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Addressing Tobacco Use in Adolescents and Young Adults

Nearly all adult smokers started using tobacco in their youth, which presents an important opportunity for healthcare providers. Dr. Richard Chung, MD, a Duke adolescent medicine specialist, shares how to address tobacco cessation in this complex population.

If youth tobacco use continues at the current rate, 1 out of 13 American children will die prematurely from a smoking-related illness, according to the CDC. Addressing tobacco use in adolescents and young adults is critical, as 80% of teens who smoke in high school will go on to become daily adult smokers. Nearly all adult smokers tried their first cigarette by 26, and 88% first started smoking by 18. E-cigarette use remains a top concern for this group. The 2021 National Youth Tobacco Survey found that 2.55 million students (9.3%) had used a tobacco product in the last 30 days with e-cigarette use being most common (7.6%).

Addressing youth tobacco use is an important skill for tobacco treatment specialists that requires a nuanced approach, which is why we are excited to share a new 1-day training through Duke-UNC TTS Training Program on treating tobacco use in adolescents and young adults, coming May 17, 2023. I sat down with Duke pediatrician and youth tobacco treatment expert, Dr. Richard Chung, MD—one of the co-leaders of this new training—to understand how to appropriately tailor treatment to this dynamic population.

Share a little bit about your background and how you started doing this work.

I’ve been working with teens and young adults for over a decade, seeing that there was a lot of opportunity to make a substantial difference. Not a lot of people or resources are being focused on this group. Tobacco use and smoking behaviors are so increasingly common. It’s hard not to contend with them when serving this population. So much of this work involves simply informing teenagers appropriately about the risks of certain behaviors. I did the Duke-UNC Comprehensive Tobacco Treatment Specialist Training, which provided a foundation to do high quality assessment and treatment for teenagers.

How do you tailor your smoking cessation message to adolescents?

The approach to any health issue is different with teens than with older adults. You have to keep in mind the developmental context, knowing who you are talking to and being able to assess that through conversation. That creates a moving target aspect to this work. You also have to try to understand the perspective of the teenager, what will hold water for them, near term and longer-term impacts.

You also have to contend with issues around health decision making, privacy, and confidentiality. You are usually working with some sort of parenting or adult figure, which can complicate matters. You want teens to feel comfortable and safe. They often have layers of guilt and shame around their tobacco use—they are doing something that their parent told them not to. Our role is to help a young person move toward a place of help.

How do you address e-cigarette use in this population?

It is always important to state the truth. We have less evidence about the longer-term impact of e-cigarettes versus traditional smoking. There is reason to believe that combustible cigarettes puff for puff are more harmful. We know that there are near-term issues with e-cigarette use and likely longer-term problems that are on par with combustible cigarettes. There is also data to suggest that youths move from e-cigarette use to combustible cigarettes. I do see this some in my practice. The key is getting away from the comparison between two harmful smoking behaviors and focusing on the harm of e-cigarettes versus breathing fresh air. Young people and parents get into a mental trap with this comparison. Parents are widely variable. Some are very concerned. Some are permissive of e-cigarette use or vaping.

How do you approach medication therapy in his population?

With teens we do use nicotine replacement therapies, particularly patch therapies for people under 18. We have good clinical experience with this, though using nicotine replacement in people under 18 is still considered off-label use. Less commonly we will be thinking about bupropion for patients who have a depressive disorder—the evidence is less robust. We have less experience with varenicline in the under 18 group. However, we do use varenicline a lot in the young adult population.

What are some of the challenges of working with this population, and what do you enjoy about the work?

Teens are just so interesting. This is a transitional time of life. They are heading towards all sorts of change. Being able to help someone try to be as healthy as possible during that whirlwind of change is rewarding. There is a compounding impact of that for years to come. This work is high-stakes, and you have a real opportunity to make an impact.

One of the biggest challenges is navigating privacy issues. You always want to do what’s right for a teen, and that can make it harder. We don’t have a system that’s built for them. The system is designed for younger kids or adults.

What can attendees expect to get out of this new 1-day training on youth tobacco use?

It will provide a broad and comprehensive foundation for youth tobacco use and cessation from a variety of vantage points. This includes caring adults who are engaging this population in school settings or in the community. We want to have a broader perspective. There is a rich interplay between individual health and the broader prevention perspective. We are going to take multiple perspectives so people leave with a holistic view of how to address youth tobacco use. We also plan to go into depth around the practical nuts and bolts of care for this population with a very keen focus on teenagers and what is different as opposed to adults.

Learn more about our NEW 1-day training on May 17, 2023 to help healthcare professionals learn how to treat tobacco use in adolescents and young adults.

What is your takeaway message for our TTS community on youth tobacco treatment?

Trust is critical. It’s a process to gain that trust. Their day is filled with adults that they barely know giving them unsolicited advice. Like anyone else they want to be respected, heard, and cared for. If they sense those things in you, it may not take them that long to trust you. If you express genuine care and concern, they will hear you better versus a generic message.

Dr. Chung and Dr. Lucien Gonzalez, MD, Associate Professor in the Division of General Pediatrics & Adolescent Medicine at UNC-Chapel Hill, will be leading a 1-day training on treating tobacco use in adolescent and young adult populations on May 17, 2023 in collaboration with the Duke-UNC TTS Training Program. Click here to learn more about the training curriculum, other course faculty, and details on how to register!

About The Author Rachael Joyner is a family nurse practitioner with the Duke Smoking Cessation Program. She holds a National Certificate in Tobacco Treatment Practice and received her Doctorate in Nursing Practice from the University of Florida. She loves working collaboratively with patients to help them become tobacco free.


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