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Am Fam Physician. 2004;69(3):651-652

Smoking rates in adolescents remain high, with an approximate prevalence of 15 percent in middle school students and 34 percent in high school students. More than one half of smokers in these age groups have reported wanting to stop smoking, and more than one half have attempted to quit within the past year. Nicotine dependence is high in adolescent smokers, and nicotine replacement therapy has been considered for use in this age group. Attempts recently have been made to make nicotine replacement therapy more accessible by reducing restrictions, expanding the type of sales outlets, reducing the cost of the products, and recommending that physicians offer this therapy to adolescents who are interested in smoking cessation. This increase in accessibility offers some benefits but does have some risks, including the potential use of nicotine replacement therapy in nonsmokers. Adolescent smokers will need assistance in maximizing the smoking cessation potential of this therapy. Klesges and associates evaluated the prevalence, ease of access, and reasons for using nicotine replacement therapy. They also examined the inappropriate use of nicotine replacement therapy in this age group.

The study design was a cross-sectional survey of high school students from 40 eligible high schools in a large, urban system. Questions about nicotine replacement therapy were included in a six-year prospective study of smoking initiation and cessation. Most students who took the survey were in 11th grade. Students 18 years and older were excluded because they met the legal age requirement for buying nicotine replacement therapy. Specific examples of smoking habits were used to categorize students as smokers or nonsmokers. The survey also asked about use of nicotine replacement therapy, ease of access to this therapy, and reasons for using it. The main outcome measured was self-reported use of nicotine replacement therapy and characteristics of students who used therapy.

Of the 4,078 students included in the data analysis, 5.9 percent were former smokers, 26.0 percent were experimental smokers, and 13.1 percent were regular smokers. A total of 5.3 percent of all participants reported using nicotine replacement therapy. Approximately 40 percent of former smokers used nicotine replacement therapy as a cessation aid. Three fourths of current smokers used nicotine replacement therapy when they were not able to smoke. Of the adolescents who used nicotine replacement therapy, 18 percent said they were nonsmokers. More than one half of the respondents said it would be easy for them to get nicotine replacement products.

The authors conclude that adolescent smokers and nonsmokers use nicotine replacement therapy. They add that this therapy is easily obtained and used for reasons other than smoking cessation. Efforts should be made to ensure that nicotine replacement therapy is used appropriately in adolescents interested in smoking cessation. Physicians should discourage the use of nicotine replacement therapy in nonsmokers.

editor's note: One of the more important issues that we address in our adolescent patients is tobacco abuse. Despite recent declines in total smoking rates in the general population, the rate in adolescents has been increasing. This increase makes smoking cessation even more difficult because of the substantial impact of peer pressure on adolescents. The use of adjuvant medications and counseling have been shown to improve smoking cessation rates. Nicotine replacement has been shown to be beneficial in adolescent smokers. Recent attempts to make these products more available to adolescents have been a mixed blessing. Nicotine replacement therapy provides us with another tool in our attempts to improve smoking cessation rates in this age group. Unfortunately, it also increases the abuse potential. Klesges and colleagues have shown that the potential for abuse is present not only in smokers but also in nonsmokers. Physicians should be aware of this potential when they provide care for adolescent patients.—K.E.M.

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