TABLE 1

Conceptual Framework for Parental Tobacco Control in Child Health Care Settings

Solberg Processes IMPROVE Model31, 43, 44Wagner Components Chronic Illness Care Model32, 33, 50, 51
Providing guidelinesOrganization of care
    Providing the current PHS guideline that the American Academy of Pediatrics Tobacco Consortium has endorsed3, 21    Making tobacco preventive services a key goal of the organization
    Ensuring that leadership is committed and visibly involved with parental tobacco control
    Suggesting office-specific benchmarks for guideline adherence that the practice can endorse    Encouraging periodic measurement of key intervention components
Clinical information systems
Screening    Implementing a universal screening system (see Solberg screening)
    Screening for parents' smoking status, and for rules prohibiting smoking in the home and car    Delivering proactive care to those who screen positive for tobacco use
    Following individual's and practice's progress over time
Summarizing
    Organizing and updating the information obtained in the screening process so that it is all in one place and easily reviewable by those needing to know the current tobacco-use prevention status of a particular parent
CueingDelivery system design
    Systematically cueing clinic staff and clinicians to address parental tobacco control and how to do it    Ensuring that the composition of the practice team52 can handle the key components of parental tobacco control and that every team member knows his or her responsibilities
Following upDecision Support
    Communicating back to the practices results of preventive services delivered to parents by quitlines, along with the appropriate information and recommendations for follow-up visits with parents    Providing evidence-based support for all aspects of the recommended intervention (see Solberg providing guidelines)
    Establishing a prompting system to increase adherence to those guidelines (see Solberg cueing)53
ResourcesSelf-management support
    Organizing and maintaining parent education materials and enrollment forms needed by both patients and clinic personnel    Offering parental smokers educational resources, skills training, and psychosocial support
Community resources
Counseling
    Assisting parents to make needed changes in their behavior through very brief and focused messaging to parents who smoke
    Specifying messages needed to address teachable moments relevant to the parent-child dyad, such as using child health characteristics, such as ear infections and asthma exacerbations, as part of the longitudinal messaging process    Improving performance of child health care systems by establishing linkages with effective parental tobacco control in the community and at the state level (quitlines)90
Tracking and recall
    Documenting tobacco control services delivery to enable provision of patient centered follow-up counseling at subsequent visits
Patient activation
    Encouraging parents to take greater responsibility for their own smoking behavior particularly in the context of the child's well-being and specific health concerns
  • The Solberg and Wagner models provided a rich framework for our adaptation of current state-of-the-art tobacco control strategies available for adult practices into the pediatric office setting. Personal behavior change theory can be thought of in the context of the counseling process of Solberg's framework and the self-management support component of Wagner's model. These behavior change constructs are derived and often operationalized in terms of conceptual models of the smoking cessation process, including the stages of change model, motivations for smoking cessation, and self-efficacy theory.49, 5458 The 5 As framework in the current PHS guideline, adapted for pediatrics as part of our intervention, also addresses elements of systems, clinician, and personal behavior change.21 The 5 As have been used previously in conjunction with Wagner's model to optimize the care of other chronic conditions.59, 60 IMPROVE indicates Improving Prevention through Organization, Vision, and Empowerment.31