You will appraise the clinical practice guideline using the cadth

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Primary Care Interventions for Prevention and Cessation of Tobacco Use
in Children and Adolescents
US Preventive Services Task Force Recommendation Statement
US Preventive Services Task Force

Summary of Recommendations

The USPSTF recommends that primary care clinicians provide interventions, including education or
brief counseling, to prevent initiation of tobacco use among school-aged children and adolescents. B

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and
harms of primary care–feasible interventions for the cessation of tobacco use among school-aged
children and adolescents.

I

See the Figure for a more detailed summary of the recommendation for clinicians. See the Practice Considerations section for more information on effective
interventions to prevent initiation of tobacco use and for suggestions for practice regarding the I statement. USPSTF indicates US Preventive Services Task Force.

IMPORTANCE Tobacco use is the leading cause of preventable death in the US. An estimated
annual 480 000 deaths are attributable to tobacco use in adults, including from secondhand
smoke. It is estimated that every day about 1600 youth aged 12 to 17 years smoke their first
cigarette and that about 5.6 million adolescents alive today will die prematurely from a
smoking-related illness. Although conventional cigarette use has gradually declined among
children in the US since the late 1990s, tobacco use via electronic cigarettes (e-cigarettes) is
quickly rising and is now more common among youth than cigarette smoking. e-Cigarette
products usually contain nicotine, which is addictive, raising concerns about e-cigarette use
and nicotine addiction in children. Exposure to nicotine during adolescence can harm the
developing brain, which may affect brain function and cognition, attention, and mood; thus,
minimizing nicotine exposure from any tobacco product in youth is important.

OBJECTIVE To update its 2013 recommendation, the USPSTF commissioned a review of the
evidence on the benefits and harms of primary care interventions for tobacco use prevention
and cessation in children and adolescents. The current systematic review newly included
e-cigarettes as a tobacco product.

POPULATION This recommendation applies to school-aged children and adolescents younger
than 18 years.

EVIDENCE ASSESSMENT The USPSTF concludes with moderate certainty that primary
care–feasible behavioral interventions, including education or brief counseling, to prevent
tobacco use in school-aged children and adolescents have a moderate net benefit. The
USPSTF concludes that there is insufficient evidence to determine the balance of benefits
and harms of primary care interventions for tobacco cessation among school-aged children
and adolescents who already smoke, because of a lack of adequately powered studies on
behavioral counseling interventions and a lack of studies on medications.

RECOMMENDATION The USPSTF recommends that primary care clinicians provide
interventions, including education or brief counseling, to prevent initiation of tobacco use
among school-aged children and adolescents. (B recommendation) The USPSTF concludes
that the current evidence is insufficient to assess the balance of benefits and harms of
primary care–feasible interventions for the cessation of tobacco use among school-aged
children and adolescents. (I statement)

JAMA. 2020;323(16):1590-1598. doi:10.1001/jama.2020.4679

Editorial page 1563

Related article page 1599 and
JAMA Patient Page page 1626

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Group Information: The US
Preventive Services Task Force
(USPSTF) members are listed at the
end of this article.

Corresponding Author: Douglas K.
Owens, MD, MS, Stanford University,
615 Crothers Way, Encina Commons,
Mail Code 6019, Stanford, CA
94305-6006 ([email protected]).

Clinical Review & Education

JAMA | US Preventive Services Task Force | RECOMMENDATION STATEMENT

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T obacco use is the leading cause of preventable death in
the US.1 An estimated annual 480 000 deaths are attrib-
utable to tobacco use in adults, including secondhand

smoke.1 It is estimated that every day about 1600 youth aged 12 to
17 years smoke their first cigarette2 and that about 5.6 million ado-
lescents alive today will die prematurely of a smoking-related
illness.1,3 Although conventional cigarette use has gradually
declined among children in the US since the late 1990s,4 tobacco
use via electronic cigarettes (e-cigarettes) is quickly rising and is
now more common among youth than cigarette smoking.
e-Cigarette sales in the US market have risen rapidly since 2007,5

and e-cigarette use by youth has been tracked in the National
Youth Tobacco Survey since 2011.1 From 2011 to 2019, current
e-cigarette use increased from 1.5% to 27.5% among high school
students6,7 (from an estimated 220 000 to 4.11 million students);
in 2019, 5.8% of high school students (an estimated 860 000 stu-
dents) used conventional cigarettes.7

e-Cigarette products usually contain nicotine,8 which is addic-
tive, raising concerns about e-cigarette use and nicotine addiction
in children.5 Evidence suggests an association between e-cigarette
use in nonsmoking adolescents and subsequent cigarette smoking
in young adults. Ever use of e-cigarettes is associated with
increased risk of ever use of combustible tobacco products.9 In
addition, as the degree of e-cigarette use increases, frequency and
intensity of smoking cigarettes also increases.9 Exposure to nico-
tine during adolescence can harm the developing brain, which may
affect brain function and cognition, attention, and mood1,5,10,11;
thus, minimizing nicotine exposure from any tobacco product in
youth is important. In 2019, an outbreak of e-cigarette, or vaping,
product use–associated lung injury (EVALI) occurred in the US;
approximately 15% of patients hospitalized with EVALI were
younger than 18 years.12 Vitamin E acetate, an additive to some
tetrahydrocannabinol-containing e-cigarettes, was found to be
strongly linked to the outbreak.12 Other tobacco products high
school students report using include cigars, cigarillos, and little
cigars (7.6%); smokeless tobacco (4.8%); hookahs (3.4%); and pipe
tobacco (1.1%).7 In 2019, cigar use (including cigarillos and little
cigars) surpassed cigarette use in high school students.7 See the
Definitions section for more information on tobacco products and
terminology used in this US Preventive Services Task Force
(USPSTF) recommendation.

USPSTF Assessment of Magnitude of Net Benefit
Available evidence on interventions to prevent and help youth quit
tobacco use almost exclusively focus on cigarette smoking. For this
recommendation, the US Preventive Services Task Force (USPSTF)
found this evidence to be most applicable to smoking combustible
products (including cigarettes, cigars, cigarillos, and little cigars) and
use of e-cigarettes (“vaping”).

See the Figure and Table 1 for more information on the USPSTF
recommendation rationale and assessment. For more details on the
methods the USPSTF uses to determine the net benefit, see the
USPSTF Procedure Manual.13 For a summary of the evidence that
served as the basis for the recommendations, see the review of the
evidence on the benefits and harms of primary care interventions for
tobacco use prevention and cessation in children and adolescents.14,15

Prevention
The USPSTF concludes with moderate certainty that primary care–
feasible behavioral interventions, including education or brief coun-
seling, to prevent tobacco use in school-aged children and adoles-
cents have a moderate net benefit. The USPSTF found adequate
evidence that behavioral counseling interventions, such as face-to-
face or telephone interaction with a health care clinician, print ma-
terials, and computer applications, can have a moderate effect in pre-
venting initiation of tobacco use in school-aged children and
adolescents. The USPSTF sought but found no evidence on the
harms of behavioral counseling interventions for the prevention or
cessation of tobacco use; however, the USPSTF bounds the magni-
tude of potential harms of behavioral counseling interventions as
no greater than small, based on the absence of reported harms in
the literature and the noninvasive nature of the interventions
(Table 1).

Cessation
The USPSTF concludes that there is insufficient evidence to de-
termine the balance of benefits and harms of primary care interven-
tions for tobacco cessation among school-aged children and ado-
lescents who already smoke, because of a lack of adequately
powered studies on behavioral counseling interventions and a lack
of studies on medications.

The USPSTF found inadequate evidence on the benefit of be-
havioral counseling interventions for tobacco cessation in school-
aged children and adolescents because many studies had small
sample sizes and may not have been adequately powered to de-
tect a benefit, making it unclear whether the observed lack of ef-
fect of interventions was the result of intervention failure or lack of
statistical power. Although the USPSTF found no evidence on the
harms of behavioral counseling interventions, it bounds the mag-
nitude of potential harms of behavioral counseling interventions as
no greater than small, based on the absence of reported harms in
the literature and the noninvasive nature of the interventions.

The USPSTF found inadequate evidence on the benefits and
harms of medications for tobacco cessation in children and adoles-
cents, primarily because of an inadequate number of studies that
have evaluated tobacco cessation medications in this population.
Potential harms depend on the specific medication (Table 1).

Practice Considerations
Patient Population Under Consideration
This recommendation applies to school-aged children and adoles-
cents younger than 18 years. The USPSTF has issued a separate rec-
ommendation statement on interventions for tobacco use cessa-
tion in adults 18 years and older, including pregnant persons.16

Definitions
“Tobacco use” refers to use of any tobacco product. As defined by
the US Food and Drug Administration (FDA), tobacco products in-
clude any product made or derived from tobacco intended for hu-
man consumption (except products that meet the definition of
drugs), including, but not limited to, cigarettes, cigars (including ciga-
rillos and little cigars), dissolvable tobacco, hookah tobacco, nico-
tine gels, pipe tobacco, roll-your-own tobacco, smokeless tobacco

USPSTF Recommendation: Tobacco Use Prevention and Cessation in Children and Adolescents US Preventive Services Task Force Clinical Review & Education

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products (including dip, snuff, snus, and chewing tobacco), vapes,
e-cigarettes, hookah pens, and other electronic nicotine delivery sys-
tems. “Smoking” generally refers to the inhaling and exhaling of

smoke produced by combustible tobacco products such as ciga-
rettes, cigars, and pipes. “Vaping” refers to the inhaling and exhal-
ing of aerosols produced by e-cigarettes.17 Vape products usually

Table 1. Summary of USPSTF Rationalea

Rationale Prevention Cessation
Benefits of
intervention

Adequate evidence that behavioral counseling interventions
can have a moderate effect in preventing initiation of tobacco
use in school-aged children and adolescents

• Inadequate evidence on behavioral counseling interventions for cessation
of tobacco use in school-aged children and adolescents because many
studies had small sample sizes and may not have been adequately
powered to detect a benefit

• Inadequate evidence on medications for cessation of tobacco use in
school-aged children and adolescents because of an inadequate number
of studies

Harms of
intervention

Adequate evidence to bound harms of behavioral counseling
interventions as no greater than small based on the absence of
reported harms in the evidence, the noninvasive nature of the
interventions, and the low likelihood of serious harms

• Adequate evidence to bound harms of behavioral counseling interventions
as no greater than small, based on the absence of reported harms in the
evidence, the noninvasive nature of the interventions, and the low
likelihood of serious harms

• Inadequate evidence on harms of medications
USPSTF
assessment

Moderate certainty that primary care–relevant behavioral
interventions to prevent tobacco use in school-aged children
and adolescents have a moderate net benefit

Insufficient evidence to determine the balance of benefits and harms
of primary care interventions for tobacco cessation in school-aged
children and adolescents who already smoke

Abbreviation: USPSTF, US Preventive Services Task Force.
a See the eFigure in the Supplement for explanation of USPSTF grades and levels of evidence.

Figure. Clinician Summary: Primary Care Interventions for Prevention and Cessation of Tobacco Use in Children and Adolescents

What does the USPSTF
recommend?

School-aged children and adolescents who have not started to use tobacco: Grade B

To whom does this
recommendation apply?

What’s new?

How to implement this
recommendation?

The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize
decision-making to the specific patient or situation.

School-aged children and adolescents younger than 18 years.

This recommendation is consistent with the 2013 USPSTF recommendation, with some key updates:
• Adds a new I statement on interventions for the cessation of tobacco use in school-aged children and adolescents.
• Includes e-cigarettes as a tobacco product.

What are other
relevant USPSTF
recommendations?

The USPSTF has made recommendations on behavioral and pharmacotherapy interventions for tobacco smoking cessation in
adults, including pregnant women, and primary care behavioral interventions to reduce illicit drug and nonmedical pharmaceutical
use in children and adolescents. These recommendations are available at https://www.uspreventiveservicestaskforce.org.

Definition of tobacco use: Tobacco use refers to any tobacco product, including cigarettes, cigars (including cigarillos and
little cigars), as well as vaping e-cigarettes.

1. Determine if youth are using tobacco.
2. If youth are not using tobacco:

• Provide behavioral counseling interventions to all youth to prevent tobacco use.
• Effective behavioral counseling interventions to prevent initiation of tobacco use include face-to-face

counseling, telephone counseling, and computer-based and print-based interventions.
3. If youth are using tobacco:

• The evidence is insufficient to recommend for or against providing interventions to youth for cessation of tobacco use.
• Existing studies on behavioral interventions to help youth quit tobacco use have been too heterogeneous and too

small to detect a benefit.
• No medications are currently approved by the US Food and Drug Administration for tobacco cessation in children

and adolescents.
• Use clinical judgment to decide how to best help youth who use tobacco.

Where to read the full
recommendation
statement?

Visit the USPSTF website (https://www.uspreventiveservicestaskforce.org) to read the full recommendation statement.
This includes more details on the rationale of the recommendation, including benefits and harms; supporting evidence;
and recommendations of others.

Provide interventions, including education or brief counseling, to prevent initiation of tobacco use.

School-aged children and adolescents who use tobacco: I statement
The evidence is insufficient to assess the balance of benefits and harms of primary care–feasible interventions for
cessation of tobacco use.

April 2020

USPSTF indicates US Preventive Services Task Force.

Clinical Review & Education US Preventive Services Task Force USPSTF Recommendation: Tobacco Use Prevention and Cessation in Children and Adolescents

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contain nicotine, which is the addictive ingredient in tobacco. Sub-
stances other than tobacco can also be used to smoke or vape.

Assessment of Risk
All youth are considered at risk of initiating tobacco use. Interven-
tions to prevent the initiation of tobacco use should be provided
to all youth who have not started using tobacco products yet,
regardless of the presence or absence of other risk factors. The
following risk factors may increase the risk of tobacco use in
youth: being male, white race, not college-bound, from a rural
area, having parents with lower levels of education, parental
smoking, having childhood friends who smoke, being an older
adolescent, experiencing highly stressful events, and perceiving
tobacco use as low risk.18,19

Interventions to Prevent Tobacco Use and Implementation
Considerations
Various behavioral counseling intervention types are effective in pre-
venting tobacco initiation in children, including face-to-face coun-
seling, telephone counseling, and computer-based and print-
based interventions.14

Individual interventions target specific audiences (the child/
adolescent, the parent, or both) and a variety of age ranges. For ex-
ample, in the reviewed studies,14 interventions for children aged 7
to 10 years tended to be print-based materials, whereas face-to-
face counseling and telephone- and computer-based interven-
tions typically targeted children older than 10 years. Interventions
targeting parents tended to be print- or telephone-based. The num-
ber of contacts made with intervention recipients also varied, rang-
ing from 1 to 8 contacts.14 The intensity of the interventions varied,
with the content of the print materials ranging from stickers to in-
formational newsletters or an activity book (for children) or activ-
ity guide (for parents). For telephone-based interventions, tele-
phone counseling was usually provided in conjunction with another

modality such as print materials or face-to-face counseling. Based
on the evidence reviewed,14 no specific component of behavioral
counseling interventions (such as intervention modality, target au-
dience, duration of intervention, or intervention setting) appeared
to make an intervention more or less effective. Thus, clinicians have
a broad range of effective behavioral counseling interventions from
which to choose. For additional information about behavioral coun-
seling interventions to prevent tobacco use, see Table 2, the Addi-
tional Tools and Resources section, and the Box.

Most of the evidence on behavioral counseling interventions
to prevent tobacco use focused on prevention of cigarette
smoking.14 Given the similar contextual and cultural issues cur-
rently surrounding the use of e-cigarettes in youth and the inclu-
sion of e-cigarettes as a tobacco product by the FDA, the USPSTF
concludes that the evidence on interventions to prevent cigarette
smoking could be applied to prevention of e-cigarette use as well.
The USPSTF also concludes that the evidence could be applied to
prevention of cigar use, which includes cigarillos and little cigars.

Additional Tools and Resources
Primary care clinicians may find the resources listed in the Box
useful in talking with children and adolescents about the harms of
tobacco use.

Other Related USPSTF Recommendations
The USPSTF has made recommendations on behavioral and phar-
macotherapy interventions for tobacco smoking cessation in adults,
including pregnant women,16 and primary care behavioral interven-
tions to reduce illicit drug and nonmedical pharmaceutical use in chil-
dren and adolescents.35

Table 2. Behavioral Counseling Interventions for Prevention of Tobacco Use in Children and Adolescentsa

Characteristic

Mode of intervention delivery

Print20-28 Face-to-face20,21,29-32 Telephone21,22,24,28-30 Computer21,31,33

Intervention
recipient

Child (aged 7-19 y), parent, or both Child (aged 11-19 y) or both
parent and child

Child (aged 9-17 y), parent, or both Child (aged
10-17 y)

Intervention
intensity

Variable. Included stickers,
newsletters, activity books,
or activity guides

1 to 8 visits 1 to 4 booster calls 1 to 6 sessions

Main intervention or part of
multimodal intervention

Always provided in conjunction with print
material or face-to-face counseling

Interactive or
web-based
programs

Examples of
materials
provided for
practiceb

Prescriptions with preprinted
antitobacco messages were given to
adolescents covering tobacco-free
offices, tobacco advertising, tobacco
and sports, smokeless tobacco,
nicotine and tobacco addiction,
passive smoking, tobacco’s effect on
teeth, and negative consequences of
tobacco use20

Use of 5A model: Clinician asked
about smoking, advised continued
abstinence, and referred to peer
counselor who continued the
model (assess, assist, arrange
follow-up) using motivational
interviewing and behavior change
counseling29

Use of 5A model: Clinician asked about
smoking, advised continued abstinence, and
referred to peer counselor who continued
the model (assess, assist, arrange follow-up)
using motivational interviewing and
behavior change counseling29

Computer
screenshots31

Practice settings Medical care settings (primary care, dental care, or family planning) and nonmedical settings (school setting after school hours)

Interventionist Clinicians or other health care practitioners, dentists, dental hygienists, health educators, health counselors, peer counselors, study-trained
counselor, or study-trained workshop leader

Demonstrated
benefit

No difference in effectiveness was seen by intervention recipient, clinician, modality, or setting. Overall, behavioral interventions had a relative
risk reduction for initiation of smoking of 0.82 (95% CI, 0.73-0.92).

a Adapted from Table 7 in Selph et al14 and a modified Template for Intervention
Description and Replication (TIDieR) checklist.34

b The US Preventive Services Task Force does not endorse any specific
intervention. Materials listed here represent examples of materials that were

used in reviewed studies and that are publicly available. Other studies may
reference practice materials, but either their websites are no longer active,
they use outdated modes of communication (eg, VHS tape), or the material is
in a non-English language.

USPSTF Recommendation: Tobacco Use Prevention and Cessation in Children and Adolescents US Preventive Services Task Force Clinical Review & Education

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Suggestions for Practice Regarding the I Statement
on Cessation
Potential Preventable Burden
Nearly 90% of adult daily smokers smoked their first cigarette by
age 18 years.1 In 2019, an estimated 1.43 million high school and
middle school students reported current use of cigars, 1.15 million
high school and middle school students reported current use of
conventional cigarettes, and 5.38 million high school and middle
school students reported current use of e-cigarettes.7 Of high
school and middle school students who used any tobacco product
in the past 12 months, 57.5% reported that they had at least 1 quit
attempt7; however, most quit attempts fail, and about 80% will go
on to smoke into adulthood.36 Immediate adverse health effects in
child and adolescent cigarette smokers include increased negative
respiratory effects such as impaired lung growth, early onset of
lung function decline, respiratory and asthma-related symptoms
(eg, coughing and wheezing), and early abdominal aortic
atherosclerosis.1,36 Concerns regarding use of e-cigarettes in ado-
lescence includes nicotine dependence and toxicity, harm to the

developing brain, its use as a bridge to conventional cigarette
smoking, and inhalation of carcinogens.5

Although the evidence on behavioral counseling interventions
to prevent tobacco use in children and adolescents is robust, fewer
studies with smaller sample sizes are available that evaluate the ef-
fect of behavioral counseling interventions or pharmacotherapy on
tobacco cessation.14 The pooled effect of the trials that evaluated
behavioral counseling interventions for tobacco cessation in pri-
mary care settings did not find a significant reduction in smokers af-
ter the intervention.14 However, the study interventions were hetero-
geneous and most of the studies were small, making it difficult to
determine whether interventions were unsuccessful at helping chil-
dren and adolescents to stop using tobacco, or whether they were
underpowered to detect a difference in tobacco cessation.

No medications are currently approved by the FDA for to-
bacco cessation in children and adolescents. The label for vareni-
cline now states that it is not indicated in children and adolescents
16 years and younger because its efficacy in this population has not
been demonstrated.37 Few trials have been published on medica-
tion use for tobacco cessation in children and adolescents (1 trial on
nicotine replacement therapy [NRT] and 2 trials on bupropion sus-
tained-release [SR]). Trials were relatively small, and all included be-
havioral counseling in addition to pharmacotherapy. None found a
significant difference in quit rates at the end of treatment.14 One ad-
ditional published trial on varenicline for cessation was identified;
however, it was not considered in the USPSTF evidence review be-
cause the trial included young adults and the mean age of partici-
pants was older than the age in the inclusion criteria of the evi-
dence review.

Given the insufficient evidence to identify effective interven-
tions to help youth quit using tobacco, the USPSTF is calling for more
research in this area.

Potential Harms
The USPSTF found no evidence on harms from behavioral counsel-
ing interventions for tobacco cessation14; however, these harms are
likely small to none based on the absence of reported harms in the
evidence, the noninvasive nature of the interventions, and the low
likelihood of serious harms.

The USPSTF found the evidence on harms from medications for
tobacco cessation in children and adolescents to be inadequate. None
ofthepublishedtrialsreportedanyseriousharms;however,studysizes
were relatively small.14 The single trial of NRT found a greater num-
ber of headaches, cough, abnormal dreams, muscle pain, and patch-
related adverse events with NRT.38 Bupropion carries a boxed warn-
ing for increased risk of suicidality in children, adolescents, and young
adults, with other concerns for increased risk of seizure, hyperten-
sion, mania, visual problems, and unusual thoughts and behaviors.39

Varenicline is not indicated in children 16 years and younger; there-
fore, no warnings specific to this age group are included in its label.37

For older populations, labeling includes warnings and precautions for
neuropsychiatric adverse events, including suicidality, seizures, inter-
action with alcohol, cardiovascular events, sleepwalking, angio-
edema, serious skin reactions, and nausea.37

Current Practice
Approximately one-third to one-half of children and adolescents who
have visited a clinician in the past year were asked about their tobacco

Box. Additional Tools and Resources for Talking With Children
and Adolescents About the Harms of Tobacco Use

Centers for Disease Control and Prevention
Youth Tobacco Prevention
https://www.cdc.gov/tobacco/basic_information/youth/index.htm

Fact Sheet on Youth and Tobacco Use
https://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_
data/tobacco_use/index.htm

Quick Facts on the Risks of e-Cigarettes for Kids, Teens,
and Young Adults

https://www.cdc.gov/tobacco/basic_information/e-cigarettes/
Quick-Facts-on-the-Risks-of-E-cigarettes-for-Kids-Teens-and-
Young-Adults.html

US Food and Drug Administration
Think e-Cigs Can’t Harm Teens’ Health?
http://www.fda.gov/tobacco-products/public-health-education/
think-e-cigs-cant-harm-teens-health

The Real Cost Campaign
https://www.fda.gov/tobacco-products/public-health-education/
real-cost-campaign

National Cancer Institute
Become a Smokefree Teen
https://teen.smokefree.gov

1-800-QUIT-NOW

Office of the Surgeon General
Know the Risks: e-Cigarettes & Young People
https://e-cigarettes.surgeongeneral.gov/knowtherisks.html

2016 Surgeon General’s Report: e-Cigarette Use Among Youth
and Young Adults
https://www.cdc.gov/tobacco/data_statistics/sgr/e-cigarettes/
index.htm

2012 Surgeon General’s Report: Preventing Tobacco Use
Among Youth and Young Adults
https://www.cdc.gov/tobacco/data_statistics/sgr/2012/index.htm

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use.40,41 Of those who reported tobacco use in the past 30 days, ap-
proximately one-fourth were advised to quit.40,41

Update of Previous USPSTF Recommendation
This recommendation replaces the 2013 USPSTF recommenda-
tion on primary care interventions to prevent tobacco use in chil-
dren and adolescents.42 It is consistent with the 2013 recommen-
dation, which similarly issued a B recommendation for primary
care clinicians to provide interventions to prevent initiation of
tobacco use among children and adolescents. New to the current
recommendation is the inclusion of e-cigarettes as a tobacco
product. Also new to the current recommendation is the I state-
ment on insufficient evidence on interventions for cessation of
tobacco use among this population. The USPSTF is calling for
more research to identify interventions (behavioral counseling or
pharmacotherapy) to help children and adolescents who use
tobacco to quit.

Supporting Evidence
Scope of Review
The USPSTF commissioned a systematic review14,15 to evaluate the
benefits and harms of primary care interventions for tobacco use pre-
vention and cessation in children and adolescents. The current sys-
tematic review newly included e-cigarettes as a tobacco product.

Benefits of Primary Care Interventions
Nearly all studies evaluated the effect of interventions on smoking
prevention and cessation. As mentioned previously, the USPSTF
determined that this evidence could be applied to other forms of
tobacco use, including e-cigarette use.

Prevention
Fourteen trials (n = 25 049) reported on the effects of behavioral
counseling interventions to prevent the initiation of smoking.14 Nine
of these trials enrolled only children who were nonsmokers at base-
line, while 5 trials enrolled both smokers and nonsmokers but re-
ported results by baseline smoking status. The weighted mean age
of participants was 12.8 years, although eligible ages ranged from 7
to 19 years across studies.14

Most studies used interventions that targeted the child/
adolescent, although some targeted both children and parents/
caregivers and a few targeted only the parents/caregivers. Inter-
vention content included health education, readiness to act or
change, and parenting skills (communication and positive parent-
ing). Delivery settings of interventions varied and included pri-
mary care clinics, dental clinics, schools (after hours), and the
child’s home. Various types of interventions were used, including
print materials, face-to-face counseling, telephone support, and
computer-based interventions. Six of the studies used only a
single intervention type, and 8 studies used combinations of vari-
ous interventions (eg, telephone counseling plus print materials
or face-to-face counseling plus a computer-based intervention).
Most studies reported that fewer youth initiated smoking when
they received a behavioral counseling intervention (follow-up was

most commonly at 12 months but ranged from 7 to 36 months).14

This finding was not always statistically significant for individual
studies; however, this reduction was statistically significant when
results from trials were pooled: 7.4% vs 9.2% of participants initi-
ated smoking in the intervention groups vs the control groups
(relative risk, 0.82 [95% CI, 0.73-0.92]; 13 studies; n = 21 700).14

No effect modification was found by intervention type, setting, or
target population (child vs parent).14

Cessation
Nine trials (n = 2516) reported on the effects of behavioral coun-
seling interventions on smoking cessation in youth; 6 trials had
fewer than 65 participants analyzed per intervention group.14

Four trials enrolled only smokers, while 5 trials enrolled both
smokers and nonsmokers but reported results by baseline smok-
ing status.14 The weighted mean average age of participants in
cessation trials was much older than in the prevention trials (16.6
years [range, 12-19 years]).14

Nearly all interventions targeted the child/adolescent and very
few targeted parents/caregivers. Intervention content most com-
monly focused on assessing and facilitating the youth’s readiness to
change; a few interventions included health education. The deliv-
ery setting of interventions was most commonly a primary care or
dental clinic; a few studies delivered interventions at home. Nearly
all interventions used combinations of intervention types, most
commonly face-to face counseling; telephone- and computer-
based interventions and print materials (1 intervention) were used
less commonly. Two trials reported significant increases in smoking
cessation rates in youth receiving interventions.21,43 One trial used
a combination of motivational interviewing supplemented with
handouts, a computer program, and telephone calls21; the other
trial used a combination of 1 face-to-face session supplemented
with 1 telephone call.43 Meta-analysis of all 9 trials reported a risk
reduction of percent smokers after the intervention that was not
statistically significant (relative risk, 0.97 [95% CI, 0.93-1.01]);
80.6% of participants in the intervention groups were still smoking
at the end of the study (range, 6-18 months), vs 84.1% in the con-
trol groups.14 However, given the small study sizes, it was unclear
whether this finding was a result of the studies being underpow-
ered to detect a change in smoking behavior. Additional analyses
were performed to evaluate if various factors, such as intervention
type, setting, target population (child vs parent), or study duration
may modify whether an intervention was effective. No factors
were identified that modified the effect of interventions.14

Three trials (n = 788) reported on the effect of medications on
smoking cessation in youth.14 Two trials evaluated bupropion SR44,45

and 1 trial evaluated NRT.46 All trials were relatively small (211 to 312
participants per trial), and all trials also included behavioral coun-
seling interventions in addition to medications. One of the bupro-
pion SR trials also included NRT for all participants.44 None of the
trials reported that medications improved cessation rates;
smoking rates remained high in both the treatment and the control
groups in all trials. In the bupropion SR trials, 87.5% to 93.8% of par-
ticipants were still smoking at the 6-month follow-up44,45; 95.6%
of the NRT group and 93.4% of the control group were still
smoking at 12 months in the NRT trial.46 The USPSTF also identi-
fied 1 published trial of varenicline for tobacco cessation in older ado-
lescents and young adults47 and 1 unpublished trial of varenicline for

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tobacco cessation in adolescents.48,49 Results from these trials were
not considered by the USPSTF because of the older age of
participants47 and because the study results were not published in
a peer-reviewed journal.48,49

Harms of Primary Care Interventions
The USPSTF evaluated harms of behavioral counseling interven-
tions from the 18 trials that reported on benefits of interventions on
smoking prevention and smoking cessation, as well as 4 additional
trials that reported on the effect of behavioral counseling interven-
tions on smoking prevalence irrespective of baseline smoking
status.14 None of the 22 trials reported adverse events or harms as-
sociated with behavioral counseling interventions.14 Some trials re-
ported higher smoking rates at follow-up in intervention groups com-
pared with control groups, but this finding was not statistically
significant in any of the trials.

The USPSTF evaluated harms of medications for smoking
cessation from 4 trials (n = 914)14; the 3 trials described above
(2 of bupropion and 1 of NRT), as well as a fourth trial of bupropion
SR that did not meet inclusion criteria for evidence on benefits be-
cause its follow-up was less than 6 months.50 No difference in se-
rious or severe adverse events was reported with bupropion vs con-
trol groups, although 2 trials reported that 4% of participants
withdrew because of adverse events with bupropion.14 Some stud-
ies reported more headaches, cough, dream disturbance, insom-
nia, and irritability with bupropion than the control group.14 Al-
though no cases were reported in the studies included in the current
review, bupropion carries a boxed warning for increased risk of sui-
cidality in children, adolescents, and young adults, and the insert also
includes other concerns for increased risk of seizure, hypertension,
mania, visual problems, and unusual thoughts and behaviors.39

In the single NRT trial, NRT was associated with more headaches,
cough, abnormal dreams, muscle pain, and patch-related adverse
events than placebo.38

Response to Public Comment
A draft version of this recommendation statement was posted for
public comment on the USPSTF website from June 25 to July 22,
2019. Several comments requested that the USPSTF recommend
behavioral counseling interventions for tobacco cessation in
youth, given the known harms of tobacco use in youth and the
lack of proven harms from counseling interventions. The USPSTF
only recommends a preventive service when there is at least
adequate evidence that there is a net benefit to providing the ser-
vice; absence of harms from a service is not sufficient evidence
for the USPSTF to recommend a preventive service. However, as
with all findings of insufficient evidence, the USPSTF calls for
more research on identifying ways to help youth who use tobacco
to quit. The USPSTF has also clarified in its Practice Consider-
ations section that given the finding of insufficient evidence,
health care practitioners should determine if offering behavioral
counseling for tobacco cessation to certain individuals is reason-
able. Other comments requested clarification about which
tobacco products the USPSTF recommendation addresses.
The USPSTF clarified this in the USPSTF Assessment of Magni-
tude of Net Benefit section. Additional changes made to the rec-
ommendation statement in response to public comment include
clarification of which population the recommendation applies to

(see the Practice Considerations section), use of the term
“e-cigarettes” instead of “Electronic Nicotine Delivery Systems
(ENDS)” throughout the document to be consistent with the
field, and consideration of additional Research Needs and Gaps
and Suggested Tools.

Research Needs and Gaps
More studies are needed to identify effective interventions to help
children and adolescents who use tobacco products to quit.
• Larger, adequately powered studies and studies of new behav-

ioral counseling interventions for cessation are needed.
• These studies should report tobacco cessation outcomes at

6 months or later and should also provide information on com-
ponents of the behavioral counseling intervention provided
in the study (such as intensity of delivery, frequency of con-
tacts, content and type of counseling or materials provided,
delivery setting of studies, and training of persons delivering
the intervention).

• More studies are needed that evaluate the benefits and harms of
medications to help youth with tobacco cessation.

• More research is needed on interventions tailored specifically to
prevent initiation of use and promote cessation of e-cigarette use
in youth. The landscape of e-cigarette devices is rapidly evolving,
so research in this area is challenged by the need to be timely, flex-
ible, and comprehensive.

• More research is also needed on interventions tailored specifically
to prevent initiation of use and promote cessation of other types
of tobacco (such as, but not limited to, cigars and smokeless
tobacco) and interventions tailored to subpopulations with
elevated tobacco use rates (such as African American youth,
Native American/Alaska Native youth, LGBTQ youth, and youth
with mental illness).

Recommendations of Others
The American Academy of Pediatrics (AAP) recommends that
pediatricians provide brief counseling to all children and adoles-
cents to prevent tobacco use initiation, and that all teenagers be
screened for tobacco and nicotine use. For adolescents who want
to stop using tobacco, it recommends that tobacco dependence
treatment, referral, or both be offered, and that tobacco depen-
dence pharmacotherapy can be considered for adolescents who
are moderately to severely dependent on tobacco who want to
stop smoking. e-Cigarettes are not recommended as a treatment
for tobacco dependence.51 The AAP also recommends that pedia-
tricians screen children and adolescents, parents, and caregivers
for e-cigarette use, and provide prevention counseling for chil-
dren and adolescents. Further, it recommends that parents, care-
givers, and adolescents who use e-cigarettes should be offered or
referred to tobacco cessation counseling and FDA-approved
tobacco dependence pharmacotherapy appropriate to their level
of addiction and readiness to change and, again, that e-cigarettes
are not recommended as a treatment for tobacco dependence.
Last, the AAP recommends addressing parent and caregiver
tobacco dependence as part of the pediatric visit.52 According to

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the US Surgeon General, smoking cessation is beneficial at any
age,53 tobacco prevention efforts must focus on both adolescents
and young adults,36 and health care professionals should warn

youth of the health risks of e-cigarettes and other nicotine-
containing products.5 The American Academy of Family Physi-
cians supports the 2013 USPSTF recommendation.54

ARTICLE INFORMATION

The US Preventive Services Task Force (USPSTF)
members: Douglas K. Owens, MD, MS; Karina W.
Davidson, PhD, MASc; Alex H. Krist, MD, MPH;
Michael J. Barry, MD; Michael Cabana, MD, MA,
MPH; Aaron B. Caughey, MD, PhD; Susan J. Curry,
PhD; Katrina Donahue, MD, MPH; Chyke A.
Doubeni, MD, MPH; John W. Epling Jr, MD, MSEd;
Martha Kubik, PhD, RN; Gbenga Ogedegbe, MD,
MPH; Lori Pbert, PhD; Michael Silverstein, MD,
MPH; Melissa A. Simon, MD, MPH; Chien-Wen
Tseng, MD, MPH, MSEE; John B. Wong, MD.

Affiliations of The US Preventive Services Task
Force (USPSTF) members: Veterans Affairs
Palo Alto Health Care System, Palo Alto, California
(Owens); Stanford University, Stanford, California
(Owens); Feinstein Institute for Medical Research at
Northwell Health, Manhasset, New York
(Davidson); Fairfax Family Practice Residency,
Fairfax, Virginia (Krist); Virginia Commonwealth
University, Richmond (Krist); Harvard Medical
School, Boston, Massachusetts (Barry); University
of California, San Francisco (Cabana); Oregon
Health & Science University, Portland (Caughey);
University of Iowa, Iowa City (Curry); University of
North Carolina at Chapel Hill (Donahue); Mayo
Clinic, Rochester, Minnesota (Doubeni); Virginia
Tech Carilion School of Medicine, Roanoke (Epling
Jr); Temple University, Philadelphia, Pennsylvania
(Kubik); New York University, New York, New York
(Ogedegbe); University of Massachusetts Medical
School, Worcester (Pbert); Boston University,
Boston, Massachusetts (Silverstein); Northwestern
University, Evanston, Illinois (Simon); University of
Hawaii, Honolulu (Tseng); Pacific Health Research
and Education Institute, Honolulu, Hawaii (Tseng);
Tufts University School of Medicine, Boston,
Massachusetts (Wong).

Author Contributions: Dr Owens had full access to
all of the data in the study and takes responsibility
for the integrity of the data and the accuracy of the
data analysis. The USPSTF members contributed
equally to the recommendation statement.

Conflict of Interest Disclosures: Authors followed
the policy regarding conflicts of interest described
at https://www.uspreventiveservicestaskforce.org/
Page/Name/conflict-of-interest-disclosures. All
members of the USPSTF receive travel
reimbursement and an honorarium for participating
in USPSTF meetings. Dr Barry reported receiving
grants and personal fees from Healthwise.

Funding/Support: The USPSTF is an independent,
voluntary body. The US Congress mandates that
the Agency for Healthcare Research and Quality
(AHRQ) support the operations of the USPSTF.

Role of the Funder/Sponsor: AHRQ staff assisted
in the following: development and review of the
research plan, commission of the systematic
evidence review from an Evidence-based Practice
Center, coordination of expert review and public
comment of the draft evidence report and draft
recommendation statement, and the writing and
preparation of the final recommendation statement
and its submission for publication. AHRQ staff had
no role in the approval of the final recommendation
statement or the decision to submit for publication.

Disclaimer: Recommendations made by the
USPSTF are independent of the US government.
They should not be construed as an official position
of AHRQ or the US Department of Health and
Human Services.

Additional Contributions: We thank Tina Fan, MD,
MPH (AHRQ), who contributed to the writing of the
manuscript, and Lisa Nicolella, MA (AHRQ), who
assisted with coordination and editing.

Additional Information: The USPSTF makes
recommendations about the effectiveness of
specific preventive care services for patients
without obvious related signs or symptoms. It
bases its recommendations on the evidence of both
the benefits and harms of the service and an
assessment of the balance. The USPSTF does not
consider the costs of providing a service in this
assessment. The USPSTF recognizes that clinical
decisions involve more considerations than
evidence alone. Clinicians should understand the
evidence but individualize decision-making to the
specific patient or situation. Similarly, the USPSTF
notes that policy and coverage decisions involve
considerations in addition to the evidence of clinical
benefits and harms.

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Clinical Review & Education US Preventive Services Task Force USPSTF Recommendation: Tobacco Use Prevention and Cessation in Children and Adolescents

1598 JAMA April 28, 2020 Volume 323, Number 16 (Reprinted) jama.com

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