The Southern Medical Journal (SMJ) is the official, peer-reviewed journal of the Southern Medical Association. It has a multidisciplinary and inter-professional focus that covers a broad range of topics relevant to physicians and other healthcare specialists.
SMJ // Article
Original Article
Screening and Counseling for Youth Tobacco Use: A Qualitative Study of Primary Care Providers in Northeast Tennessee
Abstract
Objectives: In 2021, Tennessee high school youth reported a cigarette smoking rate of 4.9% and an electronic cigarette (e-cigarette) use rate of 19%, surpassing national averages of 2.3% and 11.3%, respectively. In 2019, 15.5% of 8th- and 9th-grade youth in northeast Tennessee reported current e-cigarette use. Primary care providers (PCPs) can prevent youth tobacco initiation and promote cessation through screening and counseling, yet little is known about these services in Tennessee. This study explored the experiences of PCPs in northeast Tennessee regarding youth tobacco use screening and counseling and identified barriers and facilitators to these services.Methods: Semistructured interviews with 12 PCPs were conducted via Zoom between November 2023 and March 2024 using an interview guide based on McLeroy’s ecological health promotion model. Transcripts were analyzed using ATLAS.ti 23.4 software. Coding and analysis followed Braun and Clarke’s thematic analysis using a blended deductive-inductive approach.
Results: PCPs recognize the importance of youth tobacco use screening and counseling and employ tool-based screening, verbal questioning, motivational interviewing, and warm hand offs to behavioral health clinicians. Key barriers included knowledge gaps on e-cigarettes, balancing rapport and trust with screening and counseling, confidentiality and privacy issues, time constraints, negative social norms around tobacco use, limited community resources for youth tobacco cessation, and tobacco regulatory concerns. Facilitators included training and educational resources for PCPs, an integrated behavioral health model, and effective clinic policies and workflows.
Conclusions: Supportive policies and quality improvement measures are needed to strengthen youth tobacco prevention and cessation efforts in northeast Tennessee and statewide.
This content is limited to qualifying members.
Existing members, please login first
If you have an existing account please login now to access this article or view purchase options.
Purchase only this article ($25)
Create a free account, then purchase this article to download or access it online for 24 hours.
Purchase an SMJ online subscription ($75)
Create a free account, then purchase a subscription to get complete access to all articles for a full year.
Purchase a membership plan (fees vary)
Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.
References
1. Birdsey J, Cornelius M, Jamal A, et al. Tobacco product use among U.S. middle and high school students—National Youth Tobacco Survey, 2023. MMWR Morb Mortal Wkly Rep 2023;72:1173–1182.
2. Food and Drug Administration. Products, ingredients & components. https://www.fda.gov/tobacco-products/products-guidance-regulations/products-ingredients-components. Published August 31, 2022. Accessed December 1, 2023.
3. US Preventive Services Task Force. Primary care interventions for prevention and cessation of tobacco use in children and adolescents: US Preventive Services Task Force recommendation statement. JAMA 2020;323:1590–1598.
4. Truth Initiative. Tobacco nation: a call to eliminate geographic smoking disparities in the U.S. https://truthinitiative.org/tobacconation. Published 2023. Accessed March 26, 2024.
5. Campaign for Tobacco-Free Kids. The toll of tobacco in Tennessee. https://www.tobaccofreekids.org/problem/toll-us/tennessee. Accessed September 5, 2023.
6. Truth Initiative. Smoking rates decline steeply in teens in 2021. https://truthinitiative.org/research-resources/traditional-tobacco-products/smoking-rates-decline-steeply-teens-2021. Published 2022. Accessed March 26, 2024.
7. Appalachian Regional Commission. About the Appalachian region. https://www.arc.gov/about-the-appalachian-region/. Accessed April 4, 2023.
8. Mamudu HM, Nwabueze CA, Yang JS, et al. Social media and use of electronic nicotine delivery systems among school-going adolescents in a rural distressed Appalachian community. Prev Med Rep 2022;29:101953.
9. Mamudu HM, Wang L, Owusu D, et al. Prospective study of dual use of e-cigarettes and other tobacco products among school-going youth in rural Appalachian Tennessee. Ann Thorac Med 2019;14:127–133.
10. Mamudu HM, Nwabueze C, Weierbach FM, et al. Exploring associations between susceptibility to the use of electronic nicotine delivery systems and e-cigarette use among school-going adolescents in rural Appalachia. Int J Environ Res Public Health 2020;17:5133.
11. Owusu D, Aibangbee J, Collins C, et al. The use of e-cigarettes among school-going adolescents in a predominantly rural environment of central Appalachia. J Community Health 2017;42:624–631.
12. Owusu D, Mamudu HM, Collins C, et al. The usage and associated factors of alternative tobacco products among school-going youth in central Appalachia. J Health Care Poor Underserved 2019;30:249–264.
13. Owusu D, Mamudu HM, Robertson C, et al. Intention to try tobacco among middle school students in a predominantly rural environment of central Appalachia. Substance Use Misuse 2019;54:449–458.
14. Bailey SR, Fankhauser K, Marino M, et al. Smoking assessment and current smoking status among adolescents in primary care settings. Nicotine Tob Res 2020;22:2098–2103.
15. Fiore MC, Baker TB, Bailey WC, et al. A clinical practice guideline for treating tobacco use and dependence: 2008 update. Am J Prev Med 2008;35:158–176.
16. Jenssen BP, Walley SC, Boykan R, et al. Protecting children and adolescents from tobacco and nicotine. Pediatrics 2023;151:e2023061805.
17. Stead LF, Buitrago D, Preciado N, et al. Physician advice for smoking cessation. Cochrane Database Syst Rev 2013;2013(5):CD000165.
18. Theis RP, Malik AM, Thompson LA, et al. Considerations of privacy and confidentiality in developing a clinical support tool for adolescent tobacco prevention: qualitative study. JMIR Form Res 2019;3:e12406.
19. Farber HJ, Groner J, Walley S, et al. Protecting children from tobacco, nicotine, and tobacco smoke. Pediatrics 2015;136:e1439–e1467.
20. Gribben V, Klein JD. Practical implications of the US Preventive Services Task Force recommendations on adolescents and tobacco. J Adolesc Health 2020;67:328–330.
21. Moyer VA. Primary care interventions to prevent tobacco use in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Pediatrics 2013;132:560–565.
22. Selph S, Patnode C, Bailey S, et al. Primary care-relevant interventions for tobacco and nicotine use prevention and cessation in children and adolescents: updated evidence report and systematic review for the U.S. Preventive Services Task Force. JAMA 2020;323:1599–1608.
23. Boakye E, Osuji N, Erhabor J, et al. Healthcare provider screening for tobacco product and electronic cigarette use among youth in the United States. J Adolesc Health 2023;72:819–822.
24. Gorukanti AL, Kimminau KS, Tindle HA, et al. Cross-sectional online survey of clinicians’ knowledge, attitudes and challenges to screening and counselling adolescents and young adults for substance use. BMJ Open 2022;12:e059019.
25. Pepper JK, McRee AL, Gilkey MB. Healthcare providers’ beliefs and attitudes about electronic cigarettes and preventive counseling for adolescent patients. J Adolesc Health 2014; 54:678–683.
26. Salloum RG, Theis RP, Pbert L, et al. Stakeholder engagement in developing an electronic clinical support tool for tobacco prevention in adolescent primary care. Children (Basel) 2018; 5:170.
27. Gorzkowski JA, Whitmore RM, Kaseeska KR, et al. Pediatrician knowledge, attitudes, and practice related to electronic cigarettes. J Adolesc Health 2016;59:81–86.
28. Klein JD, Gorzkowski J, Resnick EA, et al. Delivery and impact of a motivational intervention for smoking cessation: a PROS study. Pediatrics 2020;146:1–10.
29. Yonek JC, Velez S, Satre DD, et al. Addressing adolescent substance use in an urban pediatric federally qualified health center. J Subst Abuse Treat 2022;135:108653.
30. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007;19:349–357.
31. McLeroy KR, Bibeau D, Steckler A, et al. An ecological perspective on health promotion programs. Health Educ Q 1988;15:351–377.
32. Guest G, Bunce A, Johnson L. How many interviews are enough?: an experiment with data saturation and variability. Field Methods 2006;18:59–82.
33. Dodgson JE. Reflexivity in qualitative research. J Hum Lact 2019;35:220–222.
34. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3:77–101.
35. Delve. Essential guide to coding qualitative data. https://delvetool.com/guide. Accessed March 3, 2024.
36. Delve. What is intercoder reliability? https://delvetool.com/blog/intercoder. Published November 10, 2020. Accessed March 30, 2024.
37. O’Connor C, Joffe H. Intercoder reliability in qualitative research: debates and practical guidelines. Int J Qual Methods 2020;19:1609406919899220.
38. Saunders B, Sim J, Kingstone T, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant 2018;52:1893–1907.
39. Pepper JK, Gilkey MB, Brewer NT. Physicians’ counseling of adolescents regarding e-cigarette use. J Adolesc Health 2015;57:580–586.
40. McGee LU, Parker S, Bulsara S, et al. Adolescent electronic cigarette counselling: knowledge, attitudes and perceived barriers among clinical staff in a primary care setting. J Eval Clin Pract 2021;27:1398–1402.
41. McMillen R, O’Connor KG, Groner J, et al. Changes and factors associated with tobacco counseling: results from the AAP periodic survey. Acad Pediatr 2017;17:504–514.
42. Simoneau T, Hollenbach JP, Langton CR, et al. Smoking cessation and counseling: A mixed methods study of pediatricians and parents. PLoS One 2021;16:e0246231.
43. Tennessee Department of Mental Health and Substance Abuse Services. 2018-19 TN Together Student Survey results. https://www.tn.gov/content/dam/tn/mentalhealth/ documents/2018-2019_TN_Together_Report.pdf. Accessed March 3, 2024.
44. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health; American Psychological Association. The health consequences of smoking - 50 years of progress: a report of the Surgeon General. http://doi.apa.org/get-pe-doi.cfm?doi= 10.1037/e510072014-001. Published 2014. Accessed February 19, 2023.
45. Semer N, Ellison J, Mansell C, et al. Development and evaluation of a tobacco cessation motivational program for adolescents based on physical attractiveness and oral health. J Dent Hyg 2005;79:9.
46. Dai H, Clements M. Trends in healthcare provider advice on youth tobacco use, 2011-2015. Am J Prev Med 2018;55:222–230.
47. Kuhns LM, Carlino B, Greeley K, et al. A chart review of substance use screening and related documentation among adolescents in outpatient pediatric clinics: implications for practice. Subst Abuse Treat Prev Policy 2020;15:1–6.
48. Levy S, Weiss R, Sherritt L, et al. An electronic screen for triaging adolescent substance use by risk levels. JAMA Pediatr 2014;168:822–828.
