Tobacco Prevention and
Cessation in Pediatric Settings
Jonathan D. Klein, MD, MPH
Golisano Children’s Hospital at Strong
and the
American Academy of Pediatrics
Center for Child Health Research
University of Rochester
Rochester, NY
Center for Child Health Research
Mission
Improve the health and functioning of
children by enhancing the quantity,
quality, and utilization of research
How the Center Will Address
Child Health
• Identify what is known, not being addressed
• Identify critical questions and gaps
• Develop and implement strategies both to:
– increase our knowledge base
– better use that knowledge to shape social and
clinical policies and practices
Center Structure
•
Multi-institutional, multidisciplinary
•
Center of Center in Rochester, New York
•
PROS Network - Mort Wasserman, MD, Director, U of
Vermont; core staff at AAP headquarters
•
Functional Outcomes Project - Lynn Olson, PhD,
Director; core staff at AAP headquarters
•
Consortia members and researchers on various
projects located at universities nationwide
Critical Questions
• What are the most important research questions,
that if answered, would improve
–Children's health and development?
–Adult health, functioning and longevity?
• How to facilitate answering these questions?
• How to help research be translated into social
policy and clinical practice to improve children's
health?
Social
Improved
Strategies
Child
Health
Knowled
ge
Base
Political
Will
Studying Social
Determinants
and Outcomes
of Health
Improved
Child
Health
Assessing
Child Health
Policy and
Practice
Increasing and
Synthesizing Knowledge
Base
Children and tobacco
• 3 million adolescents smoke
• 2600/day start
• 1/3rd will become addicted, smoke
through adulthood
• 60% of smokers started before age 14
• ETS is a major heath risk for children
Past 30 Day Smoking, 1975-2002
Adapted from Johnston, et al., 2001
Why?
• Social influences
– Friends
– Parents
• Access/availability of cigarettes
• attitude toward smoking
– Media
• Personality
– Sensation seeking
– Rebelliousness
– Poor school performance
Tobacco Marketing
• Annual spending to promote tobacco = more
than half the NIH budget
• Advertising
– Targeted to youth
• Non-advertising commercial speech
– Product placement
– Clothing, gear
– Sponsorships, broadcast media
– Candy look-alike products
Exposure to Tobacco Use in Movies and
Smoking Among 5th-8th grader
8th
7th
6th
5th
Grade
Grade
Grade
Grade
Adapted from Sargent, DiFranza, 2003
Youth and Nicotine
• Adolescents more than adults:
– become dependent
– progress to daily smoking
– smoke more heavily as adults
– have difficulty with quitting prior to
smoking 100 cigarettes
Adolescent Smokers
• Know they are addicted
• Want to quit
• Do not think there are resources to help
• 75% have thought about quitting
• 64% have made a quit attempt
• Clinicians feel unprepared to help
Incidence of Initial Symptoms of
Nicotine Dependence
Adapted from DiFranza, 2002
Issues for primary and
secondary prevention
• “Social inoculation” = effective prevention
• Prevention does not work for cessation
• School /social environment roles
• Harm reduction vs. abstinence strategies
• Brief office interventions and referrals
Primary care interventions
• Health care cessation counseling interventions
are effective for adults
• Pediatric and adolescent guidelines recommend
screening & counseling
• Adolescents want to quit but do not think of
getting assistance
• Adolescents use internet resources for health
information
Pediatric interventions
• Most (>90%) clinicians report asking
about tobacco
• Many report assessing motivation to
quit, and discussing health risks
• Few provide handouts, set quit dates, or
plan smoking-related follow-up
• < 25% of patients report having
received counseling
Primary care
• Adolescents use preventive care
• 70+% report well care visits
• Nationally, almost half do not have an
opportunity to talk privately with their
clinician
• 39% girls, 24% boys report having been
too embarrassed to discuss a topic
Did Practices Deliver Interventions?
QLater
QNow
Did you and your doctor
discuss cigarettes/smoking?
88
92
p<.05
Did your doctor ask if you
smoked?
87
93
p<.001
If smoke, did your doctor
ask if you want to quit?
63
76
p<.0005
If smoke, did your doctor
18
47
p<.0001
hand you anything to help stop?
Other evidence?
• In a 2002 review, evidence for teen cessation
programs is good,
– especially school-based, motivation enhancement
programs.
– no successful brief intervention trials in primary
care for adolescent cessation.
• One successful cessation study in 2003 with
adolescents referred to an intensive expert
counseling ‘system’ after brief primary care
advice (OR=2.43) (Hollis et al.)
• Policy interventions work
GottaQuit Evaluation
• Ads have reached 94% of Monroe County teens
• Youth who smoke relate to the characters, the
themes of addiction and wanting to quit
• 75% of adolescent smokers in Monroe County
wanted to quit, and many tried in the past year
• Only 40% of smokers had ever been proofed
• 27% of smokers (vs 4% of non-smokers) had
visited GottaQuit.com, mostly for help quitting
What do we do now?
• Best practice recommendations
– Policy changes
– Clinical interventions
– Public health adjuncts
• More studies
• Implications for education
Best Practices
in Tobacco Control
• Increase price of tobacco
• Smoking bans and restrictions
• Availability of treatment for addiction
– Reduce patient costs for treatment
– Provider reminder systems
– Telephone/web counseling and support
• Mass media campaigns
Policy - School curriculum
• At least 5 session /year over 2 years
• Should include
– Social influences
– Short term health effects
– Refusal skills
• NOT self-esteem or delay based
• Be aware of dilution and confusion strategies
by tobacco interests
• School policies should reinforce goals
Policy - Community activism
• Age of sale enforcement
• Advertising limitations
• Public smoke exposure reduction
• Awareness of impact of preemptive efforts
• Reducing social acceptability of smoking
Pediatricians in Practice
• Reimbursement for Providers
• CPT coding, payment
• Certification of competency
• Media for Patients
• Ads, adjuncts, educational materials
• Education for Providers and staff
• Phrmacotherapy guides, resource lists
• Training/CME
Practice - Public Health Service
5 A’s
•
•
•
•
Ask
Advise
Assess
Assist
• Arrange
- If patient smokes
- Every patient to quit
- Readiness to quit
- In quitting and finding
services
- For cessation services and
follow up
Issues for Pediatric Practice
•
•
•
•
Prenatal Smoking
Environmental Smoke/Early Childhood
School Age Intervention
Adolescent Intervention
Pediatricians in Practice:
• Reimbursement
– Better CPT coding for tobacco counseling
– Maine Medicaid pays $20/visit for tobacco
counseling up to 3 per year
– PA Medicaid pays $15/visit after MD
training completed
• Education for providers
– Training/CME -- (Certification?)
• Adjuncts/Media for Patients
Pre/Postpartum Messages
• Intervene with women and men during
pregnancy and after delivery
• Postpartum health message should
focus on secondhand smoke
• Parents should smoke outside
Early Childhood (0-5)
• Goal:
Prevent smoke exposure (ETS)
• Ask:
About exposure
• Advise: Parents to quit, limit exposure
- Link to child’s health
• Assess: Motivation to change
• Assist:
- Provide self-help, set quit dates
- Consider Rx, referral
• Arrange:
- Reinforcement at each visit
School Age (5-12) Intervention
• Goal:
• Ask:
Prevent the onset of smoking
Experimentation and
knowledge
• Advise: Children and parents
- To quit if smoking
- Link to short term consequences
- “Inoculate” with awareness of smoking
candy/toys/gear as socially acceptable
• Assess: Motivation to change
School Age Intervention
• Assist:
–
–
–
–
If experimenting - cessation
Develop refusal skills
Show how tobacco ads mislead
Reinforce abstinence
• Arrange:
– Frequent follow-up for experimenters
Adolescent Intervention
• Goal:
– Prevent onset and promote cessation
• Ask
–
–
–
–
About friend’s use
About patterns of use
About school programs
Reassure about confidentiality
• Assess:
– Motivation and readiness
Adolescent intervention
•Advise
–To quit for short term reasons
•Athletic capacity, cost, smell, etc.
–Reinforce non-use
•Assist
–Set quit dates
–Provide self-help materials, websites
–Encourage problem-solving, refusal skills, activities
–Consider pharmacotherapy
•Arrange
--1-2 week follow-up after quit attempts
Assessing Nicotine Dependence
1)
Have you ever tried to quit, but couldn’t?
2)
Have you ever felt like you were addicted to
tobacco?
3)
Do you ever have strong cravings to smoke?
4)
Is it hard to keep from smoking where you are not
supposed to, like school?
5)
Do you:
1)
2)
3)
find it hard to concentrate
feel more irritable?
feel nervous, restless, or anxious … because you
couldn’t smoke?
Training and Certification
• Training programs
• Model curriculum
• RRC, ACGME required competencies
• Advocacy curriculum
• Quality Assurance
• Modules - like ADHD Toolkit
• Board Certification competency
• CME on tobacco and on screening and
motivational interviewing
Curriculum challenges
• Leadership in primary care settings
• Residents and medical students
• Community practitioners
• Support from academic leaders