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Letter to the Editor: Failure to address parent’s tobacco dependence can be risky :

May 24, 2016

I would like to correct misinformation in a recent Pediatricians and the Law article (http://www.aappublications.org/news/2016/03/25/Law031016) raising unjustified concerns about the medical-legal risk of pediatricians prescribing or recommending nicotine replacement therapy to tobacco-dependent parents.

I have not been able to identify any malpractice case brought because of the prescription or recommendation of nicotine replacement therapy. However, concern has been raised in the medical literature that, given the substantial harms of tobacco, failure to address tobacco dependence could be considered medical malpractice (Torrijos RM, Glantz SA. Tob Control. 2006;15:447-451).

The author raised concerns about adverse effects of nicotine replacement, citing a meta-analysis of adverse events of nicotine replacement therapy that did not identify any serious or life-threatening adverse events. Researchers found an increased risk of “palpitations” but not for heart attacks or strokes (Mills EJ, et al. Tob Induc Dis. 2010;8:8). Other research has documented that provision of nicotine replacement therapy reduces the risk of acute myocardial infarction, stroke and death in adult smokers (Hubbard R, et al. Tob Control. 2005;14:416-421).

Even in adults after acute coronary syndromes, the use of nicotine replacement therapy is not associated with risk for adverse cardiovascular events (Woolf KJ, et al. Am J Cardiol. 2012;110:968-970). The only absolute contraindication to nicotine replacement therapy is lack of nicotine or tobacco dependence.

Tobacco smoke exposure increases risk for more severe asthma, bronchiolitis and pneumonia. Children can die or be brain injured from these conditions. These adverse outcomes can and do provide the basis for malpractice lawsuits. Many malpractice insurance providers will settle defensible cases to avoid the uncertainty of a jury trial.

As with any prescribing, pediatricians should make sure their malpractice insurance will cover them and be sure to document appropriate assessment and counseling. If pediatricians are not comfortable writing a prescription for parents, the pediatrician’s recommendation can help parents seek out and obtain effective therapy for their severe disease that is affecting their child. Pediatricians can refer tobacco-dependent parents to their state quitline (1-800-QUIT-NOW).

Pediatricians can arm parents with the correct questions to ask of their own physicians. Giving parents the tools to tackle their own tobacco dependence protects their child’s health. Protecting the child’s health can decrease the pediatrician’s medical-legal risk.

-- Harold J. Farber, M.D., M.S.P.H., FAAP

Associate professor of pediatrics, Pulmonary Section,

Baylor College of Medicine and Texas Children’s Hospital


To submit a letter to the editor email Anne Hegland at ahegland@aap.org

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