Effectiveness of motivational interviewing to reduce head start children's secondhand smoke exposure. a randomized clinical trial

Associations of household tobacco smoking status with childhood temperament among U.S. preschool-aged children

BACKGROUND

This study investigated the association between household tobacco smoking status and temperament among U.S. 3-5-year-olds.

METHODS

A secondary analysis of 2019-2020 National Survey of Children's Health data (N = 11,100) was conducted. Temperament dimensions of effortful control (characterized by attention focusing), negative affectivity (characterized by anger and soothability), and surgency (characterized by activity level and shyness) were assessed. Weighted ordinal regression models were conducted while adjusting for child and family covariates.

RESULTS

Approximately 13 % of children lived with smokers. Compared to children who did not live with smokers, children living with smokers displayed behaviors of poorer effortful control and were more likely to be easily distracted (AOR = 1.59, 95%CI = 1.24-2.04) and less likely to keep working on tasks until finished (AOR = 0.56, 95%CI = 0.44-0.71). Children living with smokers displayed behaviors of greater negative affectivity and were at increased odds of being angry or anxious when transitioning between activities (AOR = 1.50, 95%CI = 1.13-1.98) and losing their temper when things did not go their way (AOR = 1.53, 95%CI = 1.20-1.96), and were at decreased odds of calming down quickly when excited (AOR = 0.54, 95%CI = 0.42-0.70). Children living with smokers displayed behaviors of poorer surgency and were less likely to play well with others (AOR = 0.58, 95%CI = 0.45-0.76) and sit still compared to same-aged children (AOR = 0.56, 95%CI = 0.44-0.71).

LIMITATIONS

The NSCH uses a cross-sectional survey design; longitudinal associations and objective measures could not be assessed. However, the NSCH is nationally representative and results are generalizable to U.S. 3-5-year-olds.

CONCLUSIONS

Findings suggest household tobacco smoking influences temperament in early childhood. Results signify the need to promote household tobacco cessation.

Lung Effects of Household Air Pollution

Biomass fuel smoke, secondhand smoke, and oxides of nitrogen are common causes of household air pollution (HAP). Almost 2.4 billion people worldwide use solid fuels for cooking and heating, mostly in low- and middle-income countries. Wood combustion for household heating is also common in many areas of high-income countries, and minorities are particularly vulnerable. HAP in low- and middle-income countries is associated with asthma, acute respiratory tract infections in adults and children, chronic obstructive pulmonary disease, lung cancer, tuberculosis, and respiratory mortality. Although wood smoke exposure levels in high-income countries are typically lower than in lower-income countries, it is similarly associated with accelerated lung function decline, higher prevalence of airflow obstruction and chronic bronchitis, and higher all-cause and respiratory cause-specific mortality. Household air cleaners with high-efficiency particle filters have mixed effects on asthma and chronic obstructive pulmonary disease outcomes. Biomass fuel interventions in low-income countries include adding chimneys to cookstoves, improving biomass fuel combustion stoves, and switching fuel to liquid petroleum gas. Still, the impact on health outcomes is inconsistent. In high-income countries, strategies for reducing biomass fuel-related HAP are centered on community-level woodstove changeout programs, although the results are again inconsistent. In addition, initiatives to encourage home smoking bans have mixed success in households with children. Environmental solutions to reduce HAP have varying success in reducing pollutants and health problems. Improved understanding of indoor air quality factors and actions that prevent degradation or improve polluted indoor air may lead to enhanced environmental health policies, but health outcomes must be rigorously examined.

Pediatrician intervention impacts parental smoking in cystic fibrosis, diabetes, and bronchiolitis

BACKGROUND

Child exposure to cigarette smoke is harmful. It should be reduced through parental smoking cessation interventions. The aim of our study was to determine the impact of simple advice provided by the pediatrician on the smoking habits of parents of children with cystic fibrosis (CF), diabetes mellitus (DM), and infants hospitalized for bronchiolitis.

METHODS

Parents were interviewed on their smoking habits. Smoking cessation advice was provided by the pediatrician. A new smoking habits assessment was done at 3 months by phone interviews.

RESULTS

A total of 260 parents were interviewed (91 in the CF group, 136 in the DM group, and 33 in the bronchiolitis group). A total of 70 parents were active smokers: 33% of parents of children with CF, 23.5% of parents of children with DM, and 24.2% for those with infants hospitalized for bronchiolitis (p = .42). In the CF group, smoking cessation had been significantly more frequently discussed with the medical team previously. A total of 67 smoking parents (95.7%) answered the 3-month assessment: 29.8% reported having started a smoking cessation process; 10.4% had quit smoking. The quitting rate was significantly higher in the groups of patients followed for a respiratory disorder (37.5% for bronchiolitis, 15% for CF vs. 0% for DM, p = .005).

CONCLUSION

This study shows the important role that information and simple advice from pediatricians can have in initiating smoking cessation in parents of patients followed in specialized clinics or who are hospitalized, with a greater efficiency in parents of patients suffering from lung disorders.

Randomised pilot trial of cash incentives for reducing paediatric asthmatic tobacco smoke exposures from maternal caregivers and members of their social network

BACKGROUND

The primary aim was to evaluate the efficacy of financial incentives for reducing paediatric tobacco smoke exposures (TSEs) through motivating cigarette usage reduction among low-income maternal caregivers and members of their social network.

DESIGN

Randomised control pilot trial over a 6-month study follow-up time period. The study was undertaken from May 2017 to -May 2018. Once monthly follow-up visits occurred over the 6-month study period.

SETTING

Baltimore City, Maryland, USA.

PARTICIPANTS

We grouped 135 participants into 45 triads (asthmatic child (2-12 years of age), maternal caregiver and social network member). Triads were assigned in a 1:1 allocation ratio. The maternal caregiver and social network members were active smokers and contributed to paediatric TSE.

INTERVENTIONS

Triads were randomised to receive either usual care (TSE education and quitline referrals) or usual care plus financial incentives. Cash incentives up to $1000 were earned by caregivers and designated social network participants. Incentives for either caregivers or social network participants were provided contingent on their individual reduction of tobacco usage measured by biomarkers of tobacco usage. Study visits occurred once a month during the 6-month trial.

MAIN OUTCOME MEASURES

The main outcome measure was mean change in monthly paediatric cotinine levels over 6 months of follow-up interval and was analysed on an intention-to-treat basis.

RESULTS

The mean change in monthly child cotinine values was not significantly different in the intervention cohort over the 6-month follow-up period, compared with the control group (p=0.098, CI -0.16 to 1.89). Trends in child cotinine could not be ascribed to caregivers or social network members. Despite decreasing mean monthly cotinine values, neither the intervention cohort's caregivers (difference in slope (control-intervention)=3.30 ng/mL/month, CI -7.72 to 1.13, p=0.144) or paired social network members (difference in slope (control-intervention)=-1.59 ng/mL/month, CI -3.57 to 6.74, p=0.546) had significantly different cotinine levels than counterparts in the control group.

CONCLUSIONS

Financial incentives directed at adult contributors to paediatric TSE did not decrease child cotinine levels.

TRIAL REGISTRATION NUMBER

NCT03099811.

Effectiveness of a School-Based 'Tobacco Free' Intervention on Adolescents' Knowledge and Exposure to Second Hand Tobacco Smoke - A Multiphase Study

BACKGROUND

There is no safe level of exposure to second hand tobacco smoke (SHS). The World Health Organization has stressed that 100% smoke-free environments are the only effective way to protect the population from the harmful effects of exposure to SHS.

DESIGN

A multiphase study with a descriptive cross-sectional questionnaire phase 1  and a phase 2 cluster randomized controlled trial (RCT), conceptualized to determine the effectiveness of a school-based 'tobacco free' health education intervention on adolescents' knowledge and attitude towards SHS.

METHODS

Baseline assessment will include a questionnaire followed by estimation of salivary cotinine levels. The experimental arm will receive the 'tobacco free' intervention, which includes 40 min health education session delivered once a week for 3 consecutive weeks. Participants will also be given 'take home brochures' every week containing messages on the effects of tobacco and how to make their homes smoke-free. The sample of 250 participants, for the Phase 2 RCT, with salivary cotinine levels of > 0.1 ng/mL will be selected from the participants of the Phase 1 study. The effect of the intervention will be quantitatively assessed by estimating the salivary cotinine levels after the intervention. Participants in the control arm will receive conventional standard health education once.

CONCLUSION

This research will help in assessing if there is any change in the salivary cotinine levels and the knowledge, attitude and behaviour scores after the health educational intervention and help in developing an effective school-based 'tobacco free' intervention program which could be incorporated into the school curriculum. This study has received the Public Health Research Initiative (PHRI) Research Grant of Rs. 18,99,205 and is registered with the Clinical Trial Registry of India (CTRI) with number CTRI/2018/09/015706 (Registered on 13/09/2018). Ethical approval has been obtained from The Institutional Ethics Committee (No.17021 dated 13 march 2017).

Motivational interviewing for smoking cessation

BACKGROUND

Motivational Interviewing (MI) is a directive patient-centred style of counselling, designed to help people to explore and resolve ambivalence about behaviour change. It was developed as a treatment for alcohol abuse, but may help people to a make a successful attempt to stop smoking.

OBJECTIVES

To evaluate the efficacy of MI for smoking cessation compared with no treatment, in addition to another form of smoking cessation treatment, and compared with other types of smoking cessation treatment. We also investigated whether more intensive MI is more effective than less intensive MI for smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register for studies using the term motivat* NEAR2 (interview* OR enhanc* OR session* OR counsel* OR practi* OR behav*) in the title or abstract, or motivation* as a keyword. We also searched trial registries to identify unpublished studies. Date of the most recent search: August 2018.

SELECTION CRITERIA

Randomised controlled trials in which MI or its variants were offered to smokers to assist smoking cessation. We excluded trials that did not assess cessation as an outcome, with follow-up less than six months, and with additional non-MI intervention components not matched between arms. We excluded trials in pregnant women as these are covered elsewhere.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Smoking cessation was measured after at least six months, using the most rigorous definition available, on an intention-to-treat basis. We calculated risk ratios (RR) and 95% confidence intervals (CI) for smoking cessation for each study, where possible. We grouped eligible studies according to the type of comparison. We carried out meta-analyses where appropriate, using Mantel-Haenszel random-effects models. We extracted data on mental health outcomes and quality of life and summarised these narratively.

MAIN RESULTS

We identified 37 eligible studies involving over 15,000 participants who smoked tobacco. The majority of studies recruited participants with particular characteristics, often from groups of people who are less likely to seek support to stop smoking than the general population. Although a few studies recruited participants who intended to stop smoking soon or had no intentions to quit, most recruited a population without regard to their intention to quit. MI was conducted in one to 12 sessions, with the total duration of MI ranging from five to 315 minutes across studies. We judged four of the 37 studies to be at low risk of bias, and 11 to be at high risk, but restricting the analysis only to those studies at low or unclear risk did not significantly alter results, apart from in one case - our analysis comparing higher to lower intensity MI.We found low-certainty evidence, limited by risk of bias and imprecision, comparing the effect of MI to no treatment for smoking cessation (RR = 0.84, 95% CI 0.63 to 1.12; I2 = 0%; adjusted N = 684). One study was excluded from this analysis as the participants recruited (incarcerated men) were not comparable to the other participants included in the analysis, resulting in substantial statistical heterogeneity when all studies were pooled (I2 = 87%). Enhancing existing smoking cessation support with additional MI, compared with existing support alone, gave an RR of 1.07 (95% CI 0.85 to 1.36; adjusted N = 4167; I2 = 47%), and MI compared with other forms of smoking cessation support gave an RR of 1.24 (95% CI 0.91 to 1.69; I2 = 54%; N = 5192). We judged both of these estimates to be of low certainty due to heterogeneity and imprecision. Low-certainty evidence detected a benefit of higher intensity MI when compared with lower intensity MI (RR 1.23, 95% CI 1.11 to 1.37; adjusted N = 5620; I2 = 0%). The evidence was limited because three of the five studies in this comparison were at risk of bias. Excluding them gave an RR of 1.00 (95% CI 0.65 to 1.54; I2 = n/a; N = 482), changing the interpretation of the results.Mental health and quality of life outcomes were reported in only one study, providing little evidence on whether MI improves mental well-being.

AUTHORS' CONCLUSIONS

There is insufficient evidence to show whether or not MI helps people to stop smoking compared with no intervention, as an addition to other types of behavioural support for smoking cessation, or compared with other types of behavioural support for smoking cessation. It is also unclear whether more intensive MI is more effective than less intensive MI. All estimates of treatment effect were of low certainty because of concerns about bias in the trials, imprecision and inconsistency. Consequently, future trials are likely to change these conclusions. There is almost no evidence on whether MI for smoking cessation improves mental well-being.

Health Coaching in Severe COPD After a Hospitalization: A Qualitative Analysis of a Large Randomized Study

BACKGROUND

We recently demonstrated in a randomized study the feasibility and effectiveness of telephone-based health coaching using motivational interviewing on decreasing hospital readmissions and improving quality of life at 6 and 12 months after hospital discharge. In this qualitative study, we sought to explore the health-coaching intervention as seen from the perspective of the participants who received the intervention and the coaches who delivered it.

METHODS

Semistructured participant interviews (n = 24) and a focus group of all health coaches (n = 3) who participated in this study were conducted. Interviews and focus group were recorded and transcribed verbatim. Transcripts were analyzed using coding and categorizing techniques and thematic analysis. Mixed-method triangulation was used to merge quantitative and qualitative data.

RESULTS

Content analysis revealed 4 predominant themes of the coaching intervention: health-coaching relationship, higher participant confidence and reassurance (most related to improvement in physical quality of life), improved health-care system access (most related to decreased hospital readmissions), and increased awareness of COPD symptoms (most related to improvement in emotional quality of life). The strongest theme was the relationship with the health coach, including coach style and motivational interviewing approach. Health coaches' focus group also noted the importance of the coaching relationship as the most significant theme.

CONCLUSIONS

This study provided themes to further inform the delivery and implementation of health-coaching interventions in patients with COPD after hospital discharge. Health coaching forged partnerships and created a platform for patient engagement, which was confirmed by both participants and health coaches.

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

BACKGROUND

Children's exposure to other people's tobacco smoke (environmental tobacco smoke, or ETS) is associated with a range of adverse health outcomes for children. Parental smoking is a common source of children's exposure to ETS. Older children in child care or educational settings are also at risk of exposure to ETS. Preventing exposure to ETS during infancy and childhood has significant potential to improve children's health worldwide.

OBJECTIVES

To determine the effectiveness of interventions designed to reduce exposure of children to environmental tobacco smoke, or ETS.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register and conducted additional searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Education Resource Information Center (ERIC), and the Social Science Citation Index & Science Citation Index (Web of Knowledge). We conducted the most recent search in February 2017.

SELECTION CRITERIA

We included controlled trials, with or without random allocation, that enrolled participants (parents and other family members, child care workers, and teachers) involved in the care and education of infants and young children (from birth to 12 years of age). All mechanisms for reducing children's ETS exposure were eligible, including smoking prevention, cessation, and control programmes. These include health promotion, social-behavioural therapies, technology, education, and clinical interventions.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies and extracted data. Due to heterogeneity of methods and outcome measures, we did not pool results but instead synthesised study findings narratively.

MAIN RESULTS

Seventy-eight studies met the inclusion criteria, and we assessed all evidence to be of low or very low quality based on GRADE assessment. We judged nine studies to be at low risk of bias, 35 to have unclear overall risk of bias, and 34 to have high risk of bias. Twenty-one interventions targeted populations or community settings, 27 studies were conducted in the well-child healthcare setting and 26 in the ill-child healthcare setting. Two further studies conducted in paediatric clinics did not make clear whether visits were made to well- or ill-children, and another included visits to both well- and ill-children. Forty-five studies were reported from North America, 22 from other high-income countries, and 11 from low- or middle-income countries. Only 26 of the 78 studies reported a beneficial intervention effect for reduction of child ETS exposure, 24 of which were statistically significant. Of these 24 studies, 13 used objective measures of children's ETS exposure. We were unable to pinpoint what made these programmes effective. Studies showing a significant effect used a range of interventions: nine used in-person counselling or motivational interviewing; another study used telephone counselling, and one used a combination of in-person and telephone counselling; three used multi-component counselling-based interventions; two used multi-component education-based interventions; one used a school-based strategy; four used educational interventions, including one that used picture books; one used a smoking cessation intervention; one used a brief intervention; and another did not describe the intervention. Of the 52 studies that did not show a significant reduction in child ETS exposure, 19 used more intensive counselling approaches, including motivational interviewing, education, coaching, and smoking cessation brief advice. Other interventions consisted of brief advice or counselling (10 studies), feedback of a biological measure of children's ETS exposure (six studies), nicotine replacement therapy (two studies), feedback of maternal cotinine (one study), computerised risk assessment (one study), telephone smoking cessation support (two studies), educational home visits (eight studies), group sessions (one study), educational materials (three studies), and school-based policy and health promotion (one study). Some studies employed more than one intervention. 35 of the 78 studies reported a reduction in ETS exposure for children, irrespective of assignment to intervention and comparison groups. One study did not aim to reduce children's tobacco smoke exposure but rather sought to reduce symptoms of asthma, and found a significant reduction in symptoms among the group exposed to motivational interviewing. We found little evidence of difference in effectiveness of interventions between the well infant, child respiratory illness, and other child illness settings as contexts for parental smoking cessation interventions.

AUTHORS' CONCLUSIONS

A minority of interventions have been shown to reduce children's exposure to environmental tobacco smoke and improve children's health, but the features that differentiate the effective interventions from those without clear evidence of effectiveness remain unclear. The evidence was judged to be of low or very low quality, as many of the trials are at a high risk of bias, are small and inadequately powered, with heterogeneous interventions and populations.

Smokers who have children with asthma: Perceptions about child secondhand smoke exposure and tobacco use initiation and parental willingness to participate in child-focused tobacco interventions

OBJECTIVE

This study examined, among parents who smoke and have children with asthma, perceptions about child secondhand smoke exposure (SHSe), child tobacco use (TU) initiation, and parent willingness to participate in child-focused tobacco interventions.

METHODS

Participants were 300 caregivers who smoked and had a child with asthma (aged 10-14). Parents completed an online survey and self-reported perceptions about child SHSe elimination, child TU prevention, and willingness to participate in three types of interventions with and without their child (SHSe reduction intervention, tobacco prevention intervention, and the combination of the two). Correlates of perceptions and willingness were examined.

RESULTS

Parents who were ready to quit smoking and who reported home smoking bans (HSBs) were more motivated to eliminate SHSe (p < 0.05). Being white, younger, ready to quit, and having HSBs were associated with greater confidence to eliminate SHSe (p < 0.05). Parents with HSBs reported higher perceived importance about preventing child TU (p < 0.05). Parents were less confident about preventing male children from using tobacco (p = 0.001). Parents were highly willing to participate in all the described intervention approaches, with or without their child.

CONCLUSIONS

Parents were willing to participate in child-focused tobacco interventions, with or without their child with asthma, including interventions that address both child SHSe and TU prevention. This research demonstrates the acceptability of child-focused tobacco interventions among a high-risk population and may be a foundational step for intervention development.

Health Coaching and Chronic Obstructive Pulmonary Disease Rehospitalization. A Randomized Study

RATIONALE

Hospital readmission for chronic obstructive pulmonary disease (COPD) has attracted attention owing to the burden to patients and the health care system. There is a knowledge gap on approaches to reducing COPD readmissions.

OBJECTIVES

To determine the effect of comprehensive health coaching on the rate of COPD readmissions.

METHODS

A total of 215 patients hospitalized for a COPD exacerbation were randomized at hospital discharge to receive either (1) motivational interviewing-based health coaching plus a written action plan for exacerbations (the use of antibiotics and oral steroids) and brief exercise advice or (2) usual care.

MEASUREMENTS AND MAIN RESULTS

We evaluated the rate of COPD-related hospitalizations during 1 year of follow-up. The absolute risk reductions of COPD-related rehospitalization in the health coaching group were 7.5% (P = 0.01), 11.0% (P = 0.02), 11.6% (P = 0.03), 11.4% (P = 0.05), and 5.4% (P = 0.24) at 1, 3, 6, 9, and 12 months, respectively, compared with the control group. The odds ratios for COPD hospitalization in the intervention arm compared with the control arm were 0.09 (95% confidence interval [CI], 0.01-0.77) at 1 month postdischarge, 0.37 (95% CI, 0.15-0.91) at 3 months postdischarge, 0.43 (95% CI, 0.20-0.94) at 6 months postdischarge, and 0.60 (95% CI, 0.30-1.20) at 1 year postdischarge. The missing value rate for the primary outcome was 0.4% (one patient). Disease-specific quality of life improved significantly in the health coaching group compared with the control group at 6 and 12 months, based on the Chronic Respiratory Disease Questionnaire emotional score (emotion and mastery domains) and physical score (dyspnea and fatigue domains) (P < 0.05). There were no differences between groups in measured physical activity at any time point.

CONCLUSIONS

Health coaching may represent a feasible and possibly effective intervention designed to reduce COPD readmissions. Clinical trial registered with www.clinicaltrials.gov (NCT01058486).

A randomised controlled trial of a complex intervention to reduce children's exposure to secondhand smoke in the home

Objectives

Exposing children to secondhand tobacco smoke (SHS) causes significant harm and occurs predominantly through smoking by caregivers in the family home. We report a trial of a complex intervention designed to reduce secondhand smoke exposure of children whose primary caregiver feels unable or unwilling to quit smoking.

Design

An open-label, parallel, randomised controlled trial.

Setting

Deprived communities in Nottingham City and County, England

Participants

Caregivers resident in Nottingham City and County in England who were at least 18 years old, the main caregiver of a child aged under 5 years living in their household, and reported that they were smoking tobacco inside their home.

Interventions

We compared a complex intervention combining personalised feedback on home air quality, behavioural support and nicotine replacement therapy for temporary abstinence with usual care.

Main outcomes

The primary outcome was change in air quality in the home, measured as average 16–24  hours levels of particulate matter of  < 2.5  µm diameter (PM_2.5), between baseline and 12 weeks. Secondary outcomes included changes in maximum PM_2.5, proportion of time PM_2.5 exceeded WHO recommended levels of maximum exposure of 25  µg/mg³, child salivary cotinine, caregivers’ cigarette consumption, nicotine dependence, determination to stop smoking, quit attempts and quitting altogether during the intervention.

Results

Arithmetic mean PM_2.5 decreased significantly more (by 35.2 %; 95%  CI 12.7% to 51.9 %) in intervention than in usual care households, as did the proportion of time PM_2.5 exceeded 25  µg/mg³, child salivary cotinine concentrations, caregivers’ cigarette consumption in the home, nicotine dependence, determination to quit and likelihood of having made a quit attempt.

Conclusions

By reducing exposure to SHS in the homes of children who live with smokers unable or unwilling to quit, this intervention offers huge potential to reduce children’s’ tobacco-related harm.

Trial registration number

ISRCTN81701383.

This trial was funded by the UK National Institute for Health Research (NIHR): RP-PG-0608-10020

The Likelihood of Preventing Respiratory Exacerbations in Children and Adolescents with either Chronic Suppurative Lung Disease or Bronchiectasis

Chronic suppurative lung disease (CSLD) and bronchiectasis in children and adolescents are important causes of respiratory morbidity and reduced quality of life (QoL), also leading to subsequent premature death during adulthood. Acute respiratory exacerbations in pediatric CSLD and bronchiectasis are important markers of disease control clinically, given that they impact upon QoL and increase health-care-associated costs and can adversely affect future lung functioning. Preventing exacerbations in this population is, therefore, likely to have significant individual, familial, societal, and health-sector benefits. In this review, we focus on therapeutic interventions, such as drugs (antibiotics, mucolytics, hyperosmolar agents, bronchodilators, corticosteroids, non-steroidal anti-inflammatory agents), vaccines and physiotherapy, and care-planning, such as post-hospitalization management and health promotion strategies, including exercise, diet, and reducing exposure to environmental toxicants. The review identified a conspicuous lack of moderate or high-quality evidence for preventing respiratory exacerbations in children and adolescents with CSLD or bronchiectasis. Given the short- and long-term impact of exacerbations upon individuals, their families, and society as a whole, large studies addressing interventions at the primary and tertiary prevention phases are required. This research must include children and adolescents in both developing and developed countries and address long-term health outcomes.

Something new in the air: Paying for community-based environmental approaches to asthma prevention and control

Despite the recommendation in national asthma guidelines to target indoor environmental exposures, most insurers generally have not covered the outreach, education, environmental assessments, or durable goods integral to home environmental interventions. However, emerging payment approaches offer new potential for coverage of home-based environmental intervention costs. These opportunities are becoming available as public and private insurers shift reimbursement to reward better health outcomes, and their key characteristic is a focus on the value rather than the volume of services. These new payment models for environmental interventions can be divided into 2 categories: enhanced fee-for-service reimbursement and set payments per patient that cover asthma-related costs. Several pilot programs across the United States are underway, and as they prove their value and as payment increasingly becomes aligned with better outcomes at lower cost, these efforts should have a bright future. Physicians should be aware that these new possibilities are emerging for payment of the goods and services needed for indoor environmental interventions for their patients with asthma.

Global Cancer in Women: Cancer Control Priorities

This review is an abbreviated version of a report prepared for the American Cancer Society Global Health department and EMD Serono, Inc., a subsidiary of Merck KGaA, Darmstadt, Germany, which was released at the Union for International Cancer Control World Cancer Congress in Paris in November 2016. The original report can be found at https://www.cancer.org/health-care-professionals/our-global-health-work/global-cancer-burden/global-burden-of-cancer-in-women.html. Staff in the Intramural Research Department of the American Cancer Society designed and conducted the study, including analysis, interpretation, and presentation of the review. The funding sources had no involvement in the study design, data analysis and interpretation, or preparation of the reviewThe global burden of cancer in women has recently received much attention, but there are few comprehensive reviews of the burden and policy approaches to reduce it. This article, second in series of two, summarizes the most important cancer control priorities with specific examples of proven interventions, with a particular focus on primary prevention in low- and middle-income countries (LMIC). There are a number of effective cancer control measures available to countries of all resource levels. Many of these measures are extremely cost-effective, especially in the case of tobacco control and vaccination. Countries must prioritize efforts to reduce known cancer risk factors and make prevention accessible to all. Effective treatments and palliative care are also needed for those who develop cancer. Given scarce resources, this may seem infeasible in many LMICs, but past experience with other diseases like HIV, tuberculosis, and malaria have shown that it is possible to make affordable care accessible to all. Expansion of population-based cancer registries and research in LMICs are needed for setting cancer control priorities and for determining the most effective interventions. For LMICs, all of these activities require support and commitment from the global community. Cancer Epidemiol Biomarkers Prev; 26(4); 458-70. ©2017 AACRSee related article by Torre et al. in this CEBP Focus section, "Global Cancer in Women."

Head Start Staff Reactions to a Novel Tobacco Intervention: A Qualitative Analysis

OBJECTIVES

As tobacco use becomes increasingly concentrated in communities of low socio-economic position (SEP), scalable cessation interventions are needed. Head Start programs offer one setting in which a family-focused intervention can be implemented in low SEP communities. We assessed the experiences of Head Start (HS) staff who received training in a pilot motivational interviewing (MI) tobacco intervention, to improve future feasibility.

METHODS

Focus group interviews were conducted with HS staff to assess their reactions to MI training and their use of MI in their work with families. Transcripts were analyzed using thematic analysis and a 4-step approach informed by grounded theory.

RESULTS

HS staff reported advantages of MI beyond its use as a tobacco intervention, despite systematic barriers to broad implementation. Facilitators of MI use included enhanced engagement with families, and opportunities for professional development. Barriers to MI use included limited institutional support and low priority for a tobacco intervention among families with pressing social and financial concerns.

CONCLUSIONS

HS Staff voiced support for broader training in MI interventions in HS programs. System-wide standards to ensure adequate training and support for an MI tobacco intervention were identified as priorities.

Barriers and motivators to reducing secondhand smoke exposure in African American families of head start children: a qualitative study

OBJECTIVE

To identify barriers and motivators for reducing secondhand smoke exposure (SHSe) for families of African-American, low-income, urban children.

METHOD

Audiotaped intervention sessions of 52 African-American caregivers of Head Start children who reported being a smoker and/or had at least one smoker in the home were randomly sampled from a larger trial examining the effectiveness of a motivational-interviewing intervention in reducing child's SHSe. Counseling sessions were qualitatively coded to identify barriers and motivators to implementing a home smoking ban or quitting smoking.

RESULTS

African-American families identified several themes that were either or both barriers and motivators for SHSe reduction, including: asking others not to smoke, other family living in the home, neighborhood safety, absence of childcare, cost/availability of cessation tools, physician support and prevention of health problems.

DISCUSSION

Urban, low-income African-American families face numerous barriers to reducing SHSe. Families were able to identify many motivators for reducing SHSe, suggesting an awareness of the importance for SHSe reduction but uncertainty in their confidence to change behaviors. Counseling should include tailoring to be most effective in supporting health behavior change. Greater emphasis on motivators is needed, such as low-cost/free cessation tools, engagement from physicians and greater involvement of extended family members.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cost Analysis of Motivational Interviewing and Preschool Education for Secondhand Smoke Exposures

INTRODUCTION

This study determines if expenditures associated with implementing a combined motivational interviewing (MI) and Head Start-level education program (MI+Education), as compared to education alone, yield cost savings to society.

METHODS

Post hoc cost analyses were applied to a randomized controlled-trial of MI among predominantly African American, low-income caregivers of 330 Baltimore City Head Start students who reside with a smoker. The primary outcome was the cost savings of MI+Education from averted direct secondhand smoke exposure (SHSe)-related acute healthcare events and inferred indirect costs (work days lost, transportation and reduction in cigarettes smoked). The net direction of savings was defined by the sum of averted direct and indirect costs of the MI+Education intervention at 3, 6 and 12 months, benchmarked against the Education alone cohort at the equivalent time periods.

RESULTS

The costs saved by the MI+Education intervention, relative to Education alone, resulted in savings at solely the 12-month follow-up time point. Significant savings were appreciated from averted emergency department (ED) visits at 12 months ($4410; 95% simulation interval [SI]: $2241, $6626) for the MI+Education group. The total savings at 12 months ($2274; 95% SI: -3916, $8442) could not overcome additional program costs of implementing MI to Head Start-level education ($13 695; 95% SI: $11 250, $16 034).

CONCLUSIONS

This study is the first to examine the cost of either intervention on SHSe-attributed pediatric healthcare costs from a population level relevant for federal and community decision makers. Intervention costs could not be offset by short-term savings but a trend towards positive savings was appreciated 1 year after implementation.

IMPLICATIONS

Behavioral interventions are effective in reducing SHSe in children. However, many of these interventions are not implemented in community settings due to lack of resources and money. Behavioral strategies may be a cost-saving addition to the national initiatives to create smoke-free home environments. The long-term benefits of MI, as evidenced from cost savings from averted ED visits, appeared to show MI+Education to be a robust long-term strategy. The decrease of acute healthcare services at 12 months may be informative for policy decision makers seeking to allocate limited resources to reduce the usage of costly ED services and hospital readmissions.

Associations Between Caregiver Health Literacy and Preschool Children's Secondhand Smoke Exposure

OBJECTIVE

Examine the associations between caregiver health literacy (HL) and smoking-related outcome expectancies, implementation of home/car smoking bans (H/CSBs), and child secondhand smoke exposure (SHSe).

METHODS

Caregivers of Head Start children residing with a smoker(s) completed measures assessing HL, outcome expectancies, and H/CSB implementation. Biomarkers of child SHSe included home air nicotine monitors and child salivary cotinine.

RESULTS

Caregivers with lower HL had higher levels of home air nicotine and child salivary cotinine in the full sample and among smokers. After controlling for child age and number of smokers in the home, lower HL was associated with higher endorsement of negative smoking expectancies in the full sample and in smokers. HL was not associated with H/CSB implementation across groups.

CONCLUSIONS

Caregiver HL is associated with child SHSe and is important in shaping smoking-related beliefs. HL is not directly related to adoption of SHSe-reduction behaviors such as H/CSBs.

Effectiveness of Interventions to Reduce Tobacco Smoke Pollution in Homes: A Systematic Review and Meta-Analysis

INTRODUCTION

Smoke-free homes can help protect children from tobacco smoke exposure (TSE). The objective of this study was to conduct a meta-analysis to quantify effects of interventions on changes in tobacco smoke pollution in the home, as measured by air nicotine and particulate matter (PM).

METHODS

We searched MEDLINE, PubMed, Web of Science, PsycINFO, and Embase. We included controlled trials of interventions which aimed to help parents protect children from tobacco smoke exposure. Two reviewers identified relevant studies, and three reviewers extracted data.

RESULTS

Seven studies were identified. Interventions improved tobacco smoke air pollution in homes as assessed by nicotine or PM. (6 studies, N = 681, p = 0.02). Analyses of air nicotine and PM separately also showed some benefit (Air nicotine: 4 studies, N = 421, p = 0.08; PM: 3 studies, N = 340, p = 0.02). Despite improvements, tobacco smoke pollution was present in homes in all studies at follow-up.

CONCLUSIONS

Interventions designed to protect children from tobacco smoke are effective in reducing tobacco smoke pollution (as assessed by air nicotine or PM) in homes, but contamination remains. The persistence of significant pollution levels in homes after individual level intervention may signal the need for other population and regulatory measures to help reduce and eliminate childhood tobacco smoke exposure.

Feasibility of Measuring Tobacco Smoke Air Pollution in Homes: Report from a Pilot Study

Tobacco smoke air pollution (TSAP) measurement may persuade parents to adopt smoke-free homes and thereby reduce harm to children from tobacco smoke in the home. In a pilot study involving 29 smoking families, a Sidepak was used to continuously monitor home PM(2.5) during an 8-h period, Sidepak and/or Dylos monitors provided real-time feedback, and passive nicotine monitors were used to measure home air nicotine for one week. Feedback was provided to participants in the context of motivational interviews. Home PM(2.5) levels recorded by continuous monitoring were not well-accepted by participants because of the noise level. Also, graphs from continuous monitoring showed unexplained peaks, often associated with sources unrelated to indoor smoking, such as cooking, construction, or outdoor sources. This hampered delivery of a persuasive message about the relationship between home smoking and TSAP. By contrast, immediate real-time PM(2.5) feedback (with Sidepak or Dylos monitor) was feasible and provided unambiguous information; the Dylos had the additional advantages of being more economical and quieter. Air nicotine sampling was complicated by the time-lag for feedback and questions regarding shelf-life. Improvement in the science of TSAP measurement in the home environment is needed to encourage and help maintain smoke-free homes and protect vulnerable children. Recent advances in the use of mobile devices for real-time feedback are promising and warrant further development, as do accurate methods for real-time air nicotine air monitoring.

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.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Reducing environmental tobacco smoke exposure of preschool children: a randomized controlled trial of class-based health education and smoking cessation counseling for caregivers

OBJECTIVES

To assess counseling to caregivers and classroom health education interventions to reduce environmental tobacco smoke exposure of children aged 5-6 years in China.

METHODS

In a randomized controlled trial in two preschools in Changsha, China, 65 children aged 5-6 years old and their smoker caregivers (65) were randomly assigned to intervention (n = 33) and control (no intervention) groups (n = 32). In the intervention group, caregivers received self-help materials and smoking cessation counseling from a trained counselor, while their children were given classroom-based participatory health education. Children's urinary cotinine level and the point prevalence of caregiver quitting were measured at baseline and after 6 months.

RESULTS

At the 6-month follow-up, children's urinary cotinine was significantly lower (Z = -3.136; p = 0.002) and caregivers' 7-day quit rate was significantly higher (34.4% versus 0%) (p < 0.001; adjusted OR = 1.13; 95% CI: 1.02-1.26) in the intervention than control group.

CONCLUSIONS

Helping caregivers quitting smoke combined with classroom-based health education was effective in reducing children's environmental tobacco smoke exposure. Larger-scale trials are warranted.

Relationship between caregivers' smoking at home and urinary levels of cotinine in children

Objective: To assess the impact of different smoking behaviors of caregivers on environmental tobacco smoke (ETS) exposure in children aged 5–6 years in Changsha, China. Methods: We conducted a cross-sectional, random digit-dial telephone survey of caregivers (n = 543) between August and October 2013. Caregivers’ smoking behaviors were collected by a questionnaire. Exposure assessment was based upon determination of urinary cotinine levels in children employing gas chromatography–triple quadrupole mass spectrometry (GC-MS/MS). Results: In children not living with a smoker, children living with one smoker, and children living with more than one smoker at home, median urinary cotinine concentrations (ng/mL) were 0.72, 2.97, and 4.46, respectively. For children living with one smoker, median urinary cotinine levels of children exposed to ETS were associated with caregiver smoking behaviors, i.e., if a caregiver consumed more cigarettes (>20 compared with ≤10; 7.73 versus 2.29 ng/mL, respectively). Conclusions: The magnitude of ETS exposure in children is correlated with the smoking behaviors of the caregiver. Counseling for smoking cessation and educational interventions are needed urgently for smoking caregivers to increase their awareness about ETS exposure and to encourage smoking cessation at home or to take precautions to protect children’s health.

Effectiveness of motivational interviewing to reduce head start children's secondhand smoke exposure. a randomized clinical trial

RATIONALE

Secondhand smoke exposure (SHSe) is a significant modifiable risk for respiratory health in children. Although SHSe is declining overall, it has increased for low-income and minority populations. Implementation of effective SHSe interventions within community organizations has the potential for significant public health impact.

OBJECTIVES

To evaluate the effectiveness of motivational interviewing (MI) delivered in the context of a SHS education reduction initiative within Head Start to reduce preschool children's SHSe.

METHODS

A total of 350 children enrolled in Baltimore City Head Start whose caregivers reported a smoker living in the home were recruited. Caregivers were randomized to MI + education or education alone. Assessments were conducted at baseline, 3, 6, and 12 months.

MEASUREMENTS AND MAIN RESULTS

The primary outcome measure was household air nicotine levels measured by passive dosimeters. Secondary outcomes included child salivary cotinine, self-report of home smoking ban (HSB), and smoking status. Participants in the MI + education group had significantly lower air nicotine levels (0.29 vs. 0.40 mg), 17% increase in prevalence of caregiver-reported HSBs, and a 13% decrease in caregiver smokers compared with education-alone group (all P values < 0.05). Although group differences in salivary cotinine were not significant, among all families who reported having an HSB, salivary cotinine and air nicotine levels declined in both groups (P < 0.05).

CONCLUSIONS

MI may be effective in community settings to reduce child SHSe. More research is needed to identify ways to tailor interventions to directly impact child SHSe and to engage more families to make behavioral change. Clinical trial registered with www.clinicaltrials.gov (NCT 00927264).