Recommendations for tobacco use prevention and cessation for infants, children, and adolescents are presented in the form of an algorithm, with two sections: "Infants and Children from Birth to 10 Years Old" and "Children and Adolescents Aged 10 Years and Above," containing a total of 17 components and accompanied by detailed annotations. Clinical highlights and selected annotations (numbered to correspond with the algorithm) follow.
Class of evidence (A-D, M, R, X) definitions are provided at the end of the "Major Recommendations" field.
Clinical Highlights
- Ask about tobacco use and secondhand smoke exposure at every opportunity. (Annotations #2, 8)
- Advise all tobacco users to stop. (Annotation #6, 17)
- Assess tobacco user's willingness to make a quit attempt. (Annotation #12)
- Assist tobacco user's efforts to quit. (Annotation #6, 14,17)
- Arrange for follow-up. (Annotations #6, 17)
Infants and Children from Birth to 10 Years Old Algorithm Annotations
- Community Intervention
Key Points:
- Tobacco use is the single most preventable cause of disease and death in our society.
- The work group urges Institute for Clinical Systems Improvement (ICSI) participating medical groups, insurance plans and employers to actively intervene within their community to reduce tobacco use.
Tobacco use is the single most preventable cause of disease and death in our society. The Centers for Disease Control recommend that tobacco control programs be established that are comprehensive, sustainable, and accountable. The goal of a comprehensive tobacco control program is to reduce disease, disability and death related to tobacco use by:
- Preventing the initiation of tobacco use among young people
- Promoting cessation among young people and adults
- Eliminating nonsmokers' exposure to second hand smoke
- Identifying and eliminating the disparities related to tobacco use and its effects among different population groups
The components of a comprehensive tobacco control program include:
- Community programs to reduce tobacco use
- Chronic disease programs to reduce the burden of tobacco related diseases
- School programs
- Enforcement
- Statewide programs
- Counter-marketing
- Cessation programs
- Surveillance and evaluation
- Administration and management
The work group urges ICSI medical groups, insurance plans, and employers to actively intervene within their community to reduce tobacco use. Participation in school-based education, limiting youth access to tobacco, restrictions on advertising, counter-advertising and increasing economic disincentives to tobacco use, and establishing smoke-free public places are among the effective actions that deserve active support. The acceptability of tobacco use is to a great extent socially determined.
Evidence supporting this recommendation is of classes: C, M, R
- Establish Tobacco Use and Second-Hand Smoke Exposure at Nearly Every Visit
Key Points:
- Smoke exposure (in home, at day care, etc.) should be established at nearly every visit.
- Establish the tobacco use status of all patients (and in the case of infants and children, the use status of everyone in the home).
Smoke exposure (in home, at day care, etc.) should be established at nearly every visit. If there is anyone smoking around the child, regard the infant or child as a passive smoker.
The only way to accomplish the objectives of this guideline is to establish the tobacco use status of all patients (and in the case of infants and children, the use status of everyone in the home) in/on the chart by staff, and to remind providers of this status in some way.
Evidence supporting this recommendation is of classes: D, M, R, X
- Document Tobacco Use Discussion
Key Point:
- Documentation should be made of every tobacco use discussion.
Documentation should be made of every tobacco-use discussion, either in the progress notes or in a separate flow-sheet or card. Documentation is necessary to facilitate follow-up, to enhance coordination between various providers and their support staff, to permit follow-up and referral arrangements, and to allow subsequent visits to build on discussions started earlier.
- Is the Child Exposed to Smoke?
Key Point:
- The adult accompanying the child should be advised of the dangers to the child of passive tobacco exposure.
The adult accompanying the child should be advised about the dangers to the child of passive tobacco exposure. Educational and self-help material should be provided. If the user is present, s/he should be encouraged to quit. If the user is a clinic patient and is interested in quitting, s/he should follow-up with his/her primary care provider. See also the National Guideline Clearinghouse (NGC) summary of the Institute for Clinical Systems Improvement (ICSI) guideline Tobacco Use Prevention and Cessation for Adults and Mature Adolescents.
Evidence supporting this recommendation is of class: R
- Assistance with Tobacco Avoidance
Advise the tobacco user to stop; provide educational and self-help material and offer phone line. If the user is a clinic patient, and is interested in quitting, encourage follow-up within one month.
Children and Adolescents Aged 10 Years and Above Algorithm Annotations
- Community Intervention
Key Points:
- Tobacco use is the single most preventable cause of disease and death in our society.
- The work group urges ICSI participating medical groups, insurance plans, and employers to actively intervene within their community to reduce tobacco use.
Tobacco use is the single most preventable cause of disease and death in our society. The Centers for Disease Control recommend that tobacco control programs be established that are comprehensive, sustainable and accountable. The goal of a comprehensive tobacco control program is to reduce disease, disability and death related to tobacco use by:
- Preventing the initiation of tobacco use among young people
- Promoting cessation among young people and adults
- Eliminating nonsmokers' exposure to second hand smoke
- Identifying and eliminating the disparities related to tobacco use and its effects among different population groups
The components of a comprehensive tobacco control program include:
- Community programs to reduce tobacco use
- Chronic disease programs to reduce the burden of tobacco related diseases
- School programs
- Enforcement
- Statewide programs
- Counter-marketing
- Cessation programs
- Surveillance and evaluation
- Administration and management
The work group urges ICSI participating medical groups, insurance plans, and employers to actively intervene within their community to reduce tobacco use. Participation in school-based education, limiting youth access to tobacco, restrictions on advertising, counter-advertising and increasing economic disincentives to tobacco use, and establishing smoke-free public places are among the effective actions that deserve active support. The acceptability of tobacco use is, to a great extent, socially determined.
Evidence supporting this recommendation is of classes: C, M, R
- Establish Patient's Tobacco Use and Secondhand Smoke Exposure at Nearly Every Visit
The patient's use of tobacco should be established at nearly every visit, as the teen years are the main age at which tobacco use begins and use may occur at any time.
See Annotation #2, "Establish Tobacco Use and Secondhand Smoke Exposure at Nearly Every Visit."
- Document Tobacco Use Discussion
Key Point:
- All tobacco use discussions should be documented.
Documentation should be made of every tobacco-use discussion, either in the progress notes or in a separate flow sheet or card. Documentation is necessary to facilitate follow-up, to enhance coordination between various providers and their support staff, to permit follow-up and referral arrangements, and to allow subsequent visits to build on discussions started earlier.
- Patient Not Interested in Quitting
Key Point:
- A "precontemplator" benefits from nonconfrontational messages about importance of quitting and the awareness that provider help is available when ready.
The scientifically-based concept of readiness stages for behavior change developed by Prochaska and DiClimente has been incorporated into this guideline. This approach requires that the provider first assess readiness to quit by asking if a user would consider quitting. The strategy taken would then be tailored to the individual user's readiness stage.
A user not ready to consider quitting is called a precontemplator and is helped most when a provider avoids confrontation while conveying both the message that quitting is important and a desire to be helpful when the user is ready to consider quitting. The short-term negative effects of tobacco, such as bad breath, yellowed fingers, and smelly clothes, should be emphasized. The benefits of quitting should also be stressed. These include fewer respiratory illnesses, better performance in sports, and the money saved by not buying tobacco. It can also be noted that it is easier to stop using tobacco in youth than later in adulthood. Educational material should be provided.
Adolescent users who are not ready to quit have been shown to be swayed by information concerning the short-term negative consequences of tobacco.
Evidence supporting this recommendation is of class: R
- Patient Interested in Quitting
Key Points:
- "Contemplators" should receive support and respectful urging to quit.
- A patient in "preparation" should set a quit date, receive self-help information, and be encouraged to accept follow-up after the quit date.
The contemplator is interested in quitting in the next 1 to 6 months. Contemplators are accepting of support and respectful urging to quit and encouragement to start thinking about a serious plan to do so. Persuasive written, audio, or video information about the pros and cons of quitting may be appropriate for contemplators.
Users in the preparation stage are ready to attempt to quit in the next month. It is always appropriate to request the user to set a quit date within the next 1 to 3 weeks, to provide self-help information or suggestions, and (most importantly) to encourage the user to accept some form of follow-up soon after the quit date. Follow-up can occur by mail or telephone.
Virtually every tobacco-cessation expert and program, including the National Cancer Institute program, recommends asking a tobacco user who is ready to quit to set his/her own quit date. They also recommend some type of follow-up, often a return visit. Because physicians are often reluctant to ask for a follow-up appointment for this purpose and users are unlikely to keep the appointment, alternatives like phone calls are usually substituted.
Evidence supporting this recommendation is of classes: A, M, R
- Does Parent, Sibling, or Friend Use Tobacco?
- Assistance with Tobacco Avoidance
Key Point:
- Patients should be assisted in developing refusal skills and given educational materials.
All patients who wish to stop using tobacco or who do not currently use tobacco should be asked if their parents, siblings, or friends use tobacco. If someone does smoke around the patient, the patient should be assisted in developing refusal skills and given educational material.
Adolescents are particularly susceptible to peer pressure. It is important to assist the nonuser in resisting this pressure by assisting the patient in developing refusal skills and by providing the patient with educational material about tobacco use and cessation techniques.
If the person who uses tobacco is present, she or he should be encouraged to quit. If the user is a clinic patient and is interested in quitting, he or she should be given encouragement, materials, and resources at this visit, and referred for follow-up by his or her primary care provider. See also the NGC summary of the ICSI guideline Tobacco Use Prevention and Cessation for Adults and Mature Adolescents.
Minnesotans have high quality free telephone line counseling for smoking cessation. Clinicians are advised to refer patients to their respective health plan quitlines. If a patient does not belong to one of the health plans listed in the original guideline document, s/he should refer to the QUITPLAN Helpline: 1-888-354-PLAN. They are also planning to offer face-to-face counseling soon. It is helpful to provide a handout with tobacco quitline numbers when referring to a quitline. These handouts are available from Blue Cross Blue Shield of Minnesota.
An important message to convey to smokers is that quitline counselors provide expert advice in a friendly and supportive manner.
- Smokers can consult quitlines for assistance about any issue related to tobacco cessation
- Quitline counselors can answer brief questions or provide counseling, depending on the needs of the smoker.
- Quitlines can help smokers who are not quite ready to quit as well as those who have set a quit date.
- Smokers who are not quite ready to quit can receive assistance in figuring out the next steps.
- Quitlines can also help smokers who have quit but are having difficulty maintaining cessation.
- Quitlines can send written self-help materials and may provide free nicotine replacement therapy (NRT).
- The quitlines also can help those who want to know how to support someone who is trying to quit.
Evidence supporting this recommendation is of class: A
Definitions:
Classes of Research Reports:
- Primary Reports of New Data Collection:
Class A:
- Randomized, controlled trial
Class B:
Class C:
- Nonrandomized trial with concurrent or historical controls
- Case-control study
- Study of sensitivity and specificity of a diagnostic test
- Population-based descriptive study
Class D:
- Cross-sectional study
- Case series
- Case report
- Reports that Synthesize or Reflect upon Collections of Primary Reports:
Class M:
- Meta-analysis
- Systematic review
- Decision analysis
- Cost-effectiveness analysis
Class R:
- Consensus statement
- Consensus report
- Narrative review
Class X:
