Smoking Cessation 12.18.2009

8/14/2019 Smoking Cessation 12.18.2009

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Case of AsthmaCase of Asthma

ID:ID: M.C. 7 year old femaleM.C. 7 year old female

Mild persistent asthma since age 2Mild persistent asthma since age 2

Four exacerbations this year.Four exacerbations this year.

ICU admission in MayICU admission in May

Multiple Environmental/animal allergies.Multiple Environmental/animal allergies.

HPIHPI::

Wheezing, cough, increased work of breathingWheezing, cough, increased work of breathing

Rapid onset, over 15-18 hoursRapid onset, over 15-18 hours

Mom gave back to back albuterol/atroventMom gave back to back albuterol/atrovent


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Case: AsthmaCase: Asthma

Meds:Meds:

Atrovent, Singular, Symbicort, Zyrtec, AlbuterolAtrovent, Singular, Symbicort, Zyrtec, Albuterol

Family History:Family

History:

Brother with asthmaBrother with asthma

Two hospital admissionsTwo hospital admissions

Social History:Social History

:

Got rid of dog since last admissionGot rid of dog since last admission

Dad smokes, but only outside.Dad smokes, but only outside.


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Second hand smoke and children:Second hand smoke and children:Empowering pediatricians and parentsEmpowering pediatricians and parents

Kevin E. NelsonKevin E. Nelson

Advocacy Morning ReportAdvocacy Morning Report

December 18, 2009December 18, 2009


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OutlineOutline

Secondhand smokeSecondhand smoke

Practice guidelinesPractice guidelines

Pediatrician practice behaviorsPediatrician practice behaviors

InterventionsInterventions

Pediatricians Against Secondhand SmokePediatricians Against Secondhand Smoke

(PASS) Initiative(PASS) Initiative

What can you do? WhatWhat can you do? What you

you can do!can do!


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Secondhand Smoke andSecondhand Smoke and

ChildrenChildren

Increased burden of illnessIncreased burden of illness

Bronchitis, pneumonia, and other URIsBronchitis, pneumonia, and other URIs Asthma more frequent and severe exacerbations.Asthma more frequent and severe exacerbations. Sudden infant death syndrome.Sudden infant death syndrome.

Four fold higher risk hospitalization forFour fold higher risk hospitalization forserious infection (age 0-4 years)serious infection (age 0-4 years)

Tobacco related childhood deaths in USTobacco related childhood deaths in US

5000/year5000/year Medical expenditures and loss of life forMedical expenditures and loss of life for

children exceed $10 billion per yearchildren exceed $10 billion per year

Winickoff JP, et al.Winickoff JP, et al. PediatricsPediatrics 2003;112:11461151.2003;112:11461151. Winickoff JP, et al.Winickoff JP, et al. PediatricsPediatrics 2005;115;750-760.2005;115;750-760.

AAP Policy Statement, Environmental Tobacco Smoke: A Hazard to Children,AAP Policy Statement, Environmental Tobacco Smoke: A Hazard to Children, PediatricsPediatrics 1997 99: 639-1997 99: 639-642.642.


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Utah SHS ExposureUtah SHS Exposure

Utah smoking ratesUtah smoking rates Adult 9.1%Adult 9.1% Youth 7.9%Youth 7.9% SL County 12.2%SL County 12.2% Weber-Morgan 12.5%Weber-Morgan 12.5%

SHS exposure rates for childrenSHS exposure rates for children Utah 1.8% (~16,000 children)Utah 1.8% (~16,000 children)

Salt Lake County 2.1% (no change since 2004)Salt Lake County 2.1% (no change since 2004)

Minimal changes for at-risk groupsMinimal changes for at-risk groups

At-risk Utah communities and groups:At-risk Utah communities and groups:

Magna, West Valley, South Salt Lake, OgdenMagna, West Valley, South Salt Lake, Ogden

African Americans 22%African Americans 22%

Tobacco Prevention and Control in Utah, 8Tobacco Prevention and Control in Utah, 8thth Annual Report, 2008, available atAnnual Report, 2008, available athttp://www.tobaccofreeutah.org/facts.htmlhttp://www.tobaccofreeutah.org/facts.html


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Practice GuidelinesPractice Guidelines

Every patient who uses tobacco should be offered atEvery patient who uses tobacco should be offered atleast one effective treatment.least one effective treatment.

Discussion and anticipatory guidancedeservesDiscussion and anticipatory guidancedeservesspecial attention when a parent or regular caretaker isspecial attention when a parent or regular caretaker is

a smoker, including repeated nonjudgmental efforts toa smoker, including repeated nonjudgmental efforts toencourage the parent to quit smoking (accompaniedencourage the parent to quit smoking (accompaniedby appropriate referral) - (2001)by appropriate referral) - (2001)

Helping parents quit smoking is now a recognizedHelping parents quit smoking is now a recognized

priority of child health care clinicians. - (2003)priority of child health care clinicians. - (2003)

Fiore MC, et. al. Treating Tobacco Use and Dependence. U.S. Department of Health and Human Services. 2000.Fiore MC, et. al. Treating Tobacco Use and Dependence. U.S. Department of Health and Human Services. 2000.

AAP Policy Statement, Pediatrics 2001 107:794-798. AAP Policy Statement, In: Etzal R, ed.AAP Policy Statement, Pediatrics 2001 107:794-798. AAP Policy Statement, In: Etzal R, ed. Pediatric EnvironmentalPediatric EnvironmentalHealthHealth. 2nd ed. Elk Grove Village, IL: AAP; 2003:147163. 2nd ed. Elk Grove Village, IL: AAP; 2003:147163


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Tobacco dependence shows many features of a chronicTobacco dependence shows many features of a chronicdiseasedisease

[A chronic disease model] recognizes the long-term nature of[A chronic disease model] recognizes the long-term nature of

the disorder with an expectation that patients may havethe disorder with an expectation that patients may have

periods of relapse and remissionperiods of relapse and remission

Clinicians should remain cognizant that relapse is likely, andClinicians should remain cognizant that relapse is likely, and

that it reflects the chronic nature of dependence, not theirthat it reflects the chronic nature of dependence, not their

personal failure, nor a failure of their patients. (2000)personal failure, nor a failure of their patients. (2000)

AAP endorses HHS Clinical Practice Guideline. (2008)AAP endorses HHS Clinical Practice Guideline. (2008)

AAP 2009 policy statementsAAP 2009 policy statements

Fiore MC, et. al. Treating Tobacco Use and Dependence. U.S. Department of Health and Human Services. 2000.Fiore MC, et. al. Treating Tobacco Use and Dependence. U.S. Department of Health and Human Services. 2000.

AAP Policy Statement, Tobacco a Pediatric Disease. Pediatrics, 2009;124:1475.AAP Policy Statement, Tobacco a Pediatric Disease. Pediatrics, 2009;124:1475.

Practice GuidelinesPractice Guidelines


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Assessment and intervention.Assessment and intervention.

5-60% report asking parent to quit.5-60% report asking parent to quit.

Screening 87%, counseling 59%. Smoking parents ofScreening 87%, counseling 59%. Smoking parents ofasthmaticsasthmatics

At WCC 90% counsel 60% of smoking parents toAt WCC 90% counsel 60% of smoking parents toquit.quit.

Self-efficacy over-reported.Self-efficacy over-reported.

Chart reviews indicate ~5% pediatricians counsel.Chart reviews indicate ~5% pediatricians counsel.

SHS often not addressed even when directlySHS often not addressed even when directlyrelevant to diagnosis.relevant to diagnosis.

Cabana MD, et. al,Pediatrics 2004;113:78-81. Collin BN, et. al, J Pediatr 2007;150:547-52.

Frankowski BL, Secker-Walker RH. AJDC. 1989;143:1901-1904. Tanski, SE, et. al, Pediatrics 2003;111;e162-e167.

Perez-Stable EJ, Arch Pediatr Adolesc Med; 2001; 155:25-31

Pediatrician PracticesPediatrician Practices


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Parents - BehaviorParents - Behavior Would ignore adviceWould ignore advice Not interestedNot interested

Do not expect adviceDo not expect advice Would be offendedWould be offended

Would leave practiceWould leave practice Pediatrician - SystemsPediatrician - Systems

Lack of timeLack of time Competing prioritiesCompeting priorities ReimbursementReimbursement IneffectiveIneffective

Lack preparationLack preparation Lack trainingLack training

Question treatment efficacyQuestion treatment efficacy Not their roleNot their role

AAP policy statement, Pediatrics 1997; 99:639-642. Frankowski BL, Secker-Walker RH. AJDC. 1989;143:1901-

1904. Nader P, et. al, Pediatrics. 1987; 79:843850. Perez-Stable EJ, Arch Pediatr Adolesc Med; 2001; 155:25-31.

Tanski, SE, et. al, Pediatrics 2003;111:e162-e167. Winnickoff, et al., Pediatrics 2005;115:1013. Zapka JG, et. al.

Pediatrics 1999; 103:e65.

Pediatrician BarriersPediatrician Barriers


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http://www.the-trukstop.com/articles/2007/wrong_place_wrong_time

Not My JobNot My Job
http://www.the-trukstop.com/articles/2007/wrong_place_wrong_timehttp://www.the-trukstop.com/articles/2007/wrong_place_wrong_time


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Unknowns among Utah pediatriciansUnknowns among Utah pediatricians

Screening, counselingScreening, counseling

Utilization of interventions/resourcesUtilization of interventions/resources

Pediatrician perceptions and attitudesPediatrician perceptions and attitudes

Salt Lake Valley Health DepartmentSalt Lake Valley Health Department

No clinician outreach for pediatriciansNo clinician outreach for pediatricians

Weber-Morgan has started to targetWeber-Morgan has started to target

pediatricianspediatricians

Utah PediatriciansUtah Pediatricians


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Behavioral/social supportBehavioral/social support CounselingCounseling

Phone - Utah QuitlinePhone - Utah Quitline

Internet Utah QuitNetInternet Utah QuitNet

Changing trigger behaviorChanging trigger behavior

Pharmacoterapy - buproprion, wellbutrin,Pharmacoterapy - buproprion, wellbutrin,

vareniclinevarenicline

Practices - systems changePractices - systems change

LegislationLegislation

Smoke free workplace/environmentSmoke free workplace/environment

Tobacco InterventionsTobacco Interventions


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5 As Ask, Advise, Assess, Assist,5 As Ask, Advise, Assess, Assist,

Arrange Follow-UpArrange Follow-Up

Stages of Change - AssessmentStages of Change - Assessment

Fiore MC, et. al. Treating Tobacco Use and Dependence. U.S. Department of Health and Human

Services. 2000; Prochaska, JO and DiClemente, CC,J Consult Clin Psych 1983:51; 390-395http://www.adultmeducation.com/FacilitatingBehaviorChange.html

Provider InterventionsProvider Interventions


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CEASECEASE

5As, nicotine replacement5As, nicotine replacement

under evaluationunder evaluation

Low SES womenLow SES women Pediatrician, literature, health educator, phonePediatrician, literature, health educator, phone

follow upfollow up

13.5% quit vs. 6.9% control13.5% quit vs. 6.9% control

Provider InterventionsProvider Interventions

Winnickoff, JP, et.al, Pediatrics 2008;122:e363-e375Curry SJ, et. al, Arch Pediatr Adolesc Med. 2003;157:295302


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Pediatricians Against Secondhand SmokePediatricians Against Secondhand Smoke

(PASS)(PASS)

Resident advocacy initiative from PCMCResident advocacy initiative from PCMC

Sustainable intervention programSustainable intervention program

Educate child health care providers at all levelsEducate child health care providers at all levels

Tailored smoking cessation resourcesTailored smoking cessation resources

Practice-based strategyPractice-based strategy

Facilitate smoking cessation interventions amongFacilitate smoking cessation interventions among

smoking parents and adolescents.smoking parents and adolescents.

P.A.S.S. InitiativeP.A.S.S. Initiative


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Assess smoking cessation attitudes and practicesAssess smoking cessation attitudes and practices

of Salt Lake Valley pediatricians.of Salt Lake Valley pediatricians.

Build coalition of medical and community anti-Build coalition of medical and community anti-

tobacco advocates.tobacco advocates. Provide tailored smoking cessation materials.Provide tailored smoking cessation materials.

Educate child healthcare providers via in-serviceEducate child healthcare providers via in-service

seminars.seminars. Provide systems instrumentProvide systems instrument

Training in motivational interviewingTraining in motivational interviewing

P.A.S.S. Initiative PhasesP.A.S.S. Initiative Phases


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Monitor changes in attitudes and practicesMonitor changes in attitudes and practicesof pediatric practices.of pediatric practices.

Additional activitiesAdditional activities

Direct education to at-risk communities by PASSDirect education to at-risk communities by PASSand community advocatesand community advocates

Working with lay community groupsWorking with lay community groups

Legislative advocacyLegislative advocacy

2009-2010 Legislative session:2009-2010 Legislative session: Tobacco taxTobacco tax Smoking in automobilesSmoking in automobiles

P.A.S.S. InitiativeP.A.S.S. Initiative


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5As5As

ASK - ScreenASK - Screen

ADVISE - EducateADVISE - Educate

ASSESS BarriersASSESS Barriers ASSIST SupportASSIST Support

ARRANGE Follow upARRANGE Follow up

DocumentDocument

Ask at next appointmentAsk at next appointment

Interim phone callInterim phone call

Refer to Quitline/QuitNetRefer to Quitline/QuitNet

Smoking:Smoking:

WhatWhat youyou can do!can do!


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Children at-risk demographic groups at risk forChildren at-risk demographic groups at risk forSHS exposureSHS exposure

Pediatricians have a role in helping parents quitePediatricians have a role in helping parents quitesmokingsmoking

Addressing barriers with pediatricians mayAddressing barriers with pediatricians mayimprove intervention and quit ratesimprove intervention and quit rates

Tailored initiatives may lead to improved providerTailored initiatives may lead to improved provider

interventions with at-risk populationsinterventions with at-risk populations

Every healthcare provider can make a differenceEvery healthcare provider can make a difference

SummarySummary


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AcknowledgmentsAcknowledgments

Karen BuchiKaren Buchi

Wendy Hobson-RohrerWendy Hobson-Rohrer

Laura DutyLaura Duty

Clarisa GarciaClarisa Garcia

Robyn NolanRobyn NolanMandy AllisonMandy Allison

Jamie BruseJamie Bruse

Dedee CaplinDedee Caplin

Emily EresumaEmily Eresuma

Heather NelsonHeather NelsonDivision of GeneralDivision of General

PediatricsPediatrics

Community PartnersCommunity PartnersAmerican HeartAmerican Heart

AssociationAssociation

American Lung AssociationAmerican Lung Association

Communidades UnidasCommunidades Unidas

Utah Latino NetworkUtah Latino NetworkSalt Lake Valley HealthSalt Lake Valley Health

DepartmentDepartment

Utah Department ofUtah Department ofHealthHealth

Utah Tobacco PreventionUtah Tobacco Prevention& Control Project& Control Project

Utah Chapter of the AAPUtah Chapter of the AAP

Department of PediatricsDepartment of Pediatrics

Pediatrics ResidencyPediatrics ResidencyProgramProgram

Smoking Cessation 12.18.2009

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Transcript of Smoking Cessation 12.18.2009