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Behavioral Ecological Model


Most efforts to prevent adolescent tobacco use have taken place in the schools. Nonetheless, the magnitude and severity of the tobacco epidemic warrants use of the widest possible array of strategies in societal endeavors to lower rates of tobacco use. One such complementary strategy is suggested by studies showing that minimal interventions by physicians and dentists can increase cessation rates among smokers. Five such cessation studies have recently been concluded by the NCI. But neither the NCI nor previous studies have sought to determine whether a similar approach--minimally time-consuming interventions by clinicians--can prevent adolescents from becoming tobacco users in the first place.

We propose to address this question in a prospective, randomized controlled trial with orthodontists, clinicians having large adolescent patient populations and whose practices are characterized by long-term doctor-patient relationships and a high frequency of doctor-patient contacts--variables highly correlated with success in the physician cessation studies. Results of a preliminary survey sent to San Diego County orthodontists show that for those indicating a willingness to participate in the proposed study, the mean patient population aged 10-18 is 500, mean treatment time is 50 months, and the mean number of doctor-patient contacts during this time is 41.

The intervention we propose is based on adaptations of principles developed in the NCI cessation studies and has three elements: 1) an in-office training session presented to each orthodontist and staff; 2) provision of posters, pamphlets, and similar "off-the-shelf" materials that can be used to create a "tobacco-free office"; and 3) provision of prescription pads containing teenage-relevant information on a tobacco-related topic (e.g., how to think critically about cigarette ads) and concluding with a signed statement from the orthodontist advising the patient not to use tobacco. Eight different prescription pads will be provided over a period of two years.

Because the unit of randomization in this design is orthodontists rather than patients, the unit of analysis will be the percentage of each orthodontist's patients who become tobacco users during the intervention phase of the study. To obtain this information, a random sample of each orthodontist's age-eligible patients (estimated necessary N=110) will be surveyed by telephone prior to beginning the intervention; initial non0-users will be re-surveyed at the end of the intervention. Effectiveness will be ascertained by comparing initiation rates of patients of orthodontists assigned to the intervention with those of orthodontists assigned to the control condition.

Sample size calculations incorporating orthodontists as the unit of randomization yield an estimated need for 65 orthodontists per group, assuming a two-year incidence of tobacco use initiation of 10% in the control group and 6% in the experimental group. This differential represents a 2% net annual reduction in the incidence of tobacco use initiation. While seemingly small, a reduction in incidence of this magnitude would have substantial public health benefits. If half of the estimated 10,300 orthodontists in the U.S. adopted the intervention and had similar results, over 50,000 adolescents would be prevented from becoming new tobacco users each year, leading eventually to the prevention of nearly 13,000 premature deaths annually. Even larger benefits would accrue were such an intervention successfully adopted by other health care professionals with significant adolescent patient populations, e.g., pediatrics.

Principal Investigator: Mel Hovell, Ph.D., M.P.H.

Project Coodinator: Jennifer Jones, M.P.H.

Funded 1991-1994

Source: Tobacco Related Disease Research Program of the University of California


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