2007 Model Practice Application (Public)

Nurses' Secondhand Smoke Education Initiative

Suffolk County Department of Health Services, Office of Health Education

Nurses’ Secondhand Smoke Education Initiative trains ER and clinic nurses to provide a medical intervention when children present with illnesses consistent with exposure to secondhand smoke. The goal of the program is to reduce or eliminate entirely the exposure of children to secondhand smoke, also known as Environmental Tobacco Smoke (ETS). ETS contains over 4,000 chemicals, over 40 of which are known to cause cancer in humans and it is a class A carcinogen. It is identified as a cause and risk for SIDS, and over 1 million asthma attacks in children each year. Children exposed to ETS on a daily basis have more than triple the risk of developing lung cancer as adults. ETS exposure is responsible for between 700,000 and 1.6 million doctor’s visits each year for middle ear infections, it intensifies a child’s allergic reactions which can last up to 4 days after exposure, and is responsible for about 15,000 hospitalizations of children and over 200 deaths per year. ETS exposure is a cause of breast cancer in young women before the age of menopause (age 50). This practice intends to provide an opportunity for a medical intervention when a child presents at a hospital emergency room or urgent care center, with symptoms consistent with exposure to ETS.

Specially trained ER nurses, PAs, physicians etc. would provide a medical intervention at a time when a parent or caregiver is seeking care for symptoms consistent with exposure to ETS would be the appropriate venue for this initiative. Research has shown that even a brief 2-3 minute intervention by a trusted health care provider who discusses a patient’s need to alter their smoking behavior is sufficient to begin the process to change behavior. And so, program staff felt that by having a trusted health care provider, such as nurses in the ER, discuss with a child’s parents or caregivers, the need to eliminate exposure to ETS at the moment a child is diagnosed with illness consistent with exposure to ETS, would be an appropriate time to introduce this intervention.

One of the goals is to change attitudes, knowledge, and behaviors of parents and caregivers who smoke around children. Program staff have received anecdotal reports from ER nurses and physicians as well as clinic staff who have indicated their success in using this initiative as a teaching tool for parents. One of the positive outcomes has been reported by the ER nurses in so far as they have reported feeling more empowered in their ability to relate to parents the seriousness and health risks of ETS exposure especially when children are presenting in the ER on numerous occasions with the recurring symptoms.

The public health issue addressed is the rising numbers of children seen in ERs and physician’s offices with severe respiratory illness, newly emerging and exacerbated cases of asthma and other respiratory diseases. These children are often seen on a recurring basis, sometimes 3-4 times a month for the same illness. There are a number of children whose illness are clearly caused or probably caused by consistent exposure to secondhand smoke. The goal is to provide a medical intervention by a trusted health care provider (nurse) at the time a parent or caregiver seeks medical treatment for that child. Most parents should be willing to listen to a trusted member of the health care community when discussing their child’s diagnosis, treatment options, and follow up care. The sheer numbers of children who become sick as a result of exposure to ETS and the fact that those illnesses are 100% preventable determined that this was a good initiative upon which the program should focus. Since the intervention involves determining a parent/caregiver’s attitudes, knowledge, and behavior regarding exposure to ETS, program staff felt that a medical intervention presented at the moment a parent seeks care for a child who is sick as a result of probable exposure to ETS would be the most appropriate time and place to address this issue.

This intervention is new to the field of public health as the program utilizes ER nurses and nurses in clinical-urgent care facilities. In developing this initiative, ER nurses were brought into the development process to assist program staff in focusing on real, doable tasks and not to overload the nurses. Nurses in the ER are now more empowered to provide a medical intervention and help their patients not only learn about the serious risks of children’s exposure to ETS, but they are able to help impact their patient’s attitudes, knowledge and subsequent behavior based upon their discussions in the ER and the real consequences their smoking has upon their children. This practice differs from other methods of educating the public about the dangers of secondhand smoke as it is a direct, medical intervention. Unlike most public information campaigns and public health promotions, this is not a public campaign. It is a one-on-one medical intervention, targeted to those who present with illnesses consistent with exposure to ETS and to parents and caregivers of those children. Time and financial resources are spared when only those who need this intervention receive this care.

The Suffolk County Department of Health Services Office of Health Education’s role was to reach out to influential community organizations (in this case the local Kiwanis Clubs of the Suffolk East Division), and educate them about the need to provide public education, have a mission statement under which they function. That mission statement is "Serving The Children of The World, One Child At A Time". The initiative and concept was embraced by the clubs at the club level and the Division level and they were and are enthusiastic in their support. A public information campaign was provided for each club about ETS and its dangers and the need for a program and the funding they could provide for this initiative. In turn, each club sent a representative to each of the hospital trainings for introductions and photos which are then sent to local newspapers. This reinforces the importance of the initiative and the support and hard work of the Kiwanis members.

The local Kiwanis Clubs and the local Tobacco Control Coalition contributed a total of $7,000 for the initiative. Some of the individual members contributed in-kind services such as reduced costs for printing, free storage of workbooks, etc. Since the workbook is now available online at the Kiwanis website, it can be downloaded and printed by anyone who wants to reproduce it and use it for their intervention. Suffolk County Department of Health Services’ Office of Health Education is available for any questions any health care entity or organization may have regarding implementation of this initiative.

The initiative began with the development of the workbook, which targets 4 different populations: children, parents, caregivers and extended family & friends. It was also produced in Spanish as well. The workbook was designed for ages 5-11 and the information is redundant in its presentation throughout. A CD rom was also developed as a training module which is used during the training of the ER nurses at the various hospitals and is left with the ER manager who can then conduct review training as needed. The workbook was developed by the Suffolk County Department of Health Services, Office of Health Education, Director of Public Information. It is printed in color and as such would be expensive to print in quantity. However, Kiwanis Clubs International Suffolk East Division and the local tobacco control coalition contributed over $7,000 for printing and distribution of the workbooks. Training takes place at the local hospitals ER at a pre-arranged time. Workbooks are distributed at the training and a quantity of both English and Spanish workbooks are left with the ER staff who can then implement the intervention when needed. The greatest investment was time. Time spent researching and developing the workbook and CDrom, time presenting the program to the various Kiwanis Club members, time spent reaching out to the various hospitals and securing their interest and commitment to be trained in the program. Once trained however, all of the hospitals and health care clinics have been extremely positive and thrilled about the opportunities presented by this program. At the introduction of the presentations, it is stressed to the medical staff that the program is not teaching medicine, but rather reinforcing and adding to the fund of knowledge they already have as medical practitioners. The program provides them with additional, up-to-date science, to help them provide the best care possible for their patients.

Now that the booklets are published and printed, they are available online and can be printed at will. The local Kiwanis Clubs have offered this workbook for all Kiwanis Divisions to replicate if they so desire. Since the most labor intensive portion of the initiative was the development of the workbook and the CD rom, the initiative is easy to replicate at will. It can be sustained by virtue of the fact that the workbook is available online and can always be printed as well as the CDrom. It can be used at the discretion of a hospital’s ER staff. The cost can be controlled by how the workbooks are reprinted. They can be printed by a professional printer for about $1 a copy or downloaded and printed on a computer printer in color or black and white. Color is preferred as children are more attracted to color and more likely to complete the workbook.

The goal of this practice is to reduce the numbers of children exposed to ETS by educating parents and caregivers of the serious health consequences of exposure to secondhand smoke. The initiative is looking to change attitudes, knowledge, and behavior of parents and caregivers who bring in children to the ER with illnesses consistent with exposure to ETS.

Objective 1: To provide a medical intervention when a child is brought into the ER with illnesses consistent with exposure to ETS.

Performance Measures: The program has trained over 2,000 medical personnel in local hospitals, clinics, and correctional facilities.

Objective 2: To educate parents and caregivers about the dangers of exposure to secondhand smoke.

Performance Measures: Nurses’ anecdotal reports of their interventions with parents and caregivers.

In order for this initiative to be successfully replicated, one would need a source of funding to purchase the workbooks, have a community organization or health department willing to reach out to local hospitals and health care community that services children, and have staff trained in the initiative. The initiative itself is fairly simple and straight forward. It involves the personal training of Emergency Room nurses,& PAs. Nurses were identified as the most likely to be able to provide this intervention as they spend the most amount of time with the patients in the ER and do the patient education and discharge planning. The timeframe for these tasks would be up to the individual community or county that wanted to undertake this initiative. It would be just a matter of having health department staff trained in the initiative, reaching out to the local hospital administration and getting them on board to receive a FREE training program along with FREE workbooks, and then scheduling the training in those various hospitals. It could be done in accordance with the local health department’s schedule and staff needs.