Shawn Ralston, MD Assistant Professor of Pediatrics Division of Inpatient Medicine

1. Smoking Cessation Counseling for Parents of Pediatric Inpatients: Reaching the Medically Underserved at a Teachable Moment Shawn Ralston, MD Assistant Professor of Pediatrics Division of Inpatient Medicine University of Texas Health Science Center San Antonio

2. Background - Parental Smoking • Children are proportionally most affected by tobacco – Smoking related excess deaths are 50% of all deaths under 15 yo (1,2) • Children cannot voluntarily remove themselves from the exposure • Anti-smoking actions by parents are the strongest predictor of non-smoking in teens (3) • Aligne CA, Stoddard JJ. Tobacco and children. An economic evaluation of the medical effects of parental smoking. Arch Pediatr Adolesc Med 1997;151(7):648-53. • Anderson RN, Smith BL. Deaths: leading causes for 2001. Natl Vital Stat Rep 2003;52(9):1-85. • Andersen MR, Leroux BG, Bricker JB, Rajan KB, Peterson AV, Jr. Antismoking parenting practices are associated with reduced rates of adolescent smoking. Arch Pediatr Adolesc Med 2004;158(4):348-52.

3. Background - Parental Smoking • Low SES and low parental educational levels correlate with increasing ETS exposure (1,2) • Texas is still the most uninsured state in the nation (www.commonwealthfund.org) • How many parents of hospitalized children have access to healthcare for themselves? • Mannino DM, et al. Health effects related to environmental tobacco smoke exposure in children in the United States. Arch PedAdolesc Med. 2001;155:36-41. • Bolte G, et al. Socioeconomic determinants of children’s environmental tobacco smoke exposure and family’s home smoking policy. Eur J Pub Health. 2008;19:52-58.

4. Preliminary Studies • Recently published: a randomized, controlled trial of smoking cessation counseling with or without nicotine replacement performed by the pediatrician during a child’s hospitalization for respiratory illness • Enrolled 21 patients per arm with the intervention consisting of a 30 minute counseling session conducted by the pediatrician, with or without provision of nicotine replacement depending on patient preference and level of addiction scoring Ralston S, Roohi M. A randomized, controlled trial of smoking cessation counseling provided during child hospitalization for respiratory illness . Peds Pulm 2008; 43:561–566

5. Study Demographics

6. Study Outcomes

7. Proposed New Study Hypothesis: A brief message to quit smoking along with referral to a free quitline during a child’s hospitalization will result in cessation rates above controls Specific Aims: To compare smoking cessation rates at 2 months post-hospitalization among parents who received a brief intervention during their child’s hospitalization and a control group

8. Study Design Randomized, controlled trial of a brief intervention to promote smoking cessation during child hospitalization Inclusion criteria:> 18 years of age and residence in the same home as the hospitalized child at least 25% of the time and a report of smoking > 1 cigarette per day for the previous week Exclusion criteria: concurrent participation in any smoking cessation program, including counseling or concurrent pharmacologic treatment for nicotine addiction supervised by a physician or counselor, failure to give informed consent, and unwillingness to provide contact information for telephone follow-up Target enrollment: 350 smoking parents What this study brings to the problem: Effectiveness vs. Efficacy

9. Study Design • Intervention: 5-10 minute discussion of smoking cessation conducted during the child’s hospitalization based on the principles of Motivational Interviewing as proposed by Miller and Rollnick and including recommended elements of a brief intervention based on the US Public Health Service’s clinical practice guideline entitled ‘‘Treating Tobacco Use and Dependence’’ with specific elements tailored to the participant’s stage of change. Furthermore, participants will be given a written referral to the state’s Quitline (1-877-YES-QUIT) and a recommendation that they acces it during the next two months. They will also receive a smoking cessation brochure created by the American Cancer Society. If the participant agrees to allow it, their contact information will be faxed to the State Quitline, which will initiate contact through their referral program. • Control: Both groups will receive the age-appropriate safety sheet from the American Academy of Pediatrics Injury Prevention Program, also known as TIPP sheets. Control: Each group receives

10. Outcomes • Primary outcomes: self-reported non-smoking status as defined as no cigarettes smoked in the previous week and self-reported use of the telephone quitline. • Secondary outcomes: duration of current non-smoking status for quitters, change in number of cigarettes smoked per day, number of self reported attempts to quit, number of days with zero cigarettes smoked since hospital discharge, stage of change and FTND score.

11. Power analysis • Sample size is based on a power analysis indicating that 175 subjects per group are needed to detect a between group difference in quit rates of 5% in the control group versus 15% in the intervention group with 80% power and alpha = 0.05 and includes a 10% over-enrollment to compensate for loss to follow-up

12. Implications • If this is a successful strategy, inpatient pediatricians may need more training in smoking cessation counseling • Hospital-based inpatient counseling programs could be redirected to include parents of hospitalized children

13. Never give up!