Clean Air for Healthy Children and Families

1. Clean Air for HealthyChildren and Families Health Care Professional Training in Smoking Cessation Counseling Techniques Pennsylvania Chapter American Academy of Pediatrics Edward G. Rendell, Governor Calvin B. Johnson, M.D., M.P.H., Secretary of Health In partnership with Pennsylvania Area Health Education Center (AHEC)

2. Program Goal Every clinician, who interacts with pregnant women, mothers, caregivers of young children, teens and others, will deliver effective smoking cessation advice and counseling.

3. Today’s Learning Objectives At the end of this training you should: • Understand the 5 A’s/2 A’s and R brief smoking cessation counseling intervention • Feel more confident in your ability to provide brief smoking cessation counseling • Be motivated to discuss smoking cessation with your patients and smoke-free environment with your patients • Develop a plan to implement the 5 A’s/2 A’s and R brief smoking cessation counseling intervention

4. What Is Your Office Doing Now? • In what ways do you feel your office is effective or ineffective? • What works well? • What do you feel your patients need? • What skills do you feel you are lacking to counsel patients? • What do you hope to gain from the training today?

5. Program Components • Identify smokers and recent quitters • Counsel (5 A’s/2 A’s and R) • Patient education materials: self-help magazines, optional materials, etc. • Practice tools: documentation forms, stickers, etc.

6. USPHS Guideline Integrating an evidence-based Intervention into practice • Practical Counseling • Problem solving • Skills training • Relapse prevention • Stress management • Support by Providers • Social Support • Pharmacotherapy • Nicotine replacement • Bupropion • Varenicline

7. A A A A A A A R CounselingIntervention 5 A’s (3-5 min.)* 2 A’s / R (1-3 min.) skabout tobacco use dviseto quit ssesswillingness ssist in quit attempt rrangefor follow-up sk dvise efer • Community Resources • 1-800-QuitNOW • Rx Pharmacotherapy *Can extend to 10-15 min. for all patients *Smoke Free Families recommends 10-15 min. for pregnant women

8. Recommendations of Center for Disease Control • Increase utilization of the 5 A’s • Every visit, every time • Reminder systems • Clinician education • Promote system change

9. The scope of the problem

10. Comparative Causes of Annual Deaths in the U.S. USDHHS, CDC (TIPS): Comparative Causes of Annual Deaths in the United States

11. The Debateis Over “We’ve known for decades that smoking is bad for your health...the toxins from cigarette smoke go everywhere the blood flows. There is no safe cigarette...the only way to avoid the health hazards of smoking is to quit completely or to never start smoking.” “The scientific evidence is now indisputable: secondhand smoke is not a mere annoyance. It is a serious health hazard that can lead to disease and premature death in children and nonsmoking adults.” U.S. Surgeon General Richard H. CarmonaNews Release, 2004, SGR, The Health Consequences of SmokingNews Release 06/27/06, SGR, The Health Consequences of Involuntary Exposure to Tobacco Smoke

12. The Life Cycle of the Effects of Smoking on Health Asthma Otitis Media Fire-related Injuries Influences to Start Smoking SIDs Bronchiolitis Meningitis Childhood Adolescence Infancy Nicotine Addiction In utero Adulthood Low Birth Weight Stillbirth Neurologic Problems Cancer Cardiovascular Disease COPD Aligne CA, Stodal JJ. Tobacco and children: An economic evaluation of the medical effects of parental smoking. Arch Pediatr Adolesc Med. 1997;151:652

13. Prenatal/Neonatal Outcomes • 20-30% low birth weight infants • Fetal growth retardation • Spontaneous abortion • Fetal death • Pre-term deliveries • Ectopic pregnancies • Placenta previa and placental abruption • Lower APGAR

14. SHS and Children: Short TermHealth Effects • Respiratory tract infections such as pneumonia & bronchitis • Decreased pulmonary function • Triggers asthma attacks • Ear Infection (Otitis Media) • Tooth decay • House fires

15. SHS and Children: Long TermHealth Effects • Sudden Infant Death Syndrome (SIDS) • Asthma • SHS accounts for 8-13% of asthma cases in children <15 years • SHS exposure increases frequency of episodes and severity of symptoms • 200,000-1 million asthmatic children are affected by SHS • Possible problems with cognitive functioning and behavioral development • More likely to become smokers

16. Risks for Women Who Smoke • Reproductive health problems • Infertility • Conception delay • Pregnancy complications • Menstrual irregularity • Earlier menopause • Compromised immune system • Respond differently to nicotine • Cancer • Less likely to breast feed • Osteoporosis • Thrombosis with use of oral contraceptives

17. Adult Health Risks AssociatedWith Tobacco Use • Cancer • Major cause of: lung, oral and nasal cavity, laryngeal, esophageal, bladder and cervical • Increased risk for:pancreas, uterine, penile, kidney, liver, anal and stomach • Visual difficulties • Decline in hearing • Facial wrinkles • Tooth loss, plaque & staining • Dementia & Alzheimer’s • House fires • Lung changes, COPD, Asthma • Cardiovascular & heart disease • Male & female reproductive problems • Digestive disorders • Rheumatoid arthritis • Impaired healing

18. SHS and AdultHealth Risks Nonsmokers who are exposed to secondhand smoke at home or at the workplace are at an increased risk of developing; • Lung cancer 20-30% • Coronary heart disease (25-30%) • Acute respiratory problems • Other significant health risks as per the SGR: http://www.surgeongeneral.gov/library/secondhandsmoke “There is no risk-free level of exposure to SHS. Breathing even a little SHS can be harmful to your health. Separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate SHS smoke exposure that controls the health risks.” USDHHS, The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the SGR (2006).

19. What can be done?

20. SmokersWant to Quit • 70% report wanting to quit • 3 out of 4 smokers want to quit • Most have made at least one quit attempt • Smokers cite physician/clinician advice as important

21. Nicotine Addiction

22. Addiction 3 Components Physical– A physical craving for tobacco and withdrawal symptoms may be present in the absence of the drug Habit – The use is ritualistic and done without thought Psychological– The belief that the user cannot function without the habit Recovery is possible when all 3 components are treated

23. The Process of BehaviorChange Pre-Contemplator Contemplator Preparation Relapse Action Ex-Smoker Maintenance Prochaska and DiClemente, 1983

24. The Process of Behavior Changeand Pregnancy • Pregnant women often are more open to change and can move through the stages of change differently than when they are not pregnant (The fetus can be a wonderful motivator) • May have more support to quit while pregnant • May not be socially acceptable to smoke in public if pregnant

25. Motivational Interviewing/Consulting Principles • Express empathyto show youunderstand the person’s point of view • Develop discrepancybetween smoking and future goals • Avoid arguing and confrontationbe collaborative and friendly • Roll with the resistanceand avoid argument • Support patient’s self-efficacyandbelief in the possibility of making a change

26. A A A A A A A R CounselingIntervention 5 A’s (3-5 min.)* 2 A’s / R (1-3 min.) skabout tobacco use dviseto quit ssesswillingness ssist in quit attempt rrangefor follow-up sk dvise efer • Community Resources • 1-800-QuitNOW • Rx Pharmacotherapy *Can extend to 10-15 min. for all patients *Smoke Free Families recommends 10-15 min. for pregnant women

27. A sk: About Tobacco Use Ask or verify responses in a non-judgmental way: • Identify smoking status • Counsel all smokers and recent quitters • Household environment • Determine possible barriers to quitting • Possible affects of SHS • If they smoke assess • Nicotine dependence • Patterns of use • Past quit attempts

28. Health Surveys

29. Chart Stickers

30. A dvise: to Quit • Advice to quit should be clear, strong and personalized while using a non-judgmental manner • Discuss the effects of smoking on the patient, fetus and children • Discuss the health benefits of quitting • Acknowledge the difficulty in quitting

31. A ssess: Willingness to Make a Quit Attempt • Assess patient’s level of interest in quitting and intention to take action to quit • Ask key questions

32. Assess: KeyQuestions

33. A ssist: in Quit Attempt Pre-Contemplation and Contemplation Stages (Unwilling to make a quit attempt) The 5 R’s: • Relevanceto patient’s individual situation • Risksof smoking • Rewardsof quitting smoking • Roadblocks or barriers to quitting • Repeat intervention at every visit In successful interventions clinicians should be empathetic, promote patient choices, avoid arguments, listen, reflect and instill self-confidence

34. A ssist: in Quit Attempt Preparation Stage (Willing to quit) • Help the patient with a quit plan • Provide practical counseling • Provide social support • Social support with treatment (Intra-treatment) • Social support outside treatment (Extra-treatment) • Recommend pharmacotherapy • Provide supplemental materials (Quitline, groups)

35. A combination of pharmacotherapy and intervention doubles a patient’s chance of successfully quitting smoking

36. Pharmacotherapy* for Cessation • Nicotine gum • Nicotine patch • Nicotine nasal spray • Nicotine inhaler • Bupropion SR (Zyban) • Lozenge • Varenicline (Chantix) *Unless contraindicated

37. Pharmacotherapy and Pregnancy “If the increased likelihood of smoking cessation, with its potential benefits, outweighs the unknown risk of nicotine replacement and potential concomitant smoking, nicotine replacement products or other pharmaceuticals may be considered.” ACOG. (2005). Committee Opinion: Smoking Cessation During Pregnancy, Number 316. Concomitant = accompanying

38. Handouts forPatients Note: Most materials available in Spanish

39. Personalized Plan forPatients Note: Most materials available in Spanish

40. PA DOH Free Quitline1-800-QUIT-NOW • In partnership with the American Cancer Society • Intake 24 hours a day/7 days a week • Proactive referral (Fast Fax) versus Reactive referral (patient calls) • Develop a personalized plan for quitting

41. PA DOH Free Quitline1-800-QUIT-NOW • Up to 5 follow-up scheduled counseling sessions (8 if pregnant) • Special counseling for pregnant smokers & available for teens • Offered printed materials, referrals, information on medications (NRTs) • English and Spanish; other languages as necessary • Confidential & HIPPA compliant

42. PA DOH Free Quitline transitioning from1-877-724 -1090 to1-800-QUIT-NOW1-800-784-8669

43. CommunityResources • Pre-Approved Tobacco Cessation Registry: Pennsylvania Department of Health http://www.dsf.health.state.pa.us(click on tobacco or Quit NOW (1-800-Quit-NOW) and follow prompts • Local tobacco coalitions, county websites, and county organizations or groups committed to smoking cessation • Quitline also refers to community resources

44. OptionalMaterials See Appendix B of the Clean Air program manual for additional patient handouts and practice tools Clean Air Website:www.cleanairforhealthychildren.org

45. A rrange: forFollow-Up • Pre-Contemplation or Contemplation stage requires continual support and encouragement • Preparation stage: • Follow-up within 1 week of Quit Date • Ask at next visit about progress • Action or Maintenance stage: • Praise success at quitting • Problem solve challenges to maintaining abstinence

46. Documentation Forms

47. Case Study #1 Sylvia • 19-year old • Smokes 16 cigarettes a day for past 3 years • Fights frequently with husband • Pregnant with first baby • One prior quit attempt for a few days • Interested in effects on baby & children 1. Ask about smoking status using a health history or survey. 2. How will you Advisewith a clear, strong, personalized message to quit smoking? 3. Assess the patient’s stage of readiness to quit. 4. To Assist* her in making a quit plan what might you include? 5. What barriers or concerns about quitting would you address and would you do this? 6. Arrange for follow-up via appointment, telephone, or referral.** 7. Document the intervention in the patient chart. *Remember to discuss pharmacotherapy if appropriate **Refer to the Quitline (1-800-QUITNOW) and/or community resources

48. Case Study#2 Linda • 27-year old • Lives with her boyfriend who smokes • Smokes a pack a day for past 13 years • Has little interest in quitting • 3 Children; 6, 4, and 2 • Several prior quit attempts; one in last pregnancy for 1 month • Reluctant to set a quit date 1. Ask about smoking status using a health history or survey. 2. How will you Advisewith a clear, strong, personalized message to quit smoking? 3. Assess the patient’s stage of readiness to quit. 4. To Assist* her in making a quit plan what might you include? 5. What barriers or concerns about quitting would you address and would you do this? 6. Arrange for follow-up via appointment, telephone, or referral.** 7. Document the intervention in the patient chart. *Remember to discuss pharmacotherapy if appropriate **Refer to the Quitline (1-800-QUITNOW) and/or community resources

49. Case Study#6 Lisa • 17-year old • 6 months pregnant, admitted to hospital for pre-term labor • Smokes a pack & a half a day and has smoked for 6 years • Boyfriend smokes • Hospitalized 4 days & medicated to stop contractions • Contraction free & being discharged • Enjoys smoking & has no interest in quitting 1. Ask about smoking status using a health history or survey. 2. How will you Advisewith a clear, strong, personalized message to quit smoking? 3. Assess the patient’s stage of readiness to quit. 4. To Assist* her in making a quit plan what might you include? 5. What barriers or concerns about quitting would you address and would you do this? 6. Arrange for follow-up via appointment, telephone, or referral.** 7. Document the intervention in the patient chart. *Remember to discuss pharmacotherapy if appropriate **Refer to the Quitline (1-800-QUITNOW) and/or community resources

50. Case Study#8 John • 32-year old father • Smokes a pack a day for past 14 years • John is sick with bronchitis • Has a son who has asthma • Concerned about stress with work & home life and avoiding weight gain • Had several prior quit attempts • Occasionally uses smokeless tobacco instead of cigarettes • Wife encourages him to quit • Not sure about trying again 1. Ask about smoking status using a health history or survey. 2. How will you Advisewith a clear, strong, personalized message to quit smoking? 3. Assess the patient’s stage of readiness to quit. 4. To Assist* him in making a quit plan what might you include? 5. What barriers or concerns about quitting would you address and would you do this? 6. Arrange for follow-up via appointment, telephone, or referral.** 7. Document the intervention in the patient chart. *Remember to discuss pharmacotherapy if appropriate **Refer to the Quitline (1-800-QUITNOW) and/or community resources