PROMOTING SMOKING CESSATION & SMOKE-FREE HOMES IN PEDIATRIC PRACTICE

1. PROMOTING SMOKING CESSATION & SMOKE-FREE HOMES IN PEDIATRIC PRACTICE Sophie J Balk MD Professor of Clinical Pediatrics AECOM

3. GOALS • To discuss • Providing smoking cessation counseling to parents and teens who smoke • Promoting smoke-free homes

4. OVERVIEW • Background • Effects of active smoking • Effects of secondhand smoke • Why smokers don’t quit • Smoking cessation counseling, pharmacotherapy • Bronx BREATHES, resources

5. The Life Cycle of the Effects of Smoking on Health Asthma Otitis Media Fire-related Injuries Influences to Start Smoking SIDs RSV/Bronchiolitis Meningitis Childhood Adolescence Infancy Nicotine Addiction In utero Adulthood Low Birth Weight Stillbirth 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

6. Adult Per Capita Cigarette Consumption and Major Smoking and Health Events – U.S. 1900-2005 Broadcast Ad Ban 1st Surgeon General’s Report 1st Great American Smoke-out End of WW II OTC Nicotine Medications Master Settlement Agreement Fairness Doctrine Messages on TV and Radio 1st Smoking-Cancer Concern Non-Smokers Rights Movement Begins Surgeon General’s Report on ETS ? WWI Federal Cigarette Tax Doubles 2009: Federal Cigarette Tax Increases and FDA Regulation Great Depression Source: United States Department of Agriculture; Centers for Disease Control and Prevention

7. SCOPE OF THE PROBLEM • 19.8% of adults smoke (2007) - ~ 43.4 million people • Kentucky – 28.3% • West Virginia – 27% • New York – 18.9% • New Jersey – 17.2% • Connecticut – 15.5% • California – 14.3% • Utah – 11.7% State-Specific Prevalence and Trends in Adult Cigarette Smoking - US, 1998-2007 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5809a1.htm

8. SMOKERS’ CHARACTERISTICS • 21.3% of men; 18.4% of women • Ethnicity • Indian/Native: 36.4% • Non-Hispanic white: 21.4% • Non-Hispanic black: 19.8% • Hispanic: 13.3% • Asian: 9.6% • Highest rates among poor, less educated Cigarette Smoking Among Adults—United States, 2007. MMWR November 14, 2008 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a2.htm

9. Adult Smoking in NYCDown Almost 30% Since 2002 Source: National smoking rates obtained from National Health Interview Survey (NHIS) and Morbidity and Mortality Weekly Report (MMWR) on Cigarette Smoking Among Adults 1993-2008. New York City smoking rates obtained from New York City Community Health Survey 2008.

10. COSTS OF TOBACCO • 2004:$193 billion annual health-related economic losses1 • $96 billion mortality-related productivity losses • >$97 billion excess med expenditures • 5.5 million Years of Potential Life Lost annually2 • 443,000 deaths/year3 - 1 in 5 deaths2 = 1,200/day 1-Treating Tobacco Use and Dependence 2008. 2-Annual Smoking-attributable Mortality, Years of Potential Life Lost, and Productivity Losses-US,1997-2001. MMWR 7/1/05 www.cdc.gov/mmwr/preview/mmwrhtml/mm5425a1.htm. 3-Smoking and Tobacco Fast Facts. www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm.

11. COMPARATIVE CAUSES OF ANNUAL DEATHS, U.S. Individuals with mental illness or substance use disorders Sum of all these causes of death << tobacco alone Number of Deaths (thousands) AIDS Obesity Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced CDC Tobacco Information and Prevention Source: www.cdc.gov/tobacco

12. ANNUAL DEATHS ATTRIBUTABLE TO CIGARETTE SMOKING: US, 2000 - 2004

13. TOBACCO AND HEALTH • ~43 million adult smokers • Smoking will result in death for half of all US smokers alive today • Adults who smoke die 13 – 14 years earlier than nonsmokers • 6.4 million youth will die prematurely from smoking if current trends continue Tobacco-related mortality. www.cdc.gov/tobacco/data_statistics/ Factsheets/tobacco_related_mortality.htm#. September 2006

14. The Life Cycle of the Effects of Smoking on Health Asthma Otitis Media Fire-related Injuries Influences to Start Smoking SIDs RSV/Bronchiolitis Meningitis Childhood Adolescence Infancy Nicotine Addiction In utero Adulthood Low Birth Weight Stillbirth Cancer Cardiovascular Disease COPD Aligni CA, Stodal JJ. Tobacco and children: An economic evaluation of the medical effects of parental smoking. Arch Pediatr Adolesc Med. 1997;151:652

15. SMOKING: FETAL EFFECTS • Spontaneous abortion • Stillbirth • Premature delivery • Low birth weight • Placental abruption • Neurodevelopmental effects

16. SECONDHAND SMOKE (SHS) • SHS • smoke exhaled by smoker • smoke released from a smoldering cigarette • SHS = ETS (Environmental Tobacco Smoke)

17. SHS • ~4000 chemicals • Irritants/systemic toxicants: Hydrogen cyanide, SO2 • Reproductive toxicants: CO, nicotine • Mutagens/Carcinogens: Benzene, benzo[a]pyrene • SHS is a Class A Carcinogen

18. SHS: EFFECTS IN ADULTS • Known effects • Lung cancer - 3,400 deaths/yr • Ischemic heart disease - ~46,000 deaths/yr • Higher risk of • Breast cancer • Nasal sinus cancer California Air Resources Board. Environmental Tobacco Smoke: SRB Approved Report. June 24, 2005. ftp://ftp.arb.ca.gov/carbis/regact/ets2006/app3exe.pdf

20. SHS & CHILDREN: CLINICAL EFFECTS • Asthma: 202,300 episodes/year1 • Bronchitis/pneumonia (<18mo)2 • 150,000 - 300,000 cases • 7,500 – 15,000 hospitalizations • 136 – 212 deaths • OM: 790,000 visits/year1 • SIDS: 430 deaths/year1 1-California Air Resources Board. June 2005. ftp://ftp.arb.ca.gov/carbis/regact/ets2006/app3exe.pdf 2-Health Effects of Exposure to Environmental Tobacco Smoke. The Report of the California Environmental Protection Agency, 1997

21. SHS: CLINICAL EFFECTS • Exposed children more likely to have respiratory complications with general anesthesia1 • Children living with smokers are at greater risk for injury and death from house fires2 • Children living with smokers are more likely to become smokers themselves3 1 - Koop CE, Anesthesiology 1998; 88: 1141-2. 2 – Difranza JR, Lew RA. Pediatrics 1996; 97:560-8. 3 – Farkas et al. Prev Med 1999.

22. SMOKING HAS SO MANY BAD HEALTH EFFECTS – WHY DON’T MORE PEOPLE QUIT?

25. Tobacco advertising targeting women Tobacco.org

26. Ads with Hip Hop Music Themes Ad targeting African Americans One of the two most popular brands among blacks in U.S. www.tobaccofreekids.org

27. NICOTINE • Effects • Increases concentration • Promotes memory recall • Improves psychomotor performance, alertness, arousal • Increases pain endurance • Decreases anxiety and tension • Decreases hunger pains, promotes weight loss

28. NICOTINE • Nicotine is a highly addictive substance • Nicotine withdrawal • Depressed mood • Insomnia • Irritability, anxiety, difficulty concentrating • Increased appetite

29. BENEFITS OF CESSATION • After 20 minutes: HR drops • 12 hours: Blood CO normalizes • 2 – 12 wks: Better lung function • 1 year: added CHD risk ½ smoker’s • 5 years: Stroke risk normalizes • 10 years: Lung Ca death rate ½ smoker’s http://www.cdc.gov/tobacco/sgr/sgr_2004/consumerpiece

30. HELPING SMOKERS QUIT • US Public Health Service1 • Clinicians should assess smoking status at every visit • Smoking cessation advise should be given routinely • AAP: Pediatricians should give cessation advice to parents who smoke2,3,4 1- Treating Tobacco Use and Dependence 2008. 2- AAP Ctte on Environmental Health, 1997. 3 – AAP Ctte on Substance Abuse, 2001

31. WHY FOCUS ON PARENTS? • ~15 million US children live with a smoker • Pediatricians may be the only clinicians a parent visits • Most smokers want to quit • Most parents are receptive to counseling by pediatricians1 1 - Frankowski BL, Weaver SO, Secker-Walker RH. Pediatrics 1993; 91: 296-300

32. INTERVENING WITH PARENTS WHO SMOKE • Interventions during clinic visits or hospitalizations increase parents' interest in stopping smoking, quit attempts, quit rates • Giving parents information about SHS reduces childhood SHS exposure and may reduce parental smoking rates Treating Tobacco Use and Dependence 2008 update

33. www.surgeongeneral.gov/tobacco

34. TREATING TOBACCO USE AND DEPENDENCE • Tobacco dependence is a chronic condition • Nicotine is an addictive substance • Effective treatments exist • Treatments are cost-effective • Systems changes important

35. COUNSELING • Brief counseling is effective • Intensive counseling is better • Repeated brief interventions are appropriate • Standard of care: identify and document tobacco use status, provide evidence-based treatments to every tobacco user

36. EFFICACY OF TOBACCO COUNSELING INTERVENTIONS Dose response between number of clinician types offering counseling and cessation success Brief counseling • 3-10 minutes • Targets smokers who are willing, unwilling, and those who recently quit Intensive counseling • Total clinician-client time >30 minutes with at least 4 sessions • Usually coordinated by tobacco dependence specialists (Fiore et al., 2008)

37. Odds Ratio of Quitting Increases with Counseling Quitting defined as abstinence for at least 5 months Treating Tobacco Use and Dependence. US Public Health Service 2000

38. THE “5 A’S” • Ask • Advise • Assess • Assist • Arrange follow-up

39. System Implementation “Ask” Identify Tobacco Use /exposure to smoke Document chart “Advise” To Quit “Assess” willingness to quit “Assist” with quitting “Arrange” Follow-up Referrals NYS Quitline Fax to Quit Individual/Group Counseling & Pharmacotherapy

40. SMOKERS’ QUITLINES • Adjunct to office counseling • Professional, evidence-based, ongoing counseling services • Effective in helping adults quit1 • Available in many states and through national quitline network • (1-800-QUITNOW) 1 – Fiore, JAMA 2008

41. PHARMACOTHERAPY • Smokers trying to quit should be encouraged to use pharmacotherapy except under special circumstances • Medical contraindications • Not recommended for pregnant women, adolescents, light smokers, smokeless tobacco users Fiore, JAMA 2008

42. PHARMACOTHERAPY • FDA-approved • Bupropion SR* *Rx needed • Nicotine gum • Nicotine inhaler* • Nicotine lozenge • Nicotine nasal spray* • Nicotine patch • Varenicline (Chantix)*

43. PHARMACOTHERAPY

44. NRT: NICOTINE REPLACEMENT THERAPY • Reduces cravings • Steady dose (patch) absorbed through the skin • Self-administered (gum, lozenge, inhaler, spray) absorbed through nasal/oral mucosa • Proven to increase quit rates • Safer way to get nicotine • Nicotine does not cause cancer NYS Smokers' Quitsite

45. Effectiveness of Medications Clinical Guideline, 2008 & Shiffman, et al, 2002

46. “A-A-R-P” • Practical alternative to the 5 A’s • Ask • Advise • Refer to Quitline/Fax-to-quit • Consider recommending or prescribing Pharmacotherapy

47. PREVENTING RELAPSE • Most relapses - first 3 months • Provide relapse prevention interventions to smokers who have recently quit • Congratulate patient • Discuss health benefits of cessation • Discuss threats to maintaining abstinence Clinical Guidelines, 2000

48. “THIRDHAND SMOKE” • Toxins remain after the cigarette is extinguished • Even when smoke is not visible • Particulate matter deposited in a layer onto surfaces • In loose household dust • Volatile compounds that “off gas” for days, weeks, months • Children especially susceptible Winickoff JP et al. Pediatrics 2009

49. HARM REDUCTION: REDUCING EXPOSURE • Promoting smoke-free homes • Use if the smoker isn’t ready to quit • Providing counseling and written materials successful1,2,3,4 • Rules prohibiting household smoking shown to reduce SHS exposure5,6 1 - Hovell et al. Chest 1994. 2 – Wahlgren et al. Chest 1997. 3 – Hovell et al. BMJ 2000. 4 – Emmons et al. Pediatrics 2001. 5 – Wakefield et al. Am J Prev Med 1995. 6 – Biener et al. Prev Med 1997.