This work may not be copied, distributed, displayed, published, reproduced, transmitted, modified, posted, sold, licensed, or used for commercial purposes. By downloading this file, you are agreeing to the publisher’s Terms & Conditions.

Brief Report

Curbing Physician Stigma Toward Adolescents With Nicotine and Opiate Use

Giselle Appel, MSa,*; Beverly Shin, MDb; Alyssa Shahc; and Jonathan D. Avery, MDa

Published: March 14, 2023

Prim Care Companion CNS Disord 2023;25(2):22br03358

To cite: Appel G, Shin B, Shah A, et al. Curbing physician stigma toward adolescents with nicotine and opiate use. Prim Care Companion CNS Disord. 2023;25(2):22br03358.
To share:

© 2023 Physicians Postgraduate Press, Inc.

aDepartment of Psychiatry, Weill Cornell Medical College, New York, New York
bDepartment of Psychiatry, University of Washington, Seattle, Washington
cUniversity of Pennsylvania, Philadelphia, Pennsylvania
*Corresponding author: Giselle Appel, MS, Department of Psychiatry, Weill Cornell Medical College, 525 East 68th St, Box 140, New York, NY (


E-cigarette use among adolescents has sky rocketed over the past decade, leading the US Surgeon General to declare youth vaping an epidemic in 2018 and the US Food and Drug Administration (FDA) to ban e-cigarette use in 2022.1,2 Meanwhile, opioid use among adolescents is also on the rise, and opioid-related deaths among adolescents have increased at an alarming rate.3 Given the vast number of adolescents who use e-cigarettes (estimated to be 2.5 million in 2019) and the rapidly escalating adolescent mortality rate from opioid overdose, there is an urgent need for physicians to recognize, diagnose, and treat these disorders in adolescents.4 However, stigma may pose a significant challenge to this endeavor, as it has in the adult population,5 thus guiding the present study.


The study used a cross-sectional survey design and was conducted between December 2019 and March 2020. Respondents included residents and board-certified attending physicians (within internal medicine, psychiatry, and pediatrics) who treat adolescents in New York City. The Weill Cornell Medicine Institutional Review Board approved the study. The questionnaire comprised the Medical Condition Regard Scale (MCRS),6 assessing for major depressive disorder (MDD), daily nicotine use, opioid use disorder (OUD), and type I diabetes. The MCRS is a valid and reliable 11-item instrument scored on a 6-point Likert scale designed to assess the degree to which clinicians find individuals with a given medical condition to be enjoyable, treatable, and worthy of medical resources. A repeated analysis of variance with post hoc tests using a Bonferroni adjustment was used to compare differences between conditions. Subsequently, a multivariable linear regression model was constructed to analyze the relationship between patient group and total MCRS scores. SurveyMonkey and SPSS v.26 (IBM, Armonk, New York) were used for survey response collection and analysis, respectively.


A total of 65 respondents completed the questionnaire. The majority identified as internal medicine physicians who treat adolescents (adolescent medicine: n = 50, 76.9%; pediatrics: n = 7, 10.8%; psychiatry: n = 1, 4.62%; and did not specify: n = 7). Mean MCRS scores for individuals with daily nicotine use or individuals with OUD were lower than MCRS scores for individuals with type 1 diabetes or MDD (Table 1). Post hoc pairwise comparisons between MCRS total scores for individuals with daily nicotine use or OUD and MCRS total scores for individuals with type 1 diabetes or MDD were statistically significant (Table 1). A multivariable linear model, adjusting for respondent age, gender, training year, specialty, time spent, and patients who endorsed using electronic nicotine delivery systems, showed that attitudes toward nicotine users and OUD patients were significantly lower than attitudes toward an adolescent with MDD (nicotine users, P < .001; OUD, P < .001).


Our results demonstrate that physicians who treat adolescents have worse attitudes toward patients who use opiates and nicotine compared with patients who have MDD or type 1 diabetes. Furthermore, physician attitudes were worst toward adolescent patients with OUD, a particularly disturbing pattern given that more patients die during adolescence from opioid overdose than MDD, nicotine, or type 1 diabetes.7,8 These negative attitudes can lead to undertreatment and decreased help seeking by patients, as well as increased substance use resulting from shame.9–12 This study was limited by a small sample size, and further studies are needed to better characterize physician attitudes in both inpatient and outpatient settings. Medical educators must carefully consider the role of knowledge, the patient-physician relationship, and stigma within medical training to reverse the trend of increasing morbidity and mortality from substance use among adolescents.

Submitted: July 5, 2022; accepted September 7, 2022.
Published online: March 14, 2023.
Relevant financial relationships: None.
Funding/support: None.

Volume: 25

Quick Links:


Buy this Article as a PDF