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

Carol Litten Touloukian, MD

Associate Clinical Professor of PediatricsIndiana University School of Medicine

Indiana Chapter, American Academy of PediatricsSmoke Free Home Champion

Consultant, Indiana Tobacco Prevention and Cessation

Monroe County, Indiana Health Board

toulouki@indiana.edu

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

AIDS Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced

17

8141

19 14 30

430

0

50

100

150

200

250

300

350

400

450

(th

ou

san

ds)

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 ProblemScope 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

27.4%

23.1%

22%

24%

26%

28%

30%

2001 2002 2003 2004 2005 2006 2007 2008 2009

National Average 2008 – 18.4%

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:Mainstream Tobacco Use:Health EffectsHealth 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.  There is no safe level of exposure to secondhand smoke."

“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 EffectsThe Life Cycle of the Effectsof Smoking on Healthof Smoking on Health

SIDsSIDsBronchiolitisBronchiolitisMeningitisMeningitis

InfancyInfancy

Low Birth WeightLow Birth WeightStillbirthStillbirthNeurologic ProblemsNeurologic Problems

In uteroIn utero

AsthmaAsthmaOtitis MediaOtitis MediaFire-related InjuriesFire-related Injuries

InfluencesInfluencesto Startto StartSmokingSmoking

Nicotine AddictionNicotine Addiction

CancerCancerCardiovascular DiseaseCardiovascular DiseaseCOPDCOPD

AdulthoodAdulthood

AdolescenceAdolescence

ChildhoodChildhood

Aligne CA, Stodal JJ. Tobacco and children: An economic evaluation of the medical effects ofAligne CA, Stodal JJ. Tobacco and children: An economic evaluation of the medical effects ofparental smoking. Arch Pediatr Adolesc Med. 1997;151:652parental 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 FetusMaternal Smoking and the FetusDefinite associations:• Stillbirth• Premature delivery• Low birth weight• Placental abruption• SIDSPossible 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).

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 Morbidity and Mortality to Children from SHSChildren 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.orghttp://www.tobaccofreekids.org

AsthmaAsthma

• 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 EffectsShort Term Effects

• Decreased pulmonary function

• Upper and lower respiratory tract infections

• Asthma

• Otitis media

• Invasive meningococcal disease

• Household fires

OverviewOverview• 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 non-smoker 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: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 QuitSmokers 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 Smoking cessation counseling (as little as 3 minutes of (as little as 3 minutes of counseling) by clinicians counseling) by clinicians

increases quit attempts and increases quit attempts and quit rates.quit rates.

Identifying smokers and Identifying smokers and advising them to quit increases advising them to quit increases

the likelihood of quitting 3 the likelihood of quitting 3 times.times.

More counseling is better, More counseling is better, and the effects are and the effects are

cumulative.cumulative.

Counseling in theCounseling in theHealth Care SettingHealth 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 ModelTrans-theoretical ModelStages of ChangeStages 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, 1983Prochaska and DiClemente, 1983

Three Easy Steps

• Step 1: Ask

• Step 2: Assist

• Step 3: Refer

Basic Counseling

• Patients and families expect you to discuss tobacco use

• If counseling is delivered in a non-judgmental manner, it is usually well-received

• 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

•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)

What motivates a person to quit using tobacco?

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

• Every year, every visit, ask families:

“Do you or anyone you live with use tobacco?”

Step One: Ask

Ask families about tobacco use and theirrules about smoking in the home and car

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

• 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

Step Two: Assist

Medications Work!

http://www.massgeneral.org/ceasetobacco/pdf/no%20smoking%20sign%20poster.pdf

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.

• Use Indiana’s fax to quit quitline enrollment form

• Know your local resources

• Arrange follow-up with tobacco users

Step Three: Refer

Refer families who use tobacco to outside help

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 AdvocacyCommunity 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

Smoke Free Homes - www.kidslivesmokefree.org Tobacco Free Kids – www.tobaccofreekids.orgIndiana 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.orgThe National Cancer Society – www.smokefree.govIndiana Tobacco Prevention & Cessation – www.in.gov/itpc/community.asp

Additional ResourcesAdditional Resources

Questions?Questions?

Skull of a Skeleton withSkull of a Skeleton withBurning CigaretteBurning CigaretteAntwerp 1885-1886Antwerp 1885-1886Van Gogh MuseumVan Gogh MuseumAmsterdamAmsterdam