Letter to the Editor
A contribution towards a world without tobacco – The TabacoPed study
A. Gama da Silvaa,
, C. Constantb,c,d, S. Madeirae,f, A.R. Sousag, T. Bandeirab,c,d
Corresponding author
silva.antonio@campus.ul.pt
Corresponding author at: Department of Pediatrics, Centro Hospitalar Universitário Lisboa Norte Av. Prof. Egas Moniz, 1649-028 Lisboa, Portugal.
Corresponding author at: Department of Pediatrics, Centro Hospitalar Universitário Lisboa Norte Av. Prof. Egas Moniz, 1649-028 Lisboa, Portugal.
a Department of Paediatrics, Hospital de Santa Maria, CHULN, Portugal
b Paediatric Respiratory Unit, Department of Paediatrics, Hospital de Santa Maria, CHULN, Portugal
c Paediatric Lung Function Laboratory, Department of Paediatrics, Hospital de Santa Maria, CHULN, Portugal
d Lisbon Academic Medical Centre, University of Lisbon, Portugal
e Unidade de Cuidados de Saúde Personalizados de Azeitão, ACES Arrábida, Portugal
f University Clinic of Family Medicine, Faculty of Medicine, University of Lisbon, Portugal
g Paediatric Cardiology Clinic, Department of Paediatrics, Hospital de Santa Maria, CHULN, Portugal
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Prof. Egas Moniz, 1649-028 Lisboa, Portugal." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0001" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1218 "Ancho" => 2667 "Tamanyo" => 178743 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0001" "detalle" => "Fig " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">Brief intervention knowledge in smoking cessation, through the 5 As model, among pediatricians during appointments performed on children/adolescents.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="para0002" class="elsevierStylePara elsevierViewall">There are approximately 1,5 million smokers in Portugal, which represents 14,2% of the population.<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a> Having a smoking parent/caregiver increases the risk of a child or adolescent becoming a smoker from 8 to 25%.<a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a></p><p id="para0004" class="elsevierStylePara elsevierViewall">Brief intervention in smoking cessation generally takes between 5 and 15 min, including five sequential steps: “Ask, Advise, Assess, Assist and Arrange – The 5A's Model”.<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a> In primary care, the efficacy of brief intervention in an appointment is approximately 15% in terms of abstinence at 30 days.<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> Data from the USA in 2016 showed that only 7% of pediatricians had training in smoking cessation and only 25% counselled parents to stop smoking. The main obstacles to intervention were lack of time, resources and training, associated with low acceptance from patients.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a></p><p id="para0005" class="elsevierStylePara elsevierViewall">In this study, we aimed to assess opinions, practices, obstacles, and knowledge in smoking cessation intervention in pediatricians regarding adolescents and parents/caregivers. To the best of our knowledge, this was the first Portuguese study assessing pediatricians’ behaviors towards smoking cessation intervention.</p><p id="para0006" class="elsevierStylePara elsevierViewall">This was a cross-sectional study through an electronic anonymous questionnaire sent to all doctors enrolled in the Portuguese Paediatric Society in 2021. The questionnaire was elaborated according to the 5A's model. Respondents were asked separately about how they approached parents/caregivers and children/adolescents. The answers were structured using a 4-point Likert scale. The TabacoPed study was approved by Centro Hospitalar Universitário Lisboa Norte Ethics Committee.</p><p id="para0007" class="elsevierStylePara elsevierViewall">We obtained 189 complete answers from a population of approximately 2300 pediatricians (response rate: 8,2%). The majority (79%, <span class="elsevierStyleItalic">n</span> = 149) were specialists, and 21% (<span class="elsevierStyleItalic">n</span> = 40) were residents. The average age was 39 years old (SD 9,5 years) and 83% (<span class="elsevierStyleItalic">n</span> = 156) were female. The majority (80%, <span class="elsevierStyleItalic">n</span> = 151) were non-smokers, 12% (<span class="elsevierStyleItalic">n</span> = 23) were ex-smokers and 8% (<span class="elsevierStyleItalic">n</span> = 15) were active smokers.</p><p id="para0008" class="elsevierStylePara elsevierViewall">As for questioning smoking habits in children/adolescents, most pediatricians (87%, <span class="elsevierStyleItalic">n</span> = 164) mentioned doing it at least at the first appointment, and 25% (<span class="elsevierStyleItalic">n</span> = 47) question them at every appointment. Average age from which they ask about smoking firsthand is 14 years old (SD 1,6 years). The majority (74%, <span class="elsevierStyleItalic">n</span> = 140) ask while alone with the patient and 26% (<span class="elsevierStyleItalic">n</span> = 49) in the presence of a caregiver.</p><p id="para0009" class="elsevierStylePara elsevierViewall">As for brief intervention in smoking cessation for children and adolescents in pediatric appointments, as we progress on the 5A's model, the number of doctors using brief intervention diminishes (<a class="elsevierStyleCrossRef" href="#fig0001">Fig. 1</a>). More than half (56%, <span class="elsevierStyleItalic">n</span> = 105) reported they never provide their patients counselling and/or pharmacotherapy (“Assist”) at any appointment.</p><elsevierMultimedia ident="fig0001"></elsevierMultimedia><p id="para0010" class="elsevierStylePara elsevierViewall">Regarding brief intervention in smoking cessation for caregivers, 68% (<span class="elsevierStyleItalic">n</span> = 129) of doctors ask about smoking habits at least during the first appointment. Two-thirds (66%, <span class="elsevierStyleItalic">n</span> = 125) of the respondents mentioned they never provide counselling and/or pharmacotherapy (“Assist”) (<a class="elsevierStyleCrossRef" href="#fig0002">Fig. 2</a>).</p><elsevierMultimedia ident="fig0002"></elsevierMultimedia><p id="para0011" class="elsevierStylePara elsevierViewall">The majority (66%, <span class="elsevierStyleItalic">n</span> = 125) of pediatricians claim they are unaware of what brief intervention in smoking cessation is. Most (89%, <span class="elsevierStyleItalic">n</span> = 168) of the respondents had never had any training in smoking cessation programs and the vast majority (96%, <span class="elsevierStyleItalic">n</span> = 181) would be interested in doing such training, mostly through online courses, with an average duration of 10 h (SD 4,6 h).</p><p id="para0012" class="elsevierStylePara elsevierViewall">The perceived main obstacles to intervention are patients’ lack of motivation (61%, <span class="elsevierStyleItalic">n</span> = 116), reduced time in appointments (59%, <span class="elsevierStyleItalic">n</span> = 112) and difficulty of referral to a smoking cessation clinic (42%, <span class="elsevierStyleItalic">n</span> = 80).</p><p id="para0013" class="elsevierStylePara elsevierViewall">The results from our study show that brief intervention on smoking cessation is not widely used by pediatricians in Portugal, neither regarding adolescents nor parents/caregivers. Most pediatricians question adolescents and caregivers on their tobacco consumption habits during their first appointments. These percentages are similar to other medical specialties, like oncology, as depicted by Lina M, et al.<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> However, the intervention remains a challenge specifically the final two steps of the 5A's model: providing counselling/pharmacotherapy (“Assist”) and scheduling follow-up contacts (“Arrange”).</p><p id="para0014" class="elsevierStylePara elsevierViewall">Lack of training could be one of the contributing factors to the decline of intervention as we progress on the 5A's model, since only a minority of the respondents (11%) reported having had training in smoking cessation. These small numbers have also been described in Italy (6%) by Lina M, et al.<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> and in Louisiana, USA, (7%) by Hall et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a></p><p id="para0015" class="elsevierStylePara elsevierViewall">Although two-thirds of respondents claimed unfamiliarity with brief intervention, nearly all were interested in having more training. The majority showed a preference for single-day online courses. This training could be offered either as part of postgraduate programs or pediatric residency. Concerning adolescents, specific strategies such as individual counselling, psychological support, nicotine replacement therapy and pharmacotherapy should also be included in the referred training programs.<a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a></p><p id="para0016" class="elsevierStylePara elsevierViewall">Acknowledging these gaps will facilitate the implementation of specific strategies adapted to pediatricians to improve their skills in brief intervention in smoking cessation, thus reducing secondhand smoke, and shaping a smoke-free generation.</p><span id="sec0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0002">Disclosures</span><p id="para0017" class="elsevierStylePara elsevierViewall">All authors have seen and approved the final version of the manuscript being submitted. All warrant that the article is the authors' original work, hasn't received prior publication and isn't under consideration for publication elsewhere.</p></span><span id="sec0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0003">Ethical considerations</span><p id="para0018" class="elsevierStylePara elsevierViewall">This study was approved by CHULN / Lisbon Academic Medical Centre's Ethical Committee on 24/07/2021.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0001" "titulo" => "Disclosures" ] 1 => array:2 [ "identificador" => "sec0002" "titulo" => "Ethical considerations" ] 2 => array:2 [ "identificador" => "xack742295" "titulo" => "Acknowledgements" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-05-28" "fechaAceptado" => "2023-08-07" "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0001" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1218 "Ancho" => 2667 "Tamanyo" => 178743 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0001" "detalle" => "Fig " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">Brief intervention knowledge in smoking cessation, through the 5 As model, among pediatricians during appointments performed on children/adolescents.</p>" ] ] 1 => array:8 [ "identificador" => "fig0002" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1221 "Ancho" => 2667 "Tamanyo" => 181780 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0002" "detalle" => "Fig " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spara002" class="elsevierStyleSimplePara elsevierViewall">Brief intervention knowledge in smoking cessation, through the 5 As model, among pediatricians during appointments performed on parents/caregivers.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "cebibsec1" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0001" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Instituto Nacional de Estatística</span> [National Health Inquiry, 2019, National Statistics Institute]" "autores" => array:1 [ 0 => array:2 [ "colaboracion" => "Inquérito Nacional de Saúde" "etal" => false ] ] ] ] "host" => array:2 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2019" ] ] 1 => array:1 [ "WWW" => array:1 [ "link" => "https://smi.ine.pt/DocumentacaoMetodologica/Detalhes/1531?modal=1" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0002" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Parent and child cigarette use: a longitudinal multigenerational study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 8 | 18 |
| 2024 October | 58 | 35 | 93 |
| 2024 September | 80 | 38 | 118 |
| 2024 August | 60 | 35 | 95 |
| 2024 July | 81 | 39 | 120 |
| 2024 June | 221 | 71 | 292 |
| 2024 May | 275 | 121 | 396 |
| 2024 April | 57 | 28 | 85 |
| 2024 March | 45 | 20 | 65 |
| 2024 February | 17 | 26 | 43 |
| 2024 January | 23 | 20 | 43 |
| 2023 December | 13 | 23 | 36 |
| 2023 November | 25 | 38 | 63 |
| 2023 October | 45 | 46 | 91 |
| 2023 September | 11 | 18 | 29 |
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