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Management of smoking and vaping cessation in adolescents

Management of smoking and vaping cessation in adolescents
Literature review current through: Jan 2024.
This topic last updated: Sep 29, 2023.

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. Tobacco use, and now vaping, remain significant public health challenges and significant causes of morbidity and mortality. Morbidity and mortality secondary to smoking are discussed in more detail separately. (See "Benefits and consequences of smoking cessation", section on 'Benefits of smoking cessation'.)

The 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 — It is very difficult to remain a "social smoker" because occasional use easily progresses to nicotine dependence. A minority of adolescents who smoke regularly 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 [4].

A majority of adolescent smokers report infrequent or occasional use [5]. Nevertheless, there are concerns about possible health risks of long-term occasional use. Furthermore, many will go on to regular smoking with nicotine dependence. Some who experiment may not continue, but it is best to address this and then encourage cessation. These occasional use smokers may be less receptive to intervention but also may be more successful if they attempt cessation before they become more nicotine dependent [6].

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 [7]. 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 [8,9]. (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 [10]. Adolescents using products with higher nicotine concentrations are more likely to have higher rates of vaping and smoking [11]. (See "Vaping and e-cigarettes".)

BEHAVIORAL SUPPORT FOR ALL ADOLESCENTS WHO SMOKE OR VAPE

General strategies — Clinicians should 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 [12]. Unfortunately, clinicians often miss opportunities for screening and counseling [13]. A 2010 survey of pediatricians by the American Academy of Pediatrics 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 [14]. 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 [15].

For adolescents who use e-cigarettes to vape nicotine, we also advise 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 had very little study in teens [16,17].

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 caregiver, if appropriate, and be available to assist if needed [18]. (See "Confidentiality in adolescent health care".)

Although the effects may be small, brief office-based behavioral counseling for cessation without pharmacotherapy has been shown to be effective. In one study, a structured counseling intervention (the five A's) did not improve quit rates at 6-month follow-up but was more likely to achieve smoking cessation by 12 months [19,20]. 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 [21]. A variety of techniques were used successfully, ranging from one session of individual counseling with follow-up phone calls [22], to six or eight sessions in a group format [21], or brief clinician counseling followed by a computer-based tobacco intervention [23]. 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 [24].

The six A's — Health care providers should screen for use of tobacco, nicotine, and vaping at every health supervision visit and at other visits when practical [25]. 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) [26,27]:

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 for adolescents with nicotine dependence' 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 caregiver 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 [28]. (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 caregivers and other household members 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 caregivers 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 [27]. 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 [29] as well as severe acute respiratory complications. Furthermore, mounting evidence indicates that vaping promotes nicotine dependence and may lead to tobacco smoking as well [30]. (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 [31,32]. 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) [33]. 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 [34]; 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 for adolescents with nicotine dependence' below.)

Assess 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 their first cigarette. Waiting less than an hour before having the first cigarette of the day is a strong indicator of nicotine dependence [35]. Adolescents who report symptoms of nicotine dependence are particularly likely to benefit from nicotine replacement therapy (NRT) [36]. (See 'Nicotine replacement' below.)

Nicotine dependence is characterized by tolerance to nicotine [37] and psychobehavioral symptoms that are triggered by nicotine withdrawal [38]. These include:

Craving for cigarettes

Dysphoria or depressed mood

Sleep disturbances

Irritability and anger

Anxiety

Difficulty concentrating

Restlessness

Increased appetite

Several tools are available to assess nicotine dependence in adolescents.

Modified Fagerstrom Tolerance Questionnaire

-This tool assesses symptoms of nicotine dependence. More information, including scoring, can be found on the National Cancer Institute website.

Hooked on Nicotine Checklist

-This tool identifies the strength of nicotine dependence. More information can be found on the National Cancer Institute website.

E-cigarette Dependence Scale – A yes answer to any of the following questions suggests nicotine dependence [39]:

-When I have not been able to vape for a few hours, the craving gets intolerable.

-I drop everything to go out and get e-cigarettes or e-juice.

-I vape more before going into a situation where vaping is not allowed.

-I find myself reaching for e-cigarettes without thinking.

Youth are particularly vulnerable to becoming dependent on nicotine, compared with adults [2,12]. 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 [40]. Those with greater evidence of nicotine dependence are 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 [41]. 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 [42]. 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 [43]. Similarly, individuals who start smoking at a young age are more likely to develop severe dependence and have lower rates of smoking cessation [37]. E-cigarette use can also lead to nicotine dependence [39,44]. (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 [37,45]. Genetic factors also may influence an individual's predisposition to become dependent on nicotine [2,37,46].

Assess for 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 [26]. 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 — Adolescents who are not interested in quitting should be given serial brief interventions with messages that increase ambivalence about smoking and motivate them to consider quitting by shifting the pro/con balance. Understanding the adolescent's motivations for smoking as well as quitting provides an important basis for an effective counseling interaction. We ask the patient to make a written list of the "pros" of smoking and the "cons" of smoking. We then ask them to talk about why they like smoking. Verbalizing this may lead to the young person realizing that some or all of their reasons are trivial. Next, we focus on the cons they have listed to increase their ambivalence about continuing to smoke.

Several factors have been explored as possible predictors of smoking cessation in adolescents [47]. 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 [48,49].

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 [48,49]. 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 [49]. The cost of regular smoking is considerable and may be increased by state and/or city taxes [50]. 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 [2,51]. Accordingly, tobacco product price increases are strongly recommended by the American Academy of Pediatrics [52].

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 males than females [53]. 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 [54]. 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 [55].

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 eighth grade, progression to daily smoking was predicted by their caregivers' and peers' smoking habits [56]. Furthermore, smoking among caregivers was the most important influence on smoking initiation in younger adolescents, but smoking among peers became the more important influence in older adolescents [57].

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 [58].

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 "Substance use disorders: Motivational interviewing".)

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 for adolescents with nicotine dependence' 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 [59,60].

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 [61]. Although there is little evidence that these strategies attenuate weight gain in adults [62], 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 [63].

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 [7,64].

Bupropion, an antidepressant, has been shown to assist with smoking cessation in adults. There are 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 'Bupropion' 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 [65]. High-arousal affective states and cravings have been shown to lead to cessation lapses [66]. Furthermore, a smartphone application using mindfulness training led to increased cessation rates, and greater engagement with the app was associated with reduced cigarette use [67]. (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 caregivers 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 [2,68-70]. A smoking ban must be strictly enforced to be effective [68].

Caregiver smoking and cessation – Smoking by caregivers or other household members has a large influence on smoking by adolescents. Children whose caregivers smoke are more likely to smoke. Conversely, smoking cessation efforts by caregivers can have a positive impact on their children's efforts [71]. In one study, adolescents whose caregivers quit smoking were twice as likely to quit themselves compared with those whose caregivers continued to smoke [72]. The earlier in the child's life that the caregiver 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 [73]. 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 [74]. 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 smartphone applications have been developed and evaluated for teens [17,75]. 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 [76]. 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 low response and abstinence rates [77].

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 or 1-800-YES QUIT) or texting 'QUIT' to 47848. 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):

Help2quit (American Academy of Pediatrics)

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)

Quick Facts on the Risks of E-cigarettes for Kids, Teens, and Young Adults (Centers for Disease Control and Prevention)

The Truth (Truth Initiative)

Resources primarily for caregivers:

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 FOR ADOLESCENTS WITH NICOTINE DEPENDENCE — We suggest offering pharmacotherapy with nicotine replacement along with behavioral therapy to all adolescents who smoke or vape and have signs of nicotine dependence. The choice of pharmacotherapy for pregnant people is discussed in detail separately. (See "Tobacco and nicotine use in pregnancy: Cessation strategies and treatment options", section on 'Pharmacotherapy'.)

Rationale for pharmacotherapy — 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, as well as evidence suggesting efficacy of pharmacotherapy combined with behavioral support in adults [12,37,78]. 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 [78-80]. A meta-analysis of the efficacy of pharmacotherapy for smoking cessation among adolescent smokers suggests that pharmacotherapy increases abstinence in the short term (at 4 weeks), but not at 8, 12, 24, or 52 weeks [78,81].

Although we suggest use of pharmacotherapy for adolescents who are nicotine dependent, some authorities suggest behavioral support (counseling) alone for this age group [21]. If a teen is moderately to severely dependent with withdrawal symptoms that are difficult to tolerate, pharmacotherapy may help.

First-line therapy — A number of pharmacotherapies are available to assist with smoking cessation. However, the choice of agents differs in adolescents as compared with adults. We suggest offering nicotine replacement therapy (NRT) for smoking cessation to adolescents who report symptoms of nicotine dependence. 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 in this age group. (See 'Address nicotine withdrawal symptoms and other barriers to quitting' above.)

We do not suggest bupropion or varenicline as first-line agents due to lack of sufficient evidence on efficacy and safety in adolescents.

Nicotine replacement — NRT is the mainstay of smoking cessation pharmacotherapy and is available in several different forms. We typically offer the nicotine patch or gum. Other available preparations are shown in the table (table 5). In the United States, the nicotine patch and gum are sold without prescription to adults, but a prescription is needed for sale to those younger than 18 years. The dose of NRT is titrated as needed to overcome the symptoms of nicotine withdrawal.

Importantly, e-cigarettes (vaping nicotine) are not an acceptable option for treatment of nicotine dependence. Although vaping nicotine can eliminate nicotine withdrawal symptoms, it may promote nicotine use and dependence and is also associated with other potential harms. (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'.)

A systematic review of NRT in adolescent smokers that included two randomized trials found no clear evidence for benefit (risk ratio 1.1, 95% CI 0.5-2.6), although the low abstinence rates and wide confidence intervals preclude any firm conclusions [82]. 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'.)

One study showed somewhat higher compliance with patch therapy than with gum, but this varies with patient preference [83]. 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 supports its use.

Of note, patients should discontinue smoking and/or vaping when they initiate NRT. If used with a nicotine product, they may have symptoms from too much nicotine.

Nicotine patch – The starting dose is determined by patient weight and number of cigarettes smoked per day or quantity of nicotine vaped per day.

Patients smoking >10 cigarettes per day and weighing >45 kg (100 lbs)

-Begin with 21 mg patch and change daily for six weeks

-Decrease to 14 mg patch and change daily for two weeks

-Finish with 7 mg patch and change daily for two weeks

Patients smoking ≤10 cigarettes per day or weighing ≤45 kg (100 lbs)

-Begin with 14 mg patch and change daily for six weeks

-Finish with 7 mg patch and change daily for two weeks

The patch may be left on overnight if the patient experiences strong cravings when they wake in the morning. Patients may prefer not to leave patch on overnight if they experience vivid dreams.

Nicotine gum – Gum is available in 2 or 4 mg doses. The 4 mg dose is recommended for heavy smokers (>10 cigarettes per day) or those who smoke within 30 minutes of waking. Otherwise, 2 mg is the recommended dose. Recommended tapering schedule is as follows:

Weeks 1 to 6 – Chew one piece of gum every 1 to 2 hours (maximum: 24 pieces per day)

Weeks 7 to 9 – Chew one piece of gum every 2 to 4 hours

Weeks 10 to 12 – Chew one piece of gum every 4 to 8 hours

Each piece of gum should be chewed slowly to release the nicotine. After a few minutes of chewing, the nicotine will be released, indicated by a hot, peppery taste. The gum should then be "parked" between the cheek and gums so that the nicotine can be absorbed. The process of slowly chewing then "parking" the gum should be repeated every few minutes for 20 to 30 minutes.

Nicotine nasal spray – We do not typically start with the nicotine nasal spray; however, if the patient is not interested in other forms of NRT, we offer it. 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 [84]. 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.

There is no consensus on length of NRT. However, we advise that patients remain on NRT for at least three months. Close follow-up is essential, including a visit during the first week of NRT and a second follow-up within the first month. Further follow-up should be scheduled as indicated. (See 'Arrange follow-up' above.)

Patients who continue to smoke — When patients are unable to achieve smoking cessation, we return to the six A's (see 'The six A's' above). Additionally, we evaluate several things, including:

Were they using the NRT correctly; often there are errors in use

Are there psychosocial or mental health issues that are affecting their success that need to be addressed

Is the person ready to try again

For older patients (near 18 years old or older) who are highly motivated and not able to stop smoking despite behavioral counseling and NRT, we suggest using bupropion or varenicline (often in combination with a nicotine patch). The choice between these two agents depends on patient preference and individual medical considerations. (See "Pharmacotherapy for smoking cessation in adults", section on 'Considerations for special populations'.)

Bupropion — We do not use bupropion as a first-line pharmacologic intervention for adolescent smoking cessation due to the lack of safety and efficacy data in this age group [21]. (See "Pharmacotherapy for smoking cessation in adults".)

Few studies address bupropion for smoking cessation in adolescents.

One 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 [85]. 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 [86].

Another study found no significant effect of combination therapy with bupropion and nicotine patch therapy compared with nicotine patch therapy alone [87].

In adults, bupropion is moderately effective in increasing quit rates and is considered an appropriate first-line agent for assisting smoking cessation (as is NRT). (See "Pharmacotherapy for smoking cessation in adults".)

Varenicline — We do not recommend varenicline as first-line therapy for adolescents due to the lack of safety data. Although efficacy data are mixed, varenicline may be an option for patients who have not had success with NRT and are close to 18 years old. 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 [88,89]. (See "Pharmacotherapy for smoking cessation in adults", section on 'Varenicline'.)

In one of the trials, varenicline was associated with slightly more rapid achievement in self-reported abstinence and improvements in posttreatment abstinence outcomes [88]. However, these self-reports were not confirmed by urine cotinine levels. Treatment-emergent adverse effects were generally mild and similar to those in adults (primarily nausea and vomiting).

Another randomized trial found a lack of efficacy in teens and young adults with attention deficit hyperactivity disorder, predominantly inattentive type [90].

Patients who relapse — A relapse should be viewed as an opportunity to learn and to assess the reasons a teen went back to smoking or vaping. Relapses are common and not an indication of failure. Most adults try multiple times to quit smoking prior to quitting for good [91]. (See "Overview of smoking cessation management in adults", section on 'Relapse'.)

For adolescents who stop NRT after successfully achieving abstinence and who subsequently relapse and meet criteria for nicotine dependence, we discuss restarting the NRT formulation that was effective and reviewing factors that contributed to the relapse.

SMOKING CESSATION IN THE SETTING OF OTHER RISKY BEHAVIORS

Teen pregnancy — In the United States, between 20 and 50 percent of pregnant teenagers smoke [92,93]. Pregnant 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 [94,95]. (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 [96]. (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 health risk 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 [97,98]. 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 [27]. Moreover, baseline use of combustible tobacco or e-cigarettes is associated with initiation of marijuana use within the subsequent two years [99]. (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 [55]. 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 [100].

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 [101]. Adolescents entering substance use treatment may benefit from integrated tobacco cessation interventions that are intensive and occur early in treatment [102]. (See "Substance use disorder in adolescents: Epidemiology, clinical features, 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 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 email 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

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 electronic cigarettes [e-cigarettes] or devices) also promotes nicotine dependence and may lead to tobacco smoking. Tools to assess nicotine dependence are discussed above. (See 'Address nicotine withdrawal symptoms and other barriers to quitting' above.)

Behavioral support for all adolescents who smoke or vape – For all adolescents who smoke or vape, the first step in management is to initiate behavioral support. It is important to discuss the limits of confidentiality and to maintain confidentiality whenever possible.

General strategies – Behavioral interventions conducted by the clinician can be brief and may include discussion about the potential advantages of quitting and assist with problem-solving to overcome barriers to quitting. Other options include referral to a teen smoking cessation program, self-help program, or educational websites. (See 'General strategies' above and 'Other sources of behavior support' above.)

Six A's for counseling – We use a six-step approach called the six A's which 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, as follows:

-Assess readiness to quit. Most adolescents who smoke or vape report that they would like to quit, suggesting readiness for an intervention. Discussing aspects of smoking that appeal to teens, aspects that concern them, and barriers to quitting are valuable starting points in counseling. (See 'Risks of smoking in adolescence' above.)

-Strongly urge all adolescents to quit. 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.)

-Adolescents who are not interested in quitting should be given serial brief interventions with messages that 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 and 'Advise smoking cessation and about risks of vaping' above.)

Nicotine dependence among youth – For adolescents with symptoms of nicotine dependence, we suggest pharmacotherapy with nicotine replacement therapy (NRT; typically with a nicotine patch or gum) in conjunction with a counseling intervention (table 2 and table 5) rather than counseling alone or other pharmacotherapy (Grade 2C). This is based upon evidence of efficacy in adults because few studies have been conducted with adolescents. (See 'First-line therapy' above.)

For adolescents who are approaching 18 years and are not able to stop smoking despite consistent and optimal use of NRT, we suggest using bupropion or varenicline as second-line therapies (often together with nicotine patch) rather than other agents (Grade 2C).

E-cigarettes (vaping nicotine) are not an acceptable option for treatment of nicotine dependence. 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'.)

  1. Centers for Disease Control and Prevention (CDC). Cigarette use among high school students--United States, 1991-2005. MMWR Morb Mortal Wkly Rep 2006; 55:724.
  2. 2012 US Surgeon General's Report: Preventing Tobacco Use Among Youth and Young Adults. Available at: http://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/ (Accessed on August 22, 2019).
  3. Hu T, Gall SL, Widome R, et al. Childhood/Adolescent Smoking and Adult Smoking and Cessation: The International Childhood Cardiovascular Cohort (i3C) Consortium. J Am Heart Assoc 2020; 9:e014381.
  4. Centers for Disease Control and Prevention (CDC). High school students who tried to quit smoking cigarettes--United States, 2007. MMWR Morb Mortal Wkly Rep 2009; 58:428.
  5. Villanti AC, Johnson AL, Rath JM, et al. Identifying "social smoking" U.S. young adults using an empirically-driven approach. Addict Behav 2017; 70:83.
  6. Heffner JL, Kealey KA, Marek PM, et al. Proactive telephone counseling for adolescent smokers: Comparing regular smokers with infrequent and occasional smokers on treatment receptivity, engagement, and outcomes. Drug Alcohol Depend 2016; 165:229.
  7. Costello DM, Dierker LC, Jones BL, Rose JS. Trajectories of smoking from adolescence to early adulthood and their psychosocial risk factors. Health Psychol 2008; 27:811.
  8. Karp I, O'Loughlin J, Paradis G, et al. Smoking trajectories of adolescent novice smokers in a longitudinal study of tobacco use. Ann Epidemiol 2005; 15:445.
  9. Selya AS, Dierker L, Rose JS, et al. Early-Emerging Nicotine Dependence Has Lasting and Time-Varying Effects on Adolescent Smoking Behavior. Prev Sci 2016; 17:743.
  10. Chadi N, Schroeder R, Jensen JW, Levy S. Association Between Electronic Cigarette Use and Marijuana Use Among Adolescents and Young Adults: A Systematic Review and Meta-analysis. JAMA Pediatr 2019; 173:e192574.
  11. Goldenson NI, Leventhal AM, Stone MD, et al. Associations of Electronic Cigarette Nicotine Concentration With Subsequent Cigarette Smoking and Vaping Levels in Adolescents. JAMA Pediatr 2017; 171:1192.
  12. Pbert L, Farber H, Horn K, et al. State-of-the-art office-based interventions to eliminate youth tobacco use: the past decade. Pediatrics 2015; 135:734.
  13. Collins L, Smiley SL, Moore RA, et al. Physician tobacco screening and advice to quit among U.S. adolescents - National Survey on Drug Use and Health, 2013. Tob Induc Dis 2017; 15:2.
  14. McMillen R, O'Connor KG, Groner J, et al. Changes and Factors Associated With Tobacco Counseling: Results From the AAP Periodic Survey. Acad Pediatr 2017; 17:504.
  15. Bailey SR, Fankhauser K, Marino M, et al. Smoking Assessment and Current Smoking Status Among Adolescents in Primary Care Settings. Nicotine Tob Res 2020; 22:2098.
  16. Adams ZW, Kwon E, Aalsma MC, et al. Treatment of Adolescent e-Cigarette Use: Limitations of Existing Nicotine Use Disorder Treatment and Future Directions for e-Cigarette Use Cessation. J Am Acad Child Adolesc Psychiatry 2021; 60:14.
  17. Graham AL, Jacobs MA, Amato MS. Engagement and 3-Month Outcomes From a Digital E-Cigarette Cessation Program in a Cohort of 27 000 Teens and Young Adults. Nicotine Tob Res 2020; 22:859.
  18. Alfano CM, Zbikowski SM, Robinson LA, et al. Adolescent reports of physician counseling for smoking. Pediatrics 2002; 109:E47.
  19. Klein JD, Gorzkowski J, Resnick EA, et al. Delivery and Impact of a Motivational Intervention for Smoking Cessation: A PROS Study. Pediatrics 2020; 146.
  20. US Preventive Services Task Force, Owens DK, Davidson KW, et al. Primary Care Interventions for Prevention and Cessation of Tobacco Use in Children and Adolescents: US Preventive Services Task Force Recommendation Statement. JAMA 2020; 323:1590.
  21. Agency for healthcare research and quality clinical practice guideline. Treating tobacco use and dependence: 2008 update. Chapter 7, Specific populations and other topics https://www.ncbi.nlm.nih.gov/books/NBK63952/ (Accessed on November 14, 2019).
  22. Pbert L, Flint AJ, Fletcher KE, et al. Effect of a pediatric practice-based smoking prevention and cessation intervention for adolescents: a randomized, controlled trial. Pediatrics 2008; 121:e738.
  23. Hollis JF, Polen MR, Whitlock EP, et al. Teen reach: outcomes from a randomized, controlled trial of a tobacco reduction program for teens seen in primary medical care. Pediatrics 2005; 115:981.
  24. Pbert L, Fletcher KE, Flint AJ, et al. Smoking prevention and cessation intervention delivery by pediatric providers, as assessed with patient exit interviews. Pediatrics 2006; 118:e810.
  25. Jenssen BP, Walley SC, Boykan R, et al. Protecting Children and Adolescents From Tobacco and Nicotine. Pediatrics 2023; 151.
  26. Epps RP, Manley MW. A physicians's guide to preventing tobacco use during childhood and adolescence. Pediatrics 1991; 88:140.
  27. Sims TH, Committee on Substance Abuse. From the American Academy of Pediatrics: Technical report--Tobacco as a substance of abuse. Pediatrics 2009; 124:e1045. Reaffirmed 2015.
  28. 2008 PHS Guideline Update Panel, Liaisons, and Staff. Treating tobacco use and dependence: 2008 update U.S. Public Health Service Clinical Practice Guideline executive summary. Respir Care 2008; 53:1217.
  29. Han YY, Rosser F, Forno E, Celedón JC. Electronic vapor products, marijuana use, smoking, and asthma in US adolescents. J Allergy Clin Immunol 2020; 145:1025.
  30. Keller-Hamilton B, Lu B, Roberts ME, et al. Electronic cigarette use and risk of cigarette and smokeless tobacco initiation among adolescent boys: A propensity score matched analysis. Addict Behav 2021; 114:106770.
  31. Dai H. Prevalence and Factors Associated With Youth Vaping Cessation Intention and Quit Attempts. Pediatrics 2021; 148.
  32. Zhang L, Gentzke A, Trivers KF, VanFrank B. Tobacco Cessation Behaviors Among U.S. Middle and High School Students, 2020. J Adolesc Health 2022; 70:147.
  33. Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff. A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report. Am J Prev Med 2008; 35:158.
  34. Tan J, Zhao L, Chen H. A meta-analysis of the effectiveness of gradual versus abrupt smoking cessation. Tob Induc Dis 2019; 17:09.
  35. Branstetter SA, Muscat JE, Mercincavage M. Time to First Cigarette: A Potential Clinical Screening Tool for Nicotine Dependence. J Addict Med 2020; 14:409.
  36. Prokhorov AV, Hudmon KS, de Moor CA, et al. Nicotine dependence, withdrawal symptoms, and adolescents' readiness to quit smoking. Nicotine Tob Res 2001; 3:151.
  37. Siqueira LM, COMMITTEE ON SUBSTANCE USE AND PREVENTION. Nicotine and Tobacco as Substances of Abuse in Children and Adolescents. Pediatrics 2017; 139.
  38. Bailey SR, Harrison CT, Jeffery CJ, et al. Withdrawal symptoms over time among adolescents in a smoking cessation intervention: do symptoms vary by level of nicotine dependence? Addict Behav 2009; 34:1017.
  39. Morean ME, Krishnan-Sarin S, S O'Malley S. Assessing nicotine dependence in adolescent E-cigarette users: The 4-item Patient-Reported Outcomes Measurement Information System (PROMIS) Nicotine Dependence Item Bank for electronic cigarettes. Drug Alcohol Depend 2018; 188:60.
  40. Prokhorov AV, Pallonen UE, Fava JL, et al. Measuring nicotine dependence among high-risk adolescent smokers. Addict Behav 1996; 21:117.
  41. DiFranza JR, Rigotti NA, McNeill AD, et al. Initial symptoms of nicotine dependence in adolescents. Tob Control 2000; 9:313.
  42. DiFranza JR, Sweet M, Savageau J, Ursprung WW. An evaluation of a clinical approach to staging tobacco addiction. J Pediatr 2011; 159:999.
  43. Dierker L, Mermelstein R. Early emerging nicotine-dependence symptoms: a signal of propensity for chronic smoking behavior in adolescents. J Pediatr 2010; 156:818.
  44. Miech R, Leventhal AM, O'Malley PM, et al. Failed Attempts to Quit Combustible Cigarettes and e-Cigarettes Among US Adolescents. JAMA 2022; 327:1179.
  45. Doubeni CA, Reed G, Difranza JR. Early course of nicotine dependence in adolescent smokers. Pediatrics 2010; 125:1127.
  46. Tobacco and Genetics Consortium. Genome-wide meta-analyses identify multiple loci associated with smoking behavior. Nat Genet 2010; 42:441.
  47. Vallata A, O'Loughlin J, Cengelli S, Alla F. Predictors of Cigarette Smoking Cessation in Adolescents: A Systematic Review. J Adolesc Health 2021; 68:649.
  48. Myers MG, MacPherson L. Adolescent reasons for quitting smoking: initial psychometric evaluation. Psychol Addict Behav 2008; 22:129.
  49. Wellman RJ, O'Loughlin EK, Dugas EN, et al. Reasons for quitting smoking in young adult cigarette smokers. Addict Behav 2018; 77:28.
  50. Campaign for tobacco-free kids fact sheet, State excise and sales taxes per pack of cigarettes, 2015. Available at: http://www.tobaccofreekids.org/facts_issues/fact_sheets/policies/tax/us_state_local/ (Accessed on January 02, 2016).
  51. Moyer VA, U.S. Preventive Services Task Force. Primary care interventions to prevent tobacco use in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2013; 159:552.
  52. Farber HJ, Nelson KE, Groner JA, et al. Public Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke. Pediatrics 2015; 136:998.
  53. Riedel BW, Robinson LA, Klesges RC, McLain-Allen B. What motivates adolescent smokers to make a quit attempt? Drug Alcohol Depend 2002; 68:167.
  54. Riedel BW, Robinson LA, Klesges RC, McLain-Allen B. Characteristics of adolescents caught with cigarettes at school: implications for developing smoking cessation programs. Nicotine Tob Res 2002; 4:351.
  55. Paavola M, Vartiainen E, Puska P. Smoking cessation between teenage years and adulthood. Health Educ Res 2001; 16:49.
  56. Kim MJ, Fleming CB, Catalano RF. Individual and social influences on progression to daily smoking during adolescence. Pediatrics 2009; 124:895.
  57. Vitaro F, Wanner B, Brendgen M, et al. Differential contribution of parents and friends to smoking trajectories during adolescence. Addict Behav 2004; 29:831.
  58. Saw A, Steltenpohl CN, Bankston-Lee K, Tong EK. A Community-Based "Street Team" Tobacco Cessation Intervention by and for Youth and Young Adults. J Community Health 2018; 43:383.
  59. Tomeo CA, Field AE, Berkey CS, et al. Weight concerns, weight control behaviors, and smoking initiation. Pediatrics 1999; 104:918.
  60. Austin SB, Gortmaker SL. Dieting and smoking initiation in early adolescent girls and boys: a prospective study. Am J Public Health 2001; 91:446.
  61. American Heart Association monograph, "How to avoid weight gain when quitting smoking" http://www.americanheart.org/presenter.jhtml?identifier=3011 (Accessed on October 19, 2009).
  62. Hartmann-Boyce J, Theodoulou A, Farley A, et al. Interventions for preventing weight gain after smoking cessation. Cochrane Database Syst Rev 2021; 10:CD006219.
  63. Blank MD, Ferris KA, Metzger A, et al. Physical Activity and Quit Motivation Moderators of Adolescent Smoking Reduction. Am J Health Behav 2017; 41:419.
  64. Scherphof CS, van den Eijnden RJ, Harakeh Z, et al. Effects of nicotine dependence and depressive symptoms on smoking cessation: a longitudinal study among adolescents. Nicotine Tob Res 2013; 15:1222.
  65. Siqueira LM, Rolnitzky LM, Rickert VI. Smoking cessation in adolescents: the role of nicotine dependence, stress, and coping methods. Arch Pediatr Adolesc Med 2001; 155:489.
  66. Treloar Padovano H, Merrill JE, Colby SM, et al. Affective and Situational Precipitants of Smoking Lapses Among Adolescents. Nicotine Tob Res 2020; 22:492.
  67. Pbert L, Druker S, Crawford S, et al. Feasibility of a Smartphone App with Mindfulness Training for Adolescent Smoking Cessation: Craving to Quit (C2Q)-Teen. Mindfulness (N Y) 2020; 11:720.
  68. Wakefield MA, Chaloupka FJ, Kaufman NJ, et al. Effect of restrictions on smoking at home, at school, and in public places on teenage smoking: cross sectional study. BMJ 2000; 321:333.
  69. Andersen MR, Leroux BG, Bricker JB, et al. Antismoking parenting practices are associated with reduced rates of adolescent smoking. Arch Pediatr Adolesc Med 2004; 158:348.
  70. Farkas AJ, Gilpin EA, White MM, Pierce JP. Association between household and workplace smoking restrictions and adolescent smoking. JAMA 2000; 284:717.
  71. Males M. The influence of parental smoking on youth smoking: is the recent downplaying justified? J Sch Health 1995; 65:228.
  72. Farkas AJ, Distefan JM, Choi WS, et al. Does parental smoking cessation discourage adolescent smoking? Prev Med 1999; 28:213.
  73. Sussman S, Lichtman K, Ritt A, Pallonen UE. Effects of thirty-four adolescent tobacco use cessation and prevention trials on regular users of tobacco products. Subst Use Misuse 1999; 34:1469.
  74. Sussman S, Sun P, Dent CW. A meta-analysis of teen cigarette smoking cessation. Health Psychol 2006; 25:549.
  75. Robinson CD, Seaman EL, Grenen E, et al. A content analysis of smartphone apps for adolescent smoking cessation. Transl Behav Med 2020; 10:302.
  76. Mason M, Mennis J, Way T, et al. Text Message Delivered Peer Network Counseling for Adolescent Smokers: A Randomized Controlled Trial. J Prim Prev 2016; 37:403.
  77. Chan C, Kamke K, Assuah F, El-Toukhy S. Dropout, response, and abstinence outcomes of a national text-messaging smoking cessation intervention for teens, SmokeFreeTeen. Transl Behav Med 2021; 11:764.
  78. Myung SK, Park JY. Efficacy of Pharmacotherapy for Smoking Cessation in Adolescent Smokers: A Meta-analysis of Randomized Controlled Trials. Nicotine Tob Res 2019; 21:1473.
  79. Simon P, Kong G, Cavallo DA, Krishnan-Sarin S. Update of Adolescent Smoking Cessation Interventions: 2009-2014. Curr Addict Rep 2015; 2:15.
  80. Farber HJ, Walley SC, Groner JA, et al. Clinical Practice Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke. Pediatrics 2015; 136:1008.
  81. Fiore MC, Jaén CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. Clinical practice guidelines, Tobacco Use and Dependence Guideline Panel.; US Department of Health and Human Services, Rockville, MD 2008.
  82. Fanshawe TR, Halliwell W, Lindson N, et al. Tobacco cessation interventions for young people. Cochrane Database Syst Rev 2017; 11:CD003289.
  83. Moolchan ET, Robinson ML, Ernst M, et al. Safety and efficacy of the nicotine patch and gum for the treatment of adolescent tobacco addiction. Pediatrics 2005; 115:e407.
  84. Rubinstein ML, Benowitz NL, Auerback GM, Moscicki AB. A randomized trial of nicotine nasal spray in adolescent smokers. Pediatrics 2008; 122:e595.
  85. Muramoto ML, Leischow SJ, Sherrill D, et al. Randomized, double-blind, placebo-controlled trial of 2 dosages of sustained-release bupropion for adolescent smoking cessation. Arch Pediatr Adolesc Med 2007; 161:1068.
  86. Leischow SJ, Muramoto ML, Matthews E, et al. Adolescent Smoking Cessation With Bupropion: The Role of Adherence. Nicotine Tob Res 2016; 18:1202.
  87. Killen JD, Robinson TN, Ammerman S, et al. Randomized clinical trial of the efficacy of bupropion combined with nicotine patch in the treatment of adolescent smokers. J Consult Clin Psychol 2004; 72:729.
  88. Gray KM, Baker NL, McClure EA, et al. Efficacy and Safety of Varenicline for Adolescent Smoking Cessation: A Randomized Clinical Trial. JAMA Pediatr 2019; 173:1146.
  89. Gray KM, Rubinstein ML, Prochaska JJ, et al. High-dose and low-dose varenicline for smoking cessation in adolescents: a randomised, placebo-controlled trial. Lancet Child Adolesc Health 2020; 4:837.
  90. Green R, Baker NL, Ferguson PL, et al. ADHD symptoms and smoking outcomes in a randomized controlled trial of varenicline for adolescent and young adult tobacco cessation. Drug Alcohol Depend 2023; 244:109798.
  91. Chaiton M, Diemert L, Cohen JE, et al. Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers. BMJ Open 2016; 6:e011045.
  92. Albrecht SA, Cornelius MD, Braxter B, et al. An assessment of nicotine dependence among pregnant adolescents. J Subst Abuse Treat 1999; 16:337.
  93. Cornelius MD, Goldschmidt L, DeGenna N, Day NL. Smoking during teenage pregnancies: effects on behavioral problems in offspring. Nicotine Tob Res 2007; 9:739.
  94. Gilliland FD, Li YF, Peters JM. Effects of maternal smoking during pregnancy and environmental tobacco smoke on asthma and wheezing in children. Am J Respir Crit Care Med 2001; 163:429.
  95. Wang C, Salam MT, Islam T, et al. Effects of in utero and childhood tobacco smoke exposure and beta2-adrenergic receptor genotype on childhood asthma and wheezing. Pediatrics 2008; 122:e107.
  96. Scholl TO, Salmon RW, Miller LK. Smoking and adolescent pregnancy outcome. J Adolesc Health Care 1986; 7:390.
  97. Kandel ER, Kandel DB. Shattuck Lecture. A molecular basis for nicotine as a gateway drug. N Engl J Med 2014; 371:932.
  98. Hendrickson LM, Guildford MJ, Tapper AR. Neuronal nicotinic acetylcholine receptors: common molecular substrates of nicotine and alcohol dependence. Front Psychiatry 2013; 4:29.
  99. Audrain-McGovern J, Stone MD, Barrington-Trimis J, et al. Adolescent E-Cigarette, Hookah, and Conventional Cigarette Use and Subsequent Marijuana Use. Pediatrics 2018; 142.
  100. Vogel EA, Rubinstein ML, Prochaska JJ, Ramo DE. Associations between marijuana use and tobacco cessation outcomes in young adults. J Subst Abuse Treat 2018; 94:69.
  101. Campbell BK, Wander N, Stark MJ, Holbert T. Treating cigarette smoking in drug-abusing clients. J Subst Abuse Treat 1995; 12:89.
  102. Coleman-Cowger VH, Catlin ML. Changes in tobacco use patterns among adolescents in substance abuse treatment. J Subst Abuse Treat 2013; 45:227.
Topic 6359 Version 47.0

References

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