Addressing passive smoking in children

Towards the elimination of chronic obstructive pulmonary disease: a Lancet Commission

Despite substantial progress in reducing the global impact of many non-communicable diseases, including heart disease and cancer, morbidity and mortality due to chronic respiratory disease continues to increase. This increase is driven primarily by the growing burden of chronic obstructive pulmonary disease (COPD), and has occurred despite the identification of cigarette smoking as the major risk factor for the disease more than 50 years ago. Many factors have contributed to what must now be considered a public health emergency: failure to limit the sale and consumption of tobacco products, unchecked exposure to environmental pollutants across the life course, and the ageing of the global population (partly as a result of improved outcomes for other conditions). Additionally, despite the heterogeneity of COPD, diagnostic approaches have not changed in decades and rely almost exclusively on post-bronchodilator spirometry, which is insensitive for early pathological changes, underused, often misinterpreted, and not predictive of symptoms. Furthermore, guidelines recommend only simplistic disease classification strategies, resulting in the same therapeutic approach for patients with widely differing conditions that are almost certainly driven by variable pathophysiological mechanisms. And, compared with other diseases with similar or less morbidity and mortality, the investment of financial and intellectual resources from both the public and private sector to advance understanding of COPD, reduce exposure to known risks, and develop new therapeutics has been woefully inadequate.

Implementation of a proactive referral tool for child healthcare professionals to encourage and facilitate parental smoking cessation in the Netherlands: a mixed-methods study

Background

Recently, the parent-tailored telephone based smoking cessation counseling program ‘Smoke-free Parents’ was shown to be effective in helping parents to quit smoking. To implement this program in child healthcare settings in the Netherlands, the research team developed a proactive referral tool to refer parents to Smoke-free Parents. The aim of the present implementation study was to explore the facilitators, barriers, and suggestions for improvement in the implementation of this referral tool.

Methods

Child healthcare professionals (N = 68) were recruited via multiple strategies (e.g., social media, mailings, and word of mouth among healthcare professionals) and invited to complete two online (quantitative and qualitative) questionnaires and to participate in a telephone semi-structured qualitative interview between April 2017 and February 2019. In total, 65 child healthcare professionals were included in the analyses. After inductive coding, thematic analyses were performed on the qualitative data. Descriptive analyses were performed on the quantitative data.

Results

The data from both questionnaires and the telephone interview revealed that the majority of the child healthcare professionals (92.3 % female; average years of working as a healthcare professional: 23.0) found the Smoke-free Parents referral tool accessible and convenient to use. Yet there were several barriers that limited their use of the tool. The data revealed that one of the main barriers that healthcare professionals experienced was parental resistance to smoking cessation assistance. In addition, healthcare professionals noted that they experienced tension when motivating parents to quit smoking, as they were not the parent’s, but the child’s healthcare provider. Additionally, healthcare professionals reported being concerned about the lack of information about the costs of Smoke-free Parents, which limited professionals referring parents to the service.

Conclusions

Although healthcare professionals reported rather positive experiences with the Smoke-free Parents referral tool, the use of the tool was limited due to barriers. To increase the impact of the Smoke-free Parents telephone-based smoking cessation counseling program via child healthcare settings, it is important to overcome these barriers. Suggestions for improvement in the implementation of the referral tool in child healthcare settings are discussed.

Barriers and incentives for Italian paediatricians to become smoking cessation promoters: a GARD-Italy Demonstration Project

Background

Paediatricians rarely devote any time to screening and treatment for parental tobacco use. The present project is part of a Global Alliance against Chronic Respiratory Diseases (GARD)-Italy Demonstration Project, aimed to increase the skills of primary care physicians and paediatricians as “promoter of smoking cessation”. The aims of this study were: (I) to identify latent classes of barriers and incentives for smoking cessation counseling among paediatricians using latent class analysis (LCA); (II) to investigate risk factors for inclusion into the identified classes.

Methods

In 2018, 1,500 Italian paediatricians were invited to complete an online survey on passive smoke exposure in children. LCA was used to discover underlying response patterns, and to identify respondent groups with similar attitudes toward passive smoke exposure in children. Multinomial logistic regression helped investigate which explanatory variables influenced inclusion into a class. A P value <0.05 was considered significant.

Results

The overall response rate was 71% (n=1,071/1,500). Three classes were identified: Class 1 “passive” (n=226, 21.10%); Class 2 “unmotivated” (n=124, 11.58%); and Class 3 “proactive” (n=721, 67.32%). Assuming Class 3 as reference, ever having been a smoker was borderline associated (P=0.052) with increased probability of inclusion into Class 1 (OR =1.43, 95% CI, 1.00–2.06). Having 6–15 or ≥15 years of work experience versus having less than five years was associated with decreased probability of being in the “passive” class (OR =0.46, 95% CI, 0.22–0.96 and OR =0.49, 95% CI, 0.27–0.87, respectively), as was discussing parents’ addiction to alcohol/drugs (OR =0.50, 95% CI, 0.33–0.76).

Conclusions

We identified three profiles among Italian paediatricians related to barriers and incentives for smoking cessation promotion. Tailored educational interventions for paediatricians are required to promote smoking cessation programs.

Primary Care Healthcare Professionals' Knowledge, Attitudes, and Practices Towards Promoting the Reduction of Children's Secondhand Smoke Exposure: A Mixed-Methods Review and Synthesis

INTRODUCTION

Secondhand smoke exposure (SHSe) leads to increased mortality and morbidity. Primary care healthcare professionals (HCPs) are well placed to support patients to reduce SHSe. This paper explores HCPs': (1) knowledge around SHSe; (2) current practices to promote SHSe reduction; (3) beliefs and experiences regarding delivering interventions to reduce SHSe; and (4) identified factors that influence the delivery of SHSe-related interventions.

METHODS

Six electronic databases were searched for relevant literature published January 1980-February 2016. 17 quantitative and 3 qualitative studies were included in this mixed-methods review. Data synthesis followed the method outlined by the Joanna Briggs Institute. This segregated approach involved independent syntheses of the quantitative and qualitative data followed by an overall mixed-methods synthesis.

RESULTS

Primary care HCPs had a basic understanding of the risks associated with SHSe but required training to help them intervene. It was more common for HCPs to ask about SHSe or provide advice than to act to facilitate SHSe reduction. SHSe was viewed as an issue of high importance and considered relevant to the role of the primary care HCPs. However, barriers such as the priority given to the issue and the desire to protect the professional relationship with patients prevented HCPs from intervening around SHSe.

CONCLUSIONS

Primary care HCPs require training, guidance, and support to enable them to intervene and support patients to effectively reduce SHSe.

IMPLICATIONS

This review used rigorous methods to explore the current, global literature on how children's exposure to secondhand smoke is being addressed in primary care settings. The review findings highlight healthcare professionals' need for further training and support, which would enable them to better translate their knowledge of the risks associated with secondhand smoke exposure into actual clinical practices. The review identified a lack of practical action taken to address secondhand smoke exposure, even once it has been identified as an issue.

Evaluation and Implementation of a Proactive Telephone Smoking Cessation Counseling for Parents: A Study Protocol of an Effectiveness Implementation Hybrid Design

Detrimental health consequences of smoking for both parents and children stress the importance for parents to quit. A Dutch efficacy trial supported the efficacy of proactive telephone counseling on parents. Still, how this program would function in "real world" conditions and how parents could be optimally reached is unclear. Therefore, this study will use an innovative method to examine the recruitment success of two implementation approaches (i.e., via a healthcare approach and a mass media approach) to test the (cost)effectiveness of the program. A two-arm randomized controlled trial and an implementation study (i.e., process evaluation) are conducted. Parents (N = 158) will be randomly assigned to the intervention (i.e., telephone counseling) or control conditions (i.e., self-help brochure). Primary outcome measure is 7-day point prevalence abstinence at three months post-intervention. Qualitative and quantitative research methods are used for the process evaluation. We expect that parents in the intervention condition have higher cessation rates than parents in the control condition. We also expect that the recruitment of parents via (youth) health care services is a more promising implementation approach compared to mass media. Results will have implications for the effectiveness of a proactive telephone counseling and provide directions for its successful implementation.

Motivational interviewing and urine cotinine feedback to stop passive smoke exposure in children predisposed to asthma: a randomised controlled trial

We tested the effectiveness of a program consisting of motivational interviewing (MI) and feedback of urine cotinine to stop passive smoking (PS) in children at risk for asthma. Fifty-eight families with children 0-13 years with a high risk of asthma and PS exposure were randomised in a one-year follow-up study. The intervention group received the intervention program during 6 sessions (1/month) and the control group received measurements (questionnaires, urine cotinine, and lung function) only. The primary outcome measure was the percentage of families stopping PS (parental report verified and unverified with the child's urine cotinine concentration <10 μg/l) in children during the intervention program. The analyses were performed with Mixed Logistic Regression. After 6 months, a significant group difference was observed for the unverified parental report of stopping PS in children: 27% of parents in the intervention group versus 7% in the control group. For the verified parental report, the difference was similar (23% versus 7%) but was not statistically significant. Despite a limited sample size, the results suggest that the intervention program is probably an effective strategy to stop PS in children. A program longer than 6 months might be necessary for a longer lasting intervention effect.

Chinese Pediatrician Attitudes and Practices Regarding Child Exposure to Secondhand Smoke (SHS) and Clinical Efforts against SHS Exposure

Background: Secondhand Smoke (SHS) exposure is a leading cause of childhood illness and premature death. Pediatricians play an important role in helping parents to quit smoking and reducing children’s SHS exposure. This study examined Chinese pediatricians’ attitudes and practices regarding children’s exposure to SHS and clinical efforts against SHS exposure. Methods: A cross-sectional survey of pediatricians was conducted in thirteen conveniently selected hospitals in southern China, during September to December 2013. Five hundred and four pediatricians completed self-administered questionnaires with a response rate of 92%. χ² tests were used to compare categorical variables differences between smokers and non-smokers and other categorical variables. Results: Pediatricians thought that the key barriers to encouraging parents to quit smoking were: lack of professional training (94%), lack of time (84%), resistance to discussions about smoking (77%). 94% of the pediatricians agreed that smoking in enclosed public places should be prohibited and more than 70% agreed that smoking should not be allowed in any indoor places and in cars. Most of the pediatricians thought that their current knowledge on helping people to quit smoking and SHS exposure reduction counseling was insufficient. Conclusions: Many Chinese pediatricians did not have adequate knowledge about smoking and SHS, and many lacked confidence about giving cessation or SHS exposure reduction counseling to smoking parents. Lack of professional training and time were the most important barriers to help parents quit smoking among the Chinese pediatricians. Intensified efforts are called for to provide the necessary professional training and increase pediatricians’ participation in the training.