A daughter hugs her mother, while both smile.

In 2022, College of Public Health researchers Bradley Collins and Stephen Lepore published results of a groundbreaking clinical trial establishing the efficacy of a program they designed to help low-income mothers quit smoking. An innovative element of their intervention was counseling to help mothers learn how to protect their children from tobacco smoke. Mothers who participated in the program, called Babies Living Safe and Smokefree (BLiSS), were 9.55 times more likely to be abstaining from smoking 12 months following the start of the intervention than a control group. Even mothers who had no prior intention to quit smoking did quit.

Now a deeper look into the study’s data, newly published in the Journal of Behavioral Medicine, establishes a clear connection between protecting children from tobacco-smoke exposure (TSE) and long-term abstinence success.  

“We tested four hypothesized mediators that could explain why the BLiSS intervention helped mothers quit smoking. Only the success in eliminating their children’s TSE during the 12-week intervention, which included success in their adoption of a smokefree home, accounted for the effect of our intervention on facilitating long-term abstinence measured nine months after the end of treatment,” says Collins, professor and PhD program director in the Department of Social and Behavioral Sciences. “Moms who were reporting that their child was not exposed to any tobacco smoke, either in their home or outside their home, were more likely to quit smoking in the long term, compared to moms who had not totally eliminated their children’s exposure.”

Collins and Lepore, chair of the Department of Social and Behavioral Sciences, collaborated on the research with Brian Egleston, a member of the Biostatistics and Bioinformatics Facility at Temple’s Fox Chase Cancer Center. Linda Kilby, executive director of North Inc., the nonprofit that manages the Philadelphia WIC program, was an integral partner in facilitating the implementation of Collins and Lepore’s training of WIC staff in the clinic-based part of the BLiSS intervention.

Tobacco-smoke exposure is a leading cause of preventable disease and death. The World Health Organization estimated in 2020 that tobacco kills more than 8 million people annually, including more than 1 million nonsmokers exposed to its smoke. Children’s TSE has been linked to childhood ear infections, asthma severity, increased risk of sudden infant death syndrome, increased risk of chronic disease, and greater likelihood that children themselves will later start smoking. The problem is especially prevalent in low-income households: Over 40% of low-income children have daily TSE, and maternal smoking is the primary source.

BLiSS is a multi-level intervention that begins with an initial in-person session when participants seek food and nutrition services through the WIC program, which provides food and nutrition financial support and education to low-income families. Collins and Lepore teamed with North Inc., the nonprofit that manages the Philadelphia WIC program, training nutrition counselors to include tobacco screening and brief intervention with clients.

“This population of smokers has a much more difficult time quitting than other smokers,” Lepore said. Low-income neighborhoods tend to have more densely concentrated tobacco vendors and tobacco advertising, including billboards that might not be permissible in higher-income neighborhoods. Some smokers feel it reduces their stress, and residents in lower income communities can experience more intensive stress than those in higher income neighborhoods. Smoking rates in low-income neighborhoods range from around 25 to 30%, compared to higher-income neighborhoods, where rates are closer to 10 to 14%, Lepore said.

Approximately 400 young mothers who smoke were recruited into the BLiSS study after receiving WIC nutrition counselor advice. In the 12-week behavioral intervention, mothers in the BLiSS intervention received up to five phone counseling sessions based on cognitive behavioral therapy for smoking intervention, supportive text messaging and video clips sent to their mobile phones, a BLiSS mobile app that helps with self-monitoring of smoking, and eight weeks of nicotine-replacement (gum, patches or lozenges). The mothers also received the “Family Guide to a Smokefree Home” that contained materials such as ”no smoking” signs that could be posted to remind family members in a household to achieve a smokefree home. Results from the initial study were published in the March 2022 issue of The American Journal of Public Health.

In the end, mothers in the BLiSS program had a significantly higher abstinence rate, bioverified by saliva samples, than mothers in the control group who did not receive the same follow-up, even up to 12 months later. The findings suggest new approaches to smoking reduction that could have a dual impact: empowering young parents to quit smoking and reducing childhood exposure to secondhand smoke.

“Quitting smoking is difficult,” Collins says. The standard approach involves telephone quitlines, whose primary focus is on guiding smokers to build self-control skills and take nicotine replacement to manage urges to smoke, he says. "Our intervention includes a focus on child health in the family context to increase motivation and help set the stage for a quit attempt. A lot of moms live with other smokers, so our counselors try to help moms enhance their skills for enforcing the rules around a smokefree home to protect children. For example, practicing a polite but assertive stance to confront a visitor that comes to the home and starts lighting a cigarette on the sofa. To say, ‘I'm sorry, you can't smoke here, but there's an ashtray outside.’ That approach can be difficult for moms at the start. It takes a lot of guts and hard work for a smoker to make those changes.”