Pediatric Secondhand Smoke Exposure: Moving Toward Systematic Multi-Level Strategies to Improve Health

Associations Between Household Secondhand Smoke Exposure and Health Problems Among Non-Smoking Adolescents in the Republic of Korea

This study examined the association between household secondhand smoke exposure (HSHSE) and health status among non-smoking adolescents in Korea using two subsamples obtained from nationally representative cross-sectional secondary data: males (n = 25,653) and females (n = 31,187). Two self-reported HSHSE measures included exposure to household secondhand smoke during the week before the survey (yes or no) and number of days of HSHSE (1-7 days); and five self-reported health problems included asthma, perceived stress, depression, suicidal ideation, and self-rated health. For each subsample, this study performed (1) multivariate logistic regressions to examine HSHSE effects on asthma, depression, and suicidal ideation; and (2) multiple linear regressions to examine HSHSE effects on perceived stress and self-rated health. The rate and number of days of HSHSE were significantly higher among females (30.1% and 3.4 days) than among males (25.9% and 3.1 days). In both subsamples, HSHSE was associated with all five health problems (ORs 1.15-1.32; βs: 0.04-0.14). An increase in the number of days of HSHSE was positively associated with (1) greater perceived stress and poorer self-rated health in both subsamples (βs: 0.01-0.04), and (2) greater odds of asthma, depression, and suicidal ideation in the female subsample (ORs 1.03-1.12). Given the findings related to the strong associations (1) between HSHSE and physical, mental, and general health problems; and (2) between days of HSHSE and a greater number of health problems in females, health professionals should actively implement interventions that encourage adult smokers to stop smoking in their homes.

An Office-Initiated Multilevel Intervention for Tobacco Smoke Exposure: A Randomized Trial

BACKGROUND

Provider adherence to best practice guidelines (ask, advise, refer [AAR]) for addressing child tobacco smoke exposure (TSE) motivates parents to reduce TSE. However, high-risk, vulnerable populations of smokers may require more intensive treatment. We hypothesized that a pragmatic, multilevel treatment model including AAR coupled with individualized, telephone-based behavioral counseling promoting child TSE reduction would demonstrate greater child TSE reduction than would standard AAR.

METHODS

In this 2-arm randomized controlled trial, we trained pediatric providers in systems serving low-income communities to improve AAR adherence by using decision aid prompts embedded in routine electronic health record assessments. Providers faxed referrals to the study and received ongoing AAR adherence feedback. Referred participants were eligible if they were daily smokers, >17 years old, and spoke English. Participants were randomly assigned to telephone-based behavioral counseling (AAR and counseling) or nutrition education (AAR and attention control). Participants completed prerandomization and 3-month follow-up assessments.

RESULTS

Of providers, >80% (n = 334) adhered to AAR procedures and faxed 2949 referrals. Participants (n = 327) were 83% women, 83% African American, and 79% low income (below poverty level). Intention-to-treat logistic regression showed robust, positive treatment effects: more parents in AAR and counseling than in AAR and attention control eliminated all sources of TSE (45.8% vs 29.9%; odds ratio 1.99 [95% confidence interval 1.44-2.74]) and quit smoking (28.2% vs 8.2%; odds ratio 3.78 [95% confidence interval 1.51-9.52]).

CONCLUSIONS

The results indicate that the integration of clinic- and individual-level smoking interventions produces improved TSE and cessation outcomes relative to standalone clinic AAR intervention. Moreover, this study was among the first in which researchers demonstrated success in embedding AAR decision aids into electronic health records and seamlessly facilitated TSE intervention into routine clinic practice.

The Influence of Health Messaging Source and Frequency on Maternal Smoking and Child Exposure among Low-Income Mothers

Addressing maternal smoking and child tobacco smoke exposure (TSE) remains a public health priority, particularly in low-income, underserved populations which are known to experience the highest TSE rates and tobacco-related morbidity/mortality. Little is known about the types of TSE messaging received in high-risk populations, and which communication channels are influential in promoting smokers' efforts to protect children from TSE. The purpose of this study was to examine associations between reported sources and frequency of TSE-reduction health messages maternal smokers received and the effects of the messaging on smoking-and TSE-reduction related behaviors. Maternal smokers from low-income communities in Philadelphia, Pennsylvania who were enrolled at baseline in the Family Rules for Establishing Smokefree Homes (FRESH) trial (N=359) were included in this study. Each participant completed a 60-minute in-home baseline interview, which included questions about their smoking history, current smoking patterns, children's TSE, and the TSE-related health messaging they had received prior to enrollment. Multivariable analyses were conducted to determine the effect of source messaging on mothers' knowledge, behavior, and intention regarding their baby's TSE. Results suggest that different sources of messaging may differentially impact smoking behavior and intention to change. For example, messaging from healthcare and dental providers may influence efforts to protect children from TSE whereas friends and family may influence intention to quit. Future studies could examine the value of multilevel health communication strategies, utilizing advice from healthcare providers that is augmented by family and peers to help promote smoking behavior change in this high-risk group of underserved postpartum smokers.

Social disparities in parental smoking and young children's exposure to secondhand smoke at home: a time-trend analysis of repeated cross-sectional data from the German KiGGS study between 2003-2006 and 2009-2012

Background

Children who are exposed to secondhand smoke (SHS) have an increased risk of a wide range of health problems and illnesses. Smoke-free legislation aims to improve indoor air quality and in this way protect the health of people who do not smoke. This paper examines trends in SHS exposure at home among children in Germany since the introduction of smoking bans in public places. Special focus is placed on the importance of the family of origin’s socioeconomic status (SES) and on parental smoking behaviour.

Methods

The analyses are based on two waves of the “German Health Interview and Examination Survey for Children and Adolescents” (KiGGS)—one of which was conducted immediately before the introduction of central smoke-free legislation in the 2003-2006 period, the other approximately 6 years later from 2009 to 2012. A comparison is made between the answers given by the parents of children aged between 0 to 6 (KiGGS baseline study, n = 6680; KiGGS Wave 1, n = 4455). Domestic SHS exposure is covered in the parent interviews by asking whether anyone is allowed to smoke at home in the presence of their child. Parental smoking behaviour is determined separately for mothers and fathers. SES is determined on the basis of the parents’ education, occupational status and income.

Results

The percentage of 0- to 6-year-old children exposed to SHS in the parental home fell from 23.9 to 6.6 % in the period from 2003-2006 to 2009-2012. At the same time, the percentage of children with at least one parent who smokes decreased from 49.8 to 41.8 %. While relative social inequalities in parental smoking behaviour have tended to increase over time, inequalities in domestic SHS exposure have persisted. Children whose parents smoke and children from low-SES families are still most likely to be exposed to tobacco smoke. In both study periods and after statistical adjustment for parental smoking behaviour, children with a low SES had a 6.6-fold higher risk for SHS exposure in the parental home than children from high-SES households.

Conclusions

The results of the KiGGS study show that the proportion of children in Germany who are exposed to SHS at home has declined significantly over the last few years. There is much to suggest that the smoke-free legislation that has been introduced in Germany has led to a heightened awareness of the health risks of SHS both in public and in the private sphere, as well as to a denormalization of smoking. Children whose parents smoke, and among them particularly children from socially disadvantaged families, should be recognised as key target groups when implementing future tobacco-control measures.

Reducing Underserved Children's Exposure to Tobacco Smoke: A Randomized Counseling Trial With Maternal Smokers

INTRODUCTION

Addressing maternal smoking and child tobacco smoke exposure is a public health priority. Standard care advice and self-help materials to help parents reduce child tobacco smoke exposure is not sufficient to promote change in underserved populations. We tested the efficacy of a behavioral counseling approach with underserved maternal smokers to reduce infant's and preschooler's tobacco smoke exposure.

DESIGN

A two-arm randomized trial: enhanced behavior counseling (experimental) versus enhanced standard care (control). Assessment staff members were blinded.

SETTING/PARTICIPANTS

Three hundred randomized maternal smokers were recruited from low-income urban communities. Participants had a child aged <4 years exposed to two or more maternal cigarettes/day at baseline.

INTERVENTION

Philadelphia Family Rules for Establishing Smoke-free Homes (FRESH) included 16 weeks of counseling. Using a behavioral shaping approach within an individualized cognitive-behavioral therapy framework, counseling reinforced efforts to adopt increasingly challenging tobacco smoke exposure-protective behaviors with the eventual goal of establishing a smoke-free home.

MAIN OUTCOME MEASURES

Primary outcomes were end-of-treatment child cotinine and reported tobacco smoke exposure (maternal cigarettes/day exposed). Secondary outcomes were end-of-treatment 7-day point-prevalence self-reported cigarettes smoked/day and bioverified quit status.

RESULTS

Participation in FRESH behavioral counseling was associated with lower child cotinine (β=-0.18, p=0.03) and reported tobacco smoke exposure (β=-0.57, p=0.03) at the end of treatment. Mothers in behavioral counseling smoked fewer cigarettes/day (β=-1.84, p=0.03) and had higher bioverified quit rates compared with controls (13.8% vs 1.9%, χ(2)=10.56, p<0.01). There was no moderating effect of other smokers living at home.

CONCLUSIONS

FRESH behavioral counseling reduces child tobacco smoke exposure and promotes smoking quit rates in a highly distressed and vulnerable population.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02117947.

SHS-Related Pediatric Sick Visits are Linked to Maternal Depressive Symptoms among Low-Income African American Smokers: An Opportunity for Intervention in Pediatrics

Maternal smoking and depressive symptoms are independently linked to poor child health outcomes. However, little is known about factors that may predict maternal depressive symptoms among low-income, African American maternal smokers - an understudied population with children known to have increased morbidity and mortality risks. The objective of this study was to test the hypothesis that secondhand smoke exposure (SHSe)-related pediatric sick visits are associated with significant maternal depressive symptoms among low-income, African American maternal smokers in the context of other depression-related factors. Prior to randomization in a behavioral counseling trial to reduce child SHSe, 307 maternal smokers in Philadelphia completed the CES-D and questionnaires measuring stressful events, nicotine dependence, social support, child health and demographics. CES-D was dichotomized at the clinical cutoff to differentiate mothers with significant vs. low depressive symptoms. Results from direct entry logistic regression demonstrated that maternal smokers reporting more than one SHSe-related sick visit (OR 1.38, p<.001), greater perceived life stress (OR 1.05, p<.001) and less social support (OR 0.82, p<.001) within the last 3 months were more likely to report significant depressive symptoms than mothers with fewer clinic visits, less stress, and greater social support. These results suggest opportunities for future hypothesis-driven evaluation, and exploration of intervention strategies in pediatric primary care. Maternal depression, smoking and child illness may present as a reciprocally-determined phenomenon that points to the potential utility of treating one chronic maternal condition to facilitate change in the other chronic condition, regardless of which primary presenting problem is addressed. Future longitudinal research could attempt to confirm this hypothesis.