Cara J. Krulewitch CNM PHD 1 Environmental Tobacco Smoke Cara J. Krulewitch CNM PhD Assistant Professor University of Maryland School of Nursing NEETF.

Cara J. Krulewitch CNM PHD 1

Environmental Tobacco SmokeEnvironmental Tobacco Smoke

Cara J. Krulewitch CNM PhDCara J. Krulewitch CNM PhD

Assistant ProfessorAssistant Professor

University of Maryland School of NursingUniversity of Maryland School of Nursing

NEETFNEETF

Children’s Environmental Health Faculty Champions WorkshopChildren’s Environmental Health Faculty Champions Workshop

2Cara J. Krulewitch CNM PHD

OutlineOutlineo BackgroundBackgroundo Hot off the pressesHot off the presseso Environment Environment o Measuring exposureMeasuring exposureo Prevalence of ETSPrevalence of ETSo Toxic compoundsToxic compoundso Sequelae of ETS ExposureSequelae of ETS Exposureo Assessment and protection from ETS Assessment and protection from ETS

Exposure-what works?Exposure-what works?


BackgroundBackgroundo First addressed in 1972 SG reportFirst addressed in 1972 SG report

• Involuntary smoking/Passive Smoking/ETSInvoluntary smoking/Passive Smoking/ETS

o Research on effects beganResearch on effects began• CO concentrationsCO concentrations• Effects in childrenEffects in children• Nicotine concentrationsNicotine concentrations

o US focus 1986US focus 1986• In children:In children:

• Conflicting results on asthmaConflicting results on asthma• Significant results on ear infections/URISignificant results on ear infections/URI

o Classified as group A carcinogen in 1992Classified as group A carcinogen in 1992


Latest Findings:Latest Findings:ETS/Secondhand SmokeETS/Secondhand Smoke

USDHHS, 2006USDHHS, 2006o Causes premature death and diseaseCauses premature death and diseaseo Increased risk for SIDS, respiratory and Increased risk for SIDS, respiratory and

ear infections, severe asthma in childrenear infections, severe asthma in childreno Slows lung growth in childrenSlows lung growth in childreno No safe level of exposureNo safe level of exposureo Elimination of indoor exposure fully Elimination of indoor exposure fully

protects nonsmokers, ventilation protects nonsmokers, ventilation systems and cleaning do not.systems and cleaning do not.


Estimated Effects of ETS in USEstimated Effects of ETS in US(Cal/EPA, 1997)(Cal/EPA, 1997)

o 50,000 excess deaths annually50,000 excess deaths annually • Lung CALung CA• Cardiac diseasesCardiac diseases• SIDSSIDS

o 24,000-70,000 excess low birth 24,000-70,000 excess low birth weight/preterm birthsweight/preterm births

o 200,000+ excess asthma episodes200,000+ excess asthma episodeso 150,000+ excess lower respiratory infection150,000+ excess lower respiratory infectiono 789,000+ excess middle ear infections789,000+ excess middle ear infections


Environment and ETSEnvironment and ETS

o Characteristics change over time and Characteristics change over time and distance traveleddistance traveled• Gas volatilityGas volatility• Moisture contentMoisture content• Air content Air content

• Indoor/outdoorIndoor/outdoor• Other particlesOther particles

o Current recommendation:Current recommendation:• Secondhand smoke versus ETSSecondhand smoke versus ETS• Involuntary smokingInvoluntary smoking



Measuring ExposureMeasuring Exposureo QuestionnairesQuestionnaires

• Example: Seifert et al, 2002 5-question surveyExample: Seifert et al, 2002 5-question survey• Compare to gold standard biomarkerCompare to gold standard biomarker

• May reflect metabolism as well as exposureMay reflect metabolism as well as exposure

o BiomarkersBiomarkers• Cotinine, thiocyanate, COCotinine, thiocyanate, CO• Air monitoringAir monitoring

o Risk for misclassificationRisk for misclassification• Measurement and metabolismMeasurement and metabolism• Former smokers classified a lifetime nonsmokersFormer smokers classified a lifetime nonsmokers


PrevalencePrevalenceNHANES began cotinine measurements in 1988NHANES began cotinine measurements in 1988


Prevalence in ChildrenPrevalence in Children

o 59.6% ages 3-11, significantly higher 59.6% ages 3-11, significantly higher than adults (See next slide…)than adults (See next slide…)• 25% with at least 1 smoker in home25% with at least 1 smoker in home

o 22 million children exposed22 million children exposedo Numbers declining since 1988Numbers declining since 1988o Most exposure in home environmentMost exposure in home environment


Age Variation in ExposureAge Variation in Exposure


Toxic Compounds in ETSToxic Compounds in ETS

o 50 known carcinogens50 known carcinogens• Polycyclic aromatic hydrocarbons [PAHs]• N-Nitrosamines• Aromatic amines• Aldehydes• Miscellaneous organic and inorganic

o Carcinogenicity depends on metabolism and ability to excrete toxins or metabolic activation coupled with susceptibility


Respiratory Injury and ETSRespiratory Injury and ETSo In utero, possible interference with fetal In utero, possible interference with fetal

airway developmentairway development• Altered pulmonary function into late childhoodAltered pulmonary function into late childhood• Increased airway thicknessIncreased airway thickness• Lung structure may be related to nicotineLung structure may be related to nicotine• Increase in bronchial hyper-reactivity to Increase in bronchial hyper-reactivity to

histaminehistamine

o Decreased host defenses against Decreased host defenses against infectious agentsinfectious agents• Inhibits antibody responseInhibits antibody response• Impairs mucociliary clearanceImpairs mucociliary clearance


ETS and SIDSETS and SIDS

o Established epidemiologic relationshipEstablished epidemiologic relationshipo Exact mechanism not knownExact mechanism not known

• Induces adenylyl cyclase activityInduces adenylyl cyclase activity• Increase in lung C-fiber CNS response Increase in lung C-fiber CNS response

leading to prolonged respiratory apnealeading to prolonged respiratory apnea


Prenatal EffectsPrenatal Effects

o Evidence insufficient to identify causal Evidence insufficient to identify causal relationship to:relationship to:• Spontaneous abortionSpontaneous abortion• InfertilityInfertility• Neonatal mortalityNeonatal mortality• Congenital malformationsCongenital malformations• Cognitive/behavioral functioningCognitive/behavioral functioning

o Suggestive, not sufficientSuggestive, not sufficient• Childhood cancerChildhood cancer• Preterm birthPreterm birth


Prenatal Effects (Cont)Prenatal Effects (Cont)

o Sufficient evidence:Sufficient evidence:• SIDSSIDS• Low birth weightLow birth weight


Childhood EffectsChildhood Effects

o Causal relationshipCausal relationship• AsthmaAsthma

• Child onsetChild onset• In school age childrenIn school age children

• Lower respiratory illnessLower respiratory illness• Otitis mediaOtitis media• Wheezing and breathlessness among Wheezing and breathlessness among

school-aged childrenschool-aged children• Altered lung growthAltered lung growth• Altered pulmonary functionAltered pulmonary function


Strategies to Reduce ExposureStrategies to Reduce Exposure

o Smoking Bans and RestrictionsSmoking Bans and Restrictionso Community EducationCommunity Educationo Reduce tobacco initiationReduce tobacco initiationo Increase tobacco cessationIncrease tobacco cessationo Provider reminder systemsProvider reminder systems


HELPING SMOKERS QUITHELPING SMOKERS QUIT

o US Public Health ServiceUS Public Health Service• Clinicians should assess smoking Clinicians should assess smoking

status at every office visitstatus at every office visit• Smoking cessation advise should be Smoking cessation advise should be

given routinelygiven routinely

Treating Tobacco Use and Dependence. US Public Health Service 2000.

(Provided by Sophie Balk, MD, Albert Einstein College of Medicine)


WHY FOCUS ON PARENTS?WHY FOCUS ON PARENTS?

o ~15 million US children live with a ~15 million US children live with a smokersmoker

o Pediatric clinicians may be the Pediatric clinicians may be the only clinicians a parent visitsonly clinicians a parent visits

o Most smokers want to quitMost smokers want to quito Most parents are receptive to Most parents are receptive to

counseling by pediatricianscounseling by pediatricians11

1 - Frankowski BL, Weaver SO, Secker-Walker RH. Pediatrics 1993; 91: 296-300.



COUNSELINGCOUNSELINGo Brief counseling is effectiveBrief counseling is effectiveo Intensive counseling is more effective: Intensive counseling is more effective:

dose-response relationshipdose-response relationshipo Most effective Most effective

• Problem-solving skillsProblem-solving skills• Support from clinicianSupport from clinician• Social support outside of treatmentSocial support outside of treatment




Odds Ratio of Quitting Increases Odds Ratio of Quitting Increases with Counselingwith Counseling

1.0

2.3

1.61.3

0.0

0.5

1.0

1.5

2.0

2.5

Total Contact Time

Od

ds

Rat

io o

f Q

uit

tin

g

Quitting defined as abstinence for at least 5 monthsQuitting defined as abstinence for at least 5 monthsTreating Tobacco Use and Dependence. US Public Health Service 2000.



THE “5 A’S”THE “5 A’S”

o AskAsko AdviseAdviseo AssessAssesso AssistAssisto Arrange follow-upArrange follow-up



System ImplementationSystem Implementation

“Ask”Identify Tobacco Use /exposure to smoke

Document chart

“Advise”To Quit

“Assess”willingness to quit

“Assist”with quitting

“Arrange”Follow-up

Referrals

Quitline1-800-QUITNOW

Individual/Group Counseling &

Pharmacotherapy(Provided by Sophie Balk, MD,

Albert Einstein College of Medicine)


PHARMACOTHERAPYPHARMACOTHERAPY

o Smokers trying to quit should be Smokers trying to quit should be encouraged to use pharmacotherapy encouraged to use pharmacotherapy except under special circumstances except under special circumstances Medical contraindicationsMedical contraindications Pregnant women & adolescents require Pregnant women & adolescents require

special considerationspecial consideration




ADOLESCENTS & SMOKINGADOLESCENTS & SMOKINGo Tobacco industry targets the youngTobacco industry targets the young

o Children & teens constitute theChildren & teens constitute the majority of all new smokersmajority of all new smokers

o 22% of high school students22% of high school students smokesmoke

o 82% of adult smokers tried their 82% of adult smokers tried their first cigarette by age 18first cigarette by age 18

o Smoking cessation messages &Smoking cessation messages & methods are essential for teensmethods are essential for teens



THE PREGNANT SMOKERTHE PREGNANT SMOKER

o Smoking imparts risk to woman & fetus

o Offer augmented interventions that

exceed minimal advice (5 – 15 minutes)

o Tailor advice specific to pregnant smokers

o Consider pharmacotherapy for those unable to quit



OFFICE STRATEGIESOFFICE STRATEGIES

o Educate office staff

o Document tobacco use

o Assign dedicated staff

Vital SignsVital Signs

BP___Pulse__ WT.________BP___Pulse__ WT.________

Temp_______RR_______Temp_______RR_______

Tobacco use:Tobacco use:

current former nevercurrent former never

Quit attempts:Quit attempts:



ReferencesReferences

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 1 Environmental Tobacco Smoke Cara J. Krulewitch CNM PhD Assistant Professor University of Maryland School of Nursing NEETF.

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