Effective practices in promoting tobacco use cessation

1. Effective practices in promoting tobacco use cessation Your name, institution, etc. here YOUR LOGO HERE(can paste to each slide)

2. …dedicated to eliminating children’s exposure to tobacco and secondhand smoke

3. 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

4. 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

5. 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

6. Other sources of exposure Daycare Grandparents Non-custodial parents Friends Multiunit housing

7. 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!

8. Cigarette smoke components Carbon MonixideGas from car exhausts TarRoad surfaces NicotinePesticide ButaneLighter fuel AcetoneNail varnish remover AmmoniaCleaning products ArsenicRat poison MethanolRocket fuel Hydrogen CyanidePoison used on death row FormaldehydeUsed to pickle dead bodies RadonRadioactive gas CadmiumBatteries

9. 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 smoke-exposed children Shift to Th2 from Th1 immune regulation may cause increase of asthma and atopy, as well as decreased Th1 response to pathogens

10. 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!

11. 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!

12. 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

13. Your tools The 5 As (or 2 As & R) Motivational interviewing techniques Pharmacotherapy Community and public health resources

14. The theory behind the tools Stages of Change Motivational Interviewing Pharmacotherapies

15. 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

16. Factors of addiction: A chronic disease Genetics Environment Emotional, physical, psychiatric health Family, friends, society Pharmacology

17. Stages of change Behavior change occurs in stages – not all at once. Assessing Stage of Readiness Precontemplation Contemplation Ready for Action Relapse Action Maintenance

18. 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

19. 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 non-judgmental manner.

20. Ask… the right question! You don’t smoke in front of her, do you?

21. Ask… the right question! You don’t smoke in front of her, do you? No one smokes in the home, right?

22. 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?

23. 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?

24. 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?

25. 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

26. 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?

27. 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

28. 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

29. The bacon analogy

30. 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

31. The exposure ladder Smoking in the room

32. The exposure ladder Smoking elsewhere in the house Smoking in the room

33. The exposure ladder Smoking usually outside Smoking elsewhere in the house Smoking in the room

34. The exposure ladder Smoking always outside Smoking usually outside Smoking elsewhere in the house Smoking in the room

35. 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

36. 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

37. 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

38. 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

39. 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.

40. 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

41. 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!

42. Pharmacotherapies Combining pharmacotherapy with counseling DOUBLES a patient’s chance of successfully quitting smoking

43. 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)

44. 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!)

45. 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

46. 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”

47. 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

48. 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

49. 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.

50. 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