PEDIATRICS Vol. 115 No. 3 March 2005, pp. 719-725 (doi:10.1542/peds.2004-0873)
Physician and Dentist Tobacco Use Counseling and Adolescent Smoking Behavior: Results From the 2000 National Youth Tobacco Survey
* Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, New York
New York Medical College, New York, New York
American Legacy Foundation, Washington, DC
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Objective. The present study describes patterns of tobacco use counseling among physicians and dentists as reported by adolescents and determines the association between provider advice to quit and cessation activities among current smokers.
Methods. Data were analyzed from the 2000 National Youth Tobacco Survey, an anonymous, self-administered, school-based survey. The National Youth Tobacco Survey was administered to a nationally representative sample of 35828 students in grades 6 to 12 in 324 schools.
Results. Thirty-three percent of adolescents who visited a physician or a dentist in the past year reported that a physician counseled them about the dangers of tobacco use, and 20% reported that a dentist provided a similar message. Among students who smoked in the past year, 16.4% received advice to quit from a physician and 11.6% received advice to quit from a dentist. Physician or dentist advice to quit was correlated with 1 or more quit attempts in the past 12 months.
Conclusion. On the basis of adolescent reports, physician and dentist practice patterns remain well below recommended guidelines. Results suggest that provider advice to quit is associated with cessation activity. Additional studies are needed to confirm whether the low prevalence of brief provider tobacco use counseling is a missed opportunity to affect adolescent smoking behavior.
Key Words: physician practice patterns • tobacco use/smoking
Abbreviations: USPHS, United States Public Health Service • NAMCS, National Ambulatory Medical Care Survey • NYTS, National Youth Tobacco Survey • OR, odds ratio
Every day in the United States, >4000 youths who are younger than 18 years try their first cigarette.1 Half of these youths will become regular smokers, and one third will die of a smoking-related disease.2 After a 1996 peak in smoking rates among 8th, 10th, and 12th graders, youth smoking prevalence has declined steadily.3 From 1996 to 2002, current smoking (smoked in last 30 days) decreased from 21% to 10.7%. Current smoking among 12th graders (26.7%), however, remains well above the Healthy People 2010 goal for adolescents of 16% and is higher than the adult rate of 22.7%.4
A decade of national and statewide tobacco control efforts including cigarette price increases, expanded clean indoor air laws, broader restrictions on youth access to tobacco products, youth-targeted mass media campaigns, and school-based programs have combined to create an environment that is more favorable for reduced teenage use and have contributed to a 27-year low in youth smoking.5 Intervention strategies for youths, however, have focused primarily on prevention of smoking initiation and, to a lesser extent, on youth cessation. Although interest in studying cessation approaches for adolescents has intensified, little is known about the effectiveness of the health care setting as a channel for delivering both preventive and cessation interventions,6 yet health care providers are in a unique position to have an impact on adolescent tobacco use. Sixty percent to 70% of adolescents visit a physician and/or a dentist annually.7–9 Moreover, adolescents consider physicians a reliable source on medical issues, and most report a desire to have their provider discuss smoking and other health risk behaviors.10,11
In 2000, the United States Public Health Service's (USPHS) Agency for Health Care Research and Quality released the revised guideline, Treating Tobacco Use and Dependence. The guideline provides evidence that for adult tobacco users, brief office-based physician counseling yields a 30% increase in spontaneous quit rates.12 Despite lacking similar evidence for office-based youth interventions in physician and dental offices, the USPHS and several medical and dental organizations have endorsed the guidelines' 5-step approach to tobacco use screening and counseling (Ask, Advise, Assess, Assist, Arrange) for all clinicians who treat children and adolescents.13,14
Several surveys indicate that physicians are increasingly screening adolescents for smoking, but gaps remain between recommendations and practice patterns.15–23 The 1991 National Ambulatory Medical Care Survey (NAMCS) found that physicians identified adolescents' smoking status at 72.4% of visits but provided smoking counseling at only 1.6% of all visits and 16.9% of visits by adolescents who were identified as smokers.15 A more recent analysis of NAMCS from 1997 to 1999 indicated no improvement in counseling rates by physicians who treat adolescents. Of 33823 child or adolescent visits, only 1.5% included tobacco counseling.17 NAMCS may underestimate actual counseling, but physician surveys demonstrate a similar pattern of decreasing compliance with USPHS guidelines as physicians move from screening to counseling and then to arranging follow-up.18,19
The few studies that have estimated the prevalence of physician tobacco use counseling from the adolescent patient's perspective report even lower levels of adherence to guidelines than those found in provider surveys.7,20,24 Data from the 1993 Teenage Attitudes and Practices survey showed that 20.7% of 10- to 16-year-olds and 29% of 17- to 19-year-olds reported that a health care provider discussed cigarette smoking during an office visit.24 In a more recent study, 43% of adolescents surveyed reported physician screening, 42% reported receiving counseling, and 28.8% reported receiving both.20
Surveys of dentists indicate that cessation activities are not yet a routine part of dental practice.22,25–27 In a survey of counseling activities among physicians and dentists, 90% of pediatricians reported frequently or always offering preventive counseling to 16- to 18-year-olds, and 81% counseled 13- to 15-year-olds. The comparable counseling rates among dentists were only 25% for 16- to 18-year-olds and 18% for 13- to 15-year-olds.22 We are not aware of any studies of adolescent reports on dentist practice patterns as they relate to tobacco use treatment.
Clinicians are increasingly urged to adopt tobacco use counseling guidelines, yet in contrast to the adult literature, there is a dearth of information on the impact of health provider advice to quit on cessation activity among adolescents. Surveying adolescents offers an important opportunity to study the association between provider advice to quit and cessation activity. Continued surveillance of dentist and physician adoption of treatment guidelines is also an essential mechanism for assessing the need for new methods to disseminate and implement such guidelines.
In 2000, the American Legacy Foundation and the Centers for Disease Control and Prevention conducted the second National Youth Tobacco Survey (NYTS), the largest cross-sectional survey of tobacco use behaviors in grades 6 to 12. The purpose of this study was to assess the tobacco use counseling practices of physicians and dentists as reported by this national sample of adolescents and to explore variations in screening and advice to quit with respect to demographics and smoking status. Finally, we analyzed the association between provider advice to quit on cessation activity in the past 12 months among adolescents who smoked in the past year.
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METHODS |
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Subjects and Data Collection
Results are based on data collected through the 2000 NYTS, an anonymous, self-administered, school-based questionnaire. This cross-sectional study was conducted to provide a national assessment of tobacco use behaviors among high school and middle school students. Human subjects approval for the study was obtained through Research Triangle Institute International Institutional Review Board. The NYTS used a 3-stage cluster sample design to produce a nationally representative sample of 35828 students in grades 6 to 12 in 324 schools. A detailed description of the sampling method is described elsewhere.28 To ensure separate analysis of black, Hispanic, and Asian students, schools with substantial proportions of these racial/ethnic groups were oversampled. Estimates and analyses were weighted to adjust for nonresponse and the probability of selection, including oversampling of minority students. The overall response rate was 84%.
Measures
Provider Practice Behavior
Youths were asked 2 questions in regard to receiving physician or dentist counseling about tobacco use: "Has a doctor or someone in a doctor's office talked to you about the danger of tobacco use in the past 12 months?" "Has a doctor or someone in a doctor's office advised you to stop using tobacco products in the past 12 months?" These questions were asked again for dentist visits. For the purpose of analyses, the first question is referred to as preventive counseling and the second is referred to as advice to quit.
Quit Attempts
Quit attempts were measured with 1 question: "During the past 12 months, how many times have you tried to quit smoking?" The response was treated as a dichotomous variable, defined as 0 quit attempts versus 1 or more quit attempts.
Smoking Status
Smoking status was determined with 2 questions: "When was the last time you smoked a cigarette, even 1 or 2 puffs?" "During the past 30 days, on how many days did you smoke cigarettes?" Current smokers were divided into 2 categories: established and nonestablished. Established current smokers were those who reported smoking 20 or more of the last 30 days. Nonestablished current smokers were those who smoked <20 of the last 30 days. Because information on provider counseling practices was obtained for visits that occurred within 1 year of the interview, we constructed 2 categories of former smokers: those who smoked within the past year but not the past 30 days and those who had not smoked in >1 year but reported smoking in the past 1 to 5 years. Never smokers reported not having ever smoked even 1 or 2 puffs.
Statistical Analysis
Analyses were limited to students who were between the ages of 11 and 18, provided valid data on the smoking status variables, and had visited a physician or a dentist within the past year (n = 24573). Descriptive statistics were used to generate frequencies on demographics, smoking behavior, and adolescent reports of the prevalence of physician and dentist counseling practices. Associations between adolescent demographics, smoking status, and physician and dentist counseling behavior were tested with the 
2 test.
Two multiple logistic regression models were analyzed to determine the independent predictors for receiving provider preventive counseling and provider advice to quit. Patient demographics (age, gender, and race) and smoking status were included in the models and used to adjust the odds ratios (ORs). Smoking status was measured as a series of indicator variables: established smokers (smoked 20 or more of the past 30 days), nonestablished current smokers (smoked <20 cigarettes within the past 30 days), former smokers (smoked within the past year but not the past 30 days), long-term former smokers (smoked >1 year ago), and never smokers.
The "prevention counseling" model included the full population of sampled students who visited a doctor or a dentist within the past year. This model compared the likelihood of receiving counseling among established, nonestablished, and former smokers with long-term former and never smokers. Long-term former smokers and never smokers are combined as the reference group because the analysis is conducted to assess an association between provider behavior and tobacco use behavior among youths who reported seeing a provider in the past year. Therefore, those who have not smoked in the past year and those who never smoked are considered comparable within the context of the research question.
The "advice to quit" model was limited to a sample subgroup of students who visited a provider and had smoked in the past 12 months. A third logistic regression model tested the independent effect of receiving quit advice from a physician or a dentist on quit attempts in the past 12 months, controlling for demographic characteristics (gender, race, and age). This model was also limited to the sample of students who visited a provider and had smoked in the past year. These last 2 models compared established and nonestablished smokers with former smokers. Data were analyzed using the survey procedures in Stata 8.0 that correct standard errors for NYTS's cluster sample design and weighting.29
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Sample Characteristics
Seventy percent of students between the ages of 11 and 18 visited a doctor and 71% visited a dentist in the past 12 months. Among this group, 51% were female and 49% were male. Demographic differences by smoking status are presented in Table 1. The majority (63.2%) of students in this sample were white, 15.8% were Hispanic, 14.0% were black, and 4.4% were Asian (Table 1). Fewer than 2% of respondents were American Indian/Alaska Native or Native Hawaiian/Pacific Islander. No information in the survey directly measured income.
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Smoking Behavior
Overall, 9.6% of respondents were established current smokers, 13.1% were nonestablished smokers, 14.4% were former smokers, 16.8% were long-term former smokers, and 46.1% reported never having smoked (Table 1). Current smoking status increased with age. Only 1% of 11- to 12-year-olds reported smoking 20 of the past 30 days compared with 20.3% of 17- to 18-year-olds. Ethnicity was significantly associated with smoking status. White students (11.8%) and American Indian/Alaskan Native adolescents (13%) had the highest established current smoking rates, and Hispanics (4.4%) had the lowest. For students in this sample who smoked in the past year, 59% reported at least 1 quit attempt during that period.
Adolescent Reports of Preventive Counseling by Dentists and Physicians
One third of NYTS respondents who visited either a physician or a dentist in the past year reported receiving preventive counseling from a physician and 20% reported receiving preventive counseling from a dentist. Table 2 presents the regression analyses findings on adolescent reports of preventive counseling by dentists and physicians. Reports of preventive counseling differed significantly by smoking status and ethnicity. All minority groups, with the exception of Asians, were more likely than whites to report receiving preventive counseling messages from their physician or dentist. Reports of receiving a preventive message from dentists but not physicians declined with age. Established current smoking (smoked 20 or more of the past 30 days) but not lesser degrees of smoking seemed to prompt preventive counseling messages from physicians and dentists. Established smokers were more likely than all other NYTS respondents to receive preventive counseling (OR: 1.81) from either a physician or a dentist. Nonestablished current smokers (students who smoked <20 of the past 30 days) were only slightly more likely than other smokers, with the exception of established smokers, to receive preventive counseling from physicians (OR: 1.12). Former smokers (smoked within the past year but not the past 30 days) were no more likely than never smokers or those who had not smoked in >1 year to receive prevention counseling.
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Adolescent Reports of Advice to Quit by Dentists and Physicians
Among adolescents who smoked in the past year, 16.4% reported receiving advice to quit from a physician and 11.6% reported receiving advice to quit from a dentist. Smoking intensity was significantly associated with receiving quit advice. Among adolescents who were defined as established current smokers, 29.7% received advice to quit from a physician compared with 13.2% for nonestablished current smokers and 9.4% for smokers who had not smoked in the past 30 days. In the regression analysis presented in Table 3, smoking status and ethnicity remained significant predictors of receiving advice to quit from a dentist or a physician. Black and Hispanic adolescents were more likely to receive advice to quit from either dentists or physicians (P < .001) as compared with white youths, but there were no significant differences in receiving advice to quit between whites and other ethnic groups. Female students were more likely to report receiving advice to quit from physicians than male students (P < .001), as were older adolescents, but age and gender were not correlated with receiving advice to quit from a dentist.
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Current smokers, whether established or nonestablished, were significantly more likely to have received advice to quit when visiting a physician or a dentist than individuals who had smoked in the past year but not in the past 30 days (P < .01). Nonetheless, established smokers were much more likely than the less frequent current smoker to receive such advice.
Quit Attempts and Health Care Provider Advice
Table 4 represents the regression analysis of quit attempts among adolescents who smoked in the past year. Physician or dentist advice to quit in the past 12 months was positively related to 1 or more quit attempts during that period after controlling for demographic variables. The adjusted OR for at least 1 quit attempt among adolescents who smoked in the past year was 1.88 when they received advice from a physician (P < .001) and 1.25 with advice from a dentist (P < .05). Quit attempts were also related to respondent demographic characteristics. Asians were 50% more likely than whites to attempt to quit (P < .05), whereas Hispanics were 25% less likely to quit compared with white youths (P < .001). There were no significant differences between white teens and those of other ethnicities in terms of quit attempts. Girls were significantly more likely to make a quit attempt than boys (P < .001).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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This study analyzed data from a nationally representative sample of adolescents to assess how frequently physicians and dentists address tobacco use in practice and the association between provider advice to quit and cessation activity among adolescent smokers. More than 70% of adolescents visited a physician's or a dentist's office within the past year, yet only 33% of this group reported receiving preventive counseling from a physician and 20% from a dentist. In addition, clinicians were more likely to provide information about the risks of smoking than to counsel those who already smoke. Among students who smoked in the past year, only 16.4% reported receiving advice to quit from a physician and 11.6% reported receiving advice to quit from a dentist.
These counseling rates were well below recommended guidelines and considerably lower than data based on clinician reports but similar to other adolescent reports of clinician counseling.18,20,22,23,27 Poor teen recall of counseling messages may explain the discrepancy between clinician and patient reports. However, there is evidence to indicate that adolescent reports are a valid method of determining the content of preventive health services and may be more reliable than clinician reports.10,30
Not surprising, we also observed differences between reported rates of preventive counseling and advice to quit. Surveys of a wide range of providers (pediatricians, internists, dentists, and family physicians) demonstrate a pattern of decreasing compliance with tobacco treatment guidelines as providers move across the 5 A's from asking about tobacco use to arranging follow-up.18,19,31 In a study of providers in New York City, 91% reported asking adolescents about tobacco use, 77% discussed the health risks, but only 34% helped current smokers set a quit date and 28% arranged for follow-up.19
Although both preventive and cessation counseling rates were low overall, particularly among dentists, 2 factors predicted greater receipt of tobacco use treatment: ethnicity and smoking status. Nonwhite adolescents, except for Asians, were significantly more likely than white teens to report receiving preventive messages from both physicians and dentists, and black and Hispanic teens who smoked in the past year were more likely to receive advice to quit than white teens. These findings are in contrast to previous studies that documented lower counseling rates among minorities.7,15,20 However, most studies that included measures of ethnicity analyzed tobacco use treatment among adult smokers. This is the first study to report findings on provider tobacco use treatment practice patterns among Asian, Native Hawaiian/Pacific Islander, and American Indian/Alaskan Native teens.
Smoking status and intensity were strongly associated with the provision of preventive counseling and advice to quit by both doctors and dentists. Adolescents who smoked 20 or more of the past 30 days (established current smokers) were 1.8 times more likely to receive physician preventive counseling than former and never smokers and 4.6 times more likely to receive quit advice than teens who had smoked in the past year but not in the past 30 days. Other studies have also found that, among teens, providers consistently intervene at higher rates among current smokers and those who smoke more frequently.7,23
Although providers are more apt to intervene with habitual or established smokers, this study found that >80% of students who visited a provider and who smoked 20 or more of the past 30 days did not receive advice to quit from either a physician or a dentist. These data underscore the gap between provider practice and adolescent health needs as they relate to tobacco use and are particularly concerning given that most adolescent smokers in the survey were interested in quitting. Fifty-nine percent of current smokers reported at least 1 quit attempt in the past year. Furthermore, advice to quit from either a dentist or a physician was associated with at least 1 quit attempt in the past 12 months. Teens who received advice to quit from a physician were almost 90% more likely to make at least 1 quit attempt compared with teens who did not receive this advice.
In summary, we found low rates of adherence to tobacco use treatment guidelines promulgated by both medical and dental organizations and a tendency to intervene with heavier established smokers rather than infrequent or nonsmokers. More promising is the finding that brief provider advice was associated with increased quit attempts. The latter lends support for the potential benefit of brief provider tobacco use counseling to affect adolescent smoking behavior but should be interpreted with caution. Because the NYTS is a cross-sectional survey, it is not possible to draw conclusions regarding the causal association of provider advice to quit and quit attempts. Quit attempts may have been a motivation for discussing tobacco use with providers rather than a consequence of provider advice to quit. The results still provoke challenging questions. For example, how meaningful are quit attempts in predicting future abstinence? In adults, a history of quit attempts predicts smoking cessation, but there are no comparable data among youths.32 Does provider reliance on smoking intensity as a cue to action represent a missed opportunity? In other words, is intervening with youths to stop experimental smoking more effective than targeting regular smokers? Finally, a more difficult question to contemplate: are providers the most effective messengers for the prevention and treatment of tobacco use among adolescents?
To date, the evidence for or against the efficacy of the USPHS tobacco use treatment guidelines in the adolescent health care setting is lacking. Only 2 studies have found significant quit rates as a result of a provider-delivered brief intervention, and both were conducted in dental clinic settings.33,34 Longitudinal studies are needed to confirm our findings and extend them to include cessation as the outcome of interest. Currently, several adolescent smoking cessation trials, funded by the National Cancer Institute and other agencies, are under way and will contribute to the evidence on which to base treatment.16,35
There are some additional limitations to our analysis. The analysis relies on self-reports rather than chemically validated responses. However, results that are based on self-reported data are considered valid in large-scale studies in instances in which recall is restricted to <1 year and when anonymity is ensured.20,36–38 This survey met these criteria. In addition, the NYTS does not address the full spectrum of the USPHS guidelines. Adolescents reported only on whether they received advice to quit and preventive counseling. We are also unable to comment on the content of counseling. Finally, several variables that may predict cessation activity, such as level of addiction, depression, and intention to quit, were not included in the quit attempt regression model. The NYTS did not include an addiction scale, depression scale, or questions to assist in analyzing stage of change. Moreover, although these variables have predictive value among adults, it is not clear that they are relevant to adolescent quit attempts.32,39
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CONCLUSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Physicians and dentists have multiple opportunities to intervene on the issue of tobacco use among children and adolescents. Moreover, clinical settings that are youth focused are organized around prevention and health education. This orientation supports the integration of tobacco use prevention and cessation and may predict greater adherence to guidelines if combined with appropriate provider training. Calls to increase adoption of guidelines, however, must be tempered with the candid recognition that our knowledge is limited regarding the efficacy of prevention and cessation interventions in adolescent health care settings. In both cases, the impact of physician or dentist counseling must be demonstrated convincingly.
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FOOTNOTES |
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Accepted Jul 28, 2004.
Reprint requests to (D.S.) Columbia University Mailman School of Public Health, 722 W 168th St, 11th Floor, New York, NY 10032. E-mail: drs26{at}columbia.edu
No conflict of interest declared.
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