Delivery and Impact of a MotivationalIntervention for Smoking Cessation: APROS StudyJonathan D. Klein, MD, MPH,a,b Julie Gorzkowski, MSW, LSW,b Elissa A. Resnick, MPH,a Donna Harris, MA,c

Kristen Kaseeska, MPH,b Lori Pbert, PhD,d Alex Prokorov, MD, PhD,e Tianxiu Wang, PhD, MS,g James Davis, MD,c

Edward Gotlieb, MD,c Richard Wasserman, MD, MPHc,f

abstractOBJECTIVES: We tested a Public Health Service 5As-based clinician-delivered smoking cessationcounseling intervention with adolescent smokers in pediatric primary care practice.

METHODS: We enrolled clinicians from 120 practices and recruited youth (age $14) from theAmerican Academy of Pediatrics Pediatric Research in Office Settings practice-based researchnetwork. Practices were randomly assigned to training in smoking cessation (intervention) orsocial media counseling (attentional control). Youth recruited during clinical visits completedconfidential screening forms. All self-reported smokers and a random sample of nonsmokerswere offered enrollment and interviewed by phone at 4 to 6 weeks, 6 months, and 12 monthsafter visits. Measures included adolescents’ report of clinicians’ delivery of screening andcounseling, current tobacco use, and cessation behaviors and intentions. Analysis assessedreceipt of screening and counseling, predictors of receiving 5As counseling, and effects ofinterventions on smoking behaviors and cessation at 6 and 12 months.

RESULTS: Clinicians trained in the 5As intervention delivered more screening (b = 1.0605, P ,

.0001) and counseling (b = 0.4354, P , .0001). In both arms, clinicians more often screenedsmokers than nonsmokers. At 6 months, study arm was not significantly associated withsuccessful cessation; however, smokers in the 5As group were more likely to have quit at 12months. Addicted smokers more often were counseled, regardless of study arm, but were lesslikely to successfully quit smoking.

CONCLUSIONS: Adolescent smokers whose clinicians were trained in 5As were more likely toreceive smoking screening and counseling than controls, but the ability of this intervention tohelp adolescents quit smoking was limited.

WHAT’S KNOWN ON THIS SUBJECT: Tobacco use is a significanthealth issue for adolescents. Pediatricians have an opportunity toscreen and counsel youth about smoking. There is limitedevidence that brief cessation counseling for adolescent smokersresults in cessation attempts or sustained abstinence.

WHAT THIS STUDY ADDS: In a 5As randomized control trial foradolescent smokers, intervention clinicians provided morescreening and counseling than those in the control group;adolescents who received interventions more often tried to quit.Nicotine addiction was the strongest predictor of continuedsmoking.

To cite: Klein JD, Gorzkowski J, Resnick EA, et al. Deliveryand Impact of a Motivational Intervention for SmokingCessation: A PROS Study. Pediatrics. 2020;146(4):e20200644

aDepartment of Pediatrics, University of Illinois at Chicago, Chicago, Illinois; bJulius B. Richmond Center ofExcellence, American Academy of Pediatrics, Itasca, Illinois; cPrimary Care Research, American Academy ofPediatrics, Itasca, Illinois; dDepartment of Population and Quantitative Health Sciences, University ofMassachusetts Medical School, Worcester, Massachusetts; eMD Anderson Center, Houston, Texas; fDepartment ofPediatrics, Larner College of Medicine, University of Vermont, Burlington, Vermont; and gInstitute for HealthResearch and Policy, University of Illinois at Chicago, Chicago, Illinois

Drs Klein conceptualized and designed the study, drafted the initial manuscript, participated inanalyses, and reviewed and revised the manuscript; Drs Pbert, Prokorov, Davis, Gotlieb, andWasserman conceptualized and designed the study and reviewed and revised the manuscript; MsGorzkowski, Dr Wang, Ms Resnick, Ms Kaseeska, and Ms Harris participated in data analyses and indrafting, reviewing, and revising the manuscript; and all authors approved the final manuscript assubmitted and agree to be accountable for all aspects of the work.

Deidentified individual data will not be made available.

This trial has been registered at www.clinicaltrials.gov (identifier: NCT01312480).

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Smoking is the leading cause ofpreventable death in the UnitedStates; 88% of smokers start beforeage 18.1 Although occasional and lightsmoking is common in adolescents,1,2

these trajectories lead to addiction.3–5

Nicotine dependence occurs early1,6,7;the younger an adolescent starts, themore likely they are to smoke asadults.1 Adolescent smokingcessation is needed to prevent manyadolescents from dying of tobacco-related diseases.8

Youth identify physicians as preferredinformation sources regardingsmoking9,10; thus, clinician visits areopportunities to address tobacco use.However, this opportunity is oftenmissed because smoking messages inpediatric settings often focus only onscreening and abstinence,11–13 ratherthan on cessation for youngsmokers.14 Few clinicians set quitdates, provide resources, or arrangefollow-up for adolescent cessationattempts.15,16 Although barriers topreventive service delivery includeinadequate education, timeconstraints, and lack of informationabout resources,15,17 cliniciantraining can increase self-efficacy anddelivery of smoking interventions toyouth.18 Counseling interventionspromote cessation in adults19–21;however, evidence for effectivenessamong young smokers is limited.22

The US Public Health Service 5Asbehavior change counseling model(Ask, Advise, Assess, Assist,Arrange)22–24 was developed frombrief smoking cessation counselingstudies with adults. Althoughrecommended by consensusguidelines, whether clinician-delivered 5As interventions helpadolescent smokers quit is unknown.

In this article, we describe delivery ofan adolescent-focused adaptation ofthe 5As intervention, assess factorsassociated with youth-reportedreceipt of the intervention, anddescribe the impact of theintervention on cessation intentionsand smoking behaviors.

METHODS

We conducted a randomized clinicaltrial of an adolescent-focusedadaptation of the Public HealthService 5As smoking screening andbrief counseling interventioncompared with an attentional controlsocial media counseling interventionin pediatric primary care practices inthe American Academy of PediatricsPediatric Research in Office Settings(PROS) practice-based researchnetwork.25 The study was called“Adolescent Health in PediatricPractice” (AHIPP) to avoid disclosingthe interventions targeted duringenrollment. The study was approvedby the American Academy ofPediatrics Institutional Review Board(IRB) and 31 local IRBs inparticipating sites (see SupplementalInformation) and registered withClinicalTrials.gov (NCT01312480).

Adaptation of the 5As

The 5As 1 to 3 minute interventionincludes ask about tobacco use;advise against use; assess readinessto quit; assist by providing referrals,adjunct materials, and resources(including pharmacotherapy foradolescents age .18); and arrangefollow-up of cessation attempts. Wepreviously described the model andestablished pilot feasibility of ourmethods.26 Clinicians were trained touse a 5As checklist to guide clinicalencounters.

Practice Enrollment andParticipation

We recruited established PROSpractices and practices new toPROS.27 Eligible practices self-reported seeing at least 1 adolescentpatient per week and estimatedsmoking rates $10%. Practices wererandomly assigned into 2 arms:intervention practice clinicians weretrained in 5As, and control clinicianswere trained in social mediascreening and counseling. Eachpractice was asked to screen alladolescent patients for eligibility and

enroll 100 adolescents into the study.A practice study coordinatormonitored recruitment andenrollment procedures.

After initial recruitment and toincrease practice enrollment,pediatricians were offeredMaintenance of Certification Part IV(MOC) credit for working to improvetheir practices’ screening andenrollment of research subjects.27

Practices received $150 stipendswhen they began enrollment and$150 or $300 for completingenrollment of 100 or 200 youth,respectively.

Clinician Training

Eligible clinicians includedpediatricians, nurse practitioners, andphysician assistants. Clinicianscompleted baseline and follow-upsurveys and self-study trainings onthe study protocol and intervention.Using methods successful inachieving clinician adherence in otherPROS trials28–36 and our feasibilitypilot,26 clinicians practiced screeningand counseling delivery with at least3 patients and then participated in“teach-back” phone calls, role playingintervention delivery with study staffposing as an adolescent patient toassess fidelity and proficiency. Notethat adolescents could choose toenroll or not in a study evaluatingtheir clinician’s care delivery and itsimpact on behavior; they could notchoose which intervention (smokingor social media) their clinician hadbeen trained on. Those clinicianssuccessfully delivering interventionsduring teach-back calls beganadolescent enrollment; those who didnot received feedback, reviewedtraining materials, and repeatedteach-backs until proficient.

Adolescent Enrollment

Eligible adolescents were age $14,seen for well-child or nonurgent sickvisits between January 2012 andDecember 2014. Adolescents (andparents, for those ,18) were

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consented or assented by the practicecoordinator, staff, or clinicians in thepractice. Participating adolescentscompleted a short previsit baselinesurvey of health behaviors, includingsmoking. These were sealed at thepractice site to ensure confidentialityand sent to the study team weekly. Alladolescents who self-identified assmokers at baseline (defined as atleast 1 puff of a cigarette or little cigarin the last 30 days) and a randomsample of 10% of nonsmokers werecontacted by the Survey ResearchLaboratory at the University of SouthCarolina for follow-up phone surveys4 to 6 weeks, 6 months, and12 months after their clinical visit toassess adolescent-reported smokingand cessation behaviors and cliniciandelivery of interventions. For eachfollow-up completed, adolescentssmokers received $20 (#$60 total)and nonsmokers received $10 (#$30total).

Measures

Demographics

Clinicians reported on practices (eg,community or academic; solo, group,or clinic; and urban, suburban, orrural), and clinicians and youth self-reported demographics, includingage, sex, race, and ethnicity.

Delivery of 5As

In the 4 to 6 week follow-up survey,adolescents were asked to reporttheir clinician’s delivery of specificintervention elements during theindex visit. Specific questionsassessed tobacco screening (Ask andAdvise) and counseling (Assess,Assist, and Arrange) (see Fig 1).Scores for 5As “screening” (range0–6) and, for smokers, “counseling”scores (range 0–4) were calculated byadding 1 point for each item. Scoreswere averaged over all adolescentvisits for each clinician to yieldaverage screening and counselingscores, which were used in regressionanalyses.

Adolescents were also asked aboutother preventive services counseling,confidentiality, one-on-one timeduring their visit, and social andenvironmental risk factors aspotential moderator variables.

Adolescent Cessation and Smoking

Smoking status and other tobacco usesurvey questions included validatedmeasures for lifetime, past-year, andpast 30-day use and for addictionusing the Hooked on NicotineChecklist,37–41 which measures loss ofautonomy over smoking and cravings

(Fig 1). We categorized youth as moreor less addicted using odds ratiosbased on Hooked on NicotineChecklist compared with mean scoreat 4 to 6 weeks. Youth were alsoasked about quit behaviors includingnumber of attempts, attitudes towardsmoking and cessation, and changesin smoking before or after visits withtheir clinician.

Analysis

Demographic characteristics wereassessed at baseline for adolescentsand clinicians, respectively.

FIGURE 15A Screening and counseling and addiction questions in the AHIPP PROS Study.

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Differences were examined by usingx2 tests for proportions and t tests forcontinuous measures. Screening andbrief counseling between study armswas examined by using mixed modelsaccounting for the correlationbetween measures from the samepractice. Logistic regression modelswere fit to assess the effect of the 5Asintervention on youth smokingbehavior and cessation intentions andidentify potential factors associatedwith these outcomes at 6- and 12-month follow-up, adjusting for youthand practice-level demographics.Model fit and diagnostics wereconducted to ensure the validity ofinference. Factors associated withloss-to-follow-up were alsoinvestigated by using multivariablelogistic regression. Data wereanalyzed by using SAS 9.4 (SASInstitute Inc, Cary, NC).

RESULTS

A total of 120 PROS practices enrolledin the study: 9% solo, 53% group,10% medical school, 7% hospitalbased, and 21% other. Almost half(46%) were suburban, 19% rural,19% urban noninner city, and 16%urban inner city. Overall, 249clinicians participated: 88%pediatricians and 12% nursepractitioners or physician assistants.Pediatricians who enrolled seekingMOC credit were not different fromthose who did not with regard to age,ethnicity, and patient care hours butwere more likely to be female (P ,.005) and to identify as other thanwhite ethnicity (P , .05).27

Practices enrolled 10 967 adolescentsin the study (range = 2–208; mean =105; median = 100). Of these, 936(8.5%) self-identified as smokers atenrollment. All current smokers plus∼10% of nonsmokers (total n = 1937)were selected for follow-up. Of these,1317 completed 4 to 6 week surveys,992 completed 6-month surveys, and682 completed 12-month surveys(Fig 2). Adolescent and clinician

demographics did not differ betweenstudy arms (Table 1).

Logistic regression controlling foradolescent demographics, smoking

status, pediatrician MOCparticipation, and study armassignment showed that adolescentswho were higher socioeconomicstatus (SES), non-Hispanic, and better

Practice Enrollment249 Clinicians120 Practices

Intervention Arm: 5As 62 Practices enrolled adolescents

Control Arm: Social Media 58 Practices enrolled adolescents

Intervention Arm:5As n = 1021

Adolescent Baseline Survey10 967 completed enrollment survey

Control Arm: Social Media n = 916

4-6 weeks: n = 67647% smokers

53% nonsmokers

4-6 weeks: n = 64147% smokers

53% nonsmokers

6 months: n = 50841% smokers

59% nonsmokers

6 months: n = 48444% smokers

56% nonsmokers

12 months: n = 32336% smokers

63% nonsmokers

12 months: n = 35939% smokers

61% nonsmokers

168 Lost to follow-up

157 Lost to follow-up

125 Lost to follow-up

185 Lost to follow-up

Selected Participants: n = 1937

345 Lost to follow-up

275 Lost to follow-up

FIGURE 2Practice randomization and adolescent enrollment in the AHIPP Study (consort flowchart).

TABLE 1 Demographics for Adolescents and Clinicians Participating in the AHIPP Study

Intervention Arm:5As

Control Arm: SocialMedia

AdolescentsAge, mean (SD); median, y 16.7 (2.05); 17 16.5 (1.94); 16White, % 75.6 76.6Female, % 62.4 57.7High SES, % 54.6 54.5Hispanic, % 11.0 13.2Gets good grades, %a 47.2 49.4

CliniciansAge, mean (SD); median, y 46.9 (10.43); 48 46.5 (10.93); 46White, % 75.9 83.3Female, % 73.7 68.7Hispanic,% 8.3 3.5Hours of patient care per week, mean (SD);

median40.0 (18.37); 40 37.4 (14.46); 38

a Based on self-report of “above average” or “honor student” in response to: “What type of grades do you get in school?”or “What type of grades did you get when you were in school?”

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students were more often lost tofollow-up at 6 months (all P, .05). At12 months, adolescents who wereolder, lower SES, and in the 5Asintervention arm were more oftenlost to follow-up (all P , .05). Neitherclinician seeking MOC credit norpatient smoking status at enrollmentwere related to follow-upparticipation. No harms werereported by participants from eitherstudy arm.

Baseline Quitting Behaviors

Among smokers who completedbaseline surveys, 51% reportedhaving seriously tried to quit in thepast year: 42% motivated by wantingto improve health and 9% motivatedbecause of cost. Most (86%) reportedtrying to quit without support, 3%used nicotine gum or patches, and 9%used electronic cigarettes(e-cigarettes). None reported usingquitlines, relaxation or hypnosis, orquit Web sites, and only oneadolescent reported usingprescription drugs. Baselinequitting behaviors (assessed by self-reported endorsement of all thatapplied from a list of commonresponse items with an option to add“other” reasons for their choices) didnot vary significantly betweenstudy arms.

Training in 5As and Screening andCounseling Scores

Clinicians trained in 5Asinterventions were more likely todeliver smoking screening (b =1.0605, P , .0001) and counseling (b= .4354, P , .0001). These cliniciansprovided significantly more smokingscreening (average score, 3.89 vs2.79; P , .001) and counseling(average score, 0.73 vs 0.29; P ,.001) than those in the control arm(Table 2).

Clinician Training and Youth Receiptof 5As

Adolescents whose clinicians weretrained in the 5As intervention weremore likely to report having been

screened for smoking compared withadolescents seen by clinicians in thecontrol arm: their clinicians weremore likely to ask if they smoked(71% vs 53%), if friends smoked(43% vs 31%), and if anyone at homesmoked (51% vs 36%) (all P ,.0001). These youth were also morelikely to be encouraged toavoid smoking (70% vs 55%) andtold about the benefits of notsmoking (60% vs 46%) (allP , .0001).

Compared with the control arm,adolescent smokers whose clinicians

were trained in the 5As were alsomore likely to report that theirclinician assessed their readiness toquit (64% vs 42%), tried to help themquit (57% vs 30%), providedresources to help them quit (28% vs6%), and talked about services thatcould help them quit (38% vs 15%)(all P , .0001). Only one adolescentin the 5As arm and no adolescents inthe control arm had follow-up visitsto discuss smoking. In both studyarms, clinicians delivered moretobacco screening to adolescentsmokers than to nonsmokers (P ,.005) (Table 2).

TABLE 2 Frequency of Clinician-Delivered Smoking Screening and Counseling by Study Arm andAdolescent Baseline Smoking Status

Intervention Arm: 5As Control Arm: Social Media

Percentage ofNonsmokersa

Percentage ofSmokers

Percentage ofNonsmokers

Percentage ofSmokers

“Ask”b 67.3 83.3 53.5 65.9Clinician talked to you

about smoking67.3 83.3 53.5 65.9

Clinician asked if yousmoked

63.9 78.5 48.3 59.3

Clinician asked iffriends smoked

41.0 44.6 29.3 34.5

Clinician asked ifothers at homesmoke

45.3 57.0 31.4 42.1

“Advise”c 62.8 81.1 50.2 64.5Clinician encouraged

you not to smoke62.2 79.8 48.3 63.8

Clinician discussedbenefits of notsmoking

50.4 72.1 40.2 54.1

“Assess”: clinician asked ifyou wanted to quit

n/a 48.7 n/a 30.3

“Assist” n/a 44.2 n/a 22.1Clinician tried to help

you quitn/a 43.9 n/a 21.7

Clinician gavesomething to helpquit

n/a 21.2 n/a 4.5

Clinician told you aboutservices to help quit

n/a 27.9 n/a 12.1

Screening score mean(SD); median(range)d

3.7 (1.44); 4 (0–6) 3.7 (1.44); 4(0–6)

2.8 (1.58); 3 (0–6) 2.8 (1.58); 3(0–6)

Counseling score mean(SD); median(range)d

0.7 (0.86); 0 (0–4) 0.7 (0.86);0 (0–4)

0.3 (0.51); 0 (0–4) 0.3 (0.51);0 (0–4)

n/a, not applicable.a Nonsmokers by self-report of not having smoked in the 30 d before the survey.b Significant differences in Ask between nonsmokers and smokers (in intervention arm, difference between nonsmokersand smokers P , .001; in control arm, difference between nonsmokers and smokers P = .002).c Significant differences in Advise between nonsmokers and smokers (difference between nonsmokers and smokersP , .001).d Significant differences in screening and counseling scores between study arms (P , .001).

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In multivariable logistic regressions,clinician training in the 5As was thestrongest predictor of whether youthreported being screened for tobaccouse (adjusted odds ratio [aOR] = 3.44,95% confidence interval [CI] =2.37–5.02). Other predictors includedyouth reporting having ever triedsmoking (aOR = 3.37, 95% CI =2.40–4.75) and clinicians deliveringmore screening for other preventivecare topics during visits (aOR = 1.30,95% CI = 1.26–1.35). Amongadolescent smokers, clinician trainingin the 5As was a predictor of youthreceiving cessation counseling andsupport (aOR = 2.21, 95% CI =1.40–3.48). Other predictors ofwhether smokers were counseledincluded youth report of having hada discussion about confidentiality(aOR = 4.40, 95% CI = 1.82–10.65),having had a one-on-one privateconversation with their clinician (aOR= 1.69, 95% CI = 1.01–2.84), youth-reported addiction to nicotine (aOR =1.52, 95% CI = 1.41–1.64), and youthreport of clinicians delivering morepreventive care on other topics (aOR= 1.11, 95% CI = 1.08–1.15).

Smoking Behaviors and Intentions at6 Months

At 6-month follow-up, more youth inthe 5As arm reported having madequit attempts than in the control arm(64% vs 46%, P , .05); however,study arm was not significantlyassociated with successful quitting.More youth in the 5As arm reportedreceiving screening and counselingthan those in the control arm (72% vs49%, P , .0001); however, receipt ofscreening and counseling, regardlessof study arm, did not affect reportedmotivation to quit. In fact, those whoreceived counseling during clinicalvisits (regardless of study arm) weremore likely to have smoked in theprevious 30-days (20% vs 34%, P ,.01) than those who had not receivedany interventions. Quit attempts andsustained quitting rates are shown inTable 3.

In logistic regression modelscontrolling for study arm assignmentand demographics, receipt ofcounseling, addiction, and clinicianbehaviors (including provision ofpreventive services and private time),the only predictors of successfulquitting were a lower addiction score(aOR = 0.80, 95% CI = 0.71–0.90) andyounger age (aOR = 0.80, 95% CI =0.66–0.97). None of these factorspredicted an adolescent’s quitattempts. The strongest predictor ofwanting to quit was reported receiptof clinician counseling (aOR = 2.50,95 % CI = 1.23–5.07). Those whoreported having private time withtheir clinician were less likely to wantto quit smoking (aOR = 0.40, 95% CI= 0.16–0.99).

Smoking Behavior and Intentions at12 Months

At the 12-month follow-up, bivariateanalyses revealed that study arm wasnot significantly associated with quitattempts or quitting amongadolescents. More adolescents in the5As arm reported receiving screeningand counseling than those in thecontrol arm (71% vs 45%, P , .001).Those who received screening andcounseling (regardless of study arm)were more motivated to quit thanthose who had not receivedcounseling or screening, but thisfinding was not significant (77% vs63%, P , .06). As was seen at 6months, adolescents who receivedcounseling during their clinical visit(regardless of study arm) were morelikely to have smoked in the previous30-days at 12 months (25% vs 41%,

P , .05). Rates of quit attempts andsustained quitting at 12 months areshown in Table 3.

In logistic regression models,adolescents whose clinicians were inthe 5As arm (aOR = 2.53, 95% CI =1.04–6.18) or were female (aOR =3.16, 95% CI = 1.36–7.33) were morelikely to quit, whereas those whowere more addicted were less likelyto quit (aOR = 0.85, 95% CI =0.74–0.98). No factors predicted quitattempts. Female adolescents werealso more likely to want to quit (aOR= 2.78, 95% CI = 1.22–6.33).

CONCLUSIONS

This randomized controlled trial ofa 5As intervention to decreaseadolescent smoking found pediatricclinician training improved deliveryof smoking cessation screening andcounseling to adolescent patients.Adolescent smokers whose clinicianshad been trained in the 5As mademore quit attempts after a routineclinical encounter than those ina control arm; they were also morelikely to have quit at 12 months,although no effect on quitting wasseen at our 6 month measurement. Asin previous work,42,43 adolescentsmokers and those with higheraddiction scores were less likely toquit, regardless of their clinicians’study arm assignment or actualdelivery of cessation counselinginterventions. Adolescent smoking iscorrelated with increased likelihoodof smoking into adulthood, and youthare highly susceptible to nicotine

TABLE 3 Attempt to Quit and Sustained Quitting by Study Group

Intervention Arm: 5As, %of Smokers

Control Arm: Social Media, %of Smokers

6 moAttempted to quita 30 20Successfully quitb 57 54

12 moAttempted to quita 21 53Successfully quitb 46 20

a Based on answering “yes” to “Would you say that you are trying to quit smoking?”b Based on reporting having smoked 0 cigarettes in the 30 d before completing the survey.

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addiction.1,6,7 Our finding that greateraddiction predicted future smoking isconsistent with this and suggests thatfuture interventions may need todirectly address stronger addiction.

Most adolescents who tried to quitdid so with little support. Althoughyouth who received care inintervention practices were morelikely to have gotten assistance fromclinicians, few used nicotinereplacement or otherpharmacotherapy, and none usedquitline44 or web-based resources,even though these can successfullyaid quitting among adults.45–47 Tenpercent reported using e-cigarettes totry to quit. This study occurred earlyin the e-cigarette epidemic and beforeJuul’s dominance of the youth market;however, evidence suggests youth areoften more addicted to nicotine andless likely to quit smokingconventional cigarettes if they usee-cigarettes.48,49

Half of youth in our study whorelapsed from a quit attempt reportedstress as a reason for relapse,suggesting stress reduction could beemployed to support quit attempts.Stress has increased amongadolescents.50 This aligns withprevious research showing thatcravings and stress are reportedfrequently by adolescents who maderecent quit attempts.51 Thus, adjunctsto cessation interventions thataddress stress reduction andaddiction may be a potential focus forfuture studies.

The association between youth-reported receipt of private time withclinicians and continued smokingsuggests that clinicians may deliveradditional counseling to adolescentsthey perceived as having engaged inrisky behavior. This is consistent withrecent work showing an associationbetween private time and other high-

risk behaviors, suggesting thatclinicians may deliver more intensepreventive care interventions whenaware of the need for this care.52

Our study is limited in that cliniciansin the PROS network may not reflectall practicing pediatricians, althoughresearchers in previous PROS studieshave demonstrated that sampledpatients approximate the USnoninstitutionalized child andadolescent population.28–36

Additionally, we were not able toenroll adolescents whose parentswere not available for consent,although we had shown no differencein smoking rates between youth ableto enroll confidentially, withoutparent consent, in our feasibilitypilot.26 Although our pilot studyfound equal retention of smokers andnonsmokers using the same protocol,we also experienced significantdifferential loss of smokers comparedwith nonsmokers between baselineenrollment and follow-up surveys.Although this bias is unlikely to havelost smokers who were more likely toquit, the differential retention furtheremphasizes the need for strong initialengagement, multiple contactmodalities, and reinforcement ofinterventions for youth who smoke.Furthermore, we showed nodifference in attrition between youthwhose pediatricians received MOCcredit compared with those who didnot. These pediatricians were morelikely to work in underserved areas,27

and their inclusion and retention ofpatients for this study may haveyielded a more diverse patientpopulation for the intervention. Thestudy is also limited in that we didnot include a robust question aboutthe fifth A (arrange follow-up)besides asking about additional visits.Thus, we cannot fully assess thedelivery of this “A.”

Despite limitations, our studydemonstrates that pediatric clinicianscan deliver 5As interventions toyouth smokers, resulting in more quitattempts, and, in some cases,abstinence. A recent US PreventiveServices Task Force report foundinsufficient data for the effectivenessof adolescent cessation counseling.53

Although the ability of this brief 5Asintervention to help adolescents quitand remain abstinent was limited, theintervention is scalable, and plannedclinical follow-up with repeatedcounseling interventions andattempts (as is generally the case forsuccessful adult quitters54) and withadditional cessation resources, hasthe potential to eventually improvequit rates. To achieve a tobacco-freegeneration, public health effortsshould continue to address bothpublic policies and effectiveprevention counseling to preventnicotine addiction and delay smokinginitiation.

ACKNOWLEDGMENTS

We thank Drs Alexander Fiks, LauraShone, and Margaret Wright for theircareful reviews of earlier versions ofthis article, and the clinicians, practicestaff, parents, and adolescents whoparticipated in this study.

ABBREVIATIONS

AHIPP: Adolescent Health in Pedi-atric Practice

aOR: adjusted odds ratioCI: confidence intervale-cigarette: electronic cigaretteIRB: Institutional Review BoardMOC: Maintenance of Certification

Part IVPROS: Pediatric Research in Office

SettingsSES: socioeconomic status

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DOI: https://doi.org/10.1542/peds.2020-0644

Accepted for publication Jul 10, 2020

Address correspondence to Jonathan D. Klein, MD, MPH, Department of Pediatrics, University of Illinois College of Medicine, 840 S Wood St, MC 856, Room 1244,

Chicago, IL 60612. E-mail: jonklein@uic.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2020 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: Supported by National Institutes of Health, National Cancer Institute grant R01-CA140576 and by a grant from the Flight Attendant Medical Research

Institute to the American Academy of Pediatrics Julius B. Richmond Center of Excellence. Additional infrastructure funding was provided by the American Academy

of Pediatrics and the Health Resources and Services Administration of the US Department of Health and Human Services under UA6MC15585: MCH Research

Network Programs. The information, content and/or conclusions are those of the author(s) and should not be construed as the official position or policy of, nor

should any endorsements be inferred by Health Resources and Services Administration, Health and Human Services, or the US Government. Funded by the National

Institutes of Health (NIH).

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Kaseeska, Lori Pbert, Alex Prokorov, Tianxiu Wang, James Davis, Edward Gotlieb Jonathan D. Klein, Julie Gorzkowski, Elissa A. Resnick, Donna Harris, Kristen

PROS StudyDelivery and Impact of a Motivational Intervention for Smoking Cessation: A

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