Healthy Air for Kids Campaign

1. Healthy Air for Kids Campaign NAME TITLE Helping parents quit smoking for the health of theirchildren.

2. “The scientific evidence is now indisputable: Secondhand smoke is a serious health hazard that can lead to disease and premature death in children.” --Surgeon General Richard Carmona, Surgeon General’s Report June 27, 2006 2006 Surgeon General Report

3. Why Treat? • There are 4,000 chemicals in cigarette smoke. • There is no safe amount of secondhand smoke. • Breathing it for even a short time can haveimmediate adverse effects. According to the Surgeon General:

4. About 60 percent of children in Wisconsin suffer from second-hand smoke exposure. --Surgeon General Report, 2006 In Wisconsin, 54 percent of middle school children are exposed to secondhand smoke. --Burden of Asthma in Wisconsin, 2004 Why Treat?

5. Why Treat? As a result, these kids develop pneumonia, ear infections, bronchitis, asthma, colic, reduced pulmonary function and SIDS.

6. Why Treat? • Parents want your help. • 85% of parents who smoke want pediatricians to counsel them about quitting and prescribe tobacco cessation medications. • Parents say, “It shows you care.” • Only 8% of parents who smoke are currently offered medication or counseling • Source: Pediatrics, 2005 • “Smoking cessation interventions during physician visits were associated with increased patient satisfaction with their care among those who smoke.” • Mayo Clinic Proc. 2001;76:138-143

7. Why Treat? “In fact, when we don’t ask parents about smoking, they say, ‘What’s up?’ It’s like we don’t care. If I don’t ask parents about smoking, I’m really missing the boat.” -- John Meurer, Chief of General Pediatrics, Medical College of Wisconsin, Wisconsin Pediatrician of the Year

8. You can have a huge impact with a brief intervention. In a few minutes, you can help your patients live in a smoke-free environment and decrease the chances the children will ever light up. “Minimal interventions lasting less than 3 minutes increase overall tobacco abstinence rates.” Source: U.S. Public Health Service Clinical Practice Guideline: Treating Tobacco Use and Dependence Why Treat?

9. We’ll show you how to do it in a way that is: Brief. Safe. Effective. Why Treat?

10. Three Tools A quick reference guide to show you and your staff how to do a brief, effective intervention.

11. Three Tools • A laminated tobacco treatment chart to post on your office wall for quick reference. • 5 A’s for treatment • Medications chart

12. Three Tools A note pad of tear sheets so you can walk your patients through their individualized plan to quit.

13. Posters & Brochures We have developed posters & brochures for your waiting rooms.

14. Help your patient’s parent(s) quit smoking by following the “5 A’s”: Ask every parent at every patient visit. Advise all tobacco users to quit. Assess the parent’s willingness to quit. Assist with counseling and medication. Arrange follow-up care. How to Treat

15. How to Treat: ASK. Ask the parents, “Do you smoke?” “Clinicians should routinely ask about secondhand smoke exposure, particularly when a child has had an illness caused by secondhand smoke.” Former Surgeon General Richard Carmona, Surgeon General’s Report, June 27, 2006

16. How to Treat: ASK. CHILD VITAL SIGNS Blood Pressure: _______________________________________________ Pulse: ________________ Weight: ________________________________ Temperature: _________________________________________________ Respiratory Rate: ______________________________________________ Parent Smokes: YES no (circle one) IF YES > continue with counseling Child Exposed to Secondhand Smoke: YES no (circle one) IF YES > urge smoke-free environments at all times

17. How to Treat: ADVISE. Urge parents to quit smoking in a clear, strong, personalized manner. Connect it to the child’s symptoms. Secondhand Smoke Frequent Colds Pneumonia Ear Infections Bronchitis Asthma Research shows this is most effective.

18. How to Treat: ADVISE. • “Second-hand smoke is making Tommy’s asthma worse… it could even be the cause.” • “I strongly advise you to quit, which will help him get better.” • “It’s not easy, but you can do it. We can help.”

19. How to Treat: ADVISE. Document it. Advice to quit should be noted in the child patient’s medical record.

20. How to Treat: ASSESS. Ask the parent if he/she is willing to try to quit. • “Are you ready to quit within the next 30 days?” • If yes, move on to ASSIST. • If no, ask the parent to continue to seriously think about quitting.

21. How to Treat: ASSESS. • Strongly urge the parent not to smoke around the child. • “We know that if you smoke, it’s more likely Sally will light up later in her life.” • “There is no safe amount of second-hand smoke for Jaden.” • “It’s especially dangerous in your home and car.” • “Chemicals from smoke linger even after you put out your cigarette and the smoke disappears.”

22. How to Treat: ASSIST. • For parents willing to make a quit attempt: provide counseling and recommend medication. • This combination gives the parent the best chance to successfully quit. • Brief Intervention.Advise the parent to: • Review smoking history. This includes past quit attempts, amount smoked, current medications, etc. • Set a quit date, ideally within 2 weeks. • Completely abstain.“Not a single puff,” starting on the quit date, to prevent relapse. • Avoid alcohol. It’s strongly linked to smoking relapse. • Get support from family or peers. • Avoid other smokers. • Discuss challenges, particularly in the first few weeks, including nicotine withdrawal.

23. How to Treat: ASSIST. • Offer medication. • You can prescribe medication or recommend OTC medication. • Seven different FDA-approved cessation medications have been clinically proven to increase the chances of quitting – up to three times better than placebo.

24. How to Treat: ASSIST. • Prescription medication. • Medicaid and BadgerCare cover the following prescription medications: • Nicotine patch (when written as “legend nicotine patch”) • Nicotine inhaler • Nicotine nasal spray • Bupropion SR (generic or Zyban) • Varenicline (marketed as Chantix)

25. How to Treat: ASSIST. • Recommend OTC medication. • Nicotine patch • Nicotine gum • Nicotine lozenge

26. How to Treat: ASSIST. • Nicotine Replacement Therapy (NRT) • Nicotine is the active ingredient • No evidence of increased cardiovascular risk with NRT • Supplied as a steady dose (patch) or self-administered (gum, inhaler, nasal spray) • Self-administered products should be used on a scheduled basis initially, then tapered to ad-lib use and eventual discontinued

27. How to Treat: ASSIST. • Nicotine Replacement Therapy (NRT) • Contraindications: • Immediate myocardial infarction (< 2 weeks) • Serious arrhythmia • Serious or worsening angina pectoris • Accelerated hypertension • Use and Cost: • Varies by product and amount used • (see UW-CTRI Medications Chart for details)

28. 2 mg vs 4 mg Chew and park Absorbed in a basic environment Use enough pieces each day (6-16) OTC Nicotine gum

29. Available as both prescription and OTC A new patch is applied each morning Rotating placement site can reduce irritation Typical Dosing: 4 weeks of 21 mg/day, then 2 weeks of 14 mg/day, then 2 weeks of 7 mg/day Nicotine patch

30. 2 or 4mg Use enough Benefits OTC Use enough (6-16 lozenges/day) Nicotine lozenge

31. Nicotine inhaler • Prescription only • May irritate mouth/throat at first (but improves with use) • Don’t drink acidic beverages during use • 6-16 cartridges/day • Inhale 80 times/cartridge • May save partially-used cartridge for next day • Use up to 6 months; taper at end

32. Bupropion SR • One of two non-nicotine medications approved by the FDA as an aid to quitting smoking • Available by prescription only • Shown to be particularly effective for women and patients diagnosed with depression • Mechanism of action: blocks neural reuptake of dopamine and/or norepinephrine

33. Contraindications Seizure disorder MAO inhibitor within previous 2 weeks History of anorexia nervosa or bulimia Current use of Wellbutrin or Zyban Side effects Insomnia Dry mouth Bupropion SR

34. Bupropion SR Dosing: • Start 1-2 weeks before quit date • 150 mg orally once daily x 3 day • 150 mg orally twice daily x 7-12 weeks • No taper necessary at end of treatment Maintenance: • Efficacious as maintenance medication for 6 months

35. This new Pfizer medication was approved by the FDA in May 2006 Like Bupropion, Chantix is available by prescription only Unique: Varenicline is neither a nicotine replacement therapy nor does it actively reduce dopamine reuptake. Varenicline acts on nicotine receptors with two types of action: It blocks some of the rewarding effects of nicotine (acts as an antagonist) and at the same time stimulates the receptors in a way that reduces withdrawal (acts as an agonist). Varenicline

36. Dosing & Maintenance Start varenicline one week before the quit date for maximum effectiveness Recommended treatment is 12 weeks: Days 1-3………..1 pill (0.5 mg) per day Days 4-7………..1 pill (0.5 mg) twice a day (am & pm) Day 8-end………1 pill (1 mg) twice a day (am & pm) An additional course of 12 weeks for maintenance can be considered Varenicline

37. Varenicline • Contraindications • Use with caution and consider dose reduction in patients: • ⇒ With significant renal impairment. • ⇒ Undergoing dialysis. • Side effects • ⇒Primary side effect is nausea • ⇒Suggested solution is to reduce dosage

38. How to Treat: Coverage. • More than 70 percent of Wisconsin residents with private insurance are covered for at least one quit smoking medication. • Medicaid, BadgerCare and SeniorCare also cover tobacco dependence treatments.

39. How to Treat: REFER. Refer parents to the: • It’s free, confidential, and non-judgmental. • Callers are 4 times more likely to quit than those who try to quit cold turkey. • Services are available in virtually any language.

40. “Time is always short. I tell my patients: ‘Call the Wisconsin Tobacco Quit Line. They’re sharp. They can help you.’” -- Dr. Pierce Sherrill, Aurora Healthcare “The Quit Line was very helpful for me. I needed someone who was on my side... and they were.” --Gloria Taylor

41. How to Treat: ARRANGE. Other referral options: • A cessation program in your clinic or system. • A local community program. For a list of programs in your county, visit: http://www.ctri.wisc.edu/resources.html

42. How to Treat: ARRANGE. • Arrange for follow-up counseling. • If the parent has quit, congratulate him or her on a tremendous accomplishment! • If the parent has relapsed, reassess the situation and encourage another quit attempt. • Like diabetes or hypertension, tobacco dependence is a chronic disease and should be treated as such over time. • Continue to encourage the parent to quit, focusing on maintaining a positive outlook. • You can follow up or refer to the Quit Line.

43. Resources. CME credit. FREE online CME for tobacco cessation treatment is available for: • Physicians • Nurses • Pharmacists Visit www.medscape.com/viewprogram/3607

44. How to Treat: Fax to Quit Program How it works: • The patient signs a consent form. • Your office faxes the form to the Quit Line. • The Quit Line calls the patient at a time requested by the patient. • The Quit Line faxes back a report to your office. FREE to you and your patient!

45. www. CTRI . WISC . EDU • News • Research results • Treatment tools • Latest best practices

46. Make a Difference. Abby Kreul, right, 9 years old: “It’s better now that Mom and Dad have quit because I don’t get sick as much.”

47. www. CTRI . WISC . EDU 47