Screening for Tobacco Use in Adolescents-Teen

Summary of Recommendation and Evidence

Population	Recommendation	Grade (What's This?)
School-Aged Children and Adolescents	The USPSTF recommends that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among school-aged children and adolescents.	B

See the Clinical Considerations for more information on effective interventions.

Tobacco use is the leading cause of preventable death in the United States. An estimated 443,000 deaths occur annually that are attributable to smoking, including nearly 161,000 deaths from cancer, 128,000 from cardiovascular diseases, and 103,000 from respiratory diseases. Smoking costs the United States approximately $96 billion each year in direct medical costs and $97 billion from productivity losses due to premature death¹.

Recognition of Behavior

A person's path to daily smoking and nicotine dependence can be described in 5 stages: susceptible to smoking (never smoked); initiation (trying the first cigarette); experimentation (repeatedly trying cigarettes, may show signs of addiction); established smoking (regular smoking, likely to show signs of addiction); and nicotine dependence.

Children are susceptible to smoking experimentation and initiation. It can take up to 2 years to progress from early experimentation to addiction, although some children and adolescents progress more rapidly to nicotine dependence².

Effectiveness of Interventions to Change Behavior

The USPSTF found adequate evidence that behavioral counseling interventions, such as face-to-face or phone interaction with a health care provider, print materials, and computer applications, can reduce the risk of smoking initiation in school-aged children and adolescents.

Harms of Interventions to Change Behavior

The USPSTF found no evidence on the harms of behavioral interventions to prevent tobacco use; however, the magnitude of these potential harms is probably small to none.

USPSTF Assessment

The USPSTF concludes with moderate certainty that primary care–relevant behavioral interventions to prevent tobacco use in school-aged children and adolescents have a moderate net benefit.

Patient Population Under Consideration

This recommendation applies to school-aged children and adolescents. The USPSTF has issued a separate recommendation statement on tobacco use counseling in adults and pregnant women.

Assessment of Risk

In 2009, 8.2% of middle school students and 23.9% of high school students reported current use of any tobacco product³. Although younger children may be susceptible to smoking, research indicates that adolescents may be especially vulnerable to nicotine addiction.

The prevalence of current smoking in the United States is higher in male high school students (19.8%) than female students (19.1%)⁴. Two of the strongest factors associated with smoking initiation in children and adolescents are parental smoking and parental nicotine dependence. Other factors include low levels of parental monitoring, easy access to cigarettes, the perception that peers smoke, and exposure to tobacco promotions.

Interventions to Prevent Tobacco Use

The type and intensity of effective behavioral interventions substantially varied in the evidence review, ranging from no in-person interaction with a health care professional to 7 group sessions totaling more than 15 hours¹. In 1 intervention, families received a packet of materials for parents and children and a 28-minute video with a viewing guide. These families received 1 counseling call 3 to 6 weeks after receiving the written materials and another call 14 months after enrollment. Another intervention consisted of creating a tobacco-free office and giving patients a series of antitobacco messages on preprinted “prescription” forms. The most intensive intervention focused on universal substance abuse and problem behavior prevention for families. In this intervention, the youth and at least 1 parent participated in 7 group and family sessions over 7 weeks (each session lasted 2 to 2.5 hours) and received workbooks with activities to complete at home.

Even very minimal interventions, such as mailing materials to a youth's home, had substantial effects on reducing smoking initiation. One intervention mailed tailored newsletters addressed to the student every 3 weeks; another intervention sent age-related materials 4 times over 12 months. In a third intervention, participants were mailed 5 core activity guides with newsletters and tip sheets approximately every 2 weeks, with 1 booster guide at 1 year¹.

Many interventions had similar content, such as the participant's attitudes, beliefs, and knowledge about smoking; the consequences of smoking; the influence of the social environment, including tobacco marketing; and skills to decline cigarettes. Several interventions targeted parental attitudes and beliefs about smoking and parent–child communication.

Interventions for Tobacco Cessation

Evidence on the effectiveness of cessation interventions delivered in primary care settings to school-aged children and adolescents who have experimented with smoking or are regular smokers is limited. The USPSTF examined the evidence on behavioral interventions to promote smoking cessation in children and adolescents who were classified as smokers (1). Few studies targeted regular, established smokers or stratified findings by length or amount of smoking (such as experimenters vs. established smokers). A pooled meta-analysis of 7 trials, which included 2328 children and adolescents and examined interventions to promote smoking cessation, found a small but statistically insignificant effect at 6- to 12-month follow-up favoring the intervention (risk ratio, 0.96 [95 CI%, 0.90 to 1.02])¹.

Although evidence on the effectiveness of primary care–relevant interventions in reducing smoking in children and adolescents is limited, some evidence from other literature shows that school- and community-based behavioral counseling programs can promote smoking cessation in adolescent smokers. In a meta-analysis of 64 trials, 40 of which were school-based, Sussman and Sun⁵ found a 4% difference in smoking cessation rates between the intervention and control groups (11.8% vs. 7.5%, respectively). A longitudinal evaluation of 41 community-based programs reported biochemically validated cessation rates similar to those in randomized trials (averaging 14% at the end of the program and 12% at 12-month follow-up)⁶.

No medications are currently approved by the U.S. Food and Drug Administration for tobacco cessation in children and adolescents. Two studies that evaluated behavioral interventions plus medication (sustained-release bupropion alone or combined with nicotine replacement therapy) showed no statistically significant benefit from the medication¹. Evidence on complementary and alternative medicine, such as acupuncture, for smoking cessation in children and adolescents is not available¹, and such interventions have demonstrated no long-term benefits in adults¹⁰.

Other Approaches to Prevention and Cessation

The Community Preventive Services Task Force has made the following 4 recommendations for school-aged children and adolescents⁷.

Mobile phone–based interventions for tobacco cessation, on the basis of sufficient evidence of their effectiveness in increasing abstinence from tobacco among persons interested in quitting, as well as community-wide, proactive telephone support (proactive follow-up) combined with patient education materials, on the basis of strong evidence of their effectiveness in increasing tobacco cessation in both clinical and community settings. However, the Community Preventive Services Task Force noted that the evidence on the effectiveness of both of these interventions for school-aged children and adolescents is limited.
Interventions that increase the price of tobacco products, on the basis of strong evidence of their effectiveness in reducing tobacco use in adolescents and adults, reducing population consumption of tobacco products, and increasing tobacco use cessation.
Mass media campaigns, on the basis of strong evidence of their effectiveness in reducing tobacco use in adolescents when combined with increases in tobacco prices, school-based education, and other community education programs.
Community mobilization combined with additional interventions (such as stronger local laws directed at retailers, active enforcement of retailer sales laws, and retailer education with reinforcement), on the basis of sufficient evidence of their effectiveness in reducing youth tobacco use and access to tobacco products from commercial sources.

The Community Preventive Services Task Force also recommends provider reminder systems, whether used alone or as part of a multicomponent intervention, across a range of intervention characteristics (such as chart stickers, checklists, and flowcharts) and in various clinical settings and populations.

Useful Resources

Primary care clinicians may find the following resources useful in talking with children and adolescents about the harms of smoking and other reasons not to start smoking: Centers for Disease Control and Prevention's Smoking & Tobacco Use: Information Sheet (www.cdc.gov/tobacco/youth/information_sheet/index.htm This link goes offsite. Click to read the external link disclaimer); U.S. Department of Health and Human Services' BeTobaccoFree.gov (http://betobaccofree.hhs.gov/dont-start/index.html This link goes offsite. Click to read the external link disclaimer); Public Health Service's (PHS) Treating Tobacco Use and Dependence: 2008 Update (www.ncbi.nlm.nih.gov/books/NBK63952/This link goes offsite. Click to read the external link disclaimer); and American Academy of Pediatrics' Tobacco Prevention Policy Tool (www2.aap.org/richmondcenter/TobaccoPreventionPolicyTool/TPPT_PracticeCessation.html This link goes offsite. Click to read the external link disclaimer). The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products (A recommendation). It also recommends that clinicians ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke (A recommendation)⁸.