Management of smoking and vaping cessation in adolescents

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. Intervention to support cessation among adolescents who smoke or vape is particularly important because this may reduce or prevent nicotine dependence and avoid progression to chronic smoking.

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.

Motivation to stop smoking as well as methods to help adolescent patients stop smoking or vaping, including counseling and pharmacologic interventions, are reviewed here. The prevalence and trends in tobacco and nicotine use among adolescents, including the rising use of e-cigarettes, are discussed in separate topic reviews. (See "Prevention of smoking and vaping initiation in children and adolescents", section on 'Epidemiology' and "Vaping and e-cigarettes", section on 'Concerns related to youth and nonsmokers'.)

Behavioral and pharmacologic interventions to support smoking cessation in adults are presented separately. (See "Behavioral approaches to smoking cessation" and "Overview of smoking cessation management in adults".)

RISKS OF SMOKING IN ADOLESCENCE — Smoking in adulthood is strongly associated with smoking during adolescence: 90 percent of adult smokers smoked their first cigarette before the age of 18 [1,2]. Further, over one-half of young adults who smoke daily started at age 6 to 12 years [3]. This strong tracking of smoking from youth to adulthood may be attributable at least in part to nicotine dependence since youth are particularly vulnerable to becoming dependent on nicotine, compared with adults. (See 'Address nicotine withdrawal symptoms and other barriers to quitting' below.)

Long-term tobacco smoking can have adverse effects in nearly every organ of the body and cause a variety of diseases. In the United States, the adverse health effects from cigarette smoking account for more than 480,000 deaths among adults, or nearly one of every five deaths; more deaths are caused each year by tobacco use than by all deaths from HIV, illegal drug use, alcohol use, motor vehicle injuries, and firearm-related incidents combined [4].

Cancer was among the first diseases causally linked to smoking. Smoking causes cancers of the bladder, oral cavity, pharynx, larynx, esophagus, cervix, kidney, lung, pancreas, and stomach and also causes acute myeloid leukemia [4]. Smoking causes approximately 90 percent of lung cancer deaths in males and females. The epidemiology 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".)

Risk of using e-cigarettes to vape nicotine, including the risk of promoting nicotine dependence, are discussed separately. (See "Prevention of smoking and vaping initiation in children and adolescents", section on 'Vaping nicotine' and "Vaping and e-cigarettes", section on 'Concerns related to youth and nonsmokers' and "E-cigarette or vaping product use-associated lung injury (EVALI)".)

PATTERNS OF SMOKING BEHAVIOR AND CESSATION — A minority of adolescent smokers quit without intervention. In a national survey in the United States, 12.2 percent of adolescents who had ever smoked daily and tried to stop smoking were successful, where success was defined as not smoking during the 30 days prior to the survey [5]. Although smoking persistence is associated with several clinical risk factors including smoking frequency, these risk factors do not reliably identify individual adolescent smokers who are most likely to stop independently. Therefore, intervention to support smoking cessation is appropriate for all adolescents who smoke, regardless of risk factors.

In studies conducted before e-cigarettes became a common alternative to smoking, the overall prevalence of smoking increased from early to late adolescence and was fairly stable thereafter, with approximately equal numbers of individuals initiating smoking and quitting [6]. Factors that predicted risk for ongoing smoking include alcohol use, deviance from rules, peer smoking, and drug use, and these risk factors were similar for those who remained stable heavy smokers and those who quit or remained stable light smokers after adolescence. A distinct group initiates smoking during early adulthood ("late escalators"), and these individuals tend to have few of the risk factors that are associated with initiating smoking earlier in adolescence. Another distinct group are novice smokers who escalate rapidly during adolescence; this pattern appears to be associated with early symptoms of nicotine dependence [7,8]. (See 'Address nicotine withdrawal symptoms and other barriers to quitting' below.)

The increasing use of "vaping" products by youth has been associated with an increased risk of subsequent use of traditional cigarettes, marijuana, opioids, and other illicit drugs [9]. Those using products with higher nicotine concentrations are more likely to have higher rates of vaping and smoking [10]. (See "Vaping and e-cigarettes".)

APPROACH TO COUNSELING

General strategies — We recommend that clinicians initiate behavioral support for smoking cessation for all adolescents who smoke. Pediatricians and other pediatric health care providers can play an important role in helping teens with smoking cessation, particularly because most adolescents cite adverse health effects as their primary motivation for quitting [11]. Unfortunately, clinicians often miss opportunities for screening and counseling [12]. A 2010 survey of pediatricians by the American Academy of Pediatrics (AAP) found that most pediatricians advised patients to quit, but only approximately one-half assessed reasons for and against smoking and a minority offered help in cessation and nicotine dependence [13]. In 2020, a review of electronic medical records found that among 366 United States safety-net primary care clinics, 87 percent of teens seen were assessed for smoking, with some disparities in screening [14].

For adolescents who use e-cigarettes to vape nicotine, we also suggest behavioral support for cessation. For vaping cessation, it is reasonable to use methods similar to those used for smoking cessation, although methods to support vaping cessation have not been studied directly [15].

Screening and counseling about tobacco and other risk-taking behaviors should be performed confidentially, without caregivers present. The clinician should explicitly outline a confidentiality policy, including the issues that will be kept confidential and those in which confidentiality is conditional. The provider can talk with the adolescent about how to share such information with their parents, if appropriate, and be available to assist if needed [16]. (See "Confidentiality in adolescent health care".)

Data are mixed regarding the effectiveness of brief office-based behavioral counseling for cessation without pharmacotherapy. In one study, a structured counseling intervention (the 5 A's) did not improve quit rates at six months follow-up but was more likely to achieve smoking cessation by 12 months [17,18]. A separate meta-analysis of counseling interventions in pediatric primary care settings found that counseling doubled long-term abstinence rates compared with no treatment, although overall abstinence rates with or without treatment were low [19]. A variety of techniques were used successfully, ranging from one session of individual counseling with follow-up phone calls [20], to six or eight sessions in a group format [19], or brief clinician counseling followed by a computer-based tobacco intervention [21]. There were too few studies to allow comparison of the efficacy of different counseling techniques. In one report, the authors stated 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 [22].

The six A's — Health care providers should screen for use of tobacco, nicotine, and vaping and related health risk behaviors at every opportunity. For pediatric patients who report tobacco use, a simple six-step approach called the six A's has been developed to guide clinician counseling about smoking cessation (table 1 and algorithm 1) [23,24]:

●Anticipate the risk of initiating tobacco or e-cigarette use for nonsmokers

●Ask patients about whether they smoke, vape, or use other nicotine products (see 'Ask about smoking or vaping and exposure' below)

●Advise smokers to quit and about the risks of vaping (see 'Advise smoking cessation and about risks of vaping' below)

●Assess their readiness to quit smoking or vaping (see 'Assess readiness to quit' below)

●Assist them with their cessation effort, which may include pharmacotherapy (table 2) (see 'Assist those who are ready to quit' below and 'Pharmacotherapy' below)

●Arrange for follow-up visits or contact (see 'Arrange follow-up' below)

The first step, anticipating the risk of smoking initiation, involves inquiring about parental smoking, vaping, and nicotine use and discussing the possibility of smoking initiation in preadolescent and adolescent children. Clinicians should begin this anticipatory guidance during pediatric visits in mid-childhood. (See "Prevention of smoking and vaping initiation in children and adolescents", section on 'Smoking and vaping prevention in the primary care office'.)

The subsequent five steps are adapted from the 5 A's used for adult smokers, which are discussed in a separate topic review [25]. (See "Overview of smoking cessation management in adults", section on 'Implementing 5A's in practice'.)

IMPLEMENTING THE SIX A'S IN PRACTICE

Anticipate the risk of initiating smoking or vaping — Routinely ask parents and other household members about whether they smoke or vape and discuss the health effects of both. Discuss the possibility that preteen and adolescent children might start smoking or vaping and the need for consistent messages from parents to prevent initiation. (See "Prevention of smoking and vaping initiation in children and adolescents".)

Ask about smoking or vaping and exposure — For all adolescents at every visit, ask about use of tobacco in a confidential setting, without the caregiver present [24]. Also, specifically inquire about any alternative nicotine sources, especially e-cigarettes (common terms include vaping or juuling), alternative forms of combustible tobacco (bidis, kreteks, hookahs, and heat-not-burn cigarettes) and smokeless tobacco (table 3). It is important to ask specifically about all forms of tobacco use because teens may fail to mention vaping or other nicotine sources when asked about smoking. For preteen children, also inquire about tobacco and vaping use in an age-appropriate manner (eg, whether they have ever "tried" smoking or vaping or thought about trying). Also, inquire about tobacco use among peers as this may assist disclosure or predict smoking initiation. (See "Prevention of smoking and vaping initiation in children and adolescents", section on 'Alternative nicotine sources'.)

Advise smoking cessation and about risks of vaping — For all adolescents who report smoking, strongly urge them to quit, regardless of smoking frequency. The advice should be clearly and strongly stated and personalized by describing the specific risks of tobacco use and the specific benefits of quitting. (See 'Risks of smoking in adolescence' above.)

For patients who report vaping (e-cigarettes), provide information regarding the potential health risks. Vaping may be associated with chronic respiratory complications including higher lifetime odds of asthma [26], as well as severe acute respiratory complications. Furthermore, mounting evidence indicates that vaping promotes nicotine dependence and may lead to tobacco smoking as well [27]. (See "Vaping and e-cigarettes", section on 'Adverse health effects' and "Vaping and e-cigarettes", section on 'Concerns related to youth and nonsmokers' and "E-cigarette or vaping product use-associated lung injury (EVALI)".)

Assess readiness to quit — Ask the patient about readiness to quit smoking or vaping within the next 30 days. Explore their reasons to quit and possible barriers, including whether they have experienced nicotine withdrawal symptoms.

The majority of adolescents who smoke or vape are interested in quitting, suggesting readiness for intervention. In the National Youth Tobacco Survey, more than 60 percent of American youth who smoked or vaped intended to quit, and more than 65 percent had attempted to quit within the past year [28,29]. For adolescents who do not feel ready to quit, it is helpful to tailor counseling to their concerns and levels of readiness to quit smoking. (See 'Assist those who are not ready to quit' below.)

Assist those who are ready to quit — Key strategies in counseling an adolescent are outlined in the table (table 2 and algorithm 1) [30]. These include:

Help the patient develop a quit plan — A quit plan may include setting a quit date, providing counseling and self-help materials, and/or referral to a public resource for smoking cessation counseling (eg, a telephone "quit line" (see 'Self-help programs and educational websites' below)). Important steps include telling family and friends about the plan to solicit support and removing all nicotine products from the adolescent's environment. The utility of smoking reduction (rather than abrupt smoking cessation) is questionable, based on studies in adults [31]; relevant studies in adolescents are lacking. (See "Overview of smoking cessation management in adults", section on 'Advise smoking cessation' and "Overview of smoking cessation management in adults", section on 'Set a quit date'.)

Address nicotine withdrawal symptoms and other barriers to quitting — Counseling should include practical advice to avoid relapse, including strategies to manage nicotine withdrawal. For patients who report symptoms of nicotine dependence, consider pharmacotherapy. (See 'Pharmacotherapy' below.)

●Nicotine dependence – Nicotine dependence and nicotine withdrawal can interfere with an adolescent's success in quitting smoking. To assess for nicotine dependence, it is useful to ask how long a teen can wait after waking up to have the first cigarette. Waiting less than an hour before having the first cigarette of the day is a strong indicator of nicotine dependence [32]. Adolescents who report symptoms of nicotine dependence are particularly likely to benefit from nicotine replacement therapy (NRT) [33]. (See 'Nicotine replacement' below.)

Nicotine dependence is characterized by tolerance to nicotine [34] and psychobehavioral symptoms that are triggered by nicotine withdrawal [35]. These include:

•Craving for cigarettes

•Dysphoria or depressed mood

•Sleep disturbances

•Irritability and anger

•Anxiety

•Difficulty concentrating

•Restlessness

•Increased appetite

Youth are particularly vulnerable to becoming dependent on nicotine, compared with adults [2,11]. In a survey of adolescent smokers, approximately 20 percent of adolescents were substantially dependent on nicotine, as assessed by a modified Fagerstrom Tolerance Questionnaire (a survey tool to measure symptoms of nicotine dependence), and 42 percent had moderate dependence [36]. Those with greater evidence of nicotine dependence were less likely to be successful with a quit attempt.

Nicotine dependence can develop after as few as 100 cigarettes. 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 [37]. With increasing nicotine exposure, smokers progress through a sequence of symptoms of addiction, which they may describe at first as "wanting," to "craving," then "needing" tobacco [38]. Adolescents who report early emergence of symptoms of nicotine dependence are significantly more likely to be smokers two years later compared with those who do not report early symptoms [39]. Similarly, individuals who start smoking at a young age are more likely to develop severe dependence and have lower rates of smoking cessation [34]. E-cigarette use can also lead to nicotine dependence [40,41]. (See "Vaping and e-cigarettes", section on 'Concerns related to youth and nonsmokers'.)

The likelihood of nicotine dependence increases with the quantity and duration of smoking: Smokers who smoke more than 10 cigarettes per day report greater severity of withdrawal symptoms. However, even nondaily tobacco use can trigger the emergence of nicotine dependence in some individuals [34,42]. Genetic factors also may influence an individual's predisposition to become dependent on nicotine [2,34,43].

●Other barriers – In addition to nicotine dependence, other potential barriers to quitting include use of other substances, anxiety or depression, influences from peers or family members who smoke, or concerns about weight gain. Identifying these barriers and developing a strategy to overcome them may help avoid relapse. (See 'Address barriers to quitting' below and 'Drug and alcohol use' below.)

Arrange follow-up — Schedule follow-up contact, either in person or by telephone. Follow-up contact should occur soon after the quit date, preferably during the first week [24]. A second follow-up contact is recommended within the first month. Further follow-up contacts should be scheduled as indicated.

ASSIST THOSE WHO ARE NOT READY TO QUIT — Understanding the adolescent's motivations for smoking and quitting provides an important basis for an effective counseling interaction. For those who are ambivalent about quitting, exploring incentives to smoke or to quit is the first step in effective problem-solving. For those who are ready to quit, understanding these motivations permits personalized support for the quit attempt.

Several factors have been explored as possible predictors of smoking cessation in adolescents [44]. Some of the most common motivations that prompt adolescents to want to quit or continue smoking are discussed below.

Motivations to quit — In surveys of adolescents who smoke, concerns about future and current health, as well as physical appearance, cost of cigarettes, and athletic performance, are the most common reasons given for making an attempt to quit smoking [45,46].

●Adverse health effects – Among adolescents who are considering quitting, the long-term adverse health consequences are the most important motivating factor, cited as a quite important or very important reason to quit by approximately three-quarters of adolescent smokers [45,46]. This may not be as strong of a factor for those who are not already considering quitting.

●Monetary costs – Some adolescents cite the cost of cigarettes as a reason to quit, although this is generally ranked as less important than health effects [46]. The cost of regular smoking is considerable and may be increased by state and/or city taxes [47]. Legislative and regulatory strategies that raise prices on tobacco products are effective in reducing smoking initiation and consumption levels, especially among youth and young adults [2,48]. Accordingly, tobacco product price increases are strongly recommended by the American Academy of Pediatrics (AAP) [49].

Helping an adolescent calculate the costs of regular smoking may be motivating as they consider the current and future costs of their habit. Adolescents may derive more motivation to quit if they realize this money could be put toward videogames, music, streaming services, concerts, clothes, or even saving for a car.

●Physical fitness – Nearly one-half of the respondents reported significant concerns about short-term effects, especially coughing and difficulty exercising. Similarly, other studies reported that athletic performance was specifically cited as a reason for attempting to quit. In one study, this was cited as the most important motivator by 16 percent of participants and was only slightly more common among boys than girls [50]. Adolescents involved in sports may not be aware of the effects of smoking on current lung function and performance. A discussion of their goals for athletic performance and how smoking may limit their achievements in the future may boost their motivation to quit.

●Social concerns and peer support system – Peer habits have a powerful influence on smoking initiation and cessation [2]. In a report of teens caught smoking at school, one-half reported that all five of their five best friends smoked and most were daily smokers [51]. Among individuals who started smoking by age 15 years, only 20 percent had quit by age 28 if their best friend was a smoker, whereas 52 percent had quit if their best friend was not a smoker [52].

The cross-sectional studies cited above could be explained by self-selection of friends with like habits, rather than causation. However, longitudinal studies suggest that peer smoking has a causal influence on smoking initiation and cessation. In a study of youth who smoked occasionally but not daily in 8^th grade, progression to daily smoking was predicted by their parents' and peers' smoking habits [53]. Furthermore, smoking among parents was the most important influence on smoking initiation in younger adolescents, but smoking among peers became the more important influence in older adolescents [54].

Peer support can be valuable to encourage and support a quit attempt. Exploring whether the patient's friends smoke or vape and whether there is a friend who wants the teen to quit may be useful. One program provided nonsmoking teens with a "quit kit" to assist their peers in their cessation attempt, which motivated tobacco users to consider quitting [55].

Exploring motivations for quitting can be enhanced by the use of motivational interviewing, a specific technique in which the interviewer elicits and reflects back the patient's thoughts so that they can identify intrinsic motivations, work through ambivalence, and develop strategies for behavior change (table 4). Motivational interviewing is considered especially useful for short-term interventions. (See "Substance use disorder in adolescents: Psychosocial management", section on 'Motivational interviewing' and "Motivational interviewing for substance use disorders".)

Address barriers to quitting — A variety of physiologic and psychosocial forces may impede smoking cessation in adolescents:

●Nicotine dependence – Symptoms of nicotine withdrawal are an important barrier to quitting for many adolescent and adult smokers. Nicotine dependence develops in some individuals after relatively little nicotine exposure. Pharmacotherapy (eg, nicotine replacement therapy [NRT]) may be particularly valuable to these individuals. (See 'Address nicotine withdrawal symptoms and other barriers to quitting' above and 'Pharmacotherapy' below.)

●Weight control – Many teens view smoking as a means of weight control. Contemplation of and experimentation with smoking have been found to be related to weight concerns [56,57].

Among adults, smoking cessation is associated with a long-term average weight gain of 5 to 10 kg (see "Benefits and consequences of smoking cessation", section on 'Weight gain'). Weight patterns after smoking cessation in adolescents are not well characterized, but the 2012 United States Surgeon General's report concludes that there is no evidence that young smokers weigh less or lose weight because of their smoking [2].

If concerns about weight gain present a barrier to smoking cessation, the clinician should offer advice about other ways to control weight, such as limiting high-calorie foods and sodas and increasing physical activity. Other strategies may include identifying oral cravings and substituting them with healthy snacks and finding new activities to occupy the hands after cessation [58]. Although there is little evidence that these strategies attenuate weight gain in adults [59], they have not been studied in adolescents. Strategies to promote healthy eating behaviors among adolescents are discussed in separate topic reviews. (See "Prevention and management of childhood obesity in the primary care setting" and "Adolescent eating habits".)

Adolescent patients who are motivated to quit smoking by an interest in improving athletic performance may be particularly willing to increase their physical activity. Furthermore, engaging in physical activity has been shown to increase the success of a quit attempt [60].

●Depression – Treatment of depression may facilitate smoking cessation in this population. Depressed adolescents are significantly more likely to start smoking than those without depression. Adolescents tend to smoke cigarettes to diminish symptoms of anxiety or depression [6,61].

Bupropion, an antidepressant, has been shown to assist with smoking cessation in adults. There is minimal data on the use of bupropion for smoking cessation in adolescents, so decisions about antidepressants should be based on considerations of efficacy and safety for depression rather than for smoking cessation. (See "Pediatric unipolar depression and pharmacotherapy: Choosing a medication" and "Overview of smoking cessation management in adults" and 'Other drugs' below and "Pharmacotherapy for smoking cessation in adults", section on 'Bupropion'.)

●Stress – It may be helpful to incorporate stress reduction techniques and training in problem-solving skills into interventions to support cessation efforts. Compared with adolescent smokers who had quit, current adolescent smokers have greater levels of perceived stress and are less likely to use cognitive coping methods [62]. High-arousal affective states and cravings have been shown to lead to cessation lapses [63]. Furthermore, a smartphone application using mindfulness training led to increased cessation rates and greater engagement with the app was associated with reduced cigarette use [64]. (See "Behavioral approaches to smoking cessation", section on 'Problem solving and coping skills' and "Behavioral approaches to smoking cessation", section on 'Stress management and relaxation strategies'.)

Other influences on smoking behavior — Other factors that influence smoking and motivation to quit that may be helpful for counseling include:

●Smoking bans – Household smoking bans can be helpful even when parents or other household members are smokers. Several studies have shown that household or workplace smoking bans are associated with reduced rates of smoking among adolescents [2,65-67]. A no-smoking ban must be strictly enforced in order to be effective [65].

●Parental smoking and cessation – Smoking by parents or other household members has a large influence on smoking by adolescents. Children whose parents smoke are more likely to smoke. Conversely, smoking cessation efforts by parents can have a positive impact on their children's efforts [68]. In one study, adolescents whose parents quit smoking were twice as likely to quit themselves compared with those whose parents continued to smoke [69]. The earlier in the child's life that the parent quits, the less likely their children will become smokers. (See "Prevention of smoking and vaping initiation in children and adolescents", section on 'Factors contributing to smoking and vaping initiation'.)

●Peer and social influences – Peer habits have a powerful influence on smoking initiation and cessation, and peer support can be valuable to encourage and support a quit attempt. (See 'Motivations to quit' above.)

OTHER SOURCES OF BEHAVIOR SUPPORT — In addition to counseling by a health care provider, smoking cessation counseling for adolescents is offered in different settings, with variable success.

Adolescent smoking cessation programs — There are few reports describing techniques and outcomes for smoking cessation interventions in adolescents. Successful programs emphasize immediate negative health and other consequences of tobacco use and provide instruction in coping strategies [70]. A meta-analysis of 48 controlled smoking cessation studies in adolescents, most of which were in group format, found modest effects of smoking cessation programs overall [71]. Quit rates were higher among participants in smoking cessation programs than controls (9.1 versus 6.2 percent, absolute difference 2.9 percent, 95% CI 1.5-4.4). The treatment effect was seen in programs with five or more sessions and generally continued after the end of the program, although only a few studies included follow-up data for 12 months or more.

Several text message-based apps have been developed and evaluated for teens [72]. In one study, teens enrolled in a text message-delivered peer network counseling program significantly decreased the number of days they smoked cigarettes and the number of cigarettes they smoked per day [73]. Compared with general smoking cessation apps, those designed for teens tend to focus more on adherence; however, more research is needed regarding how much teens engage with the apps and outcomes. A study of 2685 teens using the free, publicly available National Cancer Institute's Smokefree Teen text message-based cessation program reported a high dropout rate (65 percent), with a low response and low abstinence rate [74].

Self-help programs and educational websites — A variety of self-help resources are available to support an adolescent who is motivated to quit smoking, or to inform and help motivate those who are contemplating quitting. These are also good sources of information to distribute in the office waiting room.

Adolescent and adult smokers can access free proactive telephone counseling or referrals to local services throughout the United States by calling a toll-free number (1-800-QUITNOW). Specialized materials are available for adolescents.

The following websites provide information designed for adolescent patients and families:

●Resources focused on quitting (includes support by text or mobile app):

•My Life, My Quit (National Jewish Health)

•Smokefree Teen (United States Department of Health and Human Services National Cancer Institute)

●Resources for general information:

•Center for Young Women's Health (Boston Children's Hospital)

•Centers for Disease Control and Prevention:

-You(th) and Tobacco

-Quick Facts on the Risks of E-cigarettes for Kids, Teens, and Young Adults

•The Truth (Truth Initiative)

●Resources primarily for parents:

•HealthyChildren.org (American Academy of Pediatrics)

•Talk with Your Teen About E-cigarettes: A Tip Sheet for Parents (Centers for Disease Control and Prevention)

PHARMACOTHERAPY — A number of pharmacotherapies are available to assist with smoking cessation. In adults, combination therapy with behavioral support and pharmacotherapy is generally recommended for smoking cessation. (See "Overview of smoking cessation management in adults" and "Pharmacotherapy for smoking cessation in adults".)

Our approach for adolescents — In our practice, we suggest nicotine replacement therapy (NRT) to support smoking cessation for adolescents with symptoms of nicotine dependence, given in combination with behavioral support. We also suggest NRT for adolescents who want to quit vaping and have symptoms suggestive of nicotine dependence. This practice is supported by the strong indirect evidence of efficacy for other forms of nicotine addiction, although the efficacy of NRT for vaping cessation has not been directly demonstrated. (See 'Address nicotine withdrawal symptoms and other barriers to quitting' above.)

In the adolescent age group, the long-term efficacy and safety of pharmacologic intervention for smoking cessation is not well established, although clinical use and experience in this age group is increasing [75-77]. Some authorities suggest behavioral support (counseling) alone for this age group [19]. However, we and other experts believe that there is sound rationale for using pharmacotherapy in selected adolescents as an aid for smoking cessation in the short term, given the mounting evidence that nicotine dependence can develop early and evidence suggesting efficacy of pharmacotherapy combined with behavioral support in adults [11,34,77]. (See "Overview of smoking cessation management in adults".)

Nicotine replacement — We suggest offering NRT to adolescents who report symptoms of nicotine dependence. NRT is the mainstay of smoking cessation pharmacotherapy and is available in several different forms (table 5). In the United States, three NRT products are sold without prescription to adults (patch, lozenge, and gum), but a prescription is needed for sale to those younger than 18 years. The other two (nasal spray and oral inhaler) are available by prescription only. The clinician should provide guidance regarding appropriate use of the product and alternative forms of NRT [78]. The dose of NRT is titrated as needed to overcome the symptoms of nicotine withdrawal.

The use and pharmacokinetics of these products in adults are described separately. (See "Pharmacotherapy for smoking cessation in adults", section on 'Nicotine replacement therapy'.)

Of note, we suggest against the use of electronic cigarettes (e-cigarettes) for treatment of tobacco dependence as they have not been shown to be effective [75] and because of emerging concerns that they may promote nicotine dependence and have adverse health effects. (See "Vaping and e-cigarettes", section on 'Concerns related to youth and nonsmokers' and "Prevention of smoking and vaping initiation in children and adolescents", section on 'Vaping nicotine'.)

●Nicotine patch or gum – Nicotine patch therapy has been shown to be safe in adolescent smokers. There is insufficient evidence to determine long-term efficacy in adolescents, but indirect evidence from studies in adults support its use.

In the United States, a prescription is required to allow patients under 18 years to purchase nicotine patches or gum. One study showed somewhat higher compliance with patch therapy than with gum, but this varies with patient preference [79]. The proper use of nicotine patches or gum is described in a separate topic review. Similar guidance can be given to adolescent smokers; lower starting doses are advised for smaller patients (those who weigh less than 45 kg) or those who smoke less than one-half pack a day (table 5). Users of gum should be reminded to "chew and park" the gum (chewing then holding in the buccal mucosa), rather than chew continuously, for maximum benefit. (See "Pharmacotherapy for smoking cessation in adults", section on 'Nicotine transdermal patch (long-acting)' and "Pharmacotherapy for smoking cessation in adults", section on 'Nicotine gum'.)

A systematic review of NRT in adolescent smokers that included two randomized studies found no clear evidence for benefit (risk ratio 1.11, 95% CI 0.48-2.58), although the low abstinence rates and wide confidence intervals preclude any firm conclusions [80]. Considerably more studies have been done in adults, and these generally support the efficacy of NRT. (See "Pharmacotherapy for smoking cessation in adults", section on 'Nicotine replacement therapy'.)

●Nicotine nasal spray – Nicotine nasal spray does not appear to be well tolerated by adolescents. In a randomized open-label trial in 40 adolescent smokers, 57 percent of participants assigned to use the nasal spray stopped treatment after only one week [81]. The most commonly reported adverse effect was nasal irritation and burning (34.8 percent), followed by complaints about the taste and smell (13 percent). Those assigned to use nasal spray showed no difference in cessation rates, the numbers of cigarettes smoked per day, or cotinine levels at 12 weeks as compared with counseling alone.

Other drugs — We do not recommend bupropion as a first-line pharmacologic intervention for adolescent smoking cessation [19]. In adults, bupropion and varenicline are moderately effective in increasing quit rates and are considered appropriate first-line agents for assisting smoking cessation (as is NRT). The choice between these agents depends on patient preference and individual medical considerations. (See "Pharmacotherapy for smoking cessation in adults".)

Few studies address bupropion for smoking cessation in adolescents. One study found no significant effect of combination therapy with bupropion and nicotine patch therapy compared with nicotine patch therapy alone [82]. Another study suggested that the combination of sustained-release bupropion hydrochloride (300 mg/day) and short-term counseling had short-term efficacy compared with counseling alone [83]. However, abstinence rates were lower than those reported for adults, and there was rapid relapse after the medication was discontinued. Effectiveness of bupropion for adolescent smoking cessation is contingent on achieving high rates of medication adherence [84].

Varenicline for adolescents may be an option for selected patients, although efficacy data are mixed. Although trials in adults support the efficacy of varenicline in combination with cessation counseling, two randomized trials in adolescents concluded that it did not improve end-of-treatment abstinence compared with placebo [85,86]. In one of the trials, varenicline was associated with slightly more rapid achievement in abstinence and improvements in post-treatment abstinence outcomes [85]. However, unlike the end-of-treatment abstinence rates, these were not confirmed by urine cotinine levels. Treatment-emergent adverse effects were generally mild and similar to those in adults (primarily nausea and vomiting). (See "Pharmacotherapy for smoking cessation in adults", section on 'Varenicline'.)

SMOKING CESSATION IN THE SETTING OF OTHER RISKY BEHAVIORS

Teen pregnancy — In the United States, between 20 and 50 percent of pregnant teenagers smoke [87,88]. Pregnant adolescents who smoke can cause adverse outcomes for their infants. Smokers are more likely to have small for gestational age infants compared with nonsmokers. In utero exposure to maternal smoking has been associated with an increased incidence of wheezing in infants and of clinician-diagnosed asthma in children [89,90]. (See "Cigarette and tobacco products in pregnancy: Impact on pregnancy and the neonate", section on 'Adverse outcomes'.)

Early pregnancy may be an opportune time to intervene among pregnant smokers. Pregnant teenagers can be counseled that stopping smoking substantially reduces their risk of having a baby that is small for gestational age or underweight [91]. (See "Pregnancy in adolescents", section on 'Pregnancy counseling'.)

Extrapolation from studies in adult populations suggests that intervention during pregnancy can enhance smoking cessation rates. Brief cessation counseling sessions significantly increase rates of cessation among adult pregnant smokers. Among women who successfully stopped smoking during pregnancy, there is a substantial risk of relapse postpartum. Special considerations relevant to supporting smoking cessation during pregnancy are discussed in a separate topic review. (See "Cigarette and tobacco products in pregnancy: Impact on pregnancy and the neonate".)

Drug and alcohol use — When any patient discloses use of alcohol, tobacco, or drugs, it is particularly important to inquire about concomitant use of other substances and to explore whether the youth is concerned about these behaviors. The clinician may need to prioritize the focus of counseling based on other risky behaviors. Further, this information may prompt the clinician to assess for underlying mental health issues that could contribute to substance use.

There is a high rate of smoking among adolescent substance abusers. Tobacco has been described as a gateway drug, ie, a drug that lowers the threshold for addiction to other drugs, and animal experiments offer a biologic mechanism for this pattern [92,93]. Adolescents who smoke are three times as likely to abuse alcohol and eight times as likely to use marijuana as compared with peers who do not smoke [24]. Moreover, baseline use of combustible tobacco or e-cigarettes is associated with initiation of marijuana use within the subsequent two years [94]. (See "Guidelines for adolescent preventive services", section on 'Screening'.)

Addressing problems with each substance is important for success. A study of teens who started smoking by age 15 years found that by 28 years, smoking cessation rates were lower among those who consumed more alcohol [52]. Similarly, marijuana use is associated with less success in reducing and stopping tobacco use, although it does not appear to affect motivation to stop smoking [95].

Some teens enrolled in drug rehabilitation programs that have no-smoking policies may face the challenge of nicotine withdrawal during the rehabilitation program, in addition to their dependence on other drugs. Despite their use of other drugs, such teens may be interested in quitting smoking [96]. Adolescents entering substance use treatment may benefit from integrated tobacco cessation interventions that are intensive and occur early in treatment [97]. (See "Substance use disorder in adolescents: Epidemiology, pathogenesis, clinical manifestations and consequences, course, assessment, and diagnosis" and "Substance use disorder in adolescents: Treatment overview".)

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 5^th to 6^th 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 10^th to 12^th 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 topics (see "Patient education: Vaping (The Basics)")

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 5^th to 6^th 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 10^th to 12^th 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 topics (see "Patient education: Vaping (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Nicotine dependence among youth – Youth are particularly vulnerable to becoming dependent on nicotine, compared with adults. Nicotine dependence can develop after as few as 100 cigarettes. 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. Vaping nicotine (via e-cigarettes or devices) also promotes nicotine dependence and may lead to tobacco smoking. (See 'Address nicotine withdrawal symptoms and other barriers to quitting' above.)

●Behavioral interventions – We recommend that clinicians initiate behavioral support for smoking cessation for all adolescents who smoke (Grade 1B). This may include a brief intervention by the clinician to discuss the potential advantages of quitting and to problem-solve about how to overcome barriers to quitting. We use the maximal frequency and intensity of intervention that is acceptable to the patient; referral to a teen smoking cessation program and/or to self-help interventions may be helpful. (See 'General strategies' above and 'Other sources of behavior support' above.)

For adolescents who vape nicotine (via e-cigarettes or other devices), we also suggest behavioral support for cessation (Grade 2C). For vaping cessation, it is reasonable to use methods similar to those used for smoking cessation, although methods have not been studied directly.

●Six A's for counseling – A six-step approach called the six A's has been developed to guide clinician counseling about smoking cessation (table 1 and algorithm 1). For vaping cessation, it is reasonable to use methods similar to those used for smoking cessation.

•Adolescents who smoke frequently cite concerns about future and current health, cost of cigarettes, social concerns, and athletic performance. Discussing these incentives and barriers to quitting is a valuable first step in counseling. For patients who report vaping (e-cigarettes), advise regarding the potential health risks, which include nicotine dependence and chronic and severe acute respiratory complications. (See 'Risks of smoking in adolescence' above and 'Advise smoking cessation and about risks of vaping' above.)

•A majority of adolescents who smoke or vape report that they would like to quit, suggesting readiness for intervention. Adolescents who are not interested in quitting should be given serial brief interventions with messages to increase ambivalence about smoking and motivate them to consider quitting by shifting the pro/con balance. (See 'Assess readiness to quit' above and 'Assist those who are not ready to quit' above.)

•For patients who are ready to quit, provide support and specific strategies for quitting (table 2). This may include setting a quit date, providing counseling and self-help materials, and/or referral to a public resource for smoking cessation counseling. In addition, assess and address nicotine withdrawal symptoms and other barriers to quitting. (See 'Assist those who are ready to quit' above and 'Self-help programs and educational websites' above.)

●Pharmacotherapy – For adolescents with symptoms of nicotine dependence, we suggest nicotine replacement therapy (NRT; typically with a nicotine patch or gum), in conjunction with a counseling intervention (table 2 and table 5) (Grade 2C). We suggest against the use of electronic cigarettes (vaping nicotine) for this purpose (Grade 2C). Although vaping nicotine can eliminate nicotine withdrawal symptoms, it may promote nicotine use and dependence and is also associated with other potential harms. (See 'Nicotine replacement' above and "Prevention of smoking and vaping initiation in children and adolescents", section on 'Vaping nicotine'.)