Human Papillomavirus Vaccine Completion by 13: A Quality Improvement Initiative in a Large Primary Care Network.

OBJECTIVE: Fewer than 40% of U.S. children complete the human papillomavirus (HPV) vaccine series before their 13th birthday. In our large pediatric primary care network, HPV vaccine completion rate by age 13 was 30%. We hypothesized that a phased quality improvement (QI) initiative would increase rates of HPV vaccine completion by age 13 across our network. METHODS: This QI initiative was conducted in a network of 30 practices located across two states, in urban and suburban settings, consisting of teaching and non-teaching clinics, and ranging in size from three to 50 providers per office. We used a phased approach incorporating multicomponent network-wide and iterative practice-specific interventions. Key interventions included: updating clinical decision support to default order HPV vaccine due at preventive visits starting at age nine instead of 11, data audit and feedback to providers and practices, encouraging use of a strong provider recommendation, and standing orders. RESULTS: From April 2019 to October 2022, HPV vaccine completion by age 13 across our network increased from 30% to 55% and met criteria for special cause variation on statistical process control charts. A gap in median HPV vaccine completion by age 13 between patients with public insurance and patients with private or commercial insurance decreased from 9% to 1%. CONCLUSION: A QI initiative was associated with a sustained increase in HPV vaccine series completion by age 13 and reduced variation in care across a large network of 30 primary care practices.

Cumulative Health Vulnerabilities Among Adolescents by Age and Neighborhood Opportunity.

BACKGROUND AND OBJECTIVES: Early detection of health vulnerabilities in adolescents is integral to promoting healthy behaviors into adulthood. Our objective was to quantify the prevalence of health vulnerabilities among adolescents and examine differences by age and neighborhood opportunity. METHODS: In a cross-sectional analysis of electronic health record data for adolescents aged 13 to 18 years with preventive visits in a large pediatric primary care network between September 2021 and September 2022, we examined 5 health vulnerabilities: Tobacco use, substance use, firearm access, condomless intercourse, and depressive symptoms. Health vulnerabilities were assessed via self-reported adolescent health questionnaire and the validated Patient Health Questionnaire-Modified. Prevalence of health vulnerabilities were calculated alone and in combination, and compared by age and by quintile of neighborhood Child Opportunity Index (COI) score. Multivariable logistic regression estimated associations of neighborhood COI with reporting ≥2 health vulnerabilities. RESULTS: Among 40 197 adolescents (57.7% aged 13-15 years, 66.3% living in "high"/"very high" COI neighborhoods), 29.7% reported at least 1 health vulnerability and 7.9% reported ≥2 vulnerabilities. Cumulative health vulnerabilities were more prevalent among older adolescents and adolescents from lower opportunity neighborhoods. In adjusted models, lower COI was associated with 65% higher odds of having ≥2 vulnerabilities (odds ratio 1.65, 95% confidence interval 1.43-1.91) compared with adolescents from the highest COI quintile. CONCLUSIONS: Understanding the relationship between health vulnerabilities and neighborhood opportunities among adolescents may allow pediatric primary care providers and health systems to offer more tailored community support services and transdiagnostic specialized care navigation to address the health needs of teens with multiple vulnerabilities.

Cluster Randomized Pragmatic Clinical Trial Testing Behavioral Economic Implementation Strategies to Improve Tobacco Treatment for Patients With Cancer Who Smoke.

PURPOSE: Few cancer centers systematically engage patients with evidence-based tobacco treatment despite its positive effect on quality of life and survival. Implementation strategies directed at patients, clinicians, or both may increase tobacco use treatment (TUT) within oncology. METHODS: We conducted a four-arm cluster-randomized pragmatic trial across 11 clinical sites comparing the effect of strategies informed by behavioral economics on TUT engagement during oncology encounters with cancer patients. We delivered electronic health record (EHR)-based nudges promoting TUT across four nudge conditions: patient only, clinician only, patient and clinician, or usual care. Nudges were designed to counteract cognitive biases that reduce TUT engagement. The primary outcome was TUT penetration, defined as the proportion of patients with documented TUT referral or a medication prescription in the EHR. Generalized estimating equations were used to estimate the parameters of a linear model. RESULTS: From June 2021 to July 2022, we randomly assigned 246 clinicians in 95 clusters, and collected TUT penetration data from their encounters with 2,146 eligible patients who smoke receiving oncologic care. Intent-to-treat (ITT) analysis showed that the clinician nudge led to a significant increase in TUT penetration versus usual care (35.6% v 13.5%; OR = 3.64; 95% CI, 2.52 to 5.24; P < .0001). Completer-only analysis (N = 1,795) showed similar impact (37.7% clinician nudge v 13.5% usual care; OR = 3.77; 95% CI, 2.73 to 5.19; P < .0001). Clinician type affected TUT penetration, with physicians less likely to provide TUT than advanced practice providers (ITT OR = 0.67; 95% CI, 0.51 to 0.88; P = .004). CONCLUSION: EHR nudges, informed by behavioral economics and aimed at oncology clinicians, appear to substantially increase TUT penetration. Adding patient nudges to the implementation strategy did not affect TUT penetration rates.

Protecting Children and Adolescents From Tobacco and Nicotine.

ABSTRACT: This technical report provides the evidence base for the accompanying tobacco clinical report and policy statement. It builds on, strengthens, and expands AAP recommendations from the previous version in 2015. Tobacco use remains the leading preventable cause of disease and death for adults in the United States. The tobacco epidemic takes a substantial toll on children's and adolescent's health, including harms because of prenatal exposure during pregnancy, secondhand and thirdhand exposure during infancy and childhood, and/or direct use during adolescence. Tobacco and nicotine use almost always starts in childhood or adolescence. Almost 40% of children aged 3 to 11 years are regularly exposed to secondhand tobacco smoke, and rates of secondhand exposure to e-cigarette aerosol have increased over the last decade.

Protecting Children and Adolescents From Tobacco and Nicotine.

Tobacco use remains the leading preventable cause of disease and death for adults in the United States. Significant strides have been made in reducing rates of cigarette smoking among adolescents in the United States. However, rates of e-cigarette and similar device use among youth are high, and rates of other tobacco product use, such as cigars and hookahs, have not declined. Public policy actions to protect children and adolescents from tobacco and nicotine use, as well as tobacco smoke and aerosol exposure, have proven effective in reducing harm. Effective public health approaches need to be both extended to include e-cigarettes, similar devices, and other and emerging tobacco products and expanded to reduce the toll that the tobacco epidemic takes on children and adolescents.

Protecting Children and Adolescents From Tobacco and Nicotine.

Significant strides have been made in reducing rates of cigarette smoking among adolescents in the United States. However, rates of e-cigarette and similar device use among youth are high, and rates of other tobacco product use, such as cigars and hookahs, have not declined. In addition, almost 40% of children 3 to 11 years of age are regularly exposed to secondhand tobacco smoke, and rates of secondhand exposure to e-cigarette aerosol have increased over the last decade. Pediatricians are uniquely positioned to help children, adolescents, and their families live tobacco-free lives. Actions by pediatricians can help reduce children's risk of developing tobacco and nicotine use disorder and reduce children's tobacco smoke and/or aerosol exposure.

A Clinical Decision Support System for Motivational Messaging and Tobacco Cessation Treatment for Parents: Pilot Evaluation of Use and Acceptance.

BACKGROUND: Research is needed to identify how clinical decision support (CDS) systems can support communication about and engagement with tobacco use treatment in pediatric settings for parents who smoke. We developed a CDS system that identifies parents who smoke, delivers motivational messages to start treatment, connects parents to treatment, and supports pediatrician-parent discussion. OBJECTIVE: The objective of this study is to assess the performance of this system in clinical practice, including receipt of motivational messages and tobacco use treatment acceptance rates. METHODS: The system was evaluated at one large pediatric practice through a single-arm pilot study from June to November 2021. We collected data on the performance of the CDS system for all parents. Additionally, we surveyed a sample of parents immediately after the clinical encounter who used the system and reported smoking. Measures were: (1) the parent remembered the motivational message, (2) the pediatrician reinforced the message, and (3) treatment acceptance rates. Treatments included nicotine replacement therapy, quitline referral (phone counseling), and/or SmokefreeTXT referral (text message counseling). We described survey response rates overall and with 95% confidence intervals (CIs). RESULTS: During the entire study period, 8,488 parents completed use of the CDS: 9.3% (n = 786) reported smoking and 48.2% (n = 379) accepted at least one treatment. A total of 102 parents who smoke who used the system were approached to survey 100 parents (98% response rate). Most parents self-identified as female (84%), aged 25 to 34 years (56%), and Black/African American (94%), and had children with Medicaid insurance (95%). Of parents surveyed, 54% accepted at least one treatment option. Most parents recalled the motivational message (79%; 95% CI: 71-87%), and 31% (95% CI: 19-44%) reported that the pediatrician reinforced the motivational message. CONCLUSION: A CDS system to support parental tobacco use treatment in pediatric primary care enhanced motivational messaging about smoking cessation and evidence-based treatment initiation.

Electronic Health Record-Embedded, Behavioral Science-Informed System for Smoking Cessation for the Parents of Pediatric Patients.

BACKGROUND: Helping parents quit smoking is a public health priority. However, parents are rarely, if ever, offered tobacco use treatment through pediatric settings. Clinical decision support (CDS) systems developed for the workflows of pediatric primary care may support consistent screening, treatment, and referral. OBJECTIVES: This study aimed to develop a CDS system by using human-centered design (HCD) that identifies parents who smoke, provides motivational messages to quit smoking (informed by behavioral science), and supports delivery of evidence-based tobacco treatment. METHODS: Our multidisciplinary team applied a rigorous HCD process involving analysis of the work environment, user involvement in formative design, iterative improvements, and evaluation of the system's use in context with the following three cohorts: (1) parents who smoke, (2) pediatric clinicians, and (3) clinic staff. Participants from each cohort were presented with scenario-based, high-fidelity mockups of system components and then provided input related to their role in using the CDS system. RESULTS: We engaged 70 representative participants including 30 parents, 30 clinicians, and 10 clinic staff. A key theme of the design review sessions across all cohorts was the need to automate functions of the system. Parents emphasized a system that presented information in a simple way, highlighted benefits of quitting smoking, and allowed direct connection to treatment. Pediatric clinicians emphasized automating tobacco treatment. Clinical staff emphasized screening for parent smoking via several modalities prior to the patient's visit. Once the system was developed, most parents (80%) reported that it was easy to use, and the majority of pediatricians reported that they would use the system (97%) and were satisfied with it (97%). CONCLUSION: A CDS system to support parental tobacco cessation in pediatric primary care, developed through an HCD process, proved easy to use and acceptable to parents, clinicians, and office staff. This preliminary work justifies evaluating the impact of the system on helping parents quit smoking.

Autism Spectrum Disorder Screening During the COVID-19 Pandemic in a Large Primary Care Network.

OBJECTIVE: To assess the impact of the COVID-19 pandemic on screening for autism spectrum disorder (ASD) and screening equity among eligible children presenting for well-child care in a large primary care pediatric network, we compared rates of ASD screening completion and positivity during the pandemic to the year prior, stratified by sociodemographic factors. METHODS: Patients who presented for in-person well-child care at 16 to 26 months between March 1, 2020 and February 28, 2021 (COVID-19 cohort, n = 24,549) were compared to those who presented between March 1, 2019 and February 29, 2020 (pre-COVID-19 cohort, n = 26,779). Demographics and rates of completion and positivity of the Modified Checklist for Autism in Toddlers with Follow-up (M-CHAT/F) were calculated from the electronic health record and compared by cohort using logistic regression models. RESULTS: Total eligible visits decreased by 8.3% between cohorts, with a greater decline in Black and publicly insured children. In the pre-COVID-19 cohort, 89.0% of eligible children were screened at least once, compared to 86.4% during the pandemic (P < 0.001). Significant declines in screening completion were observed across all sociodemographic groups except among Asian children, with the sharpest declines among non-Hispanic White children. Sociodemographic differences were not observed in screen-positive rates by cohort. CONCLUSIONS: Well-child visits and ASD screenings declined across groups, but with different patterns by race and ethnicity during the COVID-19 pandemic. Findings regarding screen-completion rates should not be interpreted as a decline in screening disparities, given differences in who presented for care. Strategies for catch-up screening for all children should be considered.

Promoting Healthy Childhood Behaviors With Financial Incentives: A Narrative Review of Key Considerations and Design Features for Future Research.

In the last decade, there has been a robust increase in research using financial incentives to promote healthy behaviors as behavioral economics and new monitoring technologies have been applied to health behaviors. Most studies of financial incentives on health behaviors have focused on adults, yet many unhealthy adult behaviors have roots in childhood and adolescence. The use of financial incentives is an attractive but controversial strategy in childhood. In this review, we first propose 5 general considerations in designing and applying incentive interventions to children. These include: 1) the potential impact of incentives on intrinsic motivation, 2) ethical concerns about incentives promoting undue influence, 3) the importance of child neurodevelopmental stage, 4) how incentive interventions may influence health disparities, and 5) how to finance effective programs. We then highlight empirical findings from randomized trials investigating key design features of financial incentive interventions, including framing (loss vs gain), timing (immediate vs delayed), and magnitude (incentive size) effects on a range of childhood behaviors from healthy eating to adherence to glycemic control in type 1 diabetes. Though the current research base on these subjects in children is limited, we found no evidence suggesting that loss-framed incentives perform better than gain-framed incentives in children and isolated studies from healthy food choice experiments support the use of immediate, small incentives versus delayed, larger incentives. Future research on childhood incentives should compare the effectiveness of gain versus loss-framing and focus on which intervention characteristics lead to sustained behavior change and habit formation.

Rationale and protocol for a cluster randomized pragmatic clinical trial testing behavioral economic implementation strategies to improve tobacco treatment rates for cancer patients who smoke.

BACKGROUND: Routine evidence-based tobacco use treatment minimizes cancer-specific and all-cause mortality, reduces treatment-related toxicity, and improves quality of life among patients receiving cancer care. Few cancer centers employ mechanisms to systematically refer patients to evidence-based tobacco cessation services. Implementation strategies informed by behavioral economics can increase tobacco use treatment engagement within oncology care. METHODS: A four-arm cluster-randomized pragmatic trial will be conducted across nine clinical sites within the Implementation Science Center in Cancer Control Implementation Lab to compare the effect of behavioral economic implementation strategies delivered through embedded messages (or "nudges") promoting patient engagement with the Tobacco Use Treatment Service (TUTS). Nudges are electronic medical record (EMR)-based messages delivered to patients, clinicians, or both, designed to counteract known patient and clinician biases that reduce treatment engagement. We used rapid cycle approaches (RCA) informed by relevant stakeholder experiences to refine and optimize our implementation strategies and methods prior to trial initiation. Data will be obtained via the EMR, clinician survey, and semi-structured interviews with a subset of clinicians and patients. The primary measure of implementation is penetration, defined as the TUTS referral rate. Secondary outcome measures of implementation include patient treatment engagement (defined as the number of patients who receive FDA-approved medication or behavioral counseling), quit attempts, and abstinence rates. The semi-structured interviews, guided by the Consolidated Framework for Implementation Research, will assess contextual factors and patient and clinician experiences with the nudges. DISCUSSION: This study will be the first in the oncology setting to compare the effectiveness of nudges to clinicians and patients, both head-to-head and in combination, as implementation strategies to improve TUTS referral and engagement. We expect the study to (1) yield insights into the effectiveness of nudges as an implementation strategy to improve uptake of evidence-based tobacco use treatment within cancer care, and (2) advance our understanding of the multilevel contextual factors that drive response to these strategies. These results will lay the foundation for how patients with cancer who smoke are best engaged in tobacco use treatment and may lead to future research focused on scaling this approach across diverse centers. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04737031 . Registered 3 February 2021.

COVID-19 and Adolescent Depression and Suicide Risk Screening Outcomes.

BACKGROUND: Mental health concerns increased during the coronavirus disease 2019 pandemic, but previous studies have not examined depression screening in pediatric primary care. We aimed to describe changes in screening, depressive symptoms, and suicide risk among adolescents during the coronavirus disease 2019 pandemic. METHODS: In a repeat cross-sectional analysis of electronic health record data from a large pediatric primary care network, we compared the percentage of primary care visits where adolescents aged 12 to 21 were screened for depression, screened positive for depressive symptoms, or screened positive for suicide risk between June and December 2019 (prepandemic) and June and December 2020 (pandemic). Changes were examined overall, by month, and by sex, race and ethnicity, insurance type, and income. Modified Poisson regression was used to calculate prevalence ratios (PRs) for the prepandemic to pandemic changes. RESULTS: Depression screening at primary care visits declined from 77.6% to 75.8% during the pandemic period (PR: 0.98, 95% confidence interval [CI]: 0.90-1.06). The percentage of adolescents screening positive for depressive symptoms increased from 5.0% to 6.2% (PR: 1.24, 95% CI: 1.15-1.34), with greater increases among female, non-Hispanic Black, and non-Hispanic white adolescents. Positive suicide risk screens increased from 6.1% to 7.1% (PR: 1.16, 95% CI: 1.08-1.26), with a 34% relative increase in reporting recent suicidal thoughts among female adolescents (PR: 1.34, 95% CI: 1.18-1.52). CONCLUSIONS: Results suggest that depression and suicide concerns have increased during the pandemic, especially among female adolescents. Results underscore the importance of consistent depression and suicidality screening.

Characterizing e-cigarette vaping-associated lung injury in the pediatric intensive care unit.

OBJECTIVE: Adolescent e-cigarette use has risen to epidemic levels in the US, revealing a new phenomenon of e-cigarette vaping-associated lung injury (EVALI). It is important to better characterize EVALI in critically ill adolescents as this is a vulnerable and rapidly growing demographic. METHODS: This was a retrospective case series of patients ≤21 years old with confirmed or probable EVALI (as defined by the Centers for Disease Control) that resulted in admission to the pediatric intensive care unit (PICU) of a large tertiary academic children's hospital between August 2019 and January 2020. RESULTS: There were six eligible patients, with a median age of 17 years. All patients reported tetrahydrocannabinol as well as nicotine e-cigarette use. Half of the patients had a preexisting diagnosis of asthma and four patients had mental health comorbidities. All patients presented with respiratory alkalosis and chest radiography showing diffuse bilateral infiltrates; two patients had pneumomediastinum, subcutaneous air and/or pneumothorax. The lowest documented ratio of oxygen saturation to inspired oxygen (SpO2:FiO2 or S/F ratio) ranged from 146 to 296. Two patients required an arterial line, with the lowest ratio of arterial oxygen to inspired oxygen (PaO2:FiO2 or P/F ratio) of 197 and 165. Two patients tested positive for rhinovirus and respiratory cultures were negative for all patients. Four patients underwent chest computed tomography imaging, which showed diffuse ground-glass opacities. Every patient required noninvasive positive pressure ventilation, with one progressing to invasive ventilation. All patients received broad-spectrum intravenous antibiotics and steroids, though there was considerable variability in dose, frequency, and duration of steroids. The hospital length of stay ranged from 5 to 16 days (median 8.3 days) with PICU length of stay ranging from 4 to 10 days (median 5.5 days). Four patients had pulmonary function testing before discharge, two of which showed decreased diffusing capacity of the lung for carbon monoxide. There were no patient deaths. CONCLUSIONS: This single-center case series describes the presentation, course, and treatment of EVALI in a pediatric intensive care unit setting. Our results show nuanced differences in the presentation and management of the critically ill adolescent, and raise many questions about the long term implications on lung health, morbidity, and mortality. Importantly, these cases illustrate the critical care consequences of a public health phenomenon and should spur further research and policy to address the negative health effects of vaping.

Pediatrician Delivered Smoking Cessation Messages for Parents: A Latent Class Approach to Behavioral Phenotyping.

OBJECTIVE: Message framing can be leveraged to motivate adult smokers to quit, but its value for parents in pediatric settings is unknown. Understanding parents' preferences for smoking cessation messages may help clinicians tailor interventions to increase quitting. METHODS: We conducted a discrete choice experiment in which parent smokers of pediatric patients rated the relative importance of 26 messages designed to increase smoking cessation treatment. Messages varied on who the message featured (child, parent, and family), whether the message was gain- or loss-framed (emphasizing benefits of engaging or costs of failing to engage in treatment), and the specific outcome included (eg, general health, cancer, respiratory illnesses, and financial impact). Participants included 180 parent smokers at 4 pediatric primary care sites. We used latent class analysis of message ratings to identify groups of parents with similar preferences. Multinomial logistic regression described child and parent characteristics associated with group membership. RESULTS: We identified 3 groups of parents with similar preferences for messages: Group 1 prioritized the impact of smoking on the child (n = 92, 51%), Group 2 favored gain-framed messages (n = 63, 35%), and Group 3 preferred messages emphasizing the financial impact of smoking (n = 25, 14%). Parents in Group 2 were more likely to have limited health literacy and have a child over age 6 and with asthma, compared to Group 1. CONCLUSIONS: We identified 3 groups of parent smokers with different message preferences. This work may inform testing of tailored smoking cessation messages to different parent groups, a form of behavioral phenotyping supporting motivational precision medicine.

Pediatric Resident Training in Tobacco Control and the Electronic Health Record.

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.

Parent Preferences for Pediatric Clinician Messaging to Promote Smoking Cessation Treatment.

BACKGROUND AND OBJECTIVES: Insights from behavioral economics suggests that the effectiveness of health messages depends on how a message is framed. Parent preferences for smoking cessation messaging has not been studied in pediatrics, warranting further exploration to maximize benefit. We sought to assess parents' perceptions regarding the relative importance of distinct message framings to promote their smoking cessation. METHODS: We conducted a cross-sectional discrete choice experiment in which parent smokers rated the relative importance of 26 messages designed to encourage them to begin cessation treatment. Messages varied on who was featured (child, parent, or family), whether the message was gain or loss framed, and what outcome was included (general health, cancer, respiratory illnesses, child becoming a smoker, or financial impact). The participants were 180 parent smokers attending primary care visits with their children at 4 diverse pediatric sites. The main outcome was the importance of smoking cessation messages based on who was featured, gain or loss framing, and the outcome emphasized. RESULTS: Parent smokers highly prioritized cessation messages emphasizing the impact of quitting smoking on their child versus parent or family. Messages focusing on respiratory illness, cancer, or general health outcomes consistently ranked highest, whereas messages focused on the financial benefits of quitting ranked lowest. Gain versus loss framing did not meaningfully influence rankings. CONCLUSIONS: Parent smokers identified smoking cessation messages that emphasized the impact on their child, with outcomes focused on respiratory health, cancer, or general health, as most important. The clinical impact of these messages should be tested in future research.

Implicit attribution of culpability and impact on experience of treating tobacco dependence.

OBJECTIVE: Given the number of annual interactions between people who smoke and health care providers, even low-efficacy interventions would be expected to have a large cumulative effect on smoking prevalence. Efforts to improve uptake of tobacco dependence treatment guidelines have had limited success. It remains unclear whether complex social motivations influence treatment decision-making among providers, despite widespread understanding of the condition's impact on morbidity. METHOD: Clinicians from across the United States participated in a computer-based survey of potential explicit tobacco treatment biases, relative to care of hypertension. Items corresponded to framework domains of Weiner's causal attribution theory of social motivation (Weiner, 1993). Single-word, open-response items were used to gain insight into the frequency of spontaneous perceptions regarding treatment of each condition. Implicit association testing (IAT) measured strength of association between images of smoking and evaluation of guilt versus innocence. RESULTS: Significant differences in agreement scores were identified within the causal attribution, emotional response, and help investment domains. Single-word answers confirmed a significant difference in emotional response to tobacco treatment (28.1% vs. 10.5%, p = .02), and suggested the difference was driven by the frequent perception of frustration (75% vs. 0%, p = .07). IAT revealed incompatibility between images of smoking and words conveying "innocence" compared with "guilt" (latency 1,846 ms vs. 1,113 ms, p < .001). CONCLUSIONS: Complex social motivations may be operational in the context of tobacco dependence treatment, limiting provider willingness to follow treatment guidelines. If confirmed, this represents a critical obstacle to sophisticated guideline implementation, and should be addressed in future implementation strategies. (PsycINFO Database Record (c) 2019 APA, all rights reserved).