Non-combustible nicotine product cessation interventions in adolescents and young adults: A systematic review

Abstract

New nicotine products such as e-cigarettes, heated tobacco and smokeless tobacco/nicotine products, are popular among young people. Most regret having started using these products, but little is known about how to help adolescents and young adults to quit most effectively. This systematic review aimed to identify all existing studies on the efficacy of cessation interventions on the use of novel nicotine and tobacco products in adolescents and young adults. Original randomized controlled trials on cessation of use of e-cigarettes, heated tobacco and smokeless nicotine/tobacco products aimed at young people aged between 15 and 25 were included. The exclusion criteria were interventions on cessation of cigarette/conventional tobacco smoking and studies that focused on preventing initiation rather than cessation. Both researchers independently screened articles and extracted data. The risk of bias was assessed. A total of 345 papers were screened for eligibility, and 9 original studies were included. All studies were conducted in the United States. Populations ranged from 24 to 2588. Five studies reported significant effects of the study interventions, of which 4 were extensive multi-component smokeless tobacco cessation interventions in a high school or college setting. The fifth effective intervention was an SMS text-based e-cigarette cessation program. Low-grade evidence suggests that multi-component interventions that include counseling and an SMS text-based cessation program that is also based on behavioral support may be effective in the cessation of the use nicotine products in adolescents and young adults. Further research that includes cessation of the use of all new tobacco- and nicotine products is needed.

Keywords

nicotine tobacco cessation intervention addiction adolescents young adults

Introduction

While smoking rates are decreasing in many countries,^1-3 newer products such as e-cigarettes, nicotine pouches and heated tobacco have entered the market and are becoming very popular among adolescents and young adults.^4-6

E-cigarettes are the most common tobacco/nicotine products among middle- and high school students in the United States (US); 10.6% of high school students reported current e-cigarette use in 2023.⁷ In the United Kingdom (UK), 19.2% of 11- to 20-year-olds are currently using or have used e-cigarettes.⁸ A European study of 14- to 17-year-olds showed that more than a third had tried e-cigarettes, but there was a large variation among the 7 countries investigated.⁹

Europe accounts for almost half of the global revenue from nicotine pouches,¹⁰ and these are especially popular among young people in North European countries. In Sweden, approximately 20% of 17- to 29-year-olds had used “all white snus” (nicotine pouches) within the last month.¹¹ In Denmark, more than 11% of 15- to 29-year-olds said they used a “smokeless tobacco product” daily or occasionally (in reality, more than 8 out of 10 of these used nicotine pouches)^12,13 69.4% of these young users did not smoke cigarettes and.¹²

Japan has been a major market for heated tobacco products, and use is more prevalent among young adults below age thirty than among older adults, in spite of a lower cigarette smoking rate in the younger adults.¹⁴ Moreover, in Europe, where heated tobacco products are not (yet) as popular, they primarily appeal to young people.¹⁵

The use of nicotine products is shown to lead to nicotine dependence, even in adolescents. In a large survey, 4 out of 10 middle and high school students who had used e-cigarettes in the previous 30 days reported being dependent,¹⁶ and a survey of young people showed that patterns of nicotine dependence were comparable across e-cigarette users and users of conventional cigarettes.¹⁷ Some studies, however, have reported even higher dependency among users of nicotine products than among users of conventional cigarettes.^18,19 Several studies have found that most of the adolescents and young adults who reported nicotine dependence were poly users of different nicotine-containing products.^19-21

As with cigarette smoking, there is widespread intention to quit the use of nicotine products.^22,23 More than 70% of 16- to 29-year-old daily users of smokeless nicotine products in Denmark have considered quitting in the last month.²⁴

Smoking cessation services are part of the WHO’s recommended effective MPOWER measures, the technical package designed to help countries implement the Framework Convention on Tobacco Control.²⁵ Nevertheless, knowledge is sparse when it comes to what works in helping adolescents and young adults quit smoking cigarettes,^26-29 and more so when it comes to interventions targeting the cessation of novel nicotine product usage among young people. Many cessation counselors report that they find it very difficult to help adolescents and young adults stop using nicotine products, especially because of the lack of resources and lack of training when it comes to tobacco and nicotine cessation in adolescents and young adults.³⁰

This study aimed to perform a systematic review of all existing randomized controlled trials on the cessation of e-cigarettes, heated tobacco and oral nicotine/tobacco products in adolescents and young adults.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines (PRISMA 2020) were followed when applicable.

Eligibility criteria

Original randomized controlled studies (RCTs) in any language on real-world interventions targeting adolescents and young adults between 15 and 25 years were included. The aim of the intervention was the cessation of the use of non-combustible nicotine products: e-cigarettes, heated tobacco and smokeless nicotine and tobacco products. Exclusion criteria were cessation interventions only directed towards conventional tobacco smoking (cigarettes, cigarillos, cigars, water pipes) and studies that did not report on the effect of nicotine product cessation interventions (prevention programs, evaluation of process implementation, study protocols).

Information sources

A search was carried out in PubMed and The Cochrane Library (including Embase, CT.gov, ICTRP, and CINAHL) (Supplemental Table S1).

Search strategy

The first search was conducted on December 30, 2022. It included the keywords “child” OR “adolescent” OR “adolescence” OR “young adults” AND “nicotine” OR “snus” OR “chewing tobacco” OR “nicotine pouch” OR “e-cigarette” OR “heated tobacco” OR “smokeless tobacco” AND “reduction” OR “cessation.” Keywords had to be included in the title or abstract. Further, the filters “randomized controlled trial” and “clinical trials” were applied. A second search for any newly published studies was conducted on January 4, 2024, with an updated search strategy now including the keywords “ANDS,” “ENDS,” and “VAPE.”

As young people find it difficult to tell the difference between nicotine pouches and oral tobacco products (snus, chewing tobacco, smokeless tobacco), our search also included oral tobacco products, even though they are not novel nicotine products.

Both authors first screened papers by hand for eligibility based on title and abstract. Both authors then assessed studies selected for eligibility in a full-text review after the first round of screening. Additionally, references from the eligible papers were carefully examined for missed papers. The agreement of both authors was necessary to include or exclude a title.

Data collection process

During the data collection process, each author independently read the full paper and extracted data to a predefined table framework. Results were then compared, discussed and merged into one detailed results table (Supplemental Table S2).

Data items and effect measures

The primary outcome was defined as the effect of a study cessation intervention. We gathered odds ratios (OR), adjusted odds ratios if presented (aOR), and tests for independence between the study population and the control group with a 95% confidence interval (CI).

Secondary outcomes were defined as other cessation-related factors (eg, factors associated with cessation or intervention effect). We gathered odds ratios (OR), with a 95% confidence interval, and standard mean differences (SMD) or percentages.

Study risk of bias assessment

The Revised Cochrane Risk of Bias tool for randomized trials (RoB 2) and the tool for cluster randomized trials (RoB 2 CRT)³¹ were used to assess the study’s risk of bias. The tool provided an overall bias judgment according to the rules of RoB 2 (Supplemental Figure S1). Assessment of the risk of bias was performed in cooperation between both authors and in full agreement.

Synthesis methods

Year of publication, type of study, conflict of interest, risk of bias, study method, number of participants, follow-up time and rate, description of the intervention in the intervention and control group, primary outcomes, validation, and results were extracted from all studies (Supplemental Table S2). The study results were then synthesized based on the type of tobacco- or nicotine product the intervention targeted. The methods and results from the studies were then further simplified and are presented in Table 1.

Table 1.

Primary outcomes: effects of e-cigarette or smokeless tobacco cessation interventions targeting adolescents and young adults between 12 and 25 years old.

First author, year of publication, country, conflict of interest with tobacco or nicotine industry, risk of bias	Method, follow-up time and rate	Intervention	Participants	Major outcomes (intervention group(s) compared with control group(s) under ITT)	Overall findings
E-cigarettes
³²Graham A L, 2021, USA, No COI, low	RCT, 7-month follow-up post randomization	“This is quitting” SMS text-based cessation program	2588 young adult (18-24 years) current EC users motivated to quit	Self-reported 30-day ppa of EC at follow-up (24.1% vs 18.6%)	Significant effect
³⁴Palmer A M, 2022, USA, No COI, low	Pilot RCT, 7-week follow-up post target quit date	Financial incentives when validated abstinent. Delivered via an app + provided information for “this is quitting” (SMS text-based cessation program)	27 young adults (12-21 years, >95% of participants were over 18) current EC users motivated to quit	Self-reported ppa of EC at follow-up (27.3% in the CM group and 20% in the control group) (Validated ppa for 28 days)	No significant effect compared with financial incentives, regardless of abstinence
³⁵ Sahr M, 2021, USA, No COI, high	Pilot RCT, 6-month follow-up post baseline assessment	Two intervention groups received behavioral support and either NRT or a vape-taper plan	24 young adults (18-24 years) current EC users motivated to quit	Self-reported ppa of EC at follow-up under ITT (42.9% in the NRT group, 75% in the vape-taper group and 44.4% in the control group)	No significant difference between the interventions or compared with the control group
Oral smokeless tobacco
³⁶Danaher B G, 2013, USA, No COI, low	RCT, 6-month follow-up post baseline assessment	Enhanced interactive condition of “MyLastDip” web-based smokeless tobacco cessation program	1716 young adults (14-25 years) current ST users motivated to quit all tobacco	Self-reported 7-day ppa of ST/all tobacco products at 6-month follow-up under ITT (33.3%/29.6% in the intervention group and 33.9%/29.0% in the control group)	An enhanced interactive condition is not significantly more effective than a basic condition
³⁷Gansky, 2005, USA, No COI, low	CRT, 12-month follow-up post randomization	Multiple component^a athletic trainer-directed intervention in a college setting	637 young male college baseball athletes (17-20 years), current ST users	Self-reported 30-day ppa of ST at follow-up (36% vs 37%)	No significant effect
³³Stotts R C, 2003, USA, No COI, high	RCT, 12-month follow-up post intervention	Multiple component intervention.^a Two intervention groups: nicotine patch and placebo patch	303 young male high school students (14-19), current ST users	Self-reported 30-day ppa of ST at follow-up (17% in the nicotine patch group, 25% in the placebo patch group, and 11% in the control group) (validated saliva cotinine at follow-up)	Significant effect of the behavioural component in combined intervention groups. No significant effect of the nicotine patch compared to the placebo patch
³⁸Walsh M, 1999, USA, not stated, some concerns	CRT, 12-month follow-up post baseline assessment	Multiple component^a athletic team-based intervention in a college setting + nicotine patch	360 young male college football and baseball athletes,^b current ST users	Self-reported 30-day ppa of ST at follow-up (35% vs 16%)	Significant effect
³⁹Walsh M, 2003, USA, not stated, low	CRT, 12-month follow-up post intervention start for intervention group, and post randomization for control group	Multiple component^a athletic team-based intervention in a high school setting	307 young male high school baseball athletes,^c current ST users	Self-reported 30-day ppa of ST at follow-up (27% vs 14%)	Significant effect
⁴⁰Walsh M, 2010, USA. Not stated, high	CRVT, 12-month follow-up post baseline assessment	Multiple component^a peer- and nurse-led intervention in a high school setting	458 young male high school students,^c current ST users	Self-reported 30-day ppa for all ST users at follow-up (52% vs 48%). Self-reported 30-day ppa of ST at follow-up for baseline nonsmoking only (62% vs 36%)	No significant effect on overall ST cessation Significant effect on nonsmoking ST users

CRT, cluster randomized trial; EC, e-cigarette; ITT, intention to treat; ppa, point abstinence prevalence; ST, smokeless tobacco (snuff, chewing tobacco, both); RCT, randomized controlled trial; NRT, nicotine replacement therapy.

^aAll multiple-component interventions included voluntary counseling, peer elements and a dental element.

^bAge not stated, presumed to be 18-24 years old.

^cAge not stated, presumed to be 14-18 years old.

Secondary outcomes were extracted from papers using the same methods as the primary outcome and are presented in the supplemental Table S3.

Results

Study selection

In total, 165 papers were screened for eligibility based on title and abstract (Figure 1). Eleven papers were assessed for eligibility after the first round of screening. Additionally, 8 studies were hand-searched from the eligible papers. After a full-text screening, 10 out of the 19 studies were excluded (4 studies were not nicotine product cessation interventions, 3 studies did not provide outcome data for adolescents and young adults only, 2 were study protocols, and 1 was a sub-analysis on an original study included in this review) (Figure 1, Supplemental Table S4). A total of 9 original studies were included in the final analysis (Figure 1).

Figure 1.

The PRISMA flow-chart of the search and inclusion of papers in the systematic review.

Study characteristics

All studies were conducted in the US and published in international peer-reviewed journals between 1999 and 2022. The study population ranged from 24 to 2588. Five of the studies were randomized controlled trials (RCTs)^32-36 (of which 2 were pilot studies), and 4 were cluster randomized trials.^37-40

Risk of bias in studies

Five studies were assessed as having a low risk of bias,^{32,34,36,37,39} one had some concerns regarding the randomization process and deviations from the intended intervention,³⁸ and 3 were assessed as having a high risk of bias due to a high percentage of loss to follow-up^33,35,40 (Figure S2).

Three studies reported no conflict of interest,^35,36,40 and 4 did not state any conflict of interest but disclosed being funded by national³³ or state funds.^37-39 The remaining 2 studies^32,34 disclosed conflicts of interest (see S2 for details), but none were associated with the tobacco- or nicotine industry.

Effect of the interventions (Table 1)

E-cigarette cessation

One study was an SMS text-based program targeting young adult e-cigarette users motivated to quit, and it reported that the participants receiving the full SMS text-based program had significantly higher odds of 30-day point prevalence abstinence at follow-up.³² Vaping quit rates were high; the young people in the intervention group were a third more likely to quit vaping, and the superiority of the intervention was consistent across all demographic variables and vaping characteristics that were examined.

A pilot study targeting young adult e-cigarette users motivated to quit and recommending the use of the SMS text-based program mentioned above in both the control and the intervention group, tested the effect of financial incentives.³⁴ The study found, that financial incentives (a financial reward for each cotinine test submitted) did not have a significant effect on vaping abstinence.

Another pilot study examined the difference in quit rates between behavioral support delivered in combination with either nicotine replacement therapy (NRT) or a vape-taper plan (a scheduled tapering plan reducing nicotine concentration and vape frequency over time).³⁵ The study found that cessation rates were higher among the vape-taper intervention group compared to the NRT- and control group, but the outcomes were not statistically significant.

Smokeless tobacco cessation

One older study compared the effect of an enhanced condition web-based smokeless tobacco cessation program using interactive and multimedia features, with a basic condition of the program.³⁶ The study found no significant difference in self-reported 7-day point prevalence abstinence from smokeless tobacco at follow-up.

Five studies^33,37-40 investigated the effect of multi-component smokeless tobacco cessation interventions in male high school or college students. All studies included an oral examination component performed by either a dentist/dental hygienist or a nurse, and all studies included behavioral counseling. One of the studies tested the effect of a 6-week behavioral counseling program where the intervention groups also received either a nicotine patch or a placebo patch. The control group received brief counseling only.³³ The study found the intensive behavioral counseling program had a significant long-term effect when combining the 2 intervention groups. However, there was no significant difference between the nicotine patch group and placebo patch group.

Another of the 5 studies found no effect from a peer- and nurse-led intervention among male high school students on cessation of smokeless tobacco. However, subgroup analyses showed a significant effect on the non-smoking users of smokeless tobacco (prevalence of smokeless tobacco use at follow-up among those who did not smoke at baseline).⁴⁰

The remaining 3 studies investigated the 12-month effect of multi-component interventions in athletic settings, including a peer-led educational session and brief individual counseling. The control groups received no or minimal intervention. One study on high school baseball athletes found a significant effect at follow-up.³⁹ A study in young male college football and baseball athletes additionally offered a 2-mg nicotine gum and found that abstinence rates were more than doubled in the intervention group compared to the control group at follow-up.³⁸ However, the third multi-component intervention, which was directed by the athletic trainers rather than the athletic teams, found no significant effect on smokeless tobacco cessation at follow-up.³⁷

Secondary outcomes (supplementary material, Table S3)

In total, 6 out of the 9 studies provided data on predictors for cessation, moderators of effect, perceived importance, or satisfaction with intervention elements that might have had an impact on the intervention effects.^32,36-40 However, only 2 studies found characteristics that significantly moderated the intervention effects.^39,40 High self-efficacy (confidence in quitting), being a freshman, or not smoking at baseline were associated with higher odds of intervention effect at follow-up in one study,³⁹ whereas being a dual user (using smokeless tobacco and smoking) was associated with intervention effect, ie, not using smokeless tobacco, at follow-up.⁴⁰

Discussion

This narrative analysis of a systematic review identified 9 RCTts aimed at the cessation of non-combustible nicotine and tobacco products in adolescents and young adults. Six of the studies were published before 2014, and all were conducted in the US. Three of the RCTs were targeted at the cessation of e-cigarettes, and the rest at cessation of smokeless tobacco. The interventions tested the effect of an SMS text-based cessation program, an interactive web-based cessation program, financial incentives for validated abstinence, and free nicotine replacement therapy or a vape-taper plan. All interventions included behavioral support of some kind. 5 out of 9 studies found the intervention to have had a significant effect.

Long-term quit rates were surprisingly high, mostly around 25-35% in intention-to-treat analyses. An explanation might be that participants were highly motivated to quit.³² Another explanation might be that some of them switched to another nicotine/tobacco product. The only study included that investigated transition to other products, reported higher odds of starting smoking in the intervention group than in the control group.³⁹ A secondary analysis⁴¹ of the SMS text-based program³² showed that 4% of baseline exclusive e-cigarette users who quit vaping reported use of conventional cigarettes at follow-up. Future studies must include all tobacco and nicotine products because many young people are poly-tobacco/nicotine product users. There is high-certainty evidence that financial incentives improve cigarette smoking cessation rates at long-term follow-up in adults.⁴² However, research is needed on the effect of financial incentives on tobacco- and nicotine product cessation in adolescents and young adults.

All interventions were based on or offered some behavioral support/counseling. Some of the interventions included individual counseling,^35,38,39 and others included both individual and group counseling.³⁷ When it comes to tobacco cessation interventions for young people, a Cochrane review found evidence of an effect for group counseling but not for individual counseling.²⁶ Behavioral support/counseling seems to be an important element in both tobacco and nicotine product cessation interventions. However, there is not sufficient evidence to conclude which delivery method, duration or type of counseling is the most effective.

Only one of the multi-component smokeless tobacco cessation studies did not offer peer-driven sessions.³⁸ Nevertheless, it was one of the studies showing a significant long-term effect, so the peer element might not be essential. Previous studies on smoking cessation suggest that the protective effect of peer influence seems to lie in the peer him-/herself not smoking and not in the verbal persuasion not to smoke.⁴³

Only one intervention investigated the effect of pharmacotherapy and found no significant effect of the nicotine patch compared to a placebo patch in young e-cigarette users.³⁵ In fact, higher quit rates were achieved in the intervention group that received the placebo patch. A review on pharmacotherapy for smoking cessation in adolescents has found that the use of pharmacotherapy increased the short-term abstinence rate of young adults who smoke cigarettes; however, no efficacy on abstinence was found at longer-term follow-up.²⁸

Five multi-component interventions were very intensive. Even though the 5 trials were similar in many ways, they did not all show significant effects, which underscores the importance of testing successful cessation programs in different arenas, with different people, and in different contexts. It is difficult to state which elements were essential and which could eventually be left out, or if the synergy of the components made them effective. It seems that a component showing oral damages is strongly motivating in regards to smokeless tobacco cessation.^38,39

One of the studies investigated an SMS text-based e-cigarette cessation program in the US and found a significant effect.³² The program is grounded in best practices from smoking cessation research with young people and on the social cognitive theory. As the intervention takes place on a cellphone and is not delivered by particular persons in particular social or cultural contexts, the positive results can probably be reproduced. Future text message cessation trials should build on experiences from this promising e-cigarette cessation program. It would be of great value if the trial were repeated on an even larger scale and tested in other countries.

Another large older RCT compared the effect of an enhanced interactive web-based, smokeless tobacco quitting program, with a basic condition of the program and did not find any difference.³⁶ However, in both intervention groups around a third were abstinent at follow-up, suggesting that even basic information and basic support of cessation can help young people quit the use of smokeless tobacco. The content of both conditions was based on multi-component cognitive-behavioral interventions used in smoking cessation.

Some of the studies in this review required many resources and much coordination and had high costs. Offering an automated delivery system via SMS messaging or the web has a low cost of implementation, with wide reach and acceptance among young people, and it might have a very broad public health potential.

Limitations

A very limited number of studies have been published; the interventions differed, and they were aimed at the cessation of 2 types of nicotine products. Therefore, we found it more meaningful to perform an in-depth narrative synthesis of data rather than a meta-analysis of the intervention’s effect. We considered pooling the results from the 5 smokeless cessation multi-component interventions, as these studies were similar. However, we did not, as there were variations in the target group and the methods used.

We included pilot studies (one of them with only 7 weeks of follow-up), and interventions comparing a basic program with an enhanced program, and it can also be questioned if all these should have been included. However, these studies can primarily generate ideas for new interventions. The web-based study technology from 2013 is obsolete; we should have excluded this paper.

Initially, we planned to investigate the cessation of novel nicotine products only. However, we realized that young people do not discriminate between oral nicotine and tobacco products, and few know what they actually use. Most of the trials included users of smokeless tobacco who, in the papers, were defined as users of products such as snuff, chewing tobacco, snus, and spit tobacco but not nicotine pouches, as they did not exist at the time the studies were performed. We hypothesize that evidence from these (older) studies on the cessation of smokeless tobacco can be transferred to the cessation of nicotine pouches, but this needs to be empirically evaluated.

All studies on smokeless tobacco cessation included males only, so we cannot say whether the effect of the interventions would have been the same in girls/young women. The predefined inclusion age was 15 to 25 years. However, we chose to include studies with a few younger participants and studies only describing participants who were in high school, as the vast majority of the study population was over the age of 15. Only 2 out of the 9 studies validated abstinence with saliva cotinine tests, which does not encounter the “social desirability bias” that may occur when using self-reported data only.

Strengths

We used recommended tools to assess the studies’ risk of bias. Two researchers separately assessed all studies.

Conclusion

The main finding of this systematic review is that the research area is understudied, and the overall grade of evidence is rated as very low. 5 out of 9 identified studies found the cessation interventions employed to have had a significant effect. A recent study with significant effect was a newer SMS text-based e-cigarette cessation program grounded in best practices from smoking cessation research, including elements of behavioral counseling. The remaining studies that found significant effects was older multi-component interventions aimed at cessation of smokeless tobacco in male students, including components showing oral damages and in-person behavioral counseling. There is not sufficient evidence to conclude which delivery method, duration or type of counseling is the most effective. Currently, studies do not support the use of pharmacotherapy for adolescents and young adults. Some studies shows that the effect of financial incentives seems worth investigating. Future research should draw on positive experiences from previous studies, focus on the cessation of all nicotine and tobacco products, and identify the most cost-effective cessation methods with the greatest reach.

Supplemental Material

Supplemental Material - Non-combustible nicotine product cessation interventions in adolescents and young adults: A systematic review

Supplemental Material for Non-combustible nicotine product cessation interventions in adolescents and young adults: A systematic review by Sofie K. Bergman Rasmussen and Charlotta Pisinger in Journal of Tobacco Use Insights.

Footnotes

Author contributions

Conceptualization, methodology, validation, formal analysis, data curation, writing original draft preparation, writing review, and editing, project administration, and funding acquisition: CP and SBR. Visualization, software: SBR. Supervision: CP. Both authors have read and agreed to the published version of the manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was fully funded by the Danish non-profit foundation TrygFonden, grant number ID: 156735.

ORCID iD

Sofie K. Bergman Rasmussen

Supplemental Material

Supplemental material for this article is available online.

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