September 2016

Pediatricians May Better Help Parents Quit Smoking With Decision Support Tool

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A parent’s love for a child is a powerful motivator. But when it comes to quitting smoking, often even the strongest motivation, in itself, is not enough. Only about 5 percent of smokers successfully quit each year, although many more try. That is why researchers at The Children’s Hospital of Philadelphia are refining processes and tools to help pediatricians help parents stop smoking.

“The big picture is, we’re trying to protect children, and the best way to protect a child from secondhand smoke exposure really is to help the parent quit,” said Brian Jenssen, MD, a primary care pediatrician and researcher in CHOP’s PolicyLab, who led two pilot studies of a process making it easier for pediatric clinicians to support parental smoking cessation. Findings from these studies in a primary care outpatient setting and in an inpatient setting were published this year in Pediatrics and Applied Clinical Informatics, respectively.

The work builds on decades of research showing that parents who smoke are receptive to the idea that pediatricians should address their children’s health by asking about the children’s exposure to secondhand smoke and supporting parents’ efforts to quit. The idea behind this specific effort is that there is no single magic bullet that guarantees a person will quit smoking, but there are numerous small steps that can each incrementally add to the likelihood of success. Examples include being asked by a physician about quitting, using nicotine replacement therapy (such as the patch or gum), and participating in counseling services.

“Most physicians want to encourage and support parents who wish to quit smoking, but it doesn’t fit well into our current system,” said Dr. Jenssen, who is also a faculty member in the Department of Biomedical and Health Informatics at CHOP and Instructor of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania.

Dr. Jenssen designed processes and tools built into pediatricians’ workflow to make it easier to connect parents to the right resources. This entails, first, a prompt in the child’s electronic medical record to remind pediatricians to screen for parents’ tobacco use by asking in a way that prior studies have shown to work well: “One of the best things you can do for your health and for the health of your child is to quit. What can I do to help you quit?” Next, the CHOP team’s intervention simplifies the process for pediatricians to prescribe the parent a nicotine patch or gum, if they express interest in using these therapies. Parents also receive a warm handoff to an adult tobacco treatment group to help them receive ongoing support.

The two pilot studies tested feasibility, acceptability, and usability of this clinical decision support tool and process. During the three-month pilot study at one of CHOP’s urban outpatient primary care facilities, pediatric clinicians used the tool to screen for children’s secondhand smoke exposure at more than 75 percent of patient visits. More than half of the parents present at these visits who said that they did smoke, expressed interest in quitting and were offered treatment by the clinician.

In the three-month inpatient pilot study conducted in a single hospital unit at CHOP, first-year pediatric residents used the tool to screen parents of just over half of those patients admitted to the unit who were identified as exposed to secondhand smoke. In both pilot studies, physicians who were surveyed about the tool reported that they were satisfied with it and found it helpful.

In addition, the outpatient pilot study measured the clinical impact on parents. No parents took advantage of the referral many received to an in-person smoking cessation program at the University of Pennsylvania, but by other measures, the intervention did help parents. When surveyed a few weeks after the visit to the pediatrician’s office, a large majority of parents who had expressed interest in quitting smoking reported that they were satisfied or very satisfied with the clinical visit. More than 60 percent of those surveyed said they had received a prescription for nicotine replacement, and 25 percent said they had filled the prescription and were currently using the therapy.

The potential impact for pediatricians helping parents in this way is particularly profound in high-need, lower-income communities. At the CHOP facility in Philadelphia where the outpatient pilot study was conducted, most parents are medically underserved and do not see their own medical provider. Their child’s pediatrician is the only physician they routinely see. At the same time, smoking rates are believed to be much higher in underserved communities — as many as 40 percent of adults receiving Medicaid may smoke, compared to 16 to 17 percent in the U.S. population overall. In national samples, 40 percent of children have biologically confirmed evidence of secondhand smoke exposure, and exposure rates are even higher in lower socioeconomic strata and among racial and ethnic minorities.

“In all our efforts at CHOP focused on better approaches to asthma care, reducing hospitalizations, and doing better things with preventive care to keep kids out of the hospital, we have to tackle this, too, because smoking exacerbates virtually everything,” Dr. Jenssen said.

He credits his collaborator and co-author Tyra Bryant-Stephens, MD, medical director of CHOP’s Community Asthma Prevention Program, as a kindred spirit in working to improve outcomes for children at risk for asthma and its complications, especially by reducing tobacco exposure.

Encouraged by the success of the pilot studies, the CHOP team is beginning a longer study that will connect parents with a direct referral to counseling services from Pennsylvania’s PA Free Quitline. Quitline counselors will initiate contact with parents once they are referred electronically, and parents can remain in contact via either phone calls or text messages — an advantage over the in-person counseling services that did not fit well into parents’ busy lives.

“When you help a parent quit, it reduces the majority of their children’s smoke exposure and all its associated health risk, and it also decreases the risk of their children becoming smokers when they become adults,” Dr. Jenssen said.

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