Tobacco Use Screening and Cessation Assistance During Physician Office Visits Among Persons Aged 11–21 Years — National Ambulatory Medical Care Survey, United States, 2004–2010

Ahmed Jamal, MBBS

Shanta R. Dube, PhD

Stephen D. Babb, MPH

Ann M. Malarcher, PhD

Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC

Corresponding author: Ahmed Jamal, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Telephone: 770-488-5077; E-mail: jze1@cdc.gov.

Introduction

Tobacco use continues to be the leading cause of preventable disease and death in the United States. Cigarette smoking accounts for approximately 480,000 premature deaths annually and approximately $130 billion in direct medical expenses and $150 billion in lost productivity in the United States each year (1). Approximately 88% of adults who smoke daily began smoking by the age of 18 years (2). Although tobacco cessation is beneficial at any age, intervening as early as possible is important to maximize potential health benefits. After years of steady progress in decreasing smoking prevalence, decreases in smoking among youths and young adults have slowed in recent years (2). In 2011, a total of 18.1% of U.S. high school students in the United States were current cigarette smokers, and 49.9% of these smokers had tried to quit in the past 12 months (3). The proportion of youth cigarette smokers who tried to quit smoking in the past year decreased from 57.4% in 2001 to 49.9% in 2011 (3).

Given these recent trends, continued and enhanced tobacco control efforts are needed to prevent and reduce tobacco use. Both population-based and clinical smoking prevention and cessation interventions are effective in reducing youth and adult smoking (4,5). Moreover, because daily smoking increases dramatically from early adolescence into young adulthood and an estimated 60%–85% of young tobacco users are likely to have made at least one unsuccessful quit attempt (2), a focus on youth and young adult cessation interventions might have a major impact on the prevalence of tobacco use. Primary health-care providers should assess tobacco use among their adolescent patients and counsel users to help them quit, especially because a large proportion of adolescents and young adults make annual visits to a physician's office (4,6).

The 2008 update to the U.S. Public Health Service (PHS) Clinical Practice Guideline for Treating Tobacco Use and Dependence recommends that clinicians ask pediatric and adolescent patients about tobacco use and provide a strong message regarding the importance of abstaining from tobacco use (strength of evidence rated C*) (4). The guideline also recommends that adolescent smokers should be provided with counseling interventions to help them quit smoking because evidence indicates that cessation counseling is an effective treatment for this population (strength of evidence rated B†) (4). Finally, the guideline recommends that to protect children from secondhand smoke exposure, clinicians ask parents about tobacco use and offer parents who smoke cessation advice and assistance, a guideline that is based on evidence that counseling delivered in pediatric settings increases abstinence among parents who smoke (strength of evidence rated B) (4). The guideline does not recommend use of cessation medications for adolescent smokers because of a lack of evidence that these medications promote long-term smoking abstinence in this population (4). The American Academy of Pediatrics (AAP) also recommends that pediatricians discuss substance use with youths during office visits (7).

Healthy People 2020 tobacco use objective TU-7 calls for increasing the proportion of adolescent smokers in grades 9 through 12 who attempted to quit in the past year to 64.0% from a baseline of 58.5% in 2009 (8). Healthy People 2020 objectives for health systems changes related to tobacco cessation among persons aged ≥18 years include increasing tobacco use screening and cessation counseling in office-based ambulatory care settings (objectives TU-9.1 and TU-10.1). In addition, the National Quality Forum (NQF) has endorsed specific clinical quality measures§ on tobacco use assessment and tobacco cessation intervention, which include 1) the percentage of patients aged ≥18 years who have been seen for at least two office visits and were asked about tobacco use one or more times within 24 months (NQF #0028a) and 2) the percentage of patients aged ≥18 years identified as tobacco users within the past 24 months and who have been seen for at least two office visits and received a cessation intervention (NQF #0028b). Another NQF-endorsed clinical quality measure consists of assessing the percentage of patients aged ≥18 years who are currently smokers and who were seen by a health-care provider and advised to quit and the percentage of patients whose practitioner recommended or discussed smoking cessation medications, methods, or strategies (NQF #0027). Public health agencies play an important role in increasing the use of clinical preventive services by educating health-care systems and providers about effective treatments, collaborating with stakeholders to conduct programs to improve use of these services, and identifying and implementing policies that improve the use of these services (e.g., policies for a range of recommended clinical preventive services, such as coverage for tobacco cessation services and medications [4]; vaccinations of adults and children [9]; counseling, screening, and prevention of human immunodeficiency virus [HIV] infection and sexually transmitted diseases [10]; and prevention and control of health-care–associated infections) (4,5,11,12).

The reports in this supplement provide the public and stakeholders responsible for infant, child, and adolescent health (including public health practitioners, parents or guardians and their employers, health plans, health professionals, schools, child care facilities, community groups, and voluntary associations) with easily understood and transparent information about the use of selected clinical preventive services that can improve the health of infants, children, and adolescents. The topic in this report is one of 11 topics selected on the basis of existing evidence-based clinical practice recommendations or guidelines for the preventive services and availability of data system(s) for monitoring (13). This report analyzes 2004–2010 combined data from the National Ambulatory Medical Care Survey (NAMCS) to determine the proportion of physician office visits for patients aged 11–21 years in which screening for tobacco use and tobacco cessation assistance (tobacco counseling, prescribing or ordering tobacco cessation medication, or both) occurred. Public health authorities and clinicians can use these data to identify population groups that might require additional strategies to access services to prevent and reduce tobacco use.

Methods

To estimate the percentage of office-based physician visits made by patients aged 11–21 years with documentation of screening for tobacco use, tobacco cessation counseling, and provision of tobacco cessation medications, CDC analyzed the combined 2004–2010 data from NAMCS. NAMCS is a national probability survey of outpatient visits made to office-based physicians that measures health-care use with various health-care providers (14).

The basic sampling unit for NAMCS (and the unit of analysis) is the physician-patient encounter, or visit. The NAMCS sample included 17,066 outpatient visits among patients aged 11–21 years, ranging from 2,077 visits in 2004 to 2,702 in 2007. NAMCS estimates for tobacco use screening and tobacco cessation counseling, provision of medication during visits, or both by patients aged 11–21 years were analyzed by demographic characteristics, tobacco use status, type of health insurance, and physician- or visit-related characteristics. Patient characteristics included age, sex, race/ethnicity, and type of health insurance (private insurance, Medicare, Medicaid or State Children's Health Insurance Program [SCHIP/CHIP], no insurance [having only self-pay, no charge, or charity visits as payment sources], or other [including workers' compensation; other sources of payment not covered by private insurance, Medicare, Medicaid/SCHIP, workers' compensation, self-pay, and no charge or charity; or unknown coverage/payment]). During 2005–2010, NAMCS used a hierarchical scheme to determine the primary expected source of payment. For the 2005–2007 NAMCS, respondents who were eligible both for Medicare and Medicaid were categorized as Medicaid recipients; however, these respondents were classified as Medicare recipients in 2008–2010. To account for this change, the 2005–2007 payment type variable was recoded to be consistent with the 2008–2010 classification for primary expected source of payment. In 2004, survey respondents were only allowed to report a single expected source of payment (as primary source of payment). NAMCS data for patient visits were collected on patient record forms by the physicians and their staff members or abstracted by the U.S. Census Bureau staff members. Physician-related characteristics included whether the physician was the patient's primary care physician (determined by response to the question, "Are you the patient's primary care physician/provider?"), practice type (solo or other), specialty (primary, surgical, or medical care), and electronic medical record use in the practice.

For all survey years, nonphysician providers, federally employed physicians, and physicians in anesthesiology, pathology, and radiology specialties were excluded because they were not in the scope of the survey. In addition, hospital-based outpatient care is not included in NAMCS (unless the care occurred in a private office in a hospital that meets the NAMCS definition of a physician's office). For physicians whose major professional activity was patient care, only visits classified by the American Medical Association or the American Osteopathic Association as office-based patient care were included. The survey methods and sampling frame have been described in the scope and documentation of the survey (14).

NAMCS defines tobacco use as documentation in the medical chart that the patient is a current user of tobacco, including cigarettes, cigars, snuff, and chewing tobacco. Tobacco use screening is defined as documentation on the patient record form of current tobacco use or no current use. Tobacco counseling is defined as information given in the form of health education to the patient on topics related to tobacco use in any form, including use of cigarettes, cigars, snuff, and chewing tobacco, or on exposure to secondhand smoke. Tobacco counseling also includes information on smoking cessation and prevention of tobacco use, as well as referrals to other health-care professionals for smoking cessation programs. Medication use includes medications that were ordered, supplied, administered, or continued during the visit. Only medications related to tobacco cessation were analyzed. These medications were entered as free text for each visit and were limited to no more than eight prescription and over-the-counter medications. Medications included nicotine replacement therapy (i.e., nicotine patch, gum, lozenge, nasal spray, and inhaler), bupropion, and varenicline.

All analyses were conducted using statistical software to account for the complex multistage sample design of NAMCS. Data from NAMCS were adjusted for nonresponse and weighted to provide national estimates of outpatient visits with tobacco screening and tobacco counseling, cessation medications, or both; 95% confidence intervals were calculated to account for the multistage probability sample design, and estimates were considered to be different if the confidence intervals did not overlap. The overlapping confidence interval approach is not a formal statistical test for assessing differences; formal statistical testing might result in different conclusions. Logistic regression analysis was used to analyze temporal changes from 2004 to 2010 in tobacco use screening, controlling for race/ethnicity, sex, and health insurance status, and simultaneously assessed linear trends by using orthogonal polynomial contrasts. For the trend analysis, statistical significance of differences was determined with significance set at p <0.05. Data were not shown when the sample size was <30, or the relative standard error of the estimate was >30%.

Results

During 2004–2010, patients aged 11–21 years made an average of 82.6 million outpatient visits to office-based physicians annually, for an estimated total of 578 million visits during 2004–2010 combined (range: 78.7 million in 2008 to 90.6 million in 2010). Among these total 578 million outpatient visits, an average of 57.4 million (69.5%) included tobacco screening each year, for a total of 402 million visits screened for tobacco during 2004–2010 combined (71.5% in 2004, 74.0% in 2005, 70.0% in 2006, 62.4% in 2007, 67.3% in 2008, 67.3% in 2009, and 74.2% in 2010) (Table). Of the 402 million visits in 2004–2010 that included tobacco use screening, an average of 7.1% (28.7 million visits) were made by current tobacco users (8.3% in 2004, 7.2% in 2005, 7.7% in 2006, 7.4% in 2007, 6.1% in 2008, 5.0% in 2009, and 8.0% in 2010). During 2004–2010, no trend in screening for tobacco use was found among outpatient visits to office-based physicians made by patients aged 11–21 years overall or among those aged 11–17 years or those aged 18–21 years (Figure).

The proportion of visits with tobacco screening varied by age, with visits among patients aged 11–17 years more likely to include screening for tobacco use (71.5%) than visits among patients aged 18–21 years (65.7%). Screening also varied by health insurance status. Visits among patients with private insurance (71.0%) and Medicaid or SCHIP (69.6%) as the primary expected source of payment were more likely to include tobacco screening than those among patients with workers' compensation, or covered by a source other than private insurance, Medicare, Medicaid/SCHIP, workers' compensation, self-pay, and no charge or charity, or whose insurance status was unknown (59.9%). Visits to a patient's primary care physician were more likely to include tobacco screening (72.7%) than those among patients who visited a physician who was not their primary care physician (67.9%). Screening also varied by physician specialty. Visits to a pediatrician (74.7%) were more likely to include tobacco screening than those among general or family practitioners or internal medicine physicians (68.3%), psychiatrists (62.4%), and physicians in all other specialties (65.0%). Screening also varied by physician specialty group. Primary care physicians (71.2%) were more likely to screen for tobacco use during outpatient visits than physicians in medical care specialties (62.3%).

The proportion of visits made by persons who screened positive for current tobacco use varied by patient age, with a higher proportion of visits made by those aged 18–21 years (16.1%) than by those aged 11–17 years (3.0%). Physician office visits made by non-Hispanic whites (8.0%) were more likely to have documented current tobacco use than visits made by non-Hispanic blacks (4.3%), and Hispanics (4.7%). The proportion of visits that had persons with a positive screen for current tobacco use also varied by type of health insurance, with visits made by those with Medicaid/SCHIP coverage (9.5%) and those who had no insurance (16.8%) more likely to be current tobacco users than those with private insurance (5.3%). In addition, the proportion of visits by persons who screened positive for current tobacco use was lower when the visit was with the primary care physician (5.3%) than when the visit was with a physician who was not a primary care physician (9.4%). Current tobacco use was less likely to be found during visits to pediatricians (1.9%) than visits to physicians with other specialties (general or family practice or internal medicine, 10.3%; obstetrics and gynecology, 14.2%; psychiatry, 12.4%; and all other specialties, 6.8%).

Among visits made by persons identified as current tobacco users, 19.8% received any cessation assistance, including tobacco counseling in the form of health education ordered or provided at the visit, a prescription or order for a cessation medication, or both during their visit. Cessation assistance (including counseling, medication, or both) was more likely to be delivered during visits in which preventive care was the major reason for the visit (28.9%) than during visits for other reasons (16.7%).

Discussion

The findings in this report indicate that tobacco use screening occurred during the majority (69.5%) of visits to outpatient physician offices by patients aged 11–21 years during 2004–2010. However, during visits by current tobacco users, only 19.8% received any cessation assistance, including counseling, medications, or both. This finding is consistent with a recent literature review that found that low adherence by health-care providers to recommended screening and prevention interventions for children and adolescents (2). The PHS guideline concluded that clinicians should ask children and adolescents about their tobacco use, provide a strong prevention message, and provide adolescent smokers with counseling to help them quit (4). The Healthy People 2020 objectives include increasing quit attempts among adolescent smokers (objective TU-7) and health systems changes for increasing both tobacco use screening and cessation counseling among tobacco users aged ≥18 years in office-based ambulatory care settings (objectives TU-9.1 and TU-10.1). Both primary¶ and secondary** prevention through clinical preventive services are needed to address tobacco use early in the lifespan to prevent tobacco-related morbidity and mortality (2,4).

Preventing initiation of tobacco use or progression from experimentation to established use among adolescents and young adults is critical because among adults who become daily smokers, 88% first use cigarettes by the age of 18 years, with 99% first using cigarettes by the age of 26 years (2). Providers have a clear opportunity to intervene with this population because 84.2% of adolescents (aged 10–17 years) in 2006 had visited a doctor's office in the past year (2,6). During 2004–2010, patients aged 11–21 years who were insured by private insurance or Medicaid/SCHIP were more likely to receive tobacco screening than were patients with other sources of coverage. In addition, patients who were insured by Medicaid/SCHIP or those who had no insurance were more likely to be current tobacco users than those with private insurance. Insurance coverage (compared with no insurance coverage) for tobacco dependence treatments (including both counseling and medication) increases the proportion of smokers who attempt to quit, use cessation treatment, and successfully quit (4). However, neither private insurers nor state traditional Medicaid programs consistently provide comprehensive coverage for evidence-based cessation treatments, including counseling, medications, and referrals to quitlines (4). For example, in 2014, although all 51 Medicaid programs covered some form of tobacco-dependence treatment for some Medicaid enrollees, only seven states covered all seven cessation medications approved by the Food and Drug Administration and individual and group counseling for all Medicaid enrollees (15). A Healthy People 2020 objective (TU-8) is to expand comprehensive Medicaid insurance coverage of evidence-based cessation treatments to all 50 states and the District of Columbia (8).

Ongoing changes in the U.S. health-care system offer opportunities to improve the use of clinical preventive services among infants, children, and adolescents. The Patient Protection and Affordable Care Act of 2010 (as amended by the Health Care and Education Reconciliation Act of 2010 and referred to collectively as the Affordable Care Act [ACA]) expands insurance coverage, consumer protections, and access to care and places a greater emphasis on prevention (16). Among other relevant provisions (17), some provisions of the law might be particularly relevant for adolescents. As of September 23, 2010, ACA § 1001 requires nongrandfathered private health plans to cover, with no cost-sharing, a collection of four types of clinical preventive services, including 1) recommended services of the U.S. Preventive Services Task Force (USPSTF) graded A (strongly recommended) or B (recommended) (18); 2) vaccinations recommended by the Advisory Committee on Immunization Practices (19); 3) services adopted for infants, children, and adolescents under the Bright Futures guidelines supported by the Health Resources and Services Administration (HRSA) and AAP (20) and those developed by the Discretionary Advisory Committee on Heritable Disorders in Newborns and Children (21); and 4) women's preventive services as provided in comprehensive guidelines supported by HRSA (22). USPSTF recommends that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use in school-aged children and adolescents. This is a USPSTF Grade B recommendation, which indicates that there is moderate certainty that the interventions have a moderate net benefit (23). As of October 1, 2010, ACA § 4107 requires state traditional Medicaid programs to provide tobacco cessation counseling and pharmacotherapy to pregnant women with no cost-sharing. In addition to this benefit requirement for pregnant women, states are required to cover tobacco cessation services for children when medically necessary and may rely on optional Medicaid benefit categories to provide coverage of tobacco cessation services to other Medicaid beneficiaries. The coverage of medically necessary tobacco cessation services, including both counseling and pharmacotherapy, for children and adolescents, is mandatory under the Early and Periodic Screening, Diagnostic, and Treatment benefit. This benefit includes the provision of anticipatory guidance and risk-reduction counseling with regard to tobacco use during routine well-child visits. In addition to routine visits, additional counseling and tobacco cessation drug therapy must be provided when medically necessary for persons aged <21 years (24). Effective January 1, 2014, ACA also prohibited state Medicaid programs from excluding FDA-approved cessation medications, including over-the-counter medications, from Medicaid drug coverage (ACA § 2502) (25). The Health Insurance Marketplace (or Health Insurance Exchange) began providing access to private health insurance for small employers and to persons and families interested in exploring their options for coverage, with policies taking effect as early as January 2014.†† Federal tax credits are available on a sliding scale to assist those living at 100%–400% of the federal poverty level who purchase health insurance through the Marketplace (ACA § 1401). Newly qualified health insurance plans operating in the Marketplace are required to offer their members cessation coverage without cost-sharing (25,26).

In addition to the USPSTF tobacco use intervention recommendations for children and adolescents, several national guidelines by medical societies and organizations were used to develop recommendations that physicians should routinely provide tobacco screening, education, and counseling to children and adolescents (2). In addition, employers, health plans, health-care professionals, and voluntary associations also can take steps to increase use of clinical preventive services and implementation of proven community preventive interventions by supporting policy and environmental change interventions that help to prevent youths from starting to smoke and to help adult smokers quit. These interventions include ensuring comprehensive coverage of cessation treatments, implementing provider reminder systems in health-care settings, establishing smoke-free policies, increasing the price of tobacco products, and educating the public through mass media campaigns (2,5,12).

Several barriers can impede clinician assessment and treatment of smokers, including lack of knowledge of effective intervention strategies, lack of time, inadequate payment for treatment, and lack of institutional support for routine assessment and treatment of tobacco use (4). Specifically regarding delivery of clinical preventive services to youths, physicians cite similar and additional barriers, including 1) large patient caseloads, resulting in limited time per patient; 2) competing health-care demands during preventive visits; 3) inadequate training; 4) lack of information on how to access referral and treatment resources; 5) lack of dissemination of research to physicians that supports positive treatment outcomes and negative effects from failing to intervene; 6) fear of alienating patients and their families; and 7) inadequate reimbursement (2). The findings in this report indicate that both physician and visit characteristics were related to the likelihood of screening and counseling for tobacco use occurring during a visit. Visits made to primary care physicians had a higher likelihood of screening for tobacco use than visits to physicians who were not primary care physicians. Among adolescents, visits made by non-Hispanic whites were more likely to be current tobacco users than visits by non-Hispanic blacks or Hispanics. Additional studies are needed to examine the disparity in current tobacco use status. Visits made to pediatricians were less likely to have current tobacco use status than visits to physicians with other specialties. Perhaps the older adolescents who were current smokers did not visit pediatricians any more, although pediatricians were more likely to conduct tobacco screening than other practitioners (e.g., general or family practice, internal medicine, or psychiatry). Previous studies have suggested that female providers, physicians aged <50 years, recent medical school graduates, and pediatricians were more likely to engage in certain specific types of preventive interventions and counseling with adolescents and their parents (2).

Cessation assistance was delivered more frequently during outpatient visits for which the major reason for the visit was preventive care. Health-care systems can support physician interventions by instituting effective systems-level changes that make screening for tobacco use and brief cessation interventions for tobacco users a standard part of every office visit. Provider reminder systems increase health-care providers' assessment and treatment of tobacco use in a range of clinical settings and populations (12). Provider reminder systems prompt providers to screen and treat patients for tobacco use and can be implemented as chart stickers, vital sign stamps, medical record flow sheets, checklists, or part of electronic medical records. A recent literature review concluded that provider reminder systems, and provider trainings, are promising approaches for increasing delivery of tobacco preventive services to children and adolescents (2).

Tobacco dependence costs the United States approximately $96 billion per year in direct medical expenses and $97 billion in lost productivity (5). Tobacco use treatments, ranging from clinician advice to medication to specialist-delivered intensive programs, not only are clinically effective but also are more cost-effective than other medical interventions (4,27–29). In a study on the priorities among effective clinical preventive services, tobacco-use screening and brief intervention among adults was one of the three highest ranking clinical preventive services (each with a total cost-effectiveness score of 10), equal in rank to discussing aspirin use with adults at high risk for cardiovascular events and to vaccinating children (28). Evidence-based tobacco dependence interventions yield a favorable return on investment from the perspective of both the employer and health plan because of reduced use of health-care services and lower related costs (30–32).

As part of its National Tobacco Control Program, CDC recommends that states implement population-based strategies and environmental interventions that reduce tobacco use, including working with health-care systems, insurers, and purchasers of health insurance to expand coverage for tobacco cessation treatments and to implement health systems changes that integrate cessation clinical interventions into routine care (5,12). CDC and states also support other effective interventions for increasing cessation including increasing the unit price of tobacco products, conducting emotionally evocative anti-tobacco mass media campaigns such as the recent CDC Tips from Former Smokers campaign, providing telephone cessation counseling, and making workplaces and public places smoke-free (5,12). Public health programs should implement a comprehensive approach to tobacco cessation by using population-based strategies, including media interventions, to motivate tobacco users to quit while simultaneously making evidence-based cessation treatments readily available to tobacco users who want help to quit (5,12,33).

Limitations

The findings in this report are subject to at least seven limitations. First, the definition of tobacco counseling included any information on tobacco use or secondhand smoke exposure, as well as referrals to tobacco cessation programs. Therefore, the type of information provided could not be assessed, and subsequently the use of the 5 A's for smoking cessation intervention could not be tracked (Health-care providers 1] ask about tobacco use, 2] advise tobacco users to quit, 3] assess willingness to make a quit attempt, 4] assist in a quit attempt, and 5] arrange for follow-up [4]). Second, because there were not enough data to stratify results by age (<18 years versus ≥18 years), it is likely that these age groups see different providers and receive different types of tobacco-related information and cessation treatments (i.e., medication only for those aged ≥18 years). Third, bupropion can be prescribed both as an antidepressant and for tobacco cessation, and the medical indication could not be determined from the data collected. Fourth, quality and completeness of reporting, including documentation in the medical record, might have varied over time, and year-to-year differences in tobacco use screening rates might have been due, in part, to differences in the quality of reporting. This might have resulted in an underestimation or overestimation of the proportion of screening for tobacco use and cessation counseling. Additional research is needed to understand differences in reporting over time. Fifth, because information on tobacco counseling was available only for the current visit, whether health education also occurred at previous visits is unknown. Sixth, because analysis is based on visits, if a patient had multiple visits to the sampled physician during the reporting period (1 week) and only certain visits during that reporting period had tobacco use screening, by randomly choosing the visits for the patient, some visits with tobacco use screening might have been missed. Finally, NAMCS data that are obtained through self-reporting by physicians or their staff members include no record validation.

Conclusion

Tobacco use screening and intervention is one of the most cost-effective clinical preventive services (4,23,24) and is an important component of a comprehensive strategy for increasing tobacco use cessation and reducing tobacco use. However, during 2004–2010, screening for tobacco use among patients aged 11–21 years did not increase, and among current tobacco users, only 19.8% received any cessation assistance. Treating tobacco dependence can prevent the development of various costly chronic diseases, including heart disease, cancer, and pulmonary disease, resulting in major health improvements and cost savings (4). Assessing tobacco use among adolescents and providing cessation counseling are essential (2,4). Results from this report can be used by researchers and health-care providers to track and improve adherence to the PHS guideline and to identify opportunities for other programs to reach youths and young adults, as well as to identify population-based strategies to reduce tobacco initiation and increase tobacco cessation, such as increasing the price of tobacco products, prohibiting smoking in workplaces and public places, and expanding health insurance coverage of cessation treatments.

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