A smoking cessation intervention plus proactive quitline referral in the pediatric emergency department: a pilot study

Barriers to implementation of pediatric emergency department interventions for parental tobacco use and dependence: a qualitative study using the theoretical domains framework

Background

Pediatric emergency department (PED) and urgent care (UC) professionals can play a key role in delivering evidence-based guidelines to address parental tobacco use and child tobacco smoke exposure (TSE). Understanding PED/UC professionals’ perceptions regarding these guidelines is the first step in developing and implementing a TSE screening and counseling intervention in these settings. This study aimed to use the theoretical domains framework (TDF) to identify current screening and counseling behaviors of PED/UC professionals related to parental tobacco use and child TSE, and determine barriers and enablers that influence these behaviors.

Methods

Semi-structured, focused interviews were conducted with 29 actively practicing PED/UC clinical staff who worked at one large, Midwestern children’s hospital. The interview guide was informed by the TDF and included open-ended questions. Content analysis of interview transcripts was guided by the TDF. Nurses, physicians, and healthcare administrators were assessed overall and by group membership to ensure each group was represented based on their varying PED/UC roles.

Results

Fifty-one percent were nurses, 38% were physicians, and 11% were healthcare administrators. Most PED/UC professionals did not currently follow the guidelines, but perceived addressing parental tobacco use as part of their role. All 14 TDF domains were identified by nurses, physicians, and administrators in relation to counseling for parental tobacco use and child TSE. Domains with the most sub-themes were (1) knowledge: lack of knowledge about tobacco counseling, including implementing counseling, cessation resources/referrals, and thirdhand smoke; (2) beliefs about capabilities: not comfortable counseling parents, easier to discuss with parents who are receptive and to ask and advise when patients have a TSE-related complaint, and more likely to discuss if there were resources/referrals; and (3) environmental context and resources: barriers include lack of time, training, and resources and referral information to give to parents, and an enabler is using TSE-related complaints as a context to offer counseling.

Conclusions

Study findings provide a strong foundation for developing and implementing clinical practice guidelines regarding parental tobacco use and child TSE in the PED/UC setting. Future intervention development will address all TDF domains and test the implementation of the intervention in the PED/UC setting.

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.

Program uptake of a parent-tailored telephone smoking cessation counselling: An examination of recruitment approaches

INTRODUCTION

Recently, a Dutch proactive parent-tailored telephone smoking cessation counselling program, Smoke-free Parents (SFP), was demonstrated to be effective in helping parents to quit smoking. This study aimed to examine the program’s uptake and the costs of two recruitment approaches (i.e. healthcare vs mass media) for SFP. In addition, parent’s barriers to participating in SFP and the characteristics of participating parents were assessed.

METHODS

As part of an effectiveness-implementation hybrid trial, 402 smoking parents were recruited via healthcare settings and mass media for an informal, proactive, and free phone call with a smoking cessation counsellor about SFP (the Netherlands, September 2016 – September 2018). Parents were asked whether they wanted to participate in SFP. If parents refused, reasons for decline and additional information (e.g. educational level) were collected.

RESULTS

Results revealed that 26.4% of the recruited parents participated in SFP. Although the program uptake of parents recruited via mass media was slightly, but not significantly, higher than via healthcare (27.3% vs 26.8%, p=0.92), the healthcare approach resulted in lower costs per participant (€99.62 vs €205.72). Smoking cessation counsellors were unable to reach almost one-third (32.7%) of the parents after they had agreed to be called about SFP.

CONCLUSIONS

The present study showed that more than a quarter of all recruited parents participated in SFP and that the mass media approach and healthcare approach can be used to recruit parents for SFP. To increase the number of parents participating in SFP, it is important to overcome the identified barriers that prevent parents from participating.

The Effectiveness of Smoking Cessation Interventions Tailored to Smoking Parents of Children Aged 0–18 Years: A Meta-Analysis

INTRODUCTION

A meta-analysis was conducted to examine the effectiveness of smoking cessation interventions tailored to parents of children aged 0-18 years.

METHODS

A systematic search was carried out in PsycInfo, Embase, and PubMed in March 2020. A manual search of the reference lists of the included studies and systematic reviews related to the topic was also performed. Two authors independently screened the studies based on the following inclusion criteria: (1) effect studies with control groups that examine smoking cessation interventions tailored to parents of children (0-18 years), and (2) full-text original articles written in English and published between January 1990 and February 2020. In total, 18 studies were included in the analyses. The TiDieR checklist and the Cochrane Risk of Bias Tool 2.0 were used to extract data and to assess the risk of bias. Consensus among authors was reached at each stage.

RESULTS

Random-effects meta-analyses were performed. With a total number of 8,560 parents, the pooled relative risk was 1.62 (95% CI 1.38-1.90; p < 0.00001), showing a modest effect of the interventions on smoking cessation. Overall, 13.1% of the parents in the intervention conditions reported abstinence versus 8.4% of the parents in the control conditions.

DISCUSSION/CONCLUSION

Smoking cessation interventions tailored to parents are modestly effective. To increase the effectiveness and the impact of these interventions in terms of controlling tobacco use and public health, it is crucial for further research to explore how these interventions can be improved.

A Parental Smoking Cessation Intervention in the Pediatric Emergency Setting: A Randomized Trial

We examined the efficacy of a pediatric emergency visit-based screening, brief intervention, and referral to treatment (SBIRT) condition compared to a control condition (Healthy Habits Control, HHC) to help parental smokers quit smoking. We enrolled 750 parental smokers who presented to the pediatric emergency setting with their child into a two-group randomized controlled clinical trial. SBIRT participants received brief cessation coaching, quitting resources, and up to 12-weeks of nicotine replacement therapy (NRT). HHC participants received healthy lifestyle coaching and resources. The primary outcome was point-prevalence tobacco abstinence at six weeks (T1) and six months (T2). The mean (SD) age of parents was 31.8 (7.7) years, and 86.8% were female, 52.7% were Black, and 64.6% had an income of ≤$15,000. Overall abstinence rates were not statistically significant with 4.2% in both groups at T1 and 12.9% and 8.3% in the SBIRT and HHC groups, respectively, at T2. There were statistically significant differences in SBIRT versus HHC participants on the median (IQR) reduction of daily cigarettes smoked at T1 from baseline (-2 [-5, 0] versus 0 [-4, 0], p = 0.0008),at T2 from baseline (-4 [-9, -1] vs. -2 [-5, 0], p = 0.0006), and on the mean (SD) number of quit attempts at T2 from baseline (1.25 (6.5) vs. 0.02 (4.71), p = 0.02). Self-reported quitting rates were higher in SBIRT parents who received NRT (83.3% vs. 50.9%, p = 0.04). The novel use of the pediatric emergency visit to conduct cessation interventions helped parents quit smoking. The near equivalent abstinence rates in both the SBIRT and HHC groups may be due to underlying parental concern about their child's health. Cessation interventions in this setting may result in adult and pediatric public health benefits.

Utilization of a Clinical Decision Support Tool to Reduce Child Tobacco Smoke Exposure in the Urgent Care Setting

BACKGROUND

Clinical decision support systems (CDSS) may facilitate caregiver tobacco screening and counseling by pediatric urgent care (UC) nurses.

OBJECTIVE

This study aimed to assess the feasibility of a CDSS to address caregivers' tobacco use and child tobacco smoke exposure (TSE).

METHODS

We conducted a 3-month prospective study on caregivers screened using a CDSS. Nurses used the CDSS to advise, assess, and assist caregivers to quit. We assessed caregiver sociodemographics, smoking habits, and child TSE.

RESULTS

We screened 185 caregivers whose children were exposed to TSE for study inclusion; 155 (84%) met the eligibility criteria, and 149 (80.5%) were included in the study. Study nurses advised 35.2% of the caregivers to quit, assessed 35.9% for readiness to quit, and assisted 32.4%. Of the 149 participants, 83.1% were female; 47.0% were white and 45.6% African American; 84.6% had public insurance or were self-pay; 71.1% were highly nicotine dependent; 50.0% and 50.7% allowed smoking in the home and car, respectively; and 81.3% of children were biochemically confirmed to be exposed to tobacco smoke. At follow-up (86.6% retention), 58.9% reported quit attempts at 3 months. There was a significant decrease in nicotine dependence and a significant increase in motivation to quit. Self-reported quit rate was 7.8% at 3 months.

CONCLUSIONS

An electronic health record-embedded CDSS was feasible to incorporate into busy UC nurses' workloads and was associated with encouraging changes in the smoking behavior of caregivers. More research on the use of CDSS to screen and counsel caregivers who smoke in the UC and other acute care settings is warranted.

Busgang S, Matt GE. Comparison of Liquid Chromatography Mass Spectrometry and Enzyme-Linked Immunosorbent Assay Methods to Measure Salivary Cotinine Levels in Ill Children

Objective: Cotinine is the preferred biomarker to validate levels of tobacco smoke exposure (TSE) in children. Compared to enzyme-linked immunosorbent assay methods (ELISA) for quantifying cotinine in saliva, the use of liquid chromatography tandem mass spectrometry (LC-MS/MS) has higher sensitivity and specificity to measure very low levels of TSE. We sought to compare LC-MS/MS and ELISA measures of cotinine in saliva samples from children overall and the associations of these measures with demographics and TSE patterns. Method: Participants were nonsmoking children (N = 218; age mean (SD) = 6.1 (5.1) years) presenting to a pediatric emergency department. Saliva samples were analyzed for cotinine using both LC-MS/MS and ELISA. Limit of quantitation (LOQ) for LC-MS/MS and ELISA was 0.1 ng/ml and 0.15 ng/ml, respectively. Results: Intraclass correlations (ICC) across methods = 0.884 and was consistent in sex and age subgroups. The geometric mean (GeoM) of LC-MS/MS = 4.1 (range: < LOQ - 382 ng/mL; 3% < LOQ) which was lower (p < 0.0001) than the ELISA GeoM = 5.7 (range: < LOQ - 364 ng/mL; 5% < LOQ). Similar associations of cotinine concentrations with age ( < -0.10, p < 0.0001), demographic characteristics (e.g., income), and number of cigarettes smoked by caregiver ( > 0.07, p < 0.0001) were found regardless of cotinine detection method; however, cotinine associations with sex and race/ethnicity were only found to be significant in models using LC-MS/MS-derived cotinine. Conclusions: Utilizing LC-MS/MS-based cotinine, associations of cotinine with sex and race/ethnicity of child were revealed that were not detectable using ELISA-based cotinine, demonstrating the benefits of utilizing the more sensitive LC-MS/MS assay for cotinine measurement when detecting low levels of TSE in children.

Proactive Telephone Smoking Cessation Counseling Tailored to Parents: Results of a Randomized Controlled Effectiveness Trial

A recent Dutch efficacy trial showed the efficacy of a telephone smoking cessation counseling tailored to smoking parents. Currently, it is unknown whether such telephone counseling would be effective under more real-world conditions. This study aimed to examine the effectiveness of parent-tailored telephone smoking cessation counseling in a two-arm randomized controlled effectiveness trial and whether the effectiveness depended on the recruitment approaches that were used to recruit parents (mass media vs. health care). In total, 87 parents received either telephone counseling (intervention) or a self-help brochure (control). Parents were asked to complete questionnaires at baseline and three months post-intervention. Results showed that the odds of reporting 7-day point-prevalence abstinence at three months post-intervention was 7.54 higher for parents who received telephone counseling than for parents in the control condition (53.3% vs. 13.2%, 95% CI = 2.49–22.84). Because inclusion was lower than anticipated, interaction-effects of condition and recruitment approach could not be interpreted. The present study demonstrates that the parent-tailored smoking cessation telephone counseling is effective in helping parents to quit smoking. Yet, before large-scale implementation, future research should focus on how recruitment of parents via the recruitment approaches could be improved.

Telephone counselling for smoking cessation

BACKGROUND

Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines.

OBJECTIVES

To evaluate the effect of telephone support to help smokers quit, including proactive or reactive counselling, or the provision of other information to smokers calling a helpline.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the ICTRP for studies of telephone counselling, using search terms including 'hotlines' or 'quitline' or 'helpline'. Date of the most recent search: May 2018.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials which offered proactive or reactive telephone counselling to smokers to assist smoking cessation.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We pooled studies using a random-effects model and assessed statistical heterogeneity amongst subgroups of clinically comparable studies using the I2 statistic. In trials including smokers who did not call a quitline, we used meta-regression to investigate moderation of the effect of telephone counselling by the planned number of calls in the intervention, trial selection of participants that were motivated to quit, and the baseline support provided together with telephone counselling (either self-help only, brief face-to-face intervention, pharmacotherapy, or financial incentives).

MAIN RESULTS

We identified 104 trials including 111,653 participants that met the inclusion criteria. Participants were mostly adult smokers from the general population, but some studies included teenagers, pregnant women, and people with long-term or mental health conditions. Most trials (58.7%) were at high risk of bias, while 30.8% were at unclear risk, and only 11.5% were at low risk of bias for all domains assessed. Most studies (100/104) assessed proactive telephone counselling, as opposed to reactive forms.Among trials including smokers who contacted helplines (32,484 participants), quit rates were higher for smokers receiving multiple sessions of proactive counselling (risk ratio (RR) 1.38, 95% confidence interval (CI) 1.19 to 1.61; 14 trials, 32,484 participants; I2 = 72%) compared with a control condition providing self-help materials or brief counselling in a single call. Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate.In studies that recruited smokers who did not call a helpline, the provision of telephone counselling increased quit rates (RR 1.25, 95% CI 1.15 to 1.35; 65 trials, 41,233 participants; I2 = 52%). Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate. In subgroup analysis, we found no evidence that the effect of telephone counselling depended upon whether or not other interventions were provided (P = 0.21), no evidence that more intensive support was more effective than less intensive (P = 0.43), or that the effect of telephone support depended upon whether or not people were actively trying to quit smoking (P = 0.32). However, in meta-regression, telephone counselling was associated with greater effectiveness when provided as an adjunct to self-help written support (P < 0.01), or to a brief intervention from a health professional (P = 0.02); telephone counselling was less effective when provided as an adjunct to more intensive counselling. Further, telephone support was more effective for people who were motivated to try to quit smoking (P = 0.02). The findings from three additional trials of smokers who had not proactively called a helpline but were offered telephone counselling, found quit rates were higher in those offered three to five telephone calls compared to those offered just one call (RR 1.27, 95% CI 1.12 to 1.44; 2602 participants; I2 = 0%).

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that proactive telephone counselling aids smokers who seek help from quitlines, and moderate-certainty evidence that proactive telephone counselling increases quit rates in smokers in other settings. There is currently insufficient evidence to assess potential variations in effect from differences in the number of contacts, type or timing of telephone counselling, or when telephone counselling is provided as an adjunct to other smoking cessation therapies. Evidence was inconclusive on the effect of reactive telephone counselling, due to a limited number studies, which reflects the difficulty of studying this intervention.

Association of secondhand smoke exposure with asthma symptoms, medication use, and healthcare utilization among asthmatic adolescents

OBJECTIVE

To investigate the association between secondhand smoke exposure (SHSe) and asthma symptoms, medication use, and emergency department (ED)/urgent care (UC) utilization among adolescents.

METHODS

We performed a secondary cross-sectional analysis of Population Assessment of Tobacco and Health Study Wave 2 (2014-2015) including asthmatic adolescents (N = 2198). Logistic regression models and Poisson regression models were built.

RESULTS

Participants with SHSe ≥1 hour in the past 7 days were at increased risk of reporting shortness of breath and harder to exercise aOR, 1.22; 95% CI, 1.04-1.43), wheezing (aOR, 1.26; 95% CI, 1.01-1.56), wheezing disturbing sleep (aOR, 1.88; 95% CI, 1.35-2.63), wheezing during/after exercise (aOR, 1.41; 95% CI, 1.19-1.66), wheezing limiting speech (aOR, 2.11; 95% CI, 1.55-2.86), dry cough at night (aOR, 1.86; 95% CI, 1.54-2.24), and asthma symptoms disturbing sleep (aOR, 2.25; 95% CI, 1.81-2.79). Participants with SHSe ≥1 hour were more likely to take asthma medications (aOR, 1.25; 95% CI, 1.03-1.52), including steroids (aOR, 1.86; 95% CI, 1.19-2.91), oxygen therapy (aOR, 2.88; 95% CI, 1.82-4.54), and controlling medications (aOR, 1.50; 95% CI, 1.24-1.82). Symptoms and medications varied by living with a smoker and home SHSe. Participants with SHSe were at increased risk of having a higher number of asthma attacks that required steroid use. Participants who lived with a smoker and had home SHSe were at increased risk of having higher ED/UC visits for asthma.

CONCLUSIONS

SHSe reduction efforts are needed for asthmatic adolescents, and EDs/UCs are promising venues.

Adolescent Tobacco Smoke Exposure, Respiratory Symptoms, and Emergency Department Use

OBJECTIVES

Our objective was to examine the relationship between distinct tobacco smoke exposure (TSE) measures and TSE-related symptoms and emergency department (ED) and/or urgent care (UC) use among nonsmoking adolescents without asthma diagnoses.

METHODS

We performed a secondary analysis of 7389 adolescents who completed the Population Assessment of Tobacco and Health Study wave 2. Logistic regression and Poisson regression models were built.

RESULTS

Adolescents with TSE were at increased risk of reporting: shortness of breath, finding it hard to exercise, wheezing during or after exercise, and dry cough at night. Adolescents who lived with a smoker and had home TSE were at increased odds of reporting wheezing or whistling in the chest, and only adolescents with home TSE were at increased risk of reporting wheezing that disturbed sleep. Adolescents with TSE were less likely to report very good or excellent overall health and physical health but were more likely to report they sometimes, often, or very often missed school because of illness. Participants who lived with a smoker and had TSE ≥1 hour were more likely to have had an ED and/or UC visit. Participants with any TSE were at increased risk of having a higher number of ED and/or UC visits.

CONCLUSIONS

Different TSE measures uniquely increased the risk of TSE-related symptoms, but any TSE increased the risk of having a higher number of ED and/or UC visits. The providers at these high-volume settings should offer interventions to adolescents who are exposed to tobacco smoke and their families to decrease these symptoms and related morbidity.

An Electronic Health Record-Based Strategy to Address Child Tobacco Smoke Exposure

INTRODUCTION

A high proportion of children presenting to pediatric urgent cares are exposed to tobacco smoke. An electronic health record-based clinical decision support system for nurses to facilitate guideline-based tobacco smoke exposure screening and counseling for caregivers who smoke was designed and evaluated.

DESIGN

A mixed-methods, 3-month, prospective study that began in November 2015, data were analyzed in June 2016.

SETTING/PARTICIPANTS

Five urgent cares that were part of a large children's hospital in Cincinnati, OH. Participants were urgent care nurses.

INTERVENTION

The clinical decision support system prompted nurses to Ask, Advise, Assess, and Assist caregivers to quit smoking. Monthly feedback reports were also provided.

MAIN OUTCOME MEASURE

Clinical decision support system use rates, nurses' attitudes towards tobacco smoke exposure intervention, and percentage of children screened and caregivers counseled.

RESULTS

All nurses used the clinical decision support system. Compared with Month 1, nurses were twice as likely to advise and assess during Months 2 and 3. There was significant improvement in nurses feeling prepared to assist caregivers in quitting. Nurses reported that feedback reports motivated them to use the clinical decision support system, and that it was easy to use. Almost 65% of children were screened for tobacco smoke exposure; 19.5% screened positive. Of caregivers identified as smokers, 26% were advised to quit and 29% were assessed for readiness to quit. Of those assessed, 67% were interested in quitting, and of those, 100% were assisted.

CONCLUSIONS

A clinical decision support system increased rates of tobacco smoke exposure screening and intervention in pediatric urgent cares. Rates might further improve by incorporating all components of the clinical decision support system into the electronic health record.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02489708.

Secondhand Smoke Exposure and Pediatric Healthcare Visits and Hospitalizations

INTRODUCTION

This study assessed the relationship between secondhand smoke exposure (SHSe) as measured by serum cotinine and healthcare utilization among children.

METHODS

In 2016, the 2009-2012 National Health and Nutrition Examination Survey data were analyzed including 4,985 children aged 3-19 years. Associations between SHSe and having a routine place for healthcare, type of place, and hospital utilization were examined using logistic regression models. Poisson regression analyses assessed the relationship between SHSe and number of hospital admissions. Relationships between SHSe and acute care visits and hospital utilization were examined among asthmatic children.

RESULTS

SHSe level did not differ by having a routine place for healthcare, although children with high SHSe indicative of active smoking (cotinine ≥3 ng/mL) were 3.49 times (95% CI=1.77, 6.89) more likely to use an emergency department. Children with high SHSe were 2.85 times (95% CI=1.87, 4.34) more likely to have had an overnight hospital stay. Children with high SHSe had 2.05 times (95% CI=1.46, 2.87) the risk of having a higher number of hospital admissions for overnight stays versus children with no SHSe (cotinine <0.05 ng/mL). Among asthmatic children, those with high SHSe and low SHSe (cotinine 0.05-2.99 ng/mL) were more likely to have an acute care visit, overnight hospital stay, and higher number of hospital admissions than asthmatic children with no SHSe.

CONCLUSIONS

High SHSe is associated with increased healthcare utilization. The emergency department and inpatient settings are important venues in which to routinely offer cessation and SHSe reduction interventions.

Healthy families: study protocol for a randomized controlled trial of a screening, brief intervention, and referral to treatment intervention for caregivers to reduce secondhand smoke exposure among pediatric emergency patients

Background

Involuntary exposure to secondhand smoke (SHSe) is an important cause of morbidity in children who present to the pediatric emergency department (PED) and urgent care (UC). SHSe interventions delivered in the PED and UC would benefit both the smoker and child, but there have been no large trials testing the efficacy of such interventions. The Healthy Families program is the first randomized controlled trial to test whether a screening, brief intervention, and referral to treatment (SBIRT) intervention delivered in the PED and UC will be effective in decreasing SHSe in children and increasing cessation in smokers.

Methods/design

This trial uses a randomized, two-group design in which caregiver-smokers of children 0–17 years old are recruited from the PED and UC. Eligible caregiver-smokers are randomized to either the: 1) SBIRT Condition with face-to-face, tailored counseling that focuses on the child’s illness, the importance of reducing child SHSe, caregiver smoking cessation, and the option to receive nicotine replacement therapy; or 2) Healthy Habits Control Condition which includes face-to-face, tailored attention control “5–2–1-0” counseling that focuses on improving the child’s health. Dyadic assessments are conducted in-person at baseline, and via email, phone, or in-person at 6-weeks and 6-months. The primary outcomes are biochemically-verified, 7-day point prevalence and prolonged smoking abstinence. Secondary outcomes are cigarettes smoked per week, 24 h quit attempts, and biochemically validated child SHSe at each time point. The costs of this intervention will also be analyzed.

Discussion

This study will test an innovative, multilevel intervention designed to reduce child SHSe and increase smoking cessation in caregivers. If effective and routinely used, this SBIRT model could reach at least one million smokers a year in the U.S., resulting in significant reductions in caregivers’ tobacco use, SHSe-related pediatric illness, and healthcare costs in this population of children.

Trial registration

ClinicalTrials.gov Identifier: NCT02531594. Date of registration: August 4, 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4278-8) contains supplementary material, which is available to authorized users.

Development of a Tobacco Cessation Clinical Decision Support System for Pediatric Emergency Nurses

Almost 50% of children who visit the pediatric emergency department are exposed to tobacco smoke. However, pediatric emergency nurses do not routinely address this issue. The incorporation of a clinical decision support system into the electronic health record may improve the rates of tobacco exposure screening and interventions. We used a mixed-methods design to develop, refine, and implement an evidence-based clinical decision support system to help nurses screen, educate, and assist caregivers to quit smoking. We included an advisory panel of emergency department experts and leaders and focus and user groups of nurses. The prompts include the following: (1) "Ask" about child smoke exposure and caregiver smoking; (2) "Advise" caregivers to reduce their child's smoke exposure by quitting smoking; (3) "Assess" interest; and (4) "Assist" caregivers to quit. The clinical decision support system was created to reflect nurses' suggestions and was implemented in five busy urgent care settings with 38 nurses. The nurses reported that the system was easy to use and helped them to address caregiver smoking. The use of this innovative tool may create a sustainable and disseminable model for prompting nurses to provide evidence-based tobacco cessation treatment.

Tobacco Smoke Exposure-Related Illnesses Among Pediatric Emergency Department Patients

INTRODUCTION

This study aimed to determine the relationship between patients presenting to the pediatric emergency department (PED) and potential tobacco smoke exposure (TSE)-related illnesses.

METHODS

A retrospective review of electronic medical records of pediatric emergency department patients (N = 116,084) was conducted. Sociodemographic characteristics, TSE-related illnesses, and TSE documentation were extracted. Logistic regression analyses were performed.

RESULTS

More than one fifth (21.7%) of patients had TSE-related illnesses. Patients who were younger, male, non-White, or Hispanic; had Medicaid/Medicare insurance, had low triage acuity; or were admitted to any non-intensive care unit or intensive care unit were significantly more likely to have TSE-related illnesses. Twenty-eight percent of patients with TSE documentation had positive TSE status. Although regression models for positive TSE indicated similar findings, no difference was found based on ethnicity.

DISCUSSION

Pediatric emergency departments, especially those that care for large numbers of children, should offer tobacco interventions that target at-risk populations and caregivers who are most likely not receiving interventions in other health care settings.

System change interventions for smoking cessation

BACKGROUND

System change interventions for smoking cessation are policies and practices designed by organizations to integrate the identification of smokers and the subsequent offering of evidence-based nicotine dependence treatments into usual care. Such strategies have the potential to improve the provision of smoking cessation support in healthcare settings, and cessation outcomes among those who use them.

OBJECTIVES

To assess the effectiveness of system change interventions within healthcare settings, for increasing smoking cessation or the provision of smoking cessation care, or both.

SEARCH METHODS

We searched databases including the Cochrane Tobacco Addiction Group Specialized Register, CENTRAL, MEDLINE, Embase, CINAHL, and PsycINFO in February 2016. We also searched clinical trial registries: WHO clinical trial registry, US National Institute of Health (NIH) clinical trial registry. We checked 'grey' literature, and handsearched bibliographies of relevant papers and publications.

SELECTION CRITERIA

Randomized controlled trials (RCTs), cluster-RCTs, quasi-RCTs and interrupted time series studies that evaluated a system change intervention, which included identification of all smokers and subsequent offering of evidence-based nicotine dependence treatment.

DATA COLLECTION AND ANALYSIS

Using a standardized form, we extracted data from eligible studies on study settings, participants, interventions and outcomes of interest (both cessation and system-level outcomes). For cessation outcomes, we used the strictest available criteria to define abstinence. System-level outcomes included assessment and documentation of smoking status, provision of advice to quit or cessation counselling, referral and enrolment in quitline services, and prescribing of cessation medications. We assessed risks of bias according to the Cochrane Handbook and categorized each study as being at high, low or unclear risk of bias. We used a narrative synthesis to describe the effectiveness of the interventions on various outcomes, because of significant heterogeneity among studies.

MAIN RESULTS

We included seven cluster-randomized controlled studies in this review. We rated the quality of evidence as very low or low, depending on the outcome, according to the GRADE standard. Evidence of efficacy was equivocal for abstinence from smoking at the longest follow-up (four studies), and for the secondary outcome 'prescribing of smoking cessation medications' (two studies). Four studies evaluated changes in provision of smoking cessation counselling and three favoured the intervention. There were significant improvements in documentation of smoking status (one study), quitline referral (two studies) and quitline enrolment (two studies). Other secondary endpoints, such as asking about tobacco use (three studies) and advising to quit (three studies), also indicated some positive effects.

AUTHORS' CONCLUSIONS

The available evidence suggests that system change interventions for smoking cessation may not be effective in achieving increased cessation rates, but have been shown to improve process outcomes, such as documentation of smoking status, provision of cessation counselling and referral to smoking cessation services. However, as the available research is limited we are not able to draw strong conclusions. There is a need for additional high-quality research to explore the impact of system change interventions on both cessation and system-level outcomes.

Tobacco Smoke Exposure and Health-Care Utilization Among Children in the United States

PURPOSE

The purpose of this study was to assess patterns of health-care utilization among children who potentially had tobacco smoke exposure (TSE) compared to those who were not exposed.

DESIGN

A secondary data analysis of the 2011 to 2012 National Survey on Children's Health was performed.

SETTING

Households nationwide were selected.

PARTICIPANTS

A total of 95 677 children aged 0 to 17 years.

MEASURES

Sociodemographic characteristics, TSE status, and health-care visits were measured.

ANALYSIS

Multivariable logistic regression models were performed.

RESULTS

A total of 24.1% of children lived with smokers. Approximately 5% had home TSE. Participants who lived with a smoker were significantly more likely to have had a medical care visit (odds ratio [OR] = 1.22, confidence interval [CI] = 1.21-1.22) and were more likely to seek sick care or health advice at an emergency department (OR = 1.23, CI = 1.23-1.24) but were less likely to have had a dental care visit (OR = 0.82, CI = 0.82-0.83) than those who did not live with a smoker. Similar findings were found among participants who had home TSE.

CONCLUSION

TSE is a risk factor for increased use of pediatric medical care. Based on the high number of children who potentially had TSE and received sick care or health advice at an emergency emergency department, this setting may be a venue to deliver health messages to caregivers.

Development and Testing of a Computerized Decision Support System to Facilitate Brief Tobacco Cessation Treatment in the Pediatric Emergency Department: Proposal and Protocol

Background

Tobacco smoke exposure (TSE) is unequivocally harmful to children's health, yet up to 48% of children who visit the pediatric emergency department (PED) and urgent care setting are exposed to tobacco smoke. The incorporation of clinical decision support systems (CDSS) into the electronic health records (EHR) of PED patients may improve the rates of screening and brief TSE intervention of caregivers and result in decreased TSE in children.

Objective

We propose a study that will be the first to develop and evaluate the integration of a CDSS for Registered Nurses (RNs) into the EHR of pediatric patients to facilitate the identification of caregivers who smoke and the delivery of TSE interventions to caregivers in the urgent care setting.

Methods

We will conduct a two-phase project to develop, refine, and integrate an evidence-based CDSS into the pediatric urgent care setting. RNs will provide input on program content, function, and design. In Phase I, we will develop a CDSS with prompts to: (1) ASK about child TSE and caregiver smoking, (2) use a software program, Research Electronic Data Capture (REDCap), to ADVISE caregivers to reduce their child's TSE via total smoking home and car bans and quitting smoking, and (3) ASSESS their interest in quitting and ASSIST caregivers to quit by directly connecting them to their choice of free cessation resources (eg, Quitline, SmokefreeTXT, or SmokefreeGOV) during the urgent care visit. We will create reports to provide feedback to RNs on their TSE counseling behaviors. In Phase II, we will conduct a 3-month feasibility trial to test the results of implementing our CDSS on changes in RNs’ TSE-related behaviors, and child and caregiver outcomes.

Results

This trial is currently underway with funding support from the National Institutes of Health/National Cancer Institute. We have completed Phase I. The CDSS has been developed with input from our advisory panel and RNs, and pilot tested. We are nearing completion of Phase II, in which we are conducting the feasibility trial, analyzing data, and disseminating results.

Conclusions

This project will develop, iteratively refine, integrate, and pilot test the use of an innovative CDSS to prompt RNs to provide TSE reduction and smoking cessation counseling to caregivers who smoke. If successful, this approach will create a sustainable and disseminable model for prompting pediatric practitioners to apply tobacco-related guideline recommendations. This systems-based approach has the potential to reach at least 12 million smokers a year and significantly reduce TSE-related pediatric illnesses and related costs.

A smoking cessation intervention for low-income smokers in the ED

BACKGROUND

There is a high prevalence of smoking among caregivers who bring their children to the pediatric emergency department (PED) and even higher rates of tobacco smoke exposure (TSE) and related morbidity among their children. The PED visit presents an opportunity to intervene with caregivers, but it is unknown whether they are more likely to quit if their child has a TSE-related illness. We sought to examine a PED-based smoking cessation intervention and compare outcomes based on children's TSE-related illness.

METHODS

A single-arm, prospective trial, with baseline, 3, and 6 month assessments was used in this study. Caregivers whose child had either a TSE-related (n=100) or non-TSE-related illness (n=100) were given a brief intervention consisting of counseling, referral to the Quitline, and free nicotine replacement therapy.

RESULTS

Participants were 91.5% female, 50.5% African American, 100% Medicaid recipients, 30.8 years old, child age mean of 5.5 years, 90% highly nicotine dependent, and 60.3% and 75.8% allowed smoking in the home and car, respectively. At follow-up (65% retention), 80% reported quit attempts at 3 months and 89% between 3 and 6 months. There were significant decreases in number of cigarettes smoked, time to first cigarette, and smoking in the home and car. Quit rates were 12.2% at 3 months, 14.6% at 6 months, and 7.3% at both time points (50% biochemically confirmed). There were no significant differences in outcomes based on children's illness.

CONCLUSIONS

A brief PED-based smoking cessation intervention resulted in quit attempts and successful quits. However, the presence of a TSE-related illness did not result in different cessation outcomes.

Technology-based support via telephone or web: a systematic review of the effects on smoking, alcohol use and gambling

A systematic review of the literature on telephone or internet-based support for smoking, alcohol use or gambling was performed. Studies were included if they met the following criteria: The design being a randomized control trail (RCT), focused on effects of telephone or web based interventions, focused on pure telephone or internet-based self-help, provided information on alcohol or tobacco consumption, or gambling behavior, as an outcome, had a follow-up period of at least 3months, and included adults. Seventy-four relevant studies were found; 36 addressed the effect of internet interventions on alcohol consumption, 21 on smoking and 1 on gambling, 12 the effect of helplines on smoking, 2 on alcohol consumption, and 2 on gambling. Telephone helplines can have an effect on tobacco smoking, but there is no evidence of the effects for alcohol use or gambling. There are some positive findings regarding internet-based support for heavy alcohol use among U.S. college students. However, evidence on the effects of internet-based support for smoking, alcohol use or gambling are to a large extent inconsistent.

The parent-child dyad and risk perceptions among parents who quit smoking

BACKGROUND

Most parental smokers are deeply invested in their child's health, but it is unknown what factors influence parent risk perceptions of the effects of smoking on their child's health and benefits to the child of cessation.

PURPOSE

To explore differences in former versus current smokers' beliefs about harm of continuing to smoke, benefits of quitting, and how much smoking interferes with their parenting.

METHODS

As part of a cluster RCT to increase tobacco control in the pediatric setting, we analyzed data collected at the ten control arm practices for 24 months starting in May 2010; a cross-sectional secondary data analysis was conducted in 2013. Parents were asked about smoking status and perceived harm, benefit, and well-being related to smoking behaviors.

RESULTS

Of the 981 enrolled smoking parents, 710 (72.4%) were contacted at 12 months. The odds of having successfully quit at 12 months was 4.12 times more likely (95% CI=1.57, 10.8) for parents who believed that quitting will benefit their children; 1.68 times more likely (95% CI=1.13, 2.51) for parents with more than a high school education; and 1.74 times greater (95% CI=1.13, 2.68) for parents with children under age 3 years. Another factor associated with having successfully quit was a prior quit attempt.

CONCLUSIONS

Providers' smoking-cessation advice and support should begin early and underscore how cessation will benefit the health and well-being of patients' children. Additionally, parents who have recently attempted to quit may be particularly primed for another attempt.

Real-world impact of quitline interventions for provider-referred smokers

BACKGROUND

The healthcare provider-referral quitline model has potential to help identify and connect more smokers to effective cessation services as compared to the self-referral model alone. However, research is limited as to whether provider-referred smokers, who may have more barriers to quitting, can have similar rates of quit success using traditional quitline interventions as self-referred smokers.

PURPOSE

To (1) determine how provider-referred smokers may differ from self-referred smokers in their demographics, service utilization, and quit rates and (2) quantify the impact of traditional quitline services on provider-referred smokers' ability to quit.

METHODS

Data were collected for 2,737 provider-referred and 530 self-referred Massachusetts quitline clients between November 2007 and February 2012. Analysis was performed in 2012. Wald chi-square tests and two-sample t-tests were used to identify differences between the two referral populations. A multivariable logistic regression model was used for each referral population, and smoker quit status at follow-up was the primary outcome. Tests and models were weighted using inverse probability of treatment weights propensity score weighting method.

RESULTS

Compared with self-referred smokers, provider-referred smokers were more likely to be non-white, less educated, and have public insurance. They were less ready to quit and had lower service utilization and quit rates. In both referral populations, clients who used services had greater odds of quitting than those who did not.

CONCLUSIONS

Expanding the provider-referral model may require quitlines to address the various risk factors associated with this population. Providers serve critical roles in preparing patients for quitline participation prior to referral.

Motivation to quit smoking in parental smokers in the pediatric emergency department

OBJECTIVE

To examine if motivation to quit is associated with parental smoker's perceived presence of a personal or child health illness or risk due to tobacco use.

DESIGN/METHODS

This was a cross-sectional study of a convenience sample of 218 parental smokers who presented to the pediatric emergency department with their child. We assessed factors related to motivation to quit, including personal and child smoking-related illness, perceived personal and child health risk, smoking behaviors, and demographic characteristics. Motivation to quit was measured using the Contemplation Ladder score.

RESULTS

The mean score on the Contemplation Ladder was 6.2 (SD, 2.5), representing the response: thinking about cutting down or quitting . Eighty-four participants (39%) had high motivation to quit (Contemplation Ladder score 8). Bivariate analysis showed significant associations between high motivation to quit and perceived child health risk with continued smoking and perceived personal and child health benefit following smoking cessation. Parents with high motivation to quit were more likely to have high perceived self-efficacy and confidence in their ability to quit, prior quit attempts, and lower nicotine dependence. With the exception of race/ethnicity, demographic variables were not associated with motivation to quit.

CONCLUSIONS

A significant proportion of parental smokers who present to the pediatric emergency department endorse strong motivation to quit. Parents who endorse health risk or quitting-related health benefits in their child are more likely to have high motivation to quit smoking. Future studies are needed to determine if high motivation translates into smoking cessation.

The acceptability of incorporating a youth smoking prevention intervention in the pediatric emergency department

The pediatric emergency department (PED) is under-utilized as a setting in which to provide tobacco prevention interventions for at-risk children. We sought to determine the acceptability and feasibility of incorporating a brief, parental tobacco prevention intervention to 520 parents during the PED visit. Mean age (SD) of parents and children was 38.6 (7.1) and 11.5 (1.1), respectively; 47% of children were female; 45% were African American; 36% of parents had an annual income less than $25,000; 28.8% of parents were current smokers. Over 90% of parents said the intervention provided "useful" and "easy to understand" information and 97% of practitioners said it did not "interfere with clinical care." Given the high prevalence of parental smoking in the PED, there is a high likelihood that their children will initiate smoking in the future. Thus, the use of the PED as a venue to providing tobacco prevention interventions warrants further evaluation.

Implementation of smoking cessation guidelines in the emergency department: a qualitative study of staff perceptions

Background

The US Public Health Service smoking cessation practice guideline specifically recommends that physicians and nurses strongly advise their patients who use tobacco to quit, but the best approach for attaining this goal in the emergency department (ED) remains unknown. The aim of this study was to characterize emergency physicians’ (EPs) and nurses’ (ENs) perceptions of cessation counseling and to identify barriers and facilitators to implementation of the 5 A’s framework (Ask-Advise-Assess-Assist-Arrange) in the ED.

Methods

We conducted semi-structured, face-to-face interviews of 11 EPs and 19 ENs following a pre-post implementation trial of smoking cessation guidelines in two study EDs. We used purposeful sampling to target EPs and ENs with different attitudes toward cessation counseling, based on their responses to a written survey (Decisional Balance Questionnaire). Conventional content analysis was used to inductively characterize the issues raised by study participants and to construct a coding structure, which was then applied to study transcripts.

Results

The main findings of this study converged upon three overarching domains: 1) reactions to the intervention; 2) perceptions of patients’ receptivity to cessation counseling; and 3) perspectives on ED cessation counseling and preventive care. ED staff expressed ambivalence toward the implementation of smoking cessation guidelines. Both ENs and EPs agreed that the delivery of smoking cessation counseling is important, but that it is not always practical in the ED on account of time constraints, the competing demands of acute care, and resistance from patients. Participants also called attention to the need for improved role clarity and teamwork when implementing the 5 A’s in the ED.

Conclusions

There are numerous challenges to the implementation of smoking cessation guidelines in the ED. ENs are generally willing to take the lead in offering brief cessation counseling, but their efforts need to be reinforced by EPs. ED systems need to address workflow, teamwork, and practice policies that facilitate prescription of smoking cessation medication, referral for cessation counseling, and follow-up in primary care. The results of this qualitative evaluation can be used to guide the design of future ED intervention studies.

Trial registration

ClinicalTrials.gov registration number NCT00756704

Parental tobacco screening and counseling in the pediatric emergency department: practitioners' attitudes, perceived barriers, and suggestions for implementation and maintenance

INTRODUCTION

The pediatric emergency department (PED) is a venue that underuses parental tobacco screening and brief cessation counseling. We sought to explore PED practitioners' attitudes and perceived barriers regarding the implementation and adoption of tobacco screening/cessation counseling of parental smokers in the PED setting, as well as to solicit suggestions for improving the sustainability and maintenance of such practices.

METHODS

We conducted an exploratory, qualitative study of a convenience sample of PED practitioners using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. Individual, focused interviews were conducted to determine factors that would maximize the implementation and maintenance of parental tobacco screening and intervention counseling as standard PED practice.

RESULTS

Thirty interviews were conducted from which relevant data, patterns, and themes were identified. Reach factors included targeting parental smokers with children with respiratory diseases, having adequate training of practitioners, and providing "prearranged" counseling packages. Effectiveness factors included practitioner desire for outcome data about intervention effectiveness (eg, changes in children's secondhand smoke exposure and parental quit rates). Solutions to increase intervention adoption included quick electronic health record prompts and the provision of onsite tobacco cessation experts. Implementation suggestions emphasized the importance of financial support and the alignment of tobacco screening/counseling with strategic plans. Maintenance factors included institutional and technical support, as well as the importance of intervention "champions" in the PED.

DISCUSSION

By highlighting important viewpoints of practitioners regarding tobacco screening and counseling, the findings can help guide and direct the development and evaluation of sustainable interventions to facilitate tobacco use treatment in the PED.

Telephone counselling for smoking cessation

BACKGROUND

Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines.

OBJECTIVES

To evaluate the effect of proactive and reactive telephone support via helplines and in other settings to help smokers quit.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register for studies of telephone counselling, using search terms including 'hotlines' or 'quitline' or 'helpline'. Date of the most recent search: May 2013.

SELECTION CRITERIA

randomized or quasi-randomised controlled trials in which proactive or reactive telephone counselling to assist smoking cessation was offered to smokers or recent quitters.

DATA COLLECTION AND ANALYSIS

One author identified and data extracted trials, and a second author checked them. The main outcome measure was the risk ratio for abstinence from smoking after at least six months follow-up. We selected the strictest measure of abstinence, using biochemically validated rates where available. We considered participants lost to follow-up to be continuing smokers. Where trials had more than one arm with a less intensive intervention we used only the most similar intervention without the telephone component as the control group in the primary analysis. We assessed statistical heterogeneity amongst subgroups of clinically comparable studies using the I² statistic. We considered trials recruiting callers to quitlines separately from studies recruiting in other settings. Where appropriate, we pooled studies using a fixed-effect model. We used a meta-regression to investigate the effect of differences in planned number of calls, selection for motivation, and the nature of the control condition (self help only, minimal intervention, pharmacotherapy) in the group of studies recruiting in non-quitline settings.

MAIN RESULTS

Seventy-seven trials met the inclusion criteria. Some trials were judged to be at risk of bias in some domains but overall we did not judge the results to be at high risk of bias. Among smokers who contacted helplines, quit rates were higher for groups randomized to receive multiple sessions of proactive counselling (nine studies, > 24,000 participants, risk ratio (RR) for cessation at longest follow-up 1.37, 95% confidence interval (CI) 1.26 to 1.50). There was mixed evidence about whether increasing the number of calls altered quit rates but most trials used more than two calls. Three studies comparing different counselling approaches during a single quitline contact did not detect significant differences. Of three studies that tested the provision of access to a hotline two detected a significant benefit and one did not.Telephone counselling not initiated by calls to helplines also increased quitting (51 studies, > 30,000 participants, RR 1.27; 95% CI 1.20 to 1.36). In a meta-regression controlling for other factors the effect was estimated to be slightly larger if more calls were offered, and in trials that specifically recruited smokers motivated to try to quit. The relative extra benefit of counselling was smaller when it was provided in addition to pharmacotherapy (usually nicotine replacement therapy) than when the control group only received self-help material or a brief intervention.A further eight studies were too diverse to contribute to meta-analyses and are discussed separately. Two compared different intensities of counselling, both of which detected a dose response; one of these detected a benefit of multiple counselling sessions over a single call for people prescribed bupropion. The others tested a variety of interventions largely involving offering telephone counselling as part of a referral or systems change and none detected evidence of effect.

AUTHORS' CONCLUSIONS

Proactive telephone counselling aids smokers who seek help from quitlines. Telephone quitlines provide an important route of access to support for smokers, and call-back counselling enhances their usefulness. There is limited evidence about the optimal number of calls. Proactive telephone counselling also helps people who receive it in other settings. There is some evidence of a dose response; one or two brief calls are less likely to provide a measurable benefit. Three or more calls increase the chances of quitting compared to a minimal intervention such as providing standard self-help materials, or brief advice, or compared to pharmacotherapy alone.

The emergency department action in smoking cessation (EDASC) trial: impact on cessation outcomes

INTRODUCTION

The focus on acute care, time pressure, and lack of resources hamper the implementation of smoking cessation guidelines in the emergency department (ED). The purpose of this study was to determine whether an emergency nurse- initiated intervention based on the 5A's (Ask-Advise-Assess-Assist-Arrange) framework improves quit rates.

METHODS

We conducted a pre-post implementation trial in 789 adult smokers who presented to two EDs in Iowa between August 13, 2008 and August 4, 2010. The intervention focused on improving delivery of the 5A's by ED nurses and physicians using academic detailing, charting/reminder tools, and group feedback. Performance of ED cessation counseling was measured using a 5A's composite score (ranging from 0 to 5). Smoking status was assessed by telephone interview at 3- and 6-month follow-up (with biochemical confirmation in those participants who reported abstinence at 6-month follow-up).

RESULTS

Based on data from 650 smokers who completed the post-ED interview, there was a significant improvement in the mean 5A's composite score for emergency nurses during the intervention period at both hospitals combined (1.51 vs. 0.88, difference = 0.63, 95% confidence interval [CI] [0.41, 0.85]). At 6-month follow-up, 7-day point prevalence abstinence (PPA) was 6.8 and 5.1% in intervention and preintervention periods, respectively (adjusted odds ratio [OR] = 1.7, 95% CI [0.99, 2.9]).

CONCLUSIONS

It is feasible to improve the delivery of brief smoking cessation counseling by ED staff. The observed improvements in performance of cessation counseling, however, did not translate into statistically significant improvements in cessation rates. Further improvements in the effectiveness of ED cessation interventions are needed.

Efficacy of emergency department-initiated tobacco control--systematic review and meta-analysis of randomized controlled trials

AIM

Systematic review and meta-analysis of randomized controlled trials evaluating the efficacy of emergency department-initiated tobacco control (ETC).

METHODS

Literature search in 7 databases and gray literature sources. Point prevalence tobacco abstinence at 1-, 3-, 6-, and/or 12-month follow-up was abstracted from each study. The proportionate effect (relative risk) of ETC on tobacco abstinence was calculated separately for each study and follow-up time and pooled, at different follow-up times, by Mantel-Haenszel relative risks. The effects of ETC on combined point prevalence tobacco abstinence across all follow-up times were calculated using generalized linear mixed models.

RESULTS

Seven studies with overall 1,986 participants were included. The strongest effect of ETC on point prevalence tobacco abstinence was found at 1 month: Relative risk (RR) = 1.47 (3 studies) (95% confidence interval [CI]: 1.06-2.06), while the effect at 3, 6, and 12 months was RR = 1.24 (6 studies) (95% CI: 0.93-1.65); 1.13 (5 studies) (95% CI: 0.86-1.49); and 1.25 (1 study) (95% CI: 0.91-1.72). The benefit on combined point prevalence tobacco abstinence was RR = 1.33 (7 studies) (95% CI: 0.96-1.83), p = .08; with RR = 1.33 (95% CI: 0.92-1.92), p = .10, for the 5 studies combining motivational interviewing and booster phone calls.

CONCLUSIONS

ETC combining motivational interviewing and booster phone calls showed a trend toward increased episodically measured tobacco abstinence up to 12 months. More methodologically rigorous trials are needed to effectively evaluate the impact of ETC.

Effectiveness of intervention to implement tobacco cessation counseling in community chain pharmacies

OBJECTIVES

To test the feasibility of implementing ask-advise-refer (AAR) tobacco cessation counseling approach in community chain pharmacies serving low socioeconomic areas and to assess the effectiveness of a multimodal intervention on short-term implementation of AAR.

DESIGN

Randomized controlled trial.

SETTING

South-central Wisconsin from July 2008 through March 2009.

PARTICIPANTS

Pharmacists and technicians from 16 community chain pharmacies.

INTERVENTION

Training to implement AAR, workflow integration recommendations, tobacco cessation poster to create awareness, and a support visit.

MAIN OUTCOME MEASURES

Number of pharmacy patrons asked about tobacco use, number of tobacco users advised to quit, number of tobacco users enrolled in the quit line, and number of quit line cards given.

RESULTS

As hypothesized, the multimodal intervention significantly predicted the number of patrons asked to quit (estimate 4.84, incidence rate ratio 127.2, P < 0.001), number of tobacco users advised to quit (2.12, 8.33, P < 0.01), number of tobacco users enrolled in the quit line (2.31, 10.13, P < 0.001), and number of quit line cards given (1.04, 2.82, P < 0.05).

CONCLUSION

This trial demonstrates the feasibility of implementing AAR in routine community pharmacy practice. This trial also supports the short-term effectiveness of the multimodal intervention in facilitating AAR in partnership with other public health systems. More research is needed to evaluate the generalizability, effectiveness, and sustainability of AAR, including factors influencing adoption and the impact on cessation.

Fax referrals, academic detailing, and tobacco quitline use: a randomized trial

BACKGROUND

Fax referral programs quickly and economically can link smokers' visiting primary care clinics to state-based telephone quitlines. Yet, it is unclear how to optimize use of this strategy.

PURPOSE

To evaluate the potential of enhanced academic detailing in clinics (i.e., on-site training, technical assistance, and performance feedback) to boost utilization of a fax referral program called Fax to Quit.

DESIGN

Participants were randomized to one of two intervention conditions.

SETTING/PARTICIPANTS

Participants were drawn from 49 primary care clinics in southeastern Wisconsin. The sample size was based on a power analysis in which the control intervention condition was estimated to generate 0.5 referrals/clinic/month and the experimental condition 2.0 referrals/clinic/month.

INTERVENTIONS

One of two fax referral program interventions was administered: the control condition Fax to Quit-Only (F2Q-Only) or the experimental condition Fax to Quit plus Enhanced Academic Detailing (F2Q+EAD).

MAIN OUTCOME MEASURES

Clinic- and clinician-specific referral and quality referral rates (those resulting in quitline enrollment) were measured for 13 months post-intervention, starting in March 2009.

RESULTS

Mean number of post-intervention referrals/clinician to the Wisconsin Tobacco Quitline was 5.6 times greater for F2Q+EAD (8.5, SD=7.0) compared to F2Q-Only (1.6, SD=3.6, p<0.001). The F2Q+EAD (4.8, SD=4.1) condition produced a greater mean number of quality referrals/clinician than did the F2Q-Only (0.86, SD=1.8, p<0.001) condition. Data were analyzed in 2010.

CONCLUSIONS

Enhanced academic detailing, which included on-site training, technical assistance, and performance feedback, increased the number of referrals more than fivefold over a fax referral program implemented without such enhanced academic detailing.

TRIAL REGISTRATION

This study is registered at Clinicaltrials.gov NCT00989755.

Ethnoracial differences in emergency department patients' tobacco use

INTRODUCTION

This study examined ethnoracial differences in lifetime and recent tobacco use and related problems in a large convenience sample of Latino, Black, and Non-Latino White emergency department (ED) patients. In addition, ED patients' use rates were compared with those of a statewide sample.

METHODS

Trained bilingual/bicultural health educators screened almost 53,000 ED patients in 8 ED/trauma units throughout San Diego County over a 2-year period. Measures included sociodemographic characteristics and tobacco use measures from the Alcohol, Smoking, and Substance Involvement Screening Test brief screening instrument.

RESULTS

A consistent finding was the lower prevalence of tobacco use among Latino patients compared with Black and Non-Latino White patients. Compared with their general population counterparts, Non-Latino White, Latino, and Black patients were more likely to have used tobacco in their lifetime and on a daily basis.

CONCLUSIONS

Results indicate the high tobacco risk status of ED patients, regardless of ethnicity. More work is needed to develop effective approaches for ED-initiated tobacco interventions for patients in various racial/ethnic groups. Offering tobacco cessation support in opportune venues such as the ED holds great potential to improve accessibility to public health interventions for many underserved communities who may not have regular interaction with a primary care provider.

The Association of Parental Self-Efficacy and Parent-Youth Connectedness With Youth Smoking Intentions

Little attention has been paid to understanding how parents of differing race/ethnicity perceive their effectiveness in exercising anti-smoking parenting practices and how these behaviors affect youth's smoking intentions. We explored the association of parent-youth connectedness and parental self-efficacy and youths' smoking intentions in a group of African American and Caucasian never-smokers. Based on Social Bonding Theory and Social Learning Theory, a questionnaire was administered to nonsmoking, 9-16-year-old youth and parent dyads, assessing youth smoking intentions and parental measures of connectedness and self-efficacy. Youth risk factors for intending to smoke were increased parent-youth conflict and protective factors were increased parental monitoring, increased parental rule setting, and higher parental self-efficacy. Parent-youth connectedness and parental self-efficacy did not differ by parental smoking status or by race/ethnicity. Our findings underscore the importance of strong parenting practices and parental self-efficacy in protecting against youth intention to smoke and these may be important to target in future interventions.

Development of a Web-based tobacco cessation educational program for pediatric nurses and respiratory therapists

BACKGROUND

Nurses can be effective in providing advice and counseling to tobacco-using parents of hospitalized pediatric patients. However, lack of training in effective interventions is a barrier to the incorporation of tobacco cessation interventions into routine practice. This article describes the development and evaluation of a web-based tobacco cessation educational program aimed at pediatric nurses and respiratory therapists.

METHOD

The program was developed with input from four focus groups of nurses, respiratory therapists, and educators. The interactive training program was evaluated by 33 nurses and 17 respiratory therapists employed at a children's hospital.

RESULTS

After completing the program, participants reported a significant change in their knowledge, attitudes, perceived barriers, and self-efficacy toward providing tobacco cessation interventions to their patients' parents.

CONCLUSION

The results of the evaluation of the program were extremely promising, and further investigation is warranted.

Rates of enrollment in smoking cessation services following fax referrals from a children's hospital

OBJECTIVE

The aim of this study was to describe the rates of enrollment in tobacco dependence treatment among smoking adults who accepted a fax referral from health care providers at a children's hospital, and to examine smoker characteristics associated with enrollment.

METHODS

Secondary analysis of the state-sponsored fax referral and treatment program data on all referrals from Arkansas Children's Hospital in 2005 to 2007 was conducted. Enrollment was defined as attendance at 1 or more counseling sessions within 1 year of referral. Logistic regression analyses were used to identify demographic and tobacco-related characteristics associated with enrollment versus nonenrollment in a treatment program among those contacted by the program.

RESULTS

Of the 749 faxed referrals to the program, 157 (21.0%) enrolled in a treatment program and received 1 or more treatment sessions; 505 were contacted by the program, and of these, 147 (29%) enrolled. Women were more likely to enroll than men (odds ratio [OR] 1.81; 95% confidence interval [95% CI], 1.09-3.01). Whites were twice as likely to enroll than African Americans (OR 2.35; 95% CI, 1.28-4.33). Older age (OR 1.04; 95% CI, 1.01-1.06) and higher self-efficacy scores (OR 1.13; 95% CI, 1.02-1.26) increased the likelihood of enrollment.

CONCLUSIONS

Approximately 1 in 5 smokers who accepted a fax referral enrolled in and received intensive treatment services for tobacco dependence. Thus, innovative approaches are needed to increase enrollment among younger, African American, and male smokers.

Agreement between parents and youth on measures of anti-smoking socialization

BACKGROUND AND OBJECTIVES: Despite the current literature on the importance of parental anti-smoking socialization messages, it is unclear if youth and parents agree on the content and frequency of such messages. This study's purpose was to explore the level of agreement between parents and youth on measures of anti-smoking socialization and to assess whether agreement is associated with parental smoking status and/or parental race/ethnicity. METHODS: Data were collected from parent and 9-16 year old youth dyads who presented to the emergency department with a non-urgent complaint. A self-administered questionnaire assessing demographics and five antismoking socialization measures was used. RESULTS: Items that showed statistically significant agreement between parents and youth were frequency of explicit messages about smoking. However, the absolute agreement between the items was poor at less than 50% for the complete sample. Items that did not show statistically significant agreement between parents and youth were: maternal negative reaction to smoking (for all youth); specific rules about smoking and maternal negative reaction to smoking (for youth with parental smokers); and paternal negative reaction to smoking (for youth with parental nonsmokers). When pairs that did not agree were analyzed, there were significant discrepancies in youth-parent agreement by parental smoking status, but not by race/ethnicity. CONCLUSIONS: In this study, there was poor agreement between parents and youth on measures of anti-smoking socialization. Level of agreement was associated with parental smoking status, but not race/ethnicity. Since anti-smoking socialization is an important means to decrease youth tobacco initiation and use, future studies are needed to investigate the specific content, frequency, and format of parental anti-smoking messages that are best received and recalled by youth.

The effect of linking community health centers to a state-level smoker's quitline on rates of cessation assistance

Background

Smoking cessation quitlines are an effective yet largely untapped resource for clinician referrals. The aim of this study was to assess the effect of a fax referral system that links community health centers (CHCs) with the New York State Quitline on rates of provider cessation assistance.

Methods

This study was conducted in four CHCs using a quasi experimental study design. Two comparison sites offered usual care (expanded vital sign chart stamp that prompted providers to ask about tobacco use, advice smokers to quit, assess readiness, and offer assistance (4As)) and two intervention sites received the chart stamp plus an office-based fax referral link to the New York State Quitline. The fax referral system links patients to a free proactive telephone counseling service. Provider adherence to the 4 As was assessed with 263 pre and 165 post cross sectional patient exit interviews at all four sites.

Results

Adherence to the 4As increased significantly over time in the intervention sites with no change from baseline in the comparison sites. Intervention sites were 2.4 (p < .008) times more likely to provide referrals to the state Quitline over time than the comparison sites and 1.8 (p < .001) times more likely to offer medication counseling and/or a prescription.

Conclusions

Referral links between CHCs and state level telephone quitlines may facilitate the provision of cessation assistance by offering clinicians a practical method for referring smokers to this effective service. Further studies are needed to confirm the efficacy of fax referral systems and to identify implementation strategies that work to facilitate the utilization of these systems across a wide range of clinical settings.

Youth and Their Parents' Views on the Acceptability and Design of a Video-Based Tobacco Prevention Intervention

The purpose of this study was to evaluate the acceptability of a brief, video-based parental intervention that modeled parent-child communication about tobacco, delivered within an emergency department (ED) setting. While waiting to be seen by a physician in the ED, 20 parent-youth dyads watched the video together and then private, semi-structured focused interviews were conducted around the "take home" message and views on the settings, actors, and content of the videos. Dyads agreed that the design, delivery, and content of the video intervention were acceptable, realistic, and useful in providing parental reinforcements about the importance of parent-youth tobacco communication and the ED was considered to be a good setting for watching the video. Our findings support the development and delivery of such an ED intervention and aids in determining content and scenarios for future intervention development.

Implementing a fax referral program for quitline smoking cessation services in urban health centers: a qualitative study

Background

Fax referral services that connect smokers to state quitlines have been implemented in 49 U.S. states and territories and promoted as a simple solution to improving smoker assistance in medical practice. This study is an in-depth examination of the systems-level changes needed to implement and sustain a fax referral program in primary care.

Methods

The study involved implementation of a fax referral system paired with a chart stamp prompting providers to identify smoking patients, provide advice to quit and refer interested smokers to a state-based fax quitline. Three focus groups (n = 26) and eight key informant interviews were conducted with staff and physicians at two clinics after the intervention. We used the Chronic Care Model as a framework to analyze the data, examining how well the systems changes were implemented and the impact of these changes on care processes, and to develop recommendations for improvement.

Results

Physicians and staff described numerous benefits of the fax referral program for providers and patients but pointed out significant barriers to full implementation, including the time-consuming process of referring patients to the Quitline, substantial patient resistance, and limitations in information and care delivery systems for referring and tracking smokers. Respondents identified several strategies for improving integration, including simplification of the referral form, enhanced teamwork, formal assignment of responsibility for referrals, ongoing staff training and patient education. Improvements in Quitline feedback were needed to compensate for clinics' limited internal information systems for tracking smokers.

Conclusions

Establishing sustainable linkages to quitline services in clinical sites requires knowledge of existing patterns of care and tailored organizational changes to ensure new systems are prioritized, easily integrated into current office routines, formally assigned to specific staff members, and supported by internal systems that ensure adequate tracking and follow up of smokers. Ongoing staff training and patient self-management techniques are also needed to ease the introduction of new programs and increase their acceptability to smokers.

Telephone counselling for smoking cessation

BACKGROUND

Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines.

OBJECTIVES

To evaluate the effect of proactive and reactive telephone support to help smokers quit.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register for studies using free text term 'telephone*' or the keywords 'telephone counselling' or 'Hotlines' or 'Telephone' . Date of the most recent search: January 2006.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials in which proactive or reactive telephone counselling to assist smoking cessation was offered to smokers or recent quitters.

DATA COLLECTION AND ANALYSIS

Trials were identified and data extracted by one person (LS) and checked by a second (TL). The main outcome measure was the odds ratio for abstinence from smoking after at least six months follow up. We selected the strictest measure of abstinence, using biochemically validated rates where available. We considered participants lost to follow-up to be continuing smokers. Where trials had more than one arm with a less intensive intervention we used only the most similar intervention without the telephone component as the control group in the primary analysis. We assessed statistical heterogeneity amongst sub groups of clinically comparable studies using the I(2) statistic. Where appropriate, we pooled studies using a fixed-effect model. A meta-regression was used to investigate the effect of differences in planned number of calls.

MAIN RESULTS

Forty-eight trials met the inclusion criteria. Among smokers who contacted helplines, quit rates were higher for groups randomised to receive multiple sessions of call-back counselling (eight studies, >18,000 participants, odds ratio (OR) for long term cessation 1.41, 95% confidence interval (CI) 1.27 to 1.57). Two of these studies showed a significant benefit of more intensive compared to less intensive intervention. Telephone counselling not initiated by calls to helplines also increased quitting (29 studies, >17,000 participants, OR 1.33, 95% CI 1.21 to 1.47). A meta-regression detected a significant association between the maximum number of planned calls and the effect size. There was clearer evidence of benefit in the subgroup of trials recruiting smokers motivated to quit. Of two studies that provided access to a hotline one showed a significant benefit and one did not. Two studies comparing different counselling approaches during a single session did not detect significant differences. A further seven studies were too diverse to contribute to meta-analyses and are discussed separately.

AUTHORS' CONCLUSIONS

Proactive telephone counselling helps smokers interested in quitting. There is evidence of a dose response; one or two brief calls are less likely to provide a measurable benefit. Three or more calls increases the odds of quitting compared to a minimal intervention such as providing standard self-help materials, brief advice, or compared to pharmacotherapy alone. Telephone quitlines provide an important route of access to support for smokers, and call-back counselling enhances their usefulness.