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US Public Health Service. Office of Disease Prevention and Health Promotion. Clinician's Handbook of Preventive Services. 2nd edition. Washington (DC): Department of Health and Human Services (US); 1999.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Clinician's Handbook of Preventive Services

Clinician's Handbook of Preventive Services. 2nd edition.

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Tobacco use continues to be the single largest cause of preventable illness and death in the United States. Cigarette use is related to heart disease, lung and esophageal cancer, and chronic lung disease. Smokeless tobacco use is associated with numerous cancers, including cancers of the gum, mouth, larynx, pharynx, and esophagus.

The decision to start smoking is often made during the teenage years. Approximately 22% of high school students now report smoking cigarettes daily. However, cigarette smoking is becoming increasingly common among younger children. Surveys indicate that 10% to 25% of children try cigarettes before or during sixth grade. Similarly, use of smokeless or chewing tobacco is increasing among children and adolescents. An estimated 11.4% of high school students use smokeless tobacco. The majority of smokeless tobacco users begin by 13 years of age, and some begin as early as 4 or 5 years of age. Nicotine addiction is rapidly established; therefore, initiation of tobacco use by youth perpetuates tobacco-related chronic health problems in our country. In 1993, smoking-related illnesses cost the nation $50 billion in direct health care costs.

Exposure to environmental tobacco smoke is a potential health hazard for infants and children. An estimated 31.2% of children aged 10 years and younger are exposed to tobacco smoke daily in their homes. Passive smoking can exacerbate the symptoms of asthma and allergies and decrease pulmonary function. The rates of lower respiratory tract infection and middle ear effusions are higher in children who are exposed to environmental tobacco smoke. Each year, an estimated 300,000 children suffer from lower respiratory tract infections attributable to environmental tobacco smoke.

Parental smoking is a risk factor for the initiation of smoking by youth. Children from families in which one or both parents smoke are twice as likely to smoke as are those whose parents do not smoke. See chapter 60 for information about smoking cessation.

Recommendations of Major Authorities

  • All major authorities, including American Academy of Family Physicians, American Academy of Pediatrics, American Medical Association, Bright Futures, Canadian Task Force on the Periodic Health Examination, National Cancer Institute, Smoking Cessation Guideline Panel convened by the Agency for Health Care Policy and Research and the Centers for Disease Control and Prevention and the US Preventive Services Task Force --
  • Primary care clinicians should counsel both parents and children about the importance of abstaining from initiating tobacco use and of stopping tobacco use after initiation.
  • American Academy of Family Physicians --
  • Children, adolescents, and young adults should be counseled on the risks of tobacco use. Parents who smoke while children are in the house should be counseled regarding the harmful effects of smoking on children's health. All tobacco users should be provided with tobacco cessation counseling on a regular basis. Clinicians should discuss nicotine replacement therapy as an adjunct for smoking cessation with patients desiring to quit smoking.

  • American Academy of Pediatrics and Bright Futures --
  • Inquiry into tobacco use and smoke exposure should be a routine part of pediatric health supervision visits. Clinicians should inform parents of the dangers of environmental tobacco smoke and the implications and complications of exposing their children to tobacco smoke. Information about available smoking cessation assistance should be offered. Discussion and anticipatory guidance about smoking and tobacco use should begin well before the patient enters junior high school, with particular emphasis on the importance of resisting the influence of advertising and the peer group. Clinicians should obtain a history of environmental tobacco smoke exposure when encountering a child with a respiratoryillness.
  • American Medical Association --
  • Adolescents should receive annual screening and health guidance to promote avoidance of tobacco use. A cessation plan should be provided for adolescents who use tobaccoproducts.
  • Canadian Task Force on the Periodic Health Examination --
  • There is good evidence to support counseling for smoking cessation in the periodic health examination for individuals who smoke. There is fair evidence to support counseling to prevent smoking initiation for adolescents. Counseling by physicians has not been evaluated but given the burden of disease, the benefits of preventing addiction, the effectiveness of other smoking-related counseling, and the support of expert opinion, all children and adolescents should be counseled on avoiding tobacco use.

  • National Cancer Institute --
  • Clinicians treating children should follow five principles that start with the letter A in counseling about smoking prevention/cessation:

Anticipate the risk for tobacco use at each developmental stage.


Ask about exposure to tobacco smoke and tobacco use at each visit.


Advise all smoking parents to stop and all children not to use tobacco products.


Assist children in resisting tobacco use; assist tobacco users in quitting.


Arrange follow-up visits as required.

  • US Preventive Services Task Force --
  • Tobacco cessation counseling is recommended on a regular basis to all patients who use tobacco. Parents of children living at home should be counseled on the potential harmful effects of smoking on child health. Anti-tobacco messages should be included in health promotion counseling of children and adolescents based on the proven efficacy of risk reduction from avoiding tobacco use, although the evidence for the effectiveness of clinical counseling to prevent the initiation of tobacco use is less clear. Clinicians should support school-based programs to prevent initiation of tobacco use.

Basics of Tobacco Counseling: Preventing Initiation of Use


Maintain a smoke-free environment in the medical office or clinic. Do not permit smoking by staff, patients, or their parents. Post no-smoking signs, and provide literature about the importance of smoking cessation and avoiding tobacco use.


Obtain a history for all patients regarding tobacco use in the child's household and day-care or school settings. If parents or other family members smoke, stress the importance of stopping. Emphasizing the negative health consequences for the child can be an effective strategy in dealing with parents.


Advise all parents to quit smoking, and support parents who desire to quit smoking, with either counseling or referral (chapter 60). Discourage use of ineffective measures, such as blowing smoke away from a child, attempting to increase ventilation in a room, or smoking in another but contiguous room.


Begin in the early elementary school grades to discuss tobacco use and its negative effects. When discussing avoidance of tobacco use or smoking cessation with children or adolescents, emphasize the unattractive cosmetic (stained teeth and fingernails, oral sores, and foul-smelling breath and clothes) and athletic (decreased endurance, shortness of breath) consequences of tobacco use. Also emphasize the negative social consequences, such as disapproval by peers. Such strategies generally are more effective with children and adolescents than is discussing the long-term health consequences.


Elicit information in a nonthreatening manner. Having the parents leave the room is often helpful. Discussion during a physical examination is often well received by children and adolescents. Adolescents may be asked to complete a previsit questionnaire, which is a nonthreatening way to reveal information about tobacco use and other sensitive issues.

Patient Resources

  • Chew or Snuff Is Real Bad Stuff; Why Do You Smoke? National Cancer Institute. Superintendent of Documents, Consumer Information Center — 3C, PO Box 100, Pueblo, CO 81002.
  • Stop Smoking Kit; Smoking: Steps To Help You Break the Habit. American Academy of Family Physicians, 8880 Ward Parkway, Kansas City, MO 64114-2797; (800)944-0000; Internet address:
  • Through with Chew. American Academy of Otolaryngology, 1 Prince St, Alexandria, VA 22314; (703)836-4444.
  • Smoking: Guidelines for Teens; Tobacco Abuse -- A Message to Parents and Teens; Straight Talk About Smokeless Tobacco; Smoking: Straight Talk for Teens; Environmental Tobacco Smoke: A Danger for Children. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016; Internet address:
  • Smoking and Reproductive Health; Smoking in Women. American College of Obstetricians and Gynecologists, 40912th St SW, Washington, DC 20024; (800)762-2264; Internet address:
  • Smokeless Tobacco: Think Before You Chew; Smoking Can Really Do A Number on Your Health. American Dental Association, Department of Salable Materials, 211 E Chicago Ave, Chicago, IL 60611; (800)947-4746.
  • You Can Quit Smoking: Smoking Cessation Consumer Guide, Clinical Practice Guideline Number 18. Publication number 96-0695. Agency for Health Care Policy and Research, Publications Clearinghouse, PO Box 8547, Silver Spring Md 20907; (800)358-9295, Also available through InstantFAX at (301)594-2800 (push 1 and start, wait for directions);Internet address:

Provider Resources

  • Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington VA, 22201-2617; (703)524-7802. Internet address:
  • Centers for Disease Control and Prevention Information and Prevention Source Page:
  • Clinical Interventions To Prevent Tobacco Use by Children and Adolescents. National Cancer Institute; (800)4-CANCER; Internet address:
  • Doctors Helping Smokers. For information about this office-based tobacco cessation program and video, contact: Doctors Helping Smokers at Blue Plus, PO Box 64179, R 3-11, St Paul, MN 55164; (800)382-2000, ext 1975.
  • How To Help Your Patients Stop Smoking: A National Cancer Institute Manual for Physicians; How To Help Your Patients Stop Using Tobacco: A National Cancer Institute Manual for the Oral Health Team. Office of Cancer Communications, National Cancer Institute, Bldg 31, Rm 10A16, Bethesda, MD 20892; (800)4-CANCER; Internet address:
  • Helping Smokers Quit: A Guide for Primary Care Clinicians, Clinical Practice Guideline No. 18, AHCPR Publication No. 96-0693. Agency for Health Care Policy and Research, Publications Clearinghouse, PO Box 8547, Silver Spring, MD 20907; (800)358-9295. Also available through InstantFAX at (301)594-2800 (push 1 and start, wait for directions).Internet address:
  • Nurses: Help Your Patients Stop Smoking. National Heart, Lung, and Blood Institute Smoking Education Program, PO Box 30105, Bethesda, MD 20824-0105; (301)251-1222; Available in both English and Spanish. Internet address:gopher://
  • On the Teen Scene: Young People Talk with FDA Commissioner About Smoking. FDA Office of Consumer Affairs, HFE 88 Room 1675, 5600 Fishers Ln, Rockville, MD 20857; (800)532-4440.

Selected References

  1. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examination. Kansas City, Mo: American Academy of Family Physicians; 1997.
  2. American Academy of Pediatrics, Committee on Environmental Hazards. Involuntary smoking — a hazard to children. Pediatrics. . 1986; 77:755–757. [PubMed: 3703641]
  3. American Academy of Pediatrics, Committee on Environmental Hazards. Smokeless tobacco — a carcinogenic hazard to children. Pediatrics. . 1985; 75:1009–1011. [PubMed: 4069845]
  4. American Academy of Pediatrics, Committee on Substance Abuse. Tobacco-free environment: an imperative for the health of children and adolescents. Pediatrics. . 1994; 93:866–868. [PubMed: 8165100]
  5. American Medical Association. Rationale and recommendations: use of tobacco products. In: AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale. Chicago, Ill: American Medical Association; 1994: chap. 10.
  6. Canadian Task Force on the Periodic Health Examination. Prevention of tobacco-caused disease. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 43.
  7. Centers for Disease Control and Prevention. Health-care provider advice on tobacco use to persons aged 10-22 years — United States, 1993. MMWR. . 1995; 44:826–830.
  8. Centers for Disease Control and Prevention. United States, Youth Risk Behavior Survey, 1995. In: Tobacco use and usual source of cigarettes among high school students-United States, 1995. MMWR. . 1996; 45(20):413–418. [PubMed: 8614397]
  9. Epps RP, Manley MW. Clinical Interventions to Prevent Tobacco Use by Children and Adolescents. Bethesda, Md: National Cancer Institute, US Department of Health and Human Services; 1991.
  10. Epps RP, Manley MW. A physician's guide to preventing tobacco use during childhood and adolescence. Pediatrics. . 1991; 88:140–144. [PubMed: 2057249]
  11. Fiore MC, Bailey WC, Cohen SJ, et al. Smoking Cessation. Clinical Practice Guideline No. 18. Rockville, Md: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 96-0692. April 1996.
  12. Green M, ed. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, Va: National Center for Education in Maternal and Child Health, 1994.
  13. Mannino DM, Siegel M, Husten C, et al. Environmental tobacco smoke exposure and health effects in children: results from the 1991 National Health Interview Survey. Tobacco Control. . 1996; 5:13–18. [PMC free article: PMC1759489] [PubMed: 8795853]
  14. McGinnis JM, Shopland D, Brown C. Tobacco and health: trends in smoking and smokeless tobacco consumption in the United States. Annu Rev Public Health. . 1987; 8:441–467. [PubMed: 3555529]
  15. Schonberg KS, ed. Substance Abuse: A Guide for Health Professionals. Elk Grove Village, Ill: American Academy of Pediatrics; 1988.
  16. University of Michigan. Cigarette Smoking Continues to Rise Among American Teenagers in 1996. Ann Arbor, Mich: The University of Michigan News and Information Services; December 19, 1996, news release, Monitoring the Future project.
  17. US Department of Health and Human Services, Office of Inspector General. Spit Tobacco and Youth. Washington, DC: US Government Printing Office; 1992.
  18. US Preventive Services Task Force. Counseling to prevent tobacco use.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 54.


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