Transcript Why smoking cessation counseling should be part of your job and what to do about it. Your name, institution, etc.

Why smoking cessation counseling should
be part of your job and what to do about it.
Your name, institution, etc. here
YOUR LOGO HERE
(can paste to each slide)
…dedicated to eliminating children’s exposure to tobacco
and secondhand smoke
Objectives
• Review the evidence for harm to children from
parental smoking
• Understand the rationale for the pediatrician as
smoking cessation counselor
• Gain basic skills in smoking cessation counseling
• Practice a brief motivational message in three
different clinical scenarios
So, what’s the big deal?
• In 2009, 46.6 million adults smoked, or 21% of the
general population
• 31.1% of those living below federal poverty level
smoke
• 33.6% of those who did not achieve a high school
education
But, they all smoke outside, right?
• 18% of children ages 3-11 and 17% of children ages
12-19 live in a home where someone smokes inside
• There is some evidence that parents smoke at higher
rates than non-parents and that they quit at lower
rates (Hmm, parenting may be stressful……..)
What is the leading pediatric cause of death
in the US?
Accidents, under 4 yo – 1,714 deaths
Accidents , under 9 yo – 2,997 deaths
Accidents, under 14 yo – 4,550 deaths
Smoking-related excess pediatric deaths - 5,900
Why the pediatrician?
• 24,500 excess cases of LBW
• 430 excess cases of SIDS
• 22,000 excess hospitalizations for RSV
• 3.4 million excess cases of AOM
• 110,000 excess typanostomies
• 1.8 million excess visits for asthma
• 590 excess hospitalizations for burns
Parental Smoking
• Children are proportionally most affected by tobacco
– Smoking related excess deaths are 50% of all
deaths under 15 Y/O
• Children cannot voluntarily remove themselves from
the exposure
Why the Pediatrician?
• Parents of young children tend to be young and otherwise
healthy and may visit the pediatrician more than any other
doctor
• Income cutoffs for public insurance are less strict for children
than for adults, i.e. publicly insured children frequently have
uninsured parents
Why the Pediatrician
• Low SES and low parental educational levels correlate
with increasing SHS exposure
• You have access to smokers that do not otherwise
interact with healthcare.
And, another thing……….
• Anti-smoking actions by parents are a strong
predictor of non-smoking in teens
• Anti-tobacco opinions and discussions with parents
are factors that protect against youth tobacco use,
even if the parent smokes
Practitioner Effectiveness
• 7-10% of smokers spontaneously quit with success
• 13% of smokers quit after an appropriately designed
brief message from a healthcare provider
• Up to 30% of smokers quit using guideline recommended
treatment
But, they don’t even want to quit….
100
90
80
70
60
50
40
30
20
10
0
18-24
25-44
45-64
65+
0 tries
1-2 tries
3-6 tries
7+ tries
Percent of Current Smokers Who Want to Quit by Age and
Number of Previous Quit Attempts – United States, 2000
Well, then, they don’t want to hear it from
me, do they?
• Parents do not object to smoking cessation messages
from pediatricians and may even welcome the access
to medical advice
• Some interventions in pediatric settings have been
as successful as interventions in other medical
settings
OK, so now what?
• Multiple evidence-based strategies are available and
can be combined
• 5 A’s
• Screening, Brief Intervention and Referral
• Stages of Change Model
• Motivational Interviewing
The 5 “A”s
Ask
Smoking status
Advise
To quit
Tobacco use as a
vital sign
Brief, informative,
clear, personalized
Weigh pros and cons
Assess
Willingness to quit
Assist
in quitting
Assess importance,
readiness, and confidence
Assess stage of readiness
to quit
Offer help: e.g.
- refer to counseling, quitline
- analyze past attempts
- develop quit plan,
Arrange
Follow-up
- provide pharmacotherapy
The 5 “A”s for the Pediatrician
• Asking =Do you smoke? Where do you smoke? Is the child
exposed to tobacco smoke anywhere else?
• Advising = You must at least say “I want you to quit” in some
way
• Assessing = Have you considered quitting? Assess
importance, confidence and readiness?
• Assisting = Find help or give it yourself.
• Arrange = Follow-up at each well child check, take
ownership of the problem.
Screening, Brief Intervention and Referral
• Institutionalizes screening (5th vital sign)
• Knowledge of referral resources in your local
community
• Or, reliance on national or state Quitlines
1-800-QUIT-NOW
An effective brief message is…
• Informative
• Clear
• Personalized
“Ms. Jones, as your child’s doctor I feel I need to let you know about
some concerns I have. I’m really worried that John’s frequent
respiratory infections could be aggravated by smoking. Although
you’ve said your cigarettes are important to control your stress,
I’m worried they could be causing some of John’s health problems.
Please let me know if I can help you quit.”
Suggested Brief Interview
ELICIT CONCERNS
–
–
“What concerns do you have about smoking?”
“What else concerns you about your smoking?”
CONSIDER BENEFITS
–
“What do you like about smoking” (“What does smoking do
for you?)
SUMMARIZE
–
“So on the one hand, you perceive some benefit from
smoking, but at the same time you are concerned about…”
OFFER HELP
–
“If I offered you some help, would you be willing to quit
smoking?”
Stages of Change Model
Describes how people move towards change in behavior
• Provides a framework to match counseling efforts to
patient’s “stage of readiness”
• Focuses counseling content to individual patient’s
needs
• Very easy to remember – YES, NO, MAYBE
When they say No! - Helpful Questions
• What would have to happen for it to become much more
important for you to quit?
• Scaling questions…..
• What would have to happen before you seriously
considered quitting?
• What do you like about tobacco? (smoking?)
• What concerns do you have about tobacco? (smoking?)
• Explore past quit attempts?
•
Where does this leave you now? Can we talk about this
time?
When they say Maybe - Assessing
Importance, Confidence and Readiness
• How important is it for you to quit tobacco?
(stop smoking?, on a scale of 0 to 10?)
• How much do you want to quit tobacco?
(stop smoking?, on a scale from 0 to 10?)
• How confident are you that you could quit?
(stop?, on a scale from 0 to 10?)
When they say Maybe - Helpful Questions
• What would make you more confident about quitting?
• Why have you given yourself so high/low a score on confidence?
• How could I help you succeed?
• Is there anything you found helpful when you quit before?
• What have you learned from your last try to quit?
• If you decided to quit, how might you do it?
– Do you know of things that have worked for other people?
• What would make you feel more confident?
When they say Yes! - Action
• Provide skills for coping
• Get support from friends/family
• Get nicotine replacement method
• Set quit date
• Follow-up by phone or in office
Motivational Interviewing
• Method designed to address addictive behaviors,
frequently applied by smoking cessation counselors
• Very pediatrician friendly style
• Addresses the issue of resistance in a nonconfrontational manner
Motivational Interviewing
• Origin with Miller 1983 - more complete training of addiction
counselors
• Brief interventions - Rollnick et. al. 1992
– general information exchange strategy
– health promotion with hospitalized heavy drinkers
• Definition – “a directive client-centered counseling style for eliciting
behavior change by helping clients to explore and resolve
ambivalence”
Internal Motivation is More Effective
“I want to feel better”
“I have the strength to do this”
Externally directed motivation can lead to guilt, anxiety, anger,
frustration and failure
“You gotta” counseling often elicits resistance (“I don’t
wanna”) or denial (“Problem?, What problem?”)
Philosophy of Motivational Interviewing
•
Motivation to change is elicited, not imposed
•
It is the patient’s task – not the practitioner’s – to articulate and resolve
ambivalence
•
Direct persuasion is ineffective for resolving ambivalence
•
The interviewing style is quiet and eliciting
•
The practitioner is directive only is helping the patient examine and resolve
ambivalence
•
Readiness to change is not a patient trait, but a fluctuating product of
interpersonal interaction
•
The therapeutic relationship is more like a partnership or companionship
Motivational Interviewing “Style”
• Exchange rather than convey information
• Assess your patient’s readiness to talk/share/express
feelings/change
• Use simple open questions
• Listen carefully and encourage, agree, reinforce with
verbal and non-verbal prompts
Motivational Interviewing “Style”
• Clarify and summarize at the appropriate points
• Recognize resistance and adapt to it without
confrontation
• Express empathy with reflective statements
Four General Principles
• Express Empathy
– Acceptance facilitates change
– Skillful listening is fundamental
– Ambivalence is normal
• Develop Discrepancy
– The patient should present the arguments for change
– Discrepancy between present behavior and important
personal goals or values motivates change
Four General Principles
• Roll with Resistance
–
–
–
–
–
Signal to respond differently
Avoid arguing for change: psychological reactance
Resistance is not directly opposed
New perspectives are invited but not imposed
The patient is the primary resource in finding answers and
solutions
• Support Self-Efficacy
– The patient is responsible for choosing and carrying out change
– A person’s belief in the possibility of change is important
– Good predictor of change
Signs You’ve Got It Right
• You are speaking slowly
• Your patient is doing most of the talking
• Your patient is talking about quitting tobacco
• You are listening carefully and gently directing the
interview
• Your patient appears to be “working hard,” often realizing
things for the 1st time
• Your patient asks for information and advice
“Whoa — way too much information.”
Scenario 1
• You are seeing a 4 month old for a WCC. A note in
the chart says mom quit smoking during pregnancy.
You notice she seems tired and stressed out. She
doesn’t talk about smoking but smells like smoke.
What do you do?
Scenario 2
• You are seeing an 18 month old in follow-up after his
4th ear infection in 4 months. He is well now but you
scheduled this visit to talk about PE tubes. Both
parents are smokers and the child has persistent
effusions bilaterally. What do you discuss?
Scenario 3
• You are seeing a 16 month old in May for his third
episode of wheezing. You originally diagnosed
bronchiolitis the first two times last winter but are
beginning to worry about asthma. Dad smokes but is
not here at this visit. What do you talk to Mom
about?
YOU CAN DO IT!
• Ask everyone about tobacco every time
• Advise everyone to quit
• Assist everyone who smokes in whatever way you
can (counsel or refer)
Need more information?
The AAP Richmond Center
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
CLEAR THE AIR!