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Nicotine Tob Res. 2019 May 10. pii: ntz076. doi: 10.1093/ntr/ntz076. [Epub ahead of print]

Tobacco-related counseling and documentation in adolescent primary care practice: Challenges and opportunities.

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Department of Health Outcomes and Biomedical Informatics and Institute for Child Health Policy, College of Medicine, University of Florida, Gainesville, FL.
Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL.
Department of Social and Behavioral Health, Harvard TH Chan School of Public Health and Dana-Farber Cancer Institute, Boston, MA.
Kaiser Permanente Division of Research, Oakland, CA.
Department of Psychology and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY.



Primary care visits present an opportunity to reduce tobacco use and tobacco smoke exposure (TSE) among adolescents. To date, few studies have examined tobacco-related electronic health record (EHR) documentation in adolescent visits. The purpose of this study was to 1) describe tobacco-related EHR documentation practices in adolescent care clinics, including whether alternative tobacco products, parental use, and TSE were addressed; and 2) identify aspects of adolescent tobacco use that may inform EHR updates and counseling and documentation practices.


Following a convergent mixed-methods design, we conducted an EHR review of 508 adolescent well-child visits, performed focus groups with pediatric providers and staff, and conducted in-depth interviews with adolescent patients. Record review data and interview transcripts were analyzed and interpreted concurrently.


In the EHR review, cigarette screening was documented in 92.3% of visits, smokeless tobacco screening in 51.4%, parental tobacco use in 23.2%, and home TSE in 33.1% of visits. Smoking status options were not mutually exclusive and did not include non-cigarette products. No records documented assessment of e-cigarette use, despite nearly half of adolescent interview respondents citing these as the most popular products among adolescents. In interviews, adolescents discussed their experiences with alternative tobacco/nicotine products more than cigarettes.


Tobacco use status prompts should be revised for clarity and include non-cigarette tobacco products and TSE. Provider education on non-cigarette products and TSE assessment is needed. Improvements in EHR systems, resources, and tools can lead to better tobacco screening, prevention, and treatment practices among primary care providers.


Clinical guidelines call for pediatricians to assess and treat adolescent and parental tobacco use during primary care visits. The use of electronic health records (EHRs) can improve screening and counseling practices; however, few studies have examined tobacco-related EHR documentation practices in adolescent care settings. This mixed-methods study found low rates of EHR documentation related to non-cigarette nicotine/tobacco products, parental tobacco use, and tobacco smoke exposure. These results demonstrate the need for increased provider training and EHR modifications to facilitate comprehensive tobacco control efforts in the adolescent population.


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