Parental smoking is a significant childhood risk factor for numerous respiratory tract conditions, including increased pulmonary infections, oti' tis media, impaired lung function, increased bronchial sensitivity, increased incidence and severity of asthma episodes, and increased asthma-related emergency room visits.1'7 Although the emphasis should be on providing a healthy environment for all children, it is particularly important to provide a smoke-free environment for children with asthma. Smoking cessation is the most effective means of ensuring that exposure to smoke is reduced. In addition, cessation is better for the parents' health and ensures that their children will have better role models when making their own decisions on whether to smoke. Smoking cessation counseling, therefore, is a legitimate part of the responsibilities of physicians who treat children with asthma.
Smoking may be thought of as a "career," which includes stages in initiation as well as quitting.8 Initiation stages include initial use, experimentation, and transition to habitual use. Just as an individual does not initiate smoking in one step, cessation is multiphasic as well. Stages in quitting include precontemplation of quitting, contemplation of quitting, action, maintenance, and relapse. Quitting is often a cycle of these steps with repeated efforts occurring prior to successful cessation. The specific stage of quitting the smoker is in affects the impact of the information given, with physician-based smoking cessation intervention being an important part of the cycle of quitting.9-10 The cessation intervention may plant the idea to consider quitting, help set a quit date, or provide information about support groups to prevent relapse.
Although physician-based smoking intervention
may not immediately result in the individual being able to stop smoking, the words of advice may move the smoker from one stage of cessation to the next. The Table lists tips that might help smokers in each of the stages. A smoker in the precontemplation stage may begin to contemplate quitting, a smoker who is contemplating quitting may be moved to action, or a person who has stopped smoking might be helped to avoid relapse. The movement from one stage to the next is not always readily apparent; in fact, the physician may not be aware of the long-term benefit of his or her advice.
Physicians who treat children with asthma have a unique opportunity to positively influence smoking parents. Most parents do not want to compromise the health of their children, thus the message regarding the risk to the child when they smoke may be the necessary wedge to a successful smoking intervention. Parents of children with asthma need to receive specific and candid information regarding the risks and health hazards associated with passive smoke.
Unfortunately, patient/parent contact with the physician is limited. A concept that one might embrace is the physician as an "agenda setter," ie, not as the provider of a wide range of smoking cessation services, but rather as a catalyst for a parent's cessation effort. Such a concept recognizes that physician time is limited but also acknowledges that physician advice to quit smoking may be very important in a parent's decision to quit. This concept also acknowledges that smokers are getting many messages to quit from various sources and that smoking cessation is usually a long-term process. In such a model, a successful clinical encounter does not necessarily mean that the patient or parent immediately quits smoking, but rather that he or she is given cessation advice in an unambiguous fashion and hopefully moves another step along the psychological process to cessation. The following guidelines offer practical suggestions for office-based smoking interventions.
* Set an example. The physician should serve as a role model and certainly should not smoke, especially in the office. In addition, smoking should be completely banned from the office; this includes personnel, parents, and patients.
* Look for a teachabk moment. Throughout a persons life, there will be teachable or clinically opportune moments when he or she may be particularly open to a nonsmoking message. For physicians who treat children, such moments might include office visits for recurrent otitis media or wheezing.
* Take a smoking history. All parents should be queried concerning smoking. The history should include not only asking about smoking but also a few questions relating to amount so that the physician can get a rough idea of the extent of nicotine addiction. The heavily addicted smoker may well require referral and/or nicotine replacement therapy. If a person smokes more than 20 cigarettes per day or smokes the first thing after getting out of bed, he or she is probably a physically addicted smoker.
Guidelines for Counseling During Stages of Smoking Cessation
* Personalize the health risk. Relate the child's recurrent otitis media, cough, or wheeze to parental smoking. Many parents are aware that smoking is "bad," but they may not be aware of the specifics. Make eye contact, be concise, be personal, and be prepared to hear a wide range of rationalizations.
* Emphasize the parent as role model. This is another potential psychological wedge as the majority of smokers do not want their children to smoke.
* Engage the parent in a discussion about their smoking. Focus the discussion on whether the parent is ready to consider cessation and has attempted to quit in the past, or if there are any factors that make it difficult for the parent to quit. Determine what stage of quitting the parent is in to aid progress to another stage.
* Give direct advice to quit. It is interesting to note that when surveyed, most physicians indicate they always advise smokers to quit.11 Other surveys, however; show that when smokers leave a physician's office, they often claim not to have heard such advice.12 Advice to quit should be given in an unambiguous fashion. Depending on the physician's analysis of the situation, some combination of the following three psychological "wedges" are available for directing advice: 1 ) the health effects of passive smoking on the child, 2) the health effects of active smoking on the parent, and 3 ) the parent as a smoking role model.
* Try to establish a behavioral commitment. Research has shown that smoking intervention is more likely to be successful if the patient makes a specific behavioral commitment. Hopefully, this will be to set a quit date in the near future. Just before the quit date the smoker should discard all cigarettes and ashtrays. Give the parent a prescription with the quit date written on it, For some smokers, a commitment to set a quit date may be too overwhelming. Other valid commitments can include setting a date for a family meeting, reading a self-help brochure, or enrolling in a group cessation program.
* Commit to follow-up. Plan to follow-up on any behavioral commitment the parent may have made. Let the parent see you write down his or her commitment in the chart, and use this chart notation as a basis for discussion at the next office visit. For many parents, becoming a nonsmoker may be a long-term process. Even when parents don't quit immediately, parental smoking should be addressed at each office visit.
* Have local resources available. These can include pamphlets, self-help materials, and telephone numbers for local cessation programs. Such materials can be obtained free of charge from local affiliates of the American Lung Association, American Cancer Society, or the American Heart Association. Most physicians are aware of resources in their community for parents who might have health problems, and smoking intervention should be one of these resources. Addicted smokers can be helped to quit with the use of nicotine chewing gum13·14 or nicotine transdermal patches. However, nicotine replacement therapy cannot be used in an unsupervised fashion. In fact, many smokers will say they have tried nicotine gum and it has not helped them quit. A major reason for such failures is that the gum has not been used in conjunction with a comprehensive plan for smoking cessation including follow-up and a plan for weaning the smoker off the gum.15 Many physicians do not have the time, training, or office structure to provide the supervision required for the use of nicotine replacement therapy. Similar to other referral patterns, physicians who do not intend to become experts in the area of nicotine replacement should identify at least one health professional in their area who has such expertise to whom they can refer heavy smokers who want to quit.
1. American Academy of Pediatrics, Committee on Environmental Hazards. Involuntary smoking - a hazard to children. Pediatrici. 1986;77;755-757.
2- Gnrrmaker SL, WaJkef DK, Jacobs FH, Rucb-Ross H. Parental smoking and ihe risk of childhood asthma. AmJ Public HeM. 1982:72:574-579.
3. Martin FD, Antognoni G, Macri F; et al. Parental smoking enhances bronchial responsiveness in nine-year-old children. AmRevResfxr Dis. 1 988; 138:5 18-523.
4. McConnochle KM, Roghmann KJ, Parental smoking, presence of older siblings, and family history of asthma increase risk of bronchiolitis. AmJ Dis ChUd. 1986;140:806812.
5. Geller-Bernstein G, Kenett R, Weisglass L, Tsur S, Lahav M, Levin S. Atopic babies with wheeiy bronchitis. Auergy. 1987;42:85-91.
6. O'Connor GT, Weiss ST. Taget IB, Speiier FE. The effect of passive smoking on pulmonary function and nonspecific bronchia! responsiveness in a population-based sample of children and young adults. Am Reu Rapir Dis. 1987:135:800-804.
7. Evans D, Levison MJ. Fetdman CH, et al. The impact of passive smoking on emergency room visits of urban children with airhma. Am Reti Rfspa Dis. 1937;135:567-57Z.
8. Fisher EB, Halre-Joshu D; Morgan GD, Rehberg H, Roet K. Smoking and smoking cessation. Am Rev Resprrtts. 1990; 1990: 702-720.
9. Perry CL, Silvia GL Smoking prevention: behavioral prescriptions for the pediatrician. Pediatrics. 1987;79:790-799.
10. Irons TG, Kenney RD. Let's get parents to slop smoking. Contemporary Rasatrici. March 198fl;5: 107-118.
11. Ockene JK. Physician-delivered interventions for smoking cessation: strategies for increasing effectiveness. Preu Med. 1987;16: 723-737.
12. Frankowski BL, Seeker-Walker RH. Advising parents to stop smoking - opportunities and barriers in pediatrìe practice. AmJ Dis ChM. 1989; 143: 109 1-1094.
13. Gilbert JR, Wilson DM, Best JA, et al. Smoking cessation in primary care - a randomized controled nicotine-bearing chewing gum. J Farm Pract. 1989;28:4955.
14. Fletcher DJ. Kicking the nicotine habit: how to help patients stop smoking. Postgrad Med, 1985:77:123-133.
15. Cummings SR, Hansen B, Richard RJ, Stein MJ, Coates TJ. Internats and nicotine gum. JAMA. 1988;260:1565-1569.
Guidelines for Counseling During Stages of Smoking Cessation