Tobacco smoke exposure is an important health problem for children
The United States Surgeon General’s report on the Health Consequences of Involuntary Exposure to Tobacco Smoke251 documents the following:
- Tobacco smoke exposure causes premature death and disease in children and adults who do not smoke.
- Children exposed to secondhand smoke are at an increased risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma.
- The evidence suggests a relationship between prenatal and postnatal secondhand smoke exposure and childhood cancers, including leukemia, lymphomas, and brain tumors.
- Smoking by parents causes respiratory symptoms and slows lung growth in their children.
- There is no risk-free level of exposure to secondhand smoke.
- A total ban on indoor smoking is the only way to eliminate secondhand smoke exposure in indoor environments. Exposure of nonsmokers to secondhand smoke cannot be controlled by air cleaning or mechanical air exchange
Opportunities of the Pediatric Health Care Provider
Tobacco dependence starts in childhood. Most individuals who become tobacco addicted do so before high school graduation.267 Pediatric health care providers have an important role in both preventing and treating tobacco dependence in their patients.268
Most parents who are tobacco dependent would accept treatment or referral from their child’s health care provider.269 Many young adult parents who smoke present more often to a pediatric health care provider (for care of their children) than to an internist or family physician for their own care. This situation provides a unique opportunity for intervention to address the tobacco dependence of the parents in the context of their child’s illness Routinely offering tobacco-dependence treatment to parents within the child health care setting will confer profound benefits to children and families.270
The American Academy of Pediatrics advises pediatricians to inquire about their patients’ active and secondhand smoke exposure and recommends, “Pediatric health care providers should be knowledgeable about tobacco-dependence treatment and ROUTINELY offer help and referral to those who are tobacco dependent“.271
Tobacco dependence and secondhand tobacco smoke exposure are among the most important preventable causes of morbidity and premature mortality. Pediatric health care providers need to seize available opportunities to 1) reduce secondhand smoke exposure of children, 2) reduce initiation of active tobacco smoking in children and adolescents, and 3) assist children and their parents who are active tobacco users to navigate the path to stopping smoking.
Identifying and Reducing Children’s Secondhand Smoke Exposure
Pediatric health care practitioners should routinely assess both their patients’ active smoking and secondhand smoke exposure. (see Assessment Specifics)
A child may be exposed to multiple sources of tobacco smoke both inside and outside of the primary home. Tobacco smoke exposure from a childcare provider can be as great as that from a parent.266 In assessing a child’s secondhand smoke exposure, it is important to examine all potential sources of exposure at all locations where the child regularly spends time.
Parental perception of an exposed child’s level of tobacco smoke exposure is commonly inaccurate.272 Even with a “smoke-free home”, a parent may smoke outside, yet be close to a door or window so that the smoke re-enters the home. A child may be near the parent when they are smoking “outside”. Lapses in keeping the home smoke free may occur during inclement weather, when the child is away from home, or when traveling.
Biomarkers of tobacco smoke exposure:
Urine cotinine measurement reflects the child’s previous 3 to 4 days of tobacco smoke exposure.273 274 Urine cotinine measurement may help the physician address parental misperception about the level of a child’s recent tobacco smoke exposure. When using a urine cotinine assay to assess for secondhand smoke exposure, it is important that the assay used detects cotinine levels ≥5 ng/ml. Some commercially available assays detect cotinine levels only in the range associated with active smoking (≥100 ng/ml).
Treating Tobacco Dependence in Pediatric Patients and their Parents
Pediatric health care providers should become skilled in treatment of tobacco dependence and seize the opportunity presented to them when meeting with their tobacco dependent patients and tobacco dependent parents of their patients.
Most parents who smoke are willing to consider stopping smoking. Most parents who smoke would accept referral from their child’s physician to a telephone tobacco-dependence treatment program or Quit Line (see General & Referral Resources). The vast majority of parents who smoke and who are willing to consider use of medication to treat tobacco dependence would accept that recommendation and/or prescription from their child’s doctor. The direct treatment of tobacco dependence by the pediatric health care provider presents a unique opportunity to save the lives of tobacco-dependent adolescents and adults. Many young adults may not have their own primary provider and many may lack health insurance for themselves. For those parents, their child’s doctor may be their only access to physician care and treatment of tobacco dependence.
The ARMR model discussed in section 1.6 applies to tobacco treatment in the pediatric health care setting. Anticipatory guidance is an important part of pediatric practice, and can help to prevent tobacco smoking in children and adolescents. Pediatric health care providers may wish to consider an additional “A” for anticipatory guidance.
AARMR model for pediatrics:
Give age appropriate messages on the dangers of tobacco smoking
Ask the child to make a commitment to being a lifelong non-smoker
Assess (in the child or parents, as appropriate)
Level of tobacco-smoke exposure
Level of tobacco dependence
Social and psychological factors (role of smoking in their life).
Patterns of smoking,
Triggers of tobacco smoking
Develop written tobacco-dependence treatment action plan. (see Freedom From Tobacco Action Plan)
Set Target Stop Date
Treatment plan side effects
Frequent follow-up is often needed
Treatment plan to improve effectiveness
Treatment plan to reduce side effects
How is the plan working, what changes are needed
The trans-theoretical model of behavior change assists the health care provider to offer messages tailored to the patient or parent’s stage of change, thereby leading to more productive interactions. This model postulates five stages: pre-contemplation, contemplation, preparation, action-implementation, and maintenance.
To help patients and their families negotiate these stages, discussion should be stage-matched. Discovering why a patient is stuck at a particular stage may provide a window for progress to the next stage. See “The Stages of Behavioral Change” for more information.
Parent is not ready to quit:
If the parent or caregiver is not ready to consider stopping smoking at this time, discussion can focus on other ways to reduce the child’s exposure. Helpful behavior changes include:
- Make the home and car smoke free
- Ask parents to make a no smoking rule for the home and car.
- Limit smoking to 20 feet or more from a door or open window.
- Ensure that the child is not near the tobacco-dependent person when s/he is smoking.
- Keep the child away from places where tobacco smoking occurs.
- Provide referral for quit smoking resources (such as 1 800 QUIT NOW) for when they are ready.
Unique features in the treatment of tobacco dependence in adolescence
Most adolescents who smoke consider themselves to be addicted to nicotine, recall withdrawal symptoms during previous attempts to stop smoking, and find it difficult to stop smoking. They often continue smoking well into adulthood.280Effective intervention with this group can dramatically attenuate the risk of tobacco-related morbidity and mortality. The teenage years present a critical window of opportunity for tobacco-dependence treatment to prevent decades of continued tobacco use and the severe morbidity and mortality that it causes. (see Management of Child/Adolescent Tobacco Use)
Cigarette smoking is common among children; 23% of high school students and 8% of middle school students are current cigarette smokers. Non-cigarette tobacco products are frequently used. In national surveys, 13% of high school students and 5% of middle school students smoke cigars; 3% of high school students and 2% of middle school students smoke bidis and/or kreteks (flavored tobacco products); 10%f boys in high school and 4% of boys in middle school use spit tobacco.281
In contrast to the situation with adults, there has been a relative dearth of research into effective tobacco-dependence treatment programs for youth.282 Motivation enhanced, cognitive-behavioral, and social influence theory programs have shown modest benefit, even among tobacco-dependent adolescents. The most beneficial programs were school or classroom based and had multiple sessions (5 or more). The effect appears to be sustained over time.283 More intensive tobacco-dependence treatment programs are more effective than brief interventions; however, brief interventions can show benefit, particularly with less tobacco-dependent adolescents.284 A single randomized placebo controlled clinical trial demonstrated superior cessation rates with nicotine patch therapy compared to placebo when added to cognitive behavioral therapy among tobacco dependent adolescents who were motivated to quit.285 Given the demonstrated effectiveness and safety of first line tobacco-dependence treatments in adults and the grave harm of continued tobacco dependence, a trial of medically supervised pharmacotherapy plus ongoing follow-up is warranted in tobacco-dependent adolescents who are interested in stopping smoking.
Nicotine dependence in adolescents can be assessed by the use of the Fagerström questionnaire, modified for adolescents.286, 287 (see Modified Fagerstrom Tolerance Questionnaire (mFTQ) for Adolescents). Autonomy over smoking behavior can also be assessed byThe Hooked on Nicotine Checklist 288(HONC). Many youths become hooked before they even consider themselves to be smokers, because they don’t smoke every day.
Level of nicotine dependence and history of experience with prior quit attempts can guide intensity of initial pharmacotherapy. Frequent follow-up, especially in the days to weeks surrounding the target stop date, is important to successfully facilitate smoking cessation in adolescents.
Although nicotine addiction is common, it does not drive the smoking behavior of all adolescents. Relationships, activities, emotions, and social ramifications may drive intermittent smoking. (see Intermittent, Non-Daily, Social Smoking). For these patients, adolescent-specific school- or community-based programs that teach usable social, behavioral, and coping skills are helpful.289 Intervention at this point is important, intermittent tobacco use in adolescents frequently progresses to regular tobacco use and long-term tobacco dependence.290
Once willingness to stop smoking is identified, develop a mutually agreed upon treatment plan. Building a strong partnership between patient and physician facilitates development of a realistic plan that the adolescent is interested in, invested in, and willing to implement.291
Concerns about liability for treatment of tobacco dependence in a patient, parent or guardian by a pediatric health care provider
Compared to nicotine medications cigarettes deliver higher levels of nicotine. Furthermore continued tobacco use causes severe illness and premature death. Nicotine medications are effective and not associated with serious adverse effects in adults with cardiovascular disease292 , COPD293 , the elderly294, and concurrent smokers295. According to a World Health Organization expert consensus report, “Virtually all potential users of nicotine replacement therapy are already consuming substantial quantities of the drug nicotine through its most addictive and toxic delivery system-tobacco smoke. Use of nicotine replacement therapy by a smoker can improve the chance that they will quit smoking tobacco, but will not introduce new risks not already faced by smokers and will greatly reduce or eliminate many smoking related risks.”296
If bupropion is used, check for relative contraindications: seizure disorder, head trauma, heavy alcohol abuse, and anorexia/bulimia. (see Developing a Medication Treatment Plan)
Documentation of tobacco-dependence treatment offered to parents:
Documentation can follow a similar model to other situations where the pediatrician prescribes for a parent of close family member due to a child’s illness, such as when the child has meningococcemia, pertussis, or scabies. Although specific requirements may vary by state, it is prudent to document the identity of the individual being prescribed or recommended the medication, the presence of indications for treatment (i.e., parental tobacco dependence adversely effecting the child’s health), the absence of contraindications to treatment (see Developing a Medication Treatment Plan), and counseling about risks, benefits, and potential side effects of the medication. Documentation about the parent’s treatment ideally would be placed in the parent’s medical record; however if that is not possible it is acceptable to include the documentation of the parent’s treatment in their child’s medical record (as would be done if the child had meningococcemia, pertussis, or scabies), with careful notation that this section applies to assessment and treatment offered to the parent.
Heath Insurance Concerns
Pediatric health care providers can use the same diagnosis codes for tobacco-dependence treatment services for children or their parents as adult health care providers. For a discussion on coding and billing for tobacco-dependence treatment see Coding and Reimbursement section.
For pediatric practices that are not ready to offer tobacco dependence treatment assessment, assistance, and referral should be offered. The CEASE (Clinical Effort Against Secondhand Smoke Exposure) program is an example of a program to assess, assist, and refer treatment of parental tobacco dependence. As the CEASE Program points out, “36% of all children in the United States live with a household member who smokes. Children who live with a smoking parent are more likely to start smoking themselves. Secondhand tobacco smoke lingers long after the cigarette [is] extinguished, coats every surface inside the home with toxins, [and] kills three times more children than all childhood cancers combined.” The CEASE program can be easily implemented in a busy pediatrician’s office. CEASE program description and materials can be found at http://www2.massgeneral.org/ceasetobacco.
If a pediatrician does not wish to prescribe tobacco-dependence treatment medications, counseling about available medications and referral to cessation resources (including state or national quitlines such as 1 800 QUIT NOW) can empower effective action.
Community based efforts and public policy
Involuntary tobacco smoke exposure is an important public health problem for children. The individual actions of a child’s parents and care providers may reduce that child’s tobacco smoke exposure, but elimination of a child’s involuntary tobacco smoke exposure often requires community level interventions. Pediatric health care providers have a responsibility to promote tobacco-free policies in their offices and hospital campuses; to work with school boards to ban tobacco smoking on school property; and to urge state and local governments (if they have not already done so) to prohibit smoking in child care centers, restaurants, and other public places.297
The media and entertainment industries play an important role in promoting tobacco use among children and adolescents. The odds of becoming a tobacco user are more than doubled by exposure to marketing and media. Whether the outcome is initiation or increased tobacco use, the relationship between media and smoking behavior is robust, observed across time in different countries, in cross-sectional and prospective designs using a variety of measures of exposure.298 A dose-response effect has been observed between exposure to smoking in movies and adolescent smoking initiation.299 Smoking is common in popular movies viewed by children and adolescents. Amending the movie rating system to rate any movie depicting smoking as “R” would reduce the exposure of children and adolescents.
Greater availability of tobacco-dependence treatment programs for adolescents is needed. A recent national survey of tobacco-dependence treatment programs for youth found that many counties had none, with low socio-economic status counties disproportionately underserved (53 % vs. 31%). Most available programs were multi-session school-based group programs and did not involve use of medication. The majority of programs report that obtaining sufficient operating funds is challenging.300
As advocates for and guardians of children’s respiratory health, pediatric health care providers, particularly pediatric pulmonologists, should actively promote legislation and regulation to protect children and adolescents from tobacco addictions and involuntary smoke exposure, as well as educate the public on the dangers of both active and secondhand smoking.271