PROMOTING SMOKING PROMOTING SMOKING CESSATION & SMOKE-CESSATION & SMOKE-

FREE HOMES IN FREE HOMES IN PEDIATRIC PRACTICEPEDIATRIC PRACTICE

Sophie J Balk MDSophie J Balk MD

Professor of Clinical PediatricsProfessor of Clinical Pediatrics

AECOMAECOM

GOALSGOALS To discuss To discuss

•Providing smoking Providing smoking cessation counseling to cessation counseling to parents and teens who parents and teens who smoke smoke

•Promoting smoke-free Promoting smoke-free homes homes

OVERVIEWOVERVIEW BackgroundBackground

• Effects of active smokingEffects of active smoking• Effects of secondhand smokeEffects of secondhand smoke• Why smokers don’t quit Why smokers don’t quit

Smoking cessation counseling, Smoking cessation counseling, pharmacotherapypharmacotherapy

Bronx BREATHES, resources Bronx BREATHES, resources

The Life Cycle of the EffectsThe Life Cycle of the Effectsof Smoking on Healthof Smoking on Health

SIDsSIDsRSV/BronchiolitisRSV/BronchiolitisMeningitisMeningitis

InfancyInfancy

Low Birth WeightLow Birth WeightStillbirthStillbirth

In uteroIn utero

AsthmaAsthmaOtitis MediaOtitis MediaFire-related InjuriesFire-related Injuries

InfluencesInfluencesto Startto StartSmokingSmoking

Nicotine AddictionNicotine Addiction

CancerCancerCardiovascular DiseaseCardiovascular DiseaseCOPDCOPD

AdulthoodAdulthood

AdolescenceAdolescence

ChildhoodChildhood

Aligne CA, Stodal JJ. Tobacco and children: An economic evaluation of the medical effects ofAligne CA, Stodal JJ. Tobacco and children: An economic evaluation of the medical effects ofparental smoking. Arch Pediatr Adolesc Med. 1997;151:652parental smoking. Arch Pediatr Adolesc Med. 1997;151:652

Adult Per Capita Cigarette Consumption and Major Adult Per Capita Cigarette Consumption and Major Smoking and Health Events – U.S. 1900-2005Smoking and Health Events – U.S. 1900-2005

2009: Federal Cigarette Tax

Increases and FDA Regulation0

1000

2000

3000

4000

5000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

YEAR

Num

ber

of C

igar

ette

s

End of WW II

1st Smoking-Cancer Concern

Fairness Doctrine Messages on TV

and Radio

Non-Smokers Rights Movement Begins

Federal Cigarette Tax Doubles

Surgeon General’s Report on ETS

1st Surgeon General’s Report

Broadcast Ad Ban

1st Great American Smoke-out

OTC Nicotine Medications

Master Settlement Agreement

Great Depression

?WWI

Source: United States Department of Agriculture; Centers for Disease Control and Prevention

SCOPE OF THE PROBLEMSCOPE OF THE PROBLEM 19.8% of adults smoke (2007) - 19.8% of adults smoke (2007) -

~ 43.4 million people ~ 43.4 million people • Kentucky – 28.3%Kentucky – 28.3%

• West Virginia – 27%West Virginia – 27%• New York – 18.9%New York – 18.9%• New Jersey – 17.2%New Jersey – 17.2%• Connecticut – 15.5%Connecticut – 15.5%• California – 14.3%California – 14.3%• Utah – 11.7%Utah – 11.7%State-Specific Prevalence and Trends in Adult Cigarette Smoking - US, 1998-2007

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5809a1.htm

SMOKERS’ CHARACTERISTICSSMOKERS’ CHARACTERISTICS 21.3% of men; 18.4% of women 21.3% of men; 18.4% of women EthnicityEthnicity

• Indian/Native: 36.4%Indian/Native: 36.4%• Non-Hispanic white: 21.4%Non-Hispanic white: 21.4%• Non-Hispanic black: 19.8%Non-Hispanic black: 19.8%• Hispanic: 13.3%Hispanic: 13.3%• Asian: 9.6%Asian: 9.6%

Highest rates among poor, less Highest rates among poor, less educatededucated

Cigarette Smoking Among Adults—United States, 2007. MMWR November 14, 2008 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a2.htm

Adult Smoking in NYCAdult Smoking in NYCDown Almost 30% Since 2002Down Almost 30% Since 2002

Source: National smoking rates obtained from National Health Interview Survey (NHIS) and Morbidity and Mortality Weekly Report (MMWR) on Cigarette Smoking Among Adults 1993-2008. New York City smoking rates obtained from New York City Community Health Survey 2008.

COSTS OF TOBACCOCOSTS OF TOBACCO 2004:2004: $193 billion annual health-related $193 billion annual health-related

economic losseseconomic losses11

• $96 billion mortality-related productivity losses $96 billion mortality-related productivity losses • >$97 billion excess med expenditures >$97 billion excess med expenditures

5.5 million Years of Potential Life Lost 5.5 million Years of Potential Life Lost annuallyannually22

443,000 deaths/year443,000 deaths/year33 - 1 in 5 deaths - 1 in 5 deaths2 2

= 1,200/day= 1,200/day

1-Treating Tobacco Use and Dependence 2008. 2-Annual Smoking-attributable Mortality, Years of Potential Life Lost, and Productivity Losses-US,1997-2001. MMWR 7/1/05www.cdc.gov/mmwr/preview/mmwrhtml/mm5425a1.htm. 3-Smoking and Tobacco Fast Facts. www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm.

COMPARATIVE CAUSES COMPARATIVE CAUSES OF ANNUAL DEATHS, U.SOF ANNUAL DEATHS, U.S..

CDC Tobacco Information and Prevention Source: www.cdc.gov/tobaccoCDC Tobacco Information and Prevention Source: www.cdc.gov/tobacco

0

50

100

150

200

250

300

350

400

450

Nu

mb

er

of

Death

s (

thou

san

ds)

AIDS Obesity Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced

Individuals with mental

illness or substance use

disordersSum of all these causes of death << tobacco alone

ANNUAL DEATHS ATTRIBUTABLE TO ANNUAL DEATHS ATTRIBUTABLE TO CIGARETTE SMOKING: US, 2000 - 2004CIGARETTE SMOKING: US, 2000 - 2004

TOBACCO AND HEALTHTOBACCO AND HEALTH

~43 million adult smokers~43 million adult smokers Smoking will result in death for Smoking will result in death for

half of all US smokers alive today half of all US smokers alive today Adults who smoke die 13 – 14 Adults who smoke die 13 – 14

years earlier than nonsmokersyears earlier than nonsmokers 6.4 million youth will die 6.4 million youth will die

prematurely from smoking if prematurely from smoking if current trends continuecurrent trends continue

Tobacco-related mortality. www.cdc.gov/tobacco/data_statistics/Factsheets/tobacco_related_mortality.htm#. September 2006

The Life Cycle of the EffectsThe Life Cycle of the Effectsof Smoking on Healthof Smoking on Health

SIDsSIDsRSV/BronchiolitisRSV/BronchiolitisMeningitisMeningitis

InfancyInfancy

Low Birth WeightLow Birth WeightStillbirthStillbirth

In uteroIn utero

AsthmaAsthmaOtitis MediaOtitis MediaFire-related InjuriesFire-related Injuries

InfluencesInfluencesto Startto StartSmokingSmoking

Nicotine AddictionNicotine Addiction

CancerCancerCardiovascular DiseaseCardiovascular DiseaseCOPDCOPD

AdulthoodAdulthood

AdolescenceAdolescence

ChildhoodChildhood

Aligni CA, Stodal JJ. Tobacco and children: An economic evaluation of the medical effects ofAligni CA, Stodal JJ. Tobacco and children: An economic evaluation of the medical effects ofparental smoking. Arch Pediatr Adolesc Med. 1997;151:652parental smoking. Arch Pediatr Adolesc Med. 1997;151:652

SMOKING: FETAL EFFECTSSMOKING: FETAL EFFECTS

Spontaneous abortionSpontaneous abortion StillbirthStillbirth Premature deliveryPremature delivery Low birth weightLow birth weight Placental abruptionPlacental abruption Neurodevelopmental effectsNeurodevelopmental effects

SECONDHAND SMOKE (SHS)SECONDHAND SMOKE (SHS)

SHSSHS•smoke exhaled by smoker smoke exhaled by smoker •smoke released from a smoke released from a smoldering cigarette smoldering cigarette

SHS = ETS (Environmental SHS = ETS (Environmental Tobacco Smoke) Tobacco Smoke)

SHSSHS ~4000 chemicals ~4000 chemicals

• Irritants/systemic toxicants: Irritants/systemic toxicants: Hydrogen cyanide, SOHydrogen cyanide, SO22

•Reproductive toxicants: CO, Reproductive toxicants: CO, nicotinenicotine

•Mutagens/Carcinogens: Mutagens/Carcinogens: Benzene, benzo[a]pyreneBenzene, benzo[a]pyrene

SHS is a Class A CarcinogenSHS is a Class A Carcinogen

SHS: EFFECTS IN ADULTSSHS: EFFECTS IN ADULTS

Known effectsKnown effects • Lung cancer - 3,400 deaths/yrLung cancer - 3,400 deaths/yr• Ischemic heart disease - Ischemic heart disease -

~46,000 deaths/yr ~46,000 deaths/yr • Higher risk of Higher risk of

Breast cancerBreast cancer Nasal sinus cancerNasal sinus cancer

California Air Resources Board. Environmental Tobacco Smoke: SRB Approved Report. California Air Resources Board. Environmental Tobacco Smoke: SRB Approved Report. June 24, 2005. ftp://ftp.arb.ca.gov/carbis/regact/ets2006/app3exe.pdfJune 24, 2005. ftp://ftp.arb.ca.gov/carbis/regact/ets2006/app3exe.pdf

SHS & CHILDREN: SHS & CHILDREN: CLINICAL EFFECTSCLINICAL EFFECTS

Asthma: 202,300 episodes/yearAsthma: 202,300 episodes/year11

Bronchitis/pneumonia (<18mo)Bronchitis/pneumonia (<18mo)22

• 150,000 - 300,000 cases150,000 - 300,000 cases• 7,500 – 15,000 hospitalizations7,500 – 15,000 hospitalizations• 136 – 212 deaths136 – 212 deaths

OM: 790,000 visits/yearOM: 790,000 visits/year11

SIDS: 430 deaths/yearSIDS: 430 deaths/year11

11--California Air Resources Board. June 2005. ftp://ftp.arb.ca.gov/carbis/regact/ets2006/app3exe.pdfCalifornia Air Resources Board. June 2005. ftp://ftp.arb.ca.gov/carbis/regact/ets2006/app3exe.pdf 2-Health Effects of Exposure to Environmental Tobacco Smoke. 2-Health Effects of Exposure to Environmental Tobacco Smoke. The Report of the California The Report of the California Environmental Protection Agency, 1997Environmental Protection Agency, 1997

SHS: CLINICAL EFFECTSSHS: CLINICAL EFFECTS Exposed children more likely to have Exposed children more likely to have

respiratory complications with general respiratory complications with general anesthesiaanesthesia11

Children living with smokers are at greater Children living with smokers are at greater risk for injury and death from house firesrisk for injury and death from house fires22

Children living with smokers are more likely Children living with smokers are more likely to become smokers themselvesto become smokers themselves33

1 - Koop CE, Anesthesiology 1998; 88: 1141-2.1 - Koop CE, Anesthesiology 1998; 88: 1141-2.2 – Difranza JR, Lew RA. Pediatrics 1996; 97:560-8.2 – Difranza JR, Lew RA. Pediatrics 1996; 97:560-8. 3 – Farkas et al. Prev Med 1999.3 – Farkas et al. Prev Med 1999.

SMOKING HAS SO MANY SMOKING HAS SO MANY BAD HEALTH EFFECTS – BAD HEALTH EFFECTS –

WHY DON’T MORE WHY DON’T MORE PEOPLE QUIT?PEOPLE QUIT?

Tobacco.orgTobacco.org

Tobacco advertising targeting women

www.tobaccofreekids.orgwww.tobaccofreekids.org

Ads with Hip Hop Music ThemesAds with Hip Hop Music Themes

Ad targeting African Americans One of the two most popular brands among blacks in U.S.

NICOTINE NICOTINE Effects Effects

• Increases concentrationIncreases concentration• Promotes memory recall Promotes memory recall • Improves psychomotor Improves psychomotor

performance, alertness, arousalperformance, alertness, arousal• Increases pain endurance Increases pain endurance • Decreases anxiety and tensionDecreases anxiety and tension• Decreases hunger pains, promotes Decreases hunger pains, promotes

weight loss weight loss

NICOTINENICOTINE Nicotine is a highly addictive Nicotine is a highly addictive

substancesubstance Nicotine withdrawal Nicotine withdrawal

• Depressed moodDepressed mood• InsomniaInsomnia• Irritability, anxiety, difficulty Irritability, anxiety, difficulty

concentratingconcentrating• Increased appetiteIncreased appetite

BENEFITS OF CESSATIONBENEFITS OF CESSATION

After 20 minutesAfter 20 minutes: HR drops: HR drops 12 hours12 hours: Blood CO normalizes: Blood CO normalizes 2 – 12 wks2 – 12 wks: Better lung function : Better lung function 1 year: added CHD risk ½

smoker’s 5 years: Stroke risk normalizes 10 years: Lung Ca death rate ½

smoker’shttp://www.cdc.gov/tobacco/sgr/sgr_2004/consumerpiece

HELPING SMOKERS QUITHELPING SMOKERS QUIT

US Public Health ServiceUS Public Health Service11

•Clinicians should assess Clinicians should assess smoking status at every visitsmoking status at every visit

•Smoking cessation advise Smoking cessation advise should be given routinelyshould be given routinely

AAP: Pediatricians should AAP: Pediatricians should give cessation advice to give cessation advice to parents who smokeparents who smoke2,3,42,3,4

1- Treating Tobacco Use and Dependence 2008. 2- AAP Ctte on Environmental Health, 1997. 3 – AAP Ctte on Substance Abuse, 2001

WHY FOCUS ON PARENTS?WHY FOCUS ON PARENTS?

~15 million US children live ~15 million US children live with a smokerwith a smoker

Pediatricians may be the only Pediatricians may be the only clinicians a parent visitsclinicians a parent visits

Most smokers want to quitMost smokers want to quit Most parents are receptive to Most parents are receptive to

counseling by pediatricianscounseling by pediatricians11

1 - Frankowski BL, Weaver SO, Secker-Walker RH. Pediatrics 1993; 91: 296-300

INTERVENING WITH INTERVENING WITH PARENTS WHO SMOKEPARENTS WHO SMOKE

Interventions during clinic visits Interventions during clinic visits or hospitalizations increase or hospitalizations increase parents' interest in stopping parents' interest in stopping smoking, quit attempts, quit smoking, quit attempts, quit rates rates

Giving parents information about Giving parents information about SHS reduces childhood SHS SHS reduces childhood SHS exposure and may reduce exposure and may reduce parental smoking ratesparental smoking rates

Treating Tobacco Use and Dependence 2008 update

www.surgeongeneral.gov/tobacco

TREATING TOBACCO USE TREATING TOBACCO USE AND DEPENDENCEAND DEPENDENCE

Tobacco dependence is a Tobacco dependence is a chronic conditionchronic condition

Nicotine is an addictive Nicotine is an addictive substancesubstance

Effective treatments existEffective treatments exist Treatments are cost-effectiveTreatments are cost-effective Systems changes importantSystems changes important

COUNSELINGCOUNSELING Brief counseling is effectiveBrief counseling is effective Intensive counseling is better Intensive counseling is better Repeated brief interventions are Repeated brief interventions are

appropriateappropriate Standard of care: identify and Standard of care: identify and

document tobacco use status, document tobacco use status, provide evidence-based provide evidence-based treatments to every tobacco usertreatments to every tobacco user

EFFICACY OF TOBACCO EFFICACY OF TOBACCO COUNSELING INTERVENTIONSCOUNSELING INTERVENTIONS

Brief counselingBrief counseling 3-10 minutes3-10 minutes Targets smokers who are willing, unwilling, and Targets smokers who are willing, unwilling, and

those who recently quit those who recently quit

Intensive counselingIntensive counseling Total clinician-client time >30 minutes with at Total clinician-client time >30 minutes with at

least 4 sessionsleast 4 sessions Usually coordinated by tobacco dependence Usually coordinated by tobacco dependence

specialistsspecialists

Dose response between number of clinician types offering counseling and cessation success

(Fiore et al., 2008)

Odds Ratio of Quitting Odds Ratio of Quitting Increases with CounselingIncreases with Counseling

1.0

2.3

1.61.3

0.0

0.5

1.0

1.5

2.0

2.5

Controls

3 Min.

3-10 Min.

>10 Min.

Total Contact Time

Od

ds

Rat

io o

f Q

uit

tin

g

Quitting defined as abstinence for at least 5 monthsQuitting defined as abstinence for at least 5 monthsTreating Tobacco Use and Dependence. US Public Health Service 2000

THE “5 A’S”THE “5 A’S”

AskAsk AdviseAdvise AssessAssess AssistAssist Arrange follow-upArrange follow-up

System ImplementationSystem Implementation

“Ask”Identify Tobacco Use /exposure to smoke

Document chart

“Advise”To Quit

“Assess”willingness to quit

“Assist”with quitting

“Arrange”Follow-up

Referrals

NYS QuitlineFax to Quit

Individual/Group Counseling &

Pharmacotherapy

SMOKERS’ QUITLINESSMOKERS’ QUITLINES

Adjunct to office counselingAdjunct to office counseling Professional, evidence-based, Professional, evidence-based,

ongoing counseling servicesongoing counseling services Effective in helping adults quitEffective in helping adults quit11

Available in many states and Available in many states and through national quitline through national quitline network network • (1-800-QUITNOW)(1-800-QUITNOW)

1 – Fiore, JAMA 2008

PHARMACOTHERAPYPHARMACOTHERAPY

Smokers trying to quit should be encouraged to use pharmacotherapy except under special circumstances Medical contraindications Not recommended for pregnant

women, adolescents, light smokers, smokeless tobacco users

Fiore, JAMA 2008

PHARMACOTHERAPYPHARMACOTHERAPY FDA-approved FDA-approved

• Bupropion SR*Bupropion SR* *R*Rxx needed needed

• Nicotine gumNicotine gum• Nicotine inhaler*Nicotine inhaler*• Nicotine lozengeNicotine lozenge• Nicotine nasal spray*Nicotine nasal spray*• Nicotine patchNicotine patch• Varenicline (Chantix)*Varenicline (Chantix)*

PHARMACOTHERAPYPHARMACOTHERAPY

NYS Smokers' QuitsiteNYS Smokers' Quitsite

NRT: NICOTINE REPLACEMENT NRT: NICOTINE REPLACEMENT THERAPYTHERAPY

Reduces cravings Steady dose (patch) absorbed through

the skin Self-administered (gum, lozenge,

inhaler, spray) absorbed through nasal/oral mucosa

Proven to increase quit rates Safer way to get nicotine

• Nicotine does not cause cancer

Clinical Guideline, 2008 & Shiffman, et al, Clinical Guideline, 2008 & Shiffman, et al, 2002 2002

Effectiveness of MedicationsEffectiveness of Medications

   Odds ratio Abstinence

rates

PlaceboPlacebo 1.01.0 13.813.8

VareniclineVarenicline 3.13.1 33.233.2

Nicotine nasal sprayNicotine nasal spray 2.32.3 26.726.7

Nicotine patchNicotine patch 2.32.3 26.626.6

Nicotine gumNicotine gum 2.22.2 26.126.1

Nicotine inhalerNicotine inhaler 2.12.1 24.824.8

Bupropion SRBupropion SR 2.02.0 24.224.2

Nicotine lozenge Nicotine lozenge 2 mg2 mg4 mg4 mg

2.0 2.0 2.82.8

24.2/24.2/14.214.2**

23.6/ 23.6/10.210.2

““A-A-R-P”A-A-R-P”

Practical alternative to the 5 A’sPractical alternative to the 5 A’s AskAsk AdviseAdvise Refer to Quitline/Fax-to-quitRefer to Quitline/Fax-to-quit Consider recommending or Consider recommending or

prescribing Pharmacotherapyprescribing Pharmacotherapy

Clinical Guidelines, 2000Clinical Guidelines, 2000

PREVENTING RELAPSEPREVENTING RELAPSE

Most relapses - first 3 months Provide relapse prevention

interventions to smokers who have recently quit Congratulate patient Discuss health benefits of cessation Discuss threats to maintaining

abstinence

““THIRDHAND SMOKE”THIRDHAND SMOKE”

Toxins remain Toxins remain after the cigarette is extinguished

Even when smoke is not visible• Particulate matter deposited in a

layer onto surfaces • In loose household dust • Volatile compounds that “off gas”

for days, weeks, months Children especially susceptible

Winickoff JP et al. Pediatrics 2009

HARM REDUCTION: HARM REDUCTION: REDUCING EXPOSUREREDUCING EXPOSURE

Promoting smoke-free homesPromoting smoke-free homes• Use if the smoker isn’t ready to quitUse if the smoker isn’t ready to quit• Providing counseling and written Providing counseling and written

materials successfulmaterials successful1,2,3,41,2,3,4

• Rules prohibiting household Rules prohibiting household smoking shown to reduce SHS smoking shown to reduce SHS exposureexposure5,65,6

1 - Hovell et al. Chest 1994. 2 – Wahlgren et al. Chest 1997.3 – Hovell et al. BMJ 2000. 4 – Emmons et al. Pediatrics 2001.5 – Wakefield et al. Am J Prev Med 1995. 6 – Biener et al. Prev Med 1997.

ADOLESCENTS & SMOKINGADOLESCENTS & SMOKING Tobacco industry targets the young

Children & teens constitute the majority of all new smokers

20% of HS students & 6% of MS students smoke1

80% of adult smokers tried their first cigarette by age 18

Smoking cessation messages & methods are essential

1 – www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm

TREATING ADOLESCENTSTREATING ADOLESCENTS NRT is safe in adolescents Little evidence that NRT and Bupropion are

effective in adolescents Safety & efficacy of varenicline not

established < 18 years

Counseling ~ doubles long-term teen abstinence compared to usual care or no Rx

Adolescent smokers are identified and counseled to quit in 33 – 55% of MD visits

Assess teen tobacco use, counsel, F/U

Treating Tobacco Use and Dependence 2008

SYSTEMS INTERVENTIONS SYSTEMS INTERVENTIONS

Office systems needed to Office systems needed to facilitate identification and facilitate identification and treatment of smokerstreatment of smokers

Health system administrators, Health system administrators, insurers and purchasers are insurers and purchasers are encouraged to develop systems encouraged to develop systems and policies to promote smoking and policies to promote smoking cessationcessation

OFFICE SYSTEM CHANGESOFFICE SYSTEM CHANGES

Implement tobacco user Implement tobacco user identification system identification system • Add smoking status to vital signsAdd smoking status to vital signs• Tobacco use stickerTobacco use sticker

Provide staff educationProvide staff education Dedicate staff to tobacco Dedicate staff to tobacco

treatmenttreatment

SUMMARYSUMMARY

Tobacco is a major health threatTobacco is a major health threat Clinicians must intervene consistentlyClinicians must intervene consistently Counseling and pharmacotherapy are Counseling and pharmacotherapy are

effective treatments effective treatments • All smokers should be offered consistent All smokers should be offered consistent

treatmentstreatments Promoting smoke-free homes is Promoting smoke-free homes is

important for all families important for all families Pediatricians can play an important Pediatricians can play an important

role in counseling parents and teensrole in counseling parents and teens

Bronx BREATHES Bronx BREATHES Mission & ResourcesMission & Resources

Barbara Hart, MPA – Project Manager

David Lounsbury, PhD – Co-Investigator

Shadi Nahvi, MD, MS – Co-Investigator

Claudia Lechuga, MS – Research Associate

Hal Strelnick, MD – Principal Investigator

Shaniyya Pinckney – Academic Detailer

Bronx-Einstein Alliance for Tobacco-free Health

Bronx BREATHES MissionBronx BREATHES Mission Smoking is the leading preventable cause of illness and Smoking is the leading preventable cause of illness and

death in the Bronx and United States. death in the Bronx and United States. Bronx BREATHES works with the health care community Bronx BREATHES works with the health care community

to help Bronx residents quit smoking.to help Bronx residents quit smoking. As one of 19 statewide Tobacco Cessation Centers, Bronx As one of 19 statewide Tobacco Cessation Centers, Bronx

BREATEHS aims to:BREATEHS aims to:• Provide Tobacco Control technical assistance & training to health Provide Tobacco Control technical assistance & training to health

care institutions & providers in the Bronxcare institutions & providers in the Bronx• Assist health care institutions with the design & implementation Assist health care institutions with the design & implementation

of tobacco control policy & treatment practicesof tobacco control policy & treatment practices• Identify and promote direct cessation services located in the Identify and promote direct cessation services located in the

BronxBronx• Increase the number of Bronx residents who use the services of Increase the number of Bronx residents who use the services of

the NYS Smokers’ Quitlinethe NYS Smokers’ Quitline

Bronx BREATHES:Bronx BREATHES:Support Services for CliniciansSupport Services for Clinicians

Training & follow-up for providers Training & follow-up for providers Design & implementation of systems Design & implementation of systems

to:to:• Identify & monitor tobacco users at Identify & monitor tobacco users at

each patient visiteach patient visit• Foster patient referral to smoking Foster patient referral to smoking

cessation services (e.g., local support cessation services (e.g., local support groups, NYSDOH Quitlinegroups, NYSDOH Quitline

• Incorporate tobacco control in EMRIncorporate tobacco control in EMR

Patient Referral Services: Patient Referral Services: Telephone CounselingTelephone Counseling

NYS Quitline: 1-866-NY-QUITSNYS Quitline: 1-866-NY-QUITS Services: Services:

• Free telephone counseling in English, Spanish & several other Free telephone counseling in English, Spanish & several other languageslanguages

• Free NRTFree NRT• Referrals to local counseling & cessation programsReferrals to local counseling & cessation programs• Free educational materialsFree educational materials

Efficacy of QuitlinesEfficacy of Quitlines• Multiple calls: OR 1.41 (1.27-1.57) increase in successful quit Multiple calls: OR 1.41 (1.27-1.57) increase in successful quit

attemptsattempts• Efficacy for long term cessationEfficacy for long term cessation• Effective at reaching racial/ethnic minority smokersEffective at reaching racial/ethnic minority smokers

Stead et al., Cochrane Library, 2007

Available in Available in paperpaper & & onlineonline forms forms• Provider-referred patients are contacted by Quitline Provider-referred patients are contacted by Quitline

services & offered the same services as aboveservices & offered the same services as above• Progress report sent back to youProgress report sent back to you

NYS Fax-to-Quit Referral ServiceNYS Fax-to-Quit Referral Service

Proportion of Smokers Using NYS Quitline Proportion of Smokers Using NYS Quitline by Borough, 2009by Borough, 2009

(Self-referral vs. MD-referral)(Self-referral vs. MD-referral)

Source: New York City Community Health Survey 2008 (Data checked 1/11/10) and New York State Quitline Services (Data checked 1/4/10). All estimates are weighted to the NYC adult population per Census 2000 and rounded to the nearest thousand. Referral denotes all patients registered through Fax-to-Quit Paper or On-line Service.

26%

NRT Distribution among NRT Distribution among Fax-to-Quit CallersFax-to-Quit Callers

Source: New York City Community Health Survey 2008 (Data checked 1/11/10) and New York State Quitline Services (Data checked 1/4/10). All estimates are weighted to the NYC adult population per Census 2000 and rounded to the nearest thousand. Nicotine Replacement Therapy (NRT) includes distribution of Nicotine Patch or Nicotine Gum only. * Staten Island figures include distribution to Medicaid NRT recipients.