Tobacco and Nicotine Use in Youth

Cigarette Smoking

Cigarette smoking is the primary cause of preventable death and morbidity in the United States, causing atherosclerosis with associated heart disease and stroke, cancer of the lung and other organs, emphysema, and other serious health problems. Passive exposure to cigarette smoke increases the risk of sudden infant death syndrome, asthma and middle ear disease. [Metsios: 2009] [Cook: 1999] Exposure to tobacco in-utero is associated with intrauterine growth restriction as well as obesity during adulthood. [Reeves: 2008] [Power: 2010] Recent evidence suggests that maternal smoking during pregnancy may also adversely affect auditory functioning during infancy. [Peck: 2010]
Most smokers begin smoking as adolescents.[Giovino: 1995] The risk of initiating smoking during adolescence increases if there is a parent in the home that smokes, but the risk returns to baseline if the parent successfully quits smoking. [Gilman: 2009] Daily smoking during adolescence is a strong predictor of nicotine dependence during adulthood, and quitting smoking during adolescence reduces the future risk of nicotine dependence. [Patton: 2006] [Van: 2010] Emphasis within the community should thus be directed toward the prevention of smoking in adolescents and on cessation in those who have initiated smoking, along with their family members who smoke. A review of the efficacy of smoking cessation programs for young people supports the use of behavioral programs that incorporate the patient's stage of readiness for change (e.g., motivational interviewing); there is little evidence to support the use of nicotine replacement systems in adolescents. [Grimshaw: 2006]
The Monitoring the Future 2016 Survey (NIH) is a series of annual classroom surveys of 8th-, 10th-, and 12th-grade students conducted by researchers at the University of Michigan. The data collected through the survey showed a peak prevalence of teen tobacco cigarette smoking in 1996 and 1997 followed by a gradual decline. In 2016, teen smoking reached its lowest prevalence since 1975, with 2.6% of 8th graders and 10.5% of 12th graders reporting smoking during the month prior to the survey. [Johnston: 2013]

Smokeless Tobacco

Individuals that use smokeless tobacco (snuff, dipping tobacco, chewing tobacco) are at increased risk for developing cancer of the oral cavity. [Critchley: 2003] [Lee: 2009] An increased risk of cancers of the pancreas, esophagus, and stomach has also been suggested. [Boffetta: 2009] The use of smokeless tobacco has shown an overall decline in youth from a peak in the mid-1990s; 2.5% of 8th graders and 6.6% of 12th graders had used smokeless tobacco in the 30 days prior to the Monitoring the Future survey in 2016. [Johnston: 2013]


Vaping involves the use of a handheld, battery-powered device to heat a liquid (which may contain nicotine, cannabis products, ethylene glycol, glycerin, or flavorings) into an inhaled vapor or mist. The first vaping devices were made available in the United States in 2007. E-cigarettes are the most common vaping devices. The Monitoring the Future survey has included questions about E-cigarettes and vaping since 2014. A decline in use was noted for the first time in 2016, with 6% of 8th graders and 13% of 12th graders vaping in the 30 days prior to the survey. Students perceive the least amount of risk associated with vaping and e-cigarette use than with any other substance. [Johnston: 2013] Studies are being done to assess safety and long-term effects of inhaling various vaping fluids. There is concern about the effects of components in the vaping fluid, such as formaldehyde, toluene, and glycol, on lung function. [Kaisar: 2016] Undiluted nicotine in the vaping fluid can also result in significant poisoning or death if accidentally ingested or spilled, especially in children younger than 6 years old. [Kamboj: 2016]


Information & Support

For Professionals

Tools for Clinical Practice: Pediatric Tobacco Control (AAP)
Resources to help you ask patients and families the right questions about tobacco use and second-hand smoke exposure, including information on coding and payment, training and CME courses, and clinical practice guidelines and tools; American Academy of Pediatrics Julius B. Richmond Center

Help Your Patients Quit Smoking (CDC)
Includes tips, videos, handouts for patients, and information about intervention; Centers for Disease Control and Prevention.

For Parents and Patients


Nicotine Anonymous (NicA)
Offers group support and recovery using the 12 Steps as adapted from Alcoholics Anonymous to achieve abstinence from nicotine.

American Lung Association
Offers up-to-date information about asthma, tobacco control, environmental health, and research information for clinicians.


Quit Smoking (CDC)
Compilation of resources related to smoking cessation; Centers for Disease Control and Prevention.

A Smoker's Guide to Quitting
A list of links that represent some of the best online help for those who want to quit smoking and live a smoke-free life.

Guide to Quitting Smokeless Tobacco (American Cancer Society)
Contains information, support, and treatment resources.


Tobacco and Nicotine Cessation Toolkit (AAFP)
Includes office-based tools and information about coding, payment, and working with community partners; American Academy of Family Physicians.

Authors & Reviewers

Initial publication: May 2010; last update/revision: May 2017
Current Authors and Reviewers:
Author: Catherine Jolma, MD
Reviewer: Mary Steinmann, MD

Page Bibliography

Boffetta P, Straif K.
Use of smokeless tobacco and risk of myocardial infarction and stroke: systematic review with meta-analysis.
BMJ. 2009;339:b3060. PubMed abstract / Full Text

Cook DG, Strachan DP.
Health effects of passive smoking-10: Summary of effects of parental smoking on the respiratory health of children and implications for research.
Thorax. 1999;54(4):357-66. PubMed abstract / Full Text

Critchley JA, Unal B.
Health effects associated with smokeless tobacco: a systematic review.
Thorax. 2003;58(5):435-43. PubMed abstract / Full Text

Gilman SE, Rende R, Boergers J, Abrams DB, Buka SL, Clark MA, Colby SM, Hitsman B, Kazura AN, Lipsitt LP, Lloyd-Richardson EE, Rogers ML, Stanton CA, Stroud LR, Niaura RS.
Parental smoking and adolescent smoking initiation: an intergenerational perspective on tobacco control.
Pediatrics. 2009;123(2):e274-81. PubMed abstract / Full Text

Giovino GA, Henningfield JE, Tomar SL, Escobedo LG, Slade J.
Epidemiology of tobacco use and dependence.
Epidemiol Rev. 1995;17(1):48-65. PubMed abstract

Grimshaw GM, Stanton A.
Tobacco cessation interventions for young people.
Cochrane Database Syst Rev. 2006(4):CD003289. PubMed abstract

Johnston LD, O’Malley PM, Miech RA, Bachman JG, Schulenberg JE.
Monitoring the Future: National Survey Results on Drug Use 1975–2013.
The National Institute on Drug Abuse at The National Institutes of Health; Ann Arbor: Institute for Social Research, The University of Michigan.; (2013) Accessed on May 2013.
Overview of key findings on adolescent drug use.

Kaisar MA, Prasad S, Liles T, Cucullo L.
A decade of e-cigarettes: Limited research & unresolved safety concerns.
Toxicology. 2016;365:67-75. PubMed abstract / Full Text

Kamboj A, Spiller HA, Casavant MJ, Chounthirath T, Smith GA.
Pediatric Exposure to E-Cigarettes, Nicotine, and Tobacco Products in the United States.
Pediatrics. 2016;137(6). PubMed abstract

Lee PN, Hamling J.
Systematic review of the relation between smokeless tobacco and cancer in Europe and North America.
BMC Med. 2009;7:36. PubMed abstract / Full Text

Metsios GS, Flouris AD, Koutedakis Y.
Passive smoking, asthma and allergy in children.
Inflamm Allergy Drug Targets. 2009;8(5):348-52. PubMed abstract

Patton GC, Coffey C, Carlin JB, Sawyer SM, Wakefield M.
Teen smokers reach their mid twenties.
J Adolesc Health. 2006;39(2):214-20. PubMed abstract

Peck JD, Neas B, Robledo C, Saffer E, Beebe L, Wild RA.
Intrauterine tobacco exposure may alter auditory brainstem responses in newborns.
Acta Obstet Gynecol Scand. 2010;89(4):592-6. PubMed abstract

Power C, Atherton K, Thomas C.
Maternal smoking in pregnancy, adult adiposity and other risk factors for cardiovascular disease.
Atherosclerosis. 2010. PubMed abstract

Reeves S, Bernstein I.
Effects of maternal tobacco-smoke exposure on fetal growth and neonatal size.
Expert Rev Obstet Gynecol. 2008;3(6):719-730. PubMed abstract / Full Text

Van De Ven MO, Greenwood PA, Engels RC, Olsson CA, Patton GC.
Patterns of adolescent smoking and later nicotine dependence in young adults: a 10-year prospective study.
Public Health. 2010;124(2):65-70. PubMed abstract