B-QIP and Beyond: Why Addressing Smoking Matters

1. B-QIP and Beyond:Why Addressing Smoking Matters Susan Walley, MD, FAAP University of Alabama at Birmingham Children’s of Alabama

2. Objectives • Review epidemiology of tobacco related illnesses • Discuss relevance of tobacco to pediatric hospitalists and the B-QIP collaborative • Describe evidence-based methods for smoking cessation and reducing child tobacco smoke exposure • Review case examples

3. Perspective

4. US Data • 46 million Americans or 19% of adults are current smokers • Varies among regions of the country • Varies by race and socioeconomic status • The leading cause of death in the US • One in five deaths from tobacco related illness • 443,000 deaths yearly http://www.cdc.gov/tobacco/

5. US Data

6. US Data

7. Tobacco Smoke Exposure • Consists of second and thirdhand smoke • Thirdhand smoke (THS) • residual tobacco smoke contamination after the cigarette has been extinguished • Compounds settle on surfaces and can oxidize and re-enter the air • 250 compounds found in THS, including 11 which are group 1 carcinogens Winickoff et al, Pediatrics 2009; 123:1

8. Top 5 Reasons Hospitalists Should Address Tobacco

9. Top 5 Reasons Hospitalists Should Address Tobacco • Tobacco is a pediatric disease

10. Top 5 Reasons Hospitalists Should Address Tobacco • Tobacco is a pediatric disease • Tobacco Smoke Exposure (TSE) • Up to 60% children show evidence of TSE • 40% of children live with a household smoker • 7% nonsmoking adults live with a household smoker

11. Top 5 Reasons Hospitalists Should Address Tobacco • Tobacco is a pediatric disease • Tobacco Use • 4% middle school students are current smokers • 18% high school students are current smokers • 90% smokers began smoking before the age of 18 years

12. Top 5 Reasons Hospitalists Should Address Tobacco • Tobacco is a pediatric disease • Hospitalists see (ALOT of) patients with tobacco-related diseases.

13. Top 5 Reasons Hospitalists Should Address Tobacco 2. Hospitalists see patients with tobacco-related diseases. • The top 3 inpatient diagnoses are caused/exacerbated by secondhand smoke • Bronchiolitis • Asthma • Pneumonia

14. Top 5 Reasons Hospitalists Should Address Tobacco • Tobacco is a pediatric disease. • Hospitalists see patients with tobacco-related diseases. • Tobacco has a significant impact on the child beyond the disease he/she was hospitalized for.

15. Top 5 Reasons Hospitalists Should Address Tobacco 3. Tobacco has a significant impact on the child beyond the disease he/she was hospitalized for. • Smoking related excess deaths are 50% of all deaths under 15 yo • Children with parents who smoke are more likely to become smokers • 1/3 of smokers die from a tobacco related disease

16. Top 5 Reasons Hospitalists Should Address Tobacco • Tobacco is a pediatric disease. • Hospitalists see patients with tobacco-related diseases. • Tobacco has significant impact on the child beyond the diseases we care for. • Smokers want to quit.

17. But, they don’t even want to quit…. Percent of Current Smokers Who Want to Quit by Age and Number of Previous Quit Attempts – United States, 2000

18. Top 5 Reasons Hospitalists Should Address Tobacco • Tobacco is a pediatric disease. • Hospitalists see patients with tobacco-related diseases. • Tobacco has significant impact on these diseases. • Smokers want to quit. • Smoking cessation counseling really works and is recommended by the AAP, AMA, and other healthcare agencies! AAP Policy Statement-Tobacco Use: A Pediatric Disease. Pediatrics 2009

19. Smoking Cessation Counseling Effective therapies exist Every person who uses tobacco shouldbe offered treatment Parental smoking cessation interventions are effective Fiore et al. Treating Tobacco Use and Dependence 2008 Rosen et al. Pediatrics 2012; 129: 1

20. B-QIP Measures Achieve 90% compliance in children admitted with bronchiolitis: Screening for Secondhand Smoke (SHS) Interventions for SHS

21. Ask Advise Assess Assist Arrange The 5 As “2As and an R” Ask Advise Refer

22. 2 As and an R: ASK Ask about tobacco use and Tobacco Smoke Exposure at every visit Make asking routine, consistent, and systematic Use standardized documentation Document as a “vital sign”

23. 2 As and an R: ADVISE Strongly advise every tobacco user to quit Provide information about cessation to all tobacco users Strongly urge smoke free homes and cars Look for “teachable moments” Personalize health risks

24. 2 As and an R: REFER National quitline1-800-QUIT-NOW To community and internet resources Give every tobacco user written information that contains information about quitting, the harms of tobacco use, etc.

25. Ask/Identify Case #1 You assume care for a 3 month old admitted last night with bronchiolitis. The History documents “no smoke exposure” but the room smells heavily of tobacco smoke and you see a pack of cigarettes on the bedside table.

26. Ask/IdentifyCase #1 • ASK using depersonalized language • “Does anyone who cares for your child smoke cigarettes” • “Who is it?” and “Where do they smoke?” • Avoid leading or judgmental questions • “You don’t smoke, do you?” • “Does your child have any smoke exposure?”

27. Ask/Identify Interventions • Embed the right questions into the nursing and physician documentation • If your institution documents on paper • Add to standard HPI template • If your institution has Electronic Health Records • Add to nurse intake form • Physician history template • Bronchiolitis order set

28. Advise Case #2 You are caring for a 12 month old infant admitted for the 2nd time with bronchiolitis. The mother states she quit smoking during her pregnancy because her OB told her it was bad for the fetus but restarted smoking cigarettes after the baby was born.

29. Advise Case #2 • Provide a clear personal message to the parent or caregiver • “Quitting is most important thing you can do to protect Jonny and improve his health.” • Advise smoke free cars and homes • “ I’m glad that you planning to cut down even if you aren’t ready to quit. The next most important step is to make sure no one ever smokes inside the house or car.”

30. Advise Case #2 • During the hospitalization: • “I want to make sure that I am thinking of everything to try to prevent Jonny from getting sick again. I understand you smoke. Do you mind if I share with you some information to try to prevent Jonny from wheezing again/developing asthma, etc etc.”

31. Advise Case #2 • At discharge: • “I’m glad Jonny is going home today. I know being in the hospital was tough and I don’t want him to ever come back. I understand you smoke cigarettes. Do you mind if I share with you some information to try to prevent Jonny from wheezing again/developing asthma, etc etc.”

32. Advise 201 (Assess/Assist)Case #2 • Assess • “Have you every thought about/tried to quit smoking?” • “Are you interested in quitting? ” • Assist • “I can help you quit.” • Nicotine Replacement Therapy • Nicotine patch for physical addiction • Nicotine gum for cravings

33. Advise Interventions • Delegate others to reinforce your message • Staff (nursing, respiratory therapy, social workers) • DVD directed to parents and caregivers • Standardize documentation of counseling • EHR standard statement “I discussed the effects of TSE with the family and advised the mother that quitting smoking will improve her child’s health. I gave the mother written smoking cessation materials that included the 1-800-QUIT-LINE number”

34. Refer Case #3 You are caring for a 6 month old infant admitted with bronchiolitis. The mother attends school during the day and lives with the infant’s grandparents. The mother reports the grandparents smoke cigarettes inside the house and are not interested in quitting.

35. Refer Case #3 • Provide written smoking cessation information • Provide the 1-800-QUIT-NOW number • Quitlines are staffed by trained cessation experts who tailor a plan and advice for each caller. • Text QUIT to iquit (4-7848)

36. Refer Interventions • Confirm written smoking cessation information is available on the floor • Empower other healthcare providers to refer (nurses, RT, and social workers) • Add referral to quitline to order set • Automatic referral to the 1-800-QUIT-NOW unless the parent “opt-out”

37. Ask Advise Assess Assist Arrange The 5 As “2As and an R” Ask Advise Refer

38. 2 As and an R • Ask/Identify everyone about tobacco every time • Advise (Assess/Assist) everyone to quit and give them written materials • Refer smokers to local resources or the 1-800-QUIT-NOW line

39. Additional Resources • B-QIP change package • AAP Provisional Section for Tobacco Control • Julius Richmond Center for Excellence • CDC • Treating Tobacco Use and Dependence CPG

40. Counseling 201: Motivational Interviewing • Method designed to address addictive behaviors, frequently applied by smoking cessation counselors • Addresses the issue of resistance in a non-confrontational manner • Internal motivation is more effective • Motivation to change is elicited, not imposed

41. Motivational Interviewing • Ask permission • Develop Discrepancy • Determine Readiness • Refer

42. Motivational Interviewing • Ask permission “Do you mind if we talk a bit about your tobacco use?”

43. Motivational Interviewing • Ask permission • Develop Discrepancy • Create gap between where patients are and where they want to be • GOAL: Have patients resolve discrepancy by quitting smoking • “What are some of the good things about smoking?” • “What are some of the not so good things about smoking?”

44. Motivational Interviewing • Ask permission • Develop Discrepancy • Determine Readiness • “Are you interested in quitting? What would make you more interested?

45. Motivational Interviewing • Ask permission • Develop Discrepancy • Determine Readiness • Refer • “Would you like some information or resources about quitting?”