Pediatric smoking prevention interventions delivered by care providers: A systematic review

doi:10.1016/S0749-3797(03)00214-9

American Journal of Preventive Medicine

Volume 25, Issue 4, November 2003, Pages 358-362

https://doi.org/10.1016/S0749-3797(03)00214-9 Get rights and content

Abstract

Objective

To conduct a systematic review of randomized controlled trials of smoking prevention interventions for youth delivered via medical or dental providers' offices.

Methods

Online bibliographic databases were searched as of July 2002, and reference lists from review articles and the selected articles were also reviewed for potential studies. The methodology and findings of all retrieved articles were critically evaluated. Data were extracted from each article regarding study methods, intervention studied, outcomes measured, and results.

Results

The literature search returned 81 abstracts from MEDLINE and 49 from Cochrane Clinical Trials Registry (CCTR); of these, four articles met the inclusion criteria. Included were two studies conducted in primary care, and one each in dental and orthodontic offices. Only one study demonstrated a significant effect on smoking initiation; in that study, 5.1% of the intervention group and 7.8% of the control group reported smoking at 12-month follow-up (odds ratio= 0.63; 95% confidence interval, 0.44–0.91). None of the studies had follow-up times greater than 3 years.

Conclusions

There is very limited available evidence demonstrating efficacy of smoking prevention interventions in adolescents conducted in providers' offices and no evidence for long-term effectiveness of such interventions.

Introduction

T obacco use is very much a pediatric problem; 36% of middle school students in the United States have tried smoking and 21% of high students have ever been daily smokers.1 While tobacco use among adults has remained steady, recent studies show it is becoming more prevalent among youth.2 Furthermore, children and adolescents are the targets of cigarette advertising.3, 4

Because the vast majority of people who smoke initiated smoking before the age of 18 years, primary prevention targeting children and young adolescents has the potential to significantly affect the prevalence of smoking among adults.5 The American Academy of Pediatrics (AAP) committee on substance abuse recommends counseling patients not to smoke.6 Despite the potential benefits and the current recommendations to promote prevention, there is little empiric evidence that provider-based prevention programs are effective. Therefore, a systematic review was designed to summarize the current best evidence regarding interventions delivered via providers' offices to prevent smoking initiation among young children and adolescents.

Section snippets

Study identification and assessment of quality

Searches were conducted on the MEDLINE database (January 1966 through July 2002), the Cochrane Clinical Trials Registry (CCTR, as of July 2002), as well as PsycInfo (as of July 2002). Search terms used include (tobacco OR smoking OR cigarette) and (prevention OR prevent*) and (doctor OR physician OR pediatric* OR dental OR dentist OR orthodontist OR nurse OR provider OR clinic). Studies were restricted to controlled trials of smoking prevention interventions delivered by healthcare providers

Literature search

The original literature search returned 81 articles from MEDLINE and 49 from CCTR, of which eight were deemed potentially relevant after reviewing the abstracts, and the full-text articles were retrieved for review. No additional articles were located from CCTR, PsycInfo, the Medical Editors Trial Amnesty, or hand searches of relevant bibliographies. After the full-text articles were reviewed, four articles met the inclusion criteria. The most common reasons for exclusion were: (1) the study

Discussion

This systematic review of the literature on provider-based prevention programs targeting patients and their families found scant evidence of the programs' effectiveness. Although the number of trials that had sufficient rigor to be included in this review was small, it nevertheless represents the current state of knowledge with respect to these prevention efforts. Three of the four studies were negative, and one showed a small but significant difference in smoking abstinence. Unfortunately, the

Acknowledgements

This study was funded by a grant from The Robert Wood Johnson Foundation.

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A cross-sectional sample of orthodontic patients reported hypothesized risk factors for smoking and susceptibility to tobacco use initiation. Exploratory analyses regressed susceptibility to tobacco initiation on each hypothesized predictor variable in a separate logistic model that included a standard set of covariates.
Significant odds ratios (OR) were found for the presence of a smoker in the home (OR, 2.168; 95% confidence interval [CI], 1.144-4.107), a friend having no-smoking rules in his or her home and car (OR, 0.337; 95% CI, 0.128-0.886), having been offered a cigarette (OR, 4.526; 95% CI, 1.190-17.207), and exposure to tobacco advertisements (OR, 1.910; 95% CI, 1.044-3.496).
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This review considered studies identified in a recent USPSTF review on the same topic (Patnode, O'Connor, Whitlock, Perdue, & Soh, 2012) [AMSTAR (Shea et al., 2007) rating of 10/11]; these studies were either included in that review or were excluded by the USPSTF for study quality. The USPSTF evaluated trials considered and included in three previous reviews (Christakis, Garrison, Ebel, Wiehe, & Rivara, 2003; Grimshaw & Stanton, 2006; Thomas, Baker, & Lorenzetti, 2007) that covered the tobacco prevention literature through July 2002 and the tobacco cessation literature through August 2009 (the USPSTF only considered studies published in or after 1980). The USPSTF then searched for English citations in MEDLINE, PsycINFO, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, PubMed, and the Database of Abstracts of Reviews of Effects starting January 2002 to September 14, 2012 for prevention and starting January 2009 to September 14, 2012 for cessation.
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After screening 2118 records, we included nine randomized controlled trials. The mostly moderate quality evidence suggested targeted behavioral interventions can prevent smoking and assist with cessation. Meta-analysis showed intervention participants were 18% less likely to report having initiated smoking at the end of intervention relative to controls (Risk Ratio 0.82; 95% confidence interval 0.72, 0.94); the absolute effect is 1.92% for smoking initiation, Number Needed to Treat is 52 (95% confidence interval 33, 161). For cessation, meta-analysis showed intervention participants were 34% more likely to report having quit smoking at the end of intervention relative to controls (Risk Ratio 1.34; 95% confidence interval 1.05, 1.69); the absolute effect is 7.98% for cessation, Number Needed to Treat is 13 (95% confidence interval 6, 77). Treatment harms were not mentioned in the literature and no data were available to assess long-term effectiveness.
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Effects are small on young people's alcohol use and long-term results of these interventions are unknown.44,45,60,115–117 Scarce evidence is available for the efficacy of screening and brief interventions for tobacco smoking in primary-care settings.49 Good-quality evidence shows that brief screening questionnaires can detect illicit drug use problems in adolescents in primary-care settings,52 but insufficient evidence exists on their efficacy in reducing drug use and associated harms in young people in these settings.52
We did a systematic review of reviews with evidence on the effectiveness of prevention, early intervention, harm reduction, and treatment of problem use in young people for tobacco, alcohol, and illicit drugs (eg, cannabis, opioids, amphetamines, or cocaine). Taxation, public consumption bans, advertising restrictions, and minimum legal age are effective measures to reduce alcohol and tobacco use, but are not available to target illicit drugs. Interpretation of the available evidence for school-based prevention is affected by methodological issues; interventions that incorporate skills training are more likely to be effective than information provision—which is ineffective. Social norms and brief interventions to reduce substance use in young people do not have strong evidence of effectiveness. Roadside drug testing and interventions to reduce injection-related harms have a moderate-to-large effect, but additional research with young people is needed. Scarce availability of research on interventions for problematic substance use in young people indicates the need to test interventions that are effective with adults in young people. Existing evidence is from high-income countries, with uncertain applicability in other countries and cultures and in subpopulations differing in sex, age, and risk status. Concerted efforts are needed to increase the evidence base on interventions that aim to reduce the high burden of substance use in young people.
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Genetic tests for nicotine addiction susceptibility may someday offer preventive medicine specialists new tools to reduce smoking among adolescents. This paper examines adolescents' interest in, and reasons behind interest in, such testing and correlates of interest.
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Sixty-two percent of adolescents were interested in genetic testing. Among the 72% of adolescents who provided a reason for their interest, 35% would find the information interesting for general or nonspecific reasons, 30% would find it personally useful, 8% noted it would be irrelevant, and 13% stated it would be unimportant; school performance and interest in cancer susceptibility testing were associated with interest in nicotine addiction susceptibility testing (adjusted r² = 21%; P < 0.0001).
Adolescent primary care patients will likely be receptive to comprehensive tobacco control programs incorporating genetic testing. Higher levels of educational achievement and greater interest in DNA-based preventive medicine may characterize those most interested. Offering testing will be contingent upon the development of safe and effective genetic tests.
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By age 85, there would be 127,670 smoking-attributable deaths among women and 284,502 deaths among men, for a total 412,172 smoking-attributable deaths in the United States among the cohort of 3,964,704 people aged 18 years alive in 2000. Through large-scale multimedia campaigns and a $1 increase in the price per pack of cigarettes, smoking prevalence could be reduced by 26% and would result in an annual savings of 108,466 lives and 1.6 million YPLL.
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Review and special articlePediatric smoking prevention interventions delivered by care providers: A systematic review

Abstract

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Study identification and assessment of quality

Literature search

Discussion

Acknowledgements

Prev Med

J Clin Epidemiol

J Clin Epidemiol

Cigarette smoking among adults—United States, 1999

MMWR Morb Mortal Wkly Rep

Increased levels of cigarette use among college studentsa cause for national concern

JAMA

RJR Nabisco's cartoon camel promotes camel cigarettes to children

JAMA

Tobacco industry promotion of cigarettes and adolescent smoking

JAMA

Preventing Tobacco Use among Young PeopleA Report of the Surgeon General

Tobacco's tollimplications for the pediatrician

Pediatrics

Feasibility of a lifestyle cardiovascular health promotion programme for 8–15 year olds in Irish general practiceResults of the Galway Health Project

Health Promot Int

A prescription for healtha primary care based intervention to maintain the non-smoking status of young people

Tob Control

A pediatric, practice-based, randomized trial of drinking and smoking prevention and bicycle helmet, gun, and seatbelt safety promotion

Pediatrics

An adolescent tobacco-use prevention trial in orthodontic offices

Am J Public Health

Promoting patient participation in the cancer consultationevaluation of a prompt sheet and coaching in question-asking

Br J Cancer

Review and special article
Pediatric smoking prevention interventions delivered by care providers: A systematic review