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TABLE 3

Suggested Structural Interventions to Reduce Tobacco-Related Disparities

Structural InterventionRationaleComment
End predatory targeting by the tobacco industry Tobacco companies target vulnerable and marginalized groups. Regulating predatory marketing tactics used by 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) access to evidence-based therapies for smoking cessation, (2) early recognition and treatment of tobacco use–related diseases, and (3) coverage for mental health services. Coverage also increases the likelihood that people with mental health problems who also smoke receive needed health services. 
Make funds for tobacco-dependence treatment available for people without insurance Adequate tobacco-dependence treatment should be accessible to all. Tobacco taxes are a potential source of funding. 
Advocate for employers to provide effective tobacco-dependence treatment to employees who smoke Tobacco-dependence treatment in the workplace may help workers stop smoking, stay in the workforce, and gain a better economic footing. Efforts may thus reduce the burden of unemployment on those already experiencing poverty. 
Incorporate smoking cessation for caregivers into pediatric visits Caregivers often visit pediatric clinicians more frequently than their own clinicians, creating important opportunities to discuss tobacco use and need for cessation. Clinicians aware of structural issues may be more likely to understand counseling efforts as interventions to address these issues. They may be more likely to use a chronic disease model and motivational interviewing techniques. 
Support reimbursement for clinicians treating caregivers who smoke; ensure consistent coverage for tobacco-dependence treatment Pediatricians should be compensated for time spent treating caregivers’ tobacco dependence.102  Consistent payment by health insurers for health 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. ICD-10 codes allow pediatricians to code for SHS exposurea but not for time to assist caregivers with smoking cessation. 
Improve access to counseling and medications by investing in streamlined referrals from EHRs to smoking quitlines Greater access may improve referral rates to counseling services; many quitlines provide free NRT to their users. EHR systems also can be modified to allow opening a linked medical record for the child’s caregiver. This can facilitate documentation of pediatrician support given to the caregiver. 
Partner with schools to monitor absences; provide educational opportunities for children chronically absent because of illness Children exposed to SHS are more likely to miss school, impeding academic achievement.  Strategies to help children stay on track educationally may help improve educational outcomes. 
Urge all child care centers to follow guidance about tobacco exposure For young children, out-of-home care may represent a significant portion of their day and a source of exposure—particularly for low-income parents 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. This guidance is provided by the National Resource Center for Health and Safety in Child Care and Early Education in Caring for Our Children.103  
Structural InterventionRationaleComment
End predatory targeting by the tobacco industry Tobacco companies target vulnerable and marginalized groups. Regulating predatory marketing tactics used by 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) access to evidence-based therapies for smoking cessation, (2) early recognition and treatment of tobacco use–related diseases, and (3) coverage for mental health services. Coverage also increases the likelihood that people with mental health problems who also smoke receive needed health services. 
Make funds for tobacco-dependence treatment available for people without insurance Adequate tobacco-dependence treatment should be accessible to all. Tobacco taxes are a potential source of funding. 
Advocate for employers to provide effective tobacco-dependence treatment to employees who smoke Tobacco-dependence treatment in the workplace may help workers stop smoking, stay in the workforce, and gain a better economic footing. Efforts may thus reduce the burden of unemployment on those already experiencing poverty. 
Incorporate smoking cessation for caregivers into pediatric visits Caregivers often visit pediatric clinicians more frequently than their own clinicians, creating important opportunities to discuss tobacco use and need for cessation. Clinicians aware of structural issues may be more likely to understand counseling efforts as interventions to address these issues. They may be more likely to use a chronic disease model and motivational interviewing techniques. 
Support reimbursement for clinicians treating caregivers who smoke; ensure consistent coverage for tobacco-dependence treatment Pediatricians should be compensated for time spent treating caregivers’ tobacco dependence.102  Consistent payment by health insurers for health 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. ICD-10 codes allow pediatricians to code for SHS exposurea but not for time to assist caregivers with smoking cessation. 
Improve access to counseling and medications by investing in streamlined referrals from EHRs to smoking quitlines Greater access may improve referral rates to counseling services; many quitlines provide free NRT to their users. EHR systems also can be modified to allow opening a linked medical record for the child’s caregiver. This can facilitate documentation of pediatrician support given to the caregiver. 
Partner with schools to monitor absences; provide educational opportunities for children chronically absent because of illness Children exposed to SHS are more likely to miss school, impeding academic achievement.  Strategies to help children stay on track educationally may help improve educational outcomes. 
Urge all child care centers to follow guidance about tobacco exposure For young children, out-of-home care may represent a significant portion of their day and a source of exposure—particularly for low-income parents 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. This guidance is provided by the National Resource Center for Health and Safety in Child Care and Early Education in Caring for Our Children.103  

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.

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