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Preventing child and adolescent use of which of the following would result in the largest reduction in overall
mortality and societal costs?

AAlcohol
BCannabis
CInhalants
DOpiates
ETobaccoCorrect Answer

Correct Answer ( E )
Explanation:

The most prevalent, lethal, and costly of all the substance use disorders is tobacco use disorder. In those
individuals who start smoking in adolescence, approximately 80% will continue to smoke during
adulthood, and smoking-related premature death will occur in one-third of these individuals. Although
smoking has decreased, smokeless tobacco use has increased, particularly vaping with electronic cigarettes (e-
cigarettes). While the DSM-5 uses the term “tobacco-related disorders,” the addictive component is nicotine in
both combustible and smokeless tobacco products. Vaping often is associated with higher nicotine exposure than
smoking. Combustible tobacco products include cigarettes, cigars, pipe tobacco, hookah, bidis, and kreteks.
Noncombustible forms of tobacco or nicotine include electronic nicotine delivery devices (e-cigarette, vape pipe
or pen, pod mod), heat-not-burn products, dissolvable tobacco, chewing tobacco, snuff, and snus. Although some
indicate that screening and prevention activities can occur in just a few minutes, screening requires specifically
asking about multiple products, rather than simply asking about smoking, and prevention activities include
multiple levels that may be time-consuming. For instance, recommendations for prevention include asking
parents or caregivers about whether they smoke or vape, advising cessation, offering referrals, providing
education about health consequences to the child (exposure to vapor or smoke, promoting similar behaviors by
child); asking all patients over 5 years for their thoughts about smoking or vaping and whether they have used
any of these products by using a variety of terms, including popular brand names; providing psychoeducation
and advising against initiation of tobacco or nicotine use; assessing for risk factors for initiation (e.g.,
depression, previous level of experimentation, academic struggles); providing guidance to parents on skills to
prevent their child from tobacco use and promoting tobacco-resistance skills in youth by increasing awareness of
the influence of peers, marketing, and media. In particular, marketing practices falsely portray smokeless
products as safe and add flavoring or provide forms mimicking candy to target youth.
Clinicians, especially mental health practitioners, tend to underestimate the risks of tobacco products when
compared to other substances. This is partially due to tobacco’s delayed consequences, whereas more import is
given to the following substances, which demonstrate more visible acute risks as well as long-term effects.
Alcohol (A) is the most widely used substance among adolescents, although it has declined since the 1980s.
Even so, the annual epidemiological survey of adolescents’ drug use (Monitoring the Future Survey) reported in
2014 a lifetime prevalence of ever being drunk as 11% among 8th graders and 50% among 12th graders.
Cannabis (B) is the most commonly used illicit substance among adolescents and, although uneven, there has
been an overall upward trend of use. Sorting out the effects of legalization in some states and a perceived lack of
risk likely contributes to this trend. After cannabis, inhalants (C) were found to be the most commonly used
illicit substance among 8th graders. Inhalants are primarily used by adolescents, peak at nearly 5% prevalence at
age 14, and decline to < 1% for adults. Fatalities may occur unrelated to dose, and there is a risk of long-term
neuropsychological deficits. Opiates (D) are a major risk to adolescents, with almost half a million adolescents
using opiates for pain relief in 2014, of whom about one-third had an opiate use disorder. Overdose is a real risk,
especially in combination with other CNS depressants.
Question: What is the time frame for the detection of the metabolite of cocaine (benzoylecgonine) in the urine?

Reveal Answer: Up to 3 days after a single dose and up to 14 days for repeated high doses.

Tobacco, Nicotine Products

*DSM-5 refers to tobacco-related disorders, but the addictive component is nicotine in both combustible and
smokeless tobacco products*

Combustible (smoking) forms

Cigarettes
Cigars
Pipe tobacco
Hookah
Bidis
Kreteks

Noncombustible (smokeless) forms

Electronic nicotine delivery devices

E-cigarette
Vape pipe or pen
Pod mod
Heat-not-burn products
Dissolvable tobacco
Chewing tobacco
Snuff
Snus

References:

1. 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed.
American Psychiatric Publishing; 2013.
2. 2. Hopfer C, Hinckley JD, Riggs P. Substance use disorders. In: Martin A, Bloch MH, Volkmar FR, eds.
Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook. 5th ed. Wolters Kluwer; 2018:(Ch)
5.8.
3. 3. Sockrider M, Rosen JB. Prevention of smoking and vaping initiation in children and adolescents. Post
TW, ed. UpToDate. UpToDate Inc. Accessed November 11, 2020.
4. 4. Ziedonis DM, Tonelli ME, Das S. Tobacco-related disorders. In: Sadock BJ, Sadock VA, Ruiz P, eds.
Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 10th ed. Wolters Kluwer; 2017:(Ch) 11.8.

Reviewed February 2021

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Category: Substance-​Related & Addictive Disorders

Subcategory: Tobacco-​Related Disorders

Question: 127277

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Peer Comparison
 A. A 34%
B. B 9%
C. C 3%
D. D 10%
E. E 45%

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Normal Lab Values

25-hydroxyvitamin D, serum 25–80 ng/mL 62–200 nmol/L
Activated partial thromboplastin time (APTT) 25–35 seconds 25–35 seconds
Adrenocorticotropic hormone (ACTH) 9–52 pg/mL 2–11 pmol/L
Alanine aminotransferase (ALT) 0–35 U/L 0–0.58 µkat/L
Albumin 3.5–5.5 g/dL 35–55 g/L
Alkaline phosphatase 45–115 U/L (men), 30–100 U/L (women) 0.75–1.92 µkat/L (men), 0.50–1.67 µkat/L
(women)
Ammonia 40–80 µg/dL 23–47 µmol/L
Amylase 0–130 U/L
Anion Gap 8–16 mEq/L 8–16 mmol/L
Aspartate aminotransferase (AST) 0–35 units/L 0–0.58 µkat/L
Bands < 1 x 10,000/µL < 1 x 10,000/mm3
Bicarbonate 23–28 mEq/L 23–28 mmol/L
Bilirubin, direct/conjugated 0–0.3 mg/dL 0–5.1 µmol/L
Bilirubin, total 0.3–1.2 mg/dL 5.1–20.5 µmol/L
Blood urea nitrogen (BUN) 8–20 mg/dL 2.9–7.1 mmol/L
B-type natriuretic peptide (BNP) <100 pg/mL < 100 ng/L
Calcium (ionized, adult) 4.5–5.6 mg/dL 1.05–1.3 mmol/L
Calcium (total) 9–10.5 mg/dL 2–2.6 mmol/L
Ceruloplasmin 16–31 mg/dL (men), 19–39 mg/dL (women)
Chloride 98–106 mEq/L 98–106 mmol/L
Cholesterol (Total: Adult) 150–199 mg/dL 3.88–5.15 mmol/L
COHb (%) Non Smoker: < 2% Smoker: <9% Non Smoker: < 2% Smoker: <9%
Copper 63.7–140.12 µg/dL 12–22 µmol/L
Cortisol (bedtime) 3–13 µg/dL 83–359 nmol/L
Cortisol (free, urine) < 50 µg/24 h 138 nmol/24 h
Cortisol (morning) 10–20 µg/dL 275.88–551.76 nmol/L
C-peptide - serum 0.5–2.0 ng/mL 0.17–0.66 nmol/L
C-reactive protein (CRP) < 5 mg/L
Creatine kinase (CK) 30–170 U/L 0.50–2.84 µkat/L
Creatinekinase – MB fraction (CK-MB) 0–7 ng/mL 0–7 µg/L
Creatinine 0.7–1.3 mg/dL 61.9–115 µmol/L
CSF Cell count 0-5 cells/µL 0-5 × 10⁶ cells/L
CSF Glucose 40–80 mg/dL 2.2–4.4 mmol/L
CSF Opening pressure 7-20 cm of H20
CSF Protein 15–50 mg/dL 150–500 mg/L
D-dimer < 0.5 µg/mL < 500 ng/mL
Erythrocyte sedimentation rate (ESR) 0–15 mm/hr (men) 0–20 mm/hr (women)
Estradiol (female, day 1-10) 14–27 pg/mL 50–100 pmol/L
Estradiol (female, day 11-20) 14–54 pg/mL 50–200 pmol/L
Estradiol (female, day 21-30) 19–41 pg/mL 70–150 pmol/L
Estradiol (male) 10–30 pg/mL 37–110 pmol/L
Ferritin, serum 15–200 ng/mL 15–200 µg/L
Fibrinogen, plasma 150–350 mg/dL 1.5–3.5 g/L
Follicle-stimulating hormone (female, follicular/luteal phase) 5–20 mU/mL 5–20 U/L
Follicle stimulating hormone (female, midcycle) 30–50 mU/mL 30–50 U/L
Follicle stimulating hormone (female, postmenopausal) > 35 mU/mL > 35 U/L
Follicle stimulating hormone (male) 5–15 mU/mL 5–15 U/L
Free Thyroxine (T4), serum 0.9–2.4 ng/dL 12–31 nmol/L
Free Triiodothyronine (T3), serum 2.3 - 4.2 pg/mL 0.04-0.06 pmol/L
Gastrin 0–180 pg/mL 0–86.58 pmol/L
GGT level 0 to 30 IU/L
Glucose (fasting) 70–100 mg/dL 3.9–5.6 mmol/L
Glycosylated hemoglobin 4%–5.9% 4%–5.9%
Haptoglobin 50–150 mg/dL 500–1500 mg/L
HDL (Men) ≥ 40 mg/dL 1.0 mmol/dL
HDL (Women) ≥ 50 mg/dL 1.3 mmol/dL
Hematocrit (Hct) (Female) 36–47% 0.36–0.47
Hematocrit (Hct) (Male) 41–51% 0.41–0.51
Hemoglobin (Hgb) (Female) 12–16 g/dL 120–160 g/L
Hemoglobin (Hgb) (Male) 14–17 g/dL 140–170 g/L
Insulin - serum < 25 mU/L < 174 pmol/L
Iron 60–160 µg/dL 11–29 µmol/L
Lactate dehydrogenase (LDH) 60–100 units/L 1.00–1.67 µkat/L
Lactic acid 6–16 mg/dL 0.67–1.8 mmol/L
LDL < 100 mg/dL
Lipase < 95 U/L < 1.59 µkat/L
Luteinizing hormone (female, follicular/luteal phase) 5–22 mU/mL 5–22 units/L
Luteinizing hormone (female, midcycle) 30–250 mU/mL 30–250 units/L
Luteinizing hormone (female, postmenopausal) > 30 mU/mL > 30 units/L
Luteinizing hormone (male) 3–15 mU/mL 3–15 units/L
Lymphocytes 1,000–4,000/µL (20–40%) 1,000–4,000/mm3 (20–40%)
Magnesium 1.5–2.4 mg/dL 0.62–0.99 mmol/L
Mean corpuscular hemoglobin concentration (MCHC) 32–36 g/dL 320–360 g/L
Mean corpuscular hemoglobin (MCH) 28–32 pg 0.4–0.5 fmol/cell
Mean corpuscular volume (MCV) 80–100 fL/red cell
Metanephrines (urine) < 1.2 mg/24 hours < 6.1 mmol/24 hours
Monocytes 100–700/µL (2–8%) 100–700/mm3 (2–8%)
Neutrophils 2500–8000/µL (55–70%) 2500–8000/mm3 (55–70%)
Parathyroid hormone (PTH) 10–65 pg/mL 10–65 ng/L
PCO₂ 35–45 mm Hg 4.7–6 kPa
pH 7.35-7.45 7.35-7.45
Phosphorus 3–4.5 mg/dL 0.97–1.45 mmol/L
Platelets 150,000–350,000/µL 150–350 × 10⁹/L
PO₂ 80–100 mm Hg 10.6–13.3 kPa
Potassium 3.5–5.0 mEq/L 3.5–5.0 mmol/L
Procalcitonin (adults and children > 72 hours old) < 0.15 ng/mL
Prolactin (Men) < 15 ng/mL < 15 µg/L
Prolactin (Nonpregnant women) < 20 ng/mL < 20 µg/L
Prolactin (Pregnant women) 36–372 ng/mL 36–372 µg/L
Protein C 65 to 135 IU dL-1
Prothrombin time (PT) 11–13 seconds 11–13 seconds
Pyruvate 300–900 µg/dL 34068.00–102204.00 µmol/L
Red blood cells (RBC) 4.7–6.1 x 10⁶/µL (men), 4.2–5.4 x 10⁶/µL (women)
Red cell distribution width (RDW) 11.6–14.6% 11.6–14.6%
Reticulocytes 0.5%–1.5% 0.5%–1.5%
Reverse Triiodothyronine (T3), serum 10–24 ng/dL 10–24 ng/dL
Sodium 136–145 mEq/L 136–145 mmol/L
Testosterone (adult male) 300–1200 ng/dL 10–42 nmol/L
Testosterone (female) 20–75 ng/dL 0.7–2.6 nmol/L
Thyroid-stimulating hormone (TSH) 0.5–5.0 µU/mL 0.5–5.0 mU/L
Total iron-binding capacity (TIBC) 250–460 µg/dL 45–82 µmol/L
Total Serum Protein 6.0–7.8 g/dL 60–78 g/L
Total Thyroxine (T4), serum 5–12 µg/dL 64–155 nmol/L
Total Triiodothyronine (T3), serum 70–195 ng/dL 1.1–3.0 nmol/L
Transferrin 200–360 mg/dL 24.60–44.28 µmol/L
Transferrin saturation 20–50% 20–50%
Triglycerides <150 mg/dL < 1.69 mmol/L
Troponin I 0–0.5 ng/mL 0–0.5 μg/L
Troponin T 0–0.10 ng/mL 0–0.10 µg/L
Tryptase < 11.5 ng/mL < 11.5 ng/mL
Urea 17–43 mg/dL 2.8–7.2 mmol/L
Uric acid, serum 2.5–8 mg/dL 0.15–0.47 mmol/L
White blood cells (WBCs) 4,000–10,000/µL 4.0–10.0 x 10⁹/L