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Health-Care Provider Advice on Tobacco Use to Persons Aged 10-22 Years -- United States, 1993

Among U.S. adults who have ever smoked daily, 91% tried their first cigarette and 77% became daily smokers before age 20 years (1). Among high school seniors who had ever tried smokeless tobacco (SLT), 73% did so by the ninth grade (1). Despite the widely publicized risks of tobacco use, in 1993, 61% of high school sophomores believed that the risk from cigarette smoking was "great," and 44% believed the risk from SLT use was "great" (2). The low levels of understanding about the harmfulness of tobacco products underscore the need for health-care providers and others to provide adolescents and young adults with information to counter the allure of tobacco use created by marketing efforts. This report summarizes an analysis of data from the 1993 Teenage Attitudes and Practices Survey (TAPS II) regarding the provision of information about tobacco use by health-care providers to persons aged 10-22 years.

Data about knowledge of, attitudes toward, and practices regarding tobacco use among persons aged 10-22 years were collected by TAPS II by telephone interviews and by personal interviews among respondents not available by telephone. The sample for this analysis comprised 7960 respondents who had participated in the 1989 TAPS interview and who subsequently responded to TAPS II (aged 15-22 years at the time of the second interview), and an additional 4992 persons from a new probability sample in 1993 of 5590 persons aged 10-15 years (89.3% response rate). Data were weighted to provide national estimates. Adjusted odds ratios were computed by multiple logistical regression simultaneously adjusting for all other variables, and 95% confidence intervals were calculated using SUDAAN (3). Questions included: "Has a doctor, dentist, or nurse ever said anything to you about cigarette smoking?" and "Has a doctor, dentist, or nurse ever said anything to you about using chewing tobacco or snuff?" Correlations with affirmative responses were analyzed in relation to five categories of smoking and SLT use: Never smoked/used (never), tried but never smoked/used on daily basis or during the month preceding the interview (tried), smoked/used daily for at least 1 month but no smoking/use during the month preceding the interview (past daily), smoked/used during the month preceding the interview but never smoked/used daily for at least 1 month (current, never daily), and smoked/ used daily for at least 1 month and on greater than or equal to 1 day during the month preceding the interview (current, ever daily).

One fourth (25%) of respondents reported that a health-care provider had said something to them about cigarette smoking, and 12% said the same about SLT. More females (27%) than males (24%) answered "yes" to the question about cigarettes, and more males (14%) than females (9%) answered "yes" about SLT (Table_1 and Table_2). The proportion of respondents who answered "yes" increased significantly with age for cigarette smoking but not for SLT.

Affirmative responses were most strongly correlated with having a history of tobacco use (Table_1 and Table_2). Young persons who reported current or previous smoking or SLT use on a daily basis for at least 1 month (current or past daily) were significantly more likely than persons who had never smoked/used to answer "yes." Among current, ever daily users, 50% of smokers and 48% of SLT users answered "yes" compared with 21% of never smokers and 10% of never SLT users.

Reported by: LS Baker, MPH, Center for the Future of Children, The David and Lucile Packard Foundation, Los Altos, California. GE Morley, The Robert Wood Johnson Foundation, Princeton, New Jersey. DC Barker, MHS, The California Wellness Foundation, Woodland Hills, California. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: One of the national health objectives for the year 2000 is to increase to at least 75% the proportion of primary-care physicians who routinely provide smoking-cessation advice to their patients (objective 3.16) (4). In addition, the American Medical Association has recommended that primary-care physicians and other health-care providers ask adolescents annually about their use of tobacco products and patterns of use and provide a cessation plan to adolescents who use tobacco products (5). The findings in this report indicate that only approximately half of those persons aged 10-22 years who had ever smoked or used SLT daily and were current cigarette smokers or users of SLT recall ever receiving any communication about the use of cigarettes or SLT from physicians, dentists, or nurses.

The analysis of the TAPS II data is subject to at least two limitations. First, because these self-reported data are based on respondents' recollection of their communication with a health-care provider, they probably underestimate the interactions between patients and their health-care providers. Second, TAPS and TAPS II do not contain information about the number of visits to health-care providers. However, the likelihood that health-care providers will advise against tobacco use is directly related to the number of visits, and the average annual number of physician contacts varies by age, sex, race/ethnicity, and income level (6).

The analysis of TAPS is consistent with other reports documenting missed opportunities to provide information before adolescents begin to use tobacco (1,7,8). Although use of cigarettes and SLT begins early in adolescence (1), the TAPS findings indicate that only 24% of respondents who had tried a cigarette and only 13% of those who had tried SLT recalled hearing about tobacco use from a health-care provider. In addition, health-care providers were more likely to say something about tobacco use to patients who were current or heavy users, a pattern consistent with that for adults (9).

Basic strategies to prevent nicotine addiction in adolescents and young adults include tobacco tax increases, enforcement of laws preventing the access of minors to tobacco, youth-oriented mass media campaigns, and school-based tobacco-use prevention programs (1). In addition, the role of health-care providers is critical in preventing patients from initiating tobacco use or quitting if they become addicted to nicotine: patients who are told to quit smoking by their physician are nearly twice as likely to be preparing to quit than were those who had never been so advised (10). The National Cancer Institute and the American Medical Association have developed guidelines and national training programs to assist health-care providers in discussing both cigarette and SLT use with young patients (5,7,8). In addition, CDC, in conjunction with the American Medical Association, is funding new initiatives to foster development of innovative cessation services for adolescents.

References

  1. US Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994.

  2. Johnston LD, O'Mally PM, Bachman JG. National survey results on drug use from the Monitoring the Future study, 1975-1993. Volume 1: secondary school students. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute on Drug Abuse, 1994; NIH publication no. 94-3809.

  3. Shah BV, Barnwell BG, Hunt PN, LaVange LM. Software for survey data analysis (SUDAAN) version 5.5 {Software documentation}. Research Triangle Park, North Carolina: Research Triangle Institute, 1991.

  4. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

  5. American Medical Association. Guidelines for adolescent preventive health services. Chicago: American Medical Association, 1993.

  6. Benson V, Marano MA. Current estimates from the National Health Interview Survey, 1993. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, NCHS, 1994. (Vital and health statistics; series 10, no. 190).

  7. Epps RP, Manley MW. Prevention of tobacco use during childhood and adolescence: five steps to prevent the onset of smoking. Cancer 1993;72:1002-4.

  8. Mecklenberg RE, Christen AG, Gerbert B, et al. How to help your patients stop using tobacco: a manual for the oral health team. Bethesda, Maryland: US Department of Health and Human Services, National Institutes of Health, National Cancer Institute, 1993; NIH publication no. 93-3191.

  9. Frank E, Winkleby MS, Altman DG, Rockhill B, Fortmann SP. Predictors of physicians' smoking cessation advice. JAMA 1991;266:3139-44.

  10. Gilpin EA, Pierce JP, Johnson M, Bal D. Physician advice to quit smoking: results from the 1990 California Tobacco Survey. J Gen Intern Med 1993;8:549-53.



Table_1
Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 1. Percentage of persons aged 10-22 years * who reported that a health-care
provider + ever said anything to them about cigarette smoking, by selected
characteristics -- United States, Teenage Attitudes and Practices Survey, 1993.
===================================================================================
                                                     Adjusted
Characteristic                %     (95% CI) &       Odds Ratio @   (95% CI)
-----------------------------------------------------------------------------------
Sex
 Male                       23.6  (22.5%-24.8%)         1.0        Referent
 Female                     26.5  (25.3%-27.8%)         1.2        (1.1-1.3)

Age group (yrs)
 10-16                      20.7  (19.6%-21.8%)         1.0        Referent
 17-19                      29.0  (27.4%-30.6%)         1.2        (1.1-1.4)
 20-22                      33.7  (31.8%-35.7%)         1.4        (1.3-1.6)

Poverty status **
 At/Above poverty level     25.6  (24.6%-26.5%)         1.0        Referent
 Below poverty level        22.6  (20.4%-24.8%)         1.1        (0.9-1.3)
 Unknown                    23.8  (20.6%-27.0%)         1.0        (0.8-1.2)

Health Status
 Excellent                  24.4  (23.2%-25.6%)         1.0        Referent
 Very good/Good             25.6  (24.3%-26.9%)         1.1        (1.0-1.2)
 Fair/Poor                  29.4  (24.7%-34.1%)         1.3        (1.0-1.7)

Region ++
 Northeast                  27.6  (25.7%-29.4%)         1.0        Referent
 Midwest                    24.0  (22.4%-25.7%)         1.1        (1.0-1.3)
 South                      24.8  (23.2%-26.4%)         0.9        (0.8-1.1)
 West                       24.6  (22.8%-26.5%)         1.0        (0.9-1.2)

Smoking history &&
 PM-,ED-,ET-                20.9  (19.8%-21.9%)         1.0        Referent
 PM-,ED-,ET+                24.0  (22.2%-25.7%)         1.1        (1.0-1.2)
 PM-,ED+                    41.5  (36.0%-46.9%)         2.2        (1.7-2.8)
 PM+,ED-                    26.1  (22.6%-29.6%)         1.2        (1.0-1.5)
 PM+,ED+                    50.2  (47.3%-53.2%)         3.2        (2.8-3.7)

Total                       25.1  (24.2%-25.9%)
-----------------------------------------------------------------------------------
*  n=12,871. Persons who had missing data on any variable (n=81) were excluded from
   this analysis.
+  Doctor, dentist, or nurse.
&  Confidence interval.
@  Each odds ratio was simultaneously adjusted by multiple logistical regression
   for all other characteristics and for race/ethnicity.
** Poverty statistics are based on a definition originated by the Social Security
   Administration in 1964, subsequently modified by federal interagnecy committees
   in 1969 and 1980, and prescribed by the Office of Management and Budget as the
   standard to be used by federal agencies for statistical purposes.
++ Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New
   York, Pennsylvania, Rhode Island, and Vermont; Midwest=Illinois, Indiana, Iowa,
   Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South
   Dakota, and Wisconsin; South=Alabama, Arkansas, Delaware, District of Columbia,
   Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina,
   Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia;
   West=Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada,
   New Mexico, Oregon, Utah, Washington, and Wyoming.
&& PM-=Did not smoke during the month preceding the interview; ED-=Never smoked
   daily for at least 1 month preceding the interview; ET-=Never tried cigarette
   smoking; ET+=Ever tried cigarette smoking; ED+=Ever smoked daily for at least
   1 month preceding the interview; PM+=Smoked on >=1 day during the month
   preceding the interview.
===================================================================================

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Table_2
Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 2.  Percentage of persons aged 10-22 years * who reported that a health-care
provider + ever said anything to them about using chewing tobacco or snuff, by
selected characteristics -- United States, Teenage Attitudes and Practices Survey,
1993.
===================================================================================
                                                     Adjusted
Characteristic                 %    (95% CI &)      Odds Ratio @   (95% CI)
-----------------------------------------------------------------------------------
Sex
 Male                       14.3  (13.4%-15.2%)         1.0       Referent
 Female                      9.2  ( 8.4%-10.0%)         0.7       (0.6-0.8)

Age group (yrs)
 10-16                      11.3  (10.4%-12.1%)         1.0       Referent
 17-19                      12.0  (10.9%-13.1%)         0.9       (0.8-1.1)
 20-22                      13.0  (11.6%-14.5%)         1.0       (0.8-1.2)

Poverty status **
 At/Above poverty level     11.9  (11.2%-12.7%)         1.0       Referent
 Below poverty level        10.6  ( 9.1%-12.2%)         1.0       (0.8-1.3)
 Unknown                    12.0  ( 9.5%-14.5%)         0.9       (0.7-1.2)

Health status
 Excellent                  11.7  (10.9%-12.6%)         1.0       Referent
 Very good/Good             11.9  (10.9%-12.9%)         1.0       (0.9-1.2)
 Fair/Poor                  11.5  ( 7.7%-15.2%)         1.0       (0.7-1.6)

Region ++
 Northeast                  10.0  ( 8.7%-11.3%)         1.0       Referent
 Midwest                    11.2  ( 9.9%-12.5%)         0.9       (0.7-1.1)
 South                      13.6  (12.3%-14.8%)         1.0       (0.8-1.2)
 West                       11.0  ( 9.8%-12.3%)         1.2       (1.0-1.4)

Smokeless tobacco
 use history &&
 PM-,ED-,ET-                10.4  ( 9.7%-11.2%)         1.0       Referent
 PM-,ED-,ET+                13.2  (11.5%-14.9%)         1.2       (1.0-1.4)
 PM-,ED+                    27.3  (19.9%-34.6%)         2.7       (1.8-4.1)
 PM+,ED-                    20.2  (15.1%-25.4%)         1.8       (1.3-2.6)
 PM+,ED+                    47.9  (41.5%-54.2%)         6.3       (4.7-8.5)

Total                       11.8  (11.1%-12.4%)
-----------------------------------------------------------------------------------
*  n=12,843. Persons who had missing data on any variable (n=109) were excluded
   from this analysis.
+  Doctor, dentist, or nurse.
&  Confidence interval.
@  Each odds ratio was simultaneously adjusted by multiple logistical regression
   for all other characteristics and for race/ethnicity.
** Poverty statistics are based on a definition originated by the Social Security
   Administration in 1964, subsequently modified by federal interagency committess
   in 1969 and 1980, and prescribed by the Office of Management and Budget as the
   standard to be used by federal agencies for statistical purposes.
++ Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New
   York, Pennsylvania, Rhode Island, and Vermont; Midwest=Illinois, Indiana, Iowa,
   Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South
   Dakota, and Wisconsin; South=Alabama, Arkansas, Delaware, District of Columbia,
   Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina,
   Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia;
   West=Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada,
   New Mexico, Oregon, Utah, Washington, and Wyoming.
&& PM-=Did not use SLT during the month preceding the interview; ED-=Never used SLT
   daily for at least 1 month preceding the interview; ET-=Never tried SLT;
   ET+=Ever tried SLT; ED+=Ever used SLT daily for at least 1 month preceding the
   interview; PM+=Used SLT on >=1 day during the month preceding the interview.
===================================================================================

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