Pediatricians

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Pediatricians play an important role in tobacco use prevention and tobacco use cessation in their patients and patients’ parents.

Pediatricians are in the unique position to counsel children, adolescents, and their patients’ parents on the health risks of tobacco use and aid in tobacco cessation. The U.S. Preventive Services Task Force has recently recommended that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among school-aged children and adolescents.1

Unfortunately, fewer than half of adolescents who visited a physician or a dentist in 2011 reported receiving preventive counseling regarding tobacco use. 2 Research has also shown that pediatricians do not feel comfortable prescribing nicotine replacement therapies (NRTs) to their patients.  In a survey of pediatricians’ use of NRT and the 5 A’s counseling with adolescent smokers, only 53% of pediatricians rated themselves as confident in their ability to use NRTs.3

How does tobacco affect youth?

  • In utero
    • Smoking in utero can lead to low birth weight, still birth, and neurologic problems.4
  • Infancy
    • Secondhand smoke exposure during infancy can lead to SIDS, bronchiolitis, and meningitis.4
    • Exposure to secondhand smoke killed approximately 430 newborns from sudden infant death syndrome (SIDS) in 2005.5
  • Childhood
    • Secondhand smoke exposure during childhood can lead to asthma, fire-related injuries, and ear infections.4
    • If either parent smokes, the risk of childhood asthma increases by 40%.5
    • About 1/4 of all children aged 3 – 11 years and 1/5 of youth aged 12 – 15 years live with at least one smoker in the home.5
  • Adolescence
    • Secondhand smoke or adolescent smoking can lead to nicotine addiction.4

How can pediatricians help prevent tobacco use in their patients?

Pediatricians can use the SBIRT model to help prevent tobacco use and aid patients in quitting.6 The SBIRT model involves:

  • Screening: Quickly assess the severity of tobacco use and identify the appropriate level of intervention.6 
  • Brief intervention: Increase insight and awareness of tobacco use, help the patient articulate his/her motivation, and/or help enhance motivation toward behavioral change.6 
  • Referral to treatment: Provide those identified as needing more extensive treatment with access to specialty care.6 

SCREENING

Why screen for tobacco use?

  • Smoking during adolescence is the most powerful predictor of smoking during adulthood.7
  • ~90% of adult smokers smoked their first cigarette before they were 18 years old.7
  • ~70% of adult smokers were daily smokers by 18 years old.7
  • Screening helps detect current health problems related to tobacco use at an early stage before they result in more serious disease or other health problems.7
  • Screening helps pediatricians intervene and educate patients about tobacco use.7
  • Screening helps patients protect children from the harm and danger associated with tobacco use.7

Before you screen…7

  • Review the confidentiality policy in your practice setting with parents and patients.
  • Discuss any state limits that may justify breaking confidentiality.
  • Review patient’s family and social history.
  • Screen patients 12 years and older alone.
    • Patients are more likely to be honest when tobacco use screening is confidential and parents or guardians are not present.

Screening for patients 0 – 4 years old8

Ask the patient’s parents:

  • “Do you smoke?”
  • “Where do you smoke?”
  • “Is the child exposed to tobacco smoke anywhere else?”
  • Ask at all clinical encounters

Screening for patients 5 – 8 years old8

Ask the patient’s parents:

  • The above questions about tobacco use and tobacco exposure
  • If parents smoke, emphasize that they are modeling smoking for their child.
  • Continue to ask at all clinical encounters.

Screening for patients 9 – 11 years old8

  • Continue to ask parents about tobacco use and secondhand smoke exposure.
  • Continue to ask parents at all clinical encounters.
  • Emphasize with patients resisting the influence of advertising and rehearsing peer refusal.
  • If there is concern, ask patients:
    • “Do you have any friends who smoke cigarettes?”
    • “Have you ever tried smoking?”

Screening for patients 12 and older8

  • Ask patients AND parents separately:
    • “Have you ever tried smoking cigarettes or used other tobacco products?”
    • “Have you ever smoked even a puff of a cigarette or used other tobacco products in the past 30 days?”
  • If the patient responds yes:
    • “On average, how many cigarettes do you smoke per day?”
    • “How long have you been smoking at this rate?”

BRIEF INTERVENTIONS (BI)

How do people change?

People change voluntarily only when:9

  • They become interested and concerned about the need for change.
  • They become convinced change is in their best interest and the benefits will be greater than the costs.
  • They organize a plan of action that they are committed to implementing.
  • They take the actions necessary to make and sustain the change.

Use OARS9

Open-ended questions: Open-ended questions allow for longer answers and give you a chance to probe for more information.

            Example: “What concerns you about this?”

Affirmations: Affirmations are statements and gestures that acknowledge patients’ strengths and behaviors that led toward positive change.

            Example: “I appreciate you being so open with me about your tobacco use today.”

Reflective listening: Reflective listening demonstrates to the patient that you are listening and trying to understand what they are saying.

            Example: “So you feel like the amount of your smoking is not a problem for you.”

Summarizing: Summaries are helpful in calling attention to salient parts of the conversation and shifting attention or concern.

            Example: “Here is what I have heard. Tell me if I have missed anything…”

Follow the 5 A’s

BI for 0 – 4 years old9

Ask: Screen the parents

  • If the parents tell you neither parent smokes, nor does anyone smoke around the home or near the child = NO risk
    • Advise: Reinforce this with positive messages
  • If the parent does not smoke, but someone at home does (low/moderate risk) OR the parent at visit smokes (moderate risk)
    • Advise: to quit and reinforce risks of continued use, especially as they may relate to any current medical conditions
    • Assess: Gauge the parent’s readiness to talk to smoker about secondhand smoke OR to change his or her own tobacco use
    • Assist: Problem-solve about how to avoid smoke
    • Arrange: Discuss following up with the parent at the patient’s next visit

BI for 5 –8 years old9

  • Follow all previous recommendations for 0 – 4 year olds.
  • Advise: Modify advice to include counseling for children and parents
    • The American Academy of Pediatrics (AAP) Tobacco Use Policy Statement recommends discussing and offering anticipatory guidance to patients about tobacco use as they get older.

BI for 9 – 11 years old9

  • Follow all previous recommendations for 0 – 8 year olds.
  • Ask: Modify screening to include patient.
    • If patient has tried smoking = HIGH risk
    • If patient is high risk, continue with 5 A’s.
  • Advise: to quit and discuss risks of continued use, especially as they may relate to any medical conditions
    • Review current patterns of use and state your concerns.
    • Provide medical information about the concern.
    • Make a clear recommendation.
  • Assess: willingness to try quitting or cutting back
  • Assess the patient’s readiness to change.
  • “On a scale of 0 – 10, how ready are you to change any aspect of your tobacco use?
    • If > 1, ask “Why did you choose that number and not a 0?”
    • If ≤ 1, ask “What would make this a problem for you?”
    • If > 5, ask “On a scale of 0 – 10, how confident are you that you can make this change?”
  • Assist: Help the patient make connections between health and tobacco use, weigh pros and cons of use, negotiate a plan, provide or refer for counseling or additional treatment.
    • Ask patient if he or she sees any connection between their tobacco use and the visit.
    • If the patient sees a connection, reflect what he or she has said.
    • If the patient does not see a connection, help him or her make one.
    • Reinforce what the patient has stated are change goals and/or negotiate a specific goal.
    • Give advice and try to come up with a specific plan.
    • Summarize the plan.
    • Provide educational materials.
  • Arrange: for follow-up
    • Ask the patient about checking in with him or her.
    • Provide information on specific programs, if necessary/appropriate.
    • If change has occurred at point of follow-up appointment, reinforce and support continued adherence.
    • If change has not occurred at point of follow-up appointment, acknowledge that change is difficult, address barriers to change, and engage friends and family.

BI for 12+ years old9

  • Ask: screen the patient
    • If patient responds “yes” to more consistent smoking = HIGH risk
    • If patient is high risk, continue with the above BI steps for patients 9 to 11 years of age.

REFRRAL TO TREATMENT

When do you refer to treatment?9

  • When detox or a more intensive treatment setting is necessary
  • When the problem is too severe for BI
  • When you want further assessment
  • When the patient wants or needs more assistance

Steps of a referral9

  • Assess the patient’s needs including co-occurring medical and psychiatric disorders.
  • Plan the referral.
  • Help the patient access referral services.
  • Document the referral.
  • Provide feedback and follow-up.

Resources

American Academy of Pediatrics' Tobacco Prevention Policy Tool www2.aap.org/richmondcenter/TobaccoPreventionPolicyTool/TPPT_PracticeCessation.html

Centers for Disease Control and Prevention's Smoking & Tobacco Use: Information Sheet www.cdc.gov/tobacco/youth/information_sheet/index.htm

Clinical Effort Against Secondhand Smoke Exposure (CEASE) at Massachusetts General Hospital. Smoking Cessation Strategies: Options for the Family Physician

Public Health Service's (PHS) Treating Tobacco Use and Dependence: 2008 Update www.ncbi.nlm.nih.gov/books/NBK63952/

State of New York: Department of Public Health. Talk To Your Patients About Smoking

American Medical Association. Motivational Interviewing - Counseling Parents About Thirdhand and Secondhand Smoke Exposure

United States Department of Health and Human Services. Helping Smokers Guide: A Guide for Clinicians

University of Maryland School of Medicine. Maryland M.D.s Making a Difference: SBIRT in Pediatrics

U.S. Department of Health and Human Services' BeTobaccoFree.gov http://betobaccofree.hhs.gov/dont-start/index.html

Last updated: July 03, 2014
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References
  1. U.S. Preventive Services Task Force. (2013). Primary Care Interventions to Prevent Tobacco Use in Children and Adolescents U.S. Preventive Services Task Force Recommendation Statement. Retrieved from: http://www.uspreventiveservicestaskforce.org/uspstf12/tobacco/tbacfinalrs.htm 
  2. Patnode CD, O'Connor E, Whitlock EP, Perdue LA, Soh C. (2012). Primary Care Relevant Interventions for Tobacco Use Prevention and Cessation in Children and Adolescents: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 97. AHRQ Publication No. 12-05175-EF-1. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from: http://www.uspreventiveservicestaskforce.org/uspstf12/tobacco/tobchpreves.pdf 
  3. Price, J. H., Jordan, T. R., & Dake, J. A. (2007). Pediatricians' use of the 5 A's and nicotine replacement therapy with adolescent smokers. Journal of Community Health: The Publication For Health Promotion And Disease Prevention, 32(2), 85-101. doi:10.1007/s10900-006-9035-3
  4. Aligne, C.A., & Stoddard, J.J. (1997). Tobacco and children: An economic evaluation of the medical effects of parental smoking. Archives of Pediatrics & Adolescent Medicine, 151(7), 648-53.
  5. UNC Cecil G. Sheps Center for Health Services Research (2009). Smokefree families’ helping families thrive: Key policies to  promote tobacco-free environments for families. Retrieved from: http://tobacco-cessation.org/sf/pdfs/pub/Final%20Final%20Indicator%20with%20all%20edits%203-30-09.pdf
  6. SAMHSA. Screening, brief intervention, and referral to treatment (SBIRT). Retrieved  from http://www.samhsa.gov/prevention/sbirt/
  7. Forman, S. & Levy, S. (2010). Adolescent substance abuse: Screening, brief intervention and referral to treatment “SBIRT” [PowerPoint slides]. Retrieved  from the Center for Adolescent Substance Abuse Research (CeASAR) at Children's Hospital Boston website: www.ceasar.org.
  8. AAP. (2009). Policy statement: Tobacco use: A pediatric disease and the AAP Richmond Center’s presentation: “Promoting smoke-free families.” Retrieved  from http://www2.aap.org/richmondcenter/PowerpointPresentations.html
  9. Fiore, M. C., Jaen, C. R., & Baker, T.B. (2008). A clinical practice guideline for treating tobacco use and dependence: 2008 update. American Journal of Preventive Medicine, 35(2), 158-176.