Tobacco, vaping and nicotine dependence — formative SAQs

SAQ 1 — Dependence assessment and evidence-based cessation (10 marks)

A 16-year-old seen alone discloses daily use of a pod vaping device for nine months, with craving on waking, irritability without it, and two failed attempts to stop. They want help quitting. They have no acute symptoms. [9] [8]

Questions

1. Frame the assessment you will perform, including the principle that guides when dependence can begin. (4 marks) [5]
2. Outline the stepwise cessation plan, naming the 5 A's, the brief-intervention method, and the pharmacotherapy you would offer and in what order. (6 marks) [8] [7]

Model answer

Assessment (4). First secure time alone and state conditional confidentiality with its limits. Take a product-specific history — which product (pod device), age of initiation, frequency (daily, with use on waking), triggers, withdrawal symptoms (irritability, craving), and failed quit attempts. Quantify use (any, past-30-day, daily). Apply DSM-5 tobacco use disorder criteria and a validated tool such as the Hooked on Nicotine Checklist to grade dependence. Assess readiness to change and screen for co-occurring depression, anxiety, other substance use and pregnancy risk. The guiding principle is that nicotine dependence in adolescents is a biological process that can begin before daily use, often within days to weeks of first exposure, because the developing brain is highly nicotine-sensitive — so craving on waking and failed quit attempts already indicate established dependence despite the young person's framing. [5] [9]

Cessation plan (6). Run the 5 A's: Ask about all products, Advise with a clear personalised message, Assess willingness and dependence, Assist with counselling and medication, Arrange follow-up within one to two weeks. Deliver the brief intervention with motivational interviewing — open questions, affirmation, reflective listening, summaries — to evoke the young person's own reasons for quitting rather than lecture. Add structured behavioural support: a quit date, trigger management, coping skills, social support, and a digital or text-message program (a randomised trial showed a tailored text program increased abstinence in adolescent e-cigarette users). For pharmacotherapy, offer nicotine replacement therapy first-line — a patch for baseline nicotine plus a short-acting form for breakthrough craving; consider bupropion SR or varenicline where NRT is inadequate or dependence is severe, with region-specific licensing caution and neuropsychiatric monitoring. Frame relapse as part of the quitting process, not failure. [8] [7] [10]

SAQ 2 — EVALI recognition and the gateway association (10 marks)

A. A 16-year-old presents to the emergency department with three days of progressive dyspnoea, cough, fever and gastrointestinal symptoms; they have vaped a modified cartridge daily for two weeks. B. Separately, an examiner asks why paediatricians treat adolescent e-cigarette use as a priority given falling cigarette rates. [2] [3]

Questions

1. Outline your immediate assessment and management of the presentation in part A, including the diagnosis you must exclude-and-treat. (6 marks) [2]
2. Explain the gateway association and its clinical implication for prevention. (4 marks) [3]

Model answer

EVALI (6). Treat this as suspected EVALI (e-cigarette or vaping product use-associated lung injury) until proven otherwise, because respiratory distress with recent vaping fits the syndrome and EVALI can deteriorate rapidly. Assess and stabilise airway, breathing and circulation; give supplemental oxygen as needed. Perform the diagnostic work-up — chest radiograph (expect bilateral opacities), inflammatory markers, and an infectious work-up to exclude alternative diagnoses, because EVALI is a diagnosis of exclusion supported by a consistent exposure history. Arrange admission or transfer for progressive respiratory failure, counsel immediate cessation, ask exactly what was in the device (the 2019 outbreak was strongly linked to vitamin E acetate and illicit or THC-containing products), and report as required by local guidance. [2]

Gateway association (4). A meta-analysis and systematic reviews show that adolescents who use e-cigarettes are more likely to subsequently take up combustible cigarettes than those who do not; the association is consistent in direction even as the causal mechanism is debated. The clinical implication is that preventing and detecting vaping early is a priority, because most lifelong smoking begins in adolescence, so youth tobacco control is among the highest-yield prevention levers in paediatrics. Paediatricians must not be reassured by falling cigarette rates alone while vaping remains common. [3] [1]