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Tobacco Counseling at Well-Child and Tobacco-Influenced Illness Visits: Opportunities for Improvement

Susanne E. Tanski, MD^*, Jonathan D. Klein, MD, MPH^*,, Jonathan P. Winickoff, MD, MPH, Peggy Auinger, MS^*, and Michael Weitzman, MD^*,

^* Strong Children’s Research Center, University of Rochester, Rochester, New York
AAP Center for Child Health Research, Rochester, New York
MGH Center for Child and Adolescent Health Policy and Tobacco Research and Treatment Center, Boston, Massachusetts

	ABSTRACT

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Objective. To assess the frequency of clinician-reported delivery of counseling for avoidance of child environmental tobacco smoke (ETS) exposure and tobacco use at periodic well-child visits and at illness visits for asthma and otitis media (OM).

Methods. Combined data from the National Ambulatory Medical Care Survey and the outpatient portion of the National Hospital Ambulatory Medical Care Survey from 1997 to 1999 were analyzed. The frequency of pediatric visits (18 years) that included clinician-reported counseling for tobacco use/exposure prevention was assessed. Diagnosis-specific visits were determined by using International Classification of Diseases, Ninth Revision codes for asthma (493-), OM (381-, 382-), and well-child visits. Bivariate and regression analyses were performed.

Results. Of 33 823 ambulatory care visits by children, 1.5% were reported to include delivery of tobacco counseling. Only 4.1% of well-child visits, 4.4% of illness visits for asthma, and 0.3% of illness visits for OM included tobacco counseling. With the use of logistic regression models, adolescent patient visits (13–18 years) were more likely to include delivery of tobacco counseling than younger child visits [OR = 15.8, 95% CI (7.5–33.5)]. Visits by children with Medicaid and those seen by a nurse practitioner or a physician’s assistant were also more likely to include tobacco counseling (odds ratio: 1.6; 95% confidence interval: 1.002–2.50; and odds ratio: 3.0; 95% confidence interval: 1.5–6.0, respectively). There were no significant differences in counseling delivery by race, ethnicity, or clinician specialty.

Conclusions. Rates of tobacco counseling at well-child visits and at illness visits for diagnoses directly affected by tobacco use and ETS are extremely low. Significant opportunities exist to improve counseling rates for child ETS exposure and adolescent tobacco use in primary care.

Key Words: environmental tobacco smoke • smoking • tobacco use • counseling • parental smoking • second-hand smoke • pediatrics • asthma • otitis media

Abbreviations: ETS, environmental tobacco smoke • OM, otitis media • SIDS, sudden infant death syndrome • NHAMCS, National Hospital Ambulatory Care Survey • NAMCS, National Ambulatory Medical Care Survey • OR, odds ratio • CI, confidence interval

	INTRODUCTION

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Environmental tobacco smoke (ETS) is a major preventable environmental cause of morbidity and mortality in the United States. ETS has been linked to numerous adverse health outcomes, including lung cancer, asthma, respiratory infections, otitis media (OM), low birth weight, and sudden infant death syndrome (SIDS).^1–4 In addition, children and adolescents who are exposed to smokers in their household are 3 times more likely to initiate smoking themselves.⁵ Approximately 23.5% of US adults⁶ and an alarming 28.5% of high school students are current smokers.⁷ Data from the National Health and Nutrition Examination Survey III indicate that as many as 43% of US children,⁸ >15 million,⁹ are exposed to ETS by household members. In addition, 12.3% of women who gave birth in the United States in 1999 smoked during pregnancy.¹⁰ The direct cost of children’s medical care attributable to ETS was approximately $1.97 billion in 1997.¹¹

Given the burden of ETS, there is an imperative to intervene to limit such exposure for the improved health and well-being of both children and adults. Well-child and illness-related visits are important opportunities for intervention because parents of young children visit pediatricians and family practitioners frequently.¹² The American Academy of Pediatrics^13,14 and the American Academy of Family Physicians¹⁵ advise parents to limit children’s ETS exposure. In addition, surveys have demonstrated that 79% to 93%^16,17 of smoking parents agree that it is appropriate for their child’s pediatrician to provide smoking cessation advice, and 48% to 56% of parents believe that it is a pediatrician’s job to advise smoking parents to quit.^12,16

Physician and other clinician counseling interventions for parental smoking cessation and reduction of children’s exposure to ETS have been shown to have some effect. Observed positive effects have included a decrease in the reported number of cigarettes to which children were exposed in the home,^18–21 decreases in levels of nicotine measured in the home,²² increase in parent-reported smoke-free households, and increased parent quit rates.²³ Most of these studies have specifically targeted parents of children with asthma.

Despite the benefits of counseling interventions and the known adverse ETS effects on illnesses such as OM and asthma, many physicians do not deliver smoking cessation counseling to pediatric patients and their parents.²⁴ Several regional studies to date that have assessed attitudes and self-reported practice of tobacco use and cessation screening and interventions have found widely varying rates of counseling and intervention. In 2 studies that assessed counseling of adolescent patients, physicians reported screening 71.4% of younger adolescents and 84.8% of older adolescents about tobacco use in a California survey²⁵ and 91% of adolescents in an upstate New York survey.²⁶ In a study of Connecticut physicians and dentists, 65% of practitioners reported "frequently" or "always" counseling patients about tobacco between ages 16 and 18, 54% between ages 13 and 15, and 38% between ages 10 and 12.²⁷ With respect to parent counseling, a study in Vermont found that 94% of pediatricians surveyed reported that they advised at least 60% of their smoking parents to quit,¹² and a similar study in Maine found that 91% of pediatricians reported that they advised their smoking parents to quit.²⁸ There is little information on practices at the national level, but 1 study found that only 15% of general pediatricians reported offering specific assistance to parents for smoking cessation and 85% offered only nonspecific advice.²⁹

This study presents data from a national sample of clinicians who provide medical care to children on the frequency of their reported tobacco counseling. This information was recorded after individual visits and reported in the National Hospital Ambulatory Care Survey (NHAMCS) and National Ambulatory Medical Care Survey (NAMCS) from 1997 to 1999.

	METHODS

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The NAMCS and NHAMCS are part of the ambulatory portion of the National Health Care Survey administered by the National Center for Health Statistics to measure health care utilization. The NAMCS is an ongoing survey (from 1972) of US office-based physicians, and NHAMCS is a similar ongoing survey (from 1992) of hospital outpatient and emergency departments. For this study, emergency department visits were excluded. The NAMCS includes visits made in the United States to the offices of non–federally employed physicians classified as "office-based, patient care" by the American Medical Association and/or the American Osteopathic Association. Visits to private, non–hospital-based clinics and health maintenance organizations were included in NAMCS, whereas visits to federally operated facilities and hospital-based outpatient departments were not. NHAMCS includes in-person visits made in the United States to outpatient departments of non-federal, short-stay hospitals.

Participating physicians and other clinicians in their offices complete a 1-page patient record form for a systematic random sample of ambulatory care visits during a randomly assigned week. Clinicians record demographic information, expected source of payment, reason for visit, diagnoses, diagnostic and screening procedures, patient management, counseling and education provided, and medications prescribed (including immunizations). For the NHAMCS, characteristics of the hospital are also collected. Within the same years of the survey, NAMCS and Outpatient NHAMCS participants completed identical encounter forms. There were minor additions to the forms between the 1998 and 1999 editions, but these added questions were not included in the current analyses.

Data from the 1997, 1998, and 1999 NAMCS and NHAMCS were combined for these analyses. Data from both NAMCS and NHAMCS were included to capture a broader number and range of patients, as hospital ambulatory patients frequently differ from office patients in their demographic and medical characteristics.³⁰ Combining data sets also provided information on a significant number of children missed by using NAMCS alone: in 1997, 77.1% of ambulatory medical visits of children aged 15 and younger occurred in office-based practices, and 10.3% occurred in hospital outpatient departments.³⁰ Although these survey instruments do not capture the type or quality of counseling intervention, they do demonstrate simple frequencies of clinician-reported counseling at the time of visit.

For this study, all patients who were older than 18 years (in both NAMCS and NHAMCS) were excluded, as were emergency visits from NHAMCS. In addition, visits at which patients were seen only by registered nurses, licensed practical nurses, nurse midwives, or medical or nursing assistants were excluded. All percentages in this study are weighted to reflect national estimates. Independent predictors of tobacco counseling were determined with weighted logistic regression. Asthma and OM were used as predictor variables on the basis of their well-established association with environmental smoke exposure. Diagnoses for asthma and OM were based on International Classification of Diseases, Ninth Revision codes of asthma (493-) and OM (381-, 382-). Covariates were visit diagnosis (well-child visit, asthma, or OM), patient demographics (age, gender, race, and ethnicity), expected payment source for the visit, type of clinician seen (physician or midlevel practitioner), and physician specialty. Source of payment was divided into 4 categories: private, Medicaid, self-pay, or other. Physician specialty was categorized as general/family practice, pediatrics, or all other. SUDAAN software³¹ was used to account for the complex sample design.

	RESULTS

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Data were available for 33 823 child and adolescent (18 years) patient visits for well-child and illness/injury care. Of these visits, only 520 included tobacco counseling as reported by the clinician on the patient record form. Table 1 shows the prevalence of tobacco counseling in the ambulatory setting, with an overall rate of tobacco counseling at 1.5% of all visits. There was a greater prevalence of counseling with increasing patient age at visits for any diagnosis, with 0.7% of 0- to 1-year-olds receiving counseling compared with 3.5% of 13- to 18-year-olds. Visits for well-child care included counseling 4.1% of the time; with 0- to 1-year-olds receiving counseling at 1.4% of visits, 2- to 4-year-olds at 2.2% of visits, 5- to 12-year-olds at 6.13% of visits, and 13- to 18-year-olds at 12.1% of visits (Table 2). The difference in prevalence rates at well-child visits by age was statistically significant (P = .001). Tobacco counseling occurred in only 4.4% of visits for asthma and 0.3% of visits for OM. The difference in prevalence rates by visit diagnosis was statistically significant (P < .001).

	DISCUSSION

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Smoking is a pediatric disease,³² with effects that begin in utero and continue throughout life. SIDS, OM, and asthma all are directly affected by children’s exposure to ETS. SIDS is the leading cause of death in children from 1 month to 1 year of age, and infants who live in homes in which the mothers smoke postnatally are at twice the risk for SIDS as compared with infants who do not live with a smoking mother.³³ With the success of the Back to Sleep campaign, smoking is now the greatest modifiable risk factor for SIDS.³⁴ Parental smoking also is linked to an increased risk of serous OM and recurrent OM, the most common bacterial infection seen in children and the most common reason for antibiotic therapy in children. The pooled ORs if either parent smokes are 1.48 (95% CI: 1.08–2.04) for recurrent OM and 1.38 (95% CI: 1.23–1.55) for middle ear effusion.³⁵ There is significant cost associated with OM from treatment and missed work by parents, and the antibiotics prescribed for this frequent illness have been cited as major contributors to the development of antibiotic-resistant strains of bacteria. Asthma is the most common chronic disease in children, affecting roughly 4.8 million children and leading to several hundred deaths in children each year.³⁶ In 1993, asthma accounted for an estimated 198 000 hospitalizations and 342 deaths among people younger than 25 years.³⁶ Children who live in a home with a smoker are more likely to have wheezing, with the risk of developing asthma being 1.37 if either parent smokes.³⁷ Those who are exposed and have a diagnosis of asthma are more likely to have more severe disease with increased number of emergency department visits³⁸ and increased risk of intubation.³⁹ Much of the morbidity of asthma could be lessened if children and adults had less exposure to ETS. In a study from 1974, asthma severity improved in children when exposure was reduced. Ninety percent of a group of children with asthma improved when their parents stopped smoking, compared with 27% of children whose parents continued to smoke.⁴⁰

The counseling rate for visits of infants from birth to 1 year in this study was extremely low, with only 1.4% of well-child visits and 0.7% of all visits including tobacco counseling. The reported counseling rate in visits for OM is also extremely low, with clinicians indicating that they provide tobacco counseling in only 0.3% of visits for OM. These visits certainly represent counseling directed to parents regarding tobacco cessation or ETS reduction, given the young ages of the patients themselves. Although this frequency unfortunately cannot be correlated with parental smoking status, it is distinctly lower than the previously cited regional data on self-reported tobacco counseling to smoking parents.^12,28 Similarly, the 1997 National Heart, Lung, and Blood Institute guidelines for the diagnosis and management of asthma also recommend screening and counseling parents for smoking,⁴¹ but in this sample, only 4.4% of visits of children for asthma were reported to include tobacco counseling. This rate is also markedly lower than physician self-report data previously published.²⁹

The existing recommendations by the American Academy of Pediatrics,^13,14,42 the American Academy of Family Physicians,⁴³ the American Medical Association,⁴³ the United States Preventive Services Task Force,⁴⁴ the Maternal and Child Health Bureau (Bright Futures Guidelines),⁴⁵ and Healthy People 2010⁴⁶ all advocate counseling parents on the potentially harmful effects of smoking on fetal and child health. These recommendations extend to every well-child visit and especially should begin in the newborn period to minimize the health hazards of ETS. Parents often do not know of the significant effects of ETS. A recent study of parents of hospitalized children found that 41% of smoking parents did not believe that their smoking had a negative effect on their child’s health.⁴⁷

Beyond the specific adverse physical effects of ETS is the impact that smoking parents have on their children’s risk of smoking initiation. Among US smokers who have ever smoked on a daily basis, 91% tried their first cigarette before the age of 20.⁴⁸ Adolescents who live in a household with a smoking parent are more likely to become smokers themselves.⁵ Previous studies have shown that adolescents who were known to be smokers and presented with lower respiratory tract infections were more likely to be counseled about tobacco use.⁴⁹ Similarly, in this study, adolescents were indeed 15.8 times more likely to receive tobacco cessation/ETS counseling at visits for any diagnosis, but the overall prevalence of counseling in this age group was only 3.5%. Although it could not be determined through this survey who received tobacco cessation counseling at a visit, it is important that these messages be continued to parents of adolescents as well as to adolescents who smoke. Parental smoking cessation leads to nearly one third less smoking initiation and twice the rate of smoking cessation in adolescents aged 15 to 17 years.⁵⁰

Although >30 years of published research amply demonstrates the hazards of smoking and ETS for children, these and other data clearly demonstrate that physicians are not providing counseling frequently enough. Several studies have investigated the barriers that preclude physicians from discussing smoking cessation with patients and parents.^{12,16,24,27,28,51–53} One such barrier is lack of belief that a counseling intervention will be effective. Some older research has suggested that brief physician cessation counseling without additional counseling or pharmacotherapy does not improve long-term cessation rates,^54–56 but more recent studies,⁵⁷ including the 2000 Agency for Health Care Policy and Research Tobacco Cessation Guideline⁵⁸ and a recent Cochrane Collaboration review,⁵⁹ suggested that even simple advice from a physician is effective in promoting long-term cessation. Studies regarding use of brief motivational counseling have been in the medical literature since well before the dates of this survey.^49,54–56 In the adult population, there have been improvements in the identification of smoking status and increases in the prescription of smoking cessation pharmaceuticals as they have become available. The rate of physicians’ advice to smokers has now become a quality assurance measure for managed care health plans⁶⁰; however, no such incentive has been placed on counseling of smoking parents. As stated earlier, parents often welcome such input from pediatricians.^12,16,17

There are several limitations to this study. Unfortunately, smoking status is no longer part of the NAMCS/NHAMCS encounter records, and there is no question regarding ETS exposure; thus, correlations of recommendations based on known risk cannot be made. In addition, it is difficult both to quantify and to qualify physician counseling behavior without direct observations of the patient interviews. One physician’s definition of a counseling intervention may not be the same as another’s, and as such counseling may be variably reported on a questionnaire such as the NAMCS/NHAMCS. The NAMCS/NHAMCS is also a broad survey, not specifically focused on tobacco issues, and may not capture sufficient detail of the actual patient encounter. Thus, the low rates of counseling seen here may be attributable to underreporting of actual counseling, differences in perception of a counseling intervention, or actual low rates of tobacco cessation and ETS counseling. However, the NAMCS has previously been used to assess patterns of treatment of adult smokers,⁶¹ finding then, too, that physicians’ practices fell short of national health objectives and practice guidelines. In that analysis, physicians identified patients’ smoking status at 67% of primary care visits and counseled for smoking cessation in 33% of these visits.⁶¹ The NAMCS survey has also been used previously to demonstrate low rates of smoking cessation counseling in adolescent populations.⁴⁹

	CONCLUSION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Rates of physician and other clinician counseling to parents regarding tobacco use and ETS exposure seem to be extremely low despite well-established links of tobacco and ETS to multiple childhood illnesses and national recommendations for such counseling. Previous studies have shown that smoking parents are generally receptive to counseling from their children’s pediatrician, and simple counseling interventions have a positive effect on parents’ efforts to quit smoking and/or limit their child’s exposure to ETS. Extrapolating information on current smoking rates and the morbidity and mortality of smoking and ETS exposure, pediatricians and other clinicians who care for children will see roughly 2 children each day who will succumb in adulthood to tobacco-related deaths.⁶² Childhood exposures to ETS undoubtedly play variable but important roles in many of these impending deaths. Counseling regarding smoking cessation and ETS exposure reduction at children’s medical care visits can reduce morbidity and mortality both in children and in their parents.

	ACKNOWLEDGMENTS

 
Dr Tanski is supported by Faculty Development in Primary Care, Bureau of Health Professions grant DO8HP50000809.

	FOOTNOTES

 
Received for publication Jul 25, 2002; Accepted Sep 23, 2002.

Reprint requests to (S.E.T.) General Pediatric Academic Fellow, University of Rochester Department of Pediatrics, 1351 Mount Hope Ave, Rochester, NY 14620-3917. E-mail: susanne_tanski{at}urmc.rochester.edu

	REFERENCES

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1. National Cancer Institute. Health Effects of Exposure to Environmental Tobacco Smoke: The Report of the California Environmental Protection Agency. Bethesda, MD: National Cancer Institute, US Department of Health and Human Services; 1999
2. American Academy of Pediatrics, Committee on Environmental Health. Environmental tobacco smoke: a hazard to children. Pediatrics.1997; 99 :639 –642[Abstract/Free Full Text]
3. Cook DG, Strachan DP. Health effects of passive smoking-10: summary of effects of parental smoking on the respiratory health of children and implications for research. Thorax.1999; 54 :357 –366[Abstract/Free Full Text]
4. DiFranza JR, Lew RA. Morbidity and mortality in children associated with the use of tobacco products by other people. Pediatrics.1996; 97 :560 –568[Abstract/Free Full Text]
5. Farkas AJ, Gilpin EA, White MM, Pierce JP. Association between household and workplace smoking restrictions and adolescent smoking. JAMA.2000; 284 :717 –722[Abstract/Free Full Text]
6. Cigarette smoking among adults–United States, 1999. MMWR Morb Mortal Wkly Rep.2001; 50 :869 –873[Medline]
7. Trends in cigarette smoking among high school students–United States, 1991–2001. MMWR Morb Mortal Wkly Rep.2002; 51 :409 –412[Medline]
8. Pirkle JL, Flegal KM, Bernert JT, et al. Exposure of the US population to environmental tobacco smoke: the Third National Health and Nutrition Examination Survey, 1988 to 1991. JAMA.1996; 275 :1233 –1240[Abstract]
9. State-specific prevalence of cigarette smoking among adults, and children’s and adolescents’ exposure to environmental tobacco smoke–United States, 1996. MMWR Morb Mortal Wkly Rep.1997; 46 :1038 –1043[Medline]
10. Mathews TJ. Smoking during pregnancy in the 1990s. Natl Vital Stat Rep.2001; 49 :1 –14[Medline]
11. Aligne CA, Stoddard JJ. Tobacco and children. An economic evaluation of the medical effects of parental smoking. Arch Pediatr Adolesc Med.1997; 151 :648 –653[Abstract]
12. Frankowski BL, Weaver SO, Secker-Walker RH. Advising parents to stop smoking: pediatricians’ and parents’ attitudes. Pediatrics.1993; 91 :296 –300[Abstract/Free Full Text]
13. American Academy of Pediatrics, Committee on Substance Abuse. Tobacco’s toll: implications for the pediatrician. Pediatrics.2001; 107 :794 –798[Abstract/Free Full Text]
14. American Academy of Pediatrics, Committee on Environmental Hazards. Involuntary smoking: a hazard to children. Pediatrics.1986; 77 :755 –757[Abstract/Free Full Text]
15. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examination. Kansas City, MO: American Academy of Family Physicians; 2002
16. Klein JD, Portilla M, Goldstein A, Leininger L. Training pediatric residents to prevent tobacco use. Pediatrics.1995; 96 :326 –330[Abstract/Free Full Text]
17. Groner J, Ahijevych K, Grossman L, Rich L. Smoking behaviors of women whose children attend an urban pediatric primary care clinic. Women Health.1998; 28 :19 –32[CrossRef][ISI][Medline]
18. Hovell MF, Zakarian JM, Matt GE, et al. Effect of counselling mothers on their children’s exposure to environmental tobacco smoke: randomised controlled trial. BMJ.2000; 321 :337 –342[Abstract/Free Full Text]
19. Wahlgren DR, Hovell MF, Meltzer SB, Hofstetter CR, Zakarian JM. Reduction of environmental tobacco smoke exposure in asthmatic children. A 2-year follow-up. Chest.1997; 111 :81 –88[Abstract/Free Full Text]
20. Greenberg RA, Strecher VJ, Bauman KE, et al. Evaluation of a home-based intervention program to reduce infant passive smoking and lower respiratory illness. J Behav Med.1994; 17 :273 –290[CrossRef][ISI][Medline]
21. Hovell MF, Meltzer SB, Zakarian JM, et al. Reduction of environmental tobacco smoke exposure among asthmatic children: a controlled trial. Chest.1994; 106 :440 –446[Abstract/Free Full Text]
22. Emmons KM, Hammond SK, Fava JL, et al. A randomized trial to reduce passive smoke exposure in low-income households with young children. Pediatrics.2001; 108 :18 –24[Abstract/Free Full Text]
23. Wall MA, Severson HH, Andrews JA, Lichtenstein E, Zoref L. Pediatric office-based smoking intervention: impact on maternal smoking and relapse. Pediatrics.1995; 96 :622 –628[Abstract/Free Full Text]
24. Zapka JG, Fletcher K, Pbert L, et al. The perceptions and practices of pediatricians: tobacco intervention. Pediatrics.1999; 103(5) . Available at: www.pediatrics.org/cgi/content/full/103/5/e65
25. Franzgrote M, Ellen JM, Millstein SG, Irwin CE Jr. Screening for adolescent smoking among primary care physicians in California. Am J Public Health.1997; 87 :1341 –1345[Abstract/Free Full Text]
26. Klein JD, Levine LJ, Allan MJ. Delivery of smoking prevention and cessation services to adolescents. Arch Pediatr Adolesc Med.2001; 155 :597 –602[Abstract/Free Full Text]
27. Gregorio DI. 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]
28. Frankowski BL, Secker-Walker RH. Advising parents to stop smoking. Opportunities and barriers in pediatric practice. Am J Dis Child.1989; 143 :1091 –1094[Abstract]
29. Burnett KF, Young PC. Ask, advise, assist: pediatricians and passive smoke exposure. Clin Pediatr (Phila).1999; 38 :339 –345[Abstract/Free Full Text]
30. Schappert SM. Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 1997. Vital Health Stat1999; 13 :i-39
31. Shah BV, Barnwell BG, Bieler GS. SUDAAN User’s Manual, Release 7.5. Research Triangle Park, NC: Research Triangle Institute; 1997
32. Kessler DA, Natanblut SL, Wilkenfeld JP, et al. Nicotine addiction: a pediatric disease. J Pediatr.1997; 130 :518 –524[CrossRef][ISI][Medline]
33. Anderson HR, Cook DG. Passive smoking and sudden infant death syndrome: review of the epidemiological evidence. Thorax.1997; 52 :1003 –1009[Abstract]
34. Mitchell E. Commentary: cot death—the story so far. BMJ.1999; 319 :1461 –1462
35. Strachan DP, Cook DG. Health effects of passive smoking. 4. Parental smoking, middle ear disease and adenotonsillectomy in children. Thorax.1998; 53 :50 –56[Abstract]
36. Asthma mortality and hospitalization among children and young adults–United States, 1980–1993. MMWR Morb Mortal Wkly Rep.1996; 45 :350 –353[Medline]
37. Strachan DP, Cook DG. Health effects of passive smoking. 6. Parental smoking and childhood asthma: longitudinal and case-control studies. Thorax.1998; 53 :204 –212[Abstract/Free Full Text]
38. Evans D, Levison MJ, Feldman CH, et al. The impact of passive smoking on emergency room visits of urban children with asthma. Am Rev Respir Dis.1987; 135 :567 –572[ISI][Medline]
39. LeSon S, Gershwin ME. Risk factors for asthmatic patients requiring intubation. I. Observations in children. J Asthma.1995; 32 :285 –294[ISI][Medline]
40. O’Connell EJ, Logan GB. Parental smoking in childhood asthma. Ann Allergy.1974; 32 :142 –145[ISI][Medline]
41. National Heart, Lung and Blood Institute. Guidelines for the Diagnosis and Management of Asthma (publication no. 97-4051). Bethesda, MD, National Institutes of Health; 1997
42. American Academy of Pediatrics, Committee on Substance Abuse. Tobacco, alcohol, and other drugs: the role of the pediatrician in prevention and management of substance abuse. Pediatrics.1998; 101 :125 –128[Abstract/Free Full Text]
43. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examination. Kansas City, MO: American Academy of Family Physicians; 1998
44. US Preventive Services Task Force. Guide to Clinical Preventive Services: Report of the US Preventive Services Task Force. 2nd ed. Baltimore, MD: Williams & Wilkins; 1996
45. Green M, Palfrey J, United States, et al. Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents. 2nd ed. Arlington, VA: National Center for Education in Maternal and Child Health; 2000
46. United States, Office of Disease Prevention and Health Promotion, United States, et al. Healthy People 2010. Washington, DC: US Department of Health and Human Services, Office of Public Health and Science; 2000
47. Winickoff JP, Hibberd PL, Case B, Sinha P, Rigotti NA. Child hospitalization: an opportunity for parental smoking intervention. Am J Prev Med.2001; 21 :218 –220[CrossRef][ISI][Medline]
48. US Department of Health and Human Services. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta, GA, US 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
49. Thorndike AN, Ferris TG, Stafford RS, Rigotti NA. Rates of U.S. physicians counseling adolescents about smoking. J Natl Cancer Inst.1999; 91 :1857 –1862[Abstract/Free Full Text]
50. Farkas AJ, Distefan JM, Choi WS, Gilpin EA, Pierce JP. Does parental smoking cessation discourage adolescent smoking? Prev Med.1999; 28 :213 –218[CrossRef][ISI][Medline]
51. Hopper JA, Craig KA. Environmental tobacco smoke exposure among urban children. Pediatrics.2000; 106(4) . Available at: www.pediatrics.org/cgi/content/full/106/4/e47
52. McIlvain HE, Backer EL, Crabtree BF, Lacy N. Physician attitudes and the use of office-based activities for tobacco control. Fam Med.2002; 34 :114 –119[ISI][Medline]
53. McIlvain HE, Crabtree BF, Gilbert C, Havranek R, Backer EL. Current trends in tobacco prevention and cessation in Nebraska physicians’ offices. J Fam Pract.1997; 44 :193 –202[ISI][Medline]
54. Cummings SR, Coates TJ, Richard RJ, et al. Training physicians in counseling about smoking cessation. A randomized trial of the "Quit for Life" program. Ann Intern Med.1989; 110 :640 –647
55. Cummings SR, Richard RJ, Duncan CL, et al. Training physicians about smoking cessation: a controlled trial in private practice. J Gen Intern Med.1989; 4 :482 –489[ISI][Medline]
56. McIlvain H, Susman JL, Davis C, Gilbert C. Physician counseling for smoking cessation: is the glass half empty? J Fam Pract.1995; 40 :148 –152[ISI][Medline]
57. Russell MA, Stapleton JA, Jackson PH, Hajek P, Belcher M. District programme to reduce smoking: effect of clinic supported brief intervention by general practitioners. Br Med J (Clin Res Ed).1987; 295 :1240 –1244
58. Fiore MC, Bailey WC, Cohen SJ. Treating Tobacco Use and Dependence Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services, Public Health Service; 2000
59. Silagy C, Ketteridge S. Physician advice for smoking cessation. The Cochrane Library. San Diego, CA: Update Software; 1999
60. HEDIS 2001, Volume 2: Technical Specifications. Washington, DC: National Committee for Quality Assurance; 2001
61. Thorndike AN, Rigotti NA, Stafford RS, Singer DE. National patterns in the treatment of smokers by physicians. JAMA.1998; 279 :604 –608[Abstract/Free Full Text]
62. Projected smoking-related deaths among youth–United States. MMWR Morb Mortal Wkly Rep.1996; 45 :971 –974[Medline]

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