Tobacco use is the leading cause of preventable death in the United States, and this public health issue almost always begins before adulthood, with nearly 90% of smokers trying their first cigarette before age 18.
The definition of tobacco use in this instance includes conventional smoking (e.g., cigarette smoking) and vaping (e.g., using e-cigarettes). It's important to note that vaping is now more common among youth than cigarette smoking.
On June 25, the U.S. Preventive Services Task Force posted a draft recommendation statement(www.uspreventiveservicestaskforce.org) and draft evidence review(www.uspreventiveservicestaskforce.org) addressing this issue and examining how primary care interventions affect tobacco use prevention and cessation in children and adolescents.
Based on its review of the evidence, the USPSTF recommended primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among school-age children and adolescents; this is a "B" recommendation.(www.uspreventiveservicestaskforce.org)
"Preventing tobacco use among our young people is critical to the health of the nation," said task force member Michael Silverstein, M.D., M.P.H., in a news release.(www.uspreventiveservicestaskforce.org) "All youth are at risk for tobacco use and should be provided with interventions to help prevent them from ever starting."
- The U.S. Preventive Services Task Force recently posted a draft recommendation statement examining how primary care interventions affect tobacco use prevention and cessation in children and teens.
- Based on its review of the evidence, the USPSTF recommended primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among school-age children and adolescents.
- The task force also concluded that current evidence is insufficient to assess the balance of benefits and harms of primary care-feasible interventions for cessation of tobacco use in this population.
Additionally, the USPSTF looked at evidence on interventions to help children and teens who are already using tobacco quit. However, it concluded that current evidence is insufficient to assess the balance of benefits and harms of primary care-feasible interventions for cessation of tobacco use in this population -- an "I" recommendation.
"Helping youth quit using tobacco is vital to their health," said task force member Chien-Wen Tseng, M.D., M.P.H., M.S.E.E., in the release. "Unfortunately, studies have not yet identified effective ways to help children and teens quit, and the task force is calling for more research in this area."
This draft recommendation statement updates the USPSTF's 2013 final recommendation statement(www.uspreventiveservicestaskforce.org) on the topic, with the biggest change being the inclusion of e-cigarettes as a tobacco form. The AAFP supported that final recommendation.
The draft statement also is the first time the task force has issued a separate recommendation calling for more research on tobacco cessation in children/adolescents.
Prevention Evidence Review
In the systematic review the USPSTF commissioned to evaluate the benefits and harms of primary care interventions for tobacco use prevention and cessation in children and teens, 14 trials reported on the effects of behavioral counseling interventions to prevent initiation of smoking, and nine reported on the effects of such interventions on smoking cessation.
Most prevention studies reviewed used interventions that targeted the child/adolescent, although some targeted both children and parents/caregivers and a few trials targeted only the parents/caregivers. Intervention content included health education, readiness to act/change and parenting skills.
Delivery settings for these preventive interventions varied and included primary care clinics, dental clinics, schools and the child's home, and the types of interventions used included print materials, face-to-face counseling, telephone support and computer-based systems. About half of the studies used only a single intervention type.
Most studies found on follow-up that fewer youth started smoking when they received a behavioral counseling intervention. This finding wasn't always statistically significant for individual studies, but the reduction was statistically significant when trial results were pooled: 7.4% versus 9.2% of participants initiated smoking in the intervention versus control group.
Results from the cessation trials -- many of which were underpowered -- were largely inconclusive. Nearly all used combinations of intervention types, most commonly face-to face counseling; telephone- and computer-based interventions and print materials were less commonly used. Three trials examined use of smoking cessation medications in combination with behavioral interventions.
Although two trials reported significant increases in smoking cessation rates in youth receiving interventions, meta-analysis of all nine trials reported a postintervention risk reduction that was not statistically significant.
Family Physician Expert's Perspective
Thomas Houston, M.D., of Dublin, Ohio, former chair of the AAFP Commission on Health of the Public and Science and of the Academy's now-dissolved Smoking Cessation Advisory Committee, told AAFP News that the draft recommendations come as no surprise.
"As the AAFP and other authorities have noted in the past, family physicians should ask about tobacco and electronic nicotine delivery system use at every visit with youth and provide counseling to prevent youth onset," he said. FPs should keep in mind that patients this age are especially susceptible to peer and social media pressures.
Houston noted that prevention is especially important when considering e-cigarettes, since many youth don't perceive them as dangerous or addictive. The leading e-cigarette brand, in particular -- JUUL -- packs a very strong nicotine punch, with one "pod" containing the equivalent of a pack of traditional cigarettes.
"Children are being exposed to very high levels of nicotine in these devices, use them frequently during the day, and can become dependent very quickly," said Houston. "They are easy to get, easy to hide, very attractive and kids like the taste better than the harsh smoke from conventional cigarettes."
There's also the concern that youth will move from e-cigarettes to conventional cigarettes, and that ENDS use will normalize smoking again.
As for cessation, Houston confirmed that the evidence review found few new studies that looked at cessation interventions for youth, and even fewer that focused on ENDS. Pharmacotherapy use trials among this population also were "few and small" and showed no demonstrable impact past a very short initial period -- as little as four weeks in one study, he said.
"This is no different from previously published results by USPSTF and the 2008 Public Health Service guidelines regarding pharmacotherapy use among youth,(www.ncbi.nlm.nih.gov)" Houston said. "I strongly agree with their bottom line: We need more data from well-designed studies on the subject."
The key takeaway, according to Houston? "Family physicians need to be vocal, strong advocates for policy changes that keep youth from initiating ENDS, such as increasing the age of sale for all tobacco products to 21 and removing flavored tobacco and ENDS products from the market, including menthol, and supporting federal and state-level funding for comprehensive tobacco control programs," he concluded.
The USPSTF is accepting comments on the draft recommendation statement(www.uspreventiveservicestaskforce.org) and draft evidence review(www.uspreventiveservicestaskforce.org) until 8 p.m. EDT on July 22. All comments received will be considered as the task force prepares its final recommendation.
The AAFP will review the USPSTF's draft recommendation statement and supporting evidence and will provide comments to the task force. The Academy will release its own recommendation on the topic after the task force finalizes its guidance.
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