My research interests include preventive services, confidentiality, access to care, youth development, tobacco control, and the translation of research into clinical and public health practice and global child health policy. Current projects address engagement of clinical leaders in countries and communities in health care delivery improvement, accountability measurement, and advocacy for adolescent health, comprehensive sexuality education, and non-communicable disease prevention.

Clinical Focus

  • Adolescent Medicine

Academic Appointments

Boards, Advisory Committees, Professional Organizations

  • Member, World Health Organization Strategic and Technical Advisory Committee for Maternal, Newborn, Child and Adolescent Health and Nutrition (STAGE) (2022 - Present)
  • President, International Association for Adolescent Health (2021 - Present)
  • Treasurer (2021-present) and Executive Committee/Standing Committee (2019-present), International Pediatric Association (2019 - Present)
  • Member (2016-present) and Co-Chair (2021-present), American Pediatric Society Career Support Committee (2016 - Present)
  • Editorial Board (1999-2012; 2023 - present), Journal of Adolescent Health (1999 - Present)

Professional Education

  • Board Certification: American Board of Pediatrics, Adolescent Medicine (1994)
  • Board Certification: American Board of Pediatrics, Pediatrics (1988)
  • Fellowship, University of North Carolina at Chapel Hill, RWJ Clincal Scholars Program (1990)
  • Residency: Floating Hospital for Children Pediatric Residency (1988) MA
  • Internship, Boston Floating Hospital, New England Medical Center, Pediatrics (1985)
  • MPH, Harvard School of Public Health, Health Policy and Management (1984)
  • MD, UMDNJ- New Jersey Medical School, Medicine (1984)
  • BA, Brandeis University, Biology (1979)

Research Interests

  • Adolescence
  • Leadership and Organization
  • Poverty and Inequality

Current Research and Scholarly Interests

Confidentiality and Access to Care for Adolescents and Young Adults:

Adolescent preventive care guidelines recommend screening and counseling for healthy and risky behaviors. This requires confidential discussions between clinicians and young people, often, but not always in the context of parents’ involvement in their children’s care. In the US, only about half of all adolescents have ever had a private 1 on 1 discussion with their clinician without other people in the exam room. Thus, recommended screening and counseling is often not completed. Relatively little is known about the factors that would shift the dynamics of the parent, teen, clinician triads towards better quality adolescent health care delivery. The continued evolution of electronic health record interoperability presents additional challenges and opportunities for young people, their caregivers, and their clinicians.
Ongoing and planned work in this area includes 1) qualitative and quantitative studies of the delivery of and receipt of care by adolescents and young adults and barriers and facilitators of confidential time during well-visits; 2) policy analyses addressing changes in electronic health records confidentiality provisions, quality of care measures, and access to care in US States; and 3) policy analyses addressing global adolescent health delivery by front line health workers and accountability measures for adolescent health and well-being commitments by countries and other health system stakeholders during the 2023 Global Forum for Adolescents.

Tobacco, nicotine, and second-hand smoke prevention research:

1. Despite abundant evidence for the harm of tobacco and nicotine, marketing continues to be vigorously targeting adolescents and young adults, and many become addicted users. Dual use of E cigarettes remains highly prevalent and dual use of nicotine and marijuana is also common for young people. Many youth both know they are addicted, want to quit and have tried unsuccessfully to do so. Cessation counseling techniques and cessation adjuncts that are effective for youth are needed, but evidence for effective interventions remains limited. Building on previous randomized trials of cessation counseling for adolescence, we are planning and will conduct additional preliminary studies needed for a successful primary care practice-based intervention to reduce nicotine addiction in adolescents.

2. Second-hand smoke exposure is responsible for significant proportions of tobacco related diseases. Protecting non-smokers from secondhand smoke (SHS) exposure (and secondhand vapor exposure) is an important component of risk-reduction counseling as well as important in tobacco cessation. Two decades of evidence-based advocacy in child health has reduced childrens’ SHS exposure and lead to increased rates of risk reduction counseling for clean air around children, and smoke-free homes and cars. Many adults, including those at high risk for adverse health outcome from exposure (such as those with cardiac and pulmonary disease,) receive little or no secondhand smoke exposure reduction advice. We have done preliminary work with vascular surgeons to identify opportunities to change this trajectory through motivating clinical systems and documentation changes salient to reduction in procedure complication rates; follow-up qualitative study and documentation of this preliminary work in vascular surgery is planned. We will identify partners and funding streams and launch a similar intervention in neurology and geriatric medicine for people with Alzheimer’s disease, and will also explore opportunities to use these strategies with other medical and surgical specialties.

Graduate and Fellowship Programs

  • Adolescent Medicine (Fellowship Program)

All Publications

  • Global Action for Measurement of Adolescent Health: A Key Tool for Improving Adolescent Health and Well-Being. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Klein, J. D. 2024; 74 (6S): S1-S2

    View details for DOI 10.1016/j.jadohealth.2024.02.008

    View details for PubMedID 38762252

  • Analysis of Candy Tobacco Imitation Products Available Online in the United States. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco Bearman, D. S., Sheeran, T. J., Kowitt, S. D., Clark, S. A., Klein, J. D., Goldstein, A. O. 2024


    Youth tobacco use remains a critical public health concern, and childhood use of candy tobacco imitation products (CTIP) is associated with cigarette use among youth. However, no research has examined the full extent of CTIP available for purchase in the United States.We conducted a content analysis of CTIP available on English-language, US-based websites. We identified sites that marketed CTIP utilizing Google and candy retail websites, examining each product for product names, the tobacco product being replicated (eg, cigar and cigarette), manufacturer, candy flavor, images, product rating, pack color, and if the product had packaging that may appeal to youth.We found 66 CTIP available. The most popular CTIP were cigars, with 39 separate products (59%), followed by candy cigarettes-14 products (21%), candy pipes-8 products (12%), and chewing tobacco-5 products (8%). In the 52 products where packaging design was available, 39 (75%) had packaging that may appeal to youth.CTIP, many of which contain packaging appealing to youth, are widely available for purchase online across the United States. These findings could stimulate policy actions, such as removal of CTIP from popular retail websites, labeling of CTIP as potentially dangerous to youth, or age verification requirements for purchasing CTIP.CTIP continues to be sold on the internet despite research indicating candy cigarette product use by youth increases their likelihood of smoking. We conducted research to understand the extent to which CTIP are sold on the internet and whether these products are being marketed to youth. The results provide evidence that some of the largest retail companies in the world continue to sell CTIP, and the majority are sold in packaging that likely appeals to youth. The results suggest that further research into the market for these products is needed, and regulatory measures should be considered to prevent CTIP from leading to youth tobacco use.

    View details for DOI 10.1093/ntr/ntae055

    View details for PubMedID 38584415

  • Answering the Call: International Policy Statement Provides the Framework for Adolescent Health care Professional Education Globally. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Turetsky, R., Galagali, P. M., Churchill, R. D., Jansen, D. D., Sawyer, S. M., Klein, J. D. 2024

    View details for DOI 10.1016/j.jadohealth.2023.11.017

    View details for PubMedID 38206226

  • Developing a Global Approach for Measurement of Adolescent Well-Being. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Guthold, R., Newby, H., Keogh, S., Afifi, R. A., Austrian, K., Baird, S., Blum, R. W., Bundy, D. A., Deardorff, J., Engel, D., Klein, J. D., Kostelecky, S. M., Mackworth-Young, C., Marquez, J., NicGabhainn, S., Requejo, J., Ross, D. A., Saewyc, E., Mohan, A. 2023; 73 (6): 972-974

    View details for DOI 10.1016/j.jadohealth.2023.08.029

    View details for PubMedID 37815774

    View details for PubMedCentralID PMC10654044

  • Transforming women's, children's, and adolescents' health and wellbeing through primary health care LANCET Homer, C., Abajobir, A., Agarwal, K., Agustina, R., Albuhairan, F., Ariff, S., Kumararora, N., Aryeetey, R., Ashorn, P., Azzopardi, P., Bazirete, O., Berkley, J., Darmstadt, G. L., Dewey, K., Duke, T., El Kak, F., Jehan, F., Kabiru, C., Kanbur, N., Kirkwood, B., Klein, J., Garcia, D., Postma, S., Richter, L., Sandall, J., Suwantika, A., Ahmed, N., Waiswa, P., Walker, D., Zlotkin, S., WHO Strategic Tech Advisory Grp 2023; 402 (10413): 1606-1608
  • The 1.8 Billion Campaign: Adolescents and Their Well-Being Take Center Stage. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Ross, D. A., Kostelecky, S. M., Bustreo, F., Klein, J., Khalil, M., Caffe, S., Güler, D., Bains, A., Bushan, R., Omollo, S., Mohan, A. 2023; 73 (4): 622-624

    View details for DOI 10.1016/j.jadohealth.2023.07.001

    View details for PubMedID 37542508

  • Young Professionals are Key Stakeholders in Adolescent Health and Wellbeing: Perspectives From the International Association for Adolescent Health Young Professionals Network. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Partridge, S. R., O'Sullivan, M., Pehlivanturk-Kizilkan, M., Velies, D. S., Klein, J. D. 2023; 73 (3): 410-411

    View details for DOI 10.1016/j.jadohealth.2023.06.004

    View details for PubMedID 37395696

  • Multiple Perspectives on Motivating Parents in Pediatric Primary Care to Initiate Participation in Parenting Programs. Academic pediatrics Mehus, C. J., Buchanan, G., Ballard, J., Berkel, C., Borowsky, I. W., Estrada, Y., Klein, J. D., Kuklinski, M., Prado, G., Shaw, D., Smith, J. D. 2023


    To use multiple perspectives to identify the key components of pediatric primary care conversations for motivating parents to utilize parenting programs. We aim to develop an actionable framework that primary care clinicians (PCCs) can follow for effective conversations with parents.We conducted focus groups and interviews with researchers (n = 6) who have experience delivering parenting interventions through primary care, clinical personnel in federally qualified health centers (FQHCs) (n = 9), parents of 3-5-year olds who receive services at a FQHC pediatric clinic (n = 6), and parent educators (n = 5). Groups and interviews were informed by nominal group technique, and researchers triangulated consolidated strategies across the groups.Key strategies for PCCs to motivate parents to utilize parenting programs followed three steps: 1) learning about a parent's questions and concerns, 2) sharing resources, and 3) following up. PCCs can learn about parents' needs by empathizing, listening and responding, and asking questions that acknowledge parents' expertise. When sharing resources, PCCs can motivate participation in parenting programs by explaining each resource and its benefits, providing options that support parents' autonomy, and framing resources as strengthening rather than correcting parents' existing strategies or skills. Finally, PCCs can continue to engage parents by scheduling follow-up conversations or designating a staff member to check-in with parents. We provide examples for each strategy.Findings provide guidance from multiple perspectives on strategies to motivate parents in pediatric primary care setting for utilizing parenting programs.

    View details for DOI 10.1016/j.acap.2023.07.020

    View details for PubMedID 37543083

  • Second-hand smoke surveillance and COVID-19: a missed opportunity. Tobacco control Klein, J. D., Resnick, E. A., Chamberlin, M. E., Kress, E. A. 2023; 32 (2): 265-266

    View details for DOI 10.1136/tobaccocontrol-2021-056532

    View details for PubMedID 34117098

  • Advocacy for Global Tobacco Control and Child Health. Pediatric clinics of North America Scott-Wellington, F., Resnick, E. A., Klein, J. D. 2023; 70 (1): 117-135


    Tobacco and secondhand smoke remain leading threats to public health. Evidence since the 1950s has shown that the tobacco industry has acted in bad faith to deceive the public about the health effects of smoking. They have specifically targeted vulnerable populations including children and adolescents with various-and often misleading-marketing efforts and promotions. The increased popularity and weak regulation of electronic cigarettes have created a new generation of smokers who mistakenly believe they are "safer" from harm. Continued research, advocacy, and government action are needed to protect public health. Public health advocates must know the evidence, build coalitions, and prepare for industry countermeasures. Persistence is key, but public health efforts have successfully decreased tobacco-related deaths.

    View details for DOI 10.1016/j.pcl.2022.09.011

    View details for PubMedID 36402463

  • Development of a Definition of Postacute Sequelae of SARS-CoV-2 Infection. JAMA Thaweethai, T., Jolley, S. E., Karlson, E. W., Levitan, E. B., Levy, B., McComsey, G. A., McCorkell, L., Nadkarni, G. N., Parthasarathy, S., Singh, U., Walker, T. A., Selvaggi, C. A., Shinnick, D. J., Schulte, C. C., Atchley-Challenner, R., Horwitz, L. I., Foulkes, A. S., RECOVER Consortium, Alba, G. A., Alicic, R., Altman, N., Anglin, K., Argueta, U., Ashktorab, H., Baslet, G., Bassett, I. V., Bateman, L., Bedi, B., Bhattacharyya, S., Bind, M., Blomkalns, A. L., Bonilla, H., Bush, P. A., Castro, M., Chan, J., Charney, A. W., Chen, P., Chibnik, L. B., Chu, H. Y., Clifton, R. G., Costantine, M. M., Cribbs, S. K., Davila Nieves, S. I., Deeks, S. G., Duven, A., Emery, I. F., Erdmann, N., Erlandson, K. M., Ernst, K. C., Farah-Abraham, R., Farner, C. E., Feuerriegel, E. M., Fleurimont, J., Fonseca, V., Franko, N., Gainer, V., Gander, J. C., Gardner, E. M., Geng, L. N., Gibson, K. S., Go, M., Goldman, J. D., Grebe, H., Greenway, F. L., Habli, M., Hafner, J., Han, J. E., Hanson, K. A., Heath, J., Hernandez, C., Hess, R., Hodder, S. L., Hoffman, M. K., Hoover, S. E., Huang, B., Hughes, B. L., Jagannathan, P., John, J., Jordan, M. R., Katz, S. D., Kaufman, E. S., Kelly, J. D., Kelly, S. W., Kemp, M. M., Kirwan, J. P., Klein, J. D., Knox, K. S., Krishnan, J. A., Kumar, A., Laiyemo, A. O., Lambert, A. A., Lanca, M., Lee-Iannotti, J. K., Logarbo, B. P., Longo, M. T., Luciano, C. A., Lutrick, K., Maley, J. H., Marathe, J. G., Marconi, V., Marshall, G. D., Martin, C. F., Matusov, Y., Mehari, A., Mendez-Figueroa, H., Mermelstein, R., Metz, T. D., Morse, R., Mosier, J., Mouchati, C., Mullington, J., Murphy, S. N., Neuman, R. B., Nikolich, J. Z., Ofotokun, I., Ojemakinde, E., Palatnik, A., Palomares, K., Parimon, T., Parry, S., Patterson, J. E., Patterson, T. F., Patzer, R. E., Peluso, M. J., Pemu, P., Pettker, C. M., Plunkett, B. A., Pogreba-Brown, K., Poppas, A., Quigley, J. G., Reddy, U., Reece, R., Reeder, H., Reeves, W. B., Reiman, E. M., Rischard, F., Rosand, J., Rouse, D. J., Ruff, A., Saade, G., Sandoval, G. J., Schlater, S. M., Shepherd, F., Sherif, Z. A., Simhan, H., Singer, N. G., Skupski, D. W., Sowles, A., Sparks, J. A., Sukhera, F. I., Taylor, B. S., Teunis, L., Thomas, R. J., Thorp, J. M., Thuluvath, P., Ticotsky, A., Tita, A. T., Tuttle, K. R., Urdaneta, A. E., Valdivieso, D., VanWagoner, T. M., Vasey, A., Verduzco-Gutierrez, M., Wallace, Z. S., Ward, H. D., Warren, D. E., Weiner, S. J., Welch, S., Whiteheart, S. W., Wiley, Z., Wisnivesky, J. P., Yee, L. M., Zisis, S. 2023


    Importance: SARS-CoV-2 infection is associated with persistent, relapsing, or new symptoms or other health effects occurring after acute infection, termed postacute sequelae of SARS-CoV-2 infection (PASC), also known as long COVID. Characterizing PASC requires analysis of prospectively and uniformly collected data from diverse uninfected and infected individuals.Objective: To develop a definition of PASC using self-reported symptoms and describe PASC frequencies across cohorts, vaccination status, and number of infections.Design, Setting, and Participants: Prospective observational cohort study of adults with and without SARS-CoV-2 infection at 85 enrolling sites (hospitals, health centers, community organizations) located in 33 states plus Washington, DC, and Puerto Rico. Participants who were enrolled in the RECOVER adult cohort before April 10, 2023, completed a symptom survey 6 months or more after acute symptom onset or test date. Selection included population-based, volunteer, and convenience sampling.Exposure: SARS-CoV-2 infection.Main Outcomes and Measures: PASC and 44 participant-reported symptoms (with severity thresholds).Results: A total of 9764 participants (89% SARS-CoV-2 infected; 71% female; 16% Hispanic/Latino; 15% non-Hispanic Black; median age, 47 years [IQR, 35-60]) met selection criteria. Adjusted odds ratios were 1.5 or greater (infected vs uninfected participants) for 37 symptoms. Symptoms contributing to PASC score included postexertional malaise, fatigue, brain fog, dizziness, gastrointestinal symptoms, palpitations, changes in sexual desire or capacity, loss of or change in smell or taste, thirst, chronic cough, chest pain, and abnormal movements. Among 2231 participants first infected on or after December 1, 2021, and enrolled within 30 days of infection, 224 (10% [95% CI, 8.8%-11%]) were PASC positive at 6 months.Conclusions and Relevance: A definition of PASC was developed based on symptoms in a prospective cohort study. As a first step to providing a framework for other investigations, iterative refinement that further incorporates other clinical features is needed to support actionable definitions of PASC.

    View details for DOI 10.1001/jama.2023.8823

    View details for PubMedID 37278994

  • A Cluster Randomized Controlled Trial of a Primary Care Provider-Delivered Social Media Counseling Intervention. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Moreno, M. A., Klein, J. D., Kaseeska, K., Gorzkowski, J., Harris, D., Davis, J., Gotlieb, E., Wasserman, R. 2023; 73 (5): 924-930


    PURPOSE: Evidence and clinical policy support that providers screen and counsel for media use for youth, but most pediatricians lack this training. The purpose of this study was to test a primary care provider (PCP)-delivered intervention to promote safe social media use among youth.METHODS: We enrolled pediatric PCP practices for this clinical trial to test a social media counseling intervention (SMCI) between 2011 and 2013. Youth were recruited during clinic visits; follow-up interviews were conducted at 6months. Outcomes included media behaviors and caregiver communication. Multivariate regression models examined associations between social media counseling and PCP counseling score. Multivariate logistic regression evaluated four social media behavior outcomes.RESULTS: A total of 120 practices enrolled; PCPs in the SMCI were more likely to provide social media counseling (B= 1.43, 95% confidence interval [CI]: 1.1-1.7). Youth whose PCP received the SMCI were twice as likely to report a decrease in online "friending" of strangers (adjusted odds ratio= 2.23, 95% CI 1.17-4.25) and were more likely to report communication with their caregivers about their social media use (adjusted odds ratio= 1.2; 95% CI: 1.1-1.4) compared to youth whose PCPs were in the active control group.DISCUSSION: Youth whose PCP had received social media counseling training reported a higher receipt of counseling about social media and improved safety behaviors.

    View details for DOI 10.1016/j.jadohealth.2023.06.007

    View details for PubMedID 37578406

  • Reply to Campagna and Caci: Taking for Granted Conclusions from Studies that Cannot Prove Causality of Respiratory Symptoms and Vaping. American journal of respiratory and critical care medicine Klein, J. D. 2022; 206 (12): 1569-1570

    View details for DOI 10.1164/rccm.202207-1432LE

    View details for PubMedID 35921659

  • Intervening With Smoking Parents of Inpatients to Reduce Exposure: The INSPIRE Randomized Controlled Trial. Academic pediatrics Wilson, K. M., Moss, A., Lowary, M., Holstein, J., Gambino, J., Juarez-Colunga, E., Kerby, G. S., Klein, J. D., Hovell, M., Winickoff, J. P. 2022; 22 (6): 997-1005


    Hospitalized children have high rates of tobacco smoke exposure; parents who smoke may be receptive to interventions during their child's hospitalization.We tested the efficacy of a smoking cessation intervention for parents of hospitalized children.We conducted a randomized, single-blind clinical trial from 12/14-5/18 at the Children's Hospital Colorado. Hospitalized children who had a parent who smoked tobacco were eligible.Intervention participants received motivational interviewing sessions, 2 weeks of nicotine replacement therapy; both groups received referral to the Quitline Consenting parents completed a questionnaire; urine was collected from the child for measurement of cotinine. Our primary outcome was: 1) increase in reporting "no one is allowed to smoke anywhere" in the home (smoke-free home rule). Additional outcomes included: 2) change in child's cotinine from baseline to 1 year, and 3) parental quitting at 1 year. Data were analyzed using Chi-square and t tests for bivariable data, and multivariable logistic and linear regression.Of 1641 eligible families approached, 252 were randomized (15%); 149 families had follow-up data at 12 months (59%). In the adjusted analysis, there was no difference between the groups in smoke free home rules, or child cotinine level; in an intention-to-treat analysis, 15% in the intervention group versus 8% of controls reported quit (p=0.07).A smoking cessation intervention can be delivered to parents of hospitalized children. While hospitalization provides an opportunity to help parents quit smoking, more efficient and effective engagement strategies are needed to optimize tobacco control success.

    View details for DOI 10.1016/j.acap.2021.11.010

    View details for PubMedID 34818588

    View details for PubMedCentralID PMC9123095

  • Another Study Shows Electronic Cigarettes Harm Lungs: It Is Time for Researchers to Move from the Tobacco Playbook to a Tobacco Endgame. American journal of respiratory and critical care medicine Klein, J. D. 2022; 205 (11): 1265-1266

    View details for DOI 10.1164/rccm.202201-0169ED

    View details for PubMedID 35436170

    View details for PubMedCentralID PMC9873108

  • Parents' Sources of Adolescent Sexual Health Information and Their Interest in Resources From Primary Care. Academic pediatrics Mehus, C. J., Aldrin, S., Steiner, R. J., Brar, P., Gewirtz O'Brien, J. R., Gorzkowski, J., Grilo, S., Klein, J. D., McRee, A. L., Ross, C., Santelli, J., Sieving, R. E. 2022; 22 (3): 396-401


    To examine sources of information used by parents to facilitate parent-adolescent communication about sexual and reproductive health (SRH), parents' preferences for receiving SRH information through primary care, and factors associated with parents' interest in primary-care-based SRH information (ie, resources recommended or offered in the primary care setting).In this cross-sectional study, a nationally representative sample of 11-17-year-old adolescents and their parents (n = 1005 dyads) were surveyed online; 993 were retained for these analyses. Parents were asked about their use of 11 resources to help them talk with their adolescents about SRH and rated the likelihood of using specific primary-care-based resources. We used multivariable logistic regression to examine characteristics associated with parent interest in primary-care-based SRH resources.Only 25.8% of parents reported receiving at least a moderate amount of SRH information from primary care; half (53.3%) reported receiving no SRH information from their adolescent's provider. Parents received the most information from personal connections (eg, spouse/partner, friends). Most parents (59.1%) reported being likely to utilize a primary-care-based resource for SRH information. Parents who previously received SRH information from primary care sources had greater odds of reporting they would be likely to utilize a primary-care-based resources (AOR = 4.06, 95% CI: 2.55-6.46).This study provides insights into parents' sources of information for communicating with their adolescents about SRH and ways primary care practices might increase support for parents in having SRH conversations with their adolescents. Future studies are needed to establish clinical best practices for promoting parent-adolescent communication about SRH.

    View details for DOI 10.1016/j.acap.2021.09.007

    View details for PubMedID 34547518

    View details for PubMedCentralID PMC9125412

  • Receipt of Private Time Among Adolescents and Young Adults With and Without Special Healthcare Needs. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Klein, J. D., Resnick, E. A., Danawala, S., Grilo, S. A., Catallozzi, M., Li, B., Gorzkowski, J., Kaseeska, K., Santelli, J. S. 2022; 70 (3): 414-420


    Private time is an opportunity for the adolescent patient to speak directly to a healthcare provider and a marker of quality preventive health care. Little is known about whether adolescents and young adults (AYAs) with special healthcare needs (SHCNs) are afforded private discussions with their primary care clinicians.We surveyed a nationally representative sample of 1,209 adolescents (13-18 years) and 709 young adults (19-26 years) about whether they had SHCNs and whether they had ever had private, one-on-one time with their healthcare providers.SHCNs were reported by 20.3% of adolescents and 15.6% of young adults. Among adolescents, older age was associated with more SHCNs. Among young adults, women and blacks were more likely to report SHCNs than men and those reporting other race categories. For both AYAs, those with SHCNs more often received private time than those without SHCNs: 54.2% of adolescents and 88.1% of young adults with SHCNs reported ever having received private time, compared with 29.6% of adolescents and 62.1% of young adults without SHCNs.Lack of private time continues to impact quality primary care for AYAs; however, AYAs with SHCNs are more likely to have received private time than AYAs who do not have SHCNs. Further research is needed to understand whether increased number of clinical visits, clinician-related factors, or other factors lead to more opportunities for young people with SHCNs to receive private time from their clinicians.

    View details for DOI 10.1016/j.jadohealth.2021.10.014

    View details for PubMedID 35033426

  • Correlates of Sexual and Reproductive Health Discussions During Preventive Visits: Findings From a National Sample of U.S. Adolescents. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Sieving, R. E., Mehus, C., Gewirtz O'Brien, J. R., Steiner, R. J., Wang, S., Catallozzi, M., Gorzkowski, J., Grilo, S. A., Kaseeska, K., McRee, A. L., Santelli, J., Klein, J. D. 2022; 70 (3): 421-428


    This study examines characteristics of healthcare delivery, providers, and adolescents associated with provider-adolescent discussions about sexual and reproductive health (SRH) during preventive visits.Data were from a 2019 national internet survey of U.S. adolescents ages 11-17 years and their parents. Adolescents who had a preventive visit in the past 2 years (n = 853) were asked whether their provider discussed each of eight SRH topics at that visit: puberty, safe dating, gender identity, sexual orientation, whether or not to have sex, sexually transmitted infections including human immunodeficiency virus, birth control methods, and where to get SRH services. Eight multivariable logistic regression models were examined (one for each SRH topic as the outcome), with each model including modifiable healthcare delivery and provider characteristics, adolescent beliefs, behaviors, and demographic characteristics as potential correlates.Provider-adolescent discussions about SRH topics at the last preventive visit were positively associated with face-to-face screening about sexual activity for all eight topics (range of adjusted odds ratios [AORs] = 3.40-9.61), having time alone with the adolescent during that visit (seven topics; AORs = 1.87-3.87), and ever having communicated about confidentiality with adolescents (two topics; AORs = 1.88-2.19) and with parents (one topic; AOR = 2.73). Adolescents' perception that a topic was important to discuss with their provider was associated with provider-adolescent discussions about seven topics (AORs = 2.34-5.46).Findings that provider-adolescent discussions about SRH during preventive visits were associated with modifiable practices including time alone between providers and adolescents and screening about sexual activity can inform efforts to improve the delivery of adolescent SRH services within primary care.

    View details for DOI 10.1016/j.jadohealth.2021.10.013

    View details for PubMedID 34838444

    View details for PubMedCentralID PMC9066357

  • Barriers and Motivators for Smoking Cessation Among Caregivers of Inpatient Pediatric Patients. Hospital pediatrics Holstein, J. A., O'Hara, K., Moss, A., Lowary, M., Kerby, G., Hovell, M., Klein, J. D., Winickoff, J. P., Wilson, K. 2022; 12 (2): 220-228


    To examine perceived barriers and motivators for smoking cessation among caregivers of inpatient pediatric patients.From December 2014 to June 2018, trained tobacco counselors conducted motivational interviews (MI) with caregivers of inpatient pediatric patients ages 0 to 17, who participated in the intervention arm of a smoking cessation randomized controlled trial. By using NVivo 12 software, the first MI session with each caregiver was evaluated by 3 individuals to identify and categorize motivators and barriers; agreement among reviewers was reached. Barriers and motivators were examined in bivariable analysis with χ2 or Fisher's exact tests for categorical factors and with t-tests for continuous factors by using SAS 9.4 software.Of the 124 caregivers randomized to intervention, 99 subjects (80%) completed ≥1 MI sessions. The most prevalent barriers to cessation were stress (57%) and social influence (37%).The most prevalent motivators were desire to lead a healthy life (54%) and desire to improve the child and family's well-being (47%). Older parent age was associated with wanting to lead a healthy life, and younger child age was associated with wanting to improve the child and family's well-being.Understanding barriers and motivators to cessation among caregivers is crucial in reducing pediatric secondhand smoke (SHS). When developing caregiver cessation programs in an inpatient clinic encounter, caregiver barriers and motivators may help in targeting education and strategies to help counselors and clinicians better identify and support caregivers who wish to quit smoking.

    View details for DOI 10.1542/hpeds.2021-005984

    View details for PubMedID 35083490

  • Cross-sectional online survey of clinicians' knowledge, attitudes and challenges to screening and counselling adolescents and young adults for substance use. BMJ open Gorukanti, A. L., Kimminau, K. S., Tindle, H. A., Klein, J. D., Gorzkowski, J., Kaseeska, K., Ali, R., Singh, L., David, S. P., Halpern-Felsher, B. 2022; 12 (11): e059019


    OBJECTIVE: To examine adolescent healthcare clinicians' self-reported screening practices as well as their knowledge, attitudes, comfort level and challenges with screening and counselling adolescents and young adults (AYA) for cigarette, e-cigarette, alcohol, marijuana, hookah and blunt use.DESIGN: A 2016 cross-sectional survey.SETTING: Academic departments and community-based internal medicine, family medicine and paediatrics practices.PARTICIPANTS: Adolescent healthcare clinicians (N=771) from 12 US medical schools and respondents to national surveys. Of the participants, 36% indicated male, 64% female, mean age was 44 years (SD=12.3); 12.3% of participants identified as Asian, 73.7% as white, 4.8% as black, 4.2% as Hispanic and 3.8% as other.PRIMARY AND SECONDARY OUTCOME MEASURES: Survey items queried clinicians about knowledge, attitudes, comfort level, self-efficacy and challenges with screening and counselling AYA patients about marijuana, blunts, cigarettes, e-cigarettes, hookah and alcohol.RESULTS: Participants were asked what percentage of their 10-17years old patients they screened for substance use. The median number of physicians reported screening 100% of their patients for cigarette (1st, 3rd quartiles; 80, 100) and alcohol use (75, 100) and 99.5% for marijuana use (50,100); for e-cigarettes, participants reported screening half of their patients and 0.0% (0, 50), (0, 75)) reported screening for hookah and blunts, respectively. On average (median), clinicians estimated that 15.0% of all 10-17years old patients smoked cigarettes, 10.0% used e-cigarettes, 20.0% used marijuana, 25.0% drank alcohol and 5.0% used hookah or blunts, respectively; yet they estimated lower than national rates of use of each product for their own patients. Clinicians reported greater comfort discussing cigarettes and alcohol with patients and less comfort discussing e-cigarettes, hookah, marijuana and blunts.CONCLUSIONS: This study identified low rates of screening and counselling AYA patients for use of e-cigarettes, hookahs and blunts by adolescent healthcare clinicians and points to potential missed opportunities to improve prevention efforts.

    View details for DOI 10.1136/bmjopen-2021-059019

    View details for PubMedID 36414284

  • School-based Sex Education in the U.S. at a Crossroads: Taking the Right Path. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Santelli, J. S., Bell, D. L., Trent, M., Klein, J. D., Grubb, L., Barondeau, J., Stager, M., North, S. 2021; 69 (6): 886-890

    View details for DOI 10.1016/j.jadohealth.2021.09.007

    View details for PubMedID 34666955

  • Adolescent Health - Indicators for Measurement and Accountability-A Necessary Step Towards Achieving Global Goals. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Klein, J. D. 2021; 69 (3): 357-358

    View details for DOI 10.1016/j.jadohealth.2021.06.018

    View details for PubMedID 34452724

  • Sexual and Reproductive Health Discussions During Preventive Visits. Pediatrics Sieving, R. E., McRee, A. L., Mehus, C., Gewirtz O'Brien, J. R., Wang, S., Brar, P., Catallozzi, M., Gorzkowski, J., Grilo, S., Kaseeska, K., Santelli, J., Steiner, R. J., Klein, J. D. 2021; 148 (2)


    To quantify adolescent- and parent-perceived importance of provider-adolescent discussions about sexual and reproductive health (SRH), describe prevalence of provider confidentiality practices and provider-adolescent discussions about SRH topics during preventive visits, and identify missed opportunities for such conversations.We used data from a national Internet survey of 11- to 17-year-old adolescents and their parents. Data were weighted to represent the noninstitutionalized US adolescent population. Adolescents who had a preventive visit in the past 2 years and their parents reported on perceived importance of provider-adolescent discussions about SRH topics: puberty, safe dating, gender identity, sexual orientation, sexual decision-making, sexually transmitted infections and HIV, methods of birth control, and where to get SRH services. Adolescents and parents reported whether they had ever discussed confidentiality with the adolescent's provider. Adolescents reported experiences at their most recent preventive visit, including whether a provider spoke about specific SRH topics and whether they had time alone with a provider.A majority of adolescents and parents deemed provider-adolescent discussions about puberty, sexually transmitted infections and HIV, and birth control as important. However, fewer than one-third of adolescents reported discussions about SRH topics other than puberty at their most recent preventive visit. These discussions were particularly uncommon among younger adolescents. Within age groups, discussions about several topics varied by sex.Although most parents and adolescents value provider-adolescent discussions of selected SRH topics, these discussions do not occur routinely during preventive visits. Preventive visits represent a missed opportunity for adolescents to receive screening, education, and guidance related to SRH.

    View details for DOI 10.1542/peds.2020-049411

    View details for PubMedID 34253569

    View details for PubMedCentralID PMC9125413

  • The nutrition agenda must include tobacco control. Lancet (London, England) Klein, J. D. 2021; 398 (10297): 300-301

    View details for DOI 10.1016/S0140-6736(21)01235-6

    View details for PubMedID 34303432

  • Adolescent Health Measurement-A Necessary Step Toward Achieving Global Goals. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Klein, J. D. 2021; 68 (5): 836-839

    View details for DOI 10.1016/j.jadohealth.2021.01.022

    View details for PubMedID 33896549

  • International Adolescent Health Week: Nothing About Them Without Them. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Oketah, N., Wokoma, C., Klein, J. D., Galagali, P., Simpson, T., Offutt, L. 2021; 68 (4): 646-647

    View details for DOI 10.1016/j.jadohealth.2021.01.012

    View details for PubMedID 33582016

  • Pediatric Resident Training in Tobacco Control and the Electronic Health Record. American journal of preventive medicine Boykan, R., Gorzkowski, J., Wellman, R. J., Jenssen, B. P., Klein, J. D., Krugman, J., Pbert, L., Salloum, R. G. 2021; 60 (3): 446-452


    Given the dangers posed by tobacco use and tobacco smoke exposure, pediatricians should address tobacco use and exposure with patients and parents at every opportunity, but this is not consistently done in practice. One reason may be that many medical residents do not receive education on how to address tobacco use and tobacco smoke exposure with patients and their parents. In a 2012 survey of U.S. pediatric program directors, 65% of programs reported covering tobacco control in their curricula, but most training programs focused on tobacco's health effects and not intervention strategies for clinical practice. Since that survey, electronic health records have been implemented broadly nationwide and utilized to address tobacco smoke exposure. Investigators surveyed U.S. program directors in 2018 and residents in 2019 to explore the ways in which the residents learn about tobacco use and tobacco smoke exposure, components and use of the electronic record specific to tobacco use and tobacco smoke exposure, and perceived resident effectiveness in this area. All the program directors and 85% of the residents valued training, but 21% of the residents reported receiving none. Moreover, a minority of the residents assessed themselves as effective at counseling parents (19%) or adolescents (23%), and their perceived effectiveness was related to small group learning and active learning workshops, modalities that were infrequently implemented in training. Respondents also reported infrequent use of electronic health record prompts regarding tobacco and the absence of prompts about critical issues (e.g., addressing tobacco smoke exposure in vehicles or other settings or offering treatment or referrals to parents who smoke). This paper provides recommendations about augmenting pediatric resident training in simple ways.

    View details for DOI 10.1016/j.amepre.2020.07.016

    View details for PubMedID 33131991

  • Tobacco Smoke Exposure Reduction Strategies-Do They Work? Academic pediatrics Gambino, J., Moss, A., Lowary, M., Kerby, G., Winickoff, J. P., Klein, J. D., Hovell, M., Wilson, K. M. 2021; 21 (1): 124-128


    Many children experience tobacco smoke exposure (TSE) and parents may take preventive measures to reduce TSE. The study goal is to assess if these strategies are associated with lower cotinine values, an objective biological measure of TSE.Families admitted to Children's Hospital Colorado from 2014 to 2018 who screened positive for TSE were invited to participate in a tobacco smoking cessation/reduction program. Caregivers were consented and asked about demographics, beliefs around smoking, and strategies to reduce TSE. Child urine samples were collected, tested for cotinine levels, and analyzed using geometric means. Bivariable comparisons and multivariable linear regression were completed using SAS v9.4 (SAS Institute, Cary, NC).Two hundred thirteen children (81.4%) are included in this analysis. The median ages of children and parents were 4 and 32 years respectively. Fifty-seven percent of children were male, 36% were Hispanic, and 55% were white. Fifty-six percent of parents had at least some college education and 69% had an annual income less than $50K. The median daily cigarettes smoked per day were 10. Eighty-eight percent reported using at least 1 type of protective measure to prevent TSE and 90% believed they protect other household members from TSE. None of the strategies had a significant relationship with lower cotinine levels on bivariable or multivariable analyses.Parental strategies to decrease TSE did not result in lower cotinine levels. Many measures are not evidence-based and do not protect children. Parent's clothing and homes may create a reservoir for nicotine. Education should focus on exposure elimination and cessation rather than protective measures.

    View details for DOI 10.1016/j.acap.2020.02.022

    View details for PubMedID 32097784

    View details for PubMedCentralID PMC7442659

  • Asking the Right Questions About Secondhand Smoke. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco Klein, J. D., Chamberlin, M. E., Kress, E. A., Geraci, M. W., Rosenblatt, S., Boykan, R., Jenssen, B., Rosenblatt, S. M., Milberger, S., Adams, W. G., Goldstein, A. O., Rigotti, N. A., Hovell, M. F., Holm, A. L., Vandivier, R. W., Croxton, T. L., Young, P. L., Blissard, L., Jewell, K., Richardson, L., Ostrow, J., Resnick, E. A. 2021; 23 (1): 57-62


    Despite knowledge about major health effects of secondhand tobacco smoke (SHS) exposure, systematic incorporation of SHS screening and counseling in clinical settings has not occurred.A three-round modified Delphi Panel of tobacco control experts was convened to build consensus on the screening questions that should be asked and identify opportunities and barriers to SHS exposure screening and counseling. The panel considered four questions: (1) what questions should be asked about SHS exposure; (2) what are the top priorities to advance the goal of ensuring that these questions are asked; (3) what are the barriers to achieving these goals; and (4) how might these barriers be overcome. Each panel member submitted answers to the questions. Responses were summarized and successive rounds were reviewed by panel members for consolidation and prioritization.Panelists agreed that both adults and children should be screened during clinical encounters by asking if they are exposed or have ever been exposed to smoke from any tobacco products in their usual environment. The panel found that consistent clinician training, quality measurement or other accountability, and policy and electronic health records interventions were needed to successfully implement consistent screening.The panel successfully generated screening questions and identified priorities to improve SHS exposure screening. Policy interventions and stakeholder engagement are needed to overcome barriers to implementing effective SHS screening.In a modified Delphi panel, tobacco control and clinical prevention experts agreed that all adults and children should be screened during clinical encounters by asking if they are exposed or have ever been exposed to smoke from tobacco products. Consistent training, accountability, and policy and electronic health records interventions are needed to implement consistent screening. Increasing SHS screening will have a significant impact on public health and costs.

    View details for DOI 10.1093/ntr/ntz125

    View details for PubMedID 31407779

    View details for PubMedCentralID PMC7974019

  • Smoking Behaviors Among Tobacco-Using Parents of Hospitalized Children and Association With Child Cotinine Level. Hospital pediatrics Wilson, K. M., Moss, A., Lowary, M., Gambino, J., Klein, J. D., Kerby, G. S., Hovell, M., Winickoff, J. P. 2021; 11 (1): 17-24


    Understanding patterns of parental tobacco use and their association with child exposure can help us target interventions more appropriately. We aimed to examine the association between parental smoking practices and cotinine levels of hospitalized children.This is a secondary analysis of data collected from parents of hospitalized children, recruited for a cessation intervention randomized controlled trial. Smoking parents were identified by using a medical record screening question. Parent-reported demographics and smoking habits were compared to child urine cotinine by using geometric means and log-transformed cotinine levels in multivariable linear regression analyses.A total of 213 patients had complete baseline parent-interview and urine cotinine data. The median age was 4 (interquartile range: 1-9); 57% were boys; 56% were white, 12% were Black, and 23% were multiracial; 36% identified as Hispanic. Most families (54%) had 1 smoker in the home; 36% had 2, and 9% had ≥3. Many (77%) reported having a ban on smoking in the home, and 86% reported smoking only outside. The geometric mean cotinine level of the cohort was 0.98 ng/mL. Higher cotinine levels were associated with more smokers in the home (ratio of 2.99) and smoking inside the house (ratio of 4.11).Having more smokers in the home and parents who smoke inside are associated with increased smoke exposure; however, even children whose families who smoke only outside the home have significant levels of cotinine, a marker for toxin exposure.

    View details for DOI 10.1542/hpeds.2020-0122

    View details for PubMedID 33272923

    View details for PubMedCentralID PMC7769203

  • COVID-19 and multisystem inflammatory syndrome in children and adolescents. The Lancet. Infectious diseases Jiang, L., Tang, K., Levin, M., Irfan, O., Morris, S. K., Wilson, K., Klein, J. D., Bhutta, Z. A. 2020; 20 (11): e276-e288


    As severe acute respiratory syndrome coronavirus 2 continues to spread worldwide, there have been increasing reports from Europe, North America, Asia, and Latin America describing children and adolescents with COVID-19-associated multisystem inflammatory conditions. However, the association between multisystem inflammatory syndrome in children and COVID-19 is still unknown. We review the epidemiology, causes, clinical features, and current treatment protocols for multisystem inflammatory syndrome in children and adolescents associated with COVID-19. We also discuss the possible underlying pathophysiological mechanisms for COVID-19-induced inflammatory processes, which can lead to organ damage in paediatric patients who are severely ill. These insights provide evidence for the need to develop a clear case definition and treatment protocol for this new condition and also shed light on future therapeutic interventions and the potential for vaccine development. TRANSLATIONS: For the French, Chinese, Arabic, Spanish and Russian translations of the abstract see Supplementary Materials section.

    View details for DOI 10.1016/S1473-3099(20)30651-4

    View details for PubMedID 32818434

    View details for PubMedCentralID PMC7431129

  • Innovations in parental smoking cessation assistance delivered in the child healthcare setting. Translational behavioral medicine Nabi-Burza, E., Winickoff, J. P., Drehmer, J. E., Gorzkowski, J. A., Klein, J. D., Levy, D. E., Ossip, D. J., Regan, S., Rigotti, N. A., Hipple Walters, B. 2020; 10 (4): 1039-1052


    Addressing parental smoking in the child healthcare setting improves the health of all family members. Innovative approaches, such as mobilizing technology-based platforms, may streamline screening and motivate acceptance of behavioral health services to treat tobacco use and dependence. The obective of this study was to describe innovations added to the CEASE intervention and to track 2 year post-intervention implementation data on families who were screened for tobacco use. Child healthcare practices in five states (IN, NC, OH, TN, and VA) used an electronic tablet screener to identify tobacco use within families and deliver tobacco cessation assistance to smokers. Motivational/educational videos on cessation were displayed via the screener to enhance its utility. Five CEASE intervention practices screened 50,111 family members for tobacco use and identified 6,885 families with children exposed to tobacco smoke. The mean number of screeners per practice per month was 417; the mean number of households with smokers identified per month was 57. Of 2,764 smokers who were at visits and consented, 57% indicated that they wanted a prescription to reduce or quit smoking; 94% of these were given preprinted prescriptions. Of 41% who requested connection to the quitline, 93% were given enrollment forms. Electronic screening was used to routinely identify tobacco users, leading to increased potential for offering cessation assistance to all household members who smoke. Improved delivery of smoking cessation services to families may be achieved by integrating technological innovations into routine pediatric practice. CLINICAL TRIALS REGISTRATION: Trial Number NCT01882348.

    View details for DOI 10.1093/tbm/ibz070

    View details for PubMedID 31157864

    View details for PubMedCentralID PMC7543078

  • Understanding Primary Care Providers' Perceptions and Practices in Implementing Confidential Adolescent Sexual and Reproductive Health Services. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Sieving, R. E., Mehus, C., Catallozzi, M., Grilo, S., Steiner, R. J., Brar, P., Gewirtz O'Brien, J. R., Gorzkowski, J., Kaseeska, K., Kelly, E. D., Klein, J. D., McRee, A. L., Randazzo, L., Santelli, J. 2020; 67 (4): 569-575


    Substantial gaps exist between professional guidelines and practice around confidential adolescent services, including private time between health-care providers and adolescents. Efforts to provide quality sexual and reproductive health services (SRHS) require an understanding of barriers and facilitators to care from the perspectives of primary care providers working with adolescents and their parents.We conducted structured qualitative interviews with a purposive sample of pediatricians, family physicians, and nurse practitioners (n = 25) from urban and rural Minnesota communities with higher and lower rates of adolescent pregnancy. Provider interviews included confidentiality beliefs and practices; SRHS screening and counseling; and referral practices.The analysis identified two key themes: (1) individual and structural factors were related to variations in SRH screening and counseling and (2) a wide range of factors influenced provider decision-making in initiating private time. A nuanced set of factors informed SRHS provided, including provider comfort with specific topics; provider engagement and relationship with parents; use of adolescent screening tools; practices, policies, and resources within the clinic setting; and community norms including openness with communication about sex and religious considerations regarding adolescent sexuality. Factors that shaped providers' decisions in initiating private time included adolescent age, developmental stage, health behaviors and other characteristics; observed adolescent-parent interactions; parent support for private time; reason for clinic visit; laws and professional guidelines; and cultural considerations.Findings suggest opportunities for interventions related to provider and clinic staff training, routine communication with adolescents and their parents, and clinic policies and protocols that can improve the quality of adolescent SRHS.

    View details for DOI 10.1016/j.jadohealth.2020.03.035

    View details for PubMedID 32389456

    View details for PubMedCentralID PMC9062682

  • Delivery and Impact of a Motivational Intervention for Smoking Cessation: A PROS Study. Pediatrics Klein, J. D., Gorzkowski, J., Resnick, E. A., Harris, D., Kaseeska, K., Pbert, L., Prokorov, A., Wang, T., Davis, J., Gotlieb, E., Wasserman, R. 2020; 146 (4)


    We tested a Public Health Service 5As-based clinician-delivered smoking cessation counseling intervention with adolescent smokers in pediatric primary care practice.We enrolled clinicians from 120 practices and recruited youth (age ≥14) from the American Academy of Pediatrics Pediatric Research in Office Settings practice-based research network. Practices were randomly assigned to training in smoking cessation (intervention) or social media counseling (attentional control). Youth recruited during clinical visits completed confidential screening forms. All self-reported smokers and a random sample of nonsmokers were offered enrollment and interviewed by phone at 4 to 6 weeks, 6 months, and 12 months after visits. Measures included adolescents' report of clinicians' delivery of screening and counseling, current tobacco use, and cessation behaviors and intentions. Analysis assessed receipt of screening and counseling, predictors of receiving 5As counseling, and effects of interventions on smoking behaviors and cessation at 6 and 12 months.Clinicians trained in the 5As intervention delivered more screening (β = 1.0605, P < .0001) and counseling (β = 0.4354, P < .0001). In both arms, clinicians more often screened smokers than nonsmokers. At 6 months, study arm was not significantly associated with successful cessation; however, smokers in the 5As group were more likely to have quit at 12 months. Addicted smokers more often were counseled, regardless of study arm, but were less likely to successfully quit smoking.Adolescent smokers whose clinicians were trained in 5As were more likely to receive smoking screening and counseling than controls, but the ability of this intervention to help adolescents quit smoking was limited.

    View details for DOI 10.1542/peds.2020-0644

    View details for PubMedID 32989082

    View details for PubMedCentralID PMC7546094

  • Practical Implications of the US Preventive Services Task Force Recommendations on Adolescents and Tobacco. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Gribben, V., Klein, J. D. 2020; 67 (3): 328-330

    View details for DOI 10.1016/j.jadohealth.2020.06.005

    View details for PubMedID 32646826

  • Distrust, but use it anyway - adolescent online health-information searching behavior. The Journal of pediatrics Bernstein, K. S., Klein, J. D. 2020; 224: 179-183

    View details for DOI 10.1016/j.jpeds.2020.07.020

    View details for PubMedID 32826020

  • The Unmet Need for Discussions Between Health Care Providers and Adolescents and Young Adults. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Santelli, J. S., Grilo, S. A., Klein, J. D., Liu, Y., Yan, H., Li, B., Kaseeska, K., Gorzkowski, J., Urquhart, G., Catallozzi, M. 2020; 67 (2): 262-269


    The aims of the study were to identify factors related to (1) adolescents and young adults (AYA) desire to discuss health topics; (2) whether discussions occurred at their last medical visit; and (3) the gap (unmet need) between desire and actual discussion.We used data from a nationally representative, cross-sectional online survey of AYA aged 13-26 years (n = 1,509) who had had a visit in the past 2 years. Bivariate analyses examined 11 topics. Multivariable regression identified health care factors and demographic factors related to unmet need across four salient topics (HIV/sexually transmitted infections, alcohol and drug use, tobacco, and contraception).Across 11 topics, unmet need averaged 28% and ranged as high as 60%; unmet need generally increased with AYA age. In multivariable analyses, ever having discussed confidentiality with a health care provider was associated with greater desire to discuss three of four salient topics, increased discussions (four of four topics), and reduced unmet need (two topics). Patient use of a clinical checklist/questionnaire at the last medical visit was associated with an increase in discussions (four topics) and reduced unmet need (four topics). Longer office visits were associated with an increase in discussions (three topics) and reduced unmet need (two topics). Older and minority youth had greater desire for discussions and unmet need.A considerable gap exists between young people's desire to discuss health topics with their health care providers and actual practice.

    View details for DOI 10.1016/j.jadohealth.2020.01.019

    View details for PubMedID 32169522

  • Marijuana and the Pediatric Population. Pediatrics Dharmapuri, S., Miller, K., Klein, J. D. 2020; 146 (2)


    Cannabinoids, the psychoactive compounds in marijuana, are one of the most commonly used substances in the United States. In this review, we summarize the impact of marijuana on child and adolescent health and discuss the implications of marijuana use for pediatric practice. We review the changing epidemiology of cannabis use and provide an update on medical use, routes of administration, synthetic marijuana and other novel products, the effect of cannabis on the developing brain, other health and social consequences of use, and issues related to marijuana legalization.

    View details for DOI 10.1542/peds.2019-2629

    View details for PubMedID 32661188

  • Promoting and supporting children's health and healthcare during COVID-19 - International Paediatric Association Position Statement. Archives of disease in childhood Klein, J. D., Koletzko, B., El-Shabrawi, M. H., Hadjipanayis, A., Thacker, N., Bhutta, Z. 2020; 105 (7): 620-624

    View details for DOI 10.1136/archdischild-2020-319370

    View details for PubMedID 32381517

  • Medical Cannabinoid Products in Children and Adolescents. Pediatrics in review Miller, K. K., Klein, J. D. 2020; 41 (5): 262-264

    View details for DOI 10.1542/pir.2019-0083

    View details for PubMedID 32358035

  • The Effects of Nicotine on Development. Pediatrics McGrath-Morrow, S. A., Gorzkowski, J., Groner, J. A., Rule, A. M., Wilson, K., Tanski, S. E., Collaco, J. M., Klein, J. D. 2020; 145 (3)


    Recently, there has been a significant increase in the use of noncombustible nicotine-containing products, including electronic cigarettes (e-cigarettes). Of increasing popularity are e-cigarettes that can deliver high doses of nicotine over short periods of time. These devices have led to a rise in nicotine addiction in adolescent users who were nonsmokers. Use of noncombustible nicotine products by pregnant mothers is also increasing and can expose the developing fetus to nicotine, a known teratogen. In addition, young children are frequently exposed to secondhand and thirdhand nicotine aerosols generated by e-cigarettes, with little understanding of the effects these exposures can have on health. With the advent of these new nicotine-delivery systems, many concerns have arisen regarding the short- and long-term health effects of nicotine on childhood health during all stages of development. Although health studies on nicotine exposure alone are limited, educating policy makers and health care providers on the potential health effects of noncombustible nicotine is needed because public acceptance of these products has become so widespread. Most studies evaluating the effects of nicotine on health have been undertaken in the context of smoke exposure. Nevertheless, in vitro and in vivo preclinical studies strongly indicate that nicotine exposure alone can adversely affect the nervous, respiratory, immune, and cardiovascular systems, particularly when exposure occurs during critical developmental periods. In this review, we have included both preclinical and clinical studies to identify age-related health effects of nicotine exposure alone, examining the mechanisms underlying these effects.

    View details for DOI 10.1542/peds.2019-1346

    View details for PubMedID 32047098

    View details for PubMedCentralID PMC7049940

  • The age of paediatrics. The Lancet. Child & adolescent health Sawyer, S. M., McNeil, R., Francis, K. L., Matskarofski, J. Z., Patton, G. C., Bhutta, Z. A., Esangbedo, D. O., Klein, J. D. 2019; 3 (11): 822-830


    The epidemiological transition towards non-communicable diseases is characterised by an upward shift in age of disease burden across the lifecourse. One response, within a suite of wider actions, would be to extend the upper age limit of paediatric practice to embrace adolescent health. We did an online survey to explore the upper age limit of paediatric care, obtaining responses from 1372 paediatricians in 115 countries. Marked variation in the upper age limit was apparent. Among high-income countries, a higher upper age limit was associated with greater disease burden in adolescents relative to young children (<5 years). Although paediatricians reported the mean upper age limit of paediatrics had risen over the past 20 years, the mean preferred age of 18·7 (SD 2·6) years was higher than the mean current age of 17·4 (SD 2·5) years (p<0·0001). Paediatricians reported the main reasons for the rising age over time was their greater awareness of adolescent health and leadership by professional associations. Reports of the quality of adolescent health education within national paediatric training suggest that this education is largely inadequate. A greater focus on adolescent health is required within paediatrics to ensure that the future paediatric workforce is appropriately equipped to respond to the changing disease burden across childhood and adolescence.

    View details for DOI 10.1016/S2352-4642(19)30266-4

    View details for PubMedID 31542355

  • Characteristics of Daily E-Cigarette Use and Acquisition Means Among a National Sample of Adolescents. American journal of health promotion : AJHP Merianos, A. L., Jandarov, R. A., Klein, J. D., Mahabee-Gittens, E. M. 2019; 33 (8): 1115-1122


    To examine the relationship between several e-cigarette-related characteristics and daily e-cigarette use among adolescent current users.Secondary analysis of 2016 National Youth Tobacco Survey data.United States middle schools and high schools.One thousand five hundred seventy-nine current e-cigarette users.Daily e-cigarette use and e-cigarette flavors, brands, device type, and acquisition were measured.Logistic regression and Poisson regression models were built.A total of 13.6% of current users reported daily use. Results indicated that daily users were at increased odds of using all flavor types (all P < .001), with the exception of menthol/mint, and using a higher number of flavors than nondaily users (P < .001). Daily users were more likely to use Blu, eGo, Logic, Halo, NJOY, and another unlisted brand but less likely to report they did not know the brand used (all P ≤ .01). Daily users also reported using a higher number of brands than nondaily users (P < .001). Daily users were at increased odds of using marijuana/tetrahydrocannabinol (THC) oil wax as device ingredients (P < .001) and less likely to use only nicotine (P < .001) or unknown ingredients (P = .004). Daily users were more likely to acquire e-cigarettes from a vape shop, gas station/convenience store, Internet, mall/shopping center kiosk, drug store, grocery store, or other place (all P ≤ .01).Comprehensive efforts are needed to reduce e-cigarette use and nicotine addiction among adolescents.

    View details for DOI 10.1177/0890117119854051

    View details for PubMedID 31159556

    View details for PubMedCentralID PMC6824948

  • NCDs and the WHO Essential Medicines Lists: children need universal health coverage too. The Lancet. Child & adolescent health Gray, N. J., Chanoine, J. P., Farmer, M. Y., Jarvis, J. D., Armstrong, K., Barr, R. D., Faunce, T. A., Lashley, P. M., Ndikumwenayo, F., Hauerslev, M., Karekezi, C. W., Klein, J. D. 2019; 3 (11): 756-757

    View details for DOI 10.1016/S2352-4642(19)30294-9

    View details for PubMedID 31537467

  • Treating Parents for Tobacco Use in the Pediatric Setting: The Clinical Effort Against Secondhand Smoke Exposure Cluster Randomized Clinical Trial. JAMA pediatrics Nabi-Burza, E., Drehmer, J. E., Hipple Walters, B., Rigotti, N. A., Ossip, D. J., Levy, D. E., Klein, J. D., Regan, S., Gorzkowski, J. A., Winickoff, J. P. 2019; 173 (10): 931-939


    Despite the availability of free and effective treatment, few pediatric practices identify and treat parental tobacco use.To determine if the Clinical Effort Against Secondhand Smoke Exposure (CEASE) intervention can be implemented and sustained in pediatric practices and test whether implementing CEASE led to changes in practice-level prevalence of smoking among parents over 2 years.This cluster randomized clinical trial was conducted from April 2015 to October 2017. Ten pediatric practices in 5 states were randomized to either implement the CEASE protocol or maintain usual care (as a control group). All parents who screened positive for tobacco use by exit survey after their child's clinical visit 2 weeks (from April to October 2015) and 2 years after intervention implementation (April to October 2017) were eligible to participate. Data analysis occurred from January 2018 to March 2019.The CEASE intervention is a practice-change intervention designed to facilitate both routine screening in pediatric settings of families for tobacco use and delivery of tobacco cessation treatment to individuals in screened households who use tobacco.The primary outcome was delivery of meaningful tobacco treatment, defined as the prescription of nicotine replacement therapy or quit line enrollment. Furthermore, changes in practice-level smoking prevalence and cotinine-confirmed quit rates over the 2 years of intervention implementation were assessed.Of the 8184 parents screened after their child's visit 2 weeks after intervention implementation, 961 (27.1%) were identified as currently smoking in intervention practices; 1103 parents (23.9%) were currently smoking in control practices. Among the 822 and 701 eligible parents who completed the survey in intervention and control practices, respectively 364 in the intervention practices (44.3%) vs 1 in a control practice (0.1%) received meaningful treatment at that visit (risk difference, 44.0% [95% CI, 9.8%-84.8%]). Two years later, of the 9794 parents screened, 1261 (24.4%) in intervention practices and 1149 (25.0%) in control practices were identified as currently smoking. Among the 804 and 727 eligible parents completing the survey in intervention and control practices, respectively, 113 in the intervention practices (14.1%) vs 2 in the control practices (0.3%) received meaningful treatment at that visit (risk difference, 12.8% [95% CI, 3.3%-37.8%]). Change in smoking prevalence over the 2 years of intervention implementation favored the intervention (-2.7% vs 1.1%; difference -3.7% [95% CI, -6.3% to -1.2%]), as did the cotinine-confirmed quit rate (2.4% vs -3.2%; difference, 5.5% [95% CI, 1.4%-9.6%]).In this trial, integrating screening and treatment for parental tobacco use in pediatric practices showed both immediate and long-term increases in treatment delivery, a decline in practice-level parental smoking prevalence, and an increase in cotinine-confirmed cessation, compared with usual identifier: NCT01882348.

    View details for DOI 10.1001/jamapediatrics.2019.2639

    View details for PubMedID 31403675

    View details for PubMedCentralID PMC6692696

  • E-Cigarette Use and Future Cigarette Initiation Among Never Smokers and Relapse Among Former Smokers in the PATH Study. Public health reports (Washington, D.C. : 1974) McMillen, R., Klein, J. D., Wilson, K., Winickoff, J. P., Tanski, S. 2019; 134 (5): 528-536


    Any potential harm-reduction benefit of electronic cigarettes (e-cigarettes) could be offset by nonsmokers who initiate e-cigarette use and then smoke combustible cigarettes. We examined correlates of e-cigarette use at baseline with combustible cigarette smoking at 1-year follow-up among adult distant former combustible cigarette smokers (ie, quit smoking ≥5 years ago) and never smokers.The Population Assessment of Tobacco and Health Study, a nationally representative, longitudinal study, surveyed 26 446 US adults during 2 waves: 2013-2014 (baseline) and 2014-2015 (1-year follow-up). Participants completed an audio computer-assisted interview in English or Spanish. We compared combustible cigarette smoking at 1-year follow-up by e-cigarette use at baseline among distant former combustible cigarette smokers and never smokers.Distant former combustible cigarette smokers who reported e-cigarette past 30-day use (9.3%) and ever use (6.7%) were significantly more likely than those who had never used e-cigarettes (1.3%) to have relapsed to current combustible cigarette smoking at follow-up (P < .001). Never smokers who reported e-cigarette past 30-day use (25.6%) and ever use (13.9%) were significantly more likely than those who had never used e-cigarettes (2.1%) to have initiated combustible cigarette smoking (P < .001). Adults who reported past 30-day e-cigarette use (7.0%) and ever e-cigarette use (1.7%) were more likely than those who had never used e-cigarettes (0.3%) to have transitioned from never smokers to current combustible cigarette smokers (P < .001). E-cigarette use predicted combustible cigarette smoking in multivariable analyses controlling for covariates.Policies and counseling should consider the increased risk for nonsmokers of future combustible cigarette smoking use as a result of using e-cigarettes and any potential harm-reduction benefits e-cigarettes might bring to current combustible cigarette smokers.

    View details for DOI 10.1177/0033354919864369

    View details for PubMedID 31419184

    View details for PubMedCentralID PMC6852065

  • Public Support for Smoke-Free Section 8 Public Housing. Western journal of nursing research McMillen, R. C., Winickoff, J. P., Gottlieb, M. A., Tanski, S., Wilson, K., Klein, J. D. 2019; 41 (8): 1170-1183


    The U.S. Department of Housing and Urban Development (HUD) recently issued rules requiring that federally funded authorities administering public housing must have smoke-free policies. Importantly, this requirement does not extend to Section 8 housing. Under the Section 8 program, public housing vouchers provide subsidies for private rental housing to low-income residents. This study examines support for smoke-free policy options in Section 8 housing. Using a nationally representative survey of adults, we asked 3,070 respondents to agree or disagree with two potential policies. The majority (71%) supported prohibiting indoor smoking everywhere inside buildings that have Section 8 housing units. Alternatively, respondents were less supportive (38%) of a policy to prohibit smoking only inside units with Section 8 subsidies, and allowing smoking in nonsubsidized units. Prohibiting smoking in all units in multiunit housing (MUH) buildings would help protect the health of both the 2.2 million households who receive Section 8 subsidies and their neighbors.

    View details for DOI 10.1177/0193945919826238

    View details for PubMedID 30741120

  • Parental Smoking and E-cigarette Use in Homes and Cars. Pediatrics Drehmer, J. E., Nabi-Burza, E., Hipple Walters, B., Ossip, D. J., Levy, D. E., Rigotti, N. A., Klein, J. D., Winickoff, J. P. 2019; 143 (4)


    To determine how smoke-free and vape-free home and car policies differ for parents who are dual users of cigarettes and electronic cigarettes (e-cigarettes), who only smoke cigarettes, or who only use e-cigarettes. To identify factors associated with not having smoke-free or vape-free policies and how often smoke-free advice is offered at pediatric offices.Secondary analysis of 2017 parental interview data collected after their children's visit in 5 control practices participating in the Clinical Effort Against Secondhand Smoke Exposure trial.Most dual users had smoke-free home policies, yet fewer had a vape-free home policies (63.8% vs 26.3%; P < .01). Dual users were less likely than cigarette users to have smoke-free car (P < .01), vape-free home (P < .001), or vape-free car (P < .001) policies. Inside cars, dual users were more likely than cigarette users to report smoking (P < .001), e-cigarette use (P < .001), and e-cigarette use with children present (P < .001). Parental characteristics associated with not having smoke-free or vape-free home and car policies include smoking ≥10 cigarettes per day, using e-cigarettes, and having a youngest child >10 years old. Smoke-free home and car advice was infrequently delivered.Parents may perceive e-cigarette aerosol as safe for children. Dual users more often had smoke-free policies than vape-free policies for the home. Dual users were less likely than cigarette-only smokers to report various child-protective measures inside homes and cars. These findings reveal important opportunities for intervention with parents about smoking and vaping in homes and cars.

    View details for DOI 10.1542/peds.2018-3249

    View details for PubMedID 30858346

    View details for PubMedCentralID PMC6564069

  • Confidentiality Discussions and Private Time With a Health-Care Provider for Youth, United States, 2016. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Grilo, S. A., Catallozzi, M., Santelli, J. S., Yan, H., Song, X., Heitel, J., Kaseeska, K., Gorzkowski, J., Dereix, A. E., Klein, J. D. 2019; 64 (3): 311-318


    The objective of the study was to define factors associated with adolescent and young adult (AYA) experiences with private time and having discussed confidentiality and the impact of these experiences on improving delivery of clinical preventive services.In 2016, a nationally representative sample of 1,918 US AYAs (13- to 26-year-olds) was surveyed. Survey questionnaire domains were based on prior research and Fishers' information-motivation-behavior skills conceptual model. Data were weighted to represent US households with AYA and analyzed to identify factors independently associated with ever experiencing private time and discussions of confidentiality with a regular health-care provider (HCP). We examined the association of these experiences on AYA attitudes about health care.Fifty-five percent of female and 49% of male AYA reported ever having had private time with an HCP and 55% of female and 44% of male AYA had spoken to an HCP about confidentiality. Independent predictors of having experienced private time and confidentiality included older age, race, higher household income, gender of the provider, amount of years with the provider, and involvement in risk behaviors. AYA who had experienced private time and confidentiality discussions had more positive attitudes about their providers, were more willing and comfortable discussing sensitive topics, and thought that these discussions should happen at younger ages.Although confidentiality and private time are important to AYA, many are not experiencing these components of care. Providing private time and discussions of confidentiality can improve the delivery of health care for young people by enhancing positive youth attitudes about preventive care.

    View details for DOI 10.1016/j.jadohealth.2018.10.301

    View details for PubMedID 30638752

  • Discussion of Potentially Sensitive Topics With Young People. Pediatrics Santelli, J. S., Klein, J. D., Song, X., Heitel, J., Grilo, S., Wang, M., Yan, H., Kaseeska, K., Gorzkowski, J., Schneider, M., Dereix, A. E., Catallozzi, M. 2019; 143 (2)


    To identify modifiable factors that facilitate discussion of potentially sensitive topics between health care providers and young people at preventive service visits after Patient Protection and Affordable Care Act implementation.We used data from a national internet survey of adolescents and young adults (13-26 years old) in the United States. Questionnaire construction was guided by formative research and Fisher's Information-Motivation-Behavioral Skills model. Those who had seen a regular health care provider in the past 2 years were asked about 11 specific topics recommended by national medical guidelines. Four multivariable regression models were used to identify independent predictors of discussions of (1) tobacco use, (2) drug and/or alcohol use, (3) sexually transmitted infections or HIV, and (4) the number of topics discussed.Fewer than half of young people reported having discussed 10 of 11 topics at their last visit. Predictors were similar across all 4 models. Factors independently associated with health discussions included the following: ever talked with a provider about confidentiality (4/4 models; adjusted odds ratio [aOR] = 1.85-2.00), ever had private time with a provider (1 model; aOR = 1.50), use of health checklist and/or screening questionnaire at last visit (4 models; aOR = 1.78-1.96), and time spent with provider during last visit (4 models). Number of years that young men had seen their regular provider was significant in 1 model. Other independent factors were positive youth attitudes about discussing specific topics (3/3 models) and youth involvement in specific health risk behaviors (3/3 models).Discussions about potentially sensitive topics between health care providers and young people are associated with modifiable factors of health care delivery, particularly provider explanations of confidentiality, use of screening and/or trigger questionnaires, and amount of time spent with their provider.

    View details for DOI 10.1542/peds.2018-1403

    View details for PubMedID 30651304

  • Parent and Adolescent Attitudes Towards Preventive Care and Confidentiality. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Song, X., Klein, J. D., Yan, H., Catallozzi, M., Wang, X., Heitel, J., Kaseeska, K., Gorzkowski, J., Santelli, J. S. 2019; 64 (2): 235-241


    Little is known about whether parents and adolescents agree in their attitudes towards preventive care, private time, and confidentiality for adolescent care.We surveyed a nationally representative sample of 1,209 13-18 year-old U.S. adolescents and their parents. Parent and adolescents attitudes towards preventive services, private time, and confidentiality were compared. Parent-youth dyad agreement was measured using Cohen's kappa and Spearman coefficients and modeled for association with demographic variables.Parents are more likely than adolescents to think preventive services are important (71% vs. 48%; p < .001). Parent-youth attitudes were weakly to moderately correlated (Cohen's kappa coefficient = .22; p < .001). Parents and adolescents report similar ages for when teens should start having private time (median 16 years for both) and many think this age should be at 18, the legal age of adulthood). Fewer than half believe confidentiality should be provided for 10 services, ranging from routine care to abortion care (parents range: 12.8%-52.3%; adolescents: 24.0%-58.8%). While most adolescents agreed with their parents, teens were more likely to report wanting confidential access than parents. Older age, Hispanic ethnicity, having divorced parents and higher family income were associated with both adolescent/parent and adolescent endorsement of confidentiality.Adolescents and parents generally agree about the importance of preventive services, private time, confidentiality, and what should and should not be confidential. On average, parents value clinical preventive services more than youth, and youth value confidentiality more than parents. Both believe private time should start at ages older than those recommended in clinical guidelines.

    View details for DOI 10.1016/j.jadohealth.2018.08.015

    View details for PubMedID 30396723

  • Smoke Exposure, Cytokine Levels, and Asthma Visits in Children Hospitalized for Bronchiolitis. Hospital pediatrics Willis, A. L., Moss, A., Torok, M., Lowary, M., Klein, J. D., Wilson, K. M. 2019; 9 (1): 46-50


    To determine if cigarette smoke exposure, marijuana smoke exposure, or cytokine levels at admission to the hospital for bronchiolitis are associated with follow-up visits for asthma.We enrolled a cohort of children aged 31 days to 2 years who were hospitalized with bronchiolitis from January 2013 to April 2014. Data included the results of a baseline survey about children's health and demographics, nasal wash samples, the results of a 6-month postdischarge follow-up survey, and a chart review. Nasal wash samples were tested for interleukin (IL)-6, IL-13, and tumor necrosis factor α (TNF-α); values were categorized for analysis. χ2, Fisher's exact, and Wilcoxon rank tests were done to test bivariable differences; all analyses were done using SAS.We approached 180 families for enrollment; 99 consented to participate, and 74% of these completed follow-up surveys. Half of those with high levels of IL-13 had follow-up visits for asthma, whereas only 4.2% of those with low levels had follow-up visits for asthma (P = .02). Marijuana exposure was reported for 12.5% (n = 7) of study participants. There was a significant association between marijuana exposure and TNF-α levels (P = .03).Our study revealed an association between IL-13 and follow-up visits for asthma in children who were hospitalized with bronchiolitis. We found an association between family-reported marijuana smoke exposure and detectable but lower levels of TNF-α. Further research is needed to study these relationships.

    View details for DOI 10.1542/hpeds.2018-0067

    View details for PubMedID 30530718

  • Protecting Youth From the Risks of Electronic Cigarettes. The Journal of adolescent health : official publication of the Society for Adolescent Medicine 2019


    The rapid increase in e-cigarette use among adolescents and young adults has led to drastic changes in patterns of nicotine consumption worldwide. The use of e-cigarettes, many of which contain high levels of nicotine, is especially harmful in this age group and is associated with increased use of cigarettes and other substances among youth. While the risks of short- and long-term e-cigarette use and secondhand aerosol exposure remain only partially understood, e-cigarettes should not be recommended for smoking cessation for youth in any circumstances given the lack of evidence for effectiveness and potential harmful physical and mental health effects. The perceptions of low e-cigarette risk of adolescents and young adults combined with few market regulations and the appeal of youth-friendly flavors, have created ideal conditions for the e-cigarette industry to thrive and place millions of youth at risk of developing an addiction to nicotine. Policies and regulations aiming to prevent youth-directed marketing and sales of e-cigarette and all nicotine delivery products are needed to protect young people. Public health-led education campaigns and educational curricula are also needed to help inform youth and families about the risks of e-cigarette use. While more research is required to determine the best ways to help youth quit e-cigarette use, adolescent health providers can play a key role in screening and counseling youth about e-cigarette use and should be adequately trained and supported to care for youth with e-cigarette addiction.

    View details for DOI 10.1016/j.jadohealth.2019.10.007

    View details for PubMedID 31780385

  • Perceptions of Parental Tobacco Dependence Treatment Among a Children's Hospital Staff. Hospital pediatrics Torok, M. R., Lowary, M., Ziniel, S. I., Rohde, J., Kerby, G. S., Hovell, M. F., Winickoff, J. P., Klein, J. D., Wilson, K. 2018; 8 (11): 724-728


    To assess employee support for and knowledge of smoking cessation programs for patients' parents and staff and employees' level of comfort discussing smoking with patients and their families before and during a hospital-wide study of a tobacco cessation and/or exposure reduction program for inpatients' parents who smoke.Clinical staff were invited to complete online surveys at the beginning of and 19 months into a randomized controlled trial to test the efficacy of an inpatient tobacco cessation and exposure reduction program for parents of hospitalized children. The program included educating pediatric inpatient clinical staff about available resources, such as the Colorado QuitLine, and smoking cessation interventions for the parents of hospitalized children. Clinical staff were recruited via e-mail listservs, a weekly e-mail newsletter, and posted flyers. Baseline and midstudy results were compared, and χ2 tests were performed.At the baseline, 192 clinical staff responded; 235 responded midstudy. At the baseline and midstudy, at least 90% of the respondents believed that the hospital should support parents in quitting smoking, although the support for free nicotine replacement therapy was low (27% at the baseline to 35% at midstudy). One-fifth of the respondents were uncomfortable discussing smoking; this proportion decreased after educational interventions. Knowledge about hospital cessation resources had also increased at midstudy.There was strong support for helping parents and staff quit smoking. Comfort among clinical staff in addressing tobacco dependence in patients and families and awareness of cessation resources increased over the course of the study.

    View details for DOI 10.1542/hpeds.2018-0009

    View details for PubMedID 30377220

    View details for PubMedCentralID PMC6207095

  • Assessing pediatric tobacco exposure using parent report: comparison with hair nicotine. Journal of exposure science & environmental epidemiology Groner, J. A., Rule, A. M., McGrath-Morrow, S. A., Collaco, J. M., Moss, A., Tanski, S. E., McMillen, R., Whitmore, R. M., Klein, J. D., Winickoff, J. P., Wilson, K. 2018; 28 (6): 530-537


    The purpose of this study was to examine the relationships between screening questions for secondhand smoke (SHS) exposure and biomarker results using hair nicotine levels. Our ultimate goal was to develop sensitive and valid screening tools in pediatric clinical settings for SHS exposure.Investigators developed a core set of questions regarding exposure. Data from two separate ongoing studies of well children and those with bronchopulmonary dysplasia (BPD) were used to assess the concordance between responses and hair nicotine levels. Sensitivity, a positive predictive value, and accuracy were examined.There was no single question with similar sensitivity in both populations. The question with the highest positive predictive value (90.8% well-cohort and 84.6% BPD cohort) for both the groups was whether the child had been exposed to in-home smoking in the last 7 days. The question with the highest accuracy for both groups was the number of smokers at home (0 vs ≥ 1), with an accuracy of 72.4% for well children and 79.0% for the BPD cohort.There was a wide variability in the performance of specific questions. These data demonstrate that a "one-size-fits-all" approach to screening for secondhand tobacco smoke exposure may not be appropriate for all pediatric populations.

    View details for DOI 10.1038/s41370-018-0051-z

    View details for PubMedID 30013229

  • Screening Tools for Who Will Start Smoking and the Future of Clinical Prediction. Pediatrics Klein, J. D. 2018; 142 (5)

    View details for DOI 10.1542/peds.2018-2298

    View details for PubMedID 30275238

  • Adolescent Use of Different E-cigarette Products. Pediatrics McMillen, R., Tanski, S., Wilson, K., Klein, J. D., Winickoff, J. P. 2018; 142 (4)


    : media-1vid110.1542/5804914521001PEDS-VA_2018-0260Video Abstract BACKGROUND: Little is known about the characteristics of electronic cigarettes (e-cigarettes) used by adolescents. Understanding the product landscape of adolescent e-cigarette use may inform counseling and policy strategies.Results are from 13 651 adolescents in wave 1 and 12 172 adolescents in wave 2 of the Population Assessment of Tobacco and Health Study, a nationally representative longitudinal study. Past 30-day regular e-cigarettes users were asked about the characteristics of the e-cigarette they used most of the time.In waves 1 and 2, 2.1% and 2.8% of adolescents were regular users in the past 30 days, respectively. These adolescents more often used rechargeable rather than disposable devices (wave 1: 76.0%; wave 2: 82.9%) and refillable rather than nonrefillable devices (wave 1: 66.6%; wave 2: 84.4%) and tended not to use cartridge systems (wave 1: 33.7%; wave 2: 30.5%). Most adolescent past 30-day users (wave 1: 87.5%; wave 2: 89.4%) reported using flavored e-cigarettes. An increased frequency of use was associated with the use of rechargeable (wave 1 adjusted odds ratio [aOR]: 2.7; wave 2 aOR: 2.7) and refillable e-cigarettes (wave 1 aOR: 2.0; wave 2 aOR: 2.7; P < .05). Most users in wave 1 did not continue regular use in wave 2 (70.2%). Among those who continued to use and had reported using closed systems (nonrechargeable and/or nonrefillable) in wave 1, most had progressed to open systems (rechargeable and refillable) in wave 2.Most adolescents use open-system e-cigarettes, and frequent users are even more likely to use open-system e-cigarettes. The majority of regular users use rechargeable devices that are refillable. A change in product preferences across waves suggests a starter product phenomenon, with a graduation to products that have weaker quality controls and may increase health risks.

    View details for DOI 10.1542/peds.2018-0260

    View details for PubMedID 30201626

  • Adolescent electric cigarette use is associated with subsequent marijuana use. The Journal of pediatrics Klein, J. 2018; 200: 291-294

    View details for DOI 10.1016/j.jpeds.2018.07.015

    View details for PubMedID 30144923

  • E-Cigarette Advice to Patients From Physicians and Dentists in the United States. American journal of health promotion : AJHP Drouin, O., McMillen, R. C., Klein, J. D., Winickoff, J. P. 2018; 32 (5): 1228-1233


    To report on adults' recall of discussion by physicians and dentists about e-cigarettes.A nationally representative cross-sectional survey (Internet and random digit dialing) in the United States.Adults who ever used e-cigarettes.Participant-reported discussion about the potential benefits and harms of e-cigarettes with their doctor, dentist, or child's doctor in the past 12 months.Fisher exact test for the analysis between benefits and harms for each type of provider and for rates of advice between provider types.Among the 3030 adults who completed the survey, 523 (17.2%) had ever used e-cigarettes. Of those who had seen their doctor, dentist, or child's doctor in the last year, 7.3%, 1.7%, and 10.1%, respectively, reported discussing potential harms of e-cigarettes. Conversely, 5.8%, 1.7%, and 9.3% of patients who had seen their doctor, dentist, or child's doctor in the last year reported that the clinician discussed the potential benefits of e-cigarettes. Each clinician type was as likely to discuss harms as benefits. Rates of advice were similar between doctors and child's doctors but lower for dentists. Rates were comparable when the analysis was limited to current e-cigarette users, participants with children, or those who reported using both e-cigarettes and combusted tobacco.Few physicians and dentists discuss either the harms or benefits of e-cigarettes with their patients. These data suggest an opportunity to educate, train, and provide resources for physicians and dentists about e-cigarettes and their use.

    View details for DOI 10.1177/0890117117710876

    View details for PubMedID 28558492

  • Adult Attitudes and Practices Regarding Smoking Restrictions and Child Tobacco Smoke Exposure: 2000 to 2015. Pediatrics McMillen, R., Wilson, K., Tanski, S., Klein, J. D., Winickoff, J. P. 2018; 141 (Suppl 1): S21-S29


    Since 2000, tobacco control efforts have greatly increased state and local protections from childhood tobacco smoke exposure. The objective of this study is to examine changes in attitudes and practices regarding smoking bans in multiple public and private settings from 2000 to 2015, as well as to examine the changes in pediatrician and family practitioner screening and counseling for tobacco smoke exposure.Cross-sectional data from the annual Social Climate Survey of Tobacco Control were analyzed.The majority of adults, 69.3%, reported household smoking restrictions in 2000, and these restrictions increased to 79.5% through 2015 (P < .05). Car smoking prohibitions increased from 68.3% to 81.8% (P < .05). A growing majority of adults supports smoke-free policies in public settings, and tobacco counseling by child health care providers also increased. However, members of 1 in 5 households still permit smoking inside the home and family vehicle, and half of the US population is not protected by state or local laws prohibiting smoking inside of hospitality venues.Despite dramatic progress since 2000, these trend data reveal potential areas where child health care clinicians might focus effort at the family and community level to accelerate the protection of children from tobacco smoke exposure.

    View details for DOI 10.1542/peds.2017-1026F

    View details for PubMedID 29292303

  • E-Cigarettes: A 1-Way Street to Traditional Smoking and Nicotine Addiction for Youth. Pediatrics Klein, J. D. 2018; 141 (1)

    View details for DOI 10.1542/peds.2017-2850

    View details for PubMedID 29203522

  • The Role of Secondhand Smoke Research in Protecting Nonsmokers. Pediatrics Gorzkowski, J. A., Klein, J. D. 2018; 141 (Suppl 1): S6-S9

    View details for DOI 10.1542/peds.2017-1026D

    View details for PubMedID 29292301

  • Tobacco-Smoke Incursions and Satisfaction Among Residents With Children in Multiunit Housing, United States, 2013. Public health reports (Washington, D.C. : 1974) Wilson, K. M., Torok, M. R., McMillen, R. C., Klein, J. D., Levy, D. E., Winickoff, J. P. 2017; 132 (6): 637-645


    Residents of multiunit housing can be exposed to tobacco smoke even if they do not permit smoking in their homes. Although even low levels of tobacco smoke exposure can cause health problems for children and adults, some landlords are reluctant to ban smoking for fear of decreased occupancy rates or tenant satisfaction. The objective of this study was to assess the impact of tobacco smoke-free policies and tobacco-smoke incursions on housing satisfaction in multiunit housing residences with children.In 2013, 3696 randomly sampled US adult multiunit housing dwellers were invited to participate in a survey, and 3253 (88%) participated. Of these, 3128 responded to the question about having a child in the home, and 835 (27%) reported having a child in the home. We collected data on demographic characteristics, tobacco-smoke incursions, knowledge and attitudes about smoking policies, and housing satisfaction for this sample of 835 residents.Of the 827 residents who responded to the question, 755 (91.3%) agreed that tenants have a right to live in a tobacco smoke-free building. Although 672 of 835 (80.5%) residents were not cigarette smokers, most lived where smoking was permitted in the units (n = 463, 56.9%) or on the property (n = 571, 70.5%). Of 580 non-cigarette smoking residents who lived where no one had smoked cigarettes in the home for the past 3 months, 144 (25.2%) reported a recent tobacco-smoke incursion. Of these 144 residents, 143 (99%) were bothered. Few (36/143, 25.2%) complained to the landlord. Reasons for not complaining were reluctance to upset neighbors or concern about retaliation. Tobacco-smoke incursions and housing/landlord satisfaction were inversely related ( P < .05).Multiunit housing residents living with children in the United States strongly support smoke-free multiunit housing.

    View details for DOI 10.1177/0033354917732767

    View details for PubMedID 28977766

    View details for PubMedCentralID PMC5692161

  • Changes and Factors Associated With Tobacco Counseling: Results From the AAP Periodic Survey. Academic pediatrics McMillen, R., O'Connor, K. G., Groner, J., Tanski, S., Park, E. R., Klein, J. D. 2017; 17 (5): 504-514


    The American Academy of Pediatrics (AAP) advises pediatricians to counsel parents and patients who use tobacco to quit. This study assesses changes in counseling between 2004 and 2010, and factors associated with counseling in 2010.In 2004 and 2010, the Periodic Survey, a national survey of AAP members, inquired about tobacco counseling. Chi-square tests were performed to compare responses by survey year. Bivariate and multivariable analyses examined factors associated with counseling.Similar proportions of pediatricians in both years (N2004 = 535 and N2010 = 549) advised adolescents who smoke to quit (85% vs 81%), discussed quitting techniques (34% vs 32%), and recommended nicotine replacement medications (17% vs 18%). More pediatricians in 2010 reported helping patients assess reasons for and against continuing to smoke (56% vs 48%), providing quitting materials (20% vs 15%), and referring patients to cessation programs (18% vs 13%). More pediatricians in 2010 reported providing quitting materials to parents who smoke (14% vs 10%) and referring to smoking cessation programs (16% vs 11%) (all P < .05). Pediatricians' confidence in their ability to counsel, with more tobacco prevention training, and routine documentation of patients' tobacco smoke exposure were associated with counseling about cessation.Most pediatricians advised patients and parents who smoke to quit, and these percentages did not change from 2004 to 2010. Although percentages for assisting with cessation did increase for several activities, most pediatricians still do not do so. Opportunities exist to improve clinicians' protection of children from tobacco and tobacco smoke through quit-line referrals, motivational interviewing, and offering medications.

    View details for DOI 10.1016/j.acap.2017.01.002

    View details for PubMedID 28104489

  • Delivering an action agenda for nutrition interventions addressing adolescent girls and young women: priorities for implementation and research. Annals of the New York Academy of Sciences Bhutta, Z. A., Lassi, Z. S., Bergeron, G., Koletzko, B., Salam, R., Diaz, A., McLean, M., Black, R. E., De-Regil, L. M., Christian, P., Prentice, A. M., Klein, J. D., Keenan, W., Hanson, M. 2017; 1393 (1): 61-71


    Adolescent nutritional behaviors are assuming considerable importance in nutrition interventions given their important relationships with medium- and long-term outcomes. This is the period when young people undergo major anatomical and physiological maturational changes in preparation for adulthood. Nutritional requirements during puberty are higher during adolescence than during the prepubertal stage and during adulthood. A significant proportion of adolescents also become parents, and hence the importance of their health and nutritional status before as well as during pregnancy has its impact on their own health, fetal well-being, and newborn health. In this paper, we describe the evidence-based nutrition recommendations and the current global guidance for nutrition actions for adolescents. Despite the limitations of available information, we believe that a range of interventions are feasible to address outcomes in this age group, although some would need to start earlier in childhood. We propose packages of preventive care and management comprising nutrition-specific and nutrition-sensitive interventions to address adolescent undernutrition, overnutrition, and micronutrient deficiencies. We discuss potential delivery platforms and strategies relevant to low- and middle-income countries. Beyond the evidence synthesis, there is a clear need to translate evidence into policy and for implementation of key recommendations and addressing knowledge gaps through prioritized research.

    View details for DOI 10.1111/nyas.13352

    View details for PubMedID 28436103

  • Tobacco Use Disorders. Child and adolescent psychiatric clinics of North America Camenga, D. R., Klein, J. D. 2016; 25 (3): 445-60


    Tobacco use is a pervasive public health problem and the leading cause of preventable morbidity and mortality in the United States. This article reviews the epidemiology of tobacco use in youth, with a description of cigarettes, alternative tobacco product, and polytobacco use patterns among the general population and among adolescents with psychiatric and/or substance use disorders. The article also provides an update on the diagnosis and assessment of tobacco use disorder in adolescents, with a particular focus on the clinical management of tobacco use in adolescents with co-occurring disorders.

    View details for DOI 10.1016/j.chc.2016.02.003

    View details for PubMedID 27338966

    View details for PubMedCentralID PMC4920978

  • Pediatrician Knowledge, Attitudes, and Practice Related to Electronic Cigarettes. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Gorzkowski, J. A., Whitmore, R. M., Kaseeska, K. R., Brishke, J. K., Klein, J. D. 2016; 59 (1): 81-6


    Electronic cigarettes (e-cigarettes) have grown rapidly in popularity, creating concerns for pediatricians and families. Evaluating pediatricians' understanding of e-cigarettes is an important first step in effectively addressing these products in practice. This qualitative study assesses pediatricians' knowledge, attitudes, and current clinical practices related to e-cigarettes.We conducted six focus groups with 37 pediatric clinicians in 2014. Groups were led by a trained facilitator using a semistructured discussion guide. Responses were recorded, transcribed, and coded to identify relevant themes.Pediatricians know that e-cigarettes generally contain nicotine and that adolescents and young adults are most likely to use them. However, most feel uninformed about the health effects of e-cigarettes and report wanting scientific evidence for safety or harm from credible sources. Pediatricians are skeptical of claims that e-cigarettes are safe, either for users or for those exposed to second-hand e-cigarette vapor or emissions. Participants noted that clinical conversations about e-cigarettes were rare, citing barriers including a lack of systematic screening, competing priorities during clinical visits, and, for some, limited confidence in their ability to address e-cigarettes during clinical encounters. No participants recommended e-cigarettes for cessation.Pediatricians feel poorly informed about e-cigarettes and are concerned about their potential health effects. While clinical discussions about e-cigarettes are rare, recent increases in their use leaves many clinicians wanting guidance about what to say to patients and families.

    View details for DOI 10.1016/j.jadohealth.2016.03.036

    View details for PubMedID 27338665

  • Combining Global Elimination Of Measles And Rubella With Strengthening Of Health Systems In Developing Countries. Health affairs (Project Hope) Andrus, J. K., Cochi, S. L., Cooper, L. Z., Klein, J. D. 2016; 35 (2): 327-33


    Global efforts to eliminate measles and rubella can be combined with other actions to accelerate the strengthening of health systems in developing countries. However, there are several challenges standing in the way of successfully combining measles and rubella vaccination campaigns with health systems strengthening. Those challenges include the following: achieving universal vaccine coverage while integrating the initiative with other primary care strategies and developing the necessary health system resilience to confront emergencies, ensuring epidemiological and laboratory surveillance of vaccine-preventable diseases, developing the human resources needed to effectively manage and implement national strategies, increasing community demand for health services, and obtaining long-term political support. We describe lessons learned from the successful elimination of measles and rubella in the Americas and elsewhere that strive to strengthen national health systems to both improve vaccine uptake and confront emerging threats. The elimination of measles and rubella provides opportunities for nations to strengthen health systems and thus to both reduce inequities and ensure national health security.

    View details for DOI 10.1377/hlthaff.2015.1005

    View details for PubMedID 26858388

  • Electronic Cigarettes Are Another Route to Nicotine Addiction for Youth. JAMA pediatrics Klein, J. D. 2015; 169 (11): 993-4

    View details for DOI 10.1001/jamapediatrics.2015.1929

    View details for PubMedID 26349006

  • Trends in Electronic Cigarette Use Among U.S. Adults: Use is Increasing in Both Smokers and Nonsmokers. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco McMillen, R. C., Gottlieb, M. A., Shaefer, R. M., Winickoff, J. P., Klein, J. D. 2015; 17 (10): 1195-202


    We assessed trends in use of electronic cigarettes among U.S. adults, demographic predictors of use, and smoking status of current electronic cigarette users.Mixed-mode surveys were used to obtain representative, cross-sectional samples of U.S. adults in each of 4 years.Sample sizes for 2010, 2011, 2012, and 2013 were 3,240, 3,097, 3,101, and 3,245, respectively. Ever use of electronic cigarettes increased from 1.8% (2010) to 13.0% (2013), while current use increased from 0.3% to 6.8%, p < .001. Prevalence of use increased significantly across all demographic groups. In 2013, current use among young adults 18-24 (14.2%) was higher than adults 25-44 (8.6%), 45-64 (5.5%), and 65+ (1.2%). Daily smokers (30.3%) and nondaily smokers (34.1%) were the most likely to currently use e-cigarettes, compared to former smokers (5.4%) and never-smokers (1.4%), p < .001. However, 32.5% of current electronic cigarette users are never- or former smokers.There has been rapid growth in ever and current electronic cigarette use over the past 4 years. Use is highest among young adults and current cigarette smokers. Although smokers are most likely to use these products, almost a third of current users are nonsmokers, suggesting that e-cigarettes contribute to primary nicotine addiction and to renormalization of tobacco use. Regulatory action is needed at the federal, state, and local levels to ensure that these products do not contribute to preventable chronic disease.

    View details for DOI 10.1093/ntr/ntu213

    View details for PubMedID 25381306

  • Adult Behavior in Male Mice Exposed to E-Cigarette Nicotine Vapors during Late Prenatal and Early Postnatal Life. PloS one Smith, D., Aherrera, A., Lopez, A., Neptune, E., Winickoff, J. P., Klein, J. D., Chen, G., Lazarus, P., Collaco, J. M., McGrath-Morrow, S. A. 2015; 10 (9): e0137953


    Timed-pregnant C57BL/6J mice were exposed to 2.4% nicotine in propylene glycol (PG) or 0% nicotine /PG once a day from gestational day 15 until delivery. After delivery, offspring and mothers were exposed to E-cigarette vapors for an additional 14 days from postnatal day 2 through 16. Following their last exposure serum cotinine levels were measured in female juvenile mice. Male mice underwent behavioral testing at 14 weeks of age to assess sensorimotor, affective, and cognitive functional domains.Adult male mice exposed to 2.4% nicotine/PG E-cigarette vapors had significantly more head dips in the zero maze test and higher levels of rearing activity in the open field test compared to 0% nicotine/PG exposed mice and untreated controls. In the water maze test after reversal training, the 2.4% nicotine/PG mice spent more than 25% of time in the new location whereas the other groups did not.Adult male mice exhibited increased levels of activity in the zero maze and open field tests when exposed to E-cigarette vapor containing nicotine during late prenatal and early postnatal life. These findings indicate that nicotine exposure from E-cigarettes may cause persistent behavioral changes when exposure occurs during a period of rapid brain growth.

    View details for DOI 10.1371/journal.pone.0137953

    View details for PubMedID 26372012

    View details for PubMedCentralID PMC4570802

  • Black versus white differences in rates of addressing parental tobacco use in the pediatric setting. Academic pediatrics Dempsey, J., Regan, S., Drehmer, J. E., Finch, S., Hipple, B., Klein, J. D., Murphy, S., Nabi-Burza, E., Ossip, D., Woo, H., Winickoff, J. P. 2015; 15 (1): 47-53


    To examine racial differences in rates of screening parents for cigarette smoking during pediatric outpatient visits and to determine if a parental tobacco control intervention mitigates racial variation in whether cigarette smoking is addressed.As part of the Clinical Effort Against Secondhand Smoke Exposure (CEASE) randomized controlled trial, exit interviews were conducted with parents at 10 control and 10 intervention pediatric practices nationally. Parents were asked to report if during the visit did anyone ask if they smoke cigarettes. A generalized linear mixed model was used to estimate the effect of black vs white race on asking parents about cigarette smoking.Among 17,692 parents screened at the exit interview, the proportion of black parents who were current smokers (16%) was lower than the proportion of white parents who smoked (20%) (P < .001). In control group practices, black parents were more likely to be asked (adjusted risk ratio 1.23; 95% confidence interval 1.08, 1.40) about cigarette smoking by pediatricians than whites. In intervention group practices both black and white parents were more likely to be asked about smoking than those in control practices and there was no significant difference between black and white parents in the likelihood of being asked (adjusted risk ratio 1.01; 95% confidence interval 0.93, 1.09).Although a smaller proportion of black parents in control practices smoked than white, black parents were more likely to be asked by pediatricians about smoking. The CEASE intervention was associated with higher levels of screening for smoking for both black and white parents.

    View details for DOI 10.1016/j.acap.2014.06.018

    View details for PubMedID 25528125

    View details for PubMedCentralID PMC4273106

  • Higher cost, but poorer outcomes: the US health disadvantage and implications for pediatrics. Pediatrics Fairbrother, G., Guttmann, A., Klein, J. D., Simpson, L. A., Thomas, P., Kempe, A. 2015; 135 (6): 961-4

    View details for DOI 10.1542/peds.2014-3298

    View details for PubMedID 25941300

  • State-of-the-art office-based interventions to eliminate youth tobacco use: the past decade. Pediatrics Pbert, L., Farber, H., Horn, K., Lando, H. A., Muramoto, M., O'Loughlin, J., Tanski, S., Wellman, R. J., Winickoff, J. P., Klein, J. D. 2015; 135 (4): 734-47


    Tobacco use and tobacco smoke exposure are among the most important preventable causes of premature disease, disability, and death and therefore constitute a major pediatric health concern. The pediatric primary care setting offers excellent opportunities to prevent tobacco use in youth and to deliver cessation-related treatment to youth and parents who use tobacco. This report updates a "state-of-the-art" article published a decade ago on office-based interventions to address these issues. Since then there has been marked progress in understanding the nature, onset, and trajectories of tobacco use and nicotine addiction in youth with implications for clinical practice. In addition, clinicians need to remain abreast of emerging nicotine delivery systems, such as electronic cigarettes, that may influence uptake or continuation of smoking. Although evidence-based practice guidelines for treating nicotine addiction in youth are not yet available, research continues to build the evidence base toward that goal. In the interim, practical guidelines are available to assist clinicians in addressing nicotine addiction in the pediatric clinical setting. This article reports current practices in addressing tobacco in pediatric primary care settings. It reviews our increasing understanding of youth nicotine addiction, summarizes research efforts on intervention in the past decade and additional research needed going forward, and provides practical guidelines for pediatric health care providers to integrate tobacco use prevention and treatment into their clinical practice. Pediatric providers can and should play an important role in addressing tobacco use and dependence, both in the youth they care for and in parents who use tobacco.

    View details for DOI 10.1542/peds.2014-2037

    View details for PubMedID 25780075

  • Hair nicotine levels in children with bronchopulmonary dysplasia. Pediatrics Collaco, J. M., Aherrera, A. D., Breysse, P. N., Winickoff, J. P., Klein, J. D., McGrath-Morrow, S. A. 2015; 135 (3): e678-86


    Tobacco smoke exposure (TSE) may increase respiratory morbidities in young children with bronchopulmonary dysplasia (BPD). Rapid respiratory rates, close proximity to a smoking caregiver, and increased dermal absorption of tobacco smoke components can contribute to systemic exposure. In this study, hair nicotine levels were used as a biomarker of chronic TSE in young children with BPD to determine if hair nicotine levels correlate with caregiver self-report of TSE and respiratory morbidities.From 2012 to 2014, hair nicotine levels were measured from consecutive children seen in a BPD outpatient clinic and compared with caregiver questionnaires on household smoking. The relationship between respiratory morbidities and self-reported TSE or hair nicotine level was assessed.The mean hair nicotine level from 117 children was 3.1 ± 13.2 ng/mg. Hair nicotine levels were significantly higher in children from smoking households by caregiver self-report compared with caregivers who reported no smoking (8.2 ± 19.7 ng/mg vs 1.8 ± 10.7; P < .001). In households that reported smoking, hair nicotine levels were higher in children with a primary caregiver who smoked compared with a primary caregiver who did not smoke. Among children with BPD who required respiratory support (n = 50), a significant association was found between higher log hair nicotine levels and increased hospitalizations and limitation of activity.Chronic TSE is common in children with BPD, with hair nicotine levels being more likely to detect TSE than caregiver self-report. Hair nicotine levels were also a better predictor of hospitalization and activity limitation in children with BPD who required respiratory support at outpatient presentation.

    View details for DOI 10.1542/peds.2014-2501

    View details for PubMedID 25647675

    View details for PubMedCentralID PMC4533246

  • The effects of electronic cigarette emissions on systemic cotinine levels, weight and postnatal lung growth in neonatal mice. PloS one McGrath-Morrow, S. A., Hayashi, M., Aherrera, A., Lopez, A., Malinina, A., Collaco, J. M., Neptune, E., Klein, J. D., Winickoff, J. P., Breysse, P., Lazarus, P., Chen, G. 2015; 10 (2): e0118344


    Electronic cigarette (E-cigarettes) emissions present a potentially new hazard to neonates through inhalation, dermal and oral contact. Exposure to nicotine containing E-cigarettes may cause significant systemic absorption in neonates due to the potential for multi-route exposure. Systemic absorption of nicotine and constituents of E-cigarette emissions may adversely impact weight and lung development in the neonate. To address these questions we exposed neonatal mice to E-cigarette emissions and measured systemic cotinine levels and alveolar lung growth.Neonatal mice were exposed to E-cigarettes for the first 10 days of life. E-cigarette cartridges contained either 1.8% nicotine in propylene glycol (PG) or PG vehicle alone. Daily weights, plasma and urine cotinine levels and lung growth using the alveolar mean linear intercept (MLI) method were measured at 10 days of life and compared to room air controls. Mice exposed to 1.8% nicotine/PG had a 13.3% decrease in total body weight compared to room air controls. Plasma cotinine levels were found to be elevated in neonatal mice exposed to 1.8% nicotine/PG E-cigarettes (mean 62.34± 3.3 ng/ml). After adjusting for sex and weight, the nicotine exposed mice were found to have modestly impaired lung growth by MLI compared to room air control mice (p<.054 trial 1; p<.006 trial 2). These studies indicate that exposure to E-cigarette emissions during the neonatal period can adversely impact weight gain. In addition exposure to nicotine containing E-cigarettes can cause detectable levels of systemic cotinine, diminished alveolar cell proliferation and a modest impairment in postnatal lung growth.

    View details for DOI 10.1371/journal.pone.0118344

    View details for PubMedID 25706869

    View details for PubMedCentralID PMC4338219

  • A new commitment to newborn survival. Pediatrics Niermeyer, S., Tobin, A., Schoen, E., Carter, T., Klein, J. D. 2015; 135 (2): 211-2

    View details for DOI 10.1542/peds.2014-3185

    View details for PubMedID 25560443

  • Sustainability of a parental tobacco control intervention in pediatric practice. Pediatrics Winickoff, J. P., Nabi-Burza, E., Chang, Y., Regan, S., Drehmer, J., Finch, S., Wasserman, R., Ossip, D., Hipple, B., Woo, H., Klein, J., Rigotti, N. A. 2014; 134 (5): 933-41


    To determine whether an evidence-based pediatric outpatient intervention for parents who smoke persisted after initial implementation.A cluster randomized controlled trial of 20 pediatric practices in 16 states that received either Clinical and Community Effort Against Secondhand Smoke Exposure (CEASE) intervention or usual care. The intervention provided practices with training to provide evidence-based assistance to parents who smoke. The primary outcome, assessed by the 12-month follow-up telephone survey with parents, was provision of meaningful tobacco control assistance, defined as discussing various strategies to quit smoking, discussing smoking cessation medication, or recommending the use of the state quitline after initial enrollment visit. We also assessed parental quit rates at 12 months, determined by self-report and biochemical verification.Practices' rates of providing any meaningful tobacco control assistance (55% vs 19%), discussing various strategies to quit smoking (25% vs 10%), discussing cessation medication (41% vs 11%), and recommending the use of the quitline (37% vs 9%) were all significantly higher in the intervention than in the control groups, respectively (P < .0001 for each), during the 12-month postintervention implementation. Receiving any assistance was associated with a cotinine-confirmed quitting adjusted odds ratio of 1.89 (95% confidence interval: 1.13-3.19). After controlling for demographic and behavioral factors, the adjusted odds ratio for cotinine-confirmed quitting in intervention versus control practices was 1.07 (95% confidence interval: 0.64-1.78).Intervention practices had higher rates of delivering tobacco control assistance than usual care practices over the 1-year follow-up period. Parents who received any assistance were more likely to quit smoking; however, parents' likelihood of quitting smoking was not statistically different between the intervention and control groups. Maximizing parental quit rates will require more complete systems-level integration and adjunctive cessation strategies.

    View details for DOI 10.1542/peds.2014-0639

    View details for PubMedID 25332492

    View details for PubMedCentralID PMC4210792

  • Maintenance of Certification Part 4 Credit and recruitment for practice-based research. Pediatrics Gorzkowski, J. A., Klein, J. D., Harris, D. L., Kaseeska, K. R., Whitmore Shaefer, R. M., Bocian, A. B., Davis, J. B., Gotlieb, E. M., Wasserman, R. C. 2014; 134 (4): 747-53


    Competing priorities in pediatric practice have created challenges for practice-based research. To increase recruitment success, researchers must design studies that provide added value to participants. This study evaluates recruitment of pediatricians into a study, before and after the development and addition of a quality improvement (QI) curriculum approved for American Board of Pediatrics Maintenance of Certification (MOC) Part 4 Credit as an enrollment incentive.Researchers implemented multiple outreach methods to enroll pediatric practices over 28 months. Field note review revealed that many physicians declined enrollment, stating that they prioritized MOC Part 4 projects over research studies. A QI curriculum meeting standards for MOC Part 4 Credit was developed and added to the study protocol as an enrollment incentive. Enrollment rates and characteristics of practitioners enrolled pre- and post-MOC were compared.Pre-MOC enrollment contributed 48% of practices in 22 months; post-MOC enrollment contributed 49% of practices in 6 months. An average of 3.5 practices enrolled per month pre-MOC, compared with 13.1 per month post-MOC (P < .001). Clinicians in pre- and post-MOC groups were similar in age, gender, race, and time spent on patient care; practices enrolled post-MOC were more likely to be located in federally designated Medically Underserved Areas than those enrolled pre-MOC (28.6% vs 12%, P = .03).Addition of MOC Part 4 Credit increased recruitment success and increased enrollment of pediatricians working in underserved areas. Including QI initiatives meeting MOC Part 4 criteria in practice-based research protocols may enhance participation and aid in recruiting diverse practice and patient populations.

    View details for DOI 10.1542/peds.2014-0316

    View details for PubMedID 25180282

    View details for PubMedCentralID PMC4179094

  • Delivering tobacco control interventions in adolescent health care visits: time for action. Pediatrics Klein, J. D. 2014; 134 (3): 600-1

    View details for DOI 10.1542/peds.2014-1925

    View details for PubMedID 25136047

  • Tobacco smoke incursions in multiunit housing. American journal of public health Wilson, K. M., Torok, M., McMillen, R., Tanski, S., Klein, J. D., Winickoff, J. P. 2014; 104 (8): 1445-53


    We sought to describe the prevalence of secondhand tobacco smoke incursions reported by multiunit housing (MUH) residents, pinpoint factors associated with exposure, and determine whether smoke-free building policy was associated with prevalence of reported tobacco smoke incursions.Data are from a 2011 nationally representative dual-frame survey (random-digit-dial and Internet panels) of US adults aged 18 years and older. Individuals who lived in MUH and who reported no smoking in their homes for the past 3 months, whether or not they reported being smokers themselves, were included in this study. Incursions were defined as smelling tobacco smoke in their building or unit.Of 562 respondents, 29.5% reported smoke incursions in their buildings. Of these, 16% reported incursions in their own unit, 36.2% of which occurred at least weekly. Government-subsidized housing and partial smoke-free policies were associated with a higher likelihood of reporting smoke incursions.Many residents of multiunit housing are exposed to tobacco smoke in their units and buildings. Partial smoke-free policies do not appear to protect residents and might increase the likelihood of incursions in residents' individual units.

    View details for DOI 10.2105/AJPH.2014.301878

    View details for PubMedID 24922124

    View details for PubMedCentralID PMC4103233

  • Strict smoke-free home policies among smoking parents in pediatric settings. Academic pediatrics Ossip, D. J., Chang, Y., Nabi-Burza, E., Drehmer, J., Finch, S., Hipple, B., Rigotti, N. A., Klein, J. D., Winickoff, J. P. 2013; 13 (6): 517-23


    To examine strict smoke-free home policies among smoking parents assessed in pediatric offices.We analyzed baseline parental survey data from 10 control practices in a national trial of pediatric office-based tobacco control interventions (Clinical Effort Against Secondhand Smoke Exposure, CEASE). We used logistic regression models with generalized estimating equations to examine factors associated with strict smoke-free home policies.Subjects were 952 parents who were current smokers. Just over half (54.3%) reported strict smoke-free home policies. Few reported being asked (19.9%) or advised (17.1%) regarding policies by pediatricians. Factors associated with higher odds of policies were child 5 years or younger (adjusted odds ratio [aOR] 2.43, 95% confidence interval [CI] 1.53, 3.86), nonblack race/ethnicity (aORs 2.17-2.60, 95% CIs 1.25-5.00), non-Medicaid (HMO/private (aOR 1.84, 95% CI 1.31, 2.58); self-pay/other aOR 1.76, 95% CI 1.12, 2.78); well-child versus sick child visit (aOR 1.61, 95% CI 1.11, 2.34), fewer than 10 cigarettes per day (aOR 1.80, 95% CI 1.31, 2.47), no other home smokers (aOR 1.68, 95% CI 1.26, 2.25), only father smoking (aOR 1.73, 95% CI 1.06, 2.83), and strict smoke-free car policy (aOR 3.51, 95% CI 2.19, 5.64).Nearly half of smoking parents did not have strict smoke-free home policies. Parents were less likely to report policies if they were heavier smokers, black, living with other smokers, or attending a sick child visit; if they did not have a young child or smoke-free car policy; if they had a child on Medicaid; and if anyone other than only the father smoked. Few pediatricians addressed or recommended strict smoke-free home policies in an office visit. The pediatric office encounter represents a currently missed opportunity to intervene regarding smoke-free homes, particularly for high-risk groups.

    View details for DOI 10.1016/j.acap.2013.06.003

    View details for PubMedID 24238677

    View details for PubMedCentralID PMC4046861

  • Admission screening for secondhand tobacco smoke exposure. Hospital pediatrics Wilson, K. M., Wesgate, S. C., Best, D., Blumkin, A. K., Klein, J. D. 2012; 2 (1): 26-33


    Secondhand smoke (SHS) exposure is an important and preventable cause of mortality and morbidity among children; hospitalization represents a sentinel event that may offer opportunities for intervention. The goal of this study was to determine the frequency and validity of SHS exposure screenings by emergency department (ED) providers, residents, and nurses.A total of 140 inpatient pediatric families consented to a salivary cotinine measurement, in-person SHS exposure interview, and chart review to assess ED provider, pediatric resident, and nurse SHS exposure screenings and documentation validity.ED providers documented screening for SHS exposure 46% of the time, pediatric residents 42% of the time, and nurses 79% of the time. ED providers, pediatric residents, and nurses reported 18%, 38%, and 12% of patients exposed to SHS, respectively, whereas 46% of patients were identified as smoke-exposed according to cotinine level and/or parent report. Those with SHS exposure outside the home were least likely to be identified as exposed.The majority of smoke-exposed children were not identified as exposed based on documentation of admission screenings. Future research is important to identify accurate and efficient methods of screening for and identifying SHS exposure among children admitted to the hospital.

    View details for DOI 10.1542/hpeds.2011-0005

    View details for PubMedID 24319810

  • Community participatory research with deaf sign language users to identify health inequities. American journal of public health Barnett, S., Klein, J. D., Pollard, R. Q., Samar, V., Schlehofer, D., Starr, M., Sutter, E., Yang, H., Pearson, T. A. 2011; 101 (12): 2235-8


    Deaf people who use American Sign Language (ASL) are medically underserved and often excluded from health research and surveillance. We used a community participatory approach to develop and administer an ASL-accessible health survey. We identified deaf community strengths (e.g., a low prevalence of current smokers) and 3 glaring health inequities: obesity, partner violence, and suicide. This collaborative work represents the first time a deaf community has used its own data to identify health priorities.

    View details for DOI 10.2105/AJPH.2011.300247

    View details for PubMedID 22021296

    View details for PubMedCentralID PMC3222424

  • Fish consumption and prenatal methylmercury exposure: cognitive and behavioral outcomes in the main cohort at 17 years from the Seychelles child development study. Neurotoxicology Davidson, P. W., Cory-Slechta, D. A., Thurston, S. W., Huang, L. S., Shamlaye, C. F., Gunzler, D., Watson, G., van Wijngaarden, E., Zareba, G., Klein, J. D., Clarkson, T. W., Strain, J. J., Myers, G. J. 2011; 32 (6): 711-7


    People worldwide depend upon daily fish consumption as a major source of protein and other nutrients. Fish are high in nutrients essential for normal brain development, but they also contain methylmercury (MeHg), a neurotoxicant. Our studies in a population consuming fish daily have indicated no consistent pattern of adverse associations between prenatal MeHg and children's development. For some endpoints we found performance improved with increasing prenatal exposure to MeHg. Follow up studies indicate this association is related to the beneficial nutrients present in fish.To determine if the absence of adverse outcomes and the presence of beneficial associations between prenatal MeHg and developmental outcomes previously reported persists into adolescence.This study was conducted on the Main Cohort of the Seychelles Child Development Study (SCDS). We examined the association between prenatal MeHg exposure and subjects' performance at 17 years of age on 27 endpoints. The test battery included the Wisconsin Card Sorting Test (WCST), the California Verbal Learning Test (CVLT), the Woodcock-Johnson (W-J-II) Achievement Test, subtests of the Cambridge Neuropsychological Test Automated Battery (CANTAB), and measures of problematic behaviors. Analyses for all endpoints were adjusted for postnatal MeHg, sex, socioeconomic status, maternal IQ, and child's age at testing and the child's IQ was added for problematic behavioral endpoints.Mean prenatal MeHg exposure was 6.9 ppm. There was no association between prenatal MeHg and 21 endpoints. Increasing prenatal MeHg was associated with better scores on four endpoints (higher W-J-II math calculation scores, reduced numbers of trials on the Intra-Extradimensional Shift Set of the CANTAB), fewer reports of substance use and incidents of and referrals for problematic behaviors in school. Increasing prenatal MeHg was adversely associated with one level of referrals to a school counselor.At age 17 years there was no consistent pattern of adverse associations present between prenatal MeHg exposure and detailed domain specific neurocognitive and behavioral testing. There continues to be evidence of improved performance on some endpoints as prenatal MeHg exposure increases in the range studied, a finding that appears to reflect the role of beneficial nutrients present in fish as demonstrated previously in younger subjects. These findings suggest that ocean fish consumption during pregnancy is important for the health and development of children and that the benefits are long lasting.

    View details for DOI 10.1016/j.neuro.2011.08.003

    View details for PubMedID 21889535

    View details for PubMedCentralID PMC3208775

  • Micronutrient levels in children exposed to secondhand tobacco smoke. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco Wilson, K. M., Finkelstein, J. N., Blumkin, A. K., Best, D., Klein, J. D. 2011; 13 (9): 800-8


    Antioxidant micronutrients are the body's primary defense against the oxidative stress of secondhand smoke (SHS). Micronutrient levels have been associated with lung function; decreased levels of vitamin C and β-carotene have been associated with SHS exposure in children. We sought to determine the association between SHS exposure and micronutrient levels in children.Data from the 2003-2004 National Health and Nutrition Examination Survey (NHANES) were analyzed. Serum cotinine levels were categorized into no (<0.015 ng/mL), moderate (0.015 to <2.0 ng/mL), and high (2.0-15.0 ng/mL) smoke exposure; t-tests determined associations between exposure and levels of micronutrients. Significant bivariate associations were tested further using linear regression.In all, 2,218 children, aged 6-18 years, were included (response rate of 82%); 17% had no, 76% moderate, and 7% high exposure. Children with no exposure had higher levels of vitamin A, C, and E, cis- and trans-β-carotene, and folate, while levels of vitamins B(6), B(12), and D did not differ. In regression analysis, higher cotinine levels were negatively associated with levels of vitamin C (β = -.03; p < .01), cis-β-carotene (β = -.04; p < .01), trans-β-carotene (β = -.7; p < .01), folate (β = -.5; p < .001) and vitamin A (β = -.6; p < .01).Children exposed to SHS have lower levels of antioxidants controlling for dietary and supplement intake. This antioxidant depletion may increase systemic inflammation and sensitivity to other oxidant stresses. Parents should be counseled on these specific risks from SHS exposure for their children, and the importance of smoking cessation and eliminating children's exposure to tobacco smoke.

    View details for DOI 10.1093/ntr/ntr076

    View details for PubMedID 21558135

  • US Attitudes About Banning Menthol in Cigarettes: Results From a Nationally Representative Survey AMERICAN JOURNAL OF PUBLIC HEALTH Winickoff, J. P., McMillen, R. C., Vallone, D. M., Pearson, J. L., Tanski, S. E., Dempsey, J. H., Healton, C., Klein, J. D., Abrams, D. 2011; 101 (7): 1234-1236


    Menthol is a cigarette flavoring that makes smoking more appealing to smokers. The US Food and Drug Administration (FDA) has regulatory authority to ban mentholated cigarettes to reduce youth uptake and encourage adult cessation. Survey findings indicate that more than half of all Americans (56.1%) and of Blacks alone (68.0% in one sample and 75.8% in another) support banning menthol. Endorsement of a ban-especially by Blacks, who have the highest rates of menthol cigarette use-would support FDA action to ban menthol to protect the public's health.

    View details for DOI 10.2105/AJPH.2011.300146

    View details for Web of Science ID 000291514100021

    View details for PubMedID 21566038

    View details for PubMedCentralID PMC3110223

  • Restrictive anorexia nervosa and set-shifting in adolescents: a biobehavioral interface. The Journal of adolescent health : official publication of the Society for Adolescent Medicine McAnarney, E. R., Zarcone, J., Singh, P., Michels, J., Welsh, S., Litteer, T., Wang, H., Klein, J. D. 2011; 49 (1): 99-101


    Set-shifting is a neurocognitive concept defined as the ability to switch tasks flexibly. Set-shifting scores are worse in adults with restrictive anorexia nervosa (AN-R) than in controls. Adolescence is a developmental period when young people must respond flexibly to new situations. The purpose of this study was to compare the set-shifting scores of 24 adolescent females with AN-R with 37 matched normal adolescent controls (ages, 14-20).Methods used for the study included sociodemographic, psychological, and biological data, and neurocognitive testing using the Behavior Rating of Executive Function - Self- and Parent-Reports, the Cambridge Neuropsychological Automated Battery, and the Wisconsin Card-Sorting Test. Statistical analyses included t-tests, multiple analysis of variance, and correlations.Sociodemographic data and intelligence quotient of study and control subjects were similar. There were differences in body mass index and the Eating Disorder Inventory-3 evaluation. Significant differences in the composite score of set-shifting between the study and control groups were found using multiple analysis of variance.Adolescent females with AN-R had significantly worse set-shifting scores than the control subjects. Future studies of adolescent AN-R subjects should include biological (functional magnetic resonance imaging) and neurocognitive measures to determine the mechanisms at the brain-behavioral interface so that treatment can be directed specifically to set-shifting deficits.

    View details for DOI 10.1016/j.jadohealth.2010.11.259

    View details for PubMedID 21700167

    View details for PubMedCentralID PMC3286875

  • Tobacco-smoke exposure in children who live in multiunit housing. Pediatrics Wilson, K. M., Klein, J. D., Blumkin, A. K., Gottlieb, M., Winickoff, J. P. 2011; 127 (1): 85-92


    There is no safe level of secondhand tobacco-smoke exposure, and no previous studies have explored multiunit housing as a potential contributor to secondhand tobacco-smoke exposure in children. We hypothesized that children who live in apartments have higher cotinine levels than those who live in detached homes, when controlling for demographics.We analyzed data from the 2001-2006 National Health and Nutrition Examination Survey. The housing types we included in our study were detached houses (including mobile homes), attached houses, and apartments. Our study subjects were children between the ages of 6 and 18 years. Cotinine levels were used to assess secondhand tobacco-smoke exposure, and those living with someone who smoked inside the home were excluded. χ(2) tests, t tests, and Tobit regression models were used in Stata. Sample weights accounted for the complex survey design.Of 5002 children in our study, 73% were exposed to secondhand tobacco smoke. Children living in apartments had an increase in cotinine of 45% over those living in detached houses. This increase was 212% (P < .01) for white residents and 46% (P < .03) for black residents, but there was no significant increase for those of other races/ethnicities. At every cutoff level of cotinine, children in apartments had higher rates of exposure. The exposure effect of housing type was most pronounced at lower levels of cotinine.Most children without known secondhand tobacco-smoke exposure inside the home still showed evidence of tobacco-smoke exposure. Children in apartments had higher mean cotinine levels than children in detached houses. Potential causes for this result could be seepage through walls or shared ventilation systems. Smoking bans in multiunit housing may reduce children's exposure to tobacco smoke.

    View details for DOI 10.1542/peds.2010-2046

    View details for PubMedID 21149434

  • How are restrictive abortion statutes associated with unintended teen birth? The Journal of adolescent health : official publication of the Society for Adolescent Medicine Coles, M. S., Makino, K. K., Stanwood, N. L., Dozier, A., Klein, J. D. 2010; 47 (2): 160-7


    Legislation that restricts abortion access decreases abortion. It is less well understood whether these statutes affect unintended birth. Given recent increases in teen pregnancy and birth, we examined the relationship between legislation that restricts abortion access and unintended births among adolescent women.Using 2000-2005 Pregnancy Risk Assessment Monitoring System data, we examined the relationship between adolescent pregnancy intention and policies affecting abortion access: mandatory waiting periods, parental involvement laws, and Medicaid funding restrictions. Logistic regression controlled for individual characteristics, state-level factors, geographic regions, and time trends. Subgroup analyses were done for racial, ethnic, and insurance groups.In our multivariate model, minors in states with mandatory waiting periods were more than two times as likely to report an unintended birth, with even higher risk among blacks, Hispanics, and teens receiving Medicaid. Medicaid funding restrictions were associated with higher rates of unwanted birth among black teens. Parental involvement laws were associated with a trend toward more unwanted births in white minors and fewer in Hispanic minors.Mandatory waiting periods are associated with higher rates of unintended birth in teens, and funding restrictions may especially affect black adolescents. Policies limiting access to abortion appear to affect the outcomes of unintended teen pregnancy. Subsequent research should clarify the magnitude of such effects, and lead to policy changes that successfully reduce unintended teen births.

    View details for DOI 10.1016/j.jadohealth.2010.01.003

    View details for PubMedID 20638008

  • Knowledge gaps and misconceptions about over-the-counter analgesics among adolescents attending a hospital-based clinic. Academic pediatrics Wilson, K. M., Singh, P., Blumkin, A. K., Dallas, L., Klein, J. D. 2010; 10 (4): 228-32


    Although many adolescents use over-the-counter (OTC) analgesics, their knowledge about these drugs is unclear. This study evaluates misconceptions and knowledge gaps about OTC side effects, risks, and interactions among adolescents attending a hospital-based clinic.Adolescents aged 14 to 20 years presenting to an outpatient clinic were surveyed using a computer-administered instrument. Participants answered questions regarding their use of specific OTC medications and knowledge of side effects, risks, and interactions of these drugs. A summary score of percent correct answers on knowledge questions was created, and univariate and multivariate statistical techniques examined differences between groups.Ninety-six adolescents completed the survey. Most (78%) adolescents had used OTC medications in the previous month. The most frequently reported OTC medications used were analgesics, including ibuprofen (46%), and Tylenol (45%); acetaminophen ingestion was reported by 15% of respondents. Although 35% reported knowing what acetaminophen is, 37% of these did not correctly identify acetaminophen and Tylenol as the same medication. The average overall knowledge score was 44%. In regression models including demographics, and OTC product use, older adolescents had higher overall average knowledge scores. Hispanic teens had less reported use and lower knowledge scores than adolescents of other race/ethnicities.Most adolescents use OTC analgesics, but many are confused about generic and brand name forms. There were also significant knowledge gaps about OTC use, side effects, and contraindications, especially for acetaminophen. Clinicians should be aware of the potential for OTC medication misuse by adolescent patients.

    View details for DOI 10.1016/j.acap.2010.04.002

    View details for PubMedID 20542751

  • Screening and counseling for childhood obesity: results from a national survey. Journal of the American Board of Family Medicine : JABFM Sesselberg, T. S., Klein, J. D., O'Connor, K. G., Johnson, M. S. 2010; 23 (3): 334-42


    To examine family physicians' beliefs and practices about using body mass index (BMI) percentiles to screen for childhood overweight and obesity.Surveys about management of childhood overweight were mailed to 1800 American Academy of Family Physician members in 2006.729 surveys were returned; 445 were eligible. Most (71%) members were familiar with BMI guidelines; 41% were familiar with American Academy of Family Physician recommendations about overweight. Most (78%) had tools available to calculate BMI; fewer have enough time for overweight screening (55%), and only 45% reported computing BMI percentile at most or every well visit for children older than 2. Having an electronic health record increased BMI screening rates. Family physicians felt prepared to discuss weight, but only 43% believed their counseling was effective and many (55%) lack community or referral services. Most (72%) wanted simple diet and exercise recommendations for patients. Reimbursement for weight-related services is insufficient: 86% say that patients cannot pay for services not covered by insurance. Factor analysis identified clinician self-efficacy, resources, and reimbursement as factors related to calculating BMI percentiles.BMI is underutilized by family physicians. Most believe they should try to prevent overweight and have tools to use BMI, but clinicians have few resources available for treatment, have low self-efficacy, and report inadequate reimbursement.

    View details for DOI 10.3122/jabfm.2010.03.090070

    View details for PubMedID 20453179

  • Childhood obesity: the new tobacco. Health affairs (Project Hope) Klein, J. D., Dietz, W. 2010; 29 (3): 388-92


    Overcoming the childhood obesity epidemic will require changes on the scale of a social movement similar to the shift in attitudes and regulations toward smoking and tobacco. Tobacco control became a successful public health movement because of shifts in social norms and because cigarette companies came to be perceived by many as a common enemy. In contrast, obesity advocates have not identified a common threat or mobilized grass-roots change, nor have they identified strategies that resonate across diverse settings and constituencies. Framing obesity as a common threat can lead to consensus regarding the interventions needed to achieve healthier children and communities.

    View details for DOI 10.1377/hlthaff.2009.0736

    View details for PubMedID 20194977

  • Adoption of body mass index guidelines for screening and counseling in pediatric practice. Pediatrics Klein, J. D., Sesselberg, T. S., Johnson, M. S., O'Connor, K. G., Cook, S., Coon, M., Homer, C., Krebs, N., Washington, R. 2010; 125 (2): 265-72


    The purpose of this study was to examine pediatrician implementation of BMI and provider interventions for childhood overweight prevention and treatment.Data were obtained from the American Academy of Pediatrics (AAP) Periodic Survey of Fellows No. 65, a nationally representative survey of AAP members. Surveys that addressed the provision of screening and management of childhood overweight and obesity in primary care settings were mailed to 1622 nonretired US AAP members in 2006.One thousand five (62%) surveys were returned; 677 primary care clinicians in active practice were eligible for the survey. Nearly all respondents (99%) reported measuring height and weight at well visits, and 97% visually assess children for overweight at most or every well-child visit. Half of the respondents (52%) assess BMI percentile for children older than 2 years. Most pediatricians reported that they do not have time to counsel on overweight and obesity, that counseling has poor results, and that having simple diet and exercise recommendations would be helpful in their practice. Pediatricians in large practices and those who had attended continuing medical education on obesity were more familiar with national expert guidelines, were more likely to use BMI percentile, and had higher self-efficacy in practices related to childhood and adolescent overweight and obesity. Multivariate analysis revealed that pediatricians with better access to community and adjunct resources were more likely to use BMI percentile.BMI-percentile screening in primary pediatric practice is underused. Most pediatricians believe that they can and should try to prevent overweight and obesity, yet few believe there are good treatments once a child is obese. Training, time, and resource limitations affect BMI-percentile use. Awareness of national guidelines may improve rates of BMI-percentile use and recognition of opportunities to prevent childhood and adolescent obesity.

    View details for DOI 10.1542/peds.2008-2985

    View details for PubMedID 20083518

    View details for PubMedCentralID PMC5354356

  • Exposure to tobacco on the internet: content analysis of adolescents' internet use. Pediatrics Jenssen, B. P., Klein, J. D., Salazar, L. F., Daluga, N. A., DiClemente, R. J. 2009; 124 (2): e180-6


    We performed a content analysis of all Web pages viewed by a random sample of adolescents to describe exposure to tobacco- and smoking-related text and images.Adolescents (14-17 years of age) with home Internet access were recruited. Internet-tracking software was installed on home computers used by 346 eligible consenting participants. All Web pages viewed by adolescent participants were captured during a 30-day period for each subject. Keywords on smoking and tobacco were used to identify tobacco images or text.The 346 participants viewed 1.2 million Web pages, of which 8702 (0.72%) contained tobacco or smoking content. Exposure to tobacco content did not vary according to smoking status. Content was protobacco on 1916 pages, antitobacco on 1572, and complex or unclear on 5055. Social networking sites, mainly MySpace, represented 53% of pages (n = 4612) on which tobacco content was found. All pages with smoking content contained references in text, and 256 (3%) contained images. Many (43%) of the adolescents were exposed to protobacco imagery (median: 3 pages per month). Cigarettes were mentioned on 20% of pages. Tobacco products were sold on 50 pages, and 242 pages contained links to tobacco products sold on other pages. On social networking sites, 4121 pages included a mention of smoking status in the authors' individual profiles, with 23% of authors identifying themselves as smokers.Many adolescents are consistently exposed to tobacco content on the Internet, but the volume of exposure is limited and not all content represents protobacco content.

    View details for DOI 10.1542/peds.2008-3838

    View details for PubMedID 19620193

    View details for PubMedCentralID PMC2818533

  • Managed Care Quality of Care and Plan Choice in New York SCHIP HEALTH SERVICES RESEARCH Liu, H., Phelps, C. E., Veazie, P. J., Dick, A. W., Klein, J. D., Shone, L. P., Noyes, K., Szilagyi, P. G. 2009; 44 (3): 843-861


    To examine whether low-income parents of children enrolled in the New York State Children's Health Insurance Program (SCHIP) choose managed care plans with better quality of care.2001 New York SCHIP evaluation data; 2001 New York State Managed Care Plan Performance Report; 2000 New York State Managed Care Enrollment Report.Each market was defined as a county. A final sample of 2,325 new enrollees was analyzed after excluding those in markets with only one SCHIP plan. Plan quality was measured using seven Consumer Assessment of Health Plans Survey (CAHPS) and three Health Plan Employer Data and Information Set (HEDIS) scores. A conditional logit model was applied with plan and individual/family characteristics as covariates.There were 30 plans in the 45 defined markets. The choice probability increased 2.5 percentage points for each unit increase in the average CAHPS score, and the association was significantly larger in children with special health care needs. However, HEDIS did not show any statistically significant association with plan choice.Low-income parents do choose managed care plans with higher CAHPS scores for their newly enrolled children, suggesting that overall quality could improve over time because of the dynamics of enrollment.

    View details for DOI 10.1111/j.1475-6773.2009.00946.x

    View details for Web of Science ID 000266111600006

    View details for PubMedID 19208091

    View details for PubMedCentralID PMC2699911

  • Improved health care among children with special health care needs after enrollment into the State Children's Health Insurance Program. Ambulatory pediatrics : the official journal of the Ambulatory Pediatric Association Szilagyi, P. G., Shone, L. P., Klein, J. D., Bajorska, A., Dick, A. W. 2007; 7 (1): 10-7


    To assess the impact of New York's State Children's Health Insurance Program (SCHIP) on health care for children with special health care needs (CSHCN).Little is known about the impact of health insurance on CSHCN. Parents of a stratified random sample of new enrollees onto New York's SCHIP were interviewed by telephone at enrollment (n = 2644) and 1 year later (n = 2290, 87% response). At baseline, the cohort of CSHCN was defined by means of the standardized CSHCN screener instrument. The impact of SCHIP was assessed for CSHCN and for subgroups of CSHCN stratified by prior insurance (uninsured or insured) or type of chronic condition (physical or mental/behavioral). Access (having a usual source of care [USC], unmet medical needs); and quality (continuity of care at the USC, parent rating of quality of care or worry about child) were measured. Bivariate and multivariate analyses compared measures 1 year before SCHIP versus the year during SCHIP.A total of 398 (17%) of 2290 children had special health care needs identified at baseline. Enrollment onto SCHIP was generally associated with improved access: unmet needs for prescription medications declined 3-fold for all subgroups (eg, 36% to 9% among the previously uninsured) and unmet needs for specialty care declined >4-fold among CSHCN who were previously insured (48% to 10%) or had mental/behavioral conditions (32% to 2%; all P < .05). Enrollment was associated with improved continuity with the USC, parent-reported quality of care, and worry, irrespective of prior insurance or type of chronic condition (P < .05).Enrollment onto New York's SCHIP improved medical care for CSHCN.

    View details for DOI 10.1016/j.ambp.2006.09.006

    View details for PubMedID 17261477

  • Internet surveys with adolescents: promising methods and methodologic challenges. Adolescent medicine: state of the art reviews Sutter, E., Klein, J. D. 2007; 18 (2): 293-304, x


    The use of Web-based surveys and methods has grown substantially in recent years. Internet surveys have the potential to produce data rapidly and efficiently, provide access to hard-to-reach populations, and reduce response biases. Although some methodologic questions require further exploration, Web-based survey methods can accurately represent many adolescent and young-adult populations and will be an increasingly relevant part of how we learn about the attitudes and behaviors of youth in our society. This article reviews current literature and some of the strengths and limitations of Web-based survey research with adolescent and young-adult populations.

    View details for PubMedID 18605647

  • Measuring quality of adolescent preventive services of health plan enrollees and school-based health center users. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Klein, J. D., Handwerker, L., Sesselberg, T. S., Sutter, E., Flanagan, E., Gawronski, B. 2007; 41 (2): 153-60


    To evaluate whether quality of care provided to adolescents enrolled in a community-based managed care plan was better for those who also received some care at school-based health centers (SBHCs).The Young Adult Health Care Survey (YAHCS) was administered to 374 adolescents (commercially insured, Medicaid-insured, and SBHC users) to assess risk behaviors, provision of preventive screening and counseling, and quality of care.SBHC users were most likely to report that their provider told them their discussions were confidential, and that they received screening/counseling on sexually transmitted diseases (STDs), HIV/AIDS, condom use, and birth control. Commercially insured adolescents were least likely to report discussion of sexual health issues. SBHC users had the highest mean YAHCS quality measure scores for screening/counseling on pregnancy/STDs, diet and exercise, and helpfulness of counseling provided; Medicaid-insured teens had the lowest scores on four of seven measures. Regression models controlled for demographics, use of screener, and site of care showed that use of a screener had a significant impact on six of seven quality measure models. Younger age predicted screening for risk behaviors; being female, African-American, and an SBHC user predicted screening on pregnancy/STDs.SBHCs may increase adolescents' access to confidential care, and SBHC providers may be more likely than those in other settings to screen and counsel patients about sexual health. Overall quality of preventive care reported by commercially insured adolescents may be better in some health content areas and worse in others compared with care reported by Medicaid-insured youth and SBHC users.

    View details for DOI 10.1016/j.jadohealth.2007.03.012

    View details for PubMedID 17659219

  • Self-reported smoking in online surveys: prevalence estimate validity and item format effects. Medical care Klein, J. D., Thomas, R. K., Sutter, E. J. 2007; 45 (7): 691-5


    We assessed validity of self-reported smoking prevalence estimates from an online sample, and explored the impact of different item response formats on estimates.Self-reported current smoking status was obtained from 110,837 respondents from the Harris Poll Online (HPOL) panel from April 2004 to January 2005. Current smoking prevalence was compared with national estimates from the 2004 Behavioral Risk Factor Surveillance System (BRFSS), 2003 National Health Interview Survey (NHIS), and 2001-2002 National Health and Nutrition Examination Survey (NHANES). All estimates were weighted to reflect the US population. A separate survey section measured smoking prevalence using randomly assigned response formats, including yes/no grid, multiple response, numeric box, category grid, and drop-down box formats.24.0% (95% confidence interval [CI] = 23.7-24.4) of HPOL respondents reported current smoking. BRFSS, NHIS, and NHANES estimates found 20.9%, 21.5% (95% CI = 20.9-22.1), and 24.9% (95% CI = 22.4-27.5), respectively, reporting current smoking. An additional 4.5% of NHANES respondents reporting not smoking had cotinine levels > or =15 ng/mL, indicating current smoking. Estimates of smoking prevalence varied by prevalence period and response format.Prevalence estimates obtained from the HPOL panel are comparable to those from national surveys. Online response format choices result in variation in estimated behavioral prevalence. Online surveys may be useful for public health surveillance of the US population.

    View details for DOI 10.1097/MLR.0b013e3180326145

    View details for PubMedID 17571019

  • History of childhood candy cigarette use is associated with tobacco smoking by adults. Preventive medicine Klein, J. D., Thomas, R. K., Sutter, E. J. 2007; 45 (1): 26-30


    We examined whether childhood candy cigarette use was associated with adult tobacco smoking.25,887 U.S. adults from the Harris Poll Online (HPOL) were surveyed about current smoking status from November 2005 to May 2006. Respondents were randomly assigned to a yes/no item or a dose-response scale to assess candy cigarette use. Data were weighted to reflect the U.S. adult population.26.4% of respondents reported current smoking and 29.4% reported former smoking. Candy cigarette use was reported by 88% of both current and former smokers and 78% of never smokers (p

    View details for DOI 10.1016/j.ypmed.2007.04.006

    View details for PubMedID 17532370

  • Impact of the State Children's Health Insurance Program on adolescents in New York. Pediatrics Klein, J. D., Shone, L. P., Szilagyi, P. G., Bajorska, A., Wilson, K., Dick, A. W. 2007; 119 (4): e885-92


    Adolescents face financial and nonfinancial barriers to health care. Little is known about the impact of health insurance on health care for adolescents. We assessed the impact of New York's State Children's Health Insurance Program on access, use, and quality of care for adolescents.Adolescents and their parents from a stratified random sample of new enrollees in New York's State Children's Health Insurance Program were interviewed by telephone shortly after enrollment (baseline, n = 1118 adolescents and their parents) and 1 year later (follow-up, n = 970). Outcome measures included access (having a usual source of care and reported unmet health needs), use (preventive care and other types of visits), and quality (satisfaction with care, receipt of confidential care and preventive counseling). Outcomes were assessed at baseline (year before the State Children's Health Insurance Program) versus follow-up (year during the State Children's Health Insurance Program).The proportion of adolescents who reported having a usual source of care increased during State Children's Health Insurance Program compared with before (69.9% to 87.1%). The proportion with any unmet health care need (54.3% to 42.1%) or with unmet need for preventive care (53.8% to 40.6%) decreased, with elimination of racial disparities that existed before the State Children's Health Insurance Program. After enrollment in the State Children's Health Insurance Program, more adolescents reported having had a preventive care visit (65.9% to 74.2%); emergency department use did not change. No differences in satisfaction were noted, although significant increases were noted in both parent- and adolescent-reported rates of having received confidential care and preventive counseling.Adolescents who enrolled in New York's State Children's Health Insurance Program experienced improved access, use, and quality of care. These findings suggest that the provision of health insurance can help to improve health care for adolescents.

    View details for DOI 10.1542/peds.2006-1953

    View details for PubMedID 17403831

  • National health care visit patterns of adolescents: implications for delivery of new adolescent vaccines. Archives of pediatrics & adolescent medicine Rand, C. M., Shone, L. P., Albertin, C., Auinger, P., Klein, J. D., Szilagyi, P. G. 2007; 161 (3): 252-9


    To prepare for new adolescent vaccinations by examining current use of adolescent outpatient health care visits throughout the United States.Cross-sectional analysis of visits.Outpatient hospital- and office-based practices in the United States included in the 1994-2003 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey.Adolescents ages 11 to 21 years (n = 63 529) with outpatient visits.Type of physician seen for overall and preventive visits, visit trends over time, demographics of adolescents seen by pediatricians vs family physicians, and visit type during which a vaccine was provided.Late-adolescence females (18-21 years old) had the most overall visits, 36% of which were to obstetrician-gynecologists. Pediatricians were seen at most outpatient visits for adolescents 14 years or younger, with fewer visits for those older than 14 years. Family practitioners were seen at one quarter of all outpatient visits. Only 9% of all adolescent visits were for preventive care. Early adolescents (11-14 years old) had 3 times more preventive visits than late adolescents (P<.001). Pediatricians were more likely to see adolescents who were younger, male, black, and urban and were more likely to be seen for preventive visits compared with family physicians (P<.001 for all). Altogether, 80%, 70%, and 64% of visits that included measles-mumps-rubella, hepatitis B, and diphtheria-tetanus vaccinations, respectively, were for preventive care.On the basis of current utilization patterns, adolescent vaccinations should be delivered during early or middle adolescence. If vaccines are to be provided to older adolescent females, involvement of obstetrician-gynecologists in vaccine delivery is critical.

    View details for DOI 10.1001/archpedi.161.3.252

    View details for PubMedID 17339506

  • Community as laboratory: reflections from Rochester, New York, in celebration of the dedication of the Robert J. Haggerty child health services research laboratories. Ambulatory pediatrics : the official journal of the Ambulatory Pediatric Association Florin, T. A., Klein, J. D., Szilagyi, P. G., Weitzman, M., McAnarney, E. R. 2006; 6 (3): 130-3


    The dedication of the Robert J. Haggerty Child Health Services Research Laboratories at the University of Rochester (New York) Medical Center in October 2004 provided an opportunity to reflect on the current state of child health services research. Dr Haggerty had a grand vision for using the community in which children live as a laboratory for studying the varied medical, psychosocial, and behavioral morbidities that affect them. He believed that the diverse problems faced by children were best studied by a multidisciplinary team, including both academic and community pediatricians, epidemiologists, sociologists, policy makers, and community leaders. Research done in the community involving front-line providers allows investigation into the most challenging and relevant problems faced by children. To this end, Dr Haggerty made collaboration and cooperation between the community and the academic medical center a priority during his tenure at Rochester. His vision of community as laboratory continues through the child health services research emanating from the Haggerty Laboratories. Nevertheless, many barriers remain that need to be overcome for the sake of improving the lives of children in the United States and throughout the world.

    View details for DOI 10.1016/j.ambp.2005.11.006

    View details for PubMedID 16713929

  • Prior health care experiences of adolescents who enroll in SCHIP. Journal of health care for the poor and underserved Klein, J. D., Shenkman, E., Brach, C., Shone, L. P., Col, J., Schaffer, V. A., Dick, A. W., VanLandeghem, K., Szilagyi, P. G. 2006; 17 (4): 789-807


    The State Children's Health Insurance Program (SCHIP) was designed to provide health insurance to low-income children and adolescents. Little is known about prior access to care and health care experiences of new SCHIP enrollees. We surveyed Florida and New York new adolescent SCHIP enrollees about their health status, prior health care utilization, access, and unmet needs. Most enrollees were younger (ages 12-16 years), Black or Hispanic, lived in poverty, and were without health insurance the year before SCHIP. Most had a usual source of care (USC) prior to enrollment; Blacks and Hispanics were less likely than Whites to have had a USC. Although 69% of Florida and 80% of New York adolescents reported seeing a physician the year before enrollment, 24% and 40%, respectively, reported unmet health care needs. Only 32% of Florida and 40% of the New York adolescents who were surveyed reported ever having met privately with their clinicians. Many new SCHIP enrollees report unmet needs, disparities in access, and sub-optimal care prior to enrollment. Adolescents' needs should be considered in SCHIP program and quality assurance efforts.

    View details for DOI 10.1353/hpu.2006.0127

    View details for PubMedID 17242531

  • Measuring youth development outcomes for community program evaluation and quality improvement: findings from Dissemination of the Rochester Evaluation of Asset Development for Youth (READY) tool. Journal of public health management and practice : JPHMP Sabaratnam, P., Klein, J. D. 2006; Suppl: S88-94


    The Rochester Evaluation of Asset Development for Youth (READY) is a brief program-controlled evaluation and quality improvement tool used for assessment of four developmental assets for youth: caring adult relationships, basic social skills, decision making, and constructive use of leisure time. This article reports on the early implementation and combined benchmark data generated from the use of the READY tool by community-based youth-serving agencies in Rochester, New York.Nine youth-serving agencies used the 40-item READY tool in 2002-2003. In addition to individual program evaluation and quality improvement, a combined dataset was developed and analyzed to establish community benchmarks. Program leaders' qualitative feedback on their experience with the READY tool is also reviewed.1,070 youth participated. Those youth who reported feeling more connected to the programs in which they participated and having more active and frequent participation had consistently higher scores on measured outcomes. Overall, most agencies required some technical assistance to first field READY. Most agencies successfully used their own data to address program quality improvement, and reported being happy with their ability to do so.READY is a promising tool for measuring community-based program-attributable positive developmental outcomes for youth.

    View details for DOI 10.1097/00124784-200611001-00016

    View details for PubMedID 17035909

  • Adolescents and smoking: the first puff may be the worst. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne Klein, J. D. 2006; 175 (3): 262

    View details for DOI 10.1503/cmaj.060737

    View details for PubMedID 16880446

    View details for PubMedCentralID PMC1513424

  • Development and factor structure of a brief instrument to assess the impact of community programs on positive youth development: The Rochester Evaluation of Asset Development for Youth (READY) tool. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Klein, J. D., Sabaratnam, P., Auerbach, M. M., Smith, S. M., Kodjo, C., Lewis, K., Ryan, S., Dandino, C. 2006; 39 (2): 252-60


    Positive youth development is increasingly recognized as important to the health and well-being of adolescents. We describe the development of a brief, standardized instrument for measuring outcomes and indicators important for youth development evaluation. Additionally, we describe the psychometric properties of these constructs.A coalition of representatives from 12 community organizations, funders, and researchers identified four core outcomes associated with positive youth development likely able to be affected by community-based youth-serving agencies. Items were piloted and field tested to test feasibility and establish face validity with experts and with adolescents. Furthermore, we tested construct reliability using factor analysis to determine how well the items reflected underlying constructs.Items representing four empirical constructs were used to survey 389 adolescents. Those who participated in the pilot took an average of 11 minutes to complete the survey. Overall, 24 items loaded on to six discrete factors representing the outcomes of basic social skills, caring adult relationships, and decision-making. When participants under age 13 years were eliminated from the analysis, items were more cohesive, resulting in a five-factor solution with all items loading at .40 or higher.The four youth development outcomes identified by community-based youth-serving organizations factor into reliable constructs with acceptable alpha coefficients for adolescents over age 13. A major strength of this youth development outcome measurement is that it has an easy-to-administer format, which allows community-based programs to receive feedback for program improvement, and to track the effectiveness of their programs for funders.

    View details for DOI 10.1016/j.jadohealth.2005.12.004

    View details for PubMedID 16857538

  • The effects of marriage, civil union, and domestic partnership laws on the health and well-being of children. Pediatrics Pawelski, J. G., Perrin, E. C., Foy, J. M., Allen, C. E., Crawford, J. E., Del Monte, M., Kaufman, M., Klein, J. D., Smith, K., Springer, S., Tanner, J. L., Vickers, D. L. 2006; 118 (1): 349-64

    View details for DOI 10.1542/peds.2006-1279

    View details for PubMedID 16818585

  • The changing risk profile of the American adolescent smoker: implications for prevention programs and tobacco interventions. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Camenga, D. R., Klein, J. D., Roy, J. 2006; 39 (1): 120.e1-10


    To determine how the association between cigarette smoking and other risky behaviors, such as substance use, violence, and risky sexual practices, has changed between 1991 and 2003.Youth Risk Behavior Surveys (YRBS) from 1991 to 2003 were analyzed. For each cohort, logistic regression models controlling for gender, race/ethnicity, and school grade were used to describe the associations between smoking and other risky behaviors. Changes in the odds ratios over time were confirmed with a trend analysis.The strength of the relationship between smoking and other risky behaviors increased for lifetime number of sexual partners (1991 odds ratio [OR] 1.49; 2003 OR 1.61 (p < .001)), sexual partners in the past 3 months (1991 OR 1.77; 2001 OR 2.05 (p < .001)), and never wearing a bicycle helmet 1991 OR 1.40; 1997 OR 5.94 (p < .001). Increases were also seen for binge drinking, and physical fighting. The association between cigarette smoking and marijuana use decreased slightly.Future prevention efforts and tobacco intervention programs should recognize that current adolescent smokers are even more likely to engage in risky sexual behavior, risky alcohol-related behaviors, and to not use a seatbelt or bicycle helmet than were adolescents in the early nineties.

    View details for DOI 10.1016/j.jadohealth.2005.10.014

    View details for PubMedID 16781972

  • Do physicians discuss needed diet and nutrition health topics with adolescents? The Journal of adolescent health : official publication of the Society for Adolescent Medicine Klein, J. D., Postle, C. K., Kreipe, R. E., Smith, S. M., McIntosh, S., Spada, J., Ossip-Klein, D. 2006; 38 (5): 608.e1-6


    Preventive services guidelines recommend screening all adolescents for diet habits, physical activity and growth, counseling underweight teens about body image and dieting patterns, and counseling overweight or obese teens about dietary habits and exercise. In this study, we assess whether adolescents at risk for overweight or for eating disorders have discussed recommended diet and nutrition topics with their physicians.We surveyed 14-18-year-old adolescents who had been seen for well care in primary care pediatric and family medicine practices. Adolescents self-reported their weight, height, body image, dieting habits, and issues they had discussed with their clinicians. Body mass index (BMI) was used to define those "at risk for an eating disorder" (< 5% BMI), "at risk of becoming overweight" (85%-95% BMI), and "overweight" (> 95% BMI).A total of 8384 adolescents completed surveys (72% completion rate). Nearly one-third of adolescents were "at risk" or overweight. Females were less likely to be overweight than males (9.4% vs. 15.7%; p < .001). Although 26.4% were attempting to lose weight, only 12.2% of all teens were actually overweight. Exercise and restricting intake were the preferred methods of weight loss. Physicians routinely discussed adolescents' weight during visits, and were more likely to discuss it with those "at risk" (p < .001). Body image was more often discussed with girls than with boys (52% vs. 44.6%, p < .001) and with those at risk (51.6% vs. 45.5%; p < .001). Discussion of healthy eating and weight loss occurred more often with adolescents "at risk" for becoming overweight (p < .001).Many adolescents are at risk for being overweight or are currently overweight, confirming the importance of clinicians discussing diet and nutrition health topics with all teens. Many adolescents also misclassify their body image, and hence perceive their body image to be different from their actual BMI; clinicians should discuss body image with all adolescents, not just those at risk for eating disorders. Better interventions are needed to promote healthy nutrition and physical activity to all adolescents.

    View details for DOI 10.1016/j.jadohealth.2005.06.009

    View details for PubMedID 16635776

  • Herbal products and their association with substance use in adolescents. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Yussman, S. M., Wilson, K. M., Klein, J. D. 2006; 38 (4): 395-400


    To describe the prevalence of herbal product use in adolescents and the association between herbal product use and tobacco, alcohol, and other drug use.The 1999 Monroe County, New York Youth Risk Behavior Survey provided data on a random sample of 2,006 high school students. Herbal product use was defined by lifetime use of "herbal or other natural products--to feel better, or perform better in sports or school." Bivariate analyses using chi2 tests and logistic regressions were used to describe the independent associations between herbal product use and substance use.Overall, 28.6% reported using herbal products. Herbal product use increased with age (24.5% of 9th graders to 29.9% of 12th graders; p < .04) and varied by ethnicity (33% of Hispanics, 30.9% of Caucasians, 28.8% of Asians, Native Americans, or Pacific Islanders, and 12.1% of African Americans; p < .001), but not by gender. After controlling for gender, grade, and ethnicity, logistic regression models showed herbal product use to be associated with lifetime use of: cigarettes (OR = 2.2; 95% CI = 1.8-2.8), alcohol (OR = 3.5; 2.5-4.9), marijuana (OR = 2.2; 1.8-2.7), and other drugs (odds ratios from 4.4 to 14.5). All p values were < .001.Over one-quarter of high school students report herbal product use, and this use is associated with drug use. Health care providers should inquire about adolescents' herbal product use, and disclosure should prompt an in-depth substance use history.

    View details for DOI 10.1016/j.jadohealth.2004.10.015

    View details for PubMedID 16549300

  • Use of complementary medicine and dietary supplements among U.S. adolescents. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Wilson, K. M., Klein, J. D., Sesselberg, T. S., Yussman, S. M., Markow, D. B., Green, A. E., West, J. C., Gray, N. J. 2006; 38 (4): 385-94


    Use of complementary and alternative medicine (CAM) is increasing, but some dietary supplements have potentially negative side effects. This study examines CAM and dietary supplement use among a national sample of adolescents.A total of 1280 adolescents 14-19 years old completed an online survey in 2002 about lifetime and past-30-day use of all CAM modalities, and specifically about use of herbal medicines and dietary supplements. We e-mailed invitations to 12,353 members of Harris Interactive's national Youth Query panel, and filled age/gender quotas sample targets. Data were then weighted to reflect the U.S. adolescent population by gender, race/ethnicity, urbanicity, region, parents' education, propensity to be online, and likelihood of nonresponse. Chi-square and logistic regression analyses were done using SPSS.Seventy-nine percent of adolescents had used CAM in their lifetime, 48.5% in the previous month; 46.2% had used dietary supplements in their lifetime, 29.1% in the previous month; 9.3% reported concurrent use of supplements and prescription medication in the previous month. Factors associated with CAM and supplement use included being female, positive attitudes towards CAM, and being age 16-17 years (rather than in younger or older age groups). Commonly used supplements included ginseng, zinc, echinacea, ginkgo, weight loss supplements, and creatine.Many adolescents use CAM and dietary supplements, including a significant number concurrent with prescription medications. Commonly used supplements (weight loss supplements and creatine) are closely linked to attempts to change body shape. Health care providers should be aware of CAM and supplement use by adolescents.

    View details for DOI 10.1016/j.jadohealth.2005.01.010

    View details for PubMedID 16549299

  • Predictors of partner abuse in a nationally representative sample of adolescents involved in heterosexual dating relationships. Violence and victims Roberts, T. A., Auinger, P., Klein, J. D. 2006; 21 (1): 81-9


    This article's goals are to identify the characteristics of abusive heterosexual dating relationships among adolescents. Using the National Longitudinal Study of Adolescent Health dataset, an analysis of 4,441 heterosexual relationships was completed using logistic regression models (SAS PROC GENMOD). The associations between being verbally and physically abused were examined with respect to the following relationship characteristics: involvement in sexual intercourse or pregnancy with the relationship partner, description of the relationship as a "special romantic relationship," duration of the relationship, age at relationship initiation, and age difference between partners. The findings indicate that involvement in a sexual or "special romantic" relationship was associated with greater likelihood of being abused in both genders. Increased length of time in the relationship was associated with verbal abuse in both genders. Involvement in a pregnancy was associated with being verbally and physically abused among males. It is thus concluded that relationship characteristics play an important role in the development of abusive relationships among adolescents.

    View details for PubMedID 16494134

  • Improved asthma care after enrollment in the State Children's Health Insurance Program in New York. Pediatrics Szilagyi, P. G., Dick, A. W., Klein, J. D., Shone, L. P., Zwanziger, J., Bajorska, A., Yoos, H. L. 2006; 117 (2): 486-96


    Uninsured children with asthma are known to face barriers to asthma care, but little is known about the impact of health insurance on asthma care.We sought to assess the impact of New York's State Children's Health Insurance Program (SCHIP) on health care for children with asthma.Parents of a stratified random sample of new enrollees in New York's SCHIP were interviewed by telephone shortly after enrollment (baseline, n = 2644 [74% of eligible children]) and 1 year later (follow-up, n = 2310 [87%]). Asthma was defined by parent report using questions based on National Heart, Lung, and Blood Institute criteria. A comparison group (n = 401) who enrolled in SCHIP 1 year later was interviewed as a test for secular trends.Access (having a usual source of care [USC], unmet health needs, problems receiving acute asthma care), asthma-related medical visits, quality (continuity of care at the USC, problems receiving chronic asthma care, use of antiinflammatory medications), and asthma outcomes (change in asthma care or severity) were the main outcome measures used. Bivariate and multivariate analyses compared measures at baseline (year before SCHIP) versus follow-up (year during SCHIP).Three-hundred eighty-three children (14%) had asthma at baseline, and 364 had asthma at follow-up (16%). No secular trends were detected between the baseline study group and the comparison group. After enrollment in SCHIP, improvements were noted in access: lacking a USC (decrease from 5% to 1%), unmet health needs (48% to 21%), and problems getting to the USC for asthma (13 to 4%). Children had fewer asthma-related attacks and medical visits after SCHIP (mean number of attacks: 9.5 to 3.8: mean number of asthma visits: 3.0 to 1.5; hospitalizations: 11% to 3%). Quality of asthma care improved for general measures (most/all visits to USC: 53% to 94%; mean rating of provider: 7.9 to 8.8 of 10) and asthma-specific measures (problems getting to the USC for asthma care when child was well: 13% to 1%). More than two thirds of the parents at follow-up reported that both quality of asthma care and asthma severity were "better or much better" than at baseline, generally because of insurance coverage or lower costs of medications and medical care.Enrollment in New York's SCHIP was associated with improvements in access to asthma care, quality of asthma care, and asthma-specific outcomes. These findings suggest that health insurance improves the health of children with asthma.

    View details for DOI 10.1542/peds.2005-0340

    View details for PubMedID 16452369

  • Adolescents' knowledge of and beliefs about herbs and dietary supplements: a qualitative study. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Klein, J. D., Wilson, K. M., Sesselberg, T. S., Gray, N. J., Yussman, S., West, J. 2005; 37 (5): 409


    To explore adolescents' knowledge of and beliefs about dietary supplements, including herbs, and over-the-counter (OTC) medications.Eighteen focus groups with 81 adolescents in Monroe County, New York, explored teens' familiarity with and beliefs about CAM, specifically dietary supplements. We asked about general health beliefs and opinions of OTC medications to provide a framework for understanding how dietary supplements are conceptualized. Groups were conducted with suburban adolescents, urban minority adolescents, adolescents with chronic illness, (asthma, eating disorders, and diabetes), and patients of complementary/alternative practitioners ("CAM practitioners"). Transcripts were analyzed for themes relating to prevention ("staying healthy") and treatment of illness ("getting better"); direct quotations are used to illustrate adolescents' views.Most adolescents are familiar with "herbal medicine," "herbal remedies," or "nutritional supplements," and are able to name specific products or complementary/alternative medicine (CAM) therapies; however, many are unfamiliar with the term "alternative medicine." Adolescents are more familiar with remedies or CAM therapies commonly used by people from their own cultural or ethnic background. Older suburban females and those with chronic illnesses are more familiar with herbs and supplements than other adolescents. Most supplement use is conceptually linked with treating illness rather than with preventive care.Most adolescents are familiar with culturally based herbal products and nutritional supplements, used for treatment of illnesses, and not for preventive care. Providers and researchers should consider chronic illness status and culture/family tradition, and clarify terms, when asking adolescents about self-care, OTCs, or CAM.

    View details for DOI 10.1016/j.jadohealth.2005.02.003

    View details for PubMedID 16227127

  • Evaluation of an adolescent smoking-cessation media campaign: Pediatrics Klein, J. D., Havens, C. G., Carlson, E. J. 2005; 116 (4): 950-6


    To evaluate the impact of a smoking-cessation media campaign for teens on utilization of a cessation Web site, surveys were conducted before and after the implementation of a countywide media campaign to promote the use of a smoking-cessation Web site for youths. The surveys were designed to assess teen awareness and utilization of the Web site, as well as tobacco use and cessation attempts. Supplemental 2003 Youth Risk Behavior Survey items also assessed use of the Web site.Most teen smokers reported that they wanted to quit smoking. Almost all teens reported exposure to ads and accurately identified as a Web site that offers cessation help for youths. Nearly 1 in 4 smokers who were trying to quit had visited or another Web site for cessation assistance.The campaign effectively reached almost all teens, regardless of smoking status. Smokers were more likely than nonsmokers to have visited the Web site for help with quitting. Web adjuncts are likely to be used by adolescents who seek assistance in quitting.

    View details for DOI 10.1542/peds.2005-0492

    View details for PubMedID 16199707

  • Evaluation of the parents as primary sexuality educators program. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Klein, J. D., Sabaratnam, P., Pazos, B., Auerbach, M. M., Havens, C. G., Brach, M. J. 2005; 37 (3 Suppl): S94-9


    To determine the effectiveness of a sexuality education program designed to help parents become more confident and competent in communicating with their children about sex and sexuality.Parents attending a four- to five-part workshop series between February 2001 and April 2002 were recruited to participate. A total of 27 workshop series were conducted at various sites in neighborhoods with high teen pregnancy and STD rates. For each series, program staff administered written pre- and post-workshop surveys to parents and parent surrogates. A follow-up telephone survey was conducted with participants 10 weeks after the last workshop. Matched pre-workshop and follow-up surveys were obtained from 174 participants.Comparison of follow-up to pre-workshop responses revealed that more participants thought discussing sexuality with their children was very important (83% vs. 75%; p < .01). More participants also reported that they often initiate conversations with their children on a variety of topics including sex/intercourse, human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), pregnancy, sexuality and gender issues, and their personal standards for sexual behavior. Participants also became more comfortable discussing sensitive topics with their children. At follow-up, more participants responded that they were very comfortable answering their children's questions on the above topics. (All p values < .01.)The Parents as Primary Sexuality Educators program may be an effective way to increase parent-child communication about health, sexuality, and values. Enhancing parents' ability to communicate expectations and values about sexuality may help support children in making healthy decisions about sexual behavior as adolescents.

    View details for DOI 10.1016/j.jadohealth.2005.05.004

    View details for PubMedID 16115575

  • Preventive counseling at adolescent ambulatory visits. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Rand, C. M., Auinger, P., Klein, J. D., Weitzman, M. 2005; 37 (2): 87-93


    To evaluate factors that independently predict counseling for diet, exercise, sexually transmitted diseases (STDs), pregnancy, smoking, and injuries at adolescent well visits, and compare these rates to the frequency of counseling at adolescent acute visits.The 1997-2000 National Ambulatory Medical Care and National Hospital Ambulatory Medical Care Surveys were combined for patients aged 11-21 years. Acute visits were identified by ICD-9 code for: sexual health, obesity, asthma, injury, and well care. Bivariate analyses were used to determine differences in relevant counseling provided at acute visits compared with well visits. Logistic regression was used to assess factors that predict counseling on each of the above topics at well adolescent visits.Of 23,378 adolescent ambulatory visits, 1508 (6.5%) were for well care. Only 0.8% of visits were for obesity, 3.7% for sexual health, 2.6% for asthma, and 13% for injuries. Counseling was more frequent at acute than well visits for diet (72% vs. 28%), exercise (52% vs. 23%), human immunodeficiency virus/sexually transmitted diseases (HIV/STD; 14% vs. 6.2%), and family planning (FP) (24% vs. 10%), (all p values < .05). Pediatric clinicians were more likely than other specialists to provide counseling for diet (OR 2.3), HIV/STD (OR 2.7), FP (OR 2.9), tobacco use (OR 2.8), and injury prevention (OR 4.7). Blacks received less exercise counseling than Whites (OR 0.4), and counseling about sensitive issues (STDs, family planning) occurred more often in older adolescents (OR 1.3).Despite recommendations, more counseling occurs at acute rather than well visits, and still does not reach all those adolescents in need. There remains much room for improvement in physicians' adherence to national guidelines for adolescent care.

    View details for DOI 10.1016/j.jadohealth.2005.02.008

    View details for PubMedID 16026717

  • Recruitment of physician offices for an office-based adolescent smoking cessation study. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco McIntosh, S., Ossip-Klein, D. J., Hazel-Fernandez, L., Spada, J., McDonald, P. W., Klein, J. D. 2005; 7 (3): 405-12


    Physician office settings play an important role in tobacco cessation intervention. However, few tobacco cessation trials are conducted at these sites, in part because of the many challenges associated with recruiting community physician offices into research. The present study identified and implemented strategies for recruiting physician offices into a randomized clinical trial of tobacco screening and cessation interventions with adolescent patients. A total of 30 community physicians participated in focus groups to elicit their perceptions of facilitators of and barriers to initial engagement of physician practices and the subsequent enrollment of the practices in long-term research projects. Physicians identified facilitators such as (a) the involvement of office staff in the recruitment process and (b) on-site presentations of the study's background and aims. Some of the barriers identified were time commitment concerns and the lack of incentives in exchange for participation. These focus group findings were then integrated with theory-based and empirically driven recruitment strategies for a 12-month randomized tobacco intervention trial with adolescent patients. Of 185 office practices approached to participate (screened from a pool of 273 practices), 103 agreed to on-site presentations of the study. Subsequently, almost all of the practices (101) that received the presentation agreed to enroll in the study. Conclusions are that (a) recruitment is a multicomponent process, (b) the processes of communication, engagement, and enrollment must be carefully planned and implemented to achieve maximal results, and (c) the development of effective strategies for recruiting health care provider practices presents an important infrastructure for testing adolescent smoking cessation interventions.

    View details for DOI 10.1080/14622200500125567

    View details for PubMedID 16085508

  • Reduction in racial and ethnic disparities after enrollment in the State Children's Health Insurance Program. Pediatrics Shone, L. P., Dick, A. W., Klein, J. D., Zwanziger, J., Szilagyi, P. G. 2005; 115 (6): e697-705


    Racial/ethnic disparities are associated with lack of health insurance. Although the State Children's Health Insurance Program (SCHIP) provides health insurance to low-income children, many of whom are members of racial/ethnic minority groups, little is known about whether SCHIP affects racial/ethnic disparities among children who enroll.The objectives of this study were to (1) describe demographic characteristics and previous health insurance experiences of SCHIP enrollees by race, (2) compare racial/ethnic disparities in medical care access, continuity, and quality before and during SCHIP, and (3) determine whether disparities before or during SCHIP are explained by sociodemographic and health system factors.Pre/post-parent telephone survey was conducted just after SCHIP enrollment and 1 year after enrollment of 2290 children who had an enrollment start date in New York State's SCHIP between November 2000 and March 2001, stratified by race/ethnicity (non-Hispanic white, non-Hispanic black, and Hispanic). The main outcome measures were usual source of care (USC), preventive care use, unmet needs, patterns of USC use, and parent-rated quality of care before versus during SCHIP.Children were white (25%), black (31%), or Hispanic (44%); 62% were uninsured > or =12 months before SCHIP. Before SCHIP, a greater proportion of white children had a USC compared with black or Hispanic children (95%, 86%, and 81%, respectively). Nearly all children had a USC during SCHIP (98%, 95%, and 98%, respectively). Before SCHIP, black children had significantly greater levels of unmet need relative to white children (38% vs 27%), whereas white and Hispanic children did not differ significantly (27% vs 29%). During SCHIP, racial/ethnic disparities in unmet need were eliminated, with unmet need at 19% for all 3 racial/ethnic groups. Before SCHIP, more white children made all/most visits to their USC relative to black or Hispanic children (61%, 54%, and 34%, respectively); all improved during SCHIP with no remaining disparities (87%, 86%, and 92%, respectively). Parent-rated visit quality improved for all groups, but preexisting racial/ethnic disparities remained during SCHIP, with improved yet relatively lower levels of satisfaction among parents of Hispanic children. Sociodemographic and health system factors did not explain disparities in either period.Enrollment in SCHIP was associated with (1) improvement in access, continuity, and quality of care for all racial/ethnic groups and (2) reduction in preexisting racial/ethnic disparities in access, unmet need, and continuity of care. Racial/ethnic disparities in quality of care remained, despite improvements for all racial groups. Sociodemographic and health system factors did not add to the understanding of racial/ethnic disparities. SCHIP improves care for vulnerable children and reduces preexisting racial/ethnic disparities in health care.

    View details for DOI 10.1542/peds.2004-1726

    View details for PubMedID 15930198

  • Intimate partner abuse and the reproductive health of sexually active female adolescents. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Roberts, T. A., Auinger, P., Klein, J. D. 2005; 36 (5): 380-5


    The purpose of this study was to determine the associations between verbal and minor physical abuse by an intimate partner and reproductive health behavior.Logistic regression analyses of 1996 cross-sectional data from 973 sexually active, dating female adolescents surveyed for wave II of the National Longitudinal Study of Adolescent Health Public Use Dataset examining the relationship between abuse by an intimate partner and reproductive health. We measured verbal (insulted in public, sworn at, or threatened with violence) and minor physical (threw something at them, pushed them, or shoved them) abuse by any intimate partner during the past 18 months and by any current intimate partner. Reproductive health variables included condom use with most recent intercourse, contraception use with most recent intercourse, history of sexually transmitted infection, and history of pregnancy.After adjusting for sociodemographic factors, number of intimate partners, and history of forced sexual intercourse, the current involvement in a verbally abusive relationship was associated with not using a condom during the most recent intercourse (odds ratio, 1.56; 95% confidence interval, 1.02-2.40), and both a history of involvement and current involvement in a physically abusive relationship were associated with a history of pregnancy (odds ratio, 2.50; 95% confidence interval, 1.47-4.17; and odds ratio, 3.57; 95% confidence interval, 1.85-6.67, respectively). Neither verbal nor physical abuse were associated with the other reproductive health outcomes.Physical abuse by an intimate partner is associated with pregnancy and current involvement in a verbally abusive relationship is associated with decreased condom use among sexually experienced female adolescents. Health care providers should be attentive to the association between abuse and pregnancy among adolescents.

    View details for DOI 10.1016/j.jadohealth.2004.06.005

    View details for PubMedID 15837341

  • SCHIP's impact in three states: how do the most vulnerable children fare? Health affairs (Project Hope) Dick, A. W., Brach, C., Allison, R. A., Shenkman, E., Shone, L. P., Szilagyi, P. G., Klein, J. D., Lewit, E. M. 2004; 23 (5): 63-75


    This study provides consistent evidence, from three very diverse states with heterogeneous populations and distinct programs (Florida, Kansas, and New York), that the State Children's Health Insurance Program (SCHIP) increased access to and satisfaction with health care among enrolled low-income children and that vulnerable children-minorities, children and adolescents with special health care needs, and children who were uninsured for long periods of time-shared in these improvements. We highlight some areas to target for future improvement, such as reducing the high levels of unmet needs among special-needs children and increasing preventive care, especially for Hispanic children.

    View details for DOI 10.1377/hlthaff.23.5.63

    View details for PubMedID 15371371

  • Adolescent smoking cessation. Current opinion in pediatrics Camenga, D. R., Klein, J. D. 2004; 16 (4): 368-72


    Approximately 25% of high school students report current cigarette use, 85% of adolescents think about quitting, and around 80% of current smokers made a quit attempt in the past year. This review analyzes recent additions to the adolescent smoking cessation literature from June 1, 2003 to May 1, 2003.Adolescent attitudes toward smoking cessation are largely affected by their smoking history. Youth cessation interventions largely focus on behavioral interventions, and research concerning these interventions has yielded mixed results. Little data exist about the effectiveness of nicotine replacement therapy in adolescents, but there is growing evidence that youth use this pharmacotherapy. Recent research has explored the use of nicotine replacement therapy as an adjunct for enhanced smoking reduction in adults, and future research may focus on this tactic for youth as well. Internet cessation adjuncts and telephone quit lines also serve as future frontiers for adolescent smoking cessation research.Information concerning adolescent smoking behaviors, effective interventions, and smoking cessation therapy continue to grow and provide data that improve our understanding of adolescent smoking cessation. Although we cannot directly extrapolate the adult findings to this population, adult cessation research continues to inform future adolescent cessation efforts.

    View details for DOI 10.1097/01.mop.0000133080.47631.c6

    View details for PubMedID 15273495

  • Screening for suicide risk in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Annals of internal medicine Gaynes, B. N., West, S. L., Ford, C. A., Frame, P., Klein, J., Lohr, K. N. 2004; 140 (10): 822-35


    Suicide is the 11th leading cause of death and the seventh leading cause of years of potential life lost in the United States. Although suicide is of great public health significance, its clinical management is complicated.The authors systematically reviewed the literature to determine whether screening for suicide risk in primary care settings decreases morbidity, mortality, or both.MEDLINE (1966 to 17 October 2002), PsycINFO, Cochrane databases, hand-searched bibliographies, and experts.For screening, only English-language studies performed in primary care settings were examined. For treatment, randomized, controlled trials and cohort studies were included if they were performed in any setting where suicide completions, suicide attempts, or suicidal ideation were reported.A primary reviewer abstracted data on key variables of study sample, design, and outcomes; a second reviewer checked information accuracy against the original articles.No study directly addressed whether screening for suicide in primary care reduces morbidity and mortality. The remainder of the review focused on the questions of reliable screening tests for suicide risk and the effectiveness of interventions to decrease depression, suicidal ideation, and suicide attempts or completion. One screening study provided limited evidence for the accuracy of suicide screening in a primary care setting. Intervention studies provided fair and mixed evidence that treating those at risk for suicide reduces the number of suicide attempts or completions. The evidence suggests mild to moderate improvement for interventions addressing intermediate outcomes such as suicidal ideation, decreased depressive severity, decreased hopelessness, or improved level of function.Because of the complexity of studying the risk for suicide and the paucity of well-designed research studies, only limited evidence guides the primary care clinician's assessment and management of suicide risk.

    View details for DOI 10.7326/0003-4819-140-10-200405180-00015

    View details for PubMedID 15148072

  • Improved access and quality of care after enrollment in the New York State Children's Health Insurance Program (SCHIP). Pediatrics Szilagyi, P. G., Dick, A. W., Klein, J. D., Shone, L. P., Zwanziger, J., McInerny, T. 2004; 113 (5): e395-404


    Although many studies have noted that uninsured children have poorer access and quality of health care than do insured children, few studies have been able to demonstrate the direct benefits of providing health insurance to previously uninsured children. The State Children's Health Insurance Program (SCHIP), enacted as Title XXI of the Social Security Act, was intended to improve insurance coverage and access to health care for low-income, uninsured children. With limited state and federal resources for health care, continued funding of SCHIP requires demonstration of success of the program. As yet, little is known about the effectiveness of SCHIP on improving access and quality of care to enrollees.To measure the impact of the New York State (NYS) SCHIP on access, utilization, and quality of health services for enrolled children.NYS, stratified into 4 regions. The NYS SCHIP is modeled on commercial insurance (32 managed care plans) and at the time of the study had 18% of SCHIP enrollees nationwide.For the study group, the design used pre/poststudy telephone interviews of parents of children enrolling in the NYS SCHIP, with baseline interviews soon after enrollment and follow-up interviews 1 year after enrollment. Baseline interviews reflected the child's experience during the 1-year period before enrollment in SCHIP. The follow-up interviews reflected the 1-year period after enrollment in SCHIP. For the comparison group, the design used baseline interviews of a comparison group enrolled 1 year after the study group to test for secular trends; these interviews reflected the 1-year period before enrollment in SCHIP.Children (n = 2644) 0 to 18 years of age who enrolled in the NYS SCHIP for the first time (November 2000 to March 2001), stratified by age (0-5, 6-11, and 12-18 years), race/ethnicity (white non-Hispanic, black non-Hispanic, and Hispanic; others excluded), and region of NYS. The comparison group consisted of 400 children. Telephone interviews were conducted in English or Spanish throughout the day and evening, 7 days per week, to obtain measures.Demographic and health measures (child and family characteristics, health status, presence of a special health care need, and prior health insurance), access (usual source of care [USC] and unmet needs for health care), utilization (visits for specific health services), and quality (continuity with USC and measures of primary care interactions). Analyses included bivariate tests, comparing the pre-SCHIP period to the 1-year period after enrollment in SCHIP. Multivariate models were computed to generate standardized populations comprised of key characteristics of the sample to test for differences in measures (after SCHIP versus before SCHIP), controlling for demographic characteristics.Of the 2644 study-group children who completed the initial interview, 2290 (87%) completed the follow-up interview. Key measures for the pre-SCHIP period and short-term "postenrollment" measures for the study group were not statistically different from measures for the comparison group, suggesting no major secular trends. Participants were non-Hispanic white (25%), non-Hispanic black (31%), and Hispanic (45%). Fifty-one percent of the parents were single, and 61% had a high school education or less; 81% of families had income <160% of the federal poverty level. Sixty-two percent of the children were uninsured > or = 12 months before the NYS SCHIP; of those insured, 43% previously had Medicaid. The proportion of children who had a USC increased after enrollment in the NYS SCHIP (86% to 97%). Two measures of accessibility (difficulty getting a medical person by telephone and difficulty getting an appointment) improved after enrollment in SCHIP. The proportion of children with any unmet health care needs decreased (31% to 19%). Specific types of unmet need also were reduced after enrollment; for example, among SCHIP enrollees who had a need for specific type of care, unmet needs wds were significantly lower postenrollment versus pre-SCHIP for specialty care (-15.5% in unmet need), acute care (-10.1%), preventive care (-9.6%), dental care (-13.0%%), and vision care (-13.2%). Emergency and total ambulatory visits did not change, but the proportion of children with a preventive care visit increased (74% to 82%). The proportion of children who used their USC for most or all visits increased (47% to 89%), demonstrating increased continuity of care. Several indicators of health care quality improved, including an overall rating of quality, the 4 indicators of physician-patient interaction used by the Consumer Assessment of Health Plans Survey, and a measure of parental worry about their child's health. Improvements were noted among major subgroups of children, with the greatest improvements for those with the lowest baseline levels. For example, at baseline, a lower percentage of children living at <160% of the federal poverty level had a presence of a USC or continuity with their USC than children living in families at >160% of the federal poverty level, and these poorer children experienced the greatest gains in having a USC or having continuity with their USC after enrollment in SCHIP.Enrollment in the NYS SCHIP was associated with 1) improved access, continuity, and quality of care and 2) a change in the pattern of health care, with a greater proportion of care taking place within the usual source of primary care.

    View details for DOI 10.1542/peds.113.5.e395

    View details for PubMedID 15121980

  • Tobacco prevention and cessation in pediatric patients. Pediatrics in review Klein, J. D., Camenga, D. R. 2004; 25 (1): 17-26

    View details for DOI 10.1542/pir.25-1-17

    View details for PubMedID 14702518

  • The evolution of the State Children's Health Insurance Program (SCHIP) in New York: changing program features and enrollee characteristics. Pediatrics Dick, A. W., Klein, J. D., Shone, L. P., Zwanziger, J., Yu, H., Szilagyi, P. G. 2003; 112 (6 Pt 2): e542


    The State Children's Health Insurance Program (SCHIP) has been operating for >5 years. Policy makers are interested in the characteristics of children who have enrolled and changes in the health care needs of enrolled children as programs mature. New York State's SCHIP evolved from a similar statewide health insurance program that was developed in 1991 (Child Health Plus [CHPlus]). Understanding how current SCHIP enrollees differ from early CHPlus enrollees together with how program features changed during the period may shed light on how best to serve the evolving SCHIP population.To 1) describe changes in the characteristics of children enrolled in 1994 CHPlus and 2001 SCHIP; 2) determine if changes in the near-poor, age-eligible population during the time period could account for the evolution of enrollment; and 3) describe changes in the program during the period that could be responsible for the enrollment changes.New York State, stratified into 4 regions: New York City, New York City environs, upstate urban counties, and upstate rural counties.Retrospective telephone interviews of parents of 2 cohorts of CHPlus enrollees: 1) children who enrolled in CHPlus in 1993 to 1994 and 2) children who enrolled in New York's SCHIP in 2000 to 2001. The Current Population Survey (CPS) 1992 to 1994 and 1999 to 2001 were used to identify secular trends that could explain differences in the CHPlus and SCHIP enrollees. PROGRAM CHARACTERISTICS: 1994 CHPlus and 2001 SCHIP were similar in design, both limiting eligibility by age, family income, and insurance status. SCHIP 2001 included 1) expansion of eligibility to adolescents 13 to 19 years old; 2) expansion of benefits to include hospitalizations, mental health, and dental benefits; 3) changes in premium contributions; 4) more participating insurance plans, limited to managed care; 5) expansions in marketing and outreach; and 6) a combined enrollment application for SCHIP and several low-income programs including Medicaid.Cohort 1 included 2126 new CHPlus enrollees 0 to 13 years old who were enrolled for at least 9 months, stratified by geographic region. Cohort 2 included 1100 new SCHIP enrollees 0 to 13 years old who were enrolled for at least 9 months, stratified by geographic region, age, race, and ethnicity. Results were weighted to be representative of statewide CHPlus or SCHIP new enrollees who met the sampling criteria. Samples of age- and income-eligible children from New York State were drawn from the CPS and pooled and reweighted (1992-1994 and 1999-2001) to generate a comparison group of children targeted by CHPlus and SCHIP.Sociodemographic characteristics, race and ethnicity (white non-Hispanic, black non-Hispanic, and Hispanic), prior health insurance, health care access, and first source of information about the program.Weighted bivariate analyses (comparisons of means and rates) adjusted for the complex sampling design to compare measures between the 2 program cohorts and between the 2 CPS samples. We tested for equivalence by using chi2 statistics.As the program evolved from CHPlus to SCHIP, relatively more black and Hispanic children enrolled (9% to 30% black from 1994 to 2001, and 16% to 48% Hispanic), more New York City residents (46% to 69% from 1994 to 2001), more children with parents who had less than a high school education (10% to 25%), more children from lower income families (59% to 75% below 150% of the federal poverty level), and more children from families with parents not working (7% to 20%) enrolled. These socioeconomic and demographic changes were not reflected in the underlying age- and income-eligible population. A greater proportion of 2001 enrollees were uninsured for some time immediately before enrollment (57% to 76% had an uninsured gap), were insured by Medicaid during the year before enrollment (23% to 48%), and lacked a USC (5% to 14%). Although "word of mouth" was the most common means by which families heard about both programs, a greater proportion of 2001 enrollees learned about SCHIP from marketing or outreach sources.As New York programs for the uninsured evolved, more children from minority groups, with lower family incomes and education, and having less baseline access to health care were enrolled. Although changes in the underlying population were relatively small, progressively increased marketing and outreach, particularly in New York City, the introduction of a single application form for SCHIP and Medicaid, and expansions in the benefit package may have accounted, in part, for the large change in the characteristics of enrollees.

    View details for PubMedID 14654676

  • The role of race and ethnicity in the State Children's Health Insurance Program (SCHIP) in four states: are there baseline disparities, and what do they mean for SCHIP? Pediatrics Shone, L. P., Dick, A. W., Brach, C., Kimminau, K. S., LaClair, B. J., Shenkman, E. A., Col, J. F., Schaffer, V. A., Mulvihill, F., Szilagyi, P. G., Klein, J. D., VanLandeghem, K., Bronstein, J. 2003; 112 (6 Pt 2): e521


    Elimination of racial and ethnic disparities in health has become a major national goal. The State Children's Health Insurance Program (SCHIP) has the potential to reduce disparities among the children who enroll if they exhibit the same disparities that have been documented in previous studies of low-income children. To determine the potential impact of SCHIP on racial and ethnic disparities, it is critical to assess baseline levels of health disparities among children enrolling in SCHIP.To use data from the Child Health Insurance Research Initiative (CHIRI) to 1) describe the sociodemographic profile of new enrollees in SCHIP in Alabama, Florida, Kansas, and New York; 2) determine if there were differences in health insurance and health care experiences among white, black, and Hispanic SCHIP enrollees before enrollment in SCHIP; and 3) explore whether race or ethnicity, controlled for other factors, affected pre-SCHIP access to health coverage and health care.SCHIP programs in Alabama, Florida, Kansas, and New York, which together include 26% of SCHIP enrollees nationwide.Telephone interview (mailed survey in Alabama) about the child's health, health insurance, and health care experiences conducted shortly after SCHIP enrollment to assess experience during the time period before SCHIP.New SCHIP enrollees (0-17.9 years old in Alabama, Kansas, and New York and 11.5-17.9 years old in Florida). Stratified sampling was performed in Kansas and New York, with results weighted to reflect statewide populations of new SCHIP enrollees.Sociodemographic characteristics including income, education, employment, and other characteristics of the child and the family, race and ethnicity (white non-Hispanic, black non-Hispanic, and Hispanic [any race]), prior health insurance, health care access and utilization, and health status.Bivariate analyses were used to compare baseline measures upon enrollment for white, black, and Hispanic SCHIP enrollees. Multivariate analyses were performed to assess health status and health care access measures (prior insurance, presence of a usual source of care (USC), and use of preventive care), controlling for demographic factors described above. Weighted analyses (where appropriate) were performed by using SPSS, STATA, or SUDAAN.Racial and ethnic composition varied across the SCHIP cohorts studied, with black and Hispanic children comprising the following proportion of enrollees, respectively: Alabama, 33% and <1%; Florida, 16% and 26%; Kansas, 12% and 15%; and New York, 24% and 36%. Black and Hispanic children were more likely to reside in single-parent and lower-income families. With some variation by state, children from minority groups were more likely to report poorer health status than were white children. Relative to white children, children from minority groups in Florida and New York were more likely to have been uninsured for the entire year before SCHIP enrollment. In all states, children from minority groups who had prior coverage were more likely to have previously been enrolled in Medicaid than in private health insurance and were less likely to have had employer-sponsored coverage compared with white children. Except in Alabama, there was a difference in having a USC, with children from minority groups less likely to have had a USC before SCHIP enrollment compared with white children. No consistent pattern of health care utilization before SCHIP was noted across states with respect to race or ethnicity. Findings from multivariate analyses, controlling for sociodemographic factors, generally confirmed that black and Hispanic children were more likely to have lacked insurance or a USC before enrollment in SCHIP and to have poorer health status compared with white children.SCHIP is enrolling substantial numbers of racial and ethnic minority children. There are baseline racial and ethnic disparities among new enrollees in SCHIP, with black and Hispanic children faring worse than white children on many sociodemographic and health system measures, and there are differences among states in the prevalence and magnitude of these disparities. After controlling for sociodemographic factors, these disparities persisted. IMPLICATIONS FOR MONITORING AND IMPROVING SCHIP: SCHIP has the potential to play a critical role in efforts to eliminate racial and ethnic disparities in health among the children it serves. However, study findings indicate that programmatic efforts are necessary to ensure that disparities are not perpetuated. Program effectiveness and outcomes should be monitored by race and ethnicity to ensure equity in access, use, and outcomes across all racial and ethnic groups. Assessing the health characteristics and needs of new SCHIP enrollees can provide a benchmark for evaluating the program's impact on eliminating racial and ethnic disparities in health and inform service delivery enhancements.

    View details for PubMedID 14654674

  • Children with special health care needs enrolled in the State Children's Health Insurance Program (SCHIP): patient characteristics and health care needs. Pediatrics Szilagyi, P. G., Shenkman, E., Brach, C., LaClair, B. J., Swigonski, N., Dick, A., Shone, L. P., Schaffer, V. A., Col, J. F., Eckert, G., Klein, J. D., Lewit, E. M. 2003; 112 (6 Pt 2): e508


    Children with special health care needs (CSHCN) often require more extensive services than children without special needs. The State Children's Health Insurance Program (SCHIP) in many states typically provides less extensive benefits and services than do state Medicaid programs. To design SCHIP to address the needs of CSHCN adequately, it is important to measure the degree to which children who enroll in SCHIP have special health care needs and to assess their health status and unmet health care needs. Little is known about the characteristics or preenrollment experience of CSHCN who enroll in SCHIP.To use data from the Child Health Insurance Research Initiative to measure the prevalence of CSHCN in SCHIP in 4 states, describe their demographic and health care features at enrollment, and compare their sociodemographic characteristics, health status, prior health care experiences, and unmet needs versus children without special health care needs.Children (0-18 years old) newly enrolled in SCHIP in 4 states were eligible for the study: New York, Florida (adolescents only), Kansas, and Indiana (CSHCN only). Telephone interviews were conducted shortly after enrollment and identified CSHCN by using the Child and Adolescent Health Measurement Initiative CSHCN screener. A common set of core questions assessed demographic characteristics, health status, special health care need status, insurance experience, access, use, quality of health care, and unmet needs during the year before enrollment. Bivariate and multivariate analyses were used to compare characteristics of CSHCN with characteristics of children without special needs.Interviews were completed for parents of 5296 children enrolled in SCHIP in the 4 states. By using the Child and Adolescent Health Measurement Initiative CSHCN screener, the prevalence of CSHCN among SCHIP enrollees was 17% (New York), 18% (Florida), and 25% (Kansas), higher than the prevalence of CSHCN reported in the general population in those states. More than half of CSHCN reported the use of a chronic medication. Demographic characteristics of CSHCN were similar to those of children without special needs, although CSHCN were more likely to reside in single-parent households. Although CSHCN had poorer health status than children without special needs, many CSHCN were reported to be in good health, suggesting a wide spectrum of severity of illnesses within the CSHCN group. Although CSHCN were more likely than children without special needs to have been insured before SCHIP, a large proportion of CSHCN were nevertheless uninsured for at least 12 months before SCHIP (New York, 56%; Florida, 68%; Kansas, 24%; Indiana, 25%). Although most SCHIP enrollees had a usual source of care (USC) before SCHIP and there was some variation across states, between 4% and 13% of CSHCN lacked a USC on enrollment, and 23% to 38% of CSHCN changed their USC after enrollment in SCHIP. The majority of all SCHIP enrollees (including CSHCN) had used some health care during the year before SCHIP including preventive, acute, or specialty care. A high proportion of all SCHIP enrollees, including >30% to 40% of CSHCN, were reported to have unmet health care needs at enrollment in SCHIP. A variety of unmet needs were reported by CSHCN including specialty care, mental health care, dental care, and prescription medications. Nevertheless, the vast majority of CSHCN as well as children without special needs rated the quality of their medical care before SCHIP highly on several specific quality measures. Findings from multivariate analyses were similar to bivariate results with CSHCN in several states having higher use of care and more unmet health care needs before enrollment.SCHIP is enrolling many CSHCN, with the prevalence of these children occurring at least as high as the prevalence of CSHCN in the general population. CSHCN enrolled in SCHIP represent a heterogeneous population with a wide range of health status and health care needs. Although most CSHCN were already already connected to the health care system with a USC and prior health care visits, many had unmet health care needs before enrolling in SCHIP. IMPLICATIONS FOR MONITORING AND IMPROVING SCHIP FOR CSHCN ENROLLEES: 1) SCHIP benefit packages need to adequately cover services required by CSHCN such as prescription medications and specialty, mental health, developmental, and home services; 2) because utilization of care will be high among this large group of children, alternative methods of financing and managing care should be considered such as risk adjustment and special programs that involve case management and care coordination; 3) coordination of care across programs (such as between SCHIP and the state Title V Maternal and Child Health Services program, a component of which serves CSHCN) and ensuring adequate access to primary care and specialty providers might improve access to services for CSHCN; and 4) it is critical to monitor the quality of care for CSHCN enrolled in SCHIP, because these children are among the most vulnerable children covered by public health insurance programs and many of them are enrolling in SCHIP.

    View details for PubMedID 14654673

  • Longitudinal effect of intimate partner abuse on high-risk behavior among adolescents. Archives of pediatrics & adolescent medicine Roberts, T. A., Klein, J. D., Fisher, S. 2003; 157 (9): 875-81


    To determine the longitudinal effect of abuse by an intimate partner on risk behavior among adolescents.Linear regression analyses of longitudinal data from 4443 adolescents surveyed in 1995 (Wave I) and 1996 (Wave II) from the National Longitudinal Study of Adolescent Health Public Use Dataset.Abuse was assessed using a 5-point scale measuring if the subject had been insulted in public, sworn at, threatened with violence, pushed or shoved, or had something thrown at them by an intimate partner. The primary outcome measures were changes between Waves I and II in each of the following 5-risk behaviors: illicit substance use, antisocial behavior, violent behavior, suicidal behavior, and depression.Abuse between Waves I and II was associated with higher rates of all 5 risk behaviors at both Waves I and II among both sexes. After adjusting for sociodemographic factors, number of intimate partners, time between interviews, baseline risk behavior scores, and the most abusive relationship experienced prior to Wave I, more severe abuse having occurred between Waves I and II was significantly associated with increased levels of depression in both sexes and increased involvement in illicit substance use, antisocial behavior, and suicidal behavior among female adolescents.Abuse by an intimate partner is associated with higher levels of risk behavior in both sexes and incident abuse is associated with increased depression in both sexes and increased illicit substance use, antisocial behavior, and suicidal behavior among females. Intimate partner violence interventions should address the negative behaviors associated with abuse, particularly among female adolescents.

    View details for DOI 10.1001/archpedi.157.9.875

    View details for PubMedID 12963592

  • Improving adolescent preventive services through state, managed care, and community partnerships. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Klein, J. D., Sesselberg, T. S., Gawronski, B., Handwerker, L., Gesten, F., Schettine, A. 2003; 32 (6 Suppl): 91-7


    To develop and evaluate a multipronged, guideline-based initiative to improve quality of adolescent preventive care.Activities included: (a) academic institution-based grand rounds and insurance company-sponsored community rounds continuing education sessions on preventive care for primary care clinicians, (b) academic detailing during chart review visits to practices by nurse reviewers, to encourage adolescent-specific confidentiality policies and use of screener or trigger questionnaires during well visits, and (c) partnerships with community corporate leaders to promote awareness of quality preventive services. Interventions were evaluated by comparing 2000 and 2001 chart reviews for rates of tobacco use, substance use, and human immunodeficiency virus (HIV) prevention screening and counseling.A total of 285 clinicians attended continuing education (CE) sessions and 96 offices received detailing visits. Improvements in adolescent preventive health services delivery were noted in both commercial and Medicaid populations. We found the following when comparing 2001 results with those from 2000: Tobacco use screening or counseling increased from 42.5% to 45.5% for the commercial population and from 32.0% to 43.5% for the Medicaid population; substance use screening increased from 42.5% to 44.0% for the commercial population and from 32.0% to 43.5% for the Medicaid population. HIV counseling increased from 26.5% to 35.5% for the commercial population, and from 28.0% to 40.0% for the Medicaid population (all Medicaid and HIV differences are significant at p <.05).These activities have been successful in improving adolescent preventive services for Medicaid populations in New York. Academic detailing can assist health plans in promoting preventive care improvements by primary care clinicians. Further measurement is needed to assess the effect on commercially insured populations.

    View details for DOI 10.1016/s1054-139x(03)00072-7

    View details for PubMedID 12782447

  • Intimate partner abuse and high-risk behavior in adolescents. Archives of pediatrics & adolescent medicine Roberts, T. A., Klein, J. 2003; 157 (4): 375-80


    To determine the associations between abuse by an intimate partner and risk behaviors among adolescents and to determine whether these associations vary by gender.Ordinal and linear regression analyses of 1996 cross-sectional data from 4347 adolescents surveyed for wave 2 of the National Longitudinal Study of Adolescent Health public use data set.A 5-point scale was used to measure whether the adolescent had been the victim of any of the following behaviors by an intimate partner: insulted in public, sworn at, threatened with violence, or had something thrown at them. Risk behavior involvement was determined using 5 measures: substance use, antisocial behavior, violent behavior, suicidal behavior, and depressed mood.There was no significant difference in the frequency of abuse by an intimate partner for males (21.0%) vs females (22.1%). In females, after adjusting for sociodemographic factors and number of intimate partners, a history of abuse was significantly associated with substance use (values given as beta, 99% confidence interval) (0.87, 0.51-1.23), antisocial behavior (0.15, 0.10-0.20), violent behavior (0.06, 0.01-0.11), depressed mood (1.82, 1.21-2.43), and suicidal behavior (odds ratio, 1.37, 1.14-1.63). In males, abuse was independently associated with antisocial behavior (0.11, 0.03-0.19), violent behavior (0.09, 0.04-0.14), and depressed mood (1.29, 0.53-2.06). Abuse by an intimate partner had a significantly stronger association with substance use in females (0.87, 0.51-1.23) vs males (0.34, -0.09 to 0.77).Abuse by an intimate partner is common among adolescents and has strong associations with risk behaviors among male and female victims of abuse.

    View details for DOI 10.1001/archpedi.157.4.375

    View details for PubMedID 12695234

  • Tobacco counseling at well-child and tobacco-influenced illness visits: opportunities for improvement. Pediatrics Tanski, S. E., Klein, J. D., Winickoff, J. P., Auinger, P., Weitzman, M. 2003; 111 (2): E162-7


    To assess the frequency of clinician-reported delivery of counseling for avoidance of child environmental tobacco smoke (ETS) exposure and tobacco use at periodic well-child visits and at illness visits for asthma and otitis media (OM).Combined data from the National Ambulatory Medical Care Survey and the outpatient portion of the National Hospital Ambulatory Medical Care Survey from 1997 to 1999 were analyzed. The frequency of pediatric visits (

    View details for DOI 10.1542/peds.111.2.e162

    View details for PubMedID 12563090

  • Adolescent girls' use of the Internet for health information: issues beyond access. Journal of medical systems Gray, N. J., Klein, J. D., Cantrill, J. A., Noyce, P. R. 2002; 26 (6): 545-53


    Whilst the "digital divide" in access to Internet technology has rightly concerned commentators on health inequalities, there are issues beyond physical access that must be tackled if adolescents and adults are to optimize the benefits of this developing medium. Emerging themes from an exploratory qualitative study of adolescents' use of the Internet for information about health and medicines describe four major challenges. Access issues persist if there are insufficient school computers that are unable to cope with increasing Web site sophistication. Software on school-based machines preventing exposure to material that is deemed to be unsuitable may also prohibit access to educational sites about sexual health and drug misuse. Strategies to manage the volume of available information are needed. The interplay of active and passive information seeking challenges whether the Internet can be truly useful during acute illness episodes. This exploration with future health service users highlights important questions for further study.

    View details for DOI 10.1023/a:1020296710179

    View details for PubMedID 12385536

  • Adolescents' use of complementary and alternative medicine. Ambulatory pediatrics : the official journal of the Ambulatory Pediatric Association Wilson, K. M., Klein, J. D. 2002; 2 (2): 104-10


    To examine the prevalence of complementary and alternative medicine (CAM) use in a random sample of adolescents living in Monroe County, New York.Questions about use of a variety of CAM therapies in the previous 6 months were asked of adolescents during a random-digit-dial telephone survey.A total of 54% of the 361 adolescents surveyed had used at least 1 CAM remedy. The most frequently used therapies were massage (13.2%), prayer or faith healing (13.1%), herbs (11.5%), megadose vitamins (10.6%), and special exercises (10.1%). Natural performance enhancers were used by 14.7% of the boys, but less than 1% of the girls (P <.001). Use of health care without parental knowledge, time spent in school clubs, and perceived parental use and friend use of CAM were all associated with CAM use in a logistic regression model.More than half of the adolescents in this county use CAM therapies, and a significant number use pharmacologically active substances. Physicians treating adolescents should ask adolescents about CAM use.

    View details for DOI 10.1367/1539-4409(2002)002<0104:auocaa>;2

    View details for PubMedID 11926841

  • Prevention and risk of adolescent substance abuse. The role of adolescents, families, and communities. Pediatric clinics of North America Kodjo, C. M., Klein, J. D. 2002; 49 (2): 257-68


    Adolescents as young as 12 to 14 years of age are engaging in substance use [16]. Those who use substances are at risk for immediate and future consequences that affect morbidity and mortality. The theoretical models of substance use in adolescents provide a framework for understanding risk and protective factors. These risk and protective factors are pertinent to all contexts, including the individual traits, interpersonal relationships, and greater society. Knowledge of these factors should help the clinician in assessment of the individual adolescent. Knowledge of these factors also should help the clinician provide appropriate interventions. In the case of primary prevention, clinicians can advocate for families and communities to teach children how to be more goal-oriented, insightful, and in tune with their cultures and beliefs. Parents also can be encouraged to set clear limits, monitor their adolescents' behaviors, be good role models, and provide a loving and supportive environment. Advocacy to address some of the societal factors that are less easily changed also has its place. Addressing media portrayal of drug use, availability of substances, and poverty would have a broad impact on the problem of adolescent substance use and would help to improve the health status of many adolescents in the United States.

    View details for DOI 10.1016/s0031-3955(01)00003-7

    View details for PubMedID 11993282

  • Opportunities for appropriate care: health care and contraceptive use among adolescents reporting unwanted sexual intercourse. Archives of pediatrics & adolescent medicine Wilson, K. M., Klein, J. D. 2002; 156 (4): 341-4


    Unwanted sexual contact, reported by 30% to 42% of young women and 10% to 34% of young men, has been associated with negative health outcomes and increased teenaged pregnancy.To determine health services and contraceptive use among adolescents reporting unwanted sexual intercourse.Random-digit dial methods were used to survey 1040 adolescents in Monroe County, New York; 389 (37%) were sexually active and answered a question about whether they had ever been forced or pressured to have sexual intercourse. The data were weighted to reflect the county population.Among sexually active adolescents, 20% of females and 7% of males reported unwanted intercourse (P<.001). For 37% of male and 17% of female adolescents, the survey was the first time they had disclosed the incident (P =.17). Among female adolescents reporting unwanted intercourse, 91% have a usual source of care and 62% reported a well visit in the previous 6 months. Female adolescents reporting unwanted sex were more likely to have wanted contraceptives but not gotten them because of fear their parents would find out (32% vs 11%; P =.01) and to have had sex without contraception (69% vs 52%; P =.05) than those who had not had unwanted sex.Many adolescents have been forced or pressured to have sexual intercourse. Although many have never told anyone about the incident, most have visited a primary care physician or clinician. Physicians and other clinicians should screen for a history of unwanted intercourse and provide needed referrals for counseling and/or contraceptive information.

    View details for DOI 10.1001/archpedi.156.4.341

    View details for PubMedID 11929367

  • Delivering quality care: adolescents' discussion of health risks with their providers. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Klein, J. D., Wilson, K. M. 2002; 30 (3): 190-5


    To compare adolescents' report of topics they wanted to discuss with their providers with what they actually discussed, and whether they talked to their providers about their self-reported health risks.We analyzed the 1997 Commonwealth Fund Survey of the Health of Adolescent Girls, a nationally representative sample of 6728 in-school adolescent boys and girls in 5th through 12th grade. Respondents reported on health risks, whether they believed their provider should discuss certain topics, and whether their provider did talk about health-related topics. Logistic regression was used to compare proportions and assess the associations among variables.Adolescents most frequently discussed healthy dietary habits (49%), weight (43%), and exercise (41%) with their clinicians but most frequently wanted to discuss drugs (65%), smoking (59%), and healthy dietary habits (57%). Overall, 70.9% of the sample reported at least one of eight potential health risks, but 63% of these adolescents had not spoken to their doctor about any of these risks. Using logistic regression models, having a female provider (odds ratio [OR] 1.41), obtaining health care information from a doctor (OR 1.72) and from the Internet (OR 1.50), speaking privately with their provider (OR 1.45), and reporting more total risk factors (OR 1.59) were each associated with having discussed any risks.Adolescents want and need to discuss health care issues with their providers but often do not. Providing quality preventive care to adolescents will require increased physician screening and counseling about these issues.

    View details for DOI 10.1016/s1054-139x(01)00342-1

    View details for PubMedID 11869926