Secondhand Smoke Exposure – the Pediatrician’s Role

Presenter name, title, and institution here

Learning objectives

At the end of the lecture, the audience will:• View smoking & SHS exposure as a health

disparity• Understand concepts of nicotine addiction• Review evidence of harm from SHS exposure• Learn how to discuss parental tobacco use in a

pediatric office visit• Describe methods of encouraging tobacco use

cessation in parents and adolescents

47 Years After the 1st Surgeon General’s Report –People Still Smoke!

21% of US adults are smokers

18% of children ages 3-11 are regularly exposed to secondhand tobacco smoke (SHS) in the home

Smoking as a health disparity

Who smokes?• About 20% of US population, slightly lower

rates among women• In STATE, __% current daily smokers• Geographical diversity

o (higher rates in Kentucky, West Virginia, lower in California, Connecticut)

• Smoking rates inversely related to education & income

• People who can least afford cigarettes & tobacco-related disease

Secondhand smoke (SHS) exposure as a health disparity

Who is exposed to SHS? • Overall, about 25% of US children• Children in low-income homes – as high as 79%• 12.3% in lowest income families ADMIT to in-

home SHS exposure/ compared to 2.3% in highest income

• At least 50% of African American children• More than 1/3 of children in low SES homes• Medicaid status independently associated with

hair nicotine level in children (exposure measure)

SHS exposure as a health disparity

Why does this matter?• Concentration of multiple exposures among

low SES children o Lead, air pollution, SHSo Obesity

• Exposure throughout the lifespan• Modeling behavior – more likely to become

active smokers • Teens are twice as likely to smoke if they have

one parent who smokes

Why do people smoke?Nicotine

Tobacco is a substance of abuse/ Nicotine is the addictive drug• Appetite suppression• Alert relaxation• Increases metabolism• Can be titrated via depth/frequency of puff• And causes withdrawal after seven cigarettes

in a row

Distribution of Nicotine from Cigarettes

Enters body via pulmonary circulation

Moves quickly (6-8 seconds) into brain

Rapid behavioral reinforcement

Smoker can control concentration in the brain

Nicotine - Relief of Aversive States

Reduction of anxiety/stress from nicotine deprivation

Relief from hunger

Nicotine’s “enhancement” of attention and cognition - mainly reversal of withdrawal effects

SHS - Cigarette smoke components

Carbon MonoxideGas from car exhausts

TarRoad surfaces

ButaneLighter fuel

AmmoniaCleaning products

MethanolRocket fuel

FormaldehydeUsed to pickle dead bodies

CadmiumBatteries

RadonRadioactive gas

Hydrogen CyanidePoison used on death row

ArsenicRat poison

AcetoneNail varnish remover

NicotinePesticide

Sources of exposure

Home

Car

Daycare

Grandparents

Non-custodial parents

Friends

Multiunit housing

Secondhand smoke affects families

Average cost of pack of cigarettes - $5.50

In _______, over $___

State-state differences in price

A half pack per day habit costs $1000 to $1500 a year

Parental smoking related to food insecurity

SHS 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

Principles of Tobacco Dependence Treatment

Nicotine is addictive

Tobacco dependence is a chronic condition

Effective treatments exist

Every person who uses tobacco should be offered treatment

Smokers Want to Quit

70% of tobacco users report wanting to quit

Most have made at least one quit attempt

Cite physician/clinician/health expert advice as important

Previous quit attempts – most important determinant of ultimate success

So attempts, and relapse --- mean that eventually smoker may succeed!

Adolescent Smoking

Tobacco addiction begins in childhood & adolescence

80% of adult smokers began during adolescence

2/3 of those became daily smokers before age 19

26% of high school students are current smokers

Disparities - Inverse relationship to SES & education level – (same as adult smokers)

Adolescent Smoking - Prevention

Public heath approaches• adolescents are cost sensitive• changing social norms• advertising• smoke-free movies • clean indoor air legislation

Patient-level strategies• another A – “anticipate” – discuss

tobacco use early

Adolescent Smoking – Nicotine addiction

Recent evidence - addiction in teens occurs after short term use

‘loss of autonomy’ - 10% w/in 2 days of smoking; 25% w/in 1 month

Physical and psychological withdrawal symptoms even without daily use

Adolescents underestimate addictive nature of nicotine

Adolescent Smoking - Treatment

Most teens want to quit

But few do

Motivation – need short term goals • Decreased cough• Increased exercise tolerance• Nicotine staining• Smell of cigarettes

Adolescent Smoking - Treatment

Tobacco dependence treatment• evidence base strong in adults• evolving evidence in adolescents• cognitive-behavioral counseling approach –

shown to be effective• pharmacotherapy – approved for 18 yrs & older• may be useful for clinician but off label use• NRT has been shown to be safe in adolescents

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.

Minimal Advise/Refer strategy doesn’t cost anything….

We’ll teach you how!

Theory

Nicotine Addiction

Stages of Change

Motivational Interviewing

Pharmacotherapy

Stages of change

• Behavior change occurs in stages – not all at once.

Assessing Stage of Readiness

Precontemplation

Contemplation

Ready for Action

Action

Maintenance

Relapse

The 5 As

Assess Assess readiness to quitreadiness to quit

AskAsk about tobacco use and SHS exposure about tobacco use and SHS exposure

AdviseAdvise to quitto quit

AssistAssist in quit attemptin quit attempt

ArrangeArrange follow-upfollow-up

The 5 As

AssessAssess

AskAsk

AdviseAdvise

AssistAssist

ArrangeArrange

AskAsk

AdviseAdvise

ReferRefer

“2As and an R”

Identification of Smokers

Increases the rate of clinician intervention

Document in SHS exposure in child’s chart

Use of electronic medical record, if available

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.

Ask: How

Say: “Does your child live with anyone who uses tobacco?”

Avoid judgment – check your body language, tone of voice, the phrasing of the question

Avoid leading: “You don’t smoke, do you?” Depersonalize the question

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!

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

The exposure ladder

Smoking in the room

Smoking usually outside

Smoking always outside

Complete smoking ban in house and

cars

Completely non-smoking family

Smoking elsewhere in the

house

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 national Quitline 1-800-QUIT NOW

• On line and phone counseling, and free NRT• www.smokefree.gov• Document referral given to families in child’s

chart• Arrange follow-up with tobacco users

Pharmacotherapies

Combining pharmacotherapy with counselling 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)

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

Non-nicotine components of tobacco cause most adverse health effects• Tars, carbon monoxide, etc.

The benefits of NRT outweigh the risks, even in smokers with cardiovascular disease (remember they already smoke!)

Not addictive – do not reach brain in 6-8 seconds!

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”

www.aap.org/richmondcenter

Need more information?The AAP Richmond Center

Audience-Specific Resources State-Specific ResourcesCessation InformationFunding Opportunities

Reimbursement InformationTobacco Control E-mail List

Pediatric Tobacco Control Guide