Transcript CMEQI Powerpoint Nov 8th 2014(v2)

Protecting Children:
Tobacco Exposure Reduction
Paula Collier, M.S.
Tobacco Prevention Coordinator
Chattanooga-Hamilton County Health Department
Janie Burley, MPH, CHES
Tobacco 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
• Familiarization with CEASE and
www.ceasetobacco.org
•
Understand benefits of providers
and staff promoting tobacco
exposure and cessation
• Understand how to adapt
CEASE to meet the needs of
the population you serve
•
Gain basic skills in tobacco
exposure/smoking cessation
counseling
• Develop skills to adopt an office
tobacco exposure policy,
appropriate office signage, and
resources for sustainability.
•
Be able to provide adequate
support and resource referral for
successful tobacco exposure
reduction/cessation attempts
Cigarettes
are 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 15th 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!
100
90
80
70
60
50
40
30
20
10
0
18-24
25-44
45-64
65+
0 tries
1-2 tries
3-6 tries
7+ tries
(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
- Caregivers
- Environments
- Cigarettes & E-Cigarettes
- Marijuana
- Smokeless tobacco
Step 2 - Advise
Focus 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 - Assist
Focus 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?




4.
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
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
of 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 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:
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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:10.1186/16179625-10-10
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.)
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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.