p a ce (P revention a nd C essation E ducation )

ppaacece (P(Prevention revention aand nd CCessation essation EEducationducation))

Collaboration of 12 US medical schools funded by the National Cancer

Institute Boston University

Case Western Reserve UniversityDartmouth CollegeHarvard University

Loma Linda UniversityUniversity of Alabama – BirminghamUniversity of California – Los Angeles

University of IowaUniversity of Kentucky

University of MassachusettsUniversity of Rochester

University of South Florida

ppaacece Goals Goals

• Develop, refine, and integrate new educational modules

• Train medical school faculty• Disseminate resources to other

universities

Where You Come In…Where You Come In…

Using curricular assessments done at all 12 medical schools, our national conference

reached a consensus…

Most U.S. medical students graduate without adequate tobacco cessation and

prevention skills

Preceptorship ModuleCommunity Experience ModulePediatrics/Family Medicine Module

Tobacco EducationTobacco Educationfor the for the

Pediatrics/Family Medicine ClerkshipPediatrics/Family Medicine Clerkship

Reducing Exposure to Environmental Tobacco Smoke

(ETS)

Learning Goals for this Learning Goals for this ModuleModule

You will be able to:1. Define secondhand smoke/ETS2. Appreciate the scope and impact of

ETS on children and adults3. Assess the amount of ETS experienced

by children at each visit/contact4. Encourage a smoke free environment

during all regular and sick visits


5. Assist parents in creating a smoke free environment

6. Screen parents for current smoking status and readiness for change

7. Offer smoking cessation treatment to parents and/or refer them to their providers


You will be able to:1. Define secondhand smoke/ETS2. Appreciate the scope and impact of Appreciate the scope and impact of

ETS on children and adultsETS on children and adults3. Assess the amount of ETS experienced Assess the amount of ETS experienced

by children at each visit/contactby children at each visit/contact4. Encourage a smoke free environment Encourage a smoke free environment

during all regular and sick visitsduring all regular and sick visits

Massachusetts Medical Society Anti-Tobacco Contest Winner

Defining Secondhand Defining Secondhand Smoke/ETSSmoke/ETS


• Secondhand smoke, also known as environmental tobacco smoke (ETS), is a mixture of the smoke given off by the burning of tobacco products (sidestream smoke) and the smoke exhaled by smokers (mainstream smoke).

Refs: Health Effects of Exposure to Environment Tobacco Smoke. Smoking and Tobacco Control Monograph No. 10 National Cancer Institute; 1999. NIH Pub. No. 99-4645.

10th Report on Carcinogens. Research Triangle Park, NC: U.S. Department of Health and Human Services, Public Health Service, National Toxicology Program, December 2002.


• Secondhand smoke contains a complex mixture of more than 4,000 chemicals

• Over 50 of these chemicals are carcinogenic.


You will be able to:1. Define secondhand smoke/ETSDefine secondhand smoke/ETS2. Appreciate the scope and impact

of ETS on children and adults3. Assess the amount of ETS experienced Assess the amount of ETS experienced

by children at each visit/contactby children at each visit/contact4. Encourage a smoke free environment Encourage a smoke free environment

during all regular and sick visitsduring all regular and sick visits

The Scope and Impact of ETSThe Scope and Impact of ETS


Health Effects of ETSHealth Effects of ETS

• More than 1 out of 3 children have a parent who smokes

• Because their lungs are not fully developed, young children are particularly susceptible to secondhand smoke.

• Parents who smoke subject their children (and unborn children) to a range of health risks that can be divided into prenatal, post-natal and longer term

Refs: Health Effects of Exposure to Environment Tobacco Smoke. Smoking and Tobacco Control Monograph No. 10 National

Cancer Institute; 1999. NIH Pub. No. 99-4645.

Women and Smoking: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General; 2001.

Prenatal RisksPrenatal Risks

• Low birthweight• Miscarriage• Premature delivery• Stillbirth• Sudden Infant Death Syndrome (SIDS)• Neurobehavioral problems

Postnatal RisksPostnatal Risks

• Higher rates of:– Pneumonia– Otitis Media– Asthma and asthma exacerbations– Invasive meningitis– Colic

• Respiratory complications under anesthesia

• Sudden Infant Death Syndrome (SIDS)

Longer-term RisksLonger-term Risks

• Reduced pulmonary function

• Dental decay

Other Points to ConsiderOther Points to Consider

• The health consequences of ETS are significant for all family members

• The American Heart Association now recommends limiting ETS for everyone

• More than 70% of mothers who stop smoking during pregnancy will relapse after giving birth

Estimated U.S. Morbidity and Mortality in Estimated U.S. Morbidity and Mortality in Nonsmokers Associated with ETSNonsmokers Associated with ETS

Condition Outcome (annual rate)Development effects -Low birthweight -Sudden Infant Death Syndrome

9,700 to 18,600 births 1,900 to 2,700 deaths

Respiratory effects in children -Otitis media

-New asthma -Asthma exacerbation

0.7 to 1.6 million office visits

8,000 to 26,000 cases 400,000 to 1,000,000

Acute lower respiratory illness -Bronchitis and pneumonia -Hospitalizations -Deaths

Children up to 18 months 150,000 to 300,000 cases 7,500 to 15,000 cases 136 to 212 deaths

Lung cancer (adults) 3,000 deaths

Ischemic heart disease (adults) 35,000 to 62,000 deaths

But Can You Make A But Can You Make A Difference?Difference?

Becoming a Piece of the Puzzle

Why Why InterveneIntervene? Teachable ? Teachable MomentsMoments

• Health effects associated with ETS are substantial but often hidden

• Physicians are a respected source of information

• Many opportunities to intervene• Brief interventions are effective• Limiting exposure to ETS results in

proven benefit to children

Respected Source of Respected Source of InformationInformation

• Pediatrician and Family Medicine counseling has been recommended for:– physical activity– motor vehicle injuries– youth violence– injuries– unintended pregnancy

• ETS counseling is a natural extension

Many Opportunities to Many Opportunities to InterveneIntervene

• Newborn visits• 12 well-child visits are recommended

during the first 6 years of life • Unscheduled, acute care visits (may

be ETS-related)– Otitis media– Asthma and asthma exacerbations – Bronchitis

Brief Interventions are Brief Interventions are EffectiveEffective

• Simple advice (brief interventions) from a physician is effective in promoting long-term cessation

• Parents may not be aware of the serious health effects of ETS–ask parents to name effects

Proven Benefits of Limiting Proven Benefits of Limiting ETSETS

• Breathe better and grow better• 33% fewer school absences• Four times less likely to become a

cigarette smoker

Refs: Need refs here


You will be able to:1. Define secondhand smoke/ETSDefine secondhand smoke/ETS2. Appreciate the scope and impact of ETS Appreciate the scope and impact of ETS

on children and adultson children and adults3. Assess the amount of ETS

experienced by children at each visit/contact

4. Encourage a smoke free environment Encourage a smoke free environment during all regular and sick visitsduring all regular and sick visits

Assessing the Amount of ETSAssessing the Amount of ETS


Brief Counseling ModelBrief Counseling Model

Remembering the 5 A’s• Ask • Assess• Advise• Assist• Arrange

Start by AskingStart by Asking

• Open ended questions• Use a non-confrontational style and

tone• Link your questioning to the reason for

visit/contact

Assessing ExposureAssessing Exposure

Include all potential sources of exposure– Home– Car– Daycare– Family– Relative– Friends


You will be able to:1. Define secondhand smoke/ETSDefine secondhand smoke/ETS2. Appreciate the scope and impact of ETS Appreciate the scope and impact of ETS

on children and adultson children and adults3. Assess the amount of ETS experienced Assess the amount of ETS experienced

by children at each visit/contactby children at each visit/contact4. Encourage a smoke free

environment during all regular and sick visits

Encourage a Smoke Free Encourage a Smoke Free EnvironmentEnvironment



Remembering the 5 A’s• Ask • Assess

•Advise• Assist• Arrange

Encourage a Smoke Free Encourage a Smoke Free EnvironmentEnvironment

• Give a positive message• Focus on benefits to child• Roll with resistance/obstacles• Recognize and acknowledge barriers

Common Barriers to QuittingCommon Barriers to Quitting

• Fear of failure• Nicotine withdrawal• Loss of a coping tool• Family and friends who smoke• Weight gain

Barriers to Limiting ETSBarriers to Limiting ETS

• Logistics• Parenting is stressful• Do not want to upset others by asking

them to change their behavior

Motivating Caregivers to Motivating Caregivers to Quit!Quit!

• They will have more energy and breathe easier

• Saves money that can be spent on other things

• Clothes, hair, and home smell better• Food tastes better• Can feel good about what they have

done for themselves and their child

How to Motivate Limiting ETSHow to Motivate Limiting ETS

• Remain focused on the health benefits for the child– Fewer acute care visits– Less absenteeism

• Empower parent/caregiver to act on behalf of the child– Make mom a hero

Make Mom a Hero!Make Mom a Hero!

• Keeps message positive and focused on the child’s benefit

• Consider using a Smoke Free Pledge

Another Piece of the Puzzle!Another Piece of the Puzzle!


5. Assist parents in creating a smoke free environment

6. Screen parents for current smoking Screen parents for current smoking status and readiness for changestatus and readiness for change

7. Offer smoking cessation treatment to Offer smoking cessation treatment to parents and/or refer them to their parents and/or refer them to their providersproviders

Creating a Smoke Free Creating a Smoke Free EnvironmentEnvironment



Remembering the 5 A’s• Ask • Assess• Advise

•Assist• Arrange

Creating a Smoke Free Creating a Smoke Free EnvironmentEnvironment

• Set realistic goals• Provide a range of options from

smoking cessation to any gains in limiting ETS

• Empower parent/caregiver• Provide handouts

Practical SuggestionsPractical Suggestions

• Quit• Smoke outside ONLY• Open a window• Ask others to do the same


5. Assist parents in creating a smoke Assist parents in creating a smoke free environmentfree environment

6. Screen parents for current smoking status and readiness for change

7. Offer smoking cessation treatment to Offer smoking cessation treatment to parents and/or refer them to their parents and/or refer them to their providersproviders

Screening Parents/CaregiversScreening Parents/Caregivers


A Missed OpportunityA Missed Opportunity

• In the event that the parent or caregiver is interested in smoking cessation, it provides an opportunity to benefit two patients

• Simply asking them about their desire to quit may open up an otherwise missed opportunity

• It is not Pandora’s Box- Be prepared to respond to a positive response


5. Assist parents in creating a smoke Assist parents in creating a smoke free environmentfree environment

6. Screen parents for current smoking Screen parents for current smoking status and readiness for changestatus and readiness for change

7. Offer smoking cessation treatment to parents and/or refer them to their providers

Helping Parents/Caregivers to Helping Parents/Caregivers to QuitQuit


PrecontemplationPrecontemplation

ActionAction

DeterminationDetermination

ContemplatContemplationion

MaintenanceMaintenance

RelapseRelapse

Stages of Change ModelStages of Change Model

PrecontemplationPrecontemplation

ActionAction

DeterminationDetermination

ContemplatContemplationion

MaintenanceMaintenance

RelapseRelapse

Counseling for Smoking Counseling for Smoking CessationCessation

• Motivational Interviewing is the tool used by clinicians to effect behavior change

• Key factors to behavior modification are:– A patient’s Desire to Change– Confidence in their Ability

Desire to ChangeDesire to Change

• Gauge parent’s readiness to quit (ask, for example, on a scale of 1 to 10 with 10=being ready to quit in the next week)

• Reflective listening – express that you understand parent’s link between stress and smoking

• Express empathy about the length and difficulty of quitting process

Desire to ChangeDesire to Change• Show difference between parent’s goals

and current behavior through reflective listening and objective feedback

• Roll with resistance rather than confronting or opposing it – use the 5Rs– Relevance –Ask why quitting is/is not personally

relevant– Risks –Ask them to identify consequences of smoking– Rewards –Ask them to identify benefits of quitting– Roadblocks –Have patient identify barriers to quitting– Repetition –Repeat 5R’s at every visit

Confidence in Ability to QuitConfidence in Ability to Quit

• Gauge the parent’s confidence in ability to quit (on a scale of 1 to 10, with 10 being very confident . . .)

• Ask for an example when patient says confidence to quit is low

• Highlight the positive and/or suggest alternative harm reduction strategies (e.g., smoke outside)

Confidence in Ability to QuitConfidence in Ability to Quit

• Show optimism – express your confidence that they will be able to change

• Set goals together – how to reduce smoking in front of children

Six Common MistakesSix Common Mistakes

1. Not communicating genuine concern– Give the patient your full attention

2. Pushing patients to commit – Follow the patient’s cues

3. Not recognizing patient’s resistance

– Ask permission and give choices

4. Using leading suggestions– Use open-ended questions

Six Common MistakesSix Common Mistakes

5. Thinking you have failed– Motivating the patient may take several

sessions, but time is on your side– You may not score a “knock out” punch

in the first round (visit)– Planting seeds for harvesting later

6. Thinking you have no time to counsel– Brief interventions work – IF YOU DON’T, WHO WILL?

You Can Make A Difference!You Can Make A Difference!

Become a Piece of the Puzzle

VideoVideo

Case ExamplesCase Examples

Example #1Example #1

Ms. Jackson is a 23-year-old mother of two (two-year-old son and three-month old daughter). She says she knows she should quit and would like to save the money, but is just too stressed out right now to try quitting. Where would you start?

Example #2Example #2

Jess and Marianne are parents of a six-month-old son, Damian. They have brought him in for an episode of bronchitis and are both heavy smokers. When you ask whether they are interested in quitting, both say they are not interested. How would you counsel them?

Tobacco EducationTobacco Educationfor the for the

Pediatrics/Family Medicine ClerkshipPediatrics/Family Medicine Clerkship

Thank You for Participating

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