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Secondhand Smoke Exposure

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Secondhand Smoke Exposure the Pediatrician s Role Presenter name, title, and institution here * The Ask, Advise, Refer approach integrates the 5 As into an ... – PowerPoint PPT presentation

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Title: Secondhand Smoke Exposure


1
Secondhand Smoke Exposure the Pediatricians
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 Generals 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
  • (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
  • Lead, air pollution, SHS
  • 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
  • Nicotines enhancement of attention and
    cognition - mainly reversal of withdrawal effects

10
SHS - Cigarette smoke components
Carbon MonoxideGas from car exhausts
TarRoad surfaces
ButaneLighter fuel
NicotinePesticide
AmmoniaCleaning products
AcetoneNail varnish remover
MethanolRocket fuel
ArsenicRat poison
FormaldehydeUsed to pickle dead bodies
Hydrogen CyanidePoison used on death row
CadmiumBatteries
RadonRadioactive gas
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. Were already too busy!
  • No. Parents arent our patients.
  • No. Well alienate parents and theyll go
    somewhere else.
  • No. We wont be reimbursed for the time we spend.
  • And besides, we dont 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 wont alienate them.
  • Minimal Advise/Refer strategy doesnt cost
    anything.
  • Well teach you how!

23
Theory
  • Nicotine Addiction
  • Stages of Change
  • Motivational Interviewing
  • Pharmacotherapy

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

25
The 5 As
26
The 5 As
2As and an R
Ask
Advise
Refer
27
Identification of Smokers
  • Increases the rate of clinician intervention
  • Document in SHS exposure in childs 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.
  • Its 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 dont 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
Completely non-smoking family
Complete smoking ban in house and cars
Smoking always outside
Smoking usually outside
Smoking elsewhere in the house
Smoking in the room
33
Refer
  • REFER families who use tobacco to outside help
  • Using the Quitline handout or your states 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 childs
    chart
  • Arrange follow-up with tobacco users

34
Pharmacotherapies
  • Combining pharmacotherapy with counselling
    DOUBLES a patients 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
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
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