1. Why smoking cessation counseling should be part of your job and what to do about it. Your name, institution, etc. here YOUR LOGO HERE (can paste to each slide)

2. …dedicated to eliminating children’s exposure to tobacco and secondhand smoke

3. Objectives Review the evidence for harm to children from parental smoking Understand the rationale for the pediatrician as smoking cessation counselor Gain basic skills in smoking cessation counseling Practice a brief motivational message in three different clinical scenarios

4. So, what’s the big deal? In 2009, 46.6 million adults smoked, or 21% of the general population 31.1% of those living below federal poverty level smoke 33.6% of those who did not achieve a high school education

5. But, they all smoke outside, right? 18% of children ages 3-11 and 17% of children ages 12-19 live in a home where someone smokes inside There is some evidence that parents smoke at higher rates than non-parents and that they quit at lower rates (Hmm, parenting may be stressful……..)

6. What is the leading pediatric cause of death in the US? Accidents, under 4 yo – 1,714 deaths Accidents, under 9 yo – 2,997 deaths Accidents, under 14 yo – 4,550 deaths Smoking-related excess pediatric deaths - 5,900

7. Why the pediatrician? 24,500 excess cases of LBW 430 excess cases of SIDS 22,000 excess hospitalizations for RSV 3.4 million excess cases of AOM 110,000 excess typanostomies 1.8 million excess visits for asthma 590 excess hospitalizations for burns

8. Parental Smoking Children are proportionally most affected by tobacco – Smoking related excess deaths are 50% of all deaths under 15 Y/O Children cannot voluntarily remove themselves from the exposure

9. Why the Pediatrician? Parents of young children tend to be young and otherwise healthy and may visit the pediatrician more than any other doctor Income cutoffs for public insurance are less strict for children than for adults, i.e. publicly insured children frequently have uninsured parents

10. Why the Pediatrician Low SES and low parental educational levels correlate with increasing SHS exposure You have access to smokers that do not otherwise interact with healthcare.

11. And, another thing………. Anti-smoking actions by parents are a strong predictor of non-smoking in teens Anti-tobacco opinions and discussions with parents are factors that protect against youth tobacco use, even if the parent smokes

12. Practitioner Effectiveness 7-10% of smokers spontaneously quit with success 13% of smokers quit after an appropriately designed brief message from a healthcare provider Up to 30% of smokers quit using guideline recommended treatment

13. 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

14. Well, then, they don’t want to hear it from me, do they? Parents do not object to smoking cessation messages from pediatricians and may even welcome the access to medical advice Some interventions in pediatric settings have been as successful as interventions in other medical settings

16. OK, so now what? Multiple evidence-based strategies are available and can be combined 5 A’s Screening, Brief Intervention and Referral Stages of Change Model Motivational Interviewing

17. Ask Smoking status Advise To quit Assess Willingness to quit Assist in quitting Arrange Follow-up Tobacco use as a vital sign Brief, informative, clear, personalized Weigh pros and cons Assess importance, readiness, and confidence Assess stage of readiness to quit Offer help: e.g. - refer to counseling, quitline - analyze past attempts - develop quit plan, - provide pharmacotherapy The 5 “A”s

18. The 5 “A”s for the Pediatrician Asking =Do you smoke? Where do you smoke? Is the child exposed to tobacco smoke anywhere else? Advising = You must at least say “I want you to quit” in some way Assessing = Have you considered quitting? Assess importance, confidence and readiness? Assisting = Find help or give it yourself. Arrange = Follow-up at each well child check, take ownership of the problem.

19. Screening, Brief Intervention and Referral Institutionalizes screening (5 th vital sign) Knowledge of referral resources in your local community Or, reliance on national or state Quitlines 1-800-QUIT-NOW

20. An effective brief message is… Informative Clear Personalized “ Ms. Jones, as your child’s doctor I feel I need to let you know about some concerns I have. I’m really worried that John’s frequent respiratory infections could be aggravated by smoking. Although you’ve said your cigarettes are important to control your stress, I’m worried they could be causing some of John’s health problems. Please let me know if I can help you quit.”

21. Suggested Brief Interview ELICIT CONCERNS – “What concerns do you have about smoking?” – “What else concerns you about your smoking?” CONSIDER BENEFITS – “What do you like about smoking” (“What does smoking do for you?) SUMMARIZE – “So on the one hand, you perceive some benefit from smoking, but at the same time you are concerned about…” OFFER HELP – “If I offered you some help, would you be willing to quit smoking?”

22. Stages of Change Model Describes how people move towards change in behavior Provides a framework to match counseling efforts to patient’s “stage of readiness” Focuses counseling content to individual patient’s needs Very easy to remember – YES, NO, MAYBE

23. When they say No! - Helpful Questions What would have to happen for it to become much more important for you to quit? Scaling questions….. What would have to happen before you seriously considered quitting? What do you like about tobacco? (smoking?) What concerns do you have about tobacco? (smoking?) Explore past quit attempts? Where does this leave you now? Can we talk about this time?

24. When they say Maybe - Assessing Importance, Confidence and Readiness How important is it for you to quit tobacco? (stop smoking?, on a scale of 0 to 10?) How much do you want to quit tobacco? (stop smoking?, on a scale from 0 to 10?) How confident are you that you could quit? (stop?, on a scale from 0 to 10?)

25. When they say Maybe - Helpful Questions What would make you more confident about quitting? Why have you given yourself so high/low a score on confidence? How could I help you succeed? Is there anything you found helpful when you quit before? What have you learned from your last try to quit? If you decided to quit, how might you do it? – Do you know of things that have worked for other people? What would make you feel more confident?

26. When they say Yes! - Action Provide skills for coping Get support from friends/family Get nicotine replacement method Set quit date Follow-up by phone or in office

27. Motivational Interviewing Method designed to address addictive behaviors, frequently applied by smoking cessation counselors Very pediatrician friendly style Addresses the issue of resistance in a non- confrontational manner

28. Origin with Miller 1983 - more complete training of addiction counselors Brief interventions - Rollnick et. al. 1992 – general information exchange strategy – health promotion with hospitalized heavy drinkers Definition – “a directive client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence” Motivational Interviewing

29. Internal Motivation is More Effective “I want to feel better” “I have the strength to do this” Externally directed motivation can lead to guilt, anxiety, anger, frustration and failure “You gotta” counseling often elicits resistance (“I don’t wanna”) or denial (“Problem?, What problem?”)

30. Philosophy of Motivational Interviewing Motivation to change is elicited, not imposed It is the patient’s task – not the practitioner’s – to articulate and resolve ambivalence Direct persuasion is ineffective for resolving ambivalence The interviewing style is quiet and eliciting The practitioner is directive only is helping the patient examine and resolve ambivalence Readiness to change is not a patient trait, but a fluctuating product of interpersonal interaction The therapeutic relationship is more like a partnership or companionship

31. Motivational Interviewing “Style” Exchange rather than convey information Assess your patient’s readiness to talk/share/express feelings/change Use simple open questions Listen carefully and encourage, agree, reinforce with verbal and non-verbal prompts

32. Motivational Interviewing “Style” Clarify and summarize at the appropriate points Recognize resistance and adapt to it without confrontation Express empathy with reflective statements

33. Four General Principles Express Empathy – Acceptance facilitates change – Skillful listening is fundamental – Ambivalence is normal Develop Discrepancy – The patient should present the arguments for change – Discrepancy between present behavior and important personal goals or values motivates change

34. Four General Principles Roll with Resistance – Signal to respond differently – Avoid arguing for change: psychological reactance – Resistance is not directly opposed – New perspectives are invited but not imposed – The patient is the primary resource in finding answers and solutions Support Self-Efficacy – The patient is responsible for choosing and carrying out change – A person’s belief in the possibility of change is important – Good predictor of change

35. Signs You’ve Got It Right You are speaking slowly Your patient is doing most of the talking Your patient is talking about quitting tobacco You are listening carefully and gently directing the interview Your patient appears to be “working hard,” often realizing things for the 1st time Your patient asks for information and advice

36. “Whoa — way too much information.”

37. Scenario 1 You are seeing a 4 month old for a WCC. A note in the chart says mom quit smoking during pregnancy. You notice she seems tired and stressed out. She doesn’t talk about smoking but smells like smoke. What do you do?

38. Scenario 2 You are seeing an 18 month old in follow-up after his 4 th ear infection in 4 months. He is well now but you scheduled this visit to talk about PE tubes. Both parents are smokers and the child has persistent effusions bilaterally. What do you discuss?

39. Scenario 3 You are seeing a 16 month old in May for his third episode of wheezing. You originally diagnosed bronchiolitis the first two times last winter but are beginning to worry about asthma. Dad smokes but is not here at this visit. What do you talk to Mom about?

40. YOU CAN DO IT! Ask everyone about tobacco every time Advise everyone to quit Assist everyone who smokes in whatever way you can (counsel or refer)

41. www.aap.org/richmondcenter Need more information? The AAP Richmond Center Audience-Specific Resources State-Specific Resources Cessation Information Funding Opportunities Reimbursement Information Tobacco Control E-mail List Pediatric Tobacco Control Guide

42. CLEAR THE AIR!