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Viewing tobacco use through structural framework can help pediatricians disrupt cycle of addiction :

December 21, 2020

Jamie, a 34-year-old mother of two, started smoking as a teenager and now smokes about a pack a day. She quit during her pregnancies but started smoking again after her children were born. Both kids have asthma. Jamie knows smoking is bad for her and her children’s health. She has tried to quit many times but has been unsuccessful. She used the patch for a few weeks through her state helpline but is unemployed and couldn’t afford to continue paying for it. Jamie was fired from her job because she missed work due to her kids’ asthma. She is chronically stressed and says the only way she can relax is by going to her back porch to smoke — her version of a “trip to Hawaii.” Recently, Jamie found her 10-year-old son with one of her cigarettes.

Jamie is one of millions of people struggling with nicotine addiction, a chronic, relapsing and remitting disease. Because the vast majority of adults addicted to tobacco started using products in adolescence, tobacco dependence is considered a pediatric disease.

Tobacco use and exposure are more likely to occur in vulnerable and marginalized groups, including people living in poverty. Therefore, the consequences of tobacco use and exposure are more concentrated in people already more likely to face greater health and economic challenges.

Tobacco use often is viewed as a personal choice. A new AAP clinical report from the Section on Tobacco Control, however, proposes viewing tobacco use and dependence through a structural framework that calls attention to larger societal forces that lead people to use tobacco. The report, Health Disparities in Tobacco Use and Exposure: A Structural Competency Approach, is available at and will be published in the January issue of Pediatrics.

Pediatricians who gain a deeper understanding of structural factors perpetuating tobacco dependence may be better able to help families like Jamie’s break the cycle of tobacco use and addiction.

Societal forces in tobacco use

A number of structural factors promote and reinforce tobacco use, including targeting by the tobacco industry, lack of enforcement of age-of-sale laws, inferior access to health insurance and health care, poor access to cessation resources and economic stressors. Each of these forces perpetuates tobacco use. In turn, tobacco use perpetuates the user’s adverse health and economic situation.

Tobacco companies have long employed deceptive marketing techniques to recruit smokers from marginalized groups, including children; lesbian, gay, bisexual and transgender individuals; and people of color. Vaping companies are using some of the same tactics to attract youths to e-cigarettes.

A lack of universal basic health insurance and inadequate coverage of tobacco cessation medications approved by the Food and Drug Administration limit access to treatment smokers need to break the cycle of nicotine addiction.

Smoking is linked to unemployment, and those who are addicted to nicotine may find themselves in a cycle of poverty, which can be perpetuated — at least in part — by nicotine addiction.

Smoke exposure during pregnancy and early childhood can cause early childhood illnesses and has been linked to behavioral and learning issues. These illnesses and issues are associated with poor educational outcomes, which also can perpetuate the cycle of poverty. Children whose parents smoke are more likely to smoke themselves,giving rise to new generations addicted to nicotine and susceptible to the same economic hardships.

Role of the pediatrician

Pediatricians are optimally positioned to help disrupt the cycle of tobacco use and addiction. They have trusting relationships with parents, and parents often see their child’s pediatrician more than they see their own doctors. Parents and pediatricians also share the goal of optimal health for children and families.

The clinical report advises that pediatricians view family tobacco use as a social determinant of health, systematically screen for tobacco exposure and offer tobacco-dependence treatment to caregivers who smoke.

The report also includes suggestions for systems-level interventions for pediatricians to support families in breaking the cycle of nicotine addiction. These include advocacy to end predatory targeting by the tobacco industry, ensuring basic health coverage for all and advocating for employers to provide effective tobacco dependence treatment to employees who smoke.

To break the cycle of nicotine addiction, pediatricians must engage on a patient level and a systems level. Viewing tobacco use and dependence through a structural framework can disrupt patterns of tobacco use and increase opportunities for children and their caregivers to live healthy, tobacco-free lives.

Dr. Marbin is a co-author of the clinical report and a member of the AAP Section on Tobacco Control Executive Committee.

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