WELCOME - AAP.org · Participants will view the webinar via an internet connection. Upon completion of the webinar, participants will complete post-event evaluation. Participants

Three Steps to Smoke-free Families: Clinical Systems Change and Policy Prescriptions

Artwork by Isabella X. © 2009 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.

WELCOME

Verification information ACCME Accreditation Statement

• The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

• The AAP designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

• This activity is acceptable for a maximum of 1.25 AAP credits. These credits can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Members of the American Academy of Pediatrics.

• The American Academy of Physician Assistants accepts AMA PRA Category 1 Credits™ from organizations accredited by the ACCME.

• This program is accredited for 1.25 NAPNAP CE contact hours of which 0.5 contain Pharmacology (Rx) content per the National Association of Pediatric Nurse Practitioners Continuing Education Guidelines.

Purpose of Course

• The purpose of this course is to discuss the Clinical Effort Against Secondhand smoke Exposure (CEASE) program which addresses family tobacco use and exposure to both secondhand and thirdhand smoke in clinical practice.

Minimum Performance Level: Per the 2010 revision of the American Medical Association (AMA) Physician’s Recognition Award (PRA) and credit system, a minimum performance level must be established on enduring material and journal-based CME activities that are certified for AMA PRA Category 1 Credit™. In order to successfully complete this AAP Richmond Center Webinar- Three Steps to Smoke-free Families: Clinical Systems Change and Policy Prescriptions CME activity for AMA PRA Category 1 Credit™, learners must demonstrate a minimum performance level of 5 out of 6 or higher on the post-activity evaluation which measures achievement of the educational purpose and/or objectives of the activity. Once minimum performance level has been met, learner will be sent a certificate of completion for this activity via email. Three weeks following receipt of certificate, learner can access credits through PediaLink.

Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities

The AAP CME program aims to develop, maintain, and improve the competence, skills, and professional performance of pediatricians and pediatric healthcare professionals by providing quality, relevant, accessible, and effective educational experiences that address gaps in professional practice. The AAP CME program strives to meet participants' educational needs and support their life-long learning with a goal of improving care for children and families. (AAP CME Program Mission Statement, September 2010) The AAP recognizes that there are a variety of financial relationships between individuals and commercial interests that require review to identify possible conflicts of interest in a CME activity. The AAP Policy on Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities is designed to ensure quality, objective, balanced, and scientifically rigorous AAP sponsored or jointly sponsored Continuing Medical Education (CME) activities by identifying and resolving all potential conflicts of interest prior to the confirmation of service of those in a position to influence and/or control CME content. All AAP CME activities will strictly adhere to the Accreditation Council for Continuing Medical Education (ACCME) Standards for Commercial Support: Standards to Ensure the Independence of CME Activities. In accordance with these Standards, the following decisions will be made free of the control of a commercial interest: identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the CME activity (ACCME Standard 1.1). The purpose of this policy and its associated procedures is to ensure all potential conflicts of interest are identified and mechanisms to resolve them prior to the CME activity are implemented in ways that are consistent with the public good. The content of this CME activity does not necessarily reflect the views or policies of the AAP.

Disclosure of Financial Relationships • All individuals in a position to influence and/or control the content of AAP CME activities are required to

disclose to the AAP and subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in CME activities. *Commercial interest is defined as any entity producing, marketing, re‐selling, or distributing health care goods or services consumed by, or used on, patients.

Name Relevant Financial Relationship (Please indicate Yes, or No)

Name of Commercial Interest(s)* (Please list name(s) of entity) AND Nature of Relevant Financial Relationship(s) (Please list: Research Grant, Speaker's Bureau, Stock/Bonds excluding mutual funds, Consultant, Other - identify)

Disclosure of Off‐Label (Unapproved)/ Investigational Uses of Products AAP CME faculty are required to disclose to the AAP and to learners when they plan to discuss or demonstrate pharmaceuticals and/or medical devices that are not approved by the FDA and/or medical or surgical procedures that involve an unapproved or “off-label” use of an approved device or pharmaceutical.

(Do intend to discuss or Do not intend to discuss)

Shawn Ralston, MD, FAAP (Moderator)

Yes Journal Editorship Do not intend to discuss

Jonathan Winickoff, MD, MPH, FAAP (Presenter)

No None Do not intend to discuss

Cathy McDonald, MD, MPH, FAAP (Presenter)


Janet Brishke, MPH (staff)


Commercial Supporters : There is no commercial support associated with this course. This webinar is funded by a grant from the Legacy Foundation and by a Communities Putting Prevention to Work grant from the US Department of Health and Human Services. Product‐Specific Advertising: No product-specific advertising of any type appears in this course. Name of Medium or Combination of Media Used: Webinar course (via Cisco WebEx System) Method of Physician Participation in the Learning Process: Participants will view the webinar via an internet connection. Upon completion of the webinar, participants will complete post-event evaluation. Participants will notify AAP Richmond Center staff, who will review evaluation. Following obtainment of minimum performance level, participants will receive their CME certificate via email. Estimated time to complete the educational activity: The webinar is scheduled to last 1.5 hours Dates of original release and most recent review or revision: Live webinar was held July 12, 2012 Date of termination (expiration) for CME credit is July 11, 2015. List of Hardware/Software Requirements

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Provider Contact Information If you have questions about this course or encounter technical problems, please contact AAP Richmond Center staff at [email protected]. Privacy and Confidentiality Statement At the American Academy of Pediatrics, we take the issue of privacy very seriously. We do not sell, distribute, barter, or transfer personally identifiable information obtained from a user to a third party. Any information collected on the Web site is only used for the purpose stated. The AAP list is only for important Academy communications, and your e-mail address will not be sold or provided to third parties. You will not receive advertising or promotional material on this list. The American Academy of Pediatrics may use "cookie" technology to obtain non-personal information from its online visitors. We do not extract personal information in this process nor do we provide this information to third parties. We also do not contact you based on information in your cookie file. The American Academy of Pediatrics has taken steps to make all information received from our online visitors as secure as possible against unauthorized access and use. All information is protected by our security measures, which are periodically reviewed. The slide sets for this educational activity were developed specifically for this course. All presenters are aware this event will be recorded and archived on the Richmond Center website. Copyright © 2012 by the American Academy of Pediatrics. All rights reserved.

mailto:[email protected]

At the conclusion of this activity, participants should be able to:

• Describe the importance of utilizing an office-based system to address tobacco use and exposure

• Describe the three steps to address family tobacco use and secondhand smoke exposure used by the CEASE program

• Explain how to incorporate the concept of thirdhand smoke into motivational messaging for families when addressing tobacco use and exposure

• Describe how to implement the CEASE program into practice to address family tobacco use and exposure

• Articulate how to incorporate local resources into addressing family tobacco use and exposure

• Explain potential challenges that may arise when implementing the CEASE program into practice, and ways to overcome those challenges

Three Steps to Smoke-free Families: Clinical Systems Change and Policy Prescriptions

Artwork by Isabella X. © 2009 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.

WELCOME

Disclosure Statement

• I currently have a financial relationship or interest with an entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients: – Editor: Hospital Pediatrics

• I do not intend to discuss an unapproved/investigative use of a commercial product/device.

Registration Questions: Common Themes

• Titles: RN, Health Educator, Tobacco Prevention Coordinator

• 80% don’t work in a practice setting

• 20% always ask about use and exposure

• Reasons to not ask: – Already noted in EMR from last visit – No time! – Someone else is designated to ask

Intriguing Responses “When would you not ask about use/exposure?”

• "I see patients by referral, so by the time they see me tobacco use has already been noted in their chart.“

• "All patients are asked about tobacco use not smoke exposure.“

• "If they are over 30 or so and have never smoked, I think it is unlikely they will start.“

• “It’s a hospital setting, so we do not ask patients about exposure to secondhand smoke. "

Pediatricians as Cessation Counselors

• Parents are young and otherwise healthy – no doctor

• Less strict income cutoffs

• Protective factors

• Pediatricians have access to smokers who may not otherwise interact with healthcare– 25%

Jonathan Winickoff, MD, MPH, FAAP


• Neither I nor any member of my immediate family has a financial relationship or interest (currently or within the past 12 months) with any entity producing health care goods or services consumed by, or used on, patients related to the content of this CME activity.


Comparative Causes of Annual Preventable Deaths in the United States

050

100150200250300350400450

30 81

41 19 14

112

430

(thou

sand

s)

Suicide Alcohol Motor Homicide Drug Obesity Smoking Vehicle Induced

Children and Tobacco Smoke

• Asthma, RSV pneumonia, SIDS, Otitis media, Metabolic Syndrome, Dental caries

• School absenteeism • Sleep problems • Hospitalizations • Developmental delay

NO risk‐free level of exposure

What is Thirdhand Smoke?

• Thirdhand smoke is the left-over contamination in a room/car/clothing that persists after the cigarette is extinguished – The condensate on the glass from a smoking chamber

was used in one of the first studies linking smoking and cancer

– Homes and cars in which people have smoked may smell of cigarettes for long periods

Thirdhand Smoke: The 3 R’s

Remain on surfaces, in dust

Re-emitted into gas phase

React with oxidants to yield secondary pollutants

Thirdhand Smoke

Nicotine

Nitrous acid/ozone

Tobacco-specific nitrosamines

Second-Hand Smoke

Secondhand Smoke

Thirdhand Smoke

The Media has Popularized the Thirdhand Smoke Concept

The Cessation Imperative

The only way to protect non-smoking family

members completely is for all family smokers to quit completely

Tobacco Users Want to Quit

• 70% of tobacco users report wanting to quit

• 44% have made at least one quit attempt in the past year

• Users say expert advice is important to their

decision to quit – The expert can be a physician, clinician, health care

worker, etc.

Research in Child Healthcare Settings

• Majority of parents would accept medications to help them quit—only 7% get it

• Majority of parents want to be enrolled in a telephone quitline—only 1% get enrolled

• Majority of parents would be more satisfied with visit if child’s doctor addressed their smoking

Principles of Tobacco Dependence Treatment

• Tobacco dependence is a chronic, relapsing condition – Nicotine is addictive – Effective treatments exist – Every person who uses tobacco should be offered

treatment

Three Easy Steps

Step 1: Ask Step 2: Assist Step 3: Refer

Ask families about tobacco use and rules about smoking in the home and car

Every year, ask families: “Does any member of the household use tobacco?”

Step One: Ask

Step One: Ask

If the parent/patient you’re speaking with uses

tobacco.. ask if they are: • Interested in quitting? • Would they like a medication to help them quit? • Want to be enrolled in the free quitline?

• Use the responses on Step One to guide how you assist with addressing tobacco use. • Interested in Quitting?

• Set a quit date in the next 30 days • Prescribe or recommend medication for assisting

quit • Enroll in Quitline

• Document services delivered to enhance

complexity of visit to level 4— code 989.84

Step Two: Assist

A New Health Message: Tobacco Smoke Contamination, or

Thirdhand Smoke…

Direct to consumer marketing: Medications poster

http://www.massgeneral.org/ceasetobacco/pdf/no smoking sign poster.pdf

Refer families who use tobacco to outside help

• Use your state’s “fax to quit” quitline

enrollment form

• Arrange follow-up with tobacco users

• Record in the child’s medical record

Step Three: Refer

CEASE Training Manual

A quick reference for your office

CEASE training materials

CEASE intervention materials

CEASE Action Sheet

Front

CEASE Action Sheet

Back

Pre-printed prescription for NRT

patch

Pre-printed prescription for NRT

gum

CEASE brochure

Home halflet

Car halflet

CEASE direct to consumer marketing

Asthma poster

Practice initiated materials

Do the math poster Press release about CEASE participation

But How?

• Clinical Staff: Can ASK, ASSIST, and REFER

• Administrative Staff: Can keep materials stocked and administer screening questionnaires

• Management: Need to support the “cause”

National CEASE experience

Summary

• Outpatient settings should be used to deliver tobacco dependence treatments to all patients and household members

• Families should be the number one priority population for tobacco control efforts

Cathy McDonald, MD, MPH, FAAP

Alameda County ATOD Network 510-653-5040-315

Funded by First 5 Alameda County Project Director, Mindy Benson, MSN, PNP


• Neither I nor any member of my immediate family has a financial relationship or interest (currently or within the past 12 months) with any entity producing health care goods or services consumed by, or used on, patients related to the content of this CME activity.


History of CEASE Project at Children’s Hospital Oakland

Project Director of Tobacco Treatment Project of County Health Dept. Tobacco Control funded through tobacco tax then tobacco settlement funds trained primary care providers to systematically address tobacco since 1998.

• Conference and training at Children’s

• Work with Asthma Coalition – Children’s actively involved

• 2008: finally ready

• Wrote joint grant to asthma funding source- not funded


• Learned from Helpline staff that county agency for <5 interested

• Children’s applied for grant from First 5 funded 2yrs. beginning 7/2009

• I was included as a consultant the first year


Demographics CHRCO Primary Care 99% < 300% Poverty

African American

60%

Other10%

Asian/ Pacific

Islander10%

Hispanic20%

• Primary care clinic provides 29,000 visits per year

• Teaching hospital with 85 residents who rotate through primary care and have continuity clinics in primary care

• Serves large low income population in urban center with high rates of asthma


Implementation

• Discussed and planned for implementation: changing clinic forms, devising data collection

• Devised modified CEASE action form. Coordinated with Helpline/CEASE for fax forms & CA-specific halflets

Implementation

• Planned the timing of the start up

• Did chart review and determined no clients referred to Helpline at baseline

• Start date 10/1/09

Implementation

• Planned to have forms changed, action sheets and halflets ready and have group training with lunch for all residents & MAs at beginning of the implementation

• Planned brief 15 min training with each group of continuity clinic residents M- F first week

Training- We now ask everyone about tobacco

MA says “We now ask everyone about tobacco. Does Dante live with anyone who smokes?” If yes, record on progress note Live with smoker Y/N- circle yes If yes, give lavender sheet- ask parent to fill out and give to doctor

Physician intervention

CEASE intake form (3 Talking Points)

1. Smoke even a puff in past 7 days? Yes → Halflet 2. Want info on free counseling? Yes → Referral Family completes fax referral to Helpline Referral gets faxed Helpline calls child’s parent or caregiver 3. Want info for family member who smokes? Yes → Give halflet/gold card- with Helpline info

Awesome Results 10/09 to 6/12

• 424 patients have been fax referred to the Helpline

• This represents 16% of all Helpline fax referrals in the state same time

• This is 10x greater than if clients were given card and had to call

• Direct connect even better

How to incorporate local resources

• Public Health with Children’s Hospital

• Public Health with Asthma Coalition

• Children’s Hospital with First 5

• Helpline with Children’s Hospital and CEASE Program

• Public Health with AAP Chapter for FAMRI-funded AAP Richmond Center Visiting Lectureship at Children’s/CME

• Grand Rounds, noon conference & clinic by Winickoff for Lectureship 9/10


Expand service and appeal to include Nicotine Replacement: Evidence-based work with pharmacy and public health to develop template of what’s covered and train (change CEASE form)

Nicotine Replacement Therapy

1 Pack (20cigs) / Day

Med

i-Cal

Half Pack (10cigs) / Day

Nicotine patch* 21 mg 2 weeks 2 refills Then 14 mg 2 weeks 0 refills Then 7 mg 2 weeks 0 refills Apply patch morning of quit date &

remove next morning + apply new patch

Dispense 2 weeks at a time

Nicotine patch* 14 mg 2 weeks 0 refills Then 7 mg 2 weeks 0 refills

Apply patch morning of quit date &

remove next morning + apply new patch

Dispense 2 weeks at a time

Medi-Cal does NOT cover gum.

Nicotine patch

21 mg 4 weeks 0 refills Then 14 mg 2 weeks 0 refills Then 7 mg 2 weeks 0 refills

Apply patch morning of quit date & remove next morning +

apply new patch

Ala

med

a A

llian

ce &

Blu

e C

ross

Med

i-Cal

1 Pack (20cigs) / Day Half Pack (10cigs) / Day

Nicotine patch*

14 mg 2 weeks 0 refills Then 7 mg 2 weeks 0 refills

Apply patch morning of quit date & remove next morning +

apply new patch

4 Mg Flavored Nicotine Gum

4mg up to 6/day 4wks 0 refills (#168) Then


4mg up to 2/day 4 wks 1 refill (#56) Chew until tongue tingly. Park between cheek and gum until not tingly. Chew max. 30 min. Dispense 4 wks at a time. Cut gum in half if too strong.

4 Mg Flavored Nicotine Gum


4mg up to 2/day 4 wks 1 refill (#56)

Chew until tongue tingly. Park between cheek and gum until not tingly. Chew max. 30 min. Dispense 4 wks at a time. Cut gum in half if too strong.


Worked with Helpline to offer CME webinar on CEASE in California, make California a CEASE state, and post materials in English and Spanish


• Children’s staff worked to establish tobacco-free hospital and successfully did that January of 2012 (Direct goal and outcome of FAMRI-funded AAP Richmond Center Visiting Lectureship)

• Children’s invites Dr. Winickoff back for Asthma Forum 2012 focused on tobacco


Executive Director of First 5 statewide invited to speak about addressing tobacco in parents of children under 5 at the 2012 Forum


• May 2012- Met with Chapter and First 5 representatives and Helpline and Dr. Winickoff after Forum to devise strategy to spread program

• June 2012- Chapter voted to focus on CEASE as a priority over the next few years.


• First 5 county organizations throughout California considering making CEASE a priority

• Hope to incorporate into First 5 statewide as direct to consumer marketing

Challenges & Solutions

• MAs asking if child around secondhand smoke instead of asking:

“Does Jimmy live with anyone who smokes cigarettes?”

S: Training, training & more training

• Parent not signing the fax referral- Helpline can’t call. Phone # illegible.

S: Someone screens form before family leaves


• Staff don’t realize proactive referral with fax much more effective then cards; still give cards

• S: Training, training & more training


• Teaching hospital great place to instill as standard of care. However, increases chance that docs not know what to do.

• S: Learn protocol in asthma clinic & watch webinar on CA CEASE site.

Teach CEASE in Ambulatory conference every 3- 4 months.

1 wk/yr review in continuity clinic


• Convincing clinicians to prescribe NRT: patches, gum and lozenges

• S: Training, addressing key points: OTC, AMA statement any doc seeing a person who smokes can treat, provide protocol, very safe, no lawsuits. - Bring in Jonathan-


• Getting Buy-in: Keep introducing the topic and exploring it with group

• Adapting EHR to include

• S: Helpline wants to do this and won’t have to have patient signature

• Monitoring outcomes

• S: Helpline data very helpful


• Residents actually learning the program and resources well enough to incorporate into pediatric setting after training

• Improved training and follow-up can help this


• The program has bled into inpatient and emergency room- want to optimize this. Forms are available in one inpatient site but may not be in other site and/or ER

• Planning and training and follow-up to assess this further. Hospital and ER may be even more important sites for this.

2008 2009 2010 2012 • Public Health Tobacco Control

•Conference

• Training

• Asthma Coalition

• Asthma Grant Application

• Public Health Tobacco Control

• Children’s Hospital


• Helpline

• CEASE

• First Five

• Children’s CEASE Project – Fax Referral


• FAMRI Lecture

• Children’s Hospital

• Asthma Coalition

• AAP CA Chapter 1

• Helpline

• First Five Funding

• Children’s CEASE Project – Fax Referral + NRT

• CA CEASE State


• Children’s Hospital Tobacco-Free

• Board of Supervisor Award – World Asthma Day

• Asthma Forum

• Strategy Meeting

• AAP Chapter endorses CEASE

• First Five County + State consider project

EVOLUTION of Tobacco Interventions

Boxes indicate OUTCOMES

1998‐2007

Questions?

Artwork by Zoey L. © 2009 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.

More on CEASE

• www.ceasetobacco.org

• Facebook Search: Clinical and Community Effort Against Secondhand Smoke Exposure

• Webinar: MI in exposure counseling (Winickoff) http://eo2.commpartners.com/users/ama/series.php?id=1214

• AAP EQIPP: Eliminate Tobacco Use and Exposure AMA PRA Category 1 Credit(s)™: 26.00 PediaLink> CME> EQIPP Courses

http://www.ceasetobacco.org/

http://eo2.commpartners.com/users/ama/series.php?id=1214

http://eo2.commpartners.com/users/ama/series.php?id=1214

AAP Richmond Center

• Visit us: www.aap.org/richmondcenter – Audience-specific information – State-specific resources – Funding opportunities – Tobacco control listserv – Downloadable PowerPoint presentations – Pediatric tobacco control resource guide

• Contact us: [email protected]

• Evaluation: https://www.surveymonkey.com/s/SBK2VRW

http://www.aap.org/richmondcenter



https://www.surveymonkey.com/s/SBK2VRW

References Slide 9: Tanski, S.E., Klein, J.D., Winickoff, J.P., Auinger, P., Weitzman, M. (2003). Tobacco Counseling at Well-Child and Tobacco-Influenced Illness Visits: Opportunities for Improvement. Pediatrics, 111(2), 162-7.

Slide 12: (AIDS) HIV/AIDS Surveillance Report 1998; (Alcohol) McGinnis MJ, Foege WH. Review: Actual Causes of Death in the United States. JAMA 1993; 270:2207-12; (Motor vehicle) National Highway Transportation Safety Administration, 1998; (Homicide, Suicide) NCHS, vital statistics, 1997; (Drug Induced) NCHS, vital statistics, 1996; (Smoking) SAMMEC, 1995

Slide 13: Delpisheh A, Kelly Y, Rizwan S, Brabin BJ. Salivary cotinine, doctor-diagnosed asthma and respiratory symptoms in primary schoolchildren. Matern Child Health J 2008;12:188-93.

Mahid SS, Minor KS, Stromberg AJ, Galandiuk S. Active and passive smoking in childhood is related to the development of inflammatory bowel disease. Inflamm Bowel Dis 2007;13:431-8.

Slide 14: (Wynder, 1953); Slide 15: (Burton, 2011); Slide 16: (Burton, 2011) (Dreyfuss 2010) (Tuma 2010)

Slide 20: Centers for Disease Control and Prevention. (2002). Cigarette Smoking Among Adults- United States, 2000. Morbidity and Mortality Weekly Report, 51(29), 642-5.

Slide 21: Winickoff, J.P., Tanski, S.E., McMillen, R.C., Klein, J.D., Rigotti, N.A., Weitzman, M. (2005). Child Health Care Clinicians' Use of Medications to Help Parents Quit Smoking: A National Parent Survey. Pediatrics, 115(4), 1013-7.

Slide 22: Fiore M.C., Jaén, C.R., Baker, T.B., et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008. Slides 56‐57: Alameda County Public Health Care Services Agency, Public Health Department, Tobacco Control Program, Master Settlement Funds

Documents

WELCOME - AAP.org · Participants will view the webinar via an internet connection. Upon completion of the webinar, participants will complete post-event evaluation. Participants