Supporting Teens with Smoking Cessation – PediaCast CME 109

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Show Notes

Description

Drs Kelsey Schmuhl, Amy JZ, and Jen Berg visit the studio as we consider smoking cessation in teenagers. We explore the scope of nicotine use disorder and strategies for prevention, diagnosis, and management. We hope you can join us!

Instructions to obtain CME/CE (/FD-ED) Credit

1. Read this information page.
2. Listen to the podcast.
3. Complete the post-test at Nationwide Children’s CloudCME.

• CME credit expires 3 years from this episode’s release date.
• You can view your transcript and print a certificate of completion at Cloud CME.
• Need help creating a Cloud CME account? Click Here.
• Still have questions? Contact CMEOffice@nationwidechildrens.org

Topics

Supporting Teens with Smoking Cessation
Nicotine Use Disorder

Presenters

Dr Mike Patrick
PediaCast and PediaCast CME
Nationwide Children’s Hospital

Dr Kelsey Schmuhl
Patient Care Pharmacist
Nationwide Children’s Hospital

Dr Amy JZ
Adolescent Medicine Fellow
Nationwide Children’s Hospital

Dr Jennifer Berg
Patient Care Pharmacist
Nationwide Children’s Hospital

Learning Objectives

At the end of this activity, participants should be able to:

1. Describe recent trends in adolescent and young adult nicotine use.
2. Identify DSM-5 criteria and clinical features of nicotine use disorder in adolescents.
3. Compare treatment options for adolescent nicotine dependence, including pharmacologic and behavioral interventions.
4. Develop tailored smoking cessation plans based on an adolescent’s readiness to change.

Links

Adolescent Medicine at Nationwide Children’s Hospital
Nicotine Replacement Therapy and Adolescent Patients
E-Cigarette (Vaping) Products Visual Dictionary
Penn State Nicotine Dependence Index
Prescribing Guidelines for Nicotine Dependence

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No one in a position to control content has any relationships with ACCME-defined ineligible companies.

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Episode Transcript

[Dr Mike Patrick]
This episode of PediaCast CME is brought to you by Adolescent Medicine at Nationwide Children's Hospital. 

Hello everyone and welcome once again to PediaCast CME. We are a continuing medical education podcast for health care providers.

This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. It's episode 109. We're calling this one Supporting Teens with Smoking Cessation.

I want to welcome all of you to the program. So, we have an important topic for you today as we explore support for teenagers who are ready to quit nicotine, which is not an easy thing to do, and it really does require lots of support from parents but also from their medical providers. Many of us, however, may not feel equipped to support teens through this process, which is something we hope to remedy today with this episode.

We're going to explore the evolution of nicotine use among adolescents and young adults. Cigarette use is down, which is terrific, but e-cigarette or vaping use is way up, which is not so great. So, we're going to explore the latest prevention, diagnosis, and treatment strategies for nicotine use disorder in teenagers, along with assessing readiness to quit, evidence for pharmacologic interventions, harm reduction, and practical tips for pediatric health care providers.

We have a trio of guests joining us in the studio to discuss the topic. Dr. Kelsey Schmuhl is a patient care pharmacist at Nationwide Children's Hospital, as is Dr. Jennifer Berg, and Dr. Amy JZ is an adolescent medicine fellow at Nationwide Children's. Don't forget, after listening to this episode, be sure to claim your Category 1 credit.

It's absolutely free. Just head over to the show notes for this episode at pdacascme.org. It's episode 109, and you'll find a link to the post-test there in the show notes.

Follow that link to CloudCME, click on the Materials tab, and then take and pass the post-test, and the free Category 1 credit is yours. And we do offer credit to many pediatric professionals, not just physicians, but also nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. And since Nationwide Children's is jointly accredited by all of those professional organizations, it's likely we offer the credits you need to fulfill your state's continuing medical education requirements.

Of course, you want to be sure the content of this episode matches your scope of practice. Complete details are available at pdacascme.org. Also, I want to remind you the information presented in every episode of our podcast is for general educational purposes only.

We do not diagnose medical conditions or formulate treatment plans for specific individuals. Also, your use of this audio program is subject to the PDACAST CME Terms of Use Agreement, which you can find at pdacastcme.org. So, let's take a quick break.

We'll get our expert panel settled into the studio, and then we will be back to talk about supporting teens with smoking cessation. It's coming up. Right after this.

Dr. Kelsey Schmuhl is a patient care pharmacist with adolescent medicine at Nationwide Children's Hospital and an assistant professor of clinical pharmacy at the Ohio State University College of Pharmacy. Dr. Amy JZ is an adolescent medicine fellow at Nationwide Children's, and Dr. Jen Berg is also a patient care pharmacist at our hospital. All three have a passion for supporting teenagers in their quest to quit smoking.

That's what they're here to talk about, smoking cessation. But before we dive into our topic, let's offer a warm PDACAST CME welcome to our guests. Dr. Kelsey Schmuhl, Dr. Amy JZ, and Dr. Jen Berg. Thank you all for visiting the studio today.

Dr Kelsey Schmuhl]
Thank you for having me.

[Dr Amy JZ]
Yeah, I'm really excited to get to be here. 

[Dr Jennifer Berg]
Great to be here.

[Dr Mike Patrick]
Yeah, we are really excited to have all of you here as well. You're all busy people and it's great when we can find a time when everybody's schedules fall in line and we can record these things. Kelsey, I wanted to start with you.

How has adolescent nicotine use changed over time? I'm thinking that cigarettes aren't really the focus as much as vaping these days. Is that the case?

[Dr Kelsey Schmuhl]
You are absolutely right. So, among adolescents, we know that combustible cigarette use remains low. Where we've really seen a dramatic increase is in e-cigarette or vape use among this age group.

In our National Youth Tobacco Survey, which is conducted annually, our most recent data show that we have seen a decrease in e-cigarette use from 2023 to 2024. We saw a decrease from 2.1 million to about 1.6 million e-cigarette users among middle and high schoolers. And now while we're really happy about that decrease, that's still a lot of people and that's a lot of young people using substances.

And we know that that has consequences later in life. So, we really believe that this should be a focus of adolescent care and somewhere where we can intervene. So, I hope that after today people are feeling more confident asking about e-cigarette use and also treating e-cigarette use in their practices.

And we know that among people who vape or use e-cigarettes, the highest age group are people 12 to 25. E-cigarette use is really highest among our young people, whereas combustible cigarette use is more likely to occur in adults 26 and over.

[Dr Mike Patrick]
The e-cigarettes, there's so many different form factors for those. And so, providers and also for parents, you may want some knowledge in terms of what these things look like, especially if you do not use them yourself. The CDC does have an e-cigarette products visual dictionary and we're going to put a link to that in the show notes so folks can find that easily.

And then there's also the concern with the vapes that they can have other things in them like THC, for example. Are we seeing teenagers also using combination products like that?

[Dr Kelsey Schmuhl]
We are and we've seen that vaping devices or e-cigarette devices can actually be modified to use other substances as well. That visual dictionary is a really nice resource for people to learn more about how e-cigarettes have evolved over time, how people are modifying them and how they're used. I think that's a great resource to check out.

I use it myself a lot when I'm learning about new things. But yeah, most of our adolescents today are using e-cigarettes, like you mentioned, and mostly disposable products. We've seen kind of an evolution of these vaping devices.

When I first got started in this work, probably around 2018-2019, it was mostly those cartridge-based devices where you could buy a device, and you buy cartridges separate and then you utilize the cartridge with the same kind of overall device. Now, we're seeing more disposable products, meaning they're pre-filled. They come in many different sizes and shapes.

They have a wide range of not only nicotine concentration, but also the number of puffs or uses you can get out of that device. I will say that most young people that I've interacted with were seeing disposable products are more common. I think this likely stems from a ban that the FDA put in back around 2020 that really banned the use of those cartridge-based systems.

But there was a loophole that allowed for disposable products to still be used. So, we saw a lot of young people switch over to these disposable devices. And as you may guess, our young people are more attracted to the flavored devices as well.

I think that's another big attraction for youth. They come in all kinds of different flavors that teenagers see as fun and they like the flavor. Much different than how a lot of people feel about the smell and taste of cigarettes.

The most common flavors that we really see are the fruit flavors. There are candy flavors and there's mint flavors. Those are probably the most popular that we're seeing.

And another thing to know about e-cigarettes is that they use what's called nicotine salts, which have a lower pH, meaning more acidic, whereas cigarettes are freebase nicotine, which means they're more basic. Now, what that does is it allows people to use higher doses or higher amounts of nicotine, and they have less irritation in their throats. So, we're seeing that that's another reason we really have to pay attention.

Because even though there might be this kind of perceived image of safety, a lot of folks are using more nicotine than they even intend to unintentionally just because they can and they don't have those consequences associated with it.

[Dr Mike Patrick]
Yeah, it's interesting just to be clear. So, there was legislation to stem the use of the cartridges, which led to more of the disposable kind and then those end up in the landfill. So, like we've not really fixed the problem.

All that we did was create another problem.

[Dr Kelsey Schmuhl]
Yes, and it's hard to keep up, you know, Dr. Mike. It's, you know, things are constantly evolving, and it is really hard to keep up with what folks are doing. But yes, it seems like we're always one step behind sometimes.

But there's also been similar kind of legislation. I'll give you another example as you've probably heard of nicotine pouches increasing in use. So, while nicotine pouch use actually remains quite low among young people, we are hearing about them more as they also are introducing things like flavors to them.

But when those first came out, since they are called a synthetic nicotine, meaning the nicotine is made in the lab, they technically didn't fall under control of the FDA because the FDA can only control tobacco related products. And that nicotine didn't stem directly from the tobacco leaf. So, it's really interesting.

That has since been remedied and the FDA can now regulate non-tobacco nicotine products. But it is really interesting how we kind of always had to play catch up.

[Dr Mike Patrick]
Yeah, and I think folks don't understand that the concentration in the vapes is so much higher than it is with the cigarettes. And so that you can really become addicted very easily because of just how easily then that chemical is transferred into the body through the lungs and in higher amounts. Amy, why is this important?

Like why are we talking about this today and in particular on a CME podcast for providers?

[Dr Amy JZ]
Yeah, I think, you know, there's really two parts to this question. I think, you know, why are we talking about nicotine use in general? But I think I'm going to start with just like why we should be talking about substance use in teenagers and adolescents.

We know that the adolescent brain is still developing, right? Everyone knows that. We talk about that all the time.

It's, you know, developing into the mid-20s. But it's also this huge time of growth and plasticity. And then also it's about the areas of the brain that are growing that's so important, right?

It's your prefrontal cortex that's still learning to regulate, you know, that executive functioning, that decision making, the planning, the impulse control. And then also the limbic system is actively maturing during this time. And that's the place that really is your motivation and reward center.

So, what we think about when we think about addiction. And there's really two mechanisms by which the brain is kind of growing during this time that can be really affected. One is myelination.

So those nerve fibers getting enhanced myelination. So, allowing for more effective signaling of all of the brain signals. And then synaptic pruning is also happening.

So, while you're having this huge period of growth, then the brain starts pruning these areas back that aren't being used. So, there's this kind of saying we like to use, use it or lose it. So, the areas that you're not using are going to get pruned back.

But the areas you are using are just going to be heightened. And so, at this time the brain is super sensitive to novel experiences. So, if you start using a substance earlier and then using it over and over again, those are the areas of the brain that are going to continue to grow and aren't going to get pruned back.

And this is true for any substance that gets used during this time. When we think about nicotine specifically, adolescents are really even more vulnerable to that because of a few unique aspects. So, in the limbic system itself, that reward pathway, there's actually an increased number and activity of the nicotine receptors in that area.

And then on top of that, there's an increase in nicotine-induced dopamine release, which again is that reward pathway. So that puts these teenagers at even higher risk for becoming dependent on nicotine. And I think there's some really interesting data out there in animal studies that actually look at like the acute behavioral effects of nicotine.

And what they found is that when you compare an adolescent to an adult, you find that adolescents are actually more sensitive to the rewarding effects, so the positive rewarding effects. They actually have blunted withdrawal symptoms, where an adult they might have worse withdrawal symptoms. And they can actually tolerate higher doses without aversion, whereas in adults those higher amounts are actually going to cause aversion.

So, they have this like unique increased positive short-term effects and a decrease in these negative short-term effects, which again like puts them at higher risk to develop dependence. So, this is like the key time frame in which we can prevent this from happening. And so, I think sometimes people are like it's an all or nothing, but really, I think all of us on this podcast would agree that a harm reduction approach is even appropriate, right?

So, any delay in use for a teen is going to be a positive because you're going to get them through this part of brain development that is so critical because we know almost 90% of adult smokers start before the age of 18. So, if we can delay that onset, we might delay the dependence that develops from it.

[Dr Mike Patrick]
And in addition to the brain effects, just the addiction, does that make it more likely that you'll continue to use nicotine throughout your life? And then as adults, we really see a lot of cardiovascular, heart attack, stroke kind of risks and that you could potentially prevent if you stop smoking or stop having nicotine ingestion in adolescence.

[Dr Amy JZ]
Exactly, correct. Yeah, all of the like long-term, even longer-term negative effects that you think of when you think of nicotine use, if we can just prevent an adolescent from even starting use, right, you might prevent all of those downstream effects later on in life. And it's so much harder to get them to quit once they've started than just to prevent them from starting in the beginning.

[Dr Mike Patrick]
Yeah, yeah, absolutely. So, we have we want to prevent nicotine use, but you know, sometimes it's already started, and we can get to the point that we would actually call it a nicotine use disorder. What exactly is that then and how is it diagnosed?

[Dr Amy JZ]
Yeah, that's a great question. I think actually kind of goes back to Dr. Schmal's point of that, you know, there's actually not a nicotine use disorder in the DSM-5. It's tobacco use disorder because again, that's kind of what it used to be that it was combustible cigarettes were kind of the main source of nicotine.

Nowadays, I would still say we would call it a nicotine use disorder because that's the main component in it. But like most substance use disorders, it's really defined by a problematic pattern use that leads to some sort of clinical impairment or distress. And then there's kind of a whole list of criteria and you have to meet two of them in the last 12 months.

I think it's really hard to remember all of the criteria. I think there's like 11 of them. So, when I think about it, I like to break it up kind of into parts.

And so, the first like the first four criteria really are around behaviors of use. So, are adolescents having to use more? Are they using it over longer periods than they intended?

Is there this persistent desire to use and they are unable to cut back? Are they spending a lot of time in activities that they need to like obtain a vape or find somebody who they can, you know, use it off of? And then cravings and urges.

So those are kind of like the behaviors that that make up this disorder. And then the kind of five through nine criteria are really around the consequences of that use. So, are they failing to kind of fulfill major obligations?

And really when we think about teens, we think about like is school starting to be impacted? Are they having continued use despite maybe having recurring problems? So, are they getting into arguments with parents?

Are they still using at school despite maybe an expulsion or a suspension? They're giving up activities because of use. So maybe no longer playing sports because of it.

Are they using it in situations that maybe are hazardous? And then even though they maybe have some knowledge that it's causing physical or psychological problems, they're still using it on top of it. And then the last set of kind of areas is really around dependence.

So that's tolerance and withdrawal. So again, needing to use more and more nicotine to get the same effect, that would be tolerance. And then withdrawal, those effects you see when you stop using.

So, they have to have only two of those. Usually, they're coming to us because they're already getting in trouble at school or maybe they've tried to quit and they're having some withdrawal effects. So usually, they're meeting these criteria pretty quickly.

[Dr Mike Patrick]
As clinicians, when we see teenagers, you know, they're probably not vaping or using cigarettes in the exam room. Hopefully not. So how can we kind of get an idea of who we need to talk to a little bit more about this and to try to assess if nicotine dependence is occurring?

You know, are there some signs that would give us a clue that this is someone we need to spend a bit more time with?

[Dr Amy JZ]
Yeah, that's a great question. And I know you joke about patients probably not smoking in the room. That's true.

I have had patients pull out their vapes when I ask them like, what are you vaping? And they're like, oh, let me show you. And I'm like, I don't know if I really want to see it, but I can now at least get a better idea.

So yeah, I think there's several things that we can look at when we think about like dependence. It really kind of again encompasses that tolerance piece of it. So, if you've been maybe seeing a patient over several visits, are they telling you they're having to use more and more?

They are using more and more nicotine is one way to look at that. And then the other is those withdrawal symptoms, which really can come in two flavors. It can be physical withdrawal symptoms that they're having.

So, asking them about are they having some sleep issues? Are they having like an increased appetite when they're trying to cut back? Are they having restlessness?

And then also psychological and behavioral issues. And sometimes these can be even more bothersome than the physical symptoms. So, a lot of like irritability or anger.

They may have like a really depressed or anxious mood that may even be worse than somebody who already has anxiety or depression or a lot of difficulty concentrating as well. And I think these withdrawal symptoms can really interfere with successful cessation, which is why it's so important for us to be able to really figure out what someone's dependence level is.

[Dr Mike Patrick]
And then how do we go about doing that? So, Jen, is there a tool to sort of assess where folks are in terms of nicotine dependence?

[Dr Jennifer Berg]
Yes, there are a lot of tools available online. Some of the older ones are more geared toward the traditional combustible cigarette use, but a lot of newer questionnaires are more specific toward e-cig use. So, one example of that would be the Penn State Electronic Cigarette Dependence Index, which is 10 questions.

And if answered truthfully can kind of help gauge how high of dependence a teen might have on nicotine. And when these conversations are happening in clinic or in the hospital, we really need to be direct and ask for specifics. So, the tools do a great job of kind of quantifying and getting patients to answer, how soon are you using?

How frequently are you using? But really important to make sure we get the numbers. So how many cigarettes are you going through a day?

Or kind of as we've mentioned with this focus on e-cig use, how many puffs are you using a day? What specific device are you using? Kelsey alluded to the fact that there are many devices.

So, we need to know what device, how frequently they're switching out cartridges or going through devices. How long does it last? And then again, we collect this information, but then sometimes we have to do some math and googling in the background because there's so many devices.

And e-cig devices range from having anywhere from 300 puffs per device to 25,000 puffs per device. So, as you can imagine, a kid that's going through a 300-puff device in a week has a different level of dependence than a kid going through a 25,000-puff device in a week. And again, even once we've collected that information, the conversion isn't exact.

There's one study that suggests that one Juul pod is equivalent to one pack of cigarettes. So, we can kind of backtrack and do some math to say, oh, you're using this many puffs. That comes out to like X amount of packs of cigarettes.

But again, the math is not perfect on that. And then in addition to doing these questionnaires and having these conversations, I always think it's a good idea to kind of ask about some of the like social and economic factors surrounding use. Because we know kids are using these age-restricted substances.

So how are you getting access to nicotine products? How are you affording it? Are there any like access barriers?

And what does that look like? Because some kids might just be using you know puffs in their friend's car on the way to school. Whereas some kids have a whole side hustle of like purchasing and reselling pods on the side.

So, kind of having an idea of how integrated their use is to their everyday life will also help us gauge in addition to their level of dependence, like what quitting might look like for them.

[Dr Mike Patrick]
And we'll put a link to the Penn State Nicotine Dependence Index, the questionnaire in the show notes. So, folks can find that easily over at pediacastcme.org. This is episode 109.

But that's something that at least it does take into account the vaping aspect of it as opposed to just solely looking at combustible nicotine-based cigarettes. So, here's I think where the rubber really meets the road. So, we may find a teenager that we've identified as using nicotine and perhaps we've even you know gone through the survey and we are concerned that they have nicotine dependence.

Amy, how do we then get teens to quit? Like they want to do this, and we know it's harmful, but they probably don't see it as harmful at their age and with the condition of their brain and where it is in development. And they may even have parents who vape or smoke cigarettes.

And so, there's a role model in the house saying, hey, this is okay. So how do you know try to convince them that this is something that they should stop and then how do you know when they're actually ready to do that?

[Dr Amy JZ]
Yeah, this question I could talk about for hours. It's a lot of obviously what we do in our clinic and Dr. Schmoll does and Dr. Berg does as well. I think it starts with, you know, talking about behavior change models and I'll get to that in a second.

But I really like to start visits just by like setting the stage. Because like you said some patients may have families that are also vaping and at the same time sometimes, we have patients that get brought in because a parent's concerned about their vaping or their substance use, and the child doesn't know why they're there. There have been a lot of times especially in our substance use clinic where a patient is brought in has no idea.

So, I like to kind of set the stage like tell me why you're here today. Tell me a little bit about what your idea is. I also like to make sure that they know as we're talking about substance use that if they're not able to make a change or if they do and they return to use that that's not going to like impact, you know, the therapeutic relationship I have with them.

I'm always there. You know, when it comes to substance use disorders, there's this cycle that happens and sometimes use occurs again and that's okay. And then the other thing I think that's really important for both patients and families to know is that you know, we really have to meet them where they are.

Because if we if they feel like they're not being heard or if they feel like we're just telling them what to do or their parents telling them what to do they're probably not going to come back or they're not going to engage with us. So, I like to kind of set the stage and when it comes to that that this may be talking about harm reduction how can we just decrease use without completely stopping? But when it comes to actually assessing kind of where a patient is at in terms of like their readiness to quit, I think probably the most commonly used behavior change model is stages of change.

It's six different stages and it kind of looks at where a patient what's a patient's readiness to change. So, the first two are really that pre-contemplative stage and the contemplative stage where in the pre-contemplative stage patients have really no idea that this is causing harm. They don't understand the risks of harm at all.

And the goal in that stage is really just to increase a teen's awareness that there is a problem. In the contemplative stage, they may have heard that it's a problem. They may kind of understand that it's a problem.

They may be considering change. And the goal there is really to help kind of tip the balance between pros and cons of their use. And so, I often like asking questions like what do you like about vaping?

I think people have never asked them that because they're always like don't do it. Don't do it. Don't do it.

I think trying to figure out what why do they enjoy it? Are they using it to treat some sort of underlying anxiety? Do they use it because all their friends are using it?

And then also asking them are there any downsides, right? And trying to figure out what would happen if they didn't vape or didn't buy a new one. I think it's really in these first two stages where we can do a lot of change talk and a lot of you know motivational interviewing which is a big buzzword nowadays, but kind of I think using scales can be a really helpful tool.

Sometimes I think clinicians don't know even know where to start. Like what if they tell me they're using you know, like Jen said a pot a week or something and you're like well now what do I even do? I think again trying to understand where they're at.

So how important is it for you to cut down in your vaping and on a scale of one to ten where are you at? And that scale of one to ten kind of helps give like a very objective number that the next time you follow up with them you can ask well, where are we at now? Has that scale moved at all?

And then the last three stages of change are really when they've decided to make that change. So, they're kind of in this determination or preparation phase, the action phase where they're actively making it and then the maintenance where they've made it and now, you're just continuing that. And once they hit where they've decided to make a change doing some of that motivational interviewing can actually be a little counterproductive because they've already decided to make the change.

So, turning now your focus onto the reasons that they have decided to make a change, how confident are they in their abilities and what barriers may there be to actually being able to implement that change and then working with them on okay, is there anything I can do? Is there anything your parent can do to help you overcome those barriers now that we've already decided that we want to make that change? And then the last and final stage is really that relapse or return to use and again reminding patients like this happens.

It's not, you know, a negative. It's just now that we know we kind of have to renew that process of contemplation. Reminding them, you know, the reasons they had to change previously, the positive aspects that came from when they weren't using in the past and just kind of starting that cycle over again.

But I think figuring out where somebody is along this spectrum helps you tailor your conversation because somebody who's in a pre-contemplative stage where they haven't even decided their use is problem some, if you just jump all the way to like, let's set some goals to quit, you're not going to get there and it's going to again be kind of productive.

[Dr Mike Patrick]
We have a lot of pediatric providers who listen to this podcast, and I think this also probably holds true for anti-vax messaging. Like if you go full bore into someone who really has their mind set that vaccines are harmful, this is like the mirror, this is like the exact opposite, but the same concepts hold true that you do have to approach it, you know, carefully and sort of assess where they are and then, you know, once they're open to hearing messages, then providing them at that point.

[Dr Amy JZ]
Exactly. And I love this model because it can be used, right? Like we're talking about it from a substance use standpoint, but this behavior changes model works for any behaviors, right?

So, whether it's vaccine hesitancy, whether it's like lifestyle changes that we're trying to work on changing, it can be used, that framework can be used for anything. So, I think it's a really great one and the CDC actually has some really great guidance too, if people need or want some more structure to having that conversation.

[Dr Mike Patrick]
Yeah, like based on where they are on their own journey. Kelsey, I wanted to ask about medications then to help with smoking cessation. You know, it's nicotine is really like the cravings for nicotine and then how folks feel before they use and then after they've used it is really huge compared to like even opioids.

So that craving can just be very, very intense. And so just to tell someone, hey, it's not good for you, stop. But then not giving them the tools to stop, you're not going to get very far.

So, what kind of tools do we have in terms of medications to help teens quit smoking or vaping?

[Dr Kelsey Schmuhl]
Yeah, you're absolutely right, Dr. Mike. You know, when we think about going cold turkey on nicotine, that has a very low success rate among all populations. So, it is important that we equip teens with some appropriate tools.

Now, I will say before I start talking about medicines, that the studies for these medicines were all done in adults and to people who smoke cigarettes. So, we've had to kind of make some adaptations and use our clinical judgment when we're using these in younger people. Now, like I said, none of them are approved for 18 and younger, but we do have some evidence of their use.

So, I'm going to go through that today. There are three FDA approved medications for smoking cessation. First medication or class of medications is called nicotine replacement therapy.

Among nicotine replacement therapy or NRT, we have patches, we have gum, we have lozenges, and we have a nasal spray. There used to be an inhaler, but that is no longer available. Another thing to note about these is that patches, lozenges, and gum are available over the counter for people 18 and over, and the inhaler is prescription only.

I'm sorry, the nasal spray, not the inhaler. That's no longer available. But we can still use these in people 18 and under in certain circumstances.

Now, none of these are over the counter for people under 18. So, if you're going to treat somebody with a medicine for nicotine cessation, you should write a prescription. This also helps with insurance coverages as these products can be quite expensive if you buy them over the counter.

So where do we have the data? American Academy of Pediatrics actually has a guideline out for nicotine replacement therapy, and it kind of tells us when would be an appropriate time to use that. So, after you've gone through all of the assessment that we just did and determined that an adolescent or young person is moderate to severely dependent, they consider using nicotine replacement therapy as appropriate.

We don't have a lot of efficacy around nicotine replacement in young people, but we do have data that show it's safe. So, if I have somebody who's under 18 who presents with moderate to severe nicotine dependence, that's usually my first go-to. Now, there are other medications for nicotine cessation.

One is varenicline. That is a prescription only, and it's a pill formulation. And we have bupropion, which is also a pill that's prescription.

We do not have the data for those medications as safe and effective in younger people. Although I will say, hot off the press, there is some new evidence coming out, a new study that actually did look at varenicline in people down to 16 years old that show that it may be safe and effective. So, you know, practice might change as we have more evidence coming out around some of those other medications in use.

[Dr Mike Patrick]
A quick question. In terms of the nicotine replacement therapy, I think it's going to be really important for providers out there to recognize that it is okay to prescribe nicotine to kids under the age of 18. Because when you think, oh, it's unlawful for anyone who is under the age of 18 to purchase nicotine over the counter, it's not illegal for them to use it.

It's only illegal for them to purchase it. Is that correct?

[Dr Kelsey Schmuhl]
You're correct. And, you know, in pediatrics, we use things off-label quite a bit. I think there is some stigma around substance use, and maybe people won't want to use things off-label as much.

But this is something that we do quite frequently in pediatrics, actually, because there is not as many studies around for pediatric populations with some of these medications. So, it is absolutely appropriate to use this off-label if the situation is appropriate for that. You know, with nicotine replacement therapy, we're going to get into some of the specifics here in a minute.

But the way it works is that, as the name implies, it's going to replace the nicotine that would be delivered by your vape device or your cigarette. So that means it hits the same receptor in the brain, that nicotinic acetylcholine receptor, and acts as a full agonist. So, the more you use, the more the response you're going to get.

Okay. So, one of the things that's hard about nicotine replacement is that you really have to stop using your other forms of nicotine when you switch over to nicotine replacement. Otherwise, you can get a lot of nicotine in the system and actually have kind of too much and feel sick.

A lot of people say if they continue to use their vape or smoking when they're on these products, they often feel nauseous is the biggest symptom. So that can be hard. So that's another way of like meeting somebody where they're at and saying, you know, we have these products available, but are you going to be able to do this?

Do we need to work behavioral strategies first to get you down to a lower level of nicotine so they're actually successful when you start nicotine replacement? And I will say, the guidelines will say in people under 18, really the gold standard is behavioral therapy. That's the only thing that's really been studied.

And a lot of patients benefit from co-occurring medicines and behavioral therapy. For nicotine replacement therapy, combination therapy is going to be first line. Dr. Berge is going to talk about that in just a minute. And combination means using a long-acting product like a patch and a short-acting product like gum or a lozenge or nasal spray for in the moment. So, you kind of have both on board. You have nicotine being delivered by the patch all day.

And then when you have cravings, you would use gum or lozenge kind of in the moment. And you can use that quite frequently throughout the day. So that would be kind of if you had somebody under 18, you should feel comfortable starting those in that patient.

With a fairly close follow-up, I would say, you know, nicotine cessation is really difficult. So, when I'm working with somebody, especially early in their treatment, I like to see them, you know, every one to two weeks to make sure things are going well.

[Dr Mike Patrick]
I'm wondering from the family's perspective, I would think that a lot of families would think, well, why don't we just decrease the amount that we use slowly? So, in other words, if when it was cigarettes, you know, we could say, hey, there's a lot of harmful chemicals in cigarettes. And so, switching to nicotine replacement is really your better choice.

And, you know, so we cut out the exposure of the carcinogens. But with vaping, there's also chemicals in there, but their effect is not quite as known as for cigarettes. And so, it's kind of harder to say, oh, we've got to get you off of the vape pen.

And so, from a family's point of view, couldn't you just say, well, if I'm doing 10 puffs a day, you know, this week and then go down to nine puffs a day for a week and then eight puffs a day for a week, could you do something like that? Or do we really see that the nicotine replacement products and getting rid of the vape completely is more efficacious?

[Dr Kelsey Schmuhl]
It's a good question. And I think the example that you just mentioned, Dr. Mike, if it was a low number of puffs like that, if it was going from 10 to 9 to 8, I think I wouldn't use nicotine replacement because to me that doesn't indicate a really high level of dependence. And we would just work on behavior change.

But oftentimes the more likely situation is somebody has a device with 15,000 puffs in it and they're using, you know, close to a thousand puffs a day. They might have it with them all the time. And like I said, they're not really getting a lot of those adverse effects like the irritation in the throat and things like that.

So, they often don't even really realize how much they're using. It's much easier. It doesn't smell.

It tastes good, you know. So, a lot of my patients can't really quantify how many puffs they're using a day. But when I tell them, OK, what's your device?

How many puffs are in it? And how often do you have to buy a new one? It's really eye-opening to them that maybe they're using over a thousand puffs a day.

[Dr Mike Patrick]
See, that's eye-opening to me. I would have thought like they're doing 10 a day. That's a lot.

[Dr Amy JZ]
The amount of times that I have told patients using that calculation, which again is a very rough calculation based on fairly old data, that Juul to cigarette pack data, where I have an adolescent coming in who's probably vaping like two and a half packs of cigarettes a day. Like that's what I can tell them. And they are like, and again, that's probably actually an underestimation given that like the products we have nowadays are actually a lot higher concentration of nicotine.

I think that almost sometimes is jarring to them as it is to you and I and on all providers that are out there. But I think again being able to quantify that because they're just so used to having it at their bedside, you know, they're just like I'm basically puffing on it all day. Like I don't have an exact answer for you.

[Dr Kelsey Schmuhl]
You don't have to go outside. You don't have to wait for a break. It's easier to sneak.

But to answer your original question about, you know, why can't we just decrease our use? It's almost impossible for somebody to go from that level of use to just decreasing. So, it often takes a long time.

And, you know, when I'm working with patients, a lot of them it's the physical dependence as much as the actual vaping. The vape devices are small. I've heard a lot of people say it's like the perfect size for my hand.

It's like a fidget toy. I have to have it in my hand. Okay, so working on those behaviors is really important as well.

And, you know, kind of unlike cigarettes, I think like they just like the taste. They're going to miss the taste. So, it really understanding kind of those motivations that we've talked about is important and maybe our decreasing use is like, okay, you're not going to take your vape when you drive to the grocery store today.

And like very small goals like that. And or if we give you nicotine replacement, maybe you're going to use it in this specific situation just for this week, you know, setting those small goals. I'm going to talk about varenicline, or brand name is Chantix in just a moment.

But sometimes that can help with people who really struggle with decreasing their use before switching over to nicotine replacement.

[Dr Mike Patrick]
Jen, let's talk a little bit about that combination therapy. So, the long-acting like with the patch and then the short acting with gum or lozenges. What's the best way to go about prescribing the combo therapy?

[Dr Jennifer Berg]
Yes, so our ultimate goal in combining short and long-acting agents is to provide kids with a steady level of nicotine in their system throughout the day with our long-acting agent. So, when we think about taking all X thousand amount of puffs a day, those are just like peaks and valleys of exposure. And with a long-acting agent like a patch, we can provide a steady amount of nicotine in the system to hopefully decrease the amount of cravings or withdrawal symptoms they might have from those peaks and valleys of all of those puffs throughout the day.

And then kind of like Kelsey mentioned, it's a reflex for patients just to have it in their hand and kind of have that muscle memory of putting something to their mouth. So, our short acting agents like a lozenge or gum or nasal spray can be used for those acute cravings or just that desire to just have something pick it up, all that muscle memory that they have. So just to reiterate, long-acting agent is our patch, short acting agents are gum, lozenge, and nasal spray.

And again, because there are so many different formulations, it's important to kind of have that shared clinical decision making with your patient. Like which agent do you think you could reasonably use and be adherent to? Because we know that the products work best when they're used consistently.

So, for example, like with the gum, we know it works best if patients chew at least nine pieces a day, up to 24 pieces a day even. So just making sure like we get buy-in on what formulations we're going to prescribe so we know they're actually going to use it. And then once we've identified a combination therapy that a patient has agreed would be suitable for day-to-day life as providers, making sure that we're prescribing the appropriate dosage.

So, depending on the product, dosing will be based on how many cigarettes per day are used, which again is kind of that old prescribing based off of traditional cigarette use. So, the patch, for instance, is just based on how many packs per day are used. And then again, we can do that equivalent-ish equation to figure that out for our e-cig users.

Or the lozenge and gum dose is based off of how soon patients are using nicotine upon awakening. So, making sure that we get the dosage right. And for a lot of these kids that might have like this high dependence, like we mentioned, we can't just add it on and have them keep using all of those puffs.

So back to some of those like behavioral and plans to get them to cut back. And we shouldn't be prescribing this if we don't think they're going to be able to cut back. Because like we mentioned, they're just going to feel sick.

And then lastly, once the agents are identified, we need to make sure that we counsel adequately on use so that patients get the most effect. So, the gum, for example, isn't just like your average bubble gum. You can't just pop it in and chew it and blow bubbles with it.

You need to chew it, park it in your cheek, chew it. And it's a process that oftentimes isn't known to patients until we kind of have that conversation and counsel them through it. And then from a side effect standpoint, too, like we love using the patch for that long-term relief.

Kind of giving patients heads up, like one side effect of the patch could be vivid dreams that could be very alarming to a teenager that is just starting on their smoking cessation journey. So, kind of setting that expectation ahead of time, like, hey, if this happens to you, take off your patch at night and just put it back on in the morning. That way, if that happens to them, they're not scared and stop using it altogether.

They kind of have that advanced notice just from an adherence standpoint is really helpful.

[Dr Mike Patrick]
Use of the gum. I think that's going to be really important for providers to understand that chewing it and then parking it, you know, against your cheek so that you get some absorption of the chemical. Because if you just chew it like regular gum, they're going to feel like, oh, this isn't working.

And then they may just go back to using their vape.

[Dr Jennifer Berg]
Exactly. And I will say our institutions, Partners for Kids, has a really great prescribing guideline online that we could link to that kind of goes through each formulation, major counseling points, and kind of what like a streamlined what to know about each agent, just because we want to make sure if we're prescribing this, it's going to work for our teens.

[Dr Mike Patrick]
Yeah, and we'll put a link to that document that you're talking about. We also have some materials from the American Academy of Pediatrics in terms of nicotine replacement therapy and sort of best practices for prescribing those things. And those will all be in the show notes over at pediacastcme.org.

You mentioned that this is a long process. Is there such a thing as like rehab for nicotine, like an inpatient stay to maybe do it more quickly? Or is that not really a thing?

[Dr Kelsey Schmuhl]
I've never seen anything like that. And unfortunately, you know, this is more of a kind of, for me at least, when I'm working with patients, it's just kind of, I've warned them this is not going to happen overnight. This is a long road.

We're going to work together. And like Dr. JZ said earlier, I'm not going to abandon you if you return to use, you know. So unlike other substances, there's not really like an inpatient rehabilitation program.

[Dr Mike Patrick]
Okay. And then in terms of the other two medicines that you had mentioned, let's go through those, Kelsey. And if you could just let us know what their mechanism of action is and then when we should consider using those things in addition or instead of nicotine replacement.

[Dr Kelsey Schmuhl]
Yeah, sure. Well, so, you know, I think it's important to reiterate our first line or our first-choice options when somebody is looking for nicotine cessation, especially in the adult world, are either that combination nicotine replacement therapy that we've covered or varenicline. Okay.

Bupropion is considered a second line agent. So, I'm going to talk about varenicline first. So varenicline is currently approved for patients 18 and older.

And until that recent data that I mentioned before, we really didn't have evidence for people under 18. I am hopeful that as new evidence emerges, we'll be feeling more comfortable using it in younger ages, maybe down 16 and 17 years old. For now, that's kind of what we're doing right now.

I'm not really starting varenicline yet in anybody under 18. But it has a lot of advantages if you do have a young adult who's 18 or older on using varenicline. First, I think convenience.

So, as we mentioned with nicotine replacement, it's something you have to actively do all day. So, you put the patch on and then you're actively using the gum or the lozenge or the nasal spray pretty much the whole day. Whereas varenicline comes as an oral tablet.

So, you have to take it twice a day when you're at maintenance. So, it makes it maybe a little bit easier. Another big advantage of varenicline is that you can have more of a flexible quit date.

And what I mean by that is you don't have to stop vaping before you start varenicline. Okay, and that has to do with the mechanism of action like you mentioned before. So, whereas nicotine replacement is a full agonist at the nicotine receptor, varenicline is what's called a partial agonist.

The way the partial agonist works is that it binds to the nicotinic receptor in a slightly different way than a full agonist would. But it is going to stimulate the receptor enough so that the patient shouldn't feel withdrawal, nicotine withdrawal. So, we're stimulating the receptor to a lesser extent than a cigarette or a vape or a nicotine replacement would, but enough so that they don't feel bad.

And the cool thing about partial agonists is that they act as a blocker or an antagonist when they're in the presence of a full agonist. So let me explain as an example. So, if somebody is on Chantix or varenicline and they are taking their medication consistently, say they're in a really stressful situation and they decide to smoke a cigarette or they decide to use their vape.

Since the varenicline is blocking the receptor and binding really tight to it, they really shouldn't get the effect that they did before from their vape because it can't find its target. So that's a really nice thing about varenicline because it allows people to set their own goals at their own pace and decrease their vaping or their cigarette use over time. So, I think that's a big advantage, especially for young adults, to use varenicline.

So, when we talk about combining products, I will say since varenicline is going to kind of block that nicotine receptor, the data don't really show that there's a big advantage for adding nicotine replacement on top of it. So, for example, if you add a patch or you add gum or lozenge, pharmacologically, it doesn't make a lot of sense that it would provide additional benefit because the varenicline is blocking that receptor. But I will say anecdotally, it does help with hand-to-mouth physical dependence.

So it's not going to harm somebody if you put a nicotine lozenge on top of the varenicline or gum, but if it helps them, like say they're going out with their friends and they always use their vape when they're going out with their friends and they just need something in that moment, I have given people gum or lozenges to put on top of their varenicline in those certain situations, just so they feel like they are able to do something in the moment and they don't reach for their vape.

So that's an option. And there have been some studies with bupropion in combination with varenicline that may have some additional benefit, but and what does that medicine do? Yeah, so bupropion is interesting, and many people have probably heard of it because it's also approved for depression.

So, we use it a lot actually in people under 18 for treatment of depression, but it also has an advantage of helping with smoking cessation. In the mechanism of bupropion, actually it works on a couple neurotransmitters, dopamine and norepinephrine. So, it is a reuptake inhibitor of norepinephrine and dopamine.

And I think the idea is that, you know, nicotine is so tied to that reward center and dopamine release that by having bupropion in there, kind of increasing levels of dopamine may help with smoking cessation if they're interested. So, like I said, this one doesn't have as great of data in terms of efficacy. It would be considered second line.

But, you know, it might be a compelling reason to use bupropion if you have somebody who is under 18 who has undiagnosed or untreated depression. It may help with that and then consequently it may also help with smoking cessation.

[Dr Mike Patrick]
Yeah, it sounds like that one really focuses more on the physical aspect of, you know, needing something in your mouth or you know in terms of the antidepressant, anti-anxiety kind of effects that those medicines have that maybe you don't feel that urge to have something in your mouth.

[Dr Kelsey Schmuhl]
Yeah, kind of more of a on a chemical level, you know.

[Dr Mike Patrick]
And then in terms of the varenicline, how do you wean that? Like is that, is that how that, like how do you just stay on it forever? Or do you, like when do you know that you can start going down on that?

[Dr Kelsey Schmuhl]
You know, that's such a good question, Dr. Mike. And, you know, working in the substance use space, we get this question a lot. And I think even for other medications that we use for substance use disorders, like when we look at opioid use disorder and we use buprenorphine a lot, people ask, well, when do you taper off?

When do you taper off? When I first started in pharmacy, there was a thought of like maybe you taper it off after six months or a year or try to get them off as quickly as possible. I think like we as a, as a group of people helping folks with substance use disorders, we are now of the idea of as long as it's benefiting the patient, you continue it.

So, I kind of use that in nicotine cessation as well. If you look in the package inserts, it's going to say 12 weeks for all of these. But that is why, that is because the studies were only for 12 weeks.

So, I think it's really important to not, to not view that as like an absolute. If I have somebody who's doing really well on Chantix and we get to the three-month mark and they are not feeling super confident, I am not going to say, well, you have to stop it at 12 weeks, you know? So that's really kind of, I think, where you work with the patient and continue the medicine as long as it's continuing to benefit them.

If I were to taper off Varenicline, what I might do is a maintenance dose is one milligram twice a day. It comes as 0.5 and one milligram tablets. I may try to go down to 0.5 twice a day for a while and then work down to 0.5 once a day and then wean off. I probably wouldn't just take everything off at once just because I want the patient to feel confident at each step that they're going to be able to do it.

[Dr Mike Patrick]
Another barrier to all of these things is going to be financial. Especially given that they're off-label use, do you find difficulty with insurance companies and Medicaid paying for these medicines?

[Dr Kelsey Schmuhl]
You know, knock on wood, Dr. Mike, I've had a lot of success with getting these through insurance, especially our Medicaid managed care programs. They have been covered for, I can't think of any patients right now who haven't had it covered by a Medicaid managed care program. So, I've really been happy about that and thankful for that.

And so, I say if you have somebody who you want to prescribe, send a prescription, even if they're over 18, because a lot of insurance companies, even in the private sector, are covering these. They know that somebody with a long-term nicotine use disorder is going to cost them way more in the end than if we treat it right now. So, I recommend always trying to write a prescription.

Now, some other options. You can look, you know, there's some pharmacy discount cards that might be able to be used that may bring the cost down a little bit. But if you're in Ohio, there's also the ability to receive free nicotine replacement therapy through the Ohio Tobacco Quit Line, which is 1-800-QUIT-NOW.

And you can call them, and I think they have a brief screener. And if you qualify, you can get nicotine replacement therapy at no cost. So, I would also look into that if access was a big barrier.

[Dr Mike Patrick]
Yeah, very, very good to know. Jen, what about you? I think we have mentioned this concept of harm reduction in the course of this episode.

What exactly is harm reduction?

[Dr Jennifer Berg]
So, harm reduction will be kind of the conversations and education. We provide patients individually, kind of what we can provide to our communities to just raise awareness about what the harmful effects of nicotine can be and provide resources for cessation. Kind of like on a one-on-one level with patients.

We talked about at the beginning delaying use as much as possible. So, kind of counseling patients and you know, the American Academy of Pediatrics does recommend screening for nicotine use at every clinical encounter. So just having that conversation at every visit, even if it's not in clinic for nicotine use disorder.

So, our primary care providers, our hospitalists even, can be screening just to kind of take inventory of are you using and if not, like supporting. And encouraging them in that decision to not use yet. And then we talked about, too, reducing use as able.

So, harm reduction can be going from 10,000 puffs a week to 5,000 puffs a week. And it doesn't have to be that all-or-nothing mentality, just supporting patients through their different journeys. And I think the framework for this next one is important because we alluded to this earlier.

Vaping is thought to be less harmful than our traditional combustible cigarettes. From a chemical standpoint and kind of the carcinogens we know, we've known for decades, are in traditional cigarettes. So, it's important about how we frame it.

We don't want to recommend e-cig use per se. But if we have a patient that's using traditional cigarettes and we can encourage them to switch to e-cigs or, you know, that can be one step in their journey. And that would also be considered harm reduction as well.

[Dr Mike Patrick]
Yeah, and because we're not really endorsing full-blown use, we're endorsing a strategy for quitting being the end goal, recognizing it's not going to happen right this second.

[Dr Jennifer Berg]
Absolutely. And it's, like we said, could take months to years. And it's a process that takes a lot of support in clinic, out of clinic, at home, and just providing that education and having that rapport with patients.

Never being punitive and just letting them know like we are here for your journey. If you return to use is really important dialogue to have while still being straightforward about the risk of nicotine, use at all. So that messaging needs to stay consistent throughout any conversation you have with a teen.

[Dr Mike Patrick]
Yeah, absolutely. Well, this has been a really enlightening conversation and I'm hopeful that it's also been helpful to providers who may be, you know, you know, it's important to get your teenage patients off of nicotine, but just not really understanding how best that you could do that. So hopefully we've raised awareness, and we'll put some resources.

There's going to be lots of those resources in the show notes for you that we've been mentioning along the way, but particularly from the CDC and the American Academy of Pediatrics and then Nationwide Children's and Partners for Kids. Lots of stuff there for you. So be sure to check out the show notes over at pediacastcme.org.

And again, this is episode 109. You'll find all that stuff there for you. Before we go, Amy, can you tell us a little bit more about adolescent medicine at Nationwide Children's Hospital?

You guys do lots more than just smoking cessation. What sort of services do you provide?

[Dr Amy JZ]
Yeah, we do a lot more than smoking cessation. I think we do provide primary care for adolescents and young adults. Adolescent programs across the country kind of do things all a little differently, but we do provide primary care.

So, well visits, vaccines, sports physicals, as well as like care for chronic and acute conditions that come up. And then we also provide subspecialty care for adolescents and young adults. And so, this does look like obviously substance use treatment and recovery like we've been talking about.

We have a nicotine cessation program. But we also provide eating disorder care. We provide gynecologic care for those with menstrual disorders.

We provide sexual and gender health care as well as reproductive health care. And then we also collaborate with a lot of different subspecialties in several different multidisciplinary clinics, which is some of my favorite parts about what we do. So, we work with endocrinology, dermatology, sleep medicine, dietician, a PCOS clinic.

We also work with hematology around patients with bleeding disorders and sickle cell. We just recently started working with rheumatology in their lupus and vasculitis clinic. Behavioral health we work with kind of throughout all of what we do as well as developmental pediatrics and then pediatric and adolescent gynecology.

And then lastly, we also provide care for our justice-involved youth at Franklin County Juvenile Intervention Center. So, we definitely wear a lot of hats. But I think as Jen and Kelsey have mentioned throughout all of this is, you know, substance use, smoking cessation can be talked about in a lot of these different realms as well.

So, it's a part of our every day.

[Dr Mike Patrick]
Yeah, yeah, and we'll put a link to Adolescent Medicine at Nationwide Children's Hospital also in the show notes so folks can discover more about all the different things that you guys do. So once again, Dr. Kelsey Schmuhl, Dr. Amy JZ and Dr. Jennifer Berg. Thank you all so much for stopping by today.

[Dr Kelsey Schmuhl]
Thanks, Dr. Mike. 

[Dr Amy JZ]
It was a pleasure.

[Dr Jennifer Berg]
Yeah, thank you so much for having us. We appreciate it.

[Dr Mike Patrick]
We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast CME a part of it. Really do appreciate that. Also, thanks again to our guests this week, Dr. Kelsey Schmuhl, Dr. Jennifer Berg, both patient care pharmacists at Nationwide Children's Hospital and Dr. Amy JZ, Adolescent Medicine Fellow also at Nationwide Children's. Don't forget you can find our podcast wherever podcasts are found. We're in the Apple Podcast app, Spotify, iHeartRadio, Amazon Music, Audible, YouTube and most other podcast apps for iOS and Android. Our landing site is pediacastcme.org.

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