Effective practices in promoting
tobacco use cessation
Your name, institution, etc. here
YOUR LOGO HERE
(can paste to each slide)
…dedicated to eliminating children’s exposure to tobacco
and secondhand smoke
Learning objectives
• At the end of the lecture, the audience will:
– Review the scientific evidence of harm of tobacco smoke
exposure
– Discuss strategies for reduction of tobacco smoke
exposure
– Describe methods of encouraging tobacco use cessation in
parents and adolescents
– Learn the particular challenges and opportunities of
intervention in the inpatient setting
Background
• 18% of children ages 3-11 are regularly exposed to
secondhand tobacco smoke (SHS) in the home
• 54% of children ages 3-11 had detectable cotinine
levels in the 2007-2008 NHANES
– 19 million children ages 3-11
• Increased conduct disorder and decreased
antioxidant levels even at low levels of exposure
Population attributable risks
• Annually:
– 200,000 childhood asthma episodes
– 150,000-300,000 cases of lower
respiratory illness
– 790,000 middle ear infections
– 25,000-72,000 low birth weight
or preterm infants
– 430 cases of SIDS
Other sources of exposure
• Daycare
• Grandparents
• Non-custodial parents
• Friends
• Multiunit housing
Secondhand smoke affects families
• Children whose parents smoke are more likely to
smoke themselves
• A pack-a-day habit costs $1000 to
$1500 a year – a considerable
expense!
Cigarette smoke components
Carbon Monixide
Tar
Gas from car exhausts
Road surfaces
Nicotine
Butane
Pesticide
Lighter fuel
Acetone
Ammonia
Nail varnish remover
Cleaning products
Arsenic
Methanol
Rat poison
Rocket fuel
Hydrogen Cyanide
Formaldehyde
Poison used on death row
Used to pickle dead bodies
Radon
Cadmium
Radioactive gas
Batteries
Biological evidence
• Several studies have found an association between
SHS exposure and decreased levels of antioxidant
vitamins in children
• Studies have found increased levels of Eosinophilic
Cationic Protein (ECP), CRP, and IL-13 in smokeexposed children
• Shift to Th2 from Th1 immune regulation may cause
increase of asthma and atopy, as well as decreased
Th1 response to pathogens
Can pediatricians help eliminate SHS
exposure?
• No. We’re already too busy!
• No. Parents aren’t our patients.
• No. We’ll alienate parents and they’ll go somewhere
else.
• No. We won’t be reimbursed for the time we spend.
• And besides, we don’t know what to do!
Yes, you can!
• You can be effective in 3 minutes or less!
• Parents EXPECT you to discuss tobacco use.
• If you respect the parent during your discussion, you
won’t alienate them.
• You got me there. (Reimbursement.)
• We’ll teach you how!
What can pediatricians and other
child health advocates do?
• Ask all parents about smoking
• Educate parents about SHS
• Offer treatment or referral (Quitline or local system)
• Advocate for smoke free areas
• Advocate for tobacco control
Your tools
• The 5 As (or 2 As & R)
• Motivational interviewing techniques
• Pharmacotherapy
• Community and public
health resources
The theory behind the tools
• Stages of Change
• Motivational Interviewing
• Pharmacotherapies
Addiction and substance abuse
• Addiction (dependence): “a cluster of cognitive,
behavioral, and physiological symptoms indicating that
the individual continues use of the substance despite
significant substance-related problems ” (DSM-IV-TR)
• Abuse: “a maladaptive pattern of substance use
manifested by recurrent and significant adverse
consequences related to the repeated use [or misuse]
of substances” (DSM-IV-TR)
• Unfortunately, tobacco is typically used as indicated
Factors of addiction: A chronic disease
• Genetics
• Environment
– Emotional, physical, psychiatric health
– Family, friends, society
• Pharmacology
Stages of change
Assessing Stage of Readiness
Precontemplation
Contemplation
Ready for Action
Relapse
Action
Maintenance
• Behavior change occurs in stages – not all at once.
PHS guidelines on tobacco 2008:
Key recommendations
• Brief Clinical Intervention: the 5A’s (2 A’s & R)
• Offer Pharmacotherapy
• Refer to Quitline
• Provide SHS Counseling
Ask…
• Parents, even those who smoke, want and expect
providers to bring up second-hand smoke exposure.
• It’s important to address smoking in a nonjudgmental manner.
Ask… the right question!
• You don’t smoke in front of her, do you?
Ask… the right question!
• You don’t smoke in front of her, do you?
• No one smokes in the home, right?
Ask… the right question!
• You don’t smoke in front of her, do you?
• No one smokes in the home, right?
• Does anyone smoke in the home?
Ask… the right question!
• You don’t smoke in front of her, do you?
• No one smokes in the home, right?
• Does anyone smoke in the home?
• Is your child ever exposed to cigarette smoke?
Ask… the right question!
• You don’t smoke in front of her, do you?
• No one smokes in the home, right?
• Does anyone smoke in the home?
• Is your child ever exposed to cigarette smoke?
• Is there anyone in your household that uses
tobacco? Who is that? Where do they smoke? Is
that inside the house?
Ask… the right question!
• Don’t forget other sources of exposure:
– Other homes the child may stay at:
• Divorced parents
• Grandparents
• Daycare providers
– Cars
– Seepage from other apartments
Ask… the right question!
• Explore:
– You say no one smokes around your son. Can you tell me
what that means?
– You say you always smoke outside, but I know it’s hard
when it’s cold outside- are there ever times when you
smoke in the house?
Advise… Be specific
• Quitting smoking is the best thing you can do to help
protect your health and the health of your child.
• I can help you.
• Have you thought about quitting (Assess)?
– No- exposure reduction
– Yes- exposure reduction and Assist/Arrange
Advise… Exposure reduction
• Having a smoke free home means no smoking
ANYWHERE - home or car.
• It does NOT mean smoking:
–
–
–
–
–
–
Near a window or exhaust fan
In a basement, garage, or screen porch
In the car with the windows open
Inside only when the weather is bad
Cigars, pipes, or hookahs
On the other side of the room
The bacon analogy
Negotiation over time
• Even small doses of counseling can add up over time.
• A complete ban may not be a reasonable first step
for some smoking parents:
– Negotiate small, acceptable steps with the parent
– Reinforce health benefits to the child of reducing smoke
exposure
The exposure ladder
Smoking in the room
The exposure ladder
Smoking elsewhere in
the house
Smoking in the room
The exposure ladder
Smoking usually outside
Smoking elsewhere in
the house
Smoking in the room
The exposure ladder
Smoking always outside
Smoking usually outside
Smoking elsewhere in
the house
Smoking in the room
The exposure ladder
Complete smoking ban
in house and cars
Smoking always outside
Smoking usually outside
Smoking elsewhere in
the house
Smoking in the room
The exposure ladder
Completely non-smoking family
Complete smoking ban
in house and cars
Smoking always outside
Smoking usually outside
Smoking elsewhere in
the house
Smoking in the room
Other suggestions
• Non-evidence-based, but potentially helpful interim
measures for smokers outside:
– Washing hands after smoking
– Wearing a separate smoking jacket or shirt
– Using indoor air filters
(NOT to smoke indoors)
– Keeping young kids’ hands clean
When it’s grandma who smokes…
• Other family members can be even more
challenging:
–
–
–
–
Teen parents may not feel empowered to take a stand
Financial dependence
Dependence on child care
Domestic abuse situations
Grandma, continued
• Potential ways to mediate:
– Write a letter to the child’s family stating that cigarette
smoke exposure could make the child more likely to be
sick, and that you are recommending that no one smoke
inside the house.
– Ask that the smoking family member come to the next
appointment, so they can be a part of the discussion.
– Give the parent information, handouts, etc that support
their position that SHS is bad for their child.
– Work with social work and local agencies to try to find
alternate child care or housing for the child.
Refer
REFER families who use tobacco to outside help
– Using the Quitline handout or your state’s fax enrollment
form, refer tobacco users to the Quitline 1-800-QUIT NOW
– www.smokefree.gov
– Document referral given to families in the child’s chart
– Arrange follow-up with tobacco users
Motivational interviewing
• Patient-centered, directive method for enhancing
motivation to change
– By exploring and resolving AMBIVALENCE
– “I want to quit smoking, but I like to smoke”
– Can be used in brief doses!
Pharmacotherapies
• Combining pharmacotherapy with counseling
DOUBLES a patient’s chance of successfully quitting
smoking
Pharmacotherapy types
• Nicotine replacement therapy (NRT) (many brands,
some generics)
– Many OTC
– Some states reimburse, even for OTC (prescription may be
required)
• Bupropion SR (Zyban, Wellbutrin)
• Varenicline (Chantix)
NRT
• Non-nicotine components of tobacco cause most of
the adverse health effects
– Tars, carbon monoxide, etc.
• The benefits of NRT outweigh the risks, even in
smokers with cardiovascular disease (remember they
already smoke!)
Using NRT: Treatment goals
• Overall reduction of nicotine withdrawal symptoms –
not to replace tobacco!
• Help with momentary urges
• Modify habitual behavior
• Postponement of smoking
• May be used to defer smoking when in environment
in which smoking is not allowed
NRT products can be combined
• Use the patch for “daily maintenance”
• Add gum or lozenge for intense urges
• Read and follow the directions!!
• Warn about symptoms of nicotine overdose
• Nausea, dyspepsia, “the jitters”
NRT dosing
• Maintain a consistent level of nicotine during waking
hours with “breakthrough” dosing initiated by the
patient
• Most users UNDERDOSE – frequent cause of
treatment failure
• See book for detailed discussion of dosing NRT
Relevance to inpatients
• Second-hand smoke exposure is associated with
poor outcomes for many children's illnesses
– RSV
– Asthma
• Hospital admission is an opportunity to identify SHS
exposure and encourage parental smoking cessation
– Parents of children with respiratory illness are particularly
receptive
• Little is known about the prevalence or accuracy of
SHS screening of children in this setting
Smoking cessation in the hospital
• Parents of children hospitalized with respiratory
illnesses want to hear about smoking cessation
interventions.
• Hospitalization may offer a time of increased
receptivity to cessation:
– Difficulty leaving the child to smoke
– “Teachable moment” around admissions for smoking
sensitive conditions
• However screening is usually not standardized.
Smoking cessation in the hospital
• Hospitalization allows for more intensive
interventions:
–
–
–
–
Motivational interviewing
Repeat visits
Trials of NRT
Referral to quitlines
• But has challenges:
– STRESS
Smoking cessation in the hospital
• Offer nicotine replacement therapy for parents
• Find a person who can take responsibility for
interventions
– Nursing staff and residents are often too busy
• But a “champion” can make all the difference!
– Social work
– Lactation consultant model
• Use resources such as Quitlines
Need more information?
The AAP Richmond Center
www.aap.org/richmondcenter
Audience-Specific Resources
State-Specific Resources
Cessation Information
Funding Opportunities
Reimbursement Information
Tobacco Control E-mail List
Pediatric Tobacco Control Guide