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To discuss strategies for integrating evidence-based tobacco use screening, cessation assistance, and referral to outside services into visits with families in outpatient child health care settings.
Presentation of counseling scenarios used in the Clinical Effort Against Secondhand Smoke Exposure (CEASE) training video and commentary.
Demonstrated strategies include: eliciting information about interest and readiness to quit smoking, respectfully setting an agenda to discuss smoking, tailoring advice and education to the specific circumstances, keeping the dialogue open, prescribing cessation medication, helping the smoker set an action plan for cessation, enrolling the smoker in free telephone counseling through the state quitline, and working with family members to establish a completely smoke-free home and car. Video demonstrations of these techniques are available at www.ceasetobacco.org.
Child health care clinicians have a unique opportunity to address family smoking and can be most effective by adapting evidence-based tobacco cessation counseling strategies for visits in the pediatric setting.
Over 30% of all children in the United States are exposed to secondhand smoke within their own homes [1,2]. Each year, more than 5000 children die from tobacco exposure, which is triple the number who die from all childhood cancers combined [3,4]. For all children and adults, there is no safe level of secondhand smoke exposure .
Offering smoking cessation advice and assistance to parents in the pediatric setting can increase abstinence rates among parents who smoke and protect children from secondhand smoke exposure [6,7]. The pediatrician’s office is an ideal setting to address tobacco use at the family level, as many parents visit their child’s doctor more often than their own [8,9]. Indeed, a majority of parents report they would be more satisfied with their visit if their child’s doctor addressed their smoking [10,11]. Interventions as brief as 3 minutes significantly increase adult cessation rates  and can be readily incorporated into the pediatric visit. Such interventions are recommended by the U.S. Public Health Service and the American Medical Association .
This paper provides an overview of evidence-based strategies for addressing family smoking in outpatient child health care settings drawing on clinical scenarios created by the CEASE (Clinical Effort Against Secondhand Smoke Exposure) program. There is an accompanying video for each clinical scenario presented and its Web address is provided. The CEASE program, developed by the Massachusetts General Hospital Center for Child and Adolescent Health Policy in collaboration with local and national partners, is a module to help clinicians assess tobacco exposure and quit readiness, give evidence-based brief cessation advice, provide pharmacologic management of tobacco dependence, and refer tobacco users to free quitlines (www.ceasetobacco.org) . These actions are summarized in their 3-step model, Ask, Assist, and Refer (Table).
Asking about smoking status is the first critical step in addressing family smoking and secondhand smoke exposure in children. The best question to ask is, “Does your child live with anyone who uses tobacco?” If the answer is yes, the clinician should move towards respectfully discussing the family member’s smoking by asking about his or her readiness to quit and interest in assistance.
Key questions about tobacco use can be added to a health history form, which would be later filed in the chart. Systematically handing out this form prior to the clinical exam is recommended. Questions about how ready the family member is to quit smoking and what help they might like can be included. With information gathered before the visit, both the family and the clinician will be more prepared to discuss smoking during the visit. Documenting the information in the patient’s chart ensures that it will be available at subsequent visits.
Mary is an 8-year-old with asthma. The clinician sees in the chart that Mary is exposed to tobacco and recognizes that she is trapped in a situation that exacerbates her chronic condition. A brief discussion about establishing a smoke-free environment is a priority. With information gathered in the chart beforehand, the clinician can use his limited time with the mother most effectively. In the following clinical scenario, the clinician uses brief motivational messaging to discuss the effects of tobacco toxins on Mary’s health. He assists the mother with quitting smoking and establishing a smoke-free environment.
Clinician: I see here in your chart that the grandmother smokes and you live with her. Is that right?
Clinician: And you actually are interested in quitting?
Mother: Yeah, I’m always interested in quitting, it’s just the time is never right.
Clinician: I understand. Do you have any questions about secondhand smoke and Mary’s asthma?
Mother: I guess it must make the asthma worse? I always smoke outside, but I can’t get my mom to do that, especially in the winter. She smokes in the kitchen or in her bedroom.
Clinician: Well first of all, it sounds like you’re always smoking outside, so that’s really good, and maybe we need to talk through how to handle the situation with your mom. It’s important that she understand that those poisons that are in the cigarette smoke go everywhere in the home, and they’re very sticky. They stick to all other surfaces, and those poisons make a big difference for Mary’s asthma. They can make it much worse. Do you think that she has an understanding of that?
Mother: No, she says the air is already bad around here from the highway and the factories.
Clinician: Well it is even more important, then, to keep the home as clear as possible. Let me give you this to take home to your mother. This is the smoke-free home halflet, and it talks about how no matter where you’re smoking in the home, it’s never safe, even with a window open or even with the fan on. Even though she doesn’t see the smoke going into Mary’s nose, it still is contaminating the home. So I’m going to give you this to give to her from me, and it’s really important that we try to establish a smoke-free home. And then in terms of your being interested in quitting, I think that’s great. Would you like to work with me on getting to that point where you want to get to?
Clinician: Okay, great. Well there are a couple of things that we have for you that can help you. One of them is this “Be a Star” halflet. It talks about the importance of quitting for your health and for Mary’s health. It offers you the chance to set a quit date. Is that something that you might be interested in today?
Mother: I’ll think about it. It should probably be soon.
Clinician: Okay, so what I’d like to do is see Mary and you, and hopefully your mother in follow-up?
Mother: Yeah, we can do that.
Clinician: Okay, great. So let’s do that in two weeks so I can listen to Mary’s lungs and make sure that they’re getting better. I want to hear about how things are going with a smoke-free home and a smoke-free car, and let me know how it goes with your mom. The only way to do it is to try, and it can come from me, not from you. And then the other thing is, I want you to think about quitting smoking, and when you’re ready, we can talk about medication, and maybe even enrolling you in the quitline to get you additional support. So I’ll see you on follow-up.
Mother: Okay, thank you.
Even in a complex situation like Mary’s, the clinician can have a major impact by problem solving with the parent to reduce the family’s exposure to secondhand smoke. The mother expressed interest in quitting, and the clinician was prepared to offer assistance. He offered her the chance to set a quit date, but her hesitation showed him that she was not ready yet. The clinician provided her with information about quitting smoking, and invited her to continue the conversation during their next visit. He made use of Mary’s follow-up visit to enhance motivation for services in the future.
The clinician provided a brief motivational message using the thirdhand smoke concept—tobacco smoke contamination that remains after the cigarette is extinguished —to encourage a complete smoking ban in the home [13–17]. Beliefs about the health effects of thirdhand smoke are associated with home smoking bans . Since the smoking grandmother was not present, the clinician sent a CEASE health education sheet (halflet) home to her. He also suggested that the grandmother attend Mary’s next visit.
In the following clinical scenario, the clinician and the mother have a history of discussing her smoking, as documented in the child’s chart. The clinician touches briefly on the subject to see if the mother is interested in pursuing it.
Clinician: So, Billy’s 6-month exam is just great. Before we get to the vaccines, I just wondered if you’ve given any further thoughts to your smoking.
Mother: Yes, now that he’s up more, it is quite hard to go out to get a cigarette. I drink a lot of water. I try to distract myself by doing things with him, like reading with him, but I think it is time to quit again.
Clinician: Oh that’s terrific. So it sounds like you’ve really sort of thought about this, and you are able to postpone having the cigarettes at least. Well, I fully support you in wanting to try to quit again, and I think I can help. There are some ways that we can do that, some ways that we can give you the support that you need.
The clinician approached the subject of the mother’s smoking in a considerate manner. Without using judgmental language, he made it clear that he wanted to discuss the mother’s smoking. Open to doing so, she told him that she felt ready to quit again. The interaction might have gone quite differently had the clinician opened with “Well, you know that you shouldn’t smoke, right?” Such a statement could have led mother to feel defensive, ashamed, and closed to further discussion. Instead, he showed empathy by offering support and assistance.
The forms of assistance clinicians can offer include social support, information on the harms of smoking and secondhand smoke, strategies to reduce secondhand smoke exposure, and a prescription for nicotine replacement therapy (NRT). This assistance can be built upon, with the clinician offering social support and information until the smoker is ready to quit, at which point the clinician can offer further support and medication.
Clinician (continued from above): First of all, I want us to look through this halflet, called the Be a Star halflet, and on the other side it has information about setting a quit date. So would you be interested in setting a quit date at this time?
Mother: Yes, how about 2 weeks from today?
Clinician: Terrific. Why don’t you go ahead and write it down. There are a couple of things that can help you along in your quit attempt. One thing that can really help is medication to help you quit. Medicine can double or triple the chances of you being successful with your quit attempt. So, we have a few choices. Let me just tell you about them, and then you can decide if you’d be interested. The first is a nicotine gum. You may have heard of the gum, or the patch. We also have the lozenge, which is like a hard candy. These are all over-the-counter medicines, but if I write a prescription for you, then you can get the medicine for free or for the price of a co-pay.
Mother: Oh, great. I think I would be interested in the gum.
Clinician: Okay, terrific. Now, how much are you smoking these days?
Mother: 3 to 4 cigarettes a day.
Clinician: Okay, so let’s just see here, 3 to 4 cigarettes, so that would be the low dose of the gum— 2 milligrams.
Clinician: And I want you to be chewing as much of this as you need to completely stay off the cigarettes once you’ve hit your quit date. It comes in 3 flavors: We have original, which is a peppery flavor, orange, and mint.
Clinician: Directions for use are right here on the back.
Mother was amenable to assistance with smoking cessation in the forms of support, information, and medication. To improve her chances of success, the clinician can refer her to a cessation support service, such as the telephone quitline or an online smoking cessation program. Referral to an ongoing source of support like a quitline gives the smoker the best chance of achieving a successful quit. The CEASE program advocates following Step 3: Refer, to provide the smoker with an ongoing source of support beyond what the practice is capable of in a brief intervention.
Clinician (continued from above): Another thing that can help is having the quitline give you some additional counseling to sort of make a plan and to give you the support on an ongoing basis that maybe we can’t give you here.
Mother: So, they call me?
Clinician: Yeah, they call you, that’s the idea. We have a form here. It’s mostly filled out. We want you to fill in your contact information and a good time for them to call you.
Clinician: Okay, and then you just sign the bottom and give it to the receptionist on your way out.
Clinician: So we have a quit date, we have the quitline calling you after you turn in the form to the receptionist, and we have you getting the nicotine gum. Do you have any questions about smoking cessation or about today’s visit?
Mother: No, I think I’m all set. Thank you very much, Doctor.
The clinician was able to provide a great deal of assistance in this brief interaction. By simply asking, he learned that mother was interested in quitting—a readiness that might have otherwise gone undetected. He helped mother set a firm quit date, prompting her to write the date on a material to bring home with her. Setting a quit date can be key to helping smokers quit, as it places a time limit on current smoking behavior. It is important to be specific when discussing the goals for quitting smoking; strive to help the smoker set a quit date within the next 30 days.
The clinician also gave mother a prescription for nicotine gum. Using NRT can double or triple a smoker’s likelihood of successfully quitting . While a majority of parents would accept medication to help them quit, only 7% get it . NRT is available over the counter, but with a prescription many can obtain it free or for a co-pay.
The mother enrolled in the quitline, which would be a source of ongoing support during her quit attempt. The quit-line is an evidence-based intervention [6,20]. Almost every state offers this free service through a fax enrollment by the clinician or a phone number that can be given out. Some quit-lines will also provide free medications to smokers who meet their qualifications (clinicians can call 1-800-QUITNOW or log on to www.naquitline.org for information on their state quitline). A national survey showed that a majority of parents who smoke want to be enrolled in a telephone quitline, but only 1% enroll .
At the close of the interaction, the clinician summarized their discussion. He described the action plan for how mother will make her quit attempt—by using the nicotine gum that he prescribed and the ongoing quitline counseling for which he enrolled her. Setting an action plan is an important conclusion to the conversation around smoking.
Jen is a teenager who does not want to discuss her smoking. The clinician offers support, now and in the future, keeping the lines of communication open. Simply bringing up smoking can help a smoker move closer towards quitting while also showing that you are committed to the family’s health.
Clinician: Jen, there’s really only one more thing I need to discuss with you, and that’s the blue form that you filled out in the waiting area. It says that you’ve been smoking cigarettes.
Jen: Yeah, sometimes. Not every day.
Clinician: Okay, you know I’ve been your doctor for a long time, and it’s something that is extremely important to me, to have you be a nonsmoker. Is there any chance that you’d consider quitting?
Jen: Not really. Like I said, I don’t smoke every day and I just don’t think smoking is that big of a deal.
Clinician: Do you have any concerns at all about your smoking?
Jen: I mean… I know I don’t want to smoke my whole life, but it’s just not a big deal right now.
Clinician: Okay, well given that you don’t want to smoke for your whole life, and it’s definitely high up on my list to help you get off the cigarettes, would you mind if we continued to bring it up at our future visits?
Jen: I mean, if that’s what you want to do, I guess we can, but I don’t think I’m going to want to talk about it anytime soon.
Clinician: I understand that you feel that way, but it sounds like you’re hearing me too that there’s almost nothing better you could do for your health right now than quitting smoking.
Jen: Yeah I hear you, and I know you have to say that.
Clinician: Okay, so would you mind if I continue to check in about the smoking at future visits?
Jen: I guess so, sure.
The clinician created an open dialogue with the possibility for future discussion. He gathered information about how open Jen was to quitting and what concerns she might have. While the clinician provided a strong message about the importance of quitting, he also expressed empathy for her position. He respected Jen’s desire to close the conversation, and invited her to return to it when she might be more open to quitting. The clinician did not force a discussion about smoking. He approached the subject, and because the smoker was not interested, he moved on.
Peter and Lauren are in for their second visit with 14-day-old Emma. The parents disclosed their tobacco use at the previous visit; the mother had quit smoking when she was pregnant and had resisted smoking since the baby’s birth, and the father was given a prescription for nicotine gum to help him avoid smoking around his family or in the home and car. This clinical scenario illustrates how a teachable moment, such as the birth of a baby, can be used to help families become smoke-free. The clinician helps Peter set a firm quit date and summarizes the action plan for quitting with the nicotine gum, the patch, and possible help from the quitline.
Clinician: So, Emma’s growth is great today. She’s just doing excellently and her exam is completely normal again, so congratulations. You’re just doing a great job together. How are things going for you?
Mother: Well, I’m still a little tired, but I haven’t been smoking.
Clinician: Congratulations! That is fabulous news. Peter, how are things going for you?
Father: I haven’t been smoking in the home or car, and I have been smoking less.
Clinician: That’s great. How much would you say you’re down to?
Father: Just a few cigarettes a day.
Clinician: Congratulations. I wanted to ask if there’s something I can do to help you go the rest of the way. We have some excellent medications that we could add to the gum that you got last week. That would be something like the patch or the pill. Would you be interested in trying out one of those?
Father: Yeah, I think I could try the patch.
Clinician: Okay, excellent. So in terms of the gum, how have you been using the gum?
Father: Just when I’m craving it, and especially when I’m at home and I want a cigarette.
Clinician: Perfect, that’s great. With the patch, what it will do is it will knock down the level of the cravings to the point where you might just have a few break-through cravings per day, and with those break-through cravings when you’re wearing the patch, I want you to still chew the gum. So, you’ll be using both medicines at once.
Clinician: Okay, and is that something you’d be willing to try?
Clinician: Okay, great. It sounds like you’re willing to try to quit. Do you want to actually set a quit date?
Clinician: What would be good for you?
Father: A couple of weeks.
Clinician: Okay, let’s try and get specific. What would actually be a firm date that you could commit to?
Father: How ‘bout a week from Wednesday?
Clinician: Terrific, let’s try that. I’ll write it down. Do you have some friends you can tell?
Clinician: Okay. That’s a terrific day to quit. Here’s a pamphlet about quitting smoking. It will give you information about quit support, telling loved ones, even how to get in touch with the quitline if you’re interested. We have a free quitline in this state.
Clinician: So go ahead and read that at home and that should give you extra support in your quit. So, let’s summarize for today. Emma had a terrific visit. In terms of the smoking, Mom, you’re committing to not having even a single cigarette.
Clinician: Great. And Dad, you’ve made a quit date. This is a firm date. We’re hoping that this is the last day that you ever smoke a cigarette. I will see you both again at the one month visit?
The clinician established a positive rapport with the parents, congratulating them on their progress towards becoming a smoke-free family. His open-ended question, “How are things going?” invited them to raise whatever concerned them. Their report on their tobacco use encouraged the conversation, and he invited Peter to expand on his success.
While offering social support, the clinician also provided and described additional forms of assistance, including setting a firm quit date and prescription for the nicotine patch. The clinician made sure to emphasize the importance of having a firm quit date—the last time father would ever smoke a cigarette. He recommended that the father tell people about his plans to quit. Finally, the clinician confirmed that both the mother and smoking father would return for the next visit, ensuring an opportunity to check on father’s progress.
We have provided an overview of strategies for integrating tobacco cessation screening, assistance, and referral into visits with families in the pediatric setting. Clinicians should strive to complete the 3 simple steps, Ask, Assist, and Refer, with all smoking families. As we have demonstrated through the dialogues, these strategies are feasible in clinical practice.
While each clinical situation will present unique challenges, learning effective methods of addressing family smoking allows clinicians to be prepared for those family members who are ready to take the important step towards quitting. Helping one family member quit smoking reduces the entire family’s exposure to tobacco toxins so all adults and children can live longer, healthier lives, with children less likely to take up smoking as adolescents . The greatest cause of house fire mortality is eliminated [3,23], and the family’s financial circumstances improve without the expenses for tobacco, which now average over $2000 per year for the pack-a-day parent. By providing evidence-based assistance at a crucial moment, a child health care clinician can have a powerful, positive impact on an entire family’s future.
We acknowledge the significant contributions of the AAP PROS network, especially Richard Wasserman, Heide Woo, Stacia Finch, Jennifer Steffes, Eric Slora, Jonathan Klein, Victoria Weiley, and the PROS Chapter Coordinators. We thank the Massachusetts Department of Public Health, especially Donna Warner and John Bry. Feedback and collaboration with Nancy Rigotti and the MGH Tobacco Research and Treatment Center were also integral to this project.
Funding/support: The CEASE program is supported by many local and national partners, including the AAP Julius B. Richmond Center of Excellence and the Flight Attendant Medical Research Institute.
Financial disclosures: None.
To learn more about implementing CEASE or to view the full-length CEASE training video, please visit www.ceasetobacco.org.