Tobacco

=Tobacco =

These two videos are approximately 50 years apart and seem to reflect the zeitgeist of society toward smoking during each era. As one can see in the old black and white commercial, smoking was widely accepted and tobacco companies even used children cartoons as a form of promotion. Today our society has become aware of the detriments of smoking and anti-tobacco groups place provocative and graphic ads to send out their message.

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**FACILITATORS: Erin Ross, Wolfgang Riedl**


 * **Contents**
 * Learner Objectives
 * Required Readings and Websites
 * Recommended Readings
 * Healthy People 2020 Objective
 * Related Epidemiological Data
 * Screening Guidelines and Assessment Parameters
 * Behavioral Intervention Recommendations
 * Discussion of Intervention Efficacy ||

Learner Objectives »

 * Analyze how tobacco use impacts Healthy People 2020 goals.
 * Compare and contrast approaches to tobacco risk screening, counseling, and immunization across the lifespan.
 * Use appropriated USPSTF screening and immunization recommendations for people at risk due to tobacco use.

 Required readings and Websites »

 * McDaniel, Campbell, Hepworth, & Lorenz, (2005)
 * Chap 13. Family Oriented care of adolescents
 * Martinelli, A.M. (1999). An explanatory model of variables influencing health promotion behaviors in smoking and nonsmoking college students. Public Health Nursing, 16(4), 263-269.
 * <span style="color: #0000ff; font-family: Verdana,Geneva,sans-serif;">WEBSITE: Healthy People 2020 Tobacco overview
 * <span style="color: #0000ff; font-family: Verdana,Geneva,sans-serif;">WEBSITE: AMA Guidelines for Adolescent Health
 * <span style="color: #0000ff; font-family: Verdana,Geneva,sans-serif;">WEBSITE: CDC smoking cessation
 * <span style="color: #0000ff; font-family: Verdana,Geneva,sans-serif;">WEBSITE: Nurses smoking cessation
 * <span style="color: #0000ff; font-family: Verdana,Geneva,sans-serif;">WEBSITE: USPSTF website use to identify appropriate prevention interventions
 * <span style="color: #0000ff; font-family: Verdana,Geneva,sans-serif;">[|WEBSITE: HHS Quick Reference Guide for Clinicians]
 * <span style="color: #0000ff; font-family: Verdana,Geneva,sans-serif;">[|Tobacco article 1.pdf]
 * <span style="color: #0000ff; font-family: Verdana,Geneva,sans-serif;">[|Tobacco article 2.pdf]

Recommended Readings

 * [|WEBSITE: CDC smoking and tobacco use]
 * [|Surgeon Generals Executive Summary: Preventing Tobacco use among youth and young adults]
 * [|NRT.pdf]
 * [|Chantix.package.insert.pdf]
 * [|interactions.with.smoking.table.pdf]

<span style="color: #000099; font-family: Verdana,Geneva,sans-serif;">Healthy People 2020 Goal »
<span style="font-family: Verdana,Geneva,sans-serif;">"Reduce illness, disability, and death related to tobacco use and secondhand smoke exposure." (Healthy People 2020, 2012)

<span style="color: #000099; font-family: Verdana,Geneva,sans-serif;">Related Epidemiological Data »
<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Tobacco use is a huge public health concern because it leads to many diseases such as heart disease, lung disease, cancer, and stroke. Tobacco use is one of the largest preventable causes of premature death in the country, which is why it is so important to address this issue at an early age. There is a large amount of data which shows that smoking is typically initiated during adolescence. More than 80% of current adult smokers began smoking before the age of 18 (CDC, 2012). The CDC (2012) reports that appoximately 3,800 young people under the age of 18 smoke their first cigarette every day, and 1,000 people in that group become daily smokers.

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">There are many factors associated with the initiation of tobacco use in adolescence. Some of the common factors include use and approval of tobacco use by peers or siblings, smoking by parents/guardians and/or lack of parental support or involvement, low self-image or self-esteem, aggressive behavior, a perception that tobacco use is the norm, exposure to tobacco advertising, and low levels of academic achievement (CDC, 2012). There are also significant health disparities related to tobacco use. The prevalence of cigarette smoking is highest among American Indians and Alaskin Natives, followed closely by Whites and Hispanics, then Asians and African Americans (Surgeon Generals Report, 2012). The prevalence of cigarette smoking also is increased for individuals of lower socioeconomic status. Adolescent use of tobacco has also been associated with other high risk behaviors such as drug and alcohol use and high-risk sexual behavior.

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">There are many national, state, and local programs aimed at prevention and cessation of tobacco use. When it comes to adolesents some activities which have helped to reduce tobacco use have included mass media campaigns targeted toward youth to encourage abstinence from tobacco use, school-based tobacco use prevention policys and programs, and higher cost for tobacco products through increased taxes (CDC, 2012). Other tobacco cessation programs include counsiling through face-to-face session, telephone or online programs, and medications have shown to be useful in helping individuals to stop smoking or lessening their urge to smoke.

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Potential impact of tobacco use on health of individuals and society.**

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">There are more deaths caused yearly from tobacco use than HIV, drug use, alcohol use, motor vehicle accidents, suicides, and murders combined (CDC, 2012). Tobacco harms nearly every organ in the human body and leads to many diseases such as cardiovascular disease, lung disease, cancer, and stroke. Between the years of 2000-2004 an estimated 443,000 people in the U.S. died prematurely due to health problems causes by smoking or exposure to second hand smoke. In addition to these overall health problems according to the Surgeon General (2012) the health consequences of young people who start smokeing include addiction to nicotene, reduced lung function, reduced lung growth, asthma, and early abdominal aortic artherosclerosis. These health problems that develop in young smokers are precursors for the long-term chronic diseases that are shown to develop later in life.



<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">In addition to being a public health concern tobacco use also has a huge impact on society and the economy. According to the CDC (2011) in the U.S. during the period of 2000-2004 smoking was estimated to be responsible for $193 billion in annual health-related economic losses. The federal and state governments began raising the price on cigarettes in 2009 in an attempt to off-set health related costs and in hopes of reducing the number of people who buy tobacco products. The effects of increased prices have in fact lead to significant reductions in smoking prevelance by increasing cessation among active smokers and reducing initiation among potential young smokers (CDC, 2011).

<span style="color: #000099; font-family: Verdana,Geneva,sans-serif;">Screening Guidelines and Assessment Parameters »
The Guidlines for Adolescent Preventative Services (AMA, 1997) recommends that "all adolescents should receive health guidance annually to promote avoidance of tobacco, alcohol, and other abuseable drugs". These adolescents should be asked yearly about their use of tobacco products. If the adolescents admit to use of such products they should then be assessed further to determine the pattern of use. A cessation plan should then be developed and discussed with the adolescent.

The U.S. Department of Health and Human Services (2012) says the most important step in addressing tobacco use and dependence is to screen for use. After use is determined and the individuals willingness to quit is established the provider can then assist the patient in quitting if they state they are ready by using the "5A's" or if the patient states they are not ready they can promote motivation to quit by using the "5R's" (HHS, 2012).



The "5R's" are used to assess and explore an individuals motivation to quit using tobacco products. The "5R's" stand for relavance, risks, rewards, roadblocks, and repitition. In the relavance portion of the assessment the provider can ask the patient how quitting may be personally relavant. Factors that the provider can present to assist in this area include longer and better quality of life, extra money, people around you will be healthier, decrased chance of diseases such as heart disease, stroke, and cancer, and if the individual is pregnant a provider could address the issue of improving the chance of having a healthy baby. In the risks portion of the assessment the provider can talk with the individual about their perception of risks continued use. In the short-term acute conditions such as asthma and breathing problems could be addressed and long-term risks such as heart disease, lung disease, and cancer could be addressed. In the rewards portion of the assessment the provider can talk with the individual about what they feel benefits/reward to quitting tobacco use would be. Some examples of benifits/rewards that could be disscussed include better health of self or others, additional years added to life, feel better, and for adolescents being an example for their younger siblings. In the roadblocks portion of the assessment the provider can talk with the patient about their perceived roadblocks to quitting. Some examples of perceived roadblocks that may have to be addressed include withdrawl symptoms, weight gain, depression, fear of failure, and lack of support. In the repitition portion of the assessment includes repeating the "5R's" each visit by providing motivation and information until the patient is ready to attempt to quit, then the provider can move into the "5A's" and providing appropriate treatment options.

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">USPSFT (n.d.) prevention recommendations for males age 18 who use tobacco and are not sexually active include the following:


 * Grade || Title ||
 * **[[file:///ePSS/gradedef.jsp%23old|A]]** || **HIV**: Screening -- Adults and Adolescents at Increased Risk ||
 * **[[file:///ePSS/gradedef.jsp%23new|A*]]** || **High Blood Pressure**: Screening -- Adults 18 and Over ||
 * **[[file:///ePSS/gradedef.jsp%23new|A*]]** || **Tobacco Use**: Counseling and Interventions for Adults ||
 * **[[file:///ePSS/gradedef.jsp%23old|B]]** || **Alcohol Misuse**: Screening and Behavioral Counseling -- Men, Women, and Pregnant Women ||
 * **[[file:///ePSS/gradedef.jsp%23new|B*]]** || **Depression**: Screening -- Adolescents, 12-18 years of age, in Clinical Practices with Systems of Care ||
 * **[[file:///ePSS/gradedef.jsp%23new|B*]]** || **Depression**: Screening -- Adults age 18 and over -- When staff-assisted depression care supports //are// in place ||
 * **[[file:///ePSS/gradedef.jsp%23old|B]]** || **Healthy Diet**: Counseling -- Adults with Hyperlipidemia and Other Risk Factors for CVD ||
 * **[[file:///ePSS/gradedef.jsp%23old|B]]** || **Obesity**: Screening and Intensive Counseling -- Obese Men and Women ||
 * **[[file:///ePSS/gradedef.jsp%23new|B*]]** || **Type 2 Diabetes Mellitus**: Screening Men and Women -- Sustained BP 135/80+ ||


 * Grade || Title ||
 * **[[file:///ePSS/gradedef.jsp%23new|D*]]** || **Aspirin to Prevent CVD**: Men younger than 45 years of age, to prevent myocardial infarction ||
 * **[[file:///ePSS/gradedef.jsp%23new|D*]]** || **Asymptomatic Bacteriuria:** Screening -- Men and Non-Pregnant Women ||
 * **[[file:///ePSS/gradedef.jsp%23old|D]]** || **CHD**: Screening Using ECG, ETT, EBCT -- Adults, Low Risk ||
 * **[[file:///ePSS/gradedef.jsp%23new|D*]]** || **Carotid Artery Stenosis**: Screening -- General Adult Population ||
 * **[[file:///ePSS/gradedef.jsp%23new|D*]]** || **Chronic Obstructive Pulmonary Disease**: Screening -- Adults, Using Spirometry ||
 * **[[file:///ePSS/gradedef.jsp%23old|D]]** || **Genital Herpes**: Screening -- Adolescents and Adults, Asymptomatic ||
 * **[[file:///ePSS/gradedef.jsp%23old|D]]** || **Gonorrhea**: Screening -- Men and Women at Low Risk ||
 * **[[file:///ePSS/gradedef.jsp%23old|D]]** || **Hemochromatosis**: Screening -- Asymptomatic Men and Women ||
 * **[[file:///ePSS/gradedef.jsp%23old|D]]** || **Hepatitis B**: Screening -- Asymptomatic Men and Women ||
 * **[[file:///ePSS/gradedef.jsp%23old|D]]** || **Hepatitis C**: Screening -- Asymptomatic Men and Women ||
 * **[[file:///ePSS/gradedef.jsp%23old|D]]** || **Pancreatic Cancer**: Screening -- Adults, Asymptomatic ||
 * **[[file:///ePSS/gradedef.jsp%23old|D]]** || **Peripheral Arterial Disease**: Screening -- Adults ||
 * **[[file:///ePSS/gradedef.jsp%23old|D]]** || **Routine Aspirin or NSAIDs for the Primary Prevention of Colorectal Cancer**: Preventive Medication -- All Adults, Average Risk ||
 * **[[file:///ePSS/gradedef.jsp%23old|D]]** || **Syphilis**: Screening -- Asymptomatic Men and Women ||
 * **[[file:///ePSS/gradedef.jsp%23new|D*]]** || **Testicular Cancer**: Screening -- Adolescent and Adult Men ||
 * **[[file:///ePSS/gradedef.jsp%23old|D]]** || **Vitamin Supplementation to Prevent Cancer and CVD**: Preventive Medication -- Beta Carotene ||


 * Grade || Title ||
 * **[[file:///ePSS/gradedef.jsp%23new|C*]]** || **Depression**: Screening -- Adults age 18 and over -- When staff-assisted depression care supports //are not// in place ||
 * **[[file:///ePSS/gradedef.jsp%23old|C]]** || **HIV**: Screening -- Adults and Adolescents, Not at Increased Risk ||
 * **[[file:///ePSS/gradedef.jsp%23new|I*]]** || **Bladder Cancer**: Screening -- All Adults ||
 * **[[file:///ePSS/gradedef.jsp%23new|I*]]** || **CHD**: Risk assessment using non-traditional risk factors -- Asymptomatic Men and Women ||
 * **[[file:///ePSS/gradedef.jsp%23old|I]]** || **CHD**: Screening Using ECG, ETT, EBCT -- Adults, Increased Risk ||
 * **[[file:///ePSS/gradedef.jsp%23new|I*]]** || **Drug Use - Illicit** : Screening -- Adolescent, Adults, and Pregnant Women ||
 * **[[file:///ePSS/gradedef.jsp%23old|I]]** || **Family and Intimate Partner Violence**: Screening ||
 * **[[file:///ePSS/gradedef.jsp%23old|I]]** || **Glaucoma**: Screening -- Adults ||
 * **[[file:///ePSS/gradedef.jsp%23old|I]]** || **Healthy Diet**: Counseling -- Unselected Patients, Primary Care Setting ||
 * **[[file:///ePSS/gradedef.jsp%23old|I]]** || **Lipid Disorders**: Screening -- Children, 1-20 ||
 * **[[file:///ePSS/gradedef.jsp%23old|I]]** || **Low Back Pain**: Counseling -- Adults ||
 * **[[file:///ePSS/gradedef.jsp%23old|I]]** || **Lung Cancer**: Screening -- Asymptomatic Men and Women ||
 * **[[file:///ePSS/gradedef.jsp%23old|I]]** || **Obesity**: Screening and Counseling at Any Intensity -- Overweight Men and Women ||
 * **[[file:///ePSS/gradedef.jsp%23old|I]]** || **Obesity**: Screening and Moderate/Low Intensity Counseling -- Obese Men and Women ||

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Immunization guidelines (CDC, 2012) for adolescents include the following:


 * 1) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap). (Minimum age: 10 years for Boostrix® and 11 years for Adacel®)
 * 2) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Human papillomavirus vaccine (HPV). (Minimum age: 9 years).
 * 3) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Meningococcal Conjugate vaccine 1 dose (usually at age 11 or 12) and a booster (age 16).
 * 4) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Varicella 2 doses (for persons who lack immunity, **contraindicated** if immuno-compromising condition).
 * 5) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Measles, mumps, rubella (MMR) 1 or 2 doses (for persons who lack immunity, **contraindicated** if immuno-compromising condition)
 * 6) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Polio (IPV) if not caught up.
 * 7) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Influenza 1 dose annually. (Recommended for all children and adolescents)
 * 8) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Pneumococcal, Hepatitis A, Hepatitis B (recommended if some other risk factor is present).

Counseling and Interventions to Prevent Tobacco Use and Tobacco-Caused Disease in Adults and Pregnant Women
>> **A**sk about tobacco use. >> **A**dvise to quit through clear personalized messages. >> **A**ssess willingness to quit. >> **A**ssist to quit. >> **A**rrange follow-up and support. > Intensity of counseling matters: brief one-time counseling works; however, longer sessions or multiple sessions are more effective.
 * ~ Population ||~ Adults Age ≥18 Years ||~ Pregnant Women of Any Age ||
 * **Recommendation** || **Ask about tobacco use. Provide tobacco cessation interventions to those who use tobacco products.** || **Ask about tobacco use. Provide augmented pregnancy-tailored counseling for women who smoke.** ||
 * ^  || **Grade: A** || **Grade: A** ||
 * **Counseling** |||| > The "5-A" framework provides a useful counseling strategy:

> Telephone counseling "quit lines" also improve cessation rates. || >> Instituting a tobacco user identification system. >> Promoting clinician intervention through education, resources, and feedback. >> Dedicating staff to provide treatment, and assessing the delivery of treatment in staff performance evaluations. || Clinical Summary of U.S. Preventive Services Task Force Recommendation (2009)
 * **Pharmacotherapy** || > Combination therapy with counseling and medications is more effective than either component alone. FDA-approved pharmacotherapy includes nicotine replacement therapy, sustained-release bupropion, and varenicline. || > The USPSTF found inadequate evidence to evaluate the safety or efficacy of pharmacotherapy during pregnancy. ||
 * **Implementation** |||| > Successful implementation strategies for primary care practice include:
 * **Relevant Recommendations from the USPSTF** |||| > Recommendations on other behavioral counseling topics are available at [[file:///|http://www.uspreventiveservicestaskforce.org]]. ||

===The following pharmacotherapy is an extract from National Guideline Clearinghouse (2008):Treating tobacco use and dependence: 2008 update.=== Clinicians should encourage all patients attempting to quit to use effective medications for tobacco dependence treatment, except where contraindicated or for specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents). (Strength of Evidence = A)
 * Medication Evidence**

First-line medications are those that have been found to be safe and effective for tobacco dependence treatment and that have been approved by the FDA for this use, except in the presence of contraindications or with specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents). These first-line medications have an established empirical record of effectiveness, and clinicians should consider these agents first in choosing a medication. For the 2008 update, the first-line medications are listed in Table 6.26 in the original guideline document by size of the odds ratio and in the text alphabetically by generic name. Bupropion SR is an effective smoking cessation treatment that patients should be encouraged to use. (Strength of Evidence = A) Varenicline is an effective smoking cessation treatment that patients should be encouraged to use. (Strength of Evidence = A) See FDA warning for increased risk of certain cardiovascular adverse events in patients who have cardiovascular disease. Nicotine gum is an effective smoking cessation treatment that patients should be encouraged to use. (Strength of Evidence = A) Clinicians should offer 4 mg rather than 2 mg nicotine gum to highly dependent smokers. (Strength of Evidence = B) The nicotine inhaler is an effective smoking cessation treatment that patients should be encouraged to use. (Strength of Evidence = A) The nicotine lozenge is an effective smoking cessation treatment that patients should be encouraged to use. (Strength of Evidence = B) Nicotine nasal spray is an effective smoking cessation treatment that patients should be encouraged to use. (Strength of Evidence = A) The nicotine patch is an effective smoking cessation treatment that patients should be encouraged to use. (Strength of Evidence = A)
 * Recommendations Regarding Individual Medications: First-Line Medications**
 * Bupropion SR (Sustained Release)
 * Varenicline
 * Nicotine Replacement Therapies (NRTs)
 * Nicotine Gum
 * Nicotine Inhaler
 * Nicotine Lozenge
 * Nicotine Nasal Spray
 * Nicotine Patch

Second-line medications are medications for which there is evidence of effectiveness for treating tobacco dependence, but they have a more limited role than first-line medications because: (1) the FDA has not approved them for a tobacco dependence treatment indication; and (2) there are more concerns about potential side effects than exist with first-line medications. Second-line medications should be considered for use on a case-by-case basis after first line treatments (either alone or in combination) have been used without success or are contraindicated. The listing of the second-line medications is alphabetical by generic name. Clonidine is an effective smoking cessation treatment. It may be used under a physician's supervision as a second-line agent to treat tobacco dependence. (Strength of Evidence = A) Nortriptyline is an effective smoking cessation treatment. It may be used under a physician's supervision as a second-line agent to treat tobacco dependence. (Strength of Evidence = A)
 * Recommendations Regarding Second-Line Medications**
 * Clonidine
 * Nortriptyline

Certain combinations of first-line medications have been shown to be effective smoking cessation treatments. Therefore, clinicians should consider using these combinations of medications with their patients who are willing to quit. Effective combination medications are:
 * Combination Medications**
 * Long-term (>14 weeks) nicotine patch + other NRT (gum and spray)
 * The nicotine patch + the nicotine inhaler
 * The nicotine patch + bupropion SR (Strength of Evidence = A)

The number and variety of analyzable articles was sufficient to assess the effectiveness of five combinations of medications relative to placebo. Only the patch + bupropion combination has been approved by the FDA for smoking cessation. See the original guideline document for evidence regarding the following combinations:
 * Nicotine patch + bupropion SR
 * Nicotine patch + nicotine inhaler
 * Long-term nicotine patch use + ad libitum NRT
 * Nicotine patch + nortriptyline
 * Nicotine patch + second generation antidepressants


 * Medications Not Recommended by the Guideline Panel**
 * Antidepressants other than bupropion SR and nortriptyline
 * Selective serotonin re-uptake inhibitors (SSRIs)
 * Anxiolytics/benzodiazepines/beta-blockers
 * Opioid antagonists/naltrexone
 * Silver acetate
 * Mecamylamine
 * Extended use of medications
 * Use of NRT in cardiovascular patients

Over-the-counter nicotine patch therapy is more effective than placebo, and its use should be encouraged. (Strength of Evidence = B)
 * Use of Over-the-Counter Medications**

Cutler (2004) divides behavioral interventions into groups: (1) individual, (2) community, and (3) national. Cutler (2004) lists counseling and help with behavior-modification as individual interventions. Community interventions include population screening, community organizations to promote healthy behavior, and public policies such as taxation on cigarettes or limiting smoking areas. Additionally, Cutler (2004) lists national interventions, such as the Surgeon General who has been warning about of hazards of smoking since 1964.

The CDC (2012) has a podcast, audio only, about ways to quit smoking: Ways to Quit & [|Youth and Smoking]

Another website is smokefree.gov (2012) which has general information about quitting smoking and special sites for teens and women.

<span style="color: #000099; font-family: Verdana,Geneva,sans-serif;">Discussion of Intervention Efficacy »
<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">The United States Preventive Services Task Force (USPSTF) has updated its definitions of the grades it assigns to recommendations and now includes "suggestions for practice" associated with each grade. The USPSTF has also defined levels of certainty regarding net benefit.

What the Grades Mean and Suggestions for Practice
U.S. Preventive Services Task Force Recommendation (2008)
 * ~ Grade ||~ Definition ||~ Suggestions for Practice ||
 * **A** || The USPSTF recommends the service. There is high certainty that the net benefit is substantial. || Offer or provide this service. ||
 * **B** || The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. || Offer or provide this service. ||
 * **C** || //Note: The following statement is undergoing revision.// Clinicians may provide this service to selected patients depending on individual circumstances. However, for most individuals without signs or symptoms there is likely to be only a small benefit from this service. || Offer or provide this service only if other considerations support the offering or providing the service in an individual patient. ||
 * **D** || The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. || Discourage the use of this service. ||
 * **I Statement** || The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. || Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms. ||

Evidence Grades of the National Guideline Clearinghouse (2008): Treating tobacco use and dependence: 2008 update
A. Multiple well-designed randomized clinical trials, directly relevant to the recommendation, yielded a consistent pattern of findings. B. Some evidence from randomized clinical trials supported the recommendation, but the scientific support was not optimal. For instance, few randomized trials existed, the trials that did exist were somewhat inconsistent, or the trials were not directly relevant to the recommendation. C. Reserved for important clinical situations in which the Panel achieved consensus on the recommendation in the absence of relevant randomized controlled trials.

Hi, I am Joe. I am 15 year old White male, and I have been smoking since I was 13 years old. I came today because I have a cough all the time. My cough is caused by my parents who smoke all the time in the house. Because I am underage I cannot purchase cigarettes, but can take them from my parents when they are not around. A lot of movies I go to show actors smoking and they look really tough when they smoke. I need to be tough or the kids at school will make fun of me. People tell me smoking can cause cancer, however I will never get cancer and I could care less if I do when I am old.

Discussion question prompt

In one paragraph

(a) summarize Joe’s risk factors.

(b) Use the “5 Rs”—relevance, risk, reward, road block, and repetition—for the “Advise” portion of the screening tool to address tobacco use.

(c) Identify 2 other clinical prevention strategies that are appropriate for Joe today. Review the family levels of care (e.g., minimal, information & collaboration, feeling & support, primary care family assessment & counseling, and medical family therapy) in Mc Daniel, et al. (2005) Chapter 1.

(d) Select one of the family levels of care that you will use to guide your interventions with Joe in order to mobilize his parents in the client’s care,

(e) identify 2 corresponding interventions based on the level of care you selected.