Secondhand smoke risk in infants discharged from an NICU: potential for significant health disparities?

Development of a Smoke-Free Home Intervention for Families of Babies Admitted to Neonatal Intensive Care

Neonatal intensive care units (NICUs) have a disproportionately higher number of parents who smoke tobacco compared to the general population. A baby’s NICU admission offers a unique time to prompt behaviour change, and to emphasise the dangerous health risks of environmental tobacco smoke exposure to vulnerable infants. We sought to explore the views of mothers, fathers, wider family members, and healthcare professionals to develop an intervention to promote smoke-free homes, delivered on NICU. This article reports findings of a qualitative interview and focus group study with parents whose infants were in NICU (n = 42) and NICU healthcare professionals (n = 23). Thematic analysis was conducted to deductively explore aspects of intervention development including initiation, timing, components and delivery. Analysis of inductively occurring themes was also undertaken. Findings demonstrated that both parents and healthcare professionals supported the need for intervention. They felt it should be positioned around the promotion of smoke-free homes, but to achieve that end goal might incorporate direct cessation support during the NICU stay, support to stay smoke free (relapse prevention), and support and guidance for discussing smoking with family and household visitors. Qualitative analysis mapped well to an intervention based around the ‘3As’ approach (ask, advise, act). This informed a logic model and intervention pathway.

Giving parents support: a randomized trial of peer support for parents after NICU discharge

BACKGROUND

Peer support during inpatient hospitalization has been recommended for NICU parents and can improve maternal mental health. Less is known about the impact of peer support after NICU discharge on parental mental health and infant healthcare utilization.

METHODS

Three hundred families of infants approaching discharge from a Level IV NICU were randomized to receive a care notebook (control) or care notebook plus peer support for 12 months (intervention). Participants reported on measures of stress, depression, anxiety, self-efficacy, and infant healthcare utilization. Analysis compared outcomes between control and treatment groups.

RESULTS

Parental depression, anxiety, stress, and self-efficacy improved significantly for all participants, yet there were no differences between control and intervention groups. Infant ED visits, hospitalizations, immunization status, and developmental status at 12 months did not differ between groups.

CONCLUSIONS

Peer support after NICU discharge did not improve self-reported parental mental health measures or infant healthcare utilization.

CLINICAL TRIAL REGISTRATION

NCT02643472.

Understanding motivation to implement smoking bans among mothers with a hospitalized infant

OBJECTIVE

Secondhand smoke exposure (SHSe) poses risks to hospitalized children upon discharge and no uniformly effective interventions have been identified. Understanding change-related processes and social-contextual factors related to motivation for implementing home and car smoking bans may inform interventions to reduce infant SHSe among mothers with a hospitalized infant.

METHODS

In this cross-sectional, secondary analysis, mothers of neonatal ICU infants who reported smoking or living with a smoker (N=205) were assigned to stages of change (pre-contemplation, contemplation, preparation, or action) based on behaviors and intentions for establishing smoking bans in their homes and cars. Processes of change (POC) for SHSe reduction practices, self-efficacy, depressive symptoms, generalized anxiety, and social support for not smoking in the home were examined across all four stages.

RESULTS

The majority of mothers were in the action stage for having a home smoking ban in place (55%); only 35% of participants were in action for a car smoking ban. POC use differed across the stages of change for having a home ban (p=0.004) and car ban (p=0.02), with earlier stages using fewer overall and relatively fewer cognitive/affective processes. Earlier stage women also reported lower self-efficacy to change, less familial and partner support for in-home smoking bans, and more depressive symptoms.

CONCLUSIONS

Novel intervention targets were identified, including cognitive/affective change processes, mental health, and familial/social contingencies for implementing SHSe protective practices. Creative ways in which to affect change at the individual and household level are needed in order to fully address the complexity of child SHSe.

Family Beliefs and Behaviors About Smoking and Young Children's Secondhand Smoke Exposure

INTRODUCTION

Home smoking bans (HSBs) reduce children's secondhand smoke exposure (SHSe), a contributor to health disparities. General psychosocial characteristics and SHSe beliefs and behaviors within the family may relate to HSB existence. This study's aim was to identify general psychosocial characteristics and SHSe beliefs associated with HSB presence and lower SHSe among children living with a smoker.

METHODS

Caregivers (n = 269) of Head Start preschool students (age 1-6 years) living with a smoker reported on HSBs, caregiver depressive symptoms and stress, family routines, SHSe beliefs, and household smoking characteristics. SHSe biomarkers included air nicotine in 2 areas of the home and child salivary cotinine.

RESULTS

One-quarter of families reported complete HSBs, and HSBs were more common among nonsmoking (37%) versus smoking caregivers (21%; p < .01). Perceived importance of HSBs differed between nonsmoking (9.7±1.0) versus smoking caregivers (9.1±2.0; p < .01). Smoking caregivers, more smokers in the home, and lower self-efficacy and intent to implement an HSB were consistently associated with lower likelihood of HSB existence and children's higher SHSe. Caregiver SHSe beliefs were more consistently associated with HSBs and SHSe than were general psychosocial factors.

CONCLUSIONS

Despite greater HSB likelihood and higher perceived importance of HSBs among nonsmoking versus smoking primary caregivers, SHSe reduction self-efficacy and intent are protective for Head Start students at high-risk for exposure. Pediatric healthcare providers and early education professionals may be able to support SHSe reduction efforts (e.g., smoking cessation, HSB implementation) and reduce children's SHSe with counseling strategies to address caregivers' HSB self-efficacy, intent, and related behaviors.

Thirdhand Smoke in the Homes of Medically Fragile Children: Assessing the Impact of Indoor Smoking Levels and Smoking Bans

INTRODUCTION

Thirdhand smoke (THS) residue results from secondhand smoke, and is emerging as a distinct public health hazard, particularly for medically fragile pediatric patients living with smokers. THS is difficult to remove and readily reacts with other pollutants to form carcinogens and ultrafine particles. This study investigated THS found in homes of high-risk infants admitted to a neonatal intensive care unit and their association with characteristics (eg, number of household smokers) hypothesized to influence THS.

METHODS

Baseline data from 141 hospitalized infants' homes were analyzed, along with follow-up data (n = 22) to explore household smoking characteristics and THS changes in response to indoor smoking ban policies.

RESULTS

Households with an indoor ban, in which not more than 10 cigarettes/d were smoked, had the lowest levels of THS contamination compared to homes with no ban (P < .001) and compared to homes with an indoor ban in which greater numbers of cigarettes were smoked (P < .001). Importantly, homes with an indoor ban in which at least 11 cigarettes/d were smoked were not different from homes without a ban. The follow-up sample of 22 homes provided initial evidence indicating that, unless a ban was implemented, THS levels in homes continued to increase over time.

CONCLUSIONS

Preliminary longitudinal data suggest that THS may continue to accumulate in homes over time and household smoking bans may be protective. However, for homes with high occupant smoking levels, banning indoor smoking may not be fully adequate to protect children from THS. Unless smoking is reduced and bans are implemented, medically fragile children will be exposed to the dangers of THS.

Characteristics associated with intervention and follow-up attendance in a secondhand smoke exposure study for families of NICU infants

OBJECTIVE

The neonatal intensive care unit (NICU) is an ideal setting to intervene with an under served population on secondhand smoke exposure (SHSe). Unfortunately, attrition may compromise outcomes. Baseline characteristics associated with intervention and follow-up attendance were investigated in mothers who participated in a novel SHSe prevention study designed for households with a smoker and a NICU-admitted infant.

METHODS

Intervention participants received two motivational, NICU-based counseling sessions; usual care participants received pamphlets. Home-based follow-up assessments occurred at 1, 3 and 6 months. Sociodemographic, smoking history, and psychosocial factors were analyzed.

RESULTS

Mothers from households with greater numbers of cigarettes smoked and fewer children had higher odds of both intervention and follow-up attendance. Maternal smoking abstinence (lifetime), more adults in the home and higher perceived interpersonal support were also associated with higher odds of follow-up visit completion.

CONCLUSIONS

Innovative strategies are needed to engage mothers in secondhand smoke interventions, especially mothers who smoke, have lower levels of social support and have greater childcare responsibilities.

Children's exposure to secondhand and thirdhand smoke carcinogens and toxicants in homes of hookah smokers

INTRODUCTION

We examined homes of hookah-only smokers and nonsmokers for levels of indoor air nicotine (a marker of secondhand smoke) and indoor surface nicotine (a marker of thirdhand smoke), child uptake of nicotine, the carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), and the toxicant acrolein by analyzing their corresponding metabolites cotinine, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) and NNAL-glucuronides (total NNAL) and 3-hydroxypropylmercapturic acid.

METHODS

Data were collected at 3 home visits during a 7-day study period from a convenience sample of 24 households with a child 5 years or younger. Three child urine samples and 2 air and surface samples from the living room and the child bedroom were taken in homes of nonsmokers (n = 5) and hookah-only smokers (n = 19) comprised of daily hookah smokers (n = 8) and weekly/monthly hookah smokers (n = 11).

RESULTS

Nicotine levels in indoor air and on surfaces in the child bedrooms in homes of daily hookah smokers were significantly higher than in homes of nonsmokers. Uptake of nicotine, NNK, and acrolein in children living in daily hookah smoker homes was significantly higher than in children living in nonsmoker homes. Uptake of nicotine and NNK in children living in weekly/monthly hookah smoker homes was significantly higher than in children living in nonsmoker homes.

CONCLUSIONS

Our data provide the first evidence for uptake of nicotine, the tobacco-specific lung carcinogen NNK, and the ciliatoxic and cardiotoxic agent acrolein in children living in homes of hookah smokers. Our findings suggest that daily and occasional hookah use in homes present a serious, emerging threat to children's long-term health.

If mothers had their say: research-informed intervention design for empowering mothers to establish smoke-free homes

The Empowering Mothers to Establish Smoke-free Homes (EMESH) project developed in response to an interdisciplinary health team seeking effective interventions for reducing/eliminating the environmental tobacco smoke exposure of infants with compromised respiratory status. Two study phases that informed the EMESH intervention design are described. Phase I involved semi-structured interviews with 20 caretakers of infants diagnosed with Bronchopulmonary Dysplasia (BPD). In Phase II, 75 randomly selected medical records of infants with BPD were reviewed to explore the family demographics and staff behavior regarding environmental tobacco smoke (ETS) interventions. Interview results suggest that families are open to partnering with social workers and interdisciplinary team members in addressing infants' ETS exposure, families' unique circumstances indicate a need for tailored interventions, and the use of self-efficacy and decisional balance tools are feasible options. Results from the medical records review indicate that many families are economically vulnerable and reside in regions where smoking is common. There is a paucity of staff documentation regarding ETS conversations and interventions, indicating that these conversations may not take place. Together these results suggest a two-pronged approach in the next phases of EMESH: staff training in hosting and documenting ETS conversations and a tailored, parent-driven set of intervention options.

Feasibility and efficacy of an intervention to reduce secondhand smoke exposure among infants discharged from a neonatal intensive care unit

OBJECTIVE

To examine the feasibility and efficacy of a hospital-based, motivational intervention to reduce secondhand smoke exposure (SHSe) with mothers of infants in a neonatal intensive care unit (NICU).

STUDY DESIGN

One-hundred and forty-four mothers with infants ( ≤ 1500 g at birth or ≥ 12 h ventilation) in a NICU who reported a smoker in the household were randomized to two sessions of motivational interviewing (MI) conducted in the hospital, usual care (UC) or usual care-reduced measurement (UC-RM); follow-up occurred at 1- and 6-months post discharge.

RESULT

For households that did not have a total smoking ban at baseline, 63.6% of those in the MI group instituted a ban by 1-month post discharge compared with 20% of the UC group, P<0.02. Six months post discharge, fewer smoking bans were noted in the UC-RM group relative to MI and UC, P<0.01.

CONCLUSION

A need for SHSe interventions among NICU parents exists and initial evidence suggests MI can impact SHSe after discharge.

Baby's Breath II protocol development and design: a secondhand smoke exposure prevention program targeting infants discharged from a neonatal intensive care unit

BACKGROUND

Over one-third of all children live with at least one parent who smokes cigarettes, which is associated with compromised child health. The impact of secondhand smoke exposure (SHSe) in medically fragile infants born prematurely is likely to be much higher. The Baby's Breath II study tests whether a hospital-initiated, motivational-enhancement program will result in less SHSe relative to conventional care in high-risk, low birthweight (LBW) infants discharged from a neonatal intensive care unit (NICU). The design and protocol for the ongoing BBII trial is described.

METHODS/DESIGN

Eligible participants are: (1) primary caregivers (typically mothers) of NICU infants who were born at LBW (<2500g) or ventilated for more than 12h; and (2) who smoke or live with at least one smoker. This randomized controlled trial has two conditions: Motivational interviewing plus incentives (MI+) and conventional care (CC). MI+ participants receive two hospital-based and two home-based counseling sessions, as well as incentives (i.e., prize-based draws) for (a) intervention attendance and (b) biochemical validation (i.e., urine cotinine dipstick) indicative of low or no infant SHSe. Participants in the control group receive conventional education-based care. Assessments are completed at baseline, mid-point, and 1- and 4-months post-intervention.

DISCUSSION

This study is the first to determine the efficacy of a brief intervention for reducing SHSe among high-risk, LBW infants discharged from a NICU, with the potential for saving lives and healthcare costs. Strengths, limitations and challenges to the conduct of this trial are discussed.