Bonnie L. Halpern-Felsher
Department of Pediatrics
University of California, San Francisco
In addition to providing primary health care for children and adolescents, an annual health care visit provides a potentially pivotal opportunity for physicians to provide clinical preventive services that can prevent and reduce children’s and adolescents’ engagement in health risk behaviors, including tobacco use. As such, a number of national guidelines concerning physicians’ provision of preventive services have been developed (e.g., DHHS 1998; Elster and Kuznets 1994; Green and Palfrey 2002; Levenberg and Elster 1995; Stein 1997; U.S. Preventive Services Task Force 2004). In general, these guidelines recommend that all children and adolescents have an annual health care visit during which time all patients should receive confidential preventive services, including being screened, educated, and counseled on a number of biomedical, emotional, and sociobehavioral areas including health risk behaviors such as alcohol and tobacco use, sexual behavior, violence, and safety. Furthermore, guidelines, including those outlined by the American Academy of Pediatrics, recommend that pediatricians discuss substance use as part of routine health care for the prenatal visit, as a home assessment, and for youth (Kulig 2005). With regard to tobacco use, guidelines suggest that in addition to inquiring about tobacco use in general, physicians should specifically query youth about the extent to which tobacco is used, the settings in which tobacco is used, and whether tobacco use has had a negative impact on social, educational or vocational activities (Kulig 2005). Further, physicians need to inquire about tobacco use in the child’s home, including use by parents, siblings, and other family members (Kulig 2005). Health care providers need to encourage smoke-free homes, and provide guidance and assistance to parents and youth on means to smoking cessation, including counseling and use of pharmacological agents.
Despite these guidelines, research shows that physicians’ rates of screening, educating, and counseling around tobacco use are less than optimal. In this paper, we briefly review the literature describing rates of delivery of clinical preventive services to youth. We also describe physicians’ reported barriers to the provision of preventive services and review interventions aiming to increase clinical services, including effects of training healthcare providers to screen, educate, and council youth as well as the effects of such training on youth outcomes. We also review the limited literature on providers’ use of pharmacological agents to assist adolescents in tobacco cessation. We conclude with a set of recommendations to improve tobacco-related clinical preventive services for youth.
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Ending the Tobacco Problem: A Blueprint for the Nation F Interventions for Children and Youth in the Health Care Setting Bonnie L. Halpern-Felsher Department of Pediatrics University of California, San Francisco INTRODUCTION In addition to providing primary health care for children and adolescents, an annual health care visit provides a potentially pivotal opportunity for physicians to provide clinical preventive services that can prevent and reduce children’s and adolescents’ engagement in health risk behaviors, including tobacco use. As such, a number of national guidelines concerning physicians’ provision of preventive services have been developed (e.g., DHHS 1998; Elster and Kuznets 1994; Green and Palfrey 2002; Levenberg and Elster 1995; Stein 1997; U.S. Preventive Services Task Force 2004). In general, these guidelines recommend that all children and adolescents have an annual health care visit during which time all patients should receive confidential preventive services, including being screened, educated, and counseled on a number of biomedical, emotional, and sociobehavioral areas including health risk behaviors such as alcohol and tobacco use, sexual behavior, violence, and safety. Furthermore, guidelines, including those outlined by the American Academy of Pediatrics, recommend that pediatricians discuss substance use as part of routine health care for the prenatal visit, as a home assessment, and for youth (Kulig 2005). With regard to tobacco use, guidelines suggest that in addition to inquiring about tobacco use in general, physicians should specifically query youth about the extent to which tobacco is used, the settings in which tobacco is used, and whether tobacco use has had a negative impact on social, educational or vocational activities (Kulig 2005). Further, physicians need to inquire about tobacco use in the child’s home, including use by parents, siblings, and other family members (Kulig 2005). Health care providers need to encourage smoke-free homes, and provide guidance and assistance to parents and youth on means to smoking cessation, including counseling and use of pharmacological agents. Despite these guidelines, research shows that physicians’ rates of screening, educating, and counseling around tobacco use are less than optimal. In this paper, we briefly review the literature describing rates of delivery of clinical preventive services to youth. We also describe physicians’ reported barriers to the provision of preventive services and review interventions aiming to increase clinical services, including effects of training healthcare providers to screen, educate, and council youth as well as the effects of such training on youth outcomes. We also review the limited literature on providers’ use of pharmacological agents to assist adolescents in tobacco cessation. We conclude with a set of recommendations to improve tobacco-related clinical preventive services for youth.
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Ending the Tobacco Problem: A Blueprint for the Nation Provision of Clinical Preventive Services to Youth Low rates of delivery of preventive services have been found among physicians in private practice, community-based practices, and managed care settings. For example, studies have shown that fewer than 60 percent of adolescents are provided guidance about smoking (Marks et al. 1990), and only 1 percent of adolescent office visits included advice about smoking cessation (Igra and Millstein 1993). Halpern-Felsher and colleagues (2000) showed that 77 percent of adolescents in a managed care setting were screened for tobacco use (Halpern-Felsher et al. 2000). Among those who reported tobacco use, more than three-quarters were screened further about the amount they smoked, and 84 percent were educated about the risks of smoking. Halpern-Felsher and colleagues (2002) also found that 43 percent of the adolescent patients’ parents were told about the need to monitor their adolescents’ behaviors for risk behaviors, including substance use. In a study of almost 1,000 pediatricians randomly selected from a national sample, Galuska and colleagues (2002) reported that 29 percent of the pediatricians reported always counseling younger children (age 6–12) about tobacco use, and 69 percent always counseled about tobacco use among 13–18 year old patients. However, fewer than half of the pediatricians counseled about tobacco use by others in the home. In a large survey of family practitioners, pediatricians, internists, and obstetricians/gynecologists, Ewing and colleagues (1999) found that fewer than half of the providers routinely inquired about smoking. In another survey of pediatricians and family physicians, Klein and colleagues (2001a) showed that providers reported asking over 90 percent of their adolescent patients about smoking, and discussed tobacco-related health risks with more than 75 percent of their patients (Klein et al. 2001a). Inquiries about parental smoking, peer smoking, and use of smokeless tobacco were lower, ranging from 54 to 32 percent. While greater than 80 percent of the providers promoted smoking abstinence among their nonsmoking patients and assessed cessation motivation among smoking patients, fewer than half of the providers followed up with cessation materials or referrals. Rates of screening adolescents for tobacco use and other risk behaviors vary by physician characteristics, including age, gender, year of graduation, practice setting, and subspecialty. For example, Galuska and colleagues (2002) (see also Klein et al. 2001a) found that rates of counseling for tobacco use and other preventive services was greater among female providers and pediatricians who were able to spend more time with their patients. Ewing and colleagues (1999) showed that younger providers were more likely to provide tobacco-related clinical preventive services. Blum and colleagues (1996) showed that provision of clinical services was lowest among non-teen-focused practice settings, net of patient age or gender. Halpern-Felsher and colleagues (2000) showed greater provision of services among female physicians, recent graduates from medical school, and providers with a greater number of older adolescent patients (Halpern-Felsher et al. 2000). Provision of Pharmacological Agents Given that adolescent smokers who are trying to quit experience similar withdrawal symptoms to adults, it has been suggested that adolescents might benefit from the use of pharmacological agents (i.e., nicotine replacement therapy [NRT]) to aid in cessation. Despite evidence that nicotine replacement therapy, coupled with counseling, has been effective with adults, few health care providers have used NRTs with their adolescent patients and even fewer controlled clinical trials have been published. A study conducted by Hurt and colleagues (Hurt et al. 2000) examined the efficacy of NRT in adolescent smokers. The intervention consisted of 6 weeks of nicotine patch therapy plus a minimal behavioral intervention. Despite adolescent participants’ moti-
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Ending the Tobacco Problem: A Blueprint for the Nation vation to quit, the authors reported only a 5 percent smoking abstinence rate over the 6-month study period, which is a rate no greater than abstinence rates among adolescents quitting on their own. More recently, Killen and colleagues (2004) published their results of a study on the efficacy of smoking cessation treatment for adolescents that combined nicotine patch treatment with bupropion, an aminoketone antidepressant that has been successful in aiding adults to quit smoking. Adolescents were randomized into two groups for a 26-week assessment period: nicotine patch plus bupropion or nicotine patch plus placebo. Both groups also received group-based skills training. Results indicated that the addition of bupropion was not an added benefit to the use of nicotine replacement alone on smoking abstinence. After 10 weeks of assessment, adolescents’ rates of smoking abstinence were 23 percent and 28 percent for the patch plus bupropion and the patch plus placebo, respectively. After 26 weeks, these rates fell to 8 percent and 7 percent, respectively. Although bupropion did not provide added value, it was clear that the use of nicotine replacement plus the skills training was at least partly effective, suggesting that further research on the use of NRT in adolescents is encouraging. Barriers to Provision of Clinical Preventive Services to Youth Physicians site a number of barriers to their provision of clinical preventive services, including: (1) a large number of patients which results in time constraints per patient, (2) inadequate reimbursement relative to the time and effort required to provide such services, (3) fear of alienating patients and families, (4) insufficient education and training, (5) lack of dissemination to physicians of research supporting positive treatment outcomes and negative effects of failure to intervene, and (6) lack of information about how to access referral and treatment resources (Kulig 2005; Cheng et al. 1999). Research also suggests that physicians’ self-efficacy to screen adolescents about tobacco use is related to their delivery of preventive services (Cheng et al. 1999; Ozer et al. 2004). Clinical Preventive Services: Effects on Youth Smoking Physicians’ role in preventing or reducing tobacco use among children and adolescents may be either direct or indirect. Directly, physicians can screen and educate youth about tobacco use and refer youth who do smoke to cessation programs. Indirectly, physicians can encourage parents to monitor their children’s behavior and set firm expectations about not smoking. Unfortunately, little research exists to determine whether increased rates of screening, counseling, and education by physicians actually result in lower rates of tobacco use and higher rates of cessation, nor have studies determined mechanisms by which physician interventions might be most effective (Christakis et al. 2003). One study did investigate whether implementing an office systems approach would prevent or delay adolescents’ drinking and smoking behaviors (Stevens et al. 2002). The idea of the office systems approach is that not only does the primary care physician provide anticipatory guidance and screening, but also the entire office staff endorses the prevention messages and prevention materials are provided in the office. Stevens and colleagues (2002) found that, despite evidence that their intervention was implemented successfully, it had no significant impact on adolescents’ tobacco use. The authors suggested that their program might have been ineffective in part because it focused on increasing parent–child communication rather than targeting the adolescents’ behaviors per se. More recently, Ozer and colleagues (2004) presented preliminary results that compared to adolescents in comparison sites, adolescents participating in clinical preventive services in managed care settings were less likely to increase their tobacco use over a one-year period (Ozer et al. 2004). However, the effects on to-
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Ending the Tobacco Problem: A Blueprint for the Nation bacco use initiation were not reported. Three other studies, using randomized controlled trials of smoking prevention interventions in medical settings, found that preventive services had no effect on youth smoking (Kentala et al. 1999). Fidler and Lambert (2001) found a small but significant difference in smoking rates between youth in the intervention and control group (Fidler and Lambert 2001). Curry and colleagues (2003) implemented and evaluated a randomized trial of a family-based smoking prevention program in a managed care setting (Curry et al. 2003). The intervention included a smoking prevention kit mailed to parents, parent newsletters, follow-up telephone calls by health educators, materials for the children, and information placed in medical records and charts as reminders to the physician to deliver prevention messages. Despite their careful design and implementation of the intervention, evaluation results showed no program effects. Although the intervention had small but significant effects on increasing parentchild communication about tobacco, no differences between the intervention and control groups were found in rates of susceptibility to smoking, experimentation with smoking, or monthly smoking rates. INTERVENTIONS AIMED AT INCREASING CLINICAL PREVENTIVE SERVICES A number of different types of interventions (e.g., physician training, charting forms, and electronic prompts) have been developed and tested to improve the preventive services of primary care physicians, yielding small to moderate effects on clinical service provision. These various interventions are reviewed next. Physician Training Training sessions to increase physicians’ screening and counseling during routine medical visits have been implemented and evaluated, with mixed results depending on the type and intensity of training. Overall, however, the research shows that physicians’ rates of screening and educating about tobacco use can be increased through training in which physicians are provided with knowledge, attitudes, and skills that are necessary for behavior change (Lustig et al. 2001; Ozer et al. 2005). For example, Lustig and colleagues (2001) showed that the average percentage of adolescents screened for tobacco use went from 64 percent pre-training to 76 percent post-training (Lustig et al. 2001). Similarly, the average percentage of adolescent patients who received brief counseling concerning tobacco use also increased, from 60 to 69 percent. Physicians were also more likely to discuss confidentiality with adolescent patients following skills-based training (Lustig et al. 2001). This later finding is important given research indicating that adolescents are more likely to disclose their engagement in risk behaviors if they believe their discussions with their physicians will be kept confidential (Ford et al. 1997). This adolescent concern emphasizes the need to query youth about their tobacco use and other risk behaviors in a private office space with parents and other authority figures not proximal to these conversations (Kulig 2005). Klein and colleagues (2001b) conducted in-depth training of the American Medical Association Guidelines for Adolescent Preventive Services (GAPS) guidelines in 5 community health centers (Klein et al. 2001b). Their evaluation showed significant increases in the process of delivery of care, with a greater number of adolescents receiving comprehensive screening and counseling and more health education materials that were in accord with the GAPS guidelines.
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Ending the Tobacco Problem: A Blueprint for the Nation Charting Tools and Reminders Even with successful skills-based training, research suggests that physicians need charting tools and reminders in order to continue their preventive services. Further, physicians’ screening and counseling rates for tobacco use can be improved through training, introduction of charting forms concerning screening and counseling, and with the addition of an on-site health educator (e.g., Klein et al. 2001b). The addition of screening tools as well as the addition of resources from a health educator in the clinic also significantly increase the likelihood that an adolescent will be screened and counseled about their alcohol use (Ozer et al. 2001; see also Sims et al. 2004). Similarly, Gadomski and colleagues showed that integrating the GAPS questionnaire into routine medical care significantly increased the documentation of risk behaviors, although no changes in referral rates of follow-up visits were noted (Gadomski et al. 2003). Use of Electronic Prompts and Electronic Patient Records The use of Electronic Medical Records (EMRs) is an additional tool used to improve rates and quality of preventive care to youth. EMRs can improve access to patient data, provide more efficient means of documenting services, provide prompts to healthcare professionals, and provide key data and instructional information for patients (Adams et al. 2003). Despite recent development and implementation of EMRs, their use in a pediatric setting is not widespread; and few studies have examined their effectiveness at increasing provision of preventive services. Adams and colleagues (2003) conducted one of the only studies on the use of comprehensive EMRs by pediatricians and nurse practitioners (Adams et al. 2003). The authors developed a pediatric EMR that resembled traditional paper-and-pencil forms but provided healthcare professionals with prompts and areas of inquiry as to whether the service was provided. Computers containing these EMRs were located in each examination room and, through the clinic, allowed for documentation of each patient visit. Using a pre–post intervention design, the authors found that the delivery of primary care was enhanced with the implementation of the EMRs over the more traditional paper-and-pencil documentation forms in all areas, and especially for the area of risk assessment, including asking about smoking in the home. In addition to providing the pediatrician prompts for assessment areas, the computers allowed for enhanced anticipatory guidance and the provision of educational materials that could be easily printed, in multiple languages, for the patient and their family. Finally, the study showed that healthcare providers and their patients were positive about the use of the EMRs, reporting that quality of care and guidance was improved. However, the providers noted that direct eye contact with patients was reduced through the use of the EMRs. Nevertheless, all providers recommended continued use of the EMRs. In a pilot study, Toth-Pal and colleagues (2004) developed, implemented, and evaluated the use of a computer-generated on-screen reminder for physicians caring for elderly patients (Toth-Pal et al. 2004). Their pilot data indicated that both laboratory and manual screening tests, as well as emergence of new diagnoses and treatment, increased among general practitioners in the computer-generated prompt group, compared to control. Schellhase and colleagues (2003) conducted a survey of 51 primary care providers—including providers in family medicine, internal medicine, and pediatrics—to discern providers’ use of and attitudes toward reminder systems embedded within EMRs (Schellhase et al. 2003). The authors found that 75 percent of the clinicians liked or loved the EMR system, nearly half felt that the automatic reminders improved care, and the majority of respondents did not feel that the reminder system was intrusive on their decision-making autonomy. Despite these favorable attitudes, the health maintenance reminder system was under-utilized, with the overwhelming
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Ending the Tobacco Problem: A Blueprint for the Nation majority of clinicians reporting that they never or seldom looked for the reminder alert and that they typically ignored the alert when they did notice it. EMRs also provide opportunities to assess quality of preventive care, improving upon assessment methods utilizing surveys or chart reviews (Vogt et al. 2004). Studies have suggested that computer-based and computer-generated clinical reminders are an efficient and effective strategy for increasing provision of clinical services (see Shea et al. 1996 and Austin et al. 1994 for a review and meta-analysis; see also Morris et al. 2004 and Schellhase et al. 2003). Nevertheless, adherence to recommendations for clinical preventive service remains even in clinics utilizing such reminder prompts (Schellhase et al. 2003). SUMMARY AND RECOMMENDATIONS Given that most adolescents attend an annual health care visit, physicians have the opportunity to provide adolescents with confidential screening, education, and counseling concerning their engagement in risk behaviors, including tobacco use. Despite national guidelines, research clearly shows that physicians’ rates of screening, educating, and counseling their adolescent patients about tobacco use and cessation are far below recommended levels. While such delivery of preventive services has been below levels suggested by national guidelines, research clearly shows that rates of screening and anticipatory guidance can increase through skills-based training, inclusion of screening and charting tools, and resources such as health educators in the clinic. Unfortunately, there is a dearth of literature examining whether the successful implementation of preventive services actually reduces adolescent tobacco use. However, preliminary studies suggest a positive relationship between training and delivery of preventive services around tobacco use. Further, we lack information on the mechanisms by which physician screening and education effects tobacco use. Such information is critical if we are to be able to provide specific recommendations concerning the implementation of clinical preventive services as a successful route to tobacco use prevention or intervention. Thus, additional research on the implementation and evaluation of preventive services are needed to determine whether and how physician training leads to increased services and reduced tobacco use. Given the literature and promising results thus far, we recommend that every youth coming to any health care provider (including annual visits, urgent care, and ER visits as well as sports physicals and camp physicals) should be screened and counseled about tobacco use. This screening and education should include regular cigarettes, light cigarettes, bidis, loose tobacco, and so on. Youth who screen positive for tobacco use should be referred to cessation programs.
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