Protecting Children and Adolescents From Tobacco and Nicotine

Tobacco product: Any product or device that can deliver nicotine to the human brain, whether derived from tobacco or another source, except for safe and effective nicotine replacement therapies approved by the US Food and Drug Administration (FDA) for tobacco cessation. Tobacco products include, but are not limited to, e-cigarettes, cigarettes, cigars, smokeless tobacco, hookahs, pipe tobacco, heated tobacco products, and nicotine “tobacco-free” pouches.

Secondhand smoke: Smoke emitted from a tobacco product or exhaled from a person who smokes that is inhaled by a person who does not smoke.

Thirdhand smoke: Tobacco smoke that is absorbed onto surfaces and exposes a person who does not use tobacco to its components by direct contact and dermal absorption, ingestion, and/or off-gassing and inhalation. Thirdhand smoke may react with oxidants and other compounds in the environment to yield secondary pollutants.

Tobacco smoke exposure: Tobacco smoke exposure among people who do not use tobacco, which includes both secondhand and thirdhand exposure.

E-cigarettes: Handheld devices that come in a variety of shapes and sizes. Most have a battery, a heating element, and a container to hold a solution that can contain nicotine, flavorings, and other chemicals. E-cigarettes are known by many different names. They are sometimes called e-cigs, e-hookahs, mods, pods, vapes, vape pens, tank systems, and electronic nicotine delivery systems or referred to by brand name, including Juul or Puff Bar.

Aerosol exposure: The emissions from e-cigarettes to which people who do not use e-cigarettes are exposed, including secondhand and thirdhand exposure.

Tobacco use disorder: A clinical diagnosis for which treatment is within the scope of practice of pediatric providers. Moderate or severe tobacco use disorder is defined as having 4 or more symptoms that arise from tobacco use (eg, craving; withdrawal; tolerance; increasing use over time; social, occupational, or health consequences from nicotine use).

This policy statement accompanies the clinical report and technical report on protecting children and adolescents from tobacco and nicotine.^1,2  It builds on, strengthens, and expands American Academy of Pediatrics (AAP) recommendations from the 2015 policy statement.³  Although many evidence-based recommendations from the 2015 policy statement remain relevant, this revision expands on and adds policy recommendations on the basis of new evidence since the last summative review. The approach to the evidence review and grading evidence quality are described in the accompanying technical report.²  Policy recommendations were developed using the evidence-based approach as detailed by the AAP.^4,5  In addition to a “quality of evidence” summary,²  a brief “strength of recommendation” summary is provided, using the “strong recommendation,” “recommendation,” “option,” or “no recommendation” classification system.^4,5  For a summary of AAP clinical reports, policy statements, and other resources for tobacco and e-cigarettes, see Table 1.

The FDA is charged with protecting consumers and enhancing public health by maximizing compliance of FDA-regulated products and minimizing risks associated with those products. The FDA Center for Tobacco Products is responsible for enforcing the Family Smoking Prevention and Tobacco Control Act, passed in 2009 in an effort to protect the public and create a healthier future for all Americans.⁶  Tobacco products include, but are not limited to, e-cigarettes, cigarettes, cigars, smokeless tobacco, hookahs, pipe tobacco, and heated tobacco products. The Family Smoking Prevention and Tobacco Control Act put in place restrictions on marketing tobacco products to children and adolescents, and gave the FDA the authority to further regulate tobacco products to protect public health. Some of the agency’s responsibilities under the law include establishing product standards, reviewing premarketing applications for new and modified-risk tobacco products, and requiring new warning labels for tobacco products.⁷  The FDA is required by law to conduct reviews of e-cigarettes and other new tobacco products to ensure that products are not marketed unless they are “appropriate for the protection of the public health.”⁶  The AAP and other public health organizations initiated a successful legal challenge to the long FDA delays in conducting these public health reviews for e-cigarettes. A resulting federal court order required the FDA to act in 2021. As of 2022, the FDA has authorized several tobacco-flavored e-cigarette products for marketing and has denied marketing authorization to thousands of flavored e-cigarette products. At the time of publication, the legal status of a market-leading product, JUUL, remains in limbo. However, the FDA has yet to render decisions on many market-leading products and has deferred action on a number of applications for menthol-flavored products. Products with pending applications remain on the market because the FDA has declined to take enforcement action against them during application review. The FDA must monitor postmarketing data from any authorized tobacco products to ensure that these products are not used by youth.

Tobacco use treatment should be available to all individuals who use tobacco products, including adolescents and, specifically, youth from communities that have historically experienced high levels of discrimination and stigma. The Centers for Disease Control and Prevention (CDC) Community Preventive Services Task Force evidence review found strong support for the effectiveness of comprehensive tobacco control prevention and treatment programs in reducing tobacco use and secondhand smoke (SHS) exposure, independent of increases in tobacco product prices or adoption of smoke-free policies.⁸  These programs reduce the prevalence of tobacco use among adults and young people, reduce tobacco product consumption, increase quitting, and contribute to reductions in tobacco-related diseases and deaths. The CDC outlines optimal funding levels for these programs, as well as evidence that program effectiveness increases with adequate funding.⁹  States do not fund these programs at anywhere near the level suggested by the CDC.¹⁰  Further, despite receiving billions of dollars each year (estimated at approximately $27 billion in 2021) through tobacco settlement money and tobacco taxes, most states only use a small percentage of these funds to support tobacco prevention and treatment programs.¹¹  Rather than support efforts to reduce the enormous public health toll caused by tobacco use as promised in the 1998 Master Settlement Agreement between 46 states and several US territories and major tobacco companies, these funds are often used for unrelated efforts, including balancing state budgets.

Given the important benefits to society of reducing tobacco use, cost should not be a barrier to receiving tobacco cessation services. The Affordable Care Act requires most private health plans to cover, without cost-sharing, tobacco cessation services.¹²  The Departments of Health and Human Services, Labor, and the Treasury define adequate insurance coverage for cessation services as those which include, without cost-sharing or previous authorization, both counseling and medication for up to 2 quit attempts a year.¹³  Although many Medicaid and Children’s Health Insurance Program plans cover tobacco use treatment, they are not required to do so by law, so comprehensive coverage is not universal.¹⁴  Further, many insurers do not cover tobacco treatment of people younger than 18. The AAP policy statement, “Improving Substance Use Prevention, Assessment, and Treatment Financing to Enhance Equity and Improve Outcomes Among Children, Adolescents, and Young Adults,” recommends appropriate insurance coverage and payment for provider time spent counseling and prescribing tobacco cessation services to facilitate greater availability of tobacco cessation treatment of all, including adolescents and young adults.¹⁵ 

Tobacco use remains one of the leading preventable causes of disease and death in the United States.¹⁶  Use of any tobacco product by youth is unsafe, regardless of the form of use.¹⁷  Tobacco use is a pediatric epidemic, because tobacco use disorder almost always starts in childhood or adolescence.¹⁸  Tobacco control research funding should be specifically designated for clinical and policy interventions for pediatric populations, including those who are from communities that have historically experienced high levels of discrimination and stigma or have been traditionally underrepresented in research but highly impacted by tobacco use. Research is needed, in particular, to identify effective behavioral and/or pharmacotherapy interventions for tobacco cessation for youth¹⁹  and pregnant persons.²⁰  Tobacco industry funding should not be used for this purpose. The tobacco industry has a long and well-documented history of using industry-funded programs to divert attention away from effective tobacco control programs and research, as well as misusing health care providers and academia to thwart attempts at tobacco control.¹⁷ 

According to the 2014 Surgeon General’s report, “the evidence is sufficient to conclude that increases in the prices of tobacco products, including those resulting from excise tax increases, prevent initiation of tobacco use, promote cessation, and reduce the prevalence and intensity of tobacco use among youth and adults.”¹⁷  As such, increasing the price of all tobacco products is one of the most effective methods to prevent or reduce tobacco use.¹⁷  Youth are particularly sensitive to tobacco product price increases, with research suggesting that youth and young adults are 2 to 3 times as responsive to changes in price compared with adults.¹⁷  Increasing excise taxes on tobacco products is especially effective in discouraging initiation among young people who have not developed tobacco use disorder, thus protecting their health and increasing their likelihood of remaining tobacco-free.²¹  Increasing the tobacco tax has the benefit of both raising the price and providing a source of funds that can be used for tobacco control programs, helping states capture health care–related cost savings from reductions in associated financial costs from death and disease because of tobacco use.⁹  As of January 2023, e-cigarettes are not currently taxed at the federal level and other types of tobacco products are taxed at different levels. Taxes should be instituted for e-cigarettes and all tobacco products should be taxed at comparable levels to prevent substitution.

In December 2019, Congress passed a federal law to raise the sales age for all tobacco products to 21 years.²²  The new federal minimum age of sale applies to all retail establishments and persons, with no exceptions. The law penalizes retailers for selling tobacco products to youth. The law does not penalize youth who purchase, possess, or use tobacco products. The law was the culmination of research identifying these laws as effective with high levels of public support. A 2015 Institute of Medicine report summarized the evidence of effectiveness and provided evidence from two different simulation models that increasing the minimum age to 21 years would lead to a 12% reduction in smoking prevalence.²³  Survey data identified that the vast majority of Americans supported the adoption of a federal “Tobacco 21” law, with support extending across sociodemographic groups, including age, gender, race, ethnicity, and socioeconomic status, as well as political affiliation and smoking status.²⁴ 

Enforcement activities are important for age-of-purchase laws to be effective. A Cochrane review on interventions for preventing tobacco sales to minors found that active enforcement, including media coverage of that enforcement, was much more effective than educational programs alone.²⁵  A 2011 review found that enforcement programs that disrupted the sale of tobacco to minors reduced smoking among youth, whereas merely enacting a law without sufficient enforcement had minimal, if any, impact on youth tobacco use.²⁶ 

Across a range of tobacco products, flavorings are one of the main reasons that youth initiate tobacco use. More than 80% of adolescents and young adults who have tried tobacco report that their first product was flavored.²⁷  When asked why they use tobacco, young people consistently say it is because they like the flavors.²⁸  E-cigarette solutions are often flavored, with thousands of unique flavors advertised.²⁹  The 2016 Surgeon General’s report on e-cigarettes concluded that flavors are among the most commonly cited reasons for using e-cigarettes among youth and young adults.³⁰  In 2021, flavored e-liquids were used by 84.7% of youth who reported current e-cigarette use.³¹  Cigars and little cigars are also flavored, and it has been hypothesized that the flavors in these products mask the harshness of the cigar smoke, making the smoking experience more tolerable and enjoyable for young people.

Flavorings (other than menthol) have been banned in conventional cigarettes since the Family Smoking Prevention and Tobacco Control Act of 2009 because flavorings encourage cigarette experimentation and regular use, which can lead to tobacco use disorder.^18,32,33  The cigarette flavor ban appears to be working, as it has been associated with a 58% decrease in the number of cigarettes smoked among youth and a 17% decrease in the likelihood of smoking cigarettes overall in this age group.³³  However, these effects are likely diminished by the continued availability of menthol cigarettes and other flavored tobacco and nicotine products. Small cigars, e-cigarettes, and similar devices often contain flavors but are not subject to the same regulations as cigarettes. To fully protect youth from the harms of tobacco, it is necessary to prohibit all flavor ingredients, including menthol, in all tobacco and nicotine products. Emerging evidence suggests that focusing on “characterizing” flavors rather than any flavor ingredient creates potential policy loopholes that are exploited by tobacco companies to circumvent tobacco flavor bans.³⁴  Tobacco companies have historically used flavored products to target youth and, in particular, youth from communities that have experienced high levels of discrimination and stigma; for example, the targeting of Black communities with menthol cigarette advertising and promotions.^18,35  Thus, 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.

Enhanced and equitable implementation of comprehensive smoke-free laws and policies for indoor public places, workplaces, cars, and multiunit housing can dramatically reduce SHS exposure. The 2006 Surgeon General’s report concluded that smoking bans in workplaces, hospitals, restaurants, bars, and offices substantially reduce SHS exposure. Further, the report highlighted that “evidence from multiple peer-reviewed studies shows that smoke-free policies and regulations do not have an adverse economic impact on the hospitality industry.”³⁶  The 2020 Surgeon General’s report on smoking cessation also found that there is sufficient evidence “to infer that smoke-free policies reduce smoking prevalence, reduce cigarette consumption, and increase smoking cessation.”³⁷ 

Smoke-free laws are associated with improved child health outcomes. For example, implementation of smoke-free laws in England, Canada, and Scotland was associated with decreases in childhood asthma hospitalizations.^38,39  Similar laws in Kentucky were associated with decreased emergency department visits for asthma.⁴⁰  Implementation of smoke-free laws in Belgium, Scotland, and England have been associated with decreased rates of preterm births.^41,42  A study in England also found a significantly decreased risk of infants being of low birth weight and small for gestational age after implementation of smoke-free legislation.⁴³ 

Smoke-free policies for cars can also reduce SHS exposure and should be promoted in an equitable manner. Studies of tobacco smoking in automobiles found that a significant amount of tobacco smoke remains in the vehicle, even with the windows open.⁴⁴  Studies have found that nonsmoking passengers have substantially elevated levels of cotinine (a nicotine metabolite and measure of nicotine exposure), other tobacco-related toxicants, and carcinogens after sitting in a parked car with an open window while a person smoked 3 cigarettes over 1 hour.^45,46  A 2021 systematic review and meta-analysis found smoke-free car policies were associated with reductions in reported child tobacco smoke exposure in cars (risk ratio, 0.69; 95% confidence interval [CI], 0.55–0.87; n = 161 466 participants in 4 studies).⁴⁷ 

Multi-unit housing represents another potential source of SHS exposure for a large portion of US children and adults. Smoking in one unit involuntarily exposes those in nearby units.^48–50  Among multiunit housing residents, surveys suggest a majority of respondents support smoking bans in common areas and within individual units, with increased support among individuals who reside with children.^51,52  In 2016, the US Department of Housing and Urban Development announced regulations to require public housing agencies across the country to implement smoke-free policies.⁵³  Evaluation of the effectiveness of this regulation is ongoing.^54,55  Smoke-free policies for homes should be promoted in an equitable manner.

Evidence also supports the inclusion of e-cigarettes and similar devices in comprehensive smoke-free laws and policies. E-cigarette aerosol contains known harmful toxicants and carcinogens that can be discharged directly into the surrounding environment and deposited on surface areas.^30,56  Bystanders are exposed to this secondhand and thirdhand aerosol in a manner similar to that of secondhand and thirdhand cigarette smoke. Lessons learned from existing smoke-free policies, which include combustible cigarettes, along with available e-cigarette research, supports the inclusion of e-cigarettes into tobacco-free laws and ordinances where children and adolescents live, learn, play, work, and visit.²⁹ 

The 2012 Surgeon General’s report concluded, “Advertising and promotional activities by tobacco companies have been shown to cause the onset and continuation of smoking among adolescents and young adults.”^18,30  Further, the report concluded that “evidence is suggestive but not sufficient, to conclude that tobacco companies have changed the packaging and design of their products in ways that have increased these products’ appeal to adolescents and young adults.”¹⁸  Studies also suggest exposure to e-cigarette advertising on social media sites is associated with e-cigarette use among adolescents^57,58  and young adults.⁵⁹  Recently, e-cigarette and other tobacco product advertisements have increased dramatically on social media platforms.^60,61  Exposure to TV advertisements is associated with increased intentions to use e-cigarettes,⁶²  and exposure to a range of advertisement modalities (including Internet, print, retail, and TV/movies) is associated with current e-cigarette use,⁶³  with increasing exposure being associated with increased odds of use.^64,65  Therefore, reducing exposure to pro-tobacco advertising is an important component of comprehensive tobacco control strategies to prevent tobacco and nicotine initiation among youth.¹⁸  For example, social media companies should create policies to limit children’s exposure to tobacco content online, including prohibiting tobacco/e-cigarette companies from advertising on their platforms to children younger than 21 years.

Point-of-sale (POS) advertising increases tobacco initiation and tobacco product use among youth. POS advertising refers to a variety of marketing and promotion activities, including signs on the interior and exterior of retail stores, functional items like counter mats and change cups, shelving displays, and coupons and other price discounts that reduce the price for the consumer. It also includes promotional payments to retailers by tobacco companies to have their products placed in specific store locations, making it more likely that consumers will see them.⁶⁶  Tobacco companies spend the vast majority of their total marketing expenditures on price-related strategies at the POS.⁶⁷  Evidence suggests POS display bans reduce youth smoking susceptibility and denormalize smoking.^68–70  According to a 2016 meta-analysis, the odds of having tried smoking are around 1.6 times higher for children and youth who are frequently exposed to POS tobacco promotion, compared with those who are less frequently exposed.⁷¹  A virtual store experiment found that youth 13 to 17 years of age were substantially less likely to try purchasing tobacco products when tobacco products were not displayed (odds ratio, 0.30; 95% CI, 0.13–0.67).^35,72 

E-cigarette companies, the vast majority of which are owned by tobacco companies, use a wide variety of product placement strategies. The AAP policy statement “E-Cigarettes and Similar Devices” outlined e-cigarette POS advertising at various retail outlets, as well as the ability for youth to purchase these products through online vendors.²⁹  E-cigarette advertisements are also placed within music, entertainment, and sport venues, and on social media and streaming media.⁷³  Additionally, e-cigarettes have been marketed through celebrity endorsements and sponsorships and free samples at youth-oriented events.⁷⁴  These product placement strategies are illegal for conventional cigarettes, because they promote youth initiation and progression to traditional tobacco product use.^18,30 

Venues for unsupervised purchase of tobacco and nicotine products, such as vending machines and online merchants, should be eliminated. All tobacco and nicotine products should be placed behind sales counters to reduce shoplifting. Sales of tobacco and nicotine products should be eliminated from schools, health care facilities, military bases, pharmacies, and other sites that serve youth. The promotional distribution of tobacco and nicotine products should be prohibited.

Depictions of smoking in movies have been repeatedly shown to increase rates of smoking initiation among adolescents both in the United States and globally. The 2012 Surgeon General’s report concluded, “The evidence is sufficient to conclude that there is a causal relationship between depictions of smoking in the movies and the initiation of smoking among young people.”¹⁸  Numerous prospective studies of adolescents across the world have shown that exposure to depictions of smoking in movies is associated with smoking initiation.^75–77  One estimate suggests that reducing adolescent exposure to smoking depictions in movies from a current median of about 275 annual exposures per adolescent from PG-13 movies down to approximately 10 or less would reduce the prevalence of adolescent smoking by 18% (95% CI, 14%–21%).⁷⁸  According to the 2014 Surgeon General’s report, “actions that would eliminate depiction of tobacco use in movies that are produced and rated as appropriate for children and adolescents could have a significant effect toward preventing youth from becoming tobacco users.”¹⁷  With the rise of depictions of e-cigarettes in movies and episodic programs (defined as programs aired as a series on streaming platforms or broadcast or cable TV) and preliminary evidence suggesting a dose-response relationship between depictions and e-cigarette initiation among youth,⁷⁹  it is reasonable to have these recommendations apply to all depictions of tobacco and nicotine products.

Mass media and school-based tobacco control programs are often funded by federal, state, and nonprofit entities. These programs have been shown to reduce the initiation of tobacco use and increase cessation by denormalizing tobacco and nicotine product use.^9,18,80  Tobacco industry-sponsored programs do not use the same strategies, are not effective in preventing tobacco use among youth, and are counterproductive, potentially undermining effective tobacco control efforts.¹⁸  This recommendation remains relevant with the recent efforts by JUUL Laboratories to target school-aged children with youth prevention programs. A 2018 study found that the JUUL curriculum was not evidence-based and failed to adequately address the harms of e-cigarettes, youth susceptibility to the addictive nature of nicotine, or the role that targeted tobacco industry marketing plays in youth use of e-cigarettes.⁸¹ 

Mass-reach health communication interventions can be powerful tools for preventing the initiation of tobacco use, promoting and facilitating cessation, and shaping social norms related to tobacco use.⁹  The Community Preventive Services Task Force recommends mass-reach health communication interventions based on strong evidence of effectiveness in decreasing the prevalence and initiation of tobacco use among young people and increasing cessation and use of available services such as quitlines.⁸  According to a 2017 Cochrane review of mass media campaigns directed at youth, there is some evidence that certain types of media campaigns can be effective in preventing the uptake of smoking in young people.⁸²  Adolescents and young adults are very sensitive to perceived social norms and media presentations of smoking behavior. Campaigns, such as those organized by the Truth Initiative, which focus on raising awareness of tobacco companies’ targeting and manipulating of youth, has been estimated to help significant portions of youth reject tobacco, including more than 450 000 adolescents in one 4-year span.^83,84  The Florida Tobacco Pilot Program, the major component of which was a youth-oriented, counter-marketing media campaign developed to reduce the allure of smoking, was associated with a significant decline (approximately 2% to 3%) in smoking among middle and high school students.⁸⁵ 

Pictorial health warnings improve adolescents’ awareness of the harms of smoking and decrease their perceptions of the social appeal of smoking.^86,87  According to the 2020 Surgeon General’s report on smoking cessation, “The evidence is sufficient to infer that large, pictorial (also known as graphic) health warnings increase smokers’ knowledge about the health harms of smoking, interest in quitting, and quit attempts, and decrease smoking prevalence.”³⁷ 

Children and adolescents can be harmed from absorption of tobacco toxins when they participate in tobacco production.^88,89  Green tobacco sickness, or nicotine poisoning that occurs while handling tobacco plants, is well described. Dermal absorption of nicotine from moist tobacco plants can lead to symptoms of severe nicotine poisoning, including weakness, headache, nausea, vomiting, dizziness, abdominal cramps, breathing difficulty, pallor, diarrhea, chills, fluctuations in blood pressure or heart rate, seizures, and increased perspiration and excessive salivation.^89–91 

Reducing nicotine content in cigarettes has been suggested as a potential strategy to make them less addictive⁹²  or less reinforcing (eg, at a dose least likely to increase or maintain nicotine self-administration behaviors).⁹³  This strategy has been linked to cigarette smoking reduction and cessation in adults, both of which can substantially reduce tobacco-related morbidity and mortality.⁹⁴  For example, studies have shown that, when adults switch from cigarettes with regular nicotine content to cigarettes with very low nicotine content (≤0.4 mg/g), they experience reductions in biomarkers of nicotine exposure, cigarettes smoked/day, and symptoms of tobacco use disorder.^95,96  No clinical studies have assessed how nicotine reduction affects adolescents’ experiences with cigarette smoking or intentions to smoke; however, preclinical studies have shown that adolescent rats are more sensitive to lower doses of nicotine than adults.⁹⁵  In 2018, the FDA announced its intent to develop a tobacco product standard to set the maximum nicotine level for cigarettes.⁹⁷  At the time of this publication, however, the FDA has not put forth specific regulations.

The United Kingdom and Europe have adopted nicotine limits for nicotine-containing e-liquids at 20 mg/mL.⁹⁸  With the emergence of e-cigarettes, some have argued that enough nicotine needs to be available in these noncombusted products to facilitate adults’ transition from combusted to noncombusted forms of nicotine and mitigate the emergence of an illicit market of tobacco products with high nicotine content. In the United States, e-cigarettes have evolved over the past decade to have high levels of nicotine content, as well as salt-based nicotine solutions, which are more palatable than the free-based nicotine used in earlier generations of e-cigarettes.⁹⁹  These features are marketed to assist with the transition from cigarette smoking to noncombusted tobacco products; however, data show that these features may sustain long-term e-cigarette use among adults (rather than cessation) and also appeal to adolescents who do not smoke cigarettes.⁹⁵  To best minimize health harms to children when formulating a comprehensive regulatory framework for the nicotine content of cigarettes in the United States, policymakers must also create a standard that minimizes long-term use of e-cigarettes and other tobacco products by adults (which adversely impacts children through the mechanisms listed above), as well as initiation of nicotine and maintenance of tobacco use among youth.

The “tobacco endgame” reorients tobacco policy and guidelines toward plans for ending the tobacco epidemic and envisions a tobacco-free future. A variety of policy approaches have been outlined, including product-focused, user-focused, market-supply focused, and institutional structure-focused proposals.¹⁰⁰  The tobacco endgame has been discussed by the CDC and the Surgeon General.³⁷  In 2021, California formally adopted an endgame policy initiative, with a commitment toward ending the commercial tobacco epidemic in the state by 2035.¹⁰¹  The National Institutes of Health and the FDA, as well as the whole of government, should endorse and support tobacco endgame goals, and tobacco control researchers should consistently recognize and frame our research findings in alignment with endgame policies to prevent new addiction and to end the tobacco epidemic. Finally, considering how tobacco use disproportionately affects youth from communities that have historically experienced high levels of discrimination and stigma, endgame strategies should incorporate policies targeted at reducing these disparities; for example, through special outreach to these populations.

Tobacco use almost always starts in childhood or adolescence. The tobacco epidemic takes a substantial toll on the health of all pediatric populations. Public policy actions to protect infants, children, adolescents, and young adults from tobacco have proven effective in reducing harm. Effective public health approaches need to be both extended to include e-cigarettes, similar devices, and other and emerging tobacco and nicotine products, and expanded to reduce the toll that the tobacco epidemic takes on our children.

For further reading and a summary of AAP clinical reports, policy statements, and other resources for tobacco and e-cigarettes, see Table 1.

Brian P. Jenssen, MD, FAAP

Susan C. Walley, MD, FAAP

Rachel Boykan, MD, FAAP

Alice Little Caldwell, MD, FAAP

Deepa Camenga, MD, FAAP

Susan C. Walley, MD, FAAP, Chairperson

Rachel Boykan, MD, FAAP

Judith A. Groner, MD, FAAP

Brian P. Jenssen, MD, FAAP

Jyothi N. Marbin, MD, FAAP

Bryan Mih, MD, MPH, FAAP

Alice Little Caldwell, MD, FAAP

Lily Rabinow, MD – Section on Pediatric Trainees

Gregory H. Blake, MD – American Academy of Family Physicians

Karen S. Smith, Manager

James D. Baumberger, MPP, Sr Director, Federal Advocacy

Lucien Gonzalez, MD, MS, FAAP, Chairperson

Rita Agarwal, MD, FAAP

Deepa R. Camenga, MD, MHS, FAAP

Joanna Quigley, MD, FAAP

Kenneth Zoucha, MD, FAAP

Christine Kurien, DO – Section on Pediatric Trainees

Rebecca Ba’Gah, MD, FAAP – American Academy of Child and Adolescent Psychiatry

Renee Jarrett, MPH

AAP

American Academy of Pediatrics

CDC

Centers for Disease Control and Prevention

CI

confidence interval

FDA

US Food and Drug Administration

POS

point of sale

SHS

secondhand smoke