CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Health Disparities in Use and Exposure: A Structural Competency Approach Jyothi Marbin, MD, FAAP,a Sophie J. Balk, MD, FAAP,b Valerie Gribben, MD, FAAP,a Judith Groner, MD, FAAP,c SECTION ON

Fourteen percent of US adults use tobacco products. Because many of those abstract who use tobacco are parents and/or caregivers, children are disproportionately exposed to tobacco smoke. People who use tobacco aUniversity of California, San Francisco, San Francisco, California; products often become addicted to nicotine, resulting in tobacco dependence, bAlbert Einstein College of Medicine and Children’s Hospital at c a chronic, relapsing disease. Tobacco use and exposure are more likely to Montefiore, Bronx, New York; and College of Medicine, The Ohio State University and Nationwide Children’s Hospital, Columbus, Ohio occur in vulnerable and marginalized groups, including those living in poverty. Although some view tobacco use as a personal choice, evidence suggests that Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external structural forces play an important role in tobacco uptake, subsequent reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the nicotine addiction, and perpetuation of use. Viewing tobacco use and tobacco organizations or government agencies that they represent. dependence through a structural competency lens promotes recognition of Dr Marbin framed the overriding theme of the manuscript, the larger systemic forces perpetuating tobacco use, including deliberate conceptualized the manuscript, wrote a significant amount of content for the manuscript, and reviewed the manuscript; Drs Balk, Gribben, targeting of groups by the , lack of enforcement of age-for- and Groner conceptualized the manuscript, wrote a significant amount sale laws, inferior access to health insurance and health care, poor access to of content for the manuscript, and reviewed the manuscript; and all authors approved the final manuscript as submitted. cessation resources, and economic stress. Each of these forces perpetuates The guidance in this report does not indicate an exclusive course of tobacco initiation and use; in turn, tobacco use perpetuates the user’s adverse treatment or serve as a standard of medical care. Variations, taking health and economic conditions. Pediatricians are urged to view family into account individual circumstances, may be appropriate. tobacco use as a social determinant of health. In addition to screening All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, adolescents for tobacco use and providing resources and treatment of revised, or retired at or before that time. tobacco dependence, pediatricians are encouraged to systematically screen DOI: https://doi.org/10.1542/peds.2020-040253 children for secondhand smoke exposure and support family members who Address correspondence to Jyothi Marbin, MD, FAAP. E-mail: smoke with tobacco cessation. Additionally, pediatricians can address the [email protected] structural issues perpetuating tobacco use by becoming involved in policy and PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). advocacy initiatives. Copyright © 2021 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they do have no financial relationships relevant to this article to disclose.

BACKGROUND To cite: Marbin J, Balk SJ, Gribben V, et al.; AAP SECTION Tobacco use results in exposure to nicotine, a powerfully addictive ON TOBACCO CONTROL. Health Disparities in Tobacco Use substance, often leading to tobacco dependence. Tobacco dependence is and Exposure: A Structural Competency Approach. Pediatrics. 2021;147(1):e2020040253 considered a pediatric disease because most tobacco use and subsequent

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 147, number 1, January 2021:e2020040253 FROM THE AMERICAN ACADEMY OF PEDIATRICS addiction begin in adolescence.1,2 term SHS exposure is used, when counseling patients and Tobacco dependence is a chronic understanding that this designation caregivers who continue to smoke disease,3 and users are prone to may refer to both SHS and THS. despite discussions about relapse and remission.4 People who cessation15,16; however, pediatricians Although combustible tobacco use use tobacco suffer consequences, who gain a deeper understanding of has declined in the United States, including disease and premature structural factors perpetuating electronic (e-cigarette), death. Their children suffer from the tobacco dependence may be better vaping, or Juuling usage has direct impact of parental tobacco use, able to help families break the cycle accelerated, reaching epidemic including prenatal, secondhand of tobacco use. Viewing family proportions among youth12; more smoke (SHS), and thirdhand smoke tobacco use as a social determinant of than 20% of high school students (THS) exposure, as well as the health (SDH), systematically now vape.13 The American Academy economic and social consequences of screening for tobacco exposure, and of Pediatrics (AAP) policy statement family tobacco use. Most tobacco offering tobacco-dependence “E- and Similar Devices” users want to quit, and many make treatment to caregivers who smoke details the clear links between multiple quit attempts. People who are ways to overcome structural e-cigarette companies’ coordinated, smoke are more likely to quit when barriers to cessation. targeted advertising to youth and they receive treatment from Advocacy steps and policy changes subsequent rapid increase in clinicians.4 are also recommended to address e-cigarette initiation among youth. structural inequalities reinforcing Although the overall use of That report also highlights research tobacco use. combustible tobacco products is showing that adolescents and young declining,5 tobacco use and exposure adults who vape are 3.6 times more continue to affect marginalized* likely to progress to traditional STRUCTURAL ISSUES PERPETUATING populations disproportionately. These cigarettes than those who never DISPARITIES IN TOBACCO USE groups include people living in vaped, paving the way for new cycles poverty, people suffering from mental of addiction.14 Although it is clear Why Use a Structural Competency Framework? illness, and people with lower that e-cigarette use is rapidly educational attainment. Other groups changing the landscape of tobacco Although some see tobacco use as are highlighted in Table 1. The use and nicotine addiction, a personal choice among adult consequences of tobacco use and a comprehensive review of disparities informed decision-makers, looking at exposure are more concentrated in related to e-cigarette use is beyond tobacco use through a structural people already more likely to face the scope of this clinical report. This competency framework calls greater health and economic report will focus on disparities attention to the larger societal forces challenges.6 related to combustible tobacco, that lead people to use tobacco. The recognizing the need for a separate structural competency approach The same children who are exposed report on disparities related to frames health inequities “in relation to SHS are exposed to THS, or the e-cigarette uptake and use. to the institutions and social “residues left behind by smoking,” conditions that determine health which can include chemicals that This report proposes interventions to related resources” and is focused on “remain, react, re-emit, and/or are reduce disparities in combustible structural changes to address resuspended long after active tobacco use and exposure using upstream causes of health smoking ends.”11 Children are a structural competency framework. disparities.17 The structural uniquely exposed to THS because of Pediatricians treating children whose competency framework adds to the home exposure, dermal uptake from parents or other caregivers use SDHs approach by acknowledging crawling, and increased respiratory tobacco (and adolescents using that social injustice and power rates compared with adults. However, tobacco) are urged to offer consistent dynamics underlie health inequity.18 distinguishing health effects of THS cessation advice and tobacco- Although the structural competency from SHS is challenging. For the dependence treatment. Parents who approach is used in social work purpose of this clinical report, the have a primary care provider should and public health, it may be also be advised to seek additional a new paradigm for clinicians * The authors use the term “marginalized” to counseling and support from that focused on the care of individual include social groups that are intentionally clinician. If caregivers are unable to patients. excluded from mainstream society through social stop smoking, pediatricians should and political oppression. The authors recognize that it is the social processes (and not any advise maintaining smoke-free Many structural issues perpetuate 1 characteristic intrinsic to the people themselves) clothing, homes, and cars. tobacco initiation and use on both that lead to health disparities.104 Pediatricians may feel frustrated a global and domestic scale. The

Downloaded from www.aappublications.org/news by guest on September 24, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 1 Effects of Tobacco Use and Exposure on Marginalized Populations High-risk Groupa Smoking Rate Coexisting Challenges (Examples) Comments Black or African Black or African American people usually Black or African American people are more Black or African American children and adults American people7 smoke fewer cigarettes and start smoking likely to die of smoking-related diseases are more likely to be exposed to SHS than at older ages compared with white people. than are white people. other racial or ethnic groups. Hispanic peopleb Cigarette smoking prevalence generally is Acculturation plays a role: smoking prevalence Current prevalence is higher among Puerto Rican lower than for most other US racial or is higher among Hispanic people born in the adults compared with Cuban, Mexican, and ethnic groups, but rates are significantly United States. Central or South American adults. higher for men compared with women. Immigrants and Smoking rates among immigrants to the Smokers from these groups have vulnerability Research is limited because studies have been refugeesc United States (especially female compounded by economic disadvantage, focused mainly on Mexican, other Hispanic, immigrants) generally are lower than preimmigration experiences, attitudes and Asian populations. More research is rates in US populations. toward smoking, and sociocultural and/or needed to investigate tobacco exposure in language barriers influencing access to these and other immigrant populations. care, including . Incarcerated peopled Smoking prevalence is approximately 4 times Characteristics often found in individuals who The United States has the highest rate in the higher in criminal justice populations than are incarcerated, (eg, history of substance world of incarcerating adults. People of racial in the general population. abuse, mental illness, poverty, low and ethnic minority groups are educational attainment) also increase disproportionately affected; Black men are likelihood of tobacco use. incarcerated at higher rates than non- Hispanic white men and Hispanic men. LGBTQ peoplee Of lesbian, gay, and bisexual adults, 20.5% Gay men have high rates of HPV infection; The tobacco industry targets LGBTQ individuals. smoke cigarettes, versus 15.3% of straight coupled with tobacco use, this increases adults; 30.7% of transgender individuals risk for anal and/or other cancers; LGBTQ smoke. individuals are less likely to have health insurance, which may affect cessation treatment options. American Indian The American Indian population has the More American Indian women smoke during Some American Indian populations use tobacco peoplef highest cigarette smoking rates compared the last 3 mo of pregnancy compared with for religious, ceremonial, or medicinal with other US racial or ethnic groups. all other groups. reasons. It is important to distinguish traditional versus commercial use. In addition, casino smoke exposure is difficult to regulate because of jurisdictional issues on reservations. People of low Adults below the poverty level are There are higher lung cancer rates in those Low-income neighborhoods have a higher socioeconomic approximately 2 times more likely to use living in poverty compared with affluent concentration of tobacco retailers. statusg cigarettes, cigars, and smokeless tobacco groups; there is also less access to health as adults who live at greater than twice care; therefore, tobacco-related conditions the poverty level. are diagnosed at later stages. People with mental Approximately 25% of US adults have some People with mental illness more likely to have The tobacco industry perpetuates idea that it is illness and form of mental illness or substance use stressful living conditions, have low annual impossible for these individuals to stop substance use disorder; these adults consume household income, and have inferior access smoking. disorders8 approximately 40% of all cigarettes to health insurance, health care, and help smoked by adults. with quitting. People living in Tobacco Twenty-two percent of Tobacco Nation’s adults Residents of Tobacco Nation earn 20% less Compared with the rest of the country, Tobacco Nation9 smoke, compared with 15% of adults in the than those in the rest of the United States. Nation has fewer smoke-free laws and rest of the United States. Those in Tobacco There are 12% fewer doctors in Tobacco tobacco-control policies, measures which have Nation smoke many more cigarettes per Nation, meaning that accessing primary been proven to protect the public, deter youth capita annually (66.6 packs) than those in care can be more challenging. smoking, and encourage cessation. the rest of the United States (40.6 packs). People living in rural The prevalence of cigarette smoking among The health of people living in rural areas is Adolescents in rural regions begin smoking communities10 US adults is highest among those living in affected by tobacco more than the health of cigarettes earlier in life. Thirty-five percent of rural areas (28.5%). those living in urban and metropolitan children in rural areas live in a household areas, in part because of socioeconomic where someone smokes. factors and lack of health care options. HPV, human papillomavirus. a These groups may not represent all of the high-risk groups. See text for other examples. b Centers for Disease Control and Prevention. Burden of cigarette use in the U.S. Available at: https://www.cdc.gov/tobacco/campaign/tips/resources/data/cigarette-smoking-in-united- states.html#by_race. Accessed November 17, 2020. c Bosdriesz JR, Lichthart N, Witvliet MI, Busschers WB, Stronks K, Kunst AE. Smoking prevalence among migrants in the US compared to the US-born and the population in countries of origin. PLoS One. 2013;8(3):e58654. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3592805/. Accessed November 17, 2020. d Valera P, Reid A, Acuna N, Mackey D. The smoking behaviors of incarcerated smokers. Health Psychol Open. 2019;6(1):2055102918819930. Available at: https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC6328956/. Accessed November 17, 2020. e Centers for Disease Control and Prevention. Lesbian, gay, bisexual, and transgender persons and tobacco use. Available at: https://www.cdc.gov/tobacco/disparities/lgbt/index.htm. Accessed November 17, 2020. f Centers for Disease Control and Prevention. American Indians/Alaska Natives and tobacco use. Available at: https://www.cdc.gov/tobacco/disparities/american-indians/index.htm. Accessed November 17, 2020. g Centers for Disease Control and Prevention. Cigarette smoking and tobacco use among people of low socioeconomic status. Available at: https://www.cdc.gov/tobacco/disparities/low- ses/index.htm. Accessed November 17, 2020.

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 147, number 1, January 2021 3 tobacco industry aggressively targets Structural Barriers: The Tobacco Lesbian, gay, bisexual, transgender, vulnerable and marginalized groups, Industry and queer (LGBTQ) individuals are including children. People who smoke Targeting vulnerable populations is a focus of targeted campaigns, likely often have poor access to health a well-established tactic used by the contributing to higher smoking rates insurance and health care, lack access tobacco industry to recruit new compared with non-LGBTQ to cessation resources, and live in smokers and maintain current individuals. In 1992, a tobacco “ poverty, all of which, in addition to smokers. Children, the most industry memo stated, We see the other factors, perpetuate tobacco use vulnerable group, have long been gay community as an area of … and dependence. The lack of effective targeted and tasked to serve as opportunity. Philip Morris would fi fi enforcement of age-for-sale laws “replacement smokers” by the be one of the rst (if not the rst) means that too often youth have tobacco industry.21 The rapidly tobacco advertiser in this category ‘ ’”26 unregulated access to tobacco developing adolescent brain is and would thus own the market. 19,20 products. Tobacco dependence uniquely susceptible to nicotine The tobacco industry subsequently and exposure reinforces existing addiction,22 and 90% of adults who began advertising in publications health disparities, and these health smoke started smoking before 19 aimed at the LGBTQ community and fi disparities perpetuate tobacco years of age,23 thus giving tobacco nancially supporting LGBTQ 27 dependence, creating a cycle of companies great incentive to recruit organizations. intergenerational tobacco youth smokers. Documents reveal Black and African American youth dependence, poverty, and poor health that the tobacco industry has clearly and adults have been systematically (Fig 1). Pediatricians can continue to recognized this opportunity. Philip targeted through advertisements, ’ engage and support individuals in Morris executives noted, "Today s retailers, and promotion of menthol ’ cessation attempts while also teenager is tomorrow s potential products. More tobacco ”24 recognizing and addressing economic, customer... The 2014 US Surgeon advertisements are found in ’ social, and political structures that General s report acknowledged that communities with a higher density of “ reinforce tobacco dependence and the root cause of the smoking Black and African American residents. exposure. Adding a structural epidemic is evident: the tobacco In these communities, Black and competency approach to individual industry aggressively markets and African American youth have been clinical interventions will help promotes lethal and addictive recruited to smoke through pediatricians recognize and products, and continues to recruit advertising and the distribution of address some of the structural youth and young adults as new free cigarette samples.28 The ”2 factors promoting tobacco consumers of these products. proportion of Black and African dependence and will allow Although tobacco companies deny American smokers who use menthol pediatricians to push back against intentional marketing to children, cigarettes increased from 5% in 1952 a cycle of addiction and disadvantage they continue to advertise tobacco in to 89% in 2011, likely because of 25 that reinforces its use. outlets designed to reach children. aggressive racial targeting by the industry. Between 1998 and 2002, Ebony magazine, a monthly publication with a large Black and African American readership, was nearly 10 times as likely to contain ads for menthol cigarettes as People magazine, which has a larger readership among white Americans.29 This targeted advertising has contributed to nearly 90% of Black and African American smokers using menthol cigarettes, which are more addictive and more harmful than nonmenthol cigarettes.7 American Indian and Alaskan native people are also subject to predatory FIGURE 1 targeting by the tobacco industry. Tobacco use and exposure reinforce existing health disparities, and these health disparities per- Tobacco companies exploit the petuate tobacco use. federal exemptions that accompany

Downloaded from www.aappublications.org/news by guest on September 24, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS the unique sovereign status of tribal Nation”9: Alabama, Arkansas, Indiana, noted that “tobacco surcharges lands to increase their own economic Kentucky, Louisiana, Michigan, increased neither smoking cessation profit, using tactics such as Mississippi, Missouri, Ohio, Oklahoma, nor financial protection from high promotional coupons, price Tennessee, and West Virginia. health care costs.”37 Without health reductions, giveaways, and insurance, tobacco users may have 30 The industry also cultivated sponsorships. Tobacco companies relationships with organizations limited access to care for smoking- employ manipulative strategies to working with people with mental related illnesses as well as less access exploit sacred use of tobacco. For illness and funded research to to tobacco-dependence treatment. example, the Santa Fe Natural encourage the erroneous ideas that The treatment they can access may be Tobacco Company, now owned by R.J. cessation is too stressful for people inadequate, for example, providing “ Reynolds, produced an exclusive line with mental illness and that people limited medication only for a limited of authentic reproductions of Native with mental illness need to self- period of time. Such regressive American pipes, snuff containers, medicate with nicotine to relieve policies do little to treat nicotine tobacco pouches, and other natural negative moods.8 addiction as a chronic illness; instead, tobacco implements.”31 These and they limit access to treatment for other tactics are believed to Tobacco companies use targeted people who are addicted to contribute to the disproportionate marketing strategies because they are nicotine.36 burden of tobacco-related disease in incredibly effective in recruiting 30 smokers. As “big tobacco” and “big Life insurance is also more expensive Indigenous populations. 38 vaping” become increasingly for people who smoke, which Since the 1920s, women have been entwined,33 a resurgence of these affects the ability of those who smoke, targeted through appealing tobacco advertising tactics aimed at attracting who have a higher mortality rate from advertising that gave them perceived youth to e-cigarettes has been numerous health problems, to psychosocial needs around weight observed. Pediatricians need to be provide financial security for their loss, independence, stress relief, and aware of this targeted advertising and survivors, including minor children or 32 the need to escape. As smoking its impact on vulnerable grandchildren, in the event of their rates for increasingly educated populations.34 demise. women started to decrease, targeting of low-income women increased, with Structural Barriers: Decreased Structural Barriers: Employment significant resources devoted to Access to Insurance Challenges understanding the psychological Structural barriers maintain Discrimination in employment is profiles of potential customers.32 R.J. intergenerational smoking by another example of a structural Reynolds Tobacco Company reinforcing economic disparities and barrier. Cross-sectional studies have attempted to distribute coupons for limiting access to tobacco- consistently demonstrated an packs of cigarettes in envelopes with dependence treatment. association between smoking and foods stamps. Coupons were for Access to health insurance is one unemployment.39 A 2006–2007 study individual packs, not cartons, because example. In more than 40 states, of more than 52 000 construction “the lower-income groups tend to buy people who smoke can be charged workers found that those who single packs.”32 higher insurance rates than those smoked were more likely to be People living in rural areas are also at who do not smoke35; in some states, unemployed than those who did not higher risk of smoking and tobacco- these rates can be up to 25% higher smoke.40 In one study of unemployed related disease. Rural adolescents than rates for nonsmokers.36 People job seekers, people who smoke were start smoking earlier and are more from marginalized groups are already found to be less likely to be likely to be daily smokers than much less likely to have health reemployed after 1 year than those adolescents living in nonrural areas. insurance; raising premiums for who did not smoke and were paid Young rural men have historically people who smoke makes health less when they were rehired.39 The been targeted through tobacco insurance even harder and more cost of hiring someone who smokes is advertisements featuring cowboys, expensive to obtain. In a 2016 study, estimated at nearly $6000 more than hunters, and other “rugged images.” authors examined the impact of the cost of hiring a nonsmoker,41 Antitobacco media are less likely to tobacco surcharges on insurance meaning that some employers simply reach youth living in rural areas.10 coverage and cessation among people refuse to hire people who smoke.42 This targeting contributes to higher who smoked and found that smokers Those who are living in poverty, are rates of tobacco use and lower life were 7.3% less likely to have health unemployed, and have less formal expectancies in the 12 contiguous insurance coverage than education are more likely to use states collectively known as “Tobacco nonsmokers.37 The authors also tobacco. Refusing to employ smokers

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 147, number 1, January 2021 5 effectively restricts access to jobs and INTERGENERATIONAL FACTORS increased risks of obesity, behavioral ensures that people who smoke PERPETUATING DISPARITIES problems, conduct disorder, remain at an economic attention-deficit/hyperactivity Smoking Rates During Pregnancy Are disadvantage.43 disorder (ADHD), and cognitive Higher in Marginalized Groups – issues in children.53 59 Recent Smoking during pregnancy is a risk research has revealed a dose- Structural Barriers: Missing Work factor for perpetuating response relationship between and School intergenerational health disparities. maternal cotinine concentrations Adding to the economic burden is Data from the Pregnancy Risk (indicating nicotine exposure) hardship caused by missed work Assessment Monitoring System reveal during pregnancy and presence of because of caregiver or child that although prevalence of maternal ADHD in children.60 These illness. Children are more likely to smoking during pregnancy declined associations remain even after be absent from school if their significantly between 2000 and controlling for confounding factors, 49 caregiver smokes,44 meaning 2010, differences in prevalence by such as maternal income and caregivers may have to miss work race and/or ethnicity persist. In 2010, education and maternal and paternal to care for their sick child. The smoking during pregnancy was ADHD diagnoses, and are linked to cost of missing work to care for highest among American Indian poor health and lower educational a sick child can be high; caregivers women (26.0%), followed by non- attainment. The research cited here lose an estimated $227 million Hispanic white women (14.3%), non- has been conducted internationally per year caring for ill children,44 Hispanic Black women (8.9%), (United States, Canada, and Europe), which reinforces economic Hispanic women (3.4%), and Asian so it does not reflect a particular disparities. Repeated school American and/or Pacific Islander geographic confounding factor to 49 absences can hinder a child’s women (2.1%). Birth certificate data explain the association between school performance45 and, in for 2014 reveal that, overall, smoking during pregnancy and poor the long-term, may influence approximately 8.4% of women outcomes in children. Such career trajectory and earning smoked at any time during pregnancy. pregnancy exposure can be said to potential.44 Higher smoking rates during perpetuate disparities because pregnancy were observed in women children with behavioral, conduct, The cycle of health and economic with fewer than 12 years of education and learning issues are likely to have disparities among people who (14.1%), women with Medicaid amoredifficult time throughout the use tobacco is self-perpetuating; coverage (14.0%), women between 20 life span. The potential mechanisms adults who smoke who are unable and 24 years of age (13.0%), for adverse outcomes from prenatal to escape the cycle of addiction are unmarried women (14.7%), and non- smoking include direct effects of more likely to have children who Hispanic American Indian women nicotine, carbon monoxide, and other 46,47 50 smoke, giving rise to new (18.0%). Smoking during pregnancy tobacco toxicants on the developing generations addicted to nicotine and is associated with maternal fetal brain along with the potential susceptible to these same economic vulnerability: women who for fetal adaptation to an adverse hardships. experienced intimate partner violence prenatal environment, potentially were more likely to smoke during through epigenetic changes. pregnancy and less likely to stop Although epigenetic research is in Structural Barriers: Exposure in smoking.51 61 Child Care Settings the early stages, smoking-related epigenetic modifications of gene For young children, out-of-home child Smoking During Pregnancy transcription in specific cells may be care may represent a significant Perpetuates Disparities mechanisms by which the effects of portion of their day and a source of A large body of literature describes maternal smoking during pregnancy exposure, particularly for parents links between smoking during are transmitted to the next who have low incomes, do not speak pregnancy and short- and long-term generation.61,62 Further research will English, have lower educational health issues in offspring, including elucidate the epigenetic effects of levels, or are single parents. These increased infant mortality, sudden prenatal smoking on alterations in families are more likely to use unexpected infant death,52 low birth neural circuitry during fetal non–center-based care48 and weight, and respiratory problems. In development62 and may help instead may rely on child care addition to these detrimental establish mechanisms of the with less oversight, where children outcomes of exposure to smoking in relationships between prenatal may be more likely to be exposed utero, epidemiological observational smoking and poor behavioral and to SHS. evidence links prenatal smoking to cognitive outcomes in children.

Downloaded from www.aappublications.org/news by guest on September 24, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS Women who stop smoking during utero and during childhood sets increasing the challenge of addressing pregnancy are at risk for relapse after children up for poorer physical and them, but tobacco use in parents and birth, leading to SHS exposure in mental health throughout their lives, other caregivers is an SDH for which infants and children.63 Relapse may which leads to poor school there currently are effective and also perpetuate the cycle of beginning performance and may affect future actionable interventions. the next pregnancy with fetal job success and earning potential. exposure to maternal smoking. Effective Interventions for Tobacco Finally, parents who are addicted to Cessation tobacco may prioritize tobacco over SHS Exposure and Childhood Adults who smoke are able to achieve food and other basic needs,89–93 Disparities quit rates of more than 30% with exacerbating negative health Children’s SHS exposure is a combination of medication and outcomes for children. a socioeconomic and educational counseling from a primary care disparity4 that leads to differences in provider.96 The pediatric visit health outcomes. It can be difficult to OFFICE-LEVEL INTERVENTIONS FOR provides a unique opportunity for separate effects of prenatal smoking PEDIATRICIANS pediatricians to offer tobacco- and postnatal SHS exposure; several Pediatricians are well-positioned to dependence treatment to parents and of these outcomes, including sleep help break the cycle of tobacco caregivers because most young ’ problems (sleep-disordered dependence at both the individual parents see their children s breathing, sleep apnea, nighttime and structural levels. In this section, pediatrician more frequently than 64–67 awakenings) and sudden infant office-level interventions are they see their own health care 68–70 death syndrome, are linked to described. providers. Pediatricians can identify both prenatal smoking and postnatal children who are exposed to tobacco smoke exposure. Impaired sleep itself Screening for Tobacco Use and smoke and assist parents, caregivers, during childhood is linked to Exposure as SDHs and other household members who cognitive and behavior issues and want to stop smoking. 71–75 Tobacco use and exposure are SDHs poor quality of life. that contribute to a more difficult The AAP policy statement “Clinical Children exposed to SHS are more future for already marginalized Practice Policy to Protect Children likely to develop asthma, and their children, adolescents, and adults. from Tobacco, Nicotine, and Tobacco asthma is more severe than that in Pediatricians have embraced Smoke”1 clearly delineates nonexposed children.76–80 The screening and referral systems for mechanisms for screening for tobacco prevalence and severity of other SDHs (eg, food insecurity, use and exposure at each visit and bronchiolitis, acute otitis media, insurance access, mental health providing support to people who chronic otitis media, influenza, and concerns, housing insecurity, unstable smoke. This assistance may include preclinical cardiovascular employment) that connect families to connecting them to state quitlines changes81–88 is linked to childhood necessary resources.94,95 SDHs are (such as 1-800-QUIT-NOW) or SHS exposure. Smoke exposure in complex and often intertwined, cessation services and recommending

TABLE 2 AAP Policy Statements and Other Resources for Tobacco and E-cigarettes Resources for Decreasing Evidence Base for Tobacco E-cigarette and Vaping Advocacy and Policy Resources Social Justice Frameworks Tobacco Exposure at the Control Resources Individual Practice Level “Clinical Practice Policy to “Protecting Children From “E-Cigarettes and Similar “Public Policy to Protect “Health Disparities in Protect Children From Tobacco, Nicotine, and Devices” (AAP policy Children From Tobacco, Tobacco Use and Tobacco, Nicotine, and Tobacco Smoke” (AAP statement, 2019) Nicotine, and Tobacco Exposure: A Structural ” ” ” Tobacco Smoke (AAP policy technical report, 2015) Vaping, and Smoke (AAP policy Competency Approach “ statement, 2015) Nicotine and Tobacco as E-Cigarettes statement, 2015) (AAP clinical report, CEASE Resources Substances of Abuse in Presentation Toolkit Tobacco Prevention Policy Tool 2021) ” (Massachusetts General Children and Adolescents (Julius B. Richmond (Julius B. Richmond Center “The Impact of Racism on Hospital Web site) (AAP technical report, 2017) Center of Excellence of Excellence Web site) Child and Adolescent ” Pediatric Environmental Health Web site) Tobacco Education Resources Health (AAP policy manual (AAP policy manual, for Kids & Teens statement, 2019) 2018) (HealthyChildren.org) “Substance Use Screening, Brief Intervention, and Referral to Treatment” (AAP clinical report, 2016)

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 147, number 1, January 2021 7 or prescribing nicotine replacement Exposure (CEASE), a program for child’s clinic were more likely to quit therapy (NRT). This policy addresses clinicians designed to increase smoking.96,99 parameters for prescribing NRT to smoking cessation through brief parents, including potential liability, motivational interviewing, Social networks also affect disease assessment, risks versus a recommendation or prescription for smoking cessation. Smoking cessation fi 1 by a spouse, sibling, friend, or co- bene ts, and documentation. NRTs, and referral to cessation worker increases the chance that an helplines.97,98 CEASE has been shown There are many ways to help individual will also stop smoking.100 to increase tobacco-dependence caregivers cut down on or stop Therefore, it may be beneficial to ask smoking96; accessible resources are treatment offered by pediatric clinics; about other people who use tobacco available from the AAP (Table 2). One recent research has revealed within a tobacco user’s social network option for office practices is Clinical promising results that parents who and to suggest cessation resources for Effort Against Secondhand Smoke received CEASE interventions at their those people as well. In addition,

TABLE 3 Suggested Structural Interventions to Reduce Tobacco-Related Disparities Structural Intervention Rationale Comment End predatory targeting by the tobacco Tobacco companies target vulnerable and Regulating predatory marketing tactics used by industry marginalized groups. tobacco companies will protect children and other vulnerable groups and reduce tobacco initiation. Ensure basic health coverage for all Adequate health care would include the following: (1) Coverage also increases the likelihood that people access to evidence-based therapies for smoking with mental health problems who also smoke cessation, (2) early recognition and treatment of receive needed health services. tobacco use–related diseases, and (3) coverage for mental health services. Make funds for tobacco-dependence treatment Adequate tobacco-dependence treatment should be Tobacco taxes are a potential source of funding. available for people without insurance accessible to all. Advocate for employers to provide effective Tobacco-dependence treatment in the workplace may Efforts may thus reduce the burden of unemployment tobacco-dependence treatment to employees help workers stop smoking, stay in the workforce, on those already experiencing poverty. who smoke and gain a better economic footing. Incorporate smoking cessation for caregivers Caregivers often visit pediatric clinicians more Clinicians aware of structural issues may be more into pediatric visits frequently than their own clinicians, creating likely to understand counseling efforts as important opportunities to discuss tobacco use and interventions to address these issues. They may be need for cessation. more likely to use a chronic disease model and motivational interviewing techniques. Support reimbursement for clinicians treating Pediatricians should be compensated for time spent ICD-10 codes allow pediatricians to code for SHS caregivers who smoke; ensure consistent treating caregivers’ tobacco dependence.102 exposurea but not for time to assist caregivers with coverage for tobacco-dependence treatment Consistent payment by health insurers for health smoking cessation. risk assessments and preventive care counseling, already defined by CPT coding, and consistent health coverage of FDA-approved medications for tobacco-dependence treatment of household contacts,102 even when available over the counter, may improve cessation rates. Improve access to counseling and medications Greater access may improve referral rates to EHR systems also can be modified to allow opening by investing in streamlined referrals from counseling services; many quitlines provide free a linked medical record for the child’s caregiver. EHRs to smoking quitlines NRT to their users. This can facilitate documentation of pediatrician support given to the caregiver. Partner with schools to monitor absences; Children exposed to SHS are more likely to miss Strategies to help children stay on track educationally provide educational opportunities for school, impeding academic achievement. may help improve educational outcomes. children chronically absent because of illness Urge all child care centers to follow guidance For young children, out-of-home care may represent This guidance is provided by the National Resource about tobacco exposure a significant portion of their day and a source of Center for Health and Safety in Child Care and Early exposure—particularly for low-income parents Education in Caring for Our Children.103 who may rely on family day care with less oversight when it comes to these issues. Currently, even teachers in centers are often subject to the structural SDHs as they tend to be low wage workers as well. CPT, Current Procedural Terminology; EHR, electronic health record; FDA, US Food and Drug Administration; ICD-10, International Classification of Diseases, 10th Revision. a American Academy of Pediatrics. Tobacco/e-cigarettes use/exposure coding fact sheet for primary care pediatrics. Available at: https://downloads.aap.org/AAP/PDF/coding_factsheet_ tobacco.pdf. Accessed November 17, 2020.

Downloaded from www.aappublications.org/news by guest on September 24, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS tobacco users may be able to help be taught smoking cessation through generations. Pediatricians identify ways in which their social approaches by using a structural have opportunities to reframe their networks can support cessation. competency framework as part of the understanding of tobacco- advocacy curriculum required in dependence treatment to include pediatric residency training.101 both individual and structural EDUCATION AND TRAINING interventions. Viewing tobacco Evidence-based smoking cessation TOBACCO-RELATED ADVOCACY AND exposure as an SDH can help counseling techniques can be POLICY INTERVENTIONS pediatricians systematically identify and provide support to family integrated into curricula for medical Pediatricians are trusted members of members using tobacco. Framing students and residents so that trainees their communities and can play tobacco dependence through become familiar with behavioral and important roles in advocating for a structural competency lens and pharmacologic strategies to help policies to protect children from 1 supporting appropriate advocacy and people stop smoking. Trainees should tobacco use. Although policy actions can disrupt tobacco use learn that tobacco dependence is a comprehensive review of advocacy patterns and increase opportunities a chronic disease similar to other strategies is beyond the scope of this for children and their caregivers to chronic diseases that need consistent document, we encourage readers to live healthy, tobacco-free lives. treatment by clinicians. Important consult the resources available components of treatment include through the AAP (Table 2) for cessation medications approved by the advocacy and policy actions related LEAD AUTHORS US Food and Drug Administration, to tobacco use. Jyothi Marbin, MD, FAAP including the nicotine patch, gum, and Sophie J. Balk, MD, FAAP lozenge. E-cigarettes and similar Valerie Gribben, MD, FAAP devices should not be prescribed for STRUCTURAL INTERVENTIONS TO Judith Groner, MD, FAAP 13 REDUCE DISPARITIES tobacco-dependence treatment. Counseling and recommending or Larger systems that keep people in SECTION ON TOBACCO CONTROL EXECUTIVE prescribing NRT can be incorporated poverty need to change to address the COMMITTEE, 2018–2019 into their practice. Trainees who plan disparities that perpetuate tobacco Susan C. Walley, MD, FAAP to prescribe NRT for parents should use. Changing these systems may be Rachel Boykan, MD, FAAP review the guidelines described difficult because they have significant Judith Groner, MD, FAAP above.1 In addition, as part of their up-front costs and may threaten Brian P. Jenssen, MD, FAAP Jyothi Marbin, MD, FAAP curriculum, trainees can be educated existing power structures. These Bryan Mih, MD, FAAP ’ on big tobacco s history of deceptive, structural changes are discussed Nina L. Alfieri, MD, FAAP targeted marketing techniques and above; Table 3 includes several key Alice Little Caldwell, MD, FAAP encouraged to discuss potential recommendations. Actions taken by parallels with the current vaping pediatricians at local, state, and STAFF epidemic. Framing this information as federal levels can support these and Karen S. Smith a structural issue will make it clearer other initiatives aimed at addressing Colleen Spatz, MSBA to trainees that tobacco use and its structural barriers that perpetuate consequences are not uniformly intergenerational cycles of tobacco distributed in the population. dependence and health disparities. ABBREVIATIONS Including smoking cessation AAP: American Academy of counseling as part of pediatric CONCLUSIONS Pediatrics graduate medical education will help Tobacco dependence is a chronic, ADHD: attention-deficit/ trainees recognize that the most relapsing, addictive disease, and hyperactivity disorder effective way to treat children exposed tobacco use causes 480 000 deaths in CEASE: Clinical Effort Against to SHS (and to prevent the children the United States every year. Secondhand Smoke Exposure from using tobacco themselves) is to Structural barriers ensure that some e-cigarette: treat their caregivers. Regular marginalized groups initiate and use LGBTQ: lesbian, gay, bisexual, trainings in this area will increase tobacco at disproportionately high transgender, and queer workforce capacity to treat tobacco rates. Members of these groups NRT: nicotine replacement therapy dependence in families, which will continue to experience health and SDH: social determinant of health decrease structural barriers to economic disparities because of SHS: secondhand smoke smoking cessation and eventually help tobacco dependence, which, in turn, THS: thirdhand smoke improve child outcomes. Trainees can perpetuate tobacco dependence

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 147, number 1, January 2021 9 This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 147, number 1, January 2021 13 Health Disparities in Tobacco Use and Exposure: A Structural Competency Approach Jyothi Marbin, Sophie J. Balk, Valerie Gribben, Judith Groner and SECTION ON TOBACCO CONTROL Pediatrics 2021;147; DOI: 10.1542/peds.2020-040253 originally published online December 21, 2020;

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