PEDIATRICS Vol. 115 No. 3 March 2005, pp. 750-760 (doi:10.1542/peds.2004-1055)
SPECIAL ARTICLE |
State-of-the-Art Interventions for Office-Based Parental Tobacco Control
* General Pediatrics Division, MGH Center for Child and Adolescent Health Policy, MassGeneral Hospital for Children, and Tobacco Research and Treatment Center, Boston, Massachusetts
Department of Dermatology, Cancer Control Center, Boston University School of Medicine, Boston, Massachusetts
Strong Children’s Research Center, University of Rochester, Rochester, New York
|| Department of Dermatology, Cancer Control Center, and Department of Epidemiology, Boston University School of Medicine, Boston University School of Public Health
¶ MGH Tobacco Research and Treatment Center and the Pulmonary and Critical Care Unit, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
# Division of Epidemiology, University of Minnesota, Minneapolis, Minnesota
** Health Research and Policy Centers, University of Illinois, Chicago, Illinois
Department of Family and Community Medicine, University of Arizona Health Sciences Center, Tucson, Arizona
University of Texas M.D. Anderson Cancer Center, Houston, Texas
|||| Children’s National Medical Center, George Washington University, Washington, DC
¶¶ Center for Child Health Research and Strong Children’s Research Center, University of Rochester, Rochester, New York
## Division of Preventive and Behavioral Medicine, University Massachusetts Medical School, Worcester, Massachusetts
 |
ABSTRACT |
|---|
 TOP ABSTRACT HEALTH BURDEN OF PARENTAL...ECONOMIC BURDEN OF PARENTAL...THE EVIDENCE FOR TOBACCO...OPPORTUNITY TO INTERVENE IN...BARRIERS TO ADDRESSING PARENTAL...STUDIES AND CURRENT PRACTICES...SPECIAL CONSIDERATIONS FOR CHILD...DISCUSSION AND RECOMMENDATIONSREFERENCES |
|---|
Parental tobacco use is a serious health issue for all family members. Child health care clinicians are in a unique and important position to address parental smoking because of the regular, multiple contacts with parents and the harmful health consequences to their patients. This article synthesizes the current evidence-based interventions for treatment of adults and applies them to the problem of addressing parental smoking in the context of the child health care setting. Brief interventions are effective, and complementary strategies such as quitlines will improve the chances of parental smoking cessation. Adopting the 5 A’s framework strategy (ask, advise, assess, assist, and arrange) gives each parent the maximum chance of quitting. Within this framework, specific recommendations are made for child health care settings and clinicians. Ongoing research will help determine how best to implement parental smoking-cessation strategies more widely in a variety of child health care settings.
Key Words: tobacco • smoking • adolescent • child • parent • pediatrician • nicotine-replacement therapy • NRT • nicotine • tobacco dependence • guideline • clinical practice guideline • environmental tobacco smoke • secondhand smoke • SHS
Abbreviations: SHS, secondhand smoke • ETS, environmental tobacco smoke • NRT, nicotine-replacement therapy • PHS, US Public Health Service • AAP, American Academy of Pediatrics • OR, odds ratio • CI, confidence interval
Smoking remains the leading cause of preventable morbidity and mortality in the United States and a hazardous environmental exposure to children.1 Unfortunately, more than one quarter of children have at least 1 parent who smokes cigarettes.2 Secondhand smoke (SHS), also known as environmental tobacco smoke (ETS), is a complex mixture of >4000 chemical compounds including 43 known carcinogens; there is no safe level of exposure to SHS given the adverse health effects associated with even low levels of exposure.3 The smoke generated from a single cigarette in a large room causes the air to fail the national minimum standard set by the Clean Air Act of 1994.4 Based on parent self-reported exposure of their own children, national estimates of child exposure to SHS range from 25% to 43% of all children in the United States.5–78 Children are unable to avoid exposure, because they are physically unable to remove themselves from the smoke (as in the case of infants) or they depend on parents for food and shelter for many years and cannot advocate effectively for clean air in the face of parental tobacco addiction. We briefly outline the argument for child health care clinicians to treat parents who smoke, detail the current state of the art for effectively treating adult tobacco dependence, and discuss the literature specific to parental smoking cessation. We conclude by giving child health care clinicians specific methods and tools for evidence-based intervention with parents who smoke. We focus on tobacco that is smoked rather than smokeless tobacco because of the strength and quantity of the evidence for intervention with parents in child health care settings.
|
HEALTH BURDEN OF PARENTAL SMOKING ON CHILDREN |
|---|
|
TOPABSTRACTHEALTH BURDEN OF PARENTAL...ECONOMIC BURDEN OF PARENTAL...THE EVIDENCE FOR TOBACCO...OPPORTUNITY TO INTERVENE IN...BARRIERS TO ADDRESSING PARENTAL...STUDIES AND CURRENT PRACTICES...SPECIAL CONSIDERATIONS FOR CHILD...DISCUSSION AND RECOMMENDATIONSREFERENCES |
|---|
In addition to harming themselves, parents who smoke subject their children to a range of specific prenatal, postnatal, and long-term health risks (Table 1). 3,9–42 Each year, >5000 children die from tobacco exposure, 3 times the number caused by all childhood cancers combined.43,44 In addition, smoking-related materials are the leading cause of fire-related deaths, accounting for
250 child deaths each year.43,45
|
Beyond the risks from SHS, parental smoking has a significant impact on smoking initiation; children and adolescents who are exposed to smokers in their household are 3 times more likely to initiate smoking themselves.46 It is important to note that parental quitting is associated with lower adolescent smoking rates.47 Increased access to cigarettes, behavioral modeling of parent behavior, and increased nicotine receptors in the brain due to tobacco smoke exposure might explain increased rates of experimenting with cigarettes and smoking initiation by children in families in which a parent smoked during pregnancy and continues to smoke.47–52
|
ECONOMIC BURDEN OF PARENTAL SMOKING |
|---|
|
TOPABSTRACTHEALTH BURDEN OF PARENTAL...ECONOMIC BURDEN OF PARENTAL...THE EVIDENCE FOR TOBACCO...OPPORTUNITY TO INTERVENE IN...BARRIERS TO ADDRESSING PARENTAL...STUDIES AND CURRENT PRACTICES...SPECIAL CONSIDERATIONS FOR CHILD...DISCUSSION AND RECOMMENDATIONSREFERENCES |
|---|
The burden of parental smoking includes the economic impact from expenditure of family resources on cigarettes instead of other essential needs such as schooling, housing, and nutrition. Smoking remains concentrated among the poor and less well educated, precisely the families who can least afford the financial burden.53 For instance, a parent who smokes 1 pack of cigarettes a day spends, on average, more than $1800 per year after taxes, worsening the cycle of poverty for many of these families.
In the United States, the cost to society of adult smoking and exposure of children has been estimated at $157 billion in annual health-related economic losses for the years 1995-1999.54 This economic calculation includes health care costs for treating ill smokers, lost productivity from tobacco-related illness, and some effects of SHS.55 The direct medical expenditures and loss-of-life costs for SHS exposure of children alone exceeds $10 billion per year.43 Treating tobacco dependence with any of the US Public Health Service (PHS)-recommended approaches56 is one of the most cost-effective of all known health care interventions.57–59
|
THE EVIDENCE FOR TOBACCO-DEPENDENCE TREATMENT IN ADULTS |
|---|
|
TOPABSTRACTHEALTH BURDEN OF PARENTAL...ECONOMIC BURDEN OF PARENTAL...THE EVIDENCE FOR TOBACCO...OPPORTUNITY TO INTERVENE IN...BARRIERS TO ADDRESSING PARENTAL...STUDIES AND CURRENT PRACTICES...SPECIAL CONSIDERATIONS FOR CHILD...DISCUSSION AND RECOMMENDATIONSREFERENCES |
|---|
The Treating Tobacco Use and Dependence Clinical Practice Guideline,56 published by the PHS in 2000, provides a framework for provision of the effective interventions for adults who use tobacco. The tobacco treatment guideline is based on an extensive body of evidence that was developed in numerous and varied clinical settings. Overall, the PHS guideline states that clinicians and health care delivery systems should "institutionalize the consistent identification, documentation, and treatment of every tobacco user seen in a healthcare setting."56(p4) The guideline encourages clinical offices to use office-wide systems for smoker identification, to offer brief counseling interventions to all smokers, tailored to their circumstances, and to offer nicotine-replacement therapies (NRTs) for those smokers who are ready to make a cessation attempt. Having an office system in place that identifies smokers at every visit doubles cessation rates (Table 2). 56
|
The use of a brief counseling intervention greatly improves the number of cessation attempts by smokers. Table 3 shows the estimated abstinence rates by length of counseling contact, with the optimal effect achieved with
10 minutes.56 However, <3 minutes of counseling still produces significant increases in cessation compared with no counseling and improves the likelihood that the clinician will perform the intervention. By using the following 5 A’s to organize the intervention, clinicians can ensure that they are delivering the recommended treatment modalities to those who smoke:56
- Ask whether he/she uses tobacco products;
- Advise those who use tobacco to quit in a strong, clear, and personalized way;
- Assess his/her willingness to quit using tobacco at the present time; if the smoker is not willing to make a quit attempt at the present time, then try to increase motivation to quit at a later time;
- Assist in making a quit attempt, if the smoker is willing to attempt cessation, by providing brief counseling, prescription of pharmacotherapy, and provision of written self-help materials; and
- Arrange follow-up contacts to prevent the smoker from relapsing to tobacco use and enroll the smoker in telephone-quitline counseling or a local program.
|
Counseling by physicians significantly improves cessation rates, emphasizing the need to include physicians in office-based cessation interventions (Table 4). 56 Most health care clinicians have limited time for cessation counseling. Therefore, complementary strategies are extremely important to minimize clinician counseling burden while still maximizing the chances of smoking cessation. A proven strategy to increase smoking-cessation rates is to have >1 clinician type deliver the brief interventions.56 If one type is the physician, the second type might be a nurse, physician’s assistant, clinical assistant, or social worker (Table 5). 56 Using a team approach might focus physician effort on advising the smoker to quit, with immediate follow-up by a nurse or other clinical assistant to provide additional counseling, pharmacotherapy instructions, and follow-up. Because many clinicians do not have the resources or skills to deliver extended counseling interventions, they might consider the use of videotapes that can minimize the burden on nurses or clinical assistants by providing skill training and role models for smoking cessation.60,61
|
|
Involving >1 clinician and delivering even 10 minutes of face-to-face counseling may be beyond the resources of some health care settings. Enrolling smokers in multisession telephone counseling as an adjunct to office-based counseling ensures that smokers receive professional, evidence-based, ongoing counseling services that may not be possible otherwise.56,62 Quitlines have been shown to be effective in helping adults quit smoking and are currently available in 38 states.63–65 In addition, proactive telephone quitlines establish contact with a larger percentage of smokers who are initially referred compared with reactive quitlines.63,66 In February 2004, the PHS committed to establishing a national quitline network that will be federally subsidized and available by referral in all 50 states.
The use of pharmacological aids roughly doubles quit rates above those achieved with counseling alone (Table 6). Use of NRT has grown with the introduction of new NRT products and the subsequent move to over-the-counter sales.67 There are several products that are available without a prescription, including nicotine patches, gum, and lozenges. The lozenges were not yet available when the clinical practice guideline was written, but they provide 25% more nicotine delivery than nicotine gum and have been shown to be effective in short-term abstinence, including among smokers who have used pharmacotherapy for prior cessation attempts.68 Bupropion has been used as an antidepressant but also has demonstrated efficacy for smoking cessation.56 Fig. 1 provides an overview of how NRT and bupropion therapy are prescribed.
|
|
Many smokers will not be ready to make a quit attempt at any given visit.69 For smokers who do not express a willingness to quit, the 5 R’s can be an effective tool to motivate them to begin thinking more critically about their smoking, possibly leading to a quit attempt in the future:
- Relevance: ask the smoker why quitting is personally relevant to him or her;
- Risks: ask the smoker to identify the consequences of his or her smoking;
- Rewards: ask the smoker to identify the benefits that he or she might get from quitting;
- Roadblocks: ask the smoker to identify what some of his or her barriers are to quitting; and
- Repetition: these questions should be repeated at every clinical encounter.56
For those smokers who have quit recently, the PHS guideline recommends congratulating success, encouraging continued abstinence from tobacco use, and continuing discussion about the benefits of cessation and any challenges to abstinence.
|
OPPORTUNITY TO INTERVENE IN CHILD HEALTH CARE SETTINGS |
|---|
|
TOPABSTRACTHEALTH BURDEN OF PARENTAL...ECONOMIC BURDEN OF PARENTAL...THE EVIDENCE FOR TOBACCO...OPPORTUNITY TO INTERVENE IN...BARRIERS TO ADDRESSING PARENTAL...STUDIES AND CURRENT PRACTICES...SPECIAL CONSIDERATIONS FOR CHILD...DISCUSSION AND RECOMMENDATIONSREFERENCES |
|---|
Given the clinical effectiveness and benefit of smoking-cessation interventions, they should be delivered at every clinical encounter. The PHS guideline specifically recommends offering interventions to parents to limit children’s exposure to SHS.56 The child health care setting provides access and unique teachable moments to motivate parents to quit smoking because of the number of contacts a parent has with his or her child’s pediatric health care provider and the strong link between SHS and chronic and acute childhood illness. Many parents do not have any other access to a primary care provider or services that could help them try to quit smoking.66,70,71 In 1 recent Massachusetts study, <1 in 5 parents had ever had any exposure to smoking-cessation programs or telephone counseling.66 Child health care clinicians, through the schedule of primary care visits, are often in a position to intervene with parental smokers in a repeated and consistent manner over the course of many years.72 For parents without their own primary care provider, their child’s doctor may be the only access point they have to pharmacological advice and treatment for tobacco addiction.
The American Academy of Pediatrics (AAP) and American Academy of Family Physicians have policy statements that support parental smoking cessation in the context of child health care settings.73–75 The AAP states that a "tobacco-free environment is imperative, because tobacco is a major health hazard to infants, children, adolescents, and their families."74(p797) With specific regard to parents who smoke, the policy statement recommends that the dangers of SHS and the risk of role-modeling tobacco use be "discussed and reinforced with written information and cessation referrals," and that "repeated nonjudgmental efforts to encourage the parent to quit smoking (accompanied by appropriate referral)" be made.74 The pediatric clinician is also encouraged to provide relapse prevention for family members who quit, particularly to women who quit during pregnancy.74 Pediatric Environmental Health, a handbook for clinicians published by the AAP in 1999 and revised in 2003, gives suggestions about implementing some of the recommended parental smoking-cessation and SHS reduction strategies within the pediatric setting.76
One third of women spontaneously quit after learning of their pregnancy, and according to meta-analyses, an additional 20% quit with behavioral assistance during pregnancy.77–79 However, more than half of those who quit resume smoking within 6 months postpartum.80 Relapse remains high even in the context of behavioral interventions during pregnancy and postpartum.81–83 These high rates of smoking recidivism may be due to problems with longer-term continuity of cessation support once the infant is born.80,84 During this postpartum period of maximal risk of relapse to smoking, obstetrical-setting support tapers off, whereas the child health care setting has a minimum of 5 contacts with the parent, providing the opportunity to reduce relapse and support new cessation. Additionally, many mothers seen in the context of their child’s health care visit will be planning to have another child or currently be pregnant. The access that pediatric health care clinicians have to women before pregnancy and in their first trimester creates unique opportunities to address smoking in this population. Interventions with pregnant and postpartum smokers are well summarized in the PHS guideline, should include more intensive counseling than minimal advice, and can follow a similar 5 A’s approach that is used for the general adult smoker.56
|
BARRIERS TO ADDRESSING PARENTAL SMOKING |
|---|
|
TOPABSTRACTHEALTH BURDEN OF PARENTAL...ECONOMIC BURDEN OF PARENTAL...THE EVIDENCE FOR TOBACCO...OPPORTUNITY TO INTERVENE IN...BARRIERS TO ADDRESSING PARENTAL...STUDIES AND CURRENT PRACTICES...SPECIAL CONSIDERATIONS FOR CHILD...DISCUSSION AND RECOMMENDATIONSREFERENCES |
|---|
Child health care clinicians cite a number of barriers to addressing parental smoking cessation, including lack of time, lack of confidence in their ability to give smoking-cessation advice, and concern about negative reactions from parents.85–87 In 1 study, 45% of pediatricians surveyed thought that parents’ lack of interest in quitting smoking was a barrier to parental smoking-cessation counseling, and 39% felt that parents would ignore their advice.88 Some pediatricians mentioned lack of skills (26%), reimbursement (20%), and negative reaction from parents (20%) as other barriers.88 Another study found that 69% of pediatricians surveyed felt that prescribing or recommending NRT was the responsibility of another clinician.89
Many of these arguments against fully engaging parental tobacco use in the child health care setting have been successfully addressed. The long-standing belief that addressing smoking with parents will harm the therapeutic alliance proves incorrect, because the vast majority of smokers tend to give higher satisfaction ratings to pediatric clinicians who address their smoking and offer help.85,90–92 In fact, most parents believe that it is the responsibility of the pediatrician to counsel them on matters that affect their child’s health and that they ought to do more counseling regarding smoking cessation.85,90,93 Although pediatric health care clinicians generally do not have time to provide more than brief counseling, evidence-based telephone counseling is currently available in 38 states, with a free national quitline planned that can provide more extensive counseling to those parents interested in receiving additional assistance.94
|
STUDIES AND CURRENT PRACTICES IN CHILD HEALTH CARE SETTINGS |
|---|
|
TOPABSTRACTHEALTH BURDEN OF PARENTAL...ECONOMIC BURDEN OF PARENTAL...THE EVIDENCE FOR TOBACCO...OPPORTUNITY TO INTERVENE IN...BARRIERS TO ADDRESSING PARENTAL...STUDIES AND CURRENT PRACTICES...SPECIAL CONSIDERATIONS FOR CHILD...DISCUSSION AND RECOMMENDATIONSREFERENCES |
|---|
There have not yet been any randomized, controlled trials in child health care settings to study implementation of the current PHS tobacco treatment guideline, but there have been a number of surveys to determine current practices and studies of other tobacco interventions. From national surveys of practitioners and parents, rates of the first 2 A’s, asking and advising, are at or <50%, respectively.95,96 Parents report even lower national rates of assistance with medication or arranging follow-up.97 Parent-reported national rates of pediatrician and family practitioner screening and counseling for rules prohibiting smoking in the house and car are also low.96 Even in patients presenting with asthma, pediatricians documented addressing tobacco exposure as a possible factor <5% of the time.95 Physicians, moreover, tend to overestimate the rate at which they perform preventive counseling98; thus, the actual prevalence of screening and cessation counseling is likely even lower.
Individual statewide surveys demonstrate that child health care clinicians have particularly low rates of implementing effective interventions with parents who smoke.86,87 In a population-based survey of pediatricians practicing in urban areas in California, pediatricians reported low rates of the strategies shown to be most successful such as setting a quit date (18%), prescribing NRT (13%), providing nurse-mediated counseling (10%), and scheduling a follow-up visit or telephone call (5%).88
Beyond prevalence studies, there have been many studies examining the efficacy and feasibility of specific tobacco-control interventions with parents in child health care settings.66,71,81,99–111 Studies in these settings have tried to improve parental smoking-cessation rates primarily through the use of counseling and provision of written materials, with varied results. Three such studies documented some success,81,99,111 whereas others showed no effect100,103,110 or were inconclusive because they used no control group.112,113 In reducing SHS exposure of children, recent studies using counseling and provision of written materials have proven successful.104,105,108,109 In a recent randomized trial of 303 women seen at pediatric clinics, Curry et al111 evaluated the effectiveness of a smoking-cessation intervention to help mothers quit smoking. The intervention consisted of brief cessation advice given by the pediatrician (usually lasting 1-5 minutes), a parent-tailored quit-smoking guide distributed by the pediatrician, a 10-minute intervention with a practice nurse or health educator directly after the child’s visit, and up to 3 subsequent telephone calls from the practice nurse or health educator. At the 12-month follow-up, 13.5% of the intervention group abstained, compared with 6.9% of the control group, resulting in an adjusted odds ratio (OR) of 2.77 (confidence interval [CI]: 1.24-6.60), demonstrating that office-based and telephone counseling can be effective in increasing the quit rates of parents who smoke. Study participants noted that the discussions with the physicians were "somewhat or very encouraging of trying to quit."111(p299) Parents are receptive to cessation advice from their child’s doctor and child health care clinicians. If given the tools, child health care clinicians are able to counsel parents. Another study has demonstrated the feasibility of addressing parental smoking in an outpatient pediatric clinic using the currently recommended strategy of proactive telephone counseling and NRT.66 In this study, parental cessation outcomes were encouraging but difficult to interpret because the study lacked a control group. Current and planned future studies will address how to optimize implementation of the PHS tobacco treatment guideline within child health care settings.
|
SPECIAL CONSIDERATIONS FOR CHILD HEALTH CARE SETTINGS |
|---|
|
TOPABSTRACTHEALTH BURDEN OF PARENTAL...ECONOMIC BURDEN OF PARENTAL...THE EVIDENCE FOR TOBACCO...OPPORTUNITY TO INTERVENE IN...BARRIERS TO ADDRESSING PARENTAL...STUDIES AND CURRENT PRACTICES...SPECIAL CONSIDERATIONS FOR CHILD...DISCUSSION AND RECOMMENDATIONSREFERENCES |
|---|
Many child health care clinicians have difficulty with the idea of expanding their roles to include primary and secondary prevention of adult problems that directly impact the health of children, such as parental smoking. Given the depth and breadth required for high-quality pediatric primary care encounters, pediatric health care clinicians generally do not have time for more than brief counseling interventions for smokers. As such, it will be important to use ancillary staff in smoking-cessation efforts and adjuncts such as evidence-based telephone quitlines that can provide more extensive counseling. Higher rates of service delivery and better rates of documentation tracking will be possible with electronic medical record systems that contain prompts for tobacco-use assessment and intervention.114
Some child health care clinicians may be concerned about lawsuits from prescription of NRT to parents. However, NRT has been shown to be safe and effective even in patients with cardiovascular disease115,116 and pulmonary disease,117 the elderly,118 and concurrent smokers.119,120 Cigarettes themselves deliver higher levels of nicotine, cause severe disease and death when used as directed, and are available without a prescription. The World Health Organization has based regulatory recommendations for NRT on the following premise:
Virtually all potential users of NRT are already consuming substantial quantities of the drug nicotine through its most addictive and toxic delivery system—tobacco smoke. Use of NRT by a smoker can improve the chance that they will quit smoking tobacco, but will not introduce new risks not already faced by smokers and will greatly reduce or eliminate many smoking related risks.121(p1)
Many insurance carriers, including 71% of Medicaid plans,122 now cover NRT so that a prescription from a clinician will make this option available for free or for the price of a copayment. Half of parental smokers now say they would consider using a medication to help them quit, and 85% of those would accept that medication from their child’s doctor.97 Some child health care clinicians already prescribe for parents in cases of scabies, head lice, meningococcal disease, and pertussis.123 Child health care providers who are unwilling to prescribe over-the-counter NRT to parents should at least recommend appropriate medication to double the chances of success in quitting.
Clinicians might consider recommending or prescribing nicotine gum during pregnancy as a harm-reduction strategy if nonpharmacologic methods have been unsuccessful at producing cessation.124–126 NRT is not routinely recommended for pregnant smokers due to the harm that nicotine itself may cause the developing fetus.125,126 However, when used as directed, nicotine gum always delivers less nicotine than smoking cigarettes.124
Although instituting a ban on smoking in the home, car, and other settings in which a child is exposed is not included in the PHS tobacco treatment guideline, such bans are important adjuncts to cessation treatment when addressing smoking with parents in child health care settings. Encouraging the institution of household and car smoking bans can help address the problem of parental smoking in at least 3 ways. First, bans have been recommended to reduce the exposure to children and spouses to SHS from a parent’s smoking.127–132 A strict household and car prohibition on smoking also reduces the amount of tobacco toxin exposure children receive from nonparent relatives and other visiting adults. Second, bans may reduce smoking rates and cigarette consumption among youth.46,128,133–136 Finally, by making smoking more difficult, bans may also help the cessation process for the parent who smokes.46,137,138
|
DISCUSSION AND RECOMMENDATIONS |
|---|
|
TOPABSTRACTHEALTH BURDEN OF PARENTAL...ECONOMIC BURDEN OF PARENTAL...THE EVIDENCE FOR TOBACCO...OPPORTUNITY TO INTERVENE IN...BARRIERS TO ADDRESSING PARENTAL...STUDIES AND CURRENT PRACTICES...SPECIAL CONSIDERATIONS FOR CHILD...DISCUSSION AND RECOMMENDATIONSREFERENCES |
|---|
Parents who quit smoking will add an average of 7 years to their lives,139 improve the health of their spouses, eliminate the majority of SHS exposure to their children, reduce tobacco-related poor pregnancy outcomes, eliminate the greatest cause of house-fire mortality, and improve the financial resources of their families. Earlier parental quitting will also likely decrease the uptake of teen smoking.47,49,50 Child health care clinicians should ensure that their offices facilitate the delivery of evidence-based tobacco treatment for all parents who smoke. Although most child health care clinicians will not have time to spend the majority of a clinical encounter on the parent’s smoking, brief interventions are effective, and complementary strategies such as quitlines will maximize the chances of parental smoking cessation. Adopting the 5 A’s framework strategy gives each parent the maximum chance of quitting. These recommendations have been summarized in pocket-card format in Figs. 1 and 2.
- Ask: Establish a system in the clinical setting to assess and document the smoking and SHS exposure status of all parents and children in the practice. Strategies might include chart stickers for the problem list that indicate current/former/never smoker for each parent or guardian. For smokers who have already quit, reinforce continued abstinence, especially for postpartum mothers who quit during pregnancy.
- Advise: Advise all parents to quit smoking and establish a smoke-free policy in their home and cars. Use language such as "I strongly advise that you establish a no-smoking policy in your home and car and that you quit smoking yourself. I can help you." Teachable moments that the children may provide should be used to tailor the messages whenever possible: "Because of your daughter’s asthma, it is particularly important for you to stop smoking. I can help you."
- Assess: Ask all parental smokers at every visit if they are willing to make a quit attempt.
- Assist: There are 3 components to effective smoking-cessation assistance. The first is provision of brief counseling to increase a parent’s motivation to quit. For parents ready to quit, provide brief counseling including help in developing a quit plan. Figure 2 provides guidance for the child health care clinician to provide other effective behavioral interventions. The second component is a medication prescription or an offer to contact the parent’s doctor for provision of medication, perhaps with a simple form letter. The use of NRT has well-established benefit and remarkably low risk. The nicotine patch and nicotine gum are especially popular cessation therapies and should be provided to parents who would like to try to quit with smoking-cessation pharmacotherapy. The patch prescription may be written as: nicotine patch, 21-mg (>9 cigarettes per day) or 14-mg (<9 cigarettes per day) strength, 1 patch per day, and dispense a 2-month supply. The gum may be prescribed as: nicotine gum, 4-mg (>20 cigarettes per day) or 2-mg (<20 cigarettes per day) strength, 1 to 2 pieces per hour, and dispense a 2-month supply. Child health care providers who are unwilling to prescribe over-the-counter NRT to parents should at least recommend appropriate cessation medication. See Fig. 1 for additional pharmacotherapies and treatment recommendations. The third is to provide written materials on effective cessation strategies.
- Arrange: Arrange to follow-up on the parent’s progress at the next visit. In addition, proactively enroll the parent in a quitline or local program that can provide expert counseling.
|
A wide gap exists between the recommendations described in the PHS clinical practice guideline and what occurs in child health care settings with regard to tobacco treatment for parents. In addition, current child health care practice contradicts the expressed wishes and expectations of the majority of parents. The child health care provider has a responsibility to protect and improve child health, which includes reducing child exposure to SHS and the likelihood of child smoking initiation by encouraging smoking bans in the child’s environment and helping parents to quit smoking. Routinely offering smoking cessation to parents within the child health care setting will confer profound benefits to children and families.
|
ACKNOWLEDGMENTS |
|---|
Support for this work came from Flight Attendant’s Medical Research Institute grant 024032 and National Institutes of Health-National Cancer Institute grant 1 K07 CA100213 A 01 (to Dr Winickoff).
We acknowledge Sophie J. Balk, MD, Michael Fiore, MD, Jack E. Henningfield, PhD, David Kessler, MD, and Julius Richmond, MD, for contribution of key ideas, feedback, and providing inspiration for this article.
Other consortium members include Jasit S. Ahluwalia, MD, MPH, MS, Dana Best, MD, MPH, Joseph DiFranza, MD, Jonathan D. Klein, MD, MPH, Robert McMillen, PhD, Robin Mermelstein, PhD, Eric T. Moolchan, MD, Deborah Ossip-Klein, PhD, John Pierce, PhD, Julius B. Richmond, MD, James Sargent, MD, and Richard Wasserman, MD.
|
FOOTNOTES |
|---|
Accepted Aug 26, 2004.
Address correspondence to Jonathan P. Winickoff, MD, MPH, MGH Center for Child and Health Policy, 50 Staniford St, Suite 901, Boston, MA 02114. E-mail: jwinickoff{at}partners.org
The Center for Child Health Research is an independent operating branch of the American Academy of Pediatrics. The content of this article does not necessarily reflect the views of the Center for Child Health Research or the American Academy of Pediatrics.
No conflict of interest declared.
|
REFERENCES |
|---|
|
TOPABSTRACTHEALTH BURDEN OF PARENTAL...ECONOMIC BURDEN OF PARENTAL...THE EVIDENCE FOR TOBACCO...OPPORTUNITY TO INTERVENE IN...BARRIERS TO ADDRESSING PARENTAL...STUDIES AND CURRENT PRACTICES...SPECIAL CONSIDERATIONS FOR CHILD...DISCUSSION AND RECOMMENDATIONSREFERENCES |
|---|
1. Centers for Disease Control and Prevention. Cigarette smoking-attributable morbidity—United States, 2000. MMWR Morb Mortal Wkly Rep. 2003;52 :842 –844[Medline]
2. McMillen RC, Breen J, Frese W, Cosby AG. The national social climate of tobacco control, 2000-2002. Available at: www.ssrc.msstate.edu/socialclimate. Accessed January 3, 2005
3. California Environmental Protection Agency. Health Effects of Exposure to Environmental Tobacco Smoke Sacramento, CA: California Environmental Protection Agency, Office of Environmental Health Hazard Assessment; 1997
4. Moyer DB. The Tobacco Almanac: A Reference Book of Facts, Figures, and Quotations About Tobacco. Washington, DC: US Government Printing Office; 1998-783-000/88020
5. Soliman S, Pollack HA, Warner KE. Decrease in the prevalence of environmental tobacco smoke exposure in the home during the 1990s in families with children.
Am J Public Health. 2004;94
:314
–320
6. Schuster MA, Franke T, Pham CB. Smoking patterns of household members and visitors in homes with children in the United States.
Arch Pediatr Adolesc Med. 2002;156
:1094
–1100
7. Pirkle JL, Flegal KM, Bernert JT, Brody DJ, Etzel RA, Maurer KR. Exposure of the US population to environmental tobacco smoke: the Third National Health and Nutrition Examination Survey, 1988 to 1991.
JAMA. 1996;275
:1233
–1240
8. Gergen PJ, Fowler JA, Maurer KR, Davis WW, Overpeck MD. The burden of environmental tobacco smoke exposure on the respiratory health of children 2 months through 5 years of age in the United States: Third National Health and Nutrition Examination Survey, 1988 to 1994. Pediatrics. 1998;101(2) . Available at: www.pediatrics.org/cgi/content/full/101/2/e8
9. Mullen PD. Maternal smoking during pregnancy and evidence-based intervention to promote cessation. Prim Care. 1999;26 :577 –589[Web of Science][Medline]
10. Meredith HV. Relation between tobacco smoking of pregnant women and body size of their progeny: a compilation and synthesis of published studies. Hum Biol. 1975;47 :451 –472[Web of Science][Medline]
11. Lightwood JM, Phibbs CS, Glantz SA. Short-term health and economic benefits of smoking cessation: low birth weight.
Pediatrics. 1999;104
:1312
–1320
12. Ernst M, Moolchan ET, Robinson ML. Behavioral and neural consequences of prenatal exposure to nicotine. J Am Acad Child Adolesc Psychiatry. 2001;40 :630 –641[CrossRef][Web of Science][Medline]
13. Weitzman M, Gortmaker S, Sobol A. Maternal smoking and behavior problems of children.
Pediatrics. 1992;90
:342
–349
14. Wakschlag LS, Pickett KE, Cook E Jr, Benowitz NL, Leventhal BL. Maternal smoking during pregnancy and severe antisocial behavior in offspring: a review.
Am J Public Health. 2002;92
:966
–974
15. Wakschlag LS, Hans SL. Maternal smoking during pregnancy and conduct problems in high-risk youth: a developmental framework. Dev Psychopathol. 2002;14 :351 –369[CrossRef][Web of Science][Medline]
16. Wakschlag LS, Lahey BB, Loeber R, Green SM, Gordon RA, Leventhal BL. Maternal smoking during pregnancy and the risk of conduct disorder in boys.
Arch Gen Psychiatry. 1997;54
:670
–676
17. Day NL, Richardson GA, Goldschmidt L, Cornelius MD. Effects of prenatal tobacco exposure on preschoolers’ behavior. J Dev Behav Pediatr. 2000;21 :180 –188[Web of Science][Medline]
18. Tager IB, Ngo L, Hanrahan JP. Maternal smoking during pregnancy. Effects on lung function during the first 18 months of life. Am J Respir Crit Care Med. 1995;152 :977 –983[Abstract]
19. Brown RW, Hanrahan JP, Castile RG, Tager IB. Effect of maternal smoking during pregnancy on passive respiratory mechanics in early infancy. Pediatr Pulmonol. 1995;19 :23 –28[Web of Science][Medline]
20. Wang X, Tager IB, Van Vunakis H, Speizer FE, Hanrahan JP. Maternal smoking during pregnancy, urine cotinine concentrations, and birth outcomes. A prospective cohort study.
Int J Epidemiol. 1997;26
:978
–988
21. Rauh VA, Whyatt RM, Garfinkel R, et al. Developmental effects of exposure to environmental tobacco smoke and material hardship among inner-city children. Neurotoxicol Teratol. 2004;26 :373 –385[CrossRef][Web of Science][Medline]
22. DiFranza JR, Lew RA. Morbidity and mortality in children associated with the use of tobacco products by other people.
Pediatrics. 1996;97
:560
–568
23. Harlap S, Davies AM. Infant admissions to hospital and maternal smoking. Lancet. 1974;1(7857) :529 –532
24. Koop CE. Adverse anesthesia events in children exposed to environmental tobacco smoke: exposure to environmental tobacco smoke and the risk of adverse respiratory events in children receiving general anesthesia. Anesthesiology. 1998;88(5) :1141 –1142
25. Skolnick ET, Vomvolakis MA, Buck KA, Mannino SF, Sun LS. Exposure to environmental tobacco smoke and the risk of adverse respiratory events in children receiving general anesthesia. Anesthesiology. 1998;88 :1144 –1153[CrossRef][Web of Science][Medline]
26. Lakshmipathy N, Bokesch PM, Cowen DE, Lisman SR, Schmid CH. Environmental tobacco smoke: a risk factor for pediatric laryngospasm. Anesth Analg. 1996;82 :724 –727[Abstract]
27. Lyons B, Frizelle H, Kirby F, Casey W. The effect of passive smoking on the incidence of airway complications in children undergoing general anaesthesia. Anaesthesia. 1996;51 :324 –326[Web of Science][Medline]
28. Sondergaard C, Henriksen TB, Obel C, Wisborg K. Smoking during pregnancy and infantile colic.
Pediatrics. 2001;108
:342
–346
29. Reijneveld SA, Brugman E, Hirasing RA. Infantile colic: maternal smoking as potential risk factor.
Arch Dis Child. 2000;83
:302
–303
30. Kriz P, Bobak M, Kriz B. Parental smoking, socioeconomic factors, and risk of invasive meningococcal disease in children: a population based case-control study.
Arch Dis Child. 2000;83
:117
–121
31. Bek K, Tomac N, Delibas A, Tuna F, Tezic HT, Sungur M. The effect of passive smoking on pulmonary function during childhood.
Postgrad Med J. 1999;75
:339
–341
32. Gold DR, Wang XW, Wypij D, Speizer FE, Ware JH, Dockery DW. Effects of cigarette smoking on lung function in adolescent boys and girls.
N Engl J Med. 1996;335
:931
–937
33. Berkey CS, Ware JH, Dockery DW, Ferris BG Jr, Speizer FE. Indoor air pollution and pulmonary function growth in preadolescent children.
Am J Epidemiol. 1986;123
:250
–260
34. Cook DG, Strachan DP. Health effects of passive smoking-10: Summary of effects of parental smoking on the respiratory health of children and implications for research.
Thorax. 1999;54
:357
–366
35. Sandler DP, Everson RB, Wilcox AJ, Browder JP. Cancer risk in adulthood from early life exposure to parents’ smoking.
Am J Public Health. 1985;75
:487
–492
36. Sandler DP, Wilcox AJ, Everson RB. Cumulative effects of lifetime passive smoking on cancer risk. Lancet. 1985;1(8424) :312 –315
37. Arbes SJ Jr, Agustsdottir H, Slade GD. Environmental tobacco smoke and periodontal disease in the United States. Am J Public Health. 2001;91 :253 –257[Abstract]
38. Aligne CA, Moss ME, Auinger P, Weitzman M. Association of pediatric dental caries with passive smoking.
JAMA. 2003;289
:1258
–1264
39. US Environmental Protection Agency. Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders. Washington, DC: US Environmental Protection Agency, Office of Health and Environmental Assessment, Office of Research and Development; 1992. EPA/600/6-90/0006F
40. Moskowitz WB, Schwartz PF, Schieken RM. Childhood passive smoking, race, and coronary artery disease risk: the MCV Twin Study. Medical College of Virginia.
Arch Pediatr Adolesc Med. 1999;153
:446
–453
41. Tager IB, Weiss ST, Munoz A, Rosner B, Speizer FE. Longitudinal study of the effects of maternal smoking on pulmonary function in children. N Engl J Med. 1983;309 :699 –703[Abstract]
42. US Department of Health and Human Services. The Health Consequences of Involuntary Smoking: A Report of the Surgeon General. US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention. DHHS Publication No. (CDC) 87-8398, 1986
43. Aligne CA, Stoddard JJ. An economic evaluation of the medical effects of parental smoking.
Arch Pediatr Adolesc Med. 1997;151
:648
–653
44. American Cancer Society. Cancer Facts & Figures 2004. Atlanta, GA: American Cancer Society; 2004
45. Centers for Disease Control and Prevention. Nonfatal residential fire-related injuries treated in emergency departments-United States, 2001. MMWR Morb Mortal Wkly Rep. 2003;52 :906 –908[Medline]
46. Farkas AJ, Gilpin EA, White MM, Pierce JP. Association between household and workplace smoking restrictions and adolescent smoking.
JAMA. 2000;284
:717
–722
47. Farkas AJ, Distefan JM, Choi WS, Gilpin EA, Pierce JP. Does parental smoking cessation discourage adolescent smoking? Prev Med. 1999;28 :213 –218[CrossRef][Web of Science][Medline]
48. Lichtensteiger W, Ribary U, Schlumpf M, Odermatt B, Widmer HR. Prenatal adverse effects of nicotine on the developing brain. Prog Brain Res. 1988;73 :137 –157[Web of Science][Medline]
49. Chassin L, Presson C, Rose J, Sherman SJ, Prost J. Parental smoking cessation and adolescent smoking.
J Pediatr Psychol. 2002;27
:485
–496
50. Bricker JB, Leroux BG, Peterson AV Jr, et al. Nine-year prospective relationship between parental smoking cessation and children’s daily smoking. Addiction. 2003;98 :585 –593[CrossRef][Web of Science][Medline]
51. Sargent JD, Dalton M. Does parental disapproval of smoking prevent adolescents from becoming established smokers?
Pediatrics. 2001;108
:1256
–1262
52. Distefan JM, Gilpin EA, Choi WS, Pierce JP. Parental influences predict adolescent smoking in the United States, 1989-1993. J Adolesc Health. 1998;22 :466 –474[CrossRef][Web of Science][Medline]
53. Pleis J, Benson V, Schiller J. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2000. Vital Health Statistics 10 (215). National Center for Health Statistics; 2003:8-9. Available at: www.cdc.gov/nchs/data/series/sr_10/sr10_215.pdf. Accessed January 19, 2005
54. Centers for Disease Control and Prevention. Annual smoking attributable mortality, years of potential life lost and economic costs—United States, 1995-1999.
JAMA. 2002;287
:2355
–2356
55. Adams EK, Melvin C, Merritt R, Worrall B. The costs of environmental tobacco smoke (ETS): an international review. Paper presented at: International Consultation on Environmental Tobacco Smoke (ETS) and Child Health; January 11-14, 1999; Geneva, Switzerland
56. Fiore MC, Bailey WC, Cohen SJ. Treating Tobacco Use and Dependence Rockville, MD: US Department of Health and Human Services, Public Health Service; 2000
57. Parrott S, Godfrey C, Raw M, West R, McNeill A. Guidance for commissioners on the cost effectiveness of smoking cessation interventions. Health Educational Authority. Thorax. 1998;53(suppl 5 pt 2) :S1 –S38
58. Parrott S, Godfrey C. The cost-effectiveness of smoking cessation programs. J Clin Psychiatry Monogr. 2003;18 :50 –57
59. Coffield AB, Maciosek MV, McGinnis JM, et al. Priorities among recommended clinical preventive services. Am J Prev Med. 2001;21 :1 –9[Web of Science][Medline]
60. Hollis JF, Lichtenstein E, Vogt TM, Stevens VJ, Biglan A. Nurse-assisted counseling for smokers in primary care.
Ann Intern Med. 1993;118
:521
–525
61. Hollis JF, Bills R, Whitlock E, Stevens VJ, Mullooly J, Lichtenstein E. Implementing tobacco interventions in the real world of managed care. Tob Control. 2000;9(suppl 1) :I18 –I24
62. Zhu SH, Stretch V, Balabanis M, Rosbrook B, Sadler G, Pierce JP. Telephone counseling for smoking cessation: effects of single-session and multiple-session interventions. J Consult Clin Psychol. 1996;64 :202 –211[CrossRef][Web of Science][Medline]
63. Ossip-Klein DJ, McIntosh S. Quitlines in North America: evidence base and applications. Am J Med Sci. 2003;326 :201 –205[CrossRef][Web of Science][Medline]
64. Zhu SH, Anderson CM, Tedeschi GJ, et al. Evidence of real-world effectiveness of a telephone quitline for smokers.
N Engl J Med. 2002;347
:1087
–1093
65. Lichtenstein E, Glasgow RE, Lando HA, Ossip-Klein DJ, Boles SM. Telephone counseling for smoking cessation: rationales and meta-analytic review of evidence.
Health Educ Res. 1996;11
:243
–257
66. Winickoff JP, Hillis VJ, Palfrey JS, Perrin JM, Rigotti NA. Intervention for parental smokers in an outpatient pediatric clinic using counseling and nicotine replacement.
Pediatrics. 2003;112
:1127
–1133
67. Burton SL, Gitchell JG, Shiffman S. Use of FDA-approved pharmacologic treatments for tobacco dependence—United States, 1984-1998. MMWR Morb Mortal Wkly Rep. 2000;49(29) :665 –668
68. Shiffman S, Dresler CM, Rohay JM. Successful treatment with a nicotine lozenge of smokers with prior failure in pharmacological therapy [published correction appears in Addiction. 2004;99:273]. Addiction. 2004;99 :83 –92[CrossRef][Web of Science][Medline]
69. Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: toward an integrative model of change. J Consult Clin Psychol. 1983;51 :390 –395[CrossRef][Web of Science][Medline]
70. Rowland D, Lyons B, Salganicoff A, Long P. A profile of the uninsured in America. Health Aff (Millwood). 1994;13 :283 –287
71. Winickoff JP, Hillis VJ, Palfrey JS, Perrin JM, Rigotti NA. A smoking cessation intervention for parents of children who are hospitalized for respiratory illness: the stop tobacco outreach program.
Pediatrics. 2003;111
:140
–145
72. Newacheck PW, Stoddard JJ, Hughes DC, Pearl M. Health insurance and access to primary care for children.
N Engl J Med. 1998;338
:513
–519
73. American Academy of Pediatrics, Committee on Environmental Health. Environmental tobacco smoke: a hazard to children.
Pediatrics. 1997;99
:639
–642
74. American Academy of Pediatrics, Committee on Substance Abuse. Tobacco’s toll: implications for the pediatrician.
Pediatrics. 2001;107
:794
–798
75. American Academy of Family Physicians. Tobacco use, prevention and cessation. Available at: www.aafp.org/x7112.xml. Accessed February 12, 2004
76. American Academy of Pediatrics, Committee on Environmental Health. Environmental tobacco smoke and smoking cessation. In: Etzal R, ed. Pediatric Environmental Health. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003:147-163
77. Mullen PD, Quinn VP, Ershoff DH. Maintenance of nonsmoking postpartum by women who stopped smoking during pregnancy.
Am J Public Health. 1990;80
:992
–994
78. Dolan-Mullen P, Ramirez G, Groff JY. A meta-analysis of randomized trials of prenatal smoking cessation interventions. Am J Obstet Gynecol. 1994;171 :1328 –1334[Web of Science][Medline]
79. Windsor RA, Boyd NR, Orleans CT. A meta-evaluation of smoking cessation intervention research among pregnant women: improving the science and art.
Health Educ Res. 1998;13
:419
–438
80. Colman GJ, Joyce T. Trends in smoking before, during, and after pregnancy in ten states. Am J Prev Med. 2003;24 :29 –35[CrossRef][Web of Science][Medline]
81. Severson HH, Andrews JA, Lichtenstein E, Wall M, Akers L. Reducing maternal smoking and relapse: long-term evaluation of a pediatric intervention. Prev Med. 1997;26 :120 –130[CrossRef][Web of Science][Medline]
82. Secker-Walker RH, Solomon LJ, Flynn BS, Skelly JM, Mead PB. Smoking relapse prevention during pregnancy. A trial of coordinated advice from physicians and individual counseling. Am J Prev Med. 1998;15 :25 –31[CrossRef][Web of Science][Medline]
83. Secker-Walker RH, Solomon LJ, Flynn BS, et al. Smoking relapse prevention counseling during prenatal and early postnatal care [published correction appears in Am J Prev Med. 1996;12:71-72]. Am J Prev Med. 1995;11 :86 –93[Web of Science][Medline]
84. Mullen PD, Richardson MA, Quinn VP, Ershoff DH. Postpartum return to smoking: who is at risk and when. Am J Health Promot. 1997;11 :323 –330[Web of Science][Medline]
85. Cluss PA, Moss D. Parent attitudes about pediatricians addressing parental smoking. Ambul Pediatr. 2002;2 :485 –488[CrossRef][Web of Science][Medline]
86. Zapka JG, Fletcher K, Pbert L, Druker SK, Ockene JK, Chen L. The perceptions and practices of pediatricians: tobacco intervention. Pediatrics. 1999;103(5) . Available at: www.pediatrics.org/cgi/content/full/103/5/e65
87. Zapka JG, Pbert L, Stoddard AM, Ockene JK, Goins KV, Bonollo D. Smoking cessation counseling with pregnant and postpartum women: a survey of community health center providers.
Am J Public Health. 2000;90
:78
–84
88. Perez-Stable EJ, Juarez-Reyes M, Kaplan CP, Fuentes-Afflick E, Gildengorin V, Millstein SG. Counseling smoking parents of young children: comparison of pediatricians and family physicians.
Arch Pediatr Adolesc Med. 2001;155
:25
–31
89. Oncken CA, Pbert L, Ockene JK, Zapka J, Stoddard A. Nicotine replacement prescription practices of obstetric and pediatric clinicians. Obstet Gynecol. 2000;96 :261 –265[CrossRef][Web of Science][Medline]
90. Frankowski BL, Weaver SO, Secker-Walker RH. Advising parents to stop smoking: pediatricians’ and parents’ attitudes.
Pediatrics. 1993;91
:296
–300
91. Groner J, Ahijevych K, Grossman L, Rich L. Smoking behaviors of women whose children attend an urban pediatric primary care clinic. Women Health. 1998;28 :19 –32[CrossRef][Web of Science][Medline]
92. Klein JD, Portilla M, Goldstein A, Leininger L. Training pediatric residents to prevent tobacco use.
Pediatrics. 1995;96
:326
–330
93. Frankowski BL, Secker-Walker RH. Advising parents to stop smoking. Opportunities and barriers in pediatric practice.
Am J Dis Child. 1989;143
:1091
–1094
94. US Department of Health and Human Services. News release: HHS announces national smoking cessation quitline network. Available at: www.hhs.gov/news/press/2004pres/20040203.html. Accessed February 12, 2004
95. Tanski SE, Klein JD, Winickoff JP, Auinger P, Weitzman M. Tobacco counseling at well-child and tobacco-influenced illness visits: opportunities for improvement. Pediatrics. 2003;111(2) . Available at: www.pediatrics.org/cgi/content/full/111/2/e162
96. Winickoff JP, McMillen RC, Carroll BC, et al. Addressing parental smoking in pediatrics and family practice: a national survey of parents.
Pediatrics. 2003;112
:1146
–1151
97. Winickoff JP, Tanski SE, McMillen RC, Klein JD, Weitzman M. Child health care clinicians’ use of medications to help parents quit smoking: a national parent survey. Pediatrics. 2005 in press
98. Lewis CE. Disease prevention and health promotion practices of primary care physicians in the United States. Am J Prev Med. 1988;4(4 suppl) :9 –16
99. Wall MA, Severson HH, Andrews JA, Lichtenstein E, Zoref L. Pediatric office-based smoking intervention: impact on maternal smoking and relapse.
Pediatrics. 1995;96
:622
–628
100. Groner JA, Ahijevych K, Grossman LK, Rich LN. The impact of a brief intervention on maternal smoking behavior.
Pediatrics. 2000;105
:267
–271
101. Greenberg RA, Strecher VJ, Bauman KE, et al. Evaluation of a home-based intervention program to reduce infant passive smoking and lower respiratory illness. J Behav Med. 1994;17 :273 –290[CrossRef][Web of Science][Medline]
102. Chilmonczyk BA, Palomaki GE, Knight GJ, Williams J, Haddow JE. An unsuccessful cotinine-assisted intervention strategy to reduce environmental tobacco smoke exposure during infancy.
Am J Dis Child. 1992;146
:357
–360
103. Woodward A, Owen N, Grgurinovich N, Griffith F, Linke H. Trial of an intervention to reduce passive smoking in infancy. Pediatr Pulmonol. 1987;3 :173 –178[Web of Science][Medline]
104. Hovell MF, Meltzer SB, Zakarian JM, et al. Reduction of environmental tobacco smoke exposure among asthmatic children: a controlled trial.
Chest. 1994;106
:440
–446
105. Wahlgren DR, Hovell MF, Meltzer SB, Hofstetter CR, Zakarian JM. Reduction of environmental tobacco smoke exposure in asthmatic children. A 2-year follow-up.
Chest. 1997;111
:81
–88
106. McIntosh NA, Clark NM, Howatt WF. Reducing tobacco smoke in the environment of the child with asthma: a cotinine-assisted, minimal-contact intervention. J Asthma. 1994;31 :453 –462[Web of Science][Medline]
107. Irvine L, Crombie IK, Clark RA, et al. Advising parents of asthmatic children on passive smoking: randomised controlled trial.
BMJ. 1999;318
:1456
–1459
108. Hovell MF, Zakarian JM, Matt GE, Hofstetter CR, Bernert JT, Pirkle J. Effect of counselling mothers on their children’s exposure to environmental tobacco smoke: randomised controlled trial.
BMJ. 2000;321
:337
–342
109. Emmons KM, Hammond SK, Fava JL, Velicer WF, Evans JL, Monroe AD. A randomized trial to reduce passive smoke exposure in low-income households with young children.
Pediatrics. 2001;108
:18
–24
110. Eriksen W, Sorum K, Bruusgaard D. Effects of information on smoking behaviour in families with preschool children. Acta Paediatr. 1996;85 :209 –212[Web of Science][Medline]
111. Curry SJ, Ludman EJ, Graham E, Stout J, Grothaus L, Lozano P. Pediatric-based smoking cessation intervention for low-income women: a randomized trial.
Arch Pediatr Adolesc Med. 2003;157
:295
–302
112. Cohn RC, Dodson D, French A, Ervin B, Ciarlariello S, Wilson TN. A pilot smoking cessation program run by pediatric respiratory care practitioners for parents.
Clin Pediatr (Phila). 2000;39
:121
–124
113. Wadland WC, Soffelmayr B, Ives K. Enhancing smoking cessation of low-income smokers in managed care. J Fam Pract. 2001;50 :138 –144[Web of Science][Medline]
114. Bentz CJ, Davis N, Bayley B. The feasibility of paper-based tracking codes and electronic medical record systems to monitor tobacco-use assessment and intervention in an individual practice association (IPA) model health maintenance organization (HMO). Nicotine Tob Res. 2002;4(suppl 1) :S9 –S17
115. Joseph AM, Fu SS. Safety issues in pharmacotherapy for smoking in patients with cardiovascular disease. Prog Cardiovasc Dis. 2003;45 :429 –441[CrossRef][Web of Science][Medline]
116. Kimmel SE, Berlin JA, Miles C, Jaskowiak J, Carson JL, Strom BL. Risk of acute first myocardial infarction and use of nicotine patches in a general population.
J Am Coll Cardiol. 2001;37
:1297
–1302
117. Murray RP, Bailey WC, Daniels K, et al. Safety of nicotine polacrilex gum used by 3,094 participants in the Lung Health Study. Lung Health Study Research Group.
Chest. 1996;109
:438
–445
118. Orleans CT, Resch N, Noll E, et al. Use of transdermal nicotine in a state-level prescription plan for the elderly. A first look at ‘real-world’ patch users.
JAMA. 1994;271
:601
–607
119. Shaw JP, Ferry DG, Pethica D, Brenner D, Tucker IG. Usage patterns of transdermal nicotine when purchased as a non-prescription medicine from pharmacies.
Tob Control. 1998;7
:161
–167
120. Hasford J, Fagerstrom KO, Haustein KO. A naturalistic cohort study on effectiveness, safety and usage pattern of an over-the-counter nicotine patch. Cohort study on smoking cessation. Eur J Clin Pharmacol. 2003;59 :443 –447[CrossRef][Web of Science][Medline]
121. McNeill A, Hendrie A. Regulation of Nicotine Replacement Therapies: An Expert Consensus Copenhagen, Denmark: World Health Organization European Partnership Project, World Health Organization Europe; 2001
122. Centers for Disease Control and Prevention. State Medicaid coverage for tobacco-dependence treatments—United States, 1994-2002. MMWR Morb Mortal Wkly Rep. 2004;53 :54 –57[Medline]
123. Pikering LK, ed. Red Book: 2003 Report of the Committee on Infectious Diseases 26th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003
124. Oncken CA, Kranzler HR. Pharmacotherapies to enhance smoking cessation during pregnancy. Drug Alcohol Rev. 2003;22 :191 –202[CrossRef][Web of Science][Medline]
125. Benowitz NL, Dempsey DA, Goldenberg RL, et al. The use of pharmacotherapies for smoking cessation during pregnancy. Tob Control. 2000;9(suppl 3) :III91 –III94
126. Dempsey DA, Benowitz NL. Risks and benefits of nicotine to aid smoking cessation in pregnancy. Drug Saf. 2001;24 :277 –322[CrossRef][Web of Science][Medline]
127. Biener L, Cullen D, Di ZX, Hammond SK. Household smoking restrictions and adolescents’ exposure to environmental tobacco smoke. Prev Med. 1997;26 :358 –363[CrossRef][Web of Science][Medline]
128. Pizacani BA, Martin DP, Stark MJ, Koepsell TD, Thompson B, Diehr P. Household smoking bans: which households have them and do they work? Prev Med. 2003;36 :99 –107[CrossRef][Web of Science][Medline]
129. Gehrman CA, Hovell MF. Protecting children from environmental tobacco smoke (ETS) exposure: a critical review. Nicotine Tob Res. 2003;5 :289 –301[CrossRef][Web of Science][Medline]
130. Emmons KM, Hammond SK, Abrams DB. Smoking at home: the impact of smoking cessation on nonsmokers’ exposure to environmental tobacco smoke. Health Psychol. 1994;13 :516 –520[CrossRef][Web of Science][Medline]
131. Berman BA, Wong GC, Bastani R, et al. Household smoking behavior and ETS exposure among children with asthma in low-income, minority households. Addict Behav. 2003;28 :111 –128[CrossRef][Web of Science][Medline]
132. Blackburn C, Spencer N, Bonas S, Coe C, Dolan A, Moy R. Effect of strategies to reduce exposure of infants to environmental tobacco smoke in the home: cross sectional survey.
BMJ. 2003;327
:257
133. Proescholdbell RJ, Chassin L, MacKinnon DP. Home smoking restrictions and adolescent smoking. Nicotine Tob Res. 2000;2 :159 –167[Abstract]
134. Wakefield M, Banham D, Martin J, Ruffin R, McCaul K, Badcock N. Restrictions on smoking at home and urinary cotinine levels among children with asthma. Am J Prev Med. 2000;19 :188 –192[CrossRef][Web of Science][Medline]
135. Jackson C, Henriksen L. Do as I say: parent smoking, antismoking socialization, and smoking onset among children. Addict Behav. 1997;22 :107 –114[CrossRef][Web of Science][Medline]
136. Gilpin EA, White MM, Farkas AJ, Pierce JP. Home smoking restrictions: which smokers have them and how they are associated with smoking behavior. Nicotine Tob Res. 1999;1 :153 –162[Abstract]
137. Pizacani BA, Martin DP, Stark MJ, Koepsell TD, Thompson B, Diehr P. A prospective study of household smoking bans and subsequent cessation related behaviour: the role of stage of change.
Tob Control. 2004;13
:23
–28
138. Farkas AJ, Gilpin EA, Distefan JM, Pierce JP. The effects of household and workplace smoking restrictions on quitting behaviours.
Tob Control. 1999;8
:261
–265
139. Taylor DH Jr, Hasselblad V, Henley SJ, Thun MJ, Sloan FA. Benefits of smoking cessation for longevity.
Am J Public Health. 2002;92
:990
–996
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
CiteULike 
Connotea 
Del.icio.us 
Digg 
Facebook 
Reddit 
Technorati 
Twitter What's this?
This article has been cited by other articles:
|
|
 |
|
  Committee on Environmental Health, Committee on Su Tobacco Use: A Pediatric Disease Pediatrics, November 1, 2009; 124(5): 1474 - 1487. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. King, M. Martynenko, M. H. Bergman, Y.-H. Liu, J. P. Winickoff, and M. Weitzman Family Composition and Children's Exposure to Adult Smokers in Their Homes Pediatrics, April 1, 2009; 123(4): e559 - e564. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. P. Winickoff, E. R. Park, B. J. Hipple, A. Berkowitz, C. Vieira, J. Friebely, E. A. Healey, and N. A. Rigotti Clinical Effort Against Secondhand Smoke Exposure: Development of Framework and Intervention Pediatrics, August 1, 2008; 122(2): e363 - e375. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. A. B. Dodge, M. D. Cabana, M. A. O'Riordan, and A. Heneghan What Factors Are Important for Pediatric Residents' Smoking Cessation Counseling of Parents? Clinical Pediatrics, April 1, 2008; 47(3): 237 - 243. [Abstract] [PDF]
|
|
|
|
 |
|
 V. L. Tyc, M. F. Hovell, and J. Winickoff Reducing Secondhand Smoke Exposure Among Children and Adolescents: Emerging Issues for Intervening with Medically At-Risk Youth J. Pediatr. Psychol., March 1, 2008; 33(2): 145 - 155. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. M. Tomashek, C. Qin, J. Hsia, S. Iyasu, W. D. Barfield, and L. M. Flowers Infant Mortality Trends and Differences Between American Indian/Alaska Native Infants and White Infants in the United States, 1989-1991 and 1998-2000 Am J Public Health, December 1, 2006; 96(12): 2222 - 2227. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. V. Prokhorov, J. P. Winickoff, J. S. Ahluwalia, D. Ossip-Klein, S. Tanski, H. A. Lando, E. T. Moolchan, M. Muramoto, J. D. Klein, M. Weitzman, et al. Youth Tobacco Use: A Global Perspective for Child Health Care Clinicians Pediatrics, September 1, 2006; 118(3): e890 - e903. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. P. Winickoff, S. E. Tanski, R. C. McMillen, B. J. Hipple, J. Friebely, and E. A. Healey A National Survey of the Acceptability of Quitlines to Help Parents Quit Smoking Pediatrics, April 1, 2006; 117(4): e695 - e700. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
