Nicotine Addiction in Adolescence

Introduction

Today’s adolescents are serving as lab rats while the FDA and other health organizations determine the long term effects of e-cigarette and vape use. Introduced to the global market in 2005, e-cigarettes have become an epidemic. Due to clever marketing, ease of use, candy-like flavors, and misinformation, e-cigarettes have consistently grown in popularity. Particularly concerning is the recent spike in use amongst late elementary and middle school aged youth. In 2019 more than 5 million middle and high school students used e-cigarettes this was up from 3.6 million the previous year (Yale Medicine, 2021). With long term lung and brain related side effects amplified by adolescent brain chemistry and spread primarily due to peer pressure and breakdowns in the family system, family-focused, attachment-based intervention and peer-led prevention are most likely to yield positive outcomes.

Attachment-Based Intervention

The theories best suited for intervention with adolescent substance use reflect the recent shift away from individual treatments towards a relational therapeutic lens. Addiction does not happen in a vacuum. Studies have repeatedly shown that low stress, cohesive social structure, and supportive connection correlate to better mental health outcomes and less substance abuse. While chemical dependency has a strong biological component, “numerous studies since Rat Park have shown the importance of environment in influencing human drug use, particularly in early years” (Gage & Sumnall, 2019, p. 921). An attachment-based, relational-cultural approach is the best intervention for Adolescent nicotine addiction and prevention.

It is important to adapt the attachment-based, relational-cultural model to the specific needs of the adolescent population. The two highest impact social attachment spheres for young teens are: peer groups and the family system respectively. It is impossible to separate these intervention areas from one another as they share a cyclical relationship. Youth with high stress, disorganized households are less likely to form healthy peer attachments. And socially struggling teens are more likely to create distress in their households. The intervention therefore, must be two-pronged. Attachment-based family therapy will incorporate all willing parties of the adolescent’s family in the therapeutic process. Simultaneously, peer-led prevention campaigns will prevent misinformation and lower social group pressure to use e-cigarettes.

Adults and families have significant influence on adolescent behavior. A network-based analysis of three New York middle schools revealed that students who had no connections to adults were 4.7 times more likely to be a Recent EVP User versus Resolute Nonuser. Isolation from adults is consistent with lower school bonding and less help seeking (Wyman et. al, 2021, p. 5). Research on effects of home life found that adolescents were over two times more likely to use e-cigarettes if their parents owned one (Pentz et. al, 2015, p. 76). In addition to cigarette access, “substance abuse is predicted by factors such as low family cohesion, family member enmeshment, and a parenting style known as affectionless control”. Youth addiction typically indicates a “lack of trust that another is capable or willing to respond to their interpersonal and relational needs” (Lewis, 2020, p. 4). While it is not always the case, substance use can be used as a cry for connection. Parents influence teen addiction but it is important to avoid parent blame.

The first step of attachment-based family therapy is inviting the family to attend. Family involvement “increases treatment entry, enhances treatment completion and is also linked with better treatment outcomes” (Lewis, 2020, p. 2). It is critical to remain positive without implying that parents are somehow responsible for their adolescent’s disorder (Lewis, 2020, p. 4). Some studies have found that parents writing their child a letter inviting them to join when they feel ready and acknowledging a family-wide desire to change surprises teens and sparks their curiosity. Once the family is in attendance the therapist identifies breakdowns in family discourse with the understanding that family discourse is “derived from historical experiences and material which is intergenerational (Lewis, 2020, p. 2). The primary therapeutic goals are: understand generational patterns, and facilitate rebuilding of a secure family base.

John Byng-Hall’s describes a “secure family base” as one from which an adolescent can safely explore their social world (Lewis, 2020, p. 6). Many families present with narratives of contests for domination, patterns of threat and counter-threat, and adolescents testing their power through threat, withdrawal, self-harm, and substance use. These behaviors usually begin in an absence of family dialogue and proximity seeking (Lewis, 2020, p. 3). The therapist serves as a mediator and partner with which families role play new communication techniques and emotional regulation in a safe environment. When emotions are volatile, “parents are encouraged to regather their self-control and then return to seek dialogue” (Lewis, 2020, p.7). Over time changes in communication style and experiencing affects leads to shifts in the functional operation of the family (Lewis, 2020, p. 3).

It has been repeatedly shown that attachment and communication skills learned in the family of origin extend out into other social spheres. A 2020 study of middle school social networks found that peers are major drivers of adolescents’ decision to use electronic vaping products. Vaping is a highly social activity and peer groups are the most common setting for use (Kinouani et. al, 1). It has not been shown that changing a students perception of e-cigarette harm has an effect on use (Kinouani et. al, 6) but it has been shown that adolescent behavior is easily persuaded by in-group peer messaging. Psychologists used this fact to develop a clever intervention “Above the Influence of Vaping (ATI-V)” where fifty peer-nominated students were selected and trained to decrease substance use through informal peer communication. The 50 nominees represented 21.7% of the student body, but they exposed 80% of students to messaging the majority of which was received favorably (Wyman et. al, 2021, p. 2-4).

Multiple areas of influence were targeted. Peer influence encompasses several domains, including actual peer use as a modeling influence, perceived peer social norms for use, and peer pressure to try substances (Pentz et. al, 2015, p. 75). It is common for young nicotine users to overestimate the prevalence of vaping. This gives the sense that vaping is widespread (descriptive norms) and has positive social consequence (injunctive norms). Peer leaders can disseminate accurate information about use numbers and consequences of use. Recent EVP users were as integrated in the social networks as users and non-users which means all types of students received more accurate information as well as positive feedback for not vaping. The experiment results showed that a significant number of potential users moved to the adamant non-user category after 12-16 weeks of peer messaging (Wyman et. al, 2021, 1-2). Enacting further peer-led social interventions will begin to tip e-cigarette attitudes in a healthier direction.

It may not seem intuitive that chemical dependence and teen novelty seeking can be successfully approached with attachment theory. This intervention is based on a growing body of knowledge which suggests substance use emulates the positive, socially-linked neurotransmitters present in healthy human connection. It is especially dire that developing brains learn to receive serotonin, oxytocin, dopamine and related chemicals from human interaction. Teaching healthy attachment while the brain prunes, and myelinates itself increases likelihood of relational success for the remainder of the lifespan. The concept of an “internal working model” explains how early relationship experiences are carried forward as enduring styles of interpersonal relations and modes of regulating affects” (Lewis, 2020, p. 2). A healthy internal working model lowers risk of substance becoming the only available delivery mechanism of connectedness and joy. 

Nicotine Addiction

According to the National Institute of Drug Abuse, “about 23.6 million” people are addicted to nicotine in the United States (NIDA, 2022). Nicotine delivery can come from traditional cigarettes, gum, chews, or e-cigarettes. While trends in smoking cigarettes have gone down, the past five years have shown a concerning increase in teen nicotine dependence, attributed to the rise of e-cigarettes. The NIDA reports that an “estimated 7.1% of 8th graders, 14.2% of 10th graders, and 20.7% of 12th graders report nicotine use in the last 30 days” (NIDA, 2022). Not everyone who uses nicotine will become addicted. Around 80-90% of people who smoke regularly will become addicted (SmokeFreeVeteran, 2024).

Nicotine acts on the pleasure and stress systems in the brain. The effects depend on quantity, age, and sex. Nicotine mediates its effects via nicotinic cholinergic receptors (nAChRs), pentameric ligand-gated ion channels that are widely distributed throughout the brain (Leslie, 2020, p. 196). A large majority of nAChRs binding occurs in the prefrontal cortex, which is enriched in dopamine terminals, especially in adolescents (Leslie, 2020, p. 197). Dopamine controls survival instincts related to feelings of pleasure and motivation. It is also the primary neurotransmitter acted on in opioid addiction. Drugs that act on dopamine can be uniquely difficult to quit. For all addictions in the United States only 20% (or fewer) of individuals with substance use disorders seek treatment.  Among those who receive treatment, approximately 50% drop out of treatment. (Kourgiantakis, T., & Ashcroft, R., 2018, p. 2). Removing nicotine as a source of dopamine during cessation leads to a variety of adverse effects.

While many people every year are able to quit smoking on their own, withdrawal from nicotine is uncomfortable at best, and in some cases debilitating. Abrupt cessation of nicotine use in dependent smokers results in withdrawal symptoms that include bradycardia, insomnia, gastrointestinal discomfort, anger, anxiety, craving, depression, difficulty concentrating, impatience, insomnia, and restlessness. Similar to opioid withdrawal, quitting nicotine can result in avoidance behavior, weight gain, and decreased reward sensitivity (Leslie, 2020, p. 198). Many people cite e-cigarettes as a way of weening themselves from traditional cigarette which deliver far more carcinogens to the lungs. Doctors recommend gum or other nicotine replacement techniques be used instead. Vapor delivery eliminates tar but it is not without its own health risks. 

In 2019, the Centers for Disease Control and Prevention (CDC) advised people avoid e-cigarettes while officials investigated a nationwide outbreak of severe lung injuries. The condition, later named “e-cigarette, or vaping, product use associate lung injury” (EVALI) affected large groups of people nationwide. According to the CDC, 15% of these EVALI patients were below the age of 18 (Yale Medicine, 2021) making this an especially important intervention demographic. The good news is the high plasticity teen brain is usually able to quit all forms of smoking with less withdrawal symptoms. In addition, male adolescents have been found to exhibit less prominent somatic withdrawal symptoms than adults (Leslie, 2020, p. 198).

Nicotine in Adolescence

The rapidly changing, dopaminergic adolescent brain is like a super-magnet of nicotine receptors with more dopamine binding terminals in the prefrontal cortex, an area of the brain responsible for executive function. Adolescents of both sexes are more sensitive than adults to the rewarding effects of nicotine, as shown in conditioned place preference tests with some studies demonstrating reward after a single pairing of drug and context (Leslie, 2020, p. 198). Exogenous sources of dopamine during this sensitive time can dull the pleasure response and inhibit full executive function development. VTA dopamine neurons are more sensitive to nicotine-induced synaptic plasticity in adolescents than adults. Serotonin systems are also uniquely sensitive to nicotine during adolescence (Leslie, 2020, p. 197). This can result in dulled pleasure centers and increased likelihood of anxiety and depression.

If nicotine use is high, damage to pleasure centers and impulse control can increase susceptibility for future drug addiction, particularly with men and dopamine based stimulants. Studies have shown that “90% of cocaine users smoked before they began drug use, and that cocaine dependence is highest among users who initiated cocaine use after tobacco use”. Teen smoking is associated with “greater psychostimulant use and poorer treatment outcomes” (Leslie, 2020, p. 200).

Recent lab-based rat studies found significant differences in nicotinic effects between the sexes. This could be a result of the male brain having larger fluctuations in dopamine receptors during the teenage years. The largest nicotine related dopamine release occurred in male rats during early adolescence, with females showing no significant age differences. Men and women have also reported differences in anxiolytic response to nicotine treatment. Men showed a higher anti-anxiety effect which diminishes with age, whereas adolescent females have much lower anxiolytic or outright anxiogenic responses (Leslie, 2020, p.197-198).

The dopamine driven, novelty seeking teen brain is significantly less likely to respond to campaigns that warn against the dangers of smoking. Danger is unlikely to deter many teens who feel they have years ahead of them, and respond primarily to in-group peer influence. From a developmental perspective, coming of age requires a large neurological push out of the family-system “nest”. This time of identity formation and autonomy leads the majority of teens to focus on peer acceptance. While parental use of e-cigarettes directly correlates to teen use, social contact and attitudes are the largest influence. For this reason, a top-down adult-led campaign will not be as effective as a peer-led social diffusion of anti-vaping attitudes.

Current attitudes toward vaping are based largely on misinformation. When Los Angeles students were surveyed why they use e-cigarettes the top motivators were: curiosity, smoking cessation, reduction of tobacco smoking, less harm compared to tobacco smoking, copying friends, and to a lesser extent, as a substitute when tobacco smoking is banned. Entourage influence played a large role in students beginning to smoke. Another concerning statistic revealed that 40% of subjects with significant urinary cotinine in a recent study reported that they thought they used only nicotine-free products (Leslie, 2020, p. 196). Education could prevent students from using nicotine without their realization, and aid in healthy development of executive function.

Determining correlation and causation can be difficult when comparing teen nicotine use, further drug use, and executive function development. Each of these has an effect on the others. It is especially important to help high risk youth avoid e-cigarette addiction while their prefrontal cortex develops in order to avoid exacerbating future high risk behaviors. In early adolescents, problems or deficits in EF have been found to increase risk for cigarette and alcohol use, as well as other potentially addictive behaviors such as excessive videogaming and dysregulated eating. Training early adolescents in EF skills has shown longitudinal effects on preventing cigarette and alcohol use, creating a positive feedback loop (Pentz et. al, 2015, p. 75).

Biopsychosocial Model

The feedback loops of attachment wounding, substance use, prefrontal cortex development, peer relations, and family dysfunction are a primary example of the biopsychosocial model. Substance use is significantly less likely for youth who have calm, supportive homes and healthy peer connections. It is becoming more common for addiction studies to consider neurobiological and psychodynamic perspectives in a developmental model, linking attachment wounding to addiction. One neurobiological model of addiction suggests that deficits in a person’s ability to derive rewards from sustained interpersonal or intimate relationships impels reward seeking through the repeated use of psychoactive substances which stimulate these same dopaminergic brain regions (Lewis, 2020, p. 4). For these reasons attachment-based interventions and social support are the key to breaking the feedback loop.

Adolescent biology predisposes them to novelty seeking behavior. It is important to expect and embrace this as part of healthy social development. Desire for autonomy can be directed in healthy ways such as sport, study, or peer relations, helping to build a sense of industry. During this time prior to development of executive function, school curriculum can intervene by teaching discernment and impulse control. Executive function is a skill that can be trained. Intervening at the youngest possible age will prevent adolescence, especially adolescent men, from becoming more susceptible to stimulant addiction.

Psychological well being can be upheld with a healthy, securely-attached home environment. Children with less adverse childhood experiences (ACEs) are less likely to be diagnosed with substance use disorder and mental illness. Many diagnoses pathologize problems with community and social support. There are animal studies in which exposure to early life stressors predispose to later substance use which point to neural mechanisms involving alteration of neural reward pathways and separation distress regulation (Andersen, 2019, p. 50). Another line of animal research has proposed gender specific pathways beginning in adolescence. Females predisposed to a heightened stress response are more liable to seek substances as a means of ameliorating high stress reactivity. Males are more likely to respond to chronic stressors with a blunted stress reactivity and their attraction is to substances which increase arousal, increase social capacity, or provide novel sensation such as cocaine and methamphetamine which block dopamine reuptake, and increase dopaminergic activity (Lewis, 2020, p. 4). Addiction, especially in teens, is a social problem with biological consequences.

Conclusion

Adolescence is a high impact time for biopsychosocial development. Social skills and attachment styles formed in adolescence are reinforced through myelination and negative effects of substance use can be equally long lasting. While it is valuable for parents, teens, and practitioners to understand the negative effects of nicotine, the most impactful intervention takes place on a social level. Using attachment-based family therapy to foster a low-stress, securely attached home environment increases likelihood that a teen will develop healthy peer relations. After achieving a healthy peer group, peer-led social dissemination of anti-vaping attitudes can prevent the growth and continued use of nicotine during these pivotal years of brain development. 

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