A Physicians’s
Guide
to Preventing
Tobacco
Use During
Childhood
and Adolescence
Roselyn
Payne
Epps,
MD, MPH,
and
Marc
W. Manley,
MD, MPH
From the Cancer Control Sciences Program, Division of Cancer Prevention and Control,
National Cancer Institute, Bethesda, Maryland
ABSTRACT. Physicians who care for children can and
should help patients avoid the use of tobacco. Physicians
are well aware of the health hazards associated with
tobacco use, inasmuch as smoking is the chief, single
cause of premature mortality in this country. Each day,
more than 3000 children in the United States begin to
use tobacco. Physicians who care for children have
pa-tients at vastly different stages of intellectual and social
maturity. Both the theory and practical details of
to-bacco-related interventions differ among infants, chil-dren, and adolescents. The physician is in a unique
position to intervene in the early stages. Anticipatory
guidance-the practice of providing counsel regarding potential problems-is a key part of health care for the
young. If physicians provide messages about tobacco use
that are appropriate to the patient’s age and
develop-mental stage, the potential for broad public health impact
is great. Based on a series of clinical trials, the National
Cancer Institute developed a manual to assist physicians
in helping their patients stop smoking. The
recommen-dations in this manual include four physician activities
that begin with the letter A (four A’s): Ask, Advise, Assist,
and Arrange follow-up. For physicians who treat children,
a fifth A, Anticipatory guidance, is added. Pediatrics 1991;88140-144; tobacco, smoking prevention, child, ado-lescent, physician techniques.
Physicians who care for children can and should
help their patients avoid the use of tobacco. Phy-sicians are well aware of the health hazards
asso-ciated with tobacco use. Smoking is the chief, single
cause of premature mortality in this country, being responsible for one in every six deaths in the United
States each year.’ Although most patients who die
Received for publication Jan 14, 1991; accepted Jan 30, 1991. Reprint requests to (M.W.M.) Chief, Applications of Prevention
and Early Detection Section, National Cancer Institute, 9000
Rockville Pike, Executive Plaza North, Room 241, Bethesda,
MD 20892.
PEDIATRICS (ISSN 0031 4005). Copyright © 1991 by the
American Academy of Pediatrics.
because of tobacco use are adults, the addiction
usually begins in childhood.
Many very young children passively smoke on a
regular basis. The side-stream smoke from adults’
cigarettes causes illness in children. In addition, experimentation with cigarettes and smokeless to-bacco begins during childhood. (Throughout this paper, the term “smoking” is used almost
synony-mously with “tobacco use.” It should be recognized
that smokeless tobacco is used by many young
people and poses serious health hazards to users.) Each day, more than 3000 children in the United
States begin to use tobacco. Sixty percent of all
current smokers began by age 14.25 By the end of adolescence, many tobacco users are already ad-dicted.
To a child, physicians are powerful medical
ex-perts and role models for appropriate health
behav-ior.3 The messages delivered by physicians are in-terpreted as facts and influence behavior. The
phy-sician is able to provide information and alternative
health models at critical times in a child’s devel-opment.
Frequently, cigarette experimentation is followed
sequentially by alcohol, marijuana, and other illicit
drug use.#{176}Although use of one drug does not nec-essarily lead to the use of other drugs, it does increase the likelihood. For that reason, many
con-sider tobacco to be a “gateway” drug to illicit
sub-stance abuse.7#{176}.
The American Academy of Pediatrics (AAP) rec-ommends that, between birth and 21 years of age, a child should make a minimum of 20 health
super-vision visits to the physician.’#{176} These visits offer at
least 20 opportunities to prevent and deter tobacco
use. Because physicians are viewed as important
adults, they can have a positive influence on the
health behavior of the patient.
maturity. Both the theory and practice of tobacco-related interventions differ among infants, chil-dren, and adolescents. The physician is in a unique
position to intervene in the early stages of tobacco
use, having the advantage of a long-term
relation-ship with the child and the family and being
famil-iar with the developmental stages of childhood.
Furthermore, physicians recognize that some
chil-dren may be particularly vulnerable to tobacco use. To be successful in preventing tobacco use, physi-cians and other health professionals must know the
risk factors and which children are most vulnerable.
Anticipatory guidance, the practice of providing counsel regarding potential problems, is a key part
of health care for the young. Anticipatory guidance
begins prenatally and continues through
adoles-cence. Education of the individual about tobacco
should begin in childhood when family standards
and values are developing.7
If physicians provide messages about tobacco
that are appropriate to the patient’s age and
devel-opmental stage, the potential for broad public
health impact is great.
GENERAL RECOMMENDATIONS FOR
PHYSICIAN
It is important for physicians to advocate
non-smoking to counteract social factors that support
smoking as appropriate behavior. The medical of-flee provides an important opportunity for
physi-cians to communicate attitudes about smoking. By
not smoking, physicians serve as role models for others. Smoking by staff, adolescents, or parents should not be allowed in the physician’s office or reception areas.”
Smoking prevention and cessation must be
viewed as an ongoing and integral part of medical practice. Physicians can assist children and adoles-cents in resisting the temptation to smoke by em-phasizing reasons not to use tobacco and assisting those attempting to stop.
Based on a series of clinical trials, the National Cancer Institute developed a program for physi-cians to help patients stop smoking.’2 The publi-cation How to Help Your Patients Stop Smoking: A
National Cancer Institute Manual for Physicians
can be obtained from the National Cancer Institute
(telephone number, 1-800-4 CANCER).
Recom-mendations in this manual include four physician activities that begin with the letter A (four A’s): Ask, Advise, Assist, and Arrange follow-up. For
physicians who treat children, a fifth A,
Anticipa-tory guidance, is added. Thus, the activities are as
follows: ANTICIPATE the risk for tobacco use at
each developmental stage. ASK about exposure to
tobacco smoke and tobacco use at each visit. AD-VISE all smoking parents to stop and all children
not to use tobacco products. ASSIST children in
resisting tobacco use and assist tobacco users in
quitting. ARRANGE follow-up visits as required.
This article outlines a plan for an intervention
at every office visit. Because physicians have lim-ited time, often the intervention will necessarily be brief. But even a mention of tobacco use will have an impact, and repeated brief interventions are
likely to be most effective. This is best
accom-plished by making use of office staff and office
records in a systematic approach to tobacco control.
Details of effective office systems are given in the manual cited above.
Specific recommendations for these five actions
are provided for three age groups: infancy and early
childhood, late childhood, and adolescence and
young adulthood.
AGE-SPECIFIC RECOMMENDATIONS
Infancy and Early Childhood (Prenatal Visit Through Age 4)
In addition to the mother’s prenatal consultation,
the AAP recommends a minimum of 1 1 visits to
the physician prior to the child’s fifth birthday.’#{176}
The US Surgeon General has suggested that one
of the physician’s most important educational
oh-ligations is to encourage and help parents give up
smoking.’3 Many physicians talk to parents about
the effect of their smoking on their child. However,
some pediatricians are reluctant to discuss parental
smoking because they think that parents who
smoke do not expect such advice from
pediatri-cians.’4 Because adults between 18 and 35 years are
less likely than older persons to visit physicians for
their own health, the child’s physician is frequently the only doctor they visit. Unless the child’s
phy-sician advises parents who smoke to stop, no other
health professional may have an opportunity.’5 Ad-vice from a child’s physician can reinforce advice parents receive from their doctor. Physicians need
to learn skills to promote nonsmoking and to
en-courage parental attempts to stop.
Physician advice to parents who smoke should begin before the birth of the child. Smoking during pregnancy affects the fetus and is a cause of low
birth weight, possible premature delivery, and fetal
mortality. Risk of sudden infant death syndrome is
increased if the mother smokes.’#{176}During the first
2 years of life, a child whose parents smoke
expe-riences more acute respiratory illnesses and
infec-tions and is more likely to be hospitalized for
Children whose parents smoke have an increased
frequency of chronic middle ear effusions.
Parental smoking is known to be strongly asso-ciated with cigarette use by their child. A child may
view smoking by parents as a way to deal with
stress or boredom, and thus they learn the utility
and acceptability of smoking. Therefore, parents should be encouraged to examine their own beliefs and practices concerning tobacco use.
Anticipatory Guidance. During health supervision
or illness visits, the physician should ask about
smoking in the home and other environs (eg, auto-mobile, day care). The relationship between smoke and the infant’s health should be emphasized. In-tervention with parents is especially effective when the child has health problems associated with en-vironmental smoke. Try to convince parents that
smoking has immediate health consequences for
the whole family.
Ask. Ask parents about smoking by any
house-hold members, care givers, or other persons with whom the infant or young child has regular contact. At health supervision visits, compliment the
par-ents about the child’s health and inquire about the
child’s exposure to smokers. At illness visits, while
taking the history, ask whether the infant or child
is exposed to tobacco smoke. Remember that a
physician’s silence about smoking may be
inter-preted by parents to mean that smoke exposure is
not a significant health risk.
Advise. Advise parents who smoke to stop. Inform
parents about the harmful health effects of tobacco
smoke on their child. Stress the importance of
ensuring that their child grows and develops in a
smoke-free environment. Discuss the relationship
between smoking and illness, particularly in fami-lies with histories of lung or cardiovascular condi-tions. Inform parents of the relationship between a child’s exposure to tobacco smoke and illnesses.
During a prenatal consultation or a visit of a child accompanied by the pregnant mother, inform
her that mothers who smoke during pregnancy are
more likely to have a low birth weight infant.
Assist. Physicians should encourage efforts to
quit smoking by parents and should help parents to identify effective smoking cessation strategies
(see Ref. 12). All parents who want to stop smoking should be offered self-help materials. Further as-sistance, such as suggesting a quit date, also should be offered. Further treatment can be provided, or referral made to the parent’s physicians.
Arrange. Arrange follow-up visits. Monitor the
progress of all parents who try to stop smoking.
Ask about smoking in the child’s environment at
each visit. Let parents know that you think that
smoking prevention and cessation are important
for the child’s and the family’s health.
Late Childhood (Ages 5 through 12)
Between the ages 5 and 12 years, the AAP
rec-ommends that a child make a minimum of five
physician visits.10
Anticipatory Guidance. Health maintenance
vis-its during late childhood provide many
opportuni-ties to discuss tobacco use with a child. Tobacco
use can begin as early as age 5, although
experi-mentation more often occurs in preadolescence. In elementary school, boys experiment with cigarettes more than girls, although the reverse is true in high
school.5”5 Younger children tend to think of
smok-ing in negative terms. Older children, on the other
hand, think about both positive and negative
as-pects of smoking. The risk of cigarette smoking
increases with decreasing academic performance,
particularly for girls.’8 Increased risk of smoking is also associated with smoking among parents,
sib-lings, and friends.’9
Although less prevalent than cigarette smoking,
smokeless tobacco is also a significant problem.
Therefore, questions and advice should always in-elude references to smokeless tobacco.
The child should be included in discussions about tobacco use. By actively involving a child in his or her own health care, responsibility and self-control over important health behaviors may be achieved. Anticipatory guidance should include parents. Physicians should inform parents that cigarette use
often begins in grade school. Parents should be
encouraged to examine their beliefs and tobacco use and be reminded that these beliefs and practices influence their child. Children readily perceive
in-consistencies between preaching and practice.7
Ask. Ask about the child’s use of tobacco and use
by friends. Ask the child whether smoking is
dis-cussed among friends, whether the meaning of the
word tobacco is understood, and whether there is
any harm in trying smoking. Ask about school
progress. Ask whether smoking is being discussed
in school, and if so, in what classes. Ask the parents and the child whether any household members, care givers, teachers, or authority figures smoke.
Advise. Advise the child who experiments with
tobacco use to stop. Advise the child who has not experimented to refuse offers of tobacco. Tell the child about the short-term negative effects of to-bacco use: smelly clothes and hair, stained teeth
and fingers, bad breath, decreased stamina and
athletic performance, and addiction. Tell the child
Remind adults of their image as role models and of
the effects of passive smoking.
Because the use of candy cigarettes promotes the
acceptability of smoking, and because a young child
who uses them may be more likely to smoke,2#{176}
advise parents to discourage their child from using
candy cigarettes.
Assist. Assist the child in taking additional
re-ponsibility for his or her health and behavior. The
assistance will vary dependent upon risk. A child
at low risk for tobacco use and not experimenting
may need only your compliments and
encourage-ment for continued healthy behavior. A child at
higher risk, especially one who is already
experi-menting, may need more help in developing refusal
skills that maintain self-esteem and peer
relation-ships.
If a child believes that tobacco use is undesirable,
but is not sure how to refuse it, you may wish to
conduct an informal “role-play.” Tell the child you
are acting as one of his or her friends, offer a
cigarette, and ask how he or she could refuse it. If the child does refuse, compliment and reinforce this behavior. If the child finds it difficult, quickly pro-vide some words that might work, eg, “no thanks,
it makes my clothes smell,” or “not right now,” or
“my boyfriend/girlfriend doesn’t like it.”
The physician may also help the child realize
that tobacco advertising falsely portrays smoking
as glamorous, healthy, sexy, or mature.
Arrange. Arrange more frequent follow-up visits
for a child experimenting with tobacco products.
Adolescents
and Young Adults (Ages
13
through 20)
The AAP recommends a minimum of four health
supervision visits between 14 and 20 years of age.’#{176} Anticipatory Guidance. Ideally, the establishment
of the alliance between physician and adolescent
should begin during the patient’s childhood. When
the patient is aged 11 to 13, physicians should be
spending the major part of the visit with the child rather than with the parents.
An adolescent who is deviance prone and who
overestimates smoking prevalence among adults
and teenagers is at increased risk for tobacco use.
Certain characteristics of self-image (toughness,
sociability, and precocity) also are associated with an intention to smoke.2’ An adolescent, especially
one with fewer coping resources, may smoke to
alleviate stress of adjustment demands made by
peers.22 An adolescent female, responsive to social
“standards” for slenderness, is particularly
vulner-able to cigarette advertisements implying that
smoking prevents weight gain.23
Although knowledge of the health risks of
to-bacco is important, knowledge alone is not
suffi-cient to prevent use by an adolescent. Peer
model-ing is one of the most important factors in choosing
to use tobacco. A child whose peer group members are tobacco users is likely to imitate them.’9
Ask. Ask adolescents at every visit whether they
or their friends are using tobacco. Inquire about
participation in sports and extracurricular
activi-ties in which tobacco use may compromise
perform-ance. Ask whether there are health education and
smoking prevention programs in the school or in
the community.
By early adolescence, many patients are capable of completing a questionnaire. This can be an effi-cient method of data collection. Some adolescents have less trouble sharing sensitive information in this way than in face-to-face encounters with the
physician. You may then discuss the answers and
ask additional questions to elicit in-depth
infor-mation. Some adolescents are more likely to give accurate answers and not feel as if they are being interrogated or lectured when questions are asked and advice given during the physical examination. In addition, the questions may seem more sponta-neous and less formal.
Advise. Advise tobacco users to stop. Advise the
adolescent that it is easier to stop now than later. Personalize the message. Mention reduced athletic capability, cost, stained fingers and teeth, cigarette
burns and odors on clothes, and other short-term
effects of tobacco use. Congratulate every patient
not using tobacco and advise continued abstinence.
Discuss the benefits of nonuse. Share a few tobacco
advertisements with the adolescent and point out
how they make the habit seem fun and sophisti-cated but ignore all the unpleasant and harmful
effects.24
Assist. Assist tobacco users in stopping. Help set
a quit date. Provide self-help materials. Consider offering a stop-smoking contract. Rehearse how to
say no in situations where peer pressure might
influence behavioral choices. Encourage exercise and social activities incompatible with tobacco use. Encourage participation in programs that promote
the skill development in problem solving, in setting
goals, in making decisions, and in countering neg-ative peer pressure. Many schools and
youth-serv-ing organizations have adopted such programs.25’26
Nicotine gum has been tested for safety and
efficacy in adults only, so generally it should not be
prescribed. In particular, it should not be prescribed for pregnant adolescents.
Arrange. Arrange a follow-up visit within 1 to 2
progress and problems. Arrange a second visit in 1
to 2 months.
CONCLUSIONS
Smoking prevention and cessation must be
viewed as an ongoing and integral part of medical practice. The medical office provides an important opportunity for physicians to communicate atti-tudes about smoking. Physicians can assist children
and adolescents in resisting the temptation to
smoke by emphasizing reasons not to use tobacco
and assisting those attempting to stop. By provid-ing advice, physicians can contribute to the goal of achieving a smoke-free generation by the year 2000.
ACKNOWLEDGMENT
We gratefully acknowledge the useful comments on
earlier drafts provided by an ad hoc advisory committee
convened by the National Cancer Institute and the
Amer-ican Academy of Pediatrics. Members of this committee
included Drs Ruth Etzel, Jonathan Klein, Kenneth
Schonberg, Benjamin Stands, James Strain, Jonathan
Sutton, and Ms Susan Tellez. Helpful comments were
also provided by Drs Robert Hannemann and Corinne
Husten.
REFERENCES
1. US Dept of Health and Human Services. Reducing the
Health Consequences of Smoking: 25 Years of Progress. A
Report of the Surgeon (eneral. Bethesda, MD: US Dept of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1989. Publication (CDC) 89-8411
2. US Dept of Health and Human Services. Smoking and
Health: A National Status Report. A Report to Congress. Bethesda, MD: US Dept of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Health Promotion and Education, Office on Smoking and Health; 1987. DHHS publication HHS/PHS/CDC-87-8396
3. Perry CL, Silvis GL. Smoking prevention: behavioral pre-scriptions for the pediatrician. Pediatrics. 1987;79:790-799 4. Dent CW, Sussman S, Johnson CA, et al. Adolescent
smoke-less tobacco incidence: relations with other drugs and psy-chosocial variables. Prey Med. 1987;16:422-431
5. Cohen RY, Sattler J, Felix MRJ, et al. Experimentation with smokeless tobacco and cigarettes by children and ado-lescents: relationships to beliefs, peer use, and parental use. Am J Public Health. 1987;77:1454-1456
6. Voss HL, Clayton RR. Stages in involvement with drugs. Pediatrician. 1987;14:25-31
7. American Academy of Pediatrics and Center for Advanced Health Studies. Risk factors and their implications for pre-vention and intervention for the physician. In: Schonberg 5K, ed. Substance Abuse: A Guide for Health Professionals.
Elk Grove Village, IL: American Academy of Pediatrics; 1988:3
8. Kandel D. Stages in adolescent involvement in drug use.
Science 1975;190:912-914
9. Hawkins JD, Lishner DM, Catalalano LF. Childhood and the prevention of adolescent substance abuse. In: Jones CL, Battjes Ri, eds. Etiology of Drug Abuse: Implications for Prevention. Bethesda, MD: US Dept of Health and Human Services; 1985. Publication ADM 85-1335
10. American Academy of Pediatrics, Committee on Psychoso-cial Aspects of Child and Family Health. Guidelines for Health Supervision II. Elk Grove Village, IL: American Academy of Pediatrics; 1988
1 1. American Academy of Pediatrics, Committee on Adoles-cence. Tobacco use by children and adolescents. Pediatrics.
1987;79:479-481
12. Glynn TJ, Manley MW. How to Help Your Patients Stop
Smoking: A National Cancer Institute Manual for
Physi-cians. Bethesda, MD: US Dept of Health and Human Serv-ices, Public Health Service, National Institutes of Health, National Cancer Institute; March 1989. NIH publication 89-3064
13. Koop CE. The pediatrician’s obligation in smoking educa-tion. AJDC. 1985;139:973
14. Frankowski BL, Secker-Walker RH. Addressing parents to stop smoking. ADJC. 1989;143:1091
15. Perry CL, Griffin G, Murray DM. Assessing need for youth health promotion. Prey Med. 1985;14:379-393
16. US Dept of Health and Human Services. The Health
Con-sequences of Smoking for Women: A Report of the Surgeon General. Bethesda, MD: US Dept of Health and Human Services, Public Health Service, Office of the Assistant Secretary for Health, Office on Smoking and Health; 1985. DHHS publication GPO 85-470-822
17. US Dept of Health and Human Services. The Health Con-sequences of Involuntary Smoking: A Report of the Surgeon General. Bethesda, MD: US Dept of Health and Human Services, Public Health Service, Office of the Assistant Secretary for Health, Office on Smoking and Health; 1986. DHHS publication PHS 87-8398
18. Brunswick AF, Messeri PA. Gender differences in the proc-esses leading to cigarette smoking. J Psychosoc Oncol. 1984;2:49-69
19. Murray M, Swan AV, Johnson MRD, et al. Some factors associated with increased risk of smoking by children. J
Child Psychol Psychiatry Allied Disciplines. 1983;24:223-232 20. Klein JD, Forehand B, Oliveri J, Patterson C, Keupersmidt
JB. Candy cigarettes: do they encourage children’s smoking?
Pediatrics. In press
21. Chassin LA, Presson DC, Sherman SJ. Stepping backward in order to step forward: an acquisition-oriented approach to primary prevention. J Consult Clin Psychol. 1985;53:612-622
22. Penny GN, Robinson JO. Psychological resources and cig-arette smoking in adolescents. Br J Psychol. 1986;77:351-357
23. Gritz ER. Gender and the teenage smoker. In: Ray BA, Braude MO, eds. Women and Drugs: A New Era for Re-search. Bethesda, MD: US Dept of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration; National Institute on Drug Abuse Monograph 65; 1987:70-79. DHHS publication
(ADM) 87-1447
24. Richards, JW, Blum A. Health promotion. In: Taylor RB, ed. Family Medicine Principles and Practice. 3rd ed. New York, NY: Springer-Verlag; 1986:101
25. Bingham M, Stryker S. Choices: A Teen Woman’s Journal
for Self-awareness and Personal Planning. Santa Barbara,
CA: Advocacy; 1989
