Protecting Children:Tobacco Exposure Reduction

Paula Collier, M.S.Tobacco Prevention Coordinator

Chattanooga-Hamilton County Health Department

Janie Burley, MPH, CHESTobacco Settlement Fund Coordinator

Chattanooga-Hamilton County Health Department

State Tobacco Settlement Fund

• Three target Areas: (2014-16)– Eliminate pregnancy smoking– Reduce 2nd and 3rd hand tobacco exposure to infants

and children– Prevent youth and adolescent tobacco use

Objectives• Review evidence for harm to

children from tobacco exposure

• Understand benefits of providers and staff promoting tobacco exposure and cessation

• Gain basic skills in tobacco exposure/smoking cessation counseling

• Be able to provide adequate support and resource referral for successful tobacco exposure reduction/cessation attempts

• Familiarization with CEASE and www.ceasetobacco.org

• Understand how to adapt CEASE to meet the needs of the population you serve

• Develop skills to adopt an office tobacco exposure policy, appropriate office signage, and resources for sustainability.

Cigarettesare toxic

Over 7000 Chemicals

Adverse health effects on kids from tobacco exposure

- Brain development altered - Asthma

- Learning disabilities - Reduced lung functions

- Behavior and attention problems - Ear infections

- SIDS/infant mortality - Sinus and respiratory problems

- More likely to have addictions - Health problems as adults

Adverse health effects on kids from tobacco exposure, cont.

• Both clinicians and people in general tend to underestimate the effects of tobacco use and exposure on pregnancy and human development, though the science is now clear.

• Pre-term and underweight births are more likely to result from tobacco use than alcohol, marijuana or harder drugs.

(Bailey & Byrom, 2007)

Kids need your help• Most smokers with children (70%) continue to smoke

inside their homes and cars despite the adverse health effects this has on their children. (Downs et al., 2008)

• Research shows children exposed to tobacco are more likely to develop addictions.

(Winickoff et al., 2005)

How bad is it?• 1/3 of children with asthma are exposed to

smoke regularly.(Downs et al., 2008)

• 338 Hamilton County children aged 1-4 visited the ED due to asthma with 11 hospitalizations (3.35%).(Hospital Discharge Data System. Division of Policy, Planning and Assessment; Tennessee Department of Health.)

• 12.5% of children within the Chattanooga area were reported to be suffering from asthma (50% higher than national average).(http://healthychattanoogakids.blogspot.com/Dec 15 th 2013)

What it Costs…

• Low SES and low parental educational levels correlate with increasing 2nd/3rd hand exposure(Aligne & Stoddard, 1997)(Mannino et al., 2001)

• Healthcare costs for children exposed to tobacco are 19% higher than those that are not exposed.(Downs et al., 2008)

• 1 pack per day costs a family $1825 per year. 2 packs cost $3650(Winickoff et al., 2005)

Why Pediatric Providers?

• Parents of young children tend to be young and otherwise healthy and may visit the pediatrician more than any other doctor.(Newacheck et al., 1998)

• 89% of parents feel that addressing tobacco use is a very important part of a pediatricians' job.(Downs et al., 2008)

• You have access to smokers that do not otherwise interact with healthcare. (Mannino et al., 2001)

You can make a difference

• Newborn visits provide a teachable moment regarding tobacco exposure reduction and behavior. (Winickoff et al., 2013)

• Providers are an important part of consistent messaging.

Practitioner Effectiveness

• Parents who received any assistance were more likely to quit smoking and more assistance was associated with higher quit rates.

• The more intensive smoking cessation approaches delivered in the child health care setting will yield higher parental quit rates.

(Winickoff et al., 2014)

Do they want to quit? YES!

0

10

2030

40

5060

70

8090

100

0 tries 1-2 tries 3-6 tries 7+ tries

18-24

25-44

45-64

65+

(National Center for Health Stats, NHIS 2000)The average number of attempts is 11. Many people who try do not have adequate support or resources. They do not clearly understand that quitting tobacco is really addiction treatment. Their providers do not necessarily understand this either.

CEASE – The 3 A’s

• Ask everyone about tobacco use and exposure every time.

• Advise everyone to protect their children and others.

• Assist everyone who smokes in whatever way you can.

• http://www2.massgeneral.org/ceasetobacco/clinicians.htm

Step 1 = Ask

Implement an office system that ensures every patient every visit is asked about tobacco use and exposure.

Accurate assessment considers:- Relatives - Cigarettes & E-Cigarettes

- Caregivers - Marijuana

- Environments - Smokeless tobacco

Step 2 - AdviseFocus on health.

Advise elimination of tobacco exposure and cessation if appropriate.

Advise strict smoke free home and car rules.

Babies and children most vulnerable due to size and proximity to source.

Step 3 - AssistFocus on help.Be a source of education and encouragement.

Offer several options because a multilayered approach is most the effective.

An effective message is…

• Informative, clear, and personalized

• Use your motivational interviewing skills

• Your professional opinion and support is valuable

Addressing family smoking in child health care settings. Journal Of Clinical Outcomes Management, 16(8), 367-373. Hall, N., Hipple, B., Friebely, J., Ossip, D., & Winickoff, J. (2009).

When they say Yes! - Action

• Clarify what they are ready to do: achievable goals

• Offer support and resources

• Schedule follow up

• Every time you add a layer, the chance of success increases.(Miller & Rollnick, 2002)

When they say Maybe – Importance and Confidence

• Importance: Ask/establish importance of- the child’s health- the management of asthma- reducing ER/doctor visits = save money/time/stress

• Confidence: What steps can you take to get ready?

(I am not ready but…)

• I will ask you about this again next visit. I can help you.(schedule follow up) (Miller & Rollnick, 2002)

When they say No! – Empathy and Helpful Questions

• Empathy: I understand that you have other stressors right now.

• Helpful Questions: What would have to happen for it to become much more important for you to quit? What concerns do you have about your child’s health?Have you tried to cut down or quit before?

• Let’s talk about this next visit and schedule follow up.

• If you ask every visit it gives them more time to make a change and you more time to make an effect.

(Miller & Rollnick, 2002)

Four helpful tips

1. Express Empathy

- I understand it is hard to make changes.

(Acceptance facilitates change, skillful listening is fundamental, ambivalence is normal)

2. Develop Discrepancy

- You say your child’s health is important, but smoking around him is dangerous for him.

(The patient should present the arguments for change. Discrepancy between present behavior and important personal goals or values motivates change)

Four Helpful Tips (cont.)

3. Roll With Resistance

- Could you think about changing habits or cutting down? Avoid arguing for change: psychological reactance. Resistance is not directly opposed New perspectives are invited but not imposed The patient is the primary resource in finding answers and solutions

4. Support Self-Efficacy

- You can do it. I can help. The patient is responsible for choosing and carrying out change A person’s belief in the possibility of change is a good indicator of success

What are appropriate resources?

Every time you add a layer, the chance of success increases.

(Miller & Rollnick, 2002)

•Educational materials (handouts, websites •TN Quitline•PCP/Medications: Wellbutrin, Chantix•Support Group•Behavioral therapy/addiction treatment•CVS pharmacy - NRT

Ready to practice…

Among smokers who live below the poverty level, over two-thirds

say they want to quit.

6% of smokers succeed in quitting each year.

In 1996, a tobacco company executive answered the question of how infants

can avoid secondhand smoke by saying, "at some point they begin to

crawl."

In the 80s, David Goerlitz, the former Winston Man, asked RJ Reynolds executives, "Don't any Don't any of you smokeof you smoke?”

One executive answered: "Are you kidding" We reserve that right for the poor, the young, the black and the stupid. We don’t smoke the crap, We don’t smoke the crap, we just sell itwe just sell it.”

Process Changes

• What a practice will do to change their approach to tobacco exposure and cessation – (Choose at least 1)

– Adopt, review and post a formal office policy.

– Develop tobacco exposure reduction and cessation education based on CEASE model.

– Provide anticipatory tobacco exposure and cessation education at each visit in 1st year including prenatal visit.

Interventions(What to recommend during patient visit)

• Advise establishment of smoke free home and car.

• Advise to quit smoking.• Provide Quitline card and

explain service.• Provide CEASE material where

appropriate• Discuss and set quit date.

Smoke free Home and Car• No safe level of exposure regardless

of clinical setting or child’s diagnosis.

• Legislation in 8 states that prohibits smoking in vehicle with children present.

• Smoke exposure among non-smokers greatest among men, younger adults, non-Hispanic blacks, and those with a lower level of education.

(King, Dube, & Homa, 2013)

Advise to quit• If child is exposed to tobacco smoke – discuss readiness to quit and

offer to help.

• Scenarios available to assist you.

• Helping one family member quit smoking reduces the entire family’s exposure to tobacco toxins.

• Greatest cause of house fire mortality eliminated.

• Financial circumstances improved. – (1 pack costs $1825 per year)

(Hall, Hipple, Friebely, Ossip, & Winickoff, 2009)

TN Quitline

• Program is FREE to all TN residents.• Personalized support – Quit coach (1 year).• Develop plan that’s right for client.• Make call with client.

CEASE Materials

Set a quit date• For some this can greatly improve chances of

success.• Avoid stressful times such as holidays.• Practice by reducing # cigarettes per day.• Be realistic.

E-cigarettes• Provide tobacco users a smoke free source of nicotine.

• No fire, no ash and no smoky smell. (There is still an odor though.)

• Promoted as safer alternative to conventional cigarettes.

• Liquid cartridge that contains nicotine (10 x more addictive than heroin) mixed with propellants.– Propylene glycol– Diethylene glycol (anti-freeze)– Nitrosamines– Heavy metals

Are E-cigs a cessation device?

• Need to be approached with caution: a quit attempt is a quit attempt and should be encouraged.

• Nicotine is addictive, regardless of mode.• Dual use is common.• E cigs do not change the behavior.• Cessation plan necessary.

When Dr’s and Santa endorsed tobacco

Have we gone back in time?

Marketing to adolescents• Victims of aggressive marketing – online, cable TV

• Exposure to youth has increased by 321% from 2011-13

• Experimentation with e-cigs may lead to conventional cigarette use

Marijuana

• Dual use is common, so addressing smoking, whatever they smoke, is worthwhile.

• Can use same CEASE steps to address marijuana.

• Marijuana use is illegal and has similar adverse health effects as conventional cigarettes.

Breastfeeding and Smoking

• Breastfeeding recommended regardless.• Benefits of breast milk outweigh risks from

nicotine exposure (through milk, not 2nd hand smoke).

• Incidence of respiratory incidence in breastfed infants is reduced even of smoking mothers.

(Lucero et al., 2009)

Breastfeeding and NRT• Avoid fast-acting products 2-3 hours prior to and during

feeding.• Transdermal systems should be removed before

bedtime.• 21 mg Dose of NRT is equivalent to 17 cigarettes a day

when used correctly.• Pharmacists can be great resources.

(Lucero et al., 2009)

CO meters

• Inexpensive ($1000 per meter)• Objective• Accurate• Tangible: measures progress

(Smokerlyzer product line, 2014)

• Need more information?The AAP Richmond Center

• www.aap.org/richmondcenter

References:• Aligne, C.A., Stoddard, J.J. (1997). Tobacco and Children: An Economic Evaluation of the Medical Effects of Parental

Smoking. Archives of Pediatrics & Adolescent Medicine, 151(7), 648-53.• Bailey, B. A., & Byrom, A. R. (2007). Factors predicting birth weight in a low-risk sample: the role of modifiable

pregnancy health behaviors. Maternal and Child Health Journal, 11(2), 173-179.• Cluss, P.A., Moss, D. (2002). Parent attitudes about pediatricians addressing parental smoking. Ambulatory Pediatrics,

2(6), 485-8.• Downs, S. M., Zhu, V., Anand, V., Biondich, P. G., & Carroll, A. E. (2008). The CHICA smoking cessation system. In

AMIA Annual Symposium Proceedings (Vol. 2008, p. 166). American Medical Informatics Association.• Good, M. (2013, December 13). Shocking Rates of Pediatric Asthma in the Tennessee Valley are the Number One

Cause of School Absence. Retrieved September 17, 2014, from http://healthychattanoogakids.blogspot.com• Hall, N., Hipple, B., Friebely, J., Ossip, D., & Winickoff, J. (2009). Addressing family smoking in child health care

settings. Journal Of Clinical Outcomes Management, 16(8), 367-373.• Hospital Discharge Data System. Division of Policy, Planning and Assessment; Tennessee Department of Health.• King, B. A., Dube, S. R., & Homa, D. M. (2013). Smoke-Free Rules and Secondhand Smoke Exposure in Homes and

Vehicles Among US Adults, 2009-2010. Preventing Chronic Disease, 10E79.• Kruger, J., Trosclair, A., Rosenthal, A., Babb, S., & Rodes, R. (2012). Physician advice on avoiding secondhand smoke

exposure and referrals for smoking cessation services. Tobacco Induced Diseases, 10(1), 10-19. doi:10.1186/1617-9625-10-10

• Lucero, C. A., Moss, D. R., Davies, E. D., Colborn, K., Barnhart, W. C., & Bogen, D. L. (2009). An examination of attitudes, knowledge, and clinical practices among Pennsylvania pediatricians regarding breastfeeding and smoking. Breastfeeding Medicine, 4(2), 83-89.

References (cont.)• Mannino, D.M., Moorman, J.E., Kingsley, B., Rose, D., Repace, J. (2001). Health effects related to environmental

tobacco smoke exposure in children in the United States. Archives of Pediatrics & Adolescent Medicine, 155(1), 36-41.• Miller, W.R., Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change (2nd ed.). New York, NY:

Guilford Publications.• National Center for Health Stats, NHIS 2000• National Healthy Start Association. (2011). How much does infant mortality cost the nation. Retrieved from

http://www.nationalhealthystart.org/healthy_start_initiative/how_much_does_infant_mortality_cost• Newacheck, P.W., et al. (1998). Health Insurance and access to primary care for children. New England Journal of

Medicine, 338(8), 513-9.• Shershneva, M. B., Larrison, C., Robertson, S., & Speight, M. (2011). Evaluation of a collaborative program on smoking

cessation: Translating outcomes framework into practice. Journal Of Continuing Education In The Health Professions, 31S28-S36. doi:10.1002/chp.20146

• Sims, T. H., Committee on Substance Abuse. (2009). Technical Report: Tobacco as a Substance of Abuse. Pediatrics, 124(5), 1045-53.

• Smokelyzer Product Line. (2014). Retrieved September 30th, 2014, from http://www.covita.net/pico .html• Winickoff, J., Buckley, V., Palfrey, J., Perrin, J., & Rigotti, N. (2003). Intervention with parental smokers in an outpatient

pediatric clinic using counseling and nicotine replacement. Pediatrics, 112(5), 1127-1133.• Winickoff, J., Berkowitz, A., Brooks, K., Tanski, S., Geller, A., Thomson, C., & ... Pbert, L. (2005). State-of-the-art

interventions for office-based parental tobacco control. Pediatrics, 115(3), 750-760.• Winickoff, J. P., Nabi-Burza, E., Yuchiao, C., Finch, S., Regan, S., Wasserman, R., & ... Rigotti, N. A. (2013).

Implementation of a Parental Tobacco Control Intervention in Pediatric Practice. Pediatrics, 132(1), 109-117.