1.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Dana Best, MD, MPH, FAAP Jonathan Winickoff, MD, MPH, FAAP The AAP Julius B. Richmond Center of Excellence http://www.aap.org/richmondcenter/ Protecting Children from SHS Exposure

2.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Cycles of Tobacco Use Section A

3.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Learner Outcomes To train pediatricians in the following:  Brief, effective ways to assist families to quit using tobacco and make their homes and cars tobacco free To redefine success when addressing tobacco use in the pediatric setting  Success is helping a... Family move towards a tobacco free home and car Tobacco user learn more about what works when quitting 3

4.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence The Health Effects of Tobacco Use 4 Source: Aligne, C.A., Stodal, J.J.. Tobacco and children: An economic evaluation of the medical effects of parental smoking. Arch Pediatr Adolesc Med. 1997;151:652

5.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence The Social Cycle of Tobacco Use 5 Source: U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. (2004).

6.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence The Economic Cycle of Tobacco Use 6 Source: Sloan, F., Ostermann, J., Conover, C., Picone, G. (2004). The price of smoking. MIT Press.

7.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Principles of Tobacco Dependence Treatment Tobacco dependence is a chronic, relapsing condition  Nicotine is addictive  Effective treatments exist  Every person who uses tobacco should be offered treatment 7 Source: Fiore, M., Jaen, C., Baker, T., et al. (2008). Treating Tobacco Use And Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.

8.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Tobacco Users Want to Quit 70% of tobacco users report wanting to quit Most have made at least one quit attempt Users say expert advice is important to their decision to quit  The expert can be a physician, clinician, health care worker— any member of your practice! 8 Source: Fiore, M., Jaen, C., Baker, T., et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.

9.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Basic Counseling Patients and families expect you to discuss tobacco use If counseling is delivered in a non-judgmental manner, it is usually well-received Even small “doses” are effective  And cumulative! 9 Source: Frankowski, B.L., Weaver, S.O., Secker-Walker, R.H. (2008). Advising parents to stop smoking: Pediatricians' and parents' attitudes. Pediatrics. 1993; 91(2): 296-300; and Fiore.

10.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Counseling IS Effective As little as three minutes of counseling doubles quit attempts and successes Intensive counseling is more effective  Dose-response relationship Most effective is as follows:  Problem-solving skills  Support from clinician  Social support outside of treatment 10 Source: Fiore, M., Jaen, C., Baker, T., et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.

11.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence The 5 As 11 Source: Fiore, M., Jaen, C., Baker, T., et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.

12.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence The 5 As 12

13.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Ask: The Concept Ask about tobacco use and SHS exposure at every visit  Include current tobacco use, SHS exposure  If appropriate, ask about tobacco use prior to and during pregnancy Make asking routine both consistent and systematic Document as a “vital sign”  Use standardized documentation Just asking can double quit attempts 13 Source: Fiore, M., Jaen, C., Baker, T., et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.

14.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence We Can Learn Better Ways to Ask “... if someone comes at you with an accusatory tone [you’re] going to be defensive.” “... putting me down about it doesn't help. If they talk down to me, making me feel small, it makes it so I don't want to quit. It... makes me feel bad.” 14 Source: Tanski, S., Gaffney, C. Unpublished data.

15.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence When We Don’t Ask in the Right Way... We elicit social desirability bias Parents may modify tobacco use reporting to avoid lectures  Not divulge “slips”  Underreport tobacco use  Modify where and when smoking occurs 15

16.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Ask: How Say, “Does your child live with anyone who uses tobacco?” Don’t judge—check your body language, tone of voice, the phrasing of the question Don’t lead with “you don’t smoke, do you?” Depersonalize the question 16

17.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Ask: If No One Uses Tobacco Explore  “You say no one smokes around your son. What does that mean?” Congratulate and document 17

18.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Ask: If Someone Uses Tobacco “Who is it?” “How do they use tobacco?” “Where do they smoke?” “Is that inside the house?” 18

19.  2009 Johns Hopkins Bloomberg School of Public Health; American Academy of Pediatrics Julius B. Richmond Center of Excellence Assist: The Concept Ask for permission to make suggestions and offer help  “May I make a suggestion... ?”  Offer help—not “rules” Elicit ideas from the parent Offer alternatives or preparatory steps, such as making the home and car tobacco free Help the parent to set their own goals for behavior change 19 Source: Miller, W., Rollnick, S., Conforti, K. (2002). Motivational Interviewing, Second Edition: Preparing People for Change. 2nd ed. New York, NY: Guilford Press.