Engaging Mississippi’s Pediatricians in Tobacco Cessation Treatment

1. Engaging Mississippi’s Pediatricians in Tobacco Cessation Treatment

2. Engaging Mississippi Pediatricians in Tobacco Cessation TreatmentThis education program is Jointly Sponsored by the American Academy of Pediatrics, Mississippi Chapter and the University of Mississippi School of Medicine Department of Pediatrics and the University of Mississippi Medical Center’s Division of Continuing Health Professional Education.This CME is supported in part through a grant funds from the MS State Department of Health Office of Tobacco Control and produced in accordance with the ACCME Standards for Commercial Support. An Internet Based CME ActivityRelease date: June 20, 2011, Expiration date: June 20, 2012 Program DescriptionThis web-based activity is presented to provide knowledge and tools for pediatric health care providers to more effectively engage in tobacco control and cessation with their patients and families. Information on national recommendations for pediatricians’ involvement in tobacco control as well as cessation treatment options and state based resources will be provided on the webinar. Intended AudienceThis continuing medical education program is intended for practicing physicians and nurse practitioners. Learning ObjectivesUpon completion of this activity the participant should be able to: * Cite the American Academy of Pediatrics’ evidence-based recommendations for pediatrician involvement in tobacco cessation treatment; * Review the 5 A’s approach to tobacco cessation and treatment intervention by physicians; * Recall pharmacotherapy and other treatment approaches and potential side effects to tobacco cessation; and* Describe state-based resources available to support Mississippi physicians’ tobacco control efforts.

3. AccreditationThe University of Mississippi School of Medicine is accredited by the Accreditation council for continuing medical education (ACCME) to sponsor continuing medical education activities for physicians. This enduring material activity was planned and produced in accordance with the ACCME Essentials. The University of Mississippi School of Medicine designates this on-line activity for a maximum of 1 (one) AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. CEU: This activity is approved by the University of Mississippi Medical Center Division of Continuing Health Professional Education for a maximum of .10 Continuing Education Units.Author(s)C. David Hill, M.D., F.A.A.P.Dr. Hill is the State of Mississippi Medical Director for Mullen Immunization Clinics. He received his Bachelor and Doctor of Medicine degree from the University of Alabama and the University of Alabama School of Medicine. Dr. Hill completed a pediatric internship and residency at the University of Alabama Hospitals; The Children’s Hospital of Alabama. Pamela Graef Luckett, M.C.C., L.P.C.Ms. Luckett is a Licensed Professional Counselor and a Certified Tobacco Treatment Specialist. She is employed by Information and Quality Healthcare as the Manager of Tobacco Quitlines for contracted states. Ms. Luckett received a Bachelor’s Degree in Psychology at Belhaven College, a Master’s Degree in Counseling and has completed additional coursework at Jackson State University. Disclosure of Significant Relationships with Relevant Commercial Companies/Organizations’ Disclosure PolicyIn accordance with ACCME Standards for Commercial Support the University of Mississippi School of Medicine requires any author, planner or other persons who are in a position to control the content of this activity to disclose all relevant financial relationships (consultancies, honoraria, research grants, speaker’s bureau etc.) with any commercial interest as it pertains to the content of this activity within the past 12 months. Author(s) are required to disclose within the content of this publication any discussion describing the use of a device, product, or drug that is not FDA approved or the off-label use of an approved an device, product, or drug.

4. Dr. C. David Hill has no conflicts of interest to declarePamela Graef Luckett has no conflicts of interest to declareHardware/Software RequirementsA computer with internet access and a phone are required to access this webinar. Instructions for CME creditIt is estimated that it will require 1 hour to review the material in this continuing medical education program and answer the self-assessment questions. The registration form MUST be completed and submitted for credit. At the completion of the program:* answer test questions using the post test provided (a minimum of 4 questions must be answered correctly for credit) * complete the evaluation form * email both forms to msaap@integrity.com OR mail all three forms to MS Chapter AAP, P O Box 4725 Jackson, MS 39296-4725.

5. Engaging Mississippi’s Pediatricians in Tobacco Cessation Treatment

6. Review of 2009 AAP Policy Statement:Tobacco Use: A Pediatric DiseaseC. David Hill, MD, FAAP This webinar is sponsored by the Mississippi Chapter AAP with funding from the Mississippi State Department of Health’s Office of Tobacco Control

7. In November 2009, the AAP released"Tobacco Use: A Pediatric Disease" A comprehensive, straightforward approach to changing the current climate surrounding tobacco use and smoke exposure in children.

8. Pediatricians are uniquely positioned to assist patients and families with tobacco-use prevention and treatment.

9. First Step The essential first step is understanding the nature and extent of tobacco use and SHS exposure (previous webinar topic)

10. Further Steps (today’s webinar topic) Counseling for patients AND family members to avoid SHS and to cease tobacco use Advocate for policies to protect children from SHS Eliminate tobacco from the media, public places, and home

11. Principles from AAP Policy Statement There is NO safe way to use tobacco There is NO safe level of SHS Financial and political resources of individuals, organizations, and government should be used to support tobacco control

12. Recommendations for Pediatricians Personal behavior Professional behavior Clinical practice

13. For Office or Clinic Encourage and support employees to quit Use office systems that promote prevention and cessation. For example : Use paper or EMR systems that require documentation of tobacco use and SHS status Eliminate ALL forms of tobacco advertising in office (including magazines in lobby) Do not accept funding from the tobacco industry

14. For Patients and Families Ask about and document tobacco use and SHS exposure at ALL encounters (sick, well, prenatal, nursery visits, inpatients) Know the harms of tobacco use and SHS and educate patients and families Advocate for tobacco-free homes, cars, schools, child-care programs, playgrounds, and other places kids go

15. For Patients and Families Who Use Tobacco Advise all families to make home and cars tobacco free. Urge all users to quit. Counsel all parents on how to delivery anti-tobacco messages and ways to discuss addictive nature of nicotine Code for tobacco use and SHS exposure and bill for treatment

16. Special Considerations Emphasize significant health harms of SHS when treating children with chronic diseases and health risks • Annually: • 200,000 childhood asthma episodes • 150,000-300,000 cases of lower respiratory illness • 790,000 middle ear infections • 25,000-72,000 low birth weight or preterm infants • 430 cases of SIDS • SOURCE: California Environmental Protection Agency. (2005). Identification of Environmental Tobacco Smoke as a Toxic Air Contaminant: Part B: Health Effects Assessment for Environmental Tobacco Smoke. Office of Environmental Health Hazard Assessment & California Air Resources Board.

17. Conclusion Tobacco use is the leading preventable cause of death and illness in the United States. Pediatricians and other clinicians who care for children are uniquely positioned to assist patients and families with prevention AND treatment. Pediatricians and the AAP have key responsibilities in tobacco control and place a high priority on these goals for the health of children.

18. CLINICAL OFFICE TRAINING TO HELP THE TOBACCO DEPENDENT PATIENT Pamela Graef Luckett, MCC, LPC, CTTS Director, Tobacco Quitline Sponsored by IQH Funded by the Mississippi State Dept. of Health Office of Tobacco Control

19. The 5-A’s • Ask • Advise • Assess • Assist • Arrange

20. AAAAA: Ask • Ask all patients about tobacco • Ascertain tobacco use status: Every patient Every visit • Use a “Vital Sign” stamp • Involve the entire healthcare team VITAL SIGNS Blood Pressure: ____/____ Pulse: _________ Temperature: _________ Respiratory Rate: _________ Tobacco  Current Use (check one):  Former  Never

21. AAAAA: Ask • Sample Questions • How much tobacco do you use? • How soon after waking do you use tobacco? • Have you ever tried to stop? What happened?

22. Determining Level of Nicotine Addiction • Basically determined in the answer to two questions: • “How much to do smoke most days?” • “How soon after waking do you first use tobacco?” Addiction levels are higher when more than 18-20 cigarettes are smoked most days and use begins within 5 minutes of waking * FTND Survey

23. AAAAA: Advise In a clear, strong, & personalized manner, urge every tobacco user to quit • Clear:“I think that it is important for you to quit using tobacco now, & I will be happy to help you” • Strong:“As your clinician, I need you to know that quitting is the most important thing you can do to protect your health” • Personalized:Tie tobacco use to current health status and risks, economics, and impact on others

24. AAAAA: AssessReadiness to Quit • Ask Every Tobacco User if he or she is willing to make a quit attempt at this time. If a parent/guardian, ask, too. • If willing, provide assistance • Refer to specialist if intensive treatment is more appropriate or preferred • If not willing, provide a motivational intervention

25. ASSESS Motivation to Quit • 0 – 3 Low Motivation Not Ready to Quit • 4 – 7 Moderate Motivation May Be Ready to Quit • 8 – 10 High Motivation Ready to Quit

26. AAAAA: AssistAssist Motivated Tobacco Users • Consider pharmacotherapy • Self-help materials • Give key advice • Abstinence: “Not even a single puff or dip after quitting” • Alcohol: Highly associated with relapse • Anticipate:Discuss challenges and triggers • Other Smokers:Quit with others; develop strategies to cope

27. AAAAA: ArrangeFollow-Up • Follow-up contact • In person • Phone – refer to the Tobacco Quitline • Just prior to quit date • 1-2 weeks after quit date; more as needed • Actions • Congratulate success, review “slips” • Identify problems, anticipate challenges, discuss coping • Assess medication use

28. Number of Contacts Wilson DM et al., JAMA 1988

29. Intervention Time by Patient Type • Never User ½ min • Ex-User ½ min • Not Ready User 1 min • Ready User 2-3 min • Ready User + Script 4-6 min

30. Pharmacotherapy

31. Nicotine Patch Upside • Effect within 1-2 hours • Simple • 3 dose levels • No new drug • Eliminates “tar” and CO • Little concern re: concurrent use with tobacco • Downside • Systemic and skin-related S/E’s • Health risks • CV Disease • Max dose may be insufficient for some • Proper Use • Stop tobacco • 1 per day, on awakening • 6-12 weeks • Tapering option

32. Nicotine Polacrilex Upside • 2 mg and 4 mg • Mint / Fruit • Easily tailored • Oral substitute • Use prn • Proper Use • Stop tobacco • Absorbed via oral mucosa • Chew and park for 30 minutes • Up to 20 (4 mg) or 30 (2 mg) pieces per day • Downside • Insufficient use • Chewing increases S/E’s • Taste can be unpleasant • No food or drink

33. Nicotine Inhaler Upside • Easy to tailor • Oral substitute • Proper Use • Stop tobacco • 6 - 16 /day • 12 weeks; can extend • Can taper, not necessary • D/C if not quit in 4 weeks • Downside • Lower level of dosing -- may not be ideal for heavier users

34. Plasma Nicotine Concentration1st 2 Hours Henningfield JE et al., J Clin Consult Psych 1993

35. Bupropion SR Upside • Ease of Use • Initially, can use tobacco concurrently • Antidepressant effect • Proper Use • QD 3 days, then BID 3 months • Tapering at end of treatment not necessary • Downside • h/o Seizure d/o, Bulimia, Anorexia Nervosa, MAOI or other form of Bupropion • Can take 1-2 weeks to reach adequate blood levels

36. Varenicline • Approved in May 2006 • Used as part of a cessation program • Oral medication – intended ONLY for tobacco cessation • 1 mg twice per day, 12 week treatment • Additional weeks improve quit compliance • Recommended only for adult use • Dose adjustment for severe renal impairment • Most common adverse side effects: - Nausea - Insomnia - Headache - Abnormal dreams

37. Nicotine Dependence...and the Course of Treatment • First 24 to 48 hours most difficult • Withdrawal symptoms peak, then fall • First 2 weeks: Highest relapse risk • First 3 months: Most relapses have occurred • Duration of medication use • Long–term relapses indicate need for: Chronic Management

38. Dealing with Failure • Normalize • Give patient’ permission’ to stop for now • Recognize factors that interfered, in preparation for next time • If failure is related to high-risk situation, review ARRANGE and try again

39. Factors Associated with Readiness Nicotine Dependence Social Factors Psychological Dependence

40. Stopping Tobacco Use is a Process Contemplation Precontemplation Preparation Relapse Action Maintenance

41. “I ONLY Smoke When. . .” • I am with others who smoke • I’m stressed out • I’m having a drink with others • I’m having to work or study late • I’m trying to loose weight • There is nothing else to do

42. Secondhand SmokeQuick Facts • Tobacco kills nearly ½ million Americans each year • Causes premature death and disease in children and adults who do not smoke • Also known as Environmental Tobacco Smoke or ETS • A mixture of the smoke given off by the burning of tobacco products and smoke exhaled by smokers.

43. Secondhand SmokeEffects on your heart • 5 minutes – stiffens the aorta • 20 minutes – excess blood clotting • 30 minutes – increases build up of fat deposits in blood vessels. • 2 hours – increases the change of an irregular heart beat CDC – all heart disease patients should avoid exposure to secondhand smoke.

44. Secondhand SmokeIngredients • Nicotine – as addictive as heroine • Arsenic – rat poison • Benzene – fuel solvent • Formaldehyde – embalming fluid • Hydrogen Cyanide - insecticide • Carbon Monoxide – car exhaust • Ammonia - toilet cleaner

45. SecondHand Smoke • The evidence on the mechanisms by which smoking causes disease indicates that there is no risk-free level of exposure to tobacco smoke. • Secondhand smoke exposure causes disease and premature death in children and adults who do not smoke • Almost 60 percent of U.S. children aged 3-11 years—or almost 22 million children—are exposed to secondhand smoke

46. SecondHand 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. • Smoking by parents causes respiratory symptoms and slows lung growth in their children. • Secondhand smoke exposure can cause children who already have asthma to experience more frequent and severe attacks.

47. Best Idea to Pass on To Parents Who Use Tobacco Eliminating smoking in indoor spaces fully protects nonsmokers from exposure to secondhand smoke. Separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate exposures of nonsmokers to secondhand smoke.

48. How much does it cost to use tobacco? • $5.00 per pack x one pack per day for 7 days = $35.00 per week • $35.00 per week x 4 weeks a month = $140.00 per month • $140.00 per month x 12 months a year = $1680.00 per year • More than one pack? Do the math!!!

49. Suggestions for the Busy Clinic • Who will be responsible for the first question about tobacco use? • Who will discuss the options available to the patient for treatment? • Who will be responsible for completion and sending the referral form for the next step of treatment? • Who will handle the reports on referrals once they are received?

50. Tobacco Quitline1-800-QUIT-NOW1-800-784-8669 • Counseling Services for Smokers and Spit/Chew Tobacco Users at no charge • Hours of Operation • 24-hour answering service Live counseling • 7am – 9pm Monday – Thursday • 7am – 7pm, Friday and • 9:00 am – 5:30 pm Saturday