Abstract
Objectives:
Adolescents with substance use disorder report high rates of tobacco use. Despite recommendations for counseling and pharmacotherapies for tobacco cessation among adolescents, their use remains low. The objective of this study was to characterize the availability of tobacco cessation counseling and pharmacotherapies, as well as smoking and vaping policies, in adolescent-serving substance use treatment facilities in the United States.
Methods:
The present study analyzed facility-reported data from the 2023 National Substance Use and Mental Health Services Survey. Substance use treatment facilities serving adolescents only (ages 11–21) were compared with those serving both adolescents and adults on tobacco use screening, availability of tobacco cessation education/counseling and pharmacotherapies (nicotine replacement therapy, bupropion, and varenicline), and smoking and vaping policies.
Results:
Most adolescent-only facilities offered tobacco use screening (82.6% vs 82.8% in adult/adolescent facilities) and education/counseling for tobacco cessation (71.9% vs 70.0% in adult/adolescent facilities). Adolescent-only facilities were more likely than adult/adolescent facilities to prohibit onsite smoking (84.7% vs 33.1%, respectively, P < 0.001) or vaping (87.7% vs 41.9%, respectively, P < 0.001), yet less likely to offer tobacco cessation pharmacotherapies to patients (20.7% vs 45.5%, respectively, P < 0.001).
Conclusions:
While most adolescent-only substance use treatment facilities offered tobacco cessation education or counseling and restricted tobacco use at their sites, they were less likely than adult/adolescent facilities to offer pharmacotherapy for tobacco cessation. This reflects a missed opportunity to offer robust options to treat tobacco use among adolescents with substance use disorders.
Keywords: smoking cessation, adolescents, substance use treatment, vaping
In 2024, 8.1% of US middle and high school students reported tobacco product use (5.9% reported using e-cigarettes, 2.4% oral nicotine pouches, and 1.4% combustible cigarettes), increasing their risks for nicotine and tobacco addiction, future cardiopulmonary diseases, and cancer.1 Implementation of tobacco cessation strategies is key, though the optimal approach remains unclear. First-line pharmacotherapies for tobacco use disorder, including nicotine replacement therapy (NRT), bupropion, and varenicline, are not approved for individuals under age 18 (for varenicline, age 16). The evidence for using pharmacotherapy for adolescents is mixed, with some trials showing no effect on abstinence rates at 6 and 12 months post treatment and others showing positive effects.2–6 Studies of behavioral interventions like counseling have also showed mixed results for adolescent tobacco cessation.4 Still, the American Academy of Pediatrics (AAP) recommends using NRT in combination with counseling for tobacco cessation in adolescents due to the potential for benefit versus the substantial known harms of continued tobacco use.7 However, utilization of medications for treatment of adolescent tobacco use remains limited.8
Adolescents with substance use disorders (SUD) show high rates of tobacco/nicotine product use (57%), making them particularly vulnerable to tobacco-related disease.9 While there has been progress in preventing adolescent tobacco use over the past 30 years, the higher prevalence of tobacco use among adolescents with SUD highlights an opportunity for targeted cessation interventions.10 Only one-third to one-half of US SUD treatment facilities for adults offer approved tobacco cessation pharmacotherapy.11 However, the proportion of adolescent-serving SUD treatment programs that offer tobacco cessation interventions, as well as the policies of those programs regarding patient tobacco use (smoking, vaping), is unknown. Understanding the factors associated with the availability of tobacco cessation medications and services may help identify opportunities to increase tobacco treatment accessibility as continued research identifies the interventions most effective for adolescents. We aim to assess the proportion of adolescent-serving substance use treatment programs that offer tobacco cessation counseling and pharmacotherapy, program characteristics associated with offering these interventions, and their tobacco use policies.
METHODS
We conducted a cross-sectional analysis of the 2023 National Substance Use and Mental Health Services Survey data set. The survey, administered by the Substance Abuse and Mental Health Services Administration (SAMHSA), queries directors of US substance use and mental health treatment facilities on the SAMHSA Inventory of Substance Use and Mental Health Treatment Facilities (I-TF) on the treatment and services offered. The facility response rate in 2023 was 87.9%.12 We excluded facilities whose focus was exclusively mental health, facilities located outside of the United States, and those missing outcome and facility characteristic variables (Supplement, Supplemental Digital Content 1, http://links.lww.com/JAM/A735).
Using the AAP definition of adolescence as ages 11–21 years, we characterized facilities as either adolescent-only (ie, serving patients age ≤ 21) or adult/adolescent (ie, all ages).13 The goals were to compare these 2 types of facilities on: (1) the proportion offering tobacco cessation education/counseling and pharmacotherapies, and (2) their smoking and vaping policies. We used χ2 tests with significance at P < 0.05 to compare differences in proportions between adolescent-only and adult/adolescent facilities to better understand the scope of potential access issues among adolescents. Multivariable logistic regression models were used to estimate adjusted odds ratios (aOR) between availability of pharmacotherapies and ownership (private for-profit, private not-for-profit or government owned), treatment focus (substance use or both substance use and mental health), accepted insurances, treatment setting (inpatient, outpatient, or residential), integrated primary-care programs, smoking-policies, vaping-policies, tobacco use screening and counseling, U.S. census region, and state Medicaid-expansion status. Analyses used StataMP v18 (StataCorp). The University of Chicago Institutional Review Board exempted the study.
RESULTS
Of 29,113 facilities in the I-TF, 14,102 (48.4%) reported a substance use treatment focus (Supplemental Table 1, Supplemental Digital Content 1, http://links.lww.com/JAM/A735), with most (13,735; 97.4%) serving both adults and adolescents and a minority (367; 2.6%) exclusively serving adolescents. Most facilities offered tobacco screening or education/counseling for tobacco cessation with no differences between facility types (Table 1). A higher proportion of adolescent-only facilities compared with adult/adolescent facilities banned onsite e-cigarette use/vaping (87.7% vs 41.9%) and/or combustible smoking (84.7% vs 33.1%; Table 1). However, among adolescent-only facilities, only 20.7% offered any tobacco cessation medications (16.9% NRT, 14.7% bupropion or varenicline, 10.9% both NRT and bupropion or varenicline), which is significantly lower than the 45.5% of adult/adolescent facilities that offered any cessation medication (36.1% NRT, 41.2% bupropion or varenicline, 31.9% both NRT and bupropion or varenicline; Table 1).
TABLE 1.
Policies, Pharmacotherapies, and Services in Substance Use Facilities That Serve Adolescents Only Serving Compared With Those Serving Adults and Adolescents
| Adolescent* Only Facilities; 367 (2.6%)† | Adult and Adolescent Facilities; 13,735 (97.4%)† | Total; 14,102 (100.0%) | |||
|---|---|---|---|---|---|
| Characteristic | n (%) | n (%) | n (%) | X2 (Degrees of Freedom)‡ | P |
| Screened for tobacco use | |||||
| No | 64 (17.4) | 2357 (17.2) | 2421 (17.2) | 0.02 (1) | 0.889 |
| Yes | 303 (82.6) | 11,378 (82.8) | 11,681 (82.8) | — | — |
| Provided education and counseling for tobacco cessation | |||||
| No | 103 (28.1) | 4048 (29.5) | 4151 (29.4) | 0.34 (1) | 0.560 |
| Yes | 264 (71.9) | 9687 (70.5) | 9951 (70.6) | — | — |
| Restricted combustible smoking at facility | |||||
| No | 56 (15.3) | 9194 (66.9) | 9250 (65.6) | 423.01 (1) | < 0.001 |
| Yes | 311 (84.7) | 4541 (33.1) | 4852 (34.4) | — | — |
| Restricted e-cigarette vaping at facility | |||||
| No | 45 (12.3) | 7982 (58.1) | 8027 (56.9) | 306.48 (1) | < 0.001 |
| Yes | 322 (87.7) | 5753 (41.9) | 6075 (43.1) | — | — |
| Offered either nicotine∥ or non-nicotine replacement (varenicline or bupropion)§ therapies | |||||
| No | 291 (79.3) | 7493 (54.5) | 7784 (55.2) | 88.45 (1) | < 0.001 |
| Yes | 76 (20.7) | 6242 (45.5) | 6318 (44.8) | — | — |
| Offered non-nicotine replacement therapies (varenicline or bupropion)∥ | |||||
| No | 313 (85.3) | 8770 (63.9) | 9083 (64.4) | 71.64 (1) | < 0.001 |
| Yes | 54 (14.7) | 4965 (36.1) | 5019 (35.6) | — | — |
| Offered nicotine replacement therapies§ | |||||
| No | 305 (83.1) | 8080 (58.8) | 8385 (59.5) | 87.41 (1) | < 0.001 |
| Yes | 62 (16.9) | 5655 (41.2) | 5717 (40.5) | — | — |
| Offered both nicotine∥ and non-nicotine replacement (varenicline or bupropion)§ | |||||
| No | 327 (89.1) | 9357 (68.1) | 9684 (68.7) | 73.10 (1) | < 0.001 |
| Yes | 40 (10.9) | 4378 (31.9) | 4418 (31.3) | — | — |
Bold indicates statistical significance P < 0.05.
Includes facilities serving only patients who meet the AAP definition of adolescence (11–21 y).
Percentages are calculated out of a denominator of total number of facilities included in the analysis. Remaining percentages are calculated out of denominator total number of adolescent-only facilities, or adult and adolescent facilities.
χ2 tests facility characteristics between adolescent-only and adult and adolescent-serving facilities.
Nicotine replacement therapy medications typically includes formulations such as lozenges, gum, patch, nasal spray, and inhaler.
Non-nicotine replacement therapy medications include bupropion and varenicline.
Among adolescent-only facilities, factors associated with increased likelihood of offering NRT included integrated primary care services [aOR = 3.82 (95% CI, 1.67–8.74); P = 0.002] and accepting private insurance [aOR = 25.25 (95% CI, 5.09–125.16); P < 0.001]. Similarly, offering integrated primary care services [aOR = 6.51 (95% CI, 2.89–14.65); P < 0.001] and accepting private insurance [aOR = 7.89 (95% CI, 2.35–26.5); P = 0.001] increased the likelihood of offering bupropion or varenicline (Table 2).
TABLE 2.
Characteristics of Adolescent-only Serving Substance Use Treatment Facilities Associated With Offering Nicotine Replacement Therapies and Non-nicotine Replacement Therapies
| Adolescent-only Facilities; n = 367 (2.6%)* | ||||||
|---|---|---|---|---|---|---|
| NRT (n = 62) | Non-NRT (n = 54) | |||||
| Characteristic | n (%)† | Multivariate Odds Ratios; aOR (95% CI)‡ | P | n (%)† | Multivariate Odds Ratios; aOR (95% CI)‡ | P |
| Treatment Focus | ||||||
| Substance use treatment focus only | 25 (14.5) | Reference | Reference | 20 (11.6) | Reference | ref |
| Mixed substance use and mental health focus | 37 (19.0) | 0.89 (0.42, 1.9) | 0.77 | 34 (17.4) | 1.33 (0.61, 2.88) | 0.476 |
| Ownership | ||||||
| Private, for-profit | 13 (18.1) | Reference | Reference | 11 (15.3) | Reference | ref |
| Private, non-profit | 43 (17.0) | 2.14 (0.68, 6.77) | 0.194 | 36 (14.2) | 1.42 (0.44, 4.58) | 0.56 |
| State/local/federal/tribal govt | 6 (14.3) | 1.16 (0.28, 4.89) | 0.838 | 7 (16.7) | 1.28 (0.29, 5.68) | 0.741 |
| Region | ||||||
| Northeast | 11 (44.0) | Reference | Reference | 5 (20.0) | Reference | ref |
| Midwest | 15 (25.4) | 0.32 (0.08, 1.25) | 0.102 | 13 (22.0) | 1.29 (0.3, 5.63) | 0.732 |
| South | 10 (11.4) | 0.18 (0.03, 0.9) | 0.037 | 10 (11.4) | 1.54 (0.29, 8.19) | 0.61 |
| West | 26 (13.3) | 0.22 (0.06, 0.83) | 0.026 | 26 (13.3) | 1.02 (0.25, 4.11) | 0.977 |
| Integrated primary-care | ||||||
| No | 36 (12.3) | Reference | Reference | 25 (8.9) | Reference | ref |
| Yes | 26 (34.7) | 3.82 (1.67, 8.74) | 0.002 | 29 (38.7) | 6.51 (2.89, 14.65) | < 0.001 |
| Accepts Medicaid | ||||||
| No | 10 (9.4) | Reference | Reference | 7 (6.6) | Reference | ref |
| Yes | 52 (19.9) | 0.64 (0.19, 2.19) | 0.482 | 47 (18.0) | 1.42 (0.37, 5.4) | 0.608 |
| Accepts private insurance | ||||||
| No | 2 (1.4) | Reference | Reference | 4 (2.7) | Reference | ref |
| Yes | 60 (27.2) | 25.25 (5.09, 125.16) | < 0.001 | 50 (22.6) | 7.89 (2.35, 26.5) | 0.001 |
| Medicaid expanded state | ||||||
| No | 9 (13.6) | Reference | Reference | 8 (12.1) | Reference | ref |
| Yes | 53 (17.6) | 1.57 (0.44, 5.55) | 0.488 | 46 (15.3) | 2.48 (0.68, 9.09) | 0.171 |
| Outpatient substance use treatment | ||||||
| No | 29 (39.7) | Reference | Reference | 24 (32.9) | Reference | ref |
| Yes | 33 (11.2) | 0.57 (0.19, 1.68) | 0.305 | 30 (10.2) | 0.8 (0.25, 2.54) | 0.709 |
| Inpatient substance use treatment | ||||||
| No | 55 (15.7) | Reference | Reference | 49 (14.0) | — | — |
| Yes | 7 (41.2) | 2.31 (0.63, 8.41) | 0.205 | 5 (29.4) | 2.28 (0.61, 8.48) | 0.221 |
| Residential substance use treatment | ||||||
| No | 25 (9.7) | Reference | Reference | 22 (8.6) | Reference | ref |
| Yes | 37 (33.6) | 2.16 (0.75, 6.25) | 0.156 | 32 (29.1) | 2.79 (0.9, 8.67) | 0.076 |
| Screening for tobacco use | ||||||
| No | 5 (7.8) | Reference | Reference | 1 (1.6) | Reference | ref |
| Yes | 57 (18.8) | 1.51 (0.44, 5.23) | 0.514 | 53 (17.5) | 11.72 (1.40, 98.06) | 0.023 |
| Education and counseling for smoking/tobacco cessation | ||||||
| No | 5 (4.9) | Reference | Reference | 7 (6.8) | Reference | ref |
| Yes | 57 (21.6) | 6.36 (2.09, 19.34) | 0.001 | 47 (17.8) | 2.23 (0.77, 6.45) | 0.137 |
| Vaping policy | ||||||
| Not allowed | 55 (17.1) | Reference | Reference | 46 (14.3) | Reference | ref |
| Allowed | 7 (15.6) | 0.61 (0.06, 5.77) | 0.664 | 8 (17.8) | 2.5 (0.12, 51.84) | 0.553 |
| Smoking policy | ||||||
| Not allowed | 52 (16.7) | Reference | Reference | 45 (14.5) | Reference | ref |
| Allowed | 10 (17.9) | 2.17 (0.28, 16.67) | 0.457 | 9 (16.1) | 0.8 (0.05, 14.19) | 0.882 |
Bold indicates statistical significance P < 0.05. Bold indicates statistical significance P < 0.005.
Includes facilities serving only patients who meet the AAP definition of adolescence (11–21 y).
Percentages are calculated out of a denominator of number of facilities that have the characteristic.
Odds ratios are estimated using multivariable logistic regression models controlling for and ownership (private for-profit, private not-for-profit or government owned), treatment focus (substance use or both substance use and mental health), accepted insurances, treatment setting (inpatient, outpatient, or residential), integrated primary-care programs, smoking-policies, vaping-policies, tobacco use screening and counseling, US census region, and state Medicaid-expansion status.
NRT indicates nicotine replacement therapy; aOR, adjusted odds ratio.
DISCUSSION
Adolescent-only substance use treatment facilities offered tobacco cessation screening and education/counseling at similar rates to adult/adolescent facilities and were more likely to restrict smoking and vaping at their site. However, less than a quarter of adolescent-only facilities offered patients front-line tobacco cessation medications, compared with half of adult/adolescent facilities offering these medications. The limited availability of pharmacotherapy at both adolescent-serving and adult/adolescent facilities represents a treatment gap.
Ongoing efforts to evaluate the efficacy of tobacco cessation interventions for adolescents may contribute to the limited availability of these medications at adolescent-serving facilities. However, our results also identify additional factors affecting the availability of pharmacotherapies. For instance, facilities accepting private insurance were more likely to offer NRT and bupropion/varenicline. As insurance coverage plays a role in offering these medications, advocacy in this area may be valuable.14 Substance-use treatment facilities, especially those offering primary care services, represent important access points to care for adolescents with SUD. Offering a broad range of early interventions during these critical access points may reduce tobacco use and associated health risks among adolescents with high rates of tobacco use.
While current interventions specific to e-cigarette cessation are limited, the combination of facility vaping bans and on-site education and counseling may be helpful.15 Recent evidence supports varenicline’s efficacy for vaping cessation in adolescents, indicating a further opportunity to intervene on e-cigarette use as a critical early stage of tobacco dependence in adolescents.6
Strengths of this study include usage of national sample of facilities and ability to control for service delivery variables. Limitations include recall bias in facility directors/respondents, the small proportion of facilities serving adolescents only compared with those serving all ages, the lack of detail on actual prescription and receipt of pharmacotherapies, and the lack of inclusion of additional settings (eg, primary care, outpatient mental health) where adolescents with SUD seek treatment. In addition, facilities that accept all ages may not necessarily have dedicated adolescent services or treat large numbers of adolescents.
In sum, the limited availability of tobacco cessation medications for adolescents with SUD reflects a missed opportunity to offer the full range of potential interventions for tobacco use and prevent its long-term medical and psychological sequelae in this population. Future efforts should focus on conducting high-quality trials on pharmacotherapy and counseling for tobacco use in youth with SUD to further develop an evidence base for this population. Lastly, access to tobacco cessation therapies among adolescents may be improved through policy-based interventions focused on facility-based financial reimbursement, improved coverage of therapies among Medicaid plans, and advocacy efforts to increase awareness of therapies among prescribers, patients, and facilities.
Supplementary Material
Supplemental Digital Content is available for this article. Direct URL citations are provided in the HTML and PDF versions of this article on the journal’s website, www.journaladdictionmedicine.com.
Acknowledgments
AK is affiliated with the non-profit Respiratory Health Association as a consultant for tobacco cessation programming. Salary support for EB was provided by the National Institute on Drug Abuse (4R00DA054260). The remaining authors report no conflicts of interest.
Footnotes
The authors adhere to this policy and have not posted this work on a preprint server.
REFERENCES
- 1.Jamal A, Park-Lee E, Birdsey J, et al. Tobacco product use among middle and high school students - National Youth Tobacco Survey, United States, 2024. MMWR Morb Mortal Wkly Rep. 2024;73(41): 917–924. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Scherphof CS, van den Eijnden RJJM, Engels RCME, et al. Long-term efficacy of nicotine replacement therapy for smoking cessation in adolescents: a randomized controlled trial. Drug Alcohol Depend. 2014;140:217–220. [DOI] [PubMed] [Google Scholar]
- 3.Killen JD, Robinson TN, Ammerman S, et al. Randomized clinical trial of the efficacy of bupropion combined with nicotine patch in the treatment of adolescent smokers. J Consult Clin Psychol. 2004;72(4): 729–735. [DOI] [PubMed] [Google Scholar]
- 4.Selph S, Patnode C, Bailey SR, et al. Primary care-relevant interventions for tobacco and nicotine use prevention and cessation in children and adolescents: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2020;323 (16):1599–1608. [DOI] [PubMed] [Google Scholar]
- 5.Gray KM, Baker NL, McClure EA, et al. Efficacy and safety of varenicline for adolescent smoking cessation: a randomized clinical trial. JAMA Pediatr. 2019;173(12):1146–1153. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Evins AE, Cather C, Reeder HT, et al. Varenicline for youth nicotine vaping cessation: a randomized clinical trial. JAMA. 2025;333(21): 1876–1886. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Jenssen BP, Walley SC, Boykan R, et al. Protecting children and adolescents from tobacco and nicotine. Pediatrics. 2023;151(5): e2023061805. [DOI] [PubMed] [Google Scholar]
- 8.Chadi N, Rodean J, Earlywine JJ, et al. Treatment for nicotine use disorder among Medicaid-enrolled adolescents and young adults. JAMA Pediatr. 2019;173(11):1103–1105. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Cavazos-Rehg PA, Krauss MJ, Spitznagel EL, et al. Youth tobacco use type and associations with substance use disorders. Addiction. 2014;109(8):1371–1380. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Mejia MC, Adele A, Levine RS, et al. Trends in cigarette smoking among United States adolescents. Ochsner J. 2023;23(4):289–295. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Holt AG, Hussong A, Castro MG, et al. Smoking policies of outpatient and residential substance use disorder treatment facilities in the United States. Tob Use Insights. 2024;17:1179173X241254803. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Substance Abuse and Mental Health Services Administration. National Substance Use and Mental Health Services Survey (N-SUMHSS) 2023. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. 2024. Accessed December 2, 2024: https://www.samhsa.gov/data/system/files/media-puf-file/N-SUMHSS-2023-DS0001-info-codebook_v1.pdf [Google Scholar]
- 13.Hagan J, Shaw J, Duncan P. Bright futures: guidelines for health supervision of infants, children, and adolescents [Pocket Guide]. American Academy of Pediatrics; 2017, 4th edn. Elk Grove Village, IL: American Academy of Pediatrics. 2017. [Google Scholar]
- 14.DiGiulio A, Tynan MA, Schecter A, et al. State medicaid coverage for tobacco cessation treatments and barriers to accessing treatments - United States, 2018–2022. MMWR Morb Mortal Wkly Rep. 2024; 73(14):301–306. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Staff J, Mongilio JM, Maggs JL, et al. Household vaping bans and youth e-cigarette use. Addict Abingdon Engl. 2024;119(1):74–83. [DOI] [PMC free article] [PubMed] [Google Scholar]
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