Topic 2 Definitions of Tobacco Use among Children and Adolescents

Generally, tobacco use can be defined as any habitual use of the tobacco plant leaf and its products.

While the predominant use of tobacco is by smoke inhalation of cigarettes, pipes, and cigars, there are smokeless tobacco products that either sniffed, sucked, or chewed. Moreover, in recent years there has been a rise of electronic cigarettes (or e-cigarettes) and other novel and emerging nicotine- and tobacco-containing products, such as heated tobacco products (HTPs). Although e-cigarettes do not contain tobacco, and may or may not contain nicotine, it is necessary to take them into account as well due to the rise of the popularity of these products. According to WHO’s report (2020), due to long-lasting and damaging effects on the developing brain the exposure to a highly addictive substance like nicotine can have, both e-cigarettes and HTPs are particularly risky when used by children and adolescents.

Directive 2014/40/EU of the European Parliament and of the Council of 3 April 2014 on the approximation of the laws, regulations and administrative provisions of the Member States concerning the manufacture, presentation and sale of tobacco and related products and repealing Directive 2001/37/EC states that “Member States should be encouraged to prevent sales of such products to children and adolescents, by adopting appropriate measures that lay down and enforce age limits” (p.6). Given that in 26 Member States, the minimum age to purchase tobacco is 18 years, while in Austria and Belgium children from 16 years of age can purchase tobacco, any tobacco use among children and adolescents is problematic.

DSM-5 defines Tobacco Use Disorder as a problematic pattern of tobacco use leading to clinically significant impairment or distress, as manifested by at least two of the symptoms presented in Table 3 on the next slide. If there are 2-3 symptoms present, it is considered to be a mild form, if there are 4-5 symptoms moderate, and if there are 6 and more severe.

ICD-11 defines nicotine dependence as a disorder of regulation of nicotine use arising from repeated or continuous use of nicotine.

Table 3 Comparison of diagnostic criteria for problematic tobacco use in ICD-11 and DSM-5

Diagnostic criteria ICD-11 Nicotine dependence DSM-5 Tobacco Use Disorder

Consumed in larger amounts or over a longer period than was intended

There is a persistent desire or unsuccessful efforts to cut down or control the use

A great deal of time is spent in activities necessary to obtain or use it

Craving, or a strong desire or urge to use

Continued use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the use

Important social, occupational, or recreational activities are given up or reduced because of the use.

Important social, occupational, or recreational activities are given up or reduced because of the use.

Recurrent use in situations in which it is physically hazardous

Recurrent use resulting in a failure to fulfil major role obligations at work, school, or home

The use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the use

Tolerance

Withdrawal

ICD-11 also defines nicotine intoxication as a clinically significant transient condition that develops during or shortly after the consumption of nicotine that is characterised by disturbances in consciousness, cognition, perception, affect, behaviour, or coordination (such as restlessness, psychomotor agitation, anxiety, cold sweats, headache, insomnia, palpitations, paraesthesia, nausea or vomiting, abdominal cramps, confusion, bizarre dreams, burning sensations in the mouth, and salivation, and in rare instances paranoid ideation, perceptual disturbances, convulsions or coma) caused by the known pharmacological effects of nicotine and their intensity is closely related to the amount of nicotine consumed. These effects are time-limited and abate as nicotine is cleared from the body.

Nicotine intoxication occurs more commonly in non-tolerant users or among those taking higher than accustomed doses, and therefore is important to be recognized in children and adolescents.