Pulmonologist Evan Stepp, MD, FCCP, has a teenage daughter who doesn’t smoke or vape – as far as he knows, Stepp will admit – but the statistics on youth smoking are alarming enough to have him worried.
On one hand, fewer Americans are smoking today than ever before. Since 1992, the percentage of people who told Gallup that they’d had a cigarette in the past week has dropped from 28% to 11%. Meanwhile, the rate of new lung cancer cases declined from 65 per every 100,000 people in 1992 to 34 per 100,000 in 2020, according to the National Cancer Institute.
According to a November 2022 report from the Centers for Disease Control and Prevention (CDC), 1 in 6 high school students and 1 in 20 middle schoolers are using a nicotine product at least once every day.
“It’s a completely different picture for nicotine cessation in youth,” Dr. Stepp, who is an associate professor at National Jewish Health in Denver, said. “Because of the fact that the nicotine addiction is occurring in a developing brain, which raises many other nicotine-related harms.”
Why teens vape
Today’s teens are smoking less actual tobacco, and, instead, overwhelmingly prefer e-cigarettes or vaping. In fact, 85% of high school–aged smokers and 72% of middle school smokers reach for a vape over regular cigarettes or smokeless tobacco, according to the CDC.
It’s not hard to understand why: e-cigarettes use a heating element to turn a nicotine-infused liquid into an aerosol, with no open flame, ash, or lingering smoke. The vapes themselves are easy to conceal, and if someone needed to hide an e-cigarette from particularly perceptive parents or teachers, they can find vapes built into hoodies, fake smartwatches, and USB drives.
Plus, the liquids often come in flavors like fruit, bubble gum, mint, and vanilla, because unflavored nicotine isn’t exactly appealing. “Huge concentrations of nicotine salts are just miserable to breathe in,” Dr. Stepp said. “Flavors are necessary to make these products palatable, and those flavors end up being a huge draw for youth users to get exposed to nicotine addiction.”
Challenges surrounding smoking cessation in youth
The powerful effect of nicotine in youth means the need for effective cessation strategies is both more urgent and more difficult. But while physicians can prescribe to adults the antidepressants varenicline and bupropion, along with nicotine replacement therapy, to help ease withdrawal symptoms, the US Food and Drug Administration (FDA) has not approved those medications for anyone under the age of 18.
Research on cessation medications in young people is limited: A recent meta-analysis found only four studies on people between the ages of 12 and 21. In teens, antidepressants seem to help quitting for the first few weeks but are unproven as a long-term solution.
“That really has been a challenge for the 1 in 6 high school students who are current users of tobacco products,” said pediatrician, Susan Walley, MD, a co-author of the American Academy of Pediatrics’ recent position papers on children and smoking.
“One of the things that is important to keep at the forefront of the conversation is that nicotine addiction is a chronic medical disease, and it’s a form of substance abuse,” Dr. Walley said. “We know that we need more research in adolescent tobacco cessation, and it really is about the funding, about research dollars.”
Without medications, smoking cessation in teens relies largely on counseling strategies. A 2017 review published by Cochrane Library found that group counseling was the most effective quitting method, with teens participating in group sessions 35% more likely to stop using nicotine products up to a year later, compared with teens who did not receive any counseling.
Counseling can help educate teens (and parents) on some of the realities of e-cigarettes, bridging the gap between well-established anti-smoking campaigns and the anti-vape campaigns that have yet to catch up.
“We have done a great job promoting cigarette use as dangerous,” Dr. Walley said. “[But] many teens who would never pick up a cigarette –because they know the health risks – are vaping.”