Assessment of tobacco smoke exposure in the pediatric emergency department

A qualitative exploration of the provision and prioritisation of smoking cessation support to patient carers in a paediatric ward in Australia

Background

Hospitalisation of a child is a unique opportunity for health staff to offer smoking cessation support; that is screening for carer smoking status, discussing cessation and providing interventions to carers who smoke. This has the potential to reduce the child’s exposure to second-hand smoke, and in turn tobacco related illnesses in children. However, these interventions are not always offered in paediatric wards. The aim of this study was to explore the provision and prioritisation of smoking cessation support to patient carers in a paediatric ward with a high proportion of Aboriginal patients and carers in a regional area of Australia’s Northern Territory.

Methods

This is a qualitative descriptive study of data collected through semi-structured interviews with 19 health staff. The interviews were audio recorded and transcribed verbatim. Thematic analysis was performed on the transcripts.

Results

We found low prioritisation of addressing carer smoking due to, a lack of systems and procedures to screen for smoking and provide quitting advice and unclear systems for providing more detailed cessation support to carers. Staff were demotivated by the lack of clear referral pathways. There were gaps in skills and knowledge, and health staff expressed a need for training opportunities in smoking cessation.

Conclusion

Health staff perceived they would provide more cessation support if there was a systematic approach with evidence-based resources for smoking cessation. These resources would include guidelines and clinical record systems with screening tools, clear action plans and referral pathways to guide clinical practice. Health staff requested support to identify existing training opportunities on smoking cessation.

Clinical decision support for tobacco screening and counseling parents of pediatric patients: A qualitative analysis of pediatric emergency department and urgent care professionals

Background

Clinical Decision Support Systems (CDSS) embedded into electronic medical records is a best practices approach. However, information is needed on how to incorporate a CDSS to facilitate parental tobacco cessation counseling and reduce child tobacco smoke exposure (TSE) in Pediatric Emergency Department (PED) and Urgent Care (UC) settings. The objective was to explore the barriers and enablers of CDSS use to facilitate child TSE screening and parental tobacco cessation counseling by PED/UC nurses and physicians.

Methods

We conducted 29 semi-structured, focused interviews with nurses (n = 17) and physicians (n = 12) at a children's hospital PED/UC. The interview guide included a brief presentation about the design and components of a prior CDSS tobacco intervention. Participants were asked their opinions about CDSS components and recommendations for adapting and implementing the CDSS tobacco intervention in the PED/UC setting. A thematic framework analysis method was used to code and analyze qualitative data.

Results

Participant mean (± SD) age was 42 (± 10.1) years; the majority were female (82.8%), non-Hispanic white (93.1%), and never tobacco users (86.2%); all were never electronic cigarette users. Four themes emerged: (1) explore optimal timing to complete CDSS screening and counseling during visits; (2) CDSS additional information and feedback needs; (3) perceived enablers to CDSS use, such as the systematic approach; and (4) perceived barriers to CDSS use, such as lack of time and staff.

Conclusions

The CDSS intervention for child TSE screening and parental tobacco cessation during PED/UC visits received endorsements and suggestions for optimal implementation from nurses and physicians.

Barriers to implementation of pediatric emergency department interventions for parental tobacco use and dependence: a qualitative study using the theoretical domains framework

Background

Pediatric emergency department (PED) and urgent care (UC) professionals can play a key role in delivering evidence-based guidelines to address parental tobacco use and child tobacco smoke exposure (TSE). Understanding PED/UC professionals’ perceptions regarding these guidelines is the first step in developing and implementing a TSE screening and counseling intervention in these settings. This study aimed to use the theoretical domains framework (TDF) to identify current screening and counseling behaviors of PED/UC professionals related to parental tobacco use and child TSE, and determine barriers and enablers that influence these behaviors.

Methods

Semi-structured, focused interviews were conducted with 29 actively practicing PED/UC clinical staff who worked at one large, Midwestern children’s hospital. The interview guide was informed by the TDF and included open-ended questions. Content analysis of interview transcripts was guided by the TDF. Nurses, physicians, and healthcare administrators were assessed overall and by group membership to ensure each group was represented based on their varying PED/UC roles.

Results

Fifty-one percent were nurses, 38% were physicians, and 11% were healthcare administrators. Most PED/UC professionals did not currently follow the guidelines, but perceived addressing parental tobacco use as part of their role. All 14 TDF domains were identified by nurses, physicians, and administrators in relation to counseling for parental tobacco use and child TSE. Domains with the most sub-themes were (1) knowledge: lack of knowledge about tobacco counseling, including implementing counseling, cessation resources/referrals, and thirdhand smoke; (2) beliefs about capabilities: not comfortable counseling parents, easier to discuss with parents who are receptive and to ask and advise when patients have a TSE-related complaint, and more likely to discuss if there were resources/referrals; and (3) environmental context and resources: barriers include lack of time, training, and resources and referral information to give to parents, and an enabler is using TSE-related complaints as a context to offer counseling.

Conclusions

Study findings provide a strong foundation for developing and implementing clinical practice guidelines regarding parental tobacco use and child TSE in the PED/UC setting. Future intervention development will address all TDF domains and test the implementation of the intervention in the PED/UC setting.

Evaluation of tobacco screening and counseling in a large, midwestern pediatric emergency department

INTRODUCTION

The study objective was to assess tobacco screening and cessation counseling practices of pediatric emergency department (PED) and urgent care (UC) nurses and physicians, and factors associated with these practices. Secondarily, we assessed factors associated with performing tobacco smoke exposure reduction and tobacco cessation counseling.

METHODS

We conducted a cross-sectional survey of 30 PED/UC nurses and physicians working at one large, urban, Midwestern children’s hospital. Measures included current practices of performing the 5 As of tobacco counseling (Ask, Advise, Assess, Assist, Arrange), and attitude and practice factors that may influence practices.

RESULTS

Overall, 90.0% of participants had not received recent tobacco counseling training, 73.3% were unaware of the 5 As, and 63.3% did not have a standardized, routine screening system to identify patients exposed to secondhand smoke. The majority of participants reported that they: asked about patients’ secondhand smoke exposure status (70.0%) and parents’ tobacco use status (53.3%), and advised parental smokers to not smoke around their child (70.0%) and to quit smoking (50%). One in five participants reported they assessed smokers’ interest in quitting smoking, and 16.7% talked with smokers about cessation techniques and tactics; of these, 10% referred/enrolled smokers to the Tobacco Quitline or cessation program, and 6.7% made a quit plan or recommended nicotine replacement therapy medication.

CONCLUSIONS

Key findings identified are the need for professional tobacco counseling training, standardizing efforts during visits, and emphasizing pediatric patients’ potential health benefits. This information will be used for developing a PED/ UC-based parental tobacco cessation and child tobacco smoke exposure reduction intervention.

Tobacco-Related Counseling and Documentation in Adolescent Primary Care Practice: Challenges and Opportunities

INTRODUCTION

Primary care visits present an opportunity to reduce tobacco use and tobacco smoke exposure (TSE) among adolescents. To date, few studies have examined tobacco-related electronic health record (EHR) documentation in adolescent visits. The purpose of this study was to (1) describe tobacco-related EHR documentation practices in adolescent care clinics, including whether alternative tobacco products, parental use, and TSE were addressed; and (2) identify aspects of adolescent tobacco use that may inform EHR updates and counseling and documentation practices.

METHODS

Following a convergent mixed-methods design, we conducted an EHR review of 508 adolescent well-child visits, performed focus groups with pediatric providers and staff, and conducted in-depth interviews with adolescent patients. Record review data and interview transcripts were analyzed and interpreted concurrently.

RESULTS

In the EHR review, cigarette screening was documented in 92.3% of visits, smokeless tobacco screening in 51.4%, parental tobacco use in 23.2%, and home TSE in 33.1% of visits. Smoking status options were not mutually exclusive and did not include noncigarette products. No records documented assessment of e-cigarette use, despite nearly half of adolescent interview respondents citing these as the most popular products among adolescents. In interviews, adolescents discussed their experiences with alternative tobacco/nicotine products more than cigarettes.

CONCLUSIONS

Tobacco use status prompts should be revised for clarity and include noncigarette tobacco products and TSE. Provider education on noncigarette products and TSE assessment is needed. Improvements in EHR systems, resources, and tools can lead to better tobacco screening, prevention, and treatment practices among primary care providers.

IMPLICATIONS

Clinical guidelines call for pediatricians to assess and treat adolescent and parental tobacco use during primary care visits. The use of electronic health records (EHRs) can improve screening and counseling practices; however, few studies have examined tobacco-related EHR documentation practices in adolescent care settings. This mixed-methods study found low rates of EHR documentation related to noncigarette nicotine/tobacco products, parental tobacco use, and tobacco smoke exposure. These results demonstrate the need for increased provider training and EHR modifications to facilitate comprehensive tobacco control efforts in the adolescent population.

Tobacco smoke exposure disparities persist in U.S. children: NHANES 1999-2014

Tobacco smoke exposure (TSE) is a common modifiable hazard to children. The objective was to investigate how the prevalence of TSE varied from 1999 to 2014 among U.S. children and to calculate differences between sociodemographic characteristics and TSE by two-year increases. We also assessed associations between sociodemographics and TSE in 2013-2014. A secondary analysis of data from the National Health and Nutrition Examination Survey 1999-2014 was performed including 14,199 children 3-11 years old from nationwide. We conducted logistic regression analyses to assess TSE trends, and associations between sociodemographics and TSE in 2013-2014. TSE prevalence declined from 64.5% to 38.1% during 1999-2014 (a relative reduction of 44.4%). TSE declined among all sociodemographics. In 2013-2014, differences in TSE were found by race/ethnicity, family monthly poverty level [FPL], and house status. Non-Hispanic black children were 1.85 times more likely (95%CI[1.39-2.47]) to be exposed to tobacco smoke than non-Hispanic white children, whereas Non-Hispanic other (OR = 0.71, 95%CI[0.52-0.96]), Hispanic other (OR = 0.42, 95%CI[0.30-0.59]), and Hispanic Mexican (OR = 0.27, 95%CI[0.21-0.35]) children were at lower risk of exposure. Compared to those in the highest FPL category (>185%), children with FPL ≤130% were 3.37 times more likely (95%CI[2.73-4.15]) and children with FPL 131-185% were 1.80 times more likely (95%CI[1.31-2.49]) to be exposed. Children who lived in rented homes were 2.23 times more likely (95%CI[1.85-2.69]) to be exposed than children who lived in owned homes. Targeted tobacco control efforts are needed to reduce existing TSE disparities among children, especially those who are non-Hispanic black, low socioeconomic status, and live in rented homes.

Association of secondhand smoke exposure with asthma symptoms, medication use, and healthcare utilization among asthmatic adolescents

OBJECTIVE

To investigate the association between secondhand smoke exposure (SHSe) and asthma symptoms, medication use, and emergency department (ED)/urgent care (UC) utilization among adolescents.

METHODS

We performed a secondary cross-sectional analysis of Population Assessment of Tobacco and Health Study Wave 2 (2014-2015) including asthmatic adolescents (N = 2198). Logistic regression models and Poisson regression models were built.

RESULTS

Participants with SHSe ≥1 hour in the past 7 days were at increased risk of reporting shortness of breath and harder to exercise aOR, 1.22; 95% CI, 1.04-1.43), wheezing (aOR, 1.26; 95% CI, 1.01-1.56), wheezing disturbing sleep (aOR, 1.88; 95% CI, 1.35-2.63), wheezing during/after exercise (aOR, 1.41; 95% CI, 1.19-1.66), wheezing limiting speech (aOR, 2.11; 95% CI, 1.55-2.86), dry cough at night (aOR, 1.86; 95% CI, 1.54-2.24), and asthma symptoms disturbing sleep (aOR, 2.25; 95% CI, 1.81-2.79). Participants with SHSe ≥1 hour were more likely to take asthma medications (aOR, 1.25; 95% CI, 1.03-1.52), including steroids (aOR, 1.86; 95% CI, 1.19-2.91), oxygen therapy (aOR, 2.88; 95% CI, 1.82-4.54), and controlling medications (aOR, 1.50; 95% CI, 1.24-1.82). Symptoms and medications varied by living with a smoker and home SHSe. Participants with SHSe were at increased risk of having a higher number of asthma attacks that required steroid use. Participants who lived with a smoker and had home SHSe were at increased risk of having higher ED/UC visits for asthma.

CONCLUSIONS

SHSe reduction efforts are needed for asthmatic adolescents, and EDs/UCs are promising venues.

Home Smoke Exposure and Health-Related Quality of Life in Children with Acute Respiratory Illness

OBJECTIVE

This study aims to assess whether secondhand smoke (SHS) exposure has an impact on health-related quality of life (HRQOL) in children with acute respiratory illness (ARI).

METHODS

This study was nested within a multicenter, prospective cohort study of children (two weeks to 16 years) with ARI (emergency department visits for croup and hospitalizations for croup, asthma, bronchiolitis, and pneumonia) between July 1, 2014 and June 30, 2016. Subjects were surveyed upon enrollment for sociodemographics, healthcare utilization, home SHS exposure (0 or ≥1 smoker in the home), and child HRQOL (Pediatric Quality of Life Physical Functioning Scale) for both baseline health (preceding illness) and acute illness (on admission). Data on insurance status and medical complexity were collected from the Pediatric Hospital Information System database. Multivariable linear mixed regression models examined associations between SHS exposure and HRQOL.

RESULTS

Home SHS exposure was reported in 728 (32%) of the 2,309 included children. Compared with nonexposed children, SHS-exposed children had significantly lower HRQOL scores for baseline health (mean difference -3.04 [95% CI -4.34, -1.74]) and acute illness (-2.16 [-4.22, -0.10]). Associations were strongest among children living with two or more smokers. HRQOL scores were lower among SHS-exposed children for all four conditions but only significant at baseline for bronchiolitis (-2.94 [-5.0, -0.89]) and pneumonia (-4.13 [-6.82, -1.44]) and on admission for croup (-5.71 [-10.67, -0.75]).

CONCLUSIONS

Our study demonstrates an association between regular SHS exposure and decreased HRQOL with a dose-dependent response for children with ARI, providing further evidence of the negative impact of SHS.

Adolescent Tobacco Smoke Exposure, Respiratory Symptoms, and Emergency Department Use

OBJECTIVES

Our objective was to examine the relationship between distinct tobacco smoke exposure (TSE) measures and TSE-related symptoms and emergency department (ED) and/or urgent care (UC) use among nonsmoking adolescents without asthma diagnoses.

METHODS

We performed a secondary analysis of 7389 adolescents who completed the Population Assessment of Tobacco and Health Study wave 2. Logistic regression and Poisson regression models were built.

RESULTS

Adolescents with TSE were at increased risk of reporting: shortness of breath, finding it hard to exercise, wheezing during or after exercise, and dry cough at night. Adolescents who lived with a smoker and had home TSE were at increased odds of reporting wheezing or whistling in the chest, and only adolescents with home TSE were at increased risk of reporting wheezing that disturbed sleep. Adolescents with TSE were less likely to report very good or excellent overall health and physical health but were more likely to report they sometimes, often, or very often missed school because of illness. Participants who lived with a smoker and had TSE ≥1 hour were more likely to have had an ED and/or UC visit. Participants with any TSE were at increased risk of having a higher number of ED and/or UC visits.

CONCLUSIONS

Different TSE measures uniquely increased the risk of TSE-related symptoms, but any TSE increased the risk of having a higher number of ED and/or UC visits. The providers at these high-volume settings should offer interventions to adolescents who are exposed to tobacco smoke and their families to decrease these symptoms and related morbidity.

Awareness of health effects of exposure to secondhand smoke from cigarettes: A cross-sectional study of never-smoked adult primary care patients in Eastern Nigeria

Background:

Cigarette smoking whether actively or passively is a growing public health problem. Despite the wealth of information on the hazards of active cigarette smoking, awareness of the health effects of passive smoking on human population is often neglected in Nigeria.

Aim:

The study was aimed at describing the awareness of health effects of exposure to secondhand smoke from cigarettes among never-smoked adult primary care patients in Eastern Nigeria.

Materials and Methods:

A hospital-based study carried out on a cross-section of 500 adult patients in a primary care clinic in Nigeria. Data were collected using pretested, structured, and interviewer-administered questionnaire. Exposure to secondhand smoke was defined as exposure to cigarette smoke in a never-smoked adult patient in the previous 1 year. Data were analyzed using Statistical Package for Social Sciences version 21 for the calculation of percentages for categorical variables. Bivariate analysis involving Chi-square test was used to test for significance of association between categorical variables at P < 0.05.

Results:

The age of the respondents ranged from 18 to 74 years, with a mean age of 36 ± 12.4 years. There were 180 (36.0%) males with 320 (64%) females, with a sex ratio of 1.8. Awareness of general health effects of secondhand smoke on adults, children, and pregnant women was 95.6%, 92.8%, and 65.2%, respectively. The most common specific health effects the respondents were aware for adults, children, and obstetric population were lung cancer (95.6%), precipitation of asthmatic condition (92.8%), and delivery of small babies (65.2%), respectively. The predominant source of awareness of information was radio (93.6%). Awareness of general health effects of exposure to secondhand smoke on adults (P = 0.041), children (P = 0.031), and obstetrics population (P = 0.02) was significantly associated with exposure status.

Conclusion:

The most common health effects of secondhand smoke the respondents had highest awareness were lung cancer, precipitation of asthmatic attacks, and delivery of small babies in adults, children, and obstetric population, respectively. Awareness of general health effects on adults, children, and obstetrics population was significantly associated with exposure status. The current level of awareness should be improved while effort should be intensified to address identified areas of low level of awareness.

Secondhand smoke exposure, illness severity, and resource utilization in pediatric emergency department patients with respiratory illnesses

OBJECTIVE

Hospital-based data reveal that children who have secondhand smoke exposure (SHSe) experience severe respiratory illnesses and greater resource utilization. Our objective was to assess the relationship between SHSe and illness severity/resource utilization among children presenting to the pediatric emergency department (PED) with three common respiratory conditions-asthma, bronchiolitis, and pneumonia.

METHODS

A retrospective review of a yearlong consecutive sample of PED patients with SHSe status documentation and asthma, bronchiolitis, or pneumonia diagnoses was performed. PED illness severity/resource utilization variables included triage categorization, initial oxygen saturation, evaluation/testing (influenza A & B, respiratory syncytial virus, chest X-ray), procedures/interventions performed (supplemental oxygen, suctioning, intubation), medications administered, and disposition. Logistic and linear regression models were conducted to determine differences in each diagnosis group while controlling for sociodemographics, medical history, seasonality, and insurance type.

RESULTS

There were 3,229 children with documentation of SHSe status and an asthma (41%), bronchiolitis (36%), or pneumonia (23%) diagnosis. Across diagnosis groups, approximately 1/4 had positive documentation of SHSe. Asthmatic children with SHSe were more likely to receive corticosteroids (odds ratio (OR) = 1.71, 95% confidence interval (CI) = 1.19, 2.44) and/or magnesium sulfate (OR = 1.66, 95% CI = 1.14, 2.40). Children with SHSe and bronchiolitis were more likely to receive racemic epinephrine (OR = 2.48, 95% CI = 1.21, 5.08), have a chest X-ray (OR = 1.36, 95% CI = 1.00, 1.85), and/or be admitted (OR = 1.46, 95% CI = 1.09, 1.95). No differences in illness severity/resource utilization were identified for children with pneumonia.

CONCLUSIONS

SHS-exposed children with asthma or bronchiolitis have greater illness severity/resource utilization. Our findings highlight the importance of SHSe assessment, cessation, and research efforts in the PED setting.

Secondhand Smoke Exposure and Pediatric Healthcare Visits and Hospitalizations

INTRODUCTION

This study assessed the relationship between secondhand smoke exposure (SHSe) as measured by serum cotinine and healthcare utilization among children.

METHODS

In 2016, the 2009-2012 National Health and Nutrition Examination Survey data were analyzed including 4,985 children aged 3-19 years. Associations between SHSe and having a routine place for healthcare, type of place, and hospital utilization were examined using logistic regression models. Poisson regression analyses assessed the relationship between SHSe and number of hospital admissions. Relationships between SHSe and acute care visits and hospital utilization were examined among asthmatic children.

RESULTS

SHSe level did not differ by having a routine place for healthcare, although children with high SHSe indicative of active smoking (cotinine ≥3 ng/mL) were 3.49 times (95% CI=1.77, 6.89) more likely to use an emergency department. Children with high SHSe were 2.85 times (95% CI=1.87, 4.34) more likely to have had an overnight hospital stay. Children with high SHSe had 2.05 times (95% CI=1.46, 2.87) the risk of having a higher number of hospital admissions for overnight stays versus children with no SHSe (cotinine <0.05 ng/mL). Among asthmatic children, those with high SHSe and low SHSe (cotinine 0.05-2.99 ng/mL) were more likely to have an acute care visit, overnight hospital stay, and higher number of hospital admissions than asthmatic children with no SHSe.

CONCLUSIONS

High SHSe is associated with increased healthcare utilization. The emergency department and inpatient settings are important venues in which to routinely offer cessation and SHSe reduction interventions.

Tobacco Smoke Exposure and Health-Care Utilization Among Children in the United States

PURPOSE

The purpose of this study was to assess patterns of health-care utilization among children who potentially had tobacco smoke exposure (TSE) compared to those who were not exposed.

DESIGN

A secondary data analysis of the 2011 to 2012 National Survey on Children's Health was performed.

SETTING

Households nationwide were selected.

PARTICIPANTS

A total of 95 677 children aged 0 to 17 years.

MEASURES

Sociodemographic characteristics, TSE status, and health-care visits were measured.

ANALYSIS

Multivariable logistic regression models were performed.

RESULTS

A total of 24.1% of children lived with smokers. Approximately 5% had home TSE. Participants who lived with a smoker were significantly more likely to have had a medical care visit (odds ratio [OR] = 1.22, confidence interval [CI] = 1.21-1.22) and were more likely to seek sick care or health advice at an emergency department (OR = 1.23, CI = 1.23-1.24) but were less likely to have had a dental care visit (OR = 0.82, CI = 0.82-0.83) than those who did not live with a smoker. Similar findings were found among participants who had home TSE.

CONCLUSION

TSE is a risk factor for increased use of pediatric medical care. Based on the high number of children who potentially had TSE and received sick care or health advice at an emergency emergency department, this setting may be a venue to deliver health messages to caregivers.