In this issue of Pediatrics, Schauer et al1 from the Centers for Disease Control and Prevention’s Office on Smoking and Health report on data from the 2011 Youth Tobacco Survey, a nationally representative sample of >18 000 6th- through 12th-grade students. They examined tobacco use and tobacco control measures, the rate of smoking, and the likelihood of being asked about smoking and being advised to quit or assisted with quitting by a clinician.
This year marks the 50th anniversary of the first Surgeon General’s report on tobacco.2 In these 5 decades, the evidence base for the harms caused by tobacco and for the opportunity for clinicians to prevent initiation and to promote smoking cessation have continued to grow stronger. As has been seen in other youth surveys, >90% of the adolescents in this survey reported having seen a clinician in the past year. Nonetheless, rates of discussing tobacco remain relatively low, despite clear evidence for the harms of tobacco use and increasingly strong recommendations for routine counseling for prevention and cessation.
These findings are critically important for child and adolescent health care delivery and should challenge both researchers and clinicians. The 4As (Ask, Advise, Assess, Arrange) tobacco cessation counseling guidelines have existed for decades; and specific pediatric and adolescent guidelines, adding the fifth A (Anticipate) for anticipatory guidance, date to 1991.3 The adolescents surveyed have health care encounters, as is true for most teens and even most young adults,4 and adolescents are highly accurate in reporting the care they have received from their clinician.5 But the majority of adolescents’ health care encounters and clinical visits did not include discussion or interventions into the leading preventable cause of disease and death. Although the prevalence of being asked and advised about smoking was highest among youth who were smokers, these numbers, too, were low, reaching barely half of smokers with counseling interventions.
Many of the interventions needed to protect children, youth, and nonsmokers from tobacco require policy changes, rather than clinical interventions. Nonetheless, these findings are an important reminder that clinical interventions are also needed and that fully implementing strongly recommended evidence-based guidelines remains a difficult goal. It is important to recognize that this problem is not unique to pediatric care or to adolescents. For example, among adults who saw a physician or other clinician in the past year, only 66.7% of smokers were counseled to quit, 23.2% of respondents were asked about secondhand smoke exposure, and only 17.3% were advised to keep their homes smoke-free.6
Without more vigorous action to achieve universal screening and counseling, effective cessation delivery and eventual elimination of tobacco and nicotine addiction remain an elusive goal. These rates of adolescent tobacco prevention and cessation counseling in primary and specialty care settings are a painful reminder of how slow our health care system is to adopt even highly effective, low-cost, lifesaving interventions. Numerous tools exist to help clinicians implement tobacco cessation counseling and to ask the right questions in their practices (see www.aap.org/richmondcenter). However, additional new investments and efforts to implement clinical practice change are urgently needed. Our society and our patients cannot afford another 50 years of premature death and disease from tobacco.
- Accepted June 25, 2014.
- Address correspondence to Jonathan D. Klein, MD, MPH, FAAP, Julius B. Richmond Center, American Academy of Pediatrics, Elk Grove Village, IL 60007. E-mail:
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.
FUNDING: Dr Klein’s work on tobacco and secondhand smoke is supported in part by a Center of Excellence Grant from the Flight Attendant Medical Research Institute and by the Legacy Foundation.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found on page 446, and online at www.pediatrics.org/cgi/doi/10.1542/peds.2014-0458.
- Schauer GL,
- Agaku IT,
- King BA,
- Malarcher AM
- 2.↵US Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014
- Epps RP,
- Manley MW
- Ziv A,
- Boulet JR,
- Slap GB
- Copyright © 2014 by the American Academy of Pediatrics