1. Improving Children's Health by Addressing Family Tobacco Use Your name, institution, etc. here YOUR LOGO HERE (paste to each slide)

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

3. Today’s Goals To train clinicians in: – Effective ways to educate parents and caregivers on the effects tobacco use has on children. – Counseling strategies to promote smoke-free homes and cars. – The role of medications in cessation. – Creating and implementing practice systems to identify and treat tobacco use and exposure.

4. The Health Effects of Tobacco Use SIDsBronchiolitisMeningitis Infancy Low Birth Weight Stillbirth Neurologic Problems In utero Asthma Otitis Media Fire-related Injuries Influences to Start Smoking Nicotine Addiction Cancer Cardiovascular Disease COPD Adulthood Adolescence Childhood

5. 47 Years After the 1st Surgeon General’s Report – People Still Smoke! 21% of US adults are smokers More than 30% of U.S. children live with at least one smoker

6. Why Do People Use Tobacco? Nicotine is physically addictive – Tolerance develops – Withdrawal symptoms occur Nicotine is a potent drug, causing dopaminergic activation and CNS stimulation Use is reinforced by social cues and habits

7. Youth Are Especially Susceptible For many youth, symptoms of dependence develop before daily use begins, and can begin within a day after inhalation! There is no minimum requirement of number smoked, frequency, or duration of use!

8. That First Puff… The nicotine in 1-2 puffs occupies 50% of nicotinic receptors in the brain A single dose increases – Noradrenaline synthesis in the hippocampus – Neuronal potentiation lasting > month (meaning that neurons discharge action potentials at lower threshold)

9. What Can We Do?

10. Principles of Tobacco Dependence Treatment Nicotine is addictive Tobacco dependence is a chronic condition Effective treatments exist Every person who uses tobacco should be offered treatment

11. Smokers Want to Quit 70% of tobacco users report wanting to quit Most have made at least one quit attempt Cite health expert advice as important Regardless of type! THIS MEANS YOU!

12. Counseling 101 Patients and families expect you to discuss tobacco use If counseling is delivered in a non-judgmental manner, it is usually well-received Even small “doses” are effective - and cumulative! Strength of Evidence = A

13. The Theory… Behavior change occurs in stages – not all at once Assessing Stage of Readiness Precontemplation Contemplation Ready for Action Action Maintenance Relapse

14. Your Goal: Help the Tobacco User Take the Next Step Help a precontemplator become a contemplator… …a contemplator start to make plans… …someone who relapsed become “ready for action”… And so on….

15. Counseling IS Effective As little as 3 minutes doubles quit attempts and successes Intensive counseling is more effective – Dose-response relationship Most effective: – Problem-solving skills – Support from clinician – Social support outside of treatment

16. Minimal interventions lasting less than 3 minutes increase overall tobacco use abstinence rates. –Strength of Evidence = A Every tobacco user should be offered at least a minimal intervention, whether or not he or she is referred to an intensive intervention. Brief Intervention

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

18. 2 As and an R: ASK Ask about tobacco use and SHS exposure at every visit Make asking routine, consistent, and systematic – Use standardized documentation – Document as a “vital sign” Just asking can double quit attempts

19. How Do You Ask? Don’t lead: “You don’t smoke, do you?” Depersonalize the question: “Does anyone living in your home use tobacco in any way?” “Who is it?” “Where do they smoke?” “Is that inside the house?” Explore: “You say no one smokes around your son. What does that mean?” Don’t judge – check your body language, tone of voice, the phrasing of the question

20. 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 Document your advice

21. What Do You Say? Clear: “I advise you to quit smoking.” Strong: “Eliminating smoke exposure of your son is the most important thing you can do to protect the health of your child.” Personalized: Emphasize the impact on health, finances, the child, family, or patient. “Smoking is bad for you (and your child/family). I can help you quit.” “Tobacco smoke is bad for you and your family. You should make your home and car smoke free.”

22. Be Specific… Having a smoke free home means no smoking ANYWHERE inside the home or car! It DOES NOT mean smoking: – Near a window or exhaust fan – In the car with the windows open – In the basement – Inside only when the weather’s bad – Cigars, pipes, or hookahs – On the other side of the room

23. 2 As and an R: REFER To quit line, 1-800-QUIT-NOW To community and Internet resources Give every tobacco user something that contains information about quitting, the harms of tobacco use, etc.

24. What Do You Say? “You should call this number. It’s a free service – and the person on the other end of the telephone line can help you get ready to quit.” “You should learn as much as you can about quitting – the more you know, the more successful you’ll be.”

25. It only takes 30 seconds to refer a patient to a toll-free tobacco use cessation quitline. Quitlines are staffed by trained cessation experts who tailor a plan and advice for each caller. 1-800-QUIT-NOW callers are routed to state-run quitlines Quitlines

26. Accessibility Appeal to those who are uncomfortable in a group setting Smokers more likely to use a quitline than face-to- face program No cost to patient Easy intervention for healthcare professionals –Fax-back referral services Advantage of Quitlines

27. Medications Work!

28. Clinicians should encourage all patients attempting to quit to use effective medications for tobacco dependence treatment. –Except where contraindicated or for specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents). Pharmacotherapy

29. Clinician familiarity with medications Contraindications Patient preference Previous patient experience Patient characteristics (history of depression, weight gain concerns, etc.) Factors to Consider…

30. Buproprion SR Nicotine Replacement Therapies (NRT) –Nicotine gum –Nicotine inhaler –Nicotine nasal spray –Nicotine patch –Nicotine lozenge Varenicline First-line Pharmacotherapies

31. Varenicline (Chantix®) agonizes and blocks α4β2 nicotinic acetylcholine receptors. Buproprion SR (Zyban®) mechanism for smoking cessation unknown; inhibits neuronal uptake of norepinephrine, serotonin and dopamine. NRT: binds to CNS and peripheral nicotinic- cholinergic receptors.

32. Varenicline (Chantix®) $4.00 - $4.22 per day Start 0.5 mg daily for 1-3 days, then increase to twice daily for 1-4 days Increase to 1 mg twice daily on quit date. Most common side effects are nausea and vivid dreams Monitor for psychiatric symptoms Do not combine with NRT!

33. Bupropion SR (Zyban®) $3.62 - $6.04 per day Start 150 mg once daily for 3 days, then twice per day for 7-12 weeks Plan quit date around day 7 of treatment Common side effects include insomnia and dry mouth May be combined with NRT

34. Nicotine Gum $3.28 - $6.57 per day for 2 mg $4.31 - $6.51 per day for 4mg Weeks 1-6: one every 1-2 hours Weeks 7-9: one every 2-4 hours Weeks 10-12: one every 4-8 hours Common side effects are jaw pain and mouth soreness

35. Nicotine Inhaler $5.29 per day 6-16 cartridges per day, initially one every 1-2 hours Common side effects are mouth and throat irritation

36. Nicotine Nasal Spray $3.57 per day 1-2 doses (sprays) per hour Common side effects are nose and eye irritation Most addictive form of NRT

37. Nicotine Patch $1.90 - $3.89 per day >25 cigarettes per day: 21 mg every 24 hours for 4 weeks, then 14 mg for 2 weeks, then 7 mg for 2 weeks Common side effects Skin irritation Sleep problems if worn at night

38. Nicotine Lozenge $3.66 - $5.25 per day Weeks 1-6: one every 1-2 hours Weeks 7-9: one every 2-4 hours Weeks 10-12: one every 4-8 hours If first cigarette smoked within thirty minutes of awakening, use 4 mg; others use 2 mg. Common side effects include mouth soreness and dyspepsia

39. Clonidine: mechanism for smoking cessation unknown; stimulates α2-adrenergic receptors (centrally-acting antihypertensive) Nortripyline: mechanism for smoking cessation unknown; inhibits norepinephrine and serotonin uptake Second-line Pharmacotherapies* *”off label”

40. Pharmacotherapy for Lighter Smokers Medications have not been shown to be beneficial to light smokers If NRT is used, consider reducing the dose No adjustments are necessary when using Bupropion SR or Varenicline

41. Bupropion SR and NRT (especially gum and 4 mg lozenge) may delay, but not prevent weight gain The average weight gain after quitting is less than 10 pounds, more common in women Patients Concerned with Weight Gain

42. Bupropion SR Nortriptyline NRT Patients with History of Depression

43. Most will need medication Patients with bipolar disorder or eating disorders should not use Bupropion SR Patch effective for those with schizophrenia Varenicline safety not established Quitting can increase the effect of some psychiatric medications Check for relapse to mental illness with changes in smoking status Patients with Mental Illness

44. No association between the nicotine patch and acute cardiovascular events even in patients who continue to smoke while on the patch NRT packaging recommends caution in patients with acute cardiovascular disease Patients with Cardiovascular Disease

45. Counseling is best choice Risks of premature birth or stillbirth caused by smoking may be higher than the potential risk of birth defects caused by NRT use Bupropion SR and Varenicline are pregnancy category C Prescription NRT is pregnancy category D Pregnant Smokers

46. Helpful with smokers with persistent withdrawal systems Long-term use of NRT does not present a known health risk Bupropion SR approved for for up to 6 months Varenicline recommended for 12 weeks. May repeat for 12 more. Long-term Pharmacotherapy

47. Patch + gum or nasal spray = increases long-term abstinence Patch + inhaler are effective Patch + Bupropion SR is more effective than patch alone Patch + nortriptyline increases long-term abstinence Combining Varenicline with NRT is not recommended Combining Medications

48. The combination of counseling and medication is more effective for smoking cessation than either medication or counseling alone. Therefore…both counseling and medication should be provided to patients trying to quit smoking. –Strength of Evidence = A Combining Counseling and Medications

49. Role Playing Exercises

50. The Rules Role playing exercises can help you become “comfortable” with new language Role playing exercises DON’T work if you DON’T say the words out loud Be silly. Have fun!

51. Break into Pairs Take turns as the “clinician” and “patient” or “parent”

52. Clinical Practice Change

53. What Exactly is Clinical Practice Change? A change (hopefully an improvement) in the SYSTEM of care practiced in the clinical setting The system is designed to produce the results it produces –If you’re not happy with the results, you need to change the system

54. Key Components A clinical leader An administrative leader Support of Management A little bit of knowledge The desire to help children and families

55. All patients –Should be asked if they use tobacco, and –Should have their tobacco use status documented on a regular basis. Strength of Evidence = A Systems Changes Support the “Ask” Step

56. You and Your Practice: Effective Smoking Cessation Counselors Every member of your practice – clinicians, office staff, and receptionists – can play an important role in tobacco control

57. The Barriers There’s never enough time to do the things you already need to do You may not be reimbursed… Can derail efforts May not want to talk about it

58. The Assets You and your staff and colleagues Can be effective counselors Your patients and their families Expect to hear about tobacco The changing culture Is making it harder to use tobacco

59. But How? Clinical Staff Can ASK and ACT Administrative Staff Can keep materials stocked and administer screening questionnaires Management Need to support the “cause”

60. Clinical Practice Change: Best Practices Set goals Involve everyone Understand the current system Decide what needs changing Research those areas in detail Document changes Make it a continuous process

61. Plans Have Components How will success be measured? What are we doing? Who are the subject(s)? How will we start? Finish? Deliver advice? Where will it be done? When will it be done?

62. Monitor and Feedback Are procedures working as intended? Are staff completing assigned tasks? Is documentation evident? Are patient materials kept up to date? Does the team receive timely feedback and support for a job well done?

63. Reimbursement for Tobacco Use Cessation Counseling

64. Medicare Benefits CMS pays for outpatient and hospitalized Medicare beneficiaries who: 1- who use tobacco, regardless of whether they have signs or symptoms of tobacco-related disease; 2- who are competent and alert at the time that counseling is provided; 3- whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner. Signs and Symptoms of tobacco-related disease: already covered under Medicare Part B

65. Medicare Visits 2 individual tobacco cessation counseling attempts per year; maximum of 4 intermediate OR intensive sessions per attempt. –Total: covering up to 8 sessions per year per beneficiary who uses tobacco Intermediate cessation counseling = 3-10 minutes per session Intensive cessation counseling = more than 10 minutes per session.

66. CPT codes Counseling of a Symptomatic Patient –99406: 3-10 minutes –99407: More than 10 minutes Diagnosis Code 305.1: Non-dependent tobacco use disorder Diagnosis Code V15.82: History of tobacco use

67. Who Can Bill Medicare? Any qualified provider, such as physicians, clinical social workers, psychologists, hospitals, may bill for tobacco cessation counseling

68. Most Private Insurers Cover Most insurers provide coverage for at least one type of pharmacotherapy for tobacco cessation and at least one type of behavioral intervention

69. Billing Private Insurers Use billing codes in these categories: Preventive Medicine Treatments Tobacco Dependence Treatment as Part of the Initial or Periodic Comprehensive Preventive Medicine Examination Tobacco Dependence Treatment as Specific Counseling and/or Risk Factor Reduction.

70. Medicaid Provides Benefits 47 of the 51 state/DC Medicaid programs cover tobacco-dependence treatment for some enrollees 38 cover at least one form of tobacco-dependence treatment for all enrollees ( nicotine patch plus bupropion slow release) 18 cover individual counseling for all enrollees 8 cover group counseling for all enrollees Only 8 programs offer coverage of all 2008 PHS Guideline-recommended pharmacotherapy and counseling for all enrollees.

71. 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

72. Summary Tobacco use and SHS exposure is a serious disease YOU can intervene Through counseling Pharmacotherapies Reimbursement Change your clinical practice to make it happen!

73. Skull of a Skeleton with Burning Cigarette Antwerp 1885-1886 Van Gogh Museum Amsterdam Questions?