The Children’s Hospital Secondhand Smoke Initiative: Developing Provider Interventions to Reduce Secondhand Smoke Exposure
from Practice Update, Spring 2007
Diane Herrick, RRT-NPS, Coordinator, The Children’s Hospital
Keith Cavanaugh, MD, Medical Director, The Children’s Hospital
Secondhand Smoke Initiative
Smoking is the leading cause of preventable morbidity and mortality in the United States . Parental smoking seriously impacts all family members, and children are especially vulnerable. When applied in the healthcare setting, preliminary data shows that the use of evidence-based methods for adult cessation has resulted in similar success in reducing secondhand smoke (SHS) exposure in families. However, widespread implementation and evaluation has not yet occurred.
Funded through the State Tobacco Education and Prevention Partnership (STEPP), The Children’s Hospital Secondhand Smoke Initiative is to develop an evidence-based, provider-led, sustainable system that can be implemented throughout The Children’s Hospital and other community healthcare settings.
Background
Secondhand Smoke is a complex mixture of more than 4,000 chemical compounds, including 43 carcinogens. Smoke generated from a single cigarette in a large room causes air to fall below the standards set in the 1194 Clean Indoor Air Act. Smoking in a contained space such as a car is up to 23 times more toxic than smoking in a house.1
Parental smoking carries a substantial economic burden. Parents who smoke one pack of cigarettes per day spend an average of $2,100 per year. As smoking is more concentrated among the poor and less educated, a higher proportion of family resources are expended on cigarettes instead of essential needs. Direct medical expenditures and loss-of-life costs for SHS alone exceeds $10 billion per year, with the cost to society of adult smoking and SHS exposure to children estimated at $157 billion annually.1,2
The health impact of secondhand smoke exposure to children is well-documented and includes significantly increased risks for otitis media, lower respiratory tract infections, asthma, prematurity and low birth weight, and SIDS. Of note, children exposed to SHS are also more likely to become smokers when older, with 90 percent of smokers initiating before the age of 18.
More than 25 percent of children in the United States have at least one parent who smokes, with SHS exposure of 25 to 43 percent, per a national self-reported parent survey. National pediatric Emergency Department (ED) data reports between 30 to 60 percent SHS exposure to children.3, 4 Given the considerable impact, risk factors and prevalence, adult smoking should be regarded as a pediatric disease.
Rationale for smoking cessation and secondhand smoke exposure interventions in pediatric settings
Pediatric healthcare encounters offer unique and teachable moments to parents for a balanced discussion of smoking cessation and SHS exposure reduction. This is because of the number of contacts a parent has with his or her child’s provider and the strong link between SHS with chronic and acute childhood illness. Many parents do not have any other access to healthcare services for themselves and frequently use the ED as a primary care provider for their child. For some parents, the child’s provider may be the only access point they have for addressing tobacco addiction.
Current national practice in pediatric settings
Despite the strong rationale for addressing smoking and secondhand smoke in the pediatric healthcare setting, interventions for parental SHS exposure remain sparse, with pediatricians showing a slightly higher rate than family practitioners.
A large national survey of parents seen within the past year by either a pediatrician or a family practitioner (n=902) within the previous year revealed that about half of all parents reported being asked about household member smoking status (52 vs. 48 percent). Parents were asked less about rules prohibiting smoking in the home (38 vs. 29 percent). Of the 21 percent of parents who were smokers, less than half reported being counseled by either specialty about the dangers of SHS (41 vs. 33 percent) or risks of modeling smoking behavior (31 vs. 28 percent). Correspondingly, less than half of parental smokers received advice to quit (36 vs. 45 percent).5
Common barriers to addressing parental smoking that were cited by providers include child healthcare clinicians identify a number of perceived barriers, including lack of time, lack of confidence in their ability to provide smoking cessation advice and concern about negative reactions from parents. In a survey by Perez-Stable et al 45 percent of pediatricians perceived parents’ lack of interest in quitting was a barrier to cessation counseling, with 39 percent thinking that parents would ignore their advice. Also mentioned were lack of skills (26 percent), reimbursement (20 percent) and negative reaction from parents (20 percent).6
Contrary to prevailing provider perceptions, the vast majority of smoking parents expect interventions for smoking and SHS exposure, giving higher satisfaction ratings to pediatric clinicians who address their smoking and offer to help.6
Current practice at The Children’s Hospital
An online survey of physicians, physician assistants, nurse practitioners and respiratory therapists was conducted to establish a baseline at The Children’s Hospital for provider practice regarding smoking and SHS intervention. Results were consistent with national surveys and provider focus groups conducted by STEPP. (Table 1)
Adapting a successful adult cessation model to address SHS exposure in children
The Treating Tobacco Use and Dependence Clinical Practice Guidelines , published by the Public Health Service in 2000, states clinicians and healthcare delivery systems should “institutionalize the consistent identification, documentation and treatment of every tobacco user seen in a healthcare setting.” Key points include incorporating systems for smoker identification; brief individualized counseling interventions for all smokers; cessation counseling or referral to cessation resources that include nicotine replacement therapy for smokers who are ready to make a cessation attempt. Systems that incorporate the 5 A’s behavioral modification model have proven to be effective, with a modification to the 2 A’s and an R for settings with limited time and/or resources. (Table 2).7, 8
Telephone cessation programs that combine counseling with nicotine replacement therapy have substantially higher cessation rates at six months than self-attempts. 2006 data for the Colorado QuitLine shows an average of 35 percent cessation rate at six months compared with less than five percent for self-attempting smokers (Table 3). Unfortunately, national data and results of The Children’s Hospital’s Provider Survey show child healthcare providers refer parents to QuitLines as infrequently as 10 percent of the time. This is despite surveys that show enrollment in QuitLines would be acceptable to the majority of parents in the context of their child’s healthcare visit.8
Implications for pediatric healthcare settings
When applied in pediatric healthcare settings, preliminary data shows that the use of evidence-based methods for adult cessation has resulted in similar success in reducing secondhand smoke exposure in families. However, widespread implementation and evaluation has not yet occurred, and to date, there are no published studies evaluating the efficacy of adapting the adult cessation model to address SHS exposure in pediatric healthcare settings.
Beginning with the ED pilot, the goal of The Children’s Hospital Secondhand Smoke Initiative will be to develop an evidence-based, provider-led, sustainable system that can be implemented throughout Children’s and other community healthcare settings. Design will be modified based upon the adult cessation model and results of the Provider Survey, and will be tailored to the unique attributes of each clinical setting.
Conclusion
Adult smoking is a significant pediatric disease that is currently under-addressed in pediatric healthcare settings. Despite positive interests from smoking parents, successful cessation programs that incorporate counseling and nicotine replacement therapy are highly under-utilized. A model based upon current Public Health Service recommendations for adult cessation may be effective in addressing secondhand smoke exposure in children; however, the dearth of evidence mandates further evaluation. The SHS Initiative at The Children’s Hospital represents a unique opportunity to design, evaluate and implement systems that effectively address parental smoking and secondhand smoke exposure.
We are seeking interested PCPs to test the pilot. For more information, please contact Diane Herrick at (303) 861-6601 or herrick.diane@tchden.org.
References
Centers for Disease Control and Prevention. Cigarette smoking-attributable morbidity United States , 2000. MMWR Morb Mortal Wkly Rep. 2003;52 :842-844
Winickoff, Jonathan P. MD, MPH, et al; State-of-the-Art Interventions for Office-Based Parental Tobacco Control; PEDIATRICS Vol. 115 No. 3 March 2005, pp. 750-760 (doi:10.1542/peds.2004-1055)
Steven L. Bernstein and Bruce M. Becker Preventive Care in the Emergency Department: Diagnosis and Management of Smoking and Smoking-related Illness in the Emergency Department: A Systematic Review Acad. Emerg. Med. 2002
Evans D et al, The impact of passive smoking on emergency room visits of urban children with asthma Am Rev Respir Dis. 1987 Mar;135(3):567-72.
Winickoff, Jonathan P. MD, MPH, et al; Addressing Parental Smoking in Pediatrics and Family Practice: A National Survey of Parents. Pediatrics 2003;112;1146-1151
Winickoff, Jonathan P. MD, MPH, et al; State-of-the-Art Interventions for Office-Based Parental Tobacco Control; PEDIATRICS Vol. 115 No. 3 March 2005, pp. 750-760 (doi:10.1542/peds.2004-1055)
Fiore MC, Bailey WC, Cohen SJ. Treating Tobacco Use and Dependence Rockville , MD : US Department of Health and Human Services, Public Health Service; 2000
Winickoff, Jonathan P. MD, MPH, et al; A National Survey of the acceptability of QuitLines to help parents quit smoking. PEDIATRICS Vol. 117 No. 4 April 2006, pp. e695-e700 (doi:10.1542/peds.2005-1946) A National Survey of the Acceptability of Quitlines to Help Parents Quit Smoking
