Secondhand smoke exposure not only plays a role in the development and exacerbation of respiratory diseases in children, it also can lower their IQ scores, increase risk for behavioral and sleep problems, and contribute to increased infection risk. Even parents who only smoke outside may be exposing their children to tobacco smoke at levels known to cause disease.
Quitting smoking is the only way to eliminate the risk of harm.
There are excellent programs, such as the Clinical Effort Against Smoke Exposure (www.ceasetobacco.org), that improve office screening and intervention with families in the outpatient setting. The inpatient setting also has been identified as a potential opportunity for intervention. In one study, more than 75% of parents of children hospitalized for respiratory illness were willing to enroll in a smoking-cessation program, and all parents believed that this should be offered to parents who smoke (Winickoff JP, et al. Am J Prev Med. 2001;21:218-220).
However, pediatric hospitalizations often are a missed opportunity for parental screening and intervention for tobacco use. The reasons for this are complex. The Joint Commission measures on tobacco screening and intervention are limited to smokers 13 years of age and older; there are no requirements for screening and intervention for secondhand tobacco smoke exposure.
There also are concerns that pediatricians shouldn’t be intervening with parents, particularly recommending or prescribing nicotine replacement therapy (NRT), although the AAP Section on Tobacco Control has provided guidance on how to do this appropriately (http://bit.ly/298FYjX).
Programs have begun to address this gap. The AAP Quality Improvement Innovation Networks/Value in Inpatient Pediatrics Network recently completed a quality collaborative (http://bit.ly/297OvBy) to improve hospitalists’ compliance with the AAP clinical practice guideline on bronchiolitis. The evidence-based guideline was provided to teams at 21 hospitals using educational webinars, coaching and online information. Among the aims of the project was improved screening of patients for tobacco smoke exposure and providing smoking cessation interventions.
The project led to an 89% screening rate, with 52% of hospitals achieving the goal of 90% compliance with tobacco screening in the post-intervention period. In addition, smoking cessation interventions among caregivers of infants exposed to tobacco smoke increased from 20% in the pre-intervention period to 53% post-intervention.
A counseling intervention that has been effective in the outpatient setting and for adults who are hospitalized is a model based on the 5 As: Ask about smoking or exposure, Advise about the risks of continuing to smoke, Assess willingness to quit, Assist with smoking cessation through brief counseling and medication provision, and Arrange follow-up.
The 5 As model now is being tested among parents of hospitalized children in a randomized, controlled study at Children’s Hospital Colorado. Called Intervening with Smoking Parents of Inpatients to Reduce Exposure, the study is funded by the National Cancer Institute. Every child admitted is screened for secondhand smoke exposure, and if screening is positive, the cessation team is notified.
The intervention group receives brief motivational interviewing delivered by trained members of a respiratory therapy group, free over-the-counter NRT if eligible and up to three follow-up phone calls from support coaches. Parents also receive a discharge summary outlining their quit plan, which they can share with their child’s pediatrician or their own physician.
Inpatient providers can do the following to protect pediatric patients from the harms of secondhand smoke exposure:
- Screen all children on admission for secondhand tobacco smoke exposure using the question “Does anyone who lives in your home or who cares for your child smoke tobacco?” In areas where marijuana use is legal, it is important to distinguish between the two. It is advised to screen for both.
- Advise parents who smoke that the best thing they can do for their child’s health, and their own, is to quit smoking. In addition, inform parents that smoking outside or smoking electronic cigarettes doesn’t eliminate the risk.
- Ask parents if they are interested in behavior change and offer cessation resources. All states have a Quitline (www.smokefree.gov or 1-800-QUIT-NOW), and the website also provides information on the Text to Quit program. If possible, identify staff who can provide brief counseling sessions to parents interested in quitting.
- Ensure NRT is available for parents in the hospital pharmacy.
Dr. Wilson is chair of the AAP Section on Tobacco Control Executive Committee, and Dr. Walley is a member of the committee.
