According to the CDC, nearly 14 percent of adults smoke nationwide; while this number continues to drop, smoking rates in low-income and minority groups are often more than 25 percent. In those situations, more than 50 percent of children are exposed to secondhand smoke. That exposure can lead to acute problems, including ear and respiratory infections, and chronic problems, such as asthma.
After a five-year, National-Institutes of Health-funded study, primary investigators Stephen Lepore, director of the Social and Behavioral Health Interventions Laboratory and professor and chair of the Department of Social and Behavioral Sciences, and Brad Collins, director of the Health Behavior Research Clinic, have published the long-term results of a randomized controlled trial on their Kids Safe and Smokefree (KiSS) multi-level intervention, which seeks to limit child exposure to secondhand smoke. Donna Coffman, assistant professor of epidemiology and biostatistics, and members of Massachusetts General Hospital Division of Pediatrics, Temple Pediatric Care, and the Children’s Hospital of Philadelphia co-authored the article, published in The International Journal of Environmental Research and Public Health.
Researchers partnered with pediatricians serving low-income neighborhoods and used the “Ask, Advise, Refer” (AAR) model, where physicians ask patients about tobacco use, advise them they should quit and refer them to services that can help them do so. They created a brief speech for doctors to convey secondhand smoke health risks if a parent says people smoke in their house. The pediatrician also entered a secondhand smoke exposure diagnosis into the child’s electronic medical records to revisit the concern at future appointments.
Participants—who were largely female, African American, and below the poverty level—were then randomly placed into two groups: the intervention group that received AAR and counseling and a control group that received AAR and regular nutrition education.
Those in the KiSS intervention group received literature and individual telephone counseling sessions over 12 weeks that included tools and resources to help them eliminate secondhand smoke exposure for their children.
At 12 months, researchers found that those who received the KiSS phone interventions were 2.47 times more likely to quit smoking than those in the control. In addition, children of parents in both groups demonstrated lower levels of exposure to secondhand smoke at 12 months than they did before their parents started the intervention, suggesting that the discussion with the pediatrician alone was enough for a parent to limit their child’s exposure to tobacco. Both the child exposure and the parent’s quit status were verified via cotinine, the most common biomarker of nicotine exposure.
The latter finding was particularly surprising, as previous studies suggested that the clinic-level intervention (that is, the discussions with the pediatrician) wouldn’t have much effect. According to Lepore, a difference in societal attitudes over time could account for the strong influence of the pediatrician, both as parents become more aware of the dangers of secondhand exposure and as smoking becomes out of vogue—largely banned from restaurants, hotels, and other public places. In addition, because prompts to discuss secondhand smoke were embedded in electronic health records and part of workflow, pediatricians may have been more likely to discuss the topic during clinic visits.
One challenge that researchers face for future interventions, though, is what’s known as third-hand smoke: the residual contamination that resides on carpets, walls, and others surfaces, sometimes for long after a smoker has been in the area. Given the propensity for crawling on the floor and hand-to-mouth behaviors, children can be particularly susceptible. And although smoking use is increasingly stigmatized in public places, tobacco products are still heavily advertised and marketed, especially toward those living in low-income areas.
Despite these challenges, interventions such as KiSS are a promising step toward eliminating tobacco exposure. And, since KiSS incorporates already-available (and free) smoking quit lines into the telephone counseling, it’s easily reproducible at a larger scale.
“These results suggest that the pediatrician’s advice is highly motivating to the parent,” said Lepore. “We should integrate these kinds of interventions into pediatric practice—they are effective, relatively easy to implement, and scalable.”
Read more research from the Department of Social and Behavioral Sciences.