National Healthcare Quality and Disparities Report
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AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
101 to 125 of 301 Research Studies DisplayedLewis JA, Senft N, Chen H
Evidence-based smoking cessation treatment: a comparison by healthcare system.
The authors surveyed general medicine providers and specialists in a large academic health center (AHC) and its affiliated Veterans Health Administration (VHA) in the Mid-South in 2017 to determine the cross-sectional association of healthcare system in which the provider practiced (AHC versus VHA) with self-reported provision of evidence-based smoking cessation treatment at least once in the past 12 months. They found that VHA healthcare providers were significantly more likely to provide evidence-based smoking cessation treatment compared to AHC healthcare providers.
AHRQ-funded; HS026122.
Citation: Lewis JA, Senft N, Chen H .
Evidence-based smoking cessation treatment: a comparison by healthcare system.
BMC Health Serv Res 2021 Jan 7;21(1):33. doi: 10.1186/s12913-020-06016-5..
Keywords: Health Systems, Tobacco Use: Smoking Cessation, Tobacco Use, Evidence-Based Practice, Substance Abuse
Magee LA, Fortenberry JD, Rosenman M
Two-year prevalence rates of mental health and substance use disorder diagnoses among repeat arrestees.
Investigators examined the prevalence of mental health and substance use diagnoses among arrestees and repeat arrestees to identify opportunities for intervention. Their retrospective cohort study linked police arrest and clinical care data at the individual level for persons arrested in Indianapolis, Indiana, in 2016. They found that linked clinical and criminal justice data systems identified individuals at risk of repeat arrest and informed opportunities for interventions aimed at low-level offenders with behavioral health needs.
AHRQ-funded; HS023318.
Citation: Magee LA, Fortenberry JD, Rosenman M .
Two-year prevalence rates of mental health and substance use disorder diagnoses among repeat arrestees.
Health Justice 2021 Jan 7;9(1):2. doi: 10.1186/s40352-020-00126-2..
Keywords: Behavioral Health, Substance Abuse, Vulnerable Populations
Wyse J, Simmons A, Ramachandran B
"I don't mind doing what it takes to be safe." Patient perspectives of urine drug testing for pain.
This study sought to uncover patients’ beliefs regarding UDT and its implications for the patient–clinician relationship. Urine drug testing (UDT) is a standard recommendation for those prescribed long-term opioid therapy (LTOT) for pain but remains underutilized. Clinician fears regarding negative patient perceptions have been identified as a barrier to conducting UDT; however, little is known about patient perspectives of UDT.
AHRQ-funded; HS026370.
Citation: Wyse J, Simmons A, Ramachandran B .
"I don't mind doing what it takes to be safe." Patient perspectives of urine drug testing for pain.
J Gen Intern Med 2021 Jan;36(1):243-44. doi: 10.1007/s11606-020-05688-3..
Keywords: Pain, Chronic Conditions, Opioids, Medication, Medication: Safety, Patient Safety, Substance Abuse
Salvador JG, Bhatt SR, Jacobsohn VC
Feasibility and acceptability of an online ECHO intervention to expand access to medications for treatment of opioid use disorder, psychosocial treatments and supports.
This study examined acceptability and feasibility of an online Extensions for Community Healthcare Outcomes (ECHO) model intervention developed to support rural primary care clinics to expand treatment and is part of a larger study tracking the impact of participation in this ECHO on expansion of medications for opioid use disorder (MOUD) in rural primary care. Using qualitative interviews and post-session questionnaires across 27 rural clinics in New Mexico, findings suggested evidence of feasibility and acceptability of MOUD ECHO to support expansion of this treatment.
AHRQ-funded; HS025345.
Citation: Salvador JG, Bhatt SR, Jacobsohn VC .
Feasibility and acceptability of an online ECHO intervention to expand access to medications for treatment of opioid use disorder, psychosocial treatments and supports.
Subst Abus 2021;42(4):610-17. doi: 10.1080/08897077.2020.1806184..
Keywords: Opioids, Substance Abuse, Behavioral Health, Medication, Access to Care, Rural Health, Primary Care, Patient-Centered Healthcare
Tong ST, Kato EU, Nix MP
AHRQ Author: Tong ST, Kato EU, Nix, MP, Bierman, AS
Help for primary care practitioners in addressing older adult alcohol and opioid use.
Unhealthy alcohol and opioid use are growing problems among older adults who are at increased risk for harms from both alcohol and opioid use. Primary care practices can play an important role in addressing this problem, but need support in implementing evidence-based practices. This article provides help for primary care practitioners in addressing older adult alcohol and opioid use.
AHRQ-authored.
Citation: Tong ST, Kato EU, Nix MP .
Help for primary care practitioners in addressing older adult alcohol and opioid use.
Generations Journal 2020-2021 Winter;44(4)..
Keywords: Elderly, Primary Care, Alcohol Use, Opioids, Substance Abuse, Behavioral Health
Ali MM, McClellan C, West KD
AHRQ Author: McClellan C
Medical marijuana laws, marijuana use, and opioid-related outcomes among women in the United States.
This study examined whether state medical marijuana laws (MMLs) was associated with lower levels of opioid-related outcomes. Data was drawn from the 2002-2014 National Survey on Drug Use and Health to compare opioid misuse in states with and without MMLs among all women, pregnant women, and parenting women. It also invested the impact of MMLs on marijuana use and marijuana use disorder. There was found to be no association of MMLs with opioid misuse, opioid misuse initiation, or opioid use disorder among all women, pregnant women and parenting women. However there was a positive correlation with marijuana use and marijuana use disorder among all women and women with children. MMLs were also associated with an increase in the frequency of opioid misuse in pregnant women and a decrease in the frequency of opioid misuse for parenting women.
AHRQ-authored.
Citation: Ali MM, McClellan C, West KD .
Medical marijuana laws, marijuana use, and opioid-related outcomes among women in the United States.
Womens Health Issues 2021 Jan-Feb;31(1):24-30. doi: 10.1016/j.whi.2020.09.003..
Keywords: Women, Opioids, Substance Abuse, Medication, Policy, Practice Patterns
Chan B, Gean E, Arkhipova-Jenkins I
Retention strategies for medications for opioid use disorder in adults: a rapid evidence review.
This AHRQ-sponsored rapid evidence review looked at studies which include interventions to improve medications for opioid use disorder (MOUD) retention. A search of MEDLINE and the Cochrane Library from February 2009 to August 2019 was conducted for systematic reviews and randomized trials of care settings, services, logistical support, continency management, HIT, extended-release (XR) formulations, and psychosocial interventions that assessed retention for at least 3 months. Two systematic reviews and 39 primary studies were included. Some studies showed initiating MOUD in soon-to-be-released incarcerated people improved retention following release. Fewer than half the studies reviewed focused on retention as a primary outcome.
AHRQ-funded; 290201700003C; HS022981.
Citation: Chan B, Gean E, Arkhipova-Jenkins I .
Retention strategies for medications for opioid use disorder in adults: a rapid evidence review.
J Addict Med 2020 Jan-Feb;15(1):74-84. doi: 10.1097/adm.0000000000000739..
Keywords: Opioids, Substance Abuse, Medication, Evidence-Based Practice
Chan B, Freeman M, Ayers C
A systematic review and meta-analysis of medications for stimulant use disorders in patients with co-occurring opioid use disorders.
This systematic review and meta-analysis looked at medication efficacy for stimulant use disorders in patients with co-occurring opioid use disorders. Multiple databases were searched through April 2019 for randomized controlled trials, and dual-screened studies using pre-specified inclusion criteria. Thirty-four trials of 22 medications focused on cocaine use disorder in patients with opioid use disorder. Most studies used methadone treatment for patients with opioid use disorder. Primary outcomes were abstinence, defined as stimulant-negative urine for three or more consecutive weeks. However, none of the six studies that assessed abstinence found significant differences among groups. The authors found moderate strength evidence that antidepressants and disulfiram worsened treatment retention. There was low-strength evidence that psychostimulants reduced cocaine use. There was only 1 trial for methamphetamine use disorder which had insufficient strength evidence for naltrexone.
AHRQ-funded; HS022981.
Citation: Chan B, Freeman M, Ayers C .
A systematic review and meta-analysis of medications for stimulant use disorders in patients with co-occurring opioid use disorders.
Drug Alcohol Depend 2020 Nov 1;216:108193. doi: 10.1016/j.drugalcdep.2020.108193..
Keywords: Opioids, Substance Abuse, Medication, Evidence-Based Practice
Matson TE, Lapham GT, Bobb
Cannabis use, other drug use, and risk of subsequent acute care in primary care patients.
This study evaluated whether self-reported frequency of cannabis or other drug use was associated with subsequent acute care. Using EHR and claims data from 8 sites in Washington State that implemented annual substance use screening, findings showed that those reporting cannabis use less than monthly or daily had greater risk of acute care during follow-up than those reporting no use. Patients reporting other drug use less than monthly, weekly, or daily had greater risk of acute care than those reporting no other drug use. It is unclear whether findings will generalize to U.S. states with broader racial/ethnic diversity.
AHRQ-funded; HS023173.
Citation: Matson TE, Lapham GT, Bobb .
Cannabis use, other drug use, and risk of subsequent acute care in primary care patients.
Drug Alcohol Depend 2020 Nov 1;216:108227. doi: 10.1016/j.drugalcdep.2020.108227..
Keywords: Substance Abuse, Primary Care, Emergency Department
Yang J, Landrum MB, Zhou L
Disparities in outpatient visits for mental health and/or substance use disorders during the COVID surge and partial reopening in Massachusetts.
The purpose of this study was to examine changes in outpatient visits for mental health and/or substance use disorders (MH/SUD) in an integrated healthcare organization during the initial Massachusetts COVID-19 surge and partial state reopening. The investigators concluded that MH/SUD visit volume increased during the COVID surge and was supported by rapidly-scaled telemedicine.
AHRQ-funded; HS025375.
Citation: Yang J, Landrum MB, Zhou L .
Disparities in outpatient visits for mental health and/or substance use disorders during the COVID surge and partial reopening in Massachusetts.
Gen Hosp Psychiatry 2020 Nov-Dec;67:100-06. doi: 10.1016/j.genhosppsych.2020.09.004..
Keywords: Behavioral Health, Substance Abuse, COVID-19, Disparities, Access to Care, Ambulatory Care and Surgery, Telehealth, Health Information Technology (HIT)
Althoff KN, Leifheit KM, Park JN
Opioid-related overdose mortality in the era of fentanyl: monitoring a shifting epidemic by person, place, and time.
Investigators described US trends in opioid-related overdose mortality rates by race, age, urbanicity, and opioid type before and after the emergence of fentanyl. Using the CDC’s WONDER database, they found a disproportionate increase in opioid-related overdose deaths among urban non-Hispanic Black Americans and recommended interventions for this population in order to halt the increase in overdose deaths.
AHRQ-funded; HS000046.
Citation: Althoff KN, Leifheit KM, Park JN .
Opioid-related overdose mortality in the era of fentanyl: monitoring a shifting epidemic by person, place, and time.
Drug Alcohol Depend 2020 Nov 1;216:108321. doi: 10.1016/j.drugalcdep.2020.108321..
Keywords: Opioids, Medication, Substance Abuse, Mortality, Racial and Ethnic Minorities, Social Determinants of Health
Dir AL, Clifton RL
Patterns of drug screen results and court-ordered substance use treatment referrals and completion among justice-involved youth
This study examined court records of drug screens among youth to explore patterns of substance use as well as rates of court-ordered referral to substance use treatment and treatment completion. Of the studied youth with a positive oral drug screen, 96% tested positive for cannabis and 9.8% for opioids at least once; 48.5% were court-ordered to substance use treatment. Of those referred, 67% had history of completing at least one treatment episode. These results underscore the need to utilize objective measures as well as validated self-reports of substance use history in both research and justice system decision-making to aid in identifying youth in need of services.
AHRQ-funded; HS022681; HS023318.
Citation: Dir AL, Clifton RL .
Patterns of drug screen results and court-ordered substance use treatment referrals and completion among justice-involved youth
J Subst Abuse Treat 2020 Nov;118:108095. doi: 10.1016/j.jsat.2020.108095..
Keywords: Children/Adolescents, Substance Abuse, Screening, Vulnerable Populations
Kolak MA, Chen YT, Joyce S
Rural risk environments, opioid-related overdose, and infectious diseases: a multidimensional, spatial perspective.
The authors adapted a risk environment framework to characterize rural southern Illinois and to describe the relations of risk environments, opioid-related overdose, HIV, Hepatitis C, and sexually transmitted infection rates between 2015 and 2017. They identified pervasive risk hotspots in more populated locales with higher rates of overdose and HCV incidence, whereas emerging risk areas were isolated to more rural locales that had experienced an increase in analgesic opiate overdoses and generally lacked harm-reduction resources. They also found that at-risk areas were characterized with underlying socioeconomic vulnerability but in differing ways, reflecting a nuanced and shifting structural risk landscape.
AHRQ-funded; HS022433.
Citation: Kolak MA, Chen YT, Joyce S .
Rural risk environments, opioid-related overdose, and infectious diseases: a multidimensional, spatial perspective.
Int J Drug Policy 2020 Nov;85:102727. doi: 10.1016/j.drugpo.2020.102727..
Keywords: Rural Health, Opioids, Substance Abuse, Medication, Hepatitis, Risk, Behavioral Health
Mills J, Wonoprabowo L
AHRQ Author: Mills J
Primary care-based interventions to prevent illicit drug use in children, adolescents, and young adults.
This case study concerns a 14-year-old patient who presents for a well-child visit. The patient eats a healthy diet, is part of a local soccer league, is an overall good student, and just started high school in the fall. The patient denies trying any illicit substances but reports trying to “get high” from cough syrup. Three questions are presented, and answers provided.
AHRQ-authored.
Citation: Mills J, Wonoprabowo L .
Primary care-based interventions to prevent illicit drug use in children, adolescents, and young adults.
Am Fam Physician 2020 Oct 15;102(8):493-94..
Keywords: Children/Adolescents, Young Adults, Substance Abuse, Primary Care, Prevention, U.S. Preventive Services Task Force (USPSTF), Case Study, Guidelines, Evidence-Based Practice
Thompson HM, Faig W, VanKim NA HM, Faig W, VanKim NA
Differences in length of stay and discharge destination among patients with substance use disorders: The effect of Substance Use Intervention Team (SUIT) consultation service.
Addiction medicine consultation services (ACS) may improve outcomes of hospitalized patients with substance use disorders (SUD). The aim of the study was to examine the difference in length of stay and the hazard ratio for a routine hospital discharge between SUD patients receiving and not receiving ACS. The authors concluded that the Substance Use Intervention Team (SUIT) consultation service was associated with a reduced length of stay and an increased hazard of a routine discharge.
AHRQ-funded; HS026385.
Citation: Thompson HM, Faig W, VanKim NA HM, Faig W, VanKim NA .
Differences in length of stay and discharge destination among patients with substance use disorders: The effect of Substance Use Intervention Team (SUIT) consultation service.
PLoS One 2020 Oct 9;15(10):e0239761. doi: 10.1371/journal.pone.0239761..
Keywords: Substance Abuse, Hospitalization, Inpatient Care, Hospital Discharge, Hospitals
Steele DW, Becker SJ, Danko KJ
Brief behavioral interventions for substance use in adolescents: a meta-analysis.
Adolescents with problematic substance use (SU) are at risk for far-reaching adverse outcomes. The objective of this study was to synthesize the evidence regarding the effects of brief behavioral interventions for adolescents (12-20 years) with problematic SU. The investigators concluded that the use of a behavioral intervention called motivational interviewing reduced heavy alcohol use, alcohol use days, and SU-related problems in adolescents but did not reduce cannabis use days.
AHRQ-funded; 290201500002I.
Citation: Steele DW, Becker SJ, Danko KJ .
Brief behavioral interventions for substance use in adolescents: a meta-analysis.
Pediatrics 2020 Oct;146(4):e2020351. doi: 10.1542/peds.2020-0351..
Keywords: Children/Adolescents, Substance Abuse, Alcohol Use, Treatments
Alley L, Novak K, Havlin T
Development and pilot of a prescription drug monitoring program and communication intervention for pharmacists
The authors developed the Resources Encouraging Safe Prescription Opioid and Naloxone Dispensing (RESPOND) Toolkit to enhance community pharmacists' understanding of their role in addressing opioid safety; to improve integration of prescription drug monitoring program (PDMP) into daily workflow; and to enhance communication between pharmacists, prescribers, and patients. In this paper, they described the development of the RESPOND Toolkit and summarized their findings from initial pilot testing. They concluded that the RESPOND Toolkit has promise as an effective and scalable approach to providing community pharmacist-tailored training to promote behavioral shifts supporting opioid safety for patients.
AHRQ-funded; HS024227.
Citation: Alley L, Novak K, Havlin T .
Development and pilot of a prescription drug monitoring program and communication intervention for pharmacists
Res Social Adm Pharm 2020 Oct;16(10):1422-30. doi: 10.1016/j.sapharm.2019.12.023..
Keywords: Opioids, Substance Abuse, Medication, Medication: Safety, Patient Safety, Tools & Toolkits, Communication, Provider: Pharmacist, Provider, Training
Donovan E, Bratberg J, Baird J
Pharmacy leaders' beliefs about how pharmacies can support a sustainable approach to providing naloxone to the community.
The objective of this qualitative study was to understand how leaders in pharmacy organizations perceive pharmacies and pharmacy staff can optimize dispensing of naloxone. Five main themes emerged: importance of staff training to increase comfort; strength through coordination of efforts; pharmacies acting as community leaders in the opioid crisis; persisting stigma; ongoing workflow challenges. These results uniquely reflect the experiences and insights of pharmacy leaders implementing public health initiatives during the opioid crisis and can be used for gaining insight into how pharmacists can efficiently provide naloxone to their communities.
AHRQ-funded; HS024021.
Citation: Donovan E, Bratberg J, Baird J .
Pharmacy leaders' beliefs about how pharmacies can support a sustainable approach to providing naloxone to the community.
Res Social Adm Pharm 2020 Oct;16(10):1493-97. doi: 10.1016/j.sapharm.2020.01.006..
Keywords: Provider: Pharmacist, Provider, Community-Based Practice, Opioids, Medication, Substance Abuse
Zittleman L, Curcija K, Sutter C
Building capacity for medication assisted treatment in rural primary care Practices: the IT MATTTRs practice team training.
In response to rural communities and practice concerns related to opioid use disorder (OUD), the Implementing Technology and Medication Assisted Treatment Team Training in Rural Colorado study (IT MATTTRs) developed a training intervention for full primary care practice (PCP) teams in MAT for OUD. This evaluation reports on training implementation, participant satisfaction, and impact on perceived ability to deliver MAT.
AHRQ-funded; HS025065.
Citation: Zittleman L, Curcija K, Sutter C .
Building capacity for medication assisted treatment in rural primary care Practices: the IT MATTTRs practice team training.
J Prim Care Community Health 2020 Jan-Dec;11:2150132720953723. doi: 10.1177/2150132720953723..
Keywords: Medication, Primary Care, Opioids, Substance Abuse, Rural Health, Training, Education: Continuing Medical Education
Eaton EF, Lee RA, Westfall AO
An integrated hospital protocol for persons with injection-related infections may increase medications for opioid use disorder use but challenges remain.
This study looked at whether a hospital-based protocol would increase the use of medications for opioid use disorder (MOUD) for persons who are hospitalized for infectious complications. Participants who received care for an infection at the University of Alabama at Birmingham Hospital from 2015 to 2018 were included. The protocol included use of an intravenous antibiotic and addiction team (IVAT) consultation and a 9-item risk assessment. The percentage of patients with OUD receiving MOUD increased significantly with IVAT (29% to 37%) and MOUD use was higher in “high risk” participants (62%). However, the uptake of MOUD remains suboptimal at less than 50%.
AHRQ-funded; HS023009.
Citation: Eaton EF, Lee RA, Westfall AO .
An integrated hospital protocol for persons with injection-related infections may increase medications for opioid use disorder use but challenges remain.
J Infect Dis 2020 Sep 2;222(Suppl 5):S499-s505. doi: 10.1093/infdis/jiaa005..
Keywords: Opioids, Substance Abuse, Medication, Infectious Diseases, Hospitals
McClellan C, Maclean JC, Saloner B
AHRQ Author: McClellan C
Integrated care models and behavioral health care utilization: quasi-experimental evidence from Medicaid health homes.
This study provided the first population-level evidence on the effects of Medicaid health homes (HH) on behavioral health care service use. As of 2016, 16 states had adopted an HH for enrollees with serious mental illness and/or substance use disorder. Using data from the National Survey on Drug Use and Health, the authors found that HH adoption increased service use among enrollees and enrollee self-reported health improved post-HH.
AHRQ-authored.
Citation: McClellan C, Maclean JC, Saloner B .
Integrated care models and behavioral health care utilization: quasi-experimental evidence from Medicaid health homes.
Health Econ 2020 Sep;29(9):1086-97. doi: 10.1002/hec.4027..
Keywords: Behavioral Health, Medicaid, Substance Abuse, Primary Care: Models of Care, Primary Care, Ambulatory Care and Surgery, Patient-Centered Outcomes Research
Eaton EF, Vettese T
Management of opioid use disorder and infectious disease in the inpatient setting.
Interactions between patients with acute bacterial infections and acute care physicians provide an opportunity to diagnose opioid use disorder (OUD) and treat patients with medications for OUD. This paper discusses Addiction Medicine Consultation and, when this resource is unavailable, employing infectious diseases providers, hospitalists, and other clinicians to serve a valuable role in the diagnosis and treatment of OUD.
AHRQ-funded; HS023009.
Citation: Eaton EF, Vettese T .
Management of opioid use disorder and infectious disease in the inpatient setting.
Infect Dis Clin North Am 2020 Sep;34(3):511-24. doi: 10.1016/j.idc.2020.06.008..
Keywords: Opioids, Medication, Substance Abuse, Infectious Diseases, Inpatient Care
Green TC, Donovan E, Klug B
Revisiting pharmacy-based naloxone with pharmacists and naloxone consumers in 2 states: 2017 perspectives and evolving approaches.
The authors sought to examine similarities and differences in experiences obtaining naloxone at the pharmacy over a 1-year period in 2 states, and to explore reactions from people with opioid use disorder, patients taking opioids for chronic pain, caregivers of opioid users, and pharmacists to communication tools and patient outreach materials designed to improve naloxone uptake. Through focus groups in Massachusetts and Rhode Island, they found that experiences dispensing naloxone are quickly evolving, and a greater diversity of patients are obtaining pharmacy naloxone. They concluded that persistent stigma-related concerns underscore the need for tools to help pharmacists offer naloxone, facilitate patient requests, and provide reassurance when getting naloxone.
AHRQ-funded; HS024021.
Citation: Green TC, Donovan E, Klug B .
Revisiting pharmacy-based naloxone with pharmacists and naloxone consumers in 2 states: 2017 perspectives and evolving approaches.
J Am Pharm Assoc (2003) 2020 Sep-Oct;60(5):740-49. doi: 10.1016/j.japh.2020.03.005..
Keywords: Opioids, Medication, Substance Abuse, Community-Based Practice, Healthcare Delivery, Social Stigma, Access to Care
Shoemaker-Hunt SJ, Wyant BE
The effect of opioid stewardship interventions on key outcomes: a systematic review.
In this study, the investigators sought to identify potential patient safety practices to reduce high-risk opioid prescribing. They conducted a systematic review of the literature to identify opioid stewardship (OS) strategies implemented in primary care and other settings. The investigators concluded that the strength of the evidence was low to moderate that OS efforts decreased numbers of opioid prescriptions, proportion of patients on long-term opioids, or days' supply. The strength of the evidence for OS initiatives producing significant reductions in opioid dosages was moderate.
AHRQ-funded; 233201500013I.
Citation: Shoemaker-Hunt SJ, Wyant BE .
The effect of opioid stewardship interventions on key outcomes: a systematic review.
J Patient Saf 2020 Sep;16(3S Suppl 1):S36-s41. doi: 10.1097/pts.0000000000000710..
Keywords: Opioids, Medication, Medication: Safety, Patient Safety, Evidence-Based Practice, Patient-Centered Outcomes Research, Substance Abuse, Prevention
Fan T, Smith HJ
AHRQ Author: Fan T
Primary care interventions for prevention and cessation of tobacco use in children and adolescents.
In this case study, three questions are posed concerning a 13-year-old girl presenting for a routine well-child visit who reports that she has never used tobacco products in any form.
AHRQ-authored.
Citation: Fan T, Smith HJ .
Primary care interventions for prevention and cessation of tobacco use in children and adolescents.
.
Keywords: U.S. Preventive Services Task Force (USPSTF), Case Study, Children/Adolescents, Tobacco Use: Smoking Cessation, Tobacco Use, Primary Care, Prevention, Substance Abuse