Dana Best

 Help parents quit smokingfor the good of your patients! 

By Dana Best, MD, MPH, and Sophie J. Balk, MD 

 Persistence coupled with effective counseling techniques and   pharmacotherapy are the keys to good results without a huge investment of time.   You owe it to your patients to try. 

he Sullivan children are scheduled for health-care maintenance   visits this afternoon. You've been seeing Paul, a 7-year-old with moderate persistent   asthma, and Alicia, a 2-year-old with recurrent ear infections, since they were   born. Alicia is home with her mother all day. You know that Mrs. Sullivan smokes   at home. You've identified no asthma triggers or allergens other than upper   respiratory infections and tobacco smoke. Last month, when Alicia came in for   treatment of her third ear infection this year, you told Mrs. Sullivan that   smoking is bad for her kids' healthbut she keeps right on smoking. She   says she knows that smoking is bad for her and her family but that her life   is much too stressful for her to quit. Her husband works long hours, and she   has the main responsibility for the children and the housework. She says that   smoking "takes the edge off" and helps her to cope with her busy life. Although   you don't say so, you're angry that Mrs. Sullivan is exposing her children to   tobacco smoke and discouraged about her inability to quit. You feel that you're   fighting a losing battle.

 More than 40% of US children are exposed to environmental tobacco smoke (ETS)   from cigarettes, cigars, and pipes in their own home.

In 1999, 23.5%   of the US population were smokers,

 and most smokers smoke inside   their home. Evidence shows that brief counseling by primary care clinicianscounseling   that can be delivered in as little as three minutescan make a difference   in helping smokers to quit. In this article, we'll show you how to integrate   smoking cessation counseling of parents into your practice by focusing on the   effects of ETS on children. [Editor's note: For information on counseling teens   and preteens about smoking cessation, see "

Keep   up the effort with teens and preteens

 Most smokers want to quit but have great difficulty doing so because of the   highly addictive nature of nicotine.

 Understanding nicotine addiction   as a chronic disease, instead of a "weak will" or a "bad habit," can help you   develop a long-term approach to smoking cessation. Quitting is a process likely   to have cycles of relapse and remission. 

 The brain contains specific receptors for nicotine, many of which are in the   "reward" centers and areas that affect alertness, arousal, and memory. As a   result, nicotine increases concentration, promotes memory recall, improves psychomotor   performance, enhances alertness and arousal, increases pain endurance and pleasure,   decreases anxiety and tension, reduces hunger pains, and promotes weight loss.   These effects are so powerful that some smokers use nicotine to self-medicate   anxiety disorders or other psychiatric problems.

 The act of smoking itself involves a complex interaction among individual,   environmental, and pharmacologic factors. This interaction is responsible for   cues to smoke, withdrawal symptoms, and perceived barriers to quitting. Cues   to smoke include environmental factors, such as the sight of people smoking,   ashtrays, lighters, and packs of cigarettes; associations with alcohol, coffee,   sex, telephone calls, work breaks, and parties; and associations with major   life events such as holidays and deaths. The cues can persist for many months   or years following withdrawal from nicotine. 

 The withdrawal process is complex and involves social, psychological, and   physiologic changes. They include changes in social relationshipssuch   as the loss of the cigarette breakdepressed mood, insomnia, irritability,   anxiety, difficulty concentrating, restlessness, decreased heart rate, and increased   appetite. Perceived barriers to quitting include fear of weight gain, which   can be especially important to women, lack of confidence in the ability to quit,   lack of support from family members and friends, and lack of understanding of   the quitting process. 

Strong evidence exists that adult smokers can quit successfully despite the highly addictive effects of nicotine and that counseling and pharmacotherapy help them succeed. Without counseling, 4% to 9% of smokers quit each year.

 Success increases with each attempt; many quitters report that they tried to quit several times before succeeding. Interventions such as counseling, nicotine replacement products, and the antidepressant bupropion significantly raise the odds of success, especially when two or more interventions are used together.

 Strong evidence also supports the cost- effectiveness of smoking cessation treatment. When smoking cessation services are provided as a fully covered health plan benefit, their use increases and smoking prevalence decreases.

Smoking cessation counseling by pediatricians has not been as well-studied as smoking cessation counseling by internists, family practitioners, or obstetricians-gynecologists. The few studies that have been done did not employ the full evidence-based intervention (including pharmacotherapy and relapse prevention) and may have had a sample size too small to detect effects.

 Until more research is done, pediatricians can use the recommendations set forth in the clinical practice guideline 

outlined in this articleto counsel parents. 

 The clinical practice guideline is an evidence-based meta-analysis and review   of the literature on smoking cessation, covering some 6,000 articles. It discusses   the effectiveness of incorporating smoking cessation counseling into practice   and recommends that primary care clinicians offer all smokers at least a brief   smoking cessation intervention at every visit. The guideline covers how to assess   tobacco use; brief and intensive clinical interventions; systems interventions;   pharmacotherapies; counseling specific populations such as pregnant women, children,   and teens; and special topics such as weight gain and cost-effectiveness. Each   recommendation is based on the strength of evidence for that intervention. You   can order the guideline by calling the Agency for Healthcare Research and Quality's   publication service at 800-358-9295 or downloading it from the Surgeon General's   Web site: 

www.surgeongeneral.gov/tobacco/default.htm

The pediatric office visit can be a tremendous opportunity to counsel parents about smoking because the pediatrician may be the only physician the parents of young children see on a regular basis. New mothers present an especially important counseling opportunity because as many as two thirds of women who quit smoking during pregnancy relapse after delivery.

 Advising parents about behavior changes that improve the life and health of   the child is an acknowledged role for the pediatrician, so one might expect   that pediatricians would easily accept the task of smoking cessation counseling.   Surveys of pediatricians do not bear out this expectation, however.

   Opportunities to counsel parents about smoking cessation are often missed because   of physicians' reservations about such counseling (see "

 Many pediatricians worry, for example, that they   will alienate parents by asking them to stop smoking.

 The evidence   does not support this fear. A survey of parents found that more than half agreed   that it is the pediatrician's job to advise parents to quit smoking, and 52%   of current smokers said they would welcome advice on quitting.

Simply asking whether parents and patients smoke, and recommending that smokers quit, can have a positive effect. This simplest of messages has been shown to increase the number of quit attempts and the success of those attempts among patients of primary care physicians. Developing a more detailed message, especially one tailored to each smoker, increases the positive effect even more. Counseling does not need to be extensiveas few as three minutes can be effective. 

Moreover, counseling is additive: The number and success of quit attempts increases as the amount of counseling increases, even if the counseling is delivered over the course of several visits. Up to three minutes of counseling raises the odds ratio of success in smoking cessation from 1.0 (no counseling) to 1.3; three to 10 minutes of counseling increases the odds ratio to 1.6; and more than 10 minutes of counseling raises it to 2.3a 130% gain.

These increases translate to a significant effect when viewed on a population basis. If 100 parents in your practice smoke, for example, you can expect that four to nine of them will quit permanently each year without counseling. If you counsel the 100 smokers for under three minutes each, you may increase the number who quit each year by 30%, for a total of five to 11 parents. The increase of one or two parents may mean that at least one or two more children will not be exposed to ETS for the rest of their childhood. If you spend at least 10 minutes over several visits delivering the "quit smoking" message and counseling the parent in ways to quit, you may increase the number of successful quitters by 130%, to a total of nine to 21 parents. If you add up these numbers over your entire practice, you may have helped hundreds of parents to quit smoking and reduced the exposure of hundreds of children to ETS.

 Guiding smokers through the stages of change 

 Structured smoking cessation counseling is based on the theory of stages of   change, which explains how people change personal behaviors. The model can be   used to understand how smokers acquire the habit as well as the process of quitting.   The idea is that people progress through several stages on their way to establishing   a behavior and must pass through several more stages to change their behavior. 

 In the context of smoking cessation, the goal of structured counseling is   to guide a smoker through six stages of changeprecontemplation, contemplation,   preparation, action, maintenance, and terminationin a stepwise manner.   Counseling focuses on helping a precontemplator become a contemplator, a contemplator   become a preparer, and so on until the smoker enters the termination stage and   no longer perceives any cues to smoke. The flow chart "Smoking cessation: A   model of the stages of change," illustrates this process.

Effective smoking cessation counseling can be broken down into five steps, called the five A's:

 Obtain a smoking history from all patients and their parents, including current and past smoking and parental smoking before and during pregnancy.

 Provide all parents who smoke with information about   the adverse health effects of ETS (see "

Making the point with parents   about ETS

"), reducing their children's exposure to ETS, and smoking cessation.   Look for educational opportunities. Engage parents in discussions about their   smoking, and provide a strong, clear quit-smoking message. You can say, for   example, "As your child's doctor, I think the very best thing you can do for   your health and your child's health is to quit smoking." Personalize the child's   health risk by saying, "It is very likely that Alicia has more ear infections   because of her exposure to tobacco smoke" or "Paul's asthma attacks may improve   if he is not exposed to tobacco smoke. It is important that you quit smoking."   Be sure to deliver this message in a positive, nonjudgmental manner. 

 Determine the parent's readiness to quit smoking. Is the parent a precontemplator or a contemplator? Is he or she ready to quit within the next month?

 Tailor the intervention to the parent's stage. If the parent is a precontemplator, provide a motivational message (see the five R's below). If the parent is a contemplator, ask if he or she is willing to set a quit date. Ask parents who are not ready to quit to make a list of everything they like and don't like about smoking. This will help get them thinking about smoking in a more specific way. 

 If the parent is in the preparation stage and ready to set a quit date, address   his or her concerns about quitting, including withdrawal symptoms and perceived   barriers to quitting. To do this, educate the smoker about the quitting process,   including what to expect and how long symptoms will last, weight gain, cues   or triggers that prompt a desire to smoke, feelings of deprivation, and flagging   motivation. Acute nicotine withdrawal can last from several days to weeks after   quitting, typically peaking between one and three weeks after the last cigarette   is smoked.

 The table on provides tips you can pass along to parents   to help them deal with some common withdrawal symptoms. Many smokers benefit   from supports such as quit-smoking groups and community "quit lines." The availability   of these supports varies from community to community. 

Tips to offer parents who are trying to quit smoking

Counseling is equally effective with men and women, but women may be more likely to have concerns about weight gain and to be using nicotine to self-medicate depression. Early studies of counseling tailored to women suggest that addressing these gender-specific issues may increase success.

Plan to follow up on any behavioral commitments parents make when they return with their child for health maintenance or ongoing medical problems.

Not every parent is ready to consider quitting. Such parents may not have good information about quitting, may be discouraged about previous quit attempts, or may be concerned about withdrawal symptoms. Remember that your goal is to help these precontemplators become contemplators. The five R's can help:

 Ask the parent to consider important personal reasons to quit smoking, such as ameliorating the effects of ETS on the child and improving the parent's own health. Point out to parents that, when they stop smoking, they will feel better physically and perform better in physical activities such as walking up stairs; their children will be healthier, and they will be setting a good example for their children; they will save money; food will taste better; their sense of smell will improve; their home, car, clothing, and breath will smell better; they will have fewer wrinkles and their skin won't age as fast; they will be able to stop worrying about quitting and say they are former smokers; and they will be able to stop worrying about exposing others to smoke. Try to personalize the benefits of quitting to each parent.

 Ask the parent to identify negative consequences of tobacco use. Highlight consequences that seem most relevant.

Ask the parent to identify benefits of quitting. Again, highlight benefits that seem most relevant.

Help the parent identify barriers to quitting. Suggest possible measures to reduce the barriers, such as pharmacotherapy or changes in daily behaviors that trigger the urge to smoke.

 Repeat the message every time the smoker visits the office. Tobacco users who have failed in previous quit attempts need to understand that most people try several times before they succeed.

 Because of the chronic relapsing nature of tobacco dependence, pediatricians   need to provide recent quitters with counseling aimed at preventing relapse.   They should reinforce the decision to quit, review the benefits of quitting,   and help resolve any residual problems associated with quitting. Although most   relapse occurs early in the quitting process, some former smokers relapse months   or even years later. Pediatricians should continue to deliver the "stay quit"   message whenever possible. 

 Relapse prevention counseling is especially important right after the quit   date. It can be delivered during scheduled office visits, by telephone calls,   or by postcards. A reminder system is helpful for scheduling telephone calls   or postcards. Important topics to address include the smoker's success to date;   anticipatory guidance regarding weight gain, cravings, environmental cues to   smoke, and other smokers in the household or family; and counseling about lapses.   Be sure to remind the smoker that the urge to smoke lasts only a few minutes,   so distraction techniques can be helpful during "craving attacks."

 If a lapse occurs, discuss the cues to smoke that prompted the lapse and what   the smoker learned about cues and quitting. Lapses do not mean that the smoker   has failed to quitunless, of course, he or she reverts to regular smoking.   Most smokers make three to eight attempts to quit before succeeding. 

Treatments such as nicotine replacement products substantially increase the success of quit attempts and are a major advance in treating nicotine addiction. Nicotine replacement therapy helps the new quitter to manage the physiologic effects of nicotine withdrawal. Using two nicotine replacement products together, such as gum and the patch, can enhance their effect. Although it is not the role of the pediatrician to prescribe medications to parents and other adults, pediatricians need to understand the uses of the various pharmacotherapies for smoking cessation so that they can inform parents of their availabilityincluding the fact that some nicotine replacement products are sold over the counter (OTC)and effectiveness. We recommend that pediatricians advise parents to seek further guidance from their own clinician for both prescription and OTC medications. 

First-line pharmacotherapies used for smoking cessation include:

 given as sustained-release tablets, is an antidepressant approved by the Food and Drug Administration as a non-nicotine aid to smoking cessation. It is started one or two weeks before the quit date and can be used for maintenance for up to six months. It should not be taken by persons with a seizure disorder or eating disorder or those taking another form of bupropion (Wellbutrin) or a monamine oxidase (MAO) inhibitor.

 are available by prescription (Nicoderm CQ) and over the counter (Nicotrol) in 16- and 24-hour patches, which have comparable efficacy. Eight or fewer weeks of treatment are as effective as a longer period. 

is available over the counter in doses of 2 mg per piece (for patients who smoke fewer than 25 cigarettes a day) and 4 mg per piece (for those who smoke more than 25 cigarettes a day). The gum can be used for as long as 12 weeks (maximum 24 pieces a day). Remind the smoker to read and follow carefully the instructions for using the gum.

 is available by prescription only. Recommended treatment varies from a minimum of eight doses per day (a dose is one 0.5 mg delivery to each nostril) to a maximum of 40 doses per day (five doses per hour) for three to six months.

consisting of a mouthpiece and a cartridge that delivers 4 mg of nicotine over 80 inhalations, are available by prescription only. The recommended dosage is six to 16 cartridges per day for up to six months (the dosage should be tapered during the final three months).  

None of these therapies have been determined to be effective for adolescent smokers, although several studies of their use in teens are under way. Adolescents under 18 years of age cannot purchase OTC nicotine replacement products without a prescription.

 Using "the system" to help smokers quit 

An important tool available to the pediatrician who is counseling a parent or patient in smoking cessation is "the system"the physician's office and office staff, the smoker's community, the health-care system, and health policy. When all parts of  the system consistently deliver the message to quit smoking, the success rate of quitting and preventive efforts increases significantly.

Step back and look at the clinical encounter from the patient's point of view. Look for opportunities to implement the five A's, such as asking whether a parent or patient smokes while checking the patient's vital signs. "Smoking" and "nonsmoking" stickers on charts can help staff (including pediatricians) remember their role.

 Every person who interacts with patients has a role in helping smokers quit. The cessation rate increases with the number of "quit smoking" messages delivered; the goal is to have every staff member ask about smoking and deliver a "quit smoking" message.

 A variety of materials are available at low or no cost from organizations such as the American Cancer Society and the American Lung Association. These materials should be easily accessible to all staff members and patients.

 Many communities have "quit smoking" phone lines, classes in smoking cessation, and other resources. Keep an up-to-date list of these resources at hand.

 Remove cigarette advertisements, such as those in magazines, from the office and encourage all employees to quit smoking and maintain a smoke-free home. Consider offering smoking cessation counseling to employees and their families as a benefit. 

Pregnancy provides important teachable moments, and many obstetric practices have incorporated smoking cessation counseling into their prenatal care in an effective manner. Pediatricians can play an important role in reinforcing messages about the harms of tobacco use during pregnancy.

Many new mothers who have stopped smoking while pregnant relapse after delivery, and some researchers theorize that the lack of "stay quit" messages delivered by pediatricians may be a contributing factor. The pediatrician can use the health of the new baby as a teachable moment, emphasizing the mother's success at quitting during pregnancy and the continued harm to the infant of ETS. Smoking cessation information should also be included in preconception counseling.

 The evidence for the efficacy of smoking cessation counseling delivered to   adults by their own physicians is strong and compelling. Although research on   the effects of counseling given to parents who smoke by their children's pediatricians   is not yet complete, the counseling techniques we've described in this article   can improve your approach to the parent who smokes and may help parents quit.   Until the results of research focused on the pediatric setting are reported,   we suggest that you incorporate these methodsbased on the current best   evidenceinto your practice. The short- and long-term effects on the health   of the children you see could be significant. 

1.	Environmental Protection Agency: Respiratory   Health Effects of Passive Smoking: 

 Washington,   D.C.: Environmental Protection Agency, Office of Research and Development, Office   of Air and Radiation, 1992. Publication No. EPA/600/6-90/006F 

 	2.	Centers for Disease Control and Prevention:   Cigarette smoking among adultsUnited States, 1999. 

 	3.	US Department of Health and Human Services:   

Reducing Tobacco Use: A Report of the Surgeon General.

 Atlanta, Ga.,   US Department of Health and Human Services, Centers for Disease Control and   Prevention, National Center for Chronic Disease Prevention and Health Promotion,   Office on Smoking and Health, 2000 

 	4.	Fiore MC, Bailey WC, Cohen SJ, et al: 

 Clinical Practice Guideline. Rockville, Md.,   US Department of Health and Human Services, Public Health Service, June 2000   

Helping the Hard-Core   Smoker: A Clinician's Guide. 

Mahwah, N.J., Lawrence Erlbaum Associates,   1999 

 	6.	France EK: Counseling parents to quit smoking:   Little evidence of long-term success. 

 	7.	Fingerhut LA, Kleinman JC, Kendrick JS: Smoking   before, during and after pregnancy. 

 	8.	Zapka JG, Fletcher K, Pbert L, et al: The perceptions   and practices of pediatricians: Tobacco intervention. 

 	9.	Stein RJ, Haddock CK, O'Byrne KK, et al: The   pediatrician's role in reducing tobacco exposure in children. 

 	10.	Perez-Stable EJ, Juarez-Reyes M, Kaplan C,   et al: Counseling smoking parents of young children: Comparison of pediatricians   and family physicians. 

 	11.	Frankowski BL, Weaver SO, Secker-Walker RH:   Advising parents to stop smoking: Pediatricians' and parents' attitudes. 

 	12.	Prochaska JO, DiClemente CC, Norcross JC: In   search of how people change: Applications to addictive behaviors. 

Make Yours a Fresh Start Family. A Magazine   for Mothers Who Smoke.

 Pennsylvania Department of Health, 1996. Distributed   by the American Cancer Society 

How to help your patients   stop smoking: A National Cancer Institute Manual for Physicians.

 Bethesda,   Md., National Cancer Institute, US Dept of Health and Human Services, Public   Health Service, National Institutes of Health, 1990, Publication NIH 90-3064   

DR. BEST is assistant professor of pediatrics, George Washington University   School of Medicine and Health Sciences, and attending pediatrician, Children's   National Medical Center, Washington, D.C. 

 DR. BALK is associate professor of pediatrics, Albert Einstein College of   Medicine, Bronx, N.Y., and attending pediatrician, Children's Hospital at Montefiore,   Bronx. 

Keep up the effort with teens and preteens 

 Most smokers started when they were teenagers. Preventing preteenagers and   teenagers from beginning to smoke and encouraging those who smoke to quit are   important pediatric messages. The evidence supporting counseling techniques   for teens who smoke is much less well-established than it is for adult smokers,   although many studies are under way. Until the results of these studies are   reported, the clinical practice guideline 

recommends using the same kinds of counseling with teens that have been   effective with adults, with the message tailored to the teen.

 Delivering   messages about the effects of exposure to environmental tobacco smoke to children   and teens may also help reduce their exposure and increase the rate at which   parents quit.

 Similar recommendations have been made by the American   Academy of Pediatrics.

 [Editor's note: For additional resources   for youth, see "

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Articles

Persistence coupled with effective counseling and pharmacotherapy are the keys to good results without a huge investment of time.

Dana Best

Articles

Help parents quit smoking--for the good of your patients!