Download Smoke Free Families: How to Help Every Family Member Quit

Smoke Free Families: How to Help
Every Family Member Quit Smoking
Carol Litten Touloukian, MD
Associate Clinical Professor of Pediatrics
Indiana University School of Medicine
Indiana Chapter, American Academy of Pediatrics
Smoke Free Home Champion
Consultant, Indiana Tobacco Prevention and
Cessation
Monroe County, Indiana Health Board
[email protected]
Pre-test Questions
• What is the most frequent cause of death
and disability in the United States?
• What is Third Hand Smoke?
• What is the only way to prevent death and
disability from tobacco smoke?
Presentation Goals
• Review the mortality and morbidity
related to tobacco use.
• Review third hand smoke
• We must help every family member quit
smoking: Give clinicians tools they need
to help patients and parents decide to
stop smoking and then, when they are
ready, to help them actually quit.
Comparative Causes of Annual
Deaths in the United States
430
(thousands)
450
400
350
300
250
200
150
100
50
0
81
41
17
AIDS
Alcohol
19
14
Motor Homicide Drug
Vehicle
Induced
30
Suicide
Smoking
Sources: (AIDS) HIV/AIDS Surveillance Report 1998; (Alcohol) McGinnis MJ, Foege WH. Review: Actual Causes of Death in
tthe United States. JAMA 1993; 270:2207-12; (Motor vehicle) National Highway Transportation Safety Administration, 1998;
(Homicide, Suicide) NCHS, vital statistics, 1997; (Drug Induced) NCHS, vital statistics, 1996; (Smoking) SAMMEC, 1995
Scope of the Problem
• More than 6 million children alive today will
die prematurely from smoking-related
illnesses (IN 160,000)
• Causes 438,000 deaths, or about 1 of every 5
deaths, each year, including approximately
38,000 deaths from SHS exposure
• Smoking is the number one cause of
preventable death and disability in the United
States
• The lifespan of a smoker is about 10 years
less than a nonsmoker
• The tobacco industry spends billions per year
advertising and marketing (much of it aimed
towards youth and young women)
Fiscal Costs of Smoking
•Annual Smoking Caused Health Costs: 95.9 Billion
•FY 2010 Total Tobacco Prevention Spending: 629.5 Million
•2006 Tobacco Company Marketing: 12.8 Billion
•Percentage of Tobacco Company Marketing that State
Spends on Tobacco Prevention: 4.9%
•Ratio of Tobacco Company Marketing to State
Tobacco Prevention Spending: 20.4 to 1
Scope of the Problem - Indiana
• ~23.1% of Indiana adults are smokers (IN
2009) – national average is 18.4%
• 36% of children live in a home in which
cigarettes are smoked (also exposed in cars,
daycare) – only 7% of non-smoking adults
choose to live with smokers
• 4.1% of 6-8th graders smoke (IN 2008)
• 18.3% of 9-12th graders smoke (IN 2008)
• 19.1% of pregnant women smoke (IN 2007)
• 37% of women ages 18-24
Indiana Adult Smoking Rates: 2001-2009
30%
28%
27.4%
26%
24%
23.1%
22%
2001
2002
2003
2004
2005
National Average 2008 – 18.4%
2006
2007
2008
2009
Current smoking among youth,
2000-2008
* Statistically significant differences between 2000 and 2008 (p<0.05)
^ Statistically significant differences between 2006 and 2008 (p<0.05)
Mainstream Tobacco Use:
Health Effects
• Neoplasm
• Respiratory
• Cardiovascular
– Immediate increase in cardiovascular
and stroke risk with one cigarette!
• Susceptibility to infection
• Decreased male and female fertility
Does exposure to SHS matter?
• Over 250 toxic constituents of tobacco smoke
• 69 known or probable carcinogens in cigarette
smoke
• EPA classified SHS as a Group A carcinogen
– known to cause cancer in humans
• U.S. Surgeon General Richard Carmona, 2006 (The
Health Consequences of Involuntary Exposure to Tobacco
Smoke):
"The debate is over, the science is clear.
is no safe level of exposure to secondhand
smoke."
There
“Air is not nothing, air is
something, air is wind that is
not moving.”
--a 3 year old
Definition of Third-hand
Smoke
• Tobacco smoke contamination that remains
after the cigarette is extinguished – coats the
surface of every space in which the cigarette is
smoked; home, car, smoker (Winickoff, Pediatrics, Jan. 2009)
– Heavy metals – lead, arsenic
– Carcinogens – cadmium, polonium-210
– Volatile substances – butane, toluene
• Particulate matter (a well-recognized form of air
pollution) is 2-3 times higher in homes of
smokers
The Life Cycle of the Effects
of Smoking on Health
Asthma
Otitis Media
Fire-related Injuries
SIDs
Bronchiolitis
Meningitis
Childhood
Infancy
In utero
Low Birth Weight
Stillbirth
Neurologic Problems
Influences
to Start
Smoking
Adolescence
Nicotine Addiction
Adulthood
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
Health Effects of Smoking and SHS
•
•
•
•
•
Pregnant mothers
Maternal (and paternal)
SHS exposure in childhood
Adolescent smoking
Adult smoking
We need to help patients and parents
find a reason to quit smoking!
Children at Particularly High Risk
• Their consent is not given for SHS exposure
• Unable to leave when SHS is present (at home,
daycare or smoke filled cars)
• Lack social standing to be given consideration even
when they state their preference
• Receive higher dose of toxin for same exposure than
adults due to increased ventilation rate
• Kids crawl and have mouthing behaviors which
increases second and third hand exposure
• Lower to the ground where particulate matter settles
causing increased exposure
• Immature, developing organ systems (lungs,
immune systems) and smaller airways
• May not see effects from SHS for years
Maternal Smoking and the Fetus
Definite associations:
• Stillbirth
• Premature delivery
• Low birth weight
• Placental abruption
• SIDS
Possible associations:
• Childhood cancers
• Neurological/developmental effects
Reducing smoking during pregnancy by 1% would
prevent 1300 low birthweight babies and save $21
million in medical costs in the first year (US).
Morbidity and Mortality to
Children from SHS
• Thousands of children die each year in the
U.S. as a result of SHS exposure
– 2000 cases of SIDS
– 300 child deaths/year from house fires
– Respiratory disease – RSV, asthma, infections
• ~5.4 million childhood illnesses are attributed
to SHS exposure
– 8000 new cases of asthma and over a million
exacerbations
– 700,000 cases of otitis media including 5200
tympanostomies
– 150,000-300,000 episodes of bronchitis/pneumonia
http://www.tobaccofreekids.org
Asthma
• SHS accounts for 8-13% of asthma
cases in children <15 years
• SHS exposure increases frequency of
episodes and severity of symptoms
• SHS exposure increases frequency of
hospitalizations
• 200,000-1 million asthmatic children are
affected by SHS
Short Term Effects
• Decreased pulmonary function
• Upper and lower respiratory tract
infections
• Asthma
• Otitis media
• Invasive meningococcal disease
• Household fires
Overview
• Harms
– Prenatal exposure
– SHS (secondhand tobacco smoke) exposure
– THS (third hand smoke) exposure
– Smoking
– Associated with other adolescent substance
use (alcohol x14, marijuana x 100, cocaine x32)
• Interventions
– Helping the pregnant woman quit
– Helping the new parent to stay quit
– SHS and THS exposure reduction
– Smoking cessation counseling – for parent and
child/adolescent smokers
The Cessation Imperative
• The only way for patients to protect
themselves and non-smoking family
members completely is to quit
smoking
Cessation is the Goal
• Eliminate the #1 cause of preventable
morbidity and mortality
• Eliminate tobacco smoke exposure of all
household members
• Provide economic benefits
• Decrease teen smoking rates – kids who
grow up in smoke free homes are 3 times
less likely to start smoking
When smokers quit -- What are
the benefits over time?
• 20 minutes after quitting: Your heart rate and blood pressure
drops.
• 12 hours after quitting: The carbon monoxide level in your blood
drops to normal.
• 2 weeks to 3 months after quitting: Your circulation improves and
your lung function increases.
• 1 to 9 months after quitting: Coughing and shortness of breath
decrease; cilia (tiny hair-like structures that move mucus out of the
lungs) regain normal function in the lungs, increasing the ability to
handle mucus, clean the lungs, and reduce the risk of infection.
• 1 year after quitting: The excess risk of coronary heart disease is
half that of a smoker's.
• 5 years after quitting: Your stroke risk is reduced to that of a nonsmoker 5 to 15 years after quitting.
• 10 years after quitting: The lung cancer death rate is about half
that of a continuing smoker's. The risk of cancer of the mouth,
throat, esophagus, bladder, cervix, and pancreas decrease, too.
• 15 years after quitting: The risk of coronary heart disease is the
same as a non-smoker's
Addiction to Nicotine is:
A Treatable Disease
Research Tells Us:
• Nicotine is addictive
• Tobacco dependence is a chronic
medical condition
• Effective treatments exist
• Every person who uses tobacco
should be offered treatment
Smokers Want to Quit
• 70% of smokers report wanting to quit
(including teenagers)
• 90% of smokers started when they were
<19 yo and never intended to be lifelong
smokers when they started
• Most have made at least one quit attempt
• It takes most smokers multiple attempts to
quit
• Smokers cite physician/clinician advice as
important to making the decision to stop
smoking
Smoking cessation counseling
(as little as 3 minutes of
counseling) by clinicians
increases quit attempts and
quit rates.
Identifying smokers and
advising them to quit
increases the likelihood of
quitting 3 times.
More counseling is better,
and the effects are
cumulative.
Counseling in the
Health Care Setting
• Most of the research in smoking cessation
has occurred in the Family Practice
setting
• Pediatricians, OB-Gyns, Emergency
physicians may be the only doctors that
patients visit
• Most parents are receptive to counseling
by pediatricians
• Counseling does not have to be intensive
– advising to quit and referral to local
resources or a Quit Line works!
• If you don’t counsel to quit smoking, it is a
tacit approval of the patient’s continuing
to smoke!
Trans-theoretical Model
Stages of Change
• Pre-contemplation: No intention of changing
• Contemplation: Intention to change within next
6 months
• Preparation: Intention to change within 1 month
• Action: Change made for less than 6 months
• Maintenance: Change maintained for 6 months
Prochaska and DiClemente, 1983
Three Easy Steps
• Step 1:
• Step 2:
• Step 3:
Ask
Assist
Refer
Basic Counseling
• Patients and families expect you to
discuss tobacco use
• If counseling is delivered in a nonjudgmental manner, it is usually wellreceived
• Even small “doses” of counseling are
effective
– And cumulative!
Guidelines for Clinician Counseling
• Don’t be judgmental – smoking is bad,
people who smoke aren’t bad.
• Quitting is hard!
• Not everyone will be ready to quit the day
you see them.
• Focus your intervention on where your
patient is to move them closer to being ready
to quit
• It’s a process!
Tobacco Smoke is Silent
Why do people continue to
use tobacco?
• Nicotine Addiction
• 3 Addictions:
– Physiological – tolerance, dependence,
withdrawal symptoms
– Psychological – stimulation, handling,
pleasurable relaxation, tension, habit,
cravings
– Socio-cultural – one or more parents
smoke, peers, specific places
Nicotine combines with a number of
neurotransmitters in the brain and
contributes to the following effects:
• Dopamine: pleasure, suppress appetite
• Serotonin: mood modulation, suppress appetite
•
•
•
•
Norepinephrine: arousal, suppress appetite
Vasopressin: memory improvement
Beta-endorphin: reduce anxiety/tension
Acetylcholine: arousal, cognitive enhancement
These effects are pleasing and reinforce the
act of using tobacco – unfortunately it causes
death and disability as side effects.
Withdrawal symptoms begin within
hours as the nicotine level decreases
•
•
•
•
•
•
•
Irritability
Anxiety
Frustration
Increased hunger
Loss of concentration
Cravings
Hostility
Withdrawal symptoms are most severe
during the first 3-4 days, but typically last
from 1-3 weeks or longer
What motivates a person to quit
using tobacco?
•Health status (tobacco related illness)
•Money (especially influences young people)
•Embarrassment (creates closet smokers)
•Inconveniences (smoking restrictions, must go outside
to smoke)
•Cultural norms (local ordinances, use rates)
•Addiction issue (monkey on their back)
•Children (not wanting their children to use or to protect
them from the effects of second and third hand smoke)
Help patients find a reason to quit!
People make health
behavior changes over time
• The process of ending tobacco use
requires a series of choices and
changes that lead to a goal
• The change process is not linear
• People learn about tobacco, progress,
lapse, and have to start over again
• Relapse is a natural part of the change
cycle
Step One: Ask
Ask families about tobacco use and their
rules about smoking in the home and car
• Every year, every visit, ask
families:
“Do you or anyone you live with
use tobacco?”
Step One: Ask
If the patient you’re speaking with uses
tobacco, are they:
• Interested in quitting?
• Are they ready to set a quit date?
• Would they like a medication to help them
quit?
• Want to be enrolled in the free quitline?
If the patient is a non-smoker or has recently
quit, congratulate them on their good choices
Step Two: Assist
• Facilitate their getting what they will
use to help quit (e.g. write rx for NRT)
• If they don’t want anything then make
sure home and car are completely
smoke-free and agree to check in next
time
Medications Work!
Nicotine Replacement
• Nicotine Replacement
–
–
–
–
Nicotine Patch (21mg, 14mg, 7mg) – 21mg = 1 pk/d
Nicotine Gum (4mg, 2mg)
Nicotine Lozenge (4mg, 2mg)
Nicotine Inhaler (prescription only)
• Should be combined
– patch for maintenance, gum or lozenge for strong
urges
• Minimize nicotine exposure during pregnancy
• Give prescriptions for NRT even though OTC
Before the Quit Date: Bupropion
(Zyban®/Wellbutrin®)
• Start 2 weeks BEFORE quit date
• 150 mg QAM for 3 days, then
increase dose to 150 mg BID
– Doses should be at least 8 hours apart
– Use for 7-12 weeks after quit date;
longer use possible
• Don’t use with seizure disorder
• May be combined with NRT
Varenicline (Chantix®)
• Start 1 week BEFORE quit date
• Comes in starting dose pack and continuing
dose pack. Also 0.5 mg alone if can’t tolerate
1 mg
• 0.5 mg QD for 3 days, then 0.5 mg BID for 4
days, then 1 mg BID for 12 weeks or longer
– After a meal with a full glass of water
– Use for 12 weeks after quit date; longer
use possible
• Nausea, sleep problems common SE
• Don’t use with NRT
• Be cautious in patients with mental health
issues, especially depression
Some people have had changes in behavior, hostility,
agitation, depressed mood, suicidal thoughts or actions
while using CHANTIX to help them quit smoking. Some
people had these symptoms when they began taking
CHANTIX, and others developed them after several
weeks of treatment or after stopping CHANTIX. If you,
your family, or caregiver notice agitation, hostility,
depression, or changes in behavior, thinking, or mood
that are not typical for you, or you develop suicidal
thoughts or actions, anxiety, panic, aggression, anger,
mania, abnormal sensations, hallucinations, paranoia,
or confusion, stop taking CHANTIX and call your doctor
right away. Also tell your doctor about any history of
depression or other mental health problems before
taking CHANTIX, as these symptoms may worsen while
taking CHANTIX.
Step Three: Refer
Refer families who use tobacco to
outside help
• Use Indiana’s fax to quit quitline
enrollment form
• Know your local resources
• Arrange follow-up with tobacco users
www.indianatobaccoquitline.net
Fax Referral Form
What Will They Get????
Indiana Quitline current offerings:
– 4 calls w/proactive counseling to those ready
to quit
– 10 calls for pregnant patients
– 2 week starter kit/patches or gum
– Initial call made by Quit Coach
– Web Coach® - trained in cognitive behavioral therapy in
English and Spanish
– Staged-based quit guides
– Referrals made to local resources, if available
– Outcomes reported back to physician/clinic
Arrange Follow Up
• Plan to follow up on any behavioral
commitments made
• Just asking at the next visit makes a big
impression
• Schedule follow-up in person or by
telephone soon after the quit date
The Barriers
• Time: There’s never enough time to do the
things you already need to do
• Money: And it’s unlikely you’ll be
reimbursed every time
• Your staff: Can derail efforts
• Your patients and their families: May not
want to talk about it
The Assets
• You and your staff and colleagues can
be effective
• Your patients and their families expect
to hear about tobacco
• The changing culture is making it
harder to use tobacco – ordinances,
increased taxes, cultural norms – so
patients are considering quitting
Community Advocacy
• Advocate for smoke free environments –
states with most comprehensive clean air laws
have lowest smoking rates (8% of IN
population covered by comprehensive smoke
free air laws)
• Be politically active – states with highest
cigarette taxes have lowest smoking rates (IN
– 99.5 cents, nation - $1.34)
• Community and school education programs
• Participate in media presentations
• Be a good role model
But How?
• Clinical Staff: Can ASK, ASSIST, and REFER
• Administrative Staff: Can keep materials
stocked and administer screening questions
or questionnaires
• Management: Need to support the “cause”
Post-test Questions
• What is the most frequent cause of death
and disability in the United States?
• What is Third Hand Smoke?
• What is the only way to prevent death and
disability from tobacco smoke?
Summary
• Any clinical practice setting should be
used to deliver tobacco dependence
treatments to patients and their families
• Families should be the number one
priority population for tobacco control
efforts
• Every smoker should be advised to quit
and offered treatment no matter the
clinical setting
Resources
ITPC – Indiana Tobacco Prevention
and Cessation
Additional Resources
Smoke Free Homes - www.kidslivesmokefree.org
Tobacco Free Kids – www.tobaccofreekids.org
Indiana State Medical Association - www.ismanet.org
American Heart Association – www.americanheart.org
American Cancer Society – www.cancer.org
American Lung Association – www.lungusa.org
American Academy of Pediatrics – www.aap.org
The National Cancer Society – www.smokefree.gov
Indiana Tobacco Prevention & Cessation –
www.in.gov/itpc/community.asp
Questions?
Skull of a Skeleton with
Burning Cigarette
Antwerp 1885-1886
Van Gogh Museum
Amsterdam