DR. BALK is professsor of clinical pediatrics at the Albert Einstein college of Medicine in the Bronx, New York. The author has nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in an

Sophie J. Balk, MD

Rising rates of asthma and obesity, more reports of developmental disabilities and early puberty, concerns about increasing incidence of childhood cancer... parents, scientists, and pediatricians alike worry about how these health conditions relate to the environment our children live in. Indeed, children are often more vulnerable than adults to the effects of environmental hazards 

, causing their parents to be concerned about the pollutants in the natural environment, i.e., physical, chemical, and biological contaminants in air, water, food, and soil. There is also increasing attention to the man-made or "built" environment comprising the network of roads, public transportation, and physical structures where children live, play, and work.

Fortunately, our knowledge about environmental health-the field of science that concerns how the environment influences human health and disease-has expanded greatly in the past decade.

 Research has shed light on the relationship of children's health and developmental conditions to toxicants (a "toxicant" refers to a chemical agent; "toxin" is often used for a biological agent) in the air they breathe, the water they drink, and the food they eat. Many questions about these relationships, however, remain unanswered. 

Science is increasingly recognizing that gene-environment interactions can shift the balance between health and disease. Olden's line is often quoted, "Genetics loads the gun, but environment pulls the trigger."

 Our children's health is influenced by the interaction of genetic susceptibility and environmental exposures-and these gene–environment interactions are influenced by behavior, gender, age, and developmental stage.

Pediatricians are well positioned to identify children's environmental exposures, counsel on ways to help prevent exposures, and where the evidence supports it, give abatement advice. As trusted family advisors, we can also answer questions about what is known and not known about environmental exposures and health. 

The first step in evaluating a child's environment is taking an environmental history. During much of the last century, when it was common for doctors to make house calls, doctors could observe a child's environment. Since house calls are no longer standard practice, asking about surroundings is the necessary starting point. For some areas of environmental health-counseling smokers to stop smoking, and certain aspects of sun safety-scientific evidence supports the importance of taking a history and giving advice in promoting behavior change. 

In this article, we will review important areas of the environmental history to cover on well-child and well-adolescent visits. We will give you a list of questions for each area, discuss why each question is important, and then suggest interventions if you find a situation needing change. We will touch upon community, school, and advocacy issues relevant to environmental health. (A more extensive article focusing on environmental health issues in communities and schools will follow in a future issue.) We will then briefly discuss taking an exposure history when an illness or symptom raises concern about a possible environmental etiology, and list several resources. Although the "environment" can be broadly defined as mentioned above, we will concentrate on chemical and certain physical hazards (such as ultraviolet radiation) that can affect children's health.

Questionnaires and forms from the National Environmental Education & Training Foundation's (NEETF) 

 may be used to facilitate taking the history.

 gives suggestions about when to introduce environmental health questions, while 

 summarizes the suggested questions for a complete environmental history.

Young children spend 80%–90% of their time indoors. This includes the primary residence, but may also include relatives' and care-givers' homes, and daycare facilities. 

What type of home does your child live in or spend time in? Single-family home, apartment, mobile home, or temporary shelter?

What are the age and condition of your home? Is there lead, mold, or asbestos?

 The US has made great strides towards eliminating lead poisoning. Yet many children-particularly impoverished children-have elevated blood lead levels. Although the prevalence of lead poisoning in the US has decreased to near 1%, the risk of having a blood lead level greater than or equal to 10 μg/dL is highest for poor children, and those living in deteriorated housing. 

Lead paint was used in home construction until the late 1970s, but due to the concentration of lead paint used, houses built before 1950 pose the greatest risk. 

Lead paint may chalk or dust from walls, and may be released with the opening and closing of windows or during room renovation (common in preparation for the birth of a baby, or soon thereafter), potentially affecting young children's neurological development.

 Depending on the child's age, housing situation, and other risk factors, check the child with a blood lead test. Federal law requires testing these levels on children receiving Medicaid at ages 1 and 2 years.

 Water damage and damp conditions may result in mold growth, causing allergy and asthma symptoms. Exposure to the mold 

) has been associated with the development of acute idiopathic pulmonary hemorrhage (AIPH) in young infants. This association is based upon only a few studies, however, and a causative link has not been demonstrated. In a recent report, the AAP concluded that there is some evidence of biological plausibility for this association.

Epidemiologic studies suggest that exposure to SHS may be an additional risk factor for AIPH.

 Ongoing work in toxicology and epidemiology is needed to provide more information. 

 Advise parents to fix water leaks. Any areas of visible mold measuring less than or equal to nine sq. ft can be removed using a dilute solution of chlorine bleach (1 part chlorine to 10 parts water); professional removal is recommended for moldy areas larger than nine sq. ft.

 Given the known adverse effects of mold exposure and the concern about AIPH in infants, it is prudent to advise that children, particularly young infants, avoid exposure to moldy environments.

 Friable (crumbly) asbestos may be present in older homes as insulation around boilers and pipes, in ceiling and floor tiles, and in other areas. Asbestos may be released into the air during renovation or other work. When airborne, asbestos may be inhaled into the lung, possibly resulting in mesothelioma or lung cancer years after exposure. 

 It is best to leave undamaged asbestos alone if it is not likely to be disturbed. If it must be replaced, have it identified by contacting the manufacturer, or by calling an inspector or certified lab. If asbestos is in poor condition (more than a very small amount), a certified contractor should perform the removal.

Unintentional carbon monoxide (CO) poisoning causes hundreds of deaths in the US each year. Infants and children have increased susceptibility to CO poisoning because of their increased metabolic rates. Sources of CO include unvented kerosene and propane gas space heaters, leaking chimneys and furnaces, woodstoves, fireplaces, and gas appliances. Gasoline-powered portable generators, misplaced close to homes, were implicated in CO deaths following recent hurricanes in 2004 and 2005.

 Several states and municipalities, including New York City, have enacted mandatory CO detector laws for dwellings with multiple occupants.

 Chimneys should be inspected and cleaned annually. Make sure that combustion appliances are properly installed, maintained, and vented according to the manufacturers' instructions. Urge parents to install CO detectors that meet Underwriters Laboratories (UL) most recent standards in every sleeping area. Never ignore an alarming CO detector.

Is your child exposed to toxic chemicals? Where and how do you store chemicals and pesticides?

Pesticides and other chemicals ingested, inhaled, or absorbed through the skin can cause acute poisoning and death, as well as subacute and chronic poisoning. 

 Encourage parents to use the least toxic option for pest control. Have them place toxic chemicals out of reach. Never store chemicals in something other than the original container, because the child may be attracted to taste contents in soda bottles, juice bottles, or other containers. 

What type of heating/air system does your home have? 

Byproducts of heating systems, such as nitrogen dioxide (NO

), respirable particulates, and polycyclic aromatic hydrocarbons released from wood-burning stoves or fireplaces may precipitate or worsen respiratory symptoms. 

 Find out how the family heats the home, especially if there is a respiratory problem. Advise parents to properly maintain and clean heating systems.

Do you use chemicals in the garden or spray the lawn with pesticides?

Young children may be harmed if they play on lawns and in gardens freshly sprayed with pesticides or herbicides. Hand-to-mouth activities, and eating without washing hands after playing, contribute to exposure. Herbicides in general have less acute toxicity than insecticides, although this can vary from chemical to chemical. 

 There is no clearly established length of time that parents must prohibit children from playing in freshly sprayed lawns and gardens. Pediatricians should advocate for primary prevention by advising that pesticides not be applied to home or garden for ornamental purposes. If a parent has applied an herbicide, prudence dictates a minimum of 24-48 hours before having contact with the lawn. Since insecticides are generally more toxic to animals than compounds designed to kill plants, it is reasonable to avoid contact for a longer time period, such as 48-72 hours, after pesticide application.

Radon is a leading-and preventable-cause of lung cancer in the US. Ten percent of lung cancers are attributable to radon. 

 The Environmental Protection Agency (EPA) and the Surgeon General recommend testing homes below the third floor for radon.

 The EPA also recommends that radon testing be done before buying or selling a home.

 In terms of costs, radon testing and remediation are generally affordable. 

Do you think there is lead in your soil? 

Lead can contaminate soil when paint chips from old buildings mix with the soil. Lead was present in gasoline in the US until the 1970s. Because lead moves very little once deposited, lead that originated from auto emissions can remain present in soil. Indeed, studies conducted in urban areas have shown that soil lead levels are highest around building foundations, and within a few feet of busy streets. 

If high levels of lead in soil are suspected and there are young children who play there, parents may want to have the soil tested. Ways to remediate high-lead soil levels are by raising soil pH and adding organic material followed by planting of sod, by mixing or covering the high-lead soil with low-lead soil, or by physically removing the soil.

Do your children play on a wooden playset?

Outdoor playsets may have been treated with chromated copper arsenate (CCA), a preservative that protects wood from decay, from insects, and microbial agents. Normal hand-mouth and hand-object behavior may result in exposure to the arsenic leaching from CCA. Exposure to arsenic, a known human carcinogen, may increase the possibility of children developing lung or bladder cancers over their lifetimes. Manufacturers of CCA reached a voluntary agreement with the EPA to end the manufacture of CCA-treated wood for most consumer applications as of December 31, 2003. Some stocks of wood treated with CCA before then were expected to be found on shelves until mid-2004. More importantly, hundreds of thousands of play structures and decks were built before the ban, and are still in children's yards.

If there is a playset manufactured before 2003, parents can call the manufacturer to determine whether it contains CCA. If there is CCA in the deck or play structure, it should be treated with a clear sealant every six months to one year to decrease the amount of arsenic leaching out of the wood. Alternatively, parents can choose to have the set safely dismantled. They should never burn or saw CCA-treated wood, as this will increase the amount of arsenic released. If parents keep the playset, they should wash children's hands with soap and water immediately after outdoor play, and especially before eating. Children should not eat while playing on CCA-treated playground equipment. 

Between 12%–34% of children are exposed to secondhand smoke (SHS, also known as environmental tobacco smoke [ETS]) from parental smoking, making these children 

. Passive smoking has a tremendous impact on children's health, including asthma (over 200,000 episodes/yr attributable to SHS exposure including new onset and exacerbations), lower respiratory infections, otitis media (almost 800,000 episodes/yr), and Sudden Infant Death Syndrome (SIDS; 430 deaths/yr, out of a total of ~2500 cases of SIDS, are attributable to SHS).

Even a brief doctor-delivered quit-smoking message has an effect on quit-smoking rates.

 The US Public Health Service recommends that clinicians ask about smoking at every visit, and offer smokers at least a brief intervention-one to three minutes-at each visit. Asking parents if they smoke and advising them to quit is part of the 

 model of the National Cancer Institute (

Ask, Advise, Assess, Assist, and Arrange follow-up

 about smoking at all visits; asking is the first "A." Next, strongly 

 parents to quit (the second "A"): "As your child's pediatrician, I think the best thing you can do for your health and your child's health is to quit smoking. My staff and I can help you."

-determining whether smokers are interested in quitting soon (within the next 2–4 weeks). If so, provide practical cessation advice if you have the time and knowledge (the fourth "A"-

). Progress with quitting can also be addressed at subsequent visits (

-the fifth "A"). Otherwise, refer the smoker to a trained cessation counselor or suggest that the smoker contact their state's Quitline. If there is no Quitline in your state, suggest that parents contact the nationwide network of Quitlines through 1-800-QUIT-NOW. 

Drinking water comes from municipal water suppliers or private wells. It can be consumed straight from the tap, used to reconstitute infant formula and juice, or in cooking. The federal Safe Drinking Water Act of 1974 regulates standards for community water supplies serving 25 or more customers; states may have standards for smaller suppliers. Most states have rules for private wells, but since these rules may not completely protect a private well, it becomes the responsibility of a private well owner to ensure that the water is safe.

Water contaminants of particular concern for US infants and children are lead and nitrates. Most large municipal water supplies keep lead levels at or below the EPA standard of 15 ppb (parts per billion). Even though most systems have acceptable lead levels, some cities, including New York, Boston, and Chicago, still have lead piping to connect water mains to homes. 

Well water may contain nitrates that enter the water supply from runoff of agricultural fertilizers, and may also be produced by the action of bacteria on animal waste runoff. Nitrates ingested by small infants may be converted to nitrites, which may in turn cause fatal methemoglobinemia.

What is the source of your drinking water?

 Test tap water for lead if it is consumed by infants and young children. If water contains lead, it should be run for at least two minutes if it has been standing overnight in pipes, or until cold. Alternatively, bottled water can be used. Private wells should be tested initially (upon construction or upon purchasing a home) for total dissolved solids, nitrates, coliforms, inorganic compounds (iron, magnesium, calcium, chloride) and lead. Repeat testing for nitrates and coliforms should be performed annually. Consider repeat testing for other contaminants if a new source of contamination becomes known (for example, if a neighbor discovers a new containment in their well). Local health or environmental departments can advise regarding testing.

 Water high in nitrates should not be given to infants!

If parents choose to boil drinking water, one minute of a rolling boil is sufficient to kill microorganisms. They should also avoid over-boiling water, since this may concentrate any contaminants.

Fish is an excellent source of protein and can be high in omega-3 fatty acids. However, mercury and persistent organic compounds such as polychlorinated biphenyls (PCBs) in water can contaminate fish and subsequently, people who ingest the fish. Mercury from natural and combustion sources enters the air and then falls into bodies of water, where it is methylated by aquatic organisms into organic methylmercury. It is then taken up by fish, where it accumulates in their muscle tissue. Large predator fish that feed on smaller fish, such as swordfish and tuna, accumulate the most mercury. 

Fetuses and young children are most susceptible to the neurotoxic effects of mercury. In 2000, the National Research Council estimated that 60,000 American children born each year may suffer from learning disabilities due to prenatal mercury exposure.

Do you eat fish? Does your child eat fish? What kinds and how often?

Recommendations: For parents eating commercially caught fish, advise them to choose fish low in mercury and persistent organic pollutants, and higher in omega-3 fatty acids. Pregnant women, women of childbearing age, nursing mothers, and young children should completely avoid shark, tilefish, swordfish, and king mackerel because they contain high levels of methylmercury, and should limit consumption of other mercury-containing fish.

 A recent literature review suggests that for major adult health outcomes, the benefits of fish intake outweigh the potential risks.

 In this same review, the weight of evidence suggested that modest fish intake for women of childbearing age, except for the species listed above, also outweigh the risk. Several Web sites, including the Oceans Alive campaign of Environmental Defense, list best and worst fish alternatives.

Out of economic necessity or as a recreational pursuit, families may catch and eat fish from lakes and streams. These fish may be exceptionally high in contaminants. 

 Most states publish and post fish advisories regarding which fish should be limited or avoided. 

Exposure to ultraviolet (UV) light through natural and artificial sources is linked to the development of skin cancer (basal cell carcinoma [BCC], squamous cell carcinoma [SCC], and melanoma) later in life. Although melanoma comprises only 3% of all skin cancers, it causes 80% of skin cancer fatalities. The American Cancer Society predicts that in 2007, there will be 59,940 new melanoma cases with 8,110 deaths.

 People at highest risk have light skin and eyes, and sunburn easily. Although melanoma primarily affects older white men, it can also occur in teenagers and young adults. 

When detected early, melanoma has an excellent prognosis. Metastatic melanoma has a grave prognosis, with few if any successful treatment options. Our efforts must therefore focus on prevention and early detection. Intense (or "brutal") sun exposure in childhood and adolescence, enough to cause blistering sunburn, is linked with an increased risk of melanoma later in life. 

There is accumulating evidence that artificial sources of UV light-those emanating from tanning lamps and beds-are also carcinogenic. In the US in 2003, 26% of people under 25 visited a tanning parlor, compared to 8% in 1996. Between 32%–55% of college students used tanning parlors; 6%–44% of high school boys and 30%–70% of high school girls used tanning parlors. In 2001, the indoor tanning industry generated $4 billion in revenues.

The International Agency for Research on Cancer (IARC) recently convened an International Working Group to assess the evidence on the health effects (positive and detrimental) of artificial UV radiation. The IARC, part of the World Health Organization, coordinates and conducts research on the causes of cancer and the mechanisms of carcinogenesis, and develops scientific strategies for cancer control.

The 2006 IARC literature review concluded that there is a 75% increase in risk of melanoma for users of sunbeds in their teens and twenties. An increased risk of developing SCC was also associated with sunbed use during the teen years. The data suggested detrimental effects on the skin's immune response and possibly on the eyes (ocular melanoma). No positive effects were observed: artificial tanning conferred little, if any, protection against solar damage to the skin, nor did using indoor tanning facilities provide protection against vitamin D deficiency. The IARC concluded that "effective action to restrict access to artificial tanning facilities (solariums, tanning salons, tanning parlors) to minors and young adults should be strongly considered."

 Sun protection messages are best delivered in the context of promoting outdoor physical activity-in a sun-safe manner. Advise parents not to allow their child to sunburn. Children and teens should wear protective clothing, brimmed hats and sunglasses when feasible, seek shade when possible, and use extra caution near water, snow, and sand since these surfaces reflect sunlight.

 Pediatricians can work with schools, child-care settings, and communities to promote the adoption of shaded playgrounds and play areas. To prevent sunburns when sun exposure is anticipated, parents and teens should generously apply a broad-spectrum (UVA and UVB protection) sunscreen with a sun protection factor (SPF) of at least 15 before going outside, and to reapply often, especially after swimming or sweating.

The SPF, a scale for rating the level of sunburn protection in sunscreen products, applies only to UVB protection. Sunscreens with an SPF value of 2 through 11 give minimal protection against sunburns. Sunscreens with an SPF of 12 through 29 give moderate protection. Those with an SPF of 30 or higher give the most protection against sunburn.

 Although sunscreen has been shown to protect against SCC, there is no data showing that sunscreen prevents melanoma.

 The American Academy of Pediatrics advises that an SPF of 15 should be adequate in most cases.

 It is important to use enough sunscreen (1 oz per sitting is recommended for young adults; proportional amounts should be used for infants and children). Reapplying often is key-every 2 hours even on cloudy days-especially after swimming or sweating.

 Using sunscreen should not be seen as a reason to extend time spent in the sun.

 Strongly discourage teens and their parents from visiting tanning parlors. If they feel that tanned skin looks healthier or more beautiful, suggest that they may use a sunless self-tanning product-but they must continue to use sunscreen with it. It should also be noted that there is no evidence that a "pre-vacation tan" protects against solar damage. 

Parents may present with any number of concerns about known or unknown environmental exposures. Common situations include families searching for environmental causes for cryptic constellations of symptoms in their children, families searching for an environmental cause of a known disorder such as autism, or community concerns about an apparent or real cancer cluster. Pediatricians are sometimes called upon to give advice and guidance in these areas, but they may not feel knowledgeable or comfortable giving information. Resources are available. 

Experts from Pediatric Environmental Health Specialty Units (PEHSUs), developed as a joint effort of the EPA, the Agency for Toxic Substances and Disease Registry (ATSDR, a part of the CDC), and the Association of Environmental and Occupational Clinics (AEOC), are available to answer questions and provide advice. PEHSU staff includes pediatricians trained in environmental health and occupational medicine physicians. 

A comprehensive list of PEHSU locations is available at 

Toxicants encountered in parents' occupations can be brought home on clothes and shoes, contaminating the home and exposing children ("fouling one's own nest" or "para-occupational exposure"). Exposures include pesticides used in agriculture that may be tracked indoors, and lead brought home on clothes of house painters and construction workers. Parents working inside the home with lead used in stained glassmaking, soldering, or pottery making may inadvertently expose young children. Parents who refinish boats also carry the potential to bring lead into the home. 

Teen job sites may also be an area of interest. More than 80% of high school students work at some time during the year. These teens may be exposed to inappropriate situations, including the use of dangerous machinery and hazardous chemicals. Indeed, each year work-related injuries kill about 70 adolescents and children; about 70,000 more are seen in emergency departments for work-related injuries.

What are the occupations and hobbies of the adults in the household?

 Parents employed in hazardous occupations should shower at work and change clothing and shoes before driving home. If toxic substances are used inside the home during work or hobby activities, make sure that the areas are properly ventilated, cleaned regularly, and inaccessible to small children. 

Pediatricians can find out about the nature of the teen's work during health maintenance visits, sports physicals, visits for "working papers," and if there is a work-related injury. A teen's employment should be considered when diagnosing an illness, and in the medical management of illness (e.g., asthma may flare up when the teen works with certain chemicals or is exposed to SHS on the job). Pediatricians need to know their state's child labor laws.

Children's environments include hazards in the broader community. These include diesel bus terminals, loading docks, industrial sites, hazardous waste sites, landfills, and agricultural areas sprayed with pesticides or fertilized with nitrate-containing fertilizers. Poor communities are more likely to be faced with these exposures; this is referred to as "environmental disparity" or "environmental injustice." Moreover, we have come to appreciate the importance of asking about other aspects of "community" that may impact health-e.g., are there safe places to walk and exercise? Does the way the community was planned and built allow for walking to school or work? 

Any examination of a child's environmental exposures would also be incomplete without a look at the schools that house them. Each day more than 53 million school children enter the nation's 120,000 school buildings that are often "unhealthy," poorly maintained, or overcrowded. Schools are sometimes situated in less desirable areas next to roads, highways, industrial plants, or abandoned landfills. According to the EPA, half of our nation's schools have problems linked to indoor air quality.

Most clinicians don't have time to visit community schools. We can, however, use the pre-school office visit to suggest to parents that they visit the school with the purpose of conducting an "environmental audit" before their child enters. Parents can look for mold or water damage and for pets in the classroom, and determine whether they can detect the smell of harsh or hazardous cleaning products. They can check to see if newly renovated areas are cleaned up or aired out. Parents may not be able to detect more hidden hazards such as lead paint (unless there is chipped paint), PCBs, CO, mercury spills, or asbestos-but they can ask for any written statements about the known presence of such substances, such as asbestos. 

 Parents can be encouraged to be advocates for their child. It may be necessary for parents to meet with the principal or school district officials. There may be an intermediary role for pediatricians or local health department officials in situations where school officials are not fully responsive. There may also be a role for the regional Pediatric Environmental Health Specialty Unit. 

Making the connection between a child's disease and the environment requires a high index of suspicion. Illnesses caused by environmental agents may present as common medical problems. Most clinicians will think about SHS exposure when a child has asthma or recurrent ear infections. Lead poisoning is in the differential diagnosis of coma, seizures, developmental delay, irritability, and constipation. Poisoning from certain types of pesticides may present with headache, dizziness, and diarrhea. It is critical (and even life-saving) to consider CO poisoning when there is fatigue, headache, dizziness, weakness, nausea, or vomiting, especially when there is more than one family member with these symptoms. 

Articles

There is increasing evidence that environmental toxicants affect kids' health. Given this reality, pediatricians need to know the most important environmental health questions to ask, and what resources to draw from.

Safeguarding kids from environmental hazards-CME

DR. BALK is professor of clinical pediatrics at the Albert Einstein College of Medicine in the Bronx, New York. 

DR. FORMAN is associate professor of pediatrics and community and preventive medicine at the Mount Sinai School of Medicine in New York. 

DR. JOHNSON* is a Commander in the United States Navy's Medical Corps at the Naval Medical Center, San Diego. 

*The opinions or assertions contained herein are the private ones of the authors, and are not to be construed as official or reflecting the views of the Naval Medical Center, San Diego, the Department of Defense, or the United States Navy.

  Research has shed light on the relationship of children's health and developmental conditions to toxicants (a "toxicant" refers to a chemical agent; "toxin" is often used for a biological agent) in the air they breathe, the water they drink, and the food they eat. Many questions about these relationships, however, remain unanswered.  

  Our children's health is influenced by the interaction of genetic susceptibility and environmental exposures-and these gene–environment interactions are influenced by behavior, gender, age, and developmental stage. 

Pediatricians are well positioned to identify children's environmental exposures, counsel on ways to help prevent exposures, and where the evidence supports it, give abatement advice. As trusted family advisors, we can also answer questions about what is known and not known about environmental exposures and health.  

The first step in evaluating a child's environment is taking an environmental history. During much of the last century, when it was common for doctors to make house calls, doctors could observe a child's environment. Since house calls are no longer standard practice, asking about surroundings is the necessary starting point. For some areas of environmental health-counseling smokers to stop smoking, and certain aspects of sun safety-scientific evidence supports the importance of taking a history and giving advice in promoting behavior change.  

Safeguarding kids from environmental hazards

 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. 

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

Sophie J. Balk, MD

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