1. Secondhand Smoke Exposure – the Pediatrician’s Role Presenter name, title, and institution here

2. 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

3. 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

4. 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

5. 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)

6. SHS exposure as a health disparity  Why does this matter? Concentration of multiple exposures among low SES children o Lead, air pollution, SHS o 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

7. 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

8. 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

9. 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

10. SHS - Cigarette smoke components Carbon Monoxide Gas from car exhausts Tar Road surfaces Butane Lighter fuel Ammonia Cleaning products Methanol Rocket fuel Formaldehyde Used to pickle dead bodies Cadmium Batteries Radon Radioactive gas Hydrogen Cyanide Poison used on death row Arsenic Rat poison Acetone Nail varnish remover Nicotine Pesticide

11. Sources of exposure  Home  Car  Daycare  Grandparents  Non-custodial parents  Friends  Multiunit housing

12. 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

13. 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

14. 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

15. 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!

16. 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)

17. 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

18. 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

19. 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

20. 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

21. 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!

22. 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!

23. Theory  Nicotine Addiction  Stages of Change  Motivational Interviewing  Pharmacotherapy

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

25. The 5 As Assess readiness to quit Ask about tobacco use and SHS exposure Advise to quit Assist in quit attempt Arrange follow-up

26. The 5 As Assess Ask Advise Assist Arrange Ask Advise Refer “2As and an R”

27. Identification of Smokers  Increases the rate of clinician intervention  Document in SHS exposure in child’s chart  Use of electronic medical record, if available

28. 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.

29. 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

30. 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!

31. 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

32. 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

33. 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

34. Pharmacotherapies  Combining pharmacotherapy with counselling DOUBLES a patient’s chance of successfully quitting smoking

35. 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)

36. 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

37. 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!

38. 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”

39. www.aap.org/richmondcenter Need more information? The AAP Richmond Center Audience-Specific Resources State-Specific Resources Cessation Information Funding Opportunities Reimbursement Information Tobacco Control E-mail List Pediatric Tobacco Control Guide