EDITORIALS

Low Rates of Physicians Counseling Adolescents About Smoking: a Critical Wake-Up Call

Harry A. Lando, Dorothy K. Hatsukami

Affiliations of authors: H. A. Lando (Division of Epidemiology, School of Public Health), D. K. Hatsukami (Department of Psychiatry, Medical School, Tobacco Research Program), University of Minnesota, Minneapolis.

Correspondence to: Harry A. Lando, Ph.D., Division of Epidemiology, University of Minnesota, 1300 S. 2nd St., Suite 300, University of Minnesota, Minneapolis, MN 55454-1015 (e-mail: lando{at}epi.umn.edu).

The report by Thorndike et al. (1) in this issue of the Journal is an important wake-up call to physicians, academic teachers, and researchers. The overall results from this study are discouraging, especially given efforts in recent years to educate practicing physicians to identify and to treat smokers, to develop evidence-based guidelines for smoking cessation treatment (2), and to encourage the development of systems to identify smokers. Although smoking status was identified at approximately 70% of adolescent patient visits, counseling was provided at only 1.7% of all visits and 16.9% of visits of patients identified as smokers. Furthermore, and equally discouraging, there was no improvement in these percentages between 1991 through 1996 despite an article written in 1991 providing a guide for physicians on preventing tobacco use during childhood and adolescence (3). Also of concern was the finding that smoking is less likely to be addressed with minority patients.

Intervention with adolescents is critical. Ninety percent of smokers initiate smoking in adolescence, with 70% of smokers becoming nicotine dependent before the age of 18 years (4). Physicians and other clinicians are missing a potentially vital teachable moment in failing to address smoking and other tobacco use in their adolescent patients. In the adult literature, even minimal treatment intervention of 3 minutes or less has been shown to increase treatment success by 20% (2). Effective intervention should involve identification and counseling of not only young smokers but also all adolescent patients. For never smokers, counseling should include strong encouragement not to start; for experimental smokers, it should include advice and support in avoiding the transition to regular smoking. In addition, counseling of parents who smoke may also be important in contributing to both prevention and cessation efforts among youth (5,6).

Despite the importance of intervening with adolescents, there are obvious obstacles that might prevent physicians from providing intervention. Although most prior work has been focused on adult smokers, many of the barriers to intervention with adolescents are likely to parallel those to intervention with adults and may be even greater. Barriers include perceived lack of motivation on the part of smokers to quit or seek treatment, lack of confidence on the part of physicians that they can be effective in providing counseling to smokers, and lack of training and time to provide intervention. Institutional barriers include lack of organizational support and financial incentives for counseling smokers (7,8). Thus, to promote physician intervention, not only is physician training necessary as well as changes in office systems and practices, including training other staff members, but also institutional support is needed from health care administrators/insurers/purchasers (2).

Thorndike et al. (1) also point to the gaps that must be addressed to achieve greater physician intervention. For example, although absolute rates of counseling were low across the various types of physicians, primary care physicians were more likely to identify smoking status and to counsel about smoking than were specialists. Furthermore, patients who presented with smoking-related illnesses were more likely to receive counseling. Therefore, educational approaches must be more aggressively targeted at specialists as well as more generalists, and such approaches should include a focus on advising smokers who have not experienced any physical consequences from smoking. The fact that older adolescents were more likely to receive counseling than were younger adolescents may not be surprising. However, this finding underscores the potentially missed opportunity for intervention with patients for whom smoking and other tobacco use may not yet have become firmly established.

The wake-up call to academics and medical school institutions lies in the need to actively train medical students and residents as well as practicing physicians in ways to prevent disease, including identifying and intervening with smokers. The need for a more aggressive approach in this area is highlighted by a recent article in the Journal of the Medical Association (9) that revealed that nearly one third of the medical schools responding to a survey spent 3 hours or less on smoking cessation over the entire 4 years of medical school. There is sufficient literature to suggest that providing training to medical students and practicing physicians is effective in enhancing physician intervention for tobacco use (6,10).

The wake-up call to researchers is that we have relatively little information on physician intervention with adolescent tobacco use. A key challenge is to more systematically study existing barriers to physician and other clinician identification and counseling of adolescent smokers. These survey data give important but somewhat limited information in addressing these issues. What are some of the barriers to intervention in youth, especially as perceived by physicians and other clinicians? What existing model programs could be referenced as examples for improving identification of smoking status and counseling of adolescent patients? It would be useful to interview physicians, other clinicians, and representatives of health care systems to better understand barriers to intervention from each of their perspectives. Although some barriers may be obvious, others undoubtedly will be less readily apparent.

Another central issue for the field is the relative paucity of research with adolescents and especially knowledge of effective smoking-cessation interventions in the adolescent population. Methods that have demonstrated success with adults have tended to be less successful with adolescents. Especially little is known about transitions from experimental to regular smoking and effective methods of reducing the likelihood of such transitions. Clearly, more research is needed. Recent initiatives from the National Institutes of Health, notably the National Cancer Institute, have resulted in support of almost 40 projects focused on adolescent tobacco use.

Several additional initiatives currently in progress hold considerable promise. The Robert Wood Johnson Foundation (RWJ) (Princeton, NJ) is supporting a youth tobacco etiology research network. In addition, the RWJ is funding a number of projects targeted at increasing implementation of evidence-based tobacco cessation guidelines in managed care. Results from these initiatives should substantially increase both basic knowledge and application of recommended guidelines to patients, including adolescent patients.

In conclusion, despite a number of promising initiatives in progress, we still have a long way to go in addressing tobacco use among youth. To be successful, the following goals must be accomplished:

REFERENCES

1 Thorndike AN, Ferris TG, Stafford RS, Rigotti NA. Rates of U.S. physicians counseling adolescents about smoking. J Natl Cancer Inst1999 ;91:1857-62.[Abstract/Free Full Text]

2 Fiore MC, Bailey WC, Cohen SJ, et al. Smoking cessation. Clinical Practice Guideline No. 18. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service: Agency for Health Care Policy and Research. AHCPR Publ No. 96-0692. April 1996.

3 Epps, RP, Manley MW. A physician's guide to preventing tobacco use during childhood and adolescence. Pediatrics 1991;88:140-4.[Abstract]

4 U.S. Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. Atlanta (GA): U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention: National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994.

5 Flay FR. Youth tobacco use: risks, patterns, and control. In: Orleans CT, Slade J, editors. Nicotine addiction: principles and management. Chap. 19. New York (NY): Oxford University Press; 1993. p. 365-84.

6 U.S. Department of Health and Human Services. Tobacco and the clinician: interventions for medical and dental practice. U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health (NIH): NIH Publ (January 1994) No. 94-3693.

7 Orleans CT, George LK, Houpt JL, Brodie KH. Health promotion in primary care: a survey of U.S. family practitioners. Prev Med 1985;14:636-47.[Medline]

8 Fortmann SP, Sallis JF, Magnus PM, Farquhar JW. Attitudes and practices of physicians regarding hypertension and smoking: The Stanford Five City Project. Prev Med 1985;14:70-80.[Medline]

9 Ferry LH, Grissino LM, Runfola PS. Tobacco dependence curricula in US undergraduate medical education. JAMA 1999;282:825-9.[Abstract/Free Full Text]

10 Zapka JG, Fletcher K, Pbert L, Druker SK, Ockene JK, Chen L. The perceptions and practices of pediatricians: tobacco intervention. Pediatrics 1999;103:65.[Abstract/Free Full Text]



             
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