Accepted Manuscript Title: Parental receptivity to child biomarker testing for tobacco smoke exposure: A qualitative study Author: Laura J. Rosen Efrat Tillinger Nurit Guttman Shira Rosenblat David M. Zucker Frances Stillman Vicki Myers PII: DOI: Reference:
S0738-3991(15)00267-0 http://dx.doi.org/doi:10.1016/j.pec.2015.05.023 PEC 5065
To appear in:
Patient Education and Counseling
Received date: Revised date: Accepted date:
2-10-2014 20-2-2015 30-5-2015
Please cite this article as: Rosen LJ, Tillinger E, Guttman N, Rosenblat S, Zucker DM, Stillman F, Myers V, Parental receptivity to child biomarker testing for tobacco smoke exposure: A qualitative study, Patient Education and Counseling (2015), http://dx.doi.org/10.1016/j.pec.2015.05.023 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Highlights
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Most parents are willing to have their children tested for TSE using biomarkers
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Parents who favor testing desire information for reassurance or motivation
Most parents believe testing would motivate behavior change to protect the child
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Concerns include child's discomfort, mistrust of tests and powerlessness to change
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TSE biomarker testing is a promising tool for counseling interventions
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Parental receptivity to child biomarker testing for tobacco smoke exposure: A qualitative study
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Laura J. Rosen, PhDa, Efrat Tillinger, PhD a,b, Nurit Guttman, PhDc, Shira Rosenblat, MAa,c, David M. Zucker, PhDd, Frances Stillmane, and Vicki Myers, MSca
Dept. of Health Promotion, School of Public Health, Sackler Faculty of Medicine, Tel Aviv
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University, Tel Aviv, Israel; b Dept. of Sociology, Faculty of Social Sciences, Bar Ilan
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University, Ramat Gan, Israel; cDept. of Communications, Faculty of Social Sciences, Tel Aviv University, Tel Aviv, Israel; dDept. of Statistics, Hebrew University, Jerusalem, Israel; e Dept. of
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Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore,
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Maryland 21205, USA
Corresponding author: Dr L J Rosen, Department of Health Promotion, School of Public
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Health, Sackler Faculty of Medicine, Tel Aviv University, POBox 39040, Ramat Aviv, Israel
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69978, [email protected], +972-50-875-1502
Short title: Child biomarker testing for tobacco exposure Abbreviations: SHS, secondhand smoke; TSE, tobacco smoke exposure Keywords: tobacco smoke exposure, secondhand smoke, biomarker testing, parental attitudes, qualitative methods, thematic analysis, parental education and counseling Funding source: This work was funded by the Flight Attendants' Medical Research Institute (FAMRI) FAMRI Award # 072086_YCSA. Financial Disclosures: none Conflict of Interest: none
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Abstract Objective: Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their children's exposure. Biomarkers demonstrate exposure and may motivate
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behavior change, but their acceptability is not well understood. Methods: Sixty-five in-depth interviews were conducted with parents of young children, in
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smoking families in central Israel. Data were analyzed using thematic analysis.
Results: Consent to testing was associated with desire for information, for reassurance or to
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motivate change, and with concerns for long-term health, taking responsibility for one's child, and trust in research. Opposition to testing was associated with preference to avoid knowledge,
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reluctance to cause short-term discomfort, perceived powerlessness, and mistrust of research. Most parents expressed willingness to allow measurement by urine (83%), hair (88%), or saliva
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(93%), but not blood samples (43%); and believed that test results could motivate behavior change.
Conclusions: Parents were receptive to non-invasive child biomarker testing. Biomarker
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information could help persuade parents who smoke that their children need protection.
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Practice implications: Biomarker testing of children in smoking families is an acceptable and
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promising tool for education, counseling, and motivation of parents to protect their children from TSE. Additionally, biomarker testing allows objective assessment of population-level child TSE.
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1. INTRODUCTION Reduction of child exposure to tobacco smoke is an important global health challenge [1-4], and
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depends to a large degree on parental beliefs and practices. Worldwide, it is estimated that 40% of children are exposed to tobacco smoke in their homes [5], with most exposure caused by
parental smoking. The high prevalence of exposure, combined with well-documented increased
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health risks [5], leads to a large and entirely preventable population burden. In 2004, 166,000 child deaths and nearly 6 million child lower respiratory infections were attributed to secondhand
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smoke (SHS) [5]. Exposed infants are at increased risk for sudden infant death syndrome, while exposed children have a higher risk of acute respiratory infections, lower levels of childhood
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lung function [1], and increased likelihood of developmental and behavioral problems [6]. Despite the broad consensus about the need to protect children from tobacco smoke (US Surgeon
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General [1], WHO[2], the G8[3], Healthy Israel 2020[4]), questions remain about how to reduce smoking around children, in particular in their home environment. Thus, at the individual level,
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an important challenge is to convey to parents the risk to their children caused by their own or family members' smoking behaviors, and to persuade them to refrain from smoking in places
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where children live, study, and play. Another challenge is to obtain accurate population-level data to assess the magnitude of this problem [7-9]. Monitoring exposure as a means to control
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population-level risk is common to many public health endeavors, and has been used for other contaminants; for example, lead, allergens, pesticides [10], and mercury levels [11]. Biomarkers are measureable biological substances found in the body, which can be used for quantification of environmental exposures [12]. Biomarkers to assess child tobacco smoke exposure have the potential to persuade adults to stop smoking around children, and to measure population-level exposure. They are advantageous over parental reports, which may be compromised by social desirability bias, or parental unawareness of their child’s exposure, as demonstrated by discrepancies between parental reports of exposure [13] and objective markers [14]. Consequently, biomarkers are considered the gold standard for evidence of exposure [1, 15]. Several biomarkers of tobacco smoke exposure (TSE) have been studied. Cotinine, found in urine, blood, hair, saliva, and nails, is most often used, due to its high sensitivity and specificity [16-19]. There are some differences between the different modalities, for example, cotinine in 4
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hair and nails reflects long-term exposure, while cotinine in saliva, serum and urine reflect shortterm exposure [7]. Biomarkers can be used for individual feedback, and may persuade parents to protect their children by showing them in a convincing way that exposure, whether secondhand or thirdhand, is occurring. Research has shown that beliefs about thirdhand smoke are related to
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increased protective behaviors such as enforcing a 'smoke-free home' [20]. Several interventions aimed at reducing TSE of children in the home used feedback of biomarkers with varying
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degrees of success [21-24].
Despite the potential utility of biomarkers for both behavior-change interventions and
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monitoring, the topic of parental receptivity to child biomarker testing to assess TSE has received little attention in the research literature. Just two previous studies were found on this
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topic [25, 26]. One study addressed the willingness of Latino parents to allow hair sampling of their children, and found that over 90% of them were willing to provide child hair samples [25].
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A nationally-representative study conducted in the US [26] found that the majority of both smoking and nonsmoking parents were willing to have their children tested for TSE. However, investigation of parental attitudes.
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these studies addressed only one biomarker, and neither performed an in-depth qualitative
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This study aimed to explore in-depth the beliefs, attitudes, concerns and preferences about child biomarker testing among parents in whose families smoking occurs, as they relate to behavior
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change associated with protecting children from TSE.
2. METHODS
2.1 Sampling and Recruitment
The study was conducted in Israel, where smoking rates during the period 2010-2012 among Israeli adults were 20.6% (Jewish men: 23.7%, Jewish women: 15.9%, Arab men: 43.8%, Arab women: 6.7%) [27]. Though smoking in many indoor public places has been banned in Israel for several decades [28, 29], nearly 70% of Israelis were regularly exposed to tobacco smoke in 2010 [30].
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Recruitment of parents for this study began in the Meuhedet Health Care Services organization, the third largest of the four Israeli health fund organizations, which provide subsidized healthcare as part of the national healthcare system. We used a purposive sampling approach to select clinics in different geographical areas to ensure the recruitment of participants from various
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socio-economic, demographic and religious groups [31].
Potential participants were initially recruited by primary care clinic staff who were familiar with
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members of the community and trusted by them. Posters and flyers advertising for potential
participants were placed in the clinics; the clinic staff recruited members visiting the clinics for
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well-child or other services. In order to enlist a wider group of parents, parents from two Meuhedet well-baby clinics were approached as well, and additional parents were recruited using
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the 'snowball' method. Interested parents were contacted by research assistants who described the study. Inclusion criteria were parents in families in which at least one parent smoked, and with a
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child below the age of 3 years. This was later expanded to children up to age 7 to increase recruitment.
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We received names of 123 individuals who had expressed an interest in the project, of whom 65 (52.8%) were interviewed. The remainder were either unreachable (n=9), unavailable (n=30), did
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not wish to participate (n=10), quit smoking (n=2), did not meet the inclusion criteria (n=1), did not agree to have the interview recorded (n=1), or did not participate for unknown reasons (n=5).
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Signed informed consent was obtained from all participants and a gift certificate worth about $30 was given to compensate them for their time. 2.2 Interviewing process
Interviews were conducted between September 2011 and August 2012, by three interviewers (SR, AB, IR); all were trained by a medical sociologist (ET). Interviews in religious neighborhoods were conducted by same-sex interviewers. The majority of interviews were held in health clinics (70%), some took place in participants' homes or at their workplace. Interviews lasted from 35-131 minutes (mean: 62.9, STD: 18.7) and were audio-recorded and transcribed. Field notes were taken. 2.3 Research tool and Interview Guide
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Aiming for a phenomenological exploration of participants' experiences and the meanings they attributed to them, we used semi-structured interviews with open-ended questions [32]. Interview Guides (for smokers and spouses of smokers, and for secular and religious participants) were developed based on previous work (Personal communication, Elizabeth
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Gonzales, Project KISS 2009; Personal communication, Robyn Keske, 2012, Project: Breathe Free for Kids; Personal communication, Deborah Ritchie, 2012, Project: REFRESH).
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Respondents were asked to describe their daily routine and smoking habits, including previous quit attempts, and to discuss smoking restrictions in their home or car and around their children.
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Respondents were then asked what they knew about secondhand and thirdhand smoke and their risks. Questions regarding current strategies to protect their children followed. The last part of
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the interview focused on respondents’ views about possible interventions, including questions regarding biomarker testing for child exposure, with parents asked which tests would be
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acceptable, and why. The biomarker tests referred to included analysis of children's hair, urine, saliva, blood and fingernails for nicotine/cotinine, and environmental measures for home exposure assessment. Each of these methods was briefly explained. Parental responses regarding
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2.4 Analysis
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opposition to each type.
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which biomarker methods they would find acceptable were categorized according to consent and
2.4.1 Qualitative analysis
Data were transcribed and transcripts were checked for accuracy. Thematic analysis was performed (ET) and then reviewed and refined (VM, NG), with themes derived from the data, according to the process described by Braun and Clarke [33]. Preliminary descriptive codes were given to each segment of text; codes depicting similar topics were then grouped together and classified into relevant themes. It was noted which topics were most often related to either consent or opposition to testing. Once themes had been identified, the analysts went back over the text to find examples of each theme. Transcript extracts were identified to exemplify each theme, and to reflect the experiences of the participants. Further analysis clarified the specific nature of each theme moving from initial descriptive themes to more conceptual/analytical ones. 2.4.2 Quantitative analysis 7
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Demographic data on parental gender, smoking status, age, and number of children were summarized. Percentages of consenting and opposing parents were summarized for each biomarker category.
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2.6 Ethical Approval and Registration Approval for the research was obtained from the Tel Aviv University Ethics Committee and the
3. RESULTS
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3.1 Demographic characteristics of participants
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Laniado Hospital Helsinki Committee (0014-11-LND).
Table 1 presents socio-demographic characteristics of participants, including information on age,
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gender, number of children, smoker status, and heaviness of smoking. 3.2 Quantitative data – acceptability of testing
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Most of the parents interviewed said they would agree to have saliva (54/58, 93%), nail (49/56,
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87.5%) and hair (52/59, 88%) samples taken from their children, and to allow a monitor (51/56, 91%) or wet wipes (45/51, 88%) to check TSE levels in the home. Eighty-three percent (48/58)
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agreed to urine testing. Over half of parents (33/58, 57%) expressed concern about and/or unqualified opposition to drawing blood samples specifically to test exposure. A majority of parents with whom it was discussed (36/42, 86%) thought that receiving biomarker feedback might help persuade them to change their behavior to better protect their children. 3.3 Qualitative Data
Qualitative analysis identified four main themes that influence parental decisions to consent to or oppose different kinds of tests: The desire for information versus preference not to receive information; parental responsibility versus perceived powerlessness; long-term versus short-term child wellbeing; and trust or mistrust of research. These are elaborated on below. 3.3.1 Information-seeking versus "ignorance is bliss"
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Parents expressed two contrasting attitudes when it came to receiving information. Some parents welcomed the tests, hoping the results would provide a sense of relief and reassurance that their children were not exposed. Others valued the opportunity to obtain information provided by testing, expressing their genuine desire to receive an accurate picture of their children's exposure
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in order to correctly assess the risks involved and the effectiveness of the strategies they use to reduce exposure (see Table 2). Some parents took this a step further and said that if the results
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showed their children were at risk, they would make an effort to move their smoking further away from the child. One parent described the potential effects of the test results as a "wake-up
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call".
In contrast to parents who desired information, there were parents who did not want to receive
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information on their children's exposure level. Within this group, two sub-groups were identified. The first were parents who opposed testing and expressed a fear of discovering uncomfortable truths. They preferred to remain uninformed in order to avoid having to deal with feelings of
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guilt due to inadequately protecting their children, thus jeopardizing their positive parental identity. One father expressed this fear in strong terms, likening the stigma of being labeled a
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smoking parent to that of a terrorist. Some parents seemed to consider the biomarker tests as a
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kind of parenting test, which they feared they would fail. The second sub-group consisted of parents who opposed testing because they did not consider their children to be exposed and
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found the tests to be unnecessary or irrelevant. Some of these parents mentioned smoking in the vicinity of their child but did not consider this to be a form of exposure. 3.3.2 Responsibility versus powerlessness The theme of responsibility also differed between parents who supported and those who opposed biomarker testing. Some parents said they wanted to take responsibility for their children's health and discussed ways they might protect their children or reduce exposure (see Table 3). They expressed a sense of self-efficacy: they felt in control and able to act on the information received. Several parents, generally those supportive of testing, expressly mentioned their own role in causing the children to be exposed. Others, often those who opposed testing, talked of exposure in the passive tense or in the third person, distancing themselves from responsibility in the situation. In contrast, those who did not believe biomarker tests would motivate them to change, even if they indicated their child's exposure, expressed a sense of futility or inevitability, and 9
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feeling they could not do anything about the situation. These parents appeared to feel powerless to effect a change in their behavior and therefore saw no benefit in receiving information they could do nothing about.
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3.3.3 Child's wellbeing: Short-term discomfort versus long-term protection One of the most common objections to the biomarker test was parents' concern and reluctance to cause pain or discomfort to their child in the short-term, particularly regarding blood tests (see
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Table 4). Beyond causing physical pain, concerns included causing emotional pain. For example, one mother imagined her child's negative emotional response to being taken for a blood test,
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expressing this in strong terms as a betrayal. Others envisioned having to deal with the child's negative reaction such as crying at the time of the test. Children's autonomy was also mentioned,
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with some parents opposed to overriding their children's wishes. Several parents raised technical or aesthetic objections related to harming the child, particularly regarding nail and hair samples
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(for example, bald spots). The most common opposition was to invasive testing such as blood tests. Overall, many parents felt that a painless test would be acceptable, but that causing pain to their child crossed a boundary. In contrast, some parents prioritized their children’s long-term
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3.3.4 Trust
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better protect their children's health.
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health benefit and supported even testing that might be invasive as a means to enable them to
Trust emerged as an important factor in receptivity to biomarker testing. Some parents expressed a high degree of faith in the tests and regarded them as a professional-scientific tool that would offer them a reliable picture of their children's status (see Table 4). Some even expressed a willingness to contribute to research. In contrast, a sense of mistrust pervaded the discourse of some parents who were concerned that testers might have ulterior motives and that the samples might be used for other purposes. Two parents even mentioned a fear that DNA might be used in order to clone subjects (see Table 5).
3.3.5 Summary of qualitative analysis Overall, the findings indicate that a key belief contributing to parents’ attitudes towards biomarker testing was their belief that their child is or is not exposed. Those who do consider their child at risk of exposure either wish to act upon information provided by testing, or
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alternatively reject the offer of testing, feeling powerless to act upon it. The belief that one’s child is not exposed led to two different pathways: either a desire for confirmation of their belief, or a rejection of testing due to mistrust or disbelief in utility of the information. Table 6 presents
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a summary of the different attitudes to biomarker testing found among interviewees.
4. DISCUSSION & CONCLUSION
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DISCUSSION
Most parents in the study from households in which smoking occurs were willing to allow their
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children to be tested for exposure to tobacco smoke by urine, hair, or saliva. A substantial minority were even willing to allow serum testing solely for the purpose of TSE measurement, though others were strongly opposed. The overwhelming majority believed that feedback on
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objectively-measured exposure levels would persuade them to better protect their children from TSE.
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Among parents who were positively inclined towards testing, a distinction could be made among
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two groups: those who desired information for reassurance of their children's safety, and those who sought it as a motivator to make change. Likewise, among those who opposed testing
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different subgroups emerged: those preferring not to receive information either believed it to be useless in the face of their own powerlessness to effect change; did not want to 'face facts'; believed it to be inaccurate; or were suspicious of its true purpose. Other reasons for opposition to testing concerned physical or emotional effects on children. Short-term concerns of discomfort, contrasted with long-term concerns of children's health. These differences provide a conceptual approach with practical implications to address different types of parental concerns related to biomarker testing (Table 6). 4.1.2 Comparison to previous literature We identified two previous studies that addressed the topic of testing child for TSE. Winickoff et al [26], in a quantitative survey, asked about the acceptability of testing for TSE within the context of routine physician visits, and found that 60% of parents, and 62% of smoking parents, supported testing in that setting. 11
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Regarding the acceptability of a blood test for exposure when blood was already being drawn for other reasons, Winickoff's findings showed that 70.1% of parents, and 73.6% of smoking parents, supported testing [26]. Our findings address blood draw taken specifically for the purpose of TSE measurement and 43% of those with whom it was discussed were willing to
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consent to the procedure. Woodruff [34], in a study of acceptability and validity of using hair samples for TSE measurement in a Latino population, found that 8.5% of parents were unwilling
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to provide hair samples and therefore declined to participate in the study . Their objections included concerns about future thickness of hair growth and religious issues.
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Neither study fully explored attitudes to various types of biomarker testing, nor did they perform explorations of reasons for attitudes which are possible with in-depth qualitative interviews.
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Therefore, this study's findings, which point to both apprehensions about and support for screening healthy children with biomarkers, serve to expand upon previous findings but also add an important additional perspective. Previous studies that examined attitudes to screening healthy
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children for obesity, high cholesterol, or genetic susceptibility, reported mistrust of test results, perceived futility of screening, preference for painless tests and fear of being judged a bad
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parent, as well as the importance of children's autonomy [35-38], themes which also surfaced in
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the current study. Although in this study some of the parents expressed similar negative views, most parents mainly responded positively to the idea of testing and even believed results would
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motivate them to take action to protect their children. 4.1.3 Use of biomarkers for motivating behavior change Scientific measures of biochemical feedback have been used for decades as a means to improve health status. Feedback on cholesterol levels of healthy individuals is used to monitor and control heart health [39] and CO feedback has been used to convince smokers to quit [40], and to validate self-reports of smoking status [41]. Some investigators used biochemical feedback in the context of interventions to help parents reduce exposure to tobacco smoke. Four trials [22, 24, 42, 43] included in a recent meta-analysis [44] assessed the effect of biochemical feedback on exposure levels or protection behaviors. Individually, none of these trials showed a statistically significant effect, while a synthesis of all four trials showed a small advantage in the intervention groups (RR=1.14 [1.03,1.28], p=.02). Another review of five studies that used feedback of biomarkers did not show significant reduction in children’s TSE [45]. 12
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Although most of the parents interviewed in this study believed that biochemical feedback could spur them to change their behaviors, intervention trials reported in the literature found that interventions using biochemical feedback exhibited only a very small benefit [44]. This finding is unsurprising given the notorious gap between intent to change behavior and actual behavior
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change (as assessed by intervention trials) [46, 47]. However, the meta-analyses of intervention trials may underestimate the full benefit of biomarker feedback, particularly because concurrent
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improvements were observed in the control groups, most likely due to trial participation or monitoring effects [44, 48].
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4.1.4 Possible reasons for continued child exposure, and the potential for change through biomarkers
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The answer to the questions why parents continue to expose and allow their children to be exposed to tobacco smoke and what may help them to change is complex. One explanation given
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in the literature for why mothers continue to expose their children to tobacco smoke is that some of them engage in a "resistant dialogue", in which they discount potential effects of smoking on their child's health by blaming health problems on other factors, such as pollution or genetics
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[49]. Another study found that beliefs about third-hand smoke are associated with home smoking
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rules [50]. Parental risk perceptions have been shown to be associated with smoking behavior in homes with children in some studies but not others [51]. Unsurprisingly, heavier smoking is
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known to be associated with higher exposure of children [52]. As suggested by the behavioralecological model [53, 54], societal-level factors, such as smoking bans in public places, are also important, and could influence the adoption of smoking bans in the home [55]. The findings of this study suggest that parents are at least open to the idea of the provision of direct evidence of child exposure. Whether this might help overcome a resistant reaction, or change parental behavior by altering beliefs about the existence of second or third-hand smoke, warrants further study.
4.1.5 Limitations One important limitation is that it is possible that not all parental concerns were elicited. However, since specific issues were repeatedly raised by participants from diverse social backgrounds and since other researchers encountered similar responses regarding other types of biomarker testing, this suggests that important parental responses and concerns that are shared by 13
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parents from various social backgrounds were identified. Cross-cultural research, both qualitative and quantitative, is recommended in order to understand whether these findings are applicable in other cultures where social norms regarding smoking in general, smoking around children, and
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child-raising practices may differ.
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4.2 CONCLUSIONS
This study provides unique insight into parental beliefs, attitudes and barriers regarding child
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biomarker testing for tobacco smoke exposure, and for the use of such biomarkers as a means to create educational and counseling interventions. Findings indicate that several challenges need to be addressed in order to promote biomarker testing among parents who are predisposed to testing
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and those who oppose it. In particular, parental desire to know the actual 'facts' about the exposure of one's child, the issue of trust, low conceptions of self-efficacy to change the
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situation, and concerns regarding the invasiveness of the test emerged as important aspects in parental receptivity to child biomarker testing. Further, parents who were receptive to the test believed its results might help them make a change. Thus, an important challenge in developing
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educational interventions and counseling using biomarkers regarding children's exposure is to
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their homes.
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include tailored information to help motivate parents to better protect their children from TSE in
4.3 PRACTICE IMPLICATIONS
Identifying factors that encourage parental acceptance of biomarker testing may facilitate the development of interventions to reduce children's exposure as well as aid health care systems, researchers, and others, to successfully assess child TSE. Following are specific implications and recommendations regarding the way biomarker tests could be presented to parents and implemented in order to enhance parental consent. 1. Since biomarker data is personal, it is important to build trust, and to explain the ethical commitment of those who conduct the test and convey its results, and to emphasize the strict confidentiality of all research data. 2. An emphasis on the long-term benefits of measurement from the perspective of parents could help quell parental concerns about subjecting their children to short-term discomfort. 14
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3. It is important to explain to parents the benefit of biomarker tests for children's TSE regardless of the results: Specifically, it can reassure parents whose children are found not to be exposed and can help motivate change among parents whose children are found to be exposed.
non-invasive tests should be offered according to their preference.
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4. Given the prevalence of parental concerns regarding the invasiveness of some of the tests,
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5. Since most parents expressed a willingness to have their children undergo non-invasive tests, testing for secondhand smoke exposure could be incorporated into routine measurements at
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regular check-ups, similar to the routine assessment of adults' smoking status, which has already been incorporated into general practice in some countries [56]. Such a large-scale
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assessment of exposure in children could raise awareness and help reduce children's exposure on a population level.
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6. It is recommended to conduct biomarker testing in conjunction with TSE reduction intervention elements that address perceived powerlessness of parents and provide tools for
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behavior change, such as motivational interviewing.
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Table 1: Demographic information on participants Description
Age
33.3 ±4.8yrs , range 24-42 years
Number of children
1.91 (range 1-4)
Mothers vs Fathers
74% vs 26%
Smokers vs Non-smoking partners
83% vs 17%
Heaviness of smoking (interviewee or
Light smoker (0-5 cigarettes/day): N=21
smoking partner)
Moderate smoker (6-10 cigarettes/ day): N=21
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Characteristic
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Heavy smoker (10+ cigarettes/ day): N=22
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Unknown (uses rolling tobacco): N=1
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Table 2: Information as motivator or inhibitor of parental agreement to biomarker testing Sub-theme
Representative Quotes
Information-seeking Reassurance
"[It would help me] be sure I'm not stupid enough to cause them some kind of exposure, that is, to be sure that, say, okay, I'm fine, I haven't gone overboard, I haven't crossed the line, I haven't reached a point where I've actually caused them exposure" [male smoker]
“When I know, I’ll be relieved; I want the test results right away.” [female, 36, non-smoker] Risk assessment: To
"I'm dying to know if, like, what I do is really just deluding myself or
know the facts
if it's really okay, if, like, I smoke, if I make sure I'm a mother who doesn't smoke next to the kid and I just smoke a cigarette next to the 16
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window and I change my clothes afterward, if that's really, truly effective or just bullshit."[female, 30, smoker] "if I see that it harms them, just for example … if I see in it that they
reducing behavior
have a level of toxins I'll take it upon myself to go downstairs in the
change
elevator and smoke downstairs"[female, 33, smoker]
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Motivational for risk
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"It would let me, like, stop smoking near them, definitely ... I'd even go out to the balcony in the cold in a windbreaker"[male, 33,
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smoker] Information rejecting
I: Would you like to know what your children's exposure levels are?
facts and feelings of
R: No.
guilt
I: Why not?
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Fear of facing the
R: The less I know the better.
I: How would knowing affect you?
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R: I'm sure it would make me feel worse.[female, 36, smoker]
"I’m always a little reluctant to do these tests, maybe [it's] the fear of
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facing the truth or what will be done with it " [female, 38, smoker]
“Because I know it's not healthy to smoke around the kids as well, and to know that I'm doing something that's, like, worse?” [female,
32, smoker]
Threat to parental
" If you show it to a parent, what the damage is… You can prove to
identity as protective
the parent how much he's, like, not okay? … It's an attack, it's terror
parents
for the smoking parent…you're making the parent completely look like a terrorist"[male, 32, smoker]
Perceptions of lack
“It’s a waste of time, I don’t smoke at home…the exposure that my
of actual exposure
daughter might have is when we barbeque on the balcony and I’m four meters away so of course you’ll find smoke from the wood for
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the grill, or if we go to some park for a picnic and so yes, I sat with some friend ten meters away and the girls are playing there.” [male
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smoker]
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Table 3: Responsibility vs powerlessness as related to biomarker testing
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Taking responsibility "It’s important to me, the kids’ health is very important to me … I’ll know where I stand and if they also give me methods and teach me or I find some methods on my own so I can reduce
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their exposure to cigarettes " [male, 24, smoker]
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"… It would give me a so-called medical measure of how, how much damage I'm doing to my kids, maybe I'm doing fine with all my actions where I try not to smoke around them, and
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maybe I think I'm fine but in reality I'm really not fine"[female, 38, smoker] " In order to get the most exact information possible about the degree to which my lifestyle
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harms her" [male smoker]
Rejecting responsibility: sense of powerlessness
d
"what do I care what level they're at? Ultimately, understand, I want it [exposure] to be
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as low as possible, but it's impossible to keep them from any exposure at all, … I know it's harmful, I make every effort but some things are out of our hands" [female, 29, smoker].
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"there's nothing I can do with that kind of information …it's just another cause of worry that I can't do anything about"[female non-smoker]
Table 4: Short-term versus long-term concerns as related to consent to testing Future health issues
"… if a person got it at home, listen, your kid is exposed to this or that degree, and it says his chance of getting lung cancer is such and such, it would really, really prevent him…"[male smoker] Immediate concerns
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"I don't want to cause her pain"[female, 29, smoker] "As long as it doesn't hurt, take it." [male, 31, smoker]
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"It's just not pleasant to urinate into something." [female smoker] “It’s just too complicated, in my experience, because it's hard to catch her when she's
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peeing, it's almost impossible” [female smoker]
"Because it's making him suffer for nothing, if you say there are other ways, then why
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blood?"[female, 26, non-smoker]
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"he's also insulted by it, I feel like I'm betraying him"[female smoker]
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"Only if she cooperates…I won’t do anything against her wishes"[female smoker]
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Faith in science/research
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Table 5: Trust and mistrust as associated with consent to testing
"If you say it's lab tests I have no problem with that, if it's all kinds of samplings or all kinds
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of other things then no"[male, 30, smoker]
"If it's important research and I can contribute to it, I'm glad to" [male, 41, smoker] Mistrust of tests or testers
"A saliva test? Look, today there are all these databases on people, and it's not so, no … That's pretty invasive, the question is to which organization it's going, who's using it [female smoker]
"You want their DNA? To clone me or something?"[female smoker] "how can you even know it's cigarette exposure and not bus exposure?"[female, 32, smoker]
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Table 6. Four types of parental approaches to biomarker testing according to willingness to be tested and belief in the harmful exposure of their child
Parent wants to know if results
Parent does not want to know;
show exposure and plans to act
fears threat to parental identity as
upon results, and take
protector, guilt feelings, or feels
responsibility.
powerless; concerned for child's
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Unwilling to test child
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Thinks child is exposed
Willing to test child
short-term discomfort.
Does not believe in the accuracy
and wants reassurance that
and utility of the tests, and does
current practices indeed protect
see exposure as their own
their child.
responsibility. Some distrust
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Parent uses various measures,
testers.
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Thinks child is safe
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Acknowledgements: We are grateful to all of participants of the study, to the staff of Meuhedet for their assistance in recruitment, and to the following individuals: Joseph K. Rosenblum and Shosh Tchernokovski, for their assistance with study design and recruitment; Dvora Aprimov,
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for her assistance in recruitment; Uri Rubinstein, for his assistance in obtaining Helsinki
Committee approval; Idan Rani, for his assistance with conducting and transcribing interviews;
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and Assaf Buch, for conducting interviews.
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Competing Interests: None of the authors have competing interests.
Funding source: This work was funded by the Flight Attendants' Medical Research Institute
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(FAMRI) FAMRI Award # 072086_YCSA.
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DH&H, The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General, http://www.surgeongeneral.gov/library/secondhandsmoke/. 2006. World Health Organization, WHO Framework Convention on Tobacco Control, W.H.O. Publications. 2003. G8, Declaration of the Environment Leaders of the Eight on Children's Environmental Health., G8. 1997: http://www.g8.utoronto.ca/environment/1997miami/children.html. Rosen, L., et al., A framework for developing an evidence-based, comprehensive tobacco control program. Health Res Policy Syst, 2010. 8(17): p. 17-30. Oberg, M., et al., Worldwide burden of disease from exposure to second-hand smoke: a retrospective analysis of data from 192 countries. Lancet, 2011. 377(9760): p. 139-146. World Health Organization, WHO Report on the Global Tobacco Epidemic, 2009: Implementing smoke-free environments http://www.who.int/tobacco/mpower/2009/en/index.html. 2009. Avila-Tang, E., et al., Assessing secondhand smoke using biological markers. Tob Control, 2013. 22(3): p. 164-71. Avila-Tang, E., et al., Assessing secondhand smoke exposure with reported measures. Tob Control, 2013. 22(3): p. 156-63. Apelberg, B.J., et al., Environmental monitoring of secondhand smoke exposure. Tob Control, 2013. 22(3): p. 147-55. Viet, S.M., et al., Lead, allergen, and pesticide levels in licensed child care centers in the United States. J Environ Health, 2013. 76(5): p. 8-14. Tsuchiya, A., et al., Longitudinal mercury monitoring within the Japanese and Korean communities (United States): implications for exposure determination and public health protection. Environ Health Perspect, 2009. 117(11): p. 1760-6. EPA. Defining biomarkers. http://www.epa.gov/pesticides/science/biomarker.html 6th February 2015]. Wong, G., et al., Do children with asthma and their parents agree on household ETS exposure? Implications for asthma management. Pat Educ Couns, 2004. 53: p. 19-25. Borrelli, B., et al., Children with asthma versus healthy children: differences in secondhand smoke exposure and caregiver perceived risk. Nicotine Tob Res, 2014. 16(5): p. 554-61. Kalkbrenner, A.E., et al., Determinants of serum cotinine and hair cotinine as biomarkers of childhood secondhand smoke exposure. J Expo Sci Environ Epidemiol, 2010. 20(7): p. 615-24. Kim, S., et al., Utility and cutoff value of hair nicotine as a biomarker of long-term tobacco smoke exposure, compared to salivary cotinine. Int J Environ Res Public Health, 2014. 11(8): p. 8368-82. da Fonseca, B.M., et al., Determination of biomarkers of tobacco smoke exposure in oral fluid using solid-phase extraction and gas chromatography-tandem mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci, 2012. 889-890: p. 116-22. Yeh, E., G. Levasseur, and M.J. Kaiserman, Evaluation of urinary cotinine immunoassay test strips used to assess smoking status. Nicotine Tob Res, 2011. 13(11): p. 1045-51. Tzatzarakis, M.N., et al., Hair nicotine/cotinine concentrations as a method of monitoring exposure to tobacco smoke among infants and adults. Hum Exp Toxicol, 2012. 31(3): p. 258-65. Drehmer, J.E., et al., Thirdhand smoke beliefs of parents. Pediatrics, 2014. 133(4): p. e850-6. Harutyunyan, A., et al., Reducing Children’s Exposure to Secondhand Smoke at Home: A Randomized Trial. Pediatrics, 2013. 132(6): p. 1071-80.
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Wilson, S.R., et al., A randomized trial of parental behavioral counseling and cotinine feedback for lowering environmental tobacco smoke exposure in children with asthma: results of the LET'S Manage Asthma trial. Chest, 2011. 139(3): p. 581-90. Wilson, S.R., et al., A controlled trial of an environmental tobacco smoke reduction intervention in low-income children with asthma. Chest, 2001. 120(5): p. 1709-22. Rosen, L., et al., Meta-analysis of Parental Protection of Children From Tobacco Smoke Exposure. Pediatrics, 2014. 133(4): p. 698-714. Baxi, R., et al., Family and carer smoking control programmes for reducing children's exposure to environmental tobacco smoke.[Update of Cochrane Database Syst Rev. 2008;(4):CD001746; PMID: 18843622]. Cochrane Database of Systematic Reviews, 2014. 3: p. CD001746. Scholz, U., et al., Beyond behavioural intentions: planning mediates between intentions and physical activity. Br J Health Psychol, 2008. 13(Pt 3): p. 479-94. Rhodes, R.E. and G.J. de Bruijn, What predicts intention-behavior discordance? A review of the action control framework. Exerc Sport Sci Rev, 2013. 41(4): p. 201-7. Hovell, M.F., et al., Counseling to reduce children's secondhand smoke exposure and help parents quit smoking: a controlled trial. Nicotine Tob Res, 2009. 11(12): p. 1383-94. Robinson, J. and A.J. Kirkcaldy, ‘You think that I’m smoking and they’re not’: Why mothers still smoke in the home. Soc Sci Med, 2007. 65: p. 641-652. Winickoff, J.P., et al., Beliefs about the health effects of "thirdhand" smoke and home smoking bans. Pediatrics, 2009. 123(1): p. e74-9. Rosen, L. and I. Kostjukovsky, Parental risk perceptions of child exposure to tobacco smoke. BMC Public Health, 2015. In press. Liao, Y.M., et al., Factors associated with parental smoking in the presence of school-aged children: a cross-sectional study. BMC Public Health, 2013. 13: p. 819. Hovell, M.F., et al., Complete home smoking bans and antitobacco contingencies: a natural experiment. Nicotine Tob Res, 2014. 16(2): p. 186-96. Hovell, M.F. and S.C. Hughes, The behavioral ecology of secondhand smoke exposure: A pathway to complete tobacco control. Nicotine Tob Res, 2009. 11(11): p. 1254-64. Butler, K.M., et al., Smoke-free homes, strength of smoke-free law, and children in the home. Nicotine Tob Res, 2014. 16(4): p. 485-90. The Agency for Health Care Policy and Research Smoking Cessation Clinical Practice Guideline. JAMA, 1996. 275(16): p. 1270-1280.
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S0738-3991(15)00267-0 http://dx.doi.org/doi:10.1016/j.pec.2015.05.023 PEC 5065
To appear in:
Patient Education and Counseling
Received date: Revised date: Accepted date:
2-10-2014 20-2-2015 30-5-2015
Please cite this article as: Rosen LJ, Tillinger E, Guttman N, Rosenblat S, Zucker DM, Stillman F, Myers V, Parental receptivity to child biomarker testing for tobacco smoke exposure: A qualitative study, Patient Education and Counseling (2015), http://dx.doi.org/10.1016/j.pec.2015.05.023 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Highlights
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Most parents are willing to have their children tested for TSE using biomarkers
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Parents who favor testing desire information for reassurance or motivation
Most parents believe testing would motivate behavior change to protect the child
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Concerns include child's discomfort, mistrust of tests and powerlessness to change
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TSE biomarker testing is a promising tool for counseling interventions
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Parental receptivity to child biomarker testing for tobacco smoke exposure: A qualitative study
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Laura J. Rosen, PhDa, Efrat Tillinger, PhD a,b, Nurit Guttman, PhDc, Shira Rosenblat, MAa,c, David M. Zucker, PhDd, Frances Stillmane, and Vicki Myers, MSca
Dept. of Health Promotion, School of Public Health, Sackler Faculty of Medicine, Tel Aviv
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a
University, Tel Aviv, Israel; b Dept. of Sociology, Faculty of Social Sciences, Bar Ilan
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University, Ramat Gan, Israel; cDept. of Communications, Faculty of Social Sciences, Tel Aviv University, Tel Aviv, Israel; dDept. of Statistics, Hebrew University, Jerusalem, Israel; e Dept. of
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Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore,
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Maryland 21205, USA
Corresponding author: Dr L J Rosen, Department of Health Promotion, School of Public
d
Health, Sackler Faculty of Medicine, Tel Aviv University, POBox 39040, Ramat Aviv, Israel
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69978, [email protected], +972-50-875-1502
Short title: Child biomarker testing for tobacco exposure Abbreviations: SHS, secondhand smoke; TSE, tobacco smoke exposure Keywords: tobacco smoke exposure, secondhand smoke, biomarker testing, parental attitudes, qualitative methods, thematic analysis, parental education and counseling Funding source: This work was funded by the Flight Attendants' Medical Research Institute (FAMRI) FAMRI Award # 072086_YCSA. Financial Disclosures: none Conflict of Interest: none
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Abstract Objective: Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their children's exposure. Biomarkers demonstrate exposure and may motivate
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behavior change, but their acceptability is not well understood. Methods: Sixty-five in-depth interviews were conducted with parents of young children, in
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smoking families in central Israel. Data were analyzed using thematic analysis.
Results: Consent to testing was associated with desire for information, for reassurance or to
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motivate change, and with concerns for long-term health, taking responsibility for one's child, and trust in research. Opposition to testing was associated with preference to avoid knowledge,
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reluctance to cause short-term discomfort, perceived powerlessness, and mistrust of research. Most parents expressed willingness to allow measurement by urine (83%), hair (88%), or saliva
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(93%), but not blood samples (43%); and believed that test results could motivate behavior change.
Conclusions: Parents were receptive to non-invasive child biomarker testing. Biomarker
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information could help persuade parents who smoke that their children need protection.
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Practice implications: Biomarker testing of children in smoking families is an acceptable and
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promising tool for education, counseling, and motivation of parents to protect their children from TSE. Additionally, biomarker testing allows objective assessment of population-level child TSE.
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1. INTRODUCTION Reduction of child exposure to tobacco smoke is an important global health challenge [1-4], and
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depends to a large degree on parental beliefs and practices. Worldwide, it is estimated that 40% of children are exposed to tobacco smoke in their homes [5], with most exposure caused by
parental smoking. The high prevalence of exposure, combined with well-documented increased
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health risks [5], leads to a large and entirely preventable population burden. In 2004, 166,000 child deaths and nearly 6 million child lower respiratory infections were attributed to secondhand
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smoke (SHS) [5]. Exposed infants are at increased risk for sudden infant death syndrome, while exposed children have a higher risk of acute respiratory infections, lower levels of childhood
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lung function [1], and increased likelihood of developmental and behavioral problems [6]. Despite the broad consensus about the need to protect children from tobacco smoke (US Surgeon
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General [1], WHO[2], the G8[3], Healthy Israel 2020[4]), questions remain about how to reduce smoking around children, in particular in their home environment. Thus, at the individual level,
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an important challenge is to convey to parents the risk to their children caused by their own or family members' smoking behaviors, and to persuade them to refrain from smoking in places
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where children live, study, and play. Another challenge is to obtain accurate population-level data to assess the magnitude of this problem [7-9]. Monitoring exposure as a means to control
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population-level risk is common to many public health endeavors, and has been used for other contaminants; for example, lead, allergens, pesticides [10], and mercury levels [11]. Biomarkers are measureable biological substances found in the body, which can be used for quantification of environmental exposures [12]. Biomarkers to assess child tobacco smoke exposure have the potential to persuade adults to stop smoking around children, and to measure population-level exposure. They are advantageous over parental reports, which may be compromised by social desirability bias, or parental unawareness of their child’s exposure, as demonstrated by discrepancies between parental reports of exposure [13] and objective markers [14]. Consequently, biomarkers are considered the gold standard for evidence of exposure [1, 15]. Several biomarkers of tobacco smoke exposure (TSE) have been studied. Cotinine, found in urine, blood, hair, saliva, and nails, is most often used, due to its high sensitivity and specificity [16-19]. There are some differences between the different modalities, for example, cotinine in 4
Page 4 of 25
hair and nails reflects long-term exposure, while cotinine in saliva, serum and urine reflect shortterm exposure [7]. Biomarkers can be used for individual feedback, and may persuade parents to protect their children by showing them in a convincing way that exposure, whether secondhand or thirdhand, is occurring. Research has shown that beliefs about thirdhand smoke are related to
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increased protective behaviors such as enforcing a 'smoke-free home' [20]. Several interventions aimed at reducing TSE of children in the home used feedback of biomarkers with varying
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degrees of success [21-24].
Despite the potential utility of biomarkers for both behavior-change interventions and
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monitoring, the topic of parental receptivity to child biomarker testing to assess TSE has received little attention in the research literature. Just two previous studies were found on this
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topic [25, 26]. One study addressed the willingness of Latino parents to allow hair sampling of their children, and found that over 90% of them were willing to provide child hair samples [25].
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A nationally-representative study conducted in the US [26] found that the majority of both smoking and nonsmoking parents were willing to have their children tested for TSE. However, investigation of parental attitudes.
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these studies addressed only one biomarker, and neither performed an in-depth qualitative
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This study aimed to explore in-depth the beliefs, attitudes, concerns and preferences about child biomarker testing among parents in whose families smoking occurs, as they relate to behavior
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change associated with protecting children from TSE.
2. METHODS
2.1 Sampling and Recruitment
The study was conducted in Israel, where smoking rates during the period 2010-2012 among Israeli adults were 20.6% (Jewish men: 23.7%, Jewish women: 15.9%, Arab men: 43.8%, Arab women: 6.7%) [27]. Though smoking in many indoor public places has been banned in Israel for several decades [28, 29], nearly 70% of Israelis were regularly exposed to tobacco smoke in 2010 [30].
5
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Recruitment of parents for this study began in the Meuhedet Health Care Services organization, the third largest of the four Israeli health fund organizations, which provide subsidized healthcare as part of the national healthcare system. We used a purposive sampling approach to select clinics in different geographical areas to ensure the recruitment of participants from various
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socio-economic, demographic and religious groups [31].
Potential participants were initially recruited by primary care clinic staff who were familiar with
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members of the community and trusted by them. Posters and flyers advertising for potential
participants were placed in the clinics; the clinic staff recruited members visiting the clinics for
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well-child or other services. In order to enlist a wider group of parents, parents from two Meuhedet well-baby clinics were approached as well, and additional parents were recruited using
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the 'snowball' method. Interested parents were contacted by research assistants who described the study. Inclusion criteria were parents in families in which at least one parent smoked, and with a
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child below the age of 3 years. This was later expanded to children up to age 7 to increase recruitment.
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We received names of 123 individuals who had expressed an interest in the project, of whom 65 (52.8%) were interviewed. The remainder were either unreachable (n=9), unavailable (n=30), did
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not wish to participate (n=10), quit smoking (n=2), did not meet the inclusion criteria (n=1), did not agree to have the interview recorded (n=1), or did not participate for unknown reasons (n=5).
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Signed informed consent was obtained from all participants and a gift certificate worth about $30 was given to compensate them for their time. 2.2 Interviewing process
Interviews were conducted between September 2011 and August 2012, by three interviewers (SR, AB, IR); all were trained by a medical sociologist (ET). Interviews in religious neighborhoods were conducted by same-sex interviewers. The majority of interviews were held in health clinics (70%), some took place in participants' homes or at their workplace. Interviews lasted from 35-131 minutes (mean: 62.9, STD: 18.7) and were audio-recorded and transcribed. Field notes were taken. 2.3 Research tool and Interview Guide
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Aiming for a phenomenological exploration of participants' experiences and the meanings they attributed to them, we used semi-structured interviews with open-ended questions [32]. Interview Guides (for smokers and spouses of smokers, and for secular and religious participants) were developed based on previous work (Personal communication, Elizabeth
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Gonzales, Project KISS 2009; Personal communication, Robyn Keske, 2012, Project: Breathe Free for Kids; Personal communication, Deborah Ritchie, 2012, Project: REFRESH).
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Respondents were asked to describe their daily routine and smoking habits, including previous quit attempts, and to discuss smoking restrictions in their home or car and around their children.
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Respondents were then asked what they knew about secondhand and thirdhand smoke and their risks. Questions regarding current strategies to protect their children followed. The last part of
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the interview focused on respondents’ views about possible interventions, including questions regarding biomarker testing for child exposure, with parents asked which tests would be
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acceptable, and why. The biomarker tests referred to included analysis of children's hair, urine, saliva, blood and fingernails for nicotine/cotinine, and environmental measures for home exposure assessment. Each of these methods was briefly explained. Parental responses regarding
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2.4 Analysis
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opposition to each type.
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which biomarker methods they would find acceptable were categorized according to consent and
2.4.1 Qualitative analysis
Data were transcribed and transcripts were checked for accuracy. Thematic analysis was performed (ET) and then reviewed and refined (VM, NG), with themes derived from the data, according to the process described by Braun and Clarke [33]. Preliminary descriptive codes were given to each segment of text; codes depicting similar topics were then grouped together and classified into relevant themes. It was noted which topics were most often related to either consent or opposition to testing. Once themes had been identified, the analysts went back over the text to find examples of each theme. Transcript extracts were identified to exemplify each theme, and to reflect the experiences of the participants. Further analysis clarified the specific nature of each theme moving from initial descriptive themes to more conceptual/analytical ones. 2.4.2 Quantitative analysis 7
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Demographic data on parental gender, smoking status, age, and number of children were summarized. Percentages of consenting and opposing parents were summarized for each biomarker category.
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2.6 Ethical Approval and Registration Approval for the research was obtained from the Tel Aviv University Ethics Committee and the
3. RESULTS
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3.1 Demographic characteristics of participants
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Laniado Hospital Helsinki Committee (0014-11-LND).
Table 1 presents socio-demographic characteristics of participants, including information on age,
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gender, number of children, smoker status, and heaviness of smoking. 3.2 Quantitative data – acceptability of testing
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Most of the parents interviewed said they would agree to have saliva (54/58, 93%), nail (49/56,
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87.5%) and hair (52/59, 88%) samples taken from their children, and to allow a monitor (51/56, 91%) or wet wipes (45/51, 88%) to check TSE levels in the home. Eighty-three percent (48/58)
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agreed to urine testing. Over half of parents (33/58, 57%) expressed concern about and/or unqualified opposition to drawing blood samples specifically to test exposure. A majority of parents with whom it was discussed (36/42, 86%) thought that receiving biomarker feedback might help persuade them to change their behavior to better protect their children. 3.3 Qualitative Data
Qualitative analysis identified four main themes that influence parental decisions to consent to or oppose different kinds of tests: The desire for information versus preference not to receive information; parental responsibility versus perceived powerlessness; long-term versus short-term child wellbeing; and trust or mistrust of research. These are elaborated on below. 3.3.1 Information-seeking versus "ignorance is bliss"
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Parents expressed two contrasting attitudes when it came to receiving information. Some parents welcomed the tests, hoping the results would provide a sense of relief and reassurance that their children were not exposed. Others valued the opportunity to obtain information provided by testing, expressing their genuine desire to receive an accurate picture of their children's exposure
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in order to correctly assess the risks involved and the effectiveness of the strategies they use to reduce exposure (see Table 2). Some parents took this a step further and said that if the results
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showed their children were at risk, they would make an effort to move their smoking further away from the child. One parent described the potential effects of the test results as a "wake-up
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call".
In contrast to parents who desired information, there were parents who did not want to receive
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information on their children's exposure level. Within this group, two sub-groups were identified. The first were parents who opposed testing and expressed a fear of discovering uncomfortable truths. They preferred to remain uninformed in order to avoid having to deal with feelings of
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guilt due to inadequately protecting their children, thus jeopardizing their positive parental identity. One father expressed this fear in strong terms, likening the stigma of being labeled a
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smoking parent to that of a terrorist. Some parents seemed to consider the biomarker tests as a
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kind of parenting test, which they feared they would fail. The second sub-group consisted of parents who opposed testing because they did not consider their children to be exposed and
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found the tests to be unnecessary or irrelevant. Some of these parents mentioned smoking in the vicinity of their child but did not consider this to be a form of exposure. 3.3.2 Responsibility versus powerlessness The theme of responsibility also differed between parents who supported and those who opposed biomarker testing. Some parents said they wanted to take responsibility for their children's health and discussed ways they might protect their children or reduce exposure (see Table 3). They expressed a sense of self-efficacy: they felt in control and able to act on the information received. Several parents, generally those supportive of testing, expressly mentioned their own role in causing the children to be exposed. Others, often those who opposed testing, talked of exposure in the passive tense or in the third person, distancing themselves from responsibility in the situation. In contrast, those who did not believe biomarker tests would motivate them to change, even if they indicated their child's exposure, expressed a sense of futility or inevitability, and 9
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feeling they could not do anything about the situation. These parents appeared to feel powerless to effect a change in their behavior and therefore saw no benefit in receiving information they could do nothing about.
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3.3.3 Child's wellbeing: Short-term discomfort versus long-term protection One of the most common objections to the biomarker test was parents' concern and reluctance to cause pain or discomfort to their child in the short-term, particularly regarding blood tests (see
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Table 4). Beyond causing physical pain, concerns included causing emotional pain. For example, one mother imagined her child's negative emotional response to being taken for a blood test,
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expressing this in strong terms as a betrayal. Others envisioned having to deal with the child's negative reaction such as crying at the time of the test. Children's autonomy was also mentioned,
an
with some parents opposed to overriding their children's wishes. Several parents raised technical or aesthetic objections related to harming the child, particularly regarding nail and hair samples
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(for example, bald spots). The most common opposition was to invasive testing such as blood tests. Overall, many parents felt that a painless test would be acceptable, but that causing pain to their child crossed a boundary. In contrast, some parents prioritized their children’s long-term
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3.3.4 Trust
te
better protect their children's health.
d
health benefit and supported even testing that might be invasive as a means to enable them to
Trust emerged as an important factor in receptivity to biomarker testing. Some parents expressed a high degree of faith in the tests and regarded them as a professional-scientific tool that would offer them a reliable picture of their children's status (see Table 4). Some even expressed a willingness to contribute to research. In contrast, a sense of mistrust pervaded the discourse of some parents who were concerned that testers might have ulterior motives and that the samples might be used for other purposes. Two parents even mentioned a fear that DNA might be used in order to clone subjects (see Table 5).
3.3.5 Summary of qualitative analysis Overall, the findings indicate that a key belief contributing to parents’ attitudes towards biomarker testing was their belief that their child is or is not exposed. Those who do consider their child at risk of exposure either wish to act upon information provided by testing, or
10
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alternatively reject the offer of testing, feeling powerless to act upon it. The belief that one’s child is not exposed led to two different pathways: either a desire for confirmation of their belief, or a rejection of testing due to mistrust or disbelief in utility of the information. Table 6 presents
cr
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a summary of the different attitudes to biomarker testing found among interviewees.
4. DISCUSSION & CONCLUSION
us
DISCUSSION
Most parents in the study from households in which smoking occurs were willing to allow their
an
children to be tested for exposure to tobacco smoke by urine, hair, or saliva. A substantial minority were even willing to allow serum testing solely for the purpose of TSE measurement, though others were strongly opposed. The overwhelming majority believed that feedback on
M
objectively-measured exposure levels would persuade them to better protect their children from TSE.
d
Among parents who were positively inclined towards testing, a distinction could be made among
te
two groups: those who desired information for reassurance of their children's safety, and those who sought it as a motivator to make change. Likewise, among those who opposed testing
Ac ce p
different subgroups emerged: those preferring not to receive information either believed it to be useless in the face of their own powerlessness to effect change; did not want to 'face facts'; believed it to be inaccurate; or were suspicious of its true purpose. Other reasons for opposition to testing concerned physical or emotional effects on children. Short-term concerns of discomfort, contrasted with long-term concerns of children's health. These differences provide a conceptual approach with practical implications to address different types of parental concerns related to biomarker testing (Table 6). 4.1.2 Comparison to previous literature We identified two previous studies that addressed the topic of testing child for TSE. Winickoff et al [26], in a quantitative survey, asked about the acceptability of testing for TSE within the context of routine physician visits, and found that 60% of parents, and 62% of smoking parents, supported testing in that setting. 11
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Regarding the acceptability of a blood test for exposure when blood was already being drawn for other reasons, Winickoff's findings showed that 70.1% of parents, and 73.6% of smoking parents, supported testing [26]. Our findings address blood draw taken specifically for the purpose of TSE measurement and 43% of those with whom it was discussed were willing to
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consent to the procedure. Woodruff [34], in a study of acceptability and validity of using hair samples for TSE measurement in a Latino population, found that 8.5% of parents were unwilling
cr
to provide hair samples and therefore declined to participate in the study . Their objections included concerns about future thickness of hair growth and religious issues.
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Neither study fully explored attitudes to various types of biomarker testing, nor did they perform explorations of reasons for attitudes which are possible with in-depth qualitative interviews.
an
Therefore, this study's findings, which point to both apprehensions about and support for screening healthy children with biomarkers, serve to expand upon previous findings but also add an important additional perspective. Previous studies that examined attitudes to screening healthy
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children for obesity, high cholesterol, or genetic susceptibility, reported mistrust of test results, perceived futility of screening, preference for painless tests and fear of being judged a bad
d
parent, as well as the importance of children's autonomy [35-38], themes which also surfaced in
te
the current study. Although in this study some of the parents expressed similar negative views, most parents mainly responded positively to the idea of testing and even believed results would
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motivate them to take action to protect their children. 4.1.3 Use of biomarkers for motivating behavior change Scientific measures of biochemical feedback have been used for decades as a means to improve health status. Feedback on cholesterol levels of healthy individuals is used to monitor and control heart health [39] and CO feedback has been used to convince smokers to quit [40], and to validate self-reports of smoking status [41]. Some investigators used biochemical feedback in the context of interventions to help parents reduce exposure to tobacco smoke. Four trials [22, 24, 42, 43] included in a recent meta-analysis [44] assessed the effect of biochemical feedback on exposure levels or protection behaviors. Individually, none of these trials showed a statistically significant effect, while a synthesis of all four trials showed a small advantage in the intervention groups (RR=1.14 [1.03,1.28], p=.02). Another review of five studies that used feedback of biomarkers did not show significant reduction in children’s TSE [45]. 12
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Although most of the parents interviewed in this study believed that biochemical feedback could spur them to change their behaviors, intervention trials reported in the literature found that interventions using biochemical feedback exhibited only a very small benefit [44]. This finding is unsurprising given the notorious gap between intent to change behavior and actual behavior
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change (as assessed by intervention trials) [46, 47]. However, the meta-analyses of intervention trials may underestimate the full benefit of biomarker feedback, particularly because concurrent
cr
improvements were observed in the control groups, most likely due to trial participation or monitoring effects [44, 48].
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4.1.4 Possible reasons for continued child exposure, and the potential for change through biomarkers
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The answer to the questions why parents continue to expose and allow their children to be exposed to tobacco smoke and what may help them to change is complex. One explanation given
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in the literature for why mothers continue to expose their children to tobacco smoke is that some of them engage in a "resistant dialogue", in which they discount potential effects of smoking on their child's health by blaming health problems on other factors, such as pollution or genetics
d
[49]. Another study found that beliefs about third-hand smoke are associated with home smoking
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rules [50]. Parental risk perceptions have been shown to be associated with smoking behavior in homes with children in some studies but not others [51]. Unsurprisingly, heavier smoking is
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known to be associated with higher exposure of children [52]. As suggested by the behavioralecological model [53, 54], societal-level factors, such as smoking bans in public places, are also important, and could influence the adoption of smoking bans in the home [55]. The findings of this study suggest that parents are at least open to the idea of the provision of direct evidence of child exposure. Whether this might help overcome a resistant reaction, or change parental behavior by altering beliefs about the existence of second or third-hand smoke, warrants further study.
4.1.5 Limitations One important limitation is that it is possible that not all parental concerns were elicited. However, since specific issues were repeatedly raised by participants from diverse social backgrounds and since other researchers encountered similar responses regarding other types of biomarker testing, this suggests that important parental responses and concerns that are shared by 13
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parents from various social backgrounds were identified. Cross-cultural research, both qualitative and quantitative, is recommended in order to understand whether these findings are applicable in other cultures where social norms regarding smoking in general, smoking around children, and
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child-raising practices may differ.
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4.2 CONCLUSIONS
This study provides unique insight into parental beliefs, attitudes and barriers regarding child
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biomarker testing for tobacco smoke exposure, and for the use of such biomarkers as a means to create educational and counseling interventions. Findings indicate that several challenges need to be addressed in order to promote biomarker testing among parents who are predisposed to testing
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and those who oppose it. In particular, parental desire to know the actual 'facts' about the exposure of one's child, the issue of trust, low conceptions of self-efficacy to change the
M
situation, and concerns regarding the invasiveness of the test emerged as important aspects in parental receptivity to child biomarker testing. Further, parents who were receptive to the test believed its results might help them make a change. Thus, an important challenge in developing
d
educational interventions and counseling using biomarkers regarding children's exposure is to
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their homes.
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include tailored information to help motivate parents to better protect their children from TSE in
4.3 PRACTICE IMPLICATIONS
Identifying factors that encourage parental acceptance of biomarker testing may facilitate the development of interventions to reduce children's exposure as well as aid health care systems, researchers, and others, to successfully assess child TSE. Following are specific implications and recommendations regarding the way biomarker tests could be presented to parents and implemented in order to enhance parental consent. 1. Since biomarker data is personal, it is important to build trust, and to explain the ethical commitment of those who conduct the test and convey its results, and to emphasize the strict confidentiality of all research data. 2. An emphasis on the long-term benefits of measurement from the perspective of parents could help quell parental concerns about subjecting their children to short-term discomfort. 14
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3. It is important to explain to parents the benefit of biomarker tests for children's TSE regardless of the results: Specifically, it can reassure parents whose children are found not to be exposed and can help motivate change among parents whose children are found to be exposed.
non-invasive tests should be offered according to their preference.
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4. Given the prevalence of parental concerns regarding the invasiveness of some of the tests,
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5. Since most parents expressed a willingness to have their children undergo non-invasive tests, testing for secondhand smoke exposure could be incorporated into routine measurements at
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regular check-ups, similar to the routine assessment of adults' smoking status, which has already been incorporated into general practice in some countries [56]. Such a large-scale
an
assessment of exposure in children could raise awareness and help reduce children's exposure on a population level.
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6. It is recommended to conduct biomarker testing in conjunction with TSE reduction intervention elements that address perceived powerlessness of parents and provide tools for
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behavior change, such as motivational interviewing.
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Table 1: Demographic information on participants Description
Age
33.3 ±4.8yrs , range 24-42 years
Number of children
1.91 (range 1-4)
Mothers vs Fathers
74% vs 26%
Smokers vs Non-smoking partners
83% vs 17%
Heaviness of smoking (interviewee or
Light smoker (0-5 cigarettes/day): N=21
smoking partner)
Moderate smoker (6-10 cigarettes/ day): N=21
an
us
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Characteristic
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Heavy smoker (10+ cigarettes/ day): N=22
te
d
Unknown (uses rolling tobacco): N=1
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Table 2: Information as motivator or inhibitor of parental agreement to biomarker testing Sub-theme
Representative Quotes
Information-seeking Reassurance
"[It would help me] be sure I'm not stupid enough to cause them some kind of exposure, that is, to be sure that, say, okay, I'm fine, I haven't gone overboard, I haven't crossed the line, I haven't reached a point where I've actually caused them exposure" [male smoker]
“When I know, I’ll be relieved; I want the test results right away.” [female, 36, non-smoker] Risk assessment: To
"I'm dying to know if, like, what I do is really just deluding myself or
know the facts
if it's really okay, if, like, I smoke, if I make sure I'm a mother who doesn't smoke next to the kid and I just smoke a cigarette next to the 16
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window and I change my clothes afterward, if that's really, truly effective or just bullshit."[female, 30, smoker] "if I see that it harms them, just for example … if I see in it that they
reducing behavior
have a level of toxins I'll take it upon myself to go downstairs in the
change
elevator and smoke downstairs"[female, 33, smoker]
ip t
Motivational for risk
cr
"It would let me, like, stop smoking near them, definitely ... I'd even go out to the balcony in the cold in a windbreaker"[male, 33,
us
smoker] Information rejecting
I: Would you like to know what your children's exposure levels are?
facts and feelings of
R: No.
guilt
I: Why not?
M
an
Fear of facing the
R: The less I know the better.
I: How would knowing affect you?
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d
R: I'm sure it would make me feel worse.[female, 36, smoker]
"I’m always a little reluctant to do these tests, maybe [it's] the fear of
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facing the truth or what will be done with it " [female, 38, smoker]
“Because I know it's not healthy to smoke around the kids as well, and to know that I'm doing something that's, like, worse?” [female,
32, smoker]
Threat to parental
" If you show it to a parent, what the damage is… You can prove to
identity as protective
the parent how much he's, like, not okay? … It's an attack, it's terror
parents
for the smoking parent…you're making the parent completely look like a terrorist"[male, 32, smoker]
Perceptions of lack
“It’s a waste of time, I don’t smoke at home…the exposure that my
of actual exposure
daughter might have is when we barbeque on the balcony and I’m four meters away so of course you’ll find smoke from the wood for
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the grill, or if we go to some park for a picnic and so yes, I sat with some friend ten meters away and the girls are playing there.” [male
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te
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M
an
us
cr
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smoker]
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Table 3: Responsibility vs powerlessness as related to biomarker testing
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Taking responsibility "It’s important to me, the kids’ health is very important to me … I’ll know where I stand and if they also give me methods and teach me or I find some methods on my own so I can reduce
cr
their exposure to cigarettes " [male, 24, smoker]
us
"… It would give me a so-called medical measure of how, how much damage I'm doing to my kids, maybe I'm doing fine with all my actions where I try not to smoke around them, and
an
maybe I think I'm fine but in reality I'm really not fine"[female, 38, smoker] " In order to get the most exact information possible about the degree to which my lifestyle
M
harms her" [male smoker]
Rejecting responsibility: sense of powerlessness
d
"what do I care what level they're at? Ultimately, understand, I want it [exposure] to be
te
as low as possible, but it's impossible to keep them from any exposure at all, … I know it's harmful, I make every effort but some things are out of our hands" [female, 29, smoker].
Ac ce p
"there's nothing I can do with that kind of information …it's just another cause of worry that I can't do anything about"[female non-smoker]
Table 4: Short-term versus long-term concerns as related to consent to testing Future health issues
"… if a person got it at home, listen, your kid is exposed to this or that degree, and it says his chance of getting lung cancer is such and such, it would really, really prevent him…"[male smoker] Immediate concerns
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"I don't want to cause her pain"[female, 29, smoker] "As long as it doesn't hurt, take it." [male, 31, smoker]
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"It's just not pleasant to urinate into something." [female smoker] “It’s just too complicated, in my experience, because it's hard to catch her when she's
cr
peeing, it's almost impossible” [female smoker]
"Because it's making him suffer for nothing, if you say there are other ways, then why
us
blood?"[female, 26, non-smoker]
an
"he's also insulted by it, I feel like I'm betraying him"[female smoker]
M
"Only if she cooperates…I won’t do anything against her wishes"[female smoker]
te
Faith in science/research
d
Table 5: Trust and mistrust as associated with consent to testing
"If you say it's lab tests I have no problem with that, if it's all kinds of samplings or all kinds
Ac ce p
of other things then no"[male, 30, smoker]
"If it's important research and I can contribute to it, I'm glad to" [male, 41, smoker] Mistrust of tests or testers
"A saliva test? Look, today there are all these databases on people, and it's not so, no … That's pretty invasive, the question is to which organization it's going, who's using it [female smoker]
"You want their DNA? To clone me or something?"[female smoker] "how can you even know it's cigarette exposure and not bus exposure?"[female, 32, smoker]
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Table 6. Four types of parental approaches to biomarker testing according to willingness to be tested and belief in the harmful exposure of their child
Parent wants to know if results
Parent does not want to know;
show exposure and plans to act
fears threat to parental identity as
upon results, and take
protector, guilt feelings, or feels
responsibility.
powerless; concerned for child's
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Unwilling to test child
us
Thinks child is exposed
Willing to test child
short-term discomfort.
Does not believe in the accuracy
and wants reassurance that
and utility of the tests, and does
current practices indeed protect
see exposure as their own
their child.
responsibility. Some distrust
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an
Parent uses various measures,
testers.
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te
d
Thinks child is safe
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Acknowledgements: We are grateful to all of participants of the study, to the staff of Meuhedet for their assistance in recruitment, and to the following individuals: Joseph K. Rosenblum and Shosh Tchernokovski, for their assistance with study design and recruitment; Dvora Aprimov,
ip t
for her assistance in recruitment; Uri Rubinstein, for his assistance in obtaining Helsinki
Committee approval; Idan Rani, for his assistance with conducting and transcribing interviews;
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and Assaf Buch, for conducting interviews.
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Competing Interests: None of the authors have competing interests.
Funding source: This work was funded by the Flight Attendants' Medical Research Institute
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M
an
(FAMRI) FAMRI Award # 072086_YCSA.
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