Just when it seemed decades of progress in reducing youth tobacco use were making a lasting impact, a new generation of nicotine products has emerged — more potent, more discreet and, in many cases, more addictive than ever before.
Susan Walley, MD, MHCM, SFHM, FAAP, Chief, Division of Hospital Medicine, Children’s National Hospital, discusses the resurgence of youth nicotine use, the growing popularity of flavored vapes and nicotine pouches, and why these products are raising concerns among pediatricians and public health experts.
Featuring:
Susan Walley, MD, MHCM, SFHM, FAAP, Chief, Division of Hospital Medicine, Children’s National Hospital
Host/Producer: Carol Vassar
TRANSCRIPT
Announcer (00:00):
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Carol Vassar, podcast host/producer (00:12):
Each week we’ll be joined by innovators and experts from around the world, exploring anything and everything related to the 85% of child health impacts that occur outside the doctor’s office. I’m your host, Carol Vassar, and now that you’re here, let’s go.
MUSIC (00:30):
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Carol Vassar, podcast host/producer (00:36):
At the 2026 Pediatric Academic Societies meeting in Boston, PAS, I had the chance to talk with Dr. Susan Walley, the Division Chief for Hospital Medicine at Children’s National Hospital in Bethesda, Maryland. Dr. Walley is an expert in the prevention of youth tobacco use and tobacco-related diseases, and her presentation at PAS was intriguing from beginning to end, starting with its title. Oops, Tobacco Companies Did it Again. So, what’s happening now that gives Dr. Walley and her colleagues concern that history is repeating itself in some way, with regard to tobacco and our kids? Here’s Dr. Susan Walley.
Susan Walley, MD, Children’s National Hospital (01:23):
Absolutely. As pediatricians, one of our main goals is that our young people are able to live, of course, as healthy of a life as possible. And we know still that tobacco use and tobacco smoke exposure is the number one cause of preventable morbidity and mortality. And so as a parent of three boys and a pediatrician, one of the most important things are that we prevent our youth from being exposed to the use of tobacco and nicotine. And unfortunately, with some of these new tobacco products that we’re seeing that have very limited, if any, regulation, we’re seeing that youth are exposed to these very high nicotine concentrations, what we call smart vapes, otherwise known as e-cigarettes. And then oral nicotine pouches is something that we have really had a lot of concerns about the use. And many of these products have very high levels of nicotine.
Carol Vassar, podcast host/producer (02:35):
I want to roll back the clock a little bit; let’s go back to 1964. That was the Surgeon General’s report that really started this evolution, this revolution in public health toward less smoking of cigarettes, cigars, less nicotine product usage. What’s different now that is exposing kids, youth, maybe even children, to this higher level, as you talked about, the pouches and the smart vapes? What’s going on now compared to then?
Susan Walley, MD, Children’s National Hospital (03:06):
That’s a great point. We have come; the public health community and the medical community have come a very long way since 1964. We know that combusted tobacco, i.e. cigarettes and cigars, cigarillos, and that also includes hookah, cause things like cancer, cardiovascular disease, COPD. And we’re still in a period where we don’t know all of the health effects when we think about mental health, as well as physical health, around these nicotine and tobacco products, like these high-nicotine products. And so, while we have seen combusted cigarette use go down both in adults and children, which is fantastic news, we don’t want to replace them with something that is also addictive and has health effects, some of which we don’t know completely what they all are. We don’t want to wait 30 years for this generation of teens to become adults and then realize, wow, we really should have done something 30 years ago to prevent this health problem.
Carol Vassar, podcast host/producer (04:24):
How did it happen that kids now have access to such high-nicotine products? In 1998, when they had the Master Agreement, which covered how you’re going to advertise or not advertise to use, we thought the problem was over. You can’t use cartoons to get to kids to get them to start using tobacco. What has changed? How are kids finding these products today?
Susan Walley, MD, Children’s National Hospital (04:50):
Great, great point about really the underlying reasons that kids and young people are using these products. And it really hearkens back to the title, Oops, Tobacco Companies Did it Again, because they’re using flavors. We know about 87% of youth when they use these nicotine and tobacco products, they are using flavors. And so, tobacco companies have known for decades that these child-enticing flavors really work.
(05:25):
Some of the other things are the marketing and advertising that has almost no regulation when we think about vaping and these oral nicotine pouches. I flew in from DC, as you mentioned, and I saw a huge digital billboard for one of these oral nicotine pouches that everyone, whatever their age, passes by. And we know that the advertising that tobacco companies used to be able to do, like for cigarettes, does work, particularly when it’s in movies, advertisements, and commercials on television. So, it is unfortunate that so many of the lessons from the past that tobacco companies use with cigarettes are being utilized now with these other tobacco and nicotine products.
Carol Vassar, podcast host/producer (06:22):
It’s the same playbook, essentially.
Susan Walley, MD, Children’s National Hospital (06:24):
Exactly.
Carol Vassar, podcast host/producer (06:24):
How are they able to do this, given that the Master Agreement said, “This is not how you should be advertising to kids”? Is it based on the fact that it’s not a combustible product or not a cigarette or cigarillo?
Susan Walley, MD, Children’s National Hospital (06:37):
Yes, you’ve exactly got that right, Carol. The Master Agreement pertained to cigarettes, and so when we’re looking now at these high-nicotine-containing vapes or e-cigarettes, oral nicotine pouches, that is not specifically addressed in the Master Settlement Agreement.
(07:00):
Now, we do know that the Food and Drug Administration, the FDA, does have authority over tobacco and nicotine products. However, the process that was put in place by the Deeming Act, it requires a pre-market review. And at this point, unfortunately, only of the thousands to hundreds of thousands of these nicotine and tobacco products, it’s a daunting task that the FDA has to do, particularly when the FDA Center for Tobacco Products may not be resourced as much as it should be.
(07:45):
But to date, there are two manufacturers of oral nicotine products that have products that have been authorized. The FDA does not approve, but it authorizes. Unfortunately, there are many of these products that are in flavors that are not just tobacco, but also in some of these dessert-type, child-enticing flavors. And then there are four manufacturers of e-cigarettes, and that does include companies that you would have heard of, like JUUL or Vuse, and NJOY. It doesn’t, however, include some of the most commonly used vapes by kids like Geek Bar, Elf Bar, Mr. Fog. And so, those are products that are still oftentimes on the shelves if you go to your local vape store or gas station, you’ll still find them. And basically, because they’re not authorized, they’re illegal.
Carol Vassar, podcast host/producer (08:42):
They’re illegal? Is there any kind of… Well, they’re illegal for everyone; they’re illegal for everyone. There’s no age limit on-
Susan Walley, MD, Children’s National Hospital (08:51):
Exactly, yes. The-
Carol Vassar, podcast host/producer (08:52):
So kids can just buy them at the local vape store, or?
Susan Walley, MD, Children’s National Hospital (08:55):
Well, there is Tobacco 21, and so individuals under 21 should not be able to buy them. But you’re exactly right that these products that haven’t been authorized by the FDA should not be available for purchase.
Carol Vassar, podcast host/producer (09:12):
How are kids getting their hands on these things?
Susan Walley, MD, Children’s National Hospital (09:16):
Yes, that is a great question. Certainly, there have been… We’ve looked into how that has happened, different research by many different organizations. One of the real challenges is that online sales are almost completely unregulated. And so in preparation for my talk, I actually went to one of the websites of one of the most popular e-cigarette brands or vapes, and the first… And I invite the listeners to also do that. One of the first screens that you’ll see says, “Are you 21?” “Yes.” And then there’s a button that says, “No.” Now, there’s no age verification. Anyone can press the yes, anyone can press the no. So I press the yes, I’m over 21. I know that’s hard for you to believe, Carol, but-
Carol Vassar, podcast host/producer (10:11):
I want to see your license.
Susan Walley, MD, Children’s National Hospital (10:11):
Yes, but that gives you full access to these products that you can have delivered to your home.
Carol Vassar, podcast host/producer (10:19):
What should parents be looking for? And I know some of these vapes can look like regular household items, maybe even like pens.
Susan Walley, MD, Children’s National Hospital (10:27):
Exactly. Yeah.
Carol Vassar, podcast host/producer r (10:29):
What should parents be aware of? What should physicians be asking?
Susan Walley, MD, Children’s National Hospital (10:32):
Exactly. That’s such a good point and so challenging, because they are made oftentimes, these products, to be inconspicuous or things that look like household items, or to even just look like something that you would never even expect to be a vape product.
(10:52):
I think first and foremost, we do talk with parents, teachers, and administrators. We want children and young people to have good role models. So if you are a parent that uses tobacco and nicotine, seek help. There’s the 1-800-QUIT-NOW line, which does offer free counseling, and definitely medical centers are offering tobacco cessation resources, which are so important.
(11:21):
And then, look for those telltale signs, whether that is that you find the products or oftentimes you’ll notice some changes in your child’s behavior. It’s also important to know that although these products, the price point is at a place, where, oftentimes, for the equivalent amount of nicotine, you’re going to get a lot more nicotine from a vape than you would from a cigarette, they still have a price. And for many adolescents, they’re very sensitive, they’re very cost sensitive. And so that’s the other thing to really look for, like, where is their disposable income going? And if you don’t know, and I’m a parent of 17, 20 and 23, so they-
Carol Vassar, podcast host/producer (12:13):
Okay.
Susan Walley, MD, Children’s National Hospital(12:13):
Yep. They’re talking about money and asking for money, and it’s important to really talk with them about having these conversations about the harms of nicotine and tobacco.
Carol Vassar, podcast host/producer (12:23):
You raised a really good point with regard to the amount of nicotine they are getting in the vapes, which is very different than, say, in a combustible cigarette. Talk about the difference and how addictive that can be for young people in particular.
Susan Walley, MD, Children’s National Hospital (12:39):
Absolutely. I think it is really shocking, and with each kind of new generation of vapes, we’ll just see that nicotine level go higher and higher. So, just for us to all have a baseline, if you smoke a conventional cigarette, that’s about one to two milligrams of nicotine. For one of the most ubiquitous e-cigarettes like in the 2019 was JUUL, and JUUL had for each pod and some adolescents were going through two or three pods a day, it had about 40 milligrams of nicotine in one small pod. That’s a lot of nicotine. However, we’re now in a generation of these new vape products that they will… One disposable vape has about 2,000.
Carol Vassar, podcast host/producer (13:38):
2,000?
Susan Walley, MD, Children’s National Hospital (13:39):
2,000 milligrams of nicotine. There’s about a 40… or sorry, 40-milliliter tank, and it’s 5% nicotine. So we’re talking like 50 packs of cigarettes is equivalent to this one disposable vape that you can get online for about $11. It’s insane. And so, no wonder the youth that are using these products, they get addicted really quickly. And we know that about a third of the youth that are using e-cigarettes are using them daily, and really having a lot of the symptoms that we know that show that they’re dependent or addicted.
Carol Vassar, podcast host/producer (14:27):
So, talk about the effects of nicotine on the brain of a youth, and let’s define that a little bit. Maybe 11, 12, and upward.
Susan Walley, MD, Children’s National Hospital (14:37):
Yeah. Well, I think you bring up just really the most important point. We know that adolescents, their brain is developing. And of course, the data now is saying to 25. We could argue for some people, it’s never, but 25 is when we
Carol Vassar, podcast host/producer (14:55):
Let’s go up to that young adult, yeah.
Susan Walley, MD, Children’s National Hospital (14:56):
… say the brain matures. And so, the range of health effects is so broad, and we’re learning more every day. Of course, nicotine is a stimulant, and so there are some of those immediate effects that you can even see if somebody overdoses on nicotine. And we’ve seen an increase in children going to emergency departments with nicotine overdoses, either from exposure, that they get into a pouch, or have a parent’s vape. Unfortunately, we’ve seen some children die from nicotine overdoses. And I think that’s a big concern, but of course, the short-term and long-term effects are what I think when you think about the millions of adolescents that are using them, which are really worrisome.
(15:45):
One is, of course, that we know that nicotine changes brain chemistry and makes people more likely to use… We don’t like the word gateway, but an on-ramp to other drugs of abuse, and that even includes combusted cigarettes. It has the same drug, the same addictive drug, which is nicotine, but we also worry about nicotine being a gateway to other drugs. We worry, of course, about mental health; that’s certainly a big concern. And we actually know from decades of work with combusted cigarettes that many people are using them thinking this is going to help for my stress, thinking this is going to help for my anxiety.
Carol Vassar, podcast host/producer (16:34):
Or my weight.
Susan Walley, MD, Children’s National Hospital (16:35):
Yes, exactly. So, those are certainly very top of mind when we’re talking about adolescents. Respiratory issues, of course, because they’re inhaling these hundreds, if not thousands of chemicals into their lungs. Certainly, we have plenty of evidence to know that youth that are using these vapes are going to be more likely to wheeze if they have asthma, they’re more likely to have asthma attacks, and the cardiovascular effects. So, it goes on and on and on.
Carol Vassar, podcast host/producer (17:06):
Nothing good.
Susan Walley, MD, Children’s National Hospital (17:07):
Yes, nothing good. Our main goal for adolescents is that really they are breathing clean air, not vape. So I think many people will say, “Hey, let’s talk about adult smokers and how we can get them to quit.” I’m a certified tobacco treatment specialist. There’s nothing more than I want to see a 50 pack smoker, 50 pack a year smoker, which means basically somebody who’s, let’s just say they’ve been smoking two packs a day for 25 years to quit, but it should not be on the backs of our teens and our youth picking up these products because they think they’re cool, or they think they have great flavors, or they just want to use them because their friends are using them. So to me, it’s not a comparison.
Carol Vassar, podcast host/producer (18:03):
It breaks my heart to hear you talk about nicotine overdose in children. What does that look like?
Susan Walley, MD, Children’s National Hospital (18:11):
You’ll see certainly vomiting, nausea, all of the effects of overstimulation. Your heart rate is very high, your blood pressure gets high. And again, as I said, unfortunately, there have been some children, toddlers, who have died from nicotine overdose.
Carol Vassar, podcast host/producer (18:27):
So sad. So very, very, very sad.
Susan Walley, MD, Children’s National Hospital (18:29):
Yeah.
Carol Vassar, podcast host/producer (18:30):
Let’s talk about some solutions here. What can a pediatrician in the office do when talking with a youth who might be either thinking about starting to vape or actually vaping at that moment? And also, what can parents be on the lookout for?
Susan Walley, MD, Children’s National Hospital (18:45):
Absolutely. I think that prevention is the most important thing, and we know that, as much as sometimes you don’t think your teenagers are listening to you, I mean, speaking as a pediatrician and as a mother, they do, and that is one of the most effective things: to talk about prevention.
(19:03):
And then we know that adolescents are very, they need to have very specific things. So you might say, “Carol, we know that people who vape are going to be less likely to be able to keep up on a sports team, and I know soccer is so important to you.” So those prevention messages are really important, although unfortunately, oftentimes in a busy pediatric practice or in a busy just life, that can be hard to really continue to say that over and over, which is really what it needs.
(19:41):
I think it is so important for listeners to really know that policy-level changes and advocacy really do make a difference. And so, an example of that might be the Tobacco 21 legislation that was added to a budget bill. It does make it federally illegal for stores to sell to adolescents who are less than 21.
(20:13):
Another very important, and I think actually probably one of the best opportunities, is for flavors to be also illegal, because most teens are not going to pick up a tobacco-flavored vape.
Carol Vassar, podcast host/producer (20:28):
Yeah,
Susan Walley, MD, Children’s National Hospital (20:29):
They’re going to want the flavors. So, from the perspective of public health, I think those are really crucial from that one-on-one, we do need for organizations to really focus on both the screening and then also the treatment for those who are already using.
Carol Vassar, podcast host/producer (20:49):
Are there coalitions, partnerships, policymakers, clinicians such as yourself, parents, maybe former youth who were once addicted to vapes who are no longer, who are working together on this, or do we need to push that forward?
Susan Walley, MD, Children’s National Hospital (21:05):
I mean, we definitely need to continue to push, like many other public health issues, right now in 2026. Just an example of that is the Centers for Disease Control and Prevention, the CDC Office of Smoking and Health, which really got completely decimated with some of the recent cutbacks. And we know that there are so many just passionate pediatricians and public health advocates. And so, the American Academy of Pediatrics has a section on nicotine and tobacco prevention and treatment that listeners can look at. And healthychildren.org, which is an AAP product, has information. The Campaign for Tobacco-Free Kids is another group. PAVE, which is Parents Against Vaping and E-cigarettes, is another really important group to mention. But I mean, I think every individual parent, pediatrician, can definitely make an impact in this work.
Carol Vassar, podcast host/producer (22:12):
And grandparents too, because that’s where I’m at, at my point in life.
Susan Walley, MD, Children’s National Hospital (22:16):
And grandparents. Apologies, grandparents. It’s probably even more so.
Carol Vassar, podcast host/producer r (22:18):
What do you want people when they hear your presentation here at PAS, what do you want people to walk away with? You’re talking to your peers, your fellow clinicians. What do you want them to walk away with and do when they go back to their communities?
Susan Walley, MD, Children’s National Hospital (22:31):
Absolutely. Thank you for that question. I think one of the things that I’ll be talking about is some new clinical practice guidelines, and that is going to give clinicians more tools in their toolbox to think about when they have an adolescent who is addicted to tobacco and nicotine.
(22:54):
And then I think another really important point is the screening, because oftentimes parents might say, “Not my child, they’re not going to vape.” And so, maybe screening might be more of a medical term that you think about with thinking about when you go to your doctor, but as a parent talking to your child, and you know your child best. And so saying, “Hey,” maybe something to the effect of, “I was at a lecture, and I heard about vaping and these vapes that will do things even like counting the steps that you’ve taken,” or they, yes-
Carol Vassar, podcast host/producer (23:38):
Really?
Susan Walley, MD, Children’s National Hospital (23:38):
They will even sync with your phone. “Have you ever heard of this? Have you ever seen one?” There’s vapes that have games, and it’s gamifying your vaping, and so in order to get to next levels, you have to actually vape. And so the technology there is amazing, in terms of knowing how to recruit youth to vape and to keep vaping.
Carol Vassar, podcast host/producer (24:06):
There’s almost an addiction on an addiction in there.
Susan Walley, MD, Children’s National Hospital (24:09):
Yes, yes, yes.
Carol Vassar, podcast host/producer (24:10):
Just in an algorithm they borrowed from social media, it seems.
Susan Walley, MD, Children’s National Hospital (24:14):
Yes. That is a whole other topic.
Carol Vassar, podcast host/producer (24:16):
That’s a whole other topic.
Susan Walley, MD, Children’s National Hospital l (24:17):
… I’m sure you’re going to be talking about.
Carol Vassar, podcast host/producer (24:19):
You’re going to have to come back and talk about that. Before we finish up, I want to take this full circle. We started with the tobacco companies. You mentioned some of the policy levers that could be pulled. What policy levers do we need to work with the tobacco companies on to get them to stop this?
Susan Walley, MD, Children’s National Hospital(24:36):
Yeah. I think you bring up a great point. And being a pediatrician, we always think about who’s at the table and coming at every conversation with an understanding that people really care about children and they care about health. I do think that, unfortunately, the tobacco companies have shown time and time again, when they are included, that oftentimes they will utilize that seat at the table for things that don’t ultimately help child health. And so my personal thought is that we utilize partners that we know have our children’s best intent. And I mean, of course, we know that tobacco is a billion-dollar business, and so oftentimes it’s the David and Goliath story. So, we know it’s the right thing for our children not to be addicted to tobacco and nicotine, in fact, not even to try it. And so that’s, I think, the thing to mainly focus your listeners on.
Carol Vassar, podcast host/producer (25:51):
Dr. Susan Whalley is the division chief for hospital medicine at Children’s National Hospital in Bethesda, Maryland, and an expert in the prevention of youth tobacco use and tobacco-related diseases.
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Well Beyond Medicine
Carol Vassar, podcast host/producer
Thanks to Dr. Walley for stopping by our booth at PAS to talk about what’s happening in the world of tobacco use prevention for our kids – and thank you for listening.
Have you had the chance to visit our website? nemourswellbeyond.org is where you’ll find all of our podcast episodes. Head over there to subscribe to the podcast as well as our monthly e-newsletter, give us podcast feedback and reviews, or leave an idea for a future episode. That’s nemourswellbeyond.org. You’ll also find us on your favorite podcast app, the Nemours YouTube Channel, or by asking your smart speaker to play the Nemours Well Beyond Medicine podcast.
Our production team for this episode includes Cheryl Munn, Susan Masucci, Lauren Teta, and Alex Wall. Video production by SarahKate Reger. Audio production by me. Join us next time as we examine research into another growing online issue teens are facing: digital partner violence. I’m Carol Vassar. Until then, remember, we can change children’s health for good – well beyond medicine.
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