2018-19 TOW #20: Tobacco Exposure and Cessation

This week’s topic is tobacco exposure and smoking cessation in honor of the Great American Smoke Out coming up next week on Thursday November 15th. The American Cancer Society designates the 3rd Thursday of November (the Thursday before Thanksgiving) each year to encourage smokers to quit or set a plan to quit. We have a role as pediatricians to help parents and patients with reducing smoking and secondhand smoke exposure. We can practice compassionate, trauma-informed care with a supportive stance using motivational interviewing to respectfully help with smoking cessation.

Materials for next week:

 

Take-home points:

  1. How many children are exposed to secondhand smoke? How does teen smoking relate to adult smoking? More than half of US children have secondhand smoke exposure (based on biological samples of population data). Approximately 90% of adults who smoke began smoking prior to age 19 (which is why tobacco companies target ads to youth…) Each day, an estimated 4400 American teenagers try their first cigarette. 80% of youth who smoke will continue to smoke into adulthood.
  2. How does secondhand smoke exposure affect children? Strong evidence from epidemiologic and basic science research demonstrates that prenatal and childhood exposure causes respiratory illness in children. Based on observational data, tobacco smoke exposure is also associated with non-respiratory illnesses, such as SIDS, ADHD and lower cognitive scores.
  3. What’s the evidence that discussing tobacco exposure with parents is helpful? Randomized controlled trials in adults and the Clinical Effort Against Secondhand Smoke Exposure (CEASE) study have found that asking adults about their smoking and offering assistance with quitting or referral to the quitline is effective.  Parents report they expect their pediatrician to ask about smoking but only about half of parents say they have been asked about smoking. The US Preventive Services guidelines recommend we assess secondhand smoke exposure for children at each visit and refer to quitlines for parents who are smoking. All states have quitlines with counselors who are trained specifically to help smokers quit. The quitline number is meant to be remembered: 800-QUIT-NOW (800-784-8669). There’s also an online chat via the National Cancer Institute.
  4. What are the strategies for discussing smoking with parents? We are recommended to Ask, Assist and Refer. “Is your child around anyone who smokes?” is a neutral way to open up the conversation. If the parent is smoking I often follow-up with “How are you feeling about smoking?” as an MI-style question to elicit where they might be in stages of change. We can explore past quitting attempts and what worked, as well as reasons to quit to bring out change talk. Don’t forget about using 1-10 scales to assess readiness and confidence. If they are not ready to quit, we can explore strategies they are using to decrease exposure for their children (outside only, smoking jacket that is removed, washing hands, etc.) This is a great stat to highlight: Getting help through medications and counseling doubles or even triples the chance of successfully quitting. 
  5. What are the risks of vaping? Nicotine use is now increasingly in e-cigarette form, especially among teens. Teens perceive these as safer, but electronic nicotine delivery systems (ENDS) have been found to contain numerous toxins and carcinogens harmful to users and those exposed to secondhand emissions. E-cigarettes have not been found to help people quit cigarettes, but have been associated with leading to use of regular cigarettes, especially among teenagers.

TOW #50: Marijuana Use

Among 12th graders, daily use of marijuana is now more common than cigarettes. As a legalized marijuana state in Washington, we should know about important implications for adolescents, and for pregnant and breastfeeding moms, as reviewed below.

Materials for this week:

Take-home points for marijuana use among adolescents:

  1. What are the active components of marijuana? Over 200 mixtures of cannabinoids come from the cannabis plant. One of the cannabinoid chemicals, tetrahydrocannabinol (THC), has psychoactive properties that has led to its recreational use. Cannabidiol (CBD) – a non-psychoactive cannabinoid, is another of the active chemicals for medicinal use. There are varying amounts of THC and CBD in any given plant.
  2. How prevalent is marijuana use?  The National Survey on Drug Use and Health showed the prevalence of past-month marijuana use in the US more than doubled between 2001-2002 and 2014-2015, with 8.3% of those aged 12 or older reporting past-month marijuana use. According to the NIH’s Monitoring the Future Survey, in 2015 34.9% of 12th graders in the US reported past-year use of marijuana. The 2015 survey also found that daily marijuana use exceeded daily tobacco cigarette use among 12th graders for the first time since the study’s inception (in the 1970s; 6% vs. 5.5%).
  3. What are the short-term effects of useWhat are long-term effects on developing brain? Side effects of marijuana use included impaired attention, concentration, and executive functioning. Tachycardia and systolic hypertension are two consistent physical effects. Other short-term effects include drowsiness, ataxia, increased appetite/thirst, conjunctival injection, dry mouth, anxiety, insomnia, hallucinations and short-term memory loss. In the long run, heavy marijuana use in the adolescent period interferes with synaptic pruning and myelination, causing changes in the hippocampal region, prefrontal cortex and white matter volume, which correlates with impaired cognitive functioning. These changes can affect attention span, concentration and problem solving, as shown in studies analyzing functional MRIs of marijuana users. Additionally, there is emerging data supporting increased risk of psychosis and predisposition to developing schizophrenia in adolescent marijuana users.
  4. What are differences between legalization and decriminalization? Legalization refers to allowing legal cultivation, sale, use, and/or possession of marijuana. Decriminalization means eliminating criminal penalties for possessing or using small amounts of marijuana. Both concepts have been debated, particularly for how it affects the adolescent population. The biggest support for decriminalization is shifting from law enforcement to a public health approach that emphasizes medical treatment for drug dependence or addiction. One of the problems with legalization (as we are seeing in WA) is the belief among adolescents that regular use does not cause harm. Nationally in 2015, 68.1% of 12th graders did NOT view regular  marijuana use as harmful.
  5. What are the effects of levels of THC for pregnant and nursing mothers? Breast milk can be up to 8 times as concentrated as the serum levels of chronic users, and THC is readily absorbed and metabolized by infants. The American College of Obstetricians and Gynecologists (ACOG) and Academy of Breastfeeding Medicine recommend stopping marijuana use (either recreational or medicinal) during pregnancy and breastfeeding given animal studies that suggest negative effects on brain development and lack of safety data in humans. It is important we discuss these risks with moms.

TOW #43: Substance use/abuse

As pediatricians in primary care, we should be using universal screening, brief intervention, and referral to treatment (SBIRT) for adolescent substance use. Since our state legalized adult use of marijuana, we have entered a new era of adolescent substance use. For example, we recently saw a patient in clinic under age 13 (already using multiple substances) who described in detail why “marijuana was a ‘natural’ drug” that had medicinal properties.  These are real issues, for sure.

Materials for this week:

Take-home points for substance use problems:

  1. What’s the epidemiology of youth substance use?: Among US teens, average first use of alcohol is 13.1 years, ~50% have tried alcohol by 8th grade, and almost 80% have tried it by high school graduation. >50% have tried other drugs by the end of high school, most often marijuana, and ~20% have used prescription drugs non-medically (a BIG increase).
  2. What are the risk factors for substance abuse?: Parents with substance abuse, history of abuse, depression or learning disabilities (especially ADHD), family conflict, friend use, and  living in a rural area.
  3. What are the associated problems with substance use?: There are many including school drop-out, violence, motor vehicle accidents, pregnancy, and permanent decrease in IQ with prolonged use. Youth getting Ds and Fs are 3x more likely to be using alcohol than those getting As.
  4. How should we screen?: Use the HEADSSS assessment to screen all youth. It is also recommended to ask parents and teens together what they have talked about and their attitudes. If concerned, follow-up with the CRAFFT assessment: 2 or more positive responses are predictive of problem use.
  5. Where can we refer? Options to address problem use include mental health counseling and specific substance use treatmen. Local resources: Adolescent medicine at SCH offers online materials and a Adolescent Substance Abuse Program (ASAP). Additional community programs include Ryther Center for Children and Youth and Therapeutic Health Services

TOW #21: Tobacco exposure

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This week's topic is tobacco exposure and smoking cessation in honor of the Great American Smoke Out coming up on Thursday November 17th. The American Cancer Society designates the 3rd Thursday of November each year to encourage smokers to quit or set a plan to quit. We have a role as pediatricians to help parents and patients with reducing smoking and secondhand smoke exposure. We can practice compassionate, trauma-informed care with a supportive stance using motivational interviewing to respectfully help with smoking.

Materials for next week:

Take-homes points:

  1. How many children are exposed to secondhand smoke? More than half of US children have secondhand smoke exposure (based on biological samples of population data).
  2. How does secondhand smoke exposure affect children? Strong evidence from epidemiologic and basic science research demonstrates that prenatal and childhood exposure causes respiratory illness in children. Based on observational data, tobacco smoke exposure is also associated with nonrespiratory illnesses, such as SIDS, ADHD and lower cognitive scores.
  3. What's the evidence that discussing tobacco exposure with parents is helpful? Randomized controlled trials in adults and the Clinical Effort Against Secondhand Smoke Exposure (CEASE) study have found that asking adults about their smoking and offering assistance with quitting or referral to the quitline is effective. The US Preventive Services guidelines recommend we assess secondhand smoke exposure for children at each visit and refer to quitlines for parents who are smoking. Parents report they expect their pediatrician to ask about smoking but only about half of parents say they have been asked about smoking.
  4. What are the strategies for discussing smoking with parents? We are recommended to Ask, Assist and Refer. "Is your child around anyone who smokes?" is a neutral way to open up the conversation. If the parent is smoking I often follow-up with "How are you feeling about smoking?" as an MI-style question to elicit where they might be in stages of change. We can explore past quitting attempts and what worked, as well as reasons to quit to bring out change talk. Don't forget about using scales to assess readiness and confidence. If they are not ready to quit, we can explore strategies they are using to decrease exposure for their children (outside only, smoking jacket that is removed, washing hands, etc.) Using pharmacologic treatment doubles the chance that a smoker will quit.
  5. What are the risks of vaping? Nicotine use is now increasingly in e-cigarette form, especially among teens. Teens perceive these as safer, but electronic nicotine delivery systems (ENDS) have been found to contain numerous toxins and carcinogens harmful to users and those exposed to secondhand emissions. E-cigarettes have not been found to help people quit cigarettes, but have been associated with leading to use of regular cigarettes.