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AAP calls on pediatricians, policymakers to curtail youth tobacco, nicotine use

April 17, 2023

Tobacco use — the leading preventable cause of disease and death in the U.S. —  almost always starts in childhood or adolescence.

The tobacco epidemic takes a substantial toll on the health of all pediatric populations, including infants, children, adolescents and young adults, and the harm begins in utero. Pediatric clinicians can take various evidence-based clinical and policy approaches to protect families from the harms of tobacco, and they are uniquely positioned to help them live tobacco-free lives.

That is the overarching take-away from an AAP policy statement, clinical report and technical report titled Protecting Children and Adolescents from Tobacco and Nicotine.

The documents, from the AAP Section on Nicotine and Tobacco Prevention and Treatment and Committee on Substance Use Prevention, are available at, and and will be published in the May issue of Pediatrics.

Expand public health approaches, funding

The policy statement details how effective public health approaches need to include e-cigarettes and similar devices as well as other tobacco and nicotine products. These approaches also must be expanded to reduce the toll that the tobacco epidemic takes on children. For example, the policy recommends that the Food and Drug Administration (FDA) regulate all tobacco and nicotine products to protect public health. This includes prohibiting all flavor ingredients, including menthol, in all tobacco and nicotine products.

Tobacco companies have used flavored products to target youths, particularly those from communities with high levels of discrimination and stigma. Therefore, prohibiting all flavors in all tobacco and nicotine products is a policy approach that promotes social justice and racial equity, in support of the AAP Equity Agenda.

The AAP recommends adequate funding for tobacco use prevention, screening and treatment specifically for pediatric populations. Despite receiving billions of dollars each year (estimated at $27 billion in 2021) through tobacco company settlement money and tobacco taxes, most states use only a small percentage of these funds to support tobacco prevention and treatment programs for children and adolescents.

Additionally, the statement recommends that states enact comprehensive laws that prohibit use of all tobacco and nicotine products (including cigarettes, e-cigarettes and similar devices) in all places where children and adolescents live, learn, play, work and visit.

What pediatricians can do

The clinical report details how pediatricians can help reduce children’s risk of developing tobacco and nicotine use disorder and reduce their tobacco smoke and/or aerosol exposure. Following are among the steps they can take:

  • Include tobacco and nicotine use prevention as part of anticipatory guidance. Messages that focus on how the tobacco industry deceives and tries to manipulate them may resonate with children and adolescents.
  • Refer adolescents who want to quit using tobacco to behavioral interventions. Given the safety profile of nicotine replacement therapy (NRT) and the well-known consequences of untreated tobacco use, it also is reasonable to recommend and prescribe NRT to adolescents with moderate or severe tobacco use disorder. This is defined as having four or more symptoms that arise from tobacco use (e.g., craving, withdrawal, tolerance, increasing use over time, and social, occupational or health consequences from nicotine use).
  • Implement systems to identify, counsel, treat and refer caregivers who smoke or use other tobacco products. When parents quit smoking, they significantly increase their own life expectancy, eliminate the majority of their children’s secondhand smoke exposure and decrease the risk of smoking initiation among their children. Pediatricians also can recommend and prescribe FDA-approved medications, including NRT, as part of a treatment plan for parental tobacco cessation.

Evidence base for guidance

The evidence base for the clinical report and policy statement can be found in the technical report. It outlines data demonstrating that youth use of tobacco products in any form is unsafe. However, more than 16% of high school students report current use of a tobacco product.

Although e-cigarettes remain the most common tobacco product used by youths, use of multiple types of tobacco products also is common. The report highlights how tobacco use disproportionately affects youths from communities that historically have experienced high levels of discrimination and stigma, thus reinforcing and perpetuating existing health disparities.

Finally, the report describes numerous studies showing how tobacco smoke exposure causes an extensive list of health harms in children, including increased risk of infant death, asthma prevalence and severity, other respiratory illnesses, and learning and neurobehavioral problems.

Almost 40% of children ages 3-11 years are exposed regularly to secondhand smoke, and rates of secondhand exposure to e-cigarette aerosol have increased over the last decade.

Through the promotion of evidence-based clinical and policy strategies, pediatricians, pediatric clinicians and the AAP have pushed back against tobacco companies to help families live tobacco-free lives. Continued clinical and policy advocacy can help prevent addiction, end the tobacco epidemic and promote a tobacco-free future.

Dr. Jenssen is a lead author of the policy statement and reports. He is a member of the AAP Section on Nicotine and Tobacco Prevention and Treatment.




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