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Tobacco Prevention and Cessation in Pediatric Settings
Jonathan D. Klein, MD, MPHGolisano Children’s Hospital at Strong
and the American Academy of Pediatrics Center for Child Health Research
University of Rochester Rochester, NY
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Center for Child Health Research
MissionImprove the health and functioning of
children by enhancing the quantity,
quality, and utilization of research
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How the Center Will Address Child Health
• Identify what is known, not being addressed
• Identify critical questions and gaps
• Develop and implement strategies both to:
– increase our knowledge base
– better use that knowledge to shape social and
clinical policies and practices
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Center Structure• Multi-institutional, multidisciplinary
• Center of Center in Rochester, New York
• PROS Network - Mort Wasserman, MD, Director, U of Vermont; core staff at AAP headquarters
• Functional Outcomes Project - Lynn Olson, PhD, Director; core staff at AAP headquarters
• Consortia members and researchers on various projects located at universities nationwide
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Critical Questions• What are the most important research
questions, that if answered, would improve
–Children's health and development?–Adult health, functioning and longevity?
• How to facilitate answering these questions?
• How to help research be translated into social policy and clinical practice to improve children's health?
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SocialSocialStrategStrateg
iesies
PoliticalPoliticalWillWill
KnowleKnowledgedgeBaseBase
ImprovedImprovedChild Child HealthHealth
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Studying Studying Social Social
DeterminanDeterminants and ts and
Outcomes Outcomes of Healthof Health
Studying Studying Social Social
DeterminanDeterminants and ts and
Outcomes Outcomes of Healthof Health
Assessing Assessing Child Child
Health Health Policy Policy and and
PracticePractice
Assessing Assessing Child Child
Health Health Policy Policy and and
PracticePractice
Increasing and Increasing and Synthesizing Synthesizing KnowledgeKnowledge
BaseBase
Increasing and Increasing and Synthesizing Synthesizing KnowledgeKnowledge
BaseBase
Improved Improved ChildChild
HealthHealth
Improved Improved ChildChild
HealthHealth
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Children and tobacco• 3 million adolescents smoke
• 2600/day start
• 1/3rd will become addicted, smoke through adulthood
• 60% of smokers started before age 14
• ETS is a major heath risk for children
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Past 30 Day Smoking, 1975-2002
Adapted from Johnston, et al., 2001
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Why?• Social influences
– Friends– Parents
• Access/availability of cigarettes• attitude toward smoking
– Media
• Personality– Sensation seeking– Rebelliousness– Poor school performance
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Tobacco Marketing• Annual spending to promote tobacco = more
than half the NIH budget
• Advertising – Targeted to youth
• Non-advertising commercial speech– Product placement– Clothing, gear– Sponsorships, broadcast media– Candy look-alike products
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Exposure to Tobacco Use in Movies and Smoking Among 5th-8th grader
Adapted from Sargent, DiFranza, 2003
8th Grade7th Grade6th Grade5th Grade
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Youth and Nicotine
• Adolescents more than adults: – become dependent – progress to daily smoking– smoke more heavily as adults– have difficulty with quitting prior to
smoking 100 cigarettes
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Adolescent Smokers
• Know they are addicted
• Want to quit
• Do not think there are resources to help
• 75% have thought about quitting
• 64% have made a quit attempt
• Clinicians feel unprepared to help
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Incidence of Initial Symptoms of Nicotine Dependence
Adapted from DiFranza, 2002
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Issues for primary and secondary prevention
• “Social inoculation” = effective prevention
• Prevention does not work for cessation
• School /social environment roles
• Harm reduction vs. abstinence strategies
• Brief office interventions and referrals
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Primary care interventions
• Health care cessation counseling interventions are effective for adults
• Pediatric and adolescent guidelines recommend screening & counseling
• Adolescents want to quit but do not think of getting assistance
• Adolescents use internet resources for health information
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Pediatric interventions
• Most (>90%) clinicians report asking about tobacco
• Many report assessing motivation to quit, and discussing health risks
• Few provide handouts, set quit dates, or plan smoking-related follow-up
• < 25% of patients report having received counseling
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Primary care
• Adolescents use preventive care
• 70+% report well care visits
• Nationally, almost half do not have an opportunity to talk privately with their clinician
• 39% girls, 24% boys report having been too embarrassed to discuss a topic
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Did Practices Deliver Interventions?
QLater QNow
Did you and your doctor 88 92 p<.05
discuss cigarettes/smoking?
Did your doctor ask if you 87 93 p<.001
smoked?
If smoke, did your doctor 63 76 p<.0005
ask if you want to quit?
If smoke, did your doctor 18 47 p<.0001
hand you anything to help stop?
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Other evidence?• In a 2002 review, evidence for teen cessation
programs is good, – especially school-based, motivation enhancement
programs. – no successful brief intervention trials in primary care for
adolescent cessation.
• One successful cessation study in 2003 with adolescents referred to an intensive expert counseling ‘system’ after brief primary care advice (OR=2.43) (Hollis et al.)
• Policy interventions work
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GottaQuit Evaluation
• Ads have reached 94% of Monroe County teens
• Youth who smoke relate to the characters, the themes of addiction and wanting to quit
• 75% of adolescent smokers in Monroe County wanted to quit, and many tried in the past year
• Only 40% of smokers had ever been proofed
• 27% of smokers (vs 4% of non-smokers) had visited GottaQuit.com, mostly for help quitting
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What do we do now?
• Best practice recommendations– Policy changes– Clinical interventions– Public health adjuncts
• More studies
• Implications for education
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Best Practices in Tobacco Control
• Increase price of tobacco
• Smoking bans and restrictions
• Availability of treatment for addiction– Reduce patient costs for treatment– Provider reminder systems– Telephone/web counseling and support
• Mass media campaigns
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Policy - School curriculum• At least 5 session /year over 2 years
• Should include– Social influences– Short term health effects– Refusal skills
• NOT self-esteem or delay based
• Be aware of dilution and confusion strategies by tobacco interests
• School policies should reinforce goals
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Policy - Community activism• Age of sale enforcement
• Advertising limitations
• Public smoke exposure reduction
• Awareness of impact of preemptive efforts
• Reducing social acceptability of smoking
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Pediatricians in Practice
• Reimbursement for Providers• CPT coding, payment
• Certification of competency• Media for Patients
• Ads, adjuncts, educational materials
• Education for Providers and staff• Phrmacotherapy guides, resource lists
• Training/CME
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Practice - Public Health Service 5 A’s
• Ask - If patient smokes
• Advise - Every patient to quit
• Assess - Readiness to quit
• Assist - In quitting and finding services
• Arrange - For cessation services and follow up
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Issues for Pediatric Practice
• Prenatal Smoking
• Environmental Smoke/Early Childhood
• School Age Intervention
• Adolescent Intervention
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Pediatricians in Practice:
• Reimbursement– Better CPT coding for tobacco counseling– Maine Medicaid pays $20/visit for tobacco
counseling up to 3 per year – PA Medicaid pays $15/visit after MD training
completed
• Education for providers– Training/CME -- (Certification?)
• Adjuncts/Media for Patients
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Pre/Postpartum Messages
• Intervene with women and men during pregnancy and after delivery
• Postpartum health message should focus on secondhand smoke
• Parents should smoke outside
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Early Childhood (0-5)
• Goal: Prevent smoke exposure (ETS)• Ask: About exposure• Advise: Parents to quit, limit exposure
- Link to child’s health
• Assess: Motivation to change • Assist:
- Provide self-help, set quit dates
- Consider Rx, referral
• Arrange: - Reinforcement at each visit
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School Age (5-12) Intervention
• Goal: Prevent the onset of smoking• Ask: Experimentation and
knowledge• Advise: Children and parents
- To quit if smoking - Link to short term consequences- “Inoculate” with awareness of
smoking candy/toys/gear as socially acceptable
• Assess: Motivation to change
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School Age Intervention
• Assist: – If experimenting - cessation– Develop refusal skills– Show how tobacco ads mislead– Reinforce abstinence
• Arrange:– Frequent follow-up for experimenters
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Adolescent Intervention• Goal:
– Prevent onset and promote cessation
• Ask– About friend’s use– About patterns of use– About school programs– Reassure about confidentiality
• Assess: – Motivation and readiness
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Adolescent intervention•Advise
–To quit for short term reasons
•Athletic capacity, cost, smell, etc.
–Reinforce non-use
•Assist–Set quit dates–Provide self-help materials, websites–Encourage problem-solving, refusal skills, activities –Consider pharmacotherapy
•Arrange--1-2 week follow-up after quit attempts
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Assessing Nicotine Dependence
1) Have you ever tried to quit, but couldn’t?
2) Have you ever felt like you were addicted to tobacco?
3) Do you ever have strong cravings to smoke?
4) Is it hard to keep from smoking where you are not supposed to, like school?
5) Do you:1) find it hard to concentrate2) feel more irritable?3) feel nervous, restless, or anxious … because you
couldn’t smoke?
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Training and Certification
• Training programs• Model curriculum• RRC, ACGME required competencies• Advocacy curriculum
• Quality Assurance• Modules - like ADHD Toolkit
• Board Certification competency• CME on tobacco and on screening and
motivational interviewing
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Curriculum challenges
• Leadership in primary care settings• Residents and medical students
• Community practitioners• Support from academic leaders