Day: October 6, 2008

Curators Note: Evidence-based Medicine Information Added to Each Case

Beginning October 6, 2008, each case in PediatricEducation.org will now include evidence-based medicine information in the To Learn More section.

The National Guideline Clearinghouse is an automated search on the case topic.
The Cochrane Database of Systemic Reviews does not allow automated searching so a link to its main search page is used instead.

We hope you find this new feature helpful.
Donna M. D’Alessandro, M.D. and Michael P. D’Alessandro, M.D.
Curators, PediatricEducation.org

What Medications Are Recommended for Adolescents Who Are Quitting Smoking?

Patient Presentation
A 17-year-old male came to clinic for a sports participation evaluation without his parents.
During the visit he revealed that he had begun smoking 2-5 cigarettes/day for the past few months.
He began because some of his friends were smoking in social situations that did not involve alcohol or other drugs and he denied using other tobacco products.
His family members did not smoke and they wanted him to quit. “They keep nagging me about it. I only smoke outside so they shouldn’t complain,” he said.
He had thought about quitting but hadn’t made any attempts to do so, nor really had any plans to do so.
He wasn’t sure if it was affecting his athletics and his coaches didn’t know he smoked. Some of his female friends had said they noticed the smoke smell and didn’t like it.
The past medical history revealed a previous sprained ankle from lacrosse two years ago, but no other injuries.
The review of systems was negative.
The pertinent physical exam showed a healthy male with normal growth parameters and vital signs.
His did not smell of smoke nor had any discoloration of his teeth or hands.
The diagnosis of of a healthy male athlete who is a recent smoker was made.
The physician advised him to quit smoking and offered to assist him. The athlete and the physician decided on a quit smoking date and he
was referred to a community smoking cessation program that had an adolescent/young adult group.
The physician said she would look into this and they would talk about it no later than 6 weeks when he was returning for smoking followup.
Later, an Internet search found the clinical guidelines from the United States Public Health Service which confirmed that nicotine replacement and other medications are not recommended for adolescents, but that counseling, therapy and support are.

Discussion
Tobacco use is a pediatric problem. In 2006, ~3.3 million adolescents between 12-17 years currently used tobacco products and 2.6 million were current cigarette smokers.
Each day, ~ 4,000 adolescents and children < 18 years of age smoke their first cigarette. Unfortunately, nicotine dependence is established rapidly and many children and adolescents go on to continue to smoke.
Counseling helps adolescents quit and continue to remain abstinent. Adolescents enrolled in tobacco cessation programs are 2 times more likely to quit and remain abstinent.

Pediatric health care providers should discuss parental smoking as well as part of routine care, as children and adolescents benefit because of decreased second hand smoking exposure.
Treatment of patients willing to quit consists of the “5A’s” :

  • Ask – systematically identify all tobacco users at each visit
  • Advise – strongly urge all tobacco users to quit
  • Assess – determine willingness to make a quit attempt
  • Assist – help the patient in quitting
  • Arrange – scheduled followup contact

There is a national hotline number for help at 1-800-QUIT-NOW.

Learning Point
According to the U.S. Public Health Service, counseling is the mainstay of treatment for tobacco cessation.
Nicotine replacement has been found to be safe in adolescents, but there is little evidence that it is effective for long-term abstinence.
Bupropion SR also has little evidence to supportive its effectiveness.

A listing of Suggestions for the Clinical Use of Medications for Tobacco Dependence Treatment
for use in adults can be found from the U.S. Department of Human Resources.

Questions for Further Discussion
1. What treatment should be offered for light smokers or non cigarette tobacco users?
2. At what age can tobacco products be legally purchased locally?
3. Where can tobacco products be legally used locally?
4. How does second hand smoke affect non-smokers?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Smoking and Youth and Smoking Cessation and at Pediatric Common Questions, Quick Answers for this topic: Smoking and Tobacco

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

United States Public Health Service. Treating Tobacco Use and Dependence:
2008 Update.
Available from the Internet at http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf (rev. 5/2008, cited 8/28/2008).

U.S. Department of Human Resources. Helping Smokers Quit
A Guide for Clinicians.
Available from the Internet at http://www.ahrq.gov/clinic/tobacco/clinhlpsmksqt.pdf (rev. 5/2008, cited 8/28/2008).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

  • Interpersonal and Communication Skills
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

  • Professionalism
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    Date
    October 6, 2008