Doctors are prescribing off-label nicotine replacements for teens addicted to vaping

Addicted to nicotine early.
Addicted to nicotine early.
Image: Reuters/Brendan McDermid
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With over 1,000 cases and 18 deaths attributed to a mysterious vaping-related pulmonary illness (VAPI) in the United States, a growing number of teens have been going to the family doctor with concerns about their e-cigarette vaping habits. 

The young patients are worried about developing VAPI themselves, or they’re feeling anxious about their dependence on nicotine. With more than a quarter of US teenagers having vaped in the last 30 days, the number of apprehensive visits to the pediatrician are only likely to increase—especially if the number of VAPI cases continues to grow and the Trump administration makes good on its plan to ban flavored e-cigarettes.

The trouble is, there are currently no US guidelines—from federal organizations or medical groups—on how doctors should help young patients who want to quit vaping. The American Academy of Pediatrics is currently working with doctors to develop guidelines for national distribution. But for now, the association simply encourages doctors to follow existing guidelines to protect children from tobacco smoke, and to use their best judgement with each individual patient. 

So pediatricians have had to improvise solutions. Quartz spoke with several doctors who have started prescribing off-label nicotine replacement therapies (NRTs) to their young patients who have been vaping nicotine-filled e-cigarettes. 

“We’re at a little bit of a disadvantage because we don’t know what will work,” says Suzanne Tanski, a pediatrician at the Children’s Hospital at Dartmouth in New Hampshire who has prescribed NRTs to a handful of her young patients. 

Nicotine replacement therapies—like the nicotine patch, gum, and lozenges—are safe and effective for adults who want to quit smoking cigarettes. Research in adult populations suggests they work especially well when used in conjunction with one another; counseling can help, too. But the research supporting their use in children doesn’t yet exist. “I read all the literature that is coming out,” says Tanski. “I’m confident in the safety profile for anybody,” she says. “But we don’t have great efficacy data.” 

In one case, Tanski saw a teenager who did not have VAPI but was hospitalized for another reason. “She thought she was going to die [because of her vaping],” she says. The patient’s mother was aware of her daughter’s habit, and was very supportive in helping her quit, including with the help of an NRT. In another case, an 18-year-old come to Tanski saying that he was trying to quit vaping because he knew it was making him feel terrible, but he didn’t know the best way to quit. She also gave him a prescription.

For adults, nicotine replacement therapies are simply available over the counter. But teenagers have to get a prescription because NRTs haven’t been approved by the US Food and Drug Administration (FDA) for use in children. Instead, they’re considered an off-label medication for anyone under 18. 

Off-label prescribing in pediatrics isn’t unheard of; it also falls in line with the APA’s guidelines for teens addicted to cigarettes. “Many drugs aren’t approved for children because they just haven’t been tested,” says Karen Wilson, a pediatrician at Icahn School of Medicine at Mount Sinai in New York. Kids were never supposed to need nicotine replacement therapies because they shouldn’t have had access to the addictive chemical in the first place. 

Untested doesn’t necessarily mean risky, either. “[NRTs] have very low abuse potential because you don’t get a buzz or head rush,” Tanski says, which is what people experience when smoking. Instead, they’re designed to give a user a low dose of nicotine over time, so that they don’t feel withdrawal symptoms like irritability, fatigue, nausea, and headaches. While there’s always a risk that a very small child could be poisoned by nicotine by accidentally chewing gum or putting on a patch, that risk is the same as when NRTs are prescribed to adults.

Nicotine replacements that are available without a prescription for adults are the ones most commonly prescribed to teens. There’s even less data on the efficacy of nicotine inhalers and prescription drugs like varenicline (known as Chantix) and bupropion (known as Zyban), so they’re rarely given to children. A randomized clinical trial that wrapped up this year found that varenicline was not effective at helping people aged 14 to 21 quit smoking.   

Most insurance should cover NRT prescriptions for kids, including the Affordable Care Act, says Brian Jenssen, a primary care pediatrician and researcher at the Children’s Hospital of Philadelphia in Pennsylvania. For those without insurance, Jenssen recommends calling 1-800-QUIT-NOW—a federally and state-funded resource that provides free or reduced-cost NRTs (depending on where you live) in addition to free counseling at all hours. The program may be able to offer support for teens quitting, but it varies state by state.

Additionally, in January of this year the nonprofit organization Truth Initiative created a free, text-based support system for teens who want to quit vaping. The automated messages ask users motivational questions, like why they want to quit, in addition to providing support if a person is experiencing a craving. Once enrolled, a user gets a text every day for a month after their desired quit date. One of the texts I received after saying I was a 17-year-old trying to quit Juul read: “[This is Quitting]: Ashley says ‘You won’t always be this agitated.’ Quitting will be hard when life is stressful but you dealt with stress before you JUULed and you will now, too.”

It’s unclear if the campaign will work in the long run, but a letter published this summer with early results showed that 27,000 teens and young adults had enrolled within the first five weeks. After three months, 15.5% of them hadn’t vaped in the last month.

Jenssen has also prescribed NRTs to some of his teenage patients who are addicted to nicotine from e-cigarettes. But he’s not super comfortable doing it, because the best evidence that they work is anecdotal. “No one wants to be flying blind or making it up,” says Wilson.

The gold standard for teenage patients would be some sort of randomized controlled trial demonstrating NRT’s efficacy for quitting e-cigarettes—much like what physicians already have for adults who want to quit smoking. Unfortunately, those studies take years, if not decades.

This story has been updated to reflect the most recent reports of VAPI from the CDC.