Although overall teen smoking rates have dropped, tobacco use continues to increase among girls, less-educated teens, and other adolescent groups.

 First the good news: teen smoking rates have recently hit a 10-year low. The Centers for Disease Control and Prevention’s Youth Risk Behavior Survey reports that teen cigarette smoking has dropped to 28% in 2001. That is down from 36% in 1997 as measured by the same survey. Now the bad news: teenage girls are still the fastest-growing demographic of new smokers, and lung cancer has surpassed breast cancer as the number one cancer killer of women. Both the tobacco industry and public health advocates have long recognized teens as a crucial factor in the smoking equation. The tobacco industry has consistently discussed the importance of teen smokers in internal documents while denying that it in any way targets children and teens.

In the Beginning
The seeds of teenage smoking and the effects of smoking on children are often sown before birth. Smoking during pregnancy continues to be one of health care’s most significant challenges. The children of women who continued to smoke during pregnancy may have serious outcomes. These can include miscarriage, low birth weight (a predictor of frequent illness in the first year of life), perinatal death, asthma, otitis, sudden infant death syndrome (SIDS), childhood leukemia, cancer of the brain or lungs later in life, conduct disorder, and emotional as well as intellectual deficits. Recent research also indicates increased risks resulting from second-hand smoke. Nicotine, carbon monoxide, and carcinogens all pass through the placenta. In many cases, they can be detected in blood samples from newborns.

Virtually every parent has observed a pre-school-age child mimicking smoking rituals observed on TV and in restaurants. In communities where smoking is still allowed in restaurants, it is common to hear a hostess ask parents to choose “smoking or nonsmoking” as they enter a restaurant. Even when seated in a nonsmoking section, children observe adults smoking cigarettes and begin to associate it with adult behavior.

Parental smoking is an additional aggravating factor, fostering an increased incidence of smoking among teens whose parents smoke. Several teens I interviewed for this article stated that their parents buy them cigarettes, and one teenage girl mentioned that her father had “taught” her how to inhale.

Addicted Teens

Cigarette smoking is the most prevalent form of nicotine addiction in the United States of America. Each cigarette contains 10 mg or more of nicotine, but the average smoker inhales 1-2 mg of nicotine per cigarette.1

Nicotine is absorbed through the skin and mucosal lining of the mouth and nose, and through inhalation directly into the lungs. Depending on how tobacco is taken, nicotine can reach peak levels in the bloodstream and brain rapidly. Cigarette smoking, for example, results in rapid distribution of nicotine throughout the body, reaching the brain within 10 seconds of inhalation. Cigar and pipe smokers do not inhale the smoke, so nicotine is absorbed more slowly through the mucous membrane in the mouth.2

When inhaled nicotine reaches the brain, it accelerates the release of dopamine, a neurotransmitter that carries information across the synaptic clefts. This circuit, known as the pleasure center, is associated with emotions. Dopamine-releasing pathways extend from the midbrain to the hypothalamus and trigger activities that increase the likelihood of survival, such as procreating and eating. The increase of dopamine takes place in the nucleus accumbens, a small part of the brain associated with substance addictions in rats. In a new study, precise measurements were used to track nicotine-stimulated dopamine release to the shell of the nucleus accumbens. The shell is wired to the forebrain, where emotional and motivational processing occurs. The forebrain includes the amygdala, which is active in many emotional states and is associated with addictive behavior. The study also measured an increase in metabolism in the shell of the nucleus accumbens. Nicotine did not raise the concentration of sugar anywhere else in the brain.3

The stimulation of the fibers originating in the nucleus accumbens is interpreted by the brain as the neurotransmitter equivalent of “Good—let’s have it again.” High levels of dopamine result in a desire for repeated increases in dopamine. Activation of this pleasure-reward circuit also creates a memory of the event and the motivation to do it again. An addiction is formed.

The development of psychological dependence in cigarette smokers is abundantly evident in nicotine dependency. Nicotine can act as both a sedative and a stimulant. Immediately after nicotine is inhaled, it stimulates the adrenal glands, resulting in the discharge of epinephrine (adrenaline). The rush of adrenaline stimulates the body and causes a sudden release of glucose and an increase in blood pressure, respiratory rate, and heart rate. Nicotine also suppresses insulin output from the pancreas, causing hyperglycemia, which suppresses appetite.4

Nicotine combines with other neurotransmitters in the brain and may contribute to the following effects:
• Acetylcholine: Arousal, cognitive enhancement
• Serotonin: Mood changes, appetite suppressant
• Norepinephrine: Arousal, appetite suppressant
• Vasopressin: Memory improvement
• Beta-endorphin: Anxiety/tension reducer
• As a mood- and behavior-altering agent, tobacco is as addictive as heroin.

Nicotine is:
• 1,000 times more potent than alcohol
• 10-100 times more potent than barbiturates
• 5-10 times more potent than cocaine or morphine

A person who smokes one to two packs per day takes 200 to 400 hits daily, a constant intake of a fast-acting drug that affects mood, concentration, and performance and will produce dependence in a very short time.5 Nicotine withdrawal symptoms, which can include sweating and rapid pulse, increased hand tremors, insomnia, nausea or vomiting, physical agitation and anxiety, or transient visual, tactile, or auditory hallucinations or illusions, can last from weeks to months. After withdrawal subsides, urges for nicotine return in response to cues to smoke, including social gatherings and consumption of alcohol or coffee.6

—Carol Mihailuk, RRT

The Target: Young Lungs
Internal tobacco industry documents clearly demonstrate a focus on youth as essential to replacing the estimated 450,000 people who die each year from smoking-related disease. And no wonder—90% of all smokers started before the age of 18. If individuals do not begin smoking in their teen years, chances are they never will.

The Colorado Society for Respiratory Care recently honored Anne Landmann, RRT, as clinician of the year for her research into tobacco industry documents on behalf of the American Lung Association of Colorado. “A host of internal tobacco industry documents show that the tobacco companies are fully aware that children must start to smoke or they will go out of business,” she says. “Adults simply don’t enter into nicotine addiction in adequate numbers to sustain growth in the industry, but hordes of children can be made to ‘follow the leader’ into smoking when they receive the right cues to do so. Young people are far less educated, less aware, less sophisticated, and less media-literate than any other market. As such, young people are a fertile target for exploitation by the tobacco industry.”

Although the ubiquitous Joe Camel cartoon character was retired as a condition of the tobacco settlement, opponents charge that the industry continues to target teens while covertly promoting their products to young lungs. Several companies, including Camel, are now marketing orange, vanilla, cherry, and chocolate flavored cigarettes. These are not to be confused with the candy products available to children who want to play “grown-up” by pretending to smoke candy cigarettes and chewing bubble-gum chaw. These are real cigarettes, loaded with tar and nicotine.

Following an aggressive, in-your-face antismoking campaign, the Florida Youth Tobacco Survey reported an unprecedented 54% decline in middle school tobacco use over 2 years and a 24% drop among high school students. Meanwhile, the tobacco industry has jumped in with its own ads, which seem to discourage teen smoking but may have a more subversive purpose.

Lorillard Tobacco Company is not overtly promoting its product by sponsoring the ESPN Winter X Games. Its advertisements declare “Tobacco is whacko if you’re a teen.” But industry opponents point out that the hidden message is “smoking is for grown-ups” and perpetuates the image of tobacco as a forbidden fruit.

Tobacco industry internal documents suggest that the purpose of their antitobacco campaigns, including the ubiquitous “We Card” campaign, is to demonstrate to legislators they are addressing the problem, thus preempting more restrictive measures, and promoting a positive image for the industry. Effectively discouraging teens from lighting up is not even mentioned as a goal in their advertising campaign.

What American Teenagers Believe

• American Indians are less likely to agree with the negative health consequences.
• Asian Americans are more likely to endorse strong social disapproval of smoking.
• African Americans see smoking as “risky” and incompatible with the promise of a successful future.
• White American girls have expectations about smoking reinforced by mainstream culture. Among them: Smoking controls weight (an important reinforcement because thinness is highly desired in white culture); smoking helps increase a mellower mood; smoking enhances the image of sophistication and independence.
• Among nonwhite groups, smoking is seen as inappropriate for women.

• African Americans with less education and living in poverty smoke more than those with higher education and economic success.
• Among American Indians, 40% of all males smoke and do not acknowledge the negative aspects of smoking.
• Among Asian Americans, 34% to 43% of males smoke. A factor believed to be significant in this figure is the growing presence of new immigrants who lack proficient English language skills, are not aware of the hazards of smoking, and who seek to adopt the norms of American life and culture.
• American males smoke due to role models, gathering with friends for happy hour, and easing tension.7

A study on teen smoking found that teenagers got hooked within weeks of starting, following the use of only a few cigarettes per day.8 The study pointed to alcohol as the number-one reinforcement factor for teen smoking. It also indicated that current antismoking campaigns, which drive smokers together into clusters in segregated smoking areas, might be reinforcing rather than deterring smoking.9

(Survey of teenagers including a cross section of American Indian, Asian American, African American, and white youth)

Carol Mihailuk, RRT, RCP, is a critical care therapist at UCSD Medical Center, San Diego.

Fighting Back
RTs can provide leadership in their individual states and communities by supporting local smoke-free community ordinances and opposing moves to raid tobacco settlement funds to shore up sagging tax revenues. Since the November 1998 state tobacco settlement—expected to total $246 billion over 25 years—states have continually collected more money, but are increasingly spending less of it to adequately fund tobacco prevention and cessation programs. Overwhelming evidence demonstrates that such programs not only reduce smoking and save lives, but also save up to three dollars for every dollar spent by reducing smoking-related health care costs.

RTs interested in learning about tobacco control issues can find state-by-state information on smoke-free air, youth access, tobacco use prevention, control spending, and cigarette tax at:   By becoming active in their communities, RTs can contribute to the considerable momentum toward the fundamental cultural change currently taking place.

John A. Wolfe, RRT, is the Northern Region Program Coordinator for the American Lung Association of Colorado.

1. Martin WR, Van Loon GR, Iwamoto ET, Davos L, eds. Tobacco Smoking and Nicotine. New York: Plenum Press; 1987.
2. Bartecch CE, MacKenzie TD, Schrier RW. Human cost of tobacco use. N Engl J Med. 1996;330: 907-980.
3. Pontieri FE, Tanda G, Orzi F, Di Chiara G. Effects of nicotine on the nucleus accumbens and similarity to those of addictive drugs. Nature. July 18, 1996;382(6588):255-7.
4. Giovino GA, Henningfield JE, Tomar SL, Escobedo LG, Slade J. Epidemiology of tobacco use and dependence. Epidemiol Rev. 1995;17(1):48-65.
5. University of Minnesota School of Dentistry, Division of Periodontology. Nicotine addiction, Available at: http://www.umn,edu/peril/tobacco/nicoaddct.html.
6. Long PW. Nicotine dependence, Internet Mental Health. Available at: Accessed December 10, 2002.
7. Action on Smoking and Health (ASH), 2013 H Street, NW, Washington, DC 20006. Available at:
8. Monitoring the Future, National Results on Adolescent Drug Use, Overview 2000-2001. Bethesda, Md: National Institute on Drug Abuse; 2001. NIH publication No. 01-4923.
9. Huffman K. Psychology in Action. 6th ed. New York: John Wiley and Sons; 2002:89-91.