ppaacece (P(Prevention revention aand nd CCessation essation EEducationducation))
Collaboration of 12 US medical schools funded by the National Cancer
Institute Boston University
Case Western Reserve UniversityDartmouth CollegeHarvard University
Loma Linda UniversityUniversity of Alabama – BirminghamUniversity of California – Los Angeles
University of IowaUniversity of Kentucky
University of MassachusettsUniversity of Rochester
University of South Florida
ppaacece Goals Goals
• Develop, refine, and integrate new educational modules
• Train medical school faculty• Disseminate resources to other
universities
Where You Come In…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 ModuleCommunity Experience ModulePediatrics/Family Medicine Module
Tobacco EducationTobacco Educationfor the for the
Pediatrics/Family Medicine ClerkshipPediatrics/Family Medicine Clerkship
Reducing Exposure to Environmental Tobacco Smoke
(ETS)
Learning Goals for this Learning Goals for this ModuleModule
You will be able to:1. Define secondhand smoke/ETS2. Appreciate the scope and impact of
ETS on children and adults3. Assess the amount of ETS experienced
by children at each visit/contact4. Encourage a smoke free environment
during all regular and sick visits
Learning Goals for this Learning Goals for this ModuleModule
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 Learning Goals for this ModuleModule
You will be able to:1. Define secondhand smoke/ETS2. Appreciate the scope and impact of Appreciate the scope and impact of
ETS on children and adultsETS on children and adults3. Assess the amount of ETS experienced Assess the amount of ETS experienced
by children at each visit/contactby children at each visit/contact4. Encourage a smoke free environment Encourage a smoke free environment
during all regular and sick visitsduring all regular and sick visits
Massachusetts Medical Society Anti-Tobacco Contest Winner
Defining Secondhand Defining Secondhand Smoke/ETSSmoke/ETS
Defining Secondhand Defining Secondhand Smoke/ETSSmoke/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 Defining Secondhand Smoke/ETSSmoke/ETS
• Secondhand smoke contains a complex mixture of more than 4,000 chemicals
• Over 50 of these chemicals are carcinogenic.
Learning Goals for this Learning Goals for this ModuleModule
You will be able to:1. Define secondhand smoke/ETSDefine secondhand smoke/ETS2. Appreciate the scope and impact
of ETS on children and adults3. Assess the amount of ETS experienced Assess the amount of ETS experienced
by children at each visit/contactby children at each visit/contact4. Encourage a smoke free environment Encourage a smoke free environment
during all regular and sick visitsduring all regular and sick visits
The Scope and Impact of ETSThe Scope and Impact of ETS
Massachusetts Medical Society Anti-Tobacco Contest Winner
Health Effects of ETSHealth 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 RisksPrenatal Risks
• Low birthweight• Miscarriage• Premature delivery• Stillbirth• Sudden Infant Death Syndrome (SIDS)• Neurobehavioral problems
Postnatal RisksPostnatal Risks
• Higher rates of:– Pneumonia– Otitis Media– Asthma and asthma exacerbations– Invasive meningitis– Colic
• Respiratory complications under anesthesia
• Sudden Infant Death Syndrome (SIDS)
Other Points to ConsiderOther 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 Estimated U.S. Morbidity and Mortality in Nonsmokers Associated with ETSNonsmokers Associated with ETS
Condition Outcome (annual rate)Development effects -Low birthweight -Sudden Infant Death Syndrome
9,700 to 18,600 births 1,900 to 2,700 deaths
Respiratory effects in children -Otitis media
-New asthma -Asthma exacerbation
0.7 to 1.6 million office visits
8,000 to 26,000 cases 400,000 to 1,000,000
Acute lower respiratory illness -Bronchitis and pneumonia -Hospitalizations -Deaths
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
Why Why InterveneIntervene? Teachable ? Teachable MomentsMoments
• 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 Respected Source of InformationInformation
• 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 Many Opportunities to InterveneIntervene
• 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 Brief Interventions are EffectiveEffective
• 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 Proven Benefits of Limiting ETSETS
• 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 Learning Goals for this ModuleModule
You will be able to:1. Define secondhand smoke/ETSDefine secondhand smoke/ETS2. Appreciate the scope and impact of ETS Appreciate the scope and impact of ETS
on children and adultson children and adults3. Assess the amount of ETS
experienced by children at each visit/contact
4. Encourage a smoke free environment Encourage a smoke free environment during all regular and sick visitsduring all regular and sick visits
Assessing the Amount of ETSAssessing the Amount of ETS
Massachusetts Medical Society Anti-Tobacco Contest Winner
Brief Counseling ModelBrief Counseling Model
Remembering the 5 A’s• Ask • Assess• Advise• Assist• Arrange
Start by AskingStart by Asking
• Open ended questions• Use a non-confrontational style and
tone• Link your questioning to the reason for
visit/contact
Assessing ExposureAssessing Exposure
Include all potential sources of exposure– Home– Car– Daycare– Family– Relative– Friends
Learning Goals for this Learning Goals for this ModuleModule
You will be able to:1. Define secondhand smoke/ETSDefine secondhand smoke/ETS2. Appreciate the scope and impact of ETS Appreciate the scope and impact of ETS
on children and adultson children and adults3. Assess the amount of ETS experienced Assess the amount of ETS experienced
by children at each visit/contactby children at each visit/contact4. Encourage a smoke free
environment during all regular and sick visits
Encourage a Smoke Free Encourage a Smoke Free EnvironmentEnvironment
Massachusetts Medical Society Anti-Tobacco Contest Winner
Brief Counseling ModelBrief Counseling Model
Remembering the 5 A’s• Ask • Assess
•Advise• Assist• Arrange
Encourage a Smoke Free Encourage a Smoke Free EnvironmentEnvironment
• Give a positive message• Focus on benefits to child• Roll with resistance/obstacles• Recognize and acknowledge barriers
Common Barriers to QuittingCommon Barriers to Quitting
• Fear of failure• Nicotine withdrawal• Loss of a coping tool• Family and friends who smoke• Weight gain
Barriers to Limiting ETSBarriers to Limiting ETS
• Logistics• Parenting is stressful• Do not want to upset others by asking
them to change their behavior
Motivating Caregivers to Motivating Caregivers to Quit!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 ETSHow 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!Make Mom a Hero!
• Keeps message positive and focused on the child’s benefit
• Consider using a Smoke Free Pledge
Learning Goals for this Learning Goals for this ModuleModule
5. Assist parents in creating a smoke free environment
6. Screen parents for current smoking Screen parents for current smoking status and readiness for changestatus and readiness for change
7. Offer smoking cessation treatment to Offer smoking cessation treatment to parents and/or refer them to their parents and/or refer them to their providersproviders
Creating a Smoke Free Creating a Smoke Free EnvironmentEnvironment
Massachusetts Medical Society Anti-Tobacco Contest Winner
Brief Counseling ModelBrief Counseling Model
Remembering the 5 A’s• Ask • Assess• Advise
•Assist• Arrange
Creating a Smoke Free Creating a Smoke Free EnvironmentEnvironment
• Set realistic goals• Provide a range of options from
smoking cessation to any gains in limiting ETS
• Empower parent/caregiver• Provide handouts
Practical SuggestionsPractical Suggestions
• Quit• Smoke outside ONLY• Open a window• Ask others to do the same
Learning Goals for this Learning Goals for this ModuleModule
5. Assist parents in creating a smoke Assist parents in creating a smoke free environmentfree environment
6. Screen parents for current smoking status and readiness for change
7. Offer smoking cessation treatment to Offer smoking cessation treatment to parents and/or refer them to their parents and/or refer them to their providersproviders
Screening Parents/CaregiversScreening Parents/Caregivers
Massachusetts Medical Society Anti-Tobacco Contest Winner
A Missed OpportunityA 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 Learning Goals for this ModuleModule
5. Assist parents in creating a smoke Assist parents in creating a smoke free environmentfree environment
6. Screen parents for current smoking Screen parents for current smoking status and readiness for changestatus and readiness for change
7. Offer smoking cessation treatment to parents and/or refer them to their providers
Helping Parents/Caregivers to Helping Parents/Caregivers to QuitQuit
Massachusetts Medical Society Anti-Tobacco Contest Winner
PrecontemplationPrecontemplation
ActionAction
DeterminationDetermination
ContemplatContemplationion
MaintenanceMaintenance
RelapseRelapse
Stages of Change ModelStages of Change Model
PrecontemplationPrecontemplation
ActionAction
DeterminationDetermination
ContemplatContemplationion
MaintenanceMaintenance
RelapseRelapse
Counseling for Smoking Counseling for Smoking CessationCessation
• 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 ChangeDesire 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 ChangeDesire 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 QuitConfidence 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 QuitConfidence 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 MistakesSix 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 MistakesSix 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?
Example #1Example #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 #2Example #2
Jess and Marianne are parents of a six-month-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?