State-of-the-art office-based interventions to eliminate youth tobacco use: the past decade

Impact of a Multidisciplinary Curriculum Training Students and Residents in Tobacco Cessation Strategies for Adult Caregivers of Children

Introduction

Children's exposure to secondhand smoke is an underaddressed public health threat. The Clinical Effort Against Secondhand Smoke Exposure (CEASE) is a validated framework that trains pediatric providers to screen, counsel, refer to quitlines, and prescribe tobacco cessation medications to adult caregivers of children.

Methods

A physician champion at a major urban academic center delivered a longitudinal didactic curriculum of CEASE principles to medical and nurse practitioner students and pediatrics and family medicine residents. At the end of each session, participants completed an anonymous survey measuring changes in self-perceived knowledge, comfort, and familiarity with smoking cessation skills and concepts. Using a separate end-of-year questionnaire, we also surveyed a group of pediatric residents to compare the impact of CEASE training on clinical practice. Finally, we tracked the number of referrals to the state's quitline for the duration of the training.

Results

Fifty-two trainees (55% students, 45% residents) responded to the evaluation survey administered immediately following training. There were statistically significant improvements in median scores after CEASE training for comfort in screening, counseling, motivational interviewing, referring to smokers' helplines, and providing caregivers with nicotine replacement therapy (NRT) prescriptions. Fifty-one percent of pediatric residents (41 of 80) responded to the end-of-year survey, which showed statistically significant differences in the number of patients/caregivers offered a referral to California's quitline and prescription of NRT according to completion of CEASE training.

Discussion

CEASE training successfully improved the self-efficacy of health professions students and residents in smoking cessation techniques for adult caregivers of children.

Identifying high school smokers likely to persist in smoking at age 31

OBJECTIVE

Quitting smoking by the mid-30 s conveys important health benefits. Yet, although many smokers attempt to quit, few succeed. Identification of the characteristics of adolescent smokers most likely to continue smoking between ages 30 and 40 could help target early cessation efforts. Our objectives in this study were to (i) describe the course of smoking in a population-based sample of high school smokers into their 20 s and 30 s, and (ii) identify distal predictors of past-year cigarette smoking at age 31.

METHODS

Data at ages 17 (in 11th grade), 20, 24 and 31 were drawn from a 20-year longitudinal study of students ages 12-13 at inception, from 10 high schools in Montréal, Canada. Associations between 11 smoking-related characteristics measured in 11th grade and past-year smoking at age 31 were estimated in multivariable logistic regression models.

RESULTS

Among 244 11th grade smokers (67.4% female; 41% daily smokers), past-year smoking was reported by 71% at age 20, 68% at age 24, and 52% at age 31. Only 12% reported abstinence at ages 20, 24 and 31. Females were less likely than males to smoke at age 31. Parental smoking while the smoker was in 11th grade, use of other tobacco products, longer time since smoking onset, weekly or daily smoking, monthly cigarette consumption, and perceived nicotine addiction predicted past-year smoking at age 31.

CONCLUSIONS

In addition to preventive interventions, cessation programs targeting novice smokers in high school as soon as they begin smoking, are warranted.

e-Cigarettes Used by Adolescents to Try to Quit Smoking Are Associated With Less Quitting: A Cross-Sectional Analysis of the National Youth Tobacco Survey

PURPOSE

This paper determines the association between youth e-cigarette use "to try to quit using other tobacco products, such as cigarettes" and having stopped smoking cigarettes (defined as an ever cigarette smoker who did not smoke in the past 30 days).

METHODS

This study uses data from the NYTS from 2015 through 2021, focusing on youth who started smoking cigarettes before they started using e-cigarettes. Associations between using e-cigarettes to quit and having stopped smoking were computed using logistic regression accounting for the complex survey design and adjusting for level of nicotine dependence, year, age, gender, and race/ethnicity. Sensitivity analyses allowed for having started cigarettes and e-cigarettes in the same year and without regard for starting sequence.

RESULTS

The primary analytic subsample included 6435 United States middle and high school students (mean age 15.9 years, 55.4% male). Using e-cigarettes to quit was associated with significantly lower odds of having stopped smoking cigarettes (odds ratio, 0.62; 95% confidence interval, 0.45-0.85), controlling for nicotine dependence and demographics. Youth with higher levels of nicotine dependence also had lower odds of having stopped smoking. The results were stable over time. Sensitivity analyses produced similar results.

DISCUSSION

Ever-smoking youth who used e-cigarettes "to try to quit using other tobacco products, such as cigarettes" had lower odds of having stopped smoking cigarettes than those who did not use e-cigarettes as to try to quit. Physicians, regulators, and educators should discourage youth from attempting to use e-cigarettes as a way to stop smoking cigarettes.

Impacts of a Multicenter Medical Education Curriculum for Training Pediatric Residents on Tobacco Cessation for Adult Caregivers of Pediatric Patients

The Clinical Effort Against Secondhand Smoke Exposure (CEASE) is an evidence-based framework that increases pediatric providers' ability to address secondhand smoke exposure of minors. Physician champions at 4 University of California sites conducted regular 1-hour didactic trainings on CEASE principles to pediatric residents as part of a longitudinal curriculum. At the conclusion of the academic year, 111 of 284 residents (39%) completed an anonymous survey. CEASE-trained residents reported significantly higher rates than untrained residents of counseling on smoking cessation (adjusted odds ratio [OR] = 4.50, P = .009), and referring to the smokers' quitline (adjusted OR 3.6, P = .007) to 50% or more of their patients' caregivers who smoked. In addition, among CEASE-trained residents, there were significant increases in multiple post-training knowledge and self-efficacy items. Our results show that a brief educational curriculum can be helpful in changing pediatric residents' attitudes and behavior toward assisting adult caregivers to pediatric patients in smoking cessation.

Health Care Professionals' Clinical Skills to Address Vaping and e-Cigarette Use by Patients: Needs and Interest Questionnaire Study

BACKGROUND

Widespread vaping and e-cigarette use is a relatively new phenomenon. Youth vaping peaked in 2019, with over 25% of high school students currently vaping. e-Cigarettes are used where smoking is not permitted or as an alternative smoking cessation treatment instead of Food and Drug Administration-approved options. Vaping and e-cigarette use has the potential to harm health, including causing adverse respiratory effects and nicotine addiction. Health care professionals need skills training to help their patients with this relatively new and evolving health problem.

OBJECTIVE

The aim of this study is to understand health care professionals' training needs in this subject area to determine the focus for web-based continuing education training.

METHODS

We reviewed the literature on clinical aspects of vaping and e-cigarette use. Using the results and our experience in substance use continuing education, we created a list of key clinical skills and surveyed health care professionals about their training needs. We also asked about their interest in a list of related topics. We recruited individuals who completed our web-based courses on substance use, members of health care professional-related groups, and experts who had published an article on the subject. Half of the 31 health care professionals who completed the survey were physicians and the remainder were primarily nurses, social workers, and counselors. Participants self-identified as nonexperts (n=25) and experts (n=6) on vaping.

RESULTS

Participants who were nonexperts on average agreed or strongly agreed that they needed training in each of 8 clinical skills (n=25; range 3.7-4.4 agreement out of 5). The top two skills were recommending treatments for patients (4.4 out of 5, SD 0.49) and evaluating and treating the health effects of vaping and e-cigarette use (4.4 out of 5, SD 0.50). Experts agreed on the importance of training for health care professionals in all skills but rated the need for training higher than nonexperts for each topic. Over half of the participating health care professionals (44%-80%) were interested in nearly all (9/10, 90%) vaping-related topics on a checklist. The topics participants were most interested in were the pros and cons of vaping versus smoking and the health effects of second- and third-hand vaping. Primary care physicians showed more interest in vaping-related topics than nonprimary care physicians (t13=2.17; P=.02).

CONCLUSIONS

This study confirmed gaps in health care professionals' vaping-related clinical skills identified in the literature by identifying a perceived need for training in related skills and health care professionals' interest in key topics related to vaping prevention and cessation. This study provides specific guidance on which clinical skills training is most needed and which topics are most interesting to health care professionals.

Electronic cigarette knowledge, attitudes and use among students at a university in Hangzhou, China

INTRODUCTION

Electronic cigarettes are increasingly popular worldwide, especially among youth. There is growing evidence of the negative health consequences of vaping. Our objective was to assess university students’ knowledge and attitudes regarding electronic cigarettes (e-cigarettes), their use, as well as the associated influencing factors for their use.

METHODS

The study involved an online cross-sectional survey conducted between November 2019 and March 2020 in a university in Hangzhou, China. A total of 563 students completed the questionnaire. Descriptive statistics were used to assess characteristics, knowledge, and attitudes; t-tests, χ²-tests and logistic regression models were used to identify factors associated with ever e-cigarette use.

RESULTS

In all, 59.9% of respondents were female and the average age was 20.38 years (SD=1.32). Only 42.6% of the respondents thought that e-cigarettes contain nicotine, 31.1% thought e-cigarettes are tobacco products, and 8.2% of the students reported being ever e-cigarettes users. In regard to attitude, the average score of the students in the Safety dimension was 3.34 (SD=0.64), followed by the Restriction dimension (Mean=2.66, SD=0.83). Correlates of ever use included regions, friends’ and roommates’ ever e-cigarette use, and higher attitude score in the Supervision dimension.

CONCLUSIONS

The university students’ level of knowledge regarding e-cigarettes was not high, and their attitudes regarding e-cigarettes were not that supportive. Students’ ever use of e-cigarettes at a university in Hangzhou was higher than for university students in other cities in China, but lower than for those in foreign countries.

An Avatar-Led Intervention Promotes Smoking Cessation in Young Adults: A Pilot Randomized Clinical Trial

BACKGROUND

Smoking remains a global concern, especially for young adults. There is a dearth of smoking cessation programs for this population, who seldom seek help or are motivated to quit.

PURPOSE

This pilot study assessed the effectiveness of a digital avatar-led Acceptance and Commitment Therapy (ACT) smoking cessation program (Flexiquit) for young adult smokers at all levels of motivation to quit.

METHODS

Smokers with no particular interest in quitting smoking (65.45% reported being in pre-contemplation or contemplation stages of change) were recruited from three universities (105 smoking ≥ 1 cigarette per day during the past 30 days, 68 females). Those who completed questionnaires online (N = 84; M = 22.44 years, SD = 2.61, range 18-28 years old) were randomized to either a six-session avatar-led intervention (Flexiquit; N = 49) or a wait-list control (N = 35). Primary outcomes included cessation status (7-day point prevalence) and number of cigarettes smoked per day; secondary outcomes were nicotine dependence, intention-to-quit smoking and self-efficacy, assessed at pre- and post-intervention, and only for Flexiquit at 6-month follow-up.

RESULTS

In intention-to-treat analysis more participants (OR = 3.10, 95% CI = 0.92-10.41) in the treatment group (28.57%) versus the control group (11.43%) reported quitting smoking; however, the difference was not statistically significant (p = .067). There were statistically significant decreases in average number of cigarettes, nicotine dependence and increases in self-efficacy, and intention-to-quit smoking compared to controls. Treatment gains in the Flexiquit group were maintained through the 6-month follow-up.

CONCLUSIONS

An avatar-led digitized smoking cessation intervention based on ACT could increase the odds of quitting smoking. Findings suggest that a digitized program designed to engage young adults in smoking cessation may result in quitting smoking and has a high applicability potential especially among the hard-to-reach population of young adults.

QUESTION

Can an avatar-led digitized Acceptance and Commitment Therapy (ACT) smoking cessation intervention result in quitting smoking and increasing intention to quit among young smokers at various levels of motivation to quit, compared to a wait-list control group?

FINDINGS

In this pilot randomized clinical trial that included 84 smokers, 28.57% in the treatment condition versus 11.43% in the wait-list control group were abstinent at post (intention-to-treat [ITT] analysis). An avatar-led digitized ACT smoking cessation intervention results in high quitting smoking rates and has a high applicability potential especially among the hard-to-reach population of young adult smokers.

Who would be targeted by increasing the legal age of sale of cigarettes from 18 to 21? A cross-sectional study exploring the number and characteristics of smokers in England

AIMS

To establish the number of smokers in England who would be targeted by increasing the age of sale of cigarettes from 18 to 21 years and to assess the smoking and socio-demographic profile of those smokers.

DESIGN AND SETTING

Nationally representative cross-sectional survey of adults in England conducted between January 2009 and July 2019.

PARTICIPANTS

A total of 219 720 adults.

MEASUREMENTS

All participants reported their current smoking status and socio-demographic characteristics (i.e. age, gender, home ownership, social grade and ethnicity). Smokers reported motivation to quit, urges to smoke and the Heaviness of Smoking Index (HIS). Weighted prevalence statistics were calculated. Multinomial regression and logistic regression were used to assess differences in smoking characteristics among smokers and socio-demographic characteristics relative to non-smokers.

FINDINGS

The prevalence of smoking between January 2009 and July 2019 was highest among those aged 21-30. In 2019, 15.6% [95% confidence interval (CI) = 12.8-18.8%] of 18-20-year-olds reported smoking, which is estimated to represent 364 000 individuals in England. Relative to smokers aged 18-20, older smokers (aged 21+) had a higher motivation to quit smoking [odds ratios (ORs) = 1.40-1.45 range] and higher nicotine dependency as measured by urges to smoke (ORs = 1.06-1.24 range) and HSI (ORs = 1.05-2.85 range). Compared with non-smokers aged 18-20, smokers in this age group had lower odds of being female (OR = 0.89) and higher odds of being of white ethnicity (OR = 2.78) and from social grades C1-E (lower social grades) compared with AB (higher social grades) (OR = 1.19-1.83 range).

CONCLUSION

Increasing the age of sale of cigarettes to 21 years in England would currently target approximately 364 000 lower dependent smokers from more disadvantaged backgrounds aged 18-20, who have less motivation to quit.

Recruitment strategies for a pragmatic cluster randomized oral health trial in pediatric primary care settings

Objectives

To describe multilevel recruitment strategies for an ongoing clinical trial in pediatric primary care settings, and assess adoption and reach of these strategies via the RE-AIM framework.

Methods

This study is part of a larger pragmatic cluster randomized clinical trial focused on the effectiveness of interventions on the practice, provider, and caregiver levels on dental utilization for Medicaid-enrolled 3-6 year old children. Pediatric practices were recruited according to the proportion of Medicaid-eligible children, geographic region, and County. In accordance with the RE-AIM framework, providers reached were those approached directly and consented, and those who participated in the intervention training adopted to deliver the intervention. Caregivers reached were those approached and consented at their child's well-child visit to participate in the trial.

Results

Recruitment goals were met over a 21 month period, with an overall enrollment of 18 practices, 62 providers, and 1024 caregivers-child dyads. The majority of practices enrolled were small, suburban, and located in an urban county. The participation rates among approached providers and caregivers was 93% and 84% respectively. Enablers for recruitment was the one-on-one interaction with the provider and caregivers. Barriers to recruitment for caregivers included no-shows and cancellations at well-child visits. Adoption of intervention among providers was high, and caregiver reached were representative of the eligible target population.

Conclusions

Active approaches to recruitment, such as utilizing opinion leaders, in-person recruitment, and building relationships with practice staff, can result in successful enrollment and imp lementation of a multi-level intervention in pediatric primary care settings.

Shared Environmental Influences on Electronic Cigarette Use Among Adolescent and Young Adult Females

INTRODUCTION

Electronic cigarettes are now the most commonly used form of tobacco product among youth in the United States. Current evidence suggests that although e-cigarettes are perceived as less harmful and preferred over combustible cigarettes by adolescents, adolescents who try e-cigarettes are at greater risk of transitioning to combustible cigarettes. The genetic and environmental contributions to liability for e-cigarette use have not yet been examined using a behavioral genetic design.

METHODS

Behavioral genetic models of lifetime and current e-cigarette use and friends who use e-cigarettes were examined among female monozygotic and dizygotic twins.

RESULTS

A total of 41 female twin pairs (65.9% monozygotic twins; age = 19.7, SD = 1.6) with complete data on the study variables were included in the present analyses. The majority of the sample (68.1%) had at least some friends who use e-cigarettes. Additive genetic effects on e-cigarette use were not present, but the shared environment explained 98.7% of the variance in lifetime e-cigarette use, 96.6% in current e-cigarette use, and 94.9% in affiliation with friends who use e-cigarettes.

CONCLUSION

This first study on the behavioral genetics of e-cigarette use among adolescents and young adults suggest that environmental factors shared by twins within a family seem to play a predominant role in the initial stages of e-cigarette use, a finding that is consistent with what has been found for tobacco. The findings emphasize the importance of continuing population-based tobacco control interventions to reduce the burden of e-cigarette use among adolescents.

IMPLICATIONS

The shared environment significantly influences the initiation and regular use of electronic cigarettes and affiliation with friends who use electronic cigarettes among adolescent and young adult females. These findings underscore the importance of formulating preventive interventions that mitigate the social effects of familial influences on e-cigarette use through social skills training, education on harms of e-cigarettes for young people, or altering social norms regarding initiation of novel tobacco products.

Update on Preventive Cardiology

Although progress had been made in reducing cardiovascular disease (CVD) mortality, the positive trend has reversed in recent years, and CVD remains the most common cause of mortality in US women and men. Youth represent the future of CVD prevention; emerging evidence suggests exposure to risk factors in children contributes to atherosclerosis and results in vascular changes and increased CVD events. The contributors to CVD include those commonly seen in adults. This article reviews hypercholesterolemia, hypertension, obesity, diabetes, and smoking. It discusses the prevalence of each disease, diagnosis, treatment, and cardiovascular complications.

Differential typologies of current substance use among Black and White high-school adolescents: A latent class analysis

Black and White adolescents demonstrate different prototypical profiles (i.e., typologies) of substance use, with Blacks demonstrating lower risk for concurrent use of two or more substances. Despite knowledge of these differences, typologies of adolescent substance use identified by person-centered methods, such as latent class analysis, have not characterized profiles by racial group. The current study examined typologies of substance use among Black and White youth separately using person-centered methods to identify common patterns of substance use among subjects. Data were drawn from a 5-year parent study examining adolescent health outcomes. The current study examined high-school aged White (n = 7271, 45.4% male) and Black youth (n = 1301, 40.1% male) who reported past-30-day frequency of cigarette, alcohol, marijuana, inhalant, and other drug use. Latent class analysis was used to examine substance use typologies among each group adjusting for grade and sex. Black and White youth demonstrated different typologies such that four typologies emerged among Blacks: Non-Use (87.8%), Alcohol and Marijuana Use (6.3%), Alcohol, Marijuana, and Cigarette Use (3.8%), and Frequent Polysubstance Use (2.0%). Conversely, five typologies emerged among Whites: Non-Use (73.4%), Predominant Alcohol Use (13.9%), Alcohol, Marijuana, and Cigarette Use (9.4%), Moderate Polysubstance Use (1.6%), and Frequent Polysubstance Use (1.7%). Findings suggest that Black and White youth engage in similar rates of concurrent substance use. Given that Black youth face greater risk for adverse consequences from substance use, prevention efforts are needed to prevent related health disparities related to concurrent substance use.

Smoking prevention among youth

For majority of smokers, onset of smoking occurs during adolescence, period of intensive growth and development, and this early smoking initiation is associated with many adverse health effects. Smoking prevention measures include not only prevention of onset, but also prevention of transition from experimentation to chronic tobacco use and dependence and smoking cessation. Effective preventive measures should be based on relevant theory and scientific evidence on behavior determinants. In this review article, we present evidence from researches on effectiveness of school programs, community-based programs, media campaigns and stress the importance of considering new challenges in tobacco control and other promising strategies, as well as the need for early detection of nicotine dependence signs among adolescents. In practice, many preventive measures are not based on theory and some interventions can be contra productive. Regardless of type of intervention and setting in which is implemented, it is of importance to take into account context for its implementation.

Nicotine Use Disorders in Adolescents

Rates of certain tobacco products have decreased over the past decade, but nicotine use disorder is still prevalent among adolescents. New trends in tobacco use, such as in the use of electronic cigarettes, are creating alarm. This article reviews nicotine addiction and measurement in adolescents, along with potential health risks and comorbidities. Various psychosocial and pharmacologic interventions are reviewed along with novel interventions that show promise for reducing tobacco use in this vulnerable population.

Treatment for Nicotine Use Disorder Among Medicaid-Enrolled Adolescents and Young Adults

This study assesses use of nicotine replacement therapy, varenicline, and sustained-release bupropion for adolescents and young adults with nicotine use disorder who are enrolled in Medicaid.

Considerations of Privacy and Confidentiality in Developing a Clinical Support Tool for Adolescent Tobacco Prevention: Qualitative Study

Background

Electronic clinical support tools show promise for facilitating tobacco screening and counseling in adolescent well-care. However, the application of support tools in pediatric settings has not been thoroughly studied. Successfully implementing support tools in local settings requires an understanding of barriers and facilitators from the perspective of both patients and providers.

Objective

This paper aimed to present the findings of a qualitative study conducted to inform the development and implementation of a support tool for adolescent tobacco screening and counseling in 3 pediatric clinics in North Florida. The primary objective of the study was to test and collect information needed to refine a tablet-based support tool with input from patients and providers in the study clinics.

Methods

A tablet prototype was designed to collect information from adolescents on tobacco susceptibility and use before their well-care visit and to present tobacco prevention videos based on their responses. Information collected from adolescents by the support tool would be available to providers during the visit to facilitate and streamline tobacco use assessment and counseling components of well-care. Focus groups with providers and staff from 3 pediatric clinics (n=24) identified barriers and facilitators to implementation of the support tool. In-depth interviews with racially and ethnically diverse adolescent patients who screened as susceptible to tobacco use (n=16) focused on acceptability and usability of the tool. All focus groups and interviews were audio-recorded and transcribed for team-based coding using thematic analysis.

Results

Privacy and confidentiality of information was a salient theme. Both groups expressed concerns that the tool’s audio and visual components would impede privacy and that parents may read their child’s responses or exert control over the process. Nearly all adolescents stated they would be comfortable with the option to complete the tool at home via a Web portal. Most adolescents stated they would feel comfortable discussing tobacco with their doctor. Adolescent interviews elicited 3 emergent themes that added context to perspectives on confidentiality and had practical implications for implementation: (1) purity: an expressed lack of concern for confidentiality among adolescents with no reported history of tobacco use; (2) steadfast honesty: a commitment to being honest with parents and providers about tobacco use, regardless of the situation; and (3) indifference: a perceived lack of relevance of confidentiality, based on the premise that others will “find out anyway” if adolescents are using tobacco.

Conclusions

This study informed several modifications to the intervention to address confidentiality and introduce efficiency to well-care visits. The support tool was integrated into the electronic health record system used by the study clinics and modified to offer videos to all adolescents regardless of their tobacco use or susceptibility. Future studies will further test the acceptability of the intervention in practice.

Understanding the implications of the "vaping epidemic" among adolescents and young adults: A call for action

In the past 5 years, the use of nicotine delivered through electronic cigarettes ("e-cigarettes") has sky-rocketed among adolescents and young adults. E-cigarettes, with their high nicotine content, appealing flavors, low costs, wide availability, and discreet designs threaten 5 decades of progress in the fight against tobacco use. Aside from the increased risk of subsequent use of traditional cigarettes, marijuana, opioids, and other illicit drugs, building evidence indicates that e-cigarette use also exposes youth to several acute and long-term health risks that greatly outweigh the as-yet unfounded potential benefits from the use of e-cigarettes as a smoking reduction or cessation tool in this age group. We discuss some of the latest research on e-cigarettes, highlighting risks and harms associated with their use in adolescents and young adults, and suggest opportunities for action, including the enforcement of age, sales and marketing limitations, and concerted research and public health efforts to help curb what has become a new nicotine epidemic among youth.

Using Motivational Interviewing to Address Tobacco Cessation: Two Standardized Patient Cases for Pediatric Residents

INTRODUCTION

Motivational interviewing (MI) is a well-established evidence-based method of working with patients to promote health behavior change. Standardized patient (SP) simulation allows trainees to practice and receive feedback on clinical and communication skills and may be useful in applying MI techniques to address tobacco use and exposure.

METHODS

We developed two SP cases for pediatric residents to practice addressing tobacco use with parents of their patients.

RESULTS

Thirty-six residents participated, 26 of whom had prior MI training. Resident postencounter self-reflection identified MI-specific skills, including eliciting the SP's view on positive/negative aspects of smoking, identifying stressors/triggers associated with smoking, eliciting reasons for smoking, asking about motivation/willingness to quit, eliciting benefits of quitting smoking, letting the SP do the talking, and guiding the SP in making a quit plan. On paired-samples t tests, resident self-evaluation checklist scores averaged 6.79 out of 8.00 (SD = 1.018, SEM = 0.165), compared with SP checklist scores, which averaged 7.08 out of 8.00 (SD = 1.217, SEM = 0.197).

DISCUSSION

These two SP cases were useful in many ways, allowing residents with prior MI training the opportunity for practice/feedback on skills learned and introducing residents with no prior MI training to MI concepts through experience/feedback. Residents consistently identified using MI concepts on postencounter self-reflection; resident self-evaluation and SP evaluation of residents showed agreement. These sessions could be utilized within a communication/MI curriculum or as stand-alone sessions to introduce MI concepts/techniques for addressing tobacco cessation in the pediatric setting.

Stakeholder Engagement in Developing an Electronic Clinical Support Tool for Tobacco Prevention in Adolescent Primary Care

Following guideline recommendations to promote tobacco prevention in adolescent primary care, we developed a patient-facing clinical support tool. The electronic tool screens patients for use and susceptibility to conventional and alternative tobacco products, and promotes patient–provider communication. The purpose of this paper is to describe the iterative stakeholder engagement process used in the development of the tool. During the pre-testing phase, we consulted with scientists, methodologists, clinicians, and Citizen Scientists. Throughout the development phase, we engaged providers from three clinics in focus groups. Usability testing was conducted via in-depth, cognitive interviewing of adolescent patients. Citizen Scientists (n = 7) played a critical role in the final selection of educational content and interviewer training by participating in mock-up patient interviews. Cognitive interviews with patients (n = 16) ensured that systems were in place for the feasibility trial and assessed ease of navigation. Focus group participants (n = 24) offered recommendations for integrating the tool into clinical workflow and input on acceptability and appropriateness, and anticipated barriers and facilitators for adoption and feasibility. Engaging key stakeholders to discuss implementation outcomes throughout the implementation process can improve the quality, applicability, and relevance of the research, and enhance implementation success.

A Tool to Identify Adolescents at Risk of Cigarette Smoking Initiation

: media-1vid110.1542/5828318368001PEDS-VA_2017-3701Video Abstract OBJECTIVES: To describe the development of a prognostic tool to identify adolescents at risk for transitioning from never to ever smoking in the next year.

METHODS

Data were drawn from the Nicotine Dependence in Teens study, a longitudinal investigation of adolescents (1999 to present). A total of 1294 students initially age 12 to 13 years were recruited from seventh-grade classes in 10 high schools in Montreal. Self-report questionnaire data were collected every 3 months during the 10-month school year over 5 years (1999-2005) until participants completed high school (n = 20 cycles). Prognostic variables for inclusion in the multivariable analyses were selected from 58 candidate predictors describing sociodemographic characteristics, smoking habits of family and friends, lifestyle factors, personality traits, and mental health. Cigarette smoking initiation was defined as taking even 1 puff on a cigarette for the first time, as measured in a 3-month recall of cigarette use completed in each cycle.

RESULTS

The cumulative incidence of cigarette smoking initiation was 16.3%. Data were partitioned into a training set for model-building and a testing set to evaluate the performance of the model. The final model included 12 variables (age, 4 worry or stress-related items, 1 depression-related item, 2 self-esteem items, and 4 alcohol- or tobacco-related variables). The model yielded a c-statistic of 0.77 and had good calibration.

CONCLUSIONS

This short prognostic tool, which can be incorporated into busy clinical practice, was used to accurately identify adolescents at risk for cigarette smoking initiation.

Is the National Institute on Alcohol Abuse and Alcoholism Screening Guide Useful for Identifying Adolescents at Risk for Later Cigarette Smoking? A Prospective Study in Primary Care Clinics

OBJECTIVES

This paper evaluated whether a 2-item assessment of alcohol use risk, developed by the National Institute on Alcohol Abuse and Alcoholism (NIAAA SG), prospectively predicted smoking status among a sample of adolescents visiting their primary care physician.

METHODS

We analyzed a sample of 651 adolescents (57.80% female; 56.53% Hispanic, 22.73% African American, 14.44% White, 6.30% other) who completed the NIAAA SG at a baseline appointment and were assessed for future smoking risk. We obtained prospective data on smoking status using data from the 6-month post-baseline follow-up assessment.

RESULTS

Logistic regression analyses revealed that adolescents who were identified as at risk by the NIAAA SG were more likely to report smoking within 6 months. However, the association between the NIAAA SG and future smoking status became non-significant after controlling for future smoking risk measured at baseline.

CONCLUSIONS

Questions that ask about past smoking and future smoking intentions are best used to screen adolescents in primary care for smoking risk.

Knowledge on asthma, food allergies, and anaphylaxis: Assessment of elementary school teachers, parents/caregivers of asthmatic children, and university students in Uruguaiana, in the state of Rio Grande do Sul, Brazil

INTRODUCTION

Allergic diseases have become an increasingly common reality in the last years, extending beyond the family context.

OBJECTIVE

Assessing the level of knowledge on asthma, food allergies and anaphylaxis of asthmatic children's parents/caregivers (PC), elementary school teachers (EST) and university students (US) in Uruguaiana, RS, Brazil.

METHOD

577 individuals (PC - N=111; EST - N=177; US - N=299) took part in the study, answering the Newcastle Asthma Knowledge Questionnaire (validated for Portuguese) and another questionnaire on Food Allergy (FA) and anaphylaxis.

RESULTS

Although PC have asthmatic children, their asthma knowledge level was average, slightly above that of EST and EU. The lack of knowledge on passive smoking, use of medications and their side effects should be highlighted. US have shown to be better informed about FA and anaphylaxis. However, even though a significant proportion of respondents know the most common symptoms of FA and anaphylaxis, few named subcutaneous adrenaline as the drug of choice for treating anaphylaxis. Although a significant number of respondents know about the possibility of anaphylactic reactions happening at school or in activities outside the school, we were surprised by the absence of conditions in schools to provide emergency care to such students.

CONCLUSION

Despite the high prevalence of allergic diseases in childhood, asthmatic children's parents/caregivers, elementary school teachers and university students have inadequate levels of knowledge to monitor these patients.

The effects of framed messages for engaging adolescents with online smoking prevention interventions

Messages emphasizing the harms of smoking (loss-framed) or the benefits of not smoking (gain-framed) may be effective for engaging adolescents with tobacco prevention resources. This novel approach could help to close a gap in tobacco prevention intervention delivery in the pediatric primary care setting. To examine the effects of framed messages for engaging adolescents with an evidence-based smoking prevention website, adolescents ages 12 to 17 presenting for primary care well-visits were recruited for a three-arm experiment. Participants completed baseline measures including demographics, smoking behavior, and smoking susceptibility and were randomized to view 1 of 3 messages introducing an evidence-based smoking prevention website: (1) gain-framed communicating the benefits of avoiding smoking, (2) loss-framed communicating the harms of smoking, or (3) neutral. Self-reported website engagement was assessed at 1-month follow-up. Participants (279) (87% of those enrolled) completed a follow-up (M age 14.9 years, 66% female, 32% non-white race, 47% non-susceptible never smokers, 53% susceptible never smokers/ever smokers). Overall, 26% of participants reported website engagement. After adjusting for baseline intentions to visit the website, engagement was significantly greater in response to the loss-framed message than the gain-framed (odds ratio [OR] 3.05, 95% confidence interval [CI] 1.51, 6.15) and neutral (OR 2.31, 95% CI 1.15, 4.63) messages. The message framing effects did not differ by baseline smoking risk. Loss-framed messages emphasizing the harms of smoking may be effective for engaging adolescents with smoking prevention resources.

Tobacco Use and Smoke Exposure in Children: New Trends, Harm, and Strategies to Improve Health Outcomes

PURPOSE OF REVIEW

Every day in the USA, approximately 4000 adolescents begin smoking and the adolescent brain is particularly susceptible to nicotine addiction. We present current pediatric trends on tobacco use and exposures, various new products used by adolescents, the adverse biological and behavioral effects of tobacco use and exposures, and tobacco control strategies to eliminate tobacco-related illnesses and deaths in the pediatric population.

RECENT FINDINGS

Twelve-20% of women continue to smoke during pregnancy. New research reveals cognitive differences and behavior-control disorders are seen in elementary school children from prenatal and postnatal exposures. Traditional cigarette smoking has decreased in adolescents; novel and appealing tobacco products have captured their attention, particularly electronic cigarettes, and rates double and often triple from middle to high school. Children with asthma and those living in multi-housing units have higher rates of secondhand smoke exposure than non-asthmatics and children living in single-home dwellings. There is no "safe or risk-free" level of tobacco use or exposure. Tobacco use and exposure in childhood and adolescence must be decreased using evidenced-based strategies to improve child health.

A Genetic Epidemiological Mega Analysis of Smoking Initiation in Adolescents

Introduction

Previous studies in adolescents were not adequately powered to accurately disentangle genetic and environmental influences on smoking initiation (SI) across adolescence.

Methods

Mega-analysis of pooled genetically informative data on SI was performed, with structural equation modeling, to test equality of prevalence and correlations across cultural backgrounds, and to estimate the significance and effect size of genetic and environmental effects according to the classical twin study, in adolescent male and female twins from same-sex and opposite-sex twin pairs (N = 19 313 pairs) between ages 10 and 19, with 76 358 longitudinal assessments between 1983 and 2007, from 11 population-based twin samples from the United States, Europe, and Australia.

Results

Although prevalences differed between samples, twin correlations did not, suggesting similar etiology of SI across developed countries. The estimate of additive genetic contributions to liability of SI increased from approximately 15% to 45% from ages 13 to 19. Correspondingly, shared environmental factors accounted for a substantial proportion of variance in liability to SI at age 13 (70%) and gradually less by age 19 (40%).

Conclusions

Both additive genetic and shared environmental factors significantly contribute to variance in SI throughout adolescence. The present study, the largest genetic epidemiological study on SI to date, found consistent results across 11 studies for the etiology of SI. Environmental factors, especially those shared by siblings in a family, primarily influence SI variance in early adolescence, while an increasing role of genetic factors is seen at later ages, which has important implications for prevention strategies.

Implications

This is the first study to find evidence of genetic factors in liability to SI at ages as young as 12. It also shows the strongest evidence to date for decay of effects of the shared environment from early adolescence to young adulthood. We found remarkable consistency of twin correlations across studies reflecting similar etiology of liability to initiate smoking across different cultures and time periods. Thus familial factors strongly contribute to individual differences in who starts to smoke with a gradual increase in the impact of genetic factors and a corresponding decrease in that of the shared environment.

Secondhand Smoke Exposure and Pediatric Healthcare Visits and Hospitalizations

INTRODUCTION

This study assessed the relationship between secondhand smoke exposure (SHSe) as measured by serum cotinine and healthcare utilization among children.

METHODS

In 2016, the 2009-2012 National Health and Nutrition Examination Survey data were analyzed including 4,985 children aged 3-19 years. Associations between SHSe and having a routine place for healthcare, type of place, and hospital utilization were examined using logistic regression models. Poisson regression analyses assessed the relationship between SHSe and number of hospital admissions. Relationships between SHSe and acute care visits and hospital utilization were examined among asthmatic children.

RESULTS

SHSe level did not differ by having a routine place for healthcare, although children with high SHSe indicative of active smoking (cotinine ≥3 ng/mL) were 3.49 times (95% CI=1.77, 6.89) more likely to use an emergency department. Children with high SHSe were 2.85 times (95% CI=1.87, 4.34) more likely to have had an overnight hospital stay. Children with high SHSe had 2.05 times (95% CI=1.46, 2.87) the risk of having a higher number of hospital admissions for overnight stays versus children with no SHSe (cotinine <0.05 ng/mL). Among asthmatic children, those with high SHSe and low SHSe (cotinine 0.05-2.99 ng/mL) were more likely to have an acute care visit, overnight hospital stay, and higher number of hospital admissions than asthmatic children with no SHSe.

CONCLUSIONS

High SHSe is associated with increased healthcare utilization. The emergency department and inpatient settings are important venues in which to routinely offer cessation and SHSe reduction interventions.

E-Cigarette Advice to Patients From Physicians and Dentists in the United States

Purpose:

To report on adults’ recall of discussion by physicians and dentists about e-cigarettes.

Design:

A nationally representative cross-sectional survey (Internet and random digit dialing) in the United States.

Participants:

Adults who ever used e-cigarettes.

Measures:

Participant-reported discussion about the potential benefits and harms of e-cigarettes with their doctor, dentist, or child’s doctor in the past 12 months.

Analysis:

Fisher exact test for the analysis between benefits and harms for each type of provider and for rates of advice between provider types.

Results:

Among the 3030 adults who completed the survey, 523 (17.2%) had ever used e-cigarettes. Of those who had seen their doctor, dentist, or child’s doctor in the last year, 7.3%, 1.7%, and 10.1%, respectively, reported discussing potential harms of e-cigarettes. Conversely, 5.8%, 1.7%, and 9.3% of patients who had seen their doctor, dentist, or child’s doctor in the last year reported that the clinician discussed the potential benefits of e-cigarettes. Each clinician type was as likely to discuss harms as benefits. Rates of advice were similar between doctors and child’s doctors but lower for dentists. Rates were comparable when the analysis was limited to current e-cigarette users, participants with children, or those who reported using both e-cigarettes and combusted tobacco.

Conclusions:

Few physicians and dentists discuss either the harms or benefits of e-cigarettes with their patients. These data suggest an opportunity to educate, train, and provide resources for physicians and dentists about e-cigarettes and their use.

Smoking Cessation in Adolescents: targeted approaches that work

Smoking Cessation in adolescents can be considered in a developmental context to enable the clinician to individualise the appropriate assessment and management of the young person they are seeing whether it is in a primary or tertiary care setting. Adolescence is a time of rapid neurocognitive and hormonal change with these factors affected by personality and behavioural factors as well as family, cultural and psychosocial context. Adolescents are uniquely vulnerable to smoking initiation and nicotine addiction throughout these years. Increased awareness of the risks of smoking and using opportunities to assess and intervene regarding smoking cessation are integral to clinical practice for all clinicians seeing young people. This review will discuss the demographics of adolescent smoking, risk factors, assessing smoking and nicotine addiction, the importance of brief interventions, the evidence base for appropriate interventions, particularly in high risk groups and will emphasise innovative training for health professionals in adolescent smoking cessation.

Tobacco Smoke Exposure and Health-Care Utilization Among Children in the United States

PURPOSE

The purpose of this study was to assess patterns of health-care utilization among children who potentially had tobacco smoke exposure (TSE) compared to those who were not exposed.

DESIGN

A secondary data analysis of the 2011 to 2012 National Survey on Children's Health was performed.

SETTING

Households nationwide were selected.

PARTICIPANTS

A total of 95 677 children aged 0 to 17 years.

MEASURES

Sociodemographic characteristics, TSE status, and health-care visits were measured.

ANALYSIS

Multivariable logistic regression models were performed.

RESULTS

A total of 24.1% of children lived with smokers. Approximately 5% had home TSE. Participants who lived with a smoker were significantly more likely to have had a medical care visit (odds ratio [OR] = 1.22, confidence interval [CI] = 1.21-1.22) and were more likely to seek sick care or health advice at an emergency department (OR = 1.23, CI = 1.23-1.24) but were less likely to have had a dental care visit (OR = 0.82, CI = 0.82-0.83) than those who did not live with a smoker. Similar findings were found among participants who had home TSE.

CONCLUSION

TSE is a risk factor for increased use of pediatric medical care. Based on the high number of children who potentially had TSE and received sick care or health advice at an emergency emergency department, this setting may be a venue to deliver health messages to caregivers.

A Pilot Study for Linking Adolescent Patients to an Interactive Tobacco Prevention Program

CONTEXT

The American Academy of Pediatrics and professional guidelines recommend intervening with adolescents about avoiding tobacco use in the health-care setting. Barriers in the clinical setting limit consistent provision of this critical service.

OBJECTIVES

This pilot study compared 2 approaches for referring adolescents to an evidence-based tobacco prevention and cessation program in the outpatient setting. Secondary aims assessed tobacco use, knowledge, and program evaluation.

DESIGN SETTING AND PARTICIPANTS

The study setting was a medical and dental clinic. Participants aged 13 to 18 received tobacco advice and instructions to work through "A Smoking Prevention Interactive Experience." The program addresses health concerns of adolescents about tobacco use and is founded on behavioral change theories. The link to access it is featured on the website of the National Cancer Institute's Research-Tested Interventions. Participants (N = 197) were randomized to 1 of 2 approaches (ie, a program link via e-mail or referral by a printed card).

RESULTS

The program was accessed by 57% (112 of 197) of participants. Both referral approaches were equally effective. Non-Hispanics were twice as likely to access the program as Hispanics (adjusted odds ratio = 2.1, 95% confidence interval = 1.2-3.8, P < .05). Over 95% of participants identified themselves as nonusers of tobacco and evaluated the program as beneficial in increasing knowledge and motivation to remain tobacco-free.

CONCLUSION

Linking adolescent patients to an evidence-based tobacco prevention/cessation program at a community health clinic was highly promising and feasible. We present conclusions for future research.

A Qualitative Study of Adolescent Perceptions of Electronic Cigarettes and Their Marketing: Implications for Prevention and Policy

This study examined youths' perceptions of electronic cigarettes ("e-cigarettes"), sources of e-cigarettes exposure, and preferred sources of e-cigarette health information. Participants (n = 25, M age 15.0 years) recruited during primary care visits completed an in-depth qualitative interview assessing these topics. Most participants (72%) perceived e-cigarettes as "healthier" than cigarettes and reported e-cigarette advertising exposure (80%) and interpersonal exposure (60%). Participants reported advertisements portray e-cigarettes as less harmful than cigarettes and novel products. Most (72%) indicated their doctor was their preferred source of e-cigarette health information, suggesting pediatric health care providers are well-positioned to counsel patients to prevent e-cigarette use.

Intra-individual changes in Stroop-related activations linked to cigarette abstinence in adolescent tobacco smokers: Preliminary findings

BACKGROUND

Adolescence is a crucial time for initiation of tobacco-smoking. Developing more effective treatment interventions for tobacco-smoking in youth is therefore critical to reduce smoking rates in both adolescent and adult populations. Elucidation of the neural mechanisms of successful behavioral change (abstinence) will allow for improvement of therapies based on known brain mechanisms.

METHODS

Twenty-one adolescent tobacco-smokers (14-19 years) participated in functional magnetic resonance imaging (fMRI) during performance of a cognitive control (Stroop) task prior to randomization to smoking cessation treatment (trial of combined nicotine replacement therapy/placebo and contingency management for attendance/abstinence; NCT01145001). Fourteen adolescents also participated in fMRI scanning following completion of the six-week trial. fMRI data were analyzed using random-effects models in SPM12. Paired t-tests were used to identify group-level changes (main effect of treatment exposure) in neural functional responses. Regression models were used to identify individual-level changes associated with treatment-outcomes (percent days abstinent, maximum days of consecutive abstinence).

RESULTS

Main effects of Stroop task performance (contrast of incongruent versus congruent trials) were seen across a priori ROIs at both pre- and post-treatment (pFWE<0.05). At the group-level, no changes in neural responses were found following treatment. However, intra-individual reductions in Stroop-related activity (within the insula and anterior cingulate) were positively associated with measures of smoking abstinence during treatment (pFWE<0.05).

CONCLUSIONS

Abstinence from tobacco during smoking cessation treatment among adolescents is associated with cognitive-control related reductions in neural activity within specific regions (anterior cingulate, insula), suggesting that increases in cognitive efficiency may underlie optimal treatment responses in this population.

Nicotine and Tobacco Use Prevention among Youth and Families

OBJECTIVE

To review the importance of and evidence-based strategies to prevent tobacco use and promote tobacco cessation in the pediatric setting.

DATA SOURCES

Literature review of evidence-based resources on tobacco use and prevention/cessation interventions in the pediatric/adolescent population.

CONCLUSION

Knowledge of the impact of tobacco use on cancer risk, second- and third-hand smoke carcinogenesis, and newer methods of tobacco delivery is necessary to select appropriate and effective prevention and cessation strategies.

IMPLICATIONS FOR NURSING PRACTICE

Systematic evaluation of both parents and children for tobacco use can identify patients that will benefit from tobacco cessation interventions. Patients and families need education and support so they can make good decisions and adhere to recommendations for prevention and cessation of tobacco use.

Preventing smoking in children and adolescents: Recommendations for practice and policy

Canada has witnessed a general decrease in smoking prevalence among all age groups in recent years. However, despite large numbers of campaigns and interventions, thousands of young Canadians continue to initiate cigarette smoking every year. The increasing popularity of alternative tobacco products and e-cigarettes is also creating new health challenges. Research has shown that the deleterious effects of nicotine and cigarette smoke are significant and long lasting. Health care professionals have key responsibilities in preventing tobacco use among youth and their families, and need to know more about effective smoking prevention and cessation strategies. Clinicians need to integrate tobacco counselling into health assessments of teenagers and be aware of the roles that families, communities and governments can play in promoting tobacco-free environments. Information, effective strategies and opportunities for health care professionals to intervene and advocate for Canadian adolescents are discussed.

Strategies to promote smoking cessation among adolescents

In recent years, youth have been exposed to a broader spectrum of tobacco products including smokeless tobacco, hookah (water pipe) and e-cigarettes. Despite active local, provincial/territorial and national prevention strategies and legislated controls, thousands of teenagers develop an addiction to tobacco products each year. Current and available smoking cessation interventions for youth have the potential to help teens stop smoking and, as a result, greatly reduce Canada's health burden in the future. Paediatricians and health care professionals can play a key role in helping teens make informed decisions related to tobacco consumption and cessation. This practice point presents the evidence and rationales for smoking cessation interventions which have been studied in youth specifically, such as individual counselling, psychological support, nicotine replacement therapy, bupropion and varenicline. Interventions for which limited or conflicting data exist are also discussed.

White matter development and tobacco smoking in young adults: A systematic review with recommendations for future research

BACKGROUND

Adolescence and young adulthood are critical vulnerability periods for initiation of tobacco smoking. White matter development is ongoing during this time and may be influenced by exposure to nicotine. Synthesis of findings from diffusion tensor imaging (DTI) studies of adolescent and young adult smokers may be helpful in understanding the relationship between neurodevelopment and initiation and progression of tobacco-use behaviors and in guiding further research.

METHODS

A systematic literature review was conducted to identify DTI studies comparing adolescent and young adult (mean age <30 years) smokers versus nonsmokers. A total of 5 studies meeting inclusion criteria were identified. Primary study findings are reviewed and discussed within the context of neurodevelopment and in relation to findings from adult studies. Directions for further research are also discussed.

RESULTS

All identified studies reported increases in fractional anisotropy (FA) among adolescent/young adult smokers in comparison to non-smokers. Increased FA was most frequently reported in regions of the corpus callosum (genu, body and spenium), internal capsule and superior longitudinal fasciculus.

CONCLUSIONS

Findings of increased FA among adolescent/young adult smokers are contrary to those from most adult studies and thus raise the possibility of differential effects of nicotine on white matter across the lifespan. Further research including multiple time points is needed to test this hypothesis. Other areas warranting further research include DTI studies of e-cigarette use and studies incorporating measures of pubertal stage.

The Peer and Family Smoking Index: A Valid Measure of Secondhand Smoke Exposure in Adolescents

PURPOSE

Nearly half of all adolescents in the United States are exposed to secondhand smoke (SHS) daily, primarily at home, resulting in respiratory infections, asthma exacerbations, and reduced lung function. A concise self-report measure is needed to identity adolescents exposed to SHS. The purpose of this study was to test whether nonsmoking adolescents who reported exposure to peer and/or family smoking on the Peer and Family Smoking Index had higher salivary cotinine levels than those reporting no exposure to either peer or family smoking.

METHODS

A convenience sample of 135 English-speaking adolescents ages 15-18 years was recruited from two high schools. Those who reported use of nicotine replacement therapy, cigarette smoking (past 30 days), smokeless tobacco use (past 30 days), or who self-reported pregnancy were excluded. Salivary cotinine and self-report data from the Peer and Family Smoking Index were collected after obtaining parental consent and assent from the adolescent.

RESULTS

Mean salivary cotinine levels differed by exposure group (none, family, peer, or family and peer), F (3, 130) = 5.44, p = .001. The post hoc analysis identified a significantly higher mean cotinine level among those exposed to SHS from both family and peers than among those with no exposure (p = .001).

CONCLUSIONS

Known groups validity of the index was supported. Adolescents who reported family smoking or a combination of family and peer smoking had significantly higher salivary cotinine levels than unexposed adolescents. The Peer and Family Smoking Index is a concise and valid self-report measure for SHS exposure in adolescents.

Clinical Practice Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke

Tobacco dependence starts in childhood. Tobacco exposure of children is common and causes illness and premature death in children and adults, with adverse effects starting in the womb. There is no safe level of tobacco smoke exposure. Pediatricians should screen for use of tobacco and other nicotine delivery devices and provide anticipatory guidance to prevent smoking initiation and reduce tobacco smoke exposure. Pediatricians need to be aware of the different nicotine delivery systems marketed and available.Parents and caregivers are important sources of children's tobacco smoke exposure. Because tobacco dependence is a severe addiction, to protect children's health, caregiver tobacco dependence treatment should be offered or referral for treatment should be provided (such as referral to the national smoker's quitline at 1-800-QUIT-NOW). If the source of tobacco exposure cannot be eliminated, counseling about reducing exposure to children should be provided.Health care delivery systems should facilitate the effective prevention, identification, and treatment of tobacco dependence in children and adolescents, their parents, and other caregivers. Health care facilities should protect children from tobacco smoke exposure and tobacco promotion. Tobacco dependence prevention and treatment should be part of medical education, with knowledge assessed as part of board certification examinations.

Staying Young at Heart: Cardiovascular Disease Prevention in Adolescents and Young Adults

OPINION STATEMENT

Approaches to the prevention and management of cardiovascular disease (CVD) are often too narrow in scope and initiated too late. While the majority of adolescents are free of CVD, far fewer are free of CVD risk factors, especially lifestyle factors such as poor exercise and dietary habits. Most clinicians are familiar with behavioral and pharmacologic strategies for modifying these and other traditional CVD risk factors such as hypertension, hypercholesterolemia, and diabetes. In this review, we highlight those strategies most applicable to teens and also propose fundamental reframing that recognizes the importance of early choices and life experiences to achieving cardiovascular health. Population- and individual-level approaches that support the establishment of positive health behaviors early in life are the foundation of preserving ideal cardiovascular health and promoting positive cardiovascular outcomes. The Positive Youth Development movement supports a frame shift away from seeing young people as merely the sum of their risk factors and instead as developmentally dynamic youth capable of making healthy choices. Informed by the Positive Youth Development framework, our approach to cardiovascular prevention among adolescents is both broad based and proactive, paying heed as early as possible to social, familial, and developmental factors that underlie health behaviors and employing evidence-based behavioral, pharmacologic, and surgical treatments when needed.