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research-article2015
CPJXXX10.1177/0009922814567304Clinical PediatricsRobinson et al
Article
Physician Intervention for Improving Tobacco Control Among Parents Who Use Tobacco
Clinical Pediatrics 2015, Vol. 54(11) 1044–1050 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814567304 cpj.sagepub.com
Leslie A. Robinson, PhD1, Ashley H. Clawson, PhD2, Joseph A. Weinberg, MD3, Francisco I. Salgado-Garcia, MA1, and Jeanelle S. Ali, MS1
Abstract Research has demonstrated that parents who smoke are often inadvertent sources of their children’s first cigarettes. Teaching parents to restrict their tobacco may give pediatricians another method for helping parents who are not ready to quit smoking. This purpose of this study was to determine the feasibility of a program training pediatricians to discuss tobacco control with smoking parents and to examine changes in parents’ tobacco control after the physician intervention. One month after the intervention by pediatricians, parents reported significantly improved tobacco control. They were more likely to count their packs and cigarettes and to keep their tobacco products at work and on their person. Parents reported restricting household control of adult smoking, and children were exposed to significantly less secondhand smoke. These results showed that it is possible to integrate advice about tobacco control into a busy pediatric practice and to improve parents’ restrictions of their tobacco products. Keywords tobacco control, physician, intervention, parents Tobacco poses significant risks to children at all ages. Babies and children who ingest tobacco experience adverse effects, including convulsions, respiratory difficulties, and death.1 This problem is not uncommon: An alarming 13 705 child ingestions of tobacco products were reported to Poison Control Centers in the United States during 2006-2008.1 Also, secondhand smoke (SHS) exposure is experienced by up to 60% of children in the United States.2 SHS exposure is associated with health consequences such as respiratory complications, decreased lung function, and cancer.2-6 Another major risk is smoking initiation among children and adolescents themselves. Research indicates 7.1% of middle school students and 23.3% of high school students are current smokers.7 Overall, 11.8% of US adolescents consume cigarettes daily.8 One potential source of tobacco products for children involves their parents. Research has shown that children whose parents smoke are more likely to become smokers themselves.3,9-11 For example, children with one smoking parent are 64% more likely to become daily smokers than youngsters with nonsmoking parents.12 This increase in tobacco use may be due to parental modeling. Alternatively, children who have smoking
parents may find cigarettes to be more readily available. Notably, children are more likely to view cigarettes as easy to get when they have a parent who smokes.13 Emerging research indicates that family members may be a significant source of tobacco for minors. For example, adolescents often report getting their first cigarettes at home.13 One study found that approximately 5% of teenage smokers took cigarettes from family members without their knowledge.14 Other research has documented higher rates of access through family members.15 For example, up to 59% of adolescent smokers report having stolen cigarettes from parents,13 and those who obtain cigarettes at home smoke significantly more.14 Thus, one route to reducing tobacco use among youth may be to restrict their access to tobacco at home. 1
The University of Memphis, Memphis, TN, USA Brown University, Providence, RI, USA 3 The University of Tennessee Health Science Center, Memphis, TN, USA 2
Corresponding Author: Leslie A. Robinson, Department of Psychology, The University of Memphis, 202 Psychology Building, Memphis, TN 38152, USA. Email: [email protected]
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Robinson et al Given these findings, one might assume that health programs have been developed to inform parents of the dangers their tobacco poses for their offspring. However, few interventions have addressed children’s access to parental tobacco. Instead, the focus has been on trying to get parents to quit smoking.16-19 A recent meta-analysis integrated 18 trials aiming to help parents stop smoking.20 Overall, a 4% absolute difference favoring the interventions was found. However, most interventions were intensive, requiring multiple sessions and treatment components.11,21,22 As the authors noted, many parents will not quit smoking in these programs, and additional strategies are needed to protect children.20 Another approach to reducing the impact of parental smoking might be to encourage parents to control tobacco products. Such an approach might be a palatable first step for parents who are resistant to quitting. To date, only one study aimed to help parents restrict their children’s access to their tobacco products.23 This investigation used a community-, school-, and family-based program to modify parental behavior in order to reduce smoking among youth. The intervention for parents was limited in scope, including only a reminder card and a DVD urging parents to protect offspring from smoking. Unfortunately, the study’s results showed that households receiving these interventions were less likely to restrict cigarettes than control households. A different route to intervention with parents lies in pediatric practices, because 90% of children see a health care professional each year.24 Research has shown that physician-administered interventions are effective at reducing tobacco use among adolescents,25-27 reducing SHS exposure among children,28 and reducing parental smoking.11 Despite their success, physicians often underestimate adult smokers’ willingness to discuss tobacco use.10,29 However, parents who smoke have been shown to support pediatricians’ efforts to reduce smoking among their children.10,11,30,31
Aims of this Study We designed a program to teach pediatricians how to counsel smoking parents about reducing the availability of their tobacco to children. Our objectives were 1. to develop and implement a program to train physicians to interact with smoking parents about tobacco control using motivational interviewing, and 2. to examine the efficacy of the physician-delivered intervention by comparing parental tobacco control policies at baseline to those at 1-month follow-up.
Methods Program Development We chose motivational interviewing as a foundation for the program, because it has been shown to be effective for changing a range of behaviors in medical settings and can be taught easily and quickly.32-34 We designed the program so that physicians could quickly determine parents’ readiness to change and apply the corresponding intervention. Parents who were not ready to change their behavior were not pressed; instead, pediatricians asked whether they wanted help in the future. Parents who were open to restricting their tobacco were encouraged to develop their own ideas for achieving this goal. Only if they had difficulty did physicians assist them by providing examples of methods for restricting children’s access to tobacco. Brief role-play scenarios that could be used with the physicians were developed. One version of the role-play was written for use with receptive parents, and the second illustrated methods for dealing with more argumentative parents. A third version was designed for passive parents. All scenarios were included in a project manual, which also contained general information about tobacco. We also developed laminated “tip cards” for physicians, sized to fit in a lab coat pocket. These tip cards gave a brief outline of the intervention to prompt the physicians as needed. Finally, we developed a brochure to be given to parents containing information on how children access tobacco and why tobacco control is important. Included was space for pediatricians to write the parents’ individual plans for controlling tobacco. They then gave it to parents as a “prescription for health.”
Pediatrician Participants A pediatric practice with 4 physicians agreed to pilot the intervention. This practice served patients in the outskirts of a major mid-south city. The group saw approximately 42 000 patients annually, primarily from poor or middle-class families.
Physician Training Procedures for training physicians were designed by a clinical health psychologist and a board-certified senior pediatrician. We limited the training to a 1-hour program delivered during the practice’s monthly meeting. Our training protocol included 4 sections. First, we discussed the medical consequences of smoking. Second, we reviewed the goals of the study, procedures, and intervention. Third, we modeled a role-play of the intervention for the physicians. Each team of physicians then
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role-played the scenarios twice, once with each partner playing the role of parent. During this time, trainers consulted with the teams as needed. Finally, the physicians were given a supply of tip cards and brochures.
declined to complete the follow-up. According to the medical practice, inaccurate contact information was a common problem for these parents.
Measures
Parental Recruitment Several inclusion criteria were used. First, parents had to have a child between 9 and 15 years old. Second, they had to present at the pediatricians’ office for a routine visit, because we did not want to enroll parents preoccupied with an acutely ill child. Third, parents had to have smoked within the past month. Finally, parents had to be fluent in English. The University of Memphis Institutional Review Board approved procedures. Two medical assistants screened parents as they signed in for appointments. Once eligibility was determined, the assistants described the study. Parents provided written consent and were given pretest questionnaires to complete in the waiting room. Parents then sealed the completed surveys in unmarked envelopes, which were placed in a locked data storage box. The data were later transferred to our laboratory. Of the 1176 parents screened, 943 (80.2%) were screened out because they were nonsmokers, 343 (29.2%), because their child was ill, and 692 (58.8%), because their offspring was outside age limits. Only 63 parents were eligible (5.4%). Of these, one declined, leaving us with an enrolled sample of 62.
Study Procedure After parents completed the initial questionnaire, the assistants flagged their offspring’s charts, so that physicians would recognize study participants. Physicians completed their usual medical routine and then introduced the topic of tobacco control, following their prescribed protocol. Pediatricians noted that children’s first cigarettes often come from parents and asked what methods for restricting tobacco parents could consider. Pediatricians then wrote the parent’s plans for tobacco control on the brochure and gave it to the parents. One month after the intervention, our research team contacted parents by phone. We administered a second survey to assess changes in attitudes, smoking practices, and smoking restrictions. Participants could complete the posttest either by phone or by accessing a link sent to their email. Of the 62 parents who enrolled, 41 (66.1%) completed follow-up. Eleven parents (17.7%) did not return our calls, and 6 (10%) had inaccurate contact information. Two parents did not provide contact information, and 2
A 67-item pretest questionnaire included self-report demographic items and questions regarding parents’ tobacco use, their views of youth smoking, the efficacy of physicians’ efforts to reduce smoking, and parents’ methods for restricting tobacco. Response options consisted primarily of Likert scales. The follow-up questionnaire was similar. Both questionnaires are available on request.
Results Description of the Parents Of the 62 parents, 91.8% were female, averaging 36 years old. African Americans comprised 39.3% of the sample, 49.2% were Caucasian, and 11.5% were other ethnicities. Only 27.6% were married; 46.6% were never married, 12.1% divorced, 1.7% widowed, and 12.1% separated. Sixty-one percent had a high school education or less, and 52.7% earned $10 000 to $19 000 annually. All the parents had consumed at least 1 cigarette during the previous month. Three (5.0%) parents smoked more than a pack per day (ppd), 19 (31.7%) smoked a ppd, 28 (46.7%) smoked one-half ppd, 4 (6.7%) smoked 1 cigarette per day, and 8 (9.9%) smoked less. At pretest, 13 (21.7%) of the parents were in the “preparation” stage of change, 32 (53.3%) were in “contemplation,” and 15 (25.0%) were in “precontemplation.” Half the sample smoked menthol and 40.0% used regular cigarettes.
Changes in Parents’ Behavior We asked parents how difficult it would be to keep their tobacco away from their offspring. Responses ranged from 0 to 3, with higher scores indicating greater belief that tobacco control is easy. Our analyses showed significant improvement over time, paired t(39) = 3.56, P = .001. At pretest, parents indicated that it was relatively difficult to keep tobacco away from their children (M = 1.85, SD = 1.15) but by posttest, they reported that tobacco control was significantly easier (M = 2.38, SD = 0.93). Parents were also asked how many methods they used to keep tobacco from their children. At pretest, they used on average only 2.39 of 7 listed methods for
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Robinson et al Table 1. Changes in the Proportion of Participants Who Acknowledged Using Tobacco Control Techniques. Variables
n
Pre (%)
Post (%)
Cochran’s Q
P
Counted cigarettes in pack Counted the number of packs Kept tobacco with you Kept tobacco at work Hid tobacco Locked up tobacco Warned child not to take tobacco
37 36 39 37 37 36 37
27 22 67 16 30 28 68
49 44 87 35 35 31 73
4.571 4.571 4.000 4.455 0.400 0.143 0.333
.033 .033 .046 .035 .527 .705 .564
restricting tobacco. After the intervention, they used significantly more (M = 3.57) ways of controlling tobacco, paired t(32) = 3.213, P = .003. We explored changes in parental endorsement of each approach using Cochrane’s Q. The results (see Table 1) indicated that at posttest, parents were significantly more likely to count the packs and the cigarettes in their packs than at pretest. Parents were also more likely to keep their tobacco at work and to keep tobacco with them. However, parents did not endorse all methods. As Table 1 illustrates, parents were not more likely at posttest to hide their tobacco or to lock it up. Furthermore, they were no more likely to warn their offspring not to take their tobacco. Parents were also asked whether they allowed adults and children to smoke anywhere in their homes, only in some places, or not at all. These questions were repeated at posttest. Analysis revealed a ceiling effect at pretest: Almost all parents severely restricted tobacco use among children at home. At posttest, there was no significant change in parental restrictiveness. However, parents did significantly increase their restriction of smoking among adults in their homes, paired t(39) = 2.48, P = .018.
Secondhand Smoke Exposure To measure children and teens’ exposure to SHS, we asked parents specific questions about how often in the past week children were exposed to smoke at home or in a car. From pretest (M = 2.69, SD = 2.62) to posttest (M = 2.15, SD = 2.38), there was a significant decrease in the number of days offspring were exposed to smoke, paired t(38) = 2.06, P = .05.
Perceptions of Pediatricians We also asked parents how much they believed pediatricians could prevent smoking, using a 4-point scale with higher scores reflecting more positive beliefs. Analysis indicated that the parents were doubtful about pediatricians’ ability to prevent smoking prior to the
intervention (M = 1.70, SD = 0.91). Afterward, they rated pediatricians’ ability to prevent offspring from smoking to be significantly stronger (M = 2.03, SD = 0.86), paired t(39) = 2.06, P = .046. We also wondered how parents would feel if pediatricians addressed their own tobacco use, using 5-point scales in which high scores represented more positive opinions. At pretest, parents were fairly positive about physicians discussing their smoking (M = 2.46, SD = 1.05). However, they became even more positive after the intervention (M = 2.88, SD = 0.90), paired t(40) = 2.97, P = .005. These findings suggest that pediatricians should not fear that addressing tobacco use will alienate their patients’ parents.
Program Acceptability to Pediatricians After the intervention, we asked pediatricians to complete anonymous questionnaires about their experiences. Most of the questions were scored on 4-point Likerttype scales. We first asked about the content, format, and training for the intervention. All these aspects of the program were rated well. The pediatricians reported that they felt “well prepared” (75%) or “somewhat prepared” (25%) to deliver the program after the training session. The next set of questions was designed to assess the physicians’ experiences once they began the intervention. All of them reported that implementing the program was “not particularly difficult.” In fact, the pediatricians reported no negative parental responses at all. Three out of 4 physicians noted that the program was not disruptive to practice. They were overwhelmingly positive about the brochures for parents and the pocketsized tip cards summarizing the intervention. Finally, we asked the pediatricians about their expertise before and after the intervention. Before the training, the physicians rated their understanding of adolescent smoking as medium or low. After completing the intervention, three of the physicians rated their expertise regarding smoking as high, and one improved to medium.
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Improvements in motivational interviewing were also observed. Although 2 of the physicians rated their interest in providing a tobacco intervention as low at pretest, afterward, all 4 rated their motivation as high. In addition, all the physicians agreed they would continue to address tobacco with parents after the study ended.
Discussion Research has shown that parents are often inadvertent sources of their children’s first cigarettes.15 Only one investigation has attempted to improve parents’ control of their tobacco products, and its results were negative.23 The current study used a different approach to helping parents restrict their children’s access to tobacco. Given the reach that medical professionals have into the general population of smokers, we chose to train pediatricians to deliver a program. Our choice of a pediatric practice was fortuitous: The parents recruited had lower incomes and were largely minorities. These variables are associated with higher risks of smoking-related disease35,36; thus, reducing smoking among these offspring was particularly important. Our results showed that it is feasible to implement an intervention with smoking parents in the ongoing operations of a pediatric practice. Notably, the training program we developed was tailored with the pediatricians’ input. The physicians viewed our 1-hour training program as sufficient preparation, and they especially appreciated the tip cards and brochures. All the pediatricians reported improved skills in tobacco intervention and motivational interviewing. Importantly, all of them indicated that they were more motivated to address tobacco after participating in the program. For a small-scale study, these results are promising. Our central aim in this feasibility study was to determine whether the physician intervention could improve parents’ efforts to control their tobacco. As expected, after the intervention parents were significantly more likely to count their cigarettes and their packs. Parents were also more likely to keep their tobacco at work and/or with them, rather than leaving it unattended. Importantly, children’s exposure to SHS decreased significantly. Although parents thought that controlling their tobacco would be relatively difficult at pretest, 1 month later they were more likely to view tobacco control as easy. Finally, significant improvements in parents’ perceptions of the pediatricians occurred. At posttest parents rated physicians as more effective at preventing smoking than at pretest. Furthermore, parents were more receptive at posttest to talking with pediatricians about their own tobacco use. Previous research has shown that physicians
often believe parents will resent being counseled about smoking and that attempting such conversations may alienate parents.17 Our data indicate that physicians can be reassured that conversations with parents who smoke will generally be positively received. The limitations of this study should be acknowledged. First, the behavioral changes in tobacco restriction reported by parents should be validated. Although previous studies have used self-reports of household tobacco bans,37,38 parents may overestimate the extent to which they maintain such restrictions. Alternative methods for validating children’s exposure to household tobacco include measuring children’s urinary cotinine21 and placing nicotine dosimeters in the home.39 Second, future research should include a randomized controlled trial. Finally, a longer follow-up period would help determine how long the changes observed in this study are sustained. Ultimately, research will be needed to determine if effective parental control of tobacco is sufficient to prevent or delay the uptake of smoking among adolescents. Despite the benefits of restricting youths’ access to tobacco, it might be argued that a better aim would be to help parents quit smoking entirely. This goal, if achieved, would remove both the child’s exposure to tobacco and their exposure to parental modeling of smoking. However, it is clear that not all parents will be compliant with smoking cessation instructions.20 Physicians should be armed with a variety of methods for assisting families to achieve tobacco control, each of which is carefully designed to be implemented in busy medical practices. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by a Healthy People 2020 grant awarded to the Tennessee Chapter of the American Academy of Pediatrics (AAP) by the AAP Friends of Children Fund, a charitable fund of the AAP.
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15. DiFranza JR, Eddy JJ, Brown LF, Ryan JL, Bogojavlensky A. Tobacco acquisition and cigarette brand selection among youth. Tob Control. 1994;3:334-338. 16. Abdullah AS, Mak YW, Loke AY, Lam TH. Smoking cessation intervention in parents of young children: a randomised controlled trial. J Addict. 2005;100:1731-1740. doi:10.1111/j.1360-0443.2005.01231.x. 17. Frankowski BL, Weaver SO, Secker-Walker RH. Advising parents to stop smoking: pediatricians’ and parents’ attitudes. Pediatrics. 1993;91:296-300. 18. Kallio K, Jokinen E, Hämäläinen M, et al. Impact of repeated lifestyle counselling in an atherosclerosis prevention trial on parental smoking and children’s exposure to tobacco smoke. Acta Paediatr. 2006;95:283-290. doi:10.1111/j.1651-2227.2006.tb02227.x. 19. Krieger JW, Takaro TK, Song L, Weaver M. The SeattleKing County Healthy Homes Project: A randomized, controlled trial of a community health worker intervention to decrease exposure to indoor asthma triggers. Am J Public Health. 2005;95:652-659. doi:10.2105/ AJPH.2004.042994. 20. Rosen LJ, Noach MB, Winickoff JP, Hovell MF. Parental smoking cessation to protect young children: a systematic review and meta-analysis. Pediatrics. 2012;129:141-152. doi:10.1542/peds.2010-3209. 21. Hovell MF, Zakarian JM, Matt GE, et al. Counseling to reduce children’s secondhand smoke exposure and help parents quit smoking: a controlled trial. Nicotine Tob Res. 2009;11:1383-1394. doi:10.1093/ntr/ntp148. 22. Wilson SR, Farber HJ, Knowles SB, Lavori PW. 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;139:581-590. doi:10.1378/chest.10-0772. 23. Gautam J, Glover M, Scragg R, et al. Parental and retail supply of tobacco to minors: findings from a community-based social supply intervention study. Health Policy. 2014;117:120-127. doi:10.1016/j.healthpol.2014.02.004. 24. Centers for Disease Control and Prevention. Ambulatory care and physician visits. Retrieved from http://www.cdc. gov/nchs/fastats/docvisit.htm. Published 2009. Updated May 14, 2014. Accessed June 9, 2014. 25. Curry SJ, Ludman EJ, Graham E, Stout J, Grothaus L, Lozano P. Pediatric-based smoking cessation intervention for low-income women: a randomized trial. Arch Pediatr Adolesc Med. 2003;157:295-302. doi:10.1001/ archpedi.157.3.295. 26. Hum AM, Robinson LA, Jackson AA, Ali KS. Physician communication regarding smoking and adolescent tobacco use. Pediatrics. 2011;127:e1368-e1374. doi:10.1542/ peds.2010-1195. 27. Shelley D, Cantrell J, Faulkner D, Haviland L, Healton C, Messeri P. Physician and dentist tobacco use counseling and adolescent smoking behavior: results from the 2000 National Youth Tobacco Survey. Pediatrics. 2005;115:719-725. doi:10.1542/peds.2004-0873.
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28. Hovell MF, Zakarian JM, Wahlgren DR, Matt GE. Reducing children’s exposure to environmental tobacco smoke: the empirical evidence and directions for future research. Tob Control. 2000;9(suppl 2):II40-II47. doi:10.1136/tc.9.suppl_2.ii40. 29. Kviz FJ, Clark MA, Hope H, Davis AM. Patients’ perceptions of their physician’s role in smoking cessation by age and readiness to stop smoking. Prev Med. 1997;26:340349. doi:10.1006/pmed.1997.0149. 30. Cluss PA, Moss D. Parent attitudes about pediatricians addressing parental smoking. Ambul Pediatr. 2002;2: 485-488. doi:10.1367/1539-4409(2002)0022.0.CO;2. 31. Fisher M. Parents’ views of adolescent health issues. Pediatrics. 1992;90:335-341. 32. Emmons KM, Rollnick S. Motivational interviewing in health care settings: opportunities and limitations. Am J Prev Med. 2001;20:68-74. doi:10.1016/S07493797(00)00254-3. 33. Erickson SJ, Gerstle M, Feldstein SW. Brief interventions and motivational interviewing with children, adolescents, and their parents in pediatric health care settings: a review. Arch Pediatr Adolesc Med. 2005;159:1173-1180. doi:10.1001/archpedi.159.12.1173.
34. Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev. 2008;(2):CD000165. doi:10.1002/14651858.CD000165. pub3. 35. Birch S, Jerrett M, Eyles J. Heterogeneity in the determinants of health and illness: the example of socioeconomic status and smoking. Soc Sci Med. 2000;51:307-317. doi:10.1016/S0277-9536(99)00455-4. 36. Haiman CA, Stram DO, Wilkens LR, et al. Ethnic and racial differences in the smoking-related risk of lung cancer. N Engl J Med. 2006;354:333-342. doi:10.1056/ NEJMoa033250. 37. Severson HH, Andrews JA, Lichtenstein E, Wall M, Akers L. Reducing maternal smoking and relapse: longterm evaluation of a pediatric intervention. Prev Med. 1997;26:120-130. doi:10.1006/pmed.1996.9983. 38. Wall MA, Severson HH, Andrews JA, Lichtenstein E, Zoref L. Pediatric office-based smoking intervention: impact on maternal smoking and relapse. Pediatrics. 1995;96:622-628. 39. Hovell MF, Meltzer SB, Wahlgren DR, et al. Asthma management and environmental tobacco smoke exposure reduction in Latino children: a controlled trial. Pediatrics. 2002;110:946-956. doi:10.1542/peds.110.5.946.
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research-article2015
CPJXXX10.1177/0009922814567304Clinical PediatricsRobinson et al
Article
Physician Intervention for Improving Tobacco Control Among Parents Who Use Tobacco
Clinical Pediatrics 2015, Vol. 54(11) 1044–1050 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814567304 cpj.sagepub.com
Leslie A. Robinson, PhD1, Ashley H. Clawson, PhD2, Joseph A. Weinberg, MD3, Francisco I. Salgado-Garcia, MA1, and Jeanelle S. Ali, MS1
Abstract Research has demonstrated that parents who smoke are often inadvertent sources of their children’s first cigarettes. Teaching parents to restrict their tobacco may give pediatricians another method for helping parents who are not ready to quit smoking. This purpose of this study was to determine the feasibility of a program training pediatricians to discuss tobacco control with smoking parents and to examine changes in parents’ tobacco control after the physician intervention. One month after the intervention by pediatricians, parents reported significantly improved tobacco control. They were more likely to count their packs and cigarettes and to keep their tobacco products at work and on their person. Parents reported restricting household control of adult smoking, and children were exposed to significantly less secondhand smoke. These results showed that it is possible to integrate advice about tobacco control into a busy pediatric practice and to improve parents’ restrictions of their tobacco products. Keywords tobacco control, physician, intervention, parents Tobacco poses significant risks to children at all ages. Babies and children who ingest tobacco experience adverse effects, including convulsions, respiratory difficulties, and death.1 This problem is not uncommon: An alarming 13 705 child ingestions of tobacco products were reported to Poison Control Centers in the United States during 2006-2008.1 Also, secondhand smoke (SHS) exposure is experienced by up to 60% of children in the United States.2 SHS exposure is associated with health consequences such as respiratory complications, decreased lung function, and cancer.2-6 Another major risk is smoking initiation among children and adolescents themselves. Research indicates 7.1% of middle school students and 23.3% of high school students are current smokers.7 Overall, 11.8% of US adolescents consume cigarettes daily.8 One potential source of tobacco products for children involves their parents. Research has shown that children whose parents smoke are more likely to become smokers themselves.3,9-11 For example, children with one smoking parent are 64% more likely to become daily smokers than youngsters with nonsmoking parents.12 This increase in tobacco use may be due to parental modeling. Alternatively, children who have smoking
parents may find cigarettes to be more readily available. Notably, children are more likely to view cigarettes as easy to get when they have a parent who smokes.13 Emerging research indicates that family members may be a significant source of tobacco for minors. For example, adolescents often report getting their first cigarettes at home.13 One study found that approximately 5% of teenage smokers took cigarettes from family members without their knowledge.14 Other research has documented higher rates of access through family members.15 For example, up to 59% of adolescent smokers report having stolen cigarettes from parents,13 and those who obtain cigarettes at home smoke significantly more.14 Thus, one route to reducing tobacco use among youth may be to restrict their access to tobacco at home. 1
The University of Memphis, Memphis, TN, USA Brown University, Providence, RI, USA 3 The University of Tennessee Health Science Center, Memphis, TN, USA 2
Corresponding Author: Leslie A. Robinson, Department of Psychology, The University of Memphis, 202 Psychology Building, Memphis, TN 38152, USA. Email: [email protected]
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Robinson et al Given these findings, one might assume that health programs have been developed to inform parents of the dangers their tobacco poses for their offspring. However, few interventions have addressed children’s access to parental tobacco. Instead, the focus has been on trying to get parents to quit smoking.16-19 A recent meta-analysis integrated 18 trials aiming to help parents stop smoking.20 Overall, a 4% absolute difference favoring the interventions was found. However, most interventions were intensive, requiring multiple sessions and treatment components.11,21,22 As the authors noted, many parents will not quit smoking in these programs, and additional strategies are needed to protect children.20 Another approach to reducing the impact of parental smoking might be to encourage parents to control tobacco products. Such an approach might be a palatable first step for parents who are resistant to quitting. To date, only one study aimed to help parents restrict their children’s access to their tobacco products.23 This investigation used a community-, school-, and family-based program to modify parental behavior in order to reduce smoking among youth. The intervention for parents was limited in scope, including only a reminder card and a DVD urging parents to protect offspring from smoking. Unfortunately, the study’s results showed that households receiving these interventions were less likely to restrict cigarettes than control households. A different route to intervention with parents lies in pediatric practices, because 90% of children see a health care professional each year.24 Research has shown that physician-administered interventions are effective at reducing tobacco use among adolescents,25-27 reducing SHS exposure among children,28 and reducing parental smoking.11 Despite their success, physicians often underestimate adult smokers’ willingness to discuss tobacco use.10,29 However, parents who smoke have been shown to support pediatricians’ efforts to reduce smoking among their children.10,11,30,31
Aims of this Study We designed a program to teach pediatricians how to counsel smoking parents about reducing the availability of their tobacco to children. Our objectives were 1. to develop and implement a program to train physicians to interact with smoking parents about tobacco control using motivational interviewing, and 2. to examine the efficacy of the physician-delivered intervention by comparing parental tobacco control policies at baseline to those at 1-month follow-up.
Methods Program Development We chose motivational interviewing as a foundation for the program, because it has been shown to be effective for changing a range of behaviors in medical settings and can be taught easily and quickly.32-34 We designed the program so that physicians could quickly determine parents’ readiness to change and apply the corresponding intervention. Parents who were not ready to change their behavior were not pressed; instead, pediatricians asked whether they wanted help in the future. Parents who were open to restricting their tobacco were encouraged to develop their own ideas for achieving this goal. Only if they had difficulty did physicians assist them by providing examples of methods for restricting children’s access to tobacco. Brief role-play scenarios that could be used with the physicians were developed. One version of the role-play was written for use with receptive parents, and the second illustrated methods for dealing with more argumentative parents. A third version was designed for passive parents. All scenarios were included in a project manual, which also contained general information about tobacco. We also developed laminated “tip cards” for physicians, sized to fit in a lab coat pocket. These tip cards gave a brief outline of the intervention to prompt the physicians as needed. Finally, we developed a brochure to be given to parents containing information on how children access tobacco and why tobacco control is important. Included was space for pediatricians to write the parents’ individual plans for controlling tobacco. They then gave it to parents as a “prescription for health.”
Pediatrician Participants A pediatric practice with 4 physicians agreed to pilot the intervention. This practice served patients in the outskirts of a major mid-south city. The group saw approximately 42 000 patients annually, primarily from poor or middle-class families.
Physician Training Procedures for training physicians were designed by a clinical health psychologist and a board-certified senior pediatrician. We limited the training to a 1-hour program delivered during the practice’s monthly meeting. Our training protocol included 4 sections. First, we discussed the medical consequences of smoking. Second, we reviewed the goals of the study, procedures, and intervention. Third, we modeled a role-play of the intervention for the physicians. Each team of physicians then
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role-played the scenarios twice, once with each partner playing the role of parent. During this time, trainers consulted with the teams as needed. Finally, the physicians were given a supply of tip cards and brochures.
declined to complete the follow-up. According to the medical practice, inaccurate contact information was a common problem for these parents.
Measures
Parental Recruitment Several inclusion criteria were used. First, parents had to have a child between 9 and 15 years old. Second, they had to present at the pediatricians’ office for a routine visit, because we did not want to enroll parents preoccupied with an acutely ill child. Third, parents had to have smoked within the past month. Finally, parents had to be fluent in English. The University of Memphis Institutional Review Board approved procedures. Two medical assistants screened parents as they signed in for appointments. Once eligibility was determined, the assistants described the study. Parents provided written consent and were given pretest questionnaires to complete in the waiting room. Parents then sealed the completed surveys in unmarked envelopes, which were placed in a locked data storage box. The data were later transferred to our laboratory. Of the 1176 parents screened, 943 (80.2%) were screened out because they were nonsmokers, 343 (29.2%), because their child was ill, and 692 (58.8%), because their offspring was outside age limits. Only 63 parents were eligible (5.4%). Of these, one declined, leaving us with an enrolled sample of 62.
Study Procedure After parents completed the initial questionnaire, the assistants flagged their offspring’s charts, so that physicians would recognize study participants. Physicians completed their usual medical routine and then introduced the topic of tobacco control, following their prescribed protocol. Pediatricians noted that children’s first cigarettes often come from parents and asked what methods for restricting tobacco parents could consider. Pediatricians then wrote the parent’s plans for tobacco control on the brochure and gave it to the parents. One month after the intervention, our research team contacted parents by phone. We administered a second survey to assess changes in attitudes, smoking practices, and smoking restrictions. Participants could complete the posttest either by phone or by accessing a link sent to their email. Of the 62 parents who enrolled, 41 (66.1%) completed follow-up. Eleven parents (17.7%) did not return our calls, and 6 (10%) had inaccurate contact information. Two parents did not provide contact information, and 2
A 67-item pretest questionnaire included self-report demographic items and questions regarding parents’ tobacco use, their views of youth smoking, the efficacy of physicians’ efforts to reduce smoking, and parents’ methods for restricting tobacco. Response options consisted primarily of Likert scales. The follow-up questionnaire was similar. Both questionnaires are available on request.
Results Description of the Parents Of the 62 parents, 91.8% were female, averaging 36 years old. African Americans comprised 39.3% of the sample, 49.2% were Caucasian, and 11.5% were other ethnicities. Only 27.6% were married; 46.6% were never married, 12.1% divorced, 1.7% widowed, and 12.1% separated. Sixty-one percent had a high school education or less, and 52.7% earned $10 000 to $19 000 annually. All the parents had consumed at least 1 cigarette during the previous month. Three (5.0%) parents smoked more than a pack per day (ppd), 19 (31.7%) smoked a ppd, 28 (46.7%) smoked one-half ppd, 4 (6.7%) smoked 1 cigarette per day, and 8 (9.9%) smoked less. At pretest, 13 (21.7%) of the parents were in the “preparation” stage of change, 32 (53.3%) were in “contemplation,” and 15 (25.0%) were in “precontemplation.” Half the sample smoked menthol and 40.0% used regular cigarettes.
Changes in Parents’ Behavior We asked parents how difficult it would be to keep their tobacco away from their offspring. Responses ranged from 0 to 3, with higher scores indicating greater belief that tobacco control is easy. Our analyses showed significant improvement over time, paired t(39) = 3.56, P = .001. At pretest, parents indicated that it was relatively difficult to keep tobacco away from their children (M = 1.85, SD = 1.15) but by posttest, they reported that tobacco control was significantly easier (M = 2.38, SD = 0.93). Parents were also asked how many methods they used to keep tobacco from their children. At pretest, they used on average only 2.39 of 7 listed methods for
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Robinson et al Table 1. Changes in the Proportion of Participants Who Acknowledged Using Tobacco Control Techniques. Variables
n
Pre (%)
Post (%)
Cochran’s Q
P
Counted cigarettes in pack Counted the number of packs Kept tobacco with you Kept tobacco at work Hid tobacco Locked up tobacco Warned child not to take tobacco
37 36 39 37 37 36 37
27 22 67 16 30 28 68
49 44 87 35 35 31 73
4.571 4.571 4.000 4.455 0.400 0.143 0.333
.033 .033 .046 .035 .527 .705 .564
restricting tobacco. After the intervention, they used significantly more (M = 3.57) ways of controlling tobacco, paired t(32) = 3.213, P = .003. We explored changes in parental endorsement of each approach using Cochrane’s Q. The results (see Table 1) indicated that at posttest, parents were significantly more likely to count the packs and the cigarettes in their packs than at pretest. Parents were also more likely to keep their tobacco at work and to keep tobacco with them. However, parents did not endorse all methods. As Table 1 illustrates, parents were not more likely at posttest to hide their tobacco or to lock it up. Furthermore, they were no more likely to warn their offspring not to take their tobacco. Parents were also asked whether they allowed adults and children to smoke anywhere in their homes, only in some places, or not at all. These questions were repeated at posttest. Analysis revealed a ceiling effect at pretest: Almost all parents severely restricted tobacco use among children at home. At posttest, there was no significant change in parental restrictiveness. However, parents did significantly increase their restriction of smoking among adults in their homes, paired t(39) = 2.48, P = .018.
Secondhand Smoke Exposure To measure children and teens’ exposure to SHS, we asked parents specific questions about how often in the past week children were exposed to smoke at home or in a car. From pretest (M = 2.69, SD = 2.62) to posttest (M = 2.15, SD = 2.38), there was a significant decrease in the number of days offspring were exposed to smoke, paired t(38) = 2.06, P = .05.
Perceptions of Pediatricians We also asked parents how much they believed pediatricians could prevent smoking, using a 4-point scale with higher scores reflecting more positive beliefs. Analysis indicated that the parents were doubtful about pediatricians’ ability to prevent smoking prior to the
intervention (M = 1.70, SD = 0.91). Afterward, they rated pediatricians’ ability to prevent offspring from smoking to be significantly stronger (M = 2.03, SD = 0.86), paired t(39) = 2.06, P = .046. We also wondered how parents would feel if pediatricians addressed their own tobacco use, using 5-point scales in which high scores represented more positive opinions. At pretest, parents were fairly positive about physicians discussing their smoking (M = 2.46, SD = 1.05). However, they became even more positive after the intervention (M = 2.88, SD = 0.90), paired t(40) = 2.97, P = .005. These findings suggest that pediatricians should not fear that addressing tobacco use will alienate their patients’ parents.
Program Acceptability to Pediatricians After the intervention, we asked pediatricians to complete anonymous questionnaires about their experiences. Most of the questions were scored on 4-point Likerttype scales. We first asked about the content, format, and training for the intervention. All these aspects of the program were rated well. The pediatricians reported that they felt “well prepared” (75%) or “somewhat prepared” (25%) to deliver the program after the training session. The next set of questions was designed to assess the physicians’ experiences once they began the intervention. All of them reported that implementing the program was “not particularly difficult.” In fact, the pediatricians reported no negative parental responses at all. Three out of 4 physicians noted that the program was not disruptive to practice. They were overwhelmingly positive about the brochures for parents and the pocketsized tip cards summarizing the intervention. Finally, we asked the pediatricians about their expertise before and after the intervention. Before the training, the physicians rated their understanding of adolescent smoking as medium or low. After completing the intervention, three of the physicians rated their expertise regarding smoking as high, and one improved to medium.
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Improvements in motivational interviewing were also observed. Although 2 of the physicians rated their interest in providing a tobacco intervention as low at pretest, afterward, all 4 rated their motivation as high. In addition, all the physicians agreed they would continue to address tobacco with parents after the study ended.
Discussion Research has shown that parents are often inadvertent sources of their children’s first cigarettes.15 Only one investigation has attempted to improve parents’ control of their tobacco products, and its results were negative.23 The current study used a different approach to helping parents restrict their children’s access to tobacco. Given the reach that medical professionals have into the general population of smokers, we chose to train pediatricians to deliver a program. Our choice of a pediatric practice was fortuitous: The parents recruited had lower incomes and were largely minorities. These variables are associated with higher risks of smoking-related disease35,36; thus, reducing smoking among these offspring was particularly important. Our results showed that it is feasible to implement an intervention with smoking parents in the ongoing operations of a pediatric practice. Notably, the training program we developed was tailored with the pediatricians’ input. The physicians viewed our 1-hour training program as sufficient preparation, and they especially appreciated the tip cards and brochures. All the pediatricians reported improved skills in tobacco intervention and motivational interviewing. Importantly, all of them indicated that they were more motivated to address tobacco after participating in the program. For a small-scale study, these results are promising. Our central aim in this feasibility study was to determine whether the physician intervention could improve parents’ efforts to control their tobacco. As expected, after the intervention parents were significantly more likely to count their cigarettes and their packs. Parents were also more likely to keep their tobacco at work and/or with them, rather than leaving it unattended. Importantly, children’s exposure to SHS decreased significantly. Although parents thought that controlling their tobacco would be relatively difficult at pretest, 1 month later they were more likely to view tobacco control as easy. Finally, significant improvements in parents’ perceptions of the pediatricians occurred. At posttest parents rated physicians as more effective at preventing smoking than at pretest. Furthermore, parents were more receptive at posttest to talking with pediatricians about their own tobacco use. Previous research has shown that physicians
often believe parents will resent being counseled about smoking and that attempting such conversations may alienate parents.17 Our data indicate that physicians can be reassured that conversations with parents who smoke will generally be positively received. The limitations of this study should be acknowledged. First, the behavioral changes in tobacco restriction reported by parents should be validated. Although previous studies have used self-reports of household tobacco bans,37,38 parents may overestimate the extent to which they maintain such restrictions. Alternative methods for validating children’s exposure to household tobacco include measuring children’s urinary cotinine21 and placing nicotine dosimeters in the home.39 Second, future research should include a randomized controlled trial. Finally, a longer follow-up period would help determine how long the changes observed in this study are sustained. Ultimately, research will be needed to determine if effective parental control of tobacco is sufficient to prevent or delay the uptake of smoking among adolescents. Despite the benefits of restricting youths’ access to tobacco, it might be argued that a better aim would be to help parents quit smoking entirely. This goal, if achieved, would remove both the child’s exposure to tobacco and their exposure to parental modeling of smoking. However, it is clear that not all parents will be compliant with smoking cessation instructions.20 Physicians should be armed with a variety of methods for assisting families to achieve tobacco control, each of which is carefully designed to be implemented in busy medical practices. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by a Healthy People 2020 grant awarded to the Tennessee Chapter of the American Academy of Pediatrics (AAP) by the AAP Friends of Children Fund, a charitable fund of the AAP.
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