I was dismayed to read the Pediatricians and the Law Q&A in the April issue of AAP News (http://www.aappublications.org/news/2016/03/25/Law031016), which included a question regarding prescriptions of nicotine replacement therapy (NRT) for parents. The author, Jonathan M. Fanaroff, M.D., J.D., FAAP, indicated several concerns with prescribing NRT, including NRT being out of the scope of pediatric practice, concerns about adverse events from NRT, creation of a physician-patient relationship which may create liability for unrelated illnesses, and issues related to communicating with an adult patient’s medical home.
As a practicing physician scientist involved in tobacco control, I have carefully read much literature surrounding the rigorous testing of NRT over a 30-year period. This literature resoundingly supports the use of NRT with exceedingly rare serious adverse events. Side effects are due both to the pharmacological action of nicotine itself (which is in the tobacco product that NRT is designed to replace) as well as to the mode and site of NRT delivery. Hiccups and gastrointestinal upset are the most common side effects and tachycardia/heart palpitations the most common cardiac side effect. There is no excess risk for serious cardiac events with NRT, even among patients with a high risk of cardiac problems (Mills EJ, et al. Circulation. 2014;129:28-41).
NRT is so safe that it is available over the counter. A written prescription from a licensed practitioner allows a patient to obtain NRT through his or her insurance often at a much lower cost or to use a health savings account for its purchase. NRT “by prescription” is in no way different than what can be simply asked for at the pharmacy counter without a prescription. Many state quitlines and some retail pharmacy-based clinics provide NRT through standing orders, too. Aiding parents with a prescription removes a barrier to one of the most cost-effective preventive health interventions.
It would be ideal to communicate with the adult’s medical home. However, since any adult can obtain NRT without prescription, the concern about the communication with the adult patient’s medical home is somewhat spurious.
AAP policy statements on tobacco control have encouraged pediatric clinicians to intervene with NRT prescriptions to parents since 2009 (Clinical Practice Policy to Protect Children from Tobacco, Nicotine, and Secondhand Smoke. Pediatrics. 2015;136:1008-1017, http://bit.ly/1SD0XX5; Tobacco Use: A Pediatric Disease. Pediatrics. 2009;124:1474-1487, http://bit.ly/1VBd2Rv).
The American Medical Association also has had policy since 2005 that supports pediatricians addressing parental smoking (H-490.917: Physician Responsibilities for Tobacco Cessation. Adopted by House of Delegates, June 2005. Chicago, Ill.).
As to scope of practice, it is important to remember that the rate of tobacco use among high school students is 24.3% (Arrazola RA, et al. MMWR Morb Mortal Wkly Rep. 2015;64:381-385). Tobacco use is a pediatric disease, so well within our scope and charge to both treat and prevent. Extending this practice to the parents of our patients is not something to be feared but to be encouraged.
Susanne E. Tanski, M.D., M.P.H., FAAP
Chair, AAP Tobacco Consortium