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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A smoking cessation intervention for parents of children who are hospitalized for respiratory illness: the stop tobacco outreach program

OBJECTIVE

Parental smoking is associated with increased rates and severity of childhood respiratory illness. No previous studies have examined child hospitalization as an opportunity for parental smoking cessation. We evaluated the feasibility of implementing a smoking cessation intervention for parents at the time of child hospitalization for respiratory illness.

METHODS

We performed a prospective cohort study of smoking parents who had a child who was admitted to an academic children's hospital for a respiratory illness between January and April 2000. All enrollees were offered the Stop Tobacco Outreach Program, which includes an initial motivational interview, written materials, nicotine replacement therapy (NRT), telephone counseling, and fax referral to parents' primary clinician. The primary outcome was completion of all 3 counseling sessions. Two-month follow-up outcomes were quit attempts, cessation, NRT use, primary care visits, household smoking prohibition, and satisfaction.

RESULTS

A total of 126 smoking parents met eligibility criteria, and 71 (56%) enrolled in the study. Of the 71, 80% completed all counseling sessions and 56% accepted free NRT at the time of enrollment. At the 2-month follow-up, of the 71 initial enrollees, 49% reported having made a quit attempt that lasted at least 24 hours, 21% reported not smoking a cigarette in the last 7 days, 27% reported having used NRT, and 38% had had a visit with their own primary clinician. The proportion of parents who reported rules prohibiting smoking in the house increased (29% vs 71%). Parental rating of the overall usefulness of the program was 4.3 +/- 0.9 (1 standard deviation) on the 5-point scale 1 = not at all and 5 = a great extent.

CONCLUSIONS

This study demonstrates the feasibility of engaging parents in smoking cessation interventions at the time of child hospitalization for respiratory illness. Previous work done in a similar sample of parental smokers has shown extremely low ever-use rates of cessation programs. High rates of acceptance of in-hospital and telephone counseling in this study support the notion of child hospitalization as a teachable moment to address parental smoking.

Infant exposure to environmental tobacco smoke: a prevalence study in Australia

OBJECTIVE

To determine: the prevalence of exposure to environmental tobacco smoke among infants aged 0-12 months in two child health care settings; the accuracy of parent report indicators of exposure; and the factors associated with exposure to environmental tobacco smoke.

METHOD

Samples of consecutive parents of infants 12 months of age or younger who attended Hunter Region public child health and immunisation clinics were approached to complete a questionnaire and to allow a urine sample to be obtained from their infant during December and January 1998/99. Infant urine samples were analysed for cotinine and information obtained regarding the smoking status of household members, infant exposure to environmental tobacco smoke during the previous three days, and parent and infant characteristics and demographics.

RESULTS

85 (47%) [95% CI 40-54] infants in the combined sample had detectable levels of cotinine. Sensitivity of reported infant exposure of 86% was achieved through the combined measure of parent report of exposure and smoking status of households. The odds of exposure for infants of smoking parents were 14 times that of infants of nonsmokers [CI 5.26-50.0].

CONCLUSIONS

Almost half of the infants in this study had detectable levels of cotinine in their urine. Future interventions targeting infant exposure to environmental tobacco smoke should incorporate quit smoking strategies for both parents and other household members, as well as strategies for changing the pattern of smoking behaviour around infants.

IMPLICATIONS

These findings suggest that existing community education strategies and passive smoking public policies are failing to protect this vulnerable population group.

Measuring infant exposure to environmental tobacco smoke

Methods to measure infant exposure to environmental tobacco smoke (ETS) are needed to identify infants at highest risk for ETS-related health problems. The purpose of this study was to validate measures sensitive to changes in levels of infant exposure to ETS and to develop a predictive model of infant exposure to ETS. Fifteen infants of smoking mothers were followed from birth to 6 weeks of age. Exposure to ETS was measured by using a smoking habits questionnaire, cigarette "butt" collection, infant urine nicotine and cotinine levels, and ambient nicotine (personal air monitors). The 24-hour cigarette butt collection was the best predictor of acute (adjusted r2 = .83) and chronic exposure (adjusted r2 = .47) measured by infant urinary nicotine and cotinine levels when the infants were 2 weeks of age. Including scores on the smoking habits questionnaire and ambient nicotine levels increased the adjusted r2 to .88 and .61, respectively.

Urinary cotinine and parent history (questionnaire) as indicators of passive smoking and predictors of lower respiratory illness in infants

Studies of the effects of passive smoking on lower respiratory illness (LRI) have relied on questionnaires to measure exposure. We studied the association between two measures of passive smoking and the incidence of acute LRI in infants. We analyzed data from a community-based cohort study of respiratory illness during the first year of life in North Carolina. The incidence of LRI was determined by telephone calls at 2-week intervals. Environmental, demographic, and psychosocial risk factors for LRI were measured during home interviews. Tobacco smoke exposure was measured as the mean number of cigarettes smoked per day in the infant's presence. Smoke absorption by the infants was measured by the urinary cotinine/ creatinine ratio. Of the 485 infants in the study, 325 (67%) had telephone follow-up and at least two home interviews. In bivariate analyses, reported tobacco smoke exposure and urinary cotinine were associated with LRI. Only the association between reported exposure and LRI remained significant after adjusting for confounders, [adjusted incidence of LRI (episodes/child-year) non-exposed: 0.6; < or = 10 cigarettes/day: 0.9 (RR 1.5, 95% CI: 1.1, 2.0); > 10 cigarettes/day: 1.3 (RR 2.2, 95% CI: 1.3, 3.8)]. We conclude that infants reportedly exposed to tobacco smoke have an increased incidence of LRI. There are differences between questionnaire and biochemical measures of passive smoking. Urinary cotinine will not necessarily improve the validity of studies of the relationship of passive smoking to LRI in infants.

Evaluation of a home-based intervention program to reduce infant passive smoking and lower respiratory illness

We conducted a randomized controlled trial to determine whether a home-based intervention program could reduce infant passive smoking and lower respiratory illness. The intervention consisted of four nurse home visits during the first 6 months of life, designed to assist families to reduce the infant's exposure to tobacco smoke. Among the 121 infants of smoking mothers who completed the study, there was a significant difference in trend over the year between the intervention and the control groups in the amount of exposure to tobacco smoke; infants in the intervention group were exposed to 5.9 fewer cigarettes per day at 12 months. There was no group difference in infant urine cotinine excretion. The prevalence of persistent lower respiratory symptoms was lower among intervention-group infants of smoking mothers whose head of household had no education beyond high school: intervention group, 14.6%; and controls, 34.0%.

Lower respiratory illness in infants and low socioeconomic status

OBJECTIVES

Infants from families of low socioeconomic status are said to suffer higher rates of lower respiratory illness, but this assertion has not been carefully examined.

METHODS

We studied the frequency and determinants of lower respiratory illness in infants of different socioeconomic status (n = 393) by analyzing data from a community-based cohort study of respiratory illness during the first year of life in central North Carolina.

RESULTS

The incidence of lower respiratory illness was 1.41 in the low socioeconomic group, 1.26 in the middle group, and 0.67 in the high group. The prevalence of persistent respiratory symptoms was 39% in infants in the low socioeconomic group, 24% in infants in the middle group, and 14% in infants in the high group. The odds of persistent respiratory symptoms in infants of low and middle socioeconomic status were reduced after controlling for environmental risk factors for lower respiratory illness. Enrollment in day care was associated with an increased risk of persistent symptoms among infants of high but not low socioeconomic status.

CONCLUSIONS

Infants of low socioeconomic status are at increased risk of persistent respiratory symptoms. This risk can be partly attributed to environmental exposures, most of which could be changed.

Passive smoking during the first year of life

BACKGROUND AND PURPOSE

A description of passive smoking during the first year of life might assist planning preventive efforts.

METHODS

Changes in the ecology of passive smoking were investigated in a sample of infants in central North Carolina followed from birth to one year of age.

RESULTS

The prevalence of tobacco smoke absorption, indicated by excretion of cotinine, increased from 53 percent to 77 percent (95% CI of difference: 14, 35) during the first year of life. Most infants (92 percent) excreting cotinine at three weeks of age were also excreting it at one year. Moreover, 61 percent of infants not excreting cotinine at age three weeks were excreting it at one year. This increase reflected an increased exposure to household and, particularly, nonhousehold sources of smoke; the proportion of infants exposed to nonhousehold smokers increased from 14 percent to 36 percent.

CONCLUSIONS

These findings suggest that prevention of the onset of passive smoking should begin very early.