Current Pediatric Reviews (v.7, #2)

Pediatricians play an active role in ensuring that children are born healthy and live free of diseases, including those causedby tobacco use and tobacco smoke exposure. The Surgeon General’s reports [1, 2] have shown that tobacco harms nearly everyorgan in the body and there is no safe level of tobacco smoke exposure. The negative effects of smoking and smoke exposureextend across the life course from the fetuses of smoking mothers to adults whose lives are ended prematurely by a variety ofcancers, cardiovascular diseases, and respiratory diseases. Pediatricians have multiple opportunities to interrupt this cycle ofsmoking by educating pregnant women and caregivers about the health risks of tobacco use, preventing youth from ever usingtobacco products, expanding screening and access to effective treatments, and reducing tobacco smoke exposure. The articles inthis special issue will educate readers about the epidemiology and health consequences of smoking, and will provide a new wayof thinking about nicotine addiction. Readers will learn about training for pediatricians, epidemiology and health effects oftobacco use and smoke exposure, tobacco policies, and prevention and treatment programs.Physicians are a trusted source of information for parents and their medical advice to quit smoking increases abstinencerates [3] even when advice is delivered briefly. The Preventive Services Guidelines on Treating Tobacco Use and Dependence:2008 Update [3] recommends that all clinicians should consistently identify and document tobacco use status and treat everyadult tobacco user seen in a health care setting. As part of their tobacco counseling, pediatricians can use the five A’s (ask,advise, assist, arrange, and anticipate), problem solving, skills training, and social support. Motivational interviewingtechniques may be needed for smokers who are not yet ready to make quit attempts or to divulge information about theirsmoking behavior. Pediatricians have historically missed valuable opportunities to discuss smoking with parents and childrenduring routine well child visits for reasons that include the stigmatizing nature of the topic, respect for privacy, lack of tobaccocessation training during medical school [4], and insufficient time, expertise, and financial incentives. The creation of pediatricresidency smoking cessation programs and curricula has led to an improvement in residents’ self-efficacy for counselingparents, and will hopefully empower the next generation of practicing pediatricians to take more active roles in anti-smokingcounseling and advocacy.There have been numerous Surgeon General’s reports (http://www.surgeongeneral.gov/library/reports/index.html) ontobacco use, smoke exposure, health consequences, and prevention efforts in general and minority populations, women, andchildren. Links have been established between maternal smoking and increased risks for reduced fertility, stillbirths, prematureinfants, infants with low birth weight, sudden infant death syndrome, and long-term behavioral problems in infants [1].Children whose mothers smoked during pregnancy are predisposed to many long-term behavioral and learning problems andare more likely to become dependent on tobacco if they start smoking. Pregnant women have higher quit rates compared to thegeneral population, but relapse is, unfortunately, not uncommon in the months following delivery. However pediatriciansinteracting with pregnant and postpartum women can encourage them to remain tobacco free by pointing out the negativehealth effects of smoking on both mother and child.Parents are important sources of smoke exposure for their children [5] in homes and automobiles, but children are alsoexposed to smoke in daycare settings and in other environments. As many as 17-18% of children in the United States [6] live inhomes where a parent smokes; worldwide about 40% of children are exposed to tobacco smoke [7]. Tobacco smoke exposureaffects numerous organ systems, causes genetic changes, influences the developing immune system, and contributes to anestimated 165,000 deaths in children each year [7]. Health effects of smoke exposure in children include atopy, asthma,respiratory illnesses, decreased lung function, increased risk of sudden infant death syndrome (SIDS), an increase in earinfections, and associations with behavioral and sleep problems [1]......

The Epidemiology and Health Effects of Tobacco Smoke Exposure by Karen M. Wilson, Emily Weis (76-80).
Tobacco Smoke (TS) exposure is an important cause of pediatric morbidity and mortality worldwide. Estimatessuggest that over 50% of US children are exposed to tobacco smoke, and 40% of children internationally. TS exposure hasbeen linked with many specific diseases and social conditions. It is especially prevalent amongst children who live inpoverty, and is associated with increased rates of food insecurity. Children who are exposed miss more school, and thusmay miss important educational opportunities. Compounding this, exposed children show deficits in cognitive abilities,and increased behavioral problems. TS causes oxidative stress and changes in the immune system, which may result inlower antioxidant levels, and increased rates of asthma and other atopic diseases. In addition to asthma, TS exposureincreases the risk and severity of respiratory diseases, including bronchiolitis and tuberculosis. TS exposure in childrenhas been associated with diseases of other systems as well, including inflammatory bowel disease, leukemia, dental caries,and sudden infant death syndrome. Finally, we are starting to understand that the link between TS exposure andcardiovascular disease may begin in childhood, with exposed children having higher rates of metabolic syndrome, andmeasurable changes in their vascular contractility. Efforts need to continue worldwide to prevent children’s exposure tothis toxic and harmful product.

In the US 20.6% of adults and 19.5% of high school students are current cigarette smokers. Smoking isresponsible for 5 million deaths worldwide each year and is known to cause more and a greater variety of human diseasethan any other known toxin. It causes multiple cancers, significant cardiovascular, respiratory and reproductive disease,and has been linked to health problems in most organ systems of the body. The harmful effects of tobacco begin in youngsmokers, who experience respiratory symptoms, increased rates of infection, and evidence of cardiovascular effects soonafter beginning to smoke, even at low levels of cigarette use. Declines in the rate of cigarette smoking have stalled in thedeveloped world. In the US, the Healthy People 2010 goal of decreasing current smoking in youth to below 16% has notbeen met. Smoking rates are increasing in the developing world, and there is already a rise in tobacco related problems inthose areas least able to cope with the increased burden of disease. Continued efforts on a global scale are needed tocombat the persistent and growing problem of tobacco use.

The Natural History and Diagnosis of Nicotine Addiction by Joseph R. DiFranza, Robert J. Wellman, Robin Mermelstein, Lori Pbert, Jonathan D. Klein, James D. Sargent, Jasjit S. Ahluwalia, Harry A. Lando, Deborah J. Ossip, Karen M. Wilson, Sophie J. Balk, Bethany Hipple, Sussanne E. Tanski, Alexander V. Prokhorov, Dana Best, Jonathan P. Winickoff (88-96).
Addicted smokers experience nicotine withdrawal anytime they go too long without smoking. Withdrawalpresents as a continuum of symptoms of escalating severity described by smokers as “wanting,” then “craving,” andeventually “needing” to smoke. These may be followed by irritability, impatience, moodiness, difficulty concentrating,restlessness, and sleep disturbances. This spectrum of intensifying withdrawal symptoms creates a compulsion to smokethat makes quitting difficult. The compulsion to smoke is the core feature of nicotine addiction accounting for its clinicalcourse, physiological characteristics, prognosis, and behavioral manifestations. A compulsion can develop quickly, havingbeen experienced by one third of youth who have smoked only 3 or 4 cigarettes. Its physiologic basis is evident inneurophysiological measures and its recurrence after each cigarette at a characteristic interval. At first, a single cigarettecan keep withdrawal at bay for weeks, but as addiction progresses, cigarettes must be smoked at progressively shorterintervals to suppress withdrawal symptoms. The physiologic need to repeatedly self-administer nicotine at shorterintervals explains a full spectrum of addictive symptoms ranging from the prodromal symptom of wanting, to chainsmoking. The early process of nicotine addiction is recognized if a person experiences regular wanting for a cigarette.When symptoms include craving or needing, the now addicted patient is experiencing a compulsion to smoke. This simplediagnostic approach covers the full spectrum of addiction in smokers of all ages and levels of tobacco use, and is morevalid than a clinical diagnosis based on the current Diagnostic and Statistical Manual criteria.

Tobacco use is a major preventable cause of premature death and disease worldwide. In this article I brieflyreview the extent of the problem highlighting current policies that are effective in its control. I provide information onprevalence of tobacco use and tobacco smoke exposure (TSE) among children and adolescents worldwide along withmortality data and economic data. I summarize the public policies that have been shown to be effective in reducingtobacco initiation and TSE in children using as a framework the MPOWER recommendations from the World HealthOrganization (WHO). I review each one of these policies- monitoring, smoke-free environments, treatment of tobaccodependence, health warnings on packages, bans on advertising, promotion and sponsorship, and tobacco taxation- andexplain how they can prevent smoking among children and adolescents and their exposure to tobacco smoke. Finally, Idiscuss the role of the pediatrician in understanding these policies and help in their implementation.

Tobacco smoke (TS) exposure of children causes significant and completely preventable morbidity andmortality. The primary source of the TS to which children are exposed is smoking by parents or family members in thehome. Clinicians who care for children can and should counsel families to make the child’s environment completelysmoke free and ultimately, to quit using tobacco altogether. In as little as three minutes, counseling to make environmentssmoke free and tobacco users to quit can be delivered. Basic techniques of behavior change counseling and cessationresources for families are discussed, including stages of change, the “Five A’s,” brief motivational messaging, andpharmacotherapies. The evidence supporting counseling of parents and patients to promote smoke free homes and tobaccouse cessation is presented. Policies that promote smoke free homes are discussed briefly.

Parental Tobacco Control in the Child Healthcare Setting by Janelle Dempsey, Joan Friebely, Nicole Hall, Bethany Hipple, Emara Nabi, Jonathan P. Winickoff (115-122).
Each year 40% of the world’s children are exposed to tobacco smoke and 166,000 children die from thatexposure annually. The 2006 and 2010 U.S. Surgeon General Reports concluded that there is no safe level of tobaccosmoke exposure (TSE). The only way to completely protect children from the dangers of household TSE is to help allhousehold members quit. Due to the many health concerns associated with children’s TSE, parental tobacco control is apriority within the pediatric setting. Child healthcare clinicians are in a unique position to influence the smoking behaviorsof parents, thereby improving the health of their patients. The Clinical and Community Effort Against Secondhand SmokeExposure (CEASE) is a parental tobacco control intervention that uses an operational form of the U.S. Department ofHealth and Human Service’s (HHS) Treating Tobacco Use and Dependence Guideline in the context of the child’soutpatient medical visit. The CEASE method includes three steps (Ask, Assist, Refer) that encompass the goals of the5A’s (Ask, Advise, Assess, Assist, Arrange) in a simplified format, allowing for brief, tailored cessation support for theperson who smokes. This paper summarizes the research on the harms of TSE and explores how child healthcareclinicians can most effectively eliminate these health risks to children by implementing CEASE. Finally, we look atlegislative initiatives that clinicians can support to help protect children from the harms of TSE.

There is ample evidence that children are harmed by tobacco smoke exposure. Pediatricians concerned abouttobacco’s effect on children have often focused on harm reduction, i.e. counseling parents to smoke outside. Morerecently, pediatricians have become interested in directly addressing smoking cessation. This review concentrates on whypediatricians are in a unique position to access smokers, and why they should specifically act as smoking cessationcounselors. The available literature on the pediatrician as smoking cessation counselor for both parents and adolescents isreviewed. A brief introduction to the various evidence-based counseling methods is also provided.

Hospital-Based Tobacco Interventions in Pediatric Settings by Meta Lee, Bryan Mih, Jennifer Bracamontes, Raul Rudoy (128-136).
Background: Children exposed to tobacco smoke are at great risk for adverse health conditions leading tohospitalizations. Cessation interventions targeted at adult smokers in hospital settings have been shown to be effective inreducing smoking behavior. However, only a limited number of hospital-based interventions targeted at parent andhousehold smokers have been described in the pediatric literature. Objective: The purpose of this article was to identifyand compare successfully implemented pediatric hospital-based smoking cessation interventions, discuss outcomes, andidentify strategies hospital-based providers can use in pediatric inpatient settings. Methods: We searched Medline,CINAHL, and Psychinfo databases for English language studies published in the last 20 years. Articles met inclusioncriteria if the target population was limited to parent or household members of children admitted to a pediatric inpatientfacility, and if the smoking cessation intervention was provided during the inpatient period and or initiated prior todischarge. Results: Of the 126 studies reviewed, 5 met inclusion criteria. Two were randomized control trials.Interventions used brief or intensive counseling and included: partnering with state resources, training pediatricians, andfollowing-up with telephone counseling support. Outcome parameters included: enrollment into a referral program,completion of counseling sessions, quit attempts, smoking reduction, and smoking cessation. Conclusion: Our findingssupport the conclusion that hospital-based tobacco use cessation interventions for parents and household members ofchildren admitted to a hospital are implementable by any level of health care provider, using a variety of interventionmodels. Although these preliminary reports are encouraging, objective outcomes and long term follow-up studies are stillneeded.

How to Prevent Postpartum Relapse to Smoking by Kinga Polanska, Wojciech Hanke (137-142).
In view of the fact that smoking cessation is more likely during pregnancy than at other times, interventionsto maintain quitting postpartum may provide the best opportunity for a long-term abstinence. Pediatricians, morethan any other professional, see mothers of the infants and small children on a frequent basis, and pediatric well-care visitsoffer a unique opportunity for relapse prevention messages. The most important determinants of postpartum smokingrelapse, such as having smoking partners or friends, the return to smoking as a way of coping with stressful situations,relapsing following weaning from breast-feeding, and concern about weight gain, need to be addressed during postpartumvisits. The effective intervention would require pediatricians to be knowledgeable about tobacco use and how to stop,issues concerning postpartum relapse, and intervention strategies, such as role playing, problem solving and behavioralcontracting.

Tobacco use and smoke exposure are at the heart of a world-wide pandemic of tobacco-related disease andliterally condemn millions of young people to a life-time of addiction and premature morbidity and mortality. In order toprotect children and adolescents from the scourge of tobacco use and smoke exposure, pediatricians must be prepared tointervene for behavior change and to advocate for legislation, policy, and resources aimed at reducing tobacco use andcreating a smoke-free environment. The pediatric residency training years provide important opportunities to preparepediatricians to meet the tobacco challenge. This current review supports the efficacy of active and experiential approaches to learning in order to prepare residents inpediatric preventive cardiology, environmental and community pediatrics, and primary care to play a leadership role inprotecting children and adolescents from the harm of tobacco use and exposure. With proper training, pediatric residentsshould be able to acquire the knowledge, skill, and confidence to address tobacco use and smoke exposure in their clinicalpractice. There still is much work to be done, including addressing professional norms which contribute to reluctance onthe part of pediatricians and residents to go beyond ask and advise to assist and arrange as well as to address tobacco usein parents. As training to intervene becomes more accepted and integrated within the formal pediatric residencycurriculum, professional norms and mores will change, and the next generation of pediatricians will be better prepared tostem the tobacco pandemic.