PEDIATRICS Vol. 103 No. 5 May 1999, p. e65

ELECTRONIC ARTICLE:
The Perceptions and Practices of Pediatricians: Tobacco Intervention

Jane G. Zapka, ScD^*, Kenneth Fletcher, PhD, Lori Pbert, PhD^*, Susan K. Druker, MA^*, Judith K. Ockene, PhD^*, and Liping Chen, BS

From the ^* Divisions of Preventive and Behavioral Medicine, and the  Department of Psychiatry, University of Massachusetts Medical School, Worcester, Massachusetts.

	ABSTRACT

Top Abstract Methods Results Discussion References

Objectives.  To investigate pediatrician self-reported intervention practices related to tobacco use and cessation. We queried about practices with three groups 1) children/adolescents who do not smoke; 2) children/adolescents who smoke; and 3) parents, and the relationship of counseling practices with the personal and professional practice-related factors of pediatricians.

Design.  Mailed anonymous survey regarding their self-reported tobacco use prevention and cessation intervention practices.

Population.  Random sample of 350 pediatricians in one state.

Results.  A response rate of 75% was achieved. Pediatricians reported the greatest counseling practice in encouraging children/adolescents to not start smoking, followed by counseling adolescents who smoke. The lowest practice score was for intervening with parents who smoke. The age, gender, site of practice (eg, HMO, solo practice), and subspecialty status of the pediatricians were not related to practice. Pediatricians who reported at least some community involvement in local tobacco control efforts reported significantly higher levels of smoking cessation counseling with both children and adolescents and with parents who smoke. Pediatricians who reported previous training in counseling about tobacco issues also reported significantly higher levels of counseling of both adolescent smokers and parents who smoke but not of children and adolescents who do not smoke. Higher role perception, believing that smoking cessation counseling provided by pediatricians can be effective, and self-efficacy, were predictive of intervention with all three groups. The perceived barriers scale was not related to intervention with any group.

Conclusions.  Pediatricians are missing opportunities to help their patients to stop smoking and to prevent smoking initiation. Pediatricians are intervening least frequently with parents who smoke. Practices should be tailored to the specific target group.  Key words:  tobacco, smoking, counseling, survey, pediatricians.

Tobacco use has been identified as the single largest preventable cause of disease and premature death in the United States¹ and is responsible for >400 000 deaths each year.² A total of ~25% of Americans smoke,³ 53% to 76% of US homes contain at least one smoker, and 9 million American children <5 years of age live in a home with at least one cigarette smoker.⁴ Studies show that infants of parents who smoke at home have a much higher rate of serious respiratory tract illness than infants of parents who do not smoke.⁵ Asthma,^6,7 persistent middle-ear effusions and otitis media,⁸ and impaired lung function⁹ are increased also in children who have parents who smoke, compared with those whose parents are nonsmokers.

A total of ~5 million 12- to 17-year-old people smoke, and more than half of a million 8- to 11-year-old children smoke.¹⁰ Moreover, teenagers are smoking at rates that have been increasing gradually since 1987, despite a decline in overall smoking rates among the general population.^1,11 In Massachusetts in 1996, lifetime cigarette use in grades 7 through 12 was 56%, and current use in grades 7 through 12 is 31%. The average age for smoking a first entire cigarette was 12.2 years.¹² Additionally, the use of smokeless tobacco among adolescents has risen considerably in the last 15 years, particularly among males, reaching a prevalence rate of ~10%.¹³ A total of 60% of current smokers begin by age 14,¹⁴ and the most powerful predictor of adult smoking is adolescent smoking status.¹⁵ Among adult daily smokers, 90% tried their first cigarette, and 70% were daily users at or before age 18.

This new generation of smokers will be at higher risk for cancer, heart disease, stroke, and chronic obstructive lung disease, because adult mortality ratios increase as the number of cigarettes smoked increases.¹⁶ Atherosclerosis, endothelial, and epithelial injury and altered lung function, the initiating pathophysiological events that lead to coronary artery disease, cancer, and chronic obstructive pulmonary disease have been described in youth who use or who are exposed to tobacco products.^17-19 The importance of preventing the initiation of smoking and assisting with cessation during early adolescence is emphasized additionally by the knowledge that tobacco is associated often with the use of other substances.^20-23 Prevention efforts have an effect by delaying the onset and the likelihood of smoking; cessation is more common in smokers who began to smoke at 17 years of age.²⁴

Because of the importance of preventing the onset of smoking among preadolescents and adolescents and of helping adolescents and their parents to stop smoking, pediatricians are in a unique position to enhance health and prevent disease among their patients, and guidelines have been established by various organizations.^25,26 First, pediatricians provide accessible and continuous care, and their long-term relationship with patients and their parents provides them with many clinical opportunities to deliver nonsmoking messages. For instance, the American Academy of Pediatrics recommends that between birth and 21 years of age, a child should make a minimum of 20 health supervision visits to the physician.²⁷ Second, pediatricians have the credibility to offer health-related assistance to children and parents. To a child, physicians are powerful medical experts and role models for appropriate health behavior.²⁸ The physician is able to provide information and alternative health models at critical times in the development of a child.²⁹ Lastly, although evidence about pediatrician intervention is sparse, many studies have demonstrated that health care providers can have a measurable impact on the smoking behaviors of their patients. Clinical trials demonstrate that trained physicians who are prompted to intervene and assist smokers to quit have a greater effect on the smoking behavior of their patients than physicians who are not trained or prompted.^30-32 Parenthetically, because adults between ages 18 and 35 years are less likely than older persons to visit physicians for their own health, the child's physician is frequently the only doctor they visit.²⁹ Because people who quit smoking for health reasons, or in response to physician advice, are more likely to make repeated attempts and to maintain abstinence from cigarettes,³³ physicians should not underestimate their influence. Some studies with pediatricians indicate considerable promise, particularly with respect to maternal smoking. One study showed that a brief intervention delivered to mothers during postnatal baby visits had a positive impact on maternal smoking, and especially on relapse prevention.³⁴

Unfortunately, even in view of adolescent smoking as an important public health issue, pediatricians often fail to assess and counsel about tobacco use. Recent guidelines published by the Agency for Health Care Policy and Research recommend that clinicians provide their pediatric and adolescent patients and their parents or guardians with a strong message regarding the importance of abstaining from tobacco use.³⁵ The purpose of this paper is to present and discuss self-reported practice of tobacco use prevention and cessation interventions of pediatricians. We profile the levels of intervention practices with respect to three subgroups of patients 1) children/adolescents who do not smoke; 2) children/adolescents who do smoke; and 3) parents who smoke. Additionally, we investigate the relationship of counseling practices with several important personal and clinical practice-related factors of pediatricians.

	METHODS

Top Abstract Methods Results Discussion References

Subjects and Data Collection

Data were collected from a mailed survey of pediatricians in one state. The survey was conducted in cooperation with the Massachusetts Chapter of the American Pediatric Association in Winter, 1995 through 1996 as part of the needs assessment activities for the Massachusetts Tobacco Control Program in the Department of Public Health. Purportedly, the vast majority of practicing and retired pediatricians in the state belong to the association. Using the association's membership roster, a random sample of 350 pediatricians was selected. The mailed survey was accompanied by a letter signed by the association president, a stamped return envelope, and a separate return postcard with the subject's name and address. Subjects were instructed to return the postcard when they returned the survey under separate cover, allowing us to monitor who had returned the survey without linking a name to a particular survey. The card also included a check-off to indicate if the subject was retired or no longer in practice in the state with instructions not to return the survey. A total of 70 persons (or their proxy) reported themselves to be ineligible attributable to death, retirement, out-of-state practice, assumption of administrative (not clinical) positions, or not seeing general pediatric patients (eg, pediatric neurologist or radiologist). The response rate from the remaining 280 subjects was 211 (75%).

Instrument Design

The measures of the intervention practice behavior of physicians included in the survey extended the measures developed in previous work in regards to assessing practice behavior.^36-39 We were interested in the interventions of pediatricians with three specific target groups 1) adolescents who do not smoke (primary prevention); 2) adolescents who do smoke; and 3) the patients' parents who smoke. Therefore, a rating of practice behavior was determined using target-group appropriate individual steps that are considered to be a standard practice, as reported in previous studies.^36,40 See Table 1. Physicians were asked with what proportion of their patients (none, some, most, or all) they used each intervention step. Each step was scored as follows: 0 points if the physician reported use of the step for no patients; .33 points if use for some patients was reported; .66 points, most patients; and 1.0, all patients. Thus, for intervention with adolescent smokers and with parents, the possible range of a summative performance score with ten items was 0 to 10 points. For children/adolescents who do not smoke, we used a one item reported performance measure, asking what proportion of patients (none, some, most, or all) the pediatrician encourages not to initiate using tobacco products (range of score 0 to 4).

Delineation of variables potentially related to pediatricians' counseling about smoking was guided by theoretical models and previous empirical research. The theoretical models that guided the delineation of predictive or mediating variables included Social Cognitive Theory (SCT)⁴¹ and the Health Belief Model.⁴² Because of potential response burden and the difficulty in achieving physician participation in mailed surveys, we limited constructs and items to those that we believed had the greatest potential for predictive power and specificity for subsequent use in program planning and evaluation. The following general constructs and items were investigated for the three patient groups and are described briefly below 1) role perception; 2) perceptions about the effectiveness of counseling; 3) self-efficacy; 4) barriers to intervention; and 5) motivation to counsel.

SCT⁴¹ has been used widely in behavioral studies and asserts that behavior is explained by a dynamic, reciprocal interaction among behavior, personal factors, and environmental influences. An important element of SCT is self-efficacy, which is defined as the individual's beliefs of efficacy or self-appraisal of one's capabilities to execute specific actions. The survey of the physicians used in this study included four specific self-efficacy items related to smoking intervention. Each item was rated by respondents on a 5-point scale ranging from "not at all confident" to "very confident". Four items inquired about perceived role of intervening with the three target groups (5-point scale response from "not at all" to "great extent") and perceived effectiveness of counseling for the three groups (5-point scale response from "not at all effective" to "very effective"). Environmental influences include the perceptions of the social environment, including support and reinforcement from credible persons.⁴¹ Recently, investigators have designed items related to such dynamics. For example, Crooks and colleagues³⁷ designed three items related to physician involvement with the California tobacco tax initiative, as well as nine attitude items related to roles and responsibilities. We designed items to measure perceptions of their pediatrician colleagues' commitment to addressing smoking issues. Respondents rated each pediatrician on a 5-point scale ranging from "not at all committed" to "greatly committed". We also asked the extent of their involvement (none, some, or extensive) in local community tobacco control efforts.

The Health Belief Model⁴² affirms that barriers can be important factors in the interactive set of beliefs that trigger a person's action. Previous studies include investigation of barriers to physicians engaging in smoking cessation counseling.^4043-47 Building on this work, six items were designed for this survey to assess barriers to smoking cessation counseling by pediatricians (ie, time limitations, inadequate training, reimbursement, other acute care priorities, and parent resistance). Respondents rated the degree to which a potential barrier interfered with their ability to counsel a patient about his/her smoking on a 5-point scale ranging from "rarely" to "very often".

Analysis

Associations between categorical physician characteristics and counseling of nonsmokers were tested with the ² test. For evaluating the association with counseling of smokers, one-way ANOVA was used. Significant ANOVAs were followed by pairwise comparisons using Tukey's Honestly Significant Difference test. The relationship of several variables on the pediatricians' reported practice scores for children and adolescents who smoke and for parents who smoke was analyzed using linear regression. The relationship of several variables on the pediatricians' practice steps for encouraging child and adolescent patients who do not smoke not to start smoking was analyzed by logistic regression, comparing pediatricians who report encouraging most or all such patients with pediatricians who report only encouraging some or none of such patients.

In both the linear and the logistic regression analyses, all predictor variables, except for the barriers score, were dummy coded. This is a method of recoding categorical variables into a number of new variables coded "yes" or "no" (coded 1 and 0). The number of new variables equals the number of rating categories minus one. For example, in Tables 4 through 6, the 3 possible ratings of role perception (the extent to which a pediatrician thinks it is part of his or her role to stop a patient from smoking), "not at all or a small extent", "moderate or considerable extent," or "great extent," have been recoded into two new dummy variables. One dummy variable compares responses that are indicative of the original category 2, "moderate or considerable extent" versus all other possible responses. The second dummy variable compares responses that are indicative of the original category 1, "not at all or a small extent" versus all other possible responses. Each subject can receive a "yes" code on only one of these two variables, as they can not respond both ways to the same question. However, they can respond with a "no" code to both variables, as is the case when someone responds with the third choice of "great extent". In this way, two dummy variables account for all possible ways of responding to the original three category rating. All dummy variables related to the original variable must be included in any model that includes any of a set of related dummy variables. Significant regression coefficients indicate that the predictor associated with the rating that is scored as 1 on the dummy variable is predictive of performance scores. Positive regression coefficients indicate that a yes on the dummy variable is associated with higher performance scores; whereas, a negative coefficient indicates that the variable is associated with lower performance scores.

The preferred method of regression analysis is to decide what predictor variables are likely to have at least bivariate impact on the outcome variable and then to include all those predictor variables in a regression equation. This type of analysis was conducted first in this study. However, the appropriateness of these final models is called into question by moderately high intercorrelations among some of the predictor variables (notably correlations ranging from .48 to .51 between effectiveness and confidence ratings, as well as correlations ranging from .25 to .34 between perceived role and effectiveness, and from .23 to .28 between perceived role and confidence ratings). To investigate the potential effects of these intercorrelations, stepwise regression analyses were conducted also. For the linear regression analyses, stepwise regression enters into the model and whichever predictor was not already included in the model would be associated most significantly with the outcome if entered into the model, as long as it meets an inclusionary criterion (P value < .15, in this case). After a predictor is entered into the model, all predictors in the model are reevaluated to see if the significance of any now falls below the exclusionary criterion (P value < .20). The stepwise regression used for the logistic regression analysis used a forward stepwise procedure that simply adds predictors that meet the inclusion criterion until no more variables can be included. Using the stepwise procedure as an exploratory tool allows the impact of intercorrelations of the predictor variables to be taken into account.

The internal consistency of the barriers scale was analyzed using Cronbach's . The scale was tested for its factor structure using a common factor model, using Gorsuch's computer program, UniMult.⁴⁸ This model is appropriate for social science research, because it assumes that each factor can be divided into common factors, which several of the variables of interest have in common, and unique factors, which represent influences on each of the factors that are unrelated to the variables of interest, such as random measurement error. Commonalities were estimated using squared multiple correlations of each variable with all the other variables involved in the analysis. The number of factors to extract was determined by reference to Velicer's minimum average partial correlation, a method recommended by Monte Carlo studies⁴⁹ as more reliable than the eigenvalue >1.0 rule.

Factor analysis extracted one factor from the barriers to smoking counseling items that accounted for 34% of the total variance (eigenvalue = 2.67). All six items had factor loadings (factor-item correlations) between .42 and .77 on the barrier scale. The mean rating of the 184 subjects who answered every question on this scale was 15.58 (SD: 4.825; median: 15) out of a possible range of 6 to 30. The distribution of scores was normal (skewness = .48). The internal consistency was good with Cronbach's  = .74.

	RESULTS

Top Abstract Methods Results Discussion References

Respondents' Demographic Profile

With respect to gender, 57% of respondents were male and 43% were female; 16% of respondents were in solo practice, 9% in a partnership, 25% in a single specialty group practice, 9% in a multispecialty group practice, 18% in a hospital practice, 13% in a staff or group model HMO, and 11% in a community health center; and with respect to age, 29% were <40 years, 38% were from 40 to 49 years, and 33% were 50 years.

Self-reported Practice of Counseling Steps

Pediatricians on average had a score of .77 (range: 0 to 1; SD: .53) with respect to encouraging children and adolescents not to start using tobacco. With respect to intervening with children/adolescents who already smoke, the average performance was 4.73 (range: 0 to 10; SD: 1.86). Efforts to counsel parents who smoke were considerably lower, with an average of 3.23 (range: 0 to 10; SD: 1.99). As reported in Table 1, efforts to assess smoking status, explain dangers of smoking, and advise patients to stop were relatively high. However, performance of other steps were reported less commonly.

Demographics and Counseling Practice

The associations between various pediatrician demographic variables and pediatricians' self-report of counseling with all three target groups are reported in Table 2. None of the pediatrician demographic variables was associated significantly with counseling children who do not smoke, nor with counseling children and adolescents or parents who smoke already. On the other hand, those pediatricians who reported at least some community involvement in local tobacco control efforts reported higher levels of smoking cessation counseling with both children/adolescents (F_(1,192) = 21.64; P < .0001) and with parents who already smoke (F_(1,174) = 22.12; P < .0001). Moreover, pediatricians who reported previous training in smoking cessation counseling also reported significantly higher levels of counseling both child/adolescent smokers (F_(1,192) = 8.96; P = .003) and parents who smoke (F_(1,172) = 21.80; P < .0001) but not among children and adolescents who do not smoke.

Perceptions and Smoking-related Counseling
of Pediatricians

A total of 63% of the pediatricians reported that they perceived that helping prevent children and adolescents who do not smoke from starting to smoke as a great part of their role; 28% saw it as a considerable part of their role; and 9% perceived it as a moderate or lesser part. Those who reported that they considered counseling children and adolescents who do smoke to stop played a great part of their role made up 41% of the respondents; 39% perceived it as a considerable part of their role; and 20% thought it was a moderate or lesser part. On the other hand, only 25% reported that they thought counseling parents who smoke to stop played a great part of their role as a pediatrician; 31% perceived it as a considerable part of their role; and 44% perceived it as a moderate or lesser part.

With respect to the perceived effectiveness of their counseling, 25% of the pediatricians thought that helping children not to smoke was quite effective; 47% thought it to be moderately effective; and 29% thought it to have little or no effectiveness. In regard to counseling adolescents who already smoke to stop, 13% of the pediatricians thought it to be quite effective, 38% thought it to be moderately effective, and 49% thought it had little or no effect. Regarding parent counseling, only 12% of the pediatricians thought it to be quite effective, 36% thought it moderately effective, and 52% thought it has little or no effect.

Only 16% of the pediatricians were quite confident that they could prevent children who do not smoke from starting; 50% were somewhat confident; and 34% had little or no confidence. In regard to counseling adolescents who already smoke to stop, 14% were confident in their abilities; 34% were moderately confident; and 51% thought they had little or no ability to do so. Regarding parent counseling, 11% were confident of their abilities; 36% were moderately confident; and 53% thought they had little or no ability to do so.

Of the responding physicians, 28% thought that other pediatricians in their community were quite committed to prevention of smoking among children who did not smoke, 46% thought other pediatricians were moderately committed, and 26% thought other pediatricians had little or no such commitment. A total of 19% of the physicians thought that other pediatricians in their community were quite committed to cessation smoking counseling for adolescents who already smoke, 46% thought their peers were moderately committed; and 35% thought they had little or no such commitment. As for cessation smoking counseling for parents, 16% thought that other pediatricians in their community were quite committed to it, 35% thought other pediatricians were moderately committed; and 49% thought others had little or no such commitment.

Associations of psychosocial variables and pediatricians' self-report of counseling the different groups are reported in Table 3. Perception of the extent to which a pediatrician should counsel patients on smoking cessation was associated significantly and directly with counseling performance with all patient groups. The greater the pediatricians reported perceiving smoking cessation counseling as part of their role, the more likely they were to report practicing such counseling among children and adolescents who do not smoke (X²[4] = 18.37; P = .001), among those who already smoke (F_(2,194) = 10.17; P < .0001), and among parents who smoke (F_(2,174) = 23.19, P < .0001). The more that the physicians reported the belief that smoking prevention and cessation counseling provided by pediatricians can be effective, the more likely they were to report that they provided counseling, and this was true for all three groups of patients/parents (X²[4] = 18.30, P = .001; F_(2,193) = 7.02, P < .001; and F_(2,173) = 9.93, P < .0001, respectively). Greater confidence in ability to counsel (self-efficacy) also was associated with higher reported level of counseling for all groups: among children and adolescents who do not smoke (X²[6] = 13.56; P < .04), among those who do smoke (F_(3,192) = 16.33; P < .0001), and among parents who smoke (F_(3,171) = 10.71; P < .0001). The more physicians perceived other pediatricians in their community to be committed to counseling for prevention or cessation, the more likely they were to report such counseling of children and adolescents who do not smoke (X²[4] = 26.05; P = .001), of those who do smoke (F_(2,183) = 5.34; P < .005), and of parents who smoke (F_(2,163) = 13.44; P < .0001).

Barriers to Smoking Prevention and Cessation Counseling

Scores on the barriers scale were not associated with performance significantly for any group (r₍₁₉₀₎ = .10, P = .16, for performance with children and adolescents who do smoke; r₍₁₇₄₎ = .08, P = .29, for parents; and F_(2,188) = .61, P = .55, for ANOVA comparing Barriers scores for the three levels of counseling children and adolescents who do not smoke).

Regression Findings

With respect to counseling children and adolescents about abstaining from tobacco use, logistic regression analysis, regardless of how it was performed, revealed that only two psychosocial variables were associated independently with this practice. See Table 4. Pediatricians who perceived their interventions as moderately or only of little or no effectiveness were far less likely to counsel than those who perceived their counseling as quite or very effective (OR: .11, P = .04; OR: .07, P = .02, respectively). Additionally, those who thought their professional peers were not, or were only a little committed to counseling were less likely to counsel than those who believed their peers to be quite or very committed (OR: .10, P = .002).

Linear regression analysis, regardless of how it was performed, revealed that self-efficacy perceptions and community involvement were related to performance independently of counseling steps with children and adolescents who smoke. See Table 5. Pediactricians who perceived greater self-efficacy reported performing more counseling steps. In addition, pediatricians who reported no activity in community smoking activities, compared with some or a lot of activity, were less likely to report counseling activity.

Linear regression revealed also that at least three factors were related independently to counseling parents who smoke. See Table 6. Pediatricians who reported thinking that it was a greater part of their role to counsel parents who smoke performed more counseling steps with parents. The more that they thought their colleagues were committed to counseling parents to quit smoking, the more likely they themselves were to counsel parents. More community involvement was associated again with more counseling of parents. The impact of training was significant in the stepwise regression analysis and was of borderline significance (P = .07) in the full model regression analysis. This result suggests that pediatricians who had received formal training in smoking counseling were more likely to counsel parents who smoke.

	DISCUSSION

Top Abstract Methods Results Discussion References

Pediatricians in the present study report a greater tendency to encourage children and adolescents not to start using tobacco than to intervene with children and adolescents who already smoke and are even less likely to counsel parents who smoke. This study indicated a number of potential reasons why pediatricians are more likely to promote the prevention of smoking among children and adolescents who do not smoke than to intervene with current smokers, both children/adolescents and parents. First, pediatricians report a greater perception of prevention as part of their role, compared with cessation. Second, they report feeling greater self-efficacy to conduct prevention intervention, and believe it to have greater effectiveness than intervention for cessation. And lastly, pediatricians report that they perceive greater commitment to prevention than to cessation interventions among other pediatricians in their communities.

Our multivariable analyses highlight the fact that different factors are related to counseling for each of the patient target groups and that several factors should receive priority attention in interventions aimed at increasing the counseling practices of pediatricians with each patient population. In addition to pediatricians reporting more intervention with children and adolescents who do not smoke, compared with the other two groups, intervention practice variability for this group of patients is affected least by the factors investigated in this study. The only factors significantly related to smoking prevention intervention practice among pediatricians are greater perceived effectiveness of their efforts and higher perceived professional norms. Stressing these points in pediatrician interventions should be a priority. Perceiving that professional norms support counseling was related independently to counseling with nonsmokers and with parent smokers as well, in which practice is the lowest. Pediatricians are considerably less likely to report that it is part of their role to intervene with parents than with children/adolescents, and this perception is related independently and significantly to intervention practice. Practice guidelines emphasize this role, and strategies must be designed to convince pediatricians of the appropriateness and effectiveness of their intervention.

Perceived self-efficacy is related independently and significantly to counseling with child/adolescent smokers (and of borderline significance with parent smokers). Other physician surveys have shown that physicians have low levels of confidence in providing advice on smoking cessation.^50,51 Because increased self-efficacy is related to training participation,^40,52 increased exposure to skill-building should be a priority. Several investigators have noted that the self-efficacy of physicians to assist patients to stop smoking can be increased if they are given support such as training, referral information, monetary reimbursement, literature to hand out, and the ability to hire or train staff to help.^51,53

Although other studies reported that negative parental expectations and lack of time were barriers to providing advice, the barriers investigated in this study were unrelated to practice.⁵⁴ Understandably, some or a lot of pediatrician involvement in community tobacco control issues is related to cessation counseling for both pediatric smokers and parent smokers, suggesting synergy between public health and patient counseling roles.³⁷ Interestingly, this study found the personal and practice demographics of pediatricians are not related to reported counseling practices for any of the three target groups. However, in bivariate analysis, community involvement and training were related significantly to reported counseling for two target groups (adolescents and parents who smoke) but not primary prevention for nonsmoking children and adolescents. Also in bivariate analyses, role perception, perceived counseling effectiveness, self-efficacy, and perceived professional norms were related significantly to reported counseling practices with all target groups. According to a 1985 nationwide survey, only about half of the pediatricians believed it was "very important" to discuss this topic, and only 30% believed that they were "likely to be effective" in assisting patients with smoking prevention.⁵⁵ In the Maine study,⁵⁴ almost all pediatricians (94%) were moderately confident or very confident in addressing passive smoking issues, yet only 46% were moderately confident or very confident in advising parents how to stop smoking. In the Vermont study,⁵⁴ 45% of pediatricians reported confidence in providing advice to parents.

Guidelines and professional colleagues have illustrated the specific concrete strategies pediatricians can use to apply various counseling steps^{26,28,2956-58} for specific subpopulations,^54,59,60 using epidemiologic and etiologic data.²⁸ The Agency for Health Care Policy and Research Guideline emphasizes that the messages should differ according to the developmental stage of the child or adolescent. During infancy and early childhood, pediatricians should direct the messages to the child's parents to not smoke and to limit the child's exposure to smoke. During late childhood, the goal is to prevent the onset of tobacco use, and for adolescents, the goal is to prevent the onset of tobacco use and to promote cessation. Based on a series of clinical trials, the National Cancer Institute developed a program for physicians to help prevent tobacco use during childhood and early adolescence. A 5th step is added (anticipate the risk for tobacco use at each developmental stage) to the other steps (ask, advise, assist, and arrange follow-up) for use with pediatric patients.²⁹ When pediatric residents are trained and prompted to use this model, their smoking cessation counseling effectiveness improves.^60-62 Interestingly, in the present study, pediatricians clearly report performing the "ask" and "advise" steps more frequently than the "assist" and "arrange follow-up" steps with all three target populations (illustrated in Table 1).

In a study⁶³ similar to this one, tobacco screening rates with adolescents varied significantly among four primary care specialities, from 10% to 93%, by purpose of the visit and age of the adolescent. Among pediatricians, the screening rates varied from 10% of younger adolescents who were seen at acute-care visits to 74% of older adolescents who were being seen at a routine examination. In a mailed survey of primary care physicians and dentists in Connecticut, 21% of the respondents reported "always" counseling patients between the ages of 10 and 12, 39% reported "always" counseling patients between the ages of 13 and 15, and 48% reported "always" counseling patients between the ages of 16 and 18.⁶⁴ In a telephone survey of 7960 adolescents, only 25% adolescents reported that a health care provider had said something to them about cigarette smoking in the last year.⁶⁵

In regard to intervention with parents who smoke, other studies, albeit with varying reported practice, suggest that more attention could be paid to intervention with parents. For example, in the Maine study,^47,54 most pediatricians (72%) estimated that they talk to 25% of the parents who smoke about the effects of smoking on their children, with 43% of pediatricians talking to 75% of these parents. Advising parents who smoke to quit was reported by most respondents (91%). In the similar Vermont study,⁵⁴ 40% of pediatricians reported that they took a smoking history from parents routinely and 11% of these pediatricians recorded this information in the child's chart. Similar percentages were reported for advising parents who smoke to quit.

There are several limitations to this study. As with any cross-sectional study, causal relationships can not be attributed among variables. Rather, the associations between variables can inform future research and intervention planning. This study showed moderate to low levels of self-reported counseling practice. Yet previous studies have demonstrated that physicians tend to overestimate their screening practices,⁶⁶ and thus actual practice may be lower than reported here. This sample was selected from membership in the state pediatric association that may not be synonymous with the actual population of practicing pediatricians. In addition, a study limitation is the relatively small number of personal and practice variables that were investigated as potential significant predictors of counseling practice. Parsimony of items was necessary to minimize respondent burden. Even in view of these limitations, the generalizability of this study to pediatricians as a group is enhanced because of the high response rate among this random sample, often not achieved in recent studies of physicians.⁶³

	ACKNOWLEDGMENTS

This research was funded in part by a grant from the Massachusetts Department of Public Health through the Massachusetts Tobacco Control Program and the Cancer Prevention and Control Education Project National Institutes of Health Grant R25 CA71737-01.

We thank Edward Bailey, MD and Evan Charney, MD for their support; and Anne Stoddard, Ted Purcell, and Kathee Sonner for their thoughtful assistance.

	FOOTNOTES

Received for publication Jan 29, 1998; accepted Oct 28, 1998.

Reprint requests to (J.G.Z.) Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA 01655. E-mail: jzapka{at}banyan.ummed.edu

	ABBREVIATIONS

SCT, Social Cognitive Theory.

	REFERENCES

Top Abstract Methods Results Discussion References

1. US Department of Health and Human Services. Reducing the Health Consequences of Smoking: 25 Years of Progress. A report of the Surgeon General. Rockville, MD: PHS, CDC, Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health; 1989. Publication USDHHS (CDC) 89-8411
2. CDC Cigarette smoking-attributable mortality and years of potential life lost: United States, 1990. Morb Mortal Wkly Rep 1993; 42:645-649 [Medline]
3. CDC Cigarette smoking among adults: United States, 1993. Morb Mortal Wkly Rep 1994; 43:925-930 [Medline]
4. Landrigan P, DiLiberti J, Graef J, Involuntary smoking: a hazard to children. Pediatrics 1986; 77:755-757 [Abstract/Free Full Text]
5. Ferguson D, Horwood L, Shannon F, Taylor B Parental smoking and lower respiratory illness in the first three years of life. J Epidemiol Community Health 1981; 35:180-184 [Abstract/Free Full Text]
6. Weitzman M, Gortmaker S, Walker D, Sobel A Maternal smoking and childhood asthma. Pediatrics 1990; 85:505-511 [Abstract/Free Full Text]
7. Weiss S, Tager L, Speizer F, Rosner B Persistent wheeze: Its relation to respiratory illness, cigarette smoking and level of pulmonary function in a population sample of children. Am Rev Respir Dis 1980; 122:697-707 [Medline]
8. Kraemer M, Richardson M, Weiss N, Risk factors for persistent middle-ear effusions: Otitis media, catarrh, cigarette smoke exposure and atopy. JAMA 1983; 249:1022-1025 [Abstract/Free Full Text]
9. Tager J, Weiss S, Munoz A, Rosner B, Speizer F Longitudinal study of the effects of maternal smoking on pulmonary function in children. N Engl J Med 1983; 309:699-703 [Abstract]
10. DiFranza J, Tyre J Who profits from tobacco sales to children? JAMA 1990; 263:2784-2787 [Abstract/Free Full Text]
11. Fiore M, Novotony T, Hatziandreu E, Pierce J, Patel K, Davis R Trends in cigarette smoking in the US; The changing influence of gender and race. JAMA 1989; 261:49-55 [Abstract/Free Full Text]
12. Briton N, Clark T, Baker A, Posner B, Soldz S, Krakow M. Adolescent Tobacco Use in Massachusetts: Trends Among Public School Students 1984-1996. Boston, MA: Massachusetts Department of Public Health; 1997
13. Boyd G, Darby C, eds. Smokeless tobacco use in the United States. Bethesda, MD: DHHS/PHS/NIH/NCI, 1989. NCI Monographs, Vol 8
14. Department of Health and Human Services. Smoking and Health: A National Status Report. A report to Congress. Bethesda, MD: US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Health Promotion and Education, Office of Smoking and Health; 1987. Publication HHS/PHS/CDC-87-8386
15. Chassin L, Presson C, Rose J, Sherman S The natural history of cigarette smoking from adolescence to adulthood: demographic predictors of continuity and change. Health Psychol 1996; 15:478-484 [CrossRef][Medline]
16. Taioli E, Wynder E Effect of the age at which smoking begins on frequency of smoking in adulthood. N Engl J Med 1991; 325:968-969 [Medline]
17. Davis J, Shelton L, Watanable I, Arnold J Passive smoking affects endothelium and platelets. Arch Intern Med 1989; 149:386-389 [Abstract/Free Full Text]
18. PDAY Research Group Relationship of atherosclerosis in young men to serum lipo-protein cholesterol concentrations and smoking. JAMA 1990; 23:3018-3024
19. US Department of Health and Human Services. The Health Consequences of Involuntary Smoking. Rockville, MD: PHS, CDC, Center for Health Promotion and Education, Office of Smoking and Health, DHHS, CDC; Publication 87-8398. 1986
20. Bailey S Adolescents' multisubstance use patterns: the role of heavy alcohol and cigarette use. Am J Public Health 1992; 82:1220-1224 [Abstract/Free Full Text]
21. Kandel D, Yamaguchi R From beer to crack: developmental patterns of drug involvement. Am J Public Health 1993; 83:851-855 [Abstract/Free Full Text]
22. Voss H, Clayton R Stages in involvement with drugs. Pediatrician 1987; 14:25-31 [Medline]
23. Hawkins J, Lishner D, Catalalano L. Childhood and the prevention of adolescent substance abuse. In: Jones C, Battjes R, eds. Etiology of Drug Abuse: Implications for Prevention. Bethesda, MD: USDHHS; 1985
24. Breslau N, Peterson E Smoking cessation in young adults: age at initiation of cigarette smoking and other suspected influences. Am J Public Health 1996; 86:214-220 [Abstract/Free Full Text]
25. Schonberg S, ed. Substance Abuse: A Guide for Health Professionals. American Academy of Pediatrics and Center for Advances Health Studies. Risk Factors and Their implication for Prevention and Intervention for the Physician. 3rd ed. Elk Grove, IL: American Academy of Pediatrics; 1988
26. American Medical Association. Guidelines for Adolescent Preventive Services. Chicago, IL: American Medical Association; 1992
27. American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. Guidelines for Health Supervision II. Elk Grove, IL: American Academy of Pediatrics; 1988
28. Perry C, Silvis G Smoking prevention: behavioral prescription for the pediatrician. Pediatrics 1987; 79:790-799 [Abstract/Free Full Text]
29. Epps R, Manley M A physician's guide to preventing tobacco use during childhood and adolescence. Pediatrics 1991; 88:140-144 [Abstract/Free Full Text]
30. Cohen S, Christen A, Katz B, Counseling medical and dental patients about cigarette smoking. The impact of nicotine gum and chart reminder. Am J Public Health 1987; 77:313-316 [Abstract/Free Full Text]
31. Ockene J, Kristeller J, Goldberg R, Increasing the efficacy of physician-delivered smoking intervention: a randomized clinical trial. J Gen Intern Med 1991; 6:1-8 [Medline]
32. Kottke T, Battista R, KeFriese G, Krekke M Attributes of successful smoking cessation interventions in medical practice. A meta-analysis of 39 controlled trials. JAMA 1988; 259:2882-2889 [Abstract/Free Full Text]
33. Orleans C Understanding and promoting smoking cessation: overview and guidelines for physician intervention. Annu Rev Med 1985; 36:51-61 [CrossRef][Medline]
34. Wall M, Severson H, Andrews J, Lichtenstein E, Zoref L Pediatric office-based smoking intervention: impact on maternal smoking and relapse. Pediatrics 1995; 96:622-628 [Abstract/Free Full Text]
35. Fiore M, Bailey W, Cohen S, et al. Smoking Cessation: Clinical Practice Guideline No 18. Rockville, MD: US Department of Public Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1996. Publication AHCPR 96-0692
36. Lindsay E, Ockene J, Hymowitz N, Giffen C, Berger L, Pomrehen P Physicians and smoking cessation. A survey of office procedures and practices in the community intervention trial for smoking cessation. Arch Fam Med 1994; 3:341-348 [Abstract/Free Full Text]
37. Crooks C, Kenney E, Elder J, Levitz M, Johnson M, Bal D Tobacco control activities of primary care physicians in California. Eval Health Prof 1993; 16:311-321 [Abstract/Free Full Text]
38. Kviz F, Clark M, Prochaska T, Attitudes and practices for smoking cessation counseling by provider type and patient age. Prev Med 1995; 24:201-212 [CrossRef][Medline]
39. Goldstein M, DePue J, Eaton C, Niaura R, Rakowski W, Willey-Lessne C. A population-based survey of physicians' smoking counseling behavior. Paper presented at: Annual Meeting of the Society of Behavioral Medicine; 1993; San Francisco, CA
40. Zapka J, Fletcher K, Ma Y, Pbert L Physicians and smoking cessation: development of survey measures. Eval Health Prof 1997; 20:407-427 [Abstract/Free Full Text]
41. Bandura A. Social Foundation of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice-Hall; 1986
42. Janz N, Becker M The health belief model: A decade later. Health Educ Q 1984; 11:1-47 [Medline]
43. Goldberg R, Ockene I, Ockene J Physicians' attitudes and reported practices toward smoking intervention. J Cancer Educ 1993; 8:133-139 [Medline]
44. Ockene J, Goldberg R, Williams J A survey of Massachusetts physicians' smoking intervention practices. Am J Prev Med 1988; 4:14-20 [Medline]
45. Orlandi M Promoting health and preventing disease in health care settings: an analysis of barriers. Prev Med 1987; 16:119-130 [CrossRef][Medline]
46. Valente C, Sobal J, Muncie H, Levine H, Antlitz A Health promotion: Physicians' beliefs, attitudes and practices. Am J Prev Med 1986; 2:82-88 [Medline]
47. Frankowski B, Weaver S, Secker-Walker R Advising parents to stop smoking: opportunities and barriers in pediatric practice. Am J Dis Child 1989; 143:1091-1094 [Abstract/Free Full Text]
48. Gorsuch RL. UniMult. 1.1 ed. Altadena, CA: Gorsuch RL; 1991
49. Zwick W, Velicer W Comparison of five rules for determining the number of components to retain. Psychol Bull 1986; 99:432-442 [CrossRef]
50. Wells K, Ware J, Lewis C Physicians attitudes in counseling patients about smoking. Med Care 1984; 22:360-365 [CrossRef][Medline]
51. Wechsler H, Levine S, Idelson R, Rohman M, Taylor J The physician's role in health promotion: a survey of primary care practitioners. N Engl J Med 1983; 308:97-100 [Medline]
52. Cummings S, Coates T, Richard R, Hansen B, Training physicians in counseling about smoking cessation: a randomized trial of the "Quit for Life" program. Ann Intern Med 1989; 110:640-647
53. Ockene J, Zapka J Changing provider behaviour: provider education and training. Tobacco Control 1997; 6(suppl):S63-S67 [Free Full Text]
54. Frankowski B, Weaver S, Secker-Walker R Advising parents to stop smoking: pediatricians' and parents' attitudes. Pediatrics 1993; 91:296-300 [Abstract/Free Full Text]
55. Nader P, Taras H, Sallis J, Patterson T Adult heart disease prevention in childhood: a national survey of pediatricians' practices and attitudes. Pediatrics 1987; 79:843-850 [Abstract/Free Full Text]
56. Thomas R, Thomas A Preventing children from smoking. How family physicians and pediatricians can help. Can Fam Physician 1995; 41:1517-1523 [Medline]
57. Levenberg P, Elster A, eds. Guidelines for Adolescent Preventive Services (GAPS). Recommendations and Rationale. Baltimore, MD: Williams & Wilkins; 1995
58. Bykowski M How you can help teens quit smoking. Pediatr News 1997; 31:41
59. Rasco C Discouraging smoking: interventions for pediatric nurse practitioners. J Pediatr Health Care 1992; 6:200-207 [CrossRef][Medline]
60. Klein J, Portilla M, Goldstein A, Leininger L Training pediatric residents to prevent tobacco use. Pediatrics 1995; 96:326-330 [Abstract/Free Full Text]
61. Kosower E, Ernst A, Taub B, Berman N, Andrews J, Seidel J Tobacco prevention education in a pediatric residency program. Arch Pediatr Adolesc Med 1995; 148:430-435
62. Strecher V, O'Malley M, Villagra V, Can residents be trained to counsel patients about quitting smoking? Results from a randomized trial. J Gen Intern Med 1991; 6:9-17 [Medline]
63. Franzgrote M, Ellen J, Millstein S, Irwin C Screening for adolescent smoking among primary care physicians in California. Am J Public Health 1997; 87:1341-1345 [Abstract/Free Full Text]
64. Gregorio D Counseling adolescents for smoking prevention; a survey of primary care physicians and dentists. Am J Public Health 1994; 84:1151-1153 [Abstract/Free Full Text]
65. Baker L Health-care provider advice on tobacco use to persons aged 10-22 years, United States, 1993. Morb Mortal Wkly Rep 1995; 44:826-830
66. Lewis C Disease prevention and health promotion practice of primary care physicians in the United States. J Prev Med 1988; 4(suppl 4):9-16