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REVIEW ARTICLE
Year : 2009  |  Volume : 27  |  Issue : 2  |  Page : 78-84
 

A review of tobacco cessation services for youth in the dental clinic


Department of Pedodontics, Peoples College of Dental Sciences, Bhanpur Bypass Road, Bhopal, Madhya Pradesh, India

Date of Web Publication31-Aug-2009

Correspondence Address:
N D Shashikiran
Peoples College of Dental Sciences, Bhanpur Bypass Road, Bhopal - 462 037, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.55326

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   Abstract 

Tobacco use is one of the leading preventable causes of illness and death. The most powerful predictor of adult smoking is smoking during adolescence. While general and pediatric dentists have a positive attitude regarding tobacco cessation counseling, the same is not extrapolated into practice. Several barriers to counseling in the dental clinic have been identified and research into some of these has been conducted. Evidence-based cessation programs are still in the nascent stage, but this should not hinder dental professionals from rendering these services to the child and adolescent populations. Brief interventions, self-help materials, and nicotine replacement therapy for established nicotine dependence form the mainstay of therapy. The purpose of this paper is to identify the several barriers encountered in providing cessation and discuss the current status of its implementation in the dental clinic.


Keywords: Adolescent, counseling, nicotine, oral health, smoking


How to cite this article:
Vanka A, Roshan N M, Ravi K S, Shashikiran N D. A review of tobacco cessation services for youth in the dental clinic. J Indian Soc Pedod Prev Dent 2009;27:78-84

How to cite this URL:
Vanka A, Roshan N M, Ravi K S, Shashikiran N D. A review of tobacco cessation services for youth in the dental clinic. J Indian Soc Pedod Prev Dent [serial online] 2009 [cited 2019 Nov 21];27:78-84. Available from: http://www.jisppd.com/text.asp?2009/27/2/78/55326



   Introduction Top


Tobacco use is growing fastest in low-income countries, due to steady population growth coupled with tobacco industry targeting, ensuring that millions of people become fatally addicted each year. More than 80% of the world's tobacco-related deaths will be in low- and middle-income countries by 2030.[1]


   Tobacco use by Youth in India Top


Each day, 55,000 children in India start using tobacco and about 5 million children under the age of 15 are addicted to tobacco. The Global Youth Tobacco Survey (GYTS)[2] reported that in India

  • Two in every 10 boys and 1 in every 10 girls use a tobacco product.
  • 17.5% were current users of tobacco in any form, and current use (defined as use in past 30 days preceding survey) ranged from 2.7% (Himachal Pradesh) to 63% (Nagaland).
  • Current non-cigarette tobacco use (13.6%) was three times more common than current cigarette smoking (4.2%)
  • There is no statistical difference in rural–urban current tobacco use among students aged 13–15 years.
  • Many youth have the misconception that tobacco is good for the teeth or health.
  • Initiation to tobacco products before the age of 10 years is increasing.
  • Over one-third (36.4%) were exposed to second-hand smoke (environmental tobacco smoke or ETS) inside their homes.
  • In the northeastern states, over two-thirds of cigarette-smoking students (especially among boys) and nearly half of smokeless tobacco users reported needing tobacco first thing in the morning. [3]



   Effects of Tobacco use Top


Smoking during pregnancy increases the chance of a low-birth-weight baby, miscarriage, premature birth, stillbirth, sudden infant death syndrome (SIDS), and six times greater chance of cleft palate formation.?[4] Second hand (passive) smoke from parents puts the children at an increased risk of developing colds, pneumonia, bronchitis, middle-ear infections, increased severity of symptoms in asthmatic children, reduction in lung function, and delayed development of permanent teeth by as many as 4 months.[5] Although the most serious health outcomes associated with smoking typically emerge later in life, adolescent smokers show evidence of airway obstruction, slowed growth in lung function, and higher rates of cough and other respiratory symptoms, compared with non-smokers. In addition, the earlier individuals begin to smoke, the higher their risk for heart disease, stroke, and chronic obstructive lung disease nicotine addiction, and possibly their risk of developing anxiety disorders and depression.[6]

Several studies point out that tobacco use is the root of many oral health problems, including tooth loss, bone loss, and periodontal diseases. Half the cases of adult periodontitis are attributable to smoking. Moreover, tobacco use impedes the effectiveness of periodontal therapy and wound healing.[7] Smoking a pack of cigarettes a day or using smokeless tobacco quadruples the risk of developing oral cavity or oropharyngeal cancer, which kills 49% of its victims within 5 years of diagnosis. In India, a vast majority of oral cancers are preceded by precancerous lesions and conditions caused by the use of tobacco in some form.[8] These can be more easily seen because of their peculiar oral location, making oral cancers particularly amenable to prevention.


   Adult vs Children/Adolescent Tobacco use Top


Adolescent-type tobacco use is characterized by being driven by relationships, activities, positive and negative emotions, and social ramifications, while adult-type smoking is defined by the dependence of nicotine. Although most youth do not become nicotine dependent until after 2–3 years of use, addiction can occur after smoking as few as 100 cigarettes [9] or within the first few weeks.[10] However, there are unique behavioral and social factors associated with their behavior and unlike adults, nicotine dependence may not be the primary reason reported for smoking.[11] Personal characteristics of adolescent tobacco users include low self-esteem, low aspirations, depression/anxiety, and sensation seeking. This is then associated with poor school performance, school absences, school drop-out, alcohol, and other drug use. Teens who smoke are three times more likely to use alcohol and several times more likely to use drugs. Illegal drug use is rare among those who have never smoked.[12]


   Do Pediatric or General Dentists Provide Tobacco Prevention and Cessation Services for Youth? Top


A large population of dentists have a positive attitude about intervening for their adolescent patients. A study in Saudi Arabia[13] found that the majority of general dentists consider smoking cessation and prevention for adolescents and children as part of their responsibility. Members of the AAPD[14] found that over half of the respondents believed pediatric dentists should encourage, advice, and assist tobacco users to quit using tobacco. In addition, 80% reported that trying to reduce adolescent tobacco use was worth the time.

Despite a positive attitude, practice was found to be lacking in most of the studies. A recently undertaken study in Colorado, USA,[15] concluded that most dentists and hygienists did not counsel 8- through 12-year-old children to prevent tobacco use. Clear evidence of a lack of confidence and doubt about the effectiveness of their smoking intervention efforts were reported.?[13] These findings are backed up by data collected from the youth wherein only 20% reported that a dentist counseled them about the dangers of tobacco use, and among students who smoked in the past year, 11.6% received advice from a dentist to quit.[16]

Several barriers have been identified by dentists in providing these services to the youth. [13],[14],[15],[16],[17],[18],[19],[20] [Table 1] Some of the consistently reported barriers are lack of time, lack of reimbursement or incentives, resistance from the patients or parents, lack of skills or formal training translating into lack of confidence, and perception of poor effectiveness. Children and adolescents also underreport tobacco use on health history forms that ask them to specify whether they use tobacco products[21] making it difficult to identify them in the first place.

In an attempt to address these issues, a few studies have been conducted. For instance, evaluating parents attitude toward tobacco counseling by pediatric dentists in children averaging 8.2 years, it was found parents were more likely to approve than disapprove of the dentist counseling the child (about 80% vs. 8%) and the parent (74% vs. 11% .) Tobacco status of parent did not affect the approval of counseling on any issue.?[22] A large survey of the youth in India2 reported that 68.5% (average) of students who smoked wanted to stop, whereas 71.4% (average) had already tried to stop smoking during the past year. This is a strong indicator that quit attempts are common in youth and they should be helped with the same.

The lack of training at the graduate level is also an important barrier that hinders large-scale involvement of dentists. Analyzing tobacco cessation efforts by dentists, pediatric dentists with tobacco counseling training were more likely to accept their role in tobacco prevention and cessation efforts and were more confident in their ability to do so than were their counterparts.[18] Continuing education programs are needed to enhance the knowledge and skills of pediatric dentists to promote tobacco control behaviors.[23]


   Best Practices Top


Studies show that if people do not begin to use tobacco during adolescence, there is a good chance they never will. While tobacco cessation for adults is an extensively researched topic,[24] few have addressed cessation among youth.[25] Thus, with no evidence based conclusions available, the current guidelines by and large extrapolate the findings of adult studies onto youth.

Tobacco cessation methods can be broadly classified into

  1. Cognitive behavioral therapy (CBT) includes methods such as self-help and brief interventions which can be provided by health professionals,
  2. Intensive therapy at smoking cessation centers,
  3. The pharmacological means including nicotine replacement therapy (NRT) and antidepressants like bupropion.


A host of alternative means are available such as hypnosis, acupuncture, lasers, Allen Carr's Easy way, St. John's wart, nicobrevin but a thorough review of several studies on them have failed to justify their scientific usage.[26]

While intensive therapy is not in the realm of dentists providing brief interventions and NRT hold plenty of promise. Even though theoretically these methods may seem exclusive of each other, the existing data suggest that a combination of the two are often essential to achieve good success rates.[27]


   Brief Interventions Top


Available evidence suggests that behavioral interventions for tobacco use conducted by oral health professionals incorporating an oral examination component in the dental office and community setting may increase tobacco abstinence rates among smokeless tobacco users.[28] Dental treatment often necessitates frequent contact with patients over an extended period of time, providing a mechanism for long-term contact and reinforcement, coupled with visible changes in the oral cavity in response to counseling.[29]

Brief interventions typically involve an assessment of tobacco use, dependence, and motivation to quit; advice on the benefits and methods of quitting; and assistancewith quitting, including referrals to other treatment.

  • It is important to note that studies report that adolescents consistently rank physical attractiveness, dental concerns, and oral health as greatly important.?[30],[31]
  • Relating smoking to short-term adverse effects such as staining of teeth, bad breath, loss of taste may be more relevant and meaningful to an adolescent smoker than relating smoking to long-term health effects such as cardiovascular or lung diseases.[14]
  • Peer influences play a critical role as do role models. Highlighting personalities abstaining from smoking and making the dental clinic adopt a no tobacco policy can be used to guide them away from tobacco use.
  • Enhancement of athletic ability and concentration powers, being 'cool' have been associated with tobacco use. Such common myths with tobacco use need to be dispelled.
  • Few brief messages that can be effective are
  • Eating healthy foods and exercising is a better way to lose weight than smoking.
  • Smoking a pack a day costs more than that a CD.


Clinicians are currently encouraged to develop their own systems to deal with adolescents. However, it is important to realize that tobacco cessation is a process and a number of stages are encountered in the process. Some of the attributes required for the clinician are (a) not to give up, (b) to be persistent, and (c) be supportive.?[29]

The "5 A's" for brief intervention are used in cases where the adolescent wishes to quit and include[24]

  • Ask about tobacco use.
  • Identify and document tobacco use status for every patient at every visit.
  • Advise to quit. In a clear, strong, and personalized manner urge every tobacco user to quit.
  • Assess willingness to make a quit attempt.
  • Is the tobacco user willing to make a quit attempt at this time?
  • Assist in quit attempt.
  • For the patient willing to make a quit attempt, use counseling and pharmacotherapy to help him or her quit.
  • Arrange follow-up.


Anticipatory guidance—the practice of providing counsel regarding potential problems—is a key part of health care for the young, and can be considered an additional and important 'A' of this process. If dentists provide messages about tobacco use that are appropriate to the patient's age and developmental stage, the potential for broad public health impact is great.[32],[33] A congratulatory message positively reinforced can truly enhance the chances of a child desisting from tobacco use in the future.

The 5 R's is recommended in the event that tobacco quitting is not being contemplated:

Relevance

Encourage the patient to indicate why quitting is personally relevant, being as specific as possible.

Risks

Dentist can help the patient to identify potential negative consequences of tobacco use. Suggest and highlight those that seem most relevant to the patient.

Rewards

Dentist should ask the patient to identify potential benefits of stopping tobacco use.

Roadblocks

The clinician should ask the patient to identify barriers or impediments to quitting and note elements of treatment.

Repetition

The motivational intervention should be repeated every time an unmotivated patient visits the clinic setting.

Self-help [34]

The self-help, non-interactive approach includes minimal interventions that do not require responses from the adolescent and are delivered through written or audio-visual materials or on a computer, while self-help, computer interactive support approach uses computer technology to assess a person's tobacco use and motivation to quit.

Telephone counseling or support [34]

This approach delivers support or counseling by telephone rather than through face-to-face encounters. Telephone interventions can offer support of varying intensity while reducing many barriers associated with other cessation services (e.g. the need for transportation, the problem of scheduling appointments, confidentiality versus disclosure to supervisory adults). A general guideline can be adopted from the one suggested by the center for disease control- [Table 2].

Methods to avoid [34]

Two types of intervention approaches are generally deemed ineffective or inappropriate for youth.

  • Sensory deprivation environment method, which requires that youth be placed in an environment that deprives them of sensory stimulation (e.g., a dark room) to help them clarify any conflicting feelings they have about tobacco use.
  • The second method uses fear appeal tactics alone. This approach relies solely on "scare tactics" (e.g. showing pictures of diseased lungs, presenting people who have been disfigured by a tobacco related disease) to change tobacco behavior by evoking fear of the possible consequences of tobacco use.

   Environmental Tobacco Smoke Top


The AAPD[32] has laid down the following guidelines for preventing ETS:

  • Determine and document tobacco use by patients and smoking status of their parents, guardians, and caregivers.
  • Educate patients, parents, and guardians on the serious health consequences of tobacco use and exposure to ETS in the home.
  • Provide both prevention and cessation services using evidence-based interventions identified as "best practice" for treating tobacco use and nicotine addiction.

   Nicotine Replacement Therapy (with or without Bupropion) Top


Adolescent smokers are different from older smokers in that their motivation to stop smoking tends to be more unstable. It is sensible, therefore, to check that they are fully committed to trying to stop smoking permanently before offering them NRT and to attempt to establish that they are dependent.[35]

In a randomized clinical trial,[36] it was found that a large majority of adolescents in both treatment groups of NRT with bupropion and NRT with placebo reduced their consumption to a few cigarettes per day or less and maintained this reduction over time. Similarly, by the end of treatment, many had managed to avoid a return to daily smoking. This finding is supported by other studies,[37],[38] which report the nicotine patch to be safe as well .

Other studies have reported contrary to the above findings in that nicotine patch therapy plus minimal behavioral intervention did not appear to be effective for treatment of adolescent smokers.[39] Nicotine replacement therapy is used by both adolescent smokers and nonsmokers and is used for reasons other than trying to quit smoking. A report that NRT drugs were being sold on the pavement in India raises some concerns of NRT abuse.[40] However, this phenomenon is rare and although the long-term effect of nicotine replacement is unknown, this product is significantly less harmful than tobacco.[41]

The current data available indicate that NRT used by adolescents between 12 and 18 years is as well tolerated by teenagers as it is in adults and would certainly be safer than smoking. There is no evidence that indicated adolescents would abuse/misuse NRT. However, if a teenager needs to use NRT for longer than 12 weeks, they should discuss this with a healthcare professional (such as a doctor, pharmacist, or nurse).[35]


   Conclusions Top


Tobacco use is one of the leading preventable causes of illness and death. The most powerful predictor of adult smoking is smoking during adolescence. While both general and pediatric dentists hold themselves responsible for providing tobacco cessation services and encourage non-users to be tobacco free, few translate this into practice. Admittedly, there are several barriers in this process, both real and perceived, which should be addressed with further research. The evidence-based approach currently does not specify the best methods available to counsel the youth and methods used for adults that are currently adopted for youth as well. Screening for tobacco use, referring adolescents to additional resources for cessation, and establishing a follow-up system that will track each adolescent's progress should be made mandatory. Encouraging non-users to remain so is an important area where progress should be made. Brief advice from a clinician for adolescents is cost-effective (because it is provided during a visit scheduled for another purpose) and has a potentially large reach.
"Let us not treat teeth alone, but learn to treat individuals who have teeth."

 
   References Top

1.WHO. Report on the Global Tobacco Epidemic, 2008: The MPOWER package. Geneva: World Health Organization, 2008. Available from: www.who.int/tobacco/mpowers  Back to cited text no. 1    
2.Prevalence of tobacco use among the youth. In: Reddy KS, Gupta PC (eds). Report on tobacco control in India. New Delhi: Ministry of Health and Family Welfare, 37 Government of India; 2004:61-7. Available from: http://www.whoindia.org/SCN/Tobacco/ Report/TCI-Report.htm  Back to cited text no. 2    
3.Sinha DN, Gupta PC, Pednekar MS. Tobacco use among students in eight north-eastern states in India. Indian J Cancer 2003;40:43-59.  Back to cited text no. 3  [PUBMED]  Medknow Journal
4.Tobacco use and reproductive outcomes. In: Reddy KS, Gupta PC (eds). Report on tobacco control in India. New Delhi: Ministry of Health and Family Welfare, Government of India; 2004:108-10. Available from: http://www.whoindia.org/SCN/Tobacco/Report/TCI-Report.htm  Back to cited text no. 4    
5.International Consultation on Environmental Tobacco Smoke (ETS) and Child Health. Consultation Report, WHO, 1999. Available from http://old.ash.org.uk/html/passive/html/who-ets.html   Back to cited text no. 5    
6.Pbert L, Moolchan ET, Muramoto M, Winickoff JP, Curry S, Lando H, et al. The State of Office-Based Interventions for Youth Tobacco Use. Pediatrics 2003;111:e650-60.   Back to cited text no. 6    
7.Davis JM. Tobacco Cessation for the Dental Team: A Practical Guide Part: I background and overview. J Contemp Dent Pract 2005;3:158-66.  Back to cited text no. 7    
8.WHO: Tobacco-related Oral Mucosal Lesions and Dental Diseases 4.7. Available from: http://www.whoindia.org/SCN/Tobacco/Report/03-Chapter-04.7.pdf  Back to cited text no. 8    
9.Committee on Substance Abuse. American Academy of Pediatrics Committee on Substance Abuse. Tobacco′s toll: implications for the pediatrician. Pediatrics 2001;107:794-8.   Back to cited text no. 9    
10.DiFranza JR, Rigotti NA, McNeill AD, Ockene JK, Savageau JA, St Cyr D, et al. Initial symptoms of nicotine dependence in adolescents. Tob Control 2000;9:313-9.   Back to cited text no. 10    
11.Sanchez del Mazo -- May 2005. Youth Smoking Cessation - What can we do? Available from: http://www.fhi.se/Documents/Vart-uppdrag/tobak/youth-smoking-cessation-0505.pdf.   Back to cited text no. 11    
12.University of Minnesota, Department of periodontology. Tobacco use: a pediatric disease. Available from: http://www1.umn.edu/perio/tobacco/tob_pediatric_disease.html   Back to cited text no. 12    
13.Wyne AH, Chohan AN, Al-Moneef MM, Al-Saad AS. Attitudes of General Dentists about Smoking Cessation and Prevention in Child and Adolescent Patients in Riyadh, Saudi Arabia. J Contemp Dent Pract 2006;1:35-43.  Back to cited text no. 13    
14.Gansky SA, Ryan JL, Ellison JA, Isong U, Miller AJ, Walsh MM. Patterns and correlates of tobacco control behavior among American Association of Pediatric Dentistry members: a cross-sectional national study. BMC Oral Health 2007;7:13.  Back to cited text no. 14    
15.Kast KR, Berg R, Deas A, Lezotte D, Crane LA. Colorado Dental Practitioners′ Attitudes and Practices Regarding Tobacco-Use Prevention Activities for 8- Through 12-Year-Old Patients. J Am Dent Assoc 2008:139:467-75.   Back to cited text no. 15    
16.Shelley D, Cantrell J, Faulkner D, Haviland L, Healton C, Messeri P. Physician and dentist tobacco use counseling and adolescent smoking behavior: results from the 2000 National Youth Tobacco Survey. Pediatrics 2005;115:719-25.  Back to cited text no. 16    
17.Dolan TA, McGorray SP, Grinstead-Skigen CL, Mecklenburg R. Tobacco control activities in U.S. dental practices. J Am Dent Assoc 1997;128:1669-79.  Back to cited text no. 17    
18.Shenkin JD, Horowitz AM, Drury TF, Kanellis M. Attitudes of pediatric dentists towards tobacco intervention for children and adolescents: a pilot survey. Pediatr Dent 2003;25:53-60.  Back to cited text no. 18    
19. Gregorio DI. Counseling Adolescents for Smoking Prevention: A Survey of Primary Care Physicians and Dentists. Am J Public Health 1994;84:1151-3.   Back to cited text no. 19    
20.Goodman H S., Vargas C M. Shenkin J D, Horowitz A, Lin J. Maryland general and pediatric dentists′ attitudes regarding tobacco use prevention and cessation in their child and adolescent patients. Public health and the environment. APHA 2004. p. 6-10.   Back to cited text no. 20    
21.Hennrikus D, Rindal DB, Boyle RG, Stafne E, Lazovich D, Lando H. How well does the health history form identify adolescent smokers? J Am Dent Assoc 2005;136:1113-20.  Back to cited text no. 21    
22.Vergotine R J, Koerber A, Shires D. Pediatric Dentist′s role in Tobacco Counseling for Children: Parental Attitudes. IADR 86th General session and Exhibition.  Back to cited text no. 22    
23.Yee C, Gansky SA, Ellison JA, Miller AJ, Walsh MM. Tobacco control in pediatric dental practices: a survey of practitioners. Pediatr Dent 2008;30:475-9.  Back to cited text no. 23    
24.Fiore MC, Bailey WC, Cohen SJ, Dorfman SF, Goldstein MG, Gritz ER, et al. Treating tobacco use and dependence. Quick reference guide for clinicians. Rockville,Maryland: US Department for Health and Human Services, Public Health Service,October 2000. Available from: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2  Back to cited text no. 24    
25.Sussman S. Effects of sixty-six adolescent tobacco use cessation trials and seventeen prospective studies of self-initiated quitting. Tob Induc Dis 2002;1:35-81.  Back to cited text no. 25    
26.Hayden M, Hajek P, Bullen C, Feigin V: Rapid review smoking cessation programs. Non-NHS treatment. Available from: www.scsrn.org/policy_guidance/SmokingCessationNon-NHSFullReview  Back to cited text no. 26    
27. Mallin R. Smoking Cessation: Integration of Behavioral and Drug Therapies. Am Fam Physician 2002;65:1107-14.  Back to cited text no. 27    
28. Carr A, Ebbert J. Interventions for tobacco cessation in the dental setting. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD005084. DOI: 10.1002/14651858.CD005084.pub2.  Back to cited text no. 28    
29.Albert DA, Severson HH, Andrews JA. Tobacco use by adolescents: the role of the oral health professional in evidence-based cessation programs. Pediatr Dent 2006;28:177-87.  Back to cited text no. 29    
30.Johnson JG, Cohen P, Pine DS, Klein DF, Kasen S, Brook JS. Association between cigarette smoking and anxiety disorders during adolescence and early adulthood. JAMA 2000;284:2348-51.  Back to cited text no. 30    
31.American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. Guidelines for Health Supervision II. Elk Grove, IL: American Academy of Pediatrics; 1988.  Back to cited text no. 31    
32.American Academy of Pediatric Dentistry. Oral health policies. Policy on tobacco use. Reference manual v 30 / no 7. 08 / 09: 53-55.  Back to cited text no. 32    
33.Epps RP, Manley MW. A Physician′s Guide to Preventing Tobacco Use during Childhood and Adolescence. Pediatrics 1991;88:140-4.  Back to cited text no. 33    
34.Centers for Disease Control Youth. Tobacco Cessation: A Guide for making informed decisions Chapter 3. Selecting a cessation intervention for youth. Available from: www.cdc.gov/tobacco/quit_smoking/cessation/youth_tobacco_cessation  Back to cited text no. 34    
35.Nicotine replacement therapy: guidance for health professionals on changes in the licensing arrangements for nicotine replacement therapy Ash, London, December 2005. Available from: www.nrt_guidance_uk_1205.  Back to cited text no. 35    
36.Killen JD, Robinson TN, Ammerman S, Hayward C, Rogers J, Stone C, et al. Randomized Clinical Trial of the Efficacy of Bupropion Combined with Nicotine Patch in the Treatment of Adolescent Smokers," Stanford University School of Medicine. J Consult Clin Psychol 2004;72:729-35,   Back to cited text no. 36    
37.Moolchan ET, Robinson ML, Ernst M, Cadet JL, Pickworth WB, Heishman SJ, et al. Safety and Efficacy of the Nicotine Patch and Gum for the Treatment of Adolescent Tobacco Addiction. Pediatrics 2005;115;e407-14.  Back to cited text no. 37    
38.Hurt RD, Croghan GA, Beede SD, Wolter TD, Croghan IT, Patten CA. Nicotine patch therapy in 101 adolescent smokers. Arch Pediatr Adolesc Med 2000;154:31-6.  Back to cited text no. 38    
39.Klesges LM, Johnson KC, Somes G, Zbikowski S, Robinson L. Use of nicotine replacement therapy in adolescent smokers and nonsmokers. Arch Pediatr Adolesc Med 2003;157:517-22  Back to cited text no. 39    
40.Thawani V, Pande S, Turankar A. Nicotine replacement drug being sold on pavement shops. Indian J Pharm 2003;35:402-3.  Back to cited text no. 40    
41.Etter JF. Addiction to the nicotine gum in never smokers. BMC Public Health 2007;7:159.  Back to cited text no. 41    



 
 
    Tables

  [Table 1], [Table 2]


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    Introduction
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    Effects of Tobac...
    Adult vs Childre...
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    Best Practices
    Brief Interventions
    Environmental To...
    Nicotine Replace...
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