Tobacco use remains the leading preventable cause of disease and death for U.S. adults—and 90% of tobacco users began using the substance before age 18, when the body and brain are especially vulnerable to addiction.
The direct and indirect harms of tobacco and nicotine use and tobacco smoke exposure are well-documented and require urgent action to protect children, who can be harmed by exposure even before birth.
That is the message of the American Academy of Pediatrics within a new policy statement, "Protecting Children and Adolescents From Tobacco and Nicotine." Policy statements created by AAP are written by medical experts, reflect the latest evidence in the field, and go through several rounds of peer review before being approved by the AAP Board of Directors and published in Pediatrics.
The tobacco policy statement, accompanied by a clinical and a technical report, marks the first update in recommendations since 2015. The articles will be published in the May 2023 Pediatrics.
"More than 16% of high school students report current use of a tobacco product, such as e-cigarettes, cigars or cigarettes—and many use more than one kind," said Brian P. Jenssen, MD, FAAP, lead author of the statement, written by the Section on Nicotine and Tobacco Prevention and Treatment and Committee on Substance Use Prevention.
"There are multiple evidence-based clinical and policy approaches that pediatricians and pediatric clinicians can take to protect children, adolescents, and their families from the harms of tobacco and nicotine. Pediatricians are uniquely positioned to help them live tobacco-free lives."
Start tobacco prevention messaging early
Tobacco prevention messaging should start no later than 11 or 12 years of age, as approximately 3% to 7% of middle school students report current tobacco or nicotine product use, according to research cited. Messages that focus on how the tobacco industry deceives and tries to manipulate youth have been shown to resonate more with children and adolescents.
Prenatal exposure to tobacco has been shown to affect lung development and increases risks and severity of respiratory illness, with effects that may have consequences that last beyond childhood, according to research. Almost 40% of children ages 3-11 are regularly exposed to secondhand tobacco smoke, as well. Rates of secondhand exposure to e-cigarette aerosol have increased over the last decade.
"One of the most important things a child can do to prepare for a healthy life is not use nicotine or tobacco," said Susan Walley, MD, MHCM, FAAP, co-author of the reports. "Children from communities that have historically experienced high levels of discrimination and stigma are disproportionately affected by tobacco and nicotine use and tobacco smoke exposure. There are actionable steps pediatricians, parents, and communities can take to break this cycle and protect children and families."
The AAP calls for heightened prevention efforts, early intervention and federal regulations to reduce tobacco use and nicotine exposure in children and adolescents.
AAP public policy recommendations include:
The FDA should regulate all tobacco and nicotine products to protect public health.
Tobacco use prevention, screening, and treatment should be adequately funded and specifically designated for pediatric populations. Tobacco control research should be considered a high priority and funded accordingly from both government and private sources.
Tobacco and nicotine product prices should be increased to reduce child and adolescent tobacco use initiation.
Enforce the tobacco product sales age of 21 years.
All flavor ingredients, including menthol, should be prohibited in all tobacco and nicotine products.
All tobacco and nicotine product advertising and promotion in forms that are accessible to children and adolescents should be prohibited.
Depictions of tobacco and nicotine products in movies and other media, such as content through streaming platforms that can be viewed by children and adolescents, should be restricted.
Tobacco industry-sponsored mass-media and school-based tobacco control programs should be prohibited.
For pediatricians and clinicians, AAP recommends:
Screen all adolescents for tobacco and nicotine use as part of health supervision visits.
Include tobacco and nicotine use prevention as part of anticipatory guidance for children and adolescents.
Refer youth who want to quit using nicotine and tobacco to behavioral interventions. Given the safety profile of nicotine replacement therapy (NRT) and the well-known consequences of untreated tobacco use, it is also reasonable to recommend and prescribe NRT to adolescents with moderate or severe tobacco use disorder.
Inquire about parents' use of nicotine and tobacco. When parents quit tobacco use, they eliminate the majority of their children's secondhand smoke exposure and decrease the risk of smoking initiation among their children.
Implement systems to identify, counsel, treat, and refer caregivers who smoke or use other tobacco products. Pediatricians can also recommend and prescribe FDA approved medications, including NRT, as part of a treatment plan for parental tobacco cessation.
A technical report details the evidence base for each recommendation. One strong and consistent finding is that children and adolescents who use e-cigarettes are significantly more likely to go on to use traditional cigarettes.
"Though the promotion of evidence-based clinical and policy strategies, pediatricians, pediatric clinicians, and the AAP have pushed back against tobacco companies to help children, adolescents, and their families live tobacco-free lives," Dr. Jenssen said. "Continued clinical and policy advocacy can help prevent new addiction, end the tobacco epidemic, and promote a nicotine and tobacco-free future."