Treatment for Nicotine Use Disorder Among Medicaid-Enrolled Adolescents and Young Adults

Adolescents and young adults are particularly vulnerable to nicotine’s addictive properties. Decades of decreasing tobacco use are threatened by the rising popularity of e-cigarettes, use of which predicts transition to combustible cigarettes among adolescents and young adults.¹ Given rates of tobacco use that remain high among youth, timely data are needed on the extent to which adolescents and young adults with nicotine use disorder (NUD) receive evidence-based treatment with counseling and pharmacotherapy.²

As all the data were deidentified and the study was not considered to be human participants research by the Boston University School of Medicine institutional review board, approval and patient consent were waived. We used the Truven MarketScan Medicaid database (IBM Watson) to identify all individuals aged 10 to 22 years with 6 months or more of continuous enrollment who received a diagnosis of NUD (using International Classification of Diseases, Ninth Revision diagnosis codes) between January 1, 2014, and June 30, 2015, across 11 deidentified states.³ Receipt of treatment within 6 months of NUD diagnosis was confirmed using claims for counseling for NUD or pharmacy dispensing of nicotine replacement therapy, varenicline (for individuals ≥16 years), and sustained-release bupropion. We performed χ² tests to compare youth with NUD who did and did not receive treatment and multivariable logistic regression to determine sociodemographic and clinical predictors of treatment receipt. A 2-sided P value was signifcant at less than .05. Analysis began in November 2018.

Of 3 487 775 individuals, 1 796 227 (51.5%) were female, 1 663 634 (47.7%) were non-Hispanic white, 1 212 014 (34.8%) were non-Hispanic black, 235 853 (6.8%) were Hispanic, and 132 386 (3.8%) were diagnosed as having NUD. Among 81 144 youth with NUD with 6 months of follow-up after diagnosis, 3364 (4.1%) received counseling for NUD, 1095 (1.3%) received pharmacotherapy (nicotine replacement therapy or other medication), and 110 (0.1%) received both counseling and pharmacotherapy at 6 months (Table 1). Among youth with NUD receiving treatment, older age, white race, asthma, depression, anxiety, attention-deficit/hyperactivity disorder, and co-occurring alcohol or marijuana use disorder were all associated with receipt of pharmacotherapy (Table 2). Bupropion was the most commonly prescribed medication (504 [46.0%]), followed by nicotine replacement therapy (342 [31.2%]) and varenicline (249 [22.7%]).

Receipt of evidenced-based treatment for NUD was extremely low among adolescents and young adults with Medicaid coverage. Such low treatment rates during a developmental period when adolescents and young adults are at increased risk of developing lifelong nicotine addiction likely represent a missed opportunity to address NUDs in this population.

Counseling for NUD when combined with pharmacotherapy has been shown to increase quit rates 2- to 3-fold in adults,⁴ and emerging evidence suggests that similar benefits could be seen in adolescents and young adults.⁵ While very few individuals received pharmacotherapy in the present study, youth who were older and those with co-occurring mental health and substance use disorders had higher odds of receiving medication. This may represent an underappreciation among clinicians of the implications of NUD in adolescents and young adults otherwise perceived as healthy and an opportunity to increase treatment rates in this group.

Our study had limitations. The sample included only Medicaid enrollees who are known to have higher rates of tobacco use than the general population.⁶ Some youth receiving bupropion could have been treated primarily for depression; however, we only examined the sustained-release formulation at the dose recommended for smoking cessation, which differs from doses most commonly used for depression. Some youth may have purchased nicotine replacement therapy over the counter or received counseling for NUD that was not documented by clinicians, which would not be detected in claims. We were unable to account for severity of NUD, and it is possible some youth did not receive pharmacotherapy because they had mild NUD.

Cigarette smoking remains the leading cause of preventable death in North America. While cigarette use has been decreasing steadily among youth over the past 30 years, the emergence of nicotine-containing e-cigarettes, which are strongly associated with subsequent combustible cigarette use in adolescents and young adults,¹ threatens decades of public health success in decreasing use of nicotine in this population. Interventions that could help the pediatric workforce to better identify and appropriately treat NUD are greatly needed.

Corresponding Author: Nicholas Chadi, MD, MPH, Division of Adolescent Medicine, Department of Pediatrics, Sainte-Justine University Hospital Centre, University of Montreal, 3175 Ch de la Cote Sainte-Catherine, Montreal, QC, H3T 1C5, Canada (nicholas.chadi@umontreal.ca).

Accepted for Publication: April 19, 2019.

Published Online: September 23, 2019. doi:10.1001/jamapediatrics.2019.3200

Author Contributions: Mr Rodean had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Chadi, Rodean, Zima, Hadland.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Chadi.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Chadi, Rodean, Zima.

Obtained funding: Hadland.

Supervision: Zima, Bagley, Levy, Hadland.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by the National Institutes of Health/National Institute on Drug Abuse (grants K23-DA045085 and L40-DA042434, Dr Hadland), Thrasher Research Fund Early Career Award, and the Academic Pediatric Assocation.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.