INTRODUCTION — Tobacco and nicotine use by smoking or vaping (via electronic cigarettes [e-cigarettes] and other devices) often starts during adolescence but can have important health effects throughout life. Because of nicotine dependence and social factors, initiation of tobacco products during adolescence is closely associated with persistent smoking in adulthood and with the many adverse health effects associated with chronic smoking. The long-term consequences of smoking and the benefits of smoking cessation in adults are discussed in separate topic reviews. (See "Patterns of tobacco use" and "Cigarette smoking and other possible risk factors for lung cancer", section on 'Smoking'.)
While there is good consensus on the importance of preventing smoking initiation, techniques for doing so are not standardized or adequately studied. Nonetheless, some general principles arise, extrapolated from clinical interventions for other risk behaviors or from smoking interventions in adults. Similarly, methods to prevent vaping initiation are further extrapolated from techniques for smoking prevention, but outcomes have not been independently studied.
In this topic review, we use the term "smoking" to refer to use of any combustible tobacco product. Most of the data come from studies of cigarette smoking. We use the term "vaping" to refer to use of nicotine via e-cigarettes or other types of electronic delivery systems.
Preventing smoking and vaping initiation in children and adolescents will be reviewed here, focusing on interventions that can be performed in the primary care setting. Management of smoking and vaping cessation in adolescents is discussed separately. (See "Management of smoking and vaping cessation in adolescents".)
WHY PREVENTION IS IMPORTANT — It is vital that pediatric health care clinicians routinely address tobacco and nicotine use among patients and their families. Pediatric clinicians should routinely evaluate patients for smoking and vaping, systematically aim to prevent initiation by nonusers, and promote cessation among users. These goals are detailed in policy statements from many pediatric health care groups in the United States and elsewhere [1-9].
Approximately 80 percent of individuals who start smoking during adolescence will continue to smoke in adulthood, and one-third of these individuals will die prematurely due to smoking-related disease [4]. As stated in a comprehensive review on Preventing Tobacco Use Among Youth and Young Adults that was released by the United States Surgeon General in 2012, "The tobacco epidemic continues because youth and young adults begin to use—and become addicted to—cigarettes and smokeless tobacco products" [4]. (See 'Persistence of smoking into adulthood' below.)
Use of electronic nicotine products, referred to generally as vaping, has risen dramatically among youth and young adults since 2013. Both the 2016 United States Surgeon General's report E-Cigarette Use Among Youth and Young Adults and the updated 2018 Surgeon General Advisory highlight this public health epidemic and call on health care professionals to screen for use of e-cigarettes and related products and address use and risk [5,10]. The report highlights the health consequences of tobacco product use by youth, high risk of addiction, and need to intervene early to prevent onset and use of tobacco. Prevention of vaping (e-cigarette use) is strongly recommended because vaping results in nicotine dependence (often with higher nicotine exposure than cigarettes) and also can lead to increased use of combustible tobacco [11]. Vaping and nicotine products can result in adverse respiratory symptoms and other health concerns [3]. (See 'Vaping nicotine' below.)
The harms of combustible tobacco use, other forms of nicotine, and secondhand smoke exposure are detailed elsewhere (see "Benefits and consequences of smoking cessation" and "Vaping and e-cigarettes" and "Secondhand smoke exposure: Effects in children"). In addition, limited evidence raises the possibility that nicotine exposure during childhood may have adverse effects on learning and brain development. In one study, self-reported nicotine use at an early age (before 10 years) was associated with inferior cognitive performance and differences in brain morphometry (as measured by magnetic resonance imaging), after adjustment for several sociodemographic and other characteristics (though not for prior secondhand smoke or prenatal nicotine exposure) [12]. This observational study does not establish a causal effect, and the findings could be explained by reverse causality. However, the possibility that nicotine has adverse effects on the developing brain is supported by animal studies in which moderate levels of nicotine exposure were associated with biomarkers of neuritic damage and long-lasting cognitive deficits [13,14].
EPIDEMIOLOGY
Prevalence and trends
●Combustible tobacco products – The prevalence of tobacco smoking among adolescents in the United States gradually declined beginning in the late 1990s (figure 1) [4,15]. Cigarette and smokeless tobacco use has decreased more rapidly since 2012, and they are now historically low [16]. In 2022, 5.2 percent of high school students reported use of a combustible tobacco product in the past 30 days, compared with 22 percent in 2011 (figure 2A-B) [17]. Some of the decrease since 2019 may have been influenced by changes in behaviors, school attendance, and survey methodology due to the coronavirus disease 2019 (COVID-19) pandemic [17-19]. From 1999 through 2020, overall Nicotine Product Days decreased in grades 6 through 12 [20]. The decrease reversed once vaping was introduced, but the overall harm may still be diminished if vaping is in fact less harmful than cigarette smoking.
A variety of combustible tobacco products were used, including cigarettes, cigars, hookah, kreteks, pipe tobacco, and bidis. Patterns of tobacco use among adolescents in the United States vary by gender, race, and ethnicity, with marked changes over time. The prevalence of cigarette smoking was traditionally higher among White than Black students but then dropped among White students as e-cigarette use escalated [4,17]. Smoking is generally more prevalent among groups with lower levels of education and lower socioeconomic status [21,22]. Of note, smoking initiation during early adulthood (ages 18 to 23 years) has become more common, increasing from 21 percent of ever-smokers in 2002 to 43 percent in 2018 [23], suggesting that this age group is an important priority for smoking prevention.
The World Health Organization (WHO) reports a wide range of smoking rates among youth and young adults in other countries; some countries including the Russian Federation, Central and Eastern Europe, Chile, Bulgaria, and Indonesia have rates of 20 percent or more [24]. This initiative includes the Global Youth Tobacco Survey, which is a collaboration with the United States Centers for Disease Control and Prevention [25,26].
●Vaping and smokeless tobacco – Instead of or in addition to using combustible tobacco, many teens use noncombustible forms of tobacco or nicotine, especially electronic vaping devices (eg, e-cigarettes), chewing tobacco (dip), snuff, and snus (table 1). For clinical care, it is important to screen for all forms of nicotine use and to use a variety of terms to describe vaping devices and smokeless tobacco; teens may fail to mention these forms of tobacco when asked only about smoking. (See 'Alternative nicotine sources' below.)
In the United States, vaping has quickly become the most common form of nicotine use among youth. The 2021 Youth Risk Behavior Survey, a nationally representative sample of high school students, reported that 36 percent of respondents had ever used an electronic vaping device, 18 percent were currently using a vaping device, and 5 percent endorsed daily use [27]. The 2022 National Youth Tobacco Survey reported that 14 percent of high school students and 3 percent of middle school students endorsed current e-cigarette use (figure 2A-B) [17]. Although this reported prevalence is down from a peak in 2019, the findings may be influenced by changes in behaviors, school attendance, and survey methodology due to the COVID-19 pandemic [17-19]. Flavored products are used by more than 85 percent of current users (fruits, sweets, or mint). Overall trends in nicotine use are difficult to track because of rapid changes in nicotine products available and associated changes in patterns of use. A sharp increase in vaping around 2017 was attributable to increasing use of the "pod-mod" style of device, which is particularly popular among youth, likely because it resembles a USB flash drive and is difficult to detect [28,29]. Since 2020, there has been a sharp increase in the use of disposable devices [30-32]. Higher rates are generally seen among females and White students [17]. (See "Vaping and e-cigarettes", section on 'Prevalence and patterns of use'.)
The global prevalence of current vaping among youth 12 to 16 years is 9.2 percent (based on data from the Global Youth Tobacco Survey, 2012 to 2019) [33]. The prevalence varied widely among the countries surveyed and was lower in middle-income countries compared with either high- or low-income countries.
●Cannabis – Current use of combustible cannabis was reported by 23 percent of 12th grade students in the United States in a 2017 survey [34]. Although combustible cannabis, like tobacco, exposes the user to adverse effects of smoke contaminants (tar and polycyclic aromatic hydrocarbons), many young users have the false perception that it is not harmful [35]. The prevalence of vaping cannabis has increased dramatically, rising from 5 percent of 12th grade students in 2017 to 14 percent in 2019 [36]. Concurrent use of e-cigarette, cigarette, and cannabis has been associated with greater psychosocial risk factors than use of only one or two of these products [37]. (See "Cannabis use and disorder: Epidemiology, pharmacology, comorbidities, and adverse effects".)
Persistence of smoking into adulthood — Approximately 80 percent of individuals who start smoking during adolescence will continue to smoke in adulthood [4]. Conversely, more than 80 percent of adult smokers started smoking between ages 14 and 25 [4,38]. Even trying a cigarette during childhood or adolescence is associated with substantial excess risk of adult smoking. Early experimentation is particularly likely to be associated with adult smoking, as demonstrated in a study that found that younger age at first experimentation was associated with increased risk of becoming a daily smoker in young adulthood, and a reduced chance of quitting smoking by middle age [39]. Predictors of whether an individual adolescent or young adult is likely to quit smoking are discussed in a separate topic review. (See "Management of smoking and vaping cessation in adolescents", section on 'Patterns of smoking behavior and cessation'.)
FACTORS CONTRIBUTING TO SMOKING AND VAPING INITIATION
Attitudes and beliefs — Attitudes toward smoking are an important predictor of smoking initiation. As an example, in a longitudinal study of adolescents who had never smoked at baseline, 40 percent became experimenters and 8 percent had an established smoking habit during four years of follow-up [40]. The absence of a firm decision not to smoke was the strongest predictor of experimentation.
Attitudes toward smoking are influenced by several factors:
●Peer and family influence – The presence of tobacco product users in the network of family or friends is associated with less negative attitudes towards smoking or vaping and is an important predictor of initiating tobacco use during adolescence [4,41-44]. As a result, it is considered an important social determinant of health and contributor to health disparities [45]. Refusing a cigarette in the face of social pressure is challenging for many adolescents; among adolescents who were occasional or daily smokers, only 44 percent felt confident that they could refuse a cigarette at a party [46]. (See 'Advertising and media influence' below.)
●Age – Either positive or negative attitudes toward smoking often become more pronounced during adolescence [47]. As an example, in a study of Swiss children 11 to 14 years of age, parental approval significantly influenced children's intention to smoke, but this effect decreased for older adolescents [48].
●Misperceptions – Adolescents tend to overestimate the frequency of smoking among their peers and among adults [49]. Conversely, adolescents tend to underestimate their own smoking habits [50].
●Marketing – Although the direct advertising of tobacco to youth is banned in the United States, indirect marketing efforts and positive images of cigarette use in the media have important effects on teenage smoking behavior [4,42,51,52]. Many advertisements use images or other techniques to suggest that smoking is associated with good health, thinness, and social acceptance. (See 'Advertising and media influence' below.)
These factors also influence initiation of vaping (e-cigarette use) [11]. Use of any tobacco product increases the likelihood of vaping [11]. Teens often perceive that vaping is healthier than smoking combustible tobacco and underestimate the risks of vaping. (See 'Vaping nicotine' below.)
Nicotine dependence — Nicotine is a strongly addictive substance, and the first symptoms of nicotine dependence can appear within days to weeks of the onset of occasional cigarette use, and often appear before the onset of daily smoking [41,53]. Youth are particularly vulnerable to becoming dependent on nicotine, compared with adults [4]. There is a growing literature regarding the impact of nicotine on the developing adolescent brain [54], which is reviewed in a technical report from the American Academy of Pediatrics [55]. As an example, among 6th grade students (median age 12 years) who smoked at least once per month at baseline, 53 percent experienced symptoms of nicotine dependence and 40 percent escalated to daily smoking during the next four years [56]. Early emergence of dependence symptoms predicted escalation in smoking frequency, and smoking frequency accelerated the appearance of dependence symptoms [57]. Nicotine dependence is an important factor in determining which individuals become regular smokers after smoking experimentation [41,53,56,57].
Vaping nicotine is also strongly associated with development of nicotine dependence, as discussed below. Nicotine solutions used in electronic devices often deliver a higher concentration of nicotine than combustible tobacco. (See 'Vaping nicotine' below.)
The specific symptoms of nicotine dependence are discussed separately. (See "Management of smoking and vaping cessation in adolescents", section on 'Address nicotine withdrawal symptoms and other barriers to quitting'.)
Availability of flavored tobacco products — Smoking and vaping initiation appear to be related to the availability of flavored nicotine sources and other products that tend to appeal to novice users. Flavorings include cherry, grape, and bubble gum and closely resemble candy [58]. As an example, more than 40 percent of youth in the United States who smoke use flavored "little cigars," despite restrictions on the sale of flavored cigarettes [59]. Flavoring is particularly common in e-cigarettes, hookahs, and other alternative nicotine sources and is popular among youth [32,60] (see 'Alternative nicotine sources' below). Surveys of high school students in California found that teens who vaped e-cigarettes in nontraditional flavors, compared with those who exclusively vaped tobacco-flavored, mint- or menthol-flavored, or flavorless e-cigarettes, were more likely to continue vaping and take more puffs per vaping occasion six months later [61]. Legislative restrictions and marketing techniques that address this preference are discussed below. (See 'Restrictions on flavored tobacco products' below.)
Other risk factors
●Vaping – Accumulating evidence suggests that vaping nicotine (e-cigarettes and other electronic delivery devices) is often associated with symptoms of nicotine dependence and often precedes conventional smoking in adolescents. (See 'Vaping nicotine' below.)
●Previous level of experimentation – In a study of a group of adolescent experimenting tobacco smokers (defined as those who had had at least one puff but fewer than 100 cigarettes in their lifetime), 31 percent went on to become established smokers within four years [62]. The teen's level of smoking experience at baseline was the strongest independent predictor of established smoking four years later.
●Depression – Most studies show an association between depression and smoking initiation, but it is unclear whether the association is causal [4,63,64].
●Poor school performance – Skipping school and poor school performance are associated with progression along the smoking uptake continuum [4,42,65]. School misbehavior and low academic achievement can directly and indirectly contribute to the risk for smoking initiation [66]. Vocational school career, lower school performance, being out of school, and studying at a disadvantaged school have been correlated with e-cigarette use [11].
●Adverse experiences – Adverse experiences during childhood are associated with increased risks for initiating smoking and continuing smoking. These include parental separation or divorce; emotional, physical, and sexual abuse; having a battered mother; or growing up with a household member who is substance abusing, mentally ill, or incarcerated [67-69].
●Sexual and gender minority (SGM) adolescents are more likely than their heterosexual and cisgender peers to smoke cigarettes [70]. Furthermore, SGM-specific family rejection was independently associated with smoking.
●Substance abuse – There is a high rate of smoking among adolescent substance abusers. In one report of teens undergoing inpatient treatment in a hospital-based substance abuse treatment facility, 85 percent smoked [71]. In many cases, smoking precedes the use of illicit drugs [72,73]. Furthermore, in a study of adolescents who reported smoking at least one cigarette per day for the last 30 days, marijuana use was associated with greater symptoms of nicotine addiction [74]. Therefore, an adolescent who smokes should be engaged in discussions about other risk behaviors. (See "Management of smoking and vaping cessation in adolescents", section on 'Drug and alcohol use'.)
SMOKING AND VAPING PREVENTION IN THE PRIMARY CARE OFFICE — To prevent smoking and vaping initiation, we suggest that pediatric health care professionals should give anticipatory guidance to all parents and to all children five years and older during routine health care. This suggestion is consistent with guidelines from the American Academy of Pediatrics and many other organizations, although some of the older guidelines do not specifically include vaping [1-9,41]. Additional attention should be given to patients with risk factors, such as having family members and/or peers who smoke [45]. All patients should also be monitored for smoking and vaping initiation. For any who begin to use these products, the clinician should take additional steps to help the patient stop smoking as soon as possible. Staff members in the medical office should model healthy behaviors by avoiding smoking and vaping.
Primary care clinicians have a special role as a health authority for families, and there is evidence that adolescents view clinicians as the preferred source for information about smoking and smoking cessation [75]. Despite this preference, in a 2011 survey in the United States, only one-third of adolescents reported that they were asked about tobacco use by their health care clinician [76]. However, in a subsequent report that focused on documentation available in electronic health records of community health and public health clinics, more than 85 percent of adolescents were assessed for smoking; such assessments may include patient questionnaires or questioning by ancillary staff [77].
Interventions to prevent smoking initiation through counseling in the primary care office have not been well standardized or studied. However, a variety of interventions have shown moderate efficacy and feasibility [3,78-80]. In one report, the authors reported that they were able to deliver a brief smoking prevention or cessation intervention during the course of routine primary care visits, following a simple intervention protocol, and the average intervention time was just under five minutes [81].
One useful approach for smoking prevention counseling in the primary care office can be summarized as a mnemonic with five A's: Ask, Advise, Assess, Assist, and Arrange follow-up [41]. The focus of each step varies with the child's age and the smoking status of parents and child (table 2) [82-84]. This mnemonic is analogous to the steps used to assist with smoking cessation in a child or adult who is already smoking. We suggest using a similar strategy to prevent vaping initiation, although this has not been specifically studied. (See "Management of smoking and vaping cessation in adolescents", section on 'Behavioral support for all adolescents who smoke or vape'.)
Ask about smoking and vaping habits — Pediatric clinicians should ask about smoking habits at each health maintenance visit [8]. Some clinicians have successfully employed a brief questionnaire to facilitate this process [85].
●When the child is young, the clinician should ask about the smoking or vaping habits of the parents and other household members [45,82].
●For school-aged children, the clinician should additionally explore each of the following areas:
•The family and child's attitudes towards smoking and vaping
•Whether the child or his/her peers have experimented with smoking or vaping
●For adolescents, the clinician should ask about all forms of nicotine use (including smoking, vaping, oral nicotine products, and other alternative nicotine sources) by the patient and his/her peers at each health maintenance visit [8,86,87]. The clinician should inquire about vaping using a variety of terms to capture different types of electronic nicotine delivery devices, including e-cigarettes, Juuls, pods or pod-mods, e-cigars, e-pipes or e-hookahs, vape pens or pipes, or atomizers (table 1). Similarly, the clinician should specifically ask about "nontobacco" or "tobacco-free" oral nicotine products, which are available in pouches, gum, lozenges, and gummies. (See 'Oral nicotine products' below.)
Clinicians should allow time during each visit to speak with the patient without the parents present to facilitate disclosure. The clinician should establish confidentiality rules with the patient at the start of these visits to facilitate disclosure and frank discussion [88].
Advise about the health risks of tobacco products — Counseling should focus on health risks of smoking and vaping and be tailored to the age of the child and the parents' smoking status (table 3). Patients and parents/caregivers who are not smoking or vaping and those who have made clear decisions not to do so should be given praise and brief reminders of the health risks of tobacco use. Patients who are experimenting with smoking or vaping, or those who have risk factors for tobacco initiation (eg, smoking or vaping among parents or peers), require a more detailed discussion.
●Infants and toddlers – Advice to the parent or caregiver focuses on the health effects of direct and secondhand smoke [89]. If the parent smokes, they should be strongly advised to quit smoking and offered assistance. Parents should also be educated about their important role as models for not smoking or vaping [47,90]. (See 'Guidance for parents and caregivers' below.)
Limiting parental smoking to outside the home is far less effective in reducing secondhand smoke exposure than complete smoking cessation. Secondhand exposure to e-cigarette vapor raises some health concerns because the vapor includes nicotine and particulate matter, although it is expected to be less toxic than secondhand tobacco smoke. (See "Secondhand smoke exposure: Effects in children" and "Vaping and e-cigarettes", section on 'Secondhand aerosol exposure'.)
●School-aged children – The health effects of smoking should be explained at a level appropriate to the child's age. The short-term negative effects of smoking, such as smell, staining of teeth, and decreased athletic performance, should be emphasized. The potential for rapid development of addiction should be discussed; the clinician should emphasize that it is not safe to "experiment" with smoking or vaping. (See 'Nicotine dependence' above.)
If the parent smokes, they should be strongly advised to quit smoking and offered assistance. (See 'Guidance for parents and caregivers' below.)
●Adolescents – The clinician should give clear messages describing the established health risks of smoking, and state that there is no safe level of tobacco or nicotine use. Instead of focusing on the long-term effects of chronic smoking, the clinician should emphasize the immediate effects of smoking, including:
•Chronic cough
•Exacerbations of asthma
•Greater risk of pulmonary infections
•Atherosclerosis
•Potential for rapid development of nicotine dependence (see 'Nicotine dependence' above)
•Possible permanent effects on learning and brain development (see 'Why prevention is important' above)
In addition, explain that smoking by adolescents and young adults is not associated with significant weight loss, contrary to the beliefs of many young people [4] (and despite the evidence that smoking cessation causes weight gain in adults). The health consequences of smoking are discussed in detail in a separate topic review. (See "Benefits and consequences of smoking cessation", section on 'Benefits of smoking cessation'.)
The clinician should also specifically discuss the health risk of alternative nicotine sources, including the strong addictive potential for e-cigarettes (vaping) and Juuls (Juuling) [86]. (See 'Alternative nicotine sources' below.)
●Patients with chronic illnesses – Children with chronic illnesses, such as asthma or cystic fibrosis, often smoke despite their special vulnerability to the adverse health effects [91]. As examples, use of combustible tobacco or alternative nicotine sources such as e-cigarettes is more common among patients with asthma than among those without asthma [92-95], and 5 to 10 percent of individuals with cystic fibrosis smoke [91,96]. Smoking also has important disease-specific health risks for patients with sickle cell disease, cancer, diabetes mellitus, and juvenile idiopathic arthritis [91]. For adolescents with these chronic illnesses, counseling should be personalized with discussion of the risks that are specific to the patient's underlying disease (table 4).
Assess risk factors for tobacco initiation — Smoking prevention counseling can be targeted to at-risk patients by assessing risk factors for smoking initiation, including the following (see 'Factors contributing to smoking and vaping initiation' above):
●Previous level of experimentation
●Smoking and vaping by parents and among peers
●Attitudes and beliefs about the social implications and health consequences of smoking and vaping
●Depression
●Poor school performance
●Adverse experiences
●Substance use disorder
Some of these risk factors are potentially modifiable, such as parental smoking and lack of smoking ban at home. Other risk factors draw attention to associated health risks, such as depression or substance abuse (table 5). If adolescents report difficulty resisting social pressure, targeted counseling to foster smoking resistance may be helpful. (See 'Fostering smoking and vaping resistance' below.)
Assist with parenting skills and smoking and vaping resistance — Pediatric health care clinicians also have a role in facilitating smoking cessation for a child's parents and teaching practices to prevent smoking initiation.
Guidance for parents and caregivers
●Support to quit smoking and vaping – Because children whose parents or caregivers do not smoke or who successfully quit smoking are much less likely to take up smoking, pediatric health care clinicians should strongly encourage smoking cessation in those who smoke [8,41,45,84,97]. The clinician should emphasize the adverse health effects of secondhand smoke on the child and the value of serving as a role model for nonsmoking and offer referral or assistance with quit attempts [89]. Studies of smoking cessation interventions in adults suggest that counseling for as few as three minutes results in increased abstinence rates as compared with no counseling [98].
In the United States, free resources include the National Cancer Institute's quit support line (877-44U-QUIT) and smokefree.gov, which provides links to local and state telephone quit support lines (800-QUIT-NOW). A practical strategy for addressing parental smoking during pediatric health care visits is available through the CEASE website. The strategy and materials were developed through focus groups and use the "five A's" approach to brief smoking cessation counseling [99,100]. Resources include educational materials for patients designed for several age groups and languages. A cluster-randomized trial suggests that this approach is moderately effective and cost-effective for reducing parental smoking, although implementation by clinicians waned over time [101,102].
A meta-analysis found that interventions that motivated parents to stop smoking for the benefit of their child achieved 23 percent quit rates, which was modestly higher than the 18 percent quit rate in the pooled control groups [103]. Studies of smoking cessation interventions in adults suggest that counseling for as few as three minutes results in increased abstinence rates as compared with no counseling [98]. National surveys in the United States suggest that the majority of parents feel that this is part of the pediatrician's job and that most parents who smoke would welcome such advice [104], and a majority of parents who smoke reported that they would accept enrollment in a telephone cessation program if the child's doctor offered it to them [105]. A separate survey reported that 30 percent of parents who smoke received no counseling about smoking cessation or smoking risks from their child's health care clinician [106]. Telephone counseling can increase smoking cessation, and all smokers should be given the number to the free national quit-line. (See "Overview of smoking cessation management in adults".)
●Smoking bans – Pediatricians should encourage families to maintain a smoke-free and vape-free home. Household smoking bans can be helpful even when parents are smokers; a smoke-free home communicates nonsmoking expectations to the child and also supports decreased cigarette consumption and smoking cessation in adult smokers [41,107,108]. A smoking ban must be strictly enforced in order to be effective. The American Academy of Pediatrics advises that vaping also be banned from the household and cars [109].
●Parenting skills – Parents and caregivers should be encouraged to give clear and consistent messages to their children that they expect them to remain nonsmokers. Parental disapproval of smoking is associated with lower rates of smoking initiation among their children and improved resistance of the child to peer smoking influences [110]. Of note, parental disapproval helps prevent smoking initiation in the child even if the parent smokes [111,112]. The clinician should educate the parents about how adolescents are able to obtain tobacco products and encourage them to watch for signs of experimentation. (See 'Strategies to limit access to tobacco products' below.)
Parents should be advised that electronic vaping devices come in many shapes and sizes. Some look like regular cigarettes, cigars, or pipes, whereas others look like items commonly used by youth, such as pens or USB flash drives [113]. Educational materials for parents are available from the Centers for Disease Control and Prevention and other reliable resources. (See 'Vaping nicotine' below.)
Fostering smoking and vaping resistance — Several techniques are used in school-based interventions to foster resistance to smoking among children and adolescents. These techniques may also be helpful to guide an individual counseling encounter, although their use in this context has not been evaluated. These include:
●Encourage the child to value good health. Talk about how being a nonsmoker helps to improve sports performance, appearance, and self-worth.
●Correct misperceptions about the frequency of smoking among peers (most children overestimate this frequency) [49].
●Teach awareness of media and peer influences. (See 'Advertising and media influence' below.)
●Foster resistance to social influences from peers by rehearsing refusal skills. Teaching of the mnemonic REAL (Refuse, Explain, Avoid, Leave) has been successful as part of a school-based substance prevention curriculum [114]. It has not been tested as an office-based counseling strategy.
Pediatric health care clinicians can and should give messages about avoiding tobacco exposure and use to children as young as five years old. If the parent/caregiver is present during the counseling session, they may also be able to provide reinforcement at home.
Arrange follow-up — Follow-up for smoking and vaping prevention varies depending on the child's age and risk factors (table 2). For a child who expresses an attitude against smoking and who has no significant risk factors, the antismoking messages can simply be reinforced at each annual health maintenance visit.
EDUCATIONAL RESOURCES — The following resources provide reliable information designed for patients and families, which may be used to supplement the office visit or distributed in the office waiting room:
●HealthyChildren.org (American Academy of Pediatrics)
●Center for Young Women's Health (Boston Children's Hospital)
●The Truth (Truth Initiative)
●Centers for Disease Control and Prevention [115]:
•Quick facts on the risks of e-cigarettes
•How to talk to your teen about e-cigarettes
•Youth tobacco use infographics
Resources focused on quitting (includes support by text or mobile app):
●My Life, My Quit (National Jewish Health) – Good resource for information about vaping
●Smokefree Teen (United States Department of Health and Human Services)
TOBACCO PREVENTION IN OTHER SETTINGS
School-based interventions — Most smoking prevention strategies have been delivered in a school-based setting and some, but not all, have shown some efficacy [84]. A systematic review that included 134 studies found that school-based programs reduced smoking initiation by approximately 12 percent [116]. The most effective programs focused on developing social competence (skills for problem-solving and decision-making) and resisting social influences (increasing awareness of peer pressure and other influences that promote substance use). Programs using adult presenters were more effective than those with peer leaders alone. A meta-analysis of a school-based incentive program (primarily the Smokefree Class Competition, widely used in Europe) did not demonstrate a significant effect on limiting smoking initiation in youth [117]. While studies vary in conclusions, it appears that the more effective school-based programs are comprehensive, interactive, start early, and address more distal, social, and community influences as well [118].
Family-based interventions — Some counseling interventions focus on helping family members strengthen nonsmoking attitudes and promote nonsmoking among targeted children and adolescents; techniques include smoking cessation among parents and siblings, enhanced family communication, and household smoking bans. A systematic review of 27 randomized trials of various family-based interventions found moderate quality evidence that such interventions help to prevent smoking initiation [119]. The evidence was strongest for high-intensity programs. Effective interventions tended to emphasize authoritative parenting style (firm rule-setting combined with strong interest in the child). (See 'Guidance for parents and caregivers' above.)
ALTERNATIVE NICOTINE SOURCES — In addition to smoking cigarettes, many teens use alternative forms of inhaled tobacco, such as bidis, kreteks, snus, Juuls, hookahs, and e-cigarettes, as well as smokeless tobacco, including chewing tobacco (dip) and snuff (table 1) [120]. In particular, use of e-cigarettes is increasing dramatically among adolescents in the United States, and hookah use peaked in 2014 then declined (figure 2A-B). However, surveys may not capture the full range of devices used by youth, because they do not consistently include all the terms that youth use to describe the devices. It is important to ask specifically about all forms of nicotine use, including Juul and e-cigarette use, because teens may fail to mention smokeless tobacco or other nicotine sources when asked about smoking.
Vaping nicotine — Vaping refers to the use of various types of electronic nicotine devices including e-cigarettes, Juuls, pods, e-cigars, e-pipes or e-hookahs, vape pens or pipes, or atomizers (table 1). The nicotine dose varies substantially among these devices [121]. Details about these devices are discussed separately. (See "Vaping and e-cigarettes".)
Vaping by teens grew rapidly during the past decade and is now the most common form of tobacco use by youth in the United States. Overall trends are accompanied by rapid changes in the types of devices used, including a recent trend to disposable devices. (See 'Prevalence and trends' above.)
Vaping products are marketed with a variety of flavors, which probably promotes uptake by youth. Most youth select flavored products despite efforts to restrict their availability [60,122]. In addition, the use of flavored products predicts an increase in vaping [61,123]. (See 'Restrictions on flavored tobacco products' below.)
Concerns for health risks from vaping nicotine include:
●Nicotine dependence – Accumulating evidence suggests that vaping often leads to nicotine dependence. Nicotine exposure from vaping increased after 2015 due to changes in device design, which increase the size of the vape cloud, and transition to protonated nicotine (nicotine salt) products, which facilitates inhalation of nicotine by naïve users. In a large cross-sectional study of adolescents in the United States, symptoms of nicotine dependence (as measured by using nicotine within five minutes of waking) were reported by more than 10 percent of adolescents who used e-cigarettes in 2021, compared with <1 percent of e-cigarette users in 2014 [124]. Approximately 25 percent of users report daily use [32]. One study reported that the correlation between urinary nicotine concentration and nicotine dependence score among adolescents and young adults who used Juuls was similar to that previously found among combustible cigarette users [125]. These findings highlight the addiction potential of high-nicotine content electronic nicotine devices.
Other studies show an association between vaping and subsequent combustible tobacco use, suggesting that vaping nicotine may serve as a gateway [126-134]. The association is stronger for youth with low-risk characteristics for smoking initiation, including those who initially had no intention to begin smoking [135,136]. Similarly, analysis of psychosocial risk factors suggest that many youth who use e-cigarettes are unlikely to have initiated tobacco smoking with cigarettes [137]. Reasons for transitioning from e-cigarettes to cigarettes include socializing values (cigarettes are often present at parties and are shared), preference for the nicotine effect and cigarette smoke, and lower cost [138]. In addition, one report found that baseline use of e-cigarettes was associated with a three- to fourfold increased risk for initiation and ongoing marijuana use within the subsequent two years, after adjusting for shared risk factors for use of these substances, suggesting that e-cigarette use increases the adolescent's vulnerability to marijuana use [139].
These findings suggest that vaping is expanding overall use of tobacco products among youth rather than replacing other sources. In 2018, a report from the National Academies of Medicine concluded that "there is substantial evidence that e-cigarette use by youth and young adults increases their risk of ever using conventional cigarettes" [140]. In 2016, the United States Surgeon General reported that "e-cigarettes are not harmless…nicotine exposure during adolescence can cause addiction and can harm the developing brain" [141]. Animal models and epidemiologic studies in humans provide further evidence for concern about nicotine exposure in fetal life, childhood, and adolescence [142]. (See 'Nicotine dependence' above.)
●Chronic bronchitis – The possibility of direct health risks from vaping is suggested by a study in which their use by high school students doubled the risk for chronic bronchitis symptoms in a dose-related fashion [143]. The increased risk persisted after adjustment for cigarette smoking and other relevant confounders. Youth with asthma are particularly at risk for respiratory effects of e-cigarettes [144].
●Severe acute pulmonary disease – E-cigarette, or vaping, product use associated lung injury (EVALI), initially described in 2019, is an acute or subacute respiratory illness that can be severe and life-threatening [145-148]. This concern is discussed separately. (See "Vaping and e-cigarettes", section on 'Aerosol (also known as vapor) exposure' and "E-cigarette or vaping product use-associated lung injury (EVALI)".)
●Sleep disturbance – Vaping has been associated with sleep difficulties, even among non-daily users; this association is likely an effect of nicotine on nocturnal sleep architecture [149-151].
●Cancer risk – Other studies found many carcinogenic, volatile organic compounds in e-cigarette vapor [87,152].
These and other health concerns about vaping and its possible effect on smoking initiation in youth are discussed in more detail in a separate topic review. (See "Vaping and e-cigarettes".)
Given these concerns, the American Academy of Pediatrics, United States Surgeon General, and many public health authorities have recommended regulatory strategies, including restricting marketing of electronic vaping devices and advertising to youth, increasing the cost of the devices, and banning flavorings for nicotine products, similar to strategies used to reduce tobacco use by youth. Some of these changes have begun to take effect. In addition, the federal minimum age of sale of tobacco products was raised from 18 to 21 years old in 2019 [60,86,87,141,153-155]. E-cigarettes should not be used for treatment of tobacco dependence, as they have not been shown to be safe or effective [86,87,156]. (See 'Strategies to limit access to tobacco products' below.)
Resources designed for patients and families are listed above. (See 'Educational resources' above.)
Of note, e-cigarettes are often used to vaporize cannabis or other substances [36,157-159]. (See "Cannabis (marijuana): Acute intoxication", section on 'Recreational use'.)
Oral nicotine products — New forms of oral nicotine may appeal to youth and present regulatory challenges:
●Synthetic ("tobacco-free") nicotine products – These nontobacco nicotine products are available as gum, lozenges, gummies, and pouches. Aspects that may particularly appeal to youth include availability in appealing flavors, forms that are easily concealed, and marketing messages that suggest minimal harm. They are not approved as cessation aids.
These products were introduced in 2018, and their use has increased sharply since then. In a survey of 9th and 10th grade students in Southern California in late 2021, these products were the second most common nicotine source (after e-cigarettes) and more common than combustible tobacco [160]. In this study, the overall prevalence of all forms of nicotine was relatively low (perhaps related to the COVID-19 pandemic), so trends in use of these products among adolescents and potential associated harms requires further study. The US Food and Drug Administration (FDA) is authorized to regulate nontobacco nicotine products and has issued warning letters to manufacturers and retailers regarding illegal marketing [161,162].
●Tobacco-derived nicotine products – Other products are formulated as discs or chews that contain nicotine derived from tobacco but not unrefined tobacco. The FDA authorized the marketing of some of these products, with the rationale that they are less harmful than other forms of smokeless tobacco and that they are relatively unlikely to prompt initiation of tobacco use by youth and nonsmokers [163]. This decision does not mean that the products are safe or "FDA approved."
Other nicotine sources — Other less common alternative nicotine sources are:
●Heat-not-burn (HNB) cigarettes – HNB tobacco cigarettes are devices that heat a tobacco stick to a temperature below that at which tobacco cigarettes burn. A brand named IQOS ("I quit ordinary smoking") was approved in the United States in 2019. HNB devices are often associated with respiratory symptoms and produce cancer-causing chemicals, and there is no reliable evidence that they are any safer than combustible tobacco [164]. Concerns about health effects and misleading marketing practices are outlined in a fact sheet from the American Academy of Pediatrics [165,166]. (See "Patterns of tobacco use", section on 'Heat-not-burn tobacco products'.)
●Smokeless tobacco – In the United States, use of smokeless tobacco (chewing tobacco, snuff, or dip) by youth has gradually decreased; among high school students in the United States, approximately 2 percent of males and 1 percent of females use these products [17]. Rates are higher for male athletes than for male nonathletes [167]. Many adolescents are poorly informed about the dangers of smokeless tobacco, and some believe that it is a safe substitute for smoking cigarettes. The health effects of smokeless tobacco include oral, pharyngeal, and esophageal cancer, oral leukoplakia (a premalignant lesion), and periodontal disease [168,169]. Use of smokeless tobacco produces levels of nicotine that are similar to those produced by smoking, and are also addictive. Smokeless tobacco use is associated with higher levels of current and subsequent cigarette smoking and lower rates of smoking cessation [170,171]. Health concerns about these alternative nicotine sources are discussed in more detail in a separate topic review. (See "Patterns of tobacco use", section on 'Other forms of tobacco'.)
Strategies similar to those described above for smoking prevention can also be used for prevention and cessation of smokeless tobacco use. Clinicians should emphasize the specific health risks of smokeless tobacco use, as well as the cosmetic consequences of stained teeth and bad teeth (gum disease and tooth loss). Oral health professionals and medical clinicians have important opportunities for intervention, in addition to educational efforts in the community and school, although few intervention trials have been reported [172].
ADVERTISING AND MEDIA INFLUENCE — Direct advertising and indirect promotion of tobacco products has helped to perpetuate tobacco use across generations. Although regulations have attenuated this influence, it remains an important factor in tobacco initiation. Moreover, tobacco advertising has specifically targeted vulnerable populations, including Black Americans, Native Americans and Alaska Natives, sexual minorities, and people living in poverty [173-175]. This inequitable promotion of tobacco products contributes to health disparities within the United States, which are exacerbated by unequal access to medical care and treatment for tobacco dependence [45]. These disparities are important targets for legislation and advocacy by health professionals.
In the United States, tobacco advertising that targets people younger than 18 years of age has been prohibited since 1998 [176]. The federal government has added stronger health warnings and limits on tobacco products but has not yet implemented similar regulations of e-cigarette advertising, although concerns have been raised about the appearance of these devices in entertainment events and social media [87,177].
A growing number of states have enacted various limits on e-cigarettes. A regularly updated source of information on United States e-cigarette regulations by state is available at the Public Health Law Center at Mitchell Hamline School of Law.
Direct expenditures for cigarette advertising in mainstream media have decreased substantially since 2000 [178]. In 2009, tobacco brand sponsorship of sports and entertainment events was prohibited. Between 1992 and 2013, sports-related marketing expenditures decreased significantly for both cigarettes (from $136 million in 1992 to $0 in 2013) and smokeless tobacco (from $34.8 million in 1992 to $2.1 million in 2013) [179]. Despite these reductions in mainstream advertising, adolescents are exposed to tobacco advertising through point-of-sale advertising, promotional products, the internet and social media, and these marketing strategies effectively increase the use of tobacco products [180]. Furthermore, tobacco companies promote sales by reducing the prices of some tobacco products [4,181].
E-cigarettes are also marketed through multiple methods including the internet and social media, as outlined in these infographics from the Centers for Disease Control and Prevention [182]. Surveys demonstrate that 78 percent of middle and high school students in the United States are exposed to this advertising, with an upward trend [183]. A meta-analysis of 24 studies found that exposure to tobacco-related content on social media was associated with more than twofold increased risk for lifetime tobacco use and past 30-day tobacco use, as well as increased susceptibility to tobacco use among nonusers [177].
Depiction of smoking in movies also has an important influence on the initiation of smoking among youth [4,184-186]. The film industry participates in a voluntary ban of paid product placement, and depiction of tobacco use in popular youth-rated movies decreased substantially from an average of 20 incidents per movie in 2005 to seven per movie in 2010 [187]. Most of the improvements were seen in movies produced by the three companies with specific anti-tobacco policies.
To counteract the influence of the tobacco industry, antismoking advertising campaigns have been launched, and these appear to be effective in fostering smoking resistance [4,188]. Studies indicate that a child's exposure to "truth" (antismoking) advertisements was associated with positive changes in attitudes, beliefs, and intentions to avoid smoking. In another example, exposure to the "Real Cost" media campaign in the United States was associated with preventing smoking initiation among nearly 350,000 youth during a two-year period [189]. Conversely, exposure to advertisements created by the tobacco industry that purport to discourage smoking among youth (eg, Phillip Morris' "Think. Don't Smoke" campaign) was associated with more favorable beliefs and attitudes toward the tobacco industry [4,190]. The findings suggest that well-executed antismoking campaigns can positively and consistently change youths' beliefs and attitudes, whereas a tobacco industry-sponsored campaign can have a counterproductive influence. Other strategies include promoting stricter regulations that prohibit tobacco advertising and promotion in forms that are accessible to youth, such as sponsorship of celebrities and events by tobacco companies, marketing tobacco-related apparel to youth, and placement of tobacco products in movies and media [154,191].
Social media messaging is being explored as a strategy to prevent adolescent smoking. As an example, for one study youths were shown gender-specific "YouTube-style" videos addressing tobacco exposure as a modifiable risk for cancer [192]. The youths reported a positive response to the videos and an interest in sharing them on social networking sites. These observations suggest that social media messages have potential for cost-effective health promotion initiatives targeting youth.
STRATEGIES TO LIMIT ACCESS TO TOBACCO PRODUCTS
Public smoking bans — Smoke-free air laws and state tobacco control programs have been shown to be effective strategies for curbing youth smoking in the United States [193,194]. (See "Control of secondhand smoke exposure", section on 'Public smoking bans'.)
Age restrictions for sales — Parents and clinicians may be better able to limit youth access to nicotine products by understanding how youths are able to purchase these products, then taking measures to prevent this. Despite numerous laws in the United States that restrict access to cigarettes and e-cigarettes for youth, most report that they can obtain cigarettes through one or more of the following means:
●Having an older friend purchase cigarettes for them or by using false identification.
●Purchasing cigarettes themselves if the merchant fails to enforce the age limit. Merchant compliance with tobacco purchasing laws is inconsistent [195].
●Purchasing cigarettes or e-cigarettes over the internet using credit cards or money orders [196]. E-cigarettes are readily available through the internet; one survey from 2015 found that two-thirds of internet vendors required only a self-verified statement of age, and 35 percent had no age verification process [197].
Merchant compliance with youth access laws is not sufficient. A comprehensive review reported no association between retailer compliance with youth access laws and smoking susceptibility, past-year initiation, current smoking, or established smoking in adolescents [193]. As of December 2019, the minimum age for tobacco product sales was raised to 21 years [198]. Reductions in youth smoking have been observed when the minimum age is increased, and similar changes are needed for access to e-cigarettes as well [154,155,199,200].
Taxes and cost — Higher costs of cigarettes reduce adolescents' tobacco use because cigarette smoking in this age group is particularly sensitive to price [193,201]. Taxation is an effective approach to increasing cigarette prices, as shown by the decreases in smoking among youth and young adults after the 2009 tax increase [201]. However, because of inflation, the relative burden of cigarette taxes tends to decrease over time. Because smoking among young age groups is sensitive to price, tobacco companies have specifically sought ways to reduce the price of tobacco products as part of their marketing strategies [4]. The American Academy of Pediatrics has called for increasing prices on tobacco products, e-cigarettes, and other alternative nicotine sources to reduce tobacco use initiation among youth [87]. (See 'Advertising and media influence' above.)
Restrictions on flavored tobacco products — Flavored tobacco products tend to appeal to novice users and likely contribute to the risk of smoking initiation (see 'Availability of flavored tobacco products' above). As a result, sales of cigarettes with "characterizing flavors" (or "candy-flavored" tobacco) were banned in the United States in 2009 [202]. However, this legislation does not include many other types of tobacco products, including e-cigarettes, cigars, tobacco-based wraps, or smokeless tobacco, nor does it include menthol flavors, and nearly one-half of current youth cigarette smokers smoked menthol cigarettes [203]. Manufacturers have developed products that circumvent this restriction, including flavored "little cigars," which closely resemble cigarettes. Flavored versions of "little cigars," "blunt wraps" (often used to roll cannabis), smokeless tobacco, and e-cigarettes are marketed with themes, images, and media sources that target youth [204] (see 'Advertising and media influence' above). A number of municipalities in the United States have enacted local legislation to restrict the sale of these flavored nicotine products [60], and the American Academy of Pediatrics has called for comprehensive bans on all flavoring agents (including menthol) in all tobacco products [154].
As of 2020, the US Food and Drug Administration (FDA) proposed a ban on most flavorings from e-cigarettes (cartridge-based nicotine products with flavors other than tobacco and menthol) [205] and subsequently began to authorize marketing only for tobacco-flavored e-cigarette products [206]. However, the effect of this legislation on youth vaping initiation may be limited, unless menthol-flavored products are also banned, because menthol is similar to mint (a very popular flavor among youth) and because all flavors are still permitted for disposable e-cigarettes and liquids for open tank system devices [207,208]. This concern is supported by data from a survey in 2020, which showed high use of menthol flavors (37 percent of high school vapers) and high use of disposable and tank system devices [30,209]. Disposable devices were used by more than 25 percent of high school vapers, representing a sharp increase since 2019.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Smoking cessation, e-cigarettes, and tobacco control".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Vaping (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Clinical significance – Approximately 80 percent of individuals who start smoking during adolescence will continue to smoke in adulthood, and one-third of these individuals will die prematurely due to smoking-related disease. Therefore, the pediatric population is a critical target for public health efforts to reduce smoking. (See 'Why prevention is important' above.)
●Prevalence and trends – Approximately 20 percent of high school students in the United States smoke cigarettes; the rate has gradually declined since the late 1990s but has now plateaued (figure 1). Since 2011, there has been a sharp increase in vaping (via various electronic nicotine delivery devices) among youth that offsets the decreases in other tobacco products (figure 2A-B). (See 'Prevalence and trends' above and 'Vaping nicotine' above.)
●Nicotine dependence – Nicotine dependence can appear within days to weeks of the onset of occasional cigarette use and often before the onset of daily smoking. As a result, experimentation or a light smoking habit can rapidly escalate into daily or heavy smoking. Many adolescent smokers have difficulty quitting, although they are often motivated to do so. Vaping nicotine is also strongly associated with development of nicotine dependence. (See 'Nicotine dependence' above and 'Vaping nicotine' above.)
●Tobacco prevention counseling – Tobacco prevention counseling should be included in primary care visits for all children and adolescents. Basic counseling can usually be performed in three to five minutes and is welcomed by the majority of parents, including those who smoke. (See 'Smoking and vaping prevention in the primary care office' above.)
The recommended steps can be summarized as a mnemonic with five A's (table 2). The focus of each step will vary with the child's age and the smoking status of parents and child. Key elements include:
•Ask – Routinely ask the parents or caregivers of all patients whether they smoke or vape. For those who smoke, firmly advise smoking cessation and offer assistance or referral. For those who vape, discuss the potential health consequences to the child, including exposure to the vapor and promoting vaping and smoking by the child. (See 'Guidance for parents and caregivers' above.)
Ask all patients five years and older what they think about smoking or vaping and whether they have tried or currently use these products. Inquire about vaping using a variety of terms, including e-cigarettes, Juuls, pods, or pod-mods. Also inquire about use of "tobacco-free" (synthetic) oral nicotine products. (table 1). (See 'Ask about smoking and vaping habits' above and 'Alternative nicotine sources' above.)
•Advise – Advise all patients and their families about the health risks of smoking and vaping, tailored to the age of the child and the parents' smoking status (table 3). Specifically advise children to avoid tobacco initiation and include information about e-cigarettes and other vaping devices. Many adolescents are poorly informed about the dangers of vaping and other alternative nicotine sources and falsely believe that these are safe substitutes for smoking cigarettes. (See 'Advise about the health risks of tobacco products' above and 'Vaping nicotine' above.)
•Assess – Assess risk factors for smoking and vaping initiation in individual patients (table 5). (See 'Assess risk factors for tobacco initiation' above.)
•Assist – Assist parents and caregivers with skills to prevent tobacco initiation in their children; promote smoking-resistance skills among children and teens by increasing awareness of social and media influences. (See 'Guidance for parents and caregivers' above and 'Fostering smoking and vaping resistance' above.)
•Arrange – The frequency of follow-up for smoking and vaping prevention varies depending on the child's age and risk factors. For a child who expresses an attitude against smoking and has no significant risk factors, the antismoking messages can simply be reinforced at each annual health maintenance visit. (See 'Arrange follow-up' above.)
●External resources – A variety of resources provide reliable information designed for patients and families; these may be used to supplement the office visit or distributed in the office waiting room. (See 'Educational resources' above.)
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