Effects of information on smoking behaviour in families with preschool children

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.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/12654.

Preliminary exploration of secondhand smoke exposure in youth with Sickle Cell Disease: biochemical verification, pulmonary functioning, and health care utilization

Exposure to secondhand smoke (SHSe) can compound an already challenging set of health problems for youth with Sickle Cell Disease (SCD). Exposure to electronic cigarettes may also impact SCD symptomology and respiratory functioning. This study built on these previous findings by a) utilizing two objective measures of SHSe, salivary cotinine and exhaled carbon monoxide and b) examining the association of SHSe with emergency department utilization, physician-reported sickle cell crises, and pulmonary functioning. Caregivers (N = 31 dyads; Mage = 37.6 years; SD = 8.5 years) of youth with SCD (Mage = 9.0 years; SD = 4.5 years) completed self-report measures of tobacco/nicotine use. Youth provided a saliva sample to assess cotinine levels, and performed pulmonary function tests. Dyads provided breath samples for measurement of eCO. A chart review was conducted to obtain medical history and utilization. Majority of youth (88%) were exposed to SHS via salivary cotinine. Interestingly, no significant associations were observed between youth cotinine levels and emergency department utilization, physician-reported sickle cell crises, or pulmonary functioning. Present findings indicate a need to assess for SHSe using objective assessment measures. Future research should investigate which specific factors contribute to increase SHSe/SHVe in youth with SCD.

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.

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.

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Fidelity issues in secondhand smoking interventions for children

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

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

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Environmental tobacco smoke exposure in school children: parent report and urine cotinine measures

BACKGROUND

Environmental tobacco smoke (ETS) in the home continues to be a major health risk for children around the world. Measuring ETS is a central feature of clinical and epidemiological studies, with children's exposure often assessed through parental estimates. The authors examined the relationship between parent-reported estimates of children's exposure to ETS and children's urinary cotinine levels and evaluated the ETS exposure and its effect on respiratory health in children.

METHODS

A total of 188 school children were included in the study. Parents were asked to complete a questionnaire about their smoking habits, their children's respiratory morbidity status and housing conditions. Urinary cotinine levels were measured in children.

RESULTS

According to the responses, 72.3% of the children came from households with smokers, and 34.6% had daily exposure to ETS. When urine cotinine levels of >10 ng/mL were used as the yardstick of exposure, 76% of the children were identified as ETS exposed. No relation was detected between the symptoms of respiratory tract diseases and ETS exposure. To determine the amount of ETS exposure, the contribution of parental reports was low.

CONCLUSION

To evaluate the level of ETS exposure of children, the parents' reports were not reliable. The addition of a biological measure results in a more informative estimate of ETS exposure in children.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Evaluation of a counseling method for the prevention of child exposure to tobacco smoke: an example of client-centered communication

BACKGROUND

Environmental tobacco smoke (ETS) is an important risk factor. The aim of this study is to evaluate effects of the counseling method "Smoke-free children" that focuses on protection of infants.

METHODS

The counseling method, "Smoke-free children", has been developed and implemented at Swedish child health centers. The counseling method's point of departure is based upon a client-centered approach. Saliva cotinine samples from the mothers were collected when the child was 1-4 weeks and 3 months of age. Interviews regarding mothers' smoking habits and self-reported maternal smoking were also carried out.

RESULTS

Forty-one mothers participated in the study, 26 in the intervention group and 15 in the control group. Cotinine was collected from 22 subjects in the intervention and 8 in the control group. Before the intervention, the mean cotinine level was 185 ng/mL in the intervention group and 245 ng/mL in the control group. After the intervention, cotinine levels were reduced in the intervention group (165 ng/mL) and increased in the control group (346 ng/mL). Yet, after the intervention, the mothers themselves reported more smoking in the intervention group than in the control group. Only weak correlations were found between self-reported smoking and cotinine.

CONCLUSIONS

The statistical analysis supports the view that a client-centered intervention, aimed at increasing self-efficacy, exerts a positive effect on maternal smoking in the prevention of infant exposure to ETS, when applied in a routine clinical setting.

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

BACKGROUND

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

OBJECTIVE

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

DESIGN

Cross sectional survey.

SETTINGS

Coventry and Birmingham.

MAIN OUTCOME MEASURES

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

PARTICIPANTS

314 smoking households with infants.

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

REVIEWER'S CONCLUSIONS

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

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

STUDY OBJECTIVES

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

DESIGN

Randomized controlled trial of educational intervention vs usual care.

SETTING

The pediatric pulmonary service of a regional pediatric hospital.

PARTICIPANTS

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

INTERVENTION

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

MEASUREMENTS

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

RESULTS

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

CONCLUSIONS

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

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

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

Environmental tobacco smoke exposure among urban children

BACKGROUND

Environmental tobacco smoke (ETS) exposure is a well-known health hazard for children. Poor urban children may be at increased risk of exposure from nonparental sources of tobacco smoke. The unique problems of ETS exposure in urban children have previously not been well-defined.

OBJECTIVES

This study was conducted: 1) to identify the sources of ETS exposure for children attending a hospital-based pediatric resident practice; and 2) to examine caregivers' perceptions of the pediatrician's role and action in addressing ETS exposure.

DESIGN

Questionnaires were administered to a convenience sample of 174 caregivers of children visiting a children's hospital-based resident practice. A structured face-to-face interview was used.

RESULTS

All caregivers agreed to participate in the study. Most of the caregivers interviewed were mothers (87.9%). Although only 14% of caregivers were smokers, 49.4% reported caring for at least 1 smoke-exposed child. Most smoke exposure occurred in the home; smoking is allowed in the home of 75% of the children who live with a smoker (48/64). Thirty-four percent of the caregivers who reported no smoking in the home reported having a child who spends time in homes where other people smoke. Most exposure outside the home occurred at a grandparent's home. A ban on smoking in the home did not eliminate a child's risk of residential smoke exposure but did predict whether smoking occurred in the same room as the child. All caregivers reported believing that tobacco smoke is harmful. Approximately one half of caregivers who smoke (54.2%) would like smoking cessation advice from the child's pediatrician. Interest in receiving advice on helping others quit smoking was also high (51.3%) among nonsmoking caregivers who cared for a smoke-exposed child.

CONCLUSIONS

Nonparental sources of ETS exposure are reported to be common in urban children. Children may be exposed to tobacco smoke even in homes where smoking is banned. Many caregivers would like help from pediatricians in reducing children's exposure to tobacco smoke.

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

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

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA SYNTHESIS

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

CONCLUSIONS

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

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

OBJECTIVE

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

DESIGN

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

PARTICIPANTS

Approximately 2500 randomly selected adults each year.

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

DESIGN

Randomised controlled trial.

SETTING

Tayside and Fife, Scotland.

PARTICIPANTS

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

INTERVENTION

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Smoking in the home: changing attitudes and current practices

OBJECTIVES

Trends in attitudes and current practices concerning smoking in the home were examined.

METHODS

Data from population-based surveys of adults in Ontario, Canada, were analyzed.

RESULTS

Between 1992 and 1996, the percentage of respondents who agreed that parents spending time at home with small children should not smoke increased from 51% to 70%. In 1996, 34% of the homes surveyed were smoke-free. Smoke-free homes were associated with nonsmoking respondents and with the presence of children and no daily smokers in the home. Only 20% of homes with children and any daily smokers were smoke-free.

CONCLUSIONS

Efforts are needed to assist parents in reducing children's exposure to environmental tobacco smoke in the home.

Breastfeeding, smoking and the presence of the child's father in the household

The breastfeeding practice of 312 mothers attending mother and child health centres in Oslo, Norway, was measured using self-administered questionnaires. Having started with supplements at 3 months postpartum was related to having a spouse/cohabitant, smoking, and having only one child (logistic regression with civil state, age, education, smoking, number of children, social support, smoking x civil state, and education x civil state as independent variables). The frequency of having started with supplements increased with increasing maternal cigarette consumption. Among non-smoking, married/cohabiting mothers, the frequency of having started with supplements at 3 months postpartum was 41% if the spouse/cohabitant smoked, compared with 18% if he did not smoke (p < 0.01).