Paeds · adolescent-and-young-adult-medicine
Tobacco, vaping and nicotine dependence
Also known as Adolescent nicotine dependence · Youth e-cigarette and vaping use · Adolescent smoking cessation · Vaping and EVALI · Youth tobacco use disorder · Pod-device and e-liquid dependence
A fellowship approach to adolescent nicotine and tobacco use across combustible, electronic, pod and smokeless products: faster-onset dependence in the developing brain, validated dependence assessment, the 5 A's and motivational interviewing, evidence-based pharmacotherapy, EVALI recognition, and prevention across ANZ, UK, US and Canada.
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Target exams
Red flags
- Respiratory distress with recent vaping — suspect EVALI; escalate to emergency assessment
- E-liquid ingestion causing vomiting, tachycardia or reduced consciousness — acute nicotine toxicity
- Dependence features before daily use (craving, use on waking, failed quit attempts)
- Escalation from vaping to combustible cigarettes
- Co-occurring mental-health crisis or self-harm alongside heavy nicotine use
- Pregnancy in an adolescent who smokes or vapes
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Adolescent health and substance use
- Current 2026 PREP curriculum — Learning Objective 1.2.1: Communicate with a child or young person in a way which is appropriate to the position of that child within their own culture
- Renewed curriculum for first-year trainees from 2027 — Learning goal 5: Clinical assessment – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: Clinical management – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 15: Essential general paediatrics
- Clinical Applications
- Adolescent substance use, nicotine dependence and smoking cessation
- Long Cases
- Short Cases
- Communication stations
- 4. Professional skills and knowledge: Patient management
- 5. Health promotion and illness prevention
- 11. Adolescent health
- General Paediatrics: Assesses and manages adolescent tobacco, vaping and nicotine dependence
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- Adolescent health, substance use and smoking cessation
- History
- Communication
- Clinical
- General Pediatrics Content Outline — Domain 1: Preventive Pediatrics/Well-Child Care
- General Pediatrics Content Outline — Domain 11: Adolescent Medicine and Gynecology
- General Pediatrics Content Outline — Domain 16: Mental and Behavioral Health
- General Pediatrics EPA 3: Applying SBIRT and counselling for adolescent substance use
- Patient Care 5: Patient Management
- Interpersonal and Communication Skills 1: Patient- and Family-Centered Communication
- Systems-Based Practice 3: System Navigation for Patient Centered Care – Coordination of Care
- Professionalism 1: Professional Behavior and Ethical Principles
- Health Advocate
- Medical Expert
- Professional
- Pediatrics: Core EPA — Providing preventive care, substance-use screening and smoking-cessation counselling for adolescents
Overview & Definition
A 15-year-old tells you they "just vape sometimes." Three months later they are using a pod device every hour, craving it on waking, irritable without it, and failing classes. The missed signal was not the product — it was the assumption that "sometimes" means "not dependent." [13]
Nicotine dependence is the brain adaptation that follows repeated nicotine exposure: tolerance, craving, withdrawal and a loss of control over use. In adolescents it can appear within days to weeks of first use, often before a young person becomes a daily user, because the developing brain is exquisitely sensitive to nicotine. [5] [7]
The products that deliver nicotine to young people are now far broader than the cigarette. Combustible cigarettes remain the most lethal; e-cigarettes and vapes aerosolise nicotine with solvents and flavourants; pod and nicotine-salt devices (such as JUUL-type products) deliver high doses discreetly; heated tobacco products heat rather than burn leaf; waterpipe (hookah) delivers high carbon-monoxide exposure in shared sessions; and smokeless tobacco carries oral and cancer risk. Asking only about "smoking" misses most modern use. [14] [15]
The clinical task is threefold: detect use and dependence early, treat with evidence-based behavioural and pharmacological support, and prevent uptake. The first two require a clinician who asks routinely and without judgement; the third requires advocacy. [12]
The core sequence of adolescent tobacco and nicotine care
- 1
Engage
Time alone, conditional confidentiality, non-judgemental stance, ask about all products.
- 2
Detect
Screen every adolescent; quantify use; ask about craving, withdrawal, quit attempts.
- 3
Grade
Apply DSM-5 criteria; use a validated tool (HONC, mFTQ) to measure dependence.
- 4
Assist
5 A's, motivational interviewing, behavioural support, pharmacotherapy matched to readiness.
- 5
Arrange
Follow-up within 1–2 weeks; frame relapse as practice; close referral loops.
- 6
Safety
Recognise EVALI and nicotine toxicity; escalate acute presentations immediately.
References16ShowHide
- [1]Jamal A, Park-Lee E, Birdsey J, et al. Tobacco Product Use Among Middle and High School Students - National Youth Tobacco Survey, United States, 2024. MMWR Morbidity and mortality weekly report, 2024.PMID 39418216
- [2]Kalininskiy A, Bach CT, Nacca NE, et al. E-cigarette, or vaping, product use associated lung injury (EVALI): case series and diagnostic approach. The Lancet Respiratory medicine, 2019.PMID 31711871
- [3]Begh R, Conde M, Fanshawe TR, et al. Electronic cigarettes and subsequent cigarette smoking in young people: A systematic review. Addiction (Abingdon, England), 2025.PMID 39888213
- [4]Soneji S, Barrington-Trimis JL, Wills TA, et al. Association Between Initial Use of e-Cigarettes and Subsequent Cigarette Smoking Among Adolescents and Young Adults: A Systematic Review and Meta-analysis. JAMA Pediatrics, 2017.PMID 28654986
- [5]Yuan M, Cross SJ, Loughlin SE, Leslie FM Nicotine and the adolescent brain. The Journal of physiology, 2015.PMID 26018031
- [6]Leslie FM Unique, long-term effects of nicotine on adolescent brain. Pharmacology, biochemistry, and behavior, 2020.PMID 32738256
- [7]Scragg R, Wellman RJ, Laugesen M, DiFranza JR Diminished autonomy over tobacco can appear with the first cigarettes. Addictive behaviors, 2008.PMID 18207651
- [8]Rubinstein ML, Benowitz NL, Auerback GM, et al. Rate of nicotine metabolism and withdrawal symptoms in adolescent light smokers. Pediatrics, 2008.PMID 18762498
- [9]Evins AE, Cather C, Reeder HT, et al. Varenicline for Youth Nicotine Vaping Cessation: A Randomized Clinical Trial. JAMA, 2025.PMID 40266580
- [10]Butler AR, Lindson N, Livingstone-Banks J, et al. Interventions for quitting vaping. The Cochrane database of systematic reviews, 2025.PMID 39777614
- [11]Rubinstein ML, Benowitz NL, Auerback GM, et al. A randomized trial of nicotine nasal spray in adolescent smokers. Pediatrics, 2008.PMID 18762494
- [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.PMID 25780075
- [13]Kaliamurthy S, Camenga DR Clinical approach to the treatment of e-cigarette use among adolescents. Current problems in pediatric and adolescent health care, 2022.PMID 35534404
- [14]Cao DJ, Aldy K, Hsu S, et al. Review of Health Consequences of Electronic Cigarettes and the Outbreak of Electronic Cigarette, or Vaping, Product Use-Associated Lung Injury. Journal of medical toxicology, 2020.PMID 32301069
- [15]McKelvey K, Baiocchi M, Halpern-Felsher B Adolescents' and Young Adults' Use and Perceptions of Pod-Based Electronic Cigarettes. JAMA network open, 2018.PMID 30646249
- [16]Graham AL, Cha S, Jacobs MA, et al. A Vaping Cessation Text Message Program for Adolescent E-Cigarette Users: A Randomized Clinical Trial. JAMA, 2024.PMID 39110436