pediatrics
November 2015, VOLUME136 /ISSUE 5

Clinical Practice Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke

  1. SECTION ON TOBACCO CONTROL

    Abstract

    Tobacco dependence starts in childhood. Tobacco exposure of children is common and causes illness and premature death in children and adults, with adverse effects starting in the womb. There is no safe level of tobacco smoke exposure. Pediatricians should screen for use of tobacco and other nicotine delivery devices and provide anticipatory guidance to prevent smoking initiation and reduce tobacco smoke exposure. Pediatricians need to be aware of the different nicotine delivery systems marketed and available.

    Parents and caregivers are important sources of children’s tobacco smoke exposure. Because tobacco dependence is a severe addiction, to protect children’s health, caregiver tobacco dependence treatment should be offered or referral for treatment should be provided (such as referral to the national smoker’s quitline at 1-800-QUIT-NOW). If the source of tobacco exposure cannot be eliminated, counseling about reducing exposure to children should be provided.

    Health care delivery systems should facilitate the effective prevention, identification, and treatment of tobacco dependence in children and adolescents, their parents, and other caregivers. Health care facilities should protect children from tobacco smoke exposure and tobacco promotion. Tobacco dependence prevention and treatment should be part of medical education, with knowledge assessed as part of board certification examinations.

  1. Abbreviations:
    CEASE
    Clinical Effort Against Secondhand Smoke Exposure
    FDA
    US Food and Drug Administration
  2. Statement of Problem

    Tobacco harms children. There is no safe level of tobacco smoke exposure. Pediatricians have important opportunities to prevent the initiation of tobacco use and help children, parents, and caregivers obtain treatment for their tobacco dependence.

    This statement describes clinical practice recommendations. Evidence quality is graded and recommendations generated as per Fig 1. An accompanying technical report describes the evidence to support these recommendations.1 An accompanying policy statement describes public policy recommendations.2

    FIGURE 1

    Evidence quality. RCT, randomized controlled study.

    Definitions

    • Tobacco product: any nicotine delivery product, currently regulated or unregulated by the US Food and Drug Administration (FDA), which is not approved for safe and effective tobacco dependence treatment.

    • Secondhand smoke: the smoke emitted from a tobacco product that is inhaled by a nonuser.

    • Thirdhand smoke: the tobacco smoke that is absorbed onto surfaces and exposes the nonuser by either direct contact and dermal absorption and/or off-gassing and inhalation. Thirdhand smoke may react with oxidants and other compounds in the environment to yield secondary pollutants.3

    • Electronic nicotine delivery systems: handheld devices that produce an aerosol from a solution typically containing nicotine, flavoring chemicals, and carrier solvents such as propylene glycol and vegetable glycerin (glycerol) for inhalation by the user. Alternate names for these products include electronic cigarettes, e-cigarettes, e-cigs, electronic cigars, e-cigars, electronic hookah, e-hookah, hookah sticks, personal vaporizers, mechanical mods, vape pens, and vaping devices.

    New Information

    Tobacco smoke exposure in utero causes long-lasting neurocognitive, behavioral, and respiratory harms. Thirdhand smoke has become recognized as another route of tobacco toxin exposure. Noncigarette tobacco products represent emerging threats to children’s health. Teenagers become dependent on nicotine far earlier than previously believed. Tobacco dependence can be treated using the chronic disease model, with treatment initiated on the basis of severity and adjusted on the basis of control.

    Background

    More than half of children in the United States have evidence of tobacco exposure.4 Tobacco-related carcinogens measured in house dust samples of smokers are at levels sufficient to increase cancer risk,5 and young children may have greater exposure. The harm from tobacco smoke does not end when a smoker extinguishes a cigarette.

    Tobacco causes respiratory illness, cancer, cardiovascular disease, and premature death in children and adults.615 In utero tobacco exposure increases risk of adverse fetal outcomes and can have long-lasting adverse health effects for the child.1628 Although sorting out in utero from postnatal effects is challenging, emerging data points to secondhand tobacco smoke exposure as an independent risk factor for neurobehavioral disorders (including attention-deficit/hyperactivity disorder, learning disabilities, and conduct disorders),2931 decreased glomerular filtration rate in adolescents,32 and preclinical atherosclerosis in adolescents.33,34 There is no safe level of tobacco smoke exposure.35

    Parent and caregiver smoking are important sources of a child’s tobacco smoke exposure.36,37 Parental tobacco dependence increases the risk of their children’s tobacco use initiation and dependence.3840 Interventions to encourage parental tobacco cessation to benefit their children’s health are most effective when the intervention includes pharmacotherapy.41 Addressing and treating parent and caregiver tobacco dependence are important parts of children’s health care.

    Symptoms of tobacco dependence can develop rapidly after initiation of tobacco use.42 The developing brains of children and adolescents are particularly susceptible to tobacco dependence. Nearly 90% of current smokers started tobacco use before their 18th birthday.43 Adolescents from low-income families and lesbian/gay/bisexual/transgender youth shoulder a disproportionate share of the tobacco dependence burden.44,45

    Alternative (other than cigarette) tobacco product use is rapidly gaining popularity among youth.46 These include oral tobacco (chewing tobacco; moist snuff, also called “dip”), flavored cigars, pipes, snus (a moist tobacco product placed between the cheek and gum), hookahs (water pipes), and electronic nicotine delivery devices. Other tobacco products include bidis (tobacco wrapped in a tendu leaf), kreteks (tobacco flavored with cloves),47 and dissolvable tobacco products (with appearance similar to breath mints or toothpicks).48 Many adolescents use both cigarette and noncigarette tobacco products.49

    Recommended Actions for Pediatricians

    1. Inquire about tobacco use and tobacco smoke exposure as part of health supervision visits and visits for diseases that may be caused or exacerbated by tobacco smoke exposure.

      • Recommendation Strength: Strong Recommendation

    Questions for parents that can be used to identify tobacco exposure include the following50,51:

    • a. Does your child live with anyone who uses tobacco?

    • b. Does anyone who provides care for your child smoke?

    • c. Does your child visit places where people smoke?

    • d. Does anyone ever smoke in your home?

    • e. Does anyone ever smoke in your car?

    • f. Do you ever smell smoke from your neighbors in or near your home or apartment?

    Pediatricians need to be aware of the different terminology that families may use for tobacco products. Because many families may not consider electronic nicotine delivery systems as “tobacco,” questions may need to be modified to include “vape” or “vaping” and/or use of electronic cigarettes, hookah sticks, e-hookahs, and/or vape pens. Similarly, pediatricians may need to clarify what is being smoked because in some areas, marijuana smoking is also prevalent, and marijuana smoke/vapor contains many harmful, toxic, and carcinogenic chemicals.

    Children can be exposed to tobacco smoke if they live in or are cared for near places where smoking is allowed, such as in multi-unit housing.52 Pediatricians can help parents in advocating for a tobacco-free environment for their child.

    Innovative approaches to screening include using an electronically administered questionnaire that, on the basis of patient responses, generates “just in time” prompts for the pediatrician.53

    Identifying adolescent tobacco use can be challenging. Screening questions can provide an opening for the pediatrician. Keep in mind that the tobacco product used might not be cigarettes.

    Useful questions include the following50:

    • a. Do any of your friends use tobacco?

    • b. Have you ever tried a tobacco product?

    • c. How many times have you tried (name of tobacco product)?

    • d. How often do you use (name of tobacco product)?

    • e. Do you friends use e-cigarettes, e-hookah, or vape?

    • f. Have you tried an e-cigarette, e-hookah, or vape?

      • 2. Include tobacco use prevention as part of anticipatory guidance.

    • Recommendation Strength: Strong Recommendation

    The US Preventive Services Task Force recommends that primary care physicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use in school-age children and adolescents. Counseling from a health care provider reduces the risk for smoking initiation.54 Messages should be clear, personally relevant, and age appropriate.

    One of the most important things a child can do to prepare for a healthy life is not start using tobacco. Experimenting with tobacco use is not safe. Messages should start as early as children are developmentally ready to understand them, usually approximately 5 years of age. Messages that may resonate more with adolescents include the effects of tobacco use on appearance, breath, and sports performance; lack of benefit for weight loss43; how much money they would have to spend to continue their tobacco addiction; and how the tobacco industry deceives them. Other messages may include how fast tobacco dependence develops and the severity of tobacco addiction. The pediatrician should ask children and adolescents to make a commitment to be tobacco free and help them to identify their own reasons for being tobacco free.

    Messages need to include a specific focus on electronic nicotine delivery systems. The vast majority of youth are regularly exposed to electronic nicotine delivery system advertising and promotion.55 Most teens mistakenly believe that electronic nicotine delivery systems are safe, and many teens are not even aware that the devices contain nicotine or that nicotine is highly addictive.56,57

    • 3. Address parent/caregiver tobacco dependence as part of pediatric health care.

      • Recommendation Strength: Strong Recommendation

    Parental tobacco smoking is an important source of a child’s tobacco smoke exposure, thus addressing parental and caregiver tobacco dependence is important to protect the health of the child.

    •  3a. Recommend tobacco dependence treatment of tobacco-dependent parents and caregivers.

    • Recommendation Strength: Strong Recommendation

    The US Public Health Service–sponsored evidence-based guideline “Treating Tobacco Use and Dependence: 2008 Update” recommends that “Counseling and medication are effective when used by themselves for treating tobacco dependence. The combination of counseling and medication, however, is more effective than either alone. Thus, clinicians should encourage all adults making an attempt to stop tobacco to use both counseling and medication.”58

    •  3b. Implement systems to identify and offer counseling, treatment, treatment recommendations, and/or referral for tobacco-dependent parents.

    • Recommendation Strength: Recommendation

    In the context of protecting their children’s health, parents should be encouraged to stop smoking and should be offered tobacco dependence treatment, treatment recommendations, and/or referral. Specific and personally relevant information about how their tobacco dependence affects their children’s health should be offered. Most parents expect physicians to address tobacco dependence and value receiving information about treatment from their children’s pediatrician.59 Parents may be motivated to accept tobacco dependence treatment to benefit the health of their children as well as their own health.41 Even brief advice can increase smoking cessation rates.60 Recommendations should be appropriate to the parent’s readiness to change. If a parent is not yet ready for tobacco dependence treatment, smoke-free policies for the home and car should be advised.

    The Clinical Effort Against Secondhand Smoke Exposure (CEASE) program is a practical program for addressing parental tobacco dependence treatment that can be easily implemented in the pediatrician’s office. CEASE focuses on the principles of ask (“Does your child live with anyone who uses tobacco?”), assist (“As your child’s pediatrician [or nurse], I can help you quit tobacco and help you have a tobacco-free home and car”), and refer (refer to the national smokers' quitline: 1-800-QUIT-NOW).61 CEASE program materials are available at http://www.ceasetobacco.org.

    Tobacco dependence is not simply a bad habit; it is often a severe addiction. Nicotine causes changes to brain structure and chemistry such that it is difficult to feel normal without it.62 Severity of nicotine withdrawal can vary from “wanting” (a mild desire to smoke that is short lived and easily ignored) to “craving” (a stronger urge to smoke that is more persistent and difficult to ignore) or “needing” (an intense and urgent desire to smoke that is unpleasant and unremitting).63 Similar to the principles of control of other severe chronic illnesses, the disease severity guides initiation of pharmacotherapy, and disease control guides adjustment of therapy. The risk of relapse to smoking is minimized when there are minimal to no withdrawal symptoms.50

    Pharmacotherapy for tobacco dependence includes the long-acting nicotine patch (available over the counter) as well as bupropion and varenicline (which require a prescription). Shorter-acting medications can be used as needed for relief of nicotine withdrawal symptoms or as premedication before situations or events that trigger smoking. These medications include nicotine gum and lozenges (over the counter), nicotine inhaler (prescription), and nicotine nasal spray (prescription). The combination of 2 or more of these medications is more effective than 1 medication alone.58 Combination therapy is particularly useful for those with moderate or severe levels of tobacco dependence.50 Combination therapy with the nicotine patch (daily) and nicotine gum or lozenge (ad libitum) has similar effectiveness to the prescription agent varenicline58 and can be recommended for those with moderate or severe tobacco dependence.50 Starting nicotine replacement before stopping smoking can help a person to reduce smoking and get ready to stop.64,65

    Use of pharmacotherapy substantially improves rates of stopping smoking.58 Pharmacotherapy appropriate to the level of tobacco dependence severity (when initiating treatment) and control (when adjusting treatment) can be offered to or recommended for tobacco-dependent parents or caregivers. Similar to other illnesses of children (such as scabies, pertussis, and meningococcemia) that require treatment of household members, pediatricians can recommend or prescribe tobacco dependence treatment to parents or caregivers to protect the child’s health. Over-the-counter nicotine replacement therapies (nicotine patch, gum, or lozenge) are effective; however, to be covered by health insurance, a prescription may be needed.

    Before prescribing for tobacco dependence therapy to parents, pediatricians should verify that their medical liability insurance provides coverage for care provided to adults. If the pediatrician elects to prescribe for parents, he or she should conduct an appropriate assessment of disease (tobacco dependence), consider possible contraindications to the medications, counsel about risks and benefits, provide recommendations for follow-up, and provide appropriate treatment. Pediatricians should follow state regulations and institutional policies for charting on care provided for parents and caregivers to benefit the health of the child. Electronic health records systems should facilitate adherence to documentation requirements without placing excessive burdens on the parent or pediatrician. Payers should pay for services; in cases in which they do not, pediatricians should code appropriately and advocate for the appropriate payment by health care payers for services provided. Up-to-date information about coding is available online at: http://www2.aap.org/richmondcenter/CodingPayment.html.

    • 4. Offer tobacco dependence treatment and/or referral to adolescents who want to stop smoking.

      • Recommendation Strength: Strong Recommendation

      •  4a. Tobacco dependence pharmacotherapy can be considered for moderate to severely tobacco-dependent adolescents who want to stop smoking.

      • Recommendation Strength: Option

    Treatment should be appropriate to the adolescent’s level of tobacco dependence, readiness to change, and treatments he or she is ready to accept. Research on the treatment of adolescent tobacco dependence is limited. Behaviorally based programs are beneficial; however, they work best for those with minimal to mild tobacco dependence.66 Effective behaviorally based strategies have focused on problem-solving skills and providing support and encouragement.58

    The “5 As” model (Ask, Advise, Assess, Assist, Arrange follow-up) describes a counseling intervention that improves tobacco use cessation rates in adults and is recommended by US Public Health Service Clinical Practice Guidelines.58 An adaptation of this model for youth67 includes the following: (1) Ask—about and document tobacco product use at all clinical encounters. (2) Advise—in a clear strong manner the personally relevant risks of continued tobacco use and the personally relevant benefits to stopping tobacco use. (3) Assess—the severity of tobacco dependence, previous history of attempts to stop smoking, and changes that the adolescent is ready to make. (4) Assist—tailor support to the adolescent’s readiness to change and severity of addiction. For the adolescent ready to stop smoking, review lessons learned from previous attempts to stop smoking, discuss anticipated challenges, and discuss coping strategies. Provide concrete and readily accessible support and resources such as stop smoking support offered by telephone, text message, smartphone app, or the Internet and/or referral to local community or school-based resources (if available) (Table 1). (5) Arrange follow-up. Close follow-up is important because nonadherence and relapse are common. For the adolescent not ready to stop smoking, a motivational counseling intervention based on the “5Rs” (Relevance, Risks, Rewards, Roadblocks, and Repetition) can be used.

    TABLE 1

    Behaviorally Based Tobacco Cessation Resources for Adolescents

    Research on pharmacotherapy of moderate to severe adolescent tobacco dependence is limited by short courses of treatment, high rates of nonadherence, and high rates of relapse after discontinuation of therapy.6871 Given the severe harms of tobacco dependence and the documented effectiveness of tobacco dependence pharmacotherapy in adults, a tobacco-dependent adolescent who wants treatment can be offered pharmacotherapy (medications that are FDA-approved as effective for tobacco dependence treatment in adults) appropriate to the severity of his or her tobacco dependence and his or her readiness to change as part of a tobacco dependence treatment plan.

    As with treatment of any severe chronic illness, patients should be monitored for adverse effects of therapy, adherence to medication use recommendations, and achievement of treatment goals. Given the high rates of nonadherence to therapy and high rates of relapse of tobacco use among adolescents, close follow-up is recommended.

    Pediatricians should also be aware that comorbidities of substance abuse and psychiatric disorders may accompany tobacco dependence72 and may make tobacco dependence more difficult to treat. These comorbidities, when identified, should be addressed through appropriate referral.

    In the United States, tobacco dependence treatment medications have not been approved by the FDA for use by people younger than 18 years. There is, however, no biological or cognitive rationale to have 18 years as the cutoff for offering effective pharmacotherapy of tobacco dependence. To legally obtain any FDA-approved tobacco dependence treatment product (including the over-the-counter products), an adolescent needs a prescription from a licensed health care provider.

    • 5. Offer tobacco-dependent individuals quitline referral.

      • Recommendation Strength: Strong Recommendation

    Free (to the user) telephonic tobacco dependence treatment is beneficial and has been shown to improve tobacco cessation rates.73 Such support is available at 1-800-QUIT-NOW in the United States. SmokefreeTXT (to enroll, text the word QUIT to 47848 from a mobile phone) may be useful for those who prefer a text message–based intervention.

    • 6. Consider potential for neuropsychiatric symptoms with tobacco dependence treatment.

      • Recommendation Strength: Recommendation

    There is an increased risk of suicidal ideation and suicide both among continuing smokers and among those being treated for tobacco dependence.7478 In postmarketing surveillance, suicidal ideation and suicide have been reported among patients taking varenicline and bupropion, with a Black Box warning issued by the FDA for both medications.79 Population-based studies suggest that rates of fatal and nonfatal self-harm are not different among adults who received varenicline, bupropion, or nicotine replacement.80 Neuropsychiatric symptoms associated with tobacco dependence treatment may reflect inadequate control of nicotine withdrawal.50

    • 7. Do not recommend electronic nicotine delivery systems for tobacco dependence treatment.

      • Recommendation Strength: Strong Recommendation

    Electronic nicotine delivery systems are not FDA-approved for tobacco dependence treatment and have not been shown to be safe or effective for tobacco dependence treatment.81 One randomized controlled clinical trial of electronic cigarettes found low rates of stopping smoking with no significant difference between nicotine-containing and placebo devices in smoking cessation rates.82 Among adolescents, the use of electronic cigarettes is associated with decreased rates of smoking cessation.83

    There is currently no regulation on content or manufacturing standards for electronic nicotine delivery systems. Carcinogens, toxicants, metals, and silicates have been found in the emissions from these devices.8486 They can expose nonusers to the nicotine and other toxicants in the device emissions.81 Some of the commonly used flavoring chemicals are known respiratory irritants.87 These products are being aggressively marketed to youth.88 Flavorings, including candy and fruit flavors, increase the appeal to youth. The concentrated nicotine solution used in these devices is a poisoning risk for young children, with 1 child already known to have died of its accidental ingestion.89,90

    • 8. If the sources of a child’s tobacco smoke exposure cannot be eliminated, provide counseling about strategies to reduce the child’s tobacco smoke exposure.

      • Recommendation Strength: Recommendation

    As a harm reduction measure, smoking bans in the home and car and staying away from places where people are smoking should be recommended if parents and caregivers are not ready to stop smoking or consider starting tobacco dependence treatment. Smoke-free homes and cars may reduce a child’s tobacco smoke exposure but are unlikely to eliminate a child’s tobacco smoke exposure as long as household members and caregivers are smokers.37,91,92

    Best Practices for Health Care Systems

    Because research on health systems interventions to protect children from tobacco is still in its infancy, the recommendations that follow are based on American Academy of Pediatrics expert consensus.

    Health care delivery systems should be structured to facilitate the effective prevention, identification, and treatment of tobacco dependence in children and adolescents, parents, and caregivers. Health care facilities should protect children from tobacco smoke exposure and tobacco promotion.

    Health records systems should facilitate the identification of tobacco-exposed and tobacco-dependent children and adolescents and allow for rapid, accessible identification of previously documented tobacco smoke exposure and interventions. Electronic health records systems should provide easy-to-access, appropriate, and regulatory-compliant methods to document assessment, counseling, and recommendations or prescription for treatment of tobacco dependence for the child’s parents and/or caregivers provided during a medical encounter for the child. Children’s health care payers should appropriately compensate these efforts.

    Hospital systems should offer tobacco dependence treatment to parents of hospitalized children, including nicotine replacement therapy. The goals of treatment include controlling nicotine withdrawal symptoms so that the parent can stop smoking comfortably and helping the tobacco-dependent parent avoid withdrawal while not smoking on hospital property.

    Tobacco dependence treatment programs should be available to adolescents who are tobacco dependent. Health care delivery systems should consider collaborations with schools to minimize barriers to adolescents’ ability to access these programs.

    Health care facilities should not subscribe to or display magazines, videos, or other materials that contain advertisements for tobacco products or images that model any tobacco product use. Campuses of institutions or offices where children’s health care is delivered should be tobacco free, including both indoor and outdoor spaces. To protect children, retail-based clinics should not be located within or near retail establishments that promote or sell tobacco products.

    Recommendations for Medical Education

    Training should be provided to all health care providers to enable them to deliver smoking cessation interventions effectively. Tobacco dependence prevention and treatment should be part of pediatric resident education and postgraduate continuing medical education. Although many residency programs have made strides in addressing knowledge about harms of tobacco smoke exposure and tobacco dependence,93 more efforts are needed. Tobacco dependence prevention and treatment should be included as part of the core pediatric residency curriculum and assessed on pediatrics board certification and maintenance of certification examinations. This training is especially important for primary care physicians and for medical subspecialists who treat tobacco-related diseases. Training of physicians and allied health professionals in tobacco dependence treatment should be adequately funded. Because tobacco dependence is one of the most common severe chronic illnesses of adolescents and adults, it is imperative that there be adequate funding to train health care providers in treating tobacco dependence.

    Conclusions

    Tobacco dependence is a pediatric disease. Tobacco smoke exposure harms children’s health. Pediatricians can and should take actions to protect children and adolescents from tobacco dependence and tobacco smoke exposure. To protect children’s health, pediatricians can and should counsel parents and caregivers who use tobacco about the importance of and strategies for stopping tobacco product use, provide referral for additional tobacco dependence treatment resources (such as to telephone quitlines), and consider recommending or prescribing tobacco dependence treatment medication for parents and caregivers. Pediatricians should provide brief counseling to all children to prevent tobacco use initiation and screen all teenagers for tobacco and nicotine use. Tobacco dependence treatment and/or referral should be offered to adolescents who want to stop smoking.

    Lead Authors

    Harold J. Farber, MD, MSPH, FAAP

    Susan C. Walley, MD, FAAP

    Contributing Authors

    Judith A. Groner, MD, FAAP

    Kevin E. Nelson, MD, PhD, FAAP

    Section on Tobacco Control, 2015–2016

    Ruth A. Etzel, MD, PhD, FAAP, Cochairperson

    Karen M. Wilson, MD, MPH, FAAP, Cochairperson

    Harold J. Farber, MD, MSPH, FAAP, Policy Chairperson

    Sophie J. Balk, MD, FAAP

    Judith A. Groner, MD, FAAP

    John E. Moore, MD, FAAP

    Staff

    Janet Brishke, MPH

    Regina Whitmore, MPH

    Footnotes

    • This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

    • Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

    • The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

    • All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

    References