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Delivery of Smoking Prevention and Cessation Services to Adolescents
Jonathan D. Klein, MD, MPH;
Leonard J. Levine, MD;
Marjorie J. Allan, BS
Arch Pediatr Adolesc Med. 2001;155:597-602.
ABSTRACT
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Objectives To describe the delivery of smoking prevention and cessation screening
and counseling practices to adolescents and to examine the effect of physician
specialty, sex, practice characteristics, and familiarity with preventive
care guidelines on the delivery of smoking cessation counseling services.
Methods Cross-sectional self-reported survey of pediatricians and family physicians
in 3 New York metropolitan statistical areas who had seen 1 or more adolescents
for well care within the past 6 months.
Results Of 564 eligible physicians, 371 (66%) responded. Physicians reported
asking most adolescents about smoking (91%) but were less likely to ask about
peer smoking use (41%) or smokeless tobacco use (32%). Similarly, they reported
assessing motivation to quit for 81% of smokers, but less often helped set
quit dates (34%) or scheduled follow-up visits (28%). Family physicians were
more likely to provide more effective smoking cessation interactions than
pediatricians (mean smoking counseling performance score, 61 vs 53; P<.001). Family physicians were also more likely to
be familiar with National Cancer Institute guidelines than pediatricians (48%
vs 27%; P<.001). Female physicians reported having
spent more time with their last adolescent patient (mean, 26 vs 21 minutes; P<.001) and more often spent time alone with adolescent
patients (85% vs 76% of visits; P<.001) than did
male physicians. In multivariate modeling, specialty, familiarity with National
Cancer Institute guidelines, time spent, and confidentiality factors were
associated with better smoking counseling performance.
Conclusion Familiarity with smoking cessation guidelines and physician's specialty
and practice style with adolescents are associated with better delivery of
tobacco cessation counseling to adolescents.
INTRODUCTION
DESPITE EFFORTS to prevent cigarette smoking, tobacco use remains an
endemic health problem in the United States. More than 1 in 3 adolescents
smoke, and as many as 20% of high school boys report using smokeless tobacco.1 Because most smokers begin using tobacco during adolescence,
preventing and reducing tobacco use among youth has substantial long-term
health benefits to society.
Tobacco cessation counseling by physicians and other clinicians has
been shown to increase cessation rates among adult patients.2, 3, 4, 5, 6
Effective adult cessation interventions have been found to include setting
quit dates, using multiple communication modalities, scheduling follow-up
visits, and consistently reinforcing stop smoking messages.3, 5, 7
These specific activities have also been recommended for adolescents.7, 8 In addition to the recommendations
of the National Cancer Institute's (NCI's) physician guide to smoking cessation,
"How to Help Your Patients Stop Smoking,"8
tobacco prevention and cessation counseling have also been recommended by
numerous preventive service guidelines, including the American Academy of
Pediatrics' Guidelines for Child Health Supervision II,9 the American Medical Association's Guidelines for Adolescent Preventive Services,10
the American Academy of Family Physicians' age charts for periodic health
examinations,11 the Maternal and Child Health
Bureau's Bright Futures guidelines,12
the US Preventive Services Task Force's Guide to Clinical
Preventive Services,13 and the US Public
Health Service's Put Prevention Into Practice campaign.14 Despite the existence of these guidelines, there
are no published studies, to our knowledge, that address the effectiveness
of brief clinical tobacco cessation interventions with adolescents. And although
clinical trials are under way, it is unclear whether these adult intervention
strategies are ineffective among adolescents or whether the specific services
are simply not being delivered.
In this study, we examine the self-reported delivery of recommended
smoking prevention and cessation interventions among a random sample of pediatricians
and family physicians in 3 metropolitan areas in western New York State. In
addition, we assess the impact of physician specialty, sex, practice characteristics,
preventive care guidelines' familiarity, and other factors on the delivery
of tobacco prevention and cessation services to youth.
SUBJECTS AND METHODS
SAMPLE
Using the American Medical Association's Masterfile, we selected a random
sample of 661 pediatricians and family physicians from the Buffalo, Rochester,
and Syracuse, NY, metropolitan statistical areas in 1999. Physicians were
mailed a self-administered questionnaire about the health services they routinely
provide to adolescent patients. Physicians were considered eligible for the
study if they had seen 1 or more adolescents for a well-patient visit in the
6 months before receiving our survey.
MEASURES
Items included questions about physician and practice demographics,
including sex and specialty. We also asked about the physician's usual screening
and counseling practices with adolescent patients, and about the estimated
amount of time spent with patients during adolescent well-care visits. Additional
questions addressed the services offered during the physician's most recent
adolescent preventive visit. Physicians were also asked to estimate the proportion
of their patients (aged 15-18 years) to whom they provided specific tobacco
prevention and cessation services recommended by 1 or more preventive service
guidelines. These services included asking about smoking habits, smokeless
tobacco use, parental smoking, and friends' cigarette use; reinforcing nonsmokers'
decisions to remain abstinent; and discussing the health risks of tobacco
use. We also asked respondents to estimate the proportion of smokers whom
they asked about motivation to quit, provided cessation-related handouts,
helped set a quit date, and scheduled follow-up visits for smoking cessation.
These items we constructed similarly to those used in other recent studies15, 16 of preventive service delivery by
primary care physicians. An overall tobacco counseling performance score (range,
0-100) was computed for physicians responding to all 10 of these questions.
This score, the average of the percentage of adolescents the physician estimated
performing each of the targeted screening and counseling practices with, was
calculated by summing the 10 proportions, and dividing by 10. Physicians were
also asked to rate their familiarity with each of 7 preventive care and tobacco
intervention guidelines, using a 5-point Likert scale ranging from 1 ("have
never heard of these") to 5 ("have read all or most" of these).
PROCEDURES
Reminder letters were sent to nonrespondents 2 to 4 weeks after the
initial mailing, followed by telephone reminders and, as needed, third mailings.
Physicians who had not seen adolescent patients for well-care visits in the
previous 6 months (n = 86) were ineligible for our survey. An additional 24
physicians were excluded as they had moved, died, or retired, leaving 551
eligible physicians (83% of the original Masterfile sample). Each physician
received a $20 honorarium with the survey mailing. The study protocol was
approved by the University of Rochester School of Medicine Research Subjects
Review Board.
ANALYSIS
We used independent t tests to compare differences
in performance of recommended tobacco screening and counseling interventions
by physicians' demographics, practice characteristics, and familiarity with
guidelines. A  2 test and an analysis of variance were used
to examine proportions and means in stratified analyses. We also used multivariate
linear regression models to assess the correlation between factors associated
with physicians' overall tobacco screening and counseling performance. All
variables found to be significantly related in bivariate analyses were entered
into our initial model, and variables found to be significant at P<.05 were retained. First-degree interactions were tested for as
a group, and none were found to be significant. Coefficients and partial R2 scores are described for variables with a
significant association with the tobacco counseling performance score; the
partial R2 can be viewed as a reflection
of the relative amount of variance in the score that can be explained by each
specific variable.
RESULTS
Of the 551 eligible physicians, 156 (28%) did not respond, 24 (4%) refused
to participate, and 371 (67%) returned completed surveys (percentages do not
total 100 because of rounding). Respondents included 192 (75%) of 256 pediatricians
and 179 (61%) of 295 family physicians. Male physicians made up 68% and female
physicians 32% of the respondents. Approximately one third of the respondents
were from Buffalo, Rochester, or Syracuse. Response rates were not statistically
different for physician sex, type of practice setting, or geographic area.
However, when comparing physician sex by specialty, male family physicians
had a higher response rate than female family physicians (64% vs 49%; P = .04). The mean year of medical school graduation was
later for female than for male respondents (1984 vs 1976; P<.001), but it was not significantly different by specialty or
geographic area. Respondents from Buffalo and Rochester reported spending
more of their adolescent visits on preventive care encounters than did physicians
from Syracuse (44% and 40% vs 34%; F = 5.1; P = .007).
SMOKING, SCREENING, AND COUNSELING PRACTICES
Overall, physicians reported asking 91% of their adolescent patients
about their smoking habits, and discussing the health risks of tobacco with
77% of adolescents. Parental smoking, peer smoking, and personal smokeless
tobacco use were reportedly discussed with 56%, 41%, and 32% of adolescents,
respectively. The physicians reported reinforcing abstinence from tobacco
use with 84% of nonsmoking patients. Among adolescents identified as smokers,
physicians reported assessing motivation to quit among 81%, providing cessation
handouts to 40%, helping set quit dates with 34%, and scheduling smoking-related
follow-up visits with 28%.
Pediatricians reported asking more patients about peer influences than
did family physicians (Table 1).
Family physicians, however, reported more often asking about smokeless tobacco
use, assessing motivation to quit, providing cessation handouts, helping set
quit dates, and scheduling follow-up visits for smoking.
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Table 1. Adolescent Patients on Whom Physicians Routinely Perform Specific
Tobacco Screening and Counseling Interventions, by Physicians Specialty, New
York State, 1999*
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Physician sex also was associated with differences in smoking cessation
and prevention counseling practices in bivariate analyses (Table 2). Female physicians were more likely than male physicians
to ask about family or peer smoking, and were also more likely to report reinforcing
abstinence from tobacco use with nonsmoking patients. Male physicians, however,
were more likely to report asking about smokeless tobacco use. When controlled
for specialty, female physicians remained more likely than male physicians
to ask about peers (P = .001) and to reinforce nonsmokers'
abstinence (P = .02) (data not shown).
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Table 2. Adolescent Patients on Whom Physicians Routinely Perform Specific
Tobacco Screening and Counseling Interventions, by Physician Sex, New York
State, 1999*
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Familiarity with smoking cessation guidelines differed by specialty
(Table 3). Not surprisingly, pediatricians
were most familiar with the American Academy of Pediatrics' Guidelines for Child Health Supervision II and family physicians were
most familiar with the American Academy of Family Physicians' age charts for
periodic health examinations. Family physicians were also more likely than
pediatricians to report having read some or all of the NCI's Physician Guide, the US Preventive Services Task Force's Guide to Clinical Preventive Services, and the US Public Health Service's Put Prevention Into Practice program. In contrast, pediatricians
reported greater familiarity with the American Medical Association's Guidelines for Adolescent Preventive Services and with
the Maternal and Child Health Bureau's Bright Futures
guidelines.
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Table 3. Physicians Who Report Having Read All or Most of Adolescent
Health and Tobacco Intervention Guidelines, by Specialty, New York State,
1999*
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FACTORS PREDICTING SMOKING COUNSELING PERFORMANCE
The median performance score, representing overall performance of the
10 recommended screening and counseling interventions, was 56.0, and the mean
was 56.4 (SD, 17.6), for all respondents. Family physicians scored higher
on this performance index than did pediatricians (61 vs 53; P<.001). Overall performance between male and female physicians
was not significantly different (56 vs 57; P = .50).
Differences in physicians' other usual care practices provided during
preventive visits with 15- to 18-year-old patients also varied by specialty,
sex, and geographic area. Pediatricians reported spending more time than family
physicians with their most recent adolescent patient seen for a well-care
visit (26 vs 21 minutes; P<.001). In addition,
pediatricians had more well-care visits that included at least some time alone
with the adolescent than did family physicians (84% vs 73% of visits; P<.001). Female physicians reported spending more time
with the last adolescent patient they had seen for a well-care visit (26 vs
21 minutes; P<.001) and more time alone with adolescent
patients (85% vs 76% of visits; P = .001) than did
their male colleagues. When compared by metropolitan statistical area, physicians
from Rochester devoted more time to adolescent well-care visits than did physicians
from Buffalo and Syracuse (25 vs 23 and 21 minutes; P
= .02). Screening questionnaires were used by more pediatricians than family
physicians (34% vs 14%; P<.001) and by more physicians
in Syracuse than in Buffalo and Rochester (31% vs 27% and 17%; P = .04).
Using multiple linear regression with the performance index as the dependent
variable, we examined the independent effects of demographic factors (physician
specialty, sex, city, and year of graduation; percentage of adolescent visits
devoted to preventive care; and familiarity with different practice guidelines)
and practice factors (use of a screening questionnaire; the percentage of
well-care visits that include time spent alone with the adolescent; and the
time spent with the most recent adolescent patient seen for a well-care visit)
associated with screening and counseling practices (Table 4). We evaluated first-degree interactions among all of the
significant independent variables from the full model (none were significant)
and retained significantly associated variables in a final model. In this
model, familiarity with the NCI's guidelines, the amount of time spent during
the most recent adolescent well-care visit, being a family physician, familiarity
with the American Academy of Pediatrics' Guidelines for
Child Health Supervision II, and the percentage of well-care visits
that included time spent alone with the adolescent were significantly associated
with overall performance of comprehensive tobacco interventions (P<.001).
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Table 4. Linear Regression Model of Factors Associated With Better
Tobacco Counseling Performance Among Pediatricians and Family Physicians,
New York State, 1999*
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COMMENT
Many of the physicians in our study reported asking adolescents if they
smoke cigarettes. This finding is consistent with previous studies15, 16, 17, 18, 19, 20, 21, 22, 23, 24
of tobacco screening and counseling practices of primary care physicians.
However, these physicians perform many other recommended adolescent tobacco
interventions at relatively low rates. Multiple guidelines recommend specific
techniques for screening and counseling for tobacco use. Nevertheless, the
physicians in our study screen less than half of adolescent patients for smokeless
tobacco or peer tobacco use, despite evidence that smokeless tobacco use is
increasing25 and that peer influence is a factor
in the initiation of youth smoking behavior.26
Adolescent tobacco cessation counseling interventions are performed
at even lower rates than are screening practices. Despite evidence supporting
the use of specific counseling strategies to improve quit rates in adults,
and explicit guidelines that suggest strategies for use with adolescents,
with the exception of assessing motivation to quit, the physicians in our
study seldom used these interventions with adolescent patients. Others18, 22 have also shown that cessation counseling
and anticipatory guidance are performed at lower rates for youth than for
adults. In our study, asking for a quit date and planning for follow-up visits,
smoking cessation interventions that require active participation by clinicians
and adolescents, were performed at the lowest rates.
The family physicians in our study reported performing recommended smoking
cessation counseling interventions at higher rates than pediatricians, and
this variation by specialty remained when the analysis was controlled for
physician sex and geographic area. A recent study15, 16
of California physicians also found that family physicians reported screening
more of their patients for cigarette use than did pediatricians; specialty
differences in beliefs about patient compliance and level of comfort in dealing
with adolescent patients were thought to explain these differences in screening
behaviors. Better self-reported performance among family physicians may also
be attributable to greater familiarity with adult care and experience with
adult smokers. Our study confirms these specialty differences in screening
performance. However, for cessation counseling performance, we found that
neither pediatricians nor family physicians were likely to deliver guideline-based
preventive interventions. Nevertheless, we are able to examine some of the
factors other than specialty that influence physicians' practices.
Of the preventive service guidelines we asked about, the NCI's recommendations
are the only ones that deal solely with tobacco use. In the other guidelines,
tobacco prevention and cessation are one of a comprehensive set of recommended
preventive services. Greater familiarity with the NCI's guideline was highly
associated with better overall performance of tobacco screening and counseling
interventions, but this familiarity only partially explained specialty differences.
Whether this is because of the focused nature of the NCI's recommendations,
the type of educational exposures that led physicians to familiarity with
the NCI's materials, or other factors cannot be determined from this study.
However, a recent study23 of Massachusetts'
pediatricians also found that previous training was associated with self-reported
smoking counseling delivery.
Not surprisingly, we found specialty variation in physician familiarity
with various preventive service guidelines. In addition to their own specialty
organization's recommendations, pediatricians had more familiarity with guidelines
that target pediatric and adolescent populations. In contrast, family physicians
were more familiar with guidelines that address all age groups. Familiarity
with the American Academy of Pediatrics' recommendations was associated with
better adolescent smoking cessation counseling. However, when stratified by
specialty, this association was only true for family physicians, perhaps reflecting
that family physicians' overall degree of attention to age- or specialty-specific
practice guidelines may be an indicator for better service delivery across
that age span, too.
Others15 have found higher rates of screening
for regular smoking by female than male physicians during routine adolescent
visits. Similarly, sex differences have been reported in how well reproductive
health services are delivered to adults.27
However, when controlled for demographics and practice characteristics, we
did not find physician sex to be associated with smoking screening and counseling
behavior for the physicians in our study. Ellen et al15
asked their sample of California physicians only 2 questions about screening
behaviors to determine rates of smoking interventions, so the different findings
from our survey may be due to the greater detail obtained from our measure.
Our findings are also more specific for actual performance of NCI guideline
recommendations. Longer visits and spending time alone with the adolescent
were associated with better performance of comprehensive tobacco interventions.
These 2 factors are thought to enhance rapport and are necessary if confidential
screening or counseling discussions are to take place. Since sex differences
are modified by these practice factors, altering care practices, rather than
relying on a fixed characteristic such as physician sex, may help all clinicians
improve tobacco screening and counseling behaviors.
Our results are limited by selection bias, as those physicians who provide
more preventive care or who have more of an interest in adolescent care may
have been more likely to respond to the survey. We are also limited by the
validity of self-report, as physicians may overreport provision of preventive
services if they know them to be recommended. Thus, it is likely that fewer
patients actually received these interventions than the proportions reported
by clinicians. We did not explore the proportion of adolescent patients seen
by each clinician, differences by practice setting, or differences in clinician's
access to smoking cessation resources, and these factors, too, may have an
influence on a physician's prevention practices. In addition, the generalizability
of this study is limited to pediatricians and family physicians in western
New York, and may not fully represent other regions or other types of primary
care clinicians.
Our study shows that there are still many opportunities for physicians
to improve the delivery of tobacco interventions to their adolescent patients.
In addition, our findings clearly demonstrate the substantial gap between
publication and implementation of smoking cessation guidelines. In the past
few years, Guidelines for Adolescent Preventive Services10 and Bright Futures recommendations12 for comprehensive
adolescent preventive care have been developed, the Agency for Health Care
Policy and Research issued guidelines,7 and
the US Public Health Service issued smoking cessation guidelines that include
recommendations for cessation for adolescents.28
While specific evidence for the effectiveness of cessation counseling in adolescents
remains elusive, our findings suggest that physicians' limited adherence to
recommended intervention strategies may be responsible for the lack of evidence
for effective cessation counseling for adolescent smokers, rather than a lack
of effectiveness of the interventions themselves. Documentation and sustained
performance of these clinical interventions at high rates will be necessary
to truly assess the effectiveness of either tobacco cessation practices or
other preventive service guidelines.
Finally, our results suggest that implementation of preventive service
recommendations may best be accomplished through dissemination of information
through physician specialty organizations. While the cost of new preventive
visits may be significant, the cost of improving the content of the care provided
during encounters is relatively low. Additional research to determine how
to best provide specific practice-oriented materials and facilitate adoption
of preventive care delivery recommendations by primary care adolescent health
clinicians is needed, if the goal of delivering smoking cessation counseling
is to be achieved.
AUTHOR INFORMATION
Accepted for publication December 7, 2000.
This study was supported by grant R01-HS08192-02 from the Agency for
Health Care Policy and Research, Rockville, Md; a Generalist Physician Faculty
Scholar's Award from the Robert Wood Johnson Foundation, Princeton, NJ (Dr
Klein); and a Samuel Clausen Medical Student Research Fellowship (Dr Levine).
From the Division of Adolescent Medicine, Department of Pediatrics,
University of Rochester Medical Center, Rochester, NY.
Corresponding author and reprints: Jonathan D. Klein, MD, MPH, Division
of Adolescent Medicine, Department of Pediatrics, University of Rochester,
Box 690, 601 Elmwood Ave, Rochester, NY 14642 (e-mail: jonathan_klein{at}urmc.rochester.edu).
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