Case of Asthma

 ID: M.C. 7 year old female

• Mild persistent asthma since age 2
• Four exacerbations this year.
• ICU admission in May
• Multiple Environmental/animal allergies.
 HPI:
• Wheezing, cough, increased work of breathing
• Rapid onset, over 15-18 hours
• Mom gave back to back albuterol/atrovent
 Case: Asthma
 ED Course:
• Diffuse biphasic wheezes, decreased aeration at
lung bases.

• Large volume neb

• Persistent hypoxia, worse while sleeping.

 PMH:
• Asthma diagnosed at age 2

• Allergies: Feathers, cats, dogs, many trees

 Case: Asthma
 Meds:
• Atrovent, Singular, Symbicort, Zyrtec, Albuterol
 Family History:
• Brother with asthma
• Two hospital admissions
 Social History:
• Got rid of dog since last admission
• Dad smokes, but only outside.
 Second hand smoke and children:
Empowering pediatricians and parents
Kevin E. Nelson

Advocacy Morning Report

December 18, 2009
 Outline
 Secondhand smoke
 Practice guidelines
 Pediatrician practice behaviors
 Interventions
 Pediatricians Against Secondhand Smoke
(PASS) Initiative
 What can you do? What you can do!
Secondhand Smoke and
Children
 Increased burden of illness
• Bronchitis, pneumonia, and other URIs
• Asthma – more frequent and severe exacerbations.
• Sudden infant death syndrome.
 Four fold higher risk hospitalization for
serious infection (age 0-4 years)
 Tobacco related childhood deaths in US
5000/year
 Medical expenditures and loss of life for
children exceed $10 billion per year
Winickoff JP, et al. Pediatrics 2003;112:1146–1151. Winickoff JP, et al. Pediatrics 2005;115;750-760.
AAP Policy Statement, Environmental Tobacco Smoke: A Hazard to Children, Pediatrics 1997 99: 639-
642.
 Utah SHS Exposure
 Utah smoking rates
• Adult 9.1% Youth 7.9%
• SL County 12.2% Weber-Morgan 12.5%
 SHS exposure rates for children
• Utah 1.8% (~16,000 children)
• Salt Lake County 2.1% (no change since 2004)
• Minimal changes for at-risk groups

 At-risk Utah communities and groups:

• Magna, West Valley, South Salt Lake, Ogden
• African Americans 22%
Tobacco Prevention and Control in Utah, 8th Annual Report, 2008, available at
http://www.tobaccofreeutah.org/facts.html
 Practice Guidelines
 “Every patient who uses tobacco should be offered at
least one effective treatment.”

 “Discussion and anticipatory guidance…deserves

special attention when a parent or regular caretaker is
a smoker, including repeated nonjudgmental efforts to
encourage the parent to quit smoking (accompanied
by appropriate referral)” - (2001)

 “Helping parents quit smoking is now a recognized

priority of child health care clinicians.” - (2003)

Fiore MC, et. al. Treating Tobacco Use and Dependence. U.S. Department of Health and Human Services. 2000.
AAP Policy Statement, Pediatrics 2001 107:794-798. AAP Policy Statement, In: Etzal R, ed. Pediatric Environmental
Health.
Health. 2nd ed. Elk Grove Village, IL: AAP; 2003:147–163
Practice Guidelines
 “Tobacco dependence shows many features of a chronic
disease…
 “[A chronic disease model] recognizes the long-term nature of
the disorder with an expectation that patients may have
periods of relapse and remission…
 “Clinicians should remain cognizant that relapse is likely, and
that it reflects the chronic nature of dependence, not their
personal failure, nor a failure of their patients.” (2000)

 AAP endorses HHS Clinical Practice Guideline. (2008)

 AAP 2009 policy statements

Fiore MC, et. al. Treating Tobacco Use and Dependence. U.S. Department of Health and Human Services. 2000.
AAP Policy Statement, Tobacco a Pediatric Disease. Pediatrics, 2009;124:1475.
 Pediatrician Practices
 Assessment and intervention.
• 5-60% report asking parent to quit.
• Screening 87%, counseling 59%. Smoking parents of
asthmatics
• At WCC 90% counsel 60% of smoking parents to
quit.

 Self-efficacy over-reported.
• Chart reviews indicate ~5% pediatricians counsel.
• SHS often not addressed even when directly
relevant to diagnosis.
Cabana MD, et. al, Pediatrics 2004;113:78-81. Collin BN, et. al, J Pediatr 2007;150:547-52.
Frankowski BL, Secker-Walker RH. AJDC. 1989;143:1901-1904. Tanski, SE, et. al, Pediatrics 2003;111;e162-e167.
Perez-Stable EJ, Arch Pediatr Adolesc Med; 2001; 155:25-31
 Pediatrician Barriers
 Parents - Behavior
• Would ignore advice 
Not interested
• Do not expect advice Would be offended
• Would leave practice
 Pediatrician - Systems
• Lack of time Competing priorities
• Reimbursement Ineffective
• Lack preparation Lack training
• Question treatment efficacy Not their role
AAP policy statement, Pediatrics 1997; 99:639-642. Frankowski BL, Secker-Walker RH. AJDC. 1989;143:1901-
1904. Nader P, et. al, Pediatrics. 1987; 79:843–850. Perez-Stable EJ, Arch Pediatr Adolesc Med; 2001; 155:25-31.
Tanski, SE, et. al, Pediatrics 2003;111:e162-e167. Winnickoff, et al., Pediatrics 2005;115:1013. Zapka JG, et. al.
Pediatrics 1999; 103:e65.
 Not My Job

http://www.the-trukstop.com/articles/2007/wrong_place_wrong_time
Utah Pediatricians
 Unknowns among Utah pediatricians
• Screening, counseling
• Utilization of interventions/resources
• Pediatrician perceptions and attitudes

 Salt Lake Valley Health Department

• No clinician outreach for pediatricians
• Weber-Morgan has started to target
pediatricians
 Tobacco Interventions
 Behavioral/social support
• Counseling
• Phone - Utah Quitline
• Internet Utah QuitNet
• Changing trigger behavior
 Pharmacoterapy - buproprion, wellbutrin,
varenicline
 Practices - systems change
 Legislation
 Smoke free workplace/environment
 Provider Interventions
 5 A’s – Ask, Advise, Assess, Assist,
Arrange Follow-Up
 Stages of Change - Assessment

Fiore MC, et. al. Treating Tobacco Use and Dependence. U.S. Department of Health and Human
Services. 2000; Prochaska, JO and DiClemente, CC, J Consult Clin Psych 1983:51; 390-395
http://www.adultmeducation.com/FacilitatingBehaviorChange.html
 Provider Interventions
 CEASE
• 5A’s, nicotine replacement
• under evaluation
 Low SES women
• Pediatrician, literature, health educator, phone
follow up
• 13.5% quit vs. 6.9% control

Winnickoff, JP, et.al, Pediatrics 2008;122:e363-e375

Curry SJ, et. al, Arch Pediatr Adolesc Med. 2003;157:295–302
 P.A.S.S. Initiative
 Pediatricians Against Secondhand Smoke
(PASS)
 Resident advocacy initiative from PCMC
• Sustainable intervention program

• Educate child health care providers at all levels

• Tailored smoking cessation resources

• Practice-based strategy

• Facilitate smoking cessation interventions among

smoking parents and adolescents.
P.A.S.S. Initiative Phases

 Assess smoking cessation attitudes and practices

of Salt Lake Valley pediatricians.
 Build coalition of medical and community anti-
tobacco advocates.
 Provide tailored smoking cessation materials.
 Educate child healthcare providers via in-service
seminars.
• Provide systems instrument

• Training in motivational interviewing

 P.A.S.S. Initiative
 Monitor changes in attitudes and practices
of pediatric practices.
 Additional activities
• Direct education to at-risk communities by PASS
and community advocates

• Working with lay community groups

• Legislative advocacy
2009-2010 Legislative session:
 Tobacco tax
 Smoking in automobiles
 Smoking:
What you can do!
5A’s
 ASK - Screen
 ADVISE - Educate
 ASSESS – Barriers
 ASSIST – Support
 ARRANGE – Follow up
• Document
• Ask at next appointment
• Interim phone call
• Refer to Quitline/QuitNet
 Smoking:
What you can do!
 Know available resources
• Quitline/Quitnet
• Pharmacotherapy
• Support groups

 Give them something to take home

 Make it a priority, especially if diagnosis
related
 Summary
 Children at-risk demographic groups at risk for
SHS exposure
 Pediatricians have a role in helping parents quite
smoking
 Addressing barriers with pediatricians may
improve intervention and quit rates
 Tailored initiatives may lead to improved provider
interventions with at-risk populations
 Every healthcare provider can make a difference
 Acknowledgments
Karen Buchi Community Partners
Wendy Hobson-Rohrer American Heart
Association
Laura Duty American Lung Association
Clarisa Garcia Communidades Unidas
Robyn Nolan Utah Latino Network
Mandy Allison Salt Lake Valley Health
Department
Jamie Bruse
Utah Department of
Dedee Caplin Health
Emily Eresuma Utah Tobacco Prevention
Heather Nelson & Control Project
Division of General Utah Chapter of the AAP
Pediatrics Department of Pediatrics
Pediatrics Residency
Program