For many years, my lead-in question with adolescents, after I asked the parent to leave the room at pediatric appointments, was whether the kid had ever tried smoking cigarettes. It made a reasonable lead-in because it felt less highly charged than asking about marijuana or other substances, and in recent decades, the answer was very often no. Youth tobacco smoking in the United States was on the decline.
And then came vaping, e-cigarettes and Juuls. And like many parents, many pediatricians are flying a little bit blind here, not sure what questions to ask or how to respond to the answers we get. This was brought home to me vividly when an adolescent patient told me that he was vaping pretty regularly — even in school, keeping it hidden.
He told me he had tried to stop a couple of times and he couldn’t do it — high school, he said, was just too stressful.
There are frightening numbers about e-cigarette use in the young, and increasing reports of serious illness, lung damage and death related to vaping. What can we do to help an adolescent or a young adult shake a nicotine habit?
The announcement last week of the death of a 17-year-old, the first teenager known to die from a vaping-related illness, may help shift young people’s thinking about the risk.
“There’s a perception it’s safe, safer than cigarettes; youth in general agree cigarettes are not safe,” said Dr. Sarah M. Bagley, an addiction specialist who is assistant professor of medicine and pediatrics at Boston Medical Center/Boston University School of Medicine.
“Everybody who comes in smoking cigarettes knows it’s going to kill them,” said Dr. Sharon Levy, the director of the adolescent substance use and addiction program at Boston Children’s Hospital. “Till very recently, people thought vapes were the healthy alternative.” Those sobering messages are not necessarily turning up on the news sources that her adolescent patients follow, she said. “There are kids who come to our clinic thinking we’re making a big deal about nothing.”
“How do we help kids quit vaping, the million-dollar question,” Dr. Levy said. There is not a research literature yet, and understanding vaping habits is more complicated than counting the number of cigarettes a day.
Dr. Scott Hadland, a pediatrician and adolescent addiction specialist at the Grayken Center for Addiction at Boston Medical Center, said, “Before you can have these conversations with young people, you need to understand what a vaping device is, what some of the brands are, the types of cartridges.” Are they buying it from a “legitimate” source or buying it illegally? For some, vaping is about marijuana, not nicotine.
And when there is secretive vaping going on all day in school, he said, young people may be more likely to develop a physiological dependence on nicotine than they were with traditional cigarettes.
Someone who is using a high-concentration nicotine cartridge every day or two, Dr. Hadland said, is probably taking in the equivalent of about a pack of cigarettes a day, much more than adolescents typically smoke.
Nicotine is a stimulant, and like other stimulants, at low doses it can make people feel more alert and attentive; higher doses, Dr. Levy said, do just the opposite, making people jittery, revved up and unable to concentrate. The high-concentration cartridges deliver a bigger, faster hit of nicotine than was possible with traditional cigarettes. “What Juul did was it perfected nicotine delivery,” Dr. Levy said.
“My sense, and there are not data to guide this yet, is that the more severe the nicotine use disorder, the more necessary to give medication,” Dr. Hadland said. That includes nicotine replacement, with patches, and then lozenges or gum to deal with breakthrough cravings. It can also include a medication called Chantix, which can help with cravings, but has not been found to be effective for those 16 and under, and is generally used cautiously in older adolescents and younger adults. The antidepressant medication Wellbutrin is also sometimes used.
“Nicotine replacement doesn’t work as well as it does in adults, but it does increase the quit rate,” Dr. Levy said. “We do a lot of coaching of our pediatric colleagues, we tell them go ahead and be generous,” that is, for example, helping parents understand that because vaping can mean an adolescent is accustomed to a very high dose of nicotine, that kid may go through a lot of lozenges.
All of these medications are more effective with cognitive behavioral therapy to help you deal with your emotions and manage cravings, Dr. Levy said. Counseling is an important part of treatment, and one reason I try hard to refer my patients to specialty clinics is that I want them to have experienced counselors. And treatment is much more likely to be successful when there is support from a parent.
Because of the high nicotine concentrations and the physiological dependence, Dr. Hadland said, young people who are trying to quit vaping may experience symptoms that go well beyond the cravings that those who smoke traditional cigarettes experience when they try to quit. In addition to those very strong cravings, there may be general irritability, headaches or a sense of feeling sick to your stomach.
“For some, this withdrawal is almost paralyzing,” Dr. Hadland said. “They can’t go about their day, can’t go to school — it’s not something I had ever seen with regular cigarettes, it feels different to me as a clinician.” For the first time, he said, he has to write school letters asking that patients can wear the patch and chew gum when necessary.
[The site smokefree.gov offers specific advice for helping teenagers quit vaping. Other resources include the Great American Smokeout, the American Lung Association, the National Cancer Institute.]
Assessing the degree of nicotine dependency or addiction means not only looking for withdrawal symptoms, Dr. Hadland said, but also at whether someone has tried to cut back without success, and at whether there is a general sense of being out of control — spending more and more money on the habit, finding it is causing conflict with family members, getting in the way of participation in sports.
With 14-year-old patients, he said, sometimes the approach is: “Are you willing to give your Juul and your cartridges to your parents so they can get rid of them — they say yes — you can almost cut the supply off by getting rid of the access.” But for older people, he said, it becomes a lot more difficult, and it can be really hard for them to give up their devices.
Even with medications and counseling, many young people will struggle hard to quit their nicotine habits. Many will face daily temptations in high school, where vaping may be common and normalized, Dr. Bagley said. They need family support and understanding, and may do better with rewards and positive reinforcement.
To fix that high school environment, we should be thinking about what was so effective in communicating the message that cigarettes were dangerous, Dr. Bagley said, and formulating a better public health response to vaping.
But in the meantime, parents need to have those conversations, even if your child insists that the vape pen in his backpack belongs to someone else. “That’s an opportunity to say, these things are dangerous, get rid of this,” Dr. Levy said. “The sense you want to give is, your child does not have your permission to do this.” If kids say they can quit, she said, take them to a health care provider and make sure they get help — if they say they aren’t willing, if they say vaping is safe, consider taking them to talk to a pediatrician.