Pediatr Adolesc Med. 1998;152:151–156
  14. Horn K, Dino G, Kalsekar I, et al. Exploring the relationship between mental health and smoking cessation: a study of rural teens. Prev Sci. 2004;5(2):113–126
  15. Wetzels JJ, Kremers SP, Vitoria PD, et al. The alcohol-tobacco relationship: a prospective study among adolescents in six European countries. Addiction. 2003;98(12):1755–1763
  16. Panday S, Reddy SP, Bergstrom E. A qualitative study on the determinants of smoking behaviour among adolescents in South Africa. Scand J Public Health. 2003;31(3):204–210
  17. Swart D, Reddy P, Ruiter R, et al. Cigarette use among male and female grade 8–10 students of different ethnicity in South African schools. Tob Control. 2003;12(1):E1
  18. Kremers K, Mudde A, de Vries H. Development and longitudinal test of an instrument to measure behavioral stages of smoking initiation. Subst Use Misuse. 2004;39(2):225–252
  19. Dolcini MM, Adler NE, Ginsberg D. Factors influencing agreement between self-reports and biological measures of smoking among adolescents. J Res Adolesc. 1996;6(4):515–542
  20. De Vries H, Mudde A, Kremers S, et al. The European Smoking Prevention Framework Approach (ESFA): short-term effects. Health Educ Res. 2003;18(6):649–663
  21. Prokhorov AV, Pallonen UE, Fava JL, et al. Measuring nicotine dependence among high-risk adolescent smokers. Addict Behav. 1996;21(1):117–127
  22. Fagerstrom KO, Schneider N. Measuring nicotine dependence: a review of the Fagerstrom Tolerance Questionnaire. J Behav Med. 1989;12(2):159–182
  23. Kandel DB, Davies M. Epidemiology of depressive mood in adolescents. Arch Pediatr Adolesc Med. 1982;39:1205–1212
  24. Riedel BW, Robinson LA, Klesges RC, et al. Characteristics of adolescents caught with cigarettes at school: implications for developing smoking cessation programs. Nicotine Tob Res. 2002;4(3):351–354
  25. Stanton WR, Lowe JB, Gillespie AM. Adolescents’ experiences of smoking cessation. Drug Alcohol Depend. 1996;43(1–2):63–70
  26. Hurt RD, Sachs DP, Glover ED, et al. A comparison of sustained-release bupropion and placebo for smoking cessation. N Engl J Med. 1997;337(17):1195–1202
  27. Silagy C, Lancaster T, Stead L, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2004;3:CD000146
  28. Hurt RD, Croghan GA, Beede SD, et al. Nicotine patch therapy in 101 adolescent smokers: efficacy, withdrawal symptom relief, and carbon monoxide and plasma cotinine levels. Arch Pediatr Adolesc Med. 2000;154(1):31–37
  29. Smith TA, House RF, Croghan JR, et al. Nicotine patch therapy in adolescent smokers. Pediatrics. 1996;98(4 Pt 1):659–667
  30. Killen JD, Robinson TN, Ammerman S, et al. Randomized clinical trial of the efficacy of bupropion combined with nicotine patch in the treatment of adolescent smokers. J Consult Clin Psychol. 2004;72(4):729–735
  31. Killen JD, Ammerman S, Rojas R, et al. Do adolescent smokers experience withdrawal effects when deprived of nicotine?. Exp Clin Psychopharmacol. 2001;9(2):176–182
  32. Adelman WP. Nicotine replacement therapy for teenagers: about time or a waste of time?. Arch Pediatr Adolesc Med. 2004;158(3):205–206
  33. McDonald P, Colwell B, Backinger CL, et al. Better practices for youth tobacco cessation: evidence of review panel. Am J Health Behav. 2003;27(suppl 2):S144–S158
  34. O’Loughlin J, DiFranza J, Tyndale RF, et al. Nicotine-dependence symptoms are associated with smoking frequency in adolescents. Am J Prev Med. 2003;25(3):219–225
  35. DiFranza JR, Rigotti NA, McNeill AD, et al. Initial symptoms of nicotine dependence in adolescents. Tob Control. 2000;9(3):313–319
  36. DiFranza JR, Savageau JA, Fletcher K, et al. Measuring the loss of autonomy over nicotine use in adolescents: the DANDY (Development and Assessment of Nicotine Dependence in Youths) study. Arch Pediatr Adolesc Med. 2002;156(4):397–403
  37. DiFranza JR, Savageau JA, Rigotti NA, et al. Development of symptoms of tobacco dependence in youths: 30 month follow up data from the DANDY study. Tob Control. 2002;11(3):228–235
  38. Kandel DB, Chen K. Extent of smoking and nicotine dependence in the United States: 1991–1993. Nicotine Tob Res. 2000;2(3):263–274
  39. Siqueira LM, Brook JS. Tobacco use as a predictor of illicit drug use and drug-related problems in Colombian youth. J Adolesc Health. 2003;32(1):50–57
  40. Horn K, Fernandes A, Dino G, et al. Adolescent nicotine dependence and smoking cessation outcomes. Addict Behav. 2003;28(4):769–776

PII: S1054-139X(06)00337-5

doi:10.1016/j.jadohealth.2006.09.001

Journal of Adolescent Health
Volume 40, Issue 2 , Pages 144-150, February 2007

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