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Smoking among teenagers is on the rise. Statistics have shown that smoking trends were decreasing between 1976 and 1985 by approximately 10%, but have started to climb since the early 1990’s (Lawrence 1999). Over the last decade, there has been more than a seventy- percent increase in youth smoking. More than sixty-seven thousand children in Ohio become addicted to tobacco. The average age of onset of smoking is fourteen years old. Ninety percent of those who smoke began before the age of eighteen. (www.healthierohio.org.). Not all adolescents are at the same risk level to smoke. Studies have been done that demonstrate who is at more risk to smoke than others are, but adolescents of every race, socioeconomic, and sex are affected. Smoking rates are more than doubled among white adolescents than African American adolescents are. “Children who are more committed to education, religion, and family are, in general, at lower risk for cigarette use” (Lawrence, 1999, p699). Besides race, sex, and class, which influence tendencies to smoke, we also need to take into factor other variables such as peer influence, “sociodemograpic (geographic region and urbanicity of residency, parental education, number of parents in the home) and lifestyle (grade point average, truancy, work experience, student’s weekly income, religious activities, and peer activities) that are independent predictors of cigarette use.” (Lawrence, 1999, p.700).

Epidemiology of Adolescent Smoking

Epidemiology is “ the study of the distribution of health and illness within the population and the factors that determine the population’s health status.” (Clark, 1999, p 144). The major concepts that define epidemiology are that it is population-focused,

Adolescents and Smoking 4

consists of the natural history of the disease, the levels of prevention, the epidemiological triad, and all of the risk factors that contribute to the onset of the disease, or in this case, addiction. Smoking is not a disease, but it is an addiction that usually begins among high school students. An addiction is a compulsive psychological need for a habit-forming substance such as nicotine.

There are eight major risk factors that contribute to adolescent smoking. The first one is the social influences (an environmental factor) in a teen’s life. There are two types of social influences, direct and indirect. The direct social influences are all of the effects that peers and family have on a youth smoking. Peers demonstrate to each other the ease of obtaining cigarettes and the message that smoking is a normal and necessary aspect of the peer group. (Lamkin 1998). Parental influences regarding smoking has shown to “be a significant, general factor promoting youth smoking, even greater than peer smoking and socioeconomic status.” (Males, 1995, p228). The indirect social influences include the effects of the media and tobacco advertisers. They create a positive attitude related to smoking in adolescent’s minds. “Adolescents are more likely to believe information presented by sources when less certain about their own opinions.” (Lamkin, 1998, p129). Tobacco-industry documents show that they have been targeting youth as young as nine years old through their advertisements. The top three brands that are advertised the most to target youth are Marlboro, Camel, and Newport. (www.healthierohio.org.)

The next risk factor, psychological factors (environmental factor), consists of two parts. The first is depression or negative affect in adolescents. Depression is a risk factor because smoking because it helps an adolescent to deal with their emotions and feeling of

Adolescents and Smoking 5

stress. The second is self-efficacy. An adolescent’s level of self-efficacy determines whether coping behaviors will be used successfully in the face of obstacles. Therefore, by ensuring that an adolescent feels confident about himself to abstain from smoking would eliminate this risk factor. (Lamkin 1998).

The race (host) of an adolescent as a predictor of smoking is more prevalent in some races more than others are. In the MMWR (April 1998), it states that Caucasian high school students have a higher rate of use and risk versus Hispanic and Black students. Substantial increases in smoking have occurred over the last decade in all races, but especially among White students. (Lawrence 1999). “In a recent Ohio study, 80% of African-American parents said they have a “no smoking” rule in the home as compared to 48% of white parents” (www.healthierohio.org).

The fourth risk factor of youth smoking is the sex (host) of the adolescent. Overall, females have greater risk of onset of smoking than males. This stays true throughout the races studied. There is a particular vulnerability to smoking especially among white female students, who consistently hold the highest rates among all of the groups studied. (Lawrence 1999). For example, 39.9% of White females smoke and 39.6% of White males smoke. (MMWR 1998).

Social bonding (environmental factor) is a predictor of smoking that includes the adolescent’s family and peer bonding, school influences, and religiosity. Conrad (1992) found that 71% of the subjects studied, there was a correlation between social bonding and a risk of smoking.

Adolescents and Smoking 6

Interpersonal, personality, and self-image (environmental factor) of adolescents are predictors of smoking. Students who exhibited rebellious, risk taking, shyness, submissive, and aggressive behaviors were all found to be positive predictors to the onset of smoking. (Conrad 1992).

Intentions (environmental factor) to smoke predicted the onset of smoking 89% of the time. Intentions to smoke means that the adolescent intended to smoke when they got older. This is a higher risk factor for high school students than any other grade level. (Conrad 1992).

The final risk factor of adolescent smoking is previous exposure (agent). Other exposure to alcohol use and other substance use such as marijuana consistently predicts the onset of smoking in adolescents. (Conrad 1992) With these risk factors, this will explain how the natural history of disease affects adolescents and smoking.

The natural history of smoking involves the prepathogenesis, early, middle, and advanced pathogenesis period. Only the prepathogenesis and the early pathogenesis stages involve the high school adolescent. The prepathogenesis period takes into account the interrelations between the agent, host, and environmental factors. This period is the pre-exposure or susceptibility that the host has. The definition of the host is a person or organism that is capable of being infected by the agent. In this case, it is the high school student. The agent is the primary cause of a health-related condition, or the cigarette. The environment is all of the external conditions and influences that affect life and the host’s development. This includes the host’s influence that is from peers and parents, their lifestyle and school performance, sociodemographic characteristics (such as poor

Adolescents and Smoking 7

home environment), and the positive portrayal of cigarette smoking within the media, movies, magazines, etc. The previous factors are all prepathogenesis, before the high school students begins to smoke.

Early pathogenesis is in the preclinical stage. The agent, a cigarette, is introduced to the host at this time. In other words, the adolescent takes his first smoke on a cigarette. During the middle pathogenesis, tissue and physiologic changes occur. For example, the inhalation of cigarette smoke increases airway resistance, reduces ciliary action, increases mucus production, causes thickening of the alveolar-capillary membrane, and causes bronchial walls to thicken and lose their elasticity. (Taylor 1997) Signs and symptoms of addiction or withdraw also begin to occur now. “Nicotine addiction develops over the course of five stages in adolescents, with a progression starting with initial trying and ending with nicotine addiction.” (Lamkin, 1998, p 130) There is typically a two or three year interval from the initiation of smoking to addiction of nicotine. Over one half of adolescents who try to quit smoking suffer from withdrawal symptoms. Illness and disability occur in the final stage, advanced pathogenesis. Some example of illness and disease that are caused by smoking include lung cancer, cardiovascular disease, and hypertension. Short-term effects include cough, dyspnea on exertion, decreased overall fitness, phlegm production and respiratory illnesses. Middle and advanced pathogenesis have to do with the long term effects of smoking, therefore, is not an immediate effect of high school students.

Adolescents and Smoking 8

The Epidemiological triad enables us to see how the host, environment, and agent react when they come together. The model shows us how and why adolescents begin to smoke cigarettes.


High school adolescents

Ages 14-19, females 39.9%,males 39.6%

All ethnic backgrounds, higher in Caucasians

Agent Environment

Cigarettes Effects of dealing with

Emotions, attitudes/beliefs

Parental smoking, social

Influence, intentions, previous

Exposure, and psychological


Adolescents and Smoking 9

The progression from pre-exposure to resolution of adolescent smoking begins during the prepathogenesis period. During this period, the host, environment, and agent all come into play. The host, or adolescent and their environment interact. The more environmental factors that influence the host, the more their risk for smoking increases. The agent, or cigarette is then introduced. When all 3 factors of the epi triad are introduced to each other, what is left is a high school student with a high probability of smoking

Once we identify the risks of smoking, we now have an adolescent who has begun to smoke cigarettes. This is the first step in the process of becoming a smoker, initiation (trying the first cigarette). Next, experimental smoking occurs (less than weekly). The end result, or step three of the process, is a regular smoker (at least weekly). (Whaley and Wong 1999) The nicotine from the cigarette produces a feeling of “well-being, increases mental acuity and ability to concentrate, and heightens one’s sense of purpose. Nicotine may also exert a calming effect on the smoker” (Clark, 1999, p 864). Unfortunately, it is an abusive substance.

There are two possibilities for the resolution of smoking. The adolescent can either continue smoking throughout his or her lifetime, resulting in a chronic disease or illness, or quit smoking before any severely damaging effects occur.

Orem’s Self-Care Deficit Theory of Nursing

Dorothea Orem’s nursing model is based on the belief that the individual has a “need for self-care actions and that nursing can assist in meeting that need to maintain life, health, and well-being.” (Taylor,1997, p73) The activities that one carries out on

Adolescents and Smoking 10

their own behalf are called self-care. There are three categories of self-care requisites that will be looked into in further depth in relation to smoking, universal, developmental, and health deviation requisites.

Universal Self-Care Requisites


Air is the most significant requisite that is affected by smoking. The smoker will experience coughing, wheezing, and excessive sputum. Potential acute diseases of the lower respiratory tract include pneumonia, bronchitis, bronchiolitis, and in general, decreased lung function. There is also an increased risk of asthma in smokers.


Research suggests that heartburn is more prevalent in smokers than nonsmokers. This is said to be true because the lower esophageal sphincter (LES) keeps the acid solution in the stomach and out of the esophagus normally. Smoking decreases the strength of the valve, thus allowing reflux to occur towards the esophagus. The Surgeon General also said in 1989 that peptic ulcers are more likely to occur, less likely to heal, and more likely to cause death in smokers than in nonsmokers. (www.niddk.nih/gov/health/digest/pubs/smoke/smoking.htm.) The pain associated with ulcers has a definite relationship to eating because the food may cause pain and vomiting may relieve it. (Black 1997) Smoking has an influence on hunger, body weight, and nutrient status in an adolescent. Smoking eases feelings of hunger, therefore smokers

Adolescents and Smoking 11

tend to weigh less than nonsmokers, but also have a higher tendency to gain weight after quitting. (Whitney 1994) Since smoking often eases the feelings of hunger, females often smoke in order to maintain their weight. Smoking also has an effect on the taste buds, altering the taste of food.


Xerostomia or a feeling of dry mouth is a condition that affects 1000’s of people. It is a hypofunction of the salivary glands. Smoking is one of the factors that cause this condition. The depletion of the ascorbate levels contributes to the person’s quality of life by affecting their dietary habits, nutrition, and oral health. (www.accessnable.corn.au/handbook/drymouth.htm)


Research says that current and former smokers have a higher risk of developing Crohn’s Disease than nonsmokers do. It is slightly more prevalent in women and there is more risk of smoking in women than men. Theory suggests that the relationship between Crohn’s disease and smoking is that smoking may decrease the intestines defense system.


Activity and Rest

Smoking causes a decrease in overall lung function. Possible conditions that can interfere with the transfer of oxygenated blood to tissue (respiratory problems) can cause decreased activity in smokers. (Taylor 1997) Decreased lung function results in little or

Adolescents and Smoking 12

no exercise. Therefore, adolescents may rarely participate in gym activities. Smokers also experience anxiety in between cigarettes, which ultimately affects their rest.

Solitude and Social Interaction

This is one of the few requisites that smoking does not have a negative affect on adolescents. This is because one of the risk factors for smoking is peer influence. Therefor, teens usually have adequate sources of support that contribute to their onset of smoking. Even though their support received from their peers is negative (contributing to smoking, it is a group of friends for them to rely on.


Often, smoking results from daily stress. It is a way to cope with daily stresses that adolescents encounter. Adolescents often smoke in order to be a part of the crowd.


Smoking has the potential to cause many hazards. Forms of cancer, respiratory problems, peptic ulcers, asthma, and crohn’s disease are possible causes of death, all resulting from the onset of smoking.

Health Deviation Requisites

? Seeking and securing appropriate medical attention

Risk for upper respiratory infections due to smoking

Lack of money to obtain medical insurance

Lack of money to obtain assistance devices to quit smoking

Adolescents and Smoking13

? Being aware of and attending to the effects and results of pathologic conditions

Lack of education of diseases related to smoking, may consider symptoms of a serious disease to be those of a minor illness, a cold.

? Effectively carrying out prescribed diagnostic, therapeutic, or rehabilitative measures

Lack of money to fulfil prescribed diagnostic treatments

? Being aware of and attending to or regulating the discomforting or deleterious side

Effects of medical care

Adolescents experience frequent upper respiratory infections and asthma due to


? Modifying the self-concept in accepting oneself as being in a particular state of health and in need of specific health care

May not be able to quit smoking “cold turkey”

May not want or be able to quit smoking

May choose to smoke because it fits their lifestyle (high stress job, bar atmosphere)

? Learning to live with the effects of pathological conditions and the effects of medical care in a lifesytle that promotes continued personsal development

Students usually have upper respiratory infections and asthma.

Adolescents and Smoking 14

Developmental Requisites

According to Erikson, adolescents are going through a developmental stage characterized by identity versus role confusion. The transition from childhood to adulthood is occurring and hormonal changes are causing mood swings. It is characteristic of this stage for one to try on new roles, often rebellious ones, in order to acquire a sense of who one is and what direction life will take them. (Taylor 1997). The onset of adolescent smoking perfectly fits Erikson’s theory of identity versus role confusion. Smoking is a rebellious role against an adolescent’s authority figure, especially because it is an illegal activity before the age of eighteen. Teenagers often begin to smoke due to pressure and influence from peers. Smoking is an “adult thing” and teens try to experience a grown up activity. They are trying to get a sense of who they are as they are beginning to mature from childhood into adulthood.


The nursing plan is to educate high school students about the effects of smoking, the risk factors related to smoking, and to discourage the onset of smoking in adolescents. The plan consists of the nursing diagnoses that are developed. The nursing diagnosis has two parts, the problem, or goal, related to the etiology, or nursing intervention . We create the nursing intervention in order to correct the problem.

Adolescents and Smoking 15

Diagnostic Statements- In order of priority

1. Risk for smoking among adolescents related to poor self-esteem secondary to shyness and aggressive behaviors.

2. Risk for smoking among adolescents related to peer pressure secondary to social bonding.

3. Risk for smoking among adolescents related to illegal sales of tobacco secondary to poor policing of stores.

4. Risk for smoking among adolescents related to exposure to other substance use secondary to marijuana or alcohol use.

5. Risk for smoking among adolescents related to parental smoking.

6. Risk for smoking among adolescents related to influence by media (magazines, soap

operas, etc.)

7. Risk for smoking among adolescent females related to maintaining thinness or desired weight.

8. Risk for decreased appetite among adolescents related to cigarette use.

9. Risk for decreased exercise among adolescents related to the effects of smoking.

10. Risk for frequent upper respiratory infections among adolescents related to addiction to smoking.

11. Risk of negative acceptance related to nonsmokers.

Adolescents and Smoking 16

Rationalization for top three diagnosis

The priority diagnoses chosen are all related to each other because they all concern a risk for smoking. Therefore, action can be taken to help discourage teenage smoking before it occurs. We can educate adolescents on ways to help deal with and increase their low self-esteem. We can also educate adolescents how to handle peer pressure from friends who smoke. The final priority diagnosis does not deal directly with educating adolescents. Rather, it focuses around enforcing store policy regarding strict identification of tobacco sales to minors. Frequent policing needs to occur in these stores in order to stop tobacco sales to minors.

Priority diagnosis


This diagnosis has priority over the rest. The majority of the other diagnoses are related to a risk for smoking, which can be resolved through education. This one however, requires reaching out to those who do not seem self-confident and have low self-esteem. It requires watching out for those with behaviors at both ends of the spectrum, either shy or withdrawn or aggressive actions. Instead of educating these adolescents of their risks of smoking due to influences in their life, this diagnosis requires boosting their self-esteem so that they care enough about themselves to not smoke.


1. 75-80% of high school students will report that they do not or no longer smoke cigarettes.

Adolescents and Smoking 17

2. 95% of high school students will be educated about their risk factors and the effects of smoking.

3. Incidence of illegal sales of cigarettes to minors will decrease by 100% with in two years.


1. 80% of high school students will report a negative attitude toward those who smoke.

2. All stores that sell tobacco products will report having random inspections done in regards to illegal sales of cigarettes to minors.

3. The percentage of high school students who smoke will decrease by 60% within two years.

Levels of prevention

There are three levels of prevention, primary, secondary, and tertiary. Primary prevention precedes the disease or dysfunction. It is a health promoting and disease prevention intervention. The goal is to decrease the vulnerability of the targeted person or population.

Secondary prevention consists of early detection through screening and casefinding. The goal is to prevent complications and the sequelae of the disease. The level of prevention involves prompt treatment in order to cure the disease.

Tertiary prevention involves rehabilitation and hospice care. The goal is to restore the individual back to an optimal level of functioning within the constraints of the disability or condition. The individual will never have their full health again.

Adolescents and Smoking 18

Since we are dealing with high school adolescents, we will only be dealing with primary and secondary levels of prevention. It is very unlikely to have to deal with a young individual at the last stage of prevention.

Primary prevention

This level of prevention involves educating adolescents prior to their onset of smoking. Since the average age of onset of smoking is fourteen years old, intervention needs to occur in junior high schools and during the first year of high school. School nurses and health education teachers can help spread the message throughout schools. Adolescents need to be taught about the risk factors that they posses that make them vulnerable to smoking cigarettes. They also need to be told about the effects and complications of smoking. General health promotion will benefit the teens, as well. By getting the teens in the mind frame of positive health practices may help deter them away from smoking cigarettes.

Enforcing strict laws in stores that sell tobacco products about the consequences of being caught selling cigarettes to a minor will help greatly decrease the onset of adolescent smoking. Officers should patrol stores undercover so that store clerks would sell cigarettes as they normally do. They should patrol during key times of the day when adolescents are suspected to be purchasing cigarettes such as right before and after school lets out. They may be able to find alternative ways of obtaining cigarettes, such as an older friend that can purchase them, but by making it impossible for underage teens to purchase cigarettes themselves will aid in the decrease of teen smokers. The FDA contracts with the states to carry out compliance checks during which adolescents,

Adolescents and Smoking 19

accompanied by state or local officials commissioned by the FDA, attempt to purchase cigarettes from retailers. (www.fda.gov/opacom/campaigns/tobacco.html)

The media can play a positive role in the prevention of smoking. Television, movies, magazines, and billboards are all examples of sources of media that teens encounter every day that can relay this message. Magazines need to eliminate cigarette advertisements from their pages. The television and movies can help by portraying a negative image of smoking. Billboards aid in the prevention of smoking by advertising catchy phrases such as “Welcome to Loserville, Population You” portraying a young kid with a cigarette in his hand. Even though the media does encourage teens to smoke, by enforcing more positive messages than negative ones, maybe we can outweigh the results of the negative messages.

Secondary prevention

At this point, the adolescent has begun to smoke cigarettes. First, we need to encourage the individual to quit smoking. We need to provide assistance of ways to quit. For example, if he feels that he needs to smoke, suggest putting a piece of gum in his mouth. General tips such as avoiding peers when they are smoking and sitting in the non-smoking section of a restaurant will aid him by not putting him in the environment. Parents can play a major role in this level of prevention just by not condoning to smoking in the home or car.

The Tobacco Coalition provides a four-step program to quit smoking.

Step one involves writing down your reasons you want to quit smoking and reading it daily. Then wrap the pack of cigarettes with paper and rubber bands. When you smoke,

Adolescents and Smoking 20

write down the time of day and how important the cigarette is to you on a scale of one to five. Rewrap the cigarettes. During step two, continue reading the list of reasons and add to it when possible. Do not carry matches or a lighter with you and keep the pack of cigarettes out of reach. Each day, try to smoke less often. Continue with the second step during step three. Do not buy a new pack until the old one is completely finished. Change brands throughout the week, decreasing the amount of tar and nicotine with each pack bought. Try to stop smoking for forty-eight hours at one time. The final step is when you quit smoking completely. Doing deep breathing exercises when the urge to smoke hits helps make it through the desire to smoke. (www.healthierohio.org). This plan needs to be accessible to school officials and adolescents.

Early detection of smoking is the key to the resolution of smoking. If a student is caught smoking anywhere on school grounds or at a school activity, not only should they be reprimanded through the school for disobeying rules, but also a letter should be sent home to the parents to inform them of the illegal activity that their child is doing. Part of the punishment that should be included through the school is a mandatory health education class about the effects of smoking. The school can set up a class like this themselves, or possibly through the local hospital or health department.

An example of early detection and casefinding can include a lecture during their health education class about assessing their level of self-esteem and their vulnerability to peer pressure. When students are found to have low self-esteem or vulnerable to their peer pressure, they can be directed to perhaps the school nurse or guidance counselor to

Adolescents and Smoking 21

help them with this. Hopefully, through some guidance, the teen will be able to quit smoking.


This plan will need cooperation from everyone. Within the school district, members will have to come together to create programs for self-esteem and peer pressure classes, health education classes about the effects of smoking, and enforcing the faculty to address parents of their child’s behavior.

Law enforcement will play a major role in the plan to prevent adolescent smoking. Officers will have to patrol stores as often as possible and during sensible times of day.

The media needs to be encouraged to send messages to teens about the negative aspects of smoking and to ban tobacco advertisements that are aimed at young readers.


This plan would be simple to evaluate. Surveys would need to be conducted to compare the percentage of high school students who smoke prior to the plan and compare it with the amount of students who smoke each year to see if the plan is having an effect on the number of smokers. The surveys would need to be anonymous in order to avoid students lying about their habits due to fear of being caught.

If there is a substantial decrease each year, and then continue on with the designated plan. If the number of students who smoke is not decreasing, the interventions mentioned need to either be enforced more or adjusted.

Adolescents and Smoking 22

The key is to continue educating the students about the effects of smoking before they begin to smoke.


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