pace
(Prevention and Cessation Education)
Collaboration of 12 US medical schools
funded by the National Cancer Institute
Boston University
Case Western Reserve University
Dartmouth College
Harvard University
Loma Linda University
University of Alabama – Birmingham
University of California – Los Angeles
University of Iowa
University of Kentucky
University of Massachusetts
University of Rochester
University of South Florida
pace Goals
• Develop, refine, and integrate new
educational modules
• Train medical school faculty
• Disseminate resources to other
universities
Where You Come In…
Using curricular assessments done at all 12
medical schools, our national conference reached
a consensus…
Most U.S. medical students graduate without
adequate tobacco cessation and prevention skills
 Preceptorship Module
 Community Experience Module
 Pediatrics/Family Medicine Module
Tobacco Education
for the
Pediatrics/Family Medicine Clerkship
Reducing Exposure to Environmental
Tobacco Smoke (ETS)
Learning Goals for this Module
You will be able to:
1. Define secondhand smoke/ETS
2. Appreciate the scope and impact of ETS
on children and adults
3. Assess the amount of ETS experienced
by children at each visit/contact
4. Encourage a smoke free environment
during all regular and sick visits
Learning Goals for this Module
5. Assist parents in creating a smoke free
environment
6. Screen parents for current smoking
status and readiness for change
7. Offer smoking cessation treatment to
parents and/or refer them to their
providers
Learning Goals for this Module
You will be able to:
1. Define secondhand smoke/ETS
2. Appreciate the scope and impact of ETS
on children and adults
3. Assess the amount of ETS experienced
by children at each visit/contact
4. Encourage a smoke free environment
during all regular and sick visits
Defining Secondhand Smoke/ETS
Massachusetts Medical Society Anti-Tobacco Contest Winner
Defining Secondhand Smoke/ETS
• Secondhand smoke, also known as
environmental tobacco smoke (ETS), is a
mixture of the smoke given off by the
burning of tobacco products (sidestream
smoke) and the smoke exhaled by
smokers (mainstream smoke).
Refs:
Health Effects of Exposure to Environment Tobacco Smoke. Smoking and Tobacco Control
Monograph No. 10 National Cancer Institute; 1999. NIH Pub. No. 99-4645.
10th Report on Carcinogens. Research Triangle Park, NC: U.S. Department of Health and Human Services,
Public Health Service, National Toxicology Program, December 2002.
Defining Secondhand Smoke/ETS
• Secondhand smoke
contains a complex
mixture of more than
4,000 chemicals
• Over 50 of these
chemicals are
carcinogenic.
Learning Goals for this Module
You will be able to:
1. Define secondhand smoke/ETS
2. Appreciate the scope and impact of
ETS on children and adults
3. Assess the amount of ETS experienced
by children at each visit/contact
4. Encourage a smoke free environment
during all regular and sick visits
The Scope and Impact of ETS
Massachusetts Medical Society Anti-Tobacco Contest Winner
Health Effects of ETS
• More than 1 out of 3 children have a parent
who smokes
• Because their lungs are not fully developed,
young children are particularly susceptible to
secondhand smoke.
• Parents who smoke subject their children (and
unborn children) to a range of health risks that
can be divided into prenatal, post-natal and
longer term
Refs:
Health Effects of Exposure to Environment Tobacco Smoke. Smoking and Tobacco Control Monograph No. 10 National
Cancer Institute; 1999. NIH Pub. No. 99-4645.
Women and Smoking: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Public
Health Service, Office of the Surgeon General; 2001.
Prenatal Risks
•
•
•
•
•
•
Low birthweight
Miscarriage
Premature delivery
Stillbirth
Sudden Infant Death Syndrome (SIDS)
Neurobehavioral problems
Postnatal Risks
• Higher rates of:
–
–
–
–
–
Pneumonia
Otitis Media
Asthma and asthma exacerbations
Invasive meningitis
Colic
• Respiratory complications under
anesthesia
• Sudden Infant Death Syndrome (SIDS)
Longer-term Risks
• Reduced pulmonary
function
• Dental decay
Other Points to Consider
• The health consequences of ETS are
significant for all family members
• The American Heart Association now
recommends limiting ETS for everyone
• More than 70% of mothers who stop
smoking during pregnancy will relapse
after giving birth
Estimated U.S. Morbidity and Mortality in
Nonsmokers Associated with ETS
Condition
Development effects
-Low birthweight
-Sudden Infant Death Syndrome
Respiratory effects in children
-Otitis media
-New asthma
-Asthma exacerbation
Acute lower respiratory illness
-Bronchitis and pneumonia
-Hospitalizations
-Deaths
Outcome (annual rate)
9,700 to 18,600 births
1,900 to 2,700 deaths
0.7 to 1.6 million office visits
8,000 to 26,000 cases
400,000 to 1,000,000
Children up to 18 months
150,000 to 300,000 cases
7,500 to 15,000 cases
136 to 212 deaths
Lung cancer (adults)
3,000 deaths
Ischemic heart disease (adults)
35,000 to 62,000 deaths
But Can You Make A Difference?
Becoming a Piece of the Puzzle
Why Intervene? Teachable Moments
• Health effects associated with ETS are
substantial but often hidden
• Physicians are a respected source of
information
• Many opportunities to intervene
• Brief interventions are effective
• Limiting exposure to ETS results in
proven benefit to children
Respected Source of Information
• Pediatrician and Family Medicine
counseling has been recommended for:
–
–
–
–
–
physical activity
motor vehicle injuries
youth violence
injuries
unintended pregnancy
• ETS counseling is a natural extension
Many Opportunities to Intervene
• Newborn visits
• 12 well-child visits are recommended
during the first 6 years of life
• Unscheduled, acute care visits (may be
ETS-related)
– Otitis media
– Asthma and asthma exacerbations
– Bronchitis
Brief Interventions are Effective
• Simple advice (brief interventions)
from a physician is effective in
promoting long-term cessation
• Parents may not be aware of
the serious health effects
of ETS–ask parents to name
effects
Proven Benefits of Limiting ETS
• Breathe better and grow better
• 33% fewer school absences
• Four times less likely to become a
cigarette smoker
Refs:
Need refs here
Learning Goals for this Module
You will be able to:
1. Define secondhand smoke/ETS
2. Appreciate the scope and impact of ETS
on children and adults
3. Assess the amount of ETS experienced
by children at each visit/contact
4. Encourage a smoke free environment
during all regular and sick visits
Assessing the Amount of ETS
Massachusetts Medical Society Anti-Tobacco Contest Winner
Brief Counseling Model
Remembering the 5 A’s
• Ask
• Assess
• Advise
• Assist
• Arrange
Start by Asking
• Open ended questions
• Use a non-confrontational style and tone
• Link your questioning to the reason for
visit/contact
Assessing Exposure
Include all potential sources of exposure
–
–
–
–
–
–
Home
Car
Daycare
Family
Relative
Friends
Learning Goals for this Module
You will be able to:
1. Define secondhand smoke/ETS
2. Appreciate the scope and impact of ETS
on children and adults
3. Assess the amount of ETS experienced
by children at each visit/contact
4. Encourage a smoke free environment
during all regular and sick visits
Encourage a Smoke Free Environment
Massachusetts Medical Society Anti-Tobacco Contest Winner
Brief Counseling Model
Remembering the 5 A’s
• Ask
• Assess
•Advise
• Assist
• Arrange
Encourage a Smoke Free Environment
•
•
•
•
Give a positive message
Focus on benefits to child
Roll with resistance/obstacles
Recognize and acknowledge barriers
Common Barriers to Quitting
•
•
•
•
•
Fear of failure
Nicotine withdrawal
Loss of a coping tool
Family and friends who smoke
Weight gain
Barriers to Limiting ETS
• Logistics
• Parenting is stressful
• Do not want to upset others by asking
them to change their behavior
Motivating Caregivers to Quit!
• They will have more energy and breathe
easier
• Saves money that can be spent on other
things
• Clothes, hair, and home smell better
• Food tastes better
• Can feel good about what they have done
for themselves and their child
How to Motivate Limiting ETS
• Remain focused on the health benefits
for the child
– Fewer acute care visits
– Less absenteeism
• Empower parent/caregiver to act on
behalf of the child
– Make mom a hero
Make Mom a Hero!
• Keeps message positive
and focused on the
child’s benefit
• Consider using a
Smoke Free Pledge
Another Piece of the Puzzle!
Learning Goals for this Module
5. Assist parents in creating a smoke
free environment
6. Screen parents for current smoking
status and readiness for change
7. Offer smoking cessation treatment to
parents and/or refer them to their
providers
Creating a Smoke Free Environment
Massachusetts Medical Society Anti-Tobacco Contest Winner
Brief Counseling Model
Remembering the 5 A’s
• Ask
• Assess
• Advise
•Assist
• Arrange
Creating a Smoke Free Environment
• Set realistic goals
• Provide a range of options from smoking
cessation to any gains in limiting ETS
• Empower parent/caregiver
• Provide handouts
Practical Suggestions
•
•
•
•
Quit
Smoke outside ONLY
Open a window
Ask others to do the same
Learning Goals for this Module
5. Assist parents in creating a smoke free
environment
6. Screen parents for current smoking
status and readiness for change
7. Offer smoking cessation treatment to
parents and/or refer them to their
providers
Screening Parents/Caregivers
Massachusetts Medical Society Anti-Tobacco Contest Winner
A Missed Opportunity
• In the event that the parent or caregiver
is interested in smoking cessation, it
provides an opportunity to benefit two
patients
• Simply asking them about their desire to
quit may open up an otherwise missed
opportunity
• It is not Pandora’s Box- Be prepared to
respond to a positive response
Learning Goals for this Module
5. Assist parents in creating a smoke free
environment
6. Screen parents for current smoking
status and readiness for change
7. Offer smoking cessation treatment to
parents and/or refer them to their
providers
Helping Parents/Caregivers to Quit
Massachusetts Medical Society Anti-Tobacco Contest Winner
Stages of Change Model
Precontemplation
Relapse
Contemplation
Maintenance
Determination
Action
Precontemplation
Relapse
Maintenance
Contemplation
Determination
Action
Counseling for Smoking Cessation
• Motivational Interviewing is the tool used
by clinicians to effect behavior change
• Key factors to behavior modification are:
– A patient’s Desire to Change
– Confidence in their Ability
Desire to Change
• Gauge parent’s readiness to quit (ask, for
example, on a scale of 1 to 10 with
10=being ready to quit in the next week)
• Reflective listening – express that you
understand parent’s link between stress
and smoking
• Express empathy about the length and
difficulty of quitting process
Desire to Change
• Show difference between parent’s goals and
current behavior through reflective
listening and objective feedback
• Roll with resistance rather than confronting
or opposing it – use the 5Rs
–
–
–
–
–
Relevance –Ask why quitting is/is not personally relevant
Risks –Ask them to identify consequences of smoking
Rewards –Ask them to identify benefits of quitting
Roadblocks –Have patient identify barriers to quitting
Repetition –Repeat 5R’s at every visit
Confidence in Ability to Quit
• Gauge the parent’s confidence in ability
to quit (on a scale of 1 to 10, with 10
being very confident . . .)
• Ask for an example when patient says
confidence to quit is low
• Highlight the positive and/or suggest
alternative harm reduction strategies
(e.g., smoke outside)
Confidence in Ability to Quit
• Show optimism – express your confidence
that they will be able to change
• Set goals together – how to reduce
smoking in front of children
Six Common Mistakes
1. Not communicating genuine concern
–
Give the patient your full attention
2. Pushing patients to commit
–
Follow the patient’s cues
3. Not recognizing patient’s resistance
–
Ask permission and give choices
4. Using leading suggestions
–
Use open-ended questions
Six Common Mistakes
5. Thinking you have failed
–
–
–
Motivating the patient may take several
sessions, but time is on your side
You may not score a “knock out” punch in
the first round (visit)
Planting seeds for harvesting later
6. Thinking you have no time to counsel
–
–
Brief interventions work
IF YOU DON’T, WHO WILL?
You Can Make A Difference!
Become a Piece of the Puzzle
Video
Case Examples
Example #1
Ms. Jackson is a 23-year-old mother of two
(two-year-old son and three-month old
daughter). She says she knows she should
quit and would like to save the money, but
is just too stressed out right now to try
quitting. Where would you start?
Example #2
Jess and Marianne are parents of a sixmonth-old son, Damian. They have
brought him in for an episode of
bronchitis and are both heavy smokers.
When you ask whether they are
interested in quitting, both say they are
not interested. How would you counsel
them?
Tobacco Education
for the
Pediatrics/Family Medicine Clerkship
Thank You for Participating