CCPR: How does nicotine addiction impact adolescents?

Dr. Winickoff: The Surgeon General compares nicotine’s addictiveness to heroin and cocaine, including withdrawal, rapid dependence, and tolerance. Nicotine upregulates acetylcholine receptors in the nucleus accumbens and prefrontal cortex, creating euphoric sensations and a strong dopaminergic response, compulsive use, and reduced interest in nondrug rewards. Developing brains are more susceptible to low nicotine levels, leading to lasting brain changes (www.tinyurl.com/7bst945u). Nicotine levels in tobacco products are high. Disposable vaping devices with 10 mL of 5% nicotine e-juice contain 500–600 mg/device, equivalent to over 10 packs of cigarettes (Prochaska JJ et al, Tob Control 2022;31(e1):e88–e93).

CCPR: How does nicotine exposure lead to other substance and mental health problems?

Dr. Winickoff: Nicotine exposure increases transcription of proteins that potentiate reward from other addictive substances (eg, cocaine, opioids, alcohol, methamphetamine), accelerating addictive processes and creating a gateway-drug effect (Levine A et al, Sci Transl Med 2011;31(107):107ra109). Nicotine use also alters acetylcholine and glutamate receptor signaling in the maturing prefrontal cortex, causing long-term increases in impulsivity and impaired attention. High, irregular nicotine doses from vaping interfere with attention regulation, and withdrawal impairs concentration, making ADHD medication less effective (McNealy KR et al, Drug Alcohol Depend 2023;248:109906). Nicotine increases brain serotonin and endorphins involved in mood regulation. Youth vaping is linked to dose-dependent increases in suicidal thoughts, depression, anxiety, and inattention/hyperactivity (Tervo-Clemmens B et al, JAMA Pediatr 2024;178(3):310–313).

CCPR: How prevalent are vaping and nicotine use among US youth?

Dr. Winickoff: In 2019, nicotine addiction increased significantly, particularly with the eighth wave of nicotine use driven by Juul (Vallone DM et al, JAMA Pediatr 2020;174(3):277–286). Recent data indicate 10% of high school–age youth, over 2 million adolescents, vape nicotine, surpassing all other tobacco products combined (Birdsey J et al, MMWR Morb Mortal Wkly Rep 2023;72:1173–1182). Overall, 12.6% of youth, including 6.6% of middle school students, use tobacco products, often multiple products. Screening for vaping and other nicotine use should start in middle school. Vape use surpasses cigarettes, hookah, and other products. Cannabis plus tobacco is common and mutually reinforcing, with cannabis vaping becoming an entry-level drug for nicotine vaping.

CCPR: What are the effects of vaping and nicotine on adolescent development?

Dr. Winickoff: Addiction. One out of two adolescents who have tried vaping nicotine are current users (Birdsey et al, 2023). Adolescents may try vaping at parties and develop immediate cravings for nicotine. Over 60% of users recognize their addiction but feel unable to stop, largely due to the design of these products (Palmer AM et al, JAMA Netw Open 2021;4(4):e214146). 

CCPR: How does the design of the products impact use? 

Dr. Winickoff: Adolescents are drawn to tobacco products by influencers and online marketing of flavored disposables. These products are engineered with the highest tolerable levels of nicotine salts made possible by lowering the pH, making it easy to inhale high-dose flavored nicotine with a euphoric buzz that can be irresistible. Because the products are designed to be highly addictive and reinforcing, I feel it’s crucial to keep people away from them and to recognize early use (Winickoff JP et al, JAMA 2024;332(9):749–750).

CCPR: What are the health effects of vaping and nicotine use in adolescents?

Dr. Winickoff: Inflammatory changes occur immediately in the lungs, risking asthma, shortness of breath, and lower exercise tolerance. Vape products triple the chances a child will become a combustible tobacco user (Berry KM et al, JAMA Netw Open 2019;2(2):e187794). Once addicted, the brain seeks nicotine—through cigarettes, vaping, or other products. Addiction places adolescents at high risk for all the harms of combustible tobacco products. 

CCPR: How does parental smoking affect a child’s likelihood of using nicotine?

Dr. Winickoff: Among parents who use, there is an almost fourfold increased risk that their child will use nicotine (Kandel DB et al, Am J Public Health 2015;105(11):e63–e72). Access and behavioral modeling are part of it. But another underappreciated factor may be nicotine exposure from the parent’s smoke that upregulates nicotine binding sites in the child’s brain, priming the child for when they personally inhale a tobacco industry product for the first time. 

CCPR: How do you begin the conversation with middle school or high school kids about vaping and nicotine use?

Dr. Winickoff: It’s tricky. When we ask: “Do you use e-cigarettes?” we get blank stares. During the Juul epidemic, I asked: “Do you Juul?” and kids would say: “Yeah. I would never touch an e-cigarette, but I Juul.” Ask whether they know anyone who’s vaping. Name specific products such as Geek Bar, Elf Bar, Vuse, Mr. Fog, and Esco Bar. Juul is still in the top five. Ask about Zyn, Philip Morris’ new flavored nicotine pouch product (Editor’s note: For more information, visit: www.thecarlatreport.com/tobacconicotineproducts).

CCPR: What screening tools do you recommend for identifying nicotine use in adolescents?

Dr. Winickoff: Several screening tools exist, including the Screening to Brief Intervention (S2BI; www.nida.nih.gov/s2bi/) and the Brief Screen for Tobacco, Alcohol, and Drugs (B-STAD; www.nida.nih.gov/bstad/). One S2BI question asks, “In the past year, how many times have you used nicotine/tobacco (including cigarettes, electronic cigarettes, or vapes)?” Responses of “monthly” or “weekly or more” indicate nicotine/tobacco use disorder in adolescents. Both scales are validated for adolescents and consist of three to seven items. Their sensitivity for identifying tobacco use disorder ranges from 0.89 to 1.00. In a study of over 500 adolescents, these tools identified nicotine use 92%–100% of the time and cannabis use 95%–100% of the time. They also detect newer products, like Zyn.

CCPR: When should clinicians screen youth for nicotine use?

Dr. Winickoff: We need universal screening at multiple time points. If an adolescent is seen once a year for an annual physical, screening should occur annually. However, if they are in a high-risk environment where peers use nicotine products, clinicians must inquire about their usage at every clinical encounter in between. This proactive approach is necessary to prevent the spread of nicotine use among adolescents.

CCPR: What if the teen is just experimenting with nicotine? 

Dr. Winickoff: Tell kids, and tell parents to tell their kids, that nicotine is highly addictive and never safe. Tobacco use in adolescence was once seen as a rite of passage; I see it as a clinical emergency. Downplaying experimental use leads to missed chances to prevent addiction. There may be only days or weeks to intervene effectively and stop progression into addiction. Identifying initial use and preventing a shift to regular use can be lifesaving. I’ve worked on policies raising the nicotine sales age to 21 and phasing out sales to anyone born after a certain date. Preventing youth from starting tobacco use significantly improves their long-term health.

CCPR: What are the next steps after you learn that a teen is using nicotine products? 

Dr. Winickoff: Motivational interviewing (MI) can uncover what they seek from nicotine use. Your nonjudgmental, empathic support can help them voice what they are dealing with. Then you can work with the adolescent and build their motivation from their own goals: “Why do you not want to vape? What are your concerns?” Amplify their thoughts and talk about the health effects they may already be experiencing. Talk about financial effects. Many kids are motivated by money. Some steal money or deal to support their use. Listen to their ideas about what would help them quit (Editor’s note: For more on MI for teens, see the webinar by Dr. Joshua Feder at: www.tinyurl.com/4ndb9sjk). 

CCPR: How can we get kids off nicotine?

Dr. Winickoff: Cutting down works. If the person believes in it, reinforce that. Address comorbidities like ADHD, anxiety, or depression, which can reduce nicotine or substance use as coping mechanisms. Schedule regular follow-ups. Refer them to evidence-based programs for counseling youth who vape, such as This Is Quitting, a chatbot available 24/7 (www.tinyurl.com/4kekap75; Graham AL et al, JAMA 2024;332(9):713–721). Young adults might see a 5%–10% quit-rate boost. Teen data will be published in early 2025. A user might text “STRESS” and the bot might reply: “Lindsey says: The first few days are hardest, but when you push through, it gets easier every day. Journaling, supportive friends, and positive activities helped me through.”

CCPR: Are there other tech-driven resources that can help teens with nicotine addiction? 

Dr. Winickoff: Yes. My Life My Quit is an interface where teens text or talk with a counselor. This program provides a tailored experience but doesn’t have much evidence yet, although it uses cognitive behavioral therapy and MI approaches that have been shown effective in other studies of tobacco cessation.

CCPR: How do counseling and pharmacotherapy fit into nicotine treatment?

Dr. Winickoff: Nicotine/tobacco use disorder is a chronic disease that requires ongoing treatment. Expect setbacks as individuals progress toward readiness to change their behavior. Counseling is essential and most effective when combined with pharmacotherapy. My first-line medication for treating nicotine addiction is varenicline (Chantix), which is safe and FDA approved for ages 16 and up. 

CCPR: How do you use varenicline in treating nicotine addiction?

Dr. Winickoff: Start the medication before the quit date. The guidance is 35 days; however, in my experience, the patient usually sets the quit date in the next 30 days, and that’s okay if they are highly motivated to try. Start with 0.5 mg once daily for 3 days, then 0.5 mg twice daily for 4 days, and finally 1 mg twice daily for a typical duration of 11 weeks. I then go to once daily for an entire year or as long as needed to prevent relapse. 

CCPR: Why do you recommend using varenicline for an entire year?

Dr. Winickoff: Tobacco use is a chronic disease, so longer nonsmoking periods may lead to better outcomes. Successfully navigating significant events as a nonsmoker increases the likelihood of maintaining that status for life. Varenicline has three- to four-fold better success rates compared to basic nonpharmacologic interventions (www.tinyurl.com/5n9bwjhs). If the current dose is ineffective, consider increasing it. This step is often overlooked. Like other medications, varenicline can be titrated to achieve the desired effect (Cinciripini PM et al, JAMA 2024;331(20):1722–1731).

CCPR: Do you ever use nicotine replacement for treating nicotine addiction in teens? 

Dr. Winickoff: Nicotine replacement therapy has mixed results for adolescent nicotine cessation but helps make kids more comfortable during school, avoiding suspension from vaping or using banned products. That said, I add nicotine patches plus gum or lozenges with varenicline if a teen can’t quit. Combining long- and short-acting nicotine reduces overall cravings while addressing acute cravings during stressful moments.

CCPR: What other medications might you use for nicotine addiction?

Dr. Winickoff: Bupropion (Wellbutrin, Zyban) might be a first-line medication, especially when we see comorbid anxiety, depression, or ADHD. Bupropion plus varenicline provides the biggest quit rates in adults compared to any other medication combination (Rose JE et al, Am J Psychiatry 2014;171(11):1199-205).

CCPR: How likely will our efforts pay off in helping teens to quit?

Dr. Winickoff: Research shows we don’t try hard enough. There’s a gap in screening: Only 1 in 25 adolescents report receiving help for nicotine vaping from clinicians (Kleinman RA and Barnett BS, JAMA Psychiatry 2024;81(10):951–952). But we need to try anyway. You will fail more than succeed in treating tobacco dependence and helping people quit, and that’s okay. Remember, it’s a chronic disease. Succeeding occasionally is worth it because the clinical and health effects of nicotine addiction and ongoing tobacco use are so harmful.

CCPR: Thank you for your time, Dr. Winickoff.