Tobacco smoke exposure and the hospitalized child

Karen M. Wilson, MD, MPH, FAAP Section Head, Pediatric Hospital Medicine Children’s Hospital Colorado CPCE Policy Clinical Effectiveness Research Lecture June 7, 2013

Disclosure

: In the past 12 months, I have had no relevant financial relationships with the manufacturers of any commercial product or providers of commercial services discussed in this CME activity. I do not intend to discuss an unapproved or investigative use of a commercial product or device. I DO intend to mention commercial products in my presentation.

Illustrated Surgeon General’s Report on Smoking - Alfred Gescheidt, 1964

Julius B. Richmond Center of Excellence

…

dedicated to protecting children from secondhand smoke, and ensuring that

all

clinicians ask the right questions about tobacco and SHS exposure

Learning objectives

• • • • At the end of the lecture, the audience will: Identify sources of pediatric secondhand smoke exposure Describe the consequences of tobacco smoke exposure for children Apply intervention techniques with families of children who are exposed

Highlighting a couple of inpatient research projects along the way…

Background

• • 18% of children ages 3-11 are regularly exposed to secondhand tobacco smoke (SHS) in the home 54% of children ages 3-11 had detectable cotinine levels in the 2007-2008 NHANES  19 million children ages 3-11

Other sources of exposure

• • • • • • • “I only smoke outside” Grandparents Non-custodial parents Daycare Friends Multiunit housing Thirdhand smoke…

What is thirdhand smoke?

• • • • Thirdhand smoke is the residue left behind after a cigarette is extinguished.

Toxins accumulate in the air and dust of homes, even when parents smoke outside.

Nicotine reacts with other pollutants and can form toxic compounds not found in fresh tobacco smoke.

Children who are crawling may be at particular risk.

Cigarette smoke residue on walls

What are the effects of secondhand smoke exposure?

Risks of exposure in children

• • • • • • Increased risk and severity of RSV bronchiolitis 1.3 times greater odds of hospitalization 1.6 times greater risk of otitis media 1.8 times greater risk of asthma Twice the risk of developing inflammatory bowel disease 4.7 times the risk of developing metabolic syndrome

Second hand smoke and influenza severity

• • • • Chart review at Golisano Children’s Hospital in Rochester NY Discharge diagnosis of influenza (ICD-9 948.*) Influenza diagnosis verified by laboratory review  Patients with no documented influenza were excluded Charts abstracted by trained reviewers

Measures of severity

• • • Intensive care unit admission:  Documentation of admission or transfer to PICU at any time during stay Need for mechanical ventilation:  Any documentation of endotracheal intubation during stay Length of stay:  Days, abstracted from UB92 length of stay calculation

SHS exposure and covariates

• • • • • Any documentation of presence or absence of SHS exposure by any provider Patients without any documentation of presence or absence of SHS were excluded Demographics Insurance type:  Public, HMO, traditional, self-pay or other Other conditions:    Asthma Other chronic illness Prematurity

Results: demographics

• • • • 47 (40%) SHS exposed 70 (60%) not SHS exposed Gender: 50% male Race/ethnicity:    White 58% Black: 23% Other: 19% • • Mean age: 4 years Public insurance: 49%

Results: clinical picture

• • • • • 78% had influenza A 21% had an additional diagnosis of asthma 29% had an underlying chronic condition 18% required ICU care 6% required mechanical ventilation

Length of stay (LOS) by chronic condition and SHS exposure Chronic condition

No Yes

Exposed to SHS

No Yes No Yes

Overall p-value for ANOVA .010

Geometric mean LOS (days)

2.1

2.1

3.5

10.0

Regression analyses

• In a logistic regression analysis controlling for age, gender, insurance status, asthma, presence of bacterial infections, and chronic health conditions,  the odds of being admitted to the PICU for children with SHS exposure were 4.7 (95% CI: 1.4-18.5) higher than children not exposed to SHS   the odds of being intubated were 8.8 higher (95% CI: 0.9-232.4) SHS exposure was associated with a 70% longer LOS in a negative binomial regression analysis (p<.01) 17

Conclusions

• • Children with SHS exposure who are admitted to the hospital for influenza:   Are more likely to need ICU admission Have longer length of stay *

Even controlling for demographics and chronic illness

These effects are even greater for children with chronic illnesses who are SHS-exposed

Other risks of exposure

•

Higher risk for:



SIDS



School absence



Sleep problems



Dental caries

What about very low levels?

• • Yolton et al:  NHANES analysis examining cognition in children exposed to SHS  Significant inverse relationship between cotinine level and block design, reading, and math scores  Greatest decrease was at the lowest cotinine levels (.1-1 ng/mL) Particular disadvantage for poor children

Effect on antioxidant levels

• Wilson, et al  Also using NHANES  Relationship between cotinine levels and serum levels of antioxidants  Significant association between levels of cotinine and vitamin C, and carotenoids  Association was significant even at low levels of exposure (.015-2 ng/mL)

What levels do we actually see in kids?

• • • • Cotinine cutoff to distinguish adult smokers:  5 ng/mL Highest level in our inpatient study:  25 ng/ml (6 month old with parent smoking indoors) Cotinine levels in infants with:    Mothers who smoke inside: 15.47 ng/mL Mothers who smoke outside: 2.32 ng/mL Mothers who don’t smoke: .33 ng/mL Average cotinine level in children living in attached housing with no smokers in the home:  .075 ng/mL

Other biological evidence

• • Studies have found increased levels of Eosinophilic Cationic Protein (ECP), CRP, and IL-13 in smoke-exposed children Shift to Th2 from Th1 immune regulation may cause increase of asthma and atopy, as well as decreased Th1 response to pathogens • • Increased risk for viral respiratory illnesses Increased risk for asthma

Secondhand Smoke Affects Families

• Children whose parents smoke are more likely to smoke themselves  Potential role of nicotine priming • A pack-a-day habit costs $1000 to $1500 a year  Risk of food-substitution

Can Providers Help Eliminate SHS Exposure?

• • • • • No. We’re already too busy!

No. Parents aren’t our patients.

No. We’ll alienate parents and they’ll go somewhere else.

No. We won’t be reimbursed for the time we spend.

And besides, we don’t know what to do!

Yes, You Can!

• You can be effective in 3 minutes or less!

• Parents EXPECT you to discuss tobacco use.

• If you respect the parent during your discussion, you won’t alienate them.

• You got me there. (Reimbursement.) • We’ll teach you how!

PHS Guidelines on Tobacco 2008: Key Recommendations

• • • Brief Clinical Intervention: the 5A’s (2 A’s & R) Refer to Quitline Offer Pharmacotherapy

Ask…

• • Parents, even those who smoke, want and expect providers to bring up second-hand smoke exposure.

It’s important to address smoking in a non-judgmental manner.

Ask… the right question!

• You don’t smoke in front of her, do you?

Ask… the right question!

• • You don’t smoke in front of her, do you?

No one smokes in the home, right?

Ask… the right question!

• • • You don’t smoke in front of her, do you?

No one smokes in the home, right?

Does anyone smoke in the home?

Ask… the right question!

• • • • You don’t smoke in front of her, do you?

No one smokes in the home, right?

Does anyone smoke in the home?

Is your child ever exposed to cigarette smoke?

Ask… the right question!

• • • • • You don’t smoke in front of her, do you?

No one smokes in the home, right?

Does anyone smoke in the home?

Is your child ever exposed to cigarette smoke? Does anyone who lives in your home or who cares for your child smoke/use tobacco? Who is that? Where do they smoke? Is that inside the house? 

What they smoke is a different question entirely…

How well do hospitals do?

• • • • • Study of inpatient screening for SHS Pediatric inpatients recruited from Golisano Hospital in Rochester, NY Children’s New admissions reviewed each morning when a research assistant was available, and approached for participation Recruited from April 2008-June 2009 All pediatric inpatients with an available parent who had been inpatient <2 days were eligible 35

Methods

• • • Structured and validated parent interviews: • • • Demographics Health history SHS exposure:  In-home sources    Smoking outdoors by family members Home smoking bans Other sources of exposure Salivary cotinine: • • Metabolite of nicotine Most often used biological marker for SHS Saliva sample: • • 3-6 Salivettes placed on the buccal mucosa for 1 minute Analyzed for cotinine content using an immunoassay (detection limit .05 ng/mL)

Defining smoke exposure

A child was considered SHS-exposed if any of the following: • • • Living with a smoker, OR SHS exposure anytime within the last 7 days, OR Salivary cotinine ≥1 ng/mL measured using Immulite

Screening assessment

• Chart review:   Emergency Department (ED) providers Social history section of form:

None Current-amount Quit- Date

Tobacco EtOh Drugs • • Residents:  Smoke exposure status is supposed to be recorded in the Social History section Nurses:   Admission form with SHS exposure question New question: Does anyone smoke in the house or around the patient?  Yes  No

Results

• • • • • • 432 patients approached 140 participated (32%)   16% initial participation rate 49% participation rate when $5 coffee cart card was offered 81 (58%) had usable saliva samples Mean age 3.8 years (range 0-16.9) 56% male 75% White, 10% African-American, 7% multiracial, 6% Hispanic, 1% Asian

Results- smoke exposure

• • • 12% were exposed inside the home 34% had been exposed somewhere in the past 7 days 28% had cotinine levels > 1ng/mL

Prevalence of exposure by type of assessment

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 79% 54% 46% 38% 8% ED 68% 42% 69% 41% 26% 45% 16% 10% 24% 16% Residents Nurses Anyone Interview Cotinine

Type of Assessment

Exposure Not Found Exposure Found

Discussion

• • • 46% of pediatric inpatients had some form of SHS exposure  Only 24% were identified as being exposed Significant missed opportunity for intervention and risk stratification Sensitivity of current screening tools is variable, and not great:  26-67% •

Ask your parents about their child’s exposure, and make sure the residents ask too!

Advise…Be specific

• • • Quitting smoking is the best thing you can do to help protect your health and the health of your child.

I can help you.

Have you thought about quitting (Assess)?

  No- exposure reduction Yes- exposure reduction and Assist/Arrange

Advise…exposure reduction

• • Having a smoke free home means no smoking

ANYWHERE

- home or car.

It does

NOT

mean smoking:    Near a window or exhaust fan In a basement, garage, or screen porch In the car with the windows open    Inside only when the weather is bad Cigars, pipes, or hookahs On the other side of the room

The bacon analogy

Negotiation over time

• • Even small doses of counseling can add up over time.

A complete ban may not be a reasonable first step for some smoking parents:   Negotiate small, acceptable steps with the parent Reinforce health benefits to the child of reducing smoke exposure

The exposure ladder

Smoking in the room

The exposure ladder

Smoking elsewhere in the house Smoking in the room

The exposure ladder

Smoking usually outside Smoking in the room Smoking elsewhere in the house

The exposure ladder

Smoking usually outside Smoking in the room Smoking always outside Smoking elsewhere in the house

The exposure ladder

Complete smoking ban in house and cars Smoking usually outside Smoking in the room Smoking always outside Smoking elsewhere in the house

The exposure ladder

Complete smoking ban in house and cars Smoking usually outside Completely non-smoking family Smoking always outside Smoking elsewhere in the house Smoking in the room

When it’s grandma who smokes…

• Other family members can be even more challenging:  Teen parents may not feel empowered to take a stand    Financial dependence Dependence on child care Domestic abuse situations

Grandma, continued

• Potential ways to mediate:  Write a letter to the child’s family stating that cigarette smoke exposure could make the child more likely to be sick, and that you are recommending that no one smoke inside the house.

 Ask that the smoking family member come to visit, so they can be a part of the discussion.

 Give the parent information, handouts, etc that support their position that SHS is bad for their child.

 Work with social work and local agencies to try to find alternate child care or housing for the child.

Refer

• • • REFER families who use tobacco to outside help Using the Quitline handout or your state’s fax enrollment form, refer tobacco users to the Quitline 1-800-QUIT NOW Document referral given to families in the child’s chart Arrange follow-up with tobacco users

PA Quitline

• • • http://www.portal.state.pa.us/portal/server.pt/community/sm oke_free/14315/quitting_tobacco_resources/557546 http://map.naquitline.org/profile/usa/pa/ Administered by National Jewish Health 56

Artwork by Minh-Tri Vo. © 2010 American Academy of Pediatrics (AAP) Children's Art Contest. Support for the 2009 and 2010 AAP Children's Art Contest was from the Flight Attendant Medical Research Institute.

57

Pharmacotherapy

• Combining pharmacotherapy with counselling DOUBLES a patient’s chance of successfully quitting smoking • Nicotine replacement therapy (NRT) (many brands, some generics)  Many OTC  Some states reimburse, even for OTC (prescription may be required) • • Bupropion SR (Zyban, Wellbutrin) Varenicline (Chantix)

NRT

• Non-nicotine components of tobacco cause most of the adverse health effects •  Tars, carbon monoxide, etc.

The benefits of NRT outweigh the risks, even in smokers with cardiovascular disease (remember they already smoke!)

Using NRT: Treatment Goals

• • • • • Overall reduction of nicotine withdrawal symptoms – not to replace tobacco!

Help with momentary urges Modify habitual behavior Postponement of smoking May be used to defer smoking when in environment in which smoking is not allowed

NRT Products Can Be Combined

• • • • Use the patch for “daily maintenance” Add gum or lozenge for intense urges Read and follow the directions!!

Warn about symptoms of nicotine overdose  Nausea, dyspepsia, “the jitters” • • Maintain a consistent level of nicotine during waking hours with “breakthrough” dosing initiated by the patient Most users UNDERDOSE – frequent cause of treatment failure

www.aap.org/richmondcenter

 Audience-Specific Resources  State-Specific Resources  Cessation Information  Funding Opportunities  Reimbursement Information  Tobacco Control E-mail List  Pediatric Tobacco Control Guide  Tobacco Prevention Policy Tool