Download Screening and Periodicity Guidelines

TOBACCO AND SECOND HAND SMOKE
EXPOSURE
AUGUST 2014
Pediatric Continuity Clinic Curriculum
Created by: Karen Martinez
Mentor: Dr. Virginia Kockler
OBJECTIVES
Understand the risks of second hand smoke exposure
and teen tobacco use
 Discuss the epidemiology of teen tobacco use and
second hand smoke exposure
 Discuss how to perform a motivational interview and
how to approach smoking cessation with patients and
parents
 Learn about e-cigarettes and e-cigarette use

CASE #1
A 13 yo male presents to your continuity clinic for a
WCC. On his questionnaire he admits to
occasional tobacco use.
 What
is the epidemiology and risk factors
for teen smoking?
 What are the trends in teen smoking?
 What are some clinical approaches to
cessation?
EPIDEMIOLOGY
TEEN TOBACCO
USE
90% of tobacco users initiate use before age 18
 In the US 3,200 children under 18 begin smoking
every day.
 Prevalence is almost equal in males and females



23% of HS males and 22.9% of HS females smoke
Ethnicity of High School Smokers

26% White, 22% Hispanic and 16% African American
Youth and Tobacco Use:
http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_
use/
RISK AND PROTECTIVE FACTORS
TEEN TOBACCO USE

Risk Factors
Friends who smoke
 Parental behavior and attitudes
 Comorbid psychiatric disorders




Anxiety, depression, ADHD, substance abuse
Body image issues/ concern about weight gain
Protective Factors

Good communication with parents, high self-esteem,
parental support
Factors Associated with Youth Tobacco use:
http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm#estimates
Sargent JD, Dalton MA. Does parental disapproval of smoking prevent adolescents from becoming established smokers?
Pediatrics 2001; 108:1256-1262.
TEEN SMOKING- TRENDS

HS students that have ever tried cigarettes 44.7%
After years of increasing the incidence of HS students
trying cigarettes has been steadily decreasing since
1995
 Incidence in 1995 – 71.3%


HS students smoking at least once within last 30
days – 18.1%

Incidence in 1995 – 34.8%
Estimates of current tobacco use among youth:
http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm#estimates
SMOKING CESSATION


Counseling is recommended and has been shown to be a
successful cessation tool
Pharmacotherapy may be considered in certain cases but
should always be used in combination with counseling
Nicotine Replacement therapy may be used in patients less than
18 and has been deemed to be safe, but is not FDA approved
 Bupropion: Adolescent data regarding efficacy is limited, but has
been deemed to be safe for adolescents. A few clinical trials
showing some increased abstinence compared to placebo but no
long term data. Black box warning-should not be used in patient
with depression due to increased risk of suicidal ideation.
 Chantix: No trials in adolescents regarding efficacy. Safety trials
deemed the product safe in Adolescents. Black box warning for
adults neuropsychiatric symptoms-agitation, SI, depression.

J.P. Karpinski et al. Smoking Cessation Treatment for Adolescents. J Pediatr Pharmacol Ther. 2010 OctDec; 15(4): 249–263.
COUNSELING TEENS
Most teens desire to quit
 The 5 “As”

Ask, Advise, Assess, Assist, Arrange follow up
 The 6th pediatric A - Anticipate


Pharmacotherapy
Efficacy and safety are less well established than in adults
 However in light of early nicotine addiction
pharmacotherapy can be consider for some adolescents


Nicotine replacement in adolescents with symptoms of dependence
can be used in combination with counseling
6 AS






Anticipate: Assess risk of tobacco use by inquiring about parental
smoking and discussing the possibility of smoking initiation in preadolescent and adolescent children. Begin this anticipatory guidance
during pediatric visits in mid-childhood.
Ask: Obtain a smoking history from all teenage patients, with parents
out of the room. Explain confidentiality and exceptions
Advise : Strongly urge all teen tobacco users to quit. The message
should be clear, strong, personalized
Assess: Determine if the teen smoker is willing to make a quit
attempt. Assess motivation to quit or continue smoking. Assess the
stage of readiness of the patient to guide further counseling.
Assist: Help the teen smoker prepare by setting a quit date, seeking
support from family and friends and practicing problem-solving.
Materials may be helpful. Teens may benefit from being referred to a
quit-smoking line or other resources in the community.
Arrange follow up: schedule follow-up in person or by telephone
soon after the quit date. Or if unwilling to quit, schedule appointment
to continue motivational interview
STAGES OF CHANGE
Pre-contemplation: not intending to quit in the
foreseeable future
 Contemplation: intending to quit in the
foreseeable future, but hasn’t set a timeline
 Ready for action: intending to quit in the
immediate future and has set a timeline
 Action: cessation of smoking
 Maintenance: staying tobacco free!

RESOURCES TO REFER PATIENTS

National and State resources

Quitline:


On line and phone counseling, and free NRT


National Quitline 1-800-QUIT NOW
www.smokefree.gov
Local resources
 Healthy Start:
One-on-one Smoking Cessation
Counseling, at home or at work
 Alachua County Health Department: Group
Smoking Cessation Classes that offer FREE
Nicotine Replacement Therapy
 Suwannee River AHEC: 6 week Group
Smoking Cessation Program that offers FREE
Nicotine Replacement Therapy and Counseling
Services
CASE #2
You are seeing a 10 mo female in clinic with fever
and fussiness who is diagnosed with an otitis
media. The patient has a history of recurrent otitis
media. Both parents smoke cigarettes.
 What is the epidemiology and the Risks of Second
Hand Smoke (SHS)?
 How should you approach parents regarding
tobacco use?
 Review Motivational Interviewing
EPIDEMIOLOGY OF SHS EXPOSURE
 Approximately
25% of US children live with at
least one smoker
 “Children in low-income and low-education
households had 7.3 and 10.6 times higher odds of
being exposed to secondhand smoke than children
from high-income and high-educational
attainment households, respectively.”(2)
 Teens with a parent that smokes are twice as
likely to become smokers themselves
1. U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to
Tobacco Smoke: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion,
Office on Smoking and Health, 2006
2. Singh, G., Siahpush, M., Kogan, M. Disparities in children’s exposure to environmental tobacco smoke in the United
States, 2007. Pediatrics, 126(1), 4-13.
3. Melchior, M., Chastang, J.F., Mackinnon, D., Galera, C., Fombonne, E. (2010). The intergenerational transmission
of tobacco smoking--the role of parents' long-term smoking trajectories. Drug and Alcohol Dependence, 107(2-3). 257-60.
RISKS OF SHS EXPOSURE
Asthma exacerbation and poor control
 Otitis Media
 SIDS
 Lower respiratory tract infection
 Prematurity
 Low Birth weight infants
 Leukemia/Lymphoma


Evidence is suggestive but not strong enough to
suggest a causal relationship
HOW TO APPROACH PARENTS
Parents expect you to discuss tobacco use
 Avoid Judgment
 Watch body language and tone, be careful to avoid
alienation
 Depersonalize the question
 For example



Does anyone in the household use tobacco? Where do they
smoke?
If parent smokes use the 5 A’s and assess stage of
change to further guide counseling
MOTIVATIONAL INTERVIEWING
A patient centered method designed to strengthen
personal motivation and commitment to a specific goal
 Listening and guiding parents/patients as they reason
through a problem and towards a goal
 Can be done at multiple sessions to avoid arguments
and resistance


Brief interviews directed at moving slowly away from
ambivalence and towards change
MOTIVATIONAL INTERVIEW
CASE #3
A 14 yo female is being seen for a well child check.
She denies tobacco use on her questionnaire and
when asked by the physician. When asked directly
about e-cigarette use she admits to trying them
with a friend “because they are not bad for you”.
 What is the incidence of e-cigarette use?
 What are the facts and misconceptions about ecigarettes?
 What are other smokeless tobacco products teens
may use?
INCIDENCE OF E-CIGARETTE USE
High school students, who have ever tried e-cigarette
use increased from 4.7% in 2011 to 10.0% in 2012
 HS student who are current e-cigarette users
increased from 1.5% in 2011 to 2.8% in 2012
 In 2012, among high school current e-cigarette users,
80.5% reported current conventional cigarette smoking
 Both experimentation with and habitual use of ecigarettes has doubled among high school as well as
middle school students from 2011 to 2012

Data from the CDC 2011-2012 National Youth Tobacco Survey
E-CIGARETTE MISCONCEPTIONS

Misconceptions
E-cigarettes are just water vapor and are not harmful
 E-cigarettes are not addictive
 E-cigarettes are safe to smoke around children

E-CIGARETTE FACTS

Facts

E-cigarettes are not currently regulated by the federal government






No federal laws restricting marketing or sale to minors, no laws restricting
public use and chemical content not known to or regulated by the FDA
E-cigarettes contain nicotine, which is known to be addictive
There have been known carcinogens identified by the FDA in Ecigarette vapor including formaldehyde, nitrosamines, carbonyl
compounds and propylene Glycol
These carcinogens and other potentially harmful chemicals are likely
present in second hand vapor though direct studies have been
performed
Studies showing lung tissue exposed to vapor has inflammation and
increased reactivity of airways, similar to lung tissue exposed to
traditional tobacco smoke
Lung tissue exposed to vapor shows similar pre-cancerous changes as
lung tissues exposed to tobacco smoke
- Goniewicz ML, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control.
2014 Mar;23(2):133-9
- Lim HB, Kim SH. Inhallation of e-Cigarette Cartridge Solution Aggravates Allergen-induced Airway Inflammation
and Hyper-responsiveness in Mice. Toxicol Res. 2014 Mar;30(1):13-8. doi: 10.5487/TR.2014.30.1.01
- Cervellati F, et al. Comparative effects between electronic and cigarette smoke in human keratinocytes and
epitheliallung cells. Toxicol In Vitro. 2014 Aug;28
E-CIGARETTES

Many Patients and Parents do not include e-cigarette use
when asked if they smoke
Parents and patients should be asked directly about e-cigarette
use
 If parents or patients admit to use you should asses there beliefs
about e-cigarettes
 Educate patients and parents on the facts and risks of e-cigarette
use
 Motivational interviewing and assessment of stage of change
should be done just like if they were using traditional cigarettes



E-cigarette liquid refills and cartridges present a poison
control risk
Concern that with the increase in e-cigarette use there will
be an accompanying increased use of traditional cigarettes
Bunnell RE, et al. Intentions to smoke cigarettes among never-smoking U.S. middle and high school electronic
cigarette users, National Youth Tobacco Survey, 2011-2013. Nicotine Tob Res. 2014 Aug 20
OTHER TOBACCO/NICOTINE PRODUCTS
waterpipe use episode (30-45
minutes) can yield slightly
more nicotine than a single
cigarette, and about 36 times
the tar and 8 times the CO. (1)
Use of dip is rising
especially among
males
-30 day use of
smokeless tobacco up
to 15% among HS
males
Snus: 8 mg of nicotine
Spit less Tobacco
Many Dissolvable Products look
like Candy
Orbs: mint-sized; 1mg of nicotine
Strips: appear like Listerine breath
strips; 0.3-0.6 mg of nicotine
Sticks: toothpick-like; 3.1 mg of
nicotine
Cigarillos (small cigars) are regulated
like cigars which are currently exempt
from regulation on restricting flavors
and marketing to children
- In 2011, 23% of HS students used
cigarillos within the preceding year (2)
PREP QUESTION



Question 206
A 15-year-old boy presents for a routine health
supervision visit and is being seen by a resident.
Some staining of his teeth is noted, and he admits
using smokeless tobacco off and on for a year. He tells
the resident that he believes chewing tobacco does not
cause lung cancer and is not addictive because he
knows that nicotine gum is being used to help adults
who want to quit smoking. He feels chewing tobacco
relaxes him, and he is not ready to stop. Acting as
preceptor, you question the resident about his
understanding of adverse effects of smokeless tobacco.
Of the following, the MOST accurate information to
provide about smokeless tobacco use is that
ANSWER CHOICES

A. heart rate and blood pressure are minimally
affected

B. there is minimal additional risk for dental
caries

C. users are at increased risk for developing gum
and oral cancers

D. users are unlikely to move to cigarette use
later

E. users experience few withdrawal symptoms
ANSWER: C




The use of smokeless tobacco has declined since the 1990s, but this trend in use is reversing. In the United
States, smokeless tobacco is mainly used by boys. The 2 forms of chewing or “spit tobacco” are snuff
(shredded tobacco) and chew (loose leaves). With either form, the tobacco is placed between the cheek and
gum. Staining of the teeth may provide a clue to its use. Smokeless tobacco use has been associated with
leukoplakia, gum disease, gum recession, cancer (of the lip, tongue, gums, cheeks, and floor and roof of the
mouth), and an increased incidence of dental caries.
Absorption of nicotine causes systemic symptoms such as dizziness, an increase in heart rate, and an
increase in blood pressure. Late effects include coronary artery disease. Effects on male reproductive health
include decreased sperm count and abnormal sperm cells. In women, use of smokeless tobacco during
pregnancy increases the risk of preeclampsia and premature delivery. Infants born to mothers who use
smokeless tobacco are more likely to have apnea in the neonatal period and low birth weight.
Nicotine is present in all forms of tobacco and is highly addictive. Although nicotine is absorbed more slowly
from the oral cavity than by inhalation, the amount absorbed per dose is greater. Therefore, regular users of
smokeless tobacco may experience significant withdrawal symptoms. Smokeless tobacco users often change
to cigarettes because it is more socially acceptable. One-third of those who use both products start with
smokeless tobacco first and then add cigarette use, while two-thirds start with cigarette use first and then
add use of smokeless tobacco. Daily smokers who change to smokeless tobacco because they think it will
help them quit have been found to still be smoking months after making the change.
In 2001, a new form of dissolvable tobacco became available in the United States. These products are
marketed to adults with tobacco addiction in order to help them comply with ordinances that prohibit
smoking in public places. However, because these products look like candy and have added flavorings, they
are attractive to children and there is a risk for accidental poisoning. Symptoms of accidental ingestion in
children include drooling, abdominal cramps, nausea, vomiting, agitation, and tremors. Serious adverse
effects include seizures, coma, and death.
FUTURE READING
 Contemporary
pediatrics
Motivational Interviewing
 http://www2.aap.org/richmondcent
er/pdfs/ECigarette_handout.pdf
AAP Clinical Guideline or Practice
Parameter