Pediatric Annals

Healthy Baby/Healthy Child 

You Can Reduce Secondhand Smoke Exposure! Prescribing Nicotine Replacement in the Pediatrician's Office

Sabrina Fernandez, MD

Abstract

It is universally known that secondhand smoke is detrimental to children's health. There is emerging research about the negative effects of thirdhand smoke as well. Most pediatricians focus on the child's medical evaluation and treatment, without considering other family members as it impacts the child's health. Screening rates for secondhand smoke exposure are low to begin with, and when we find a family member who is smoking, most pediatricians feel comfortable counseling and referring, but many do not know how to prescribe nicotine replacement therapy (NRT). In offering a prescription for NRT, pediatricians can offer tangible, timely treatment to help the family get one step closer to being smoke-free. Additionally, families may see their pediatrician more frequently than their own adult physician, and pediatricians have a unique perspective on how smoking may affect the child's health, and can use this as a motivator for quitting. This article encourages pediatricians to screen for secondhand smoke exposure and prescribe NRT to their patient's family members. [Pediatr Ann. 2017;46(9):e315–e318.]

Abstract

It is universally known that secondhand smoke is detrimental to children's health. There is emerging research about the negative effects of thirdhand smoke as well. Most pediatricians focus on the child's medical evaluation and treatment, without considering other family members as it impacts the child's health. Screening rates for secondhand smoke exposure are low to begin with, and when we find a family member who is smoking, most pediatricians feel comfortable counseling and referring, but many do not know how to prescribe nicotine replacement therapy (NRT). In offering a prescription for NRT, pediatricians can offer tangible, timely treatment to help the family get one step closer to being smoke-free. Additionally, families may see their pediatrician more frequently than their own adult physician, and pediatricians have a unique perspective on how smoking may affect the child's health, and can use this as a motivator for quitting. This article encourages pediatricians to screen for secondhand smoke exposure and prescribe NRT to their patient's family members. [Pediatr Ann. 2017;46(9):e315–e318.]

It's worth reviewing the evidence for secondhand smoke exposure on children's health. Secondhand smoke has been linked to sudden infant death syndrome (SIDS), low birth weight, impaired lung function, lower respiratory tract illness (bronchitis and pneumonia), middle ear infections, and respiratory symptoms like wheeze, cough, and breathlessness.1 Children are also at risk for atherogenesis, or the formation of fatty plaques in their arterial walls.2 There is also even suggestive evidence linking smoke exposure to some childhood cancers.3 This is just the list for diseases affecting children. The list for adults includes coronary artery disease, lung cancer, stroke, and reproductive effects in women, among others.4

Racial and Economic Disparities in Cigarette Use and Secondhand Smoke Exposure

There are racial and economic disparities in tobacco use and secondhand smoke. According to the Centers for Disease Control and Prevention (CDC), people in lower socioeconomic groups are more likely to be surrounded by tobacco retailers, more frequently use cigarettes, and in turn are more often exposed to secondhand smoke. Not surprisingly, the health effects of cigarette smoking and secondhand smoke are more commonly seen in this group compared to higher socioeconomic groups.5 Among African Americans, smokers tend to use fewer cigarettes and start smoking at an older age, but are more likely to die of smoking-related illnesses compared to whites.6 As of 2015, 4 in 10 children age 3 to 11 years were exposed to secondhand smoke, but 7 in 10 African American children were exposed to secondhand smoke.7

Thirdhand Smoke

Thirdhand smoke is the residual contamination that is left in an environment after a cigarette is extinguished. This smoke residue can stick to carpeting, car seats, hair, clothes, and furniture. Perhaps the easiest way to see thirdhand smoke is to look at the walls underneath paintings in smokers' homes. If the walls have been exposed to thirdhand smoke, they will be a different color compared to the wall behind the painting. There are more than 250 chemicals in thirdhand smoke. It's important to know that children are at particular risk for thirdhand smoke exposure, because they are lower to the ground when they crawl on floors and put their hands in their mouths more frequently.8 Cotinine is a metabolite of nicotine that can be measured in urine. Higher cotinine levels are found in infant's bedrooms with high thirdhand smoke exposure.9

The Unique Role of the Pediatrician

As pediatricians, we are uniquely positioned to help family members quit smoking. In the first year of a child's life, we see the family approximately 8 times for well-child visits, not to mention sick visit care or follow-up appointments. According to the CDC, only 83.6% of adults had contact with a health care professional in the last year, whereas 93% of children did have contact.10 Not only do we see our patients more frequently, but sitting between the pediatrician and the family member who smokes is one of the most powerful motivators to quit—the child.

According to the 2011 Pregnancy Risk Assessment and Monitoring System, of women who smoke in the 3 months before pregnancy, 55% quit during pregnancy. However, among those postpartum mothers who quit, 40% relapse and return to smoking within 6 months of the baby's birth.11 There may be stresses with a young baby, changing family dynamics, postpartum mood changes, weight concerns, and most importantly nicotine dependence that contribute to this problem.

Unfortunately, screening for secondhand smoke exposure in pediatric visits is low. According to a 2012 study of pediatricians, fewer than half reported screening and counseling for tobacco smoke exposure most or all of the time.12 This article is intended encourage pediatricians to screen for smoke exposure and to provide practical tools for how to help families quit smoking when the screen is positive.

Types of Nicotine Replacement Therapy and Suggested Regimens

There have been many types of nicotine replacement therapy (NRT) over the years, including the patch, gum, lozenge, nasal spray, and inhaler. There are also oral therapies to help patients quit smoking, such as varenicline or bupropion. This article reviews NRT in the form of the patch and gum. An easy rule of thumb is that one cigarette is about equal to 1 mg of nicotine. A typical pack of cigarettes contains 20 cigarettes. The nicotine patch comes in doses of 21 mg, 14 mg, and 7 mg and is placed on clean skin once daily. The patch gives a steady small dose of nicotine over the course of the day. Some patients may experience vivid dreams if the patch is worn overnight, in which case they can remove it before bedtime.

Nicotine gum comes in doses of 2 mg and 4 mg and is for breakthrough cravings. The gum and lozenge are short-term nicotine replacement. The gum should be chewed until it tastes tingly and then held between the cheek and the gums so that the nicotine can be absorbed through the buccal mucosa. Patients should not eat or drink for 15 minutes before or after chewing nicotine gum, as this may alter the pH and hinder the absorption of the nicotine.13

I suggest the regimen in Table 1. This regimen combines both the long-acting patch and the short-acting 4-mg gum. The patient can wean down over 2 to 3 months. Note that several regimens exist, some which use the patch alone or the gum alone, or incorporate the 2-mg gum or the lozenge. Combination therapies (with both the long-acting patch and a short-acting NRT) seem to be more effective than single-product therapies.14 The inhaler, nasal spray, and oral therapies (varenicline or bupropion) are available by prescription only.

Suggested Nicotine Replacement Plan for Patients

Table 1:

Suggested Nicotine Replacement Plan for Patients

Contraindications to prescribing NRT include unstable angina, myocardial infarction in the last 2 weeks, or serious cardiac arrhythmias. Precautions for the patch include allergy to adhesive, skin disorders, uncontrolled hypertension, and pregnancy. Precautions for the gum include dental work, dentures, or stomach ulcers.15

Patients may feel withdrawal symptoms if they are not getting enough nicotine. Symptoms can include anxiety, irritability, difficulty concentrating, difficulty sleeping, or appetite changes.15 Some patients may also get too much nicotine, particularly if they keep smoking cigarettes while on NRT. Symptoms of too much nicotine include tachycardia, headache, stomachache, dizziness, or nausea.15

Note that both the patch and the gum are available over-the-counter. Offering a prescription for NRT takes the patient one step further to filling the prescription and quitting. Thankfully, many insurance companies, both public and private, cover NRT.

A Note on E-Cigarettes

Patients may ask about the use of e-cigarettes as a method of quitting. I do not recommend this. The first reason is that the vapor emitted from an e-cigarette is not harmless “water vapor,” but can include harmful and potentially harmful ingredients, such as ultrafine particles and chemicals linked for serious lung disease, volatile organic compounds that are also found in car exhaust, and heavy metals.16 Until 2016, e-cigarettes were not regulated by the US Food and Drug Administration (FDA), meaning that many of the safety and quality control of these products were not regulated in the same way that other drugs are. E-cigarette manufacturers were not required to tell consumers what was in their products, or regulate the amount of nicotine per puff. Nowadays, the FDA regulates these products, as well as the manufacturing, labeling, advertising, sale and distribution.16 Lastly, it's not clear that e-cigarettes are an effective method of quitting smoking, and some suggest that they may even get in the way of smoking cessation.17

Concluding Remarks

Pediatric primary care physicians have a unique role to play in reducing their patient's exposure to secondhand and thirdhand smoke. We often see families more frequently than adult primary care physicians, and can use the child's health as a motivator for quitting. We have an obligation to screen often, and refer and treat when the screen is positive. Hopefully this article empowers pediatricians to practice preventive medicine for the child by treating the caregiver, so that the entire family is healthier.

See Table 2 for some helpful resources, and Table 3 for a few Take-Home Points.

Smoking Cessation Resources

Table 2:

Smoking Cessation Resources

Take-Home Points

Table 3:

Take-Home Points

References

  1. Centers for Disease Control and Prevention. Smoking & tobacco use. Children in the home. https://www.cdc.gov/tobacco/basic_information/secondhand_smoke/children-home/index.htm. Updated June 30, 2017. Accessed August 17, 2017.
  2. Raghuveer G, White DA, Hayman LL, et al. Cardiovascular consequences of childhood secondhand tobacco smoke exposure: prevailing evidence, burden, and racial and socioeconomic disparities: a scientific statement from the American Heart Association. Circulation. 2016;134:e336–e359. doi: . doi:10.1161/CIR.0000000000000443 [CrossRef]
  3. Boffetta P, Trédaniel J, Greco A. Risk of childhood cancer and adult lung cancer after childhood exposure to passive smoke: a meta-analysis. Environ Health Perspect. 2000;108:73–82. doi:10.1289/ehp.0010873 [CrossRef]
  4. Centers for Disease Control and Prevention. Smoking & tobacco use. Health effects of secondhand smoke. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/health_effects/index.htm. Updated January 11, 2017. Accessed August 17, 2017.
  5. Centers for Disease Control and Prevention. Smoking & tobacco use. Cigarette smoking and tobacco use among people of low socioeconomic status. https://www.cdc.gov/tobacco/disparities/low-ses/index.htm. Updated February 3, 2017. Accessed August 17, 2017.
  6. Centers for Disease Control and Prevention. Smoking & tobacco use. African Americans and tobacco use. https://www.cdc.gov/tobacco/disparities/african-americans/index.htm. Updated April 26, 2017. Accessed August 17, 2017.
  7. Centers for Disease Control and Prevention. Vital signs. Secondhand smoke. https://www.cdc.gov/vitalsigns/tobacco/. Updated February 3, 2015. Accessed August 17, 2017.
  8. American Academy of Pediatrics. How parents can prevent exposure to thirdhand smoke. https://www.healthychildren.org/English/health-issues/conditions/tobacco/Pages/How-Parents-Can-Prevent-Exposure-Thirdhand-Smoke.aspx. Accessed August 29, 2017.
  9. Matt GE, Quintana PJ, Hovell MF, et al. Households contaminated by environmental tobacco smoke: sources of infant exposures. Tob Control. 2004;13(1):29–37. doi:10.1136/tc.2003.003889 [CrossRef]
  10. Centers for Disease Control and Prevention. Ambulatory care use and physician office visits. https://www.cdc.gov/nchs/fastats/physician-visits.htm. Updated May 3, 2017. Accessed August 17, 2017.
  11. Centers for Disease Control and Prevention. Reproductive health. Tobacco use and pregnancy. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/tobaccousepregnancy/index.htm. Updated July 20, 2016. Accessed August 17, 2017.
  12. McMillen R, O'Connor K, Winickoff J, Wilson K. Factors associated with counseling parents about tobacco smoke exposure: a national pediatrician survey. https://www.aap.org/en-us/professional-resources/Research/research-findings/Pages/Factors-Associated-with-Counseling-parents-about-Tobacco-Smoke-Exposure-A-National-Pediatrician-Survey.aspx. Accessed August 17, 2017.
  13. GlaxoSmithKline website. https://www.quit.com. Accessed August 17, 2017.
  14. Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev.2013;(5):CD009329. doi:10.1002/14651858.CD009329.pub2 [CrossRef].
  15. The City of New York, Department of Health and Mental Hygiene. Smoking cessation medication prescribing chart. https://www1.nyc.gov/assets/doh/downloads/pdf/csi/tobacco-med-brief-instructions.pdf. Accessed August 17, 2017.
  16. US Department of Health and Human Services. E-cigarette use among youth and young adults. A report of the surgeon general, executive summary. https://e-cigarettes.surgeongeneral.gov/documents/2016_SGR_Exec_Summ_508.pdf. Accessed August 23, 2017.
  17. Smokefree.gov. What we know about e-cigarettes. https://smokefree.gov/quitting-smoking/e-cigs-menthol-dip-more/what-we-know-about-e-cigarettes. Accessed August 23, 2017.

Suggested Nicotine Replacement Plan for Patients

Quantity of Daily Cigarette Use Weeks 1–6 Weeks 7–8 Weeks 9–10 Weeks 11 +
<0.5 pack (<10 cigarettes) per day Apply 14-mg patch once daily Chew 4-mg gum as needed up to 2–4 times daily Apply 7-mg patch once daily Chew 4-mg gum as needed up to 2 times daily Stop nicotine replacement therapy
>0.5 pack (>10 cigarettes) per day Apply 21-mg patch once daily Chew 4-mg gum as needed up to 2–6 times daily Apply 14-mg patch once daily Chew 4-mg gum as needed up to 2–4 times daily Apply 7-mg patch once daily Chew 4-mg gum as needed up to 2 times daily Stop nicotine replacement therapy

Smoking Cessation Resources

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CDC 1-800-QUIT-NOW and National Network of Tobacco Cessation Quitlines: provides individual counseling, practical information on how to quit, mailed self-help materials, information on NRT, and, sometimes free or discounted NRT

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<ext-link xmlns:xlink="http://www.w3.org/1999/xlink" xlink:type="simple" xlink:href="Smokefree.gov" ext-link-type="uri">Smokefree.gov</ext-link>: a website offering resources for patients including quit lines, text services, and information about quitting smoking

</list-item> <list-item>

California Smoker's Helpline 1-800-NO-BUTTS: provides free patch programs for qualifying patients, including pregnant women and caregivers of children up to age 5 years, as well as resources in multiple Asian languages (Chinese, Korean, Vietnamese) through the Asian Smokers' Quitline

</list-item> <list-item>

CEASE (Clinical Effort Against Secondhand Smoke Exposure) California: provides physician and trainee resources, including a free training for CME/CEU credit as well as MOC4 credit for implementing the CEASE program in your clinic

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Take-Home Points

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Pediatricians should actively screen for patients who are exposed to smoke

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Practices can consider having this screening done by the staff that checks in the patient or staff that performs vital signs

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Once a patient is identified as being exposed to secondhand smoke, pediatricians should feel empowered to counsel, refer, and prescribe nicotine replacement therapy

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The suggested nicotine replacement therapy regimen combines the patch for baseline replacement, and gum for breakthrough cravings. One cigarette is roughly equal to 1 mg of nicotine

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E-cigarettes should not be used as nicotine replacement therapy

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Many resources exist for patients motivated to quit smoking

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Authors
Sabrina Fernandez, MD

Sabrina Fernandez, MD, is a Primary Care Pediatrician, University of California San Francisco, Benioff Children's Hospital; and an Assistant Professor of Pediatrics, Department of Pediatrics, University of California San Francisco.

Address correspondence to Sabrina Fernandez, MD, via email: sabrina.fernandez@ucsf.edu.

Disclosure: The author has no relevant financial relationships to disclose.

10.3928/19382359-20170817-01

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