(99) The Kids are Not Alright: Missed Opportunities for Inpatient Adolescent Nicotine Screening

Background & Introduction: The most commonly used tobacco product in U.S. middle school and high school students is e-cigarettes.1 The U.S. Preventive Services Task Force and the American Academy of Pediatrics recommend tobacco screening for this population in the outpatient setting; however, adolescents are less likely to attend routine health supervision appointments than younger children, indicating a need for additional screening venues.2,3 Inpatient hospitalization is another opportunity to screen for nicotine use and offer nicotine replacement therapy (NRT) when indicated. Inpatient screening may not only identify adolescents who would like to cease or reduce their nicotine use, but also could identify adolescents at risk for nicotine withdrawal during hospitalization. Prior research has identified low tobacco screening rates among hospitalized adolescents.4 Limitations of previous work include the possibility that some adolescents may not consider e-cigarettes to be tobacco products, leading to inaccurate screening data.4 The objective of the current study was to identify frequency of nicotine screening and factors associated with screening in hospitalized adolescents. The study adds to previous research on a specific understudied population (hospitalized adolescents) and expands upon the types of tobacco products included in screening.

Methods: A retrospective cohort study was performed of all inpatient hospital admissions of patients aged 11 to 22 years occurring between January 2020 and January 2022 at a freestanding, children’s, teaching hospital. Eligible admissions were extracted from the electronic medical record by a data analyst from the institutional information technology (IT) resource center. Manual chart extraction was deemed necessary as nicotine use was not consistently documented in the “IT extractable” social history section of the electronic medical record. Other places that nicotine screening was documented included the admission history and physical or a separate confidential adolescent history note. Manual chart review involved searching each unique admission for any documentation of “nicotine,” “vape,” “smoke,” “tobacco,”, “NRT” and “cigar.” The main study outcome was nicotine screened (yes/no). A patient was considered screened if there was documentation of nicotine or tobacco use in an electronic note anytime during the admission. Descriptive statistics included means (standard deviations) for continuous variables and counts (percentages for categorical variables. Chi-square and t-tests were used, as appropriate, to explore unadjusted associations between factors and nicotine screening. Stepwise, multivariable logistic regression was used to identify factors independently associated with nicotine screening.

Results: There were 9597 admissions during the study period for patients 11 years old through 22 years old. The mean age of the study population was 15.5 (±2.5) years. Documentation of nicotine screening occurred in 5932 (62%) of these admissions. Among admissions where screening provider was documented (n=5939), the practitioner completing the screening was most commonly a resident physician (n=2199, 37%), followed by nurse practitioner (n=1349, 23%), and then attending physician (n=883, 15%). In unadjusted analyses, hospital admitting service (p < 0.001), age (p < 0.001), biologic sex (p < 0.001) and race (p < 0.002) were all significantly associated with odds of being screened. Nicotine screening occurred in 96% of admissions to psychiatry, 69% of admissions to surgical subspecialties, 68% of admissions to intensive care units, 63% of admissions to general hospital pediatrics and 45% of admissions to pediatric medical subspecialties. Mean age was higher among those screened compared to those not screened (15.7 ± 2.4 vs. 15.2 ± 2.6 years), and a higher percentage of female patients were screened as compared to males (66% females vs. 58% males). Percentage of adolescents screened for nicotine use varied by race (71% Native American, 67% multiracial, 63% white, 59% Black, 57% Asian, and 56% not reported). In multivariable modeling, admitting service, sex, and age remained independently associated with odds of being screened, whereas race did not. Relative to the general hospital pediatrics service, admissions to psychiatry had highest odds of being screened for nicotine (OR 17.0, 95% CI 12.7 – 22.8) while admissions to pediatric medical subspecialty teams had a decreased odds of being screened (OR 0.37, 95% CI 0.31 – 0.44). Female patients had higher odds than males of being screened (OR 1.18, 95% CI 1.08 – 1.29), and with every additional year of age, odds of being screened rose by 13% (OR 1.13, 95% CI 1.12 – 1.15).

Conclusion & Discussion: Screening for nicotine use was documented in the majority of adolescent hospital admissions. The screening rate in the current study was higher than that reported in previous studies of inpatient adolescents.4 This could be due to the broad list of search terms used to define nicotine screening in the current study. The results also illustrate significant variability in frequency of nicotine screening based on admitting service. This may reflect differences in perceived dangers of nicotine use by different specialty providers. It is important to recognize that regardless of the admitting service or diagnosis, nicotine withdrawal may complicate an adolescent’s clinical picture causing symptoms such as irritability, tremors, headaches, insomnia, or gastrointestinal discomfort. The increased odds of being screened based on age, sex, or race likely reflect an incorrect belief that only certain adolescents use nicotine, underscoring the need for systematic, standardized screening of all youth. Future work should focus on building a workflow for systematic nicotine screening and documentation for adolescents admitted to all hospital pediatric services.

References: 1. Products, Center for Tobacco. “Results from the Annual National Youth Tobacco Survey (NYTS).” U.S. Food and Drug Administration, FDA, www.fda.gov/tobacco-products/youth-and-tobacco/results-annual-national-youth-tobacco-survey#2024%20Findings%20on%20Youth%20Tobacco%20Use. Accessed 22 Jan. 2025.
2. “Tobacco Use in Children and Adolescents: Primary Care Interventions.” Recommendation: Tobacco Use in Children and Adolescents: Primary Care Interventions | United States Preventive Services Taskforce, US Preventive Services Taskforce, 28 Apr. 2020, www.uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-and-nicotine-use-prevention-in-children-and-adolescents-primary-care-interventions.
3. Brian P. Jenssen, Susan C. Walley, Rachel Boykan, Alice Little Caldwell, Deepa Camenga, SECTION ON NICOTINE AND TOBACCO PREVENTION AND TREATMENT, COMMITTEE ON SUBSTANCE USE AND PREVENTION, SECTION ON NICOTINE AND TOBACCO PREVENTION AND TREATMENT, COMMITTEE ON SUBSTANCE USE AND PREVENTION; Protecting Children and Adolescents From Tobacco and Nicotine. Pediatrics May 2023; 151 (5): e2023061806. 10.1542/peds.2023-061806
4. Ashley Alexander, Rachel Honan, Adolfo Molina, A.K.M. Fazlur Rahman, Susan C. Walley; Tobacco Screening and Use in Hospitalized Adolescents at a Children’s Hospital. Hosp Pediatr June 2021; 11 (6): 605–612.
5. Centers for Disease Control and Prevention. (n.d.). Youth and tobacco use. U.S. Department of Health and Human Services. Retrieved January 22, 2025, from https://www.cdc.gov/tobacco/php/data-statistics/youth-data-tobacco/index.html