Updated recommendation includes e-cigarettes as a tobacco product

Primary care providers (PCPs) should continue to provide interventions to prevent school-aged children and adolescents from using tobacco products, including e-cigarettes, according to the U.S. Preventive Services Task Force (USPSTF).

However, the effect of such behavioral interventions, such as education or brief counseling, offers a “moderate net benefit,” wrote Douglas K. Owens, MD, MS, of Stanford University in California, and USPSTF members, leading to the task force’s “B” grade recommendation with “moderate certainty.”

And in an “I” statement, the task force concluded that there is currently not enough evidence to get a handle on “the balance of benefits and harms of primary care-feasible interventions for the cessation of tobacco use among school-aged children and adolescents,” they wrote in JAMA.

“This recommendation replaces the 2013 USPSTF recommendation on primary care interventions to prevent tobacco use in children and adolescents… New to the current recommendation is the inclusion of e-cigarettes as a tobacco product. Also new to the current recommendation is the I statement on insufficient evidence on interventions for cessation of tobacco use among this population. The USPSTF is calling for more research to identify interventions (behavioral counseling or pharmacotherapy) to help children and adolescents who use tobacco to quit,” Owens and co-authors said.

Interventions highlighted by the task force that could be delivered by PCPs are face-to-face counseling, telephone counseling, computer-based interventions, and print-based interventions. They noted that print-based materials may be best suited for young children (ages 7 to 10 years), while kids ≥10 years could benefit more from in-person counseling, phone- or computer-based interventions.

Owens’ group pointed out that “No medications are currently approved by the FDA for tobacco cessation in children and adolescents,” such as nicotine replacement therapy (NRT), bupropion sustained-release (Wellbutrin XL), or varenicline (Chantix).

The evidence report on which the updated guidelines are based highlighted “significant gaps [in evidence], such as the absence of large trials testing primary care-relevant interventions (behavioral counseling or medication) to promote youth tobacco use cessation and any intervention research addressing e-cigarette prevention or cessation in youth,” noted Adam M. Leventhal, PhD, of the University of Southern California Keck School of Medicine in Los Angeles, and co-authors in an accompanying editorial.

“Given these gaps, it is uncertain that primary care interventions alone will reverse recent increases in youth e-cigarette use without new regulatory policies that restrict availability of tobacco products that attract youth,” they stated.

Thus far, those regulatory policies on e-cigarettes have been lackluster: In 2019, the Trump administration announced that it would enact an encompassing ban on all e-cigarette and vaping flavors. That plan would have prohibited all e-cigarette flavors except tobacco. However, by January 2020, the administration had backed off and only banned some e-cigarette flavors, such as fruit and mint, but allowed menthol and tobacco flavors to remain on the market.

An administration official called the softer stance a “smart, targeted policy that protects our kids without creating unnecessary [market] disruption,” while the American Cancer Society panned it as “a hollowed-out policy that will allow the tobacco industry to continue to attract kids to a lifetime of nicotine addiction,” according to Reuters.

In the evidence report, Shelley Selph, MD, MPH, of Oregon Health & Science University in Portland, and co-authors stated that “Behavioral interventions may reduce the likelihood of smoking initiation in nonsmoking children and adolescents,” but “Among children and adolescents who smoke cigarettes, behavioral interventions were not found to be effective for smoking cessation.”

They also reported that most of the studies done in nonsmokers were out of the U.S. and Western Europe, enrolled mostly white children and adolescents, and were required to be done in primary care settings.

As for the studies done in young smokers, the number of participants in a cessation intervention was low, neither bupropion SR nor NRT demonstrated an effect on smoking cessation in this population, and varenicline is not recommended for patients ages ≤16 years because previous research has indicated of lack of efficacy in younger children.

Selph’s group found 25 randomized clinical trials (n=44,521) that met inclusion criteria. They reported that behavioral interventions were linked with decreased likelihood of cigarette smoking initiation versus control interventions at 7 to 36 months’ follow-up in 13 trials (7.4% versus 9.2%, relative risk 0.82, 95% CI 0.73 to 0.92).

Again, there was no statistically significant difference between behavioral interventions and controls in smoking cessation in trials in smokers in nine trials (80.7% vs 84.1% continued smoking, RR 0.97, 95% CI 0.93 to 1.01).

Also, in two trials of 300-mg and 150-mg bupropion versus placebo, there were no significant benefits of medication on likelihood of smoking cessation at 26 weeks (17% for 300 mg and 6% for 150 mg versus 10%; 24% for 150 mg versus 28% placebo).

There also were no meaningful benefits at 12 months seen in a single trial of NRT versus placebo at 12 months (8.1% versus 8.2%), they stated. Also, trials found no beneficial intervention effect on health outcomes or on adult smoking, respectively.

Finally, “No trials of prevention in young adults were identified. Few trials addressed prevention or cessation of tobacco products other than cigarettes; no trials evaluated effects of interventions on e-cigarette use. There were few trials of pharmacotherapy, and they had small sample sizes.”

Leventhal’s group pointed out that e-cigarette companies are playing a different ground game when it comes to youth marketing by relying on posts to social media platforms and by engaging in product-for-play relationships with social media influencers.

As a result, the editorialists agreed with the task force that clinicians must look beyond the usual risk factors in youth — male, white race, parental smoking, stress, for example — that trigger prevention counseling and bear in mind that “the use of e-cigarettes and other tobacco products is being observed across all sociodemographic strata.”

  1. The U.S. Preventive Services Task Force (USPSTF) recommends that primary care physicians provide interventions to prevent initiation of tobacco use — including e-cigarettes — among school-aged children and adolescents.

  2. Current evidence is insufficient to assess the balance of benefits and harms of primary care-based interventions for the cessation of tobacco use among school-aged children and adolescents, according to the task force.

Shalmali Pal, Contributing Writer, BreakingMED™

USPSTF is supported by the Agency for Healthcare Research and Quality (AHRQ).

USPSTF members receive travel reimbursement and an honorarium for participating in USPSTF meetings. A member reported relationships with Healthwise.

The evidence report was supported by AHRQ.

Leventhal, Selph, and co-authors reported no relationships relevant to the contents of this paper to disclose.

Cat ID: 138

Topic ID: 85,138,730,138,43,143,192,489,925