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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-