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As the Trump administration signals a softer regulatory stance on flavored vapes, clinicians and tobacco researchers say pediatric exam rooms are becoming the front line in nicotine prevention.

The FDA authorized several fruit-flavored products for adult use in May, despite years of federal resistance to sweet-flavored vapes that public health officials say appeal strongly to teenagers. The change could normalize vaping among adolescents at a moment when nicotine use, although declining, remains widespread in this population.

“When flavored e-cigarette products receive FDA authorization, some teens may interpret that as a signal that these products are safer or more socially acceptable,” said Ruoyan Sun, PhD, assistant professor of health policy and organization at The University of Alabama at Birmingham, whose research focuses on tobacco regulation and youth vaping behaviors.

An estimated 1.63 million middle and high school students reported using e-cigarettes in 2024, making vaping the most used tobacco product among youth for the 11th consecutive year. More than 87% of the youth who vape use flavored products, including fruit, candy, and mint flavors, many of them sold through gray market disposable vape channels.

“Flavored vaping products are not a neutral policy choice, they are a key driver of youth nicotine exposure,” said Minal Patel, PhD, senior principal scientist in Surveillance & Health Equity Science with the American Cancer Society’s Tobacco Control Group.

Still, some tobacco researchers caution that the public conversation around vaping is overly simplified.

“There is the misperception that vaping is more harmful than smoking cigarettes, which is absolutely not the case,” said Robin Mermelstein, PhD, director of the Institute for Health Research and Policy at the University of Illinois Cancer Center in Chicago. “Vaping is substantially less harmful than smoking, yet most of the public, including adolescents, are now more concerned about vaping than smoking.”

Mermelstein said policymakers face a difficult balancing act between preventing youth from vaping and maintaining alternatives for adults trying to quit combustible cigarettes.

“We do need a regulated marketplace, and the authorization of flavored vaping products is a good step in that direction — providing some legal alternatives to the illicit market of vapes,” she said.

Screening for Youth Vaping

Although youth vaping rates have fallen since their 2019 peak, the numbers remain high enough to justify routine nicotine-use screening during annual visits, sports physicals, and mental health assessments, Sun said.

The American Academy of Pediatrics recommends universal screening for nicotine and tobacco exposure during visits with teens, including time alone so teens can answer questions confidentially.

“Adolescents may not fully disclose their vaping behaviors, particularly when parents are present during the visit,” Sun said.

Clinicians should avoid vague questions like “do you smoke?” and instead ask directly about vaping, flavored products, nicotine pouches, and cannabis devices using language adolescents recognize, including “JUULing.”

“There is a need for more standardized screening questions in clinical settings so pediatricians can identify vaping behaviors more consistently,” Sun said.

Clinicians should also assess frequency of use, cravings, device type, and co-occurring mental health concerns such as anxiety, depression, and attention disorders, all of which are associated with higher use of nicotine among adolescents.

Heavy vaping can produce subtle but important clinical clues. Teens may present with chronic cough, worsening asthma symptoms, throat irritation, headaches, nausea, dizziness, sleep disturbances, or difficulty concentrating when they cannot vape. Some disposable devices popular among adolescents contain nicotine concentrations comparable to — or exceeding — a pack of cigarettes.

“e-cigarettes have evolved to deliver higher concentrations of nicotine more efficiently, and many adolescents are using them frequently, even daily,” Patel said.

Signs of Vaping Dependence

More than one quarter of youth who vape report daily use, a pattern that signals nicotine dependence rather than experimentation, according to the CDC.

“We are also seeing new products, such as flavored nicotine pouches, which can contain substantial nicotine and may further reinforce dependence,” Patel said.

CDC data released in 2024 showed nicotine pouches — small pouches of powder placed in the mouth that contain tobacco-derived or synthetic nicotine — were the second most commonly used tobacco product among this population.

Mermelstein said pediatricians should pay close attention to behavioral changes that suggest nicotine use is becoming addictive.

“Some early signs to watch for include feeling like you need to start your day with a vape to get going, or that when upset, you just really want to have your vape to help you to get that moment of calm or relief,” she said.

Sun said pediatricians should ask not only whether adolescents vape but also why, which might include stress, curiosity, or dependence.

Mermelstein said adolescent nicotine use often reflects broader emotional and social dynamics rather than simple peer pressure.

“Adolescents often use cannabis, alcohol, or nicotine to achieve a sense of social belonging, identity, to feel better — both positive and negative mood management,” she said. “Mood disorders often increase the risk that adolescents may become dependent on these substances.”

Evolving Stance, Confusing Messaging

The Trump administration’s evolving stance on vaping has added another layer of complexity to counseling conversations. During his first administration, President Donald Trump initially backed restrictions on flavored vaping products amid a youth vaping epidemic.

More recently, the FDA reduced enforcement against some unauthorized products, including disposable e-cigarettes that have remained widely available despite lacking the agency’s authorization.

The shift could undermine years of prevention messaging, Patel said.

“People often assume that if a product is allowed on the market, it is safe. That is not true for e-cigarettes,” Patel said.

At the same time, researchers stress the risks of vaping exist on a continuum.

“e-cigarettes are not harmless, especially for adolescents whose brains are still developing. However, compared with combustible cigarettes, e-cigarettes generally expose users to fewer harmful chemicals,” Sun said.

But uncertainty about the long-term cancer risks of vaping should not be mistaken for proof of safety.

“We do not yet have definitive evidence on the long-term cancer risk of exclusive e-cigarette use, because these products have not been on the market long enough,” she said.

Nicotine exposure during adolescence remains a particular concern because use can affect brain development, attention, learning, and risk for long-term addiction.

“Counseling should focus on education and harm prevention rather than punishment,” Sun said. “It is key to create a nonjudgmental environment, so adolescents feel comfortable disclosing these behaviors.”

However, no nicotine-cessation medications are formally approved by the FDA specifically for adolescents, although clinicians sometimes use nicotine replacement therapy off-label for teens. Counseling, text-based quit programs, and behavioral support remain the cornerstone of treatment.

“The most effective approach would be to create a safe space, provide clear information, and support youth in quitting without stigma,” Patel said.

The experts included in the story did not disclose any relevant conflicts of interest.

Lara Salahi is a health journalist based in Boston.