Young Essentials

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Young Essentials

• Peer education for well child teams to support
  a smokefree start to life

Prepared by Education for Change 2008
www.efc.co.nz
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Welcome

• This presentation is for everyone who works in
  this well child team - managers, clinicians and
  support staff. It is a response to evidence of
  the high risk nature of smoking in pregnancy,
  high rates of family smoking and low levels of
  systematic intervention.
• Young Essentials offers the bare essentials for
  understanding smoking, its impact on children and
  the value of action. It has been designed to
  align attitudes and practices of whole teams in a
  blitz approach to supporting a smokefree start to
  life in primary care.
• We acknowledge the important contributions of
  Lesley McCowan, Associate Professor, Obstetrics
  and Gynaecology, Auckland DHB, Philip Pattemore,
  Paediatrician, Canterbury DHB and the Paediatric
  Society of NZ.

Protecting children is everyones business
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Photograph courtesy of Desley Austin
Outcome children smokefree from the start.
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Smokefree Strategies
legislation and taxation
publicity and promotion
social change
education and research
smoking cessation
systems and services
air care approach
first home approach
(Thomson et al., 2002)
To smell smoke is to breathe smoke.
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Some say

• The stress from quitting is worse for the baby
  than the womans smoking.
• Children are our patients, not their parents.
• It may be important, but theres simply no time
  for this.
• At least they say they smoke outside.
• More important issues such as obesity and family
  violence.
• Not confident to ask.

• No point. You tell them but they just keep
  smoking.
• You cant bully people to change.
• I smoke myself so I cant tell them what to do.
• Their lives are stressful so they need to smoke.
• Depends on why the child is at the doctor.
• People have to be ready.

How we think influences what we do, or, do not do.
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Shift in thinking may be needed

• From
• Diagnose and treat
• No time
• Talking smoking
• Parents quitting
• Smoking less
• Telling
• We treat sickness

• To
• Screen and discuss
• A little and often
• Talking smokefree
• Childs oxygen
• Smokefree more
• Listening
• We protect health

Smokefree language fosters smokefree thinking.
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The size of the problem
Annual rates gt18,000 pregnancies and gt90,000
pre-schoolers

• Number 1
• main cause of preventable death and health
  problems in pregnancy and childhood
• Not fair
• greater exposure for Maori, Pacific, low income
  families and children under 3 years
• Costs 7000/yr
• if two parents smoke 20 cigs/day
  _at_ 10/packet

Smoke- exposed
Smokefree
(There are a total 60,000 pregnancies and 300,000
pre-schoolers in NZ each year)

• Ministry of Health MOH Clearing the smoke, 2004
  
• New Zealand Health Information Statistics NZHIS

A smokefree intervention is the single best way
to protect health.
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Childrens needs are different

• Trapped
• in smoking wombs, homes, cars, families
• in parents cycle of addiction
• Double whammy
• exposed to both 1st and 2nd hand smoke in
  pregnancy
• Still developing
• airways narrower
• organs systems vulnerable
• breathe faster, inhale more smoke

30 breaths/min 1800/hr or 43,200/day
(Thomson et al., 2002)
Time matters more in childhood. Development does
not wait.
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Mechanisms for harm

• Vascular
• affects blood vessels, reduces blood flow,
  transports poisons
• Respiratory
• affects airway development, reduces respiratory
  function
• Compensation
• leads to tissue hypoxia, raised heart rate,
  raised blood pressure, altered autonomic
  controls, reduced immunity

and Role modelling Accidents (house
fires) Hearing loss Missed school Hardship
(from challenged family budgets) and more
Smoking is learned in families.
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Smoking in pregnancy

• leads to many, varied and far-reaching adverse
  effects for mother and child
• placenta and fetus must compensate for
  nutritional and respiratory challenges.
• these compromise fetal development and a babys
  adaptation after birth

Every reproductive outcome you can think of is
made worse by smoking (except one). Professor
Lesley McCowan, Obstetrician, National Womens
Fetal Tobacco Effects (FTE) the consequences for
a child of smoking in pregnancy
(Castles et al., 1999)
The uterus is a childs first home.
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impact on placenta

• Deprived of adequate blood supply
• Capillary networks must branch more to seek out
  oxygen
• Grows larger and thinner taking more space
• Higher risk of bleeding and placental abruption
  or praevia
• Reduced ability to support the baby with
  necessary nutrients, oxygen and removal of wastes

Comparing Placentae
smokefree
smoking
Picture courtesy A/Prof. Lesley McCowan
(Zdravkovic et al., 2005)
A smokefree placenta nourishes and protects a
baby.
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impact on newborn

• Growth restricted from reduced placental blood
  flow
• Altered autonomic controls
• e.g. reduced arousal response to low oxygen
  levels so more vulnerable to SIDS or asphyxia
• More likely to be born too premature to survive
  or require a long NICU stay
• Longer and more difficult adjustment
• More likely to die in first year

Picture courtesy A/Prof. Lesley McCowan
(Law et al., 2003)
Fetal tobacco effects last a lifetime and that
lifetime can be short.
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Smoking in families

• What is second hand smoke (SHS)?
• smoke from the burning cigarette
  exhaled smoke
• 85 of cigarette smoke becomes SHS
• Why is it harmful?
• burns at lower temperature so chemicals, while
  less concentrated, are more active
• contains 4000 chemicals carcinogens and
  irritants
• toxins hang in air and cling to surfaces

• Second-hand smoke is retained in clothing,
  curtains, dust, furniture, people and pets.

(Woodward Laugesen, 2001)
Second-hand smoke hides in children.
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impact on the child

• Risk 2-4 fold higher for
• upper respiratory infection
• tonsillitis / pharyngitis (with risk of rheumatic
  fever)
• ear infections / deafness
• bronchiolitis (most common cause of hospital
  admission during winter)
• bacterial pneumonia (common and serious)
• meningococcal disease, worsening of asthma and
  cystic fibrosis, reduced bone and skin healing,
  more hospital admissions, slower recovery,

(pc Dr Philip Pattemore, Paediatrician)
Smoking in families makes children sick.
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Respiratory effects

• Breathed in smoke
• poisons the muco-ciliary clearance system in the
  airways, nose, sinuses and Eustachian tubes
• damages the respiratory lining impairing its
  barrier function and immunity to infections
• reduces access to oxygen

(pc Dr Philip Pattemore, Paediatrician)
Access to oxygen is access to healthcare.
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Inside vs outside smoking

• Outside
• SHS found to be 5-7 times higher for children in
  smoke outside compared to smokefree
  households
• Inside
• SHS found to be 3-8 times higher in smoke
  inside compared to smoke outside households

Second-hand smoke levels
Relative risk
Household smoking
(Matt et al., 2004)
Smoking outside helps, but a smokefree household
is best.
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How people change
Becoming smokefree is a bit like crossing a
river. Support means building bridges to the
smokefree side and getting round any barriers in
the way.
What helps most is People ? Products ? Practice
People get closer to being smokefree with every
try.
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What works? Everything!

• ? Brief advice
• Also
• Multi-session counselling
• Pharmacotherapy (NRT)
• Systematic action
• Quitline
• Taxation
• Legislation
• And
• ? lots and lots of quit attempts

• Providers can help parents work toward reducing
  house-hold passive smoke exposure, regardless of
  whether the parents are ready to quit1.

Of 5 people who smoke, 4 are open to change and 1
of these is ready to go smokefree2.
(1. Emmons, 2001) (2. Fiore et al., 2000)
What works is a little and often by many over
time.
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Nicotine replacement works
International recommendations (www.nzgg.org.nz)
Using NRT is far safer than continuing to smoke,
even in pregnancy.

• NRT can be used in pregnancy
• Intermittent options preferable in pregnancy e.g.
  gum, inhaler or lozenge
• NRT delivers just nicotine without exposure to
  carbon monoxide and the 4000 other chemicals in
  smoke
• NRT relieves cravings, has a slower delivery and
  is less addictive than smoking

(Dempsey et al., 2002)
NRT takes the cravings out of going smokefree.
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Is it worth it? Yes!
Comparing interventions NNT is the number needed
to treat (advise) to prevent one bad outcome or
achieve one good outcome
Note NNT numbers much lower than for other
pregnancy interventions to improve birth outcomes.
(Cochrane Review, 2004)
Discussing smoking, even in pregnancy, is highly
cost-effective.
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Best practice means
Ask about smokefree status (and record) Of
adults, children, households, pregnancy
A
Give Brief advice State smokefree importance
and why
B
Support Cessation and Change Encourage all
attempts, offer NRT, refer
C
(NZ Guidelines for Smoking Cessation, 2007)
Best care means always ask state support.
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First Home Discussions (2 minutes)

• State what is best and why
• Babies need a smokefree place
  
  to grow. Smoking harms them because
  
  poisons replace the oxygen and food they need
  for development.
• Discuss support options
• NRT can help you have a smokefree
  baby
  now. Nicotine does pass to your
  
  baby, but it is far safer than smoking.
• Lots of smokefree practice helps.
  
  The more you try the better you
  get.
• Refer to a smokefree service

Discussions need to focus on smokefree importance.
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Air Care Discussions (2 minutes)

• State what is best and why
• Smokefree air is best. Breathing in smoke harms
  airways and less oxygen gets through.
• While smoking outside helps, a completely
  smokefree family protects a child best.
• Discuss air care options
• Your child takes about 40,000 breaths a day.
  Lets see how many are already smokefree.
• How can your family increase the number of
  smokefree breaths your child takes each day?
• Refer to Quitline/local service
• if parents want support to be smokefree

Discussions need to focus on protection for the
child.
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Personal experiences
Pregnant Woman Our last baby was born early.
When we first saw the GP this time, she asked if
we were smokefree. I was still smoking 20/day and
my partner even more. She explained how the
placenta works better if it is smokefree and was
really positive about taking small steps. So we
have! We are both down to less than 10/day and
for the first time ever being smokefree seems
possible. Anatoa
Nurse I used to find it hard to talk about
smoking with people who have very difficult
lives. It seemed wrong to make them feel guilty.
Yet I felt concern for their children and saying
nothing seemed wrong, too. So now I ask Are you
smokefree? and if they say No. I say, Im
sure you are some of the time, what about when
you sleep? That gets us all laughing and its
easy from there. I really enjoy it now. Sue
A little and often by many over time does make a
difference.
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• A smokefree child
• If you want it, walk towards it
• Thank you
• Continue for slides 26-30 (programme resources)

A smokefree start is a safer start to life.
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Why we ask leaflet

• To support staff in asking about family smoking
• To help families understand why staff need to
  know about smoking
• To save time
• To help shape a smokefree discussion

Resources
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Childs First Home (side 1)
Resources
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Childs First Home (side 2)
Resources
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Air Care Talk Card (side 1)
Resources
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Air Care Talk Card (side 2)
Resources
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Further Reading

• Benowitz, N.L., Dempsey, D.A. (2004).
  Pharmacotherapy for smoking cessation during
  Pregnancy. Nicotine Tobacco Research 6, S2,
  S189S202.
• Castles, A., Adams, K.E., Melvin, C.L., Kelsch,
  C., Boulton, M.L., (1999). Effects of smoking
  during pregnancy Five meta-analyses. American
  Journal of Preventive Medicine, 16(3), 208-215.
• Emmons, K.M., Hammond, S.K., Fava, J.L., Velicer,
  W.F., Evans, J.L., Monroe, A.D. (2001). A
  Randomized Trial to Reduce Passive Smoke
  Exposure in Low-Income Households With Young
  Children. Pediatrics, 108, 18-24.
• Fiore, M.C., Bailey, W.C., Cohen, S.J., Dorfman,
  S.F., Goldstein, M.G., Gritz, E.R. et.al. (2008).
  Treating Tobacco Use and Dependence. Clinical
  Practice Guideline. 2008 Update. Rockville, MD.
  US Department of Health and Human Services.
  Public Health Service.
• Hofhuis W., de Jongste, J.C., Merkus, P.J.F.M.
  (2003) Adverse health effects of prenatal and
  postnatal tobacco smoke exposure on children.
  Archives of Disease in Childhood, 88,1086-1090.
• Law, K.L., Stroud, L.R., LaGasse, L.L., Niaura,
  R., Liu, J., Lester, B.M., (2003) Smoking
  During Pregnancy and Newborn Neurobehavior.
  Pediatrics, 111, 1318-1323.
• Matt, G.E., Quintana, P.J.E., Hovell, M.F.,
  Bernert, J.T., Song, S., Novianti, N., Juarez,
  T., Floro, J., Gehrman, C., Garcia, M. Larson,
  S. (2004) Households contaminated by
  environmental tobacco smoke sources of infant
  exposures. Tobacco Control, 13, 29-37.
• Ministry of Health. (2007). New Zealand Smoking
  Cessation Guidelines. Wellington Ministry of
  Health.
• Rice V.H., Stead L.F. (2004). Nursing
  interventions for smoking cessation. The Cochrane
  Database of Systematic Reviews, Issue 1.
• Thomson, G.W., Wilson, N.A., ODea, D., Reid,
  P.J., and Howden-Chapman, P. (2002). Tobacco
  spending and children in low income households.
  Tobacco Control 11, 372-375.
• Woodward A., Laugesen M. (2001). Morbidity
  attributable to second-hand cigarette smoke in
  New Zealand. Wellington Ministry of Health.
• Zdravkovic, T., Genbacev, O., McMaster, M.T.,
  Fisher, S.J., (2005). The adverse effects of
  maternal smoking on the human placenta A
  review. Placenta, 26, S1, S81-S86.