Adolescents who use e-cigarettes are three times more likely to become daily cigarette smokers than those who have never vaped. The most recent survey of Minnesota’s students showed that more than one in 10 eight graders had vaped in the previous 30 days, and nearly one in 10 eleventh graders were vaping daily. Nicotine dependence progresses rapidly from experimentation to dependence. Substance use disorders, including nicotine addiction, are characterized by compulsive drug craving, drug seeking, and use that persists in the face of negative consequences, such as impaired sports performance, or trouble at school or at home.
What can a pediatrician do?
A straightforward place to start is the “5As” recommended by the Agency for Healthcare Research and Quality:
1. Ask. Use a tool to assess vaping use in adolescents. The Hooked on Nicotine Checklist and the E-Cigarette Dependence Scale are both validated for this purpose. These can identify vapers and help you assess the severity of their use. Other tools include the Modified Version of the Fagerstrom Tolerance Questionnaire and the DSM-5 criteria for tobacco use disorder.
2. Advise. Make a clear, personal recommendation to quit.
3. Assess. Is your patient willing to try to quit at this time?
4. Assist. With your patient, develop a plan to quit. Behavioral interventions are needed in all cases. There are a number of good online/app-based programs focused on adolescents. This Is Quitting, My Life My Quit, and Smokefree Teen are good places to start. Teen.smokefree.gov has a “Build My Vaping Quit Plan” function that adolescents can do on their own, or with you. Working through “Build My Plan” with your patients provides an excellent way to build your own skills in addressing smoking cessation.
Pharmacotherapy should be considered for people who are moderately to severely dependent on nicotine. Pediatricians should review full clinical drug information before prescribing. No medications for tobacco use disorder are FDA-approved for individuals under the age of 18, and there are not adequate data to demonstrate effectiveness. There is no evidence of serious safety concerns. When faced with adolescents who are vaping or using other tobacco products, remember that they are already using nicotine. Nicotine Replacement Therapy (NRT) provides a safer nicotine product, without the toxins found in tobacco products, including vape liquid. It is also designed for a slower increase in blood nicotine level and maintenance of a steady-state, avoiding the rush and crash characterized by inhaled nicotine. The rush/crash cycle leads to increased use and dependence, whereas a steady blood level facilitates weaning. NRT can be prescribed off-label to youth under 18. Detailed prescribing information can be found on the AAP website: Nicotine Replacement Therapy and Adolescent Patients: Information for Pediatricians.
Bupropion and varenicline are used in adults for tobacco cessation, but are off-label and not well-studied in adolescents. Bupropion has a history of safe use in adolescents for other conditions; varenicline does not.
For patients not ready to quit, use motivational interviewing.
5. Arrange. Check in every 1-2 weeks to provide support. This process is well-suited to telemedicine!