Doctors already have a hefty checklist of topics to go over with their patients. Will they be able to squeeze in discussions about the health hazards of tobacco during office visits?
The recommendation, published in the Annals of Internal Medicine and Pediatrics, that primary-care physicians start counseling younger patients about tobacco updates the U.S. Preventive Services Task Force (USPSTF) advice from 2003. At that time, the task force of experts could not find enough evidence to ask physicians to intervene with talks about tobacco during checkups with teens and adolescents. Since then, however, the panel says more studies have shown that conversations with physicians can have an impact in reducing smoking and other tobacco use among teens.
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The members analyzed trials that were designed to either prevent smoking among adolescents or to encourage them to quit. Youngsters who were told about antitobacco programs by their primary-care physicians were 19% less likely to start smoking than peers who were not provided with such information. Compared with other methods such as group sessions to discuss the health risks of tobacco; videos and pamphlets that provided information on tobacco; or even prescription forms preprinted with antitobacco messages, having conversations with health care professionals, either in the doctors’ office or over the phone, appeared to be the most effective.
That’s encouraging for physicians who have long struggled to help adult smokers to quit. “We now know that the smokers that have the most difficulty quitting are the smokers that start in their teenage years and smoke into young adulthood. Those are the smokers that may never be able to quit smoking, and that’s recent data,” says Dr. Len Horovitz, an internist and pulmonary specialist at Lenox Hill Hospital in New York City, who was not on the panel. “It seems incumbent upon pediatricians and internists who have experience with these patients to counsel those patients at exactly that time.”
Rates of cigarette smoking among teens have stalled, but that doesn’t mean they aren’t still using tobacco. Some have switched to cigars, which are less expensive, often flavored, and even crafted to look like cigarettes. While teen tobacco use dropped significantly in the U.S. between the years 1997 and 2003, beginning in the early 2000s, these declines started to reverse as states cut funding for tobacco-control programs. From 2009 to ’11, tobacco use remained steady, with about 1 in 5 high school students using some form of tobacco.
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Will the USPSTF recommendation help bring tobacco use down again? Already pressured to cover a significant amount of health information in a short office visit, Horovitz says doctors may find it difficult to throw another important health issue into the mix. “There’s counseling on diet, exercise, fastening your seat belt [and] nutrition; and smoking cessation measures are a part of the annual physical too,” he says. To make time for discussions about such lifestyle factors and how they affect their health, Horovitz says he allots an hour for each such visit.
Discussing such lifestyle behaviors, including tobacco use, is easier if doctors and patients have a long-standing relationship that is built on trust and familiarity. “All patients will talk about stress, and I ask questions that are pointed enough that they will volunteer that information. When you take care of a patient over a few years, there is trust and confidence in the doctor-patient relationship, and the patient will be more spontaneous in giving you facts that they might not give a doctor at first or if they don’t have a consistency in who they see,” says Horovitz.
Since not all patients have such interactions with their doctors, the task force also identified some other strategies that could help physicians to help their teen tobacco users to quit. For instance, some cessation programs send reminder text messages to teens’ smartphones, while some states, including New York and Rhode Island, have gone after their wallets by increasing the price of cigarettes. Mass-media antismoking campaigns and laws that target retailers selling cigarettes to underage customers are also effective. In an editorial accompanying the new recommendations, Dr. Michael Steinberg of Robert Wood Johnson University Hospital and Cristine Delnevo of the Rutgers School of Public Health also argue for raising the smoking age from 18 to 21, since that would make it much harder for younger people to purchase tobacco products and therefore discourage them from smoking regularly.
With the new recommendation, doctors are being asked to join antitobacco efforts for teens, based on the latest data that suggests they can have a significant impact on whether or not their young patients smoke. It’s just a matter of finding the time to discuss how smoking and tobacco can affect teens’ health, and making such conversations a priority during the office visit.