Nicotine use in adolescents looks different than it used to. The rise of e-cigarettes has disrupted what had been a steady decline. Today, more than 2 million adolescents use nicotine products daily.
Early signs of use can be subtle: inattention at school, mood changes and increased anxiety. Adolescents who use nicotine often do so daily, drawing from a growing collection of products whose long-term effects remain poorly understood. Until now, clinicians have had little formal guidance on screening for nicotine use in adolescents.
An American Thoracic Society (ATS) Clinical Practice Guideline, approved in May 2025, addresses this gap. Devika R. Rao, MD, Pediatric Pulmonologist at Children’s Health℠ and Assistant Professor at UT Southwestern, served on an expert panel behind its development. She outlines the guidelines’ recommendations and implications for clinical practice.
Why is now the right time to formalize guidelines around nicotine use in adolescents?
In recent decades, adolescent nicotine use was not a routine part of pediatric screening or management. Instead, our focus was on secondhand smoke exposure via smoking parents. Pediatricians’ awareness of youth nicotine use changed in 2019, when an outbreak of severe lung injury linked to e-cigarettes made adolescent nicotine use impossible to ignore.
Smoking cessation is well studied in adults, but far less so in adolescents. Much of what does exist on youth nicotine use focuses on combustible cigarette use in teens who are already motivated to quit. For many clinicians, screening for and treating nicotine use in adolescents has not consistently been part of standard practice. The purpose of this guideline is to increase awareness on youth nicotine use and to provide recommendations on youth nicotine cessation.
What are the new guidelines?
The most actionable recommendations for adolescents ages 10 to 18 who use nicotine include:
Counseling-based nicotine use intervention.
Technology-based tools like text messaging programs and mobile apps as a practical complement.
Consideration of the smoking cessation medications varenicline and bupropion for adolescent patients.
What role do medications play in the treatment of adolescent nicotine dependence?
Clinicians have historically been cautious about prescribing medication to adolescents for nicotine dependence, and the decision remains far from straightforward. The guidelines discuss that there is enough medical evidence to support treatment of nicotine use in adolescents with varenicline and bupropion, but patient buy-in is essential and not always easy to achieve because most kids don't want medications. The guideline reflects this reality, noting that some patients cite concerns about side effects, and there are some contraindications for clinicians to consider, like previous history of seizure disorder. Medication is one tool among several, and the right choice depends heavily on the individual patient and their readiness to engage with treatment.
How do clinicians start to align with the guidelines? What does this look like in the office?
The first thing to establish is the patient’s motivation to quit. If they're motivated, suggest a quit date. Then use the guideline to find the best way to help them get there. That could mean combining modalities: counseling as the foundation, potentially layered with a digital tool or, in some cases, medication.
Beyond clinical tools, the adolescent's environment matters too. Parental and guardian support can make a meaningful difference in whether an adolescent succeeds.
Where does the research go from here?
The recommendations stem from a limited evidence base, but the stakes for adolescents are too high to wait for stronger data. Still, the science and guidance have room to grow. We have to study the efficacy of using different modalities together to help children quit. This means larger, real-world trials, studies testing different combinations of treatment and evidence that reflects the full diversity of adolescent patients clinicians are actually seeing.
Children's Health is shaping national guidance on nicotine use
Children’s Health has been at the forefront of the research and national guidance shaping how adolescent nicotine use is treated. In addition to contributing to the first pediatric ATS Clinical Practice Guideline, their team is committed to advancing the science as it continues to evolve.
For children who develop serious lung injury, the Pediatric Pulmonary Medicine Program has the specialized expertise to evaluate and treat even the most complex cases.
