Environmental Tobacco Smoke
Cara J. Krulewitch CNM PhD Assistant Professor University of Maryland School of Nursing
NEETF
Children’s Environmental Health Faculty Champions Workshop
Cara J. Krulewitch CNM PHD 1
Outline
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Background Hot off the presses Environment Measuring exposure Prevalence of ETS Toxic compounds Sequelae of ETS Exposure Assessment and protection from ETS Exposure-what works?
Cara J. Krulewitch CNM PHD 2
Background
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First addressed in 1972 SG report
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Involuntary smoking/Passive Smoking/ETS
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Research on effects began
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CO concentrations Effects in children Nicotine concentrations
In children:
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US focus 1986
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Conflicting results on asthma Significant results on ear infections/URI
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Classified as group A carcinogen in 1992
Cara J. Krulewitch CNM PHD 3
Latest Findings: ETS/Secondhand Smoke
USDHHS, 2006
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Causes premature death and disease Increased risk for SIDS, respiratory and ear infections, severe asthma in children Slows lung growth in children No safe level of exposure Elimination of indoor exposure fully protects nonsmokers, ventilation systems and cleaning do not.
Cara J. Krulewitch CNM PHD 4
Estimated Effects of ETS in US
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(Cal/EPA, 1997) 50,000 excess deaths annually
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Lung CA Cardiac diseases SIDS
24,000-70,000 excess low birth weight/preterm births o 200,000+ excess asthma episodes o 150,000+ excess lower respiratory infection o 789,000+ excess middle ear infections
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Cara J. Krulewitch CNM PHD 5
Environment and ETS
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Characteristics change over time and distance traveled
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Gas volatility Moisture content Air content
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Indoor/outdoor Other particles
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Current recommendation:
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Secondhand smoke versus ETS Involuntary smoking
Cara J. Krulewitch CNM PHD 6
Cara J. Krulewitch CNM PHD
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Measuring Exposure
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Questionnaires
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Example: Seifert et al, 2002 5-question survey Compare to gold standard biomarker
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May reflect metabolism as well as exposure
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Biomarkers
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Cotinine, thiocyanate, CO Air monitoring
Measurement and metabolism Former smokers classified a lifetime nonsmokers
Cara J. Krulewitch CNM PHD 8
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Risk for misclassification
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Prevalence
NHANES began cotinine measurements in 1988
Cara J. Krulewitch CNM PHD
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Prevalence in Children
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59.6% ages 3-11, significantly higher than adults (See next slide…)
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25% with at least 1 smoker in home
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22 million children exposed Numbers declining since 1988 Most exposure in home environment
Cara J. Krulewitch CNM PHD
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Age Variation in Exposure
Cara J. Krulewitch CNM PHD
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Toxic Compounds in ETS
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50 known carcinogens
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Polycyclic aromatic hydrocarbons [PAHs] N-Nitrosamines Aromatic amines Aldehydes Miscellaneous organic and inorganic
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Carcinogenicity depends on metabolism and ability to excrete toxins or metabolic activation coupled with susceptibility
Cara J. Krulewitch CNM PHD 12
Respiratory Injury and ETS
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In utero, possible interference with fetal airway development
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Altered pulmonary function into late childhood Increased airway thickness Lung structure may be related to nicotine Increase in bronchial hyper-reactivity to histamine
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Decreased host defenses against infectious agents
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Inhibits antibody response Impairs mucociliary clearance
Cara J. Krulewitch CNM PHD 13
ETS and SIDS
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Established epidemiologic relationship Exact mechanism not known
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Induces adenylyl cyclase activity Increase in lung C-fiber CNS response leading to prolonged respiratory apnea
Cara J. Krulewitch CNM PHD
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Prenatal Effects
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Evidence insufficient to identify causal relationship to:
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Spontaneous abortion Infertility Neonatal mortality Congenital malformations Cognitive/behavioral functioning Childhood cancer Preterm birth
Cara J. Krulewitch CNM PHD 15
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Suggestive, not sufficient
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Prenatal Effects (Cont)
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Sufficient evidence:
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SIDS Low birth weight
Cara J. Krulewitch CNM PHD
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Childhood Effects
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Causal relationship
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Asthma
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Child onset In school age children
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Lower respiratory illness Otitis media Wheezing and breathlessness among school-aged children Altered lung growth Altered pulmonary function
Cara J. Krulewitch CNM PHD 17
Strategies to Reduce Exposure
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Smoking Bans and Restrictions Community Education Reduce tobacco initiation Increase tobacco cessation Provider reminder systems
Cara J. Krulewitch CNM PHD
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HELPING SMOKERS QUIT
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US Public Health Service • Clinicians should assess smoking status at every office visit • Smoking cessation advise should be given routinely
Treating Tobacco Use and Dependence. US Public Health Service 2000.
(Provided by Sophie Balk, MD, Albert Einstein College of Medicine) Cara J. Krulewitch CNM PHD 19
WHY FOCUS ON PARENTS?
~15 million US children live with a smoker o Pediatric clinicians may be the only clinicians a parent visits o Most smokers want to quit o Most parents are receptive to counseling by pediatricians1
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1 - Frankowski BL, Weaver SO, Secker-Walker RH. Pediatrics 1993; 91: 296-300.
(Provided by Sophie Balk, MD, Albert Einstein College of Medicine) Cara J. Krulewitch CNM PHD 20
COUNSELING
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Brief counseling is effective Intensive counseling is more effective: dose-response relationship Most effective
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Problem-solving skills Support from clinician Social support outside of treatment
Treating Tobacco Use and Dependence. US Public Health Service 2000.
(Provided by Sophie Balk, MD, Albert Einstein College of Medicine) Cara J. Krulewitch CNM PHD 21
Odds Ratio of Quitting
Odds Ratio of Quitting Increases with Counseling
2.5 2.0 1.5 1.0 0.5 0.0
Co n tro 13 ls M in 31 . 0 M >1 0 in . M in
2.3 1.3 1.0 1.6
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Total Contact Time
Quitting defined as abstinence for at least 5 months
Treating Tobacco Use and Dependence. US Public Health Service 2000.
(Provided by Sophie Balk, MD, Albert Einstein College of Medicine) Cara J. Krulewitch CNM PHD 22
THE “5 A’S”
o Ask o Advise
o Assess o Assist
o Arrange
follow-up
Cara J. Krulewitch CNM PHD 23
(Provided by Sophie Balk, MD, Albert Einstein College of Medicine)
System Implementation
“Ask”
Identify Tobacco Use /exposure to smoke Document chart
“Advise”
To Quit
“Assess”
willingness to quit
“Assist”
with quitting
“Arrange”
Follow-up
Referrals
Quitline 1-800-QUITNOW
(Provided by Sophie Balk, MD, Albert Einstein College of Medicine) Cara J. Krulewitch CNM PHD
Individual/Group Counseling & Pharmacotherapy
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PHARMACOTHERAPY
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Smokers trying to quit should be encouraged to use pharmacotherapy except under special circumstances
Medical contraindications Pregnant women & adolescents require special consideration
Treating Tobacco Use and Dependence. US Public Health Service 2000.
(Provided by Sophie Balk, MD, Albert Einstein College of Medicine) Cara J. Krulewitch CNM PHD 25
ADOLESCENTS & SMOKING
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Tobacco industry targets the young Children & teens constitute the majority of all new smokers 22% of high school students smoke 82% of adult smokers tried their first cigarette by age 18
Smoking cessation messages & methods are essential for teens
(Provided by Sophie Balk, MD, Albert Einstein College of Medicine) Cara J. Krulewitch CNM PHD 26
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THE PREGNANT SMOKER
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Smoking imparts risk to woman & fetus Offer augmented interventions that exceed minimal advice (5 – 15 minutes) Tailor advice specific to pregnant smokers Consider pharmacotherapy for those unable to quit
(Provided by Sophie Balk, MD, Albert Einstein College of Medicine) Cara J. Krulewitch CNM PHD 27
OFFICE STRATEGIES
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Educate office staff Document tobacco use
Assign dedicated staff
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Vital Signs BP___Pulse__ WT.________ Temp_______RR_______ Tobacco use: current former never Quit attempts:
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(Provided by Sophie Balk, MD, Albert Einstein College of Medicine) Cara J. Krulewitch CNM PHD 28
References
Cal/EPA. Health Effects of Exposure to Environmental Tobacco Smoke. Sacramento (CA): California Environmental Protection Agency, Office of Environmental Health Hazard Assessment, Reproductive and Cancer Hazard Assessment Section and Air Toxicology and Epidemiology Section, 1997. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD, US Department of Health and Human Services, Public Health Service, June 2000. Hopkins DP et al. Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prev Med 2001: 20(2S): 16-66. Seifert JA, Ross CA, Norris JM. Validation of a five-question survey to assess a child’s exposure to environmental tobacco smoke. Ann Epidemiol 2002 May; 12(4): 273-77.
USDHHS. The health consequences of involuntary exposure to tobacco smoke : a report of the Surgeon General. Atlanta, GA: USDHHS, CDC, Coordinating Center for Health Promotion, NCCDPHP, Office on Smoking and Health. 2006.
Cara J. Krulewitch CNM PHD 29