E-cigarettes - Are They Really Harmless? · 4/23/2015 · • Examine the impact of tobacco smoke exposure and e-cigarettes on children • Examine sources of child exposure to tobacco

E-cigarettes - Are They Really Harmless?

Kevin Nelson, MD, PhD, MSCi

Assistant Professor

Pediatric Inpatient Medicine, University of Utah Primary Children’s Hospital & Riverton Children’s Unit

April 23, 2015

Critical Care Conference Intermountain Medical Center

DISCLOSURE

• The content of this presentation relates to a product of a commercial entity

• I have no financial relationship with any commercial entity to report.

Objectives • Understand the impact of tobacco use, including e-

cigarettes, on children, families & the health care system.

• Understand the role of nurses and clinicians in smoking cessation interventions with adults, children and parents

• Understand and apply evidence-based techniques for smoking cessation interventions with children and adults.

• Understand the implications of current medical evidence and policy regarding e-cigarettes and their health effects

– Validated that Mom changed her tobacco use

– Encouraged her to avoid combustible tobacco

– Advised that the long term health effects of e-cigarettes are not known

– Hospitalized three times for respiratory illness

– Skin allergies: eczema

– Mom quit smoking 2 years ago

– Recently start using an e-cigarette

3 year old hospitalized for respiratory illness

Nicotine Addiction “A cigarette is the only consumer product which

when used as directed kills its consumer.” - Dr. Gro Harlem Brundtland Former WHO Director-General

Smoking & TSE in the U.S. • Each year

• 480,000 people die from smoking related illness1

• Over $280 billion in medical expenses and lost productivity1

• 44% of children affected by tobacco smoke exposure (TSE)2

• Each day – 3,200 children smoke their first cigarette1

– 2,100 children become regular smokers1

1CDC. The health consequences of smoking--50 years of progress: A report of the Surgeon General, US Dept of Health & Human Services, 2014. 2Quinto KB, et al. NCHS Data Brief. 2013;126:1-8.

34 35

33 30 31

36

Utah Smoking Rates by Community1

Glendale 19.2%

Magna 13.4%

West Valley West 16.8%

Kearns 15.9%

Downtown Salt Lake 11.9%

South Salt Lake 17.0%

West Valley East 17.5%

Overall Smoking Rate: Utah 10.2%1

US 17.8%2

Tooele 14.0%

Ogden 19.5%

Midvale 17.3%

Sandy (center) 15.0%

1Utah Department of Health (UDOH). 14th Annual Report, Tobacco Prevention & Control Program (TPCP), Utah Department of Health,2014; Utah Behavioral Risk Factor Surveillance System, 2009-2013, available at ibis.health.utah.gov (Accessed April 13,2015). 2CDC. MMWR Morb Mortal Wkly Rep. 2014:63;1108–12.

http://www.ibis.health.utah.gov/

1UDOH. Fourteenth Annual Report, TPCP, UDOH, 2014. 2UDOH. Asthma Report, Utah Asthma Program,UDOH, 2010. 3Nelson, Nkoy, Koopmeiners & Maloney, Primary Children’s Hospital, unpublished data.

Smoking & Child TSE in Utah • Each year

• $894 million in medical costs and lost productivity1

• 18,500 children report regular TSE at home1

• 25% of children with asthma report regular TSE2

• Primary Children’s Hospital3

• 33% among respiratory hospitalizations

• 45% of hospitalized asthmatics have TSE

CDC. 50 years of progress: A report of the Surgeon General, CDC, US DHS, 2014. Slide adapted from Richmond Center of Excellence, American Academy of Pediatrics.

SIDs Bronchiolitis Meningitis

Infancy

Low Birth Weight Stillbirth Neurologic Problems Cleft lip & pallate

In utero

Asthma Otitis Media Atherosclerosis Neurobehavioral problems Fire-related Injuries Influences

to Start Smoking

Nicotine Addiction

Cancer Cardiovascular Disease COPD

Adulthood

Adolescence

Childhood

Health Effects of TSE & Smoking

SIDs Bronchiolitis Meningitis

Infancy

Low Birth Weight Stillbirth Neurologic Problems Cleft lip & pallate

In utero

Asthma Otitis Media Atherosclerosis Neurobehavioral problems Fire-related Injuries Influences

to Start Smoking

Nicotine Addiction

Cancer Cardiovascular Disease COPD

Adulthood

Adolescence

Childhood

Health Effects of TSE & Smoking

CDC. 50 years of progress: A report of the Surgeon General, CDC, US DHS, 2014. Slide adapted from Richmond Center of Excellence, American Academy of Pediatrics.

1Kit BK, et al. Pediatrics. 2013; 3:407-414. 2Wilson KM, et al. Pediatrics. 2011;127:85-92.. 3Howrylak JA, et al. Pediatrics. 2014;133:e355-362. 4Quinto KB, et al. NCHS Data Brief. 2013;126:1-8.

Child TSE • 33% of children exposed at home by parents and

caregivers1

• 73% of children living in multiunit housing have TSE vs. 46% in detached houses2

• Parents/caregivers underreport smoking and child TSE

Care Setting - Child asthmatic

Parent/Caregiver Report

Biochemical Marker (cotinine)

Inpatient3 35% 80% Outpatient4 44% 54%

1Montella S, et al. Pediatr. Pulmonol. 2013;48:1160-1170. 2McCarville M, et al. Arch. Dis. Child. 2013;98:510-514. 3Jin Y, et al. Prev Med. 2013;57:125-128. 4Nelson KE, Jones A, Nkoy F, Primary Children’s Hospital unpublished data. 5van den Bosch GE, et al. Respir. Care. 2012;57:1391-1397.

Effect of TSE on Child Asthma • Worse outcomes among child asthmatics with

TSE

Asthma Outcome OR 95% CI Increased asthma exacerbations1 1.39* 1.08-1.78 Need for controller medication2 2.39† 1.26–4.52 Increased hospitalizations3 2.18 1.29-3.67 Increased hospital resource utilization4 1.20 1.01-1.42 PICU admission5 5.9 1.02–33.70 *Incidence risk ratio, †Adjusted odds ratio

Objectives • Examine the impact of tobacco smoke exposure and e-

cigarettes on children

• Examine sources of child exposure to tobacco smoke exposure and e-cigarettes

• Discuss pediatric hospitalizations as opportunities for evidence-based smoking cessation interventions

• Identify evidence-based strategies for managing tobacco smoke exposure and treating parent nicotine addiction

Sources of Child Tobacco Exposure

• Secondhand smoke – exhaled and sidestream smoke1

• Disparities exist in child secondhand exposure2

1Best D. American Academy of Pediatrics. Pediatrics. 2009;124:e1017-1044. 2Singh GK, et al. Pediatrics. 2010;126:4-13..

Prevalence* Race/ethnicity African American 68% White 37% Household income <200% poverty level 69% ≥400% poverty level 16% Parent education ≤ High school 72% College 14% *Population weighted prevalence from National Survey of Children’s Health, 2007

Sources of Child Tobacco Exposure

• Thirdhand smoke – Tobacco smoke deposits on surfaces and dust1 – Additional toxins produced when re-emitted into the air1

• Ingestion – Cigarettes, e-cigarettes, or other tobacco products.

– 70% of ingestions involve infants ≤1 year old2

– Utah Poison Control calls for e-cigarettes increased by 19-fold in 2014 vs. 20113

1 Martins-Green M, et al. PloS one. 2014;9:e86391. 2Connolly GN, et al. Pediatrics 2010;125:896–899. 3Utah Poison Control Center data, University of Utah, College of Pharmacy, 2015.

Child Tobacco Use • Nicotine dependence may

precede regular use

– 17% of 6th graders who had ever smoked had at ≥1 symptom of dependence1

• Child e-cigarette tripled in Utah and nationally

Utah Tobacco Product Use Children Grades 8-12 in 20132

Child E-cigarette Use U.S. & Utah, 2011-2013

2011 2013 U.S.3,4,* 1.5 4.5 Utah2,** 1.9 5.9 *High school students, **8-12 graders

1Doubeni CA, et al. Pediatrics. 2010;125:1127-1133.. 2UDOH. Health Status Update: Electronic Cigarette Use among Utah Students (Grades 8, 10, 12) and Adults. Dec 2013. 3CDC. MMWR Morb Mortal Wkly Rep.2013;62:729-730. 4CDC. MMWR Morb Mortal Wkly Rep. 2013;63:1021-1026.

1Goniewicz ML, et al. Tob. Control. 2014;23:133-139. 2Kosmider L, et al. Nicotine Tob Res. 2014;16:1319-26. 3Benowitz NL, Goniewicz ML. JAMA. 2013;310:685-686.

Electronic Cigarettes • Toxins from 5-1000 times lower than tobacco

smoke1,2

– Formaldehyde, acetone, and acetaldehyde reported at similar levels to smoke tobacco2

– Safety of exposure to low level of toxins unknown3

Comparison of e-cigarette toxin levels between regular and e-cigarettes1 Toxin compound

Amount in e-cigarette vapor (µg per 15 puffs)

Average ratio (to regular cigarette smoke)

Formaldehyde 0.20-5.61 9 Acetaldehyde 0.11-1.36 450 Acrolein 0.07-4.19 15 Toluene 0.02-0.63 120 NNN* 8x10-5-44.3x10-4 380 NNK* 1.1x10-4-2.8x10-3 40 *Tobacco specific carcinogens: N’-nitrosonornicotine (NNN) and 4-(methylonitrosoamino)-1-(3-pirydyl)-l-butanone (NNK)

Electronic Cigarettes • Health effects on children – child use, exposure

to emissions, poisonings – Child use associated with conventional cigarette use

(OR= 7.88, 95% CI 6.01-10.32)1

– Population level effects of e-cigarettes unclear2

• Efficacy for smoking cessation not yet shown3,4

• FDA-approved, evidence-based treatments for smoking cessation available5

– Barriers limit routine use in physician workflow6 1Dutra LM, Glantz SA. JAMA pediatrics. 2014;168:610-617. 2Benowitz NL, Goniewicz ML. JAMA. 2013;310:685-686. 3Bullen C, et al. Lancet. 2013;382:1629-1637. 4Grana R, et al. Circulation. 13 2014;129:1972-1986. 5Fiore MC, et al. Treating tobacco use and dependence: 2008 update. CDC, US DHS, 2008. 6Nelson KE, Hersh AL, Nkoy FL, Maselli JH, Srivastava R, Cabana MD. Prev Med. 2015;71:77-82.






Treating TSE • Evidence-based guidelines recommend treating

child TSE in the hospital and outpatient settings – U.S. Public Health Service1

– NHLBI Asthma Guidelines2

– AAP – Bright Futures3 & Tobacco Policy Statement4

• 2 A’s & R1

– Ask: identify tobacco users – Advise: strong personalized message to quit smoking – Refer: refer to quitline

• Systems change – incorporation into workflow1

1Fiore MC, et al. Treating tobacco use and dependence: 2008 update. CDC, US DHS, 2008. 2NHLBI. Guidelines for the Diagnosis and Management of Asthma. CDC; 2007. 3AAP. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. AAP; 2008.4AAP. Pediatrics. Nov 2009;124:1474-1487.

2A’s & R • US Public Health Service Guideline for Smoking

Cessation recommends the 2A’s & R approach1

• Ask - Screening – Systematic screening during clinical encounters

• Advise – Advice to quit smoking – Strong personalized message to change smoking behavior

– “One of the most important things you can do for the health of you and your child is to quit smoking.”

“One of the most important things you can do for the health of you and your child is to quit smoking.”

1Fiore MC, et al. Treating tobacco use and dependence: 2008 update. CDC, US DHS, 2008.

2A’s & R • Refer – Evidence based cessation resources

– Quitline – telephone counseling

– Nicotine Replacement Therapy (NRT)

– Pharmacotherapy


Intervention Odds Ratio –

Smoking cessation (95% CI)

Evidence

Ask Screening system 3.1* (2.2-4.2) A

No screening system Reference

Advise Physician advice to quit 2.2 (1.5-3.2) A

Other clinician advice to quit 1.7 (1.3-2.1) B

No physician/clinician advice to quit Reference

Counseling/education 2.3 (2.0–2.7) A

No counseling/education Reference

*OR for provider delivery of intervention

Guideline Recommendations

Fiore MC, et al. Treating tobacco use and dependence: 2008 update. CDC, US DHS, 2008.



Evidence

Refer Telephone counseling (Quitline) 1.6 (1.4-1.8) B

Minimal or no counseling Reference

Nicotine replacement therapy 2.3 (1.7-3.0) A

Placebo Reference

Systems Clinician training 3.2* (2.0–5.2) B

Clinician training + Charting 4.2* (3.4–5.3) B

No intervention

Communication with next provider Expert opinion C




Efficacy of TSE Interventions • Meta-analysis including multiple clinical settings

– Parents 34% more likely to quit following TSE intervention (OR 1.34, 95% CI 1.05,1.71)1

• TSE interventions - parents of children hospitalized for respiratory illness

• RCT in pediatric offices showed 12-fold increase in physician delivery of TSE interventions

1Rosen LJ, et al. Pediatrics. 2012;129:141-152. 2Ralston S, et al. Pediatr. Pulmonol. 2012. 3Winickoff JP, et al. Pediatrics. 2003;111:140-145. 4Winickoff JP, et al. Pediatrics. 2013;132:109-117.

Design

Sample size

Quit attempt Abstinence Accepted NRT

Control Intervention Control Intervention

RCT2 52 37% 53% (NS) 20% 17% (NS) -- Cohort3 71 -- 49% -- 21% 56% *NS=nonsignificant

Parent Motivation to Quit • Parents of hospitalized children may show

increased readiness to change smoking behaviors

– 47% of parents enrolled in a TSE intervention study rated the importance of quitting smoking at 10/101

– 33% of parents enrolled in a TSE intervention were preparing to quit smoking (vs. 20% did not enroll)2

– 58% believed that TSE was related to their child’s hospitalization3

Ralston S, et al. Pediatr. Pulmonol. 2013;48:608-613. 2Winickoff JP, et al. Pediatrics. 2003;111:140-145. 3Winickoff JP, et al. Pediatrics. 2010;125:518-525.

Limited Guideline Uptake • Hospital TSE management often underutilized or

implemented in piecemeal fashion

• TSE often not addressed even when directly relevant to the child’s diagnosis

• Preliminary PCH data – respiratory admissions – 53% of PCH physicians screen

– 86% of PCH nurses screen

– 22% of PCH receive a TSE intervention

Low Outpatient TSE management National (Hospital) Ambulatory Medical Care Survey 2001-2009

• TSE screening is used frequently1,2

• TSE education/ counseling underutilized in outpatient setting

• May reflect complexity of including multiple recommendations in physician workflow

1Burnett KF, Young PC. Clin Pediatr (Phila). 1999;38:339-345. 2Nelson KE, Hersh AL, Nkoy FL, Maselli JH, Srivastava R, Cabana MD. Prev Med. 2015;71:77-82.

Barriers to TSE Intervention Clinician perceptions • Patients/Parents

– Ignore advice, offended or disinterested

• Tobacco cessation counseling with parents – Time consuming

– Not their role

– Inadequate training and preparation

– Ineffective - will not produce clinical effect

Need for New Interventions • Limitations to inpatient TSE intervention practice

patterns

– Few inpatient studies

– Often implement only part of the guideline

– Single center

– Often do not reflect efforts to integrate into physician workflow

• We attempted to address these limitations and barriers through a new intervention






Smoking & Tobacco Outreach to Parents (STOP) Intervention

• Evidence based TSE intervention

– Parent smoking cessation counseling and referral

• Checklist & clinical prompts cue clinicians – Physician/Nursing screening

– Physician/Clinician advice to quit smoking

– Evidence-based TSE/smoking cessation education

– Quitline Referral

– Nicotine Replacement Therapy recommendation

– Communication with primary care physician



Evidence

Ask Screening system 3.1* (2.2-4.2) A

No screening system Reference

Advise Physician advice to quit 2.2 (1.5-3.2) A

Other clinician advice to quit 1.7 (1.3-2.1) B

No physician/clinician advice to quit Reference

Counseling/education 2.3 (2.0–2.7) A

No counseling/education Reference






Evidence

Refer Telephone counseling (Quitline) 1.6 (1.4-1.8) B

Minimal or no counseling Reference

Nicotine replacement therapy 2.3 (1.7-3.0) A

Placebo Reference

Systems Clinician training 3.2* (2.0–5.2) B

Clinician training + Charting 4.2* (3.4–5.3) B

No intervention

Communication with next provider Expert opinion C




Diagnostic Journey

Inpatient Process - TSE Intervention

Inpatient TSE Interventions

Accept patient

Hospital admission

Medical care

Coordination of care Discharge

• MD accepts • Nursing

supervisor • Transport

• Registration • MD history/

physical • RN history/

assessment • Staffing • Orders

Transferring MD Attending Admit resident Nursing supervisor Charge nurse Transfer center Floor nurse

Attending Admit resident Intern/student Charge nurse Floor nurse RT Tech Registration HUC

• Order performed

• Diagnostic testing

• Treatment • Education • Patient re-

assessment

Attending resident/intern Floor nurse RT Tech Social work Nutrition Specialists Pharmacist

• Staffing • Daily rounds • Communi-

cation w/care team

• Consults

Attending resident/intern Floor nurse RT Tech Social work Case management Nutrition Specialists/Pharmacy

• Decision • Coordin-

ation of care • Education • Follow up/

Referrals • Provider

handoff • Discharged Attending resident/intern Floor nurse Social work Case management Next provider Pharmacist

Environment

Inpatient Process - TSE Intervention

Inpatient TSE Interventions

Accept patient

Hospital admission

Medical care

Coordination of care Discharge

• MD accepts • Nursing

supervisor • Transport

• Registration • MD history/

physical • RN history/

assessment • Staffing • Orders

Transferring MD Attending Admit resident Nursing supervisor Charge nurse Transfer center Floor nurse

Attending Admit resident Intern/student Charge nurse Floor nurse RT Tech Registration HUC

• Order performed

• Diagnostic testing

• Treatment • Education • Patient re-

assessment

Attending resident/intern Floor nurse RT Tech Social work Nutrition Specialists Pharmacist

• Staffing • Daily rounds • Communi-

cation w/care team

• Consults

Attending resident/intern Floor nurse RT Tech Social work Case management Nutrition Specialists/Pharmacy

• Decision • Coordin-

ation of care • Education • Follow up/

Referrals • Provider

handoff • Discharged Attending resident/intern Floor nurse Social work Case management Next provider Pharmacist

Environment

• Screening system

• Advice to quit

• Summary

• Referrals

• Advice to quit

• Counseling/education

• Quitline Referral

• Medication

Improving TSE Interventions

Not reviewed Multiple locations

Documentation

Hard to find

Suboptimal TSE

Intervention

Lack of Knowledge

New evidence

Parent

Provider evidence Hospital staff

Timing

Lack tools

Judgmental Family social situation

Presentation Style Parent expectation Standard

format

Aggressive

Parent rapport

Appropriate?

Ownership

Not my job

Motivation

Clear process Role clarity Parent

Readiness

Leadership

Provider Handoff

Competing priorities

Lack tools

Time

Teaching rushed

Provider forgets

Reminders/ prompts

Competing priorities

Parent does not disclose

Difficult Subject

Moral issue

Parent not present

Provider uncomfortable Inappropriate

Parent not my patient

Parent heard before

Quality of Tools

Coordination

Communication

Provider uncomfortable Screening

Reminders

Barriers to TSE Interventions

TSE Intervention Flow Chart

STOP Program – Aims 1. Increase documentation of TSE screening during

hospital admission from 91% to >95%

2. Increase documentation of TSE education and treatment offered to the parents of hospitalized children from 22% to >75%

Results

Pre-STOP Intervention

Post-STOP Intervention p-value

TSE Screening 91% 92% p=0.57

Overall TSE intervention 22% 88% p<0.001

Smoking cessation advice (MD) 9% 54% p<0.001

Smoking cessation booklets 23% 51% p=0.02

STOP - TSE Screening

Quarter 1.2012 2.2012 3.2012 4.2012 2.2013 3.2013 4.2013 1.2014 2.2014 Screening (%) 94 88 86 94 94 100 98 99 93 Sample size (n) 36 25 22 31 90 52 201 602 433

Preintervention CMU/IMSU 1/1/12-12/31/12

Postintervention CMU only 4/1/13-11/30/13

CMU + IMSU 12/1/13-6/30/14

STOP - TSE Intervention

Quarter 1.2012 2.2012 3.2012 4.2012 2.2013 3.2013 4.2013 1.2014 2.2014 Intervention (%) 14 30 18 29 70 73 90 87 80 Sample size (n) 22 10 17 28 27 15 62 247 214

Preintervention CMU/IMSU 1/1/12-12/31/12

Postintervention CMU only 4/1/13-11/30/13

CMU + IMSU 12/1/13-6/30/14

Summary • TSE is frequent and preventable source of child

morbidity among hospitalized children

• The inpatient setting represents a significant opportunity to treat child TSE

• Improved TSE interventions with parents through using a nursing checklist

• Integrating TSE guidelines into routine clinical workflow improved physician compliance

• Significant improvement opportunities remain for TSE interventions among hospitalized children

Future Work • Improve the recommendation of NRT and

pharmacotherapy

• Evaluate the impact of evidence-based TSE interventions on child asthma outcomes

• Disseminate our model for improved delivery of TSE interventions to other pediatric inpatient units

Common Questions • How can I apply this in my practice?

– Screen children for TSE

– Advise all parents and children who smoke to quit:


– Refer parents who smoke to the Quitline, it takes less than 30 seconds.

Common Questions • What about adolescents who smoke?

– Emerging evidence supports smoking interventions with adolescents

– Increased intensity of counseling improves quit rates – 2 A’s & R

• Ask: identify tobacco users • Advise: strong personalized message to quit smoking • Refer: refer to Quitline/pharmacotherapy if interested in

quitting

– 90% of adult smokers start smoking before age 181


Common Questions • And what about e-cigarettes?

– Few safety or advertising regulations1

– Toxins lower than conventional tobacco2,3

– Marketed with potential for smoking cessation4

– Efficacy for smoking cessation not yet demonstrated4

• Concerns remain for health effects on children

3Benowitz NL, Goniewicz ML. JAMA. 2013;310:685-686. 2Goniewicz ML, et al. Tob. Control. 2014;23:133-139. 3Kosmider L, et al. Nicotine Tob Res. 2014;16:1319-26. 4Grana R, et al. Circulation. 2014;129:1972-1986.

E-cigarettes • Electronic cigarette – e-cigarette, hookah stick • Electronic nicotine delivery device • Nicotine liquid – “Juice” • “Vaping” • Delivers more nicotine than regular cigarette

Courtesy: Utah Department of Health












Child Ingestion of E-cigarettes • Child ingestions since

2011 – Utah - increased 19-fold1

– U.S. increased 14-fold2

• One child death attributed to e-cigarette liquid ingestion3

1Utah Poison Control Center data, University of Utah, College of Pharmacy, 2015 2American Association of Poison Control Centers, 2015. available at www.aapcc.org. 3AAP News, Dec 17, 2014. available at http://aapnews.aappublications.org. 4Connolly GN, et al. Pediatrics. 2010;125:896-899.

• Children ≤2 years account for 95% of tobacco product ingestions among children ≤5 years old4

http://www.aapcc.org/

http://aapnews.aappublications.org/

Adolescent E-cigarette Use • Tobacco product of choice for

Utah adolescents1

– Use tripled in Utah and nationally from 2011-20131,2

• 20% of U.S. and Utah children who use e-cigarettes report no other tobacco use1,2

1UDOH. Health Status Update: Electronic Cigarette Use among Utah Students (Grades 8, 10, 12) and Adults. Dec 2013. 2 CDC. MMWR Morb Mortal Wkly Rep.2015:4;103-108. 3Dutra LM, Glantz SA. JAMA pediatrics. 2014;168:610-617.

• Association between current e-cigarette use and conventional cigarette use among adolescents3

Conventional cigarette* Abstinence* Experimentation Current use 1 month 12 month 7.42 (5.63-9.79) 7.88 (6.01-10.32) 0.11 (0.08-0.15) 0.12 (0.07-0.18)

*OR (95% CI)

Anticipatory Guidance • Bright Futures recommends anticipatory

guidance on tobacco use1

– Include e-cigarettes in anticipatory guidance on tobacco use to children and parents

• Discussing smoking cessation and e-cigarettes2,3

– Support all efforts to change smoking behavior

– Most important change is to quit combustible tobacco

– E-cigarettes are likely to be less toxic than smoking

– Do not use them indoors or around children 1AAP. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. AAP; 2008.2Benowitz NL, Goniewicz ML. JAMA. 2013;310:685-686. 3Grana R, et al. Circulation. 2014;129:1972-1986.

STOP Tobacco Team Mentor – Flory Nkoy, MD, MS, MStat Administration – Judy Geiger, RN, BSN, MBA Facilitator - Karmella Koopmeiners, FNP, MS Development/Pilot testing – Lisa Nielson,

Wendy Gunnerson, Melissa Sweat

Multi-disciplinary Team Nursing – Starla Aragon, Jill Felice, Wendy

Gunnerson, Andrea Hanks, Karmella Koopmeiners, Earl Maxson, Jennifer Monson, Lisa Nielsen, Sharon Noorda, Laura Orth, Amber Rodrigue, Melissa Sweat, Micheline Shiverdecker

Pharmacy – Andrea Kemper, PharmD Respiratory Therapy – Brandon Anderson, Leanne Richardson Patient Relations – Teresa Ostler Health Unit Coordinator – Stefanie Deans, Karolyn Thomson

Systems Improvement/Data – Matthew Bryce, Kylie King, Tanya Stout, Bill Wurtz

Acknowledgements Pediatric Inpatient Medicine Chris Maloney, MD, PhD, Chief Joe Cramer, MD Per Gesteland, MD, MSc Tiffany Glasgow, MD Eun Hae Kim Michelle Hofmann, MD, MPH Chris Miller, MD Heather Oldroyd Raj Srivastava, MD, MPH Bryan Stone, MD, Msci Intermountain Healthcare Carolyn Reynolds, MS, APRN Karen Valentine, MStat Wayne Cannon, MD

Documents

E-cigarettes - Are They Really Harmless? · 4/23/2015 · • Examine the impact of tobacco smoke exposure and e-cigarettes on children • Examine sources of child exposure to tobacco