T OBACCO AND S ECOND H AND S MOKE
E XPOSURE
A UGUST 2014
Pediatric Continuity Clinic Curriculum
Created by: Karen Martinez
Mentor: Dr. Virginia Kockler

O BJECTIVES
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Understand the risks of second hand smoke exposure and teen tobacco use
Discuss the epidemiology of teen tobacco use and second hand smoke exposure
Discuss how to perform a motivational interview and how to approach smoking cessation with patients and parents
Learn about e-cigarettes and e-cigarette use

C ASE #1
A 13 yo male presents to your continuity clinic for a
WCC. On his questionnaire he admits to occasional tobacco use.
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E PIDEMIOLOGY
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90% of tobacco users initiate use before age 18
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In the US 3,200 children under 18 begin smoking every day.
Prevalence is almost equal in males and females
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23% of HS males and 22.9% of HS females smoke
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Ethnicity of High School Smokers
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26% White, 22% Hispanic and 16% African American
Youth and Tobacco Use: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_ use/

R ISK AND P ROTECTIVE F ACTORS
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Risk Factors
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Friends who smoke
Parental behavior and attitudes
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Comorbid psychiatric disorders
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Anxiety, depression, ADHD, substance abuse
Body image issues/ concern about weight gain
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Protective Factors
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Good communication with parents, high self-esteem, parental support
Factors Associated with Youth Tobacco use: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm#estimates
Sargent JD, Dalton MA. Does parental disapproval of smoking prevent adolescents from becoming established smokers?
Pediatrics 2001; 108:1256-1262.

T EEN S MOKING - T RENDS
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HS students that have ever tried cigarettes -
44.7%
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After years of increasing the incidence of HS students trying cigarettes has been steadily decreasing since
1995
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Incidence in 1995 – 71.3%
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HS students smoking at least once within last 30 days – 18.1%
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Incidence in 1995 – 34.8%
Estimates of current tobacco use among youth: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm#estimates

S MOKING CESSATION
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Counseling is recommended and has been shown to be a successful cessation tool
Pharmacotherapy may be considered in certain cases but should always be used in combination with counseling
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Nicotine Replacement therapy may be used in patients less than
18 and has been deemed to be safe, but is not FDA approved
Bupropion: Adolescent data regarding efficacy is limited, but has been deemed to be safe for adolescents. A few clinical trials showing some increased abstinence compared to placebo but no long term data. Black box warning-should not be used in patient with depression due to increased risk of suicidal ideation.
Chantix: No trials in adolescents regarding efficacy. Safety trials deemed the product safe in Adolescents. Black box warning for adults neuropsychiatric symptoms-agitation, SI, depression.
J.P. Karpinski et al. Smoking Cessation Treatment for Adolescents. J Pediatr Pharmacol Ther. 2010 Oct-
Dec; 15(4): 249–263.

C OUNSELING T EENS
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Most teens desire to quit
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The 5 “As”
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Ask, Advise, Assess, Assist, Arrange follow up
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The 6 th pediatric A - Anticipate
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Pharmacotherapy
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Efficacy and safety are less well established than in adults
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However in light of early nicotine addiction pharmacotherapy can be consider for some adolescents
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Nicotine replacement in adolescents with symptoms of dependence can be used in combination with counseling

6 A S
 Anticipate: Assess risk of tobacco use by inquiring about parental smoking and discussing the possibility of smoking initiation in preadolescent and adolescent children. Begin this anticipatory guidance during pediatric visits in mid-childhood.
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Ask: Obtain a smoking history from all teenage patients, with parents out of the room. Explain confidentiality and exceptions
Advise : Strongly urge all teen tobacco users to quit. The message should be clear, strong, personalized
Assess: Determine if the teen smoker is willing to make a quit attempt. Assess motivation to quit or continue smoking. Assess the stage of readiness of the patient to guide further counseling.
Assist: Help the teen smoker prepare by setting a quit date, seeking support from family and friends and practicing problem-solving.
Materials may be helpful. Teens may benefit from being referred to a quit-smoking line or other resources in the community.
Arrange follow up: schedule follow-up in person or by telephone soon after the quit date. Or if unwilling to quit, schedule appointment to continue motivational interview

S TAGES OF C HANGE
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Pre-contemplation: not intending to quit in the foreseeable future
Contemplation: intending to quit in the foreseeable future, but hasn’t set a timeline
Ready for action: intending to quit in the immediate future and has set a timeline
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Action: cessation of smoking
Maintenance: staying tobacco free!

R ESOURCES TO R EFER P ATIENTS
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National and State resources
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Quitline:
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National Quitline 1-800-QUIT NOW
On line and phone counseling, and free NRT
 www.smokefree.gov
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Local resources
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Healthy Start: One-on-one Smoking Cessation
Counseling, at home or at work
Alachua County Health Department: Group
Smoking Cessation Classes that offer FREE
Nicotine Replacement Therapy
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Suwannee River AHEC: 6 week Group
Smoking Cessation Program that offers FREE
Nicotine Replacement Therapy and Counseling
Services

C ASE #2
You are seeing a 10 mo female in clinic with fever and fussiness who is diagnosed with an otitis media. The patient has a history of recurrent otitis media. Both parents smoke cigarettes.
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What is the epidemiology and the Risks of Second
Hand Smoke (SHS)?
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How should you approach parents regarding tobacco use?
Review Motivational Interviewing

E PIDEMIOLOGY OF SHS EXPOSURE
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1. U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to
Tobacco Smoke: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion,
Office on Smoking and Health, 2006
2. Singh, G., Siahpush, M., Kogan, M. Disparities in children’s exposure to environmental tobacco smoke in the United
States, 2007. Pediatrics, 126(1), 4-13.
3. Melchior, M., Chastang, J.F., Mackinnon, D., Galera, C., Fombonne, E. (2010). The intergenerational transmission of tobacco smoking--the role of parents' long-term smoking trajectories. Drug and Alcohol Dependence, 107(2-3). 257-60.

R ISKS OF SHS EXPOSURE
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Asthma exacerbation and poor control
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Otitis Media
SIDS
Lower respiratory tract infection
Prematurity
Low Birth weight infants
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Leukemia/Lymphoma
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Evidence is suggestive but not strong enough to suggest a causal relationship

H OW TO APPROACH PARENTS
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Parents expect you to discuss tobacco use
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Avoid Judgment
Watch body language and tone, be careful to avoid alienation
Depersonalize the question
For example
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Does anyone in the household use tobacco? Where do they smoke?
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If parent smokes use the 5 A’s and assess stage of change to further guide counseling

M OTIVATIONAL I NTERVIEWING
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A patient centered method designed to strengthen personal motivation and commitment to a specific goal
Listening and guiding parents/patients as they reason through a problem and towards a goal
Can be done at multiple sessions to avoid arguments and resistance
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Brief interviews directed at moving slowly away from ambivalence and towards change

M OTIVATIONAL I NTERVIEW

C ASE #3
A 14 yo female is being seen for a well child check.
She denies tobacco use on her questionnaire and when asked by the physician. When asked directly about e-cigarette use she admits to trying them with a friend “because they are not bad for you”.
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What is the incidence of e-cigarette use?
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What are the facts and misconceptions about ecigarettes?
What are other smokeless tobacco products teens may use?

I NCIDENCE OF ECIGARETTE USE
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High school students, who have ever tried e-cigarette use increased from 4.7% in 2011 to 10.0% in 2012
HS student who are current e-cigarette users increased from 1.5% in 2011 to 2.8% in 2012
In 2012, among high school current e-cigarette users,
80.5% reported current conventional cigarette smoking
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Both experimentation with and habitual use of ecigarettes has doubled among high school as well as middle school students from 2011 to 2012
Data from the CDC 2011-2012 National Youth Tobacco Survey

ECIGARETTE M ISCONCEPTIONS
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Misconceptions
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E-cigarettes are just water vapor and are not harmful
E-cigarettes are not addictive
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E-cigarettes are safe to smoke around children

ECIGARETTE F ACTS
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Facts
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E-cigarettes are not currently regulated by the federal government
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No federal laws restricting marketing or sale to minors, no laws restricting public use and chemical content not known to or regulated by the FDA
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E-cigarettes contain nicotine, which is known to be addictive
There have been known carcinogens identified by the FDA in Ecigarette vapor including formaldehyde, nitrosamines, carbonyl compounds and propylene Glycol
These carcinogens and other potentially harmful chemicals are likely present in second hand vapor though direct studies have been performed
Studies showing lung tissue exposed to vapor has inflammation and increased reactivity of airways, similar to lung tissue exposed to traditional tobacco smoke
Lung tissue exposed to vapor shows similar pre-cancerous changes as lung tissues exposed to tobacco smoke
- Goniewicz ML, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control.
2014 Mar;23(2):133-9
- Lim HB, Kim SH. Inhallation of e-Cigarette Cartridge Solution Aggravates Allergen-induced Airway Inflammation and Hyper-responsiveness in Mice. Toxicol Res. 2014 Mar;30(1):13-8. doi: 10.5487/TR.2014.30.1.01
- Cervellati F, et al. Comparative effects between electronic and cigarette smoke in human keratinocytes and epitheliallung cells. Toxicol In Vitro. 2014 Aug;28

ECIGARETTES
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Many Patients and Parents do not include e-cigarette use when asked if they smoke
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Parents and patients should be asked directly about e-cigarette use
If parents or patients admit to use you should asses there beliefs about e-cigarettes
Educate patients and parents on the facts and risks of e-cigarette use
Motivational interviewing and assessment of stage of change should be done just like if they were using traditional cigarettes
E-cigarette liquid refills and cartridges present a poison control risk
Concern that with the increase in e-cigarette use there will be an accompanying increased use of traditional cigarettes
Bunnell RE, et al. Intentions to smoke cigarettes among never-smoking U.S. middle and high school electronic cigarette users, National Youth Tobacco Survey, 2011-2013. Nicotine Tob Res. 2014 Aug 20

O THER TOBACCO / NICOTINE PRODUCTS waterpipe use episode (30-45 minutes) can yield slightly more nicotine than a single cigarette, and about 36 times the tar and 8 times the CO. (1)
Use of dip is rising especially among males
-30 day use of smokeless tobacco up to 15% among HS males
Snus: 8 mg of nicotine
Spit less Tobacco
Many Dissolvable Products look like Candy
Orbs: mint-sized; 1mg of nicotine
Strips: appear like Listerine breath strips; 0.3-0.6 mg of nicotine
Sticks: toothpick-like; 3.1 mg of nicotine
Cigarillos (small cigars) are regulated like cigars which are currently exempt from regulation on restricting flavors and marketing to children
- In 2011, 23% of HS students used cigarillos within the preceding year (2)

PREP Q UESTION
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Question 206
A 15-year-old boy presents for a routine health supervision visit and is being seen by a resident.
Some staining of his teeth is noted, and he admits using smokeless tobacco off and on for a year. He tells the resident that he believes chewing tobacco does not cause lung cancer and is not addictive because he knows that nicotine gum is being used to help adults who want to quit smoking. He feels chewing tobacco relaxes him, and he is not ready to stop. Acting as preceptor, you question the resident about his understanding of adverse effects of smokeless tobacco.
Of the following, the MOST accurate information to provide about smokeless tobacco use is that

A NSWER C HOICES
 A. heart rate and blood pressure are minimally affected
 B. there is minimal additional risk for dental caries
 C. users are at increased risk for developing gum and oral cancers
 D. users are unlikely to move to cigarette use later
 E. users experience few withdrawal symptoms

ANSWER: C
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The use of smokeless tobacco has declined since the 1990s, but this trend in use is reversing. In the United
States, smokeless tobacco is mainly used by boys. The 2 forms of chewing or “spit tobacco” are snuff
(shredded tobacco) and chew (loose leaves). With either form, the tobacco is placed between the cheek and gum. Staining of the teeth may provide a clue to its use. Smokeless tobacco use has been associated with leukoplakia, gum disease, gum recession, cancer (of the lip, tongue, gums, cheeks, and floor and roof of the mouth), and an increased incidence of dental caries.
Absorption of nicotine causes systemic symptoms such as dizziness, an increase in heart rate, and an increase in blood pressure. Late effects include coronary artery disease. Effects on male reproductive health include decreased sperm count and abnormal sperm cells. In women, use of smokeless tobacco during pregnancy increases the risk of preeclampsia and premature delivery. Infants born to mothers who use smokeless tobacco are more likely to have apnea in the neonatal period and low birth weight.
Nicotine is present in all forms of tobacco and is highly addictive. Although nicotine is absorbed more slowly from the oral cavity than by inhalation, the amount absorbed per dose is greater. Therefore, regular users of smokeless tobacco may experience significant withdrawal symptoms. Smokeless tobacco users often change to cigarettes because it is more socially acceptable. One-third of those who use both products start with smokeless tobacco first and then add cigarette use, while two-thirds start with cigarette use first and then add use of smokeless tobacco. Daily smokers who change to smokeless tobacco because they think it will help them quit have been found to still be smoking months after making the change.
In 2001, a new form of dissolvable tobacco became available in the United States. These products are marketed to adults with tobacco addiction in order to help them comply with ordinances that prohibit smoking in public places. However, because these products look like candy and have added flavorings, they are attractive to children and there is a risk for accidental poisoning. Symptoms of accidental ingestion in children include drooling, abdominal cramps, nausea, vomiting, agitation, and tremors. Serious adverse effects include seizures, coma, and death.

F UTURE R EADING
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