Behavioral counseling for reducing children's ETS exposure: implementation in community clinics

Changing Exposure Perceptions: A Randomized Controlled Trial of an Intervention with Smoking Parents

Children who live with smokers are at risk of poor health, and of becoming smokers themselves. Misperceptions of the nature of tobacco smoke exposure have been demonstrated among parents, resulting in continued smoking in their children’s environment. This study aimed to change parents’ perceptions of exposure by providing information on second- and third-hand exposure and personalised information on children’s exposure [NIH registry (NCT02867241)]. One hundred and fifty-nine families with a child < 8 years and at least one smoking parent were randomized into intervention (69), control (70), and enhanced control (20) groups. Reported exposure, parental smoking details, and a child hair sample were obtained at the start of the study and 6–8 months later. Parental perceptions of exposure (PPE) were assessed via a questionnaire. The intervention consisted of motivational interviews, feedback of home air quality and child’s hair nicotine level, and information brochures. PPE were significantly higher at the study end (94.6 ± 17.6) compared to study beginning (86.5 ± 19.3) in intervention and enhanced control groups (t(72) = −3.950; p < 0.001). PPE at study end were significantly higher in the intervention group compared to the regular control group (p = 0.020). There was no significant interaction between time and group. Parallel changes in parental smoking behaviour were found. Parental perceptions of exposure were increased significantly post intervention, indicating that they can be altered. By making parents more aware of exposure and the circumstances in which it occurs, we can help parents change their smoking behaviour and better protect their children.

Kids Safe and Smokefree (KiSS) Multilevel Intervention to Reduce Child Tobacco Smoke Exposure: Long-Term Results of a Randomized Controlled Trial

BACKGROUND

Pediatricians following clinical practice guidelines for tobacco intervention (“Ask, Advise, and Refer” [AAR]) can motivate parents to reduce child tobacco smoke exposure (TSE). However, brief clinic interventions are unable to provide the more intensive, evidence-based behavioral treatments that facilitate the knowledge, skills, and confidence that parents need to both reduce child TSE and quit smoking. We hypothesized that a multilevel treatment model integrating pediatric clinic-level AAR with individual-level, telephone counseling would promote greater long-term (12-month) child TSE reduction and parent smoking cessation than clinic-level AAR alone.

METHODS

Pediatricians were trained to implement AAR with parents during clinic visits and reminded via prompts embedded in electronic health records. Following AAR, parents were randomized to intervention (AAR + counseling) or nutrition education attention control (AAR + control). Child TSE and parent quit status were bioverified.

RESULTS

Participants (n = 327) were 83% female, 83% African American, and 79% below the poverty level. Child TSE (urine cotinine) declined significantly in both conditions from baseline to 12 months (p = 0.001), with no between-group differences. The intervention had a statistically significant effect on 12-month bioverified quit status (p = 0.029): those in the intervention group were 2.47 times more likely to quit smoking than those in the control. Child age was negatively associated with 12-month log-cotinine (p = 0.01), whereas nicotine dependence was positively associated with 12-month log-cotinine levels (p = 0.001) and negatively associated with bioverified quit status (p = 0.006).

CONCLUSIONS

Pediatrician advice alone may be sufficient to increase parent protections of children from TSE. Integrating clinic-level intervention with more intensive individual-level smoking intervention is necessary to promote parent cessation.

Self-Reported Environmental Tobacco Smoke Exposure and Avoidance Compared with Cotinine Confirmed Tobacco Smoke Exposure among Pregnant Women and Their Infants

BACKGROUND

Exposure to environmental tobacco smoke (ETS) presents substantial health risks for pregnant women and newborn infants. Measurements of ETS include invasive and expensive biochemical tests, as well as less invasive and lower-cost, self-reported exposure and avoidance measures. Better understanding of self-report measures will help to select ETS assessments for evaluation.

METHODS

This analysis was conducted within the context of a tailored video intervention to reduce tobacco smoking and ETS exposure during pregnancy and after delivery in the control group sample of 147 nonsmoking women. Measurements of salivary cotinine concentration, self-reported ETS exposure, and avoidance behaviors were captured at 32 weeks’ gestation and 6 months postpartum.

RESULTS

Salivary cotinine concentration was significantly related to ETS avoidance among pregnant nonsmokers at 32 weeks’ gestation, but not ETS exposure. At 6 months postpartum, both the reported ETS exposure of the infant and maternal avoidance behaviors to reduce her infant’s exposure were associated with the infant’s salivary cotinine concentration. At 32 weeks’ gestation and 6 months postpartum, avoidance behaviors decreased as exposure increased.

DISCUSSION

This study suggests that for nonsmoking women during pregnancy, reports of tobacco smoke avoidance are more valid than reports of exposure. After delivery, self-reported ETS exposure or avoidance are associated with each other and the biochemical measurement of salivary cotinine. These results provide researchers and clinicians with evidence to support the inclusion of avoidance behaviors in the selection of ETS measures.

A Cluster Randomised Controlled Trial of a Brief Child Health Nurse Intervention to Reduce Infant Secondhand Smoke Exposure

Background Exposure to secondhand smoke (SHS) is a significant contributor to ill health in children. A study was undertaken to determine the effectiveness of two brief multi-strategic child health nurse delivered interventions in: decreasing the prevalence of infants exposed to SHS; decreasing the prevalence of smoking amongst parent/carers of infants and increasing the prevalence of household smoking bans. Methods This study was a 3 arm, cluster randomised controlled trial. Clusters were 39 community based well child health clinics in one local area health service. Clinics were stratified according to annual number of client appointments and then randomly assigned in a 1:1:1 ratio, (Intervention 1: Intervention 2: Control), with 13 clinics in each cluster. Parents/carers of infants in the intervention groups received a brief multi-strategic intervention from child health nurses during clinic consultations. Treatment condition 1 included computer delivered risk assessment and feedback and nurse brief advice. Treatment condition 2 included all elements of Treatment condition 1 with the addition of biochemical feedback of infant SHS exposure. Results When compared to the Control group at 12 months, no significant differences in the prevalence of infant exposure to SHS were detected from baseline to follow-up for Treatment condition 1 (OR 1.16, 95 % CI 0.73-1.85, p = 0.53) or Treatment condition 2 (OR 1.30, 95 % CI 0.88-1.92, p = 0.19) Similarly, no significant differences were detected in the proportion of parent/carers who reported that they were smokers (T1:OR 0.95, 95 % CI 0.78-1.15, p = 0.58 and T2:OR 0.97, 95 % CI 0.80-1.18, p = 0.77), or in the proportion of households reported to have a complete smoking ban (T1:OR 1.21, 95 % CI 0.89-1.64, p = 0.23 and T2:OR 1.06, 95 % CI 0.79-1.43, p = 0.68). Conclusions Further research is required to identify effective interventions that can be consistently provided by child health nurses if the potential of such settings to contribute to reductions in child SHS exposure is to be realised.

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.

Family-Based Smoking Cessation Intervention for Smoking Fathers and Nonsmoking Mothers with a Child: A Randomized Controlled Trial

OBJECTIVE

To examine whether a family-based intervention targeting both smoking fathers and nonsmoking mothers in well-child health clinics is effective in increasing fathers' abstinence from cigarette smoking.

STUDY DESIGN

This parallel 2-arm randomized controlled trial recruited a total of 1158 families with a daily-smoking father, a nonsmoking mother, and a child aged 0-18 months from the 22 maternal and child health centers in Hong Kong. The intervention group received the family-based intervention, including 6 nurse-led individual face-to-face and telephone counseling sessions within 1 month after recruitment and a voluntary face-to-face family counseling session (FCS). The control group received a leaflet, a self-help booklet, and brief quitting advice only. Father-reported 7-day and 6-month abstinence, smoking reduction, quit attempts, mother-reported help and support, and child salivary cotinine level were assessed at 12 months. Generalized estimating equation models were used to compare these outcomes between the 2 study groups.

RESULTS

Compared with the control group, the intervention group reported a greater prevalence of 7-day (13.7% vs 8.0%; OR, 1.92; 95% CI, 1.16-3.17; P < .01) and 6-month self-reported abstinence (13.4% vs. 7.5%; OR, 2.10; 95% CI, 1.30-3.40; P < .01). Within the intervention group, compared with receipt of individual counseling only, participation in the FCS was associated with increases in fathers' self-reported abstinence (20.2% vs 12.3%; P = .02), mothers' help (66.1% vs 43.8%; P < .01), and support to the fathers (55.0% vs 45.4%; P < .01).

CONCLUSIONS

The family-based smoking cessation intervention for the families in the well-child healthcare setting was effective in increasing the fathers' self-reported abstinence. Additional participation in the FCS increased mothers' help and support to the fathers.

TRIAL REGISTRATION

Controlled-trials.com: ISRCTN99111655; Hkuctr.com: HKUCTR-465.

A tailored video intervention to reduce smoking and environmental tobacco exposure during and after pregnancy: Rationale, design and methods of Baby's Breath

Low-cost interventions to decrease environmental tobacco smoke (ETS) exposure of pregnant women and their newborns are needed to lower health risks of exposed fetuses and infants. Baby's Breath is a tailored video intervention developed and tested in a randomized controlled trial. The study aimed to test the efficacy of tailored video versus usual care approaches to reduce the ETS exposure of fetuses of low-income women during and after pregnancy; and to assess this intervention separately among non-smoking and smoking women. Participating women, recruited early in pregnancy, who spoke English, were at least 18years old, smoke exposed (current smokers, quit smoking on their own, or were exposed to smoke of others), pregnant with only one baby, and had access to a telephone and video player, were randomized to experimental or control conditions. Intervention participants received newsletters containing content aimed at smoking cessation and avoidance (5 during and 3 after pregnancy), in addition to videos (3 during and 2 after pregnancy) individually tailored on behavioral theory-based survey questions. Comparison participants received newsletters and videos on healthy pregnancy topics. Outcomes included salivary cotinine of both mother and baby (32weeks gestation and 6months postpartum) as well as self-reported ETS exposure and avoidance behaviors. This study may demonstrate the efficacy of a low-cost intervention to decrease ETS exposure, and will fill an important gap in describing the utility of this innovative intervention technology, as well as demonstration of potential benefits to this type of intervention.

Barriers and motivators to reducing secondhand smoke exposure in African American families of head start children: a qualitative study

OBJECTIVE

To identify barriers and motivators for reducing secondhand smoke exposure (SHSe) for families of African-American, low-income, urban children.

METHOD

Audiotaped intervention sessions of 52 African-American caregivers of Head Start children who reported being a smoker and/or had at least one smoker in the home were randomly sampled from a larger trial examining the effectiveness of a motivational-interviewing intervention in reducing child's SHSe. Counseling sessions were qualitatively coded to identify barriers and motivators to implementing a home smoking ban or quitting smoking.

RESULTS

African-American families identified several themes that were either or both barriers and motivators for SHSe reduction, including: asking others not to smoke, other family living in the home, neighborhood safety, absence of childcare, cost/availability of cessation tools, physician support and prevention of health problems.

DISCUSSION

Urban, low-income African-American families face numerous barriers to reducing SHSe. Families were able to identify many motivators for reducing SHSe, suggesting an awareness of the importance for SHSe reduction but uncertainty in their confidence to change behaviors. Counseling should include tailoring to be most effective in supporting health behavior change. Greater emphasis on motivators is needed, such as low-cost/free cessation tools, engagement from physicians and greater involvement of extended family members.

Effectiveness of Interventions to Reduce Tobacco Smoke Pollution in Homes: A Systematic Review and Meta-Analysis

INTRODUCTION

Smoke-free homes can help protect children from tobacco smoke exposure (TSE). The objective of this study was to conduct a meta-analysis to quantify effects of interventions on changes in tobacco smoke pollution in the home, as measured by air nicotine and particulate matter (PM).

METHODS

We searched MEDLINE, PubMed, Web of Science, PsycINFO, and Embase. We included controlled trials of interventions which aimed to help parents protect children from tobacco smoke exposure. Two reviewers identified relevant studies, and three reviewers extracted data.

RESULTS

Seven studies were identified. Interventions improved tobacco smoke air pollution in homes as assessed by nicotine or PM. (6 studies, N = 681, p = 0.02). Analyses of air nicotine and PM separately also showed some benefit (Air nicotine: 4 studies, N = 421, p = 0.08; PM: 3 studies, N = 340, p = 0.02). Despite improvements, tobacco smoke pollution was present in homes in all studies at follow-up.

CONCLUSIONS

Interventions designed to protect children from tobacco smoke are effective in reducing tobacco smoke pollution (as assessed by air nicotine or PM) in homes, but contamination remains. The persistence of significant pollution levels in homes after individual level intervention may signal the need for other population and regulatory measures to help reduce and eliminate childhood tobacco smoke exposure.

Can a minimal intervention reduce secondhand smoke exposure among children with asthma from low income minority families? Results of a randomized trial

We report on the results of a low-intensity behavioral intervention to reduce second hand smoke (SHS) exposure of children with asthma from low income minority households in Los Angeles, California. In this study, 242 child/adult dyads were randomized to a behavioral intervention (video, workbook, minimal counseling) or control condition (brochure). Main outcome measures included child's urine cotinine and parental reports of child's hours of SHS exposure and number of household cigarettes smoked. Implementation of household bans was also considered. No differences in outcomes were detected between intervention and control groups at follow-up. Limitations included high attrition and low rates of collection of objective measures (few children with urine cotinine samples). There continues to be a need for effective culturally and linguistically appropriate strategies that support reduction of household SHS exposure among children with asthma in low income, minority households.

Interventions to reduce harm from smoking with families in infancy and early childhood: a systematic review

Exposure to adult smoking can have deleterious effects on children. Interventions that assist families with smoking cessation/reduction and environmental tobacco smoke (ETS) avoidance can improve child health outcomes and reduce the risk of smoking initiation. The purpose of this review was to describe the state of the science of interventions with families to promote smoke-free home environments for infants and young children, including parent smoking reduction and cessation interventions, ETS reduction, and anti-smoking socialisation interventions, using the socio-ecological framework as a guide. A systematic review of peer-reviewed articles identified from journal databases from 2000 to 2014 was undertaken. Of 921 articles identified, 28 were included in the review. Considerable heterogeneity characterised target populations, intervention types, complexity and intensity, precluding meta-analysis. Few studies used socio-ecological approaches, such as family theories or concepts. Studies in early parenthood (child age newborn to one year) tended to focus on parent smoking cessation, where studies of families with children aged 1-5 years were more likely to target household SHSe reduction. Results suggest that interventions for reduction in ETS may be more successful than for smoking cessation and relapse prevention in families of children aged less than 5 years. There is a need for a range of interventions to support families in creating a smoke free home environment that are both tailored and targeted to specific populations. Interventions that target the social and psychodynamics of the family should be considered further, particularly in reaching vulnerable populations. Consideration is also required for approaches to interventions that may further stigmatise families containing smokers. Further research is required to identify successful elements of interventions and the contexts in which they are most effective.

A minimal intervention to promote smoke-free homes among 2-1-1 callers: a randomized controlled trial

OBJECTIVES

We tested the efficacy of a minimal intervention to create smoke-free homes in low-income households recruited through the United Way of Greater Atlanta 2-1-1, an information and referral system that connects callers to local social services.

METHODS

We conducted a randomized controlled trial (n=498) from June 2012 through June 2013, with follow-up at 3 and 6 months. The intervention consisted of 3 mailings and 1 coaching call.

RESULTS

Participants were mostly smokers (79.7%), women (82.7%), African American (83.3%), and not employed (76.5%), with an annual household income of $10,000 or less (55.6%). At 6-months postbaseline, significantly more intervention participants reported a full ban on smoking in the home than did control participants (40.0% vs 25.4%; P=.002). The intervention worked for smokers and nonsmokers, as well as those with or without children.

CONCLUSIONS

Minimal intervention was effective in promoting smoke-free homes in low income households and offers a potentially scalable model for protecting children and adult nonsmokers from secondhand smoke exposure in their homes.

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.

Factors associated with parents&#8217; perceptions of parental smoking in the presence of children and its consequences on children

Parental smoking is the major source of children’s secondhand smoke exposure and is influenced by parents’ perception of children’s exposure. However, the factors associated with these perceptions remain unclear. The objective of this study was to examine factors associated with parents’ perceptions about parental smoking in the presence of children and its consequences. We conducted a cross-sectional study on parents’ perceptions of parental smoking and measured their evaluations of its consequences using a self-report questionnaire. Other variables include socio-demographic characteristics and smoking-related experience. Results show that parents’ gender, education level, occupational type, smoking status, and agreement on a home smoking ban independently predict parents’ evaluation of the consequences of parental smoking in the presence of children. Parents’ gender, education level, annual family income, smoking status, agreement on a home smoking ban, and evaluation of the consequences of parental smoking independently predicted parents’ perceptions. Findings indicated that a specific group expressed greater acceptance of parental smoking and was less aware of its risks. Motivating parents to create a smoke-free home and increasing awareness of the adverse consequences of parental smoking is beneficial in reinforcing attitudes opposed to parental smoking.

Assessing secondhand smoke exposure with reported measures

Non-smokers are exposed to tobacco smoke from the burning cigarette and the exhaled smoke from smokers. In spite of decades of development of approaches to assess secondhand smoke exposure (SHSe), there are still unresolved methodological issues. This manuscript summarises the scientific evidence on the use of SHSe reported measures and their methods, objectives, strengths and limitations; and discusses best practices for assessing behaviour leading to SHSe for lifetime and immediate or current SHSe. Recommendations for advancing measurement science of SHSe are provided. Behavioural measures of SHSe commonly rely on self-reports from children and adults. Most commonly, the methodology includes self, proxy and interview-based reporting styles using retrospective recall or diary-style reporting formats. The reporting method used will vary based upon the subject of interest, assessment objectives and cultural context. Appropriately implemented, reported measures of SHSe provide an accurate, timely and cost-effective method for assessing exposure time, location and quantity in a wide variety of populations.

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.

Testing an empowerment intervention to help parents make homes smoke-free: a randomized controlled trial

The objective of this randomized controlled trial was to test if parents' participation in an intervention based on an empowerment ideology and participatory experiences decreased the number of cigarettes smoked in homes. Sixty families were randomized to the intervention (n = 30) or control (n = 30) group. The intervention included three weekly group sessions followed by three weekly follow-up telephone calls over six consecutive weeks. During group sessions, parents shared experiences about environmental tobacco smoke, identified personal strengths and resources, and developed action plans. Data were collected in interviewer-administered questionnaires at baseline and 6 months follow-up. Ninety-three percent of the sample consisted of mothers, 77% of whom smoked during pregnancy. Forty-two percent of the total sample reported a household income of <$15,000. The median number of cigarettes smoked in the home daily decreased from 18 to 4 in the total sample however no statistically significant difference was detected between groups at 6 months follow-up. Participation in the study, independent of group, may have resulted in parents decreasing the number of cigarettes smoked in the home. Valuable lessons were learned about recruiting and working with this group of parents, all of whom faced the challenges of tobacco and almost half of whom lived in poverty.

The effectiveness of interventions to establish smoke-free homes in pregnancy and in the neonatal period: a systematic review

This review considers the effectiveness of interventions to encourage the establishment of smoke-free homes during pregnancy and the neonatal period. A comprehensive search of the literature was undertaken to find relevant studies via electronic databases, citations and reference lists of included studies. The searches identified 17 papers that met the inclusion criteria. These were quality assessed and data extracted. Due to heterogeneity of the papers, a narrative synthesis was completed. Interventions were categorized in terms of those based on counselling, counselling plus additional elements, individually adapted programmes and motivational interviewing. The findings suggest inconclusive evidence relating to these intervention types, with a range of outcome measures reported. There were limitations throughout the papers in terms of study quality (especially sample size) and poor reporting of results in relation to effectiveness. The review was limited by its very specific population; however, it suggests that currently there is mixed evidence for the effectiveness of interventions to reduce parental environmental tobacco smoke in early infancy.

The Assessment, Monitoring, and Enhancement of Treatment Fidelity In Public Health Clinical Trials

OBJECTIVES: To discuss methods of preservation of treatment fidelity in health behavior change trials conducted in public health contexts. METHODS: The treatment fidelity framework provided by the NIH's Behavioral Change Consortium (BCC) (1) includes five domains of treatment fidelity (Study Design, Training, Delivery, Receipt, and Enactment). A measure of treatment fidelity was previously developed and validated using these categories. RESULTS: Strategies for assessment, monitoring, and enhancing treatment fidelity within each of the five treatment fidelity domains are discussed. The previously created measure of treatment fidelity is updated to include additional items on selecting providers, additional confounders, theory testing, and multicultural considerations. CONCLUSIONS: Implementation of a treatment fidelity plan may require extra staff time and costs. However, the economic and scientific costs of lack of attention to treatment fidelity are far greater than the costs of treatment fidelity implementation. Maintaining high levels of treatment fidelity with flexible adaptation according to setting, provider, and patient is the goal for public health trials.

Latino parenting practices: a comparison of parent and child reports of parenting practices and the association with gateway drug use

Parent and adolescent self-reports are the most common sources for measuring parenting practices. This study's purpose was to compare how parent and adolescent reports of parenting behaviors differentially predict adolescent gateway drug use. The sample consisted of 252 Latino adolescent-parent dyads. After controlling for potential confounding influences, only adolescents' reports about their parents' parenting behaviors were significant and explained 38% of the variance in gateway drug use. Practitioners may recommend to parents seeking parenting advice that they solicit feedback from their adolescent to ensure parenting efforts are received in the manner they were intended.

Passive smoking in babies: the BIBE study (Brief Intervention in babies. Effectiveness)

BACKGROUND

There is evidence that exposure to passive smoking in general, and in babies in particular, is an important cause of morbimortality. Passive smoking is related to an increased risk of pediatric diseases such as sudden death syndrome, acute respiratory diseases, worsening of asthma, acute-chronic middle ear disease and slowing of lung growth.The objective of this article is to describe the BIBE study protocol. The BIBE study aims to determine the effectiveness of a brief intervention within the context of Primary Care, directed to mothers and fathers that smoke, in order to reduce the exposure of babies to passive smoking (ETS).

METHODS/DESIGN

Cluster randomized field trial (control and intervention group), multicentric and open.

SUBJECT

Fathers and/or mothers who are smokers and their babies (under 18 months) that attend pediatric services in Primary Care in Catalonia.The measurements will be taken at three points in time, in each of the fathers and/or mothers who respond to a questionnaire regarding their baby's clinical background and characteristics of the baby's exposure, together with variables related to the parents' tobacco consumption. A hair sample of the baby will be taken at the beginning of the study and at six months after the initial visit (biological determination of nicotine). The intervention group will apply a brief intervention in passive smoking after specific training and the control group will apply the habitual care.

DISCUSSION

Exposure to ETS is an avoidable factor related to infant morbimortality. Interventions to reduce exposure to ETS in babies are potentially beneficial for their health.The BIBE study evaluates an intervention to reduce exposure to ETS that takes advantage of pediatric visits. Interventions in the form of advice, conducted by pediatric professionals, are an excellent opportunity for prevention and protection of infants against the harmful effects of ETS.

TRIAL REGISTRATION

Clinical Trials.gov Identifier: NCT00788996.

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.

Biomarker evaluation of Greek adolescents' exposure to secondhand smoke

Exposure to secondhand smoke (SHS) is a significant threat to public health, and represents a danger for both the development and health status of children and adolescents. Taking the above into account, our aim was to quantify Greek adolescents' exposure to SHS using serum cotinine levels. During 2006, 341 adolescents aged 13-17 were randomly selected from high schools in Heraklion and agreed to participate as part of the European Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) study. Blood samples were drawn from a random sample of 106 adolescents, while serum cotinine/nicotine concentrations were measured by Gas Chromatography-Mass Spectrometry (GC-MS). The mean levels of serum cotinine and nicotine were calculated at 1.60 +/- 2.18 ng/mL and 4.48 +/- 4.00 ng/mL, respectively, while 97.7% of the non-smoker adolescents were found to have measureable levels of serum cotinine indicating exposure to SHS. The analysis revealed that their paternal (p = .001) and maternal smoking habits (p = .018) as also the existence of a younger brother or sister (p = .008) were the main modifiers of SHS exposure during adolescence. Conclusively, almost all of the measured Greek adolescents were exposed to SHS, even when their parents were non-smokers. This finding indicates the need for both community and school-based educational programmes as also the implementation of a comprehensive ban on smoking in public places.

From the American Academy of Pediatrics: Technical report--Secondhand and prenatal tobacco smoke exposure

Secondhand tobacco smoke (SHS) exposure of children and their families causes significant morbidity and mortality. In their personal and professional roles, pediatricians have many opportunities to advocate for elimination of SHS exposure of children, to counsel tobacco users to quit, and to counsel children never to start. This report discusses the harms of tobacco use and SHS exposure, the extent and costs of tobacco use and SHS exposure, and the evidence that supports counseling and other clinical interventions in the cycle of tobacco use. Recommendations for future research, policy, and clinical practice change are discussed. To improve understanding and provide support for these activities, the harms of SHS exposure are discussed, effective ways to eliminate or reduce SHS exposure are presented, and policies that support a smoke-free environment are outlined.

The behavioral ecology of secondhand smoke exposure: A pathway to complete tobacco control

INTRODUCTION

This article outlines a theoretical framework for research concerning secondhand smoke exposure (SHSe) prevention as a means to curtail the tobacco industry.

METHODS

The Behavioral Ecological Model (BEM) assumes interlocking social contingencies of reinforcement (i.e., rewards or punishments) from the highest level of society (e.g., taxing cigarette sales) to physiological reactions to nicotine that influence smoking and SHSe. We review selected research concerning both policy and clinical efforts to restrict smoking and/or SHSe.

RESULTS

Research to date has focused on smoking cessation with modest to weak effects. The BEM and empirical evidence suggest that cultural contingencies of reinforcement should be emphasized to protect people from SHSe, especially vulnerable children, pregnant women, the ill, the elderly, and low-income adults who have not "elected" to smoke. Doing so will protect vulnerable populations from industry-produced SHSe and may yield more and longer-lasting cessation.

CONCLUSIONS

Interventions that reduce SHSe may serve as a Trojan horse to counter the tobacco industry. Future studies should: (a) guide policies to restrict SHSe; (b) develop powerful community and clinical interventions to reduce SHSe; (c) test the degree to which policies and other contexts enhance the effects of clinical interventions (e.g., media programs disclosing the disingenuous marketing by the industry); and (d) investigate the effects of all health care providers' ability to reduce SHSe and generate an antitobacco culture, by advising all clients to avoid starting to smoke, to protect their children from SHSe, and to quit smoking.

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.

Predictors of childhood exposure to parental secondhand smoke in the house and family car

Childhood exposure to secondhand smoke (SHS) is a serious threat to public health and can be influenced by parental lifestyle habits and beliefs. Taking the above into account we aimed at locating predictors of parental induced exposure to SHS in the house and family car among 614 children who visited the emergency department of two large pediatric hospitals in Athens, Greece. The multivariate analysis revealed that the factors found to mediate household exposure to paternal SHS were the number of cigarettes smoked per day (O.R 1.13, p<0.001) while, having a non-smoking spouse had a protective effect (O.R 0.44, p=0.026). Maternally induced household SHS exposure was related to cigarette consumption. For both parents, child exposure to SHS in the family car was related to higher numbers of cigarettes smoked (p<0.001), and for fathers was also more often found in larger families. Additionally, lower educated fathers were more likely to have a spouse that exposes their children to SHS inside the family car (O.R 1.38 95%C.I: 1.04-1.84, p=0.026). Conclusively, efforts must be made to educate parents on the effects of home and household car exposure to SHS, where smoke free legislation may be difficult to apply.

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.

4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol and its glucuronides in the urine of infants exposed to environmental tobacco smoke

Biomarkers of carcinogen uptake could provide important information pertinent to the question of exposure to environmental tobacco smoke (ETS) in childhood and cancer development later in life. Previous studies have focused on exposures before birth and during childhood, but carcinogen uptake from ETS in infants has not been reported. Exposures in infants could be higher than in children or adults because of their proximity to parents who smoke. Therefore, we quantified 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol and its glucuronides (total NNAL) in the urine of 144 infants, ages 3 to 12 months, who lived in homes with parents who smoked. Total NNAL is an accepted biomarker of uptake of the tobacco-specific carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone. Cotinine and its glucuronide (total cotinine) and nicotine and its glucuronide (total nicotine) were also quantified. Total NNAL was detectable in 67 of 144 infants (46.5%). Mean levels of total NNAL in the 144 infants were 0.083 +/- 0.200 pmol/mL, whereas those of total cotinine and total nicotine were 0.133 +/- 0.190 and 0.069 +/- 0.102 nmol/mL, respectively. The number of cigarettes smoked per week in the home or car by any family member when the infant was present was significantly higher (P < 0.0001) when NNAL was detected than when it was not (76.0 +/- 88.1 versus 27.1 +/- 38.2). The mean level of NNAL detected in the urine of these infants was higher than in most other field studies of ETS exposure. The results of this study show substantial uptake of 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone in infants exposed to ETS and support the concept that persistent ETS exposure in childhood could be related to cancer later in life.