Transcript J Gary Wheeler, MD Second Hand Smoke/Vapors

Second hand smoke/vapor and kids
J. Gary Wheeler, MD, MPS
Chief Medical Officer
Arkansas Dept. of Health
May 2015
…dedicated to eliminating children’s exposure to tobacco
and secondhand smoke
Learning Objectives
To understand:
• The harms of second/third hand smoke (SHS) exposure to
kids
• The influential role YOU have when delivering the “You
should quit” message
• The importance of a smoke free home
• How to refer clients and their families to 1-800-QUIT-NOW
Local Tobacco Use
• One in four adults smoke in Arkansas
• One in five high school kids smoke in Arkansas
• > 5000 deaths every year
Many Children Are Exposed
• More than 30% of children live with at least one
smoker
• Younger children spend most of their time with a
parent; if that parent smokes, SHS exposure can
be highly significant
• Exposures occur in the home, child care, car
Tobacco-Free Homes
are Protective
• Children and adolescents who live in tobacco-free
homes are less likely to use tobacco
• Strict smoke free home rules encourage cessation
among smoking members of household
• Home smoking bans reduce smoking rates and
cigarette consumption among youth
The Health Effects of Tobacco Use
Asthma
Otitis Media
Fire-related Injuries
SIDs
Bronchiolitis
Meningitis
Childhood
Infancy
In utero
Low Birth Weight
Stillbirth
Neurologic Problems
Influences
to Start
Smoking
Adolescence
Nicotine Addiction
Adulthood
Cancer
Cardiovascular Disease
COPD
SHS Exposure Causes Death
and Disease in Children
• ~6,200 children die each year in the U.S. as a
result of SHS exposure
• ~5.4 million childhood illnesses are attributed to
SHS exposure
• Annual costs attributable to SHS exposure: ~$4.6
billion
Children’s health and tobacco: disease
• Infectious Diseases
– Meningitis (3-4 fold rate)
– Sepsis (3-4 fold rate)
– OM (3.4 million cases); OME (110,000 PE tubes)
– Pneumonia (> 2 fold risk)
– RSV (22,000 hospitalizations; 1,100 deaths)
• Respiratory Diseases
– Asthma (1.8 million outpatient visits, 28,000
hospitalizations, 14 deaths)
– CF
Children’s health and tobacco: disease
• Miscarriage (80,000 “spontaneous” abortions/yr
nationally)
• Low birth weight (46,000 cases)
• Pregnancy complications and SIDS (2,800 cases )
• Burns (10,000 visits; 590 hospitalizations; 250
deaths)
• SIDS (OR=2)
Aligne CA. Arch Pediatr Adolesc Med. In press
Pediatric ER admissions
• FY2003
• Top 50 diagnoses= 21,084 visits
• Diagnoses ass’d with higher incidence in homes with
second hand smoke = 10,706 or 51%
– Otitis media, asthma, pneumonia, URI, etc.
Dave English, ACH-ER
Tobacco Use As an Infectious Disease
• Is tobacco use a disease transmitted by exposure?
– Increased access to tobacco products for
experimentation
– Modeling of tobacco use behaviors?
– Normalization of tobacco use?
Tobacco Use
During Pregnancy
• Stillbirth, SIDS
• Premature delivery, low birth weight
• Placental abruption – the placenta tears away from the
uterus
• Cancers
• Neurological, psychological, developmental effects
• Anesthesia issues
Immediate Effects of SHS Exposure
• Decreased lung function
• Respiratory infections
• Asthma
• Ear infections
• Meningitis, pneumonia
• Household fires
SHS Health Effects in Adults
• Cancers
• Respiratory
• Heart disease
• Increased infection
• Decreased fertility
Long Term Effects of
SHS Exposure
• Increased risk of cancers
– Adult leukemia and lymphoma associated with exposure to maternal
smoking before age 10
• Increased risk of lipid and cholesterol disorders?
• Metabolic syndrome? (a newly recognized syndrome
associated with diabetes and cardiovascular disease)
SHS Exposure and Asthma
• SHS exposure increases frequency of episodes and
severity of symptoms
• SHS exposure causes asthma symptoms in 200,0001 million kids
Third hand smoke
• Increased risk to children
• Particulate– Deposited chemical compounds or physical particles which
are deposited on fabrics and surfaces
• Off-gassing
– Volatile organic compounds in cigarette smoke partition in
materials and then are released at a later time
• Nicotine
– Combines with nitrous acid from indoor air to form
carcinogens
E-cigarettes/ENDS/vapes
• What we know about disease
– Some reactive airway responses
– Some anecdotal responses
– No long term data
• What we know about the products
–
–
–
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Particulate including new nanoparticles
Some carcinogens
Heavy metals
Nicotine
E-cigarettes/ENDS/vapes
• What we know about second hand vapor
– Absorption of nicotine
– Precipitation of vapor on to floors, carpets and
accumulation
– Anecdotes of airway irritation
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 health expert advice as important
• Regardless of type! THIS MEANS YOU!
Counseling 101
• 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!
The Theory…
Assessing Stage of Readiness
Precontemplation
Contemplation
Ready for Action
Relapse
Action
Maintenance
Behavior change occurs in stages – not all at once
Your Goal: Help the Tobacco User Take the
Next Step
First, establish a system for asking
Help a precontemplator become a contemplator…
…a contemplator start to make plans…
…someone who relapsed become “ready for
action”…
And so on….
Brief Intervention
• Minimal interventions lasting less than 3 minutes
increase overall tobacco use abstinence rates.
• Every tobacco user should be offered at least a
minimal intervention, whether or not he or she is
referred to an intensive intervention.
The 5 As
Ask
“2As and an R”
Ask
Advise
Assess
Advise
Assist
Arrange
Refer
2 As and an R: ASK
• Ask about tobacco use and SHS exposure at every
visit
• Make asking routine, consistent, and systematic
– Use standardized documentation
– Document as a “vital sign”
• Just asking can double quit attempts
How Do You Ask?
• Don’t lead: “You don’t smoke, do you?”
• Depersonalize the question: “Does anyone living in your
home use tobacco in any way?” “Who is it?” “Where do
they smoke?” “Is that inside the house?”
• Explore: “You say no one smokes around your son. What
does that mean?”
• Don’t judge – check your body language, tone of voice,
the phrasing of the question
2 As and an R: ADVISE
• Strongly advise every tobacco user to quit
• Provide information about cessation to all
tobacco users
• Strongly urge smoke free homes and cars
• Look for “teachable moments”
• Personalize health risks
• Document your advice
What Do You Say?
• Clear: “I advise you to quit smoking.”
• Strong: “Eliminating smoke exposure of your son is the most
important thing you can do to protect the health of your
child.”
• Personalized: Emphasize the impact on health, finances, the
child, family, or patient.
•
•
“Smoking is bad for you (and your child/family). I can help you quit.”
“Tobacco smoke is bad for you and your family. You should make your
home and car smoke free.”
Child labor
Kristin Palitza
theguardian.com, Wednesday 14 September 2011
Be Specific…
• Having a smoke free home means no smoking
ANYWHERE inside the home or car!
• It DOES NOT mean smoking:
–
–
–
–
–
–
Near a window or exhaust fan
In the car with the windows open
In the basement
Inside only when the weather’s bad
Cigars, pipes, or hookahs
On the other side of the room
2 As and an R: REFER
• To quit line, 1-800-QUIT-NOW
• To community and Internet resources
• Give every tobacco user something that contains
information about quitting, the harms of tobacco
use, etc.
What Do You Say?
• “You should call this number. It’s a free service – and
the person on the other end of the telephone line
can help you get ready to quit.”
• “You should learn as much as you can about quitting
– the more you know, the more successful you’ll be.”
Quitlines
• It takes only 30 seconds to refer a
patient to a toll-free tobacco use
cessation quitline
• Quitlines are staffed by trained
cessation experts who tailor a plan
and advice for each caller
• 1-800-QUIT-NOW callers are routed to
state-run quitlines or the National
Cancer Institute quitline
Advantage of Quitlines
• Accessibility
• Appeal to those who are uncomfortable in a
group setting
• Tobacco users more likely to use a quitline than
face-to-face program
• No cost to patient
• Easy intervention for healthcare professionals
-Fax-back referral services
Medications Work!
• Bupropion SR (Zyban ®) & Varenicline (Chantix ®)
• Start BEFORE the quit date
• Prescription needed
• Nicotine replacement products
• Gum, patch, lozenge
• Others need prescription
• Under 18 years need prescription
• FOLLOW THE DIRECTIONS!!!
Follow Up
• Ask clients how they’re doing
• Ask them if their home and car are smoke free
• Ask them if they called 1-800-QUIT-NOW
For the
Unwilling/Not Ready
• The “5 Rs”
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–
–
–
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Relevance
Risks
Rewards
Roadblocks
Repetition
Community Advocacy
• Community and school education programs
• Be politically active
• Advocate for (and support!) smoke free
environments
• Participate in media presentations
• DON’T USE TOBACCO IN ANY FORM!
Current law in Arkansas
• No sales to minors of any tobacco product;
enforcement of illegal sales by Tobacco Control
Board
• No use of combustible or vaping/e-cig products on
school or college campuses
• No use of combustibles in public places (does not
include vaping/e-cig products).
Volunteer regulations
• Smoke free bars
• Smoke free employees
– Baptist Hospital
– Arkansas Children’s Hospital
– Heart Hospital
– Health care savings
– 3rd hand smoke
Summary
You should now understand:
• The harms of secondhand smoke (SHS) exposure
• The influential role YOU have when delivering the
message “You should quit”
• The importance of a smoke free home
• How to refer clients and their families to 1-800QUIT-NOW
Need more information?
The AAP Richmond Center
www.aap.org/richmondcenter
Audience-Specific Resources
State-Specific Resources
Cessation Information
Funding Opportunities
Reimbursement Information
Tobacco Control E-mail List
Pediatric Tobacco Control Guide
Questions?
Skull of a Skeleton with
Burning Cigarette
Antwerp 1885-1886
Van Gogh Museum
Amsterdam