Massachusetts Department of Public Health, Tobacco Cessation and Prevention Program

Second- and Thirdhand Smoke Training

This is the online version of a training that was developed for clinicians in home visiting programs. The content is also applicable for staff of other human service organizations.

The training was developed by the Institute for Health and Recovery’s Smoke-Free Families Initiative and funded by the Massachusetts Tobacco Cessation and Prevention Program (MTCP).

www.healthrecovery.org/trainings/sff

This online training has been updated in September 2019.

Getting Started

• This Second-and Thirdhand Smoke Training should take about 1.5 hours to complete.

• Before viewing this online training, be sure to download and/or print the Smoke-Free Families Handouts. Visit www.healthrecovery.org/trainings/sff to download the packet.

• If you have any difficulty downloading the packet or have questions, please contact the Institute for Health and Recovery at 617-661-3991.

• As you navigate through this training, remember to view the handouts that accompany each slide (listed in green).

• At the end of this training, you will be asked to complete a short quiz and evaluation. You will receive a training completion certificate within 2-3 weeks after submitting your information.

Training Contents

I. Training Objectives

II. Tobacco Use and Secondhand Smoke Exposure in Massachusetts

III. Risks of Secondhand and Thirdhand Smoke and/or Aerosol Exposure

IV. Nicotine Addiction and Tobacco Treatment

V. Stages of Change and Motivational Interviewing

VI. Addressing Secondhand and Thirdhand Smoke and/or Aerosol with Families

VII. Resources / Wrap-Up

VIII.Quiz and Evaluation

Part I: Training Objectives

(Expected time for completion: less than 5 minutes)

Training Objectives

• The Massachusetts Tobacco Cessation and Prevention Program (MTCP) funded this project. The training assists human service providers in incorporating secondhand and thirdhand smoke, aerosol, and other tobacco related issues into their work with families.

• After reviewing this training and supporting materials clinicians will:

– Better understand the risks of secondhand smoke (SHS) and thirdhand smoke (THS) exposure, as well as exposure to aerosol from e-cigarettes and other electronic devices

– Feel more comfortable and prepared to address SHS/THS issues with families

– Know about the free resources available from MTCP

– Incorporate SHS/THS messages and resources into work with families

Part II: Tobacco Use and Secondhand

Smoke Exposure in Massachusetts

(Expected time for completion: less than 5 minutes)

Tobacco Use and SHS Exposure in MA

Who smokes in MA?

Tobacco Use and SHS Exposure in MA

Who is exposed to SHS in MA?

8.6%

18.2% 17.6%

17.6% 16.3%

13.5% 12.5% 12.2%

12.5% 9.1%

6.9%

3.9% 3.7%

MA Adults 15+ daysof poormental

health inpast month

LGBT <$25Khousehold

income

Less thanHS

education

Havedisability

Masshealth Black Multiunithousing

Hispanic Singlefamilyhomes

$75K +household

income

Collegedegree

Source: Massachusetts BRFSS

Exposure to Secondhand Smoke at Home among MA Adults: 2014-2016

MA – Home Smoking Rules

• In 2014-2016, 17.7% of all MA BRFSS* survey respondents and 12.8% of respondents with children permitted smoking inside their homes

*Behavioral Risk Factor Surveillance System

15.6%

10.9%

22.4% 17.6%

0%

5%

10%

15%

20%

25%

30%

All households Households with children

% of MA Households that Permit Smoking Inside by Type of Housing, 2014-2016

Single-family households Multi-unit households

Source: Massachusetts BRFSS

Tobacco Use and SHS Exposure in MA

Part III Risks of SHS/THS and

Aerosol Exposure

(Expected time for completion: 10 minutes)

Risks of SHS/THS and Aerosol Exposure

• What is secondhand smoke (SHS)?

– “Secondhand smoke is a mixture of the smoke given off by the burning end of a cigarette, pipe or cigar and the smoke exhaled from the lungs of smokers.”

Source: Environmental Protection Agency (EPA)

EPA Definition

• What are other terms for secondhand smoke?

– Environmental Tobacco Smoke (ETS)

– Passive Smoking

– Involuntary Smoking

• You may see the terms “ETS”, “passive smoking” or “involuntary smoking” used in newspaper articles or scientific research. However, “secondhand smoke” is the preferred and most readily understood term.

Risks of SHS/THS and Aerosol Exposure

• There are over 7,000 chemicals in SHS, including hundreds that are toxic and about 70 that can cause cancer.

Source: Centers for Disease Control and Prevention

Secondhand Smoke (SHS) Facts

• Take a moment to view the 2-page “Secondhand Smoke: It’s Bad for Every Body” handout. The handout was produced by the Massachusetts Tobacco Cessation and Prevention Program and is available for free at the MA Clearinghouse.

Risks of SHS/THS and Aerosol Exposure

• Which of the chemicals listed on the “Secondhand Smoke: It’s Bad for Every Body” handout do you think would come as a surprise to the families you work with? Which have surprised you?

Risks of SHS/THS and Aerosol Exposure

What are the health risks associated with SHS exposure?

Take a moment to make your own list of all the ways you

know of that SHS could harm children or adults. Then continue to the next slide.

Risks of SHS/THS and Aerosol Exposure

What are the health risks associated

with SHS exposure? • View the “Hazards of Secondhand Smoke Exposure” handout for

detailed information about the risks of SHS exposure including risks of smoking during pregnancy.

– Key risks for children include asthma, ear infections, respiratory infections (such as pneumonia and bronchitis) and SIDS.

– Key risks for adults include heart disease, stroke, lung cancer, and respiratory conditions (including bronchitis and emphysema).

Risks of SHS/THS and Aerosol Exposure

Risks of SHS/THS and Aerosol Exposure

• What is thirdhand smoke (THS)?

– “Thirdhand Smoke refers to tobacco residue and stale or aged secondhand smoke. THS is not strictly smoke, but chemicals that adhere to surfaces from which they can be released back into the air, undergo chemical transformations and/or accumulate.”

Source: Jacob et al (2017) Thirdhand Smoke: New Evidence, Challenges, and Future Directions

Risks of SHS/THS and Aerosol Exposure

• THS contains more than 250 chemicals, including cancer-causing chemicals.

• Parents who believe that THS is harmful are more likely to make their homes and cars smoke-free and attempt to quit smoking.

• View more information about THS on the AAP factsheet “Thirdhand smoke: A Threat to Child Health.”

Sources: American Academy of Pediatrics (AAP) How Parents Can Prevent Exposure to Thirdhand Smoke

Drehmer et al (2014) Thirdhand Smoke Beliefs of Parents

Risks of SHS/THS and Aerosol Exposure

• What is aerosol exposure? – Contrary to popular belief, e-cigarettes do not emit a harmless

water vapor, but a concoction of chemicals toxic to human cells in the form of an aerosol (vapors are purely gases, aerosols also contain particulate matter).

– People passively exposed to e-cigarette aerosol absorb nicotine, volatile organic compounds and ultrafine particles, and thirdhand exposure to nicotine is an additional risk.

– Passive exposure to e-cigarette aerosol is associated with potential adverse health effects.

Sources: California DPH 2015 Health Advisory and State Health Officer’s Report

Hess et al (2016) A systematic review of the health risks from passive exposure to electronic cigarette vapour

Goniewicz & Lee (2015) Electronic Cigarettes Are a Source of Thirdhand Exposure to Nicotine

Risks of SHS/THS and Aerosol Exposure

• Risk of nicotine poisoning from e-liquids – While nicotine in any form can cause poisonings, since 2011

poison control centers have been most concerned about exposures to e-cigarette products and liquid nicotine, as the concentration of nicotine in liquid products is higher than in most other tobacco products.

– Since 2015, liquids or gels containing nicotine must be sold in child-resistant packaging in MA. However, children may still be attracted by colorful containers and try to drink the liquid.

– Drinking/ingesting e-liquids can lead to life-threatening and severe symptoms like seizures, decreased heart rate, and decreased blood pressure. These symptoms can happen to anyone, but the risk is greatest in children due to their size.

Source: American Association of Poison Control Centers, Tobacco and Liquid Nicotine and current case data on E-Cigarettes and Liquid Nicotine

• What does it mean to address SHS/THS and aerosol in your work?

– Help families decide to go smoke/vape-free in their homes and cars.

– Help families make connections between health issues and SHS/THS/aerosol.

– Provide tobacco treatment resources when people are interested in quitting.

• You can address SHS/THS and aerosol with clients whether or not they are interested in quitting smoking/vaping.

Risks of SHS/THS and Aerosol Exposure

• How can you tell that smoking/vaping may be happening in a home?

– Smell of smoke

– Ashtrays

– Discolored walls

– Child smells like smoke

– Use of air fresheners/incense

– Use of an air purifier

– Strong smells of candy/fruit/mint etc.

Risks of SHS/THS and Aerosol Exposure

Part IV: Nicotine Addiction and

Tobacco Treatment

(Expected time for completion: 15 minutes)

Nicotine Addiction and Tobacco Treatment

• Nicotine, a chemical found in tobacco, is as addictive as heroin or cocaine. It generally takes multiple tries before a smoker is successful in

quitting. Source: Centers for Disease Control and Prevention

Nicotine Dependence

• Each time a person tries to quit smoking they can learn valuable information about what works and what doesn’t work when trying to quit.

Nicotine Addiction and Tobacco Treatment

• It is important to address the social and psychological components of nicotine addiction in addition to the biological components.

• See the “Biopsychosocial Model of Tobacco Dependence” handout for more information.

Nicotine Addiction and Tobacco Treatment

• Nearly 7 out of 10 adult cigarette smokers (68%) want to quit.

• Smokers can double or triple their chances of successfully quitting by using a combination of counseling, Nicotine Replacement Therapy (NRT) such as patches, gum or lozenges, and/or the FDA-approved cessation medications.

Sources:

CDC: Quitting Smoking

https://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/index.htm

Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.

Nicotine Addiction and Tobacco Treatment

• MassHealth offers comprehensive coverage to quit smoking including NRT such as patches or gum and non-nicotine medications that help smokers quit (Chantix and Zyban). Click here for more information

• Massachusetts offers a FREE Helpline for any person who smokes and is interested in quitting:

– MA Smokers’ Helpline 1-800-QUIT-NOW (1-800-784-8669); all languages

– For Spanish: 1-800-8-DÉJALO (1-800-833-5256)

– TTY: 1-888-229-2182

– Online: http://makesmokinghistory.org/quit-now/ and https://ma.quitlogix.org/en-US/

– Helpline support includes coaching and free NRT (if eligible)

Nicotine Addiction and Tobacco Treatment

• The MA Smokers’ Helpline also offers programs for specific populations:

• Perinatal program – The same dedicated quit coach for all calls – Text messaging, email support, and up to $65 on a gift card

• American Indian Commercial Tobacco Program – Dedicated phone number and website: 1-855-372-0037 –

https://americanindian.quitlogix.org/ – Dedicated AI coaches

• Youth smoking and vaping program (for youth 12-17 years old) – Specifically trained Youth Coach Specialists (YCS) – Call or text “Start My Quit” to 1-855-891-9989 –

https://mylifemyquit.com/

• For more information, see the back of the MA Quitworks Fax Form in the handouts package

Nicotine Addiction and Tobacco Treatment

• Providers in any healthcare or social service agency in Massachusetts can refer to the MA Smokers’ Helpline using QuitWorks

– QuitWorks is a free, evidence-based cessation fax-referral service available for Massachusetts providers.

– Via Fax: use the MA Quitworks Fax Form in the handouts package

– Via the Provider Web Referral: https://ma.quitlogix.org/en-US/Just-Looking/Health-Professional/How-to-Refer-Patients/Provider-Web-Referral

– Tobacco users referred using QuitWorks will be contacted by the Massachusetts Smokers’ Helpline.

Nicotine Addiction and Tobacco Treatment

• Additional Handouts: – Health Consequences of Smoking and Lesser Known Health

Consequences. Brief review of the risks of smoking including cancer, cardiovascular disease, and respiratory diseases.

– How Quitting Smoking Changes Your Body. Produced by CVS Health. Helpful timeline of information about how the body recovers from tobacco use.

– Before You Light Up Look Down: My Smoke-Free Plan. Produced by MTCP as a plan for a smoke-free home, car, and quitting.

– You Can Quit Smoking. Produced by the U.S. Department of Health and Human Services. For use with pregnant women.

Part V: Stages of Change and

Motivational Interviewing

(Expected time for completion: 40 minutes)

• The Stages of Change is a great framework for thinking about the steps people go through before and after making changes in their behavior (e.g. deciding not to smoke around children, quitting smoking, changing eating habits, etc.).

Prochaska and DiClemente’s Stages of Change

Prochaska and DiClemente’s Stages of Change

• Handout: “Stages of Change”

• Review the handout to see an explanation of the five stages of change as they apply to quitting smoking.

Prochaska and DiClemente’s Stages of Change

• Key Takeaway: Your goal in working with a client is to identify what stage of change the client is in and help him/her move from one stage to the next (e.g. from contemplation to preparation) rather than focusing on achieving complete behavior change overnight.

• Remember that clients can be in different stages of change for different issues. For example, a client may be in precontemplation for quitting smoking but may be in preparation or action for addressing their children’s secondhand smoke exposure.

Motivational Interviewing (MI)

• MI is a very effective, non-confrontational approach for

working with clients on achieving behavior change.

• MI recognizes that people need to feel internally

motivated to make a successful change.

• MI asks for permission to give information (e.g. on SHS/

THS/Aerosol, tobacco use, or the benefits of speaking

with other healthcare providers about quitting smoking).

• See a description at www.motivationalinterviewing.org of

MI by Stephen Rollnick, Ph.D., & William R. Miller, Ph.D.,

two of the pioneers of Motivational Interviewing.

Motivational Interviewing (MI)

• Handout “Motivational Interviewing and Secondhand/Thirdhand Smoke (SHS/THS) and Aerosol” – Information about the principles of MI, techniques

and tips. – Includes a useful list of open-ended questions relating

to families and SHS/THS/aerosol. Open-ended questions are a great way to talk about any issue. Unlike closed-ended questions which only require a “yes” or “no” response, open-ended questions can help you start a meaningful conversation with a client and learn more about what your client already knows or feels about an issue.

Scenarios

• Review the “Stages of Change and Motivational Interviewing: Secondhand/Thirdhand Smoke and Aerosol Scenarios” handout.

• Read through the scenarios and answer the following questions for each scenario: – What stage of change (for the issue of SHS/THS/aerosol) is the

client in? – What is the clinician’s goal in this stage? – What open-ended questions might you use? (Remember to use

the Open-ended Questions from the previous handout for examples)

– What are some next steps you would want to take with the client?

– Complete the questions for all three scenarios before advancing to the next page.

Scenarios - Answers

• Scenario 1 (Diane)

– Stage of change: Pre-Contemplation

– Goal: Help Diane move to “contemplation” by introducing

ambivalence.

– Sample open-ended questions: What do you know about

secondhand and thirdhand smoke and your family’s health/your

child’s ear infections? What’s it like to be talking about this?

– Next steps might include: Helping Diane see the connection

between her children’s health problems and SHS/THS and

drawing the distinction between smoking outside of her

home/car and quitting smoking altogether.

Scenarios - Answers

• Scenario 2 (Carl)

– Stage of change: Preparation

– Goal: Help Carl move from “preparation” to “action” by working

together to come up with strategies.

– Sample open-ended questions: What have you done so far

to reduce your son’s exposure to SHS/THS? What else do you

think would work? What has helped you to not smoke when

your children are in the car?

– Next steps might include: Helping Carl make a plan for not

smoking in his car/home and identifying other sources of

SHS/THS exposure.

Scenarios - Answers

• Scenario 3 (Maria)

– Stage of change: Contemplation

– Goal: Help Maria move from “contemplation” to “preparation”

by resolving ambivalence in favor of change.

– Sample open-ended questions: What would it take for you

to feel like you could be successful in quitting vaping? What do

you know about how nicotine affects your baby’s health? What

worked well for you when you quit smoking? What was difficult?

– Next steps might include: Increasing her confidence for

quitting vaping by drawing on her success of quitting cigarettes.

Finding out if Maria is interested in receiving information about

the risks of vaping/nicotine use during pregnancy and how to

talk with Thomas about how their vaping affects their baby.

Part VI: Addressing SHS/THS and

Aerosol with Families

(Expected time for completion: 10 minutes)

Addressing SHS with Families

• Review the handout: “Talking to Families about SHS/THS

and Aerosol: Conversation Starters & Tips” for sample

language.

– What conversation starters feel comfortable to you?

– Which tips might be useful for you?

Addressing SHS with Families

• For situations where someone else other than your client is the

person who is smoking/vaping around children, review the handout

“Helping Clients Talk with Others about SHS/THS and Aerosol.”

– What are some options for helping a client who is living with a

person who smokes/vapes?

– Could the person who is living with your client speak with you?

Could they speak with a doctor at an upcoming medical

appointment for the child? Read information about secondhand

smoke?

Addressing SHS with Families

• Think about when you plan to address SHS/THS/aerosol with

families.

• For example:

– When the client mentions tobacco use

– When concerns about asthma, ear infections, respiratory

infections, SIDS or other related health issues arise

– During conversations about safety or children’s health

• Remember that SHS/THS/aerosol can be addressed as part of

a conversation about other issues or as a stand alone topic

depending on what works best given your client and the

situation.

Addressing SHS with Families

Think of a client who smokes/vapes (or an example from your personal life if you haven’t

yet worked with a client who smokes/vapes)

Refer to the MI and “Talking to Families” handouts and

decide: – When/how would you bring up the topic of SHS/THS/aerosol?

– What would you say? What do you expect your client would say?

– Which of the free resources on SHS/THS/aerosol and/or cessation would you use?

Part VII: Resources / Wrap Up

(Expected time for completion: less than 10 minutes)

Free MTCP Resources

• Free materials can be ordered at the MA Clearinghouse:

https://massclearinghouse.ehs.state.ma.us/category/TOB.html

Some of them are available in Spanish and Portuguese.

• Your office may already have materials; ask a co-worker or

supervisor where they are stored. If there aren’t any, work with

your program to order materials for the whole staff.

• Tip: Keep the materials with other resources you regularly

distribute so you have them available as needed!

• Materials are updated from time-to-time so check back for new

resources.

• Keep in mind: MassHealth covers Nicotine Replacement Therapy

and other non-nicotine medications to help smokers quit!

Free MTCP Resources

Secondhand Smoke materials:

– “Before You Light Up, Look Down” poster (English and Spanish).

– “This is a Smoke-Free Space” Cling for glass doors.

– “Secondhand Smoke: It’s Bad for Every Body” Infographic.

– Other “Before You Light Up, Look Down” materials include a

Coloring Page, 1-page Fact Sheet (in English and Spanish), and

a Smoke-Free Plan (English and Spanish) with action steps.

Examples of materials to help quit smoking and no smoking signs:

– Comprehensive booklet on step-by-step how to quit smoking.

(English and Spanish)

– Wallet card with the HelpLine information. (English, Spanish, and

Portuguese)

– No Smoking/Vaping decal sticker.

– Smoke-Free Area window decal.

Wrap Up

• Answer the questions on the handout “Incorporating SHS/THS/Aerosol Issues Into Your Work” – what steps will you take to include these issues in your work with families?

• Tip: Talk to your supervisor and/or co-workers

about how they talk about SHS/THS/aerosol or other tobacco-related issues with families.

• For more information about Tobacco Cessation and Prevention efforts in Massachusetts, visit MTCP’s website: www.makesmokinghistory.org

Additional Resources

• Centers for Disease Control and Prevention https://www.cdc.gov/tobacco/basic_information/secondhand_smoke/index.htm and http://www.cdc.gov/tobacco/

• Environmental Protection Agency http://www2.epa.gov/indoor-air-quality-iaq/secondhand-tobacco-smoke-and-smoke-free-homes

• The Health Consequences of Involuntary Exposure to Tobacco Smoke, A Report of the Surgeon General (2006) https://www.ncbi.nlm.nih.gov/books/NBK44324/ and https://www.surgeongeneral.gov/library/reports/secondhand-smoke-consumer.pdf

• American Cancer Society https://www.cancer.org/healthy/stay-away-from-tobacco.html

• American Lung Association https://www.lung.org/stop-smoking/ and https://www.lung.org/our-initiatives/tobacco/

Part VIII: Quiz and Evaluation

(Expected time for completion: 10 minutes)

Quiz & Evaluation

You are almost finished!

• To document your completion of this training you will need to complete a short 7-question quiz and a short 7-question evaluation of this training.

• A certificate of completion will be emailed to you within 2-3 weeks of completing the quiz and evaluation.

Massachusetts Department of Public Health, Tobacco Cessation and Prevention Program

Congratulations! You have completed the training. Questions? Contact Smoke-Free Families at the Institute for Health and Recovery Annegret Klaua, MSc Tobacco Education & Treatment Specialist annegretklaua@healthrecovery.org

617-661-3991

Massachusetts Department of Public Health, Tobacco Cessation and Prevention Program