Michelle Ren, MS; Shahrdad Lotfipour, PhD


Western J Emerg Med. 2019;20(5):696-709. 

In This Article


Prior to drafting this manuscript, the two authors independently evaluated and summarized research articles that addressed adolescent substance use and nicotine's impact on the developing brain and behavior. We conducted a comprehensive review of the literature using a two- to three-word combination of the following keywords: adolescence, substance use, nicotinic acetylcholine receptors, gateway, reward, smoking, tobacco, nicotine, alcohol, psychostimulant, cocaine, amphetamine, cannabis, opioids. We utilized the electronic databases of PubMed and Google Scholar for research articles published in English between January 1968 and November 2018. Articles were included in the review if they discussed nicotine exposure during adolescence, drug sequence patterns, or adolescent substance use. The references from relevant articles and websites of relevant organizations were also examined for other potential sources of information. Out of 80,000 initial search results, approximately 5,000 were reviewed as relevant and non-duplicate articles. To retain focus on adolescent initiation of nicotine products, studies related to maternal tobacco or nicotine exposure were excluded. Studies evaluating other interventions (i.e., medication, sleep, exercise) were also excluded to maintain focus on nicotine's effects on brain function and behavior. We grouped studies together according to their methodological similarities, so findings without substantial support or reproducibility (i.e., fewer than 5 comparable studies) were excluded. Following exclusion and careful analysis of studies based on key results, limitations, suitability of the methods to test the initial hypothesis, and quality and interpretation of the results obtained, 174 references were selected. The use of two reviewers and two extensive electronic databases allows for a widespread range of research articles, which maximizes scientific credibility and minimizes potential bias.