Addressing Nicotine Dependence in Pediatric Populations

Written by Fariba Rezaee, MD, and Humberto Choi, MD

Nicotine dependence among children and adolescents has emerged as a critical public health challenge, largely fueled by the proliferation of electronic nicotine delivery systems (ENDS), also known as e-cigarettes or vape pens. According to 2024 CDC data, 8.1% (2.25 million) of U.S. middle and high school students reported current use of tobacco products, while 19% (5.28 million) indicated lifetime use — highlighting the underrecognized scope of the problem.¹ Among current users, over 87% reported use of flavored e-cigarette products.

Adolescents are uniquely susceptible to the addictive properties of nicotine due to ongoing neurodevelopment, with exposure during this period associated with long-term cognitive impairment, mood disorders and increased vulnerability to other substance use. Despite these risks, nicotine use is frequently underdiagnosed and undertreated in pediatric healthcare settings.

Neurobehavioral impact and risk associations

Nicotine exposure during adolescence disrupts critical processes in brain maturation, particularly in regions involved in attention regulation, impulse control and executive functioning. Dependence can develop rapidly, even with intermittent use, and it is often accompanied by withdrawal symptoms and behavioral comorbidities such as anxiety, depression and academic decline. ENDS products — often misperceived as less harmful — enable high-dose nicotine delivery without the aversive experience of combustible tobacco. This increased tolerability facilitates sustained use among youth.

Call to action for providers

Pediatricians must assume a proactive role in addressing nicotine use by:

• Implementing routine screening and brief interventions.
• Offering evidence-based counseling and referral resources.
• Educating families about risks and signs of use.
• Advocating for community and policy-level prevention efforts, including restrictions on flavored products and enforcement of Tobacco 21 laws.²

Behavioral and digital intervention strategies

Behavioral counseling, particularly through motivational interviewing (MI), remains the cornerstone of treatment. MI fosters readiness to quit by eliciting self-motivated change and building a therapeutic alliance. Augmenting clinical care, technology-based interventions tailored to adolescents — such as This Is Quitting (Truth Initiative), MyLifeMyQuit, teen.smokefree.gov, and the My Quit Buddy app — have demonstrated promising outcomes in increasing quit attempts and reducing nicotine consumption.

Family engagement and school-based support programs, such as the American Lung Association’s NOT (Not On Tobacco) curriculum, further reinforce cessation efforts. Co-management with mental health professionals may be required for patients with significant psychiatric comorbidities.

Pharmacologic considerations

The role of pharmacotherapy remains controversial in pediatric populations due to limited clinical trial data. However, nicotine replacement therapy, including patches and lozenges, may be considered in cases of moderate to severe dependence, provided it is paired with behavioral support. Current practice requires individualized risk-benefit assessment and informed consent involving the patient and family.

Health system innovations to reduce barriers

Pediatricians and adolescent medicine specialists are strategically positioned to identify and intervene in early nicotine use; however, several challenges impede consistent recognition and management. Adolescents frequently underreport vaping behaviors, often due to misconceptions about its safety or normalization of its use within peer groups. Compounding this issue is the lack of validated, adolescent-specific screening tools routinely embedded into pediatric clinical workflows. Preventive visits may not include structured assessment for nicotine use, especially when time constraints and competing clinical priorities dominate the encounter. Additionally, many providers report limited training and confidence in addressing substance use in this population, contributing to underdiagnosis and missed opportunities for early intervention.

To address these challenges, the American Academy of Pediatrics (AAP) strongly encourages the routine implementation of structured screening beginning in early adolescence.³ The CRAFFT questionnaire, a validated tool designed specifically for adolescents, offers an efficient and effective means to identify individuals at risk for substance use.⁴ In parallel, the “5 A’s” framework—Ask, Advise, Assess, Assis, and Arrange—provides a systematic approach to guide conversations around nicotine use, assess motivation to quit, initiate counseling and ensure appropriate follow-up.

In response to the escalating prevalence of vaping among youth and the critical need for targeted intervention, Cleveland Clinic is developing a Pediatric Vaping Cessation Clinic. This innovative initiative is built on a comprehensive and multidisciplinary model of care designed to address the complex medical and behavioral aspects of nicotine dependence in adolescents. Led by pediatric pulmonologists, the clinic will offer individualized medical evaluations and evidence-based counseling.

Conclusion

Effective management of pediatric nicotine dependence requires an integrated, developmentally informed and empathetic approach. With the continued surge in adolescent vaping, the healthcare system must evolve to provide accessible, evidence-based cessation services. Through innovation, early detection and multidisciplinary engagement, we can mitigate the long-term health impacts of nicotine addiction in youth and support a trajectory toward sustained recovery and wellness.

References:

1. Jamal A, Park-Lee A, Birdsey J, et al. Tobacco Product Use Among Middle and High School Students — National Youth Tobacco Survey, United States, 2024. MMWR Morb. Mortal. Wkly. Rep. 2024;73(41). doi:https://doi.org/10.15585/mmwr.mm7341a2.
2. Abouk R, De P, Pesko MF. Estimating the Effects of Tobacco-21 on Youth Tobacco Use and Sales. J Health Econ. 2024;94:102860. doi:10.1016/j.jhealeco.2024.102860.
3. Addressing Pediatric Tobacco Use: Strategies for Clinicians. Aap.org. Published 2020. Accessed May 20, 2025. https://www.aap.org/en/patient-care/tobacco-control-and-prevention/youth-tobacco-cessation/tobacco-use-considerations-for-clinicians/?srsltid=AfmBOor3MDIqwfErCGKVa9GdigbZpAvd2UBDS603pflAlVT5EzLQoCWt
4. CRAFFT. About the CRAFFT – CRAFFT. Crafft.org. Published 2015. Accessed May 20, 2025. https://crafft.org/about-the-crafft/.