Federal health officials have previously warned that the epidemic rise in youth e-cigarette use is addicting a new generation to nicotine. Helping newly addicted teens kick the nicotine habit was identified as a top priority by former U.S. Food and Drug Administration (FDA) commissioner Scott Gottlieb, MD, in one of his last public statements before stepping down from the post last spring.
But new draft recommendations from the U.S. Preventive Services Task Force (USPSTF) illustrate the uncertainty about how to best do that.
The expert statement addressing youth tobacco use, published June 25 and open for public comment until July 22, concluded that there remains "insufficient evidence to determine the benefits and harms" of established tobacco-cessation treatments for the treatment of nicotine-addicted youth.
Specifically, the task force found "inadequate evidence" on the benefits of behavioral counseling for tobacco cessation in children and teens. And it noted that there is a paucity of research on the safety and efficacy of nicotine-replacement therapies (NRTs) and other pharmacotherapies for treating youth nicotine addiction.
None of the tobacco-cessation medications marketed in the U.S. have been approved for use in children and younger teens.
The USPSTF draft statement updates 2013 recommendations on youth tobacco use, which emphasized tobacco prevention and not cessation.
Task force member Michael Silverstein, MD, of Boston University School of Medicine, said the revised recommendations reflect the fast-changing landscape of tobacco use among teens.
Youth daily cigarette smoking rates have been declining for decades, dropping by more than half among 12th graders -- from 8.5% to 3.6% -- from 2013 through 2018 alone.
But e-cigarette use has exploded, with an estimated 3.6 million middle and high school students regularly vaping in 2018, compared with 2.1 million in 2017.
Silverstein told MedPage Today that the revised recommendations for the first time now include e-cigarettes and other electronic nicotine-delivery systems (ENDS) in the list of tobacco products that primary care clinicians should address, and they also identify cessation as a stand-alone recommendation.
The expert panel called for more research on how to best treat nicotine addiction in children and teens: "In 2013 we called the lack of data on (youth) cessation an evidence gap, and when we reviewed the cessation literature in 2019 that evidence gap still existed," Silverstein said.
Panel members identified three trials with a total of 788 participants examining the impact of medications on youth smoking cessation, including two trials examining buproprion SR and one examining NRTs.
"None of the trials reported that medications improved cessation rates; smoking rates remained high in both the treatment and control groups in all trials," the task force report noted.
The group identified nine studies with a total of 2,516 participants that examined the impact of behavioral counseling interventions on youth smoking.
"Nearly all interventions used combinations of intervention types, most commonly face-to face counseling; telephone- and computer-based interventions and print materials (one intervention) were used less commonly," the report noted.
A meta-analysis of the nine studies found a small reduction in smoking rates post-intervention, but the reduction was not statistically significant.
The task force concluded that "the current evidence is insufficient to assess the balance of benefits and harms of primary-care-feasible interventions for the cessation of tobacco use among school-age children and adolescents (grade I statement)."
Specific research needed and gaps identified by the task force included the following:
- Larger studies of "new behavioral counseling interventions" that are adequately powered and that report tobacco cessation outcomes at 6 months or later
- Studies evaluating the risk/benefit balance of tobacco-cessation medications
- Studies examining interventions "specifically to prevent initiation of use and promote cessation of ENDS use in youth"
U.S. Preventive Services Task Force