Current Pediatric Reviews - Volume 7, Issue 2, 2011

Pediatricians play an active role in ensuring that children are born healthy and live free of diseases, including those caused by tobacco use and tobacco smoke exposure. The Surgeon General's reports [1, 2] have shown that tobacco harms nearly every organ in the body and there is no safe level of tobacco smoke exposure. The negative effects of smoking and smoke exposure extend across the life course from the fetuses of smoking mothers to adults whose lives are ended prematurely by a variety of cancers, cardiovascular diseases, and respiratory diseases. Pediatricians have multiple opportunities to interrupt this cycle of smoking by educating pregnant women and caregivers about the health risks of tobacco use, preventing youth from ever using tobacco products, expanding screening and access to effective treatments, and reducing tobacco smoke exposure. The articles in this special issue will educate readers about the epidemiology and health consequences of smoking, and will provide a new way of thinking about nicotine addiction. Readers will learn about training for pediatricians, epidemiology and health effects of tobacco 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 abstinence rates [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 every adult 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 interviewing techniques may be needed for smokers who are not yet ready to make quit attempts or to divulge information about their smoking behavior. Pediatricians have historically missed valuable opportunities to discuss smoking with parents and children during routine well child visits for reasons that include the stigmatizing nature of the topic, respect for privacy, lack of tobacco cessation training during medical school [4], and insufficient time, expertise, and financial incentives. The creation of pediatric residency smoking cessation programs and curricula has led to an improvement in residents' self-efficacy for counseling parents, and will hopefully empower the next generation of practicing pediatricians to take more active roles in anti-smoking counseling and advocacy. There have been numerous Surgeon General's reports (http://www.surgeongeneral.gov/library/reports/index.html) on tobacco use, smoke exposure, health consequences, and prevention efforts in general and minority populations, women, and children. Links have been established between maternal smoking and increased risks for reduced fertility, stillbirths, premature infants, 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 and are more likely to become dependent on tobacco if they start smoking. Pregnant women have higher quit rates compared to the general population, but relapse is, unfortunately, not uncommon in the months following delivery. However pediatricians interacting with pregnant and postpartum women can encourage them to remain tobacco free by pointing out the negative health 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 also exposed to smoke in daycare settings and in other environments. As many as 17-18% of children in the United States [6] live in homes where a parent smokes; worldwide about 40% of children are exposed to tobacco smoke [7]. Tobacco smoke exposure affects numerous organ systems, causes genetic changes, influences the developing immune system, and contributes to an estimated 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 ear infections, and associations with behavioral and sleep problems [1]....

Tobacco Smoke (TS) exposure is an important cause of pediatric morbidity and mortality worldwide. Estimates suggest that over 50% of US children are exposed to tobacco smoke, and 40% of children internationally. TS exposure has been linked with many specific diseases and social conditions. It is especially prevalent amongst children who live in poverty, and is associated with increased rates of food insecurity. Children who are exposed miss more school, and thus may 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 in lower antioxidant levels, and increased rates of asthma and other atopic diseases. In addition to asthma, TS exposure increases the risk and severity of respiratory diseases, including bronchiolitis and tuberculosis. TS exposure in children has 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 and cardiovascular disease may begin in childhood, with exposed children having higher rates of metabolic syndrome, and measurable changes in their vascular contractility. Efforts need to continue worldwide to prevent children's exposure to this toxic and harmful product.

In the US 20.6% of adults and 19.5% of high school students are current cigarette smokers. Smoking is responsible for 5 million deaths worldwide each year and is known to cause more and a greater variety of human disease than 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 young smokers, who experience respiratory symptoms, increased rates of infection, and evidence of cardiovascular effects soon after beginning to smoke, even at low levels of cigarette use. Declines in the rate of cigarette smoking have stalled in the developed world. In the US, the Healthy People 2010 goal of decreasing current smoking in youth to below 16% has not been met. Smoking rates are increasing in the developing world, and there is already a rise in tobacco related problems in those areas least able to cope with the increased burden of disease. Continued efforts on a global scale are needed to combat the persistent and growing problem of tobacco use.

Addicted smokers experience nicotine withdrawal anytime they go too long without smoking. Withdrawal presents as a continuum of symptoms of escalating severity described by smokers as “wanting,” then “craving,” and eventually “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 smoke that makes quitting difficult. The compulsion to smoke is the core feature of nicotine addiction accounting for its clinical course, physiological characteristics, prognosis, and behavioral manifestations. A compulsion can develop quickly, having been experienced by one third of youth who have smoked only 3 or 4 cigarettes. Its physiologic basis is evident in neurophysiological measures and its recurrence after each cigarette at a characteristic interval. At first, a single cigarette can keep withdrawal at bay for weeks, but as addiction progresses, cigarettes must be smoked at progressively shorter intervals to suppress withdrawal symptoms. The physiologic need to repeatedly self-administer nicotine at shorter intervals explains a full spectrum of addictive symptoms ranging from the prodromal symptom of wanting, to chain smoking. 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 simple diagnostic approach covers the full spectrum of addiction in smokers of all ages and levels of tobacco use, and is more valid 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 briefly review the extent of the problem highlighting current policies that are effective in its control. I provide information on prevalence of tobacco use and tobacco smoke exposure (TSE) among children and adolescents worldwide along with mortality data and economic data. I summarize the public policies that have been shown to be effective in reducing tobacco initiation and TSE in children using as a framework the MPOWER recommendations from the World Health Organization (WHO). I review each one of these policies- monitoring, smoke-free environments, treatment of tobacco dependence, health warnings on packages, bans on advertising, promotion and sponsorship, and tobacco taxation- and explain how they can prevent smoking among children and adolescents and their exposure to tobacco smoke. Finally, I discuss 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 and mortality. The primary source of the TS to which children are exposed is smoking by parents or family members in the home. Clinicians who care for children can and should counsel families to make the child's environment completely smoke free and ultimately, to quit using tobacco altogether. In as little as three minutes, counseling to make environments smoke free and tobacco users to quit can be delivered. Basic techniques of behavior change counseling and cessation resources for families are discussed, including stages of change, the “Five A's,” brief motivational messaging, and pharmacotherapies. The evidence supporting counseling of parents and patients to promote smoke free homes and tobacco use cessation is presented. Policies that promote smoke free homes are discussed briefly.

Each year 40% of the worldapos;s children are exposed to tobacco smoke and 166,000 children die from that exposure annually. The 2006 and 2010 U.S. Surgeon General Reports concluded that there is no safe level of tobacco smoke exposure (TSE). The only way to completely protect children from the dangers of household TSE is to help all household members quit. Due to the many health concerns associated with children's TSE, parental tobacco control is a priority within the pediatric setting. Child healthcare clinicians are in a unique position to influence the smoking behaviors of parents, thereby improving the health of their patients. The Clinical and Community Effort Against Secondhand Smoke Exposure (CEASE) is a parental tobacco control intervention that uses an operational form of the U.S. Department of Health and Human Service's (HHS) Treating Tobacco Use and Dependence Guideline in the context of the child's outpatient medical visit. The CEASE method includes three steps (Ask, Assist, Refer) that encompass the goals of the 5A's (Ask, Advise, Assess, Assist, Arrange) in a simplified format, allowing for brief, tailored cessation support for the person who smokes. This paper summarizes the research on the harms of TSE and explores how child healthcare clinicians can most effectively eliminate these health risks to children by implementing CEASE. Finally, we look at legislative 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 about tobacco's effect on children have often focused on harm reduction, i.e. counseling parents to smoke outside. More recently, pediatricians have become interested in directly addressing smoking cessation. This review concentrates on why pediatricians are in a unique position to access smokers, and why they should specifically act as smoking cessation counselors. The available literature on the pediatrician as smoking cessation counselor for both parents and adolescents is reviewed. A brief introduction to the various evidence-based counseling methods is also provided.

Background: Children exposed to tobacco smoke are at great risk for adverse health conditions leading to hospitalizations. Cessation interventions targeted at adult smokers in hospital settings have been shown to be effective in reducing smoking behavior. However, only a limited number of hospital-based interventions targeted at parent and household smokers have been described in the pediatric literature. Objective: The purpose of this article was to identify and compare successfully implemented pediatric hospital-based smoking cessation interventions, discuss outcomes, and identify 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 inclusion criteria if the target population was limited to parent or household members of children admitted to a pediatric inpatient facility, and if the smoking cessation intervention was provided during the inpatient period and or initiated prior to discharge. 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, and following-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 findings support the conclusion that hospital-based tobacco use cessation interventions for parents and household members of children admitted to a hospital are implementable by any level of health care provider, using a variety of intervention models. Although these preliminary reports are encouraging, objective outcomes and long term follow-up studies are still needed.

In view of the fact that smoking cessation is more likely during pregnancy than at other times, interventions to maintain quitting postpartum may provide the best opportunity for a long-term abstinence. Pediatricians, more than any other professional, see mothers of the infants and small children on a frequent basis, and pediatric well-care visits offer a unique opportunity for relapse prevention messages. The most important determinants of postpartum smoking relapse, 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 postpartum visits. 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 behavioral contracting.

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