Smoking tends to start during the adolescent years in the United States. Studies have shown that the earlier in life children and adolescents try cigarettes, the more likely they are to become regular smokers. Thus, preventing and reducing tobacco use among children and adolescents can provide substantial health benefits. Physicians who routinely care for patients in this age group have an opportunity to provide smoking cessation counseling and are viewed as credible health experts. In adults, brief interventions have been shown to improve rates of smoking cessation, but there is little information to support this in children and adolescents. The National Cancer Institute has developed a smoking cessation training program with five components: anticipate, ask, advise, assist, and arrange. Despite the availability of this program and recommendations from other organizations concerning tobacco abuse, physicians often fail to assess or counsel their young patients regarding tobacco use. Kaplan and colleagues assessed family physicians’ and pediatricians’ practice of smoking cessation counseling among patients 18 years and younger and the barriers to it.

The study was a cross-sectional mail survey of stratified, randomly selected family physicians and pediatricians in urban practices in California. To participate in the research project, physicians had to work at least 10 percent of the time in an ambulatory setting, and at least 10 percent of their patients had to be 18 years or younger.

The authors developed a 31-item questionnaire based on the published literature on smoking cessation. The questionnaire was divided into four sections. The first section asked for background information on the physician. The next section asked physicians about their knowledge concerning the age most children and adolescents experiment with cigarettes or start smoking regularly. Recommendations on smoking cessation counseling were covered in the next section and were based on the National Cancer Institute’s five components. The final section asked physicians about potential barriers to the delivery of smoking cessation counseling.

Out of 899 physicians surveyed, 429 responded to the questionnaire. The physicians were more likely to anticipate, ask, and advise patients about smoking than they were to assist with and arrange cessation activity. Family physicians were more likely to assist with and arrange smoking cessation services than pediatricians (25.1 percent versus 11.7 percent).

Most physicians reported that they spent time counseling their young patients about smoking cessation. Of the responders, more than 65 percent stated that they assessed patients’ motivation to quit, and nearly one half provided patients with information about the negative health consequences of smoking. The most commonly identified perceived barrier to smoking cessation counseling centered around confidentiality—the belief that children would not provide accurate information with their parents present and the fear that the children’s parents would be notified of their answers. Approximately 25 percent of the family physicians and 55 percent of the pediatricians reported lack of counseling skills as a barrier to providing smoking cessation counseling.

The authors conclude that physicians are not providing children and adolescents with the recommended smoking cessation counseling. They note that physicians are more likely to ask and advise about smoking cessation but are not as likely to assist with or arrange cessation and follow-up activities. In addition, they note that physicians should assure patients in this age group that their responses about smoking are confidential. The authors’ final comment is that physicians should try to improve their skills in smoking cessation counseling.

editor’s note: One area in which prevention provides a significant impact on our patients’ health is helping them to never start smoking and, if they do smoke, assisting them in stopping. This is particularly true in children and adolescents. The current message from various media and from peers is that smoking is “cool,” and the idea that “you will never become addicted” has a powerful influence on this age group. Yet, simple prevention techniques such as “anticipate, ask, advise, assist, and arrange” can reduce the number of young patients who develop this habit.

This study by Kaplan and colleagues points out that although we know that prevention and early intervention can reduce the number of smokers, a significant number of family physicians and pediatricians still do not address this issue or, at best, only partially address the issue during office visits. All physicians with young patients should develop systems and strategies to intervene early and often to reduce the number of children and adolescents who start down the road of tobacco addiction.—k.e.m.