Trial of an intervention to reduce passive smoking in infancy

Promoting Smoke-Free Homes Through Biomarker Feedback Documenting Child Exposure to Tobacco Toxins: Protocol for a Randomized Clinical Trial

BACKGROUND

Exposure to secondhand smoke (SHS) early in life increases the risk of sudden infant death syndrome (SIDS), asthma, and respiratory illnesses. Since children's primary exposure to SHS occurs in the home, these most vulnerable members of our society are not fully protected by recent increases in the adoption of smoking bans in public spaces. Although exposure to SHS is a quickly reversible cause of excess morbidity, few low-income homes strictly enforce smoking restrictions.

OBJECTIVE

This study aims to test a novel approach to motivate the adoption of home smoking restrictions and to eliminate child SHS exposure by providing parents with objective data documenting home SHS exposure and "biomarker feedback" of child ingestion of tobacco toxins, that is, objective, laboratory-based results of assays performed on child urine, documenting levels of nicotine; cotinine; and NNAL (4-[methylnitrosamino]-1-[3-pyridyl]-1-butanol), which is a metabolite of the known tobacco carcinogen NNK (4-[methylnitro-samino]-1-[3-pyridyl]-1-butanone).

METHODS

From 2011 to 2013, 195 low-income, female smokers with children aged ≤10 years residing in their homes were recruited into a two-arm randomized clinical trial. Participants were assigned to one of two groups: biomarker feedback (n=98) and health education (n=97). In-home assessments were administered at baseline, week 16, and week 26. Children's home SHS exposure and nicotine, cotinine, and NNAL levels from urine samples, measured through a passive nicotine dosimeter and a surface sample of residual tobacco smoke (ie, thirdhand smoke), were collected at all three time points. Primary outcome was dosimeter-verified, self-reported complete home smoking restrictions at 6 months after randomization. Secondary outcomes included parental self-report of smoking behavior change and child urine tobacco toxin (biomarker) change.

RESULTS

Data collection and analyses are complete, and the results are being interpreted.

CONCLUSIONS

The study protocol describes the development of a novel community-based controlled trial designed to examine the efficacy of biomarker feedback documenting home and child exposure to SHS on parental smoking behavior change.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/12654.

Family and carer smoking control programmes for reducing children's exposure to environmental tobacco smoke

BACKGROUND

Children's exposure to other people's tobacco smoke (environmental tobacco smoke, or ETS) is associated with a range of adverse health outcomes for children. Parental smoking is a common source of children's exposure to ETS. Older children in child care or educational settings are also at risk of exposure to ETS. Preventing exposure to ETS during infancy and childhood has significant potential to improve children's health worldwide.

OBJECTIVES

To determine the effectiveness of interventions designed to reduce exposure of children to environmental tobacco smoke, or ETS.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register and conducted additional searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Education Resource Information Center (ERIC), and the Social Science Citation Index & Science Citation Index (Web of Knowledge). We conducted the most recent search in February 2017.

SELECTION CRITERIA

We included controlled trials, with or without random allocation, that enrolled participants (parents and other family members, child care workers, and teachers) involved in the care and education of infants and young children (from birth to 12 years of age). All mechanisms for reducing children's ETS exposure were eligible, including smoking prevention, cessation, and control programmes. These include health promotion, social-behavioural therapies, technology, education, and clinical interventions.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies and extracted data. Due to heterogeneity of methods and outcome measures, we did not pool results but instead synthesised study findings narratively.

MAIN RESULTS

Seventy-eight studies met the inclusion criteria, and we assessed all evidence to be of low or very low quality based on GRADE assessment. We judged nine studies to be at low risk of bias, 35 to have unclear overall risk of bias, and 34 to have high risk of bias. Twenty-one interventions targeted populations or community settings, 27 studies were conducted in the well-child healthcare setting and 26 in the ill-child healthcare setting. Two further studies conducted in paediatric clinics did not make clear whether visits were made to well- or ill-children, and another included visits to both well- and ill-children. Forty-five studies were reported from North America, 22 from other high-income countries, and 11 from low- or middle-income countries. Only 26 of the 78 studies reported a beneficial intervention effect for reduction of child ETS exposure, 24 of which were statistically significant. Of these 24 studies, 13 used objective measures of children's ETS exposure. We were unable to pinpoint what made these programmes effective. Studies showing a significant effect used a range of interventions: nine used in-person counselling or motivational interviewing; another study used telephone counselling, and one used a combination of in-person and telephone counselling; three used multi-component counselling-based interventions; two used multi-component education-based interventions; one used a school-based strategy; four used educational interventions, including one that used picture books; one used a smoking cessation intervention; one used a brief intervention; and another did not describe the intervention. Of the 52 studies that did not show a significant reduction in child ETS exposure, 19 used more intensive counselling approaches, including motivational interviewing, education, coaching, and smoking cessation brief advice. Other interventions consisted of brief advice or counselling (10 studies), feedback of a biological measure of children's ETS exposure (six studies), nicotine replacement therapy (two studies), feedback of maternal cotinine (one study), computerised risk assessment (one study), telephone smoking cessation support (two studies), educational home visits (eight studies), group sessions (one study), educational materials (three studies), and school-based policy and health promotion (one study). Some studies employed more than one intervention. 35 of the 78 studies reported a reduction in ETS exposure for children, irrespective of assignment to intervention and comparison groups. One study did not aim to reduce children's tobacco smoke exposure but rather sought to reduce symptoms of asthma, and found a significant reduction in symptoms among the group exposed to motivational interviewing. We found little evidence of difference in effectiveness of interventions between the well infant, child respiratory illness, and other child illness settings as contexts for parental smoking cessation interventions.

AUTHORS' CONCLUSIONS

A minority of interventions have been shown to reduce children's exposure to environmental tobacco smoke and improve children's health, but the features that differentiate the effective interventions from those without clear evidence of effectiveness remain unclear. The evidence was judged to be of low or very low quality, as many of the trials are at a high risk of bias, are small and inadequately powered, with heterogeneous interventions and populations.

The art and science of study identification: a comparative analysis of two systematic reviews

BACKGROUND

Systematic reviews (SRs) form the foundation for guidelines and evidence-based policy in medicine and public health. Although similar systematic reviews may include non-identical sets of studies, and it is recognized that different sets of studies may lead to different conclusions, little work has been published on why SR study cohorts differ.

METHODS

We took advantage of concurrent publication of two SRs on the same topic - prevention of child exposure to tobacco smoke - to understand why study cohorts differed in the two reviews. We identified all studies included in just one review, investigated validity of specified reasons for exclusions, and, using database records, explored reasons for study non-identification. We assessed review methods and discordancy, and attempted to assess whether changes in study cohorts would have changed conclusions.

RESULTS

Sixty-one studies were included in the two reviews. Thirty-five studies were present in just one review; of these, twenty were identified and excluded by the parallel review. Omissions were due to: review scope (9 studies, 26%), outcomes of interest not measured (8 studies, 23%), exclusion of reports with inadequate reporting (6 studies, 17%), mixed or unclear reasons (3 studies, 8%), search strategies concerning filters, tagging, and keywords (3 studies, 8%), search strategies regarding sources (PUBMED not searched) (2 studies, 6%); discordant interpretation of same eligibility criteria (2 studies, 6%), and non-identification due to non-specific study topic (2 studies, 6%). Review conclusions differed, but were likely due to differences in synthesis methods, not differences in study cohorts.

CONCLUSIONS

The process of study identification for SRs is part art and part science. While some differences are due to differences in review scope, outcomes measured, or reporting practices, others are caused by search methods or discrepancies in reviewer interpretations. Different study cohorts may or may not be a cause of differing SR results. Completeness of SR study cohorts could be enhanced by 1 - independent identification of studies by at least two reviewers, as recommended by recent guidelines, 2 - searching PUBMED with free-text keywords in addition to MEDLINE to identify recent studies, and 3 - Using validated search filters.

Secondhand Smoke Exposure Reduction Intervention in Chinese Households of Young Children: A Randomized Controlled Trial

OBJECTIVE

To assess whether a theory-based, community health worker-delivered intervention for household smokers will lead to reduced secondhand smoke exposure to children in Chinese families.

METHODS

Smoking parents or caregivers who had a child aged 5 years or younger at home were randomized to the intervention group (n = 164) to receive smoking hygiene intervention or to the comparison group (n = 154). The intervention was delivered by trained community health workers. Outcomes were assessed at 2- and 6- month follow-up.

RESULTS

Of the 318 families randomized, 98 (60%) of 164 intervention group and 82 (53%) of 154 of controls completed 6-month follow-up assessment. At the 6-month follow-up, 62% of intervention and 45% of comparison group households adopted complete smoking restrictions at home (P = .022); total exposure (mean number of cigarettes per week ± standard deviation) from all smokers at home in the past 7 days was significantly lower among children in the intervention (3.29 ± 9.06) than the comparison (7.41 ± 14.63) group (P = .021); and mean urine cotinine level (ng/mL) was significantly lower in the intervention (0.030 ± .065) than the comparison (0.087 ± .027) group, P < .001). Participants rating of the overall usefulness of the intervention was 4.8 + 0.8 (1 standard deviation) on the 5 point scale (1 not at all and 5 = very useful).

CONCLUSIONS

The findings of this very first study in China showed that smoking hygiene intervention was effective in reducing children's exposure to secondhand smoke. These findings have implications for the development of primary health care-based secondhand smoke exposure reduction and family oriented smoking cessation interventions as China moves toward a smoke-free society.

Behavioural Medicine: Research and Development in Disease Prevention

Behavioural medicine has become a popular, important and distinct field of research and clinical practice. One of the more exciting areas of behavioural medicine has been in the application of behavioural techniques to reduce cardiovascular risk-factors on a community-wide basis. Work conducted in this area highlights a key issue for the development and support of behaviour analysis and modification activities in Australia: to what extent should behavioural practitioners and their interest groups pursue a specialised, behaviour-analytic approach to the areas in which they are involved, as opposed to adopting interdisciplinary frameworks and approaches. We describe some of the activities of the Stanford Center for Research in Disease Prevention, which has been able to operate as a large, interdisciplinary organisation, guided by behavioural approaches. We also discuss some setting, provider, program and client variables relevant to research and development on health promotion and disease prevention in Australia and elsewhere.

Meta-analysis of parental protection of children from tobacco smoke exposure

BACKGROUND AND OBJECTIVE

Worldwide, roughly 40% of children are exposed to the damaging and sometimes deadly effects of tobacco smoke. Interventions aimed at reducing child tobacco smoke exposure (TSE) have shown mixed results. The objective of this study was to perform a systematic review and meta-analysis to quantify effects of interventions aimed at decreasing child TSE.

METHODS

Data sources included Medline, PubMed, Web of Science, PsycNet, and Embase. Controlled trials that included parents of young children were selected. Two reviewers extracted TSE data, as assessed by parentally-reported exposure or protection (PREP) and biomarkers. Risk ratios and differences were calculated by using the DerSimonian and Laird random-effects model. Exploratory subgroup analyses were performed.

RESULTS

Thirty studies were included. Improvements were observed from baseline to follow-up for parentally-reported and biomarker data in most intervention and control groups. Interventions demonstrated evidence of small benefit to intervention participants at follow-up (PREP: 17 studies, n = 6820, relative risk 1.12, confidence interval [CI] 1.07 to 1.18], P < .0001). Seven percent more children were protected in intervention groups relative to control groups. Intervention parents smoked fewer cigarettes around children at follow-up than did control parents (P = .03). Biomarkers (13 studies, n = 2601) at follow-up suggested lower child exposure among intervention participants (RD -0.05, CI -0.13 to 0.03, P = .20).

CONCLUSIONS

Interventions to prevent child TSE are moderately beneficial at the individual level. Widespread child TSE suggests potential for significant population impact. More research is needed to improve intervention effectiveness and child TSE measurement.

Family and carer smoking control programmes for reducing children's exposure to environmental tobacco smoke

BACKGROUND

Children's exposure to other people's cigarette smoke (environmental tobacco smoke, or ETS) is associated with a range of adverse health outcomes for children. Parental smoking is a common source of children's exposure to ETS. Older children are also at risk of exposure to ETS in child care or educational settings. Preventing exposure to cigarette smoke in infancy and childhood has significant potential to improve children's health worldwide.

OBJECTIVES

To determine the effectiveness of interventions aiming to reduce exposure of children to ETS.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register and conducted additional searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, EMBASE, CINAHL, ERIC, and The Social Science Citation Index & Science Citation Index (Web of Knowledge). Date of the most recent search: September 2013.

SELECTION CRITERIA

Controlled trials with or without random allocation. Interventions must have addressed participants (parents and other family members, child care workers and teachers) involved with the care and education of infants and young children (aged 0 to 12 years). All mechanisms for reduction of children's ETS exposure, and smoking prevention, cessation, and control programmes were included. These include health promotion, social-behavioural therapies, technology, education, and clinical interventions.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies and extracted data. Due to heterogeneity of methodologies and outcome measures, no summary measures were possible and results were synthesised narratively.

MAIN RESULTS

Fifty-seven studies met the inclusion criteria. Seven studies were judged to be at low risk of bias, 27 studies were judged to have unclear overall risk of bias and 23 studies were judged to have high risk of bias. Seven interventions were targeted at populations or community settings, 23 studies were conducted in the 'well child' healthcare setting and 24 in the 'ill child' healthcare setting. Two further studies conducted in paediatric clinics did not make clear whether the visits were to well or ill children, and another included both well and ill child visits. Thirty-six studies were from North America, 14 were in other high income countries and seven studies were from low- or middle-income countries. In only 14 of the 57 studies was there a statistically significant intervention effect for child ETS exposure reduction. Of these 14 studies, six used objective measures of children's ETS exposure. Eight of the studies had a high risk of bias, four had unclear risk of bias and two had a low risk of bias. The studies showing a significant effect used a range of interventions: seven used intensive counselling or motivational interviewing; a further study used telephone counselling; one used a school-based strategy; one used picture books; two used educational home visits; one used brief intervention and one study did not describe the intervention. Of the 42 studies that did not show a significant reduction in child ETS exposure, 14 used more intensive counselling or motivational interviewing, nine used brief advice or counselling, six used feedback of a biological measure of children's ETS exposure, one used feedback of maternal cotinine, two used telephone smoking cessation advice or support, eight used educational home visits, one used group sessions, one used an information kit and letter, one used a booklet and no smoking sign, and one used a school-based policy and health promotion. In 32 of the 57 studies, there was reduction of ETS exposure for children in the study irrespective of assignment to intervention and comparison groups. One study did not aim to reduce children's tobacco smoke exposure, but rather aimed to reduce symptoms of asthma, and found a significant reduction in symptoms in the group exposed to motivational interviewing. We found little evidence of difference in effectiveness of interventions between the well infant, child respiratory illness, and other child illness settings as contexts for parental smoking cessation interventions.

AUTHORS' CONCLUSIONS

While brief counselling interventions have been identified as successful for adults when delivered by physicians, this cannot be extrapolated to adults as parents in child health settings. Although several interventions, including parental education and counselling programmes, have been used to try to reduce children's tobacco smoke exposure, their effectiveness has not been clearly demonstrated. The review was unable to determine if any one intervention reduced parental smoking and child exposure more effectively than others, although seven studies were identified that reported motivational interviewing or intensive counselling provided in clinical settings was effective.

A summary of the recommendations for smoking cessation interventions: the quality assurance in the treatment of drug dependence project

This report presents outlines for approaches to smoking cessation. These recommendations are based on a meta-analysis of the treatment-outcome literature, a survey of current treatment practices and the views of a panel of experts. Face-to-face intervention to assist smokers to stop smoking needs to be considered in the context of a public policy approach to reducing the prevalence of smoking. The nature of face-to-face interventions is determined by the time available to practitioners. Where there is no time to intervene (e.g. in some primary health care settings) quality self-help materials should be prominently displayed. Where there is only 10 minutes or less, attention should be focused on personalizing the health effects of smoking, providing firm advice to quit, providing self-help material, setting a quit date (if appropriate), identifying social support for cessation and organizing a follow-up visit. If there is more time to intervene (up to one hour) the previous techniques can be expanded on and supplemented with nicotine replacement and discussion of methods for dealing with high-risk situations. Longer interventions would use all of these methods, presenting them in more detail, and may also address stress management and minimization of weight gain.

Parental smoking cessation to protect young children: a systematic review and meta-analysis

BACKGROUND

Young children can be protected from much of the harm from tobacco smoke exposure if their parents quit smoking. Some researchers encourage parents to quit for their children's benefit, but the evidence for effectiveness of such approaches is mixed.

OBJECTIVE

To perform a systematic review and meta-analysis to quantify the effects of interventions that encourage parental cessation.

METHODS

We searched PubMed, the Cochrane Library, Web of Science, and PsycINFO. Controlled trials published before April 2011 that targeted smoking parents of infants or young children, encouraged parents to quit smoking for their children's benefit, and measured parental quit rates were included. Study quality was assessed. Relative risks and risk differences were calculated by using the DerSimonian and Laird random-effects model.

RESULTS

Eighteen trials were included. Interventions took place in hospitals, pediatric clinical settings, well-baby clinics, and family homes. Quit rates averaged 23.1% in the intervention group and 18.4% in the control group. The interventions successfully increased the parental quit rate. Subgroups with significant intervention benefits were children aged 4 to 17 years, interventions whose primary goal was cessation, interventions that offered medications, and interventions with high follow-up rates (>80%).

CONCLUSIONS

Interventions to achieve cessation among parents, for the sake of the children, provide a worthwhile addition to the arsenal of cessation approaches, and can help protect vulnerable children from harm due to tobacco smoke exposure. However, most parents do not quit, and additional strategies to protect children are needed.

A review of interventions for reduction of residential environmental tobacco smoke exposures among children

OBJECTIVE

To describe individual-level interventions to reduce residential environmental tobacco smoke (ETS) exposure among children and to summarize the evidence of the effectiveness of the interventions.

PATIENTS AND METHODS

A search of electronic databases (from 1987 to 1998) was conducted for studies designed to reduce ETS exposure of children through the use of interventions that included strategies other than parental smoking cessation. Twelve articles that presented nine unique interventions (six interventions were designed for well children and three interventions targeted children with asthma) were found. Information about location, target population, design, sample size, tested intervention and results were summarized for each study.

RESULTS

Only one of the six interventions designed for well children produced significant reductions in ETS exposure, while all three of the interventions that targeted children with asthma reported small to moderate reductions in ETS exposure or respiratory symptoms.

CONCLUSIONS

The number of interventions for ETS reduction published to date is miniscule relative to the magnitude of the associated health problems. Some ETS reduction interventions for children have shown significant reductions in exposure, but most interventions, especially those designed for well children, have had little effect. Little is known about which specific intervention components may be effective. Parental characteristics that may predict positive response to intervention efforts have not been identified. More research is needed to develop effective interventions that can be integrated with physician visits in the perinatal and early childhood periods. Adapting standard guidelines on counselling for parental smoking cessation may be a promising approach if the barriers identified by health professionals can be addressed adequately.

Counseling to reduce children's secondhand smoke exposure and help parents quit smoking: a controlled trial

INTRODUCTION

We tested a combined intervention to reduce children's secondhand smoke exposure (SHSe) and help parents quit smoking.

METHODS

After baseline, mothers who exposed their children younger than 4 years to 10 or more cigarettes/week were randomized to the intervention (n = 76) or usual care control condition (n = 74). Outcomes were assessed at 3, 6, 12, and 18 months. Intervention families were offered 10 in-person at home and 4 telephone counseling sessions over 6 months, and additional pre- and postquit telephone sessions. Counseling procedures included behavioral contracting, self-monitoring, and problem solving.

RESULTS

Parents' reports of their smoking and children's exposure showed moderate and significant correlations with children's urine cotinine levels and home air nicotine (r = .40-.78). Thirteen (17.1%) intervention group mothers and 4 (5.4%) controls reported that they quit smoking for 7 days prior to 1 or more study measurements, without biochemical contradiction (p = .024). Results of generalized estimating equations showed significantly greater decrease in reported SHSe and mothers' smoking in the counseled group compared with controls. Reported indoor smoking and children's urine cotinine decreased, yet group differences for changes were not significant.

DISCUSSION

Nicotine contamination of the home and resulting thirdhand exposure may have contributed to the failure to obtain a differential decrease in cotinine concentration. Partial exposure to counseling due to dropouts and lack of full participation from all family members and measurement reactivity in both conditions may have constrained intervention effects. Secondhand smoke exposure counseling may have been less powerful when combined with smoking cessation.

Parent quit attempts after counseling to reduce children's secondhand smoke exposure and promote cessation: main and moderating relationships

INTRODUCTION

This study explored predictors of smoking quit attempts in a sample of low-income smoking mothers who participated in a randomized trial of a 6-month, 14-session counseling intervention to decrease their children's secondhand smoke exposure (SHSe) and eliminate smoking.

METHODS

Measures were taken at baseline and at 3, 6, 12, and 18 months on 150 mothers who exposed their children (aged <4 years) to > or = 10 cigarettes/week in the home. Reported 7-day quits were verified by saliva cotinine or urine anabasine and anatabine levels.

RESULTS

There were few quits longer than 6 months. Mothers in the counseling group reported more 24-hr quits (p = .019) and more 7-day quits (p = .029) than controls. Multivariate modeling revealed that having quit for at least 24 hr in the year prior to baseline and the number of alternative cessation methods ever tried were predictive of the longest quit attempt during the 18-month study. Mothers in the counseling group who at baseline felt SHSe posed a health risk for their children or who at baseline had more permissive home smoking policies had longer quit attempts.

DISCUSSION

Results confirm that attempts to quit smoking predict additional quit attempts. This suggests that practice may be necessary for many people to quit smoking permanently. Findings of interaction analyses suggest that participant factors may alter the effects of treatment procedures. Failure to account for or employ such factors in the analysis or design of community trials could confound the results of intervention trials.

Potential unintended consequences of tobacco-control policies on mothers who smoke: a review of the literature

BACKGROUND

Secondhand smoke poses risks to children, particularly those from low socioeconomic backgrounds. Recently, there has been an increase in tobacco-control policies designed to reduce children's exposure to secondhand smoke, including interventions to change parental smoking behaviors. However, little attention has been paid to understanding potential unintended consequences of such initiatives on mothers who smoke. As such, the objectives of this paper are to explore the potential consequences of tobacco-control policies designed to reduce children's exposure to secondhand smoke on socially disadvantaged mothers who smoke and to provide recommendations for research, policy, and practice.

EVIDENCE ACQUISITION

A theory-guided, qualitative narrative review of the perceived discrimination, stigma, and stress and coping literature was conducted. MEDLINE and PsycINFO were searched to identify relevant articles from 1980 to October 2008 for review.

EVIDENCE SYNTHESIS

There is evidence that strategies designed to reduce secondhand smoke have contributed to smoking stigmatization. However, there is little research on the consequences of these initiatives or how they affect low-income mothers who smoke. Stigmatization research suggests that such policies may have unanticipated outcomes for socially disadvantaged mothers who smoke, such as decreased mental health; increased use of cigarettes or alcohol; avoidance or delay in seeking medical care; and poorer treatment by healthcare professionals. Recommendations for researchers, practitioners, and policymakers are presented.

CONCLUSIONS

Further research is needed to understand how initiatives to reduce children's exposure to secondhand smoke, as well as broader tobacco-control initiatives, can be designed to minimize potential harm to mothers who smoke.

Fidelity issues in secondhand smoking interventions for children

This paper reviews methodological and theoretical fidelity of secondhand smoking (SHS) intervention studies (n = 29) that target protection of children in their home. In 2005, interventions were evaluated in terms of treatment fidelity according to guidelines provided by Borrelli et al. of the National Institutes of Health Behavior Change Consortium. The degree of fidelity was evaluated based on the percentage of criteria met; the inter-rater reliability based on percent agreement across independent raters was 0.78. Analysis indicated that studies with higher treatment fidelity were more likely to obtain statistically significant results (p = .003) with the average fidelity rating of 0.74 for statistically significant studies vs. 0.50 for statistically non-significant studies. Higher treatment fidelity was also significantly associated with being a more recent investigation (year 2000 or later), an efficacy as compared to effectiveness trial, more intensive as compared to less intensive intervention, a trial in the U.S. as compared to foreign nations, and having a theoretical basis. After taking all other variables into account, only treatment fidelity was significantly related to study outcome (p = .052). Ratings of treatment fidelity were ranked and compared to previous rankings based on 342 behavioral change interventions; the rank-ordered correlation between previous and current ratings was 0.84, although median fidelity ratings were 0.10 points lower in the previous than in the present study (0.52 vs. 0.62; intraclass correlation = 0.79). Improvements to the treatment fidelity evaluation guidelines were suggested, including the consideration of theoretical fidelity. Enhancing methodological and theoretical fidelity will speed identification of valid theoretical precepts that will, in turn, guide effective public health prevention programs.

Family and carer smoking control programmes for reducing children's exposure to environmental tobacco smoke

BACKGROUND

Children's exposure to other people's cigarette smoke (environmental tobacco smoke, or ETS) is associated with a range of adverse health outcomes for children. Parental smoking is a common source of children's exposure to ETS. Preventing exposure to cigarette smoke in infancy and childhood has significant potential to improve children's health worldwide.

OBJECTIVES

To determine the effectiveness of interventions aiming to reduce exposure of children to ETS.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register and conducted additional searches of two health and education databases not included in this specialised register. Date of the most recent search: October 2007.

SELECTION CRITERIA

Interventions tested using controlled trials with or without random allocation were included in this review if the interventions addressed participants (parents and other family members, child care workers and teachers) involved with the care and education of infants and young children (aged 0-12 years). All mechanisms for reduction of children's environmental tobacco smoke exposure, and smoking prevention, cessation, and control programmes were included. These include smoke-free policies and legislation, health promotion, social-behavioural therapies, technology, education and clinical interventions.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies and extracted data. Due to heterogeneity of methodologies and outcomes, no summary measures were possible and results were synthesised using narrative summaries.

MAIN RESULTS

Thirty-six studies met the inclusion criteria. Four interventions were targeted at populations or community settings, 16 studies were conducted in the 'well child' healthcare setting and 13 in the 'ill child' healthcare setting. Two further studies conducted in paediatric clinics do not make clear whether the visits are to well or ill children, and another includes both well and ill child visits. Nineteen of these studies are from North America and 12 in other high income countries. Five studies are from low- or middle-income countries. In 17 of the 36 studies there was reduction of ETS exposure for children in both intervention and comparison groups. In only 11 of the 36 studies was there a statistically significant intervention effect. Four of these successful studies employed intensive counselling interventions targeted to smoking parents. We found little evidence of difference in effectiveness of interventions between the well infant, child respiratory illness and other child illness settings as contexts for parental smoking cessation interventions. One successful intervention was in the school setting, targeting the ETS exposure of children from smoking fathers.

AUTHORS' CONCLUSIONS

While brief counselling interventions have been identified as successful ifor adults when delivered by physicians, this cannot be extrapolated to adults as parents in child health settings. However, there is limited support for more intensive counselling interventions for parents in such contexts. There is no clear evidence of differences between the respiratory, non-respiratory ill child, well child and peripartum settings as contexts for reduction of children's ETS exposure.

Clinical effort against secondhand smoke exposure: development of framework and intervention

OBJECTIVE

The purpose of this work was to describe a novel process and present results of formative research to develop a pediatric office intervention that uses available systems of care for addressing parental smoking.

METHODS

The scientific development of the intervention occurred in 3 stages. In stage 1, we designed an office system for parental tobacco control in the pediatric outpatient setting on the basis of complementary conceptual frameworks of preventive services delivery, conceptualized for the child health care setting through a process of key interviews with leaders in the field of implementing practice change; existing Public Health Service guidelines that had been shown effective in adult practices; and adaptation of an evidence-based adult office system for tobacco control. This was an iterative process that yielded a theoretically framed intervention prototype. In stage 2, we performed focus-group testing in pediatric practices with pediatricians, nurses, clinical assistants, and key office staff. Using qualitative methods, we adapted the intervention prototype on the basis of this feedback to include 5 key implementation steps for the child health care setting. In stage 3, we presented the intervention to breakout groups at 2 national meetings of pediatric practitioners for additional refinements.

RESULTS

The main result was a theoretically grounded intervention that was responsive to the barriers and suggestions raised in the focus groups and at the national meetings. The Clinical Effort Against Secondhand Smoke Exposure intervention was designed to be flexible and adaptable to the particular practices' staffing, resources, and physical configuration. Practice staff can choose materials relevant to their own particular systems of care (www.ceasetobacco.org).

CONCLUSIONS

Conceptually grounded and focus-group-tested strategies for parental tobacco control are now available for implementation in the pediatric outpatient setting. The tobacco-control intervention-development process might have particular relevance for other chronic pediatric conditions that have a strong evidence base and have available treatments or resources that are underused.

Asthma is not enough: continuation of smoking among parents with an asthmatic child

BACKGROUND

Ideally, on diagnosis of asthma in a child, parents are counselled to decrease environmental tobacco smoke exposure to their children.

OBJECTIVE

To determine whether a diagnosis of asthma in children altered parental smoking behaviour toward a reduction in environmental tobacco smoke exposure.

METHODS

In 2002/2003, a survey was sent to 12,556 households with children born in 1995 in Manitoba. Parents were asked whether their seven-year-old child had asthma, and whether smokers were present in the home in 1995 and/or currently. The likelihood (OR) of a change in parental smoking behaviour was determined according to the presence of asthma in their child, a family history of asthma, the location of residence (rural or urban) and their socioeconomic status.

RESULTS

A total of 3580 surveys (28.5%) were returned. The overall prevalence of parental smoking in 1995 and 2002/2003 was 32.2% and 23.4%, respectively (31.9%/23.2% and 32.3%/23.6% in rural and urban environments, respectively). In 2002/2003, the prevalence of parental smoking in homes with asthmatic children was 29.8%. Parents were not more likely to quit smoking (OR=1.01, 95% CI 0.66 to 1.54) or smoke outside (OR=1.02, 95% CI 0.56 to 1.83) if their child developed asthma. Parental smoking behaviour (quit smoking or smoked outside) did not change if there was a positive family history of asthma (OR=1.04, 95% CI 0.78 to 1.37), if they lived in a rural or urban location (OR=0.94, 95% CI 0.71 to 1.23), or if they were from a low- or high-income household (OR=1.12, 95% CI 0.85 to 1.47).

CONCLUSIONS

The likelihood of altering parental smoking behaviour occurred independently of a diagnosis of asthma in their child, a family history of asthma, the location of residence and their socioeconomic status.

Evaluating environmental tobacco smoke exposure in a group of Turkish primary school students and developing intervention methods for prevention

Background

In countries like Turkey where smoking is highly prevalent, children's exposure to tobacco smoke is an important public health problem. The goals of this study were to determine the self-reported environmental tobacco smoke exposure status of primary school students in grades 3 to 5, to verify self-reported exposure levels with data provided from a biomarker of exposure, and to develop methods for preventing school children from passive smoking.

Methods

The study was conducted on 347 primary school students by using a standard questionnaire and urinary cotinine tests. Children with verified ETS exposure were randomly assigned to 2 intervention groups. Two phone interviews were conducted with the parents of the first group regarding their children's passive smoking status and its possible consequences. On the other hand, a brief note concerning urinary cotinine test result was sent to parents of the second group. Nine months after the initial urinary cotinine tests, measurements were repeated in both groups.

Results

According to questionnaire data, 59.9% of the study group (208 of 347) were exposed to ETS. Urinary cotinine measurements of children were highly consistent with the self-reported exposure levels (P < 0.001). Two different intervention methods were applied to parents of the exposed children. Control tests suggested a remarkable reduction in the proportion of those children demonstrating a recent exposure to ETS in both groups. Proportions of children with urinary cotinine concentrations 10 ng/ml or lower were 79.5% in Group I and 74.2% in Group II (P > 0.05).

Conclusion

Self-reported ETS exposure was found to be pretty accurate in the 9–11 age group when checked with urinary cotinine tests. Only informing parents that their childrens' ETS exposure were confirmed by a laboratory test seems to be very promising in preventing children from ETS.

Smoking hygiene: reducing infant exposure to tobacco

The American Academy of Pediatrics recently removed nicotine from the list of drugs contraindicated during breastfeeding. The objective of this study was to evaluate the feasibility of determining the effect of a smoking hygiene intervention on infants of breastfeeding mothers who smoke cigarettes. An experimental design with repeated measures was used. A convenience sample of 35 mother-infant dyads from seven sites was recruited and randomly assigned to the intervention or control group. Of the 27 dyads completing the study, 16 were in the experimental group and 11 were in the control group. Smoking hygiene was introduced when infants were 2 weeks old and reinforced when they were 3 and 5 weeks old. At these three data points, infant health and urinary nicotine and cotinine levels were measured, as well as the mothers' breast-milk nicotine and cotinine levels and smoking hygiene behaviors. Recruiting and retaining a sample of breastfeeding mothers who smoke proved difficult. Only 27% of women in the intervention group implemented all aspects of the smoking hygiene intervention behaviors. Repeated-measures ANOVA revealed no difference in a) infant urinary nicotine and cotinine levels or b) breast-milk nicotine and cotinine levels between the two groups. The McNemar test for related samples revealed no difference between frequency of respiratory symptoms in either the control or intervention groups when Week 2 levels were compared with levels at Weeks 3 and 5. Mothers were not successful in adhering to the smoking hygiene intervention. To adequately test interventions, strategies must be developed to help women incorporate health-promoting behaviors into their lives.

Predictors of the participation of smoking parents in a proactive telephone-based smoking cessation program

OBJECTIVE

The objective of this study is to identify the predictors of participation by smoking parents in a proactive telephone-based smoking cessation program.

METHODS

The smoking parents of young children from a birth cohort were interviewed and invited to take part in a telephone-based smoking cessation program. The characteristics of the parents and the predictors of participation were analyzed by chi-square test and by logistic regression.

RESULTS

A total of 952 (82.9%) out of the 1149 smoking parents who were interviewed agreed to participate in the smoking cessation program. The analysis showed that the predictors of participation in a pro-active smoking cessation program are being from a middle-income household, being currently employed, having recently had a medical consultation or been hospitalized, being at the stage of contemplating a change in behavior, and perceiving the importance of quitting smoking.

CONCLUSIONS

Recruitment approaches should be refined according to the identified factors to target those who might decline an invitation to participate in a smoking cessation program.

Parent reported home smoking bans and toddler (18-30 month) smoke exposure: a cross-sectional survey

AIMS

To study the relation between the use of parent reported home smoking bans and smoke exposure among children aged 18-30 months.

METHODS

A total of 309 smoking households with children aged 18-30 months, who were part of the Coventry Cohort study, consented to participate in this cross-sectional survey.

RESULTS

Although parents in almost 88% of smoking households reported using harm reduction strategies to protect their toddlers from smoke exposure, only 13.9% reported smoking bans in the house. Mean log urinary cotinine:creatinine ratio was significantly lower for those children whose parents reported no smoking in the house (1.11, 95% CI 0.64 to 1.49) compared with none/less strict strategies (1.87, 95% CI 1.64 to 2.10). In linear regression models fitted on log cotinine:creatinine ratio, no smoking in the house was independently associated with a significant reduction in cotinine:creatinine ratio (B = -0.55, 95% CI -0.89 to -0.20) after adjusting for mother's and partner's average daily cigarette consumption, housing tenure, and overcrowding. The final model accounted for 44.3% of the variance.

CONCLUSIONS

Not smoking in the house was associated with a reduction in mean urinary cotinine:creatinine ratio in children aged 18-30 months; the relation persisted after adjustment for levels of mother's and partner's daily cigarette consumption and sociodemographic factors. Results suggest that home smoking bans in this age group have a small but significant effect on smoke exposure independent of levels of parental tobacco consumption.

State-of-the-art interventions for office-based parental tobacco control

Parental tobacco use is a serious health issue for all family members. Child health care clinicians are in a unique and important position to address parental smoking because of the regular, multiple contacts with parents and the harmful health consequences to their patients. This article synthesizes the current evidence-based interventions for treatment of adults and applies them to the problem of addressing parental smoking in the context of the child health care setting. Brief interventions are effective, and complementary strategies such as quitlines will improve the chances of parental smoking cessation. Adopting the 5 A's framework strategy (ask, advise, assess, assist, and arrange) gives each parent the maximum chance of quitting. Within this framework, specific recommendations are made for child health care settings and clinicians. Ongoing research will help determine how best to implement parental smoking-cessation strategies more widely in a variety of child health care settings.

Addressing parental smoking in pediatrics and family practice: a national survey of parents

BACKGROUND

Parental smoking has been associated with increased rates of sudden infant death syndrome, low birth weight, otitis media, asthma, and decreased lung growth. No prior parent surveys have assessed national rates of screening and counseling for parental tobacco use in the context of their child's visit to primary care.

OBJECTIVE

To assess and compare rates of pediatrician and family practitioner screening and counseling for parental smoking. Design/Methods. Data were collected by telephone survey of households from July to September 2001. The sample is weighted by race and gender based on 1999 US Census estimates to be representative of the US population.

RESULTS

Of 3566 eligible respondents contacted, 3002 (84%) completed surveys; 902 of those were parents who had a child seen by a pediatrician (62%) or family practitioner (38%) in the past year. About half of all parents who visited a pediatrician or family practitioner reported that they had been asked about household member smoking status (52% vs 48%). More parents who visited pediatricians had been asked if they had rules prohibiting smoking in the home than those who visited family practitioners (38% vs 29%). Of 190 (21%) parents who were smokers, fewer than half reported being counseled by either specialty about dangers of second-hand smoke (41% vs 33%) or risks of modeling smoking behavior (31% vs 28%). Similarly, fewer than half of parental smokers received advice to quit (36% vs 45%).

CONCLUSION

Overall rates of screening and counseling for parental smoking in pediatric and family practice are low. Despite some differences between specialties, significant opportunities exist to improve tobacco control activities in primary care settings that serve children.

Intervention with parental smokers in an outpatient pediatric clinic using counseling and nicotine replacement

OBJECTIVE

To evaluate the feasibility of implementing a smoking cessation intervention for parents at the time of the pediatric visit.

METHODS

A prospective cohort of smoking parents whose child was seen in an outpatient pediatric practice was offered the Stop Tobacco Outreach Program, which includes 3 brief counseling sessions, written materials, free nicotine replacement therapy (NRT), proactive referral to a free state telephone quitline, and fax referral to the parents' primary clinician. The primary outcome was completion of all three counseling sessions. Other outcomes were quit attempts, cessation, NRT use, state quitline use, and household smoking assessed at 2-month follow-up.

RESULTS

One hundred fifty-eight smoking parents met eligibility criteria and 100 (63%) enrolled in the study. Of the 100 enrollees, 81% completed all three counseling sessions and 78% accepted free NRT at the time of enrollment. At 2-month follow-up, of the 100 enrollees, 56% reported making a quit attempt of >or=24 hours, 18% reported 7-day tobacco abstinence, 34% used NRT, and 42% received additional counseling from the state telephone quitline. The mean number of cigarettes smoked inside the home and car declined over 2 months (home, 5.1 vs 1.4; and car, 2.5 vs 1.4).

CONCLUSIONS

This study demonstrates the feasibility of engaging parents in a smoking cessation intervention at the time of a child's clinic visit. This approach may be an effective way to reach smokers who otherwise are unlikely to access smoking cessation interventions. High rates of program enrollment, use of NRT, and completion of telephone counseling in this study support the hypothesis that a child's clinic visit is a teachable moment to address parental smoking cessation.

Effect of strategies to reduce exposure of infants to environmental tobacco smoke in the home: cross sectional survey

OBJECTIVE

To examine parents' reported knowledge and use of harm reduction strategies to protect their infants from exposure to tobacco smoke in the home, and the relation between reported use of strategies and urinary cotinine to creatinine ratios in the infants.

DESIGN

Cross sectional survey.

SETTINGS

Coventry and Birmingham.

MAIN OUTCOME MEASURES

Parents' reported knowledge and use of harm reduction strategies and urinary cotinine to creatinine ratios in their infants.

PARTICIPANTS

314 smoking households with infants.

RESULTS

86% of parents (264/307) believed that environmental tobacco smoke is harmful, 90% (281/314) believed that infants can be protected from it in the home, and 10% (32/314) were either unaware of measures or reported using none. 65% of parents (205/314) reported using two or more measures, but only 18% (58/314) reported not allowing smoking in the home. No difference was found in mean log e transformed urinary cotinine to creatinine ratio in infants from households that used no measures compared with households that used less strict measures. Mean log cotinine to creatinine ratios were significantly different in households banning smoking in the home compared with those using less strict or no measures. Banning smoking in the home was independently associated with a significant reduction in urinary cotinine to creatinine ratio by a factor of 2.6 (1.6 to 4.2) after adjustment for average household cigarette consumption, tenure, and overcrowding.

CONCLUSIONS

Less than a fifth of parents in smoking households ban smoking in the home. Banning smoking was associated with a small but significant reduction in urinary cotinine to creatinine ratio in infants, whereas less strict measures compared with no measures had no effect on the infants' exposure to environmental tobacco smoke.

Family and carer smoking control programmes for reducing children's exposure to environmental tobacco smoke

BACKGROUND

Exposure to other people's cigarette smoke (environmental tobacco smoke, or ETS) is an important child health issue.

OBJECTIVES

To determine the effectiveness of interventions aiming to reduce exposure of children to ETS.

SEARCH STRATEGY

The Tobacco Addiction Group register of studies was searched. MEDLINE, EMBASE and four other health and psychology databases were searched electronically, bibliographies of retrieved primary studies were checked and specialists in the area consulted.

SELECTION CRITERIA

Controlled trials with or without random allocation were included in this review if they addressed participants (parents and other family members, child care workers and teachers) involved with the care and education of infants and young children (aged 0-12 years). All mechanisms for reduction of children's environmental tobacco smoke exposure, and smoking prevention, cessation, and control programmes targeting these participants are included. These include smoke free policies and legislation, health promotion, social-behavioural therapies, technology, education and clinical interventions.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed studies and extracted data. Due to heterogeneity of methodologies and outcomes, no summary measures were possible and results were synthesised using narrative summaries.

MAIN RESULTS

Nineteen studies met the inclusion criteria, one of which was subsequently excluded. Three interventions were targeted at populations or community settings, seven studies were conducted in the well child health care setting and eight in the ill child health care setting. Twelve of these studies are from North America. In 12 of the 18 studies there was reduction of ETS exposure for children in both intervention and comparison groups. In only four of the 18 studies was there a statistically significant intervention effect. Three of these successful studies employed intensive counselling interventions targeted to smoking parents. There is little difference between the well infant, child respiratory illness and other child illness settings as contexts for parental smoking cessation interventions. The fourth successful intervention was in the school setting targeting the ETS exposure of children from smoking fathers.

REVIEWER'S CONCLUSIONS

Brief counselling interventions, successful in the adult health setting when coming from physicians, cannot be extrapolated to adults in the setting of child health. There is limited support for more intensive counselling interventions. There is no clear evidence for differences between the respiratory, non-respiratory ill child, well child and peripartum settings as contexts for reduction of children's ETS exposure.

A smoking cessation intervention for parents of children who are hospitalized for respiratory illness: the stop tobacco outreach program

OBJECTIVE

Parental smoking is associated with increased rates and severity of childhood respiratory illness. No previous studies have examined child hospitalization as an opportunity for parental smoking cessation. We evaluated the feasibility of implementing a smoking cessation intervention for parents at the time of child hospitalization for respiratory illness.

METHODS

We performed a prospective cohort study of smoking parents who had a child who was admitted to an academic children's hospital for a respiratory illness between January and April 2000. All enrollees were offered the Stop Tobacco Outreach Program, which includes an initial motivational interview, written materials, nicotine replacement therapy (NRT), telephone counseling, and fax referral to parents' primary clinician. The primary outcome was completion of all 3 counseling sessions. Two-month follow-up outcomes were quit attempts, cessation, NRT use, primary care visits, household smoking prohibition, and satisfaction.

RESULTS

A total of 126 smoking parents met eligibility criteria, and 71 (56%) enrolled in the study. Of the 71, 80% completed all counseling sessions and 56% accepted free NRT at the time of enrollment. At the 2-month follow-up, of the 71 initial enrollees, 49% reported having made a quit attempt that lasted at least 24 hours, 21% reported not smoking a cigarette in the last 7 days, 27% reported having used NRT, and 38% had had a visit with their own primary clinician. The proportion of parents who reported rules prohibiting smoking in the house increased (29% vs 71%). Parental rating of the overall usefulness of the program was 4.3 +/- 0.9 (1 standard deviation) on the 5-point scale 1 = not at all and 5 = a great extent.

CONCLUSIONS

This study demonstrates the feasibility of engaging parents in smoking cessation interventions at the time of child hospitalization for respiratory illness. Previous work done in a similar sample of parental smokers has shown extremely low ever-use rates of cessation programs. High rates of acceptance of in-hospital and telephone counseling in this study support the notion of child hospitalization as a teachable moment to address parental smoking.

Smoking hygiene: an educational intervention to reduce respiratory symptoms in breastfeeding infants exposed to tobacco

The American Academy of Pediatrics recently removed nicotine from the category of drugs contraindicated during breastfeeding. Little evidence demonstrates that infants exposed to nicotine through breastfeeding experience increased health risks beyond the airborne risks associated with passive smoking. The purpose of this longitudinal, five-week, quasi-experimental pilot study was to determine whether "smoking hygiene," an educational intervention, reduces the frequency of respiratory symptoms experienced by infants whose mothers both smoke and breastfeed. Twenty-nine mother-infant pairs entered the study with 28% dropping out. Of the 21 mother-infant pairs who completed the study, 66% of the nine infants in the control group experienced respiratory illness, compared to 42% of the 12 infants in the intervention group (x2 = .814; p > .05). Thus, the difference was statistically nonsignificant in this small sample, but the trend worsened the anticipated direction. The study demonstrates some of the difficulties of intervening with this group of mothers.

A controlled trial of an environmental tobacco smoke reduction intervention in low-income children with asthma

STUDY OBJECTIVES

To determine the effectiveness of a cotinine-feedback, behaviorally based education intervention in reducing environmental tobacco smoke (ETS) exposure and health-care utilization of children with asthma.

DESIGN

Randomized controlled trial of educational intervention vs usual care.

SETTING

The pediatric pulmonary service of a regional pediatric hospital.

PARTICIPANTS

ETS-exposed, Medicaid/Medi-Cal-eligible, predominantly minority children who were 3 to 12 years old and who were seen for asthma in the hospital's emergency, inpatient, and outpatient services departments (n = 87).

INTERVENTION

Three nurse-led sessions employing behavior-changing strategies and basic asthma education and that incorporated repeated feedback on the child's urinary cotinine level.

MEASUREMENTS

The primary measurements were the urinary cotinine/creatinine ratio (CCR) and the number of acute asthma medical visits. The secondary measurements were number of hospitalizations, smoking restrictions in home, amount smoked, reported exposures of children, and asthma control.

RESULTS

The intervention was associated with a significantly lower odds ratio (OR) for more than one acute asthma medical visit in the follow-up year, after adjusting for baseline visits (total visits, 87; OR, 0.32; p = 0.03), and a comparably sized but nonsignificant OR for one or more hospitalization (OR, 0.34; p = 0.14). The follow-up CCR measurement and the determination of whether smoking was prohibited inside the home strongly favored the intervention group (n = 51) (mean difference in CCR adjusted for baseline, -0.38; p = 0.26; n = 51) (60; OR [for proportion of subjects prohibiting smoking], 0.24; p = 0.11; n = 60).

CONCLUSIONS

This intervention significantly reduced asthma health-care utilization in ETS-exposed, low-income, minority children. Effects sizes for urine cotinine and proportion prohibiting smoking were moderate to large but not statistically significant, possibly the result of reduced precision due to the loss of patients to active follow-up. Improving ETS reduction interventions and understanding their mechanism of action on asthma outcomes requires further controlled trials that measure ETS exposure and behavioral and disease outcomes concurrently.

Environmental tobacco smoke as a risk factor for respiratory disease in children

Respiratory diseases are a frequent reason for using health care. In 1995-1996, diseases of the respiratory tract (ICD 460-519) contributed seven of the top 15 reasons for visits to physician offices among children under 15 years of age in the United States. Environmental tobacco smoke (ETS) is a wide-spread environmental pollutant that has been long linked with respiratory problems. This paper will review the available literature on the role ETS plays in respiratory diseases, including asthma. This review focuses not only on the respiratory problems caused by ETS, but also examines the influence of age at exposure on the consequences of ETS and the importance of the differing sources of ETS exposure. As ETS is a completely preventable form of environmental pollution, the success or failure of various types of interventions will also be reviewed.

A randomized trial to reduce passive smoke exposure in low-income households with young children

OBJECTIVE

Passive smoke exposure among children is widespread in the United States; estimates suggest that almost 40% of children who are younger than 5 years live with a smoker. Few randomized studies of passive smoke exposure reduction among children have been conducted, and the impact of interventions that have been evaluated has been limited. The objective of this study was to determine whether a motivational intervention for smoking parents of young children will lead to reduced household passive smoke exposure.

METHODS

Project KISS (Keeping Infants Safe From Smoke), a theory-driven exposure reduction intervention targeting low-income families with young children, was a randomized controlled study in which participants-smoking parents/caregivers (N = 291) who had children who were younger than 3 years and who were recruited through primary care settings-were randomly assigned to either the motivational intervention (MI) or a self-help (SH) comparison condition was used. Follow-up assessments were conducted at 3 and 6 months. The MI condition consisted of a 30- to 45-minute motivational interviewing session at the participant's home with a trained health educator and 4 follow-up telephone counseling calls. Feedback from baseline household air nicotine assessments and assessment of the participant's carbon monoxide level was provided as part of the intervention. Participants in the SH group received a copy of the smoking cessation manual, the passive smoke reduction tip sheet, and the resource guide in the mail. Household nicotine levels were measured by a passive diffusion monitor.

RESULTS

The 6-month nicotine levels were significantly lower in MI households. Repeated measures analysis of variance across baseline, 3-month, and 6-month time points showed a significant time-by-treatment interaction, whereby nicotine levels for the MI group decreased significantly and nicotine levels for the SH group increased but were not significantly different from baseline.

CONCLUSIONS

This study targeted a large sample of racially and ethnically diverse low-income families, in whom both exposure and disease burden is likely to be significant. This is the first study to our knowledge that has been effective in reducing objective measures of passive smoke exposure in households with healthy children. These findings have important implications for pediatric health care providers, who play an important role in working with parents to protect children's health. Providers can help parents work toward reducing household passive smoke exposure using motivational strategies and providing a menu of approaches regardless of whether the parents are ready to quit.

Intervention and policy issues related to children's exposure to environmental tobacco smoke

BACKGROUND

Children's exposure to environmental tobacco smoke (ETS) is unacceptably high; almost 40% of children in the United States are regularly exposed to ETS.

METHODS

This paper presents a review of the literature that evaluates interventions designed to reduce ETS exposure among young children. In addition, it presents the study design for Project KISS (Keeping Infants Safe from Smoke), an intervention designed to utilize exposure-related feedback to increase parents' motivation for ETS reduction and to reduce household ETS levels. Baseline data are presented to illustrate factors that should be addressed in ETS interventions.

RESULTS

The literature review demonstrates the dearth of studies in the literature targeting ETS reduction among children. Participants in Project KISS believed that smoking had affected their children's health and were in later stages of motivational readiness to quit smoking than is typically observed. However, they face a number of challenges to smoking, such as high prevalence of nicotine dependence, high prevalence of living with other smokers, and socioeconomic and stress-related barriers.

CONCLUSIONS

The policy implications of this research are discussed, and recommendations are made for future research.

The pediatrician's role in reducing tobacco exposure in children

OBJECTIVE

Pediatricians have a unique and important role to play in the prevention and treatment of childhood and adolescent tobacco use, the protection of patients from the harmful effects of environmental tobacco smoke, and the encouragement of smoking cessation among parents. However, because recent research indicates that physician training in tobacco dependence is woefully weak and lacks a model for training, this article constructs a useful approach to this problem.

METHODOLOGY

A comprehensive review of the literature served as the basis for the development of a new model for pediatrician training in tobacco dependence.

RESULTS

A comprehensive model is presented for training pediatricians in the areas of reducing infant and child exposure to environmental tobacco smoke, preventing youth smoking initiation, and providing smoking cessation assistance for adolescents and parents.

CONCLUSIONS

Pediatricians have been called on to play an active role in the antitobacco arena. Because of their unique opportunity to interact with children, adolescents, and parents, pediatricians can and should be antitobacco interventionists. For this to occur, however, additional guidance should be provided to pediatricians during their training to better prepare them to carry out effective assessment and intervention practices. smoking initiation, smoking prevention, smoking cessation, environmental tobacco smoke, pediatricians.

Reported measures of environmental tobacco smoke exposure: trials and tribulations

OBJECTIVE

This report extends previous summaries of reported environmental tobacco smoke (ETS) exposure measures, reviews the empirical evidence of their validity for children's exposure, and discusses future research.

DATA SOURCES

Studies were identified by computer search and from the authors' research.

STUDY SELECTION

Studies were selected for inclusion of nicotine and/or cotinine and quantitative reported measures of ETS exposure.

DATA SYNTHESIS

Five studies found significant associations between reported quantitative exposure of children to ETS and either environmental nicotine or urine cotinine assays. Correlation coefficients between parent reports and nicotine ranged from 0.22 to 0.75. Coefficients for cotinine ranged from 0.28 to 0.71. Correlations increased over time and were stronger for parents' reports of their own smoking as a source of children's exposure than for reports of exposure from others.

CONCLUSIONS

Empirical studies show general concordance of reported and either environmental or biological measures of ETS exposure. Relationships were moderate, and suggest sufficient validity to be employed in research and service programs. Future studies need to identify the differences in types of reported or objective measures, population characteristics, etc, contributing to observed variability in order to understand better the conditions under which more valid reported ETS exposure and other measures can be obtained. Reported and either environmental or biological measures should be used in combination, and existing measures should be directed to interventions that may reduce ETS exposure among children.

How to prevent exposure to tobacco smoke among small children: a literature review

There are many reviews of current knowledge about smoking cessation in general within the health service, which also contain guidelines about smoking cessation during pregnancy. Our aim was to review methods in child healthcare for preventing the exposure of children to tobacco smoke. Since passive smoking starts during pregnancy, we also considered methods in antenatal care. We did a search for relevant articles, especially on randomized, controlled trials, in various databases, chiefly Medline. We mainly analysed studies from the last 10 y, concentrating on the actual interventions. In antenatal care the greatest effect comes from interventions based on behavioural strategies. These can lead to a doubling of the number of women who stop smoking during pregnancy. Purely factual information, on the other hand, has no great effect. The studies in child healthcare analysed here show that decisive factors for children not being exposed to passive smoking are a concentration on strengthening the parents' faith in their ability to create a smoke-free environment, and on behavioural strategies to achieve this goal, but not primarily on getting the parents to stop smoking. However, we need further studies of different types of interventions, geared to smokers with small children, before more specific recommendations can be given as to how child healthcare should design its tobacco-preventive work.

Reducing children's exposure to environmental tobacco smoke: the empirical evidence and directions for future research

OBJECTIVE

To summarise the issues and empirical evidence for reduction of children's residential environmental tobacco smoke (ETS) exposure.

DATA SOURCES

Literature was obtained by computer search, with emphasis on studies that included quantitative measures of ETS exposure in children's residences and interventions based on social learning theory.

STUDY SELECTION

Review and empirical articles concerning ETS exposure were included and inferences were drawn based on a synthesis of these studies as contrasted with a quantitative meta-analysis.

DATA SYNTHESIS

Interventions designed for residential/child ETS exposure control have included policy/legal regulations, minimal clinical services, and counselling services. Divorce court and adoption services have limited custody to protect children from ETS exposure. Controlled trials of clinicians' one time counselling services have shown null results. One controlled trial found that repeated physician ETS counselling increased parent cessation. Three trials found that repeated counselling/shaping procedures reduced quantitative estimates of ETS exposure in asthmatic children.

CONCLUSIONS

Insufficient controlled studies of repeated session counselling procedures have been completed to determine efficacy for ETS exposure reduction, but evidence is promising. One time minimal interventions appear ineffective, but large scale studies may be warranted. No studies have been conducted to assess court or adoption agency regulations; no community ordinances for regulating residential ETS exposure have been invoked. Ethical and enforcement issues are discussed.

Measures of exposure to environmental tobacco smoke. Validity, precision, and relevance

It is often not clear what the best measures of exposure are for a risk assessment, or even how one should answer this question. Environmental tobacco smoke (ETS) provides a good example for an exploration of uncertainty. There are a variety of methods for estimating exposure and each has short-comings. In this paper we summarize the physical characteristics of ETS and the principal methods for assessing exposure. We review the accuracy and applicability of these methods, and explore major sources of uncertainty in the assessment of ETS.

Trends in environmental tobacco smoke restrictions in the home in Victoria, Australia

OBJECTIVE

To assess the extent to which smokers and non-smokers in Victoria, Australia attempt to keep their homes smoke free and to determine whether the proportion of people attempting to do so has changed over time.

DESIGN

Face to face surveys conducted in Victoria each year from 1989 to 1997.

PARTICIPANTS

Approximately 2500 randomly selected adults each year.

MAIN OUTCOME MEASURES

Proportion of respondents who discourage their visitors from smoking; proportion of smokers who always smoke outside their own homes; behaviour of smokers when they are around children. Changes in each of these measures over time.

RESULTS

Reports of visitors being discouraged from smoking rose from 27% in 1989 to 53% in 1997. Smokers who reported always smoking outside the home rose from 20% in 1995 to 28% in 1997. Not smoking in the presence of children rose from 14% in 1989 to 33% in 1996. Indoor restrictions on smoking were associated with the presence of children in the household and even more strongly with the presence of non-smoking adults. People who worked in places where smoking was totally banned were more likely to ask their visitors not to smoke than those who worked where smoking was allowed.

CONCLUSIONS

The results indicate a strong move towards homes and towards protecting children from smoke. Efforts to support and facilitate this social change should be further encouraged.

Measuring infant exposure to environmental tobacco smoke

Methods to measure infant exposure to environmental tobacco smoke (ETS) are needed to identify infants at highest risk for ETS-related health problems. The purpose of this study was to validate measures sensitive to changes in levels of infant exposure to ETS and to develop a predictive model of infant exposure to ETS. Fifteen infants of smoking mothers were followed from birth to 6 weeks of age. Exposure to ETS was measured by using a smoking habits questionnaire, cigarette "butt" collection, infant urine nicotine and cotinine levels, and ambient nicotine (personal air monitors). The 24-hour cigarette butt collection was the best predictor of acute (adjusted r2 = .83) and chronic exposure (adjusted r2 = .47) measured by infant urinary nicotine and cotinine levels when the infants were 2 weeks of age. Including scores on the smoking habits questionnaire and ambient nicotine levels increased the adjusted r2 to .88 and .61, respectively.

Advising parents of asthmatic children on passive smoking: randomised controlled trial

OBJECTIVE

To investigate whether parents of asthmatic children would stop smoking or alter their smoking habits to protect their children from environmental tobacco smoke.

DESIGN

Randomised controlled trial.

SETTING

Tayside and Fife, Scotland.

PARTICIPANTS

501 families with an asthmatic child aged 2-12 years living with a parent who smoked.

INTERVENTION

Parents were told about the impact of passive smoking on asthma and were advised to stop smoking or change their smoking habits to protect their child's health.

MAIN OUTCOME MEASURES

Salivary cotinine concentrations in children, and changes in reported smoking habits of the parents 1 year after the intervention.

RESULTS

At the second visit, about 1 year after the baseline visit, a small decrease in salivary cotinine concentrations was found in both groups of children: the mean decrease in the intervention group (0.70 ng/ml) was slightly smaller than that of the control group (0.88 ng/ml), but the net difference of 0.19 ng/ml had a wide 95% confidence interval (-0.86 to 0.48). Overall, 98% of parents in both groups still smoked at follow up. However, there was a non-significant tendency for parents in the intervention group to report smoking more at follow up and to having a reduced desire to stop smoking.

CONCLUSIONS

A brief intervention to advise parents of asthmatic children about the risks from passive smoking was ineffective in reducing their children's exposure to environmental tobacco smoke. The intervention may have made some parents less inclined to stop smoking. If a clinician believes that a child's health is being affected by parental smoking, the parent's smoking needs to be addressed as a separate issue from the child's health.

Smoking and smoking cessation among men whose partners are pregnant: a qualitative study

Smoking among partners of non-smoking pregnant women has been linked to adverse pregnancy outcome, including low birthweight. Paternal smoking also increases the risk of infant respiratory infections and sudden infant death syndrome, irrespective of maternal smoking status. Furthermore, men's smoking habits are probably one of the strongest influences on the extent to which women are able to quit smoking in pregnancy and maintain cessation post birth. In four focus group discussions, male smokers whose partners were pregnant discussed their beliefs about passive smoking in pregnancy, the barriers they perceived to quitting in pregnancy and their preparedness to support maternal cessation. Men were largely unaware that their own smoking could pose a specific risk to the fetus, but when pregnant women are smokers, men believed their own smoking habits were unimportant. For men, barriers to quitting during their partners' pregnancy were: lack of understanding as to how passive smoking can affect the fetus, including a belief that the fetus is "protected" inside its mother; lack of motivation to quit early in pregnancy due to the baby not being "real"; and concern about stress-induced marital discord associated with cigarette withdrawal. These findings are discussed with regard to messages and strategies which may influence men to quit during their partners' pregnancy.

Reduction of environmental tobacco smoke exposure in asthmatic children. A 2-year follow-up

STUDY OBJECTIVE

To examine the long-term maintenance of a previously reported behavioral counseling intervention to reduce asthmatic children's exposure to environmental tobacco smoke (ETS).

PARTICIPANTS

Families of asthmatic children (6 to 17 years), including at least one parent who smoked in the home, recruited from four pediatric allergy clinics.

DESIGN

Participants were randomized to one of three groups: behavioral counseling to reduce ETS exposure, self-monitoring control, and usual medical care control. Counseling concluded at month 6, and the original trial ended at month 12. Two follow-up interviews occurred at months 20 and 30.

MEASUREMENTS AND RESULTS

The originally reported analysis of baseline to 12 months was reanalyzed with a more robust restricted maximum likelihood procedure. The 2-year follow-up period was analyzed similarly. Significantly greater change occurred in the counseling group than the control groups and was sustained throughout the 2 years of follow-up. Further exploratory analyses suggested that printed counseling materials given to all participants at month 12 (conclusion of the original study) were associated with decreased exposure in the control groups.

CONCLUSION

Such long-term maintenance of behavior change is highly unusual in the general behavioral science literature, let alone for addictive behaviors. We conclude that ETS exposure can be reduced and that a clinician-delivered treatment may provide substantial benefit.

Effects of information on smoking behaviour in families with preschool children

An information programme on measures to prevent passive smoking by children, designed for use during well-child visits, was tested. A total of 443 consecutive families with one or two smoking parents, attending mother and child health centres in Oslo, Norway, were randomly allocated to an intervention group (n = 221) and a control group (n = 222). Eighty families (18%) dropped out during the study period. For the intervention group, the communication between the health visitor and the family was prolonged at one well-child visit with a brief session on smoking, and the parents were given three brochures. The families in the control group received no information on smoking. Changes in practical measures to prevent passive smoking by the children (e.g. no smoking indoors) as well as changes in daily smoking and smoking quantity were assessed by parental reports. We found no significant differences between the groups with respect to change in smoking behaviour.

Quitting smoking: estimation by meta-analysis of the rate of unaided smoking cessation

The rates (after 12 months' follow-up) of unassisted smoking cessation reported in the literature have varied from 13.8 per cent to 8.5 per cent. A meta-analysis was conducted of the abstinence rates observed in 14 samples of smokers who presented at primary health settings and received either no intervention aimed at smoking or usual care (which involved no deliberate intervention for smoking cessation). The estimated rate of stopping smoking without intervention, over an average 10-month period, was 7.33 per cent. This rate is consistent with others reported in the literature when motivation to quit is taken into account. The estimate provides a baseline to judge the effects of smoking-cessation interventions.

Evaluation of a home-based intervention program to reduce infant passive smoking and lower respiratory illness

We conducted a randomized controlled trial to determine whether a home-based intervention program could reduce infant passive smoking and lower respiratory illness. The intervention consisted of four nurse home visits during the first 6 months of life, designed to assist families to reduce the infant's exposure to tobacco smoke. Among the 121 infants of smoking mothers who completed the study, there was a significant difference in trend over the year between the intervention and the control groups in the amount of exposure to tobacco smoke; infants in the intervention group were exposed to 5.9 fewer cigarettes per day at 12 months. There was no group difference in infant urine cotinine excretion. The prevalence of persistent lower respiratory symptoms was lower among intervention-group infants of smoking mothers whose head of household had no education beyond high school: intervention group, 14.6%; and controls, 34.0%.

Reducing tobacco smoke in the environment of the child with asthma: a cotinine-assisted, minimal-contact intervention

Children with asthma who are exposed to environmental tobacco smoke are at increased risk for adverse health consequences. An experimental design was used to evaluate a minimal-contact intervention aimed at modifying parents' smoking behavior in their homes. All subjects received counseling on the health effects of passive smoking and advice to quit smoking inside the home. Treatment subjects were also mailed the results of a urine cotinine test on their child and a self-help manual. More treatment (35%) than control (17%) subjects reported smoking outside their homes at posttest (and their children's cotinine levels were lower), but this difference was not statistically significant.

Ecology of passive smoking by young infants

This study provides a detailed description of passive smoking by 433 infants (mean age 18 days) enrolled from a representative population of healthy neonates in central North Carolina during 1986 and 1987. Sixty-four percent (276) lived in households with smokers or had contact with nonhousehold smokers. During the week before data collection, two thirds (184) of these 276 infants reportedly had tobacco smoke produced in their presence. Seventy-five percent of smoking mothers smoked near their infants. The amount smoked by the mother near the infant correlated with the amount smoked near the infant by nonmaternal smokers. Cotinine, an indicator of smoke absorption, was found in the urine of 60% (258) of all study infants. The amount smoked in the infant's presence, as well as the amount smoked farther away from the infant, especially by the mother, were the most significant correlates of the urine cotinine concentration. The results of this study suggest that efforts to reduce passive smoking in young infants should emphasize the importance of the mother's smoking behavior, smoke produced anywhere in the home, and household social influences on smoking behavior near the infant.