7. Tobacco Exposure
This section of the Guidelines provides recommendations to pediatric care providers
on limiting tobacco exposure in their child and adolescent patients. The section
begins with background information on the importance of tobacco dependence as a
risk factor for cardiovascular disease (CVD). This is followed by the Expert Panel's
summary of the evidence review relative to tobacco exposure. The evidence review
and the development process for the Guidelines are outlined in Section I. Introduction
and are described in detail in Appendix A. Methodology. As described, the evidence
review augments a standard systematic review where the findings from the studies
reviewed constitute the only basis for recommendations with each study described
in detail. This evidence review combines a systematic review with an Expert Panel
consensus process that incorporates and grades the quality of all relevant data
based on preidentified criteria. Because of the large volume of included studies
and the diverse nature of the evidence, the Expert Panel also provides a critical
overview of the studies reviewed for each risk factor, highlighting those that,
in its judgment, provide the most important information. Detailed information from
each study has been extracted into the evidence tables. The complete evidence tables
will be available online at
http://www.nhlbi.nih.gov/guidelines/cvd_ped/index.htm. The conclusions of
the Expert Panel's review of the evidence are then summarized and graded, and the
section ends with age-based recommendations to prevent tobacco exposure. References
are listed sequentially at the end of the section, with references from the evidence
review identified by unique PubMed identifier (PMID) numbers in bold text. Additional
references do not include the PMID number.
Tobacco dependence is responsible for approximately 4 million annual deaths worldwide.
Moreover, in utero exposure to tobacco products, involuntary tobacco smoke exposure
(secondhand smoke), and tobacco use directly impair the health of fetuses, infants,
children, and adolescents. Based on an analysis of published causes of death, tobacco
use is the leading actual cause of death in the United States. The evidence that
tobacco use is harmful and addictive is unequivocal.,,,,
In childhood, nicotine is highly addicting, with symptoms of tobacco dependence
demonstrated after only brief intermittent use. Current cigarette use among
high school students declined from 1997 to 2003, but rates have been stable since,
From a public health standpoint, the need to reduce tobacco exposure is sufficiently
compelling that a role for pediatric health care providers is essential.
A clinical practice guideline update from the U.S. Public Health Service published
in May 2008 systematically reviewed almost 9,000 publications and concluded that
smoking prevention and cessation interventions are effective in adults.,
However, different approaches may be needed for children and adolescents. Physicians
who care for children are well-positioned to provide tobacco use prevention and
treatment interventions for their patients. Youth interventions should target parents
as well as their children, since parental smoking is both a risk factor for child
smoking and a source of secondhand smoke exposure.
OVERVIEW OF THE EVIDENCE FOR PREVENTION OF TOBACCO EXPOSURE
From the evidence review relative to environmental smoke exposure, a moderate number
of studies address the efficacy of physician-based interventions to alter parental
A 2003 systematic review included 19 studies published through October 2001 that
tested interventions to reduce tobacco smoke exposure in children; 6 of these were
part of the evidence review for these Guidelines. Only four interventions
were judged to be effective: Three involved intensive counseling in a clinical
setting, and one used a curricular approach in a school setting. The reviewers concluded
that there was good evidence that brief informational interventions were ineffective
and found limited support for intensive counseling in primary care. The evidence
review for these Guidelines identified eight randomized controlled trials (RCTs),
three of which showed a significant decrease in children's smoke exposure.,,,,,,,
An intervention in low-income families in a primary care setting used motivational
interviewing with informational materials supplied to controls; at 6-month followup,
household nicotine levels were significantly lower in the intervention group.
In low-income families, seven counseling sessions delivered over 3 months were effective
in significantly decreasing maternal smoking rates by self-report and children's
urine cotinine concentrations.
In a pediatric clinic setting, a brief motivational interview followed by up to
three telephone counseling calls in the following 3 months showed significantly
higher maternal abstinence rates at 3- and 12-month followups. Studies with
unsuccessful interventions used tobacco exposure demonstrations, a
home-based intervention by lay community health advisors, and a physician-delivered
report of infant urine cotinine results, with mailed information on decreasing smoke
The Special Turku Coronary Risk Factor Intervention Project, a Finnish study that
successfully reduced saturated fat intake beginning in infancy, with followup for
more than a decade, showed no differences in parental smoking between the intervention
and control groups despite repeated lifestyle counseling that included an antitobacco
Two pediatric care provider studies specifically addressed smoking cessation in
mothers following the birth of a child., As in the
obstetrical literature, these were effective in achieving smoking cessation during
pregnancy, but after 612 months, there was no evidence for postnatal effect.
Overall, interventions to decrease environmental smoke exposure carried out in pediatric
care settings have shown mixed results, with some evidence that intensive counseling
can be effective.
Office-based counseling directed at children and adolescents for prevention of tobacco
use has been a mainstay in pediatric preventive care. Although contact with preadolescents
and adolescents in primary care is sporadic, pediatricians and family physicians
retain a critical voice in conveying health information to children and their parents.
Counseling with regard to the adverse effects of tobacco products does improve patient
The evidence review identified two major systematic reviews for consideration. A
2003 systematic review of smoking prevention interventions delivered by health care
providers included four studies, of which only one showed a significant effect on
prevention of smoking initiation. A 2007 systematic review of
family-based programs for smoking prevention identified 14 RCTs for review.
Four of the nine that tested a family intervention against a control group had significant
positive effects, whereas only one of the five that tested a family intervention
against a school-based intervention had a significant positive outcome. None of
the six that compared the incremental effects of a family plus a school program
with a school program alone had significant positive effects. Overall, a significantly
lower rate of smoking initiation was achieved in approximately 40 percent of interventions.
The amount of implementer training and the quality of the implementation were related
to positive outcomes, but the number of sessions was not. Use of biomarkers of tobacco
exposure in addition to self-report of tobacco use provided no consistent benefit.
In an RCT, a pediatric practice-based smoking prevention and cessation program that
used a combined provider- and peer-delivered intervention was effective in preventing
initiation of smoking at 1-year evaluation.
Studies of the benefits of office-based counseling on smoking reduction have yielded
conflicting results. A 2006 Cochrane Collaboration review of the effectiveness of
strategies to achieve smoking cessation in adolescents identified 15 trials for
inclusion. The review found that interventions that used pharmacologic aids were
ineffective, but those that used the stages of change approach and/or motivational
interviewing did achieve statistically significant positive results at 6-month followup.
A randomized trial of more than 2,500 adolescents, both smokers and nonsmokers,
in 7 large pediatric and family practice departments of a group health maintenance
organization combined 30-second clinician advice, a 10-minute interactive computer
program, a 5-minute motivational interview, and telephone booster sessions. At followup
more than 6 months later, the abstinence rate was significantly higher in the intervention
group compared to the control group. In adolescent smokers, brief
counseling by providers in an emergency department was associated with an increase
in quit attempts by adolescent smokers. A recent combined provider-
and peer-delivered intervention set in pediatric practice settings increased abstinence
rates among smokers at 6-month but not at 12-month followup.
School-based smoking prevention programs have achieved modest success, although
there, too, results have been inconsistent, and evidence of long-term benefits is
Two systematic reviews provide important perspectives. A 2006 Cochrane review identified
23 high-quality RCTs of school-based programs to prevent smoking initiation.
The interventions included providing information, social influence approaches, social
skills training, and community approaches. Information alone was ineffective, but
the combined social influences and social skills interventions were moderately effective
in approximately half of the trials. A 2005 systematic review focused on long-term
followup of school-based smoking prevention. Of eight studies that were reviewed,
only one showed decreased smoking prevalence in the intervention group at longer
than 1-year followup.
Pharmacotherapies (i.e., nicotine replacement and medication) have been proven to
aid in smoking cessation in adults. Some RCTs have demonstrated the safety of the
nicotine patch and nicotine gum, as well as bupropion in adolescent smokers, but
cessation results are inconsistent., Overall,
such studies performed in young smokers have shown that pharmacotherapies were not
Public health measures have been the most effective methods to prevent and limit
tobacco use. Successful strategies include taxation of tobacco products, clean indoor
air legislation, and counteradvertising against tobacco products.
Regulatory efforts and activities as well as efforts to promote clean indoor air
in homes, automobiles, and schools all have been shown to have positive effects
on tobacco smoke exposure and tobacco use.,
CONCLUSIONS AND GRADING OF THE EVIDENCE REVIEW ON PREVENTION OF TOBACCO EXPOSURE
Among all the known risk factors for CVD, the dichotomy between known benefits of
risk elimination and the paucity of evidence for effective interventions to achieve
risk reduction in pediatric care provider settings is greatest for tobacco exposure.
The quality of the evidence regarding the harm of smoking and the benefits of passive
smoke exposure avoidance, smoking prevention, and smoking cessation is uniformly
Grade A. The reason that evidence grades in the recommendations are less than Grade
A reflects the lack of existing evidence on interventions impacting smoking behaviors
in specific pediatric age groups as opposed to the collective evidence.
- Good-quality interventions in pediatric care settings to decrease children's environmental
smoke exposure have shown mixed results (Grade B).
- Intervention studies to prevent smoking initiation have had moderate success, although
long-term results are limited (Grade B).
- Practice-based interventions to achieve smoking cessation in adolescents have had
moderate success with limited long-term followup (Grade B).
- School-based smoking prevention programs have been moderately successful, with limited
long-term followup (Grade B).
Although the evidence base in support of an office-based approach to tobacco intervention
is moderate and at times mixed, the evidence that cigarette use is harmful and addictive
is unequivocal. From a public health standpoint, the need to reduce tobacco exposure
is sufficiently compelling that a role for pediatric health care providers is essential.
The lack of harm associated with such interventions and the importance of communicating
the message of risk associated with tobacco provide the rationale for supporting
"Strongly recommend," despite the lack of conclusive evidence that office-based
interventions reliably reduce tobacco initiation or smoking cessation. Physicians
and nurses who care for children are well-positioned to provide intervention to
patients who smoke. The Expert Panel believes that such providers should routinely
identify patients who smoke using the medical history. Patients should be explicitly
informed about the addictive and adverse health effects of tobacco use. By using
the 5A questions (Ask, Advise, Assess, Assist, Arrange), providers can assess their
patients' readiness to quit and assist in providing resources to support smoking
cessation efforts. Information about telephone quit lines (e.g., 1800QUITNOW),
community cessation programs, and pharmacotherapy should also be made available.
As described, practice-based interventions to decrease environmental smoke exposure
have shown mixed results. Nonetheless, the Expert Panel believes that pediatric
care providers should identify parents and other caregivers who smoke and explicitly
recommend that children not be exposed to tobacco smoke in the home, in automobiles,
and in any other space where exposure can occur. For the parent who smokes, information
provided should include statements about health benefits to the individual, child,
and/or fetus, as well as referral to smoking cessation care providers.
Prenatal tobacco exposure is addressed separately in Section XIII. Perinatal Factors.
Pediatric care providers should identify mothers who use tobacco and should deliver
explicit counseling to these mothers to quit smoking before pregnancy, not smoke
during pregnancy, and remain smoke free after the baby's birth. Such counseling
has been shown to be effective during pregnancy, but postpregnancy recidivism is
The Expert Panel strongly recommends that pediatric care providers deliver a clear
and repeated antismoking and smoking cessation message. When possible, primary care
providers should attempt to integrate more intensive approaches to tobacco use prevention
and cessation in their practices. Only a small number of studies have demonstrated
that pharmacotherapies (i.e., nicotine replacement and medication) have been effective
in supporting smoking cessation efforts in adolescents. Nonetheless, pediatricians
may wish to acquire experience using these therapies or identify another health
care professional with such experience for referral.
Tobacco use is considered in risk stratification algorithms in individuals with
hypercholesterolemia, hypertension, and diabetes mellitus. Treatment thresholds
for pharmacologic treatment of elevated cholesterol and hypertension are lower with
tobacco use, and treatment goals may be more aggressively pursued in active smokers.
Public health measures have been effective in preventing and limiting tobacco use.
Pediatricians need to be involved in advocacy for such regulatory efforts, as well
as in school- and community-based efforts to prevent the initiation of smoking and
to promote effective cessation strategies.
Table 71. Evidence-Based Recommendations to Prevent Tobacco Exposure
Grades reflect the findings of the evidence review.
Recommendation levels reflect the consensus opinion of the Expert
Supportive actions represent expert consensus suggestions from
the Expert Panel provided to support implementation of the recommendations
Obtain smoking history from mothers, then provide explicit smoking cessation message
before and during pregnancy
- Identify resources to support maternal smoking cessation efforts.
- Advocate for school and community-based smoke free interventions
- See Section XIII. Perinatal Factors
Promote a smoke-free home environment
1-4 years (cont.d)
Reinforce this message at every encounter, including urgent visits for respiratory
1-4 years (cont.d)
- Provide information about health benefits of a smoke-free home to parents and children
- Advocate for school- and community-based smoke-free interventions
Obtain smoke exposure history from child, including personal history of tobacco
5-10 years (cont.d)
Counsel patients strongly about not smoking, including providing explicit information
about the addictive and adverse health effects of smoking
Obtain personal smoking history at every non-urgent health encounter
18-21 years (cont.d)
Explicitly recommend against smoking
18-21 years (cont.d)
Provide specific smoking cessation guidance
18-21 years (cont.d)
- Use 5A questions to assess readiness to quit
- Establish your health care practice as a resource for smoking cessation
- Provide quit line number
- Identify community cessation resources
- Provide information about pharmacotherapy for cessation
- Advocate for school and community-based smoke-free interventions
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