USPSTF Guidelines: Counseling Prevents Youth Smoking

Laurie Barclay, MD

August 26, 2013

New evidence has shown that simple, economical, interventions by primary care clinicians can help prevent tobacco use among children and teenagers, according to updated guidelines from the US Preventive Services Task Force (USPSTF).

The guidelines were published online August 26 in the Annals of Internal Medicine and in the September issue of Pediatrics.

"Youth tobacco prevention is an important public health issue that requires layered intervention," Annals of Internal Medicine Editor-in-Chief Christine Laine, MD, MPH, said in a news release. "Internal medicine physicians who treat both adolescents and adults are uniquely positioned to provide education and counseling to children and their parents."

In the United States, tobacco use is the leading cause of preventable death, causing approximately 443,000 deaths annually. Children are particularly vulnerable to smoking experimentation and initiation. Each day, more than 3800 children between the ages of 12 and 17 years smoke their first cigarette, and about 1000 youth younger than 18 years begin daily smoking. Early onset of tobacco use may impair lung growth and result in the early onset of lung deterioration, respiratory and asthma-related symptoms, and untimely death.

Two of the strongest predictors of smoking initiation in children and adolescents are parental smoking and parental nicotine dependence; other risk factors include low levels of parental monitoring, easy access to cigarettes, the perception that peers smoke, and exposure to tobacco promotions.

Whereas evidence reviewed by the USPSTF in 2003 was insufficient to recommend for or against primary care–relevant interventions to prevent youth from smoking, newer findings are sufficient to support the intervention.

A systematic review by the USPSTF now allows them to conclude that primary care clinicians can make a difference in helping youth choose to not use tobacco, thereby improving their health and lifespan. Trials of interventions designed to prevent starting and/or to stop tobacco use showed that at 6 to 36 months of follow-up, smoking initiation was 19% less likely in those who received primary care–relevant, behavior-based prevention interventions than in those who did not receive an intervention. The interventions targeted children and/or parents and either were administered in or were potentially feasible for primary healthcare settings.

The task force therefore recommends that healthcare professionals deliver behavioral counseling against tobacco use in person, by telephone, and/or using reading materials, computer applications, and videos.

Evidence is insufficient regarding harms of behavior-based interventions, but the USPSTF believes that potential harms are small to none. The task force therefore concludes with some certainty that the net benefit of such behavior-based interventions is at least moderate.

Raising the Legal Smoking Age

In an accompanying commentary, Michael B. Steinberg, MD, MPH, and Cristine D. Delnevo, PhD, MPH, from Rutgers–Robert Wood Johnson Medical School and the School of Public Health, New Brunswick, New Jersey, note that 90% of adults who smoke daily had their first cigarette by age 18 years. They suggest that increasing the legal age to 21 years to purchase tobacco products "has the potential to interrupt the trajectory from experimentation to regular use."

"New York City officials estimate that increasing the age of sale to 21 years will result in a 55% reduction of tobacco use among persons aged 18 to 20 years and a 67% reduction among those aged 14 to 17 years," they write. "With most current smokers wanting to stop but having difficulty doing so, it seems ill-advised to defend the right for people to start smoking, especially at a young age. Preventing persons aged 18 to 20 years from slipping down the undesirable path of lifelong tobacco addiction will certainly not be accomplished by this one piece of legislation alone, but it is a start and is the right thing to do."

Full conflict-of-interest information is available on the journal's Web site. The commentators have disclosed no relevant financial relationships.

Ann Intern Med. Published online August 26, 2013. Abstract

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