Healthy Air for Kids Campaign NAME TITLE Helping parents quit smoking for the health of their children.

2006 Surgeon General Report “The scientific evidence is now indisputable: Secondhand smoke is a serious health hazard that can lead to disease and premature death in children.” --Surgeon General Richard Carmona, Surgeon General’s Report June 27, 2006

Why Treat? According to the Surgeon General: There are 4,000 chemicals in cigarette smoke. There is no safe amount of secondhand smoke. Breathing it for even a short time can have immediate adverse effects. Notes: As you may know, secondhand smoke contains 4,000 chemicals, including formaldehyde, cyanide, carbon monoxide, ammonia. According to the surgeon general, exposure to secondhand smoke has immediate effects on the cardiovascular system and interferes with the normal functioning of the heart, blood and vascular systems in ways that increase the risk of heart attack, lung disease, cancer and ear infections, especially in children. You probably already know that it raises long-term risk of lung cancer by between 20 and 30 percent. It’s also a leading risk factor for developing cardiac-related illnesses.

Why Treat? About 60 percent of children in Wisconsin suffer from second-hand smoke exposure. --Surgeon General Report, 2006 In Wisconsin, 54 percent of middle school children are exposed to secondhand smoke. --Burden of Asthma in Wisconsin, 2004

Why Treat? As a result, these kids develop pneumonia, ear infections, bronchitis, asthma, colic, reduced pulmonary function and SIDS.

Why Treat? Parents want your help. Mayo Clinic Proc. 2001;76:138-143 85% of parents who smoke want pediatricians to counsel them about quitting and prescribe tobacco cessation medications. Parents say, “It shows you care.” Only 8% of parents who smoke are currently offered medication or counseling Source: Pediatrics, 2005 “Smoking cessation interventions during physician visits were associated with increased patient satisfaction with their care among those who smoke.” Mayo Clinic Proc. 2001;76:138-143 Notes: Some physicians fear broaching the subject with parents because they think the mom or dad will become upset, even change clinics. But a convincing body of research in Pediatrics and other peer-reviewed journals shows an overwhelming number want us to ask about smoking and help them to quit. Parent after parent says, “It shows you care.” Unfortunately, only 8% of smoking parents are offered help by pediatricians. But those pediatricians who do treat say they’re glad they do it.

Why Treat? “In fact, when we don’t ask parents about smoking, they say, ‘What’s up?’ It’s like we don’t care. If I don’t ask parents about smoking, I’m really missing the boat.” -- John Meurer, Chief of General Pediatrics, Medical College of Wisconsin, Wisconsin Pediatrician of the Year

Why Treat? You can have a huge impact with a brief intervention. In a few minutes, you can help your patients live in a smoke-free environment and decrease the chances the children will ever light up. “Minimal interventions lasting less than 3 minutes increase overall tobacco abstinence rates.” Source: U.S. Public Health Service Clinical Practice Guideline: Treating Tobacco Use and Dependence

Why Treat? We’ll show you how to do it in a way that is: Brief. Safe. Effective. Notes: We know how busy your offices are and how precious time is these days. We’ll show you how to treat and refer quickly. We know you might have concerns about the safety and efficacy of providing interventions for patients. You’ll see that the following recommendations are not only based on peer-reviewed research – they’re also effective.

Three Tools A quick reference guide to show you and your staff how to do a brief, effective intervention.

Three Tools A laminated tobacco treatment chart to post on your office wall for quick reference. 5 A’s for treatment Medications chart

Three Tools A note pad of tear sheets so you can walk your patients through their individualized plan to quit. It’s basically a checklist for you and your patient. It includes information on: Planning ahead Getting medications Calling the Quit Line

Posters & Brochures We have developed posters & brochures for your waiting rooms.

How to Treat Help your patient’s parent(s) quit smoking by following the “5 A’s”: Ask every parent at every patient visit. Advise all tobacco users to quit. Assess the parent’s willingness to quit. Assist with counseling and medication. Arrange follow-up care. These best practices are based on the Clinical Practice Guideline: Treating Tobacco Use and Dependence from the U.S. Public Health Service.

How to Treat: ASK. Ask the parents, “Do you smoke?” “Clinicians should routinely ask about secondhand smoke exposure, particularly when a child has had an illness caused by secondhand smoke.” Former Surgeon General Richard Carmona, Surgeon General’s Report, June 27, 2006

How to Treat: ASK. CHILD VITAL SIGNS Blood Pressure: _______________________________________________ Pulse: ________________ Weight: ________________________________ Temperature: _________________________________________________ Respiratory Rate: ______________________________________________ Parent Smokes: YES no (circle one) IF YES > continue with counseling Child Exposed to Secondhand Smoke: YES no IF YES > urge smoke-free environments at all times Notes: Here’s an example of what the vital signs might look like in your chart or electronic system. There’s a place to document parental smoking *here.* Some parents don’t smoke around their kids. But we know that chemicals from smoke linger in cars and homes after cigarettes are extinguished, still presenting a danger to others, especially small children. This should be institutionalized and systematic – recorded in every paper or electronic patient chart at every visit. * If the parent smokes, we continue with the 5 A’s. ** If the child is exposed to secondhand smoke from someone other than the parent, it’s critical for the child patient’s health to address it. This is a tremendous opportunity to advise parents to protect their children by finding alternative child care or asking a relative to please not smoke around the child.

How to Treat: ADVISE. Urge parents to quit smoking in a clear, strong, personalized manner. Connect it to the child’s symptoms. Secondhand Smoke Frequent Colds Pneumonia Ear Infections Bronchitis Asthma Research shows this is most effective.

How to Treat: ADVISE. “Second-hand smoke is making Tommy’s asthma worse… it could even be the cause.” “I strongly advise you to quit, which will help him get better.” “It’s not easy, but you can do it. We can help.”

How to Treat: ADVISE. Document it. Advice to quit should be noted in the child patient’s medical record.

How to Treat: ASSESS. Ask the parent if he/she is willing to try to quit. “Are you ready to quit within the next 30 days?” If yes, move on to ASSIST. If no, ask the parent to continue to seriously think about quitting.

How to Treat: ASSESS. Strongly urge the parent not to smoke around the child. “We know that if you smoke, it’s more likely Sally will light up later in her life.” “There is no safe amount of second-hand smoke for Jaden.” “It’s especially dangerous in your home and car.” “Chemicals from smoke linger even after you put out your cigarette and the smoke disappears.” Notes: Urge parents not to let others smoke around the child. It’s not easy, but parents need to protect their kids from harm – including second-hand smoke from grandma, grandpa, Uncle Rick, Julie the Daycare Provider or their friends and neighbors. Offer resources. Hand the parent a Quit Line card. “If you do decide to quit, here’s a free resource. Just call 1-800-QUIT-NOW.” “I encourage you to discuss quitting with your doctor.” Repeat the “5 A’s” at the next visit.

How to Treat: ASSIST. For parents willing to make a quit attempt: provide counseling and recommend medication. This combination gives the parent the best chance to successfully quit. Brief Intervention. Advise the parent to: Review smoking history. This includes past quit attempts, amount smoked, current medications, etc. Set a quit date, ideally within 2 weeks. Completely abstain. “Not a single puff,” starting on the quit date, to prevent relapse. Avoid alcohol. It’s strongly linked to smoking relapse. Get support from family or peers. Avoid other smokers. Discuss challenges, particularly in the first few weeks, including nicotine withdrawal.

How to Treat: ASSIST. Offer medication. You can prescribe medication or recommend OTC medication. Seven different FDA-approved cessation medications have been clinically proven to increase the chances of quitting – up to three times better than placebo.

How to Treat: ASSIST. Prescription medication. Medicaid and BadgerCare cover the following prescription medications: Nicotine patch (when written as “legend nicotine patch”) Nicotine inhaler Nicotine nasal spray Bupropion SR (generic or Zyban) Varenicline (marketed as Chantix) Notes: An important advantage to prescription smoking-cessation medications is they’re often covered by private and public health insurance. In fact, 75 percent of Wisconsin residents with private health insurance are covered for at least one tobacco cessation medication.

How to Treat: ASSIST. Recommend OTC medication. Nicotine patch Nicotine gum Nicotine lozenge One advantage of OTC meds is that they are so readily available. However, some smokers have cited the cost of medication as a barrier to quitting. OTC nicotine replacement medications are not typically covered by insurance.

How to Treat: ASSIST. Nicotine Replacement Therapy (NRT) Nicotine is the active ingredient No evidence of increased cardiovascular risk with NRT Supplied as a steady dose (patch) or self-administered (gum, inhaler, nasal spray) Self-administered products should be used on a scheduled basis initially, then tapered to ad-lib use and eventual discontinued

How to Treat: ASSIST. Nicotine Replacement Therapy (NRT) Contraindications: Immediate myocardial infarction (< 2 weeks) Serious arrhythmia Serious or worsening angina pectoris Accelerated hypertension Use and Cost: Varies by product and amount used (see UW-CTRI Medications Chart for details)

Nicotine gum 2 mg vs 4 mg Chew and park Absorbed in a basic environment Use enough pieces each day (6-16) OTC

Nicotine patch Available as both prescription and OTC A new patch is applied each morning Rotating placement site can reduce irritation Typical Dosing: 4 weeks of 21 mg/day, then 2 weeks of 14 mg/day, then 2 weeks of 7 mg/day

Nicotine lozenge 2 or 4mg Use enough Benefits OTC Use enough (6-16 lozenges/day)

Nicotine inhaler Prescription only May irritate mouth/throat at first (but improves with use) Don’t drink acidic beverages during use 6-16 cartridges/day Inhale 80 times/cartridge May save partially-used cartridge for next day Use up to 6 months; taper at end

Bupropion SR One of two non-nicotine medications approved by the FDA as an aid to quitting smoking Available by prescription only Shown to be particularly effective for women and patients diagnosed with depression Mechanism of action: blocks neural reuptake of dopamine and/or norepinephrine

Bupropion SR Contraindications Side effects Seizure disorder MAO inhibitor within previous 2 weeks History of anorexia nervosa or bulimia Current use of Wellbutrin or Zyban Side effects Insomnia Dry mouth

Bupropion SR Dosing: Maintenance: Start 1-2 weeks before quit date 150 mg orally once daily x 3 day 150 mg orally twice daily x 7-12 weeks No taper necessary at end of treatment Maintenance: Efficacious as maintenance medication for 6 months

Varenicline This new Pfizer medication was approved by the FDA in May 2006 Like Bupropion, Chantix is available by prescription only Unique: Varenicline is neither a nicotine replacement therapy nor does it actively reduce dopamine reuptake. Varenicline acts on nicotine receptors with two types of action: It blocks some of the rewarding effects of nicotine (acts as an antagonist) and at the same time stimulates the receptors in a way that reduces withdrawal (acts as an agonist). Varenicline offers another option for smokers and those who treat them. However, it is not a magic pill and should be used in conjunction with traditional methods of quitting—planning, setting a quit date, and coaching or counseling. In research studies, varenicline proved to be more effective than placebo or bupropion. Abstinence rates at the end of treatment were: 18% for placebo, 30% for bupropion and 44% for varenicline. These trials included counseling for all participants.

Varenicline Dosing & Maintenance Start varenicline one week before the quit date for maximum effectiveness Recommended treatment is 12 weeks: Days 1-3………..1 pill (0.5 mg) per day Days 4-7………..1 pill (0.5 mg) twice a day (am & pm) Day 8-end………1 pill (1 mg) twice a day (am & pm) An additional course of 12 weeks for maintenance can be considered Cost Varies: On average, it’s $3.70 per day $115 per month That’s about the cost of a pack a day of name-brand cigarettes. Pack of Marlboros…. = about $3.85 1 day of Chantix…… = about $3.70

Varenicline Contraindications Side effects Use with caution and consider dose reduction in patients: ⇒ With significant renal impairment. ⇒ Undergoing dialysis. Side effects ⇒ Primary side effect is nausea ⇒Suggested solution is to reduce dosage

How to Treat: Coverage. More than 70 percent of Wisconsin residents with private insurance are covered for at least one quit smoking medication. Medicaid, BadgerCare and SeniorCare also cover tobacco dependence treatments.

How to Treat: REFER. Refer parents to the: It’s free, confidential, and non-judgmental. Callers are 4 times more likely to quit than those who try to quit cold turkey. Services are available in virtually any language. Notes: The Quit Line has helped more than 46,000 callers throughout Wisconsin, saving about $42 million in healthcare expenses in just five years of operation.

“Time is always short. I tell my patients: ‘Call the Wisconsin Tobacco Quit Line. They’re sharp. They can help you.’” -- Dr. Pierce Sherrill, Aurora Healthcare “The Quit Line was very helpful for me. I needed someone who was on my side... and they were.” --Gloria Taylor

How to Treat: ARRANGE. Other referral options: A cessation program in your clinic or system. A local community program. For a list of programs in your county, visit: NOTE: Medicaid only covers face-to-face, one-on-one sessions. http://www.ctri.wisc.edu/resources.html

How to Treat: ARRANGE. Arrange for follow-up counseling. If the parent has quit, congratulate him or her on a tremendous accomplishment! If the parent has relapsed, reassess the situation and encourage another quit attempt. Effective phrases include: “This is a learning experience.” “You’re not alone. Most people who quit actually try a number of times before they’re successful.” “Hang in there. You can do it.” Like diabetes or hypertension, tobacco dependence is a chronic disease and should be treated as such over time. Continue to encourage the parent to quit, focusing on maintaining a positive outlook. You can follow up or refer to the Quit Line.

Resources. CME credit. FREE online CME for tobacco cessation treatment is available for: Physicians Nurses Pharmacists Visit www.medscape.com/viewprogram/3607

How to Treat: Fax to Quit Program How it works: The patient signs a consent form. Your office faxes the form to the Quit Line. The Quit Line calls the patient at a time requested by the patient. The Quit Line faxes back a report to your office. FREE to you and your patient! Notes: You can seamlessly incorporate Quit Line services into your practice through the Fax to Quit Program. It’s completely FREE. Your local UW-CTRI specialist can help you establish Fax to Quit. This includes free staff training, free technical assistance and a free site manual. The Quit Line provides ongoing customer service.

www. CTRI . WISC . EDU News Research results Treatment tools Latest best practices

Make a Difference. Abby Kreul, right, 9 years old: “It’s better now that Mom and Dad have quit because I don’t get sick as much.”

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