Case Study: Adolescent Cigarette Smoker

Chad is a 17-year old high school senior who lives with his mother (a smoker) and his younger sister. He works about 20 hrs/week at a nearby grocery store. Chad enjoys playing basketball, but does not participate in school athletics since he works most evenings. Yesterday morning, Chad was found smoking in the high school restroom and has been referred to the nurse-managed tobacco cessation program in the school. The nurse obtained Chad’s smoking history and administered the Fagerstrom Test for Nicotine Dependence, which indicated a high nicotine dependence score of 8. In addition, she assessed Chad’s positive and negative beliefs about smoking. Chad stated he wanted to quit smoking before he graduates from high school.

Based on this assessment, Chad and the nurse counselor plan to meet 15 minutes weekly on Tuesday during Chad’s study hall period. Before next Tuesday, Chad will record times of cigarettes smoked during a school day and a non-school day. Next week, Chad, with the nurse counselor’s guidance, will identify strategies to manage his specific smoking triggers, establish a quit date, and obtain nicotine replacement patches (21 mg). (Link to in Clinical Practice Guidelines (pdf) Select Chapter 7, Special populations, pp 101-2).

Chad’s Smoking History

• Started smoking at age 14
• Smokes 1½ packs of Marlboro cigarettes each day and an occasional cigar
• Tried to quit when cigarette costs increased last year. Quit “cold turkey” and was smoke-free 4 days. Relapsed when he got together with friends on the weekend and alcohol was available.
• He smoked 3 cigarettes on the way to school this morning and his carbon monoxide (CO) in exhaled air was 22 parts per million (ppm).
• Most of his friends and co-workers are smokers, as well as his mother.
• Cigarette breaks are permitted behind the grocery store.

Youth version Fagerstrom Test for Nicotine Dependence

1. How many cigarettes a day do you smoke?
1. Over 26 cigarettes a day (2)
2. About 16-25 cigarettes a day (1)
3. About 1-15 cigarettes a day (0)
4. Less than 1 a day (0)

2. Do you inhale?
1. Always (2)
2. Quite often (1)
3. Seldom (1)
4. Never (0)

3. How soon after you wake up do you smoke your first cigarette?
1. Within the first 30 minutes (1)
2. More than 30 minutes after waking but before noon (0)
3. In the afternoon (0)
4. In the evening (0)

4. Which cigarette would you hate to give up?
1. First cigarette in the morning (1)
2. Any other cigarette before noon (0)
3. Any other cigarette after noon (0)
4. Any other cigarette in the evening (0)

5. Do you find it difficult to refrain from smoking in places where it is forbidden (church, library, movies etc)?
1. Yes, very difficult (1)
2. Yes, somewhat difficult (1)
3. No, not usually difficult (0)
4. No, not at all difficult (0)

6. Do you smoke if you are so ill that you are in bed most of the day?
1. Yes, always (1)
2. Yes, quite often (1)
3. No, not usually (0)
4. No, never (0)

7. Do you smoke more during the first 2 hours than during the rest of the day?
1. Yes (1)
2. No (2)

Scoring in parentheses for each item. Total score = sum of all items.

Source: Prokhorov, AV, Pallonen, UE, Fava, JL, Ding, L, & Niaura, R. (1996). Measuring nicotine dependence among high-risk adolescent smokers. Addictive Behaviors, 21, 117-127.

Chad’s Pros and Cons of Smoking scores (Youth Version)

(Please circle the number that is most like what you believe).

1. Smoking makes kids get more respect from others.

NO no maybe yes YES

2. Smoking stinks.

NO no maybe yes YES

3. Kids who smoke have more friends.

No no maybe yes YES

4. Smoking can affect the health of others.

NO no maybe yes YES

5. Smoking helps people to cope better with frustrations.

NO no maybe yes YES

6. Smoking cigarettes is hazardous to people’s health.

NO no maybe yes YES

7. Smoking cigarettes is pleasurable.

NO no maybe yes YES

8. Cigarette smoking bothers other people.

NO no maybe yes YES

9. Smoking cigarettes relieves tension.

NO no maybe yes YES

10. Smoking is a messy habit.

NO no maybe yes YES

11. Kids who smoke go out on more dates.

NO no maybe yes YES

12. Smoking makes teeth yellow.

NO no maybe yes YES

Scoring: NO = 1; no = 2; maybe=3; yes=4; YES=5

Pros of Smoking : add all the responses for odd-numbered, blue items

Cons of Smoking: add all the responses for the even-numbered items

Pallonen, U.E. (1998). Transtheoretical measures for adolescent and adult smokers: Similarities and differences. Preventive Medicine, 27, A29-A38.

Chad’s scores were: 12 on Pros of Smoking and 24 on Cons of Smoking

The two items he scored highest on “pro” or positive aspect of smoking were #5 and #9. The highest ”con” or negative aspect items were #6, 10 and 12.

Questions for further consideration.

1. What is the purpose of the nurse having Chad record times of cigarettes smoked on a school day and a non-school day?

Provides specific data regarding times and situations that are triggers for his smoking, which forms the basis for individualized planning.

2. How would you interpret for Chad the meaning of a carbon monoxide level in exhaled air of 22 parts per million (ppm)?

A nonsmoker has a reading of 1 or 2 ppm, therefore he has increased exposure to CO – the same fumes that come out of his car exhaust. Relate to displacement of oxygen by CO and potential reduction in endurance for basketball and other sports.

3. What are the AHRQ guidelines recommendations for adolescents and tobacco cessation pharmacotherapy?

If the adolescent demonstrates evidence of nicotine dependence and an intention to quit smoking, pharmacotherapy is recommended. Since there is no evidence that bupropion SR (Zyban Ò ) or nicotine replacement is harmful to adolescents, these should be considered in a treatment plan for nicotine dependent adolescents.

4. As the nurse counselor, how many brief weekly visits would you plan with Chad? What would be the content of these multiple visits?

Based on the AHRQ Treating Tobacco Use and Dependence Clinical Practice Guideline (2000), there is an increased effect of 4 or more counseling sessions. Monitoring correct use of NRT would be an important aspect of each visit. Assessment of Chad’s frequency, duration, and severity of nicotine cravings will provide information on Chad’s response to NRT. If cravings are persistent, nicotine gum could be considered to manage the cravings, or Chad could be referred to his physician for a prescription for bupropion SR.

Problem-solving strategies can be modified with each visit depending on the events of the previous week – eg. Ways to manage tension and frustration without smoking as these were two items he identified with on the Pros and Cons instrument. Strategies to avoid difficult situations, such as parties with alcohol. Identify the positive aspects of quitting (build on the Cons of smoking Chad identified). Continue to provide encouragement and his goal of being a non-smoker on graduation.

5. What are indicators of Chad’s nicotine dependence and how realistic is his understanding of the addictive nature of nicotine?

A high Fagerstrom Test for Nicotine Dependence score and multiple early morning cigarettes are indicators of high dependence. Further information could be obtained by asking Chad how many minutes go by after he wakes up before he has a cigarette. Obviously, the shorter the time, the more dependence. According to the AHRQ guideline, youth vastly underestimate the addictiveness of nicotine. Daily adolescent smokers state they will not be smoking in 5 years, but nearly ¾ are still smoking in 5-6 years. About 75% of adolescent smokers have made at least one serious quit attempt and failed. Reframing relapse as a way to learn and prepare for the next attempt is useful.

6. How might you address Chad’s concern for the cost of pharmacotherapy?

Taking the local cost of a pack of cigarettes x Chad’s use each week (>10 packs) will help to put this in perspective, since Chad tends to buy cigarettes a pack at a time and the cost of a week of nicotine replacement seems high in comparison. It is useful to list the benefits of pharmacotherapy and quitting. The cost savings for a year of not smoking can be related to purchasing sporting equipment or music CD’s that Chad enjoys.