By Jamie Ducharme
March 21, 2019

Jami Scheetz knew that her 15-year-old son, Devon, needed help. His grades were slipping and he had been caught vaping at school so many times that he was on the brink of being expelled. Last fall, at the start of his freshman year, Devon’s school even sent him to the hospital for drug testing after getting in trouble once again. In the emergency room, Devon finally admitted it: He was addicted. “He said to me, ‘Mom, I can’t quit on my own. I need help,'” Scheetz says.

E-cigarettes are illegal for people younger than 18 (and in some states, 21) but that hasn’t stopped teens from vaping in droves. The sleekly designed devices — which heat a liquid usually packed with nicotine and other chemicals into an inhalable vapor — have eclipsed cigarettes in popularity. At a time when just 8% of high school students smoke cigarettes, more than 20% vape regularly, according to the latest federal data.

These trends have stoked concerns that e-cigarettes will hook a whole new generation on nicotine, threatening years of public-health progress against smoking. The U.S. Surgeon General called youth vaping use an “epidemic” last year, and the Food and Drug Administration (FDA) continues to introduce new restrictions on manufacturers in order to curb youth access to e-cigs.

But as more kids get hooked on nicotine, parents, like Scheetz, are learning that resources for their kids are scarce. E-cigarette use has far outpaced science when it comes to finding treatments for nicotine dependence. “It’s frustrating. It’s an epidemic because there’s no help,” Scheetz says. “The only way to fight the epidemic is to help and treat them, because it is an addiction.”

It’s not easy to find treatment for kids who smoke, since nicotine dependence is primarily seen as an adult problem. But finding treatment for vaping addiction is even harder, because nobody really knows how to treat people of any age who are addicted to vaping, as the practice is called, says Donna Richardson, clinical coordinator of the Rutgers Tobacco Dependence Program. “There are no treatment guidelines yet for these products,” Richardson says. “Providers—pediatricians—are fielding a lot of the calls and don’t necessarily have best practices in place.”

In the last year, Richardson says Rutgers’ smoking-cessation specialists have gotten about 10 calls from parents and schools worried about youth vaping addiction, compared to just a few in the past. Without specific treatment standards for young patients, clinicians often resort to standard nicotine-replacement therapies like patches and gum — even though they’re designed for adults, and evidence of their success against vaping dependence, even for adults, is mostly anecdotal. “We have nothing else,” Richardson says.

The problem has gotten so prevalent that the FDA this year began looking into ways to help kids who are addicted to vaping. But the irony, of course, is that many people vape to break their addiction to cigarettes. E-cigarettes contain fewer carcinogens and dangerous byproducts than combustible cigarettes, but still deliver nicotine, so many adults vape to kick a cigarette habit. Vapes are not FDA-approved as smoking-cessation tools — and therefore can’t legally be marketed in that way — but some research suggests they’re effective for adults who are trying to quit.

But most teens who get hooked on e-cigs aren’t using them to quit cigarettes. In fact, research suggests that vapes often drive young people toward traditional cigarettes, rather than the other way around. After years of declines, teen smoking rates actually rose slightly between 2017 and 2018 — from 7.6% of high schoolers to 8.1% — and many public health officials have blamed skyrocketing youth vaping rates for that uptick.

Plus, young vapers don’t always know what they’re getting from their device. In one study, only 37% of 15- to 24-year-olds who vaped knew that e-cigs made by Juul, the most popular brand of e-cigarette, always contain nicotine. In reality, one Juul pod, with about 200 puffs, can contain as much nicotine as a pack of cigarettes. (Juul has long maintained that its products are not meant for youth users, and says it is working to curb teen use.)

One boy, who is now 16, didn’t realize what he was inhaling, his mother says. (She asked not to publish her name or location to protect her family’s privacy.) When her son started vaping as a freshman in high school, she says he thought e-cigarettes produced “water vapor” and did not contain nicotine. Two years later, when his grades had fallen and he’d gone from athletic and sociable to sullen and withdrawn, she says she realized he needed treatment for nicotine dependence.

But everywhere she turned, she was met with rejection. “I hit a wall,” she says. A local therapist trained in youth addiction referred her to a treatment center, but the center didn’t take adolescents. Her son’s pediatrician didn’t know what to do, either. The only place she found support, she says, was the group Parents Against Vaping E-Cigarettes, which advocates for stricter regulations on e-cigarettes and offers a community for parents whose kids have gotten hooked.

The only options seemed to be in-patient treatment centers, some of which were located across the country. She and her husband told her son he had two choices: quit, or pack up and go to rehab. Playing hardball worked. After a few days of physical withdrawal and headaches, she says her son kicked the habit — but that she wishes he had had more resources.

“It was like this tsunami. I see my child going under, and you’re kind of paralyzed,” she says. “You just don’t know what to do.”

Scheetz also hit a wall when seeking treatment for her son Devon. When Devon told his mother he needed help, she turned first to his emergency room doctors. They couldn’t treat minors and suggested that Scheetz ask her son’s pediatrician. Devon’s pediatrician said he wasn’t equipped to treat vaping addiction, Scheetz says, and Devon’s school connected her with a woman who ran a local smoking-cessation class. Through her, Scheetz found Dr. Frank Leone, who runs Penn Medicine’s Comprehensive Smoking Treatment Program — but Leone’s office initially also said it couldn’t treat minors.

“At this point I’m frustrated, because it’s been like two months and everywhere I turn, I’m being turned down,” Scheetz remembers. “I just said, ‘Can you please just have the doctor call me? Maybe he could direct me somewhere else.'”

When the staff passed along her message, Leone finally gave her the answer she wanted. He said he would see Devon for an assessment, despite the insurance issues that could come from billing services for a minor. An insurance company can turn down charges for an adolescent if they come from an adult specialist, potentially triggering appeals and delayed payments, Leone explains. “It’s much more important to me that I help this kid with this major life problem than whether or not I get paid $100 from his insurance company,” Leone says. But “the burden of the system is so onerous that I can imagine a lot of folks are just like, ‘I don’t have time, I’m not going to deal with it.'”

In the end, treatment for Devon was covered. But besides the insurance issues, some doctors are also nervous to treat patients who fall outside their specialty — whether they’re addiction specialists not used to seeing kids, or pediatricians who don’t usually deal with substance misuse. “As a medical community, we haven’t spent a lot of time or sufficient resources developing really universally available tobacco dependence treatments for adolescents,” Leone says. Options are even slimmer for e-cigs.

Nonetheless, demand is growing. Leone says he’s been approached by about 10 adolescents and their parents for treatment so far, and expects to see more in coming months and years. In January, the anti-tobacco group Truth Initiative launched a text-based e-cigarette cessation program for young people; 31,000 people have registered, the group says.

A few parents have checked their kids who are struggling with vaping addiction into in-patient rehab centers, according to news reports. But the vast majority of families are simply looking for insurance-covered outpatient care, and “it just sort of doesn’t exist” in any consistent way, says Dr. Jonathan Avery, an addiction psychiatrist at NewYork-Presbyterian—Weill Cornell Medical Center.

Avery says he almost never treated kids struggling with nicotine addiction until vaping entered the picture. “We thought we were winning the game on cigarettes,” Avery says. “Suddenly, after probably seeing one adolescent for nicotine use in the last five years, there’s all sorts of [young] people looking for treatment, wondering what to do.”

Until more treatments become available, patients, parents and doctors are working with what they can.

This year, Avery started a counseling-based treatment program for adolescents with vaping dependence, and encouraged his hospital system’s adolescent psychiatrists and pediatricians to refer patients who were struggling. Over two months, he got more than 50 calls from colleagues and treated about 30 adolescent patients, he says. Most just needed counseling, but Avery resorted to guided tapering plans or nicotine replacement products like patches and gum for those who needed more, he says. Still, at this point, any vaping treatment is experimental. “We don’t have good data” on how well these strategies actually work for adolescents hooked on nicotine, he says.

Leone recommended nicotine patches to Devon, which have helped quell his cravings, his mother says — but he’s due to stop wearing one at the end of March. If the cravings don’t come back, Devon’s treatment could be over. But if he starts vaping again, “we have to come up with some other things,” Scheetz says.

Scheetz says she hopes Devon can stay strong when the patch comes off. But she’s worried about how her son will fare in an environment that tempts him to give in.

“He says he can’t go to the bathroom without seeing at least five, six kids doing it,” Scheetz says. “I’m a little nervous for him to be around that — and not have the nicotine patch to help him.”

Write to Jamie Ducharme at jamie.ducharme@time.com.

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