Cecelia A. Gaffney

Treating nicotine use and dependence of pregnant and parenting smokers: An update

A growing volume of research since 1975 has demonstrated that clinically proven, effective interventions exist to produce long-term or even permanent abstinence from tobacco for all smokers. Achieving cessation is important for all smokers but especially for pregnant and parenting smokers because their smoking poses risks not only for themselves but also for their pregnancies and children. Treatments for smokers in general apply to parenting smokers, but special considerations regarding treatment need to be made for pregnant women. Due to the harms associated with exposure to environmental tobacco smoke, or second-hand smoke (SHS), parents and caregivers of young children should receive treatment to achieve cessation or counseling on how to eliminate exposure of children to SHS. Despite the availability of these treatments, surveys show that fewer than half of all obstetricians caring for pregnant women in the United States actually provide such treatment. We review the recommendations made in 2000 regarding treatment for pregnant and parenting smokers, summarize recent findings that may affect treatment protocols, and make recommendations regarding further research in treatment approaches for pregnant and parenting smokers. We summarize recommended changes in treatment approaches for clinicians based on this review and describe the factors affecting clinician adoption and use of proven treatments and systems supports found to increase the likelihood of clinician use of these treatments.

SunSafe in the Middle School Years: A Community-wide Intervention to Change Early-Adolescent Sun Protection

OBJECTIVE. Rising rates of skin cancer associated with early-life sun exposure make it important to improve adolescent sun-protection practices. Our study objective was to determine if a multicomponent community-wide intervention could alter the decline in sun protection that begins in early adolescence. METHODS. A randomized, controlled trial was conducted in 10 communities to assess the impact of the SunSafe in the Middle School Years program. The intervention sought to (1) educate and activate adults and peers to role model and actively promote sun-protection practices and (2) create a pro–sun protection community environment. It targeted school personnel, athletic coaches, lifeguards, and clinicians and enlisted teens as peer advocates. Annual observations of cross-sectional samples of teens at community beach/pool sites were used to assess the impact of 1 and 2 years of intervention exposure compared to grade-matched controls. The outcome was percent of body surface protected by sunscreen, clothing, or shade. RESULTS. Observers determined the sun protection level of 1927 adolescents entering 6th to 8th grades. After 2 years of intervention exposure, adolescents at the beach/pool in intervention communities were significantly better protected than those in control communities. Over 2 years, the percent of body surface area protected declined by 23% in the control arm but only 8% in intervention arm. After intervention, the average percent of body surface protected at intervention sites (66.1%) was significantly greater than control sites (56.8%). Teens in intervention communities reported sun-protection advice from more adult sources, were more likely to use sunscreen, and applied it more thoroughly than control-site teens. CONCLUSIONS. Our multicomponent model addressing adolescent sun protection shows the power of engaging teens and adults from across the community as role models and educators. This new ecological approach shows promise in changing adolescent sun protection behaviors and reducing skin cancer risks.

Changing Adolescent Health Behaviors The Healthy Teens Counseling Approach

BACKGROUND Brief motivational interventions that have been provided in addition to routine primary care have changed adolescent health behaviors. Whether health screening and motivational-interviewing-based counseling provided by clinicians during routine care can change behaviors is unknown. METHODS Healthy Teens was a primary care, office-system intervention to support efficient, patient-centered counseling at well visits. Healthy Teens utilized a personal digital assistant (PDA)-based screener that provided the clinician with information about a teens health risks and motivation to change. Changes in adolescent self-report of diet and activity health behaviors 6 months later were assessed in two cross-sectional samples of teens from five rural practices in 2005 and 2006. Usual-care subjects (N=148) were recruited at well visits prior to the intervention, and the Healthy Teens subjects (N=136) were recruited at well visits after the Healthy Teens system was well established. RESULTS At 6-month follow-up, the Healthy Teens group had significantly increased self-reported exercise levels and milk-product intake. In the models exploring covariates, the only significant predictors for improvement in exercise levels were intervention-group status (p=0.009) and post-visit interest in making a change (p=0.015). Interest in changing predicted increased milk intake (p=0.028) in both groups. When teens planned an action related to nutrition, physical activity, or both after a well visit, Healthy Teens participants were more likely to report multiple planned actions (68% Healthy Teens vs 32% usual care, p<0.05). CONCLUSIONS Changes in office systems using low-cost technology to screen adolescents and promote patient-centered counseling appear to influence teens to increase exercise and milk intake.

A family-focused randomized controlled trial to prevent adolescent alcohol and tobacco use: The moderating roles of positive parenting and adolescent gender

Four years of longitudinal data from 2,153 families with a 5th- or 6th-grade preadolescent participating in a family-focused pediatric primary-care-based prevention program were used to examine whether prevention effects were moderated by positive parenting and/or adolescent gender. Alcohol and tobacco use, internalizing problems, and externalizing problems were examined. Although findings revealed no main effect of the prevention program, positive parenting and adolescent gender were moderators of internalizing problems and adolescent gender was a moderator of externalizing problems. Clinical implications and future directions for research are discussed.

Costs of a smoking cessation counseling intervention for pregnant women: comparison of three settings.

Objective. Although the rate of smoking among women giving birth in the United States has declined steadily from 19.5% in 1989 to 11.4% in 2002, it still far exceeds the Healthy People 2010 goal of 1%. The objective of this study was to estimate the costs of a recommended five-step smoking cessation counseling intervention for pregnant women. Methods. Costs were compared across three settings: a clinical trial, a quit line, and a rural managed care organization. Cost data were collected from August 2002 to September 2003. Intervention costs were compared with potential neonatal cost savings from averted adverse outcomes using data from the Centers for Disease Control and Preventions Maternal and Child Health Smoking-Attributable Mortality, Morbidity, and Economics Costs software. Results. The costs of implementing the intervention ranged from

Assessing the Impact of a Web-Based Comprehensive Somatic and Mental Health Screening Tool in Pediatric Primary Care

24 to

Longitudinal retention of families in the assessment of a prevention program targeting adolescent alcohol and tobacco use : The utility of an ecological systems framework

34 per pregnant smoker counseled across the three settings. Potential neonatal cost savings that could be accrued from women who quit smoking during pregnancy were estimated at

A Pediatric, Practice-Based, Randomized Trial of Drinking and Smoking Prevention and Bicycle Helmet, Gun, and Seatbelt Safety Promotion

881 per maternal smoker. Assuming a 30% to 70% increase over baseline quit rates, interventions could net savings up to

Use of Inexpensive Technology to Enhance Adolescent Health Screening and Counseling

8 million within the range of costs per pregnant smoker. Conclusions. Costs may vary depending on the intensity and nature of the intervention; however, this analysis found a surprisingly narrow range across three disparate settings. Cost estimates presented here are shown to be low compared with potential cost savings that could be accrued across the quit rates that could be achieved through use of the 5As smoking cessation counseling intervention.

The impact of an appearance-based educational intervention on adolescent intention to use sunscreen

OBJECTIVE To evaluate how parents and physicians perceive the utility of a comprehensive, electronic previsit screener, and to assess its impact on the visit. METHODS A mixed methods design was used. English-speaking parents were recruited from 3 primary care systems (urban MD and rural NY and VT) when they presented for a well-child visit with a child 4 to 10 years of age. Parents completed an electronic previsit screen, which included somatic concerns, health risks, and 4 mental health tools (SCARED5, PHQ-2, SDQ Impact, and PSC-17). Parents completed an exit survey, and a subset were interviewed. All primary care providers (PCPs) were interviewed. RESULTS A total of 120 parents and 16 PCPs participated. The exit surveys showed that nearly 90% of parents agreed or strongly agreed that the screener was easy to use and maintained confidentiality. During interviews, parents noted that the screener helped with recall, validated concerns, reframed issues they thought might not be appropriate for primary care, and raised new questions. PCPs thought that the screener enabled them to normalize sensitive issues, and it permitted them to simultaneously focus and be comprehensive during the visit. Parents and PCPs agreed that the screener helped guide discussion, promoted in-depth exchange, and increased efficiency. Findings were consistent across quantitative and qualitative methods and between parents and PCPs. CONCLUSIONS A comprehensive electronic previsit screening tool is an acceptable and practical strategy to facilitate well-child visits. It may help with problem identification as well as with setting agendas, engaging the family, and balancing attention between somatic and psychosocial concerns.