The CEASE program: Implementing Ask, Assist, Refer in Pediatrics

1. The CEASE program: Implementing Ask, Assist, Refer in Pediatrics Your name, institution, etc. here YOUR LOGO HERE(can paste to each slide)

2. …dedicated to eliminating children’s exposure to tobacco and secondhand smoke

3. At the end of this tutorial participants will be able to: Use the 3 step CEASE program to ask, assist, and refer family members interested in quitting to the state Quitline Describe how the program can be implemented/adapted for use in clinical practice Explain how to deal with common issues that come up during implementation

4. The Life Cycle of Smoking Asthma Otitis Media Fire-related Injuries Influences to Start Smoking SIDs Bronchiolitis Meningitis Childhood Adolescence Infancy Nicotine Addiction In utero Adulthood Low Birth Weight Stillbirth Neurologic Problems Cancer Cardiovascular Disease COPD

5. The Social Cycle of Tobacco Use Influences to Start Smoking: Media, Household Members, Peers Childhood Adolescence Infancy Alienation from peers who don’t use tobacco In utero Adulthood

6. The Economic Cycle of Tobacco Use Decreased lifetime earnings A pack-a-day smoker Spends over $2000/year Childhood Adolescence Infancy In utero Adulthood Increased likelihood of Living in poverty

7. The Cessation Imperative The only way to protect non-smoking family members completely is to quit smoking

8. Parental Cessation is the Goal Eliminate the #1 cause of preventable morbidity and mortality Eliminate tobacco smoke exposure of all household members Decrease economic impact Average cost per pack across US >$5 Decrease teen smoking rates

9. A Treatable Disease

10. CEASE • Clinicians: Adherence to evidence-based guidelines • Parents: Change at behavioral level • Practice: Implementation of systems change • Funded by NCI, NIDA, AHRQ • R01-CA127127-01 • Three step process- Ask, Assist, Refer • Testing done through AAP PROS

11. Working as a practice to address family smoking • As a practice, read and complete the CEASE Implementation Guide. The CEASE Implementation Guide will lead your office through all the steps needed to address family smoking. • Put the CEASE Implementation Guide in a public space so all staff can review it. • Work together to develop measurable benchmarks for success. Work together to identify roadblocks that may be keeping you from your benchmarks.

13. Step 1: For you to fill out Patient’s Name: Date: Other children seen here: Your name: Your Email (optional): Relationship to patient (circle one):Mother Father Other :Does anyone that you live with smoke? Yes No If yes, who? Have you smoked tobacco, even a puff, in the last 7 days? Yes No, quit in past year No, quit over a year ago No, neverIf you smoke, how interested are you in quitting? A lot Some A little Not at all If you smoke, are you interested in medicine to help you quit? Yes No Not sure If you smoke, do you want to learn free ways to help you quit? Yes No Not sure Does anyone smoke in your home ever? Yes No Does anyone smoke in your car ever?Yes No No car • Step 2: For the doctor/nurse to fill out • The doctor or nurse may talk to you about smoking and protecting • others from the harms of smoking. The doctor or nurse may use the • check boxes on this form to best meet your needs. • How to quit smoking. Quitting smoking is one of the best things that you can do for your health and the health of your family. Parents who quit help keep their children from smoking in the future. • Halflet given • Set a quit date for ________ • Treatment. Medicine can double your chance of quitting smoking for good. • Medication prescribed: ___________________________ • Free programs to help you quit smoking. Would you like to know more about the free telephone quitline or free online services to help you quit smoking? • Quitline form faxed • Online program information emailed • Have a no-smoking rule everywhere in your home and car. One of the best ways that you can take care of your children is to quit smoking and have a completely smoke-free home and car. • Halflet given Anna Reynolds July 18, 2010 None Monica Black-Reynolds Bobbie (father) Progress notes: ___/___/___ : ___/___/___ : ___/___/___ : Version 5.29.2008

14. Step 1: For you to fill out Patient’s Name: Date: Other children seen here: Your name: Your Email (optional): Relationship to patient (circle one):Mother Father Other :Does anyone that you live with smoke? Yes No If yes, who? Have you smoked tobacco, even a puff, in the last 7 days? Yes No, quit in past year No, quit over a year ago No, neverIf you smoke, how interested are you in quitting? A lot Some A little Not at all If you smoke, are you interested in medicine to help you quit? Yes No Not sure If you smoke, do you want to learn free ways to help you quit? Yes No Not sure Does anyone smoke in your home ever? Yes No Does anyone smoke in your car ever?Yes No No car • Step 2: For the doctor/nurse to fill out • The doctor or nurse may talk to you about smoking and protecting • others from the harms of smoking. The doctor or nurse may use the • check boxes on this form to best meet your needs. • How to quit smoking. Quitting smoking is one of the best things that you can do for your health and the health of your family. Parents who quit help keep their children from smoking in the future. • Halflet given • Set a quit date for ________ • Treatment. Medicine can double your chance of quitting smoking for good. • Medication prescribed: ___________________________ • Free programs to help you quit smoking. Would you like to know more about the free telephone quitline or free online services to help you quit smoking? • Quitline form faxed • Online program information emailed • Have a no-smoking rule everywhere in your home and car. One of the best ways that you can take care of your children is to quit smoking and have a completely smoke-free home and car. • Halflet given Anna Reynolds July 18, 2010 None  Monica Black-Reynolds    Patch  Bobbie (father)   Progress notes: ___/___/___ : ___/___/___ : ___/___/___ : Version 5.29.2008

15. CEASE Posters

16. CEASE Posters

17. CEASE Halflet: Third-hand Smoke

18. Reading Levels CEASE materials for parents (halflets) were tested using the Flesch-Kincaid Readability Test Eight of the nine tested CEASE halflets are at or under the 6th grade reading level The average reading level of the CEASE halflets is 4.7th grade

19. Reading Levels

20. Principles of Tobacco Dependence Treatment Tobacco dependence is a chronic, relapsing condition Nicotine is addictive Effective treatments exist Every person who uses tobacco shouldbe offered treatment

21. Tobacco Users Want to Quit 70% of tobacco users report wanting to quit 44% have made at least one quit attempt in the past year 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!

22. Three Easy Steps • Step 1: Ask • Step 2: Assist • Step 3: Refer

23. Step One: Ask Ask families about tobacco use and rules about smoking in the home and car Every year, ask families:“Does any member of the household use tobacco?”

24. Step One: Ask If the parent you’re speaking with uses tobacco.. ask if they are Interested in quitting? Would they like a medication to help them quit? Want to be enrolled in the free quitline?

25. Step One: Ask If the parent you’re speaking with uses tobacco but says NO, ask if they are: Interested in help to maintain a completely smoke free home and car? Would they like medication to help them avoid smoking or to reduce smoking?

26. Step Two: Assist • Use the responses on Step One to guide how you assist with addressing tobacco use. • Interested in Quitting? • Set a quit date in the next 30 days • Prescribe or recommend medication for assisting quit • Enroll in Quitline • Document services delivered to enhance complexity of visit to level 4

27. 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!

28. Medications Work!

29. NicotineReplacement for Reducing/Deferring Smoking Off-label in US Labeled for reduction to quit in UK, Canada, 26 countries world wide… Excellent evidence on safety Does not undermine future quits 16 of 19 studies reduce-to-quit INCREASED future cessation Can replace cigarettes 1:1 with lozenge, gum, inhaler dosing

30. Before the Quit Date: Bupropion (Zyban®/Wellbutrin®) Start 2 weeks BEFORE quit date 150 mg QAM for 3 days, then increase dose to 150 mg BID Doses should be at least 8 hours apart Use for 7-12 weeks after quit date; longer use possible Black Box warning for neuropsychiatric sx Don’t use with seizure disorder May be combined with NRT

31. The New Drug:Varenicline (Chantix®) Start 1 week BEFORE quit date 0.5 mg QD for 3 days, then 0.5 mg BID for 4 days, then 1 mg BID for 12 weeks After a meal with a full glass of water Use for 12 weeks after quit date; longer use possible Nausea, sleep problems common SE Concurrent use with NRT may increase nausea Black Box warning for neuropsychiatric Sx

32. Step Three: Refer • Refer families who use tobacco to outside help • Use your state’s “fax to quit” quitline enrollment form • Arrange follow-up with tobacco users • Record in the child’s medical record

33. _____ Quitline List resources here Phone number here Website here

34. Arrange Follow Up Plan to follow up on any behavioral commitments made Just asking at the next visit makes a big impression Schedule follow-up in person or by telephone soon after the quit date, for those who have committed to quit

35. The Barriers Time: There’s never enough time to do the things you already need to do Money: And it’s unlikely you’ll be reimbursed every time Your staff: Can derail efforts Your patients and their families: May not want to talk about it

36. The Assets 1. You and your staff and colleagues can be effective 2. Your patients and their families expect to hear about tobacco 3. The changing culture is making it harder to use tobacco

37. But How? Clinical Staff: Can ASK, ASSIST, and REFER Administrative Staff: Can keep materials stocked and administer screening questionnaires Management: Need to support the “cause”

38. Training Videos Full program training video is available on the website 5 available pediatric tobacco control scenarios www.ceasetobacco.org

39. Put it into Practice! • Using what we just discussed, partner up with someone for the following three role play scenarios. • One person will be the clinician, and one person will be the parent. • Switch roles after each scenario so that you both gain experience in each role.

40. Role Play 1: Clinician This is Emma’s first well-baby visit; she is 4 days old. Both of Emma’s parents, Lauren and Peter, are at the visit. Lauren quit smoking when she found out that she was pregnant, but Peter continues to smoke.

41. Role Play 1: Parent You are playing the role of Emma’s father Peter at the pediatrician for the first time. You filled out the CEASE Action Sheet. You’ve been smoking for many years, though Lauren quit when she found out that she was pregnant. You are a bit embarrassed about your smoking. The pediatrician asks where you smoke. You say, “I mostly smoke at work with the other guys. Sometimes when she’s not home, and the baby’s not home I smoke in the kitchen. I open the windows, so hopefully it mostly goes outside.”

42. How did you do?

43. Role Play 2: Clinician Mary is a 9 year old girl with asthma. She lives with her mother, Desiree, and her grandmother, Wanda. Desiree and Wanda both smoke in the home. Mary is being seen for her asthma, as her wheezing has been increasing.

44. Role Play 2: Parent You’re playing the role of Desiree, the mother of 9 year old Mary. You have smoked for many years and are always interested in quitting smoking, but the time never seems right. You smoke outside, but your mother smokes in the home. Dr. Kind Pediatrician has asked if you have any questions about secondhand smoke and asthma. You say, “I guess it must make the asthma worse. I always smoke outside, but I can’t get my mom to do that, especially in the winter. She smokes in the kitchen, or in her bedroom. What can I do?”

45. How did you do?

46. Role Play 3: Clinician Jen is an 18 year old woman, coming to the visit for her pre-college physical. The clinician has been her doctor for many years.

47. Role Play 3: Teen You’re playing the role of Jen, a teenage in for your pre-college physical. You filled out the CEASE Action Sheet, noting that you smoke but are not interested in quitting smoking at this time. You are not ready to quit smoking at this time and resent the clinician’s asking about it. You say, “I mean… I know I don’t want to smoke my whole life, but it’s just not a big deal right now.”

48. How did you do?

49. Summary Tobacco use is a serious disease Child healthcare clinicians can intervene Ask, Assist, and Refer Pediatric clinical practice can change to make it happen

50. http://www.ceasetobacco.org