Carrie Patnode

Effectiveness of Primary Care-Relevant Treatments for Obesity in Adults: A Systematic Evidence Review for the U.S. Preventive Services Task Force

BACKGROUND Overweight and obesity in adults are common and adversely affect health. PURPOSE To summarize effectiveness and harms of primary care-relevant weight-loss interventions for overweight and obese adults. DATA SOURCES MEDLINE, Cochrane Central Register of Controlled Trials, and PsycINFO from January 2005 to September 2010; systematic reviews for identifying trials before 2005. STUDY SELECTION Two investigators appraised 6498 abstracts and 648 articles. Clinical trials were included if control groups received minimal interventions. Articles were rated as good, fair, or poor by using design-specific criteria. DATA EXTRACTION One investigator abstracted study characteristics and findings for good- and fair-quality studies; a second checked them. DATA SYNTHESIS Behaviorally based treatment resulted in 3-kg (6.6-lb) greater weight loss in intervention than control participants after 12 to 18 months, with more treatment sessions associated with greater loss. Limited data suggest weight-loss maintenance for 1 year or more. Orlistat plus behavioral intervention resulted in 3-kg (6.6-lb) more weight loss than did placebo after 12 months. Metformin resulted in less weight loss. Data on effects of weight-loss treatment on long-term health outcomes (for example, death and cardiovascular disease) were insufficient. Weight-loss treatment reduced diabetes incidence in participants with prediabetes. Effects on intermediate outcomes (for example, lipids and blood pressure) were mixed and small. Data on serious medication harms were insufficient. Medications commonly caused withdrawals due to gastrointestinal symptoms. LIMITATIONS Few studies reported health outcomes. Behaviorally based treatments were heterogeneous and specific elements were not well-described. Many studies could not be pooled because of insufficient reporting of variance data. Medication trials had high attrition, lacked postdiscontinuation data, and were inadequately powered for rare adverse effects. CONCLUSION Behaviorally based treatments are safe and effective for weight loss and maintenance. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.

Primary Care Relevant Interventions for Tobacco Use Prevention and Cessation in Children and Adolescents: A Systematic Evidence Review for the U.S. Preventive Services Task Force

BACKGROUND Interventions to prevent smoking uptake or encourage cessation among young persons might help prevent tobacco-related illness. PURPOSE To review the evidence for the efficacy and harms of primary care-relevant interventions that aim to reduce tobacco use among children and adolescents. DATA SOURCES Three systematic reviews that collectively covered the relevant literature; MEDLINE, PsycINFO, the Cochrane Central Register of Controlled Trials, and the Database of Abstracts of Reviews of Effects through 14 September 2012; and manual searches of reference lists and gray literature. STUDY SELECTION Two investigators independently reviewed 2453 abstracts and 111 full-text articles. English-language trials of behavior-based or medication interventions that were relevant to primary care and reported tobacco use, health outcomes, or harms were included. DATA EXTRACTION One investigator abstracted data from good- and fair-quality trials into an evidence table, and a second checked these data. DATA SYNTHESIS 19 trials (4 good-quality and 15 fair-quality) that were designed to prevent tobacco use initiation or promote cessation (or both) and reported self-reported smoking status or harms were included. Pooled analyses from a random-effects meta-analysis suggested a 19% relative reduction (risk ratio, 0.81 [95% CI, 0.70 to 0.93]; absolute risk difference, -0.02 [CI, -0.03 to 0.00]) in smoking initiation among participants in behavior-based prevention interventions compared with control participants. Neither behavior-based nor bupropion cessation interventions improved cessation rates. Findings about the harms related to bupropion use were mixed. LIMITATIONS No studies reported health outcomes. Interventions and measures were heterogeneous. Most trials examined only cigarette smoking. The body of evidence was largely published 5 to 15 years ago. CONCLUSION Primary care-relevant interventions may prevent smoking initiation over 12 months in children and adolescents.

Behavioral Counseling and Pharmacotherapy Interventions for Tobacco Cessation in Adults, Including Pregnant Women: A Review of Reviews for the U.S. Preventive Services Task Force

Cigarette smoking and exposure to smoke result in more than 480000 premature deaths in the United States every year, along with substantial illness (1, 2). Despite considerable progress in tobacco control over the past 50 years, in 2013, an estimated 17.8% of U.S. adults (3) and 15.9% of pregnant women aged 15 to 44 years were current cigarette smokers (4). Many tools are available to help smokers quit, including counseling by health care providers, telephone- and print-based interventions, computer and text-messaging interventions, and pharmacologic agents (that is, nicotine replacement therapy [NRT], bupropion hydrochloride sustained release [bupropion], and varenicline). In 2009, the U.S. Preventive Services Task Force (USPSTF) reaffirmed its 2003 recommendation that clinicians ask all adults about tobacco use and provide interventions for cessation for those who use tobacco products (grade A recommendation) (5). The original USPSTF recommendation (2003) and reaffirmation (2009) were based on the Public Health Services clinical practice guidelines on treating tobacco use and dependence (6, 7). Because there were no plans to update the Public Health Service report, we undertook the current review to assess the benefits and harms of behavioral and pharmacologic interventions for tobacco cessation in adults, including pregnant women, to assist the USPSTF in updating its 2009 recommendation. Because of the rapid increase in the use of electronic nicotine delivery systems (ENDS) and the vigorous debate about the public health effect of these devices and their role in smoking cessation (813), our review also synthesized the primary trial evidence on the efficacy and safety related to this technology as a means for quitting conventional smoking. Methods We relied primarily on a review of reviews method for this update. We did not replicate quality rating or data abstraction for original studies or replicate review-specific analyses. However, we decided a priori to conduct a de novo search for primary evidence related to the effectiveness and safety of ENDS. In addition, we did a bridge search for evidence related to pharmacotherapy interventions among pregnant women because of the limited number of studies included in the available systematic reviews and the length of time that had elapsed since their last search dates. We developed an analytic framework and 3 key questions with input from the USPSTF (Appendix Figure 1). The final version of the framework and key questions reflects both USPSTF and public input. The full report provides detailed methods (14). Appendix Figure 1. Analytic framework. KQ = key question. Data Sources and Searches We searched the following databases for relevant reviews from January 2009 to 1 August 2014: PubMed, PsycInfo, Cochrane Database of Systematic Reviews, Health Technology Assessment database, and Database of Abstracts of Reviews of Effects of the Centre for Reviews and Dissemination. We also searched the following organizational Web sites: the Agency for Healthcare Research and Quality, the British Medical Journal Clinical Evidence (through 7 August 2013), the Canadian Agency for Drugs and Technologies in Health, Guide to Community Preventive Services, the Institute of Medicine, the National Institute for Health and Clinical Excellence, the National Health Service Health Technology Assessment Programme, and the Surgeon General. We supplemented our searches with suggestions from experts. We searched PubMed for primary evidence related to ENDS through 1 March 2015 and for pharmacotherapy interventions among pregnant women through 15 August 2014 (the full report outlines the search strategies for these 2 searches [14]). Study Selection Two investigators independently reviewed all identified abstracts and dually reviewed full-text articles against prespecified eligibility criteria (14). We resolved disagreements through discussion. We included systematic reviewswith or without meta-analysisthat examined the effectiveness of interventions for tobacco cessation for adults, including pregnant women, and were linked to primary care or took place in a general adult population. We excluded nonsystematic meta-analyses and narrative reviews. We also excluded reviews that focused on reduction of tobacco harms, interventions for relapse prevention, or cessation medications that were not approved by the U.S. Food and Drug Administration as first-line medications for cessation (such as nortriptyline). We included only the most recent version of updated reviews. We outlined separate selection criteria when considering primary evidence related to ENDS and pharmacotherapy among pregnant women, as described in the full report (14). Data Extraction and Quality Assessment At least 2 independent reviewers rated the quality of all included systematic reviews using a slightly modified version of the Assessment of Multiple Systematic Reviews tool (15, 16) (see the full report for modifications and methods for determining the overall quality rating of individual reviews [14]). We excluded all poor-quality studies (17). One reviewer completed primary data abstraction, and a secondary reviewer checked all data for accuracy and completeness. Data Synthesis and Analysis When we found several fair- and good-quality reviews that met the inclusion criteria in a given population and intervention subgroup, we applied criteria (Appendix Table 1) to identify 1 or more reviews that represented the most current and applicable evidence to serve as the basis for the main findings (called primary reviews). We reviewed the remaining reviews for complementary or discordant findings. When we encountered discordant bodies of evidence, we sought explanations for these differences by examining the eligibility criteria and included studies within each review. Appendix Table 1. Criteria for Choosing the Primary Existing Systematic Reviews We used the pooled point estimates presented in the included reviews when appropriate. We did not reanalyze any of the individual study evidence. We evaluated the appropriateness of meta-analytic procedures and used our technical judgment to interpret pooled analyses accounting for limitations or concerns around heterogeneity, statistical approaches (18, 19), and other factors. Role of the Funding Source This review was funded by the Agency for Healthcare Research and Quality. Agency staff provided technical oversight for the project. Liaisons from the USPSTF helped resolve issues around the reviews scope but were not involved in its conduct. Results We reviewed 638 abstracts and 114 full-text reviews for possible inclusion (Appendix Figure 2). We identified 54 systematic reviews that met our eligibility criteria (2073), and 22 of these served as the basis for the primary findings (Table 1). In general, results across all included reviews were consistent within each population and intervention grouping. Our results are organized by outcomes and subcategories by population and interventions. Eleven of the 54 included reviews synthesized evidence on interventions among specific subpopulations of adults (such as persons with depression and young adults) that are not included here but appear in detail in the full report (14). Appendix Figure 2. Summary of evidence search and selection. * 2 studies included both adults and pregnant women. Reviews can be counted in multiple intervention areas. Table 1. Characteristics of Included Systematic Reviews (n =54), by Population, Intervention, and Last Search Date Behavioral Interventions Among Adults Eleven reviews served as primary reviews examining the effects of behavioral interventions for smoking cessation among the general adult population (Table 1) (21, 22, 31, 37, 55, 58, 60, 61, 67, 71, 78). Health and Cessation Outcomes Data on health outcomes after behavioral interventions were limited to 1 study (79) that was reported in 1 review (58) (Table 2). This study reported no statistically significant differences in rates of total mortality, coronary disease mortality, and lung cancer incidence and mortality at 20-year follow-up among men at high risk for cardiorespiratory disease (n=1445) (80). However, at 33-year follow-up, there were significantly fewer deaths from respiratory illnesses among participants who received an intervention than control participants (58). Table 2. Summary of Evidence for the General Adult Population Several behavioral interventions increased smoking cessation at 6 months or more, including physician- (58) and nurse-delivered (55) counseling interventions, tailored self-help print materials (37), and telephone counseling (60), when compared with minimal intervention or usual care (Table 2 and Appendix Table 2). Smokers who were offered cessation advice by a physician, for example, were 76% more likely to have quit at 6 months or more than those who received no advice or usual care (risk ratio [RR], 1.76 [95% CI, 1.58 to 1.96]; I 2=40%; 28 trials; n=22239) (58). Both minimal and intensive advice (>20 minutes, additional materials beyond a brochure, or >1 follow-up visit) showed statistically significant increases in cessation rates when compared with control participants who did not receive advice. Direct comparisons between intensive and minimal advice in 15 trials suggested that more intensive advice offered a significant advantage (RR, 1.37 [CI, 1.20 to 1.56]; I 2=32%; 15 trials; n=9775) (58). Appendix Table 2. Summary of Smoking Abstinence Results From Reviews of Behavioral Counseling and Pharmacotherapy Interventions for Smoking Cessation Among Adults, by Type of Intervention A separate meta-analysis of 38 randomized, controlled trials (RCTs) done among more than 15000 smokers found a small relative benefit of adjunctive behavioral support to pharmacotherapy when compared with pharmacotherapy alone (RR, 1.16 [CI, 1.09 to 1.24]) (61). Cessation rates were relatively high in both the intervention (21.4%) and control (18

Multilevel predictors of adolescent physical activity: a longitudinal analysis.

BackgroundTo examine how factors from a social ecologic model predict physical activity (PA) among adolescents using a longitudinal analysis.MethodsParticipants in this longitudinal study were adolescents (ages 10-16 at baseline) and one parent enrolled in the Transdisciplinary Research on Energetics and Cancer-Identifying Determinants of Eating and Activity (TREC-IDEA) and the Etiology of Childhood Obesity (ECHO). Both studies were designed to assess a socio-ecologic model of adolescent obesity risk. PA was collected using ActiGraph activity monitors at two time points 24 months apart. Other measures included objective height and weight, adolescent and parent questionnaires on multilevel psychological, behavioral and social determinants of PA, and a home PA equipment inventory. Analysis was conducted using SAS, including descriptive characteristics, bivariate and stepped multivariate mixed models, using baseline adjustment. Models were stratified by gender.ResultsThere were 578 adolescents with complete data. Results suggest few statistically significant longitudinal associations with physical activity measured as minutes of MVPA or total counts from accelerometers. For boys, greater self-efficacy (B = 0.75, p = 0.01) and baseline MVPA (B = 0.55, p < 0.01) remained significantly associated with MVPA at follow-up. A similar pattern was observed for total counts. For girls, baseline MVPA (B = 0.58, p = 0.01) and barriers (B = -0.32, p = 0.05) significantly predicted MVPA at follow-up in the full model. The full multilevel model explained 30% of the variance in PA among boys and 24% among girls.ConclusionsPA change in adolescents is a complex issue that is not easily understood. Our findings suggest early PA habits are the most important predictor of PA levels in adolescence. Intervention may be necessary prior to middle school to maintain PA through adolescence.

Adolescent Physical Activity and Screen Time: Associations With the Physical Home Environment

BackgroundPrevious research on the environment and physical activity has mostly focused on macro-scale environments, such as the neighborhood environment. There has been a paucity of research on the role of micro-scale and proximal environments, such as that of the home which may be particularly relevant for younger adolescents who have more limited independence and mobility. The purpose of this study was to describe associations between the home environment and adolescent physical activity, sedentary time, and screen time.MethodsA total of 613 parent-adolescent dyads were included in these analyses from two ongoing cohort studies. Parents completed a Physical Activity and Media Inventory (PAMI) of their home environment. Adolescent participants (49% male, 14.5 ± 1.8 years) self-reported their participation in screen time behaviors and wore an ActiGraph accelerometer for one week to assess active and sedentary time.ResultsAfter adjusting for possible confounders, physical activity equipment density in the home was positively associated with accelerometer-measured physical activity (p < 0.01) among both males and females. Most of the PAMI-derived measures of screen media equipment in the home were positively associated with adolescent females screen time behavior (p ≤ 0.03). In addition, the ratio of activity to media equipment was positively associated with physical activity (p = 0.04) in both males and females and negatively associated with screen time behavior for females (p < 0.01).ConclusionsThe home environment was associated with physical activity and screen time behavior in adolescents and differential environmental effects for males and females were observed. Additional research is warranted to more comprehensively assess the home environment and to identify obesogenic typologies of families so that early identification of at-risk families can lead to more informed, targeted intervention efforts.

Are School Vending Machines Loaded With Calories and Fat: An Assessment of 106 Middle and High Schools

BACKGROUND The purpose of this study was to describe the extent to which vending offerings in 106 schools in the St. Paul-Minneapolis, Minnesota metropolitan area, met criteria for types of beverages, fat, and calories based on selected criteria offered by the Institute of Medicine. METHODS Schools where youth participants were attending for the 2006-2007 school year were identified and invited to participate in the study (n = 143); 81% of schools (n = 116) agreed to participate. RESULTS Of the 116 schools, 106 had vending machines. Across schools with vending machines (n = 106), 5085 food and 8442 beverage items were offered. Overall, only 18% of beverage items met criteria for calories and type of beverage; significantly more items in public schools met the criteria as compared to private schools (19% vs 12%; p < .01). This difference was also significant for high schools as compared to middle schools (18% vs 22%; p < .01). For food items, 41% met calorie criteria, 45% met fat criteria, and 22% met both fat and calorie criteria. Significantly more food items met both criteria in public than private schools (22% vs 18%; p = .01), while high schools (22%) and middle schools (21%) were similar. A very small proportion of foods (< 5%) would have met the full criteria suggested by the Institute of Medicine for competitive foods. CONCLUSION Overall, foods and beverages offered in vending machines continue to be high in fat and calories. Public schools are doing a slightly better job of providing healthy foods as compared to private schools.

Adolescent Physical Activity and the Built Environment: A Latent Class Analysis Approach

This study used latent class analysis to classify adolescent home neighborhoods (n=344) according to built environment characteristics, and tested how adolescent physical activity, sedentary behavior, and screen time differ by neighborhood type/class. Four distinct neighborhood classes emerged: (1) low-density retail/transit, low walkability index (WI), further from recreation; (2) high-density retail/transit, high WI, closer to recreation; (3) moderate-high-density retail/transit, moderate WI, further from recreation; and (4) moderate-low-density retail/transit, low WI, closer to recreation. We found no difference in adolescent activity by neighborhood class. These results highlight the difficulty of disentangling the potential effects of the built environment on adolescent physical activity.

Primary Care Interventions to Support Breastfeeding: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance Although 80% of infants in the United States start breastfeeding, only 22% are exclusively breastfed up to around 6 months as recommended by a number of professional organizations. Objective To systematically review the evidence on the benefits and harms of breastfeeding interventions to support the US Preventive Services Task Force in updating its 2008 recommendation. Data Sources MEDLINE, PubMed, Cumulative Index for Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, and PsycINFO for studies published in the English language between January 1, 2008, and September 25, 2015. Studies included in the previous review were re-evaluated for inclusion. Surveillance for new evidence in targeted publications was conducted through January 26, 2016. Study Selection Review of randomized clinical trials and before-and-after studies with concurrent controls conducted in a developed country that evaluated a primary care-relevant breastfeeding intervention among mothers of full- or near-term infants. Of 211 full-text articles reviewed, 52 studies met inclusion criteria. Thirty-one studies were newly identified, and 21 studies were carried forward from the previous review. Data Extraction and Synthesis Independent critical appraisal of all provisionally included studies. Data were independently abstracted by one reviewer and confirmed by another. Main Outcomes and Measures Child and maternal health outcomes, rates and duration of breastfeeding, and harms related to interventions as prespecified before data collection. Results Fifty-two studies (n = 66 757) in 57 publications were included. Six trials (n = 2219) reported inconsistent effects of the interventions on infant health outcomes; no studies reported maternal health outcomes. Pooled estimates based on random-effects meta-analyses using the DerSimonian and Laird method indicated beneficial associations between individual-level breastfeeding interventions and any breastfeeding for less than 3 months (risk ratio [RR], 1.07 [95% CI, 1.03-1.11]; 26 studies [n = 11 588]), at 3 to less than 6 months (RR, 1.11 [95% CI, 1.04-1.18]; 23 studies [n = 8942]), and for exclusive breastfeeding for less than 3 months (RR, 1.21 [95% CI, 1.11-1.33]; 22 studies [n = 8246]), 3 to less than 6 months (RR, 1.20 [95% CI, 1.05-1.38]; 18 studies [n = 7027]), and at 6 months (RR, 1.16 [95% CI, 1.02-1.32]; 17 studies [n = 7690]). Absolute differences in the rates of any breastfeeding ranged from 14.1% in favor of the control group to 18.4% in favor of the intervention group. There was no significant association between interventions and breastfeeding initiation (RR, 1.00 [95% CI, 0.99-1.02]; 14 studies [n = 9428]). There was limited mixed evidence of an association between system-level interventions and rates of breastfeeding from well-controlled studies as well as for harms related to breastfeeding interventions, including maternal anxiety scores, decreased confidence, and concerns about confidentiality. Conclusions and Relevance The updated evidence confirms that breastfeeding support interventions are associated with an increase in the rates of any and exclusive breastfeeding. There are limited well-controlled studies examining the effectiveness of system-level policies and practices on rates of breastfeeding or child health and none for maternal health.

Behavioral Counseling to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Known Cardiovascular Disease Risk Factors: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance Unhealthful dietary patterns, low levels of physical activity, and high sedentary time increase the risk of cardiovascular disease. Objective To systematically review the evidence on the benefits and harms of behavioral counseling for the primary prevention of cardiovascular disease in adults without known cardiovascular risk factors to inform the US Preventive Services Task Force. Data Sources MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, and PsycINFO for studies published in the English language between January 1, 2013, and May 25, 2016, and ongoing surveillance in targeted publications through March 24, 2017. Studies included in the previous review were reevaluated for inclusion. Study Selection Randomized clinical trials of behavioral interventions targeting improved diet, increased physical activity, decreased sedentary time, or a combination of these among adults without known hypertension, dyslipidemia, diabetes, or impaired fasting glucose. Data Extraction and Synthesis Independent critical appraisal and data abstraction by 2 reviewers. Main Outcomes and Measures Cardiometabolic health and intermediate outcomes, behavioral outcomes, and harms related to interventions. Results Eighty-eight studies (N = 121 190) in 145 publications were included. There was no consistent benefit of the interventions on all-cause or cardiovascular mortality or morbidity (4 trials [n = 51 356]) or health-related quality of life (10 trials [n = 52 423]). There was evidence of small, statistically significant between-group mean differences for systolic blood pressure (−1.26 mm Hg [95% CI, −1.77 to −0.75]; 22 trials [n = 57 953]), diastolic blood pressure (−0.49 mm Hg [95% CI, −0.82 to −0.16]; 23 trials [n = 58 022]), low-density lipoprotein cholesterol level (−2.58 mg/dL [95% CI, −4.30 to −0.85]; 13 trials [n = 5554]), total cholesterol level (−2.85 mg/dL [95% CI, −4.95 to −0.75]; 19 trials [n = 9325]), and body mass index (−0.41 [95% CI, −0.62 to −0.19]; 20 trials [n = 55 059]) at 6 to 12 months as well as small-to-modest associations with dietary and physical activity behaviors. There was no evidence of greater incidence of serious adverse events, injuries, or falls in intervention vs control participants. Conclusions and Relevance Diet and physical activity behavioral interventions for adults not at high risk for cardiovascular disease result in consistent modest benefits across a variety of important intermediate health outcomes across 6 to 12 months, including blood pressure, low-density lipoprotein and total cholesterol levels, and adiposity, with evidence of a dose-response effect, with higher-intensity interventions conferring greater improvements. There is very limited evidence on longer-term intermediate and health outcomes or on harmful effects of these interventions.

Primary care behavioral interventions to prevent or reduce illicit drug use and nonmedical pharmaceutical use in children and adolescents: a systematic evidence review for the U.S. Preventive Services Task Force.

Drug use among adolescents is a serious public health problem in the United States. The 2012 National Survey on Drug Use and Health reported that 9.5% of children aged 12 to 17 years reported illicit drug use during the past month. Marijuana and prescription psychotherapeutics (including pain relievers) are the most commonly used drugs among children and adolescents. Seven percent of children aged 12 to 17 years reported current use of marijuana, and an estimated 5% used marijuana for the first time within the past year. In 2012, 2.8% of children aged 12 to 17 years reported using a prescription drug for nonmedical reasons, and 2.2% reported nonmedical use of opioid pain relievers. Illicit drug use was approximately 15 times higher among young persons who smoked cigarettes and drank alcohol during the past month (61.1%) than among those who neither smoked cigarettes nor drank alcohol during the past month (4.0%) (1). Drug and alcohol use are the primary health risk behaviors that contribute to unintentional injuries, homicide, and suicidethe leading causes of morbidity and mortality among adolescents and young adults (2). Even infrequent drug or alcohol use increases the risk for serious adverse events by increasing risk-taking behaviors in intoxicated or impaired persons. The Substance Abuse and Mental Health Services Administration and the American Academy of Pediatrics recommend that universal screening, brief intervention, and referral to treatment (SBIRT) for substance use should be a part of routine health care as a method to reduce the health burden associated with substance use (3, 4). Although SBIRT is appropriate for all levels of risk, it is a particularly useful early intervention approach to identifying and intervening with persons with nondependent substance use before they require extensive or specialized treatment. Among children and adolescents, primary care interventions can include positive feedback for nonusers as primary prevention; brief advice for those at low risk for abuse (secondary prevention); or a motivational intervention directed at high-risk patients for reducing use, reducing associated high-risk behaviors, or accepting a referral to treatment. In 2008, the U.S. Preventive Services Task Force (USPSTF) concluded that the evidence was insufficient to recommend for or against screening adolescents, adults, and pregnant women for illicit drug use (5). We undertook the current review to synthesize the evidence on the benefits and harms of primary carerelevant behavioral interventions designed to prevent or reduce illicit drug use or the nonmedical use of prescription drugs among children and adolescents only. The USPSTF used this review to update its recommendation for this population. Methods With input from the USPSTF, we developed an analytic framework and 3 key questions (KQs) to guide our review (Appendix Figure 1). The proposed analytic framework and KQs were posted on the USPSTFs Web site for public comment for 4 weeks. On the basis of this input, we made appropriate revisions and received final approval for publication from USPSTF liaisons. The full report provides details on our methods and results, including search strategies and all evidence tables (www.uspreventiveservicestaskforce.org/uspstf13/drugmisuse/drugmisusedraftrep.htm). Appendix Figure 1. Analytic framework and key questions. Data Sources and Searches We searched for English-language publications in PubMed, PsycINFO, and the Cochrane Central Register of Controlled Trials from January 1992 through 4 June 2013 and in MEDLINE through 31 August 2013. We also assessed the 2 trials that were specific to children and adolescents and were included in the 2008 review (6). We examined the reference lists of 6 relevant published reviews and meta-analyses (712), as well as the reference lists of included studies. We considered gray literature sources and recommendations from experts. Study Selection Two investigators independently reviewed abstracts against prespecified eligibility criteria. We dually reviewed all full-text articles for potential inclusion. We included randomized, controlled trials (RCTs) or controlled clinical trials designed to prevent or reduce drug use in children and adolescents (aged <18 years [no lower age restriction]) who were not diagnosed with a substance use disorder or seeking treatment for substance misuse. We included trials conducted in primary care or those that tested interventions we judged feasible for conduct in primary care that had a link to a health care setting or system, with or without referral to specialty treatment services. This included interventions employing the full SBIRT model and other approaches to primary prevention (to prevent initiation of use) or tertiary prevention (to prevent continued use and adverse effects in those already using). We also included interventions delivered exclusively through electronic media (such as the Internet or CD-ROMs) that were not linked to health care. We excluded trials among youths diagnosed with substance abuse or dependence because they represented specialty treatment only. We also excluded studies conducted among adolescents who were mandated or directly referred to substance abuse or dependence treatment via the juvenile justice system, social services, parents, or a similar referral system. In addition, we excluded interventions conducted in substance abuse treatment centers, schools, worksites, and other institutions (for example, juvenile detention centers). Included trials had control groups that offered minimal or no treatment and reported drug use or health or social outcomes at least 6 months after baseline. Data Extraction and Quality Assessment Two independent investigators rated the quality of all included trials as good, fair, or poor according to USPSTF standards (13). We excluded poor-quality trials. One reviewer abstracted data from studies that were rated fair or good. A second reviewer checked all abstracted data for accuracy and completeness. We resolved discrepancies through discussion. Data Synthesis and Analysis We summarized all included studies in narrative form and summary tables detailing the important features of the study populations, design, intervention, and results. We used the between-group differences that were reported by authors of included studies, when available. We identified too few trials to conduct any meta-analysis, as well as too much variability in several factors (such as population or intervention). As a result, we conducted a qualitative analysis for all KQs and stratified the results into 2 groups based on the intervention: primary carebased or computer-based. Primary carebased studies recruited directly from or were conducted in primary care clinics. Computer-based interventions were judged to be feasible for primary care because they used only electronic methods of delivery, although they did not recruit from or take place in primary care. Role of the Funding Source Agency for Healthcare Research and Quality (AHRQ) staff provided technical oversight for the project. Although USPSTF liaisons helped resolve issues around the reviews scope, they were not involved in the reviews conduct. Results We reviewed 2253 abstracts and 144 full-text articles for possible inclusion (Appendix Figure 2). We identified 6 trials (reported in 7 publications) that met our inclusion criteria (1420). The most common reasons for exclusion included settings (for example, not linked to or feasible for primary care [k= 45]), out-of-scope populations (for example, aged >18 years, seeking treatment, or diagnosed with substance abuse or dependence [k= 26]), and not reporting any relevant outcomes (k= 19) (Appendix Figure 2). Table 1 provides a summary of evidence for the benefits and harms of each included study by outcome (drug use behaviors [KQ 2], health and social outcomes [KQ 1], and harms [KQ 3]). Appendix Figure 2. Summary of evidence search and selection. Table 1. Summary of Evidence for Benefits and Harms of Drug Use Interventions Effects of Interventions on Drug Use Primary CareBased Interventions Three of the 6 studies were conducted in or recruited patients from primary care (Appendix Tables 1 and 2) (16, 17, 20) and tested 4 active treatment groups. We rated all 3 studies as fair-quality according to USPSTF standards (13), with various threats to internal validity (see the full report for more detail on study quality). The smallest study had 41 participants (17), and the largest had more than 2500 (16). Ages ranged from 12 to 20 years, and girls were overrepresented60% to 68% of participants were girls. All 3 studies took place in the United States, and 1 of them (16) also included a sample of adolescents in the Czech Republic. Two of the studies were conducted among a general primary care population (16, 20), whereas the remaining study was conducted among a sample of young persons diagnosed with asthma (17). One of the studies screened adolescents for drug use before enrollment; only those who reported any marijuana use in the past year were randomly assigned (20). In this trial, marijuana use was the primary focus; the other studies targeted drug, alcohol, or tobacco use. Appendix Table 1. Study Characteristics of Included Trials Appendix Table 2. Intervention Characteristics of Included Trials All 3 studies took place during 1 office visit. Three of the interventions included brief counseling (2 to 40 minutes) by the primary care physician (16), family nurse practitioner (17), or trained research therapist (20), and all included a computer-based, self-administered educational component. The study by Walton and colleagues randomly assigned adolescents to a therapist-led brief intervention, computer-based brief intervention, or usual care control group (20). Interventions provided information and advice about substance use along with a decision-making exercise. One of the trials (16) was consis