Note: This draft Recommendation Statement is not the final recommendation of the U.S. Preventive Services Task Force. This draft is distributed solely for the purpose of pre-release review. It has not been disseminated otherwise by AHRQ. It does not represent and should not be interpreted to represent an AHRQ determination or policy.
This draft Recommendation Statement is based on an evidence review that was published on December 11, 2012 (available at http://www.uspreventiveservicestaskforce.org/uspstf12/tobacco/tobchprevart.htm).
The USPSTF makes recommendations about the effectiveness of specific clinical preventive services for patients without related signs or symptoms.
It bases its recommendations on the evidence of both the benefits and harms of the service, and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.
The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decisionmaking to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.
This draft Recommendation Statement was available for comment from December 11, 2012 until January 7, 2013, at 5:00 PM ET. A fact sheet that explains the draft recommendations in plain language is available here.
Interventions to Prevent Tobacco Use in Children and Adolescents: U.S. Preventive Services Task Force Recommendation Statement
Summary of Recommendation and Evidence
The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among school-aged children and adolescents (see the Clinical Considerations for more information on effective interventions).
This is a grade B recommendation.
Tobacco use is the leading cause of preventable death in the United States. An estimated 443,000 deaths occur annually that are attributable to smoking, including nearly 161,000 deaths from cancer, 128,000 from cardiovascular diseases, and 103,000 from respiratory diseases. Smoking costs the United States approximately $96 billion each year in direct medical costs and $97 billion from productivity losses due to premature death (1).
Recognition of Behavior
An individual's path to daily smoking and nicotine dependence has been described in five stages:
- Susceptible to smoking (never smoked)
- Initiation (trying the first cigarette)
- Experimentation (repeatedly trying cigarettes, may show signs of addiction)
- Established smoking (regular smoking, likely to show signs of addiction)
- Nicotine dependence
Children as young as age 10 years may be susceptible to smoking. It can take up to 2 years to progress from early experimentation to addiction, although some children and adolescents progress more rapidly to nicotine dependence (2).
Effectiveness of Interventions to Change Behavior
The USPSTF found adequate evidence that behavioral counseling interventions such as face-to-face or phone interaction with a health care provider, print materials, and computer applications can reduce the risk of smoking initiation among school-aged children and adolescents.
Harms of Interventions
None of the trials of behavioral interventions to prevent tobacco use reported on harms. The USPSTF judged the magnitude of these harms to be small to none.
The USPSTF concludes with moderate certainty that behavioral interventions in primary care for tobacco use prevention in school-aged children and adolescents has a moderate net benefit.
Patient Population Under Consideration
This recommendation applies to school-aged children and adolescents. The USPSTF has issued a separate recommendation statement about tobacco use counseling in adults and pregnant women.
Assessment of Risk
In 2009, 8.2% of middle school students and 23.9% of high school students reported current use of any tobacco product (3). Overall prevalence of smoking is higher among high school males (29.8%) than females (21.8%) (4). One of the strongest factors associated with smoking initiation among children and adolescents is parental smoking and nicotine dependence. Other factors associated with smoking initiation include: low parental monitoring; easy access to cigarettes; perception that peers smoke; and exposure to tobacco promotions.
Tobacco Use Prevention Interventions
There is substantial variation in the type and intensity of effective behavioral interventions examined in the evidence review, ranging from no interaction with a health care professional to seven group sessions totaling over 15 hours (1). In one intervention, families received a packet with materials for parents and children and a 28-minute video with a viewing guide. The families received one counseling call 3 to 6 weeks after receiving the written materials and another 14 months after enrollment. Another intervention consisted of creating a tobacco-free office and giving patients a series of antitobacco messages on preprinted “prescription” forms. The most intensive intervention focused on universal substance abuse and problem behavior prevention for families. In this intervention, the teen and at least one parent participated in seven group and family sessions over 7 weeks (each session lasting 2 to 2.5 hours) and received workbooks with activities to complete at home.
Even very minimal interventions, such as mailing print materials to a youth's home, had significant effects on smoking initiation. One intervention mailed tailored newsletters addressed to the student every 3 weeks; another intervention sent age-related materials four times over 12 months. In a third intervention, participants were mailed five core activity guides with newsletters and tip sheets approximately every 2 weeks, with one booster guide at 1 year (1).
Many of the interventions featured similar content areas, such as: the participant's attitudes, beliefs, and knowledge about smoking; the consequences of smoking; the influence of the social environment, including tobacco marketing; and skills to refuse cigarettes. Several included parents' attitudes, beliefs about smoking, and parent-child communication.
Tobacco Cessation Interventions
The evidence is limited on the effectiveness of cessation interventions delivered in primary care settings to school-aged children and adolescents who have experimented with smoking or who are regular smokers. The USPSTF examined the evidence on behavioral interventions to promote cessation of smoking in children and adolescents who were classified as smokers (1). There are few studies that target regular, established smokers or stratify findings by length or amount of smoking (e.g., experimenter vs. established smoker). A pooled meta-analysis of seven trials including 2,328 children and adolescents that examined interventions to promote smoking cessation found a small but not statistically significant effect at 6- to 12-months followup favoring the intervention (risk ratio [RR], 0.96 [95 CI%, 0.90 to 1.02]) (1).
While the available evidence on the effectiveness of primary care relevant interventions in reducing smoking in children and adolescents is limited, there is evidence from other literature that school-based and community-based behavioral counseling programs are effective in promoting smoking cessation among adolescent smokers. In a meta-analysis of 64 trials, 40 of which were based in schools, Sussman and Sun found a 4% difference in quitting smoking among the intervention group compared with the control group (11.8% vs. 7.5%, respectively) (5). A longitudinal evaluation of 41 community-based programs reported biochemically validated quit rates comparable to those in randomized trials (averaging 14% at the end of the program and 12% at 12-month followup) (6). The Community Preventive Services Task Force recommends mobile phone-based interventions for tobacco cessation, based on sufficient evidence of effectiveness in increasing tobacco use abstinence among people interested in quitting, as well as communitywide, proactive telephone support (proactive followup) combined with patient education materials, based on strong evidence of effectiveness that this combined intervention increases patient tobacco cessation and is effective in both clinical settings and when implemented communitywide. However, the task force noted that the evidence is limited on the effectiveness of both of these interventions for school-aged children and adolescents (7). Primary care providers should refer children and adolescents who smoke to these programs.
Another potential cessation treatment option for children and adolescents who smoke is medication. However, there are currently no medications approved by the U.S. Food and Drug Administration for tobacco cessation in children and adolescents. Two studies that featured behavioral interventions plus medication (i.e., buproprion sustained-release alone or as an adjunct to nicotine replacement therapy) showed no statistically significant benefit from the medication (1).
There is no vidence available on complementary and alternative medicine, such as acupuncture, for smoking cessation treatment in children and adolescents (1).
Other Approaches to Prevention and Cessation
Current noncounseling recommendations of the Community Preventive Services Task Force that apply to school-aged children and adolescents (7) include:
- Interventions that increase the price of tobacco products, based on strong evidence of their effectiveness in reducing tobacco use among adolescents and adults, reducing population consumption of tobacco products, and increasing tobacco use cessation.
- Mass media campaigns, based on strong evidence of their effectiveness in reducing tobacco use among adolescents when implemented in combination with tobacco price increases, school-based education, and other community education programs.
- Community mobilization combined with additional interventions—such as stronger local laws directed at retailers, active enforcement of retailer sales laws, and retailer education with reinforcement—on the basis of sufficient evidence of effectiveness in reducing youth tobacco use and access to tobacco products from commercial sources.
The Community Preventive Services Task Force also recommends provider reminder systems based on sufficient evidence of effectiveness in increasing provider delivery of advice to quit. Provider reminder systems are recommended whether they are used alone or as part of a multicomponent intervention, across a range of intervention characteristics (e.g., chart stickers, checklists, and flowcharts) and in a variety of clinical settings and populations.
Related USPSTF Recommendations
The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products (grade A). In addition, the USPSTF recommends that clinicians ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke (grade A) (8).
Research Needs and Gaps
There are few rigorous trials that examine the effectiveness of primary care relevant interventions—behavior, medication, or complementary medicine—to prevent the use of tobacco or to promote the cessation of tobacco use in youth. More good-quality trials are needed that:
- Replicate promising interventions
- Examine the effectiveness of specific intervention components and determine the feasibility of specific components in real-world primary care practice
- Incorporate longer-term outcomes
- Include other forms of tobacco use than cigarettes (e.g., smokeless tobacco)
- Include more diverse samples of children and adolescents with regard to demographic characteristics, various stages of initiation, and/or readiness to quit
For this population in particular, additional studies are needed to improve understanding of the effectiveness of clinicians' referral to tailored, computer-based or electronic media channels that deliver messages about remaining abstinent or quitting smoking.
There are also methodological issues related to tobacco prevention and cessation that merit additional research. These include a child or adolescent's path to daily smoking and/or nicotine dependence, the reliability and validity of self-reported measures, and the use of biochemical verification in children and adolescents.
Burden of Disease
Although purchasing tobacco products before the age of 18 years is illegal in the United States, 90% of American adults who have ever smoked on a daily basis reported that they smoked their first cigarette by the age of 18. Each day, over 3,800 children and adolescents between the ages of 12 and 17 years smoke their first cigarette, and an estimated 1,000 persons younger than age 18 years begin smoking on a daily basis (1). While most of the serious health effects from smoking occur in adulthood, children and adolescents can experience negative respiratory effects, including impaired lung growth, early onset of lung function decline, and respiratory- and asthma-related symptoms such as coughing and wheezing.
Scope of Review
The current USPSTF review focused on the effectiveness of primary care interventions on the rates of initiation or cessation of tobacco use in children and adolescents and on health outcomes such as respiratory health, dental/oral health, and adult smoking. Interventions were included that targeted children, adolescents, or their parents; were delivered individually or in small groups in a health care or comparable setting; had control groups that offered minimal or no treatment; and reported tobacco use prevalence or a comparable outcome at least 6 months after the baseline assessment.
The review also examined the potential harms of these interventions. Although the review was designed to examine all forms of tobacco use, all of the trials that were included focused primarily or exclusively on cigarette smoking (1).
Effectiveness of Interventions to Change Behavior
The USPSTF found no direct evidence of the effectiveness of primary care relevant interventions to prevent initiation of tobacco use that assessed health outcomes in children and adolescents or that examined subsequent rates of adult smoking. However, the USPSTF found 10 mostly fair-quality trials that included a behavior-based intervention to prevent initiation of smoking in children and adolescents (1). Six of these trials focused exclusively on prevention of smoking; four trials combined prevention and cessation of smoking and reported results separately for nonsmokers and smokers. Two studies were conducted outside of the United States.
There was large variation in the type and intensity of the interventions. Two of the studies were conducted in a primary care setting and two were conducted in a dental setting. Six studies used primarily home-based interventions, including mailed print materials and/or followup phone counseling. Interaction with a health provider ranged from zero to more than 15 hours. The highest-intensity trial was the only one to include group sessions and to target multiple behaviors. Six of the 10 studies targeted youth directly, three included components for both youth and their parents, and one primarily targeted parents.
The primary outcome in all the studies, smoking initiation, was based on self report. However, there was considerable variation in how the trials defined smoking status at baseline and posttest. For example, three studies examined the percentage of baseline nonsmokers, defined as not ever smoking, not even one puff, reporting ever smoking (even one puff) in 30 days posttest. One study looked at the percentage of baseline nonusers, defined by 30-day tobacco use or having ever used tobacco more than 100 times, reporting tobacco use in the past 30 days at posttest. One study reported on the percentage of baseline nonsmokers (no smoking in past 30 days) reporting smoking one or more cigarettes in the past 30 days at posttest. Several studies did not report specific measures but reported on the number of children or adolescents starting to smoke at posttest.
Because of the intermittent nature of smoking in children and adolescents, biochemical tests are not useful in substantiating self-reported smoking status. None of the studies used biochemical measures to confirm the self-reported measures.
Results from a pooled meta-analysis of nine of the 10 trials (one trial did not present adequate data and was excluded from the meta-analysis) including 26,624 children and adolescents that examined smoking initiation among baseline nonsmokers showed a statistically significant reduction in risk among youth who received the intervention at 6- to 36-months followup compared with the control (RR, 0.81 [95% CI, 0.70 to 0.93]). The behavior-based interventions reduced the absolute risk of smoking initiation at followup by 2%, resulting in a number needed to treat of 50 (1).
Potential Harms of Interventions
None of the trials reported directly on harms from the intervention. A potential harm of the intervention is the initiation of smoking. Some trials reported higher absolute prevalence of smoking in the intervention group compared with the control at followup. However, no trials reported a statistically significant difference between the groups (1).
Estimate of Magnitude of Net Benefit
The USPSTF found adequate evidence that individual behavior-based interventions, and combinations of such interventions, in primary care can reduce the risk of smoking initiation among school-aged children and adolescents. While it found no evidence on harms of behavior-based interventions, it judged the potential harms to be small to none. The USPSTF concluded with moderate certainty that the net benefit of behavior-based interventions to prevent smoking in children and adolescents is at least moderate.
Update of the Previous USPSTF Recommendation
In 2003, the USPSTF issued an I statement, concluding that the evidence was insufficient to recommend for or against routine screening for tobacco use or interventions to prevent and treat tobacco use and dependence among children or adolescents (9). The USPSTF based its recommendation on the Public Health Service's (PHS') 2000 clinical practice guideline on treating tobacco use and dependence. The PHS guideline focused on tobacco use treatment and limited its review on the effectiveness of tobacco use interventions for adolescent smokers. In this update, the USPSTF examined the benefits and harms of primary care relevant interventions for tobacco use prevention or cessation in children and adolescents. However, the USPSTF emphasizes the evidence on interventions to prevent tobacco initiation among children and adolescents.
Recommendations of Others
The 2008 PHS “Treating Tobacco Use and Dependence: Clinical Practice Guideline” (10) recommends that:
- Clinicians ask pediatric and adolescent patients about tobacco use and provide a strong message regarding the importance of totally abstaining from tobacco use.
- Clinicians provide counseling interventions for adolescent smokers to aid them in quitting smoking.
- Clinicians ask parents about tobacco use and offer them cessation advice and assistance to protect children from secondhand smoke.
In 2009, the American Academy of Pediatrics (AAP) recommended that all pediatricians counsel patients as young as age 5 years against initiating tobacco use and provide counseling on tobacco cessation. AAP also recommended that pediatricians advise all families to make their homes and cars smokefree (11).
Table 1: What the Grades Mean and Suggestions for Practice
Table 2: Levels of Certainty Regarding Net Benefit
|Level of Certainty*||Description|
|High||The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies.|
|Moderate||The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by factors such as:
As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion.
|Low||The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of:
More information may allow an estimation of effects on health outcomes.
*The U.S. Preventive Services Task Force defines certainty as "likelihood that the USPSTF assessment of the net benefit of a preventive service is correct." The net benefit is defined as benefit minus harm of the preventive service as implemented in a general, primary care population. The USPSTF assigns a certainty level based on the nature of the overall evidence available to assess the net benefit of a preventive service.
1. Patnode CD, O'Connor E, Whitlock EP, Perdue LA, Soh C. Primary Care Relevant Interventions for Tobacco Use Prevention and Cessation in Children and Adolescents: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 97. AHRQ Publication No. 12-05175-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; December 2012.
2. DiFranza JR, Wellman RJ, Mermelstein R, Pbert L, Klein JD, Sargent JD, et al. The natural history and diagnosis of nicotine addiction. Curr Pediatr Rev. 2011;7(2):88-96.
3. Centers for Disease Control and Prevention. Tobacco use among middle and high school students—United States, 2000–2009. MMWR Morb Mortal Wkly Rep. 2010;59(33):1063-8.
4. Eaton DK, Kann L, Kinchen S, Shanklin S, Ross J, Hawkins J, et al; Centers for Disease Control and Prevention. Youth risk behavior surveillance—United States, 2009. MMWR Surveill Summ. 2010;59(5):1-142.
5. Sussman S, Sun P. Youth tobacco use cessation: 2008 update. Tob Induc Dis. 2009;5:3.
6. Curry SJ, Mermelstein RJ, Emery SL, Sporer AK, Berbaum ML, Campbell RT, et al. A national evaluation of community-based youth cessation programs: end of program and twelve-month outcomes. Am J Community Psychol. 2012; Mar 1. [Epub ahead of print]
7. Community Preventive Services Task Force. Reducing Tobacco Use and Secondhand Smoke Exposure. Atlanta: Community Preventive Services Task Force; 2012. Accessed at http://www.thecommunityguide.org/tobacco/index.html on 3 December 2012.
8. U.S. Preventive Services Task Force. Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women: U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med. 2009;150(8):551-5.
9. U.S. Preventive Services Task Force. Counseling to Prevent Tobacco Use and Tobacco-Caused Disease: Recommendation Statement. Rockville, MD: Agency for Healthcare Research and Quality; 2003. Accessed at http://www.uspreventiveservicestaskforce.org/3rduspstf/tobacccoun/tobcounrs.htm on 3 December 2012.
10. Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff. A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report. Am J Prev Med. 2008;35(2):158-76.
11. Committee on Environmental Health; Committee on Substance Abuse; Committee on Adolescence; Committee on Native American Child. From the American Academy of Pediatrics: policy statement—tobacco use: a pediatric disease. Pediatrics. 2009;124(5):1474-87
AHRQ Publication No. 12-05175-EF-2
Current as of January 2013
U.S. Preventive Services Task Force. Interventions to Prevent Tobacco Use in Children and Adolescents: Draft Recommendation Statement. AHRQ Publication No. 12-05174-EF-2. http://www.uspreventiveservicestaskforce.org/uspstf12/tobacco/tbacdraftrec.htm