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Public Health Briefings

Tobacco Use Prevention in Pediatric Primary Care Settings

Alessandra Kazura, MD, Michael Goldstein, MD

Published in: Medicine and Health/Rhode Island, 1998;81(4) 149-150

Allessandra Kazura, MD is Director, Consultation Service, Child and Adolescent Psychiatry, Hasbro Hospital, Providence, RI, and Instructor of Psychiatry and Human Behavior, Brown University School of Medicine. Michael Goldstein, MD is Acting Psychiatrist-in-Chief, Miriam Hospital, Providence, RI, and Associate Professor of Psychiatry and Human Behavior, Brown University School of Medicine.

Early tobacco use

Tobacco use among youth is increasing at an alarming rate. Between 1991 and 1995, the 30-day point prevalence of cigarette smoking increased from 14% to 19% for 8th graders.¹ Because the rate of increase was higher among females in this period, the gender gap of tobacco use prevalence has almost disappeared.¹ Across all age cohorts, white youths continue to have the highest daily use prevalence, but Hispanic and African American teenagers have also shown significant increases. In 1995, 22% of Hispanic 8th graders reported trying a cigarette, compared with 21% of whites and 9% of African Americans.¹ Youth from lower socioeconomic groups are especially vulnerable to tobacco use, with a 30-day smoking prevalence rate of 25.3% for 8th graders whose parents' educational attainment averages high school or less, compared to 14.5% for students whose parents had been to graduate or professional school.¹

Peak ages for first time use of cigarettes are 11 and 12 years, with as many as 29% of 8th graders reporting first use by the end of 6th grade and 9.3% reporting first use by 4th grade.¹ The peak age for daily use is variable, ranging from 13 to 16, with strong cohort effects.² Twenty percent of 8th graders reported trying smokeless tobacco and the average age of initial smokeless tobacco use may be as early as ten years. On average, the progression from initiation of smoking to regular use takes two to three years, with considerable individual differences.³ Early use of nicotine predicts subsequent heavy smoking rates and increased difficulty in successful quit efforts during adult years.⁴ 53% of high school seniors who smoke one half pack per day or more report unsuccessful quit efforts,¹ and 75% of daily smokers in high school who are followed longitudinally are still smoking daily seven to nine years later. Breslau and Peterson recently reported that, in a representative sample of adults between the ages of 21 and 33, the likelihood of cessation for those who had ever smoked daily for one month or more was significantly higher in smokers who had initiated smoking after age 13.⁵ The hazard ratio for quitting associated with smoking initiation at ages 14 to 16 was 1.6 and with initiation at or after 17 was 2.0, compared with initiation at or before age 13. Moreover, youth who do not start smoking by age 18 are unlikely to become adult smokers.² These findings suggest delaying smoking onset until after age 13 may significantly reduce the prevalence of adult smoking.

The Consequences

The harmful effects of tobacco are directly related to duration and intensity of use, both of which are related to early onset of smoking.² The gravest and most commonly known health burdens from tobacco use, such as cancer, predominate in adult age groups. Nevertheless, adverse effects begin during childhood. Smoking alters pulmonary structure and function in young adults and adolescents. Adverse respiratory effects have been documented in children smoking as little as one cigarette per week.⁶ Pregnant adolescents who smoke have an increased risk of delivering prematurely, an outcome with serious psychosocial as well as physical consequences for the mother and baby.² Although less prevalent than cigarette use, smokeless tobacco also increases health burdens in young people due to periodontal disease.

A Theoretical Basis for Tobacco Use Prevention in Pediatric Primary Care Settings

For several reasons, primary care providers who care for children are particularly well-positioned to deliver tobacco use prevention messages. Declining perceptions of health risk from smoking have paralleled recent increases in youth smoking prevalence. This trend is most apparent in the youngest cohort assessed by the 1995 Monitoring the Future Survey. Only 50% of 8th graders endorse a serious health risk from smoking one or more packs per day, and only 34% perceive a serious risk from the regular use of smokeless tobacco.¹ In contrast, anticipated negative outcomes from smoking, particularly fear of adverse health effects, have been reported to be a significant factor in early refusals of offered cigarettes.⁷ Health care providers are therefore uniquely positioned to influence children's perceptions of health risk.

Health care providers who care for children are also trained to tailor health messages to their patients' stage of cognitive development. Messages about the health risks of smoking that are delivered to children must be developmentally appropriate. Rational decision-making processes are dependent upon a child's cognitive development, such as the ability to abstract or to anticipate consequences.⁸

Health care providers can also use their influence and expertise to address peer, family, and psychological issues which affect tobacco use. Children who are exposed to parents, older siblings, or peers who smoke are at high risk for initiating use,² and peer influences have been established as important factors in susceptibility to tobacco use.⁹ Perception of social norms mediates the influence of peers. Youth smokers underestimate the disapproval of peers and overestimate peer and adult smoking rates.¹⁰ Self-efficacy to resist peer pressures to use tobacco is also an important predictor of youth smoking. These findings suggest that preventive interventions address children's perceptions of social norms and promote strategies to enhance self-efficacy for resisting peer influences. For many children, tobacco use may be a dysfunctional coping strategy in the presence of psychosocial vulnerabilities such as depressed mood, attention and hyperactivity difficulties, high perceived stress, and body-image concerns. All are associated with increased risk of current and future smoking.¹¹ Sussman et al. note a relationship between children's experiences in managing stress and their intentions to smoke.¹² Stressful family factors, such as parental indifference, poor parent and child communication, and low adolescent involvement in family decision-making processes have been associated with adolescent smoking.¹³ Pediatricians and family physicians are uniquely positioned to identify children's psychological vulnerabilities and parental and family difficulties and to assist both parents and children to manage them.

To date, the tobacco use prevention interventions achieving the best behavioral outcomes have been school-based social influences models.² Programs that explicitly counter environmental pro-tobacco pressures and use cognitive-behavioral strategies to develop tobacco refusal skills consistently outperform programs based on information deficit and affective education models.¹⁴ Analysis of successful programs led to NCI recommendations that school-based interventions incorporate (1) information on the short-term consequences of smoking, (2) information about social influences, and (3) resistance skills training.¹⁵ These strategies are similar to adult smoking cessation strategies, which support interventions providing social support and specific skills training.¹⁶

The Advantages of Tobacco Use Prevention in Pediatric Primary Care Settings

Routine tobacco use prevention counseling by pediatric health care providers is a promising, but underdeveloped, channel of intervention. Patient receptivity to counseling about tobacco use provided in the context of pediatric health care is supported by reports that children and their parents are interested in health information from their providers¹⁷ and that they believe their personal physicians to be credible sources of health advice.¹⁸ Pediatric health care providers need to be proactive in identifying and addressing tobacco use, as adolescents are unlikely to initiate discussion even when engaging in risky behaviors.¹⁹ The average annual number of health care visits for children ages 5-11 and 12-17 are 3.5 and 3.3, respectively.²⁰ These visits provide multiple opportunities for pediatric providers to intervene to prevent and reduce tobacco use. Continuity of care allows both child and parent to experience a committed, caring relationship with the care provider, and within this context, preventive messages may be especially influential.

Children with parent-reported behavior problems are likely to have more medical visits than those without.²¹ This subset of children may be especially important to target for intervention, since they tend to affiliate with tobacco using peer groups.²² Adult smokers report that advice from physicians is an important motivation for quitting, and well-documented trials demonstrate that adult smokers who received even brief advice to quit are significantly more likely to quit during the following year than smokers who had not received this advice.²³ Because of the enormous public health benefit from even minimal interventions, the Agency for Health Care Policy and Research has issued strong practice guidelines that every patient, at every visit, be assessed for tobacco use and that smokers be strongly advised to quit.¹⁶

Pediatric health care providers have a rich tradition of support for psychosocial interventions. Professional pediatric and family medicine practice guidelines advocate early and repeated tobacco use prevention counseling.

Barriers to Tobacco Use Prevention in Pediatric Primary Care Settings

Unfortunately, actual counseling rates of adolescent smokers in primary care settings appear to be low, with only 50% of adolescent smokers recalling any queries or advice about tobacco use from patients or nurses.²⁴ Although physicians as a group support the goal of reducing tobacco use, they experience numerous barriers to implementation of routine counseling.²⁵ Barriers include lack of knowledge and skills in delivering motivational counseling or smoking cessation counseling, limited time, lack of patient education resources, and limited use of office staff to assist in delivering counseling interventions.

Overcoming the Barriers

We believe that these barriers may be overcome in pediatric primary care settings. Brief, effective smoking cessation counseling skills can be taught to pediatric health care providers. Moreover, in adult primary care settings, investigation of physician preventive care behaviors has demonstrated a clear link between performance and the presence of supportive office systems.²⁶ These systems are most successful when offices use a team approach to address key elements of care delivery: identification, assessment, patient education and counseling, patient follow-up, and monitoring and feedback to staff of the delivery of the intended services.

In the meantime, health care providers who see children are encouraged to use existing opportunities to provide anticipatory guidance to preadolescent and adolescent patients about tobacco use and also to advise those young patients who smoke to quit. To this end, we have recently applied for a grant to test a practical application of the model in Rhode Island.

References

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23. National Cancer Institute. Tobacco and the clinician: Interventions for medical and dental practice. NIH Publication No. 94-3693. Monogr Natl Cancer Inst 1994;5:1-22.

24. CDC. Health care provider advice on tobacco use to persons aged 10-22 years -- United States, 1993. MMWR 1994;44:826-830.

25. Goldstein MG, MacDonald NA, Niaura RS, Dube C. Dissemination of physician-based smoking cessation interventions. In: Burns S, Cohen S, Gritz E, Kottke T. Tobacco and the clinician: Interventions for medical and dental practice. Bethesda, MD: National Cancer Institute, 1993.

26. Carney PA, Dietrich AJ, Keller A, Landgraf J, O’Connor GT. Tools, teamwork, and tenacity: An office system for cancer prevention. J Fam Prac 1992;35(4):388-394.