Tobacco, vaping and nicotine dependence — branching viva

Stem

The examiner will test whether you can defend adolescent nicotine dependence as a biological process and run evidence-based care under pressure, including an emergency presentation. [3] [8]

Branch 1 — Biology of dependence

Examiner: A 15-year-old vapes "sometimes" but is not a daily user. Can they already be dependent? [3]

Strong answer: Yes. 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. The prefrontal cortex is still maturing into the mid-twenties, so top-down control is weak, while the dopaminergic reward system is at peak sensitivity, so reinforcement is strong. Dependence is not a choice or a moral failing. [3] [4]

Examiner: What receptor and pathway are involved? [3]

Strong answer: Inhaled nicotine binds alpha-4-beta-2 nicotinic acetylcholine receptors in the ventral tegmental area, triggering dopamine release into the nucleus accumbens. Repeated exposure drives tolerance, craving, withdrawal and loss of control. [3]

Branch 2 — Screening and the 5 A's

Examiner: How will you assess this young person? [8]

Strong answer: Secure time alone and state conditional confidentiality. Ask about all products — not just cigarettes — including vapes, pod devices, waterpipe and smokeless tobacco. Quantify use (any, past-30-day, daily, age of initiation) and assess dependence with DSM-5 criteria and a validated tool such as the Hooked on Nicotine Checklist, asking about craving, use on waking and failed quit attempts. Then run the 5 A's: Ask, Advise, Assess, Assist, Arrange. [8] [7]

Branch 3 — Pharmacotherapy

Examiner: They want medication. What do you offer and in what order? [6]

Strong answer: First-line pharmacotherapy is nicotine replacement therapy — a patch for baseline nicotine plus a short-acting form (gum, lozenge or spray) for breakthrough craving. Bupropion SR and varenicline are considered where NRT is inadequate or dependence is severe, with region-specific licensing for under-18 use and neuropsychiatric monitoring; a recent randomised trial examined varenicline specifically for youth vaping cessation. Pair medication always with behavioural support and a text-message or digital program. [6] [5]

Branch 4 — Suspected EVALI

Examiner: A 16-year-old now presents with progressive dyspnoea, cough, fever and gastrointestinal symptoms after two weeks of vaping a modified cartridge. What do you do? [2]

Strong answer: Treat as suspected EVALI until proven otherwise. Assess and stabilise airway, breathing and circulation; give oxygen as needed. Perform chest imaging (expect bilateral opacities), inflammatory markers and an infectious work-up to exclude alternative diagnoses, because EVALI is a diagnosis of exclusion supported by exposure history. Arrange admission or transfer for progressive respiratory failure, counsel immediate cessation, ask what was in the device (vitamin E acetate and THC-containing products were strongly linked), and report as required. [2]

Branch 5 — The gateway association and prevention

Examiner: Cigarette rates are falling. Why do we still treat vaping as a priority? [1]

Strong answer: Because e-cigarette use is associated with a greater likelihood of subsequent combustible cigarette smoking, shown consistently across meta-analysis and systematic review, and most lifelong smoking begins in adolescence. Youth tobacco control remains among the highest-yield prevention levers in paediatrics. The clinical task is unchanged: prevent uptake, detect dependence early, and treat with evidence-based support. [1]

Examiner extras

• Relapse is part of quitting; frame every attempt as practice, never as failure. [7]
• Engagement is itself an outcome — a young person who keeps coming back is the best predictor of eventual success. [8]
• State that local statute and licensing govern product age-of-sale, nicotine caps and pharmacotherapy availability; do not invent universal cut-offs. [8]