To protect kids from tobacco, pediatricians say, focus should be on quitting – or never starting

Although smoking rates for adults in the US are at their lowest recorded levels, more must be done to stop children from using tobacco, according to a new set of policy statements from the American Academy of Pediatrics.

The statements, published Monday, are the association’s first tobacco policy update since 2015. They’re based on newer science and better reflect how many children now use e-cigarettes as more kid-friendly products have flooded the market.

AAP policy statements are created by expert pediatricians to help leaders craft more effective public health policy and to guide physicians on how to keep kids safe – in this case, from tobacco.

High rates of tobacco use

Researchers have been telling Americans for generations that tobacco products are bad for them, yet nearly 200 US children take up smoking every day, according to the US Centers for Disease Control and Prevention.

Tobacco use is the No. 1 cause of preventable death in the United States, the CDC says.

The rates of kids who use e-cigarettes are high, the AAP says, and the use of hookahs and cigars has not declined. However, the pediatricians note, traditional cigarette smoking has declined over the years.

Specifically, in 2022, nearly 5% of middle school and about 17% of high school students reported some form of current tobacco use, according to the CDC. In 2021, about 11% of middle schoolers and 34% of high schoolers said they had ever tried tobacco.

These “try rates” are important because most adult smokers started at young ages, according to the CDC.

And in smoking rates remain disproportionately high in certain communities, including those who are Black, Hispanic, Native American, Alaska Native or LGBTQ+.

What doctors can do

In its updated policy statements, the AAP continues to encourage pediatricians to screen for tobacco use as part of a child’s regular checkup. A talk about tobacco should start no later than age 11 or 12, the report says.

For kids who want to quit tobacco, pediatricians should refer them to behavioral interventions like counseling or prescribe nicotine replacement therapy, which has been shown to be effective with children who have moderate or severe tobacco addiction.

That practice has shifted over the years, according to Dr. Susan Walley, co-author of the new policy statements. In medical school, she said, her professors didn’t talk much about smoking except to tell people to quit.

“Now, we know it’s an addiction and a chronic medical disease. Telling someone just to quit would be like telling somebody who’s diabetic, ‘you just need to think about making your blood sugar better.’ We’ve learned so much,” said Walley, a pediatrician at Children’s National in Washington, D.C.

The new report notes that children who smoke cigarettes should not be encouraged to use e-cigarettes as an alternative. Some experts have argued that e-cigarettes are a good smoking cessation tool, but the AAP says evidence is lacking.

At the checkup, pediatricians should also ask caregivers about their tobacco habits and make recommendations. Nearly 40% of kids are regularly exposed to secondhand smoke, the AAP says, and caregiver use is the biggest reason children are exposed to secondhand smoke.

In children, secondhand smoke can lead to respiratory and ear infections and asthma attacks. Since 1964, more than 2.5 million nonsmokers who didn’t smoke have died from health problems caused by exposure to secondhand smoke, according to the CDC.

What the government can do

The AAP is urging the US Food and Drug Administration to better regulate all tobacco and nicotine products and the federal government to fund child-specific tobacco prevention, screening and treatment programs.

Despite getting nearly $27 billion from a tobacco settlement and tobacco taxes this year, states shortchange programs designed to prevent kids from using tobacco products and help people quit, according to the Campaign for Tobacco-Free Kids.

The AAP recommends raising the prices on tobacco products, as higher prices can act as a deterrent for young users.

Taxes are also considered one of the most effective ways to reduce smoking, particularly among children, studies have found. However, Congress hasn’t raised federal tobacco taxes in 14 years. The federal cigarette tax remains $1.01 per pack, and taxes vary for other tobacco products. No state increased its cigarette taxes in 2022, either.

The lure of flavored products

The AAP policy statements on tobacco recommend a total flavor ban, including menthol.

In April, the FDA proposed eliminating two tobacco products popular with children: flavored cigars and menthol cigarettes. But it could be years before that becomes a reality, as even if that rule is finalized this year, manufacturers will probably sue to keep it from going into effect.

Tobacco companies have long used menthol to mask the unpleasant flavors of their products. Studies show that it makes the products more attractive to new users and makes it harder for people to quit.

Tobacco companies are also frequently introducing flavored products in child-friendly disposable vapes in flavors like blue raspberry and sour apple.

“Sadly, they also have very, very high levels of nicotine. Just the tobacco products themselves, they have really exploded. Part of it is the lack of regulation, and then on top of that, there’s these new oral nicotine products that are unfortunately gaining a lot of popularity from our youth,” Walley said.

Walley is optimistic that more children can quit tobacco or not start in the first place, but she knows that pediatricians have their work cut out for them, based on what her sons tell her about school.

“I’m a parent of three boys, and when I hear from my boys [that] they don’t want to go to the bathroom because people will be vaping in there, it just breaks my heart that they’re not having a bathroom break all day because of that,” she said. “That kids are so addicted that they have to sneak away to the bathroom, or they are vaping in class using some covert pieces of clothing, shows this really is a public health crisis.

“We at the AAP want to make sure that people remember, this is one of the most modifiable things in terms of social determinants of health,” Walley said. “A lot of the social determinants of health, we really can’t control, but whether you use tobacco or whether you start using tobacco is something that we can do something about.”