Protecting Children and Adolescents From Tobacco and Nicotine

Tobacco use remains the leading preventable cause of disease and death for adults in the United States. Significant strides have been made in reducing rates of cigarette smoking among adolescents in the United States. However, rates of e-cigarette and similar device use among youth are high, and rates of other tobacco product use, such as cigars and hookahs, have not declined. Public policy actions to protect children and adolescents from tobacco and nicotine use, as well as tobacco smoke and aerosol exposure, have proven effective in reducing harm. Effective public health approaches need to be both extended to include e-cigarettes, similar devices, and other and emerging tobacco products and expanded to reduce the toll that the tobacco epidemic takes on children and adolescents.

Protecting Children and Adolescents From Tobacco and Nicotine

This technical report provides the evidence base for the accompanying tobacco clinical report and policy statement. It builds on, strengthens, and expands AAP recommendations from the previous version in 2015. Tobacco use remains the leading preventable cause of disease and death for adults in the United States. The tobacco epidemic takes a substantial toll on children's and adolescent's health, including harms because of prenatal exposure during pregnancy, secondhand and thirdhand exposure during infancy and childhood, and/or direct use during adolescence. Tobacco and nicotine use almost always starts in childhood or adolescence. Almost 40% of children aged 3 to 11 years are regularly exposed to secondhand tobacco smoke, and rates of secondhand exposure to e-cigarette aerosol have increased over the last decade.

Protecting Children and Adolescents From Tobacco and Nicotine

Significant strides have been made in reducing rates of cigarette smoking among adolescents in the United States. However, rates of e-cigarette and similar device use among youth are high, and rates of other tobacco product use, such as cigars and hookahs, have not declined. In addition, almost 40% of children 3 to 11 years of age are regularly exposed to secondhand tobacco smoke, and rates of secondhand exposure to e-cigarette aerosol have increased over the last decade. Pediatricians are uniquely positioned to help children, adolescents, and their families live tobacco-free lives. Actions by pediatricians can help reduce children's risk of developing tobacco and nicotine use disorder and reduce children's tobacco smoke and/or aerosol exposure.

Asking the Right Questions About Secondhand Smoke

INTRODUCTION

Despite knowledge about major health effects of secondhand tobacco smoke (SHS) exposure, systematic incorporation of SHS screening and counseling in clinical settings has not occurred.

METHODS

A three-round modified Delphi Panel of tobacco control experts was convened to build consensus on the screening questions that should be asked and identify opportunities and barriers to SHS exposure screening and counseling. The panel considered four questions: (1) what questions should be asked about SHS exposure; (2) what are the top priorities to advance the goal of ensuring that these questions are asked; (3) what are the barriers to achieving these goals; and (4) how might these barriers be overcome. Each panel member submitted answers to the questions. Responses were summarized and successive rounds were reviewed by panel members for consolidation and prioritization.

RESULTS

Panelists agreed that both adults and children should be screened during clinical encounters by asking if they are exposed or have ever been exposed to smoke from any tobacco products in their usual environment. The panel found that consistent clinician training, quality measurement or other accountability, and policy and electronic health records interventions were needed to successfully implement consistent screening.

CONCLUSIONS

The panel successfully generated screening questions and identified priorities to improve SHS exposure screening. Policy interventions and stakeholder engagement are needed to overcome barriers to implementing effective SHS screening.

IMPLICATIONS

In a modified Delphi panel, tobacco control and clinical prevention experts agreed that all adults and children should be screened during clinical encounters by asking if they are exposed or have ever been exposed to smoke from tobacco products. Consistent training, accountability, and policy and electronic health records interventions are needed to implement consistent screening. Increasing SHS screening will have a significant impact on public health and costs.

Pediatric Resident Training in Tobacco Control and the Electronic Health Record

Given the dangers posed by tobacco use and tobacco smoke exposure, pediatricians should address tobacco use and exposure with patients and parents at every opportunity, but this is not consistently done in practice. One reason may be that many medical residents do not receive education on how to address tobacco use and tobacco smoke exposure with patients and their parents. In a 2012 survey of U.S. pediatric program directors, 65% of programs reported covering tobacco control in their curricula, but most training programs focused on tobacco's health effects and not intervention strategies for clinical practice. Since that survey, electronic health records have been implemented broadly nationwide and utilized to address tobacco smoke exposure. Investigators surveyed U.S. program directors in 2018 and residents in 2019 to explore the ways in which the residents learn about tobacco use and tobacco smoke exposure, components and use of the electronic record specific to tobacco use and tobacco smoke exposure, and perceived resident effectiveness in this area. All the program directors and 85% of the residents valued training, but 21% of the residents reported receiving none. Moreover, a minority of the residents assessed themselves as effective at counseling parents (19%) or adolescents (23%), and their perceived effectiveness was related to small group learning and active learning workshops, modalities that were infrequently implemented in training. Respondents also reported infrequent use of electronic health record prompts regarding tobacco and the absence of prompts about critical issues (e.g., addressing tobacco smoke exposure in vehicles or other settings or offering treatment or referrals to parents who smoke). This paper provides recommendations about augmenting pediatric resident training in simple ways.

Motivational Interviewing: A High-Yield Interactive Session for Medical Trainees and Professionals to Help Tobacco Users Quit

Introduction

Motivational interviewing (MI) is a collaborative patient-focused counseling technique that is effective in promoting smoking cessation but is not consistently taught/practiced in training.

Methods

This training session was implemented in a pediatric residency training program and also given four times to pediatric practitioners as part of a 2-day tobacco training sponsored by the American Academy of Pediatrics (AAP). Pediatric residents (N = 33) participated in a 1-hour interactive session focused on addressing tobacco. Knowledge was assessed with pre- and 6-month postsurveys. Retention of skills was evaluated between 6 and 9 months posttraining by resident performance on two scenarios with standardized patients, which was scored utilizing the Behavior Change Counseling Index (BECCI), by two MI-trained physicians. AAP trainees (N = 115) participated in tobacco trainings with a session dedicated to MI; sessions were evaluated by pre- and posttests.

Results

Residents who completed the session (n = 12) performed significantly better on eight of 10 items of the BECCI and on the overall BECCI score (p < .001) compared with those who had not completed the session (n = 12). Feedback on AAP training sessions (N = 115) indicated that practitioners felt able to perform MI and incorporate MI into practice. The percentage of trainees who felt comfortable counseling about tobacco doubled from pre- to posttraining.

Discussion

A hands-on MI training session provided pediatric residents and practicing clinicians with knowledge and skills to address tobacco use with patients/families. The session is easily incorporated into different training environments.

Evidence of Nicotine Dependence in Adolescents Who Use Juul and Similar Pod Devices

Background: The use of high-nicotine content e-cigarettes (so-called pods, such as Juul) among adolescents raises concerns about early onset of nicotine addiction. Methods: In this analysis of adolescents surveyed from April 2017–April 2018, we compare survey responses and urinary cotinine of pod vs. non-pod using past-week e-cigarette users aged 12–21. Results: More pod users categorized themselves as daily users compared to non-pod users (63.0% vs. 11.0%; p = 0.001); more pod than non-pod users had used e-cigarettes within the past day (76.2% vs. 29.6%; p = 0.001). More pod users responded affirmatively to nicotine dependence questions (21.4% vs. 7.1%; p = 0.04). Urinary cotinine levels were compared among those responding positively and negatively to dependence questions: those with positive responses had significantly higher urinary cotinine levels than those responding negatively. Conclusions: Adolescents who used pod products showed more signs of nicotine dependence than non-pod users. Pediatricians should be vigilant in identifying dependence symptoms in their patients who use e-cigarettes, particularly in those using pod devices.

Self-Reported Use of Tobacco, E-cigarettes, and Marijuana Versus Urinary Biomarkers

BACKGROUND

Surveys have been instrumental in describing adolescent use of tobacco, electronic cigarettes (e-cigarettes), and marijuana. However, objective biomarker data are lacking. We compared adolescent self-reported use to urinary biomarkers.

METHODS

From April 2017 to April 2018, adolescents 12 to 21 years old completed an anonymous questionnaire regarding tobacco, e-cigarette, and marijuana use and provided a urine sample. Urine was analyzed for biomarkers cotinine, total 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol, and tetrahydrocannabinolic acid (THCA).

RESULTS

Of 517 participants, 2.9% reported using tobacco, 14.3% e-cigarettes, and 11.4% marijuana in the past week. Only 2% reporting no smoking had total 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol levels above cutoff (14.5 pg/mL); 2% of non-e-cigarette users had cotinine above cutoff (10 ng/mL); 2% of those denying marijuana use had THCA above cutoff (10 ng/mL). Daily e-cigarette users showed significantly higher median cotinine than nondaily users (315.4 [interquartile range (IQR) 1375.9] vs 1.69 ng/mL [IQR 28.2]; P < .003). Overall, 40% who reported using nicotine-free products had cotinine >10 ng/mL. Pod users' median cotinine was significantly higher than in nonpod users (259.03 [IQR 1267.69] vs 1.61 ng/mL [IQR 16.3]; P < .003). Median THCA among daily marijuana users was higher than in nondaily users (560.1 [IQR 1248.3] vs 7.2 ng/mL [IQR 254.9]; P = .04). Sixty-one percent of those with cotinine >10 ng/mL vs 39% of those with cotinine<10 ng/mL had THCA >10 ng/mL (P < .001).

CONCLUSIONS

Adolescents' self-report correlated with measured urinary biomarkers, but subjects were unaware of their nicotine exposure. More frequent e-cigarette and pod use correlated with elevated biomarkers. Co-use of tobacco, e-cigarettes, and marijuana was corroborated by higher THCA in those with higher cotinine.

Using Motivational Interviewing to Address Tobacco Cessation: Two Standardized Patient Cases for Pediatric Residents

INTRODUCTION

Motivational interviewing (MI) is a well-established evidence-based method of working with patients to promote health behavior change. Standardized patient (SP) simulation allows trainees to practice and receive feedback on clinical and communication skills and may be useful in applying MI techniques to address tobacco use and exposure.

METHODS

We developed two SP cases for pediatric residents to practice addressing tobacco use with parents of their patients.

RESULTS

Thirty-six residents participated, 26 of whom had prior MI training. Resident postencounter self-reflection identified MI-specific skills, including eliciting the SP's view on positive/negative aspects of smoking, identifying stressors/triggers associated with smoking, eliciting reasons for smoking, asking about motivation/willingness to quit, eliciting benefits of quitting smoking, letting the SP do the talking, and guiding the SP in making a quit plan. On paired-samples t tests, resident self-evaluation checklist scores averaged 6.79 out of 8.00 (SD = 1.018, SEM = 0.165), compared with SP checklist scores, which averaged 7.08 out of 8.00 (SD = 1.217, SEM = 0.197).

DISCUSSION

These two SP cases were useful in many ways, allowing residents with prior MI training the opportunity for practice/feedback on skills learned and introducing residents with no prior MI training to MI concepts through experience/feedback. Residents consistently identified using MI concepts on postencounter self-reflection; resident self-evaluation and SP evaluation of residents showed agreement. These sessions could be utilized within a communication/MI curriculum or as stand-alone sessions to introduce MI concepts/techniques for addressing tobacco cessation in the pediatric setting.

Electronic Cigarettes and Youth in the United States: A Call to Action (at the Local, National and Global Levels)

E-cigarettes have emerged and soared in popularity in the past ten years, making them the most common tobacco product used among youth in the United States (US). In this review, we discuss what the Surgeon General has called a public health “epidemic”—the precipitous increase in youth use of e-cigarettes and the health consequences of this behavior. Further, we review tobacco control policy efforts (e.g., Tobacco 21, banning flavors, advertising restrictions, and clean indoor air laws)—efforts proven to be critical in reducing cigarette smoking and smoking-related disease and death among US children and adults—including their potential and challenges regarding managing and mitigating the emergence of e-cigarettes. Finally, we close with a discussion of the efforts of transnational tobacco companies to rebrand themselves using e-cigarettes and other new products.

The role of librarians in teaching evidence-based medicine to pediatric residents: a survey of pediatric residency program directors

Objective:

The research sought to identify the general use of medical librarians in pediatric residency training, to define the role of medical librarians in teaching evidence-based medicine (EBM) to pediatric residents, and to describe strategies and curricula for teaching EBM used in pediatric residency training programs.

Methods:

We sent a 13-question web-based survey through the Association of Pediatric Program Directors to 200 pediatric residency program directors between August and December 2015.

Results:

A total of 91 (46%) pediatric residency program directors responded. Most (76%) programs had formal EBM curricula, and more than 75% of curricula addressed question formation, searching, assessment of validity, generalizability, quantitative importance, statistical significance, and applicability. The venues for teaching EBM that program directors perceived to be most effective included journal clubs (84%), conferences (44%), and morning report (36%). While 80% of programs utilized medical librarians, most of these librarians assisted with scholarly or research projects (74%), addressed clinical questions (62%), and taught on any topic not necessarily EBM (58%). Only 17% of program directors stated that librarians were involved in teaching EBM on a regular basis. The use of a librarian was not associated with having an EBM curriculum but was significantly associated with the size of the program. Smaller programs were more likely to utilize librarians (100%) than were medium (71%) or large programs (75%).

Conclusions:

While most pediatric residency programs have an EBM curriculum and engage medical librarians in various ways, librarians’ expertise in teaching EBM is underutilized. Programs should work to better integrate librarians’ expertise, both in the didactic and clinical teaching of EBM.

Implementation of an Inpatient Electronic Referral System (Opt-to-Quit) From the Electronic Health Record to the New York State Smokers' Quitline: First Steps

OBJECTIVES

(1) To implement a new policy-driven referral program, Opt-to-Quit, using electronic data transfer from the electronic health record (EHR) to the New York State Smokers' Quitline (NYSSQL) and (2) to improve referrals to the NYSSQL for smoking caregivers of children admitted to a children's hospital.

METHODS

Smoking caregivers of pediatric patients were referred to the NYSSQL through a standardized template built into the EHR, during the child's hospitalization or emergency department encounter. Direct data exchange was based on a point-to-point protocol, without dependence on any external centralized processing service. Input and oversight were provided by a multidisciplinary task force, which included physician and nursing leadership, information technology specialists, Health Insurance Portability and Accountability Act compliance personnel and legal counsel, and NYSSQL staff. The process was refined through several iterative plan-do-study-act cycles, using a single-armed, prospective cohort study design, including surveys of nursing staff and continued input of information technology experts on both hospital and Quitline sides.

RESULTS

In 2013, 193 smokers were identified in 2 pilot units; 62% (n= 119) accepted referral to the NYSSQL. In 2014, after expansion to all inpatient units and the emergency department, 745 smokers were identified, and 36% (n = 266) accepted referral. Over the 2 years, overall increase in referrals was 124%; as of the first quarter of 2015, referral rate was sustained at 34%.

CONCLUSIONS

Hospital-wide implementation of the Opt-to-Quit program through our EHR was feasible and sustainable and has significantly improved referrals to the NYSSQL.

A Comparison of Parents of Healthy Versus Sick Neonates: Is There a Difference in Readiness and/or Success in Quitting Smoking?

OBJECTIVES

Study objectives were to compare smoking cessation rates between parents in the newborn nursery (NBN) versus the NICU and compare acceptance of referral to the New York State Smoker's Quitline (NYSSQL) between the 2 units. Secondary aims were to identify opportunities for improved smoking cessation interventions with parents of newborns.

METHODS

From January through December 2013, smoking parents/caregivers of infants in the NBN and NICU (n = 226) completed a 34-item questionnaire. For those who accepted electronic referral to the NYSSQL, participation/outcome data and questionnaire data were matched. Relationships were examined using the χ(2) test of independence.

RESULTS

The majority of respondents had cut back (56%) or quit (36%) prenatally. Seventy-nine percent of NBN parents accepted referred to the NYSSQL versus 53% of NICU parents; odds ratio = 3.31 (1.48-7.40; P < .01). At 7- to 8-month follow-up (n = 35): 11 of 28 (NBN) versus 0 of 7 (NICU) quit, 11 of 28 (NBN) versus 5 of 7 (NICU) cut back, 6 of 28 (NBN) versus 2 of 7 (NICU) did not quit/cut back (P = .13). Significantly more mothers (80%; 16/20) compared with fathers (46%; 6/13) quit/cut back, 20% (4/20) of mothers versus 54% (7/13) of fathers did not quit/cut back (P = .04). Exclusive formula-feeding rates were higher in this cohort of smokers surveyed than in all parents of infants admitted to the NBN/NICU for the same year (45% vs 13%).

CONCLUSIONS

In this study population, parents of healthy newborns were more receptive to quitline referrals than parents of infants admitted to the NICU.

Partnering with residents for evidence-based practice

Medical residents are a distinct group of health sciences library users that need detailed instruction in literature searching. Core residency competencies from the Accreditation Council for Graduate Medical Education require that all residents be competent in finding, critically appraising, and incorporating the latest clinical evidence into their daily practice with patients. With the collaboration of the library and a clinical department of pediatrics, a program was developed that teaches residents the basic elements of EBM searching and then reinforces this learning over the course of three years.