Published online April 3, 2006
PEDIATRICS Vol. 117 No. 4 April 2006, pp. e695-e700 (doi:10.1542/peds.2005-1946)
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A National Survey of the Acceptability of Quitlines to Help Parents Quit Smoking

Jonathan P. Winickoff, MD, MPHa,b, Susanne E. Tanski, MDc, Robert C. McMillen, PhDd, Bethany J. Hipple, MPHa,b, Joan Friebely, EdDa,b and Erica A. Healey, MAa,b

a MGH Center for Child and Adolescent Health Policy, Boston, Massachusetts
b MGH Tobacco Research and Treatment Center, Boston, Massachusetts
c AAP Center for Child Health Research and Strong Children's Research Center, University of Rochester, Rochester, New York
d Social Science Research Center, Mississippi State University, Mississippi


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVE. Provision of telephone smoking cessation counseling can increase the rate of quitting smoking. The US Public Health Service recently helped to establish a free national quitline enrollment service. No previous surveys have assessed the acceptability to parents of enrollment in quitline counseling in the context of their child's health care visits. Therefore, the objective of this study was to assess acceptability to parents of enrollment in quitline counseling and to compare that with the reported rate of actually being enrolled in any smoking cessation counseling outside the office in the context of the child's health care visit.

METHODS. Data were collected by a national random-digit-dial telephone survey of households from September to November 2004. The sample is weighted by race and gender on the basis of the current US Census to be representative of the US population.

RESULTS. Of 3615 eligible respondents contacted, 3011 (83.3%) completed surveys; 958 (31.8%) who completed the survey were parents with children under the age of 18 years. Of these parents, 187 (19.7%) were self-identified smokers. Of the parents who smoked, 113 (64.2%) said that they would accept enrollment in a telephone cessation program if the child's doctor offered it to them. In contrast, of the 122 smoking parents who accompanied their child to the doctor in the past year, only 11 (9%) had any counseling recommended to them, and only 1 (0.8%) was actually enrolled. These results did not vary by parent age, gender, race, or child age.

CONCLUSIONS. When interacting with parents who smoke, child health care providers have low rates of referring and enrolling parents in any services related to smoking. Enrollment in quitlines would be acceptable to the majority of parents in the context of their child's health care visit. Tobacco control efforts in the child health care setting should include implementation of office systems that can facilitate enrollment of parental smokers in telephone quitlines.

Key Words: smoking • tobacco • pediatrics • family practice • parent • smoking cessation • secondhand smoke • environmental tobacco smoke • tobacco control • quitline • telephone counseling

Abbreviations: SCS-TC—Social Climate Survey of Tobacco Control

Current guidelines support the notion that child health care clinicians should address parental tobacco dependence.1–5 Indeed, helping parents to quit smoking is now a recognized priority of child health care clinicians.5 Despite the fact that counseling significantly improves cessation rates, extended parental tobacco control counseling remains elusive for child health care clinicians because of the time constraints of a typical visit.6 However, most parents believe that it is the responsibility of the pediatrician to counsel them on matters that affect their child's health and that more counseling regarding smoking cessation is appropriate.7–9

Although child health care clinicians generally do not have time to provide more than brief counseling, they might have time to enroll parents into counseling that is available outside the office. Evidence-based telephone counseling is currently available in all 50 states.10

Quitlines are effective at helping adults quit smoking.11–13 The feasibility of linking parents to a state quitline from the pediatric office has been demonstrated.14 No previous surveys have assessed the acceptability to parents of enrollment in quitline counseling in the context of their child's health care visits.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Respondents
The Social Climate Survey of Tobacco Control (SCS-TC) was administered to a representative sample of US adults in July to September of 2004. Households were selected using random-digit-dialing procedures. Once a household was reached, the adult to be interviewed was selected through the interviewer's asking to speak with the person in the household who was 18 years of age or older and would have the next birthday. The sample was weighted by race and gender within each census region, on the basis of the most current US Census estimates. The Institutional Review Board at Mississippi State University reviewed and approved this project on June 30, 2003. Informed consent was obtained orally as part of the introduction to the telephone interview by trained interviewers.

SCS-TC
The SCS-TC is an annual cross-sectional survey that was designed to operationalize the concept of social climate on tobacco into a comprehensive set of quantifiable social and environmental indicators across the social institutions that characterize society: (1) family and friendship groups; (2) education; (3) workplace; (4) government and political order; (5) health and medical care; (6) recreation, leisure, and sports; and (7) mass culture and communication. Survey items were developed and selected on the basis of an extensive review of extant tobacco control surveys and then reviewed by a panel of tobacco control researchers.

Measures
Two questions from the Behavior Risk Factor Surveillance System and the National Health Interview Survey were used to assess the current smoking status of respondents. Respondents were asked, "Have you smoked at least 100 cigarettes in your entire life?" Respondents who reported that they had then were asked, "Do you now smoke cigarettes every day, some days, or not at all?" Respondents who reported that they now smoke every day or some days were categorized as current smokers. Four questions were asked to all parents who had accompanied their child to a pediatrician or family practitioner in the past year. Parents were asked which of the following things this physician had done in the past 12 months: (1) asked whether anyone in the house smokes, (2) asked whether smoking is allowed in the house, (3) asked whether smoking is allowed in the family vehicle, and (4) discussed the dangers of secondhand smoke. Parents who smoked were also asked which of the following things this physician had done in the past 12 months: (1) discussed the increased risk that children of smokers will become smokers; (2) advised you to quit smoking; (3) recommended medication to help you stop smoking; (4) actually prescribed medication to help you stop smoking (parents were further queried about whether they filled the prescription); (5) referred you for any additional services related to your smoking such as a quitline, local program, or web site; and (6) actually enrolled you in any of these services. An additional question for smoking parents was, "Would you accept enrollment in a telephone quit smoking program (a quitline) if your child's doctor offered it?"

Analysis
In exploratory analyses, we used {chi}2 procedures to compare differences between region, gender, race (white versus nonwhite), age, education, residence (rural versus urban), and physician type (pediatrician versus family practitioner) for the following outcome variables: (1) parent attitudes about enrollment in telephone counseling and (2) rates of referring and enrolling parents in smoking cessation programs. Associations were considered significant at the P < .05 level. In our analyses, we treated "don't know" and "refused to answer the question" as missing data. The percentage of questions that were answered in each question set is reported in the footnotes of each data table.

We also explored the same control variables with tobacco control services reported by parental smokers who accompanied their child to the health care setting. Associations were considered significant at the P < .05 level. Multivariate logistic regression models that controlled for gender, race, age, and education were specified to examine regional and rural versus urban differences in parent attitudes and delivery of services.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Of the 3615 eligible respondents who were contacted, 3011 (83%) completed surveys. The study sample included 958 parents, 688 (72%) of which had accompanied a child to the child health care clinician in the past year. Table 1 gives the demographic characteristics of the survey sample. Of all 958 parents, 187 (20%) smoked, and 122 (65%) of those saw a child health care clinician in the past year.


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  		TABLE 1 Demographic Characteristics of Survey Sample

 
Table 2 shows tobacco control service delivery among all 688 parents (smokers and nonsmokers) who accompanied the child to the health care setting in the past year. Consistent with our previous work, we found low rates of screening for tobacco use (48%) and for the presence of rules that prohibit smoking in the home (34%) and car (27%), respectively.15,16 Among the 122 smokers who accompanied the child to the health care setting in the past year, we found similarly low rates of screening and found that only 39% were advised to quit, whereas 12% had a medication recommended to help them quit (Table 3). Of the 122 smokers, 7% were actually prescribed a medication by their child's clinician to help them quit.


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  		TABLE 2 Tobacco Control Service Delivery to All Parents Who Accompanied Child to Health Care Setting

 

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  		TABLE 3 Tobacco Control Service Delivery to Parents Who Smoke

 
Of 187 parental smokers, the majority (n = 113) would accept enrollment in a telephone cessation program if the child's doctor offered it to them. In contrast, of the 122 smoking parents who accompanied their child to the doctor, only 11 (9%) had any counseling services recommended to them and only 1 (0.8%) was actually enrolled.

In bivariate analysis, no statistically significant difference in parental smoker attitudes about quitline enrollment was found by region, rural versus urban, race, gender, age, or education. Low rates of actual enrollment in counseling programs prevented meaningful bivariate analysis by specialty or other variables.

Among smokers who accompanied a child to the child health care setting in the past year, more nonwhite than white parents were screened for tobacco use (53.2% vs 45.9%; P = .097), asked whether smoking was allowed in the house (42.9% vs 30.3%; P = .003), asked whether smoking was allowed in the family vehicle (36.3% vs 23.7%; P < .001), and informed about the dangers of secondhand smoke (42.9% vs 24.9%; P < .001). Low cell size did not permit detailed comparison of racial categories. In multivariate logistic regression models that controlled for gender, race, age, and education, no regional or rural versus urban differences in parent attitudes and delivery of services to smokers were found.


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
This survey of a national sample of US adults found low rates of referring and enrolling parents in any services related to smoking. However, the majority of parents said that enrollment in quitlines would be acceptable in the context of their child's health care visit. This national study is the first to measure parental acceptability of enrollment in quitlines and compare that with reported rates of enrollment in any tobacco-related services during the child's health care visit.

In previous national surveys, we have found low rates of screening, counseling, and medication prescription for parental smoking.15,16 Previous statewide surveys also have demonstrated that child health care clinicians have particularly low rates of implementing effective interventions with parents who smoke.17,18 In a population-based survey of pediatricians who were practicing in urban areas in California, pediatricians reported low rates of the strategies that have been shown to be most successful, such as setting a quit date (18%), prescribing nicotine replacement therapy (13%), providing nurse-mediated counseling (10%), and scheduling a follow-up visit or telephone call (5%).19

Many parents do not have any other access to a primary care provider or services that could help them try to quit smoking.14,20,21 In 1 recent Massachusetts study, <1 in 5 parents had ever had any exposure to smoking cessation programs or telephone counseling.14 The schedule of primary care visits puts the child health care clinician in a position to intervene with parental smokers in a repeated and consistent manner over the course of many years.22

Despite clear recommendations from the American Academy of Pediatrics and the American Academy of Family Physicians highlighting the importance of tobacco screening and counseling activities at every well-child visit,3,4 child health care clinicians cite numerous barriers, including lack of time, lack of confidence in their smoking cessation counseling skills, and concern about negative reactions from parents.7,17–19 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% believed that parents would ignore their advice.19 Another study found that 69% of pediatricians surveyed believed that prescribing or recommending medical treatment for parents was the responsibility of another clinician.23 However, a large majority of smokers tend to give higher satisfaction ratings to pediatric clinicians who address their smoking and offer help.7,9,24,25 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 should do more counseling regarding smoking cessation.7–9 A recent cross-specialty resolution states that the American Medical Association supports efforts by any physician to identify and treat tobacco dependence in any individual, in the various clinical contexts in which they are encountered.26

Referral and enrollment in quitlines may provide a logical, practical solution to this problem of mismatched parent expectations and clinician expertise. Although individual child health care clinicians may not be able to provide extended counseling in the office setting, they might encourage office systems that will serve a linking role to connect parents to the best available counseling support through the state or national quitline. 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.6,27 Quitlines have proved effective in numerous contexts,6,11,12,28–34 and telephone counseling has been used as an effective adjunct to programs that are based in the pediatric outpatient setting.35 Proactive telephone quitlines establish contact with a larger percentage of smokers who are initially referred compared with reactive quitlines.11,14 To enhance this proactive approach, several state quitlines offer the ability to enroll a smoker by fax from the physician's office directly to the quitline. At least 1 demonstration program, known as the Clinical Effort Against Secondhand Smoke Exposure, shows how to accomplish the linkage to quitlines in the context of the child health care setting.36

Advocating for smoke-free homes and cars, although beneficial, cannot fully protect children from the harmful effects of secondhand smoke.37,38 Even if all parents complied, which is unlikely, smoke-free homes and cars will not prevent the harms from a child's prenatal exposure to maternal cigarette smoking or prevent expenditure of family resources on cigarettes instead of other essential child needs.1 By getting a parent to quit smoking, the physician will add an average of 7 years to the parent's life,39 improve the health of the spouse, eliminate the majority of secondhand smoke exposure of the children, reduce tobacco-related poor pregnancy outcomes, eliminate the greatest cause of house fire mortality, and improve the financial resources of the family.1 In addition, parental smoking cessation, in combination with smoke-free homes and cars, has the best potential to reduce adolescent smoking rates.40–43

This study had 2 primary limitations. First, parents' reported willingness to be referred to telephone quitlines is not likely to be the same as parents' actual enrollment in quitline services if such were offered to them. It is unlikely that 64.2% of the smoking parents surveyed are ready to quit. Nonetheless, that so many stated at a point in time that they would accept such an offer indicates that child health care providers are missing an important opportunity to provide assistance at far greater rates than we report here. Second, this survey relied on parental report of what occurred in the primary care office up to 1 year ago. This report may not be an accurate assessment of what actually took place, because parents may forget or remember inaccurately the details of their encounter with their child's physician over time. Although short-term recall may be accurate,44 several studies that have examining adults' recall of counseling services, including smoking services, found systematic bias toward overreporting,45–48 whereas 1 study found systematic underreporting of services.49 However, patient surveys remain an important way to obtain information on service delivery because physicians themselves tend to overestimate the rate at which they perform preventive counseling.50 In addition, because an average of 4 visits to the child health care provider occur each year,22 we cannot estimate what occurred at any 1 particular visit with regard to tobacco control. The average time delay between visit and survey was not ascertained.

The extremely low levels of quitline enrollment in child health care practice contradicts the expressed wishes of the majority of parents. The child health care clinician has a responsibility to protect and improve child health, which includes reducing child exposure to secondhand smoke and the likelihood of child smoking initiation. Linking parental smokers to telephone cessation support through the child health care setting might benefit the parent, the spouse, and all children in the family. Efforts should focus on determining how the child health care system can facilitate the delivery of effective treatments to parents who smoke, including the medications and telephone counseling that have been proved to increase the chances of successful quitting.1,16


   ACKNOWLEDGMENTS
 
Dr Winickoff was supported by a grant from the Flight Attendant Medical Research Institute (024032) and the National Cancer Institute (K07 CA100213 A 01). This publication was also made possible by grant 4 D1A RH 00005-01-01 from the Office of Rural Health Policy of the Department of Health and Human Services through the Rural Health Safety and Security Institute, Social Science Research Center, Mississippi State University; and the Center for Child Health Research affiliated with the American Academy of Pediatrics.


   FOOTNOTES
 
Accepted Sep 26, 2004.

Address correspondence to Jonathan P. Winickoff, MD, MPH, MGH Center for Child and Adolescent Health Policy, 50 Staniford St, Suite #901, Boston, MA 02114. E-mail: jwinickoff{at}partners.org

This work was presented, in part, at the Annual Meeting of the Pediatric Academic Societies; May 14–17, 2005; Washington, DC.

The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the Office of Rural Health Policy or the Center for Child Health Research.

The authors have indicated they have no financial relationships relevant to this article to disclose.


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 RESULTS
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