The Pediatrician's Obligation in Smoking Cessation
To the Editor:
Recent issues of Pediatric Annals about Environmental Health, Asthma, and Perinatology emphasize the pediatrician's obligation in smoking cessation. Former Surgeon General C. Everett Koop wrote in 1985, "Cigarette smoking is the chief single avoidable cause of death in our society."1 Despite the war against this problem, the smoking prevalence among teens (12 to 17 years) has not decreased in the past 10 years.2 Although more than 1000 deaths per day are attributed to smoking,3 nearly 3000 young people begin to use tobacco in this country daily.4 Secretary of Health and Human Services Donna Shalala points out in the current surgeon general's report, "The facts are simple: one of three adolescents in the United States is using tobacco by age 18, adolescent users become adult users, and few people begin to use tobacco after age 18."5 This is a major pediatric problem.
In fact, Surgeon General Koop's very next statement 10 years ago was that "the pediatrician is in a very favorable position to do something to discourage smoking."1 Preventing young people from ever starting to smoke is the ultimate solution to the problem, but as Koop suggested, we also must play a pivotal role in helping parents to quit. Despite the potential for intervention, the pediatric community has made little organized efforts to curb smoking. In Tennessee, one of us (WBW) has taken a variety of steps to promote preventive and smoking cessation programs for several years.6,7 The time has come for pediatricians to fight the problem at the following levels.
Paul Torrens, professor of health services at the UCLA School of Public Health, states, "The Tolls of deaths attributable to tobacco use is greater than the combined deaths from AIDS, automobile accidents, alcohol, suicide, homicide, fires, and illegal drugs. If Congress wants to take a major step to improve the health of the country, the place to begin is with the prevention of nicotine addiction in children and youth." On the national level, the American Academy of Pediatrics (AAP) has provided leadership with its 1994 policy statement, "Tobacco -Free Environment: An Imperative for the Health of Children and Adolescents," authored by the Committee on Substance Abuse.8 The statement makes specific recommendations for pediatricians: prohibiting the sale of tobacco products to minors, outlawing the use of tobacco products on school campuses, banning all forms of tobacco advertisement, and increasing excise taxes on the sale of tobacco products.
The AAP has helped develop two publications to assist the local pediatrician in prevention: the manual, Cimiceli Interventions to Prevent Tobacco Use by Children and Adolescents,8 and the brochure, Smoking: Strmght Talk for Teens.9 Although the adult literature is more complete with specific cessation strategies,10,11 two recent reviews provide advice for pediatricians.12,13
Practice on the local level will not change if the issue is not perceived as a national pediatric priority. There are too many competing interests. It must be discussed at the AAP's annual meetings. A national symposium, such as the recent one on violence prevention,14 can bring together the groups involved in this area.
The AAP has created within each state chapter a tobacco, alcohol, and drug (TAD) coordinator. This coordinator should organize a statewide symposium, mirroring the goals of the national meeting but providing greater emphasis on the issues pertinent to particular regions of the country. A coordinated approach toward smoking prevention among physicians, schools, local governments, and youth agencies would open lines of communication and bring the national legislative agenda to the local level. The TAD coordinator of each chapter also would provide opportunities for the pediatrician to be trained in smoking cessation.
Medical School and Residency Level
The National Cancer Institute (NCI) recently reported that although changes are beginning to happen, tobacco use is not routinely addressed in undergraduate medical education.15 For pediatric residents, there is little evidence of formalized training. A survey of Vermont pediatricians revealed that only 8.5% had any training in how to give cessation advice.16 A survey comparing internal medicine, family practice, and pediatric residents showed that training and practice varied considerably: 96% of internal medicine residents routinely asked their patients about smoking, and 90% of family practice residents raised the issue, while only 34% of pediatric residents mentioned it.17 Ironically, pediatricians are least trained despite being in the most favorable position for prevention.6
The NCI convened an expert panel that made a number of suggestions about integrating smoking cessation and prevention teaching into medical school curricula.15 The pediatric residency training programs need to perform a similar self-examination and devise ways to include smoking cessation in housestaff training.
The conversion over the past 10 years of most medical centers to smoke-free environments is a start. However, physicians have few, if any, resources to assist patients in quitting. A team of physicians, nurses, specialists, and social workers from the pulmonary, respiratory, or psychiatry divisions would provide education and counseling on request to inpatients, with follow-up by a trained visiting home nurse after discharge.
The hospital can be a place that emphasizes smoking cessation. All prenatal talks by nurses and doctors should devote time to smoking. Videotapes about smoking can become routine on the maternity ward, opening a dialogue between parents and pediatricians about healthy lifestyle choices that impact the family. The birth of a child provides a strategic opportunity to convince parents not to smoke.7
Pediatric Office and Clinic Level
Through the one-on-one relationship we as pediatricians have with our patients and families, we must complete the task. By the time of that first visit to the office or clinic, our mothers already should have been educated in their prenatal classes and on the maturity ward about the effects of smoking.
Within our offices, posters should provide information about the risks of smoking and smoking exposure and the benefits of quitting. Parents and children remembers the fact we display on examining room walls. Placing a sign that says simply, "If you want to stop smoking, I can help you," allows parents to open the discussion.
Questions about smoking should be a routine part of each visit, just as other aspects of a healthy lifestyle. Anticipatory guidance about the risk for tobacco use at each developmental stage is perhaps the most important step in a systematic approach.4 Parents should receive written literature to summarize our discussion and to illustrate specific cessation strategies. We have had the training to prescribe nicotine patches and provide adequate counseling. Visits to public health clinics for immunizations should reinforce our efforts. We also can make referrals to smoking cessation programs that exist locally if there are insufficient numbers to begin one at our own practice. The medical records of families who make this commitment can be set apart so that adequate follow-up can be made.
Convincing parents to stop smoking is one important means of preventing children from starting, since most children who smoke come from homes where at least one parent smokes. However, the discussion of smoking that begins at the first newborn visit must continue throughout childhood for the child's sake, even if the parents do not smoke. Reminding a 14 year old entering high school about the perils of smoking is too little, too late.
A willingness to discuss smoking is, in a sense, a marker for how we approach other lifestyle choices. The easiest problem in the world for a pediatrician to treat is a strep throat, since penicillin can provide a cure. The lasting impact a pediatrician can make is altering behaviors such as nutrition, exercise, sexual promiscuity, and violence. The stakes may be even higher for smoking since it is a "gateway" drug. Teenagers who smoke have a 100-fold increased risk of using marijuana and a 30-fold increased risk of using cocaine.18
A decade has passed since Surgeon General Koop called for pediatricians to play a greater role in the war against smoking. The most recent surgeon general's report reveals there has been no significant decrease in smoking among adolescents over the past 10 years and confirms that smoking is still a pediatric problem. Emphasis by pediatricians at the national level will result ultimately in a more cohesive approach at the state and local levels. With better training in medical schools and residencies directed toward this problem, and with more effective hospital resources, pediatricians will be better equipped to help parents stop smoking.
1. Koop CE- The pediatrician's obligation in smoking education. Am J Dis Child 1985;139;973.
2. Giovino GA, Schooley MW1 Zhu B, et al. Trends In and recent patterns of selected tobacco-use behaviors United States 1990-1993. MMWR CDC Svrvofl Summ. 1994;43(SS-3):42.
3. Cigarette smoking-attributable mortality and year» of potential lite lost-United States, 1990. MMWR. 1993;42:645-649.
4. Epps RP, Manley MW. Clinico! Interventions io Prevent Tobacco Use by Children and Adolescents. Washington, DC. US Department of Health and Human Services, National Institutes of Health. (Can be ordered by calling 1-800-CANCER.)
5. Preventing Tobacco Use Among Young People: A Report of Ae Surgeon General. Washington, DC: US Dept of Health and Human Services; 1994.
6. Wadlington WB, Gwinn K, Riley HD. A golden opportunity. Journal of Ae Tennessee Medical Association. 1993;86:483-486
7. Wadlington WB, Gwinn K1 Riley HD. Who is conseling the pregnant women who smoke? Journal of Ae Tennessee Medicai Association. 1995;88,7-9.
8. Committee on Substance Abuse, American Academy of Pediatrics. Tobacco-free environment: an imperative for rhe health of children and adolescents. Pediatrics. 1994;93;866-865.
9. Smoking. Straight Talk for Teens. Elk Grove Village, III: American Academy of Pediatrics; 1993. (Can be ordered by calling the AAP.)
10. Office on Smoking and HeaWi PidAcaoon List. Atlanta, Ga: US Department of Health and Human Services, Center for Diseased Control and Prevention; 1994. (Can be ordered by calling 1-80O-CDC-1311.)
11. Glynn TJ, Manley MW. How to Help Your Patients Stop Smoking: A National Cancer Institute Manual for Physicians. Washington, DC: US Dept of Health and Human Services, National Institute of Health; 1990. (Can be ordered by calling 1-800-4CANCER.)
12. Irons JG, Kennedy RD. Let's get parents to stop smoking. Contemporary Pediatrics. 1988;5:107-118.
13. Klein JD. Incorporating effective smoking prevention and cessation counseling into practice. Pdiatr Ann. 1995;646-652.
14. The role of the pediatrician in violence prevention. Pediatria. 1994;84(suppl):577651.
15. Flore MC, Epps RP, Manley MW. A missed opportunity: teaching medical students to help their patients successfully quit smoking. JAMA. 1994;271:624-626.
16. Frankowski BL. Weaver SO, Seeker-Walker RH. Advising parents to stop smoking: pediatricians and parents' attitudes. Pediatrics. 1993;91;296-300.
17. Kenney RD- Smoking cessation counseling by resident physicians in internal medicine, family practice, and pediatrics. Arch Intern Med. 1988;148;2469.
18. Henningfield JE, Cohen C, Slede JD. Is nicotine more addictive than cocaine? tintish Jounial o Aodicútm. 1991;86:565-569.