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

June 1, 2002

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

 

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

Jump to:Choose article section... Why don't more smokers quit? Quitting: An attainable goal A golden opportunity, often missed Guiding smokers through the stages of change The five A's Tips to offer parents who are trying to quit smoking The five R's Preventing relapse Pharmacotherapies help Using "the system" to help smokers quit Helping new mothers stay smoke-free

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.

The 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.1 In 1999, 23.5% of the US population were smokers,2 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 "Helping kids kick butts" in the February 1998 issue and "Let's help young smokers quit" in the July 1996 issue, as well as "Keep up the effort with teens and preteens".]

Why don't more smokers quit?

Most smokers want to quit but have great difficulty doing so because of the highly addictive nature of nicotine.4 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.4

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.

Quitting: An attainable goal

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.3 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.4,5 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.4

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.6 Until more research is done, pediatricians can use the recommendations set forth in the clinical practice guideline Treating Tobacco Use and Dependence4—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 .

A golden opportunity, often missed

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.7

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.8 Opportunities to counsel parents about smoking cessation are often missed because of physicians' reservations about such counseling (see "Common concerns").9 Many pediatricians worry, for example, that they will alienate parents by asking them to stop smoking.10 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.11

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.4

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.12,13

 

 

The five A's

Effective smoking cessation counseling can be broken down into five steps, called the five A's:14

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

Advise. 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.

Assess. 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?

Assist. 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.4,5 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

SymptomWhat you can recommend
Craving cigarettesWait out the urges, which last only a few minutes Use distractions such as exercise, going for walks, calling friends
IrritabilityTake walks, hot baths Learn and use relaxation techniques
FatigueTake naps, don’t push yourself
InsomniaAvoid caffeine after 6 p.m. Use relaxation techniques Exercise (but not right before going to bed)
Cough, dry throat, nasal dripDrink plenty of water; try cough drops (many smokers’ coughs worsen temporarily after quitting because of cleansing of the airways)
Inability to concentratePlan workload accordingly Avoid additional stress during the first few weeks after the quit date
HungerDrink water or low-calorie liquids; keep low-calorie snacks on hand (craving cigarettes can be confused with hunger; oral craving may be a symptom of lack of oral stimulation)
Constipation, gas, stomach painDrink plenty of water Increase fiber in diet (fruits, vegetables, whole grain cereals)
Weight gainAlthough most smokers who quit gain some weight, the gain is typically limited to 10 pounds, even without diet and exercise, and can be further limited with pharmacotherapies such as bupropion or nicotine replacement products, diet, and exercise

 

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.4

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

The five R's

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:4

Relevance. 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.

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

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

Roadblocks. 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.

Repetition. 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.

Preventing relapse

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."4,5

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.

Pharmacotherapies help

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:4

Bupropion (Zyban), 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.

Nicotine patches 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.

Nicotine gum 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.

Nicotine nasal spray 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.

Nicotine inhalers, 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.4

Use systematic assessment. 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.

Involve all staff members. 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.

Provide patient education materials. 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.

Use local resources. 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.

Establish a nonsmoking office policy. 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.

Helping new mothers stay smoke-free

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.

 

 

REFERENCES

1. Environmental Protection Agency: Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders. 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. MMWR Morbid Mortal Wkly Rep 2001;50:869

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: Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, Md., US Department of Health and Human Services, Public Health Service, June 2000

5. Seidman DF, Covey LS (ed): 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. Arch Pediatr Adolesc Med 2001;155:858

7. Fingerhut LA, Kleinman JC, Kendrick JS: Smoking before, during and after pregnancy. Am J Public Health 1990;80:514

8. Zapka JG, Fletcher K, Pbert L, et al: The perceptions and practices of pediatricians: Tobacco intervention. Pediatrics 1999;103:e65

9. Stein RJ, Haddock CK, O'Byrne KK, et al: The pediatrician's role in reducing tobacco exposure in children. Pediatrics 2000;106:e66

10. Perez-Stable EJ, Juarez-Reyes M, Kaplan C, et al: Counseling smoking parents of young children: Comparison of pediatricians and family physicians. Arch Pediatr Adolesc Med 2001;155:15

11. Frankowski BL, Weaver SO, Secker-Walker RH: Advising parents to stop smoking: Pediatricians' and parents' attitudes. Pediatrics 1993;91:296

12. Prochaska JO, DiClemente CC, Norcross JC: In search of how people change: Applications to addictive behaviors. Am Psychol 1992;47:1102

13. Make Yours a Fresh Start Family. A Magazine for Mothers Who Smoke. Pennsylvania Department of Health, 1996. Distributed by the American Cancer Society

14. Glynn TJ, Manley MW: 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 Treating Tobacco Use and Dependence recommends using the same kinds of counseling with teens that have been effective with adults, with the message tailored to the teen.1 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.1 Similar recommendations have been made by the American Academy of Pediatrics.2,3 [Editor's note: For additional resources for youth, see "Bookshelf: Books for young people under peer pressure".]

Effective messages for teens

The teen-tailored message can include an emphasis on the short-term effects of smoking, such as cost, bad breath, smelly clothes, decreased physical performance, and social unacceptability. Another tactic that has shown promise is increasing awareness of attempts by tobacco companies to "hook" teens on smoking by using seductive advertising campaigns.

Because no evidence exists that pharmacotherapy is harmful to children or teens, pediatricians can consider prescribing nicotine replacement products and bupropion to help teens quit. When doing so, it is important to determine the number of cigarettes smoked, the degree of dependence, the presence of any contraindications, body weight, and the smoker's intent to quit.1 Confidentiality is an issue with teens, especially when pharmacotherapy is prescribed. Because most health insurance companies do not reimburse for smoking cessation counseling, and some do not reimburse even for prescription pharmacotherapy, cost can be an issue.

Preteens: The sixth A—anticipate

Children are experimenting with tobacco at younger and younger ages, so begin to deliver the "Don't start smoking" message as early as possible. It is important to engage the parent in this effort, even the parent who smokes. A parent who smokes can deliver the powerful message that "quitting is hard, and I wish I had never started to smoke."4

Teens whose parents smoke are more likely to smoke themselves. Other risk factors for smoking initiation include:4

  • age 10 to18 years

  • male gender

  • belonging to a peer group that uses tobacco

  • poor academic achievement

  • other behavioral problems

  • experimentation with tobacco

  • viewing smoking as socially beneficial

  • overestimating the prevalence of smoking

  • risk-taking and rebelliousness

  • psychological factors such as depression.

The process of smoking initiation follows a stages-of-change pattern:

Preparation is the stage during which knowledge, beliefs, and expectations about nicotine use and the functions it can serve (definition of self as glamorous, mature, independent, for example) are formed. "Don't start" messages that address this stage include discussions about the declining numbers of people who smoke—because many youth overestimate the prevalence of smoking—and about how tobacco companies encourage smoking among youth.

Initial trying is the first two or three attempts to smoke, which typically occur in the company of friends. Messages that address this stage include the unpleasantness of first attempts and how bad smoke must be to make the "tryer" cough and feel nauseated and lightheaded.

Experimentation involves irregular smoking over an extended period, often several years. Emphasize how easy it is to quit during this stage and how insidious smoking can be as an addiction.

Regular use is the stage during which youth use tobacco on a regular basis (such as on weekends, on the way to school, after school). Even though many regular users are not daily users, signs of nicotine dependence and addiction begin during this stage. Emphasize that it's still easier to quit at this stage than when the smoker is smoking a pack a day or more.

Nicotine dependence or addiction is defined by development of an internally regulated need for nicotine. Messages similar to those presented to parents who smoke may be effective at this stage, especially if the message is tailored to the concerns of the teen smoker.

A number of effective prevention techniques have been identified. Evidence supports multipronged approaches that include school-based prevention programs, antismoking media messages, smoking restrictions in the home and public places, restrictions on access to tobacco products, tax policies that discourage smoking, and health-care system support for smoking cessation attempts.4

REFERENCES

1. Fiore MC, Bailey WC, Cohen SJ, et al: Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, Md, US Department of Health and Human Services, Public Health Service, June 2000

2. Committee on Environmental Health, American Academy of Pediatrics: Environmental tobacco smoke: A hazard to children (RE9716). Pediatrics 1997;99:639

3. Committee on Substance Abuse, American Academy of Pediatrics. Tobacco's toll: Implications for the Pediatrician (RE0041). Pediatrics 2001;107:794

4. Stein RJ, Haddock CK, O'Byrne KK, et al: The pediatrician's role in reducing tobacco exposure in children. Pediatrics 2000;106:e66

Common concerns

"What about reimbursement?"

Health insurance typically does not cover smoking cessation counseling of parents. Nor does it cover pharmacotherapies used for smoking cessation because many nicotine replacement products are sold over the counter. Some insurance plans, including some Medicaid plans, do cover both counseling in specific settings and pharmacotherapies, however. Consult your state's Medicaid policy for further information.

The clinical guideline Treating Tobacco Use and Dependence recommends that "all insurance plans include as a reimbursed benefit the counseling and pharmacotherapeutic treatments identified as effective" and that "clinicians [be] reimbursed for providing tobacco dependence treatment just as they are reimbursed for treating other chronic conditions." Pediatricians have an important role in lobbying their representatives for changes in insurance and Medicaid policies.

"I don't have 3 minutes."

Simply inquiring about a child's exposure to smoke or a parent's smoking status delivers the message that smoking is an important health issue. Evidence exists that asking adults whether they smoke by itself increases their quit attempts and the success of those attempts. Saying to all smokers "you should quit," further increases the number and success of quit attempts. Smoking cessation counseling is dose-responsive and cumulative; every mention of the harms of smoking boosts effectiveness. These messages can be incorporated into daily practice, especially if reminder systems, such as chart stickers that show smoking status, are in place or smoking is considered a "vital sign."1

"Why don't smokers just quit? They know smoking is bad."

Smokers are addicted to nicotine. Most know they are addicted and would like to quit, but quitting is hard and often requires multiple attempts to succeed. A supportive, nonjudgmental approach by a physician can go a long way toward moving the smoker through the stages of change toward permanent cessation. Smoking is a chronic disease, not a character defect, and the physician who incorporates this message into practice improves the odds of success.

"How do I counsel someone who lives with a smoker?"

Many smokers live with another smoker, such as a spouse or parent. This situation may present the person who is trying to quit with additional challenges, such as a lack of support for the quit attempt and the presence in the home of smoking cues such as ashtrays and cigarette packs. Whenever possible, other smokers in the household should be included in the quit attempt or at least encouraged to support the smoker who is trying to quit. Persuading the parent with whom the pediatrician has a relationship to bring in other family members for a visit to discuss the harms of ETS and the benefits of quitting may be helpful. Another strategy is to help the parent bring home the message that "the baby's pediatrician says smoking is bad for the baby and the house should be smoke-free." Encouraging other household members who smoke to seek help from their own physician also may be effective.

REFERENCE

1. Fiore MC, Bailey WC, Cohen SJ, et al: Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, Md, US Department of Health and Human Services, Public Health Service, June 2000

Making the point with parents about ETS

• Tobacco smoke contains about 4,000 chemical compounds, including carbon monoxide, ammonia, formaldehyde, hydrogen cyanide, nicotine, nitrogen oxides, phenol, sulfur dioxide, and other poisons.

• In 1992 the Environmental Protection Agency designated ETS a class A carcinogen, the class known to cause cancer in humans.1

• ETS causes adverse health effects at every stage of life. ETS exposure is especially significant for young children because they are more likely to spend more time at home in close proximity to their parents than older children, and because they have a higher rate of metabolism and their lungs and other organs are developing.2 Hundreds of studies have established short-term and long-term detrimental effects of ETS exposure.

• Strong evidence exists that children's exposure to environmental tobacco smoke is associated with an increased rate of lower respiratory illness, middle ear infection, tonsillectomy and adenoidectomy, cough, asthma and exacerbation of asthma, and sudden infant death syndrome.2,3

• ETS exposure has been estimated to cause symptoms of asthma in 200,000 to 1,000,000 children and as many as 8,000 to 26,000 new cases of asthma a year.1

• Several studies show that children exposed to ETS are more likely to have significant respiratory complications when they undergo general anesthesia.4

• Children who live in a household with smokers are at greater risk of injury and death from fire.2

• In 1993, parental smoking resulted in estimated direct medical expenditures of $4.6 billion and loss of life costs of $8.2 billion.5

• Long-term effects of environmental tobacco exposure, including lung cancer and progression of atherosclerosis and coronary heart disease, have been found in adults exposed to environmental tobacco smoke.3 Researchers are exploring whether these effects may be more pronounced in children—on the theory that developing lungs are much more susceptible to ETS than mature lungs.6

• A lifelong reduction in lung function has been demonstrated in children exposed to ETS during early childhood.1

REFERENCES

1. Environmental Protection Agency: Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders. Washington, DC: Environmental Protection Agency, Office of Research and Development, Office of Air and Radiation, 1992. Publication No. EPA/600/6-90/006F

2. DiFranza JR, Lew RA: Morbidity and mortality in children associated with the use of tobacco products by other people. Pediatrics 1996;97:560

3. California Environmental Protection Agency: Health Effects of Exposure to Environmental Tobacco Smoke. Sacramento, Calif, Environmental Protection Agency, Office of Environmental Health Hazard Assessment, 1997

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Dana Best, Sophie Balk. Help parents quit smoking--for the good of your patients!. Contemporary Pediatrics 2002;6:39.