Pediatric Anesthesia ISSN 1155-5645
ORIGINAL ARTICLE
Tobacco control education in pediatric anesthesiology fellowships Shannon M. Peters, Christina M. Pabelick & David O. Warner Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
Keywords quality improvement; anesthesia; perioperative care; pediatrics Correspondence David O. Warner, Department of Anesthesiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA Email: [email protected] Section Editor: Jerrold Lerman Accepted 8 September 2013 doi:10.1111/pan.12277
Summary Background: Cigarette smoking and secondhand smoke exposure (SHS) increase the risk of perioperative complications. Traditionally, anesthesiologists have limited involvement in tobacco control. Objective: To develop and disseminate an educational curriculum that educates pediatric anesthesia fellows in tobacco control. Methods: After IRB approval, an online survey was disseminated to pediatric anesthesiology fellowship directors. Results: Thirty-one surveys were completed. Most report that they ask pediatric patients about tobacco use. A majority advise their patients who smoke about the health effects of smoking, but only 40% advise children to quit, and the majority never provide educational materials to assist in smoking cessation. Half reported that they sometimes or always ask about SHS. Approximately one-third never advise about the ill effects of SHS, nearly half never advise parents to stop smoking, and the majority never provide educational material about quitting to parents. Two-thirds felt that it is their responsibility to advise pediatric patients not to smoke, but less than half felt the same sense of responsibility about advising parents not to smoke. Approximately two-thirds believe that fellowship programs should provide education about the effects of smoking in the perioperative period and the effects of SHS exposure, but few programs do. Almost all would implement a free teaching module about SHS exposure and tobacco control as part of fellowship education. Conclusions: Many pediatric anesthesiology fellowship directors agree that exposure to cigarette smoke adversely impacts patients in the perioperative period, but few participate in tobacco control, and issues germane to tobacco control are not consistently addressed.
Introduction Cigarette smoking continues to be a major healthrelated burden in the United States. The use of tobacco products is typically initiated during adolescence (1), so that prevention and early intervention are imperative. Each day, nearly 4000 children below the age of 18 smoke their first cigarette and a quarter of those become daily cigarette smokers (2). In addition, approximately 25% of children are exposed to secondhand smoke (SHS) (3), which has significant deleterious effects on their health (4,5). In the perioperative period, exposure to SHS increases the frequency of respiratory events © 2013 John Wiley & Sons Ltd Pediatric Anesthesia 23 (2013) 1213–1218
during and after anesthesia (6–9), and contributes to the pathogenesis of asthma and other conditions that may increase perioperative risk. Among medical specialists, anesthesiologists have had a limited role in tobacco prevention and control. However, given the deleterious effects of tobacco smoke on perioperative outcomes in both children and adults, and the potential for the surgical experience to motivate behavioral change, there has been increased interest in exploring the potential role of anesthesiologists in tobacco use interventions (10). Simple intervention strategies, such as the 5-A’s (ask, advise, assess, assist, and arrange for follow-up) and ‘AAR’ (ask, advise, and 1213
S.M. Peters et al.
Tobacco control education in fellowships
refer), performed by anesthesiologists on or before the day of surgery have been useful tools for intervention (11,12). In the former strategy (5-A’s), clinicians themselves provide five evidence-based interventions shown to be efficacious. In the later strategy, AAR provides advice to quit smoking then refers patients to resources such as tobacco treatment programs or telephone ‘quitlines’ (such as 1-800-QUITNOW). The American Society of Anesthesiologists also has a stop smoking initiative that aims to disseminate information to anesthesiologists that help patients maintain perioperative abstinence.1 To date, these efforts have been directed toward adult smokers, but there may also be significant opportunities to address tobacco exposure in pediatric patients undergoing surgery and other procedures, both smoking by the patients themselves and exposure to secondhand smoke. For example, parents who smoke are more likely to make a quit attempt smoke if their child undergoes a surgical procedure (13). One method of exploiting such opportunities would be to include tobacco control curriculum in the fellowship training programs of pediatric anesthesiologists. Our overall objective is to explore the development and dissemination of a curriculum to educate pediatric anesthesiology fellows about how exposure to tobacco smoke affects their patients and how pediatric anesthesiologists can participate in perioperative tobacco control efforts. As an initial step, this formative survey-based study of the directors of pediatric anesthesiology fellowship programs aimed to determine current curriculum regarding tobacco use and control. It further explored the attitudes and beliefs of fellowship program directors regarding perceptions of risk, responsibility, and barriers to communication about environmental smoke exposure in perioperative patients, as these individuals would be key to implementing a tobacco control curriculum. Materials and methods This study was approved by the Mayo Clinic Institutional Review Board. Procedures and participants Program directors (PD) of ACGME-accredited pediatric anesthesiology fellowship programs were identified (n = 46). An introductory email was sent to each PD inviting participation and including a link to a web-based survey instrument (Survey Monkey, www. surveymonkey.com). A reminder email was sent to each PD after 2 weeks. 1
www.asahq.org/stopsmoking, accessed May 22, 2013.
1214
Table 1 Respondent demographics and practice characteristics
Characteristics
Number (%) (N = 31)
Years in practice since completion of training? 5 years or less 2 (7) 6–10 years 4 (13) 11–20 years 14 (45) 21 years or more 11 (35) How often do you see pediatric patients preoperatively prior to the day of surgery? Always 3 (10) Almost always 2 (6) Sometimes 21 (68) Never 5 (16) How often do you see pediatric patients postoperatively? Always 5 (16) Almost always 13 (42) Sometimes 12 (39) Never 1 (3) Age 31–40 4 (13) 41–50 11 (36) 51–60 15 (48) 61 or older 1 (3) Gender Male 16 (52) Female 15 (48) Cigarette smoking status Never smoked 26 (84) Former smoker 5 (16) Current smoker 0 (0) Fellows in program 16 0 (0)
Survey Survey items were generated based primarily on prior surveys of anesthesiologists from our investigative group (14–16) and assessed the following areas. Demographics These items included the characteristics of the PDs themselves, the frequency and preoperative contact with patients prior to surgery and after surgery, and practice characteristics. Current practices These items included questions regarding both the current approaches of the PDs to smoking by pediatric patients who themselves require anesthesia care, and their approach to pediatric patients who are exposed to SHS and require anesthesia care. Items queried the frequency with which PDs incorporated elements of © 2013 John Wiley & Sons Ltd Pediatric Anesthesia 23 (2013) 1213–1218
S.M. Peters et al.
Tobacco control education in fellowships
current practice guidelines regarding clinician provision of tobacco interventions (17) (e.g., asking about tobacco use or SHS exposure, advising patients to quit or to reduce their child’s SHS exposure, assisting them in quitting or reducing SHS exposure, etc.). Attitudes and beliefs These items included those related to perceptions of risks from tobacco and benefits of reducing tobacco exposure, perceptions of barrier to intervening, and interests in learn about how to intervene. Educational practices/needs These items included what tobacco use and control education was currently offered as a part of fellowship training, and perceptions of what curriculum should be offered, including use of web-based resources. Results Of the 46 PDs contacted, 31 (67%) responded to the survey. Table 1 presents their demographic and practice characteristics. Regarding their current practices, a minority of respondents reported always or almost always asking about smoke exposure (primary or secondhand) or advising patients or their caregivers to reduce exposure (Table 2). Very few provided any type of assistance with
quitting or mitigating SHS exposure. Nonetheless, a strong majority agreed or strongly agreed that SHS exposure is of clinical significance and that reducing exposure would reduce perioperative complication rates, indicating an awareness of the issue (Table 3). A majority agreed or strongly agreed that it was part of their responsibility to advise patients and parents to quit and reduce SHS exposure, respectively. Regarding assistance, there was greater enthusiasm for helping parents reduce SHS exposure than for helping pediatric patients get assistance to quit. Regarding barriers to intervention, the majority of respondents were unsure if efforts in general to reduce SHS exposure could be effective (Table 3). However, only a minority agreed or strongly agreed with four statements regarding specific putative barriers to intervention (efficacy, time, patient or parental anxiety, and adverse parental reactions). Less than a quarter of respondents agreed that they knew how to help their patients manage their smoking, but half wanted to personally learn more about how to do so, and most would be willing to spend an extra 5 min to help reduce SHS exposure. Regarding training of fellows, the majority of programs currently provide information regarding the effects of cigarette smoking and complications, but not education in principles of tobacco control. Consistent with these results, the majority agreed or strongly agreed that formal education should be offered on SHS
Table 2 Current practices
How often do you: Primary smoke exposure Ask your pediatric patients if they smoke cigarettes? Advise your pediatric patients about the health risks of tobacco use? Advise your pediatric patients who smoke to quit? Provide resources to your pediatric patients to help them quit, such as educational materials or referral for nicotine dependence treatment? Secondhand smoke exposure Ask whether your pediatric patients are exposed to SHS? Ask the parents or guardians of your pediatric patients whether they (parent or guardian) smoke? Do you advise the parents or guardians about the health risks of SHS? If the parents or guardians smoke, do you advise them to quit? If the parents or guardians smoke, do you advise them to reduce their child’s SHS exposure? If the parents or guardians smoke, do you provide them with resources to help them quit or reduce SHS exposure?
Number of responses
Never or rarely (%)
Sometimes (
ORIGINAL ARTICLE
Tobacco control education in pediatric anesthesiology fellowships Shannon M. Peters, Christina M. Pabelick & David O. Warner Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
Keywords quality improvement; anesthesia; perioperative care; pediatrics Correspondence David O. Warner, Department of Anesthesiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA Email: [email protected] Section Editor: Jerrold Lerman Accepted 8 September 2013 doi:10.1111/pan.12277
Summary Background: Cigarette smoking and secondhand smoke exposure (SHS) increase the risk of perioperative complications. Traditionally, anesthesiologists have limited involvement in tobacco control. Objective: To develop and disseminate an educational curriculum that educates pediatric anesthesia fellows in tobacco control. Methods: After IRB approval, an online survey was disseminated to pediatric anesthesiology fellowship directors. Results: Thirty-one surveys were completed. Most report that they ask pediatric patients about tobacco use. A majority advise their patients who smoke about the health effects of smoking, but only 40% advise children to quit, and the majority never provide educational materials to assist in smoking cessation. Half reported that they sometimes or always ask about SHS. Approximately one-third never advise about the ill effects of SHS, nearly half never advise parents to stop smoking, and the majority never provide educational material about quitting to parents. Two-thirds felt that it is their responsibility to advise pediatric patients not to smoke, but less than half felt the same sense of responsibility about advising parents not to smoke. Approximately two-thirds believe that fellowship programs should provide education about the effects of smoking in the perioperative period and the effects of SHS exposure, but few programs do. Almost all would implement a free teaching module about SHS exposure and tobacco control as part of fellowship education. Conclusions: Many pediatric anesthesiology fellowship directors agree that exposure to cigarette smoke adversely impacts patients in the perioperative period, but few participate in tobacco control, and issues germane to tobacco control are not consistently addressed.
Introduction Cigarette smoking continues to be a major healthrelated burden in the United States. The use of tobacco products is typically initiated during adolescence (1), so that prevention and early intervention are imperative. Each day, nearly 4000 children below the age of 18 smoke their first cigarette and a quarter of those become daily cigarette smokers (2). In addition, approximately 25% of children are exposed to secondhand smoke (SHS) (3), which has significant deleterious effects on their health (4,5). In the perioperative period, exposure to SHS increases the frequency of respiratory events © 2013 John Wiley & Sons Ltd Pediatric Anesthesia 23 (2013) 1213–1218
during and after anesthesia (6–9), and contributes to the pathogenesis of asthma and other conditions that may increase perioperative risk. Among medical specialists, anesthesiologists have had a limited role in tobacco prevention and control. However, given the deleterious effects of tobacco smoke on perioperative outcomes in both children and adults, and the potential for the surgical experience to motivate behavioral change, there has been increased interest in exploring the potential role of anesthesiologists in tobacco use interventions (10). Simple intervention strategies, such as the 5-A’s (ask, advise, assess, assist, and arrange for follow-up) and ‘AAR’ (ask, advise, and 1213
S.M. Peters et al.
Tobacco control education in fellowships
refer), performed by anesthesiologists on or before the day of surgery have been useful tools for intervention (11,12). In the former strategy (5-A’s), clinicians themselves provide five evidence-based interventions shown to be efficacious. In the later strategy, AAR provides advice to quit smoking then refers patients to resources such as tobacco treatment programs or telephone ‘quitlines’ (such as 1-800-QUITNOW). The American Society of Anesthesiologists also has a stop smoking initiative that aims to disseminate information to anesthesiologists that help patients maintain perioperative abstinence.1 To date, these efforts have been directed toward adult smokers, but there may also be significant opportunities to address tobacco exposure in pediatric patients undergoing surgery and other procedures, both smoking by the patients themselves and exposure to secondhand smoke. For example, parents who smoke are more likely to make a quit attempt smoke if their child undergoes a surgical procedure (13). One method of exploiting such opportunities would be to include tobacco control curriculum in the fellowship training programs of pediatric anesthesiologists. Our overall objective is to explore the development and dissemination of a curriculum to educate pediatric anesthesiology fellows about how exposure to tobacco smoke affects their patients and how pediatric anesthesiologists can participate in perioperative tobacco control efforts. As an initial step, this formative survey-based study of the directors of pediatric anesthesiology fellowship programs aimed to determine current curriculum regarding tobacco use and control. It further explored the attitudes and beliefs of fellowship program directors regarding perceptions of risk, responsibility, and barriers to communication about environmental smoke exposure in perioperative patients, as these individuals would be key to implementing a tobacco control curriculum. Materials and methods This study was approved by the Mayo Clinic Institutional Review Board. Procedures and participants Program directors (PD) of ACGME-accredited pediatric anesthesiology fellowship programs were identified (n = 46). An introductory email was sent to each PD inviting participation and including a link to a web-based survey instrument (Survey Monkey, www. surveymonkey.com). A reminder email was sent to each PD after 2 weeks. 1
www.asahq.org/stopsmoking, accessed May 22, 2013.
1214
Table 1 Respondent demographics and practice characteristics
Characteristics
Number (%) (N = 31)
Years in practice since completion of training? 5 years or less 2 (7) 6–10 years 4 (13) 11–20 years 14 (45) 21 years or more 11 (35) How often do you see pediatric patients preoperatively prior to the day of surgery? Always 3 (10) Almost always 2 (6) Sometimes 21 (68) Never 5 (16) How often do you see pediatric patients postoperatively? Always 5 (16) Almost always 13 (42) Sometimes 12 (39) Never 1 (3) Age 31–40 4 (13) 41–50 11 (36) 51–60 15 (48) 61 or older 1 (3) Gender Male 16 (52) Female 15 (48) Cigarette smoking status Never smoked 26 (84) Former smoker 5 (16) Current smoker 0 (0) Fellows in program 16 0 (0)
Survey Survey items were generated based primarily on prior surveys of anesthesiologists from our investigative group (14–16) and assessed the following areas. Demographics These items included the characteristics of the PDs themselves, the frequency and preoperative contact with patients prior to surgery and after surgery, and practice characteristics. Current practices These items included questions regarding both the current approaches of the PDs to smoking by pediatric patients who themselves require anesthesia care, and their approach to pediatric patients who are exposed to SHS and require anesthesia care. Items queried the frequency with which PDs incorporated elements of © 2013 John Wiley & Sons Ltd Pediatric Anesthesia 23 (2013) 1213–1218
S.M. Peters et al.
Tobacco control education in fellowships
current practice guidelines regarding clinician provision of tobacco interventions (17) (e.g., asking about tobacco use or SHS exposure, advising patients to quit or to reduce their child’s SHS exposure, assisting them in quitting or reducing SHS exposure, etc.). Attitudes and beliefs These items included those related to perceptions of risks from tobacco and benefits of reducing tobacco exposure, perceptions of barrier to intervening, and interests in learn about how to intervene. Educational practices/needs These items included what tobacco use and control education was currently offered as a part of fellowship training, and perceptions of what curriculum should be offered, including use of web-based resources. Results Of the 46 PDs contacted, 31 (67%) responded to the survey. Table 1 presents their demographic and practice characteristics. Regarding their current practices, a minority of respondents reported always or almost always asking about smoke exposure (primary or secondhand) or advising patients or their caregivers to reduce exposure (Table 2). Very few provided any type of assistance with
quitting or mitigating SHS exposure. Nonetheless, a strong majority agreed or strongly agreed that SHS exposure is of clinical significance and that reducing exposure would reduce perioperative complication rates, indicating an awareness of the issue (Table 3). A majority agreed or strongly agreed that it was part of their responsibility to advise patients and parents to quit and reduce SHS exposure, respectively. Regarding assistance, there was greater enthusiasm for helping parents reduce SHS exposure than for helping pediatric patients get assistance to quit. Regarding barriers to intervention, the majority of respondents were unsure if efforts in general to reduce SHS exposure could be effective (Table 3). However, only a minority agreed or strongly agreed with four statements regarding specific putative barriers to intervention (efficacy, time, patient or parental anxiety, and adverse parental reactions). Less than a quarter of respondents agreed that they knew how to help their patients manage their smoking, but half wanted to personally learn more about how to do so, and most would be willing to spend an extra 5 min to help reduce SHS exposure. Regarding training of fellows, the majority of programs currently provide information regarding the effects of cigarette smoking and complications, but not education in principles of tobacco control. Consistent with these results, the majority agreed or strongly agreed that formal education should be offered on SHS
Table 2 Current practices
How often do you: Primary smoke exposure Ask your pediatric patients if they smoke cigarettes? Advise your pediatric patients about the health risks of tobacco use? Advise your pediatric patients who smoke to quit? Provide resources to your pediatric patients to help them quit, such as educational materials or referral for nicotine dependence treatment? Secondhand smoke exposure Ask whether your pediatric patients are exposed to SHS? Ask the parents or guardians of your pediatric patients whether they (parent or guardian) smoke? Do you advise the parents or guardians about the health risks of SHS? If the parents or guardians smoke, do you advise them to quit? If the parents or guardians smoke, do you advise them to reduce their child’s SHS exposure? If the parents or guardians smoke, do you provide them with resources to help them quit or reduce SHS exposure?
Number of responses
Never or rarely (%)
Sometimes (
