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Tobacco Control and Research in Pediatrics

August 21, 2023

Commentary From the Section on Nicotine and Tobacco Prevention and Treatment

Founded in 2012, the Section on Nicotine and Tobacco Prevention and Treatment is a group of pediatricians dedicated to raising awareness about the dangers of tobacco use and exposure, and to eliminating child and adolescent use of and exposure to tobacco products. To this end, we work to identify and disseminate the best evidence and to define practice guidelines to decrease risk from tobacco products; we conduct research and lead legislative efforts.

The seminal articles were chosen for their innovation and their contributions to medical science, advocacy, and policy change. You will notice the large proportion of articles selected from the last 25 years, underscoring the relatively recent growth in this important body of literature. We are so proud of the incredible work of pediatricians in addressing this enormous public health problem. We hope others may be as inspired as we are by our colleagues’ successes in this area.

Tobacco Control and Research in Pediatrics

Alice Little Caldwell, MD, MPH, FAAP1, Jose Cucalon Calderon, MD, FAAP2, Rachel Boykan, MD, FAAP3

Affiliations: 1Associate Professor of Pediatrics, Medical College of Georgia; 2Associate Professor of Pediatrics, University of Nevada, Reno School of Medicine; 3Professor of Pediatrics, Renaissance School of Medicine at Stony Brook University

A Brief History of Tobacco

Indigenous people of the Americas began cultivating tobacco around 6,000 BCE. In 1492, Christopher Columbus received a gift of Nicotiana tabacum (tobacco) leaves from the American Indians, which he took back to Europe. The stimulating and addictive properties of tobacco led to the global dissemination of tobacco over the next 150 years. Snuff was the preferred method of tobacco use in the 18th century, the cigar in the 19th century, and the cigarette in the 20th century; the electronic cigarette is the newest version. The first medical report linking lung cancer with cigarette smoking was published in 1939 (reprinted in 1999)1 and the first major report on smoking and health in 1953.2 In 1964, the US Surgeon General’s Report identified smoking as a cause of lung cancer. With the subsequent growing body of research and recognition of the health harms from tobacco use, a series of public health measures were instituted in the United States, contributing to the decline in smoking over the next decades: the broadcast ad ban on smoking (1970), the ban on smoking on domestic flights (1988), the Master Settlement Agreement (1998), the Tobacco Control Act (2009), and Tobacco 21 (2019).

A review of the published literature on tobacco in Pediatrics underscores the enormous, relatively recent, growth of research and the vital involvement of the pediatric community in addressing tobacco use in the clinical setting.


  1. Ochsner A, Debakey M. Primary pulmonary malignancy: treatment by total pneumonectomy; analysis of 79 collected cases and presentation of 7 personal cases. Ochsner J. 1999;1(3):109-125
  2. Wynder EL, Graham EA, Croninger AB. Experimental production of carcinoma with cigarette tar. Cancer Res. 1953;13(12):855-864

First Quarter Century: 1948 – October 1973

Highlighted Articles From Pediatrics

When the first issue of Pediatrics came out in 1948, knowledge about the health effects of smoking were related to the long-term effects on adult smokers with no understanding of secondhand smoke or ways to prevent adolescent initiation.

In 1967, Salber et al1 published the first longitudinal prospective study in Pediatrics, assessing youth tobacco use. Highlighting the risk of smoking initiation before age 18, the authors reported several “predictors” for initiation, including social class, educational level, and the presence of smokers within the family. Heavier smoking was linked to more difficulty quitting.

In 1969, an American Academy of Pediatrics Committee on Environmental Hazards report2 defined 3 aspects of “the smoking problem” that directly related to children and teenagers: the short-term effects of smoking by youth, the effect of tobacco smoke on non-smokers, and a call for changes in anti-smoking advertising campaigns to prevent children from “adopting the smoking habit.” The article highlighted the role of the pediatrician in prevention and observed that children who lived with smokers were more likely to smoke.

Second Quarter Century: November 1973 – October 1998

Highlighted Articles From Pediatrics

The second quarter century of Pediatrics witnessed a rise in the number of articles about the health effects of tobacco smoke exposure (TSE) on infants and children. Pediatricians expanded their role to include asking about smoke exposure (directly by the patient or indirectly by parents or caregivers) and advising about the health effects and the need for avoidance and cessation.

In 1976, Bergman et al1 found a strong association between SIDS and maternal smoking both during and after pregnancy. They demonstrated both a qualitative and a quantitative association—a greater proportion of heavier smokers had infants die of SIDS.

By 1991, the dangers of tobacco smoke and TSE were well-established. In Epps et al’s review,2 smoking was identified as the “chief, single cause of premature mortality in this country.” The authors noted that addiction began in childhood, with 60% of current smokers starting before age 14. Dual use of tobacco with alcohol, marijuana, and other drugs of abuse was concerning. The authors stressed the importance of anticipatory guidance, using the now established framework of “ask, advise, assist, and arrange.”

In a prospective study, Martinez et al3 reported a strong association between maternal smoking and childhood asthma, with a dose-dependent effect. Lower maternal education was associated with worse outcomes.

Third Quarter Century: November 1998 – Present

Highlighted Articles From Pediatrics

In the past 25 years, the number of publications on tobacco has skyrocketed. Four major foci emerge from a review of the literature: the pediatrician’s role in preventing children’s TSE through education and treatment of parental smoking; nicotine addiction in adolescents; e-cigarette use; and health disparities in tobacco exposure and use.

In a randomized controlled trial published in 2001, Emmons et al1 provided data to demonstrate efficacy of a motivational intervention (MI) for smoking parents of young children, in which MI households had significantly lower air nicotine levels 6 months after the intervention. Seven years later, Winickoff et al2 published the first of several studies that described the development of CEASE (the Clinical Effort Against Secondhand Smoke Exposure), a multi-pronged, office-based intervention for pediatricians to address parental tobacco use, which has subsequently been widely adopted.

In 2007, DiFranza et al3 published results of a 4-year prospective study in adolescents, which identified depressed mood and a sense of relaxation as 2 important predictors that drove the transition from first inhalation of nicotine toward dependence. The risk of nicotine dependence, after only one initial nicotine dose, underscores the susceptibility of the adolescent brain to addictive substances and reinforces the need for prevention and advocacy for better public health measures.

A significant portion of the published tobacco literature in the past 10 years focuses on e-cigarettes, the most used tobacco product among teens since 2014. Goniewicz et al4 published the first study on e-cigarettes in Pediatrics in 2012. In this survey of Polish students, the vast majority (86.4%) had heard of e-cigarettes, and half felt they were safer than regular cigarettes. In an early e-cigarette paper in the United States, Wills et al5 described awareness of e-cigarettes among adolescents: 96% of respondents had heard of the products, 29% had tried them, and 18% were current users. These data suggested that youth who used e-cigarettes were more likely to progress to combusted tobacco use, and that low-risk tobacco users may begin smoking through initiation with e-cigarettes. One year later, Barrington-Trimis et al6 reported on a cohort of 11th and 12th graders followed prospectively over 16 months. E-cigarette users had 6.17 times the odds of initiating cigarette use compared with adolescents who had never used e-cigarettes. Associations were stronger among those who reported no intention of smoking initially. This research added to the growing body of evidence that detailed the health harms of e-cigarettes and the potential for e-cigarette use to undo decades of public health gains.

Tobacco use and exposure disproportionately affect vulnerable and marginalized groups, including those living in poverty. Recently, the systemic and structural forces that have created and perpetuated such inequities have received greater focus. These forces include the deliberate targeting of specific groups (African Americans, those identifying as LGBTQ, American Indians, and women) by the tobacco industry; the poorer access of these groups to health insurance, health care, and cessation resources; and their greater economic stress. In 2021, Marbin et al7 published the first comprehensive report and recommendations for pediatricians, “Health Disparities in Tobacco use and Exposure: A Structural Competency Approach.” 


In the past 75 years, tobacco use has been transformed from a socially acceptable practice to one that has received intense research focus, particularly with respect to the health effects of TSE on children and the long-term consequences for youth who become addicted to nicotine. Pediatricians have played a crucial role in contributing to the literature and have been tireless advocates for public health and clinical policy to reduce harm from tobacco to children. Despite enormous gains in decreasing combustible cigarette usage, unrelenting commercial forces continue to develop new highly addictive and attractive products geared to youth. Much work is yet to be done.



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