Clean Air for Healthy Children and Families

1. Clean Air for HealthyChildren and Families Health Care Professional Training in Smoking Cessation Counseling Techniques Pennsylvania Chapter American Academy of Pediatrics Edward G. Rendell, Governor Calvin B. Johnson, M.D., M.P.H., Secretary of Health In partnership with Pennsylvania Area Health Education Center (AHEC)

2. ACS 1997 CPG, ACOG 2000 Program Development PA DOH Funding to Fox Chase 1989-1994 PA DOH Funding to PA AAP 1996-Present PA DOH Funding to AHEC to PA AAP 2005-Present Clean Air Program Adopted 1996 AAP Policy 2001 Primary Contractors 2002 Curriculum Revised & Updated 2004, 2006

3. Program Goal Every clinician, who interacts with pregnant women, mothers, caregivers of young children, teens and others, will deliver effective smoking cessation advice and counseling.

4. CAFHCF Program Objectives • Ensure that smokers are fully informed of the health risks associated with smoking and secondhand smoke • Motivate smokers to quit • Increase cessation attempts by delivering the 5 A’s/2 A’s and R brief smoking cessation counseling intervention • Increase successful cessation by providing effective counseling, pharmacotherapy, self-help materials, and referrals • Reduce the number of children and individuals who are exposed to secondhand smoke at home

5. Today’s Learning Objectives At the end of this training you should: • Understand the 5 A’s/2 A’s and R brief smoking cessation counseling intervention • Feel more confident in your ability to provide brief smoking cessation counseling • Be motivated to discuss smoking cessation with your patients and smoke-free environment with your patients • Develop a plan to implement the 5 A’s/2 A’s and R brief smoking cessation counseling intervention

6. What Is Your Office Doing Now? • In what ways do you feel your office is effective or ineffective? • What works well? • What do you feel your patients need? • What skills do you feel you are lacking to counsel patients? • What do you hope to gain from the training today?

7. Program Components • Identify smokers and recent quitters • Counsel (5 A’s/2 A’s and R) • Patient education materials: self-help magazines, optional materials, etc. • Practice tools: documentation forms, stickers, etc.

8. USPHS Guideline Integrating an evidence-based Intervention into practice • Practical Counseling • Problem solving • Skills training • Relapse prevention • Stress management • Support by Providers • Social Support • Pharmacotherapy • Nicotine replacement • Bupropion • Varenicline

9. Brief counseling is effective

10. A A A A A A A R CounselingIntervention 5 A’s (3-5 min.)* 2 A’s / R (1-3 min.) skabout tobacco use dviseto quit ssesswillingness ssist in quit attempt rrangefor follow-up sk dvise efer • Community Resources • 1-800-QuitNOW • Rx Pharmacotherapy *Can extend to 10-15 min. for all patients *Smoke Free Families recommends 10-15 min. for pregnant women

11. Efficacy of Various Levelsof Contact Fiore et al., (2000) Smoke Free Families recommends 5-15 minutes counseling in pregnancy

12. 3% 20% 23% 41% 12% Patient Outcomes Totals for cessation flow sheets through12/31/97-06/01/06 Smoking status self-reported by patients n= 9,882

13. Recommendations of Center for Disease Control • Increase utilization of the 5 A’s • Every visit, every time • Reminder systems • Clinician education • Promote system change

14. The scope of the problem

15. Comparative Causes of Annual Deaths in the U.S. USDHHS, CDC (TIPS): Comparative Causes of Annual Deaths in the United States

16. SmokingPrevalence Men Women Pregnant Women 2004 National Health Interview Survey {(MMWR 2005(54)44} 2005 PA Behavioral Risk Factor Surveillance System PA DOH Vital Statistics Resident Live Births 2004 Table B-25 National Vital Statistics Reports: Births: Final Data for 2003 (Martin, J. A. et al.)

17. Smoking DuringPregnancy USDHHS, Smoking During Pregnancy-United States, 1990-2000. MMWR, 2004;53(39):911-915

18. Smoking During Pregnancy < HighSchool High School > High School National Vital Statistics Reports: Births: Final Data for 2003 (Martin, J. A. et al.), Table 31

19. Smoking Quit Rates DuringPregnancy • Approximately 30% of quitters relapse during their pregnancy • Many women who quit smoking during pregnancy plan to smoke again once the baby is born • 70% of remaining quitters relapse within 12 months of delivery PA Department of Health, 2004 Vital Statistics Resident Live Births by Age (Table B-19A) and Race (Table B-19B)

20. The Debateis Over “We’ve known for decades that smoking is bad for your health...the toxins from cigarette smoke go everywhere the blood flows. There is no safe cigarette...the only way to avoid the health hazards of smoking is to quit completely or to never start smoking.” “The scientific evidence is now indisputable: secondhand smoke is not a mere annoyance. It is a serious health hazard that can lead to disease and premature death in children and nonsmoking adults.” U.S. Surgeon General Richard H. CarmonaNews Release, 2004, SGR, The Health Consequences of SmokingNews Release 06/27/06, SGR, The Health Consequences of Involuntary Exposure to Tobacco Smoke

21. The Life Cycle of the Effects of Smoking on Health 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 Aligne CA, Stodal JJ. Tobacco and children: An economic evaluation of the medical effects of parental smoking. Arch Pediatr Adolesc Med. 1997;151:652

22. Prenatal/Neonatal Outcomes • 20-30% low birth weight infants • Fetal growth retardation • Spontaneous abortion • Fetal death • Pre-term deliveries • Ectopic pregnancies • Placenta previa and placental abruption • Lower APGAR

23. SHS and Children: Short TermHealth Effects • Respiratory tract infections such as pneumonia & bronchitis • Decreased pulmonary function • Triggers asthma attacks • Ear Infection (Otitis Media) • Tooth decay • House fires

24. SHS and Children: Long TermHealth Effects • Sudden Infant Death Syndrome (SIDS) • Asthma • SHS accounts for 8-13% of asthma cases in children <15 years • SHS exposure increases frequency of episodes and severity of symptoms • 200,000-1 million asthmatic children are affected by SHS • Possible problems with cognitive functioning and behavioral development • More likely to become smokers

25. Risks for Women Who Smoke • Reproductive health problems • Infertility • Conception delay • Pregnancy complications • Menstrual irregularity • Earlier menopause • Compromised immune system • Respond differently to nicotine • Cancer • Less likely to breast feed • Osteoporosis • Thrombosis with use of oral contraceptives

26. Adult Health Risks AssociatedWith Tobacco Use • Cancer • Major cause of: lung, oral and nasal cavity, laryngeal, esophageal, bladder and cervical • Increased risk for:pancreas, uterine, penile, kidney, liver, anal and stomach • Visual difficulties • Decline in hearing • Facial wrinkles • Tooth loss, plaque & staining • Dementia & Alzheimer’s • House fires • Lung changes, COPD, Asthma • Cardiovascular & heart disease • Male & female reproductive problems • Digestive disorders • Rheumatoid arthritis • Impaired healing

27. SHS and AdultHealth Risks Nonsmokers who are exposed to secondhand smoke at home or at the workplace are at an increased risk of developing; • Lung cancer 20-30% • Coronary heart disease (25-30%) • Acute respiratory problems • Other significant health risks as per the SGR: http://www.surgeongeneral.gov/library/secondhandsmoke “There is no risk-free level of exposure to SHS. Breathing even a little SHS can be harmful to your health. Separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate SHS smoke exposure that controls the health risks.” USDHHS, The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the SGR (2006).

28. What can be done?

29. SmokersWant to Quit • 70% report wanting to quit • 3 out of 4 smokers want to quit • Most have made at least one quit attempt • Smokers cite physician/clinician advice as important

30. Nicotine Addiction

31. Addiction The repeated, habitual use of a substance that affects a person’s mood and the course is chronic, progressive, and ultimately fatal.

32. NicotineAddiction Characterized by: • Use stimulates the production of dopamine which changes brain chemistry and is associated with feelings of reward and pleasure • Need to use the substance to feel normal • The inability to control use resulting tolerance • Continued use regardless of the negative consequences • Being the most addictive drug • Impacting all areas of a person’s life – biopsychosocial effects

33. Addiction 3 Components Physical– A physical craving for tobacco and withdrawal symptoms may be present in the absence of the drug Habit – The use is ritualistic and done without thought Psychological– The belief that the user cannot function without the habit Recovery is possible when all 3 components are treated

34. The Process of BehaviorChange Pre-Contemplator Contemplator Preparation Relapse Action Ex-Smoker Maintenance Prochaska and DiClemente, 1983

35. Relapse or Slip? • Reframe the experience as a partial success versus a total failure • Learn from the experience and understand what happened • Develop optimism about continuing cessation or trying again

36. The Process of Behavior Changeand Pregnancy • Pregnant women often are more open to change and can move through the stages of change differently than when they are not pregnant (The fetus can be a wonderful motivator) • May have more support to quit while pregnant • May not be socially acceptable to smoke in public if pregnant

37. Requirementsfor Change X = BASIC Motivation(Should I?) Self-Confidence(Can I?) Commitment(Will I?)

38. Motivational Interviewing/Consulting A patient-centered counseling style for obtaining behavior change by helping patients explore and resolve ambivalence

39. Motivational Interviewing/Consulting Principles • Express empathyto show youunderstand the person’s point of view • Develop discrepancybetween smoking and future goals • Avoid arguing and confrontationbe collaborative and friendly • Roll with the resistanceand avoid argument • Support patient’s self-efficacyandbelief in the possibility of making a change

40. A A A A A A A R CounselingIntervention 5 A’s (3-5 min.)* 2 A’s / R (1-3 min.) skabout tobacco use dviseto quit ssesswillingness ssist in quit attempt rrangefor follow-up sk dvise efer • Community Resources • 1-800-QuitNOW • Rx Pharmacotherapy *Can extend to 10-15 min. for all patients *Smoke Free Families recommends 10-15 min. for pregnant women

41. A sk: About Tobacco Use Ask or verify responses in a non-judgmental way: • Identify smoking status • Counsel all smokers and recent quitters • Household environment • Determine possible barriers to quitting • Possible affects of SHS • If they smoke assess • Nicotine dependence • Patterns of use • Past quit attempts

42. Health Surveys

43. Chart Stickers

44. A dvise: to Quit • Advice to quit should be clear, strong and personalized while using a non-judgmental manner • Discuss the effects of smoking on the patient, fetus and children • Discuss the health benefits of quitting • Acknowledge the difficulty in quitting

45. A ssess: Willingness to Make a Quit Attempt • Assess patient’s level of interest in quitting and intention to take action to quit • Ask key questions

46. Assess: KeyQuestions

47. A ssist: in Quit Attempt Pre-Contemplation and Contemplation Stages (Unwilling to make a quit attempt) The 5 R’s: • Relevanceto patient’s individual situation • Risksof smoking • Rewardsof quitting smoking • Roadblocks or barriers to quitting • Repeat intervention at every visit In successful interventions clinicians should be empathetic, promote patient choices, avoid arguments, listen, reflect and instill self-confidence

48. A ssist: in Quit Attempt Preparation Stage (Willing to quit) • Help the patient with a quit plan • Provide practical counseling • Provide social support • Social support with treatment (Intra-treatment) • Social support outside treatment (Extra-treatment) • Recommend pharmacotherapy • Provide supplemental materials (Quitline, groups)

49. A combination of pharmacotherapy and intervention doubles a patient’s chance of successfully quitting smoking

50. Pharmacotherapy* for Cessation • Nicotine gum • Nicotine patch • Nicotine nasal spray • Nicotine inhaler • Bupropion SR (Zyban) • Lozenge • Varenicline (Chantix) *Unless contraindicated