SummaryIn an effort to reduce children's exposure to tobacco smoke, the Clinical Effort Against Secondhand Smoke Exposure program uses pediatric offices to provide smoking cessation assistance to parents who smoke, as well as to help families establish rules for a completely smoke-free home and car. With the Clinical Effort Against Secondhand Smoke Exposure, trained pediatricians and office staff consistently and systematically use a streamlined, three-step version of the traditional five-step (i.e., ask, advise, assess, assist, arrange) approach to smoking cessation and smoke-free home and car rule support. The program has led to an increase in the provision of cessation assistance and higher quit rates.
See the Results section for additional data from a randomized controlled trial (updated November 2012).Strong: The evidence consists of data from two randomized control trials showing a comparison of the provision of smoking cessation support and quit rates in intervention and control practices from 16 states with similar patient populations.
Developing OrganizationsAmerican Academy of Pediatrics Julius B. Richmond Center; Harvard Medical School; MassGeneral Hospital for Children
MassGeneral Hospital for Children is a full-service pediatric hospital housed within the Massachusetts General Hospital.
Use By Other Organizations
- The Massachusetts Department of Health has mailed out A Solution to Help Families Quit Smoking, based on CEASE research, to every pediatrician in the state.
- The Indiana Department of Health has begun working with the Indiana Academy of Pediatrics to systematically train pediatricians and family physicians on the CEASE program. (Indiana has the fifth highest smoking rate in the country.)
- The California Smokers' Helpline has also hosted grand rounds and talks by Dr. Winickoff about ways to use CEASE effectively to eliminate children's exposure to secondhand smoke. As noted earlier, all 50 states have customized CEASE materials and promote their use among pediatricians.
Date First Implemented1999
A pilot version of the program was first used in 1999. It has been routinely improved since that time to the current Clinical Effort Against Secondhand Smoke Exposure program.
Problem AddressedAlthough the dangers of tobacco use to those who smoke are well established, tobacco smoke exposure is a less recognized but still common problem that poses significant health risks, especially for children. Pediatric offices represent a promising but underutilized venue for providing effective cessation counseling and support, especially for establishing smoke-free home and car rules, to parents and other adults in regular contact with children.
- Dangers of tobacco smoke: Exposure to tobacco smoke is common and associated with a significant increase in morbidity and mortality among children, especially those aged 5 years and younger.1-3 A California study, for example, found that 35 percent of children aged 5 years and younger were exposed to environmental tobacco smoke for an average of approximately 4 hours per day.3 Children exposed to tobacco smoke have an increased risk of sudden infant death syndrome, impaired lung development, ear infections, and severe asthma; they also are more likely to become smokers themselves.4
- Unrealized potential of counseling through pediatricians: Parents often have more interaction with a pediatrician than with any other health care provider, making this setting a potentially valuable one in which to offer smoking cessation counseling and support for establishing smoke-free home and car rules. In fact, the 2008 update to the U.S. Public Health Service's Treating Tobacco Use and Dependence guideline (developed by a consortium of seven Federal agencies and nonprofit organizations) calls on clinicians, including pediatricians, to offer evidence-based treatment (counseling and access to resources to support quit attempts) to all tobacco users seen in a clinical setting, including parents and others who are not patients of the clinicians.5 Yet, studies have found that pediatricians lack adequate training and skills related to cessation counseling, which leads them to provide such services relatively infrequently.6
Description of the Innovative ActivityThe Clinical Effort Against Secondhand Smoke Exposure (CEASE) program trains pediatricians and office staff to systematically provide cessation counseling and interventions to parents and other adults who smoke. Using tools developed as part of the program, clinicians intervene with smokers, using a streamlined, three-step version of the traditional five-step (i.e., ask, advise, assess, assist, arrange) approach recommended in the U.S. Public Health Service Treating Tobacco Use and Dependence guideline. The three steps focus on identifying and asking all smoking parents if they want assistance in quitting (the ask step), assisting them if they do (the assist step), and referring them to specialized resources if necessary (the arrange step). Key elements of the program are described in the following:
- Systematically identifying and asking smokers if they want assistance in quitting: In the waiting room, office staff ask all parents to fill out the first portion of the CEASE Action Sheet, which asks whether they or any other members of their child's household smoke. The physician or other office staff member reviews this sheet when the appointment begins. When a smoker is identified, the clinician asks if the individual would be interested in any assistance in quitting, including access to free counseling programs or medications (which may be covered by the parent's health insurance). They also inquire as to whether the adult is interested in setting a quit date. For those who express an interest (typically 40 percent of smoking parents do so), the clinician moves on to the next step (see below). For the roughly 60 percent of smoking parents who do not want assistance, the clinician suggests revisiting the topic at the next appointment. If a smoking member of the household is not present at the appointment (e.g., father, mother, grandparent), the clinician asks other members of the household to strongly encourage this individual to attend the next office visit. At this stage, all parents living in households where someone smokes are asked if they have a strict policy in place related to not smoking in the car or house when a child is present. If they do not, clinicians explain that the home and car become contaminated by tobacco smoke poisons and strongly encourage them to adopt strict no smoking policies in the home and car.
- Assisting those who want help: The second step is to provide smokers the assistance they ask for, including setting a target quit date and providing brief counseling, information about free programs (typically free telephone quitlines, which are available in every state), or prescriptions for medications that can help in quitting smoking. The CEASE Action Sheet and other program materials assist clinicians in providing this assistance. (See Tools and Other Resources for more information about these materials.)
- Referring parents or other family members who smoke for ongoing smoking cessation support: This step includes the referral of the smoking adult to additional, specialized programs that can help, such as the telephone quitline. In some states, a health care provider can enroll a smoker in the quitline (meaning that a quitline representative will call the smoker proactively) rather than just giving the smoker the telephone number and relying on him or her to call.
- Repeating the cycle at every visit: The same three-step process is used at every visit so that those smokers who may have refused assistance at (or not attended) an earlier visit can receive the same assistance and support in quitting. Often, an individual who may not have been prepared to quit at the prior visit reconsiders and accepts help at a subsequent one.
Context of the InnovationThe CEASE initiative was developed by the Tobacco Research and Treatment Center and Center for Child and Adolescent Health Policy at MassGeneral Hospital for Children (part of Massachusetts General Hospital), in partnership with the American Academy of Pediatrics (AAP) and the AAP Julius B. Richmond Center. Massachusetts General Hospital, a 900-bed academic medical center located in Boston, MA, is part of Partners HealthCare, a nonprofit, integrated system that includes one other academic medical center (Brigham and Women's Hospital), along with primary care and specialty physicians, community hospitals, specialty facilities, community health centers, and other health-related entities. The AAP is an association of 60,000 pediatricians committed to the attainment of optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults. The AAP Julius B. Richmond Center is a national center of excellence funded by the Flight Attendant Medical Research Institute and the American Legacy Foundation and dedicated to the elimination of children's exposure to tobacco and secondhand smoke. The CEASE program was developed in response to the high smoking rates among parents of children seen by pediatricians in the Boston area, which raised concerns about the risks of secondhand smoke to these children. Researchers at MassGeneral Hospital for Children believed that the pediatrician's office represented a potentially effective but underutilized opportunity to provide smoking cessation support, because many young parents have more interaction with the pediatrician than with any other health care provider (particularly low-income parents who may not have insurance or a regular provider).
ResultsThe CEASE intervention has been studied in various pediatric contexts. Information provided in November 2012 indicates that a comparison of two similar pediatric practices—one offering the CEASE intervention and one providing usual care—found that practices trained to use CEASE improved 24-hour and 7-day quit rates for parents. A national study of 20 practices (10 control, 10 intervention) found that, in the intervention practices, the program significantly increased the provision of smoking cessation support through counseling, enrollment in the quitline, and provision of smoking cessation medication.
Strong: The evidence consists of data from two randomized control trials showing a comparison of the provision of smoking cessation support and quit rates in intervention and control practices from 16 states with similar patient populations.
- Increased provision of cessation support: Before the intervention, clinicians in control and intervention practices rarely provided meaningful cessation support to smoking parents, with assistance being offered to roughly 3 percent of smoking parents. After the program was introduced, assistance rates in the intervention practice for parental cigarette smoking was 43 percent (range 34 to 66 percent) in the intervention group and 3 percent (range 0 to 8 percent) in the control group. Rates of enrollment in the quitline (10 versus 0 percent), provision of smoking cessation medication (12 versus 0 percent), and counseling for smoking cessation (24 versus 2 percent) were all significantly different between intervention and control groups (added November 2012).
- Improved quit rates: The two-practice trial found that approximately 43 percent of smoking parents in the practice offering CEASE quit smoking for 24 hours, compared with 30 percent in the control group practice (representing a statistically significant difference). Roughly 12 percent of smoking parents in the CEASE practice quit for 7 days, compared with 8 percent in the control group practice. Although this latter finding did not reach the level of statistical significance, it is important to recognize that quit rates in the control group are well above the average for typical smokers, because participation in this study—even as the control group—meant that smoking parents still took part in conversations about the negative effects of smoking and the need to quit. As a result, the difference between quit rates in the intervention group and those in the general smoking population (which typically average 3 to 5 percent) would tend to be significantly greater, suggesting that this study understates the true impact of the program.
Planning and Development ProcessKey steps in the planning and development process include the following:
- Program and material development: The program was developed over a period of 10 years, based on an initial set of focus groups with eight pediatric offices to find out their needs related to providing smoking cessation assistance to parents. These focus groups helped developers figure out how to translate the guidance provided in the Treating Tobacco Use and Dependence guideline into the world of pediatrics, including consolidating the traditional five-step process into the three-step approach used by CEASE. This initial set of focus groups was followed by two discussion groups with 50 pediatricians, each held at two annual meetings of the Pediatric Research in Office Settings network. At these sessions, pediatricians provided feedback and refined guidance on the written materials and tools and other aspects of the program.
- Training of pediatricians and office staff: Pediatricians and office staff interested in implementing CEASE need to be trained on the program and the use of program materials. During the trials described earlier, pediatricians and staff attended two lunch-hour sessions (held in place of regular staff meetings) where they learned about the CEASE approach and program materials, including how to use them effectively. The training provided information and guidance on how and when to prescribe medications (thought to be among the most effective interventions) and how to better use CEASE materials to encourage smokers to quit (e.g., through use of motivational messages included on the program checklist). A CEASE training video is also available for use in training practices.
- Initial and followup trials: The initial two-practice trial described earlier tested the efficacy of the program. A followup trial with 10 pediatric practices in New York and Massachusetts, funded by the Robert Wood Johnson Foundation, tested data-gathering requirements and other aspects of program feasibility. The study team recently completed the 20-practice national trial (R01-CA127127-01), Addressing Parental Smoking by Changing Pediatric Office Systems. To test the implementation and sustainability of the intervention, a new 10-practice study of the online American Academy of Pediatrics CEASE intervention (EQIPP: Eliminate Tobacco Use and Exposure, www.eqipp.org) began in September 2012.
Resources Used and Skills Needed
- Staffing: The program requires no new staff, as pediatricians and other office-based staff participate as part of their regular duties.
- Costs: Out-of-pocket expenses are relatively small, because CEASE materials have been tailored for each of the 50 states and are available on the CEASE Web site (www.ceasetobacco.org). Minimal costs may be incurred to duplicate program materials. The program does add to the length of time for the typical visit—for the 40 percent of smoking parents who request assistance when asked, the cessation support intervention adds about 3 minutes to the visit. For those who do not want assistance when asked, visit length is extended by roughly 30 seconds.
Funding SourcesAgency for Healthcare Research and Quality; Massachusetts Department of Public Health; National Cancer Institute; National Institute on Drug Abuse; Robert Wood Johnson Foundation; Indiana Department of Public Health; American Academy of Pediatrics Julius B. Richmond Center; Flight Attendant Medical Research Institute; American Legacy Foundation
The Agency for Healthcare Research and Quality (AHRQ) and the National Cancer Institute provided funding for the national trial (AHRQ NIDA grant RO1-CA127127). These same organizations, along with the National Institute on Drug Abuse, have provided funding for the national trial.
In some cases, pediatric offices that implement the program can bill for the cessation support services provided, as additional reimbursement for cessation support services may be available from some payers. Typically, a pediatrician can bill for a more complex visit (e.g., a "level 4" instead of a "level 3" visit) when the full set of CEASE program services are provided in the context of a sick child or urgent care visit. Under current reimbursement systems, however, it is generally not possible to bill for these services when provided during a well child visit.
Tools and Other ResourcesAll program-related materials are available free of charge at http://www.ceasetobacco.org, including a video introduction to the program, the CEASE training manual, the CEASE implementation guide, the CEASE Action Sheet, and a host of other educational materials for smoking parents. Some of the key materials are available in Spanish. The site also includes materials that have been customized for each of the 50 states. In addition, materials are available for Head Start practices as part of a new initiative to reach families. The CEASE program also has an active Facebook page to connect with clinicians, families, and tobacco control advocates.
The Center for Child and Adolescent Health Policy at MassGeneral Hospital for Children has developed an interactive platform to help would-be adopters engage in this program. The online continuing medical education module is available through PediaLink at http://pedialink.aap.org/visitor. Further continuing education programs are available at the American Academy of Pediatrics Education in Quality Improvement for Pediatric Practice: http://www.eqipp.org.
The AAP Julius B. Richmond Center of Excellence works to assist child health providers in becoming active participants in the elimination of tobacco and secondhand smoke exposure in children. More information is available at http://www.aap.org/richmondcenter.
Information about state quitlines is available at http://www.naquitline.org/?page=aboutquitlines.
The U.S. Public Health Service Treating Tobacco Use and Dependence guideline is available from the National Guidelines Clearinghouse at http://www.guidelines.gov/summary/summary.aspx?ss=15&doc_id=12520&string=.
Getting Started with This Innovation
- Gain support of practice leader: The program will not work well if adopted by only one or a few physicians within a larger practice. The practice leader needs to support the initiative and endorse its use by all physicians.
- Tap into available resources: As noted, many CEASE materials are available free of charge. These resources can assist a great deal in getting the program off the ground.
- Test on a few patients, then refine as needed: The program is designed to be implemented fairly quickly. It can be used on a handful of patients, with refinements made based on the initial experience. A great deal can be learned quickly through this type of experimentation and refinement.
- Obtain training via an online course: A brief training is available through the PediaLink training course called Help Every Family Quit Smoking; more in-depth training is available through the Education in Quality Improvement for Pediatric Practice (EQIPP) course called Eliminate Tobacco Use and Exposure (see the Tools and Other Resources section for more information).
Sustaining This Innovation
- Approach payers about reimbursement: As noted, it can be difficult for pediatricians to receive additional reimbursement for the provision of smoking cessation support to parents in the context of a well child visit.
Contact the InnovatorJonathan Winickoff, MD, MPH
MGH - Center for Child and Adolescent Health Policy
15th Floor - C100
100 Cambridge Street
Boston, MA 02114
Innovator DisclosuresDr. Winickoff has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
References/Related ArticlesDempsey J, Friebely J, Hall N, et al. Parental tobacco control in the child healthcare setting. Current Pediatric Reviews. 2011;7(2):115-22.
Winickoff JP, Park ER, Hippie BJ, et al. Clinical effort against secondhand smoke exposure: development of framework and interventions. Pediatrics. 2008;122(2):e363-75. [PubMed]
Painter K. Kids of smokers have an ally in pediatricians. USA Today. March 15, 2009. Available at: http://www.usatoday.com/news/health/2009-03-15-quit-smoking-pediatricians_N.htm.
U.S. Department of Health and Human Services. The Health Consequences of Involuntary Smoking: A Report of the Surgeon General
. Washington, DC: Office of the Assistant Secretary for Health, Office on Smoking and Health, U.S. Department of Health and Human Services, Public Health Service; 1986. DHHS publication (CDC) 87-8398. Available at: http://www.surgeongeneral.gov/library/reports/secondhandsmoke/index.html
Gidding SJ, Morgan W, Perry C, et al. Active and passive tobacco exposure: a serious pediatric health problem. Circulation. 1994;90:2581-90. [PubMed]
National Cancer Institute. Health Effects of Exposure to Environmental Tobacco Smoke: The Report of the California Environmental Protection Agency
. Bethesda, MD: National Cancer Institute, U.S. Department of Health and Human Services; 1999. Smoking and tobacco control monograph 10; NIH publication 99-4645. Available at: http://www.cancer.gov/newscenter/newsfromnci/1999/ets
4 Painter K. Kids of smokers have an ally in pediatricians. USA Today. March 15, 2009. Available at: http://www.usatoday.com/news/health/2009-03-15-quit-smoking-pediatricians_N.htm.
Caponnetto P, Polosa R, Best D. Tobacco use cessation counseling of parents. Curr Opin Pediatr. 2008;20(6):729-33. [PubMed]
Perez-Stable EJ, Juarez-Reyes M, Kaplan CP, et al. Counseling smoking parents of young children: comparison of pediatricians and family physicians. Arch Pediatr Adolesc Med. 2001;155(1):25-31. [PubMed]
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Original publication: September 30, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: January 16, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: November 26, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.