USPSTF backs interventions to prevent kids from smoking; cessation needs more study
The U.S. Preventive Services Task Force recommended that primary care clinicians provide interventions to prevent school-aged children and adolescents from using tobacco, such as offering education or brief counseling. However, the task force said there is insufficient evidence to support primary care interventions for the cessation of tobacco use among children who already smoke.
Researchers wrote in JAMA that the recommendations are based on 24 randomized clinical trials comprising 44,521 participants. The B recommendation and I statement mirror the USPSTF’s 2013 recommendations on this topic.
Preventing smoking before it starts
Clinicians should “counsel youth that e-cigarettes contain nicotine, which is the addictive ingredient in traditional cigarettes” to prevent smoking before they start, Chien-Wen Tseng, MD, MPH, MSEE, an associate research director in the department of family medicine and community health at the University of Hawaii John A. Burns School of Medicine, told Healio Primary Care.
According to Tseng, who is one of the authors of the USPSTF report, clinicians should also inform youth that nicotine hinders their brain development, breathing and sports performance. She added that the websites of the CDC, Office of Surgeon General, the National Cancer Institute and the FDA provide materials to help with these interventions.
Addressing ‘growing problem’ of tobacco use
According to Tseng, “the task force recognizes that tobacco use, including vaping e-cigarettes, is an important and growing problem in children and teens.”
The USPSTF called for more research into interventions that promote cessation of e-cigarettes, combustible cigarettes, cigars and smokeless tobacco. The task force also encouraged studies that evaluate the following:
- the delivery of smoking cessation interventions;
- the frequency of contact between physicians and smokers;
- the content of the materials provided during the intervention— — and the type of counseling provided;
- the location of the interventions;
- the training of intervention leaders; and
- medications to help youth with tobacco cessation.
“Until such evidence is available, clinicians should continue to use their clinical experience and judgement to determine how to help each child and teen quit tobacco use,” Tseng said.
Parental education, regulations may stem tideIn a related editorial, James D. Sargent, MD, director of the C. Everett Koop Institute Geisel School of Medicine at Dartmouth, and colleagues suggested that clinicians help parents learn how to identify modern vaping products, “some of which can easily be mistaken for computer USB drives because of their similar appearance.”
Sargent and colleagues also proposed several regulations to reduce e-cigarette use among youth, such as limiting nontobacco flavors, permitting only product designs that align with combustible cigarettes, setting limits on e-cigarette nicotine concentrations and banning e-cigarettes that contain potentially addictive nicotine salt formulations. – by Janel Miller
References:
Sargent JD, et al. JAMA. 2020;doi:10.1001/jama.2019.22312.
Selph S, et al. JAMA. 2020;doi:10.1001/jama.2020.3332.
USPSTF. JAMA. 2020;doi:10.1001/jama.2020.4679.
Disclosures: Cheng and Sargent report no relevant financial disclosures. Please see the articles in JAMA for the other authors’ relevant financial disclosures.
Perspective
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The USPSTF recommendations on primary care-relevant interventions for nicotine and tobacco prevention and cessation in children and adolescents stresses the importance of prevention. The USPSTF is right on target here. Nicotine is one of the most addictive drugs known, and addiction can develop very quickly. Nicotine and tobacco dependence are much easier to prevent than to treat — especially in adolescents.
Tobacco dependence most commonly starts before a person reaches the age of 18 years. The USPSTF reports that primary care-based interventions for prevention of tobacco and nicotine use addition are moderately effective. As tobacco dependence is the most important preventable cause of premature death and disability among noncommunicable diseases, this USPSTF recommendation reinforces the AAP recommendation that one of the most important things that children and adolescent health care providers can do is to provide anticipatory guidance — counseling and education — to prevent tobacco and nicotine product use initiation. This guidance can be conducted with age-appropriate and personally relevant messages from as young as a child is able to understand them.
However, the tobacco industry has a long record of promoting tobacco and nicotine to young people. The e-cigarette industry has further built on this designing highly addictive products with youth appealing marketing and youth appealing flavors provided in compact devices that can be used in places (such as classrooms) where its use is otherwise prohibited. The most popular devices used by adolescents contain very addictive nicotine salt in high concentrations and bear a very close resemblance to a USB drive. The FDA’s Center for Tobacco Products, which is charged with regulating tobacco products to protect the public health, has an unfortunate track record of big talk but little action. State tobacco control programs are woefully underfunded.
The USPSTF concluded that the current evidence is insufficient to assess primary care–feasible interventions for the cessation of tobacco use among school-aged children and adolescents. Tobacco and nicotine dependence in adolescence is notoriously difficult to treat. The studies on pharmacotherapy of tobacco-dependent adolescents have been limited by either high rates of nonadherence, high rates of relapse after brief courses of treatment, or both. Nicotine dependence, social factors, easy product availability and peer influences all contribute to the continuation of nicotine use among adolescents. Psychiatric and substance abuse comorbidities can also contribute. The most effective behaviorally based programs have been school-based multisession programs such as Project EX and N-O-T: Not On Tobacco although those with more severe levels of nicotine dependence benefited least from these programs. This does not mean that primary care providers should not offer treatment, including pharmacotherapy that has been shown to be effective for adults, for nicotine- and tobacco-dependent adolescents. It does mean that the PCP needs to be fully cognizant of the difficulties in treatment and address the multiple factors that contribute to the continuation of nicotine and tobacco dependence for the adolescent.
These findings from USPSTF stress the importance of actions to prevent the initiation of tobacco and nicotine product use. As pointed out by the USPSTF, the PCP has an important role to play. The impact of counseling by the PCP should not be underestimated. However, nicotine and tobacco dependence are a disease that is aggressively sold to our children. There are important, evidence-based public health interventions for nicotine and tobacco control that need to be funded and implemented. It is time that we as a society place a priority on the health of our next generations over the profits of the tobacco and e-cigarette industries.
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