Opportunities in the Health Care System to Reduce Young Adult Tobacco Use

1. Opportunities in the Health Care System to Reduce Young Adult Tobacco Use Virginia P. Quinn, PhD Kaiser Permanente Southern California Jonathan P. Winickoff, MD, MPH Massachusetts General Hospital Center for Child and Adolescent Health Policy

2. Health Rationale • Tobacco is No. 1 cause of preventable illness & death in the US and a major factor in health care costs • In 2000, 26.8% of 18-24 year olds were current smokers • Prevention & cessation have major and immediate health benefits for smokers of all ages

3. Why Intervene in Health Care Settings? • Health care settings provide access to smokers, esp. high risk groups • Patients perceive clinicians as highly credible sources of health information • Motivation may be enhanced by tailoring advice to smokers’ health concerns • Clinician advice and assistance increase cessation rates

4. 2000 USPHS Clinical Practice Guideline: Treating Tobacco Use and Dependence • Identify, document & treat tobacco users • Brief clinical intervention: 5 As • ASK about tobacco use • ADVISE smokers to quit • ASSESS willingness to make a quit attempt • ASSIST with treatment & referrals • ARRANGE follow-up contacts

5. USPHS Clinical Practice Guideline: Efficacy Estimates for Tobacco Treatment • Estimated cessation OR for MD advice = 1.3 • Estimated cessation OR for assistance: MD counseling = 2.2 nicotine patch = 1.9 bupropion SR = 2.1

6. Delivery of Tobacco Services (over 12 months of health care visits) • In 1974, only 26% advised to quit (NHIS) • Rate improved to 60% in 1995-96 (CPS) • Receipt of advice is considerably lower among young adult smokers • In 1991 NHIS, 28% of smokers 18-24 received advice v. 44% of smokers 45-64 • Fewer smokers of any age receive help beyond advice

7. Barriers to Delivery of Tobacco Cessation Services • Concern about alienating patients who smoke • Time constraints • Limited financial reimbursement for counseling • Limited provider counseling skills • Belief that counseling is not effective • Organizational barriers in health care system • lack of a systematic way to identify smokers • comprehensive coverage for treatment

8. Additional Barriers to Delivery of Cessation Services for Young Adults • Young adults are healthier • Fewer outpatient visits (esp. males) • Lower health-related motivation to quit • Many light or occasional smokers • Social smokers may not self-identify as smokers • Little data on 18-24 yr olds • Delivery of tobacco services • Efficacy of tobacco treatment interventions

9. How Do Young Adults Access the Health Care System? • Pregnancy  Obstetrics, FP • Contraception/PapsGyn, PC • Parenting Pediatrics • Injuries  ER

10. Addressing Young Adult Smoking in Obstetric / Gynecologic Care • Ob/gyn visits are opportunities to reach pregnant and non-pregnant young women • Smoking presents multiple threats to reproductive health • 18-24 year olds have high birth rates & high rates of smoking during pregnancy • In 1999, 19% of pregnant women 18-19 years of age smoked

11. Smoking Cessation in Pregnancy: Best Clinical Practice(ACOG & RWJ) In addition to usual advice during prenatal visits: • 5-15 minute counseling session • Trained counselor • Pregnancy-tailored written material Cost-saving ($3 saved / $1 spent) Increases cessation: 5-10% to 15-20%

12. Limitations of “Best Practice” • While clinically significant, cessation rates are modest • Does not increase cessation among heavy smokers • High rates of relapse to smoking after delivery

13. To Enhance “Best Practice” • Improve counseling efficacy • at prenatal care or WIC visits • telephone outreach to smokers • Add pharmacotherapy? • Efficacy & safety during pregnancy is unknown • Conduct research in diverse populations of pregnant smokers • RWJ Smoke-Free Families Research Initiative

14. Do Providers Address Tobacco in Ob/Gyn Care? • Pregnant smokers are often identified during prenatal care • National survey data indicate only 49% of ob/gyn MDs routinely advise pregnant & nonpregnant smokers to quit (Healthy People 2000 Review) • Smoking cessation counseling is provided at fewer than 25% of prenatal visits (NAMCS, 1996)

15. National Partnership to Help Pregnant Smokers Quit • Coalition of diverse organizations with goal of disseminating best-practice cessation counseling • Includes over 40 national organizations including RWJ SFF, CDC, March of Dimes, ACOG, AMA • Find out more from www.smokefreefamilies.org

16. Addressing Young Adult Smoking in Pediatric Care? • 23% of all smokers are parents with a child under the age of 18 (McMillen et al. in press) • These parents see child’s health care provider an average of 4 times per year (Newacheck et al.) • Burden of parental smoking on children is high • Parents don’t object, and even expect, tobacco counseling at children’s health visits (e.g., Frankowski et al., Klein et al., Groner et al., and Jaen et al.)

17. American Academy of Pediatrics:Clinical recommendations • Pediatricians should address tobacco use by children and adolescents • Pediatricians should counsel parents about ETS and encourage cessation • Pediatricians should be knowledgeable about cessation and offer help and referrals • Training programs in tobacco control for pediatricians, medical students, & residents

18. Delivery of Tobacco Cessation Services in Pediatric Care Data suggest: • Pediatricians often ask about smoking (Winickoff et al., Tanski et al.) • Much less frequently provide counseling, particularly to parents who smoke (Burnett et al., Winickoff et al.) • Report lack of counseling skills for cessation (Zapka et al., Frankowski et al.)

19. Research Among Parents in Pediatric Care Settings • Studies using advice and counseling have shown some success (e.g., Curry et al., Emmons et al., Severson et al., Valanis et al.) • A feasibility study using medications and cessation program referral has shown promise (Winickoff et al.) • Studies using the full PHS guideline-based approach are planned for the pediatric setting--(stay tuned)

20. Conclusions • Although young adults use the health care system less than older adults, there are opportunities to reach them • Ob/Gyn care • Pediatric care • ER care (not covered here) • Challenges remain for taking advantage of these opportunities • To identify more effective cessation treatments • To identify optimal dissemination strategies for the effective cessation treatments that currently exist

21. Research Questions • What cessation methods work best for young adults? (e.g., can we use what we have or do we need to innovate)? • Pregnancy • Can we improve cessation rates with new strategies (drugs, more intensive counseling)? • Will national dissemination efforts work? • Pediatrics • Is pediatrician-delivered smoking counseling to parents effective? Acceptable to pediatricians?