OBJECTIVES:

To determine practices and beliefs of pediatric hospitalists regarding smoking cessation counseling for caregivers of hospitalized children.

METHODS:

An electronic survey was distributed to 249 members of the Pediatric Research in Inpatient Settings Network over 6 weeks in 2017 (83 responses [33%]). Questions explored beliefs regarding the impact of tobacco smoke exposure (TSE) and practices in TSE screening, provision of counseling, resources, and pharmacotherapy. Nonparametric tests were used to compare groups on numeric variables, χ2 tests were used to compare groups on nominal variables, and McNemar’s test was used to compare dichotomous responses within subjects.

RESULTS:

All respondents were familiar with the term “secondhand smoke,” and >75% were familiar with “thirdhand smoke” (THS). Familiarity with THS was associated with more recent completion of training (P = .04). Former smokers (7%) were less likely to agree that THS has a significant impact on a child’s health (P = .04). Hospitalists ask about TSE more often than they provide counseling, resources, or pharmacotherapy to caregivers who want to quit smoking. Hospitalists are more likely to ask about TSE and provide cessation counseling when patients have asthma as opposed to other diseases. Time was identified by 41% of respondents as a barrier for providing counseling and by 26% of respondents as a barrier for providing resources. Most respondents never prescribe pharmacotherapy (72%), nor do they follow-up with caregivers after hospitalization regarding cessation (87%).

CONCLUSIONS:

Although most respondents ask about TSE, opportunities are missed for counseling and providing support to caregivers who want to quit smoking. Providers should be educated about THS, and systems should be streamlined to facilitate brief counseling sessions.

Cigarette smoking remains a major threat to public health. The Surgeon General has determined there is no risk-free level of exposure to secondhand smoke (SHS).1  SHS disproportionately affects children between 3 and 11 years of age, causing sudden infant death syndrome and lower respiratory tract illnesses, among other diseases.2  Emerging evidence describes the impact of thirdhand smoke (THS), the residue left on surfaces after cigarettes are extinguished.3,4  THS likely impacts nonsmokers’ health, and children experience higher rates of THS than adults.3,5 

The US Department of Health and Human Services recommends that all tobacco users be screened for tobacco use, given advice to quit, and offered brief counseling and cessation medications.6  Policy statements from the American Academy of Pediatrics recommend addressing SHS, assisting parents and caregivers in cessation, and implementing systems to do so.7,8  Approximately two-thirds of current smokers want to quit. Quit rates increase by 82% with concurrent behavioral and pharmacologic interventions, compared to minimal intervention or usual care.9,10  Even brief counseling can be successful. Multiple interventions over time have an additive effect on quit rates and contribute to social denormalization of smoking.6 

Parents enforce smoke-free home rules when they believe that THS can be harmful to children, a belief more often held when pediatricians recommend smoke-free homes and cars.4,11 

Screening and counseling caregivers is challenging and infrequent in inpatient and outpatient pediatric settings.1215  Hospitalization can be a teachable moment for caregivers, increasing receptiveness to smoking cessation interventions during a child’s acute illness and promoting temporary abstinence in smoke-free institutions.16 

In this study, we aimed to determine the practices and beliefs of pediatric hospitalists regarding smoking cessation counseling for caregivers of hospitalized children. We hypothesized that hospitalists would frequently ask about SHS and recommend quitting but would not routinely assist caregivers in smoking cessation by referring them to local resources or prescribing nicotine replacement therapy (NRT). An additional hypothesis was that the majority of respondents would believe SHS and THS were harmful to children but would not recognize themselves as key players in smoking cessation efforts.

This was an electronic survey study of members of the Pediatric Research in Inpatient Settings Network, a pediatric hospitalist research network composed of >100 academic and community sites in the United States and Canada. Before survey distribution, the total number of members was confirmed by the network administration via questionnaire. Members (N = 249) were e-mailed a link to an anonymous survey administered via the Research Electronic Data Capture tool hosted at our university in 2017, receiving 5 weekly reminders and an invitation to a raffle for 5 $100 gift cards at the completion of the survey.17 

The authors iteratively developed the survey, which was adapted from previous surveys on providers’ practices in smoking cessation.18  Three focus groups at the authors’ home institutions piloted the survey for readability and clarity, openly sharing feedback and suggesting edits on question style, content, and intent. The survey addressed participant demographics, medical training, education about tobacco smoke exposure (TSE), and behaviors in and barriers to providing smoking cessation counseling.

Data were stored in Research Electronic Data Capture and analyzed by using SPSS software (IBM SPSS Statistics, IBM Corporation). For comparisons of responses within subjects (such as across questions about frequency of behaviors), Friedman rank analysis of variance was used, followed by Wilcoxon rank tests for follow-up comparisons of interest. For within-subject comparisons of yes or no variables (such as whether specific diagnoses would increase frequency of behaviors), McNemar’s tests were used. The χ2 test was used to compare groups on nominal variables (such as the difference between male and female respondents on whether they prescribed specific therapies). For comparing groups defined by various education characteristics on age and year of training, we used Mann–Whitney U tests. The university’s institutional review board approved this study.

Of 249 recipients, 83 completed the survey (33%), ranging in age from 30 to 61 years and representing 23 US states and 1 Canadian province. See Table 1 for additional demographic information.

TABLE 1

Demographics of Survey Respondents and Their Institutions (N = 83)

Value
Sex (n = 82), n (%)  
 Female 56 (68) 
 Male 26 (32) 
Former smokera (n = 82), n (%)  
 Yesb 7 (9) 
 No 75 (91) 
Type of practice (n = 81), n (%)  
 Physician (MD or DO) 81 (100) 
Geographic region (n = 81), n (%)  
 Northeast 23 (28) 
 Midwest 25 (31) 
 South 9 (11) 
 West 22 (27) 
 Canada 2(2) 
Residency training (n = 81), n (%)  
 Categorical pediatrics 74 (91) 
 Medicine-pediatrics 7 (9) 
Fellowship training (n = 81), n (%)  
 Yesc 27 (33) 
 No 54 (67) 
Practice setting (n = 82), n (%)  
 Freestanding children’s hospital 52 (63) 
 Children’s hospital within a hospital 24 (29) 
 Pediatric unit within an adult hospital 6 (7) 
Hospital systems to support screening for TSE (n = 83), n (%)  
 Forced question or hard stop on nursing questionnaire 32 (39) 
 Forced question or hard stop on electronic health record for all patients 16 (19) 
 Forced question or hard stop on electronic health record for patients with specific diagnoses 8 (10) 
 Prompt on written documentation (eg, history and physical form) 28 (34) 
 Respondent unaware of hospital systems in place to support screening 23 (28) 
Hospital systems to support caregivers who smoke (n = 83), n (%)  
 NRT available for purchase on hospital campus 16 (19) 
 NRT available for free during hospitalization 9 (11) 
 Smoking cessation counselor on-site 5 (6) 
 Smoking cessation counselor available for contact 13 (16) 
 Free quitline through state 47 (57) 
 Fax or electronic referral form to state quitline 17 (20) 
 Educational handouts for caregivers about the effects of TSE 37 (45) 
 Educational handouts for caregivers about cessation 42 (51) 
 Respondent unaware of hospital systems in place to support caregivers 14 (17) 
Mean (SD); range  
 Year of completion of residency training 2007 (6.6); 1984–2017 
 Year of completion of fellowship training 2010 (4.6); 2000–2017 
Value
Sex (n = 82), n (%)  
 Female 56 (68) 
 Male 26 (32) 
Former smokera (n = 82), n (%)  
 Yesb 7 (9) 
 No 75 (91) 
Type of practice (n = 81), n (%)  
 Physician (MD or DO) 81 (100) 
Geographic region (n = 81), n (%)  
 Northeast 23 (28) 
 Midwest 25 (31) 
 South 9 (11) 
 West 22 (27) 
 Canada 2(2) 
Residency training (n = 81), n (%)  
 Categorical pediatrics 74 (91) 
 Medicine-pediatrics 7 (9) 
Fellowship training (n = 81), n (%)  
 Yesc 27 (33) 
 No 54 (67) 
Practice setting (n = 82), n (%)  
 Freestanding children’s hospital 52 (63) 
 Children’s hospital within a hospital 24 (29) 
 Pediatric unit within an adult hospital 6 (7) 
Hospital systems to support screening for TSE (n = 83), n (%)  
 Forced question or hard stop on nursing questionnaire 32 (39) 
 Forced question or hard stop on electronic health record for all patients 16 (19) 
 Forced question or hard stop on electronic health record for patients with specific diagnoses 8 (10) 
 Prompt on written documentation (eg, history and physical form) 28 (34) 
 Respondent unaware of hospital systems in place to support screening 23 (28) 
Hospital systems to support caregivers who smoke (n = 83), n (%)  
 NRT available for purchase on hospital campus 16 (19) 
 NRT available for free during hospitalization 9 (11) 
 Smoking cessation counselor on-site 5 (6) 
 Smoking cessation counselor available for contact 13 (16) 
 Free quitline through state 47 (57) 
 Fax or electronic referral form to state quitline 17 (20) 
 Educational handouts for caregivers about the effects of TSE 37 (45) 
 Educational handouts for caregivers about cessation 42 (51) 
 Respondent unaware of hospital systems in place to support caregivers 14 (17) 
Mean (SD); range  
 Year of completion of residency training 2007 (6.6); 1984–2017 
 Year of completion of fellowship training 2010 (4.6); 2000–2017 
a

Smoked at least 100 cigarettes or the equivalent (cigars, cigarillos) in their lifetime.

b

All quit smoking between 9 and 20 y ago.

c

Fellowships completed included academic general pediatrics, quality improvement, health services research, pediatric hematology-oncology, hospital medicine, infectious diseases, and nephrology.

SHS was a familiar, easily definable term for 99% of respondents; 1% of respondents were familiar with the term but unsure of the definition. THS was familiar and easily definable to 46% of respondents; 32% were familiar with the term but unsure of the definition, and 22% were unfamiliar with the term. Familiarity with THS was associated with more recent completion of training (P = .04) but not with age (P = .21) or geographic region (P = .54).

After reviewing the definitions of SHS and THS, most respondents strongly agreed (89%) or agreed (5%) with the statement “SHS has a significant impact on a child’s health.” Most strongly agreed (59%) or agreed (33%) that “THS has a significant impact on a child’s health.” Former smokers were less likely than never smokers to agree with the latter (P = .04).

In Table 2, we describe areas in which education on TSE and smoking cessation was received and the timing (age at and year of completion of training) of such education.

TABLE 2

Education on TSE and Smoking Cessation Topics: Locations Received and Ages at and Year of Completion of Training When Received (N = 83)

Location of Education, n (%)Receipt of Education by Age at and Year of Completion of Training
Medical SchoolPediatric ResidencyFellowship TrainingContinuing Education Activity“I Did Not Receive Education on This Topic”Median Age in y (n)PMedian y of Completion of Training (n)P
Education Was ReceivedEducation Was Not ReceivedEducation Was ReceivedEducation Was Not Received
Physical effects of SHS on a child 54 (65) 61 (74) 3 (4) 15 (18) 3 (4) 38 (74) 46 (3) .11 2010 (73) 2006 (3) .4 
Mental or psychological effects of SHS on a child 7 (8) 12 (15) 1 (1) 8 (10) 56 (68) 38 (21) 38 (56) .77 2009 (21) 2010 (55) .26 
Physical effects of THS on a child 11 (13) 30 (36) 2 (2) 16 (19) 33 (40) 37 (44) 39 (33) .14 2010 (44) 2008 (32) .13 
Mental or psychological effects of THS on a child 3 (4) 2 (2) 3 (4) 70 (84) 37 (8) 38 (77) .7 2010 (8) 2009 (76) .49 
How to counsel a smoker to quit smoking 43 (52) 37 (45) 4 (5) 18 (22) 11 (13) 37 (67) 42 (10) .001 2010 (66) 2005 (10) .009 
Nicotine replacement pharmacotherapy options for smoking cessation 45 (54) 28 (34) 3 (4) 17 (20) 15 (18) 37 (63) 41 (14) .006 2010 (62) 2007 (14) .02 
Nonnicotine pharmacotherapy options for smoking cessation 45 (54) 26 (31) 3 (4) 13 (16) 18 (22) 37 (61) 42 (16) .002 2010 (60) 2006 (16) .008 
How to prescribe pharmacotherapy for smoking cessation 26 (31) 16 (19) 3 (4) 11 (13) 35 (42) 37 (44) 40 (33) .03 2010 (44) 2008 (32) .34 
The role of the pediatrician in reducing TSE 14 (17) 61 (73) 5 (6) 20 (24) 8 (10) 38 (70) 39 (7) .16 2010 (69) 2008 (7) .23 
Location of Education, n (%)Receipt of Education by Age at and Year of Completion of Training
Medical SchoolPediatric ResidencyFellowship TrainingContinuing Education Activity“I Did Not Receive Education on This Topic”Median Age in y (n)PMedian y of Completion of Training (n)P
Education Was ReceivedEducation Was Not ReceivedEducation Was ReceivedEducation Was Not Received
Physical effects of SHS on a child 54 (65) 61 (74) 3 (4) 15 (18) 3 (4) 38 (74) 46 (3) .11 2010 (73) 2006 (3) .4 
Mental or psychological effects of SHS on a child 7 (8) 12 (15) 1 (1) 8 (10) 56 (68) 38 (21) 38 (56) .77 2009 (21) 2010 (55) .26 
Physical effects of THS on a child 11 (13) 30 (36) 2 (2) 16 (19) 33 (40) 37 (44) 39 (33) .14 2010 (44) 2008 (32) .13 
Mental or psychological effects of THS on a child 3 (4) 2 (2) 3 (4) 70 (84) 37 (8) 38 (77) .7 2010 (8) 2009 (76) .49 
How to counsel a smoker to quit smoking 43 (52) 37 (45) 4 (5) 18 (22) 11 (13) 37 (67) 42 (10) .001 2010 (66) 2005 (10) .009 
Nicotine replacement pharmacotherapy options for smoking cessation 45 (54) 28 (34) 3 (4) 17 (20) 15 (18) 37 (63) 41 (14) .006 2010 (62) 2007 (14) .02 
Nonnicotine pharmacotherapy options for smoking cessation 45 (54) 26 (31) 3 (4) 13 (16) 18 (22) 37 (61) 42 (16) .002 2010 (60) 2006 (16) .008 
How to prescribe pharmacotherapy for smoking cessation 26 (31) 16 (19) 3 (4) 11 (13) 35 (42) 37 (44) 40 (33) .03 2010 (44) 2008 (32) .34 
The role of the pediatrician in reducing TSE 14 (17) 61 (73) 5 (6) 20 (24) 8 (10) 38 (70) 39 (7) .16 2010 (69) 2008 (7) .23 

When compared to asking about TSE, each additional smoking cessation–related practice was performed significantly less often (Table 3). Just 27% of respondents reported counseling and 19% reported referring to local resources >75% of the time. Seventy-two percent of hospitalists spent <5 minutes counseling, 22% spent 5 to 10 minutes counseling, 1% spent 11 to 15 minutes counseling, and 4% spent >15 minutes counseling (n = 76). Pharmacotherapy was prescribed by 28%, and 13% contacted caregivers post hospitalization regarding quit attempts. Barriers can also be found in Table 3.

TABLE 3

Frequency of Cessation Practices and Barriers to Cessation Practices

BehaviorHospitalist or Inpatient Team Frequency of Behavior Completion (%)aBarriers to Behavior Completion (%)b
I or We Never Do This≤25% of the Time26%–50% of the Time51%–75% of the Time76%–99% of the TimeI or We Always Do ThisI Do Not Have TimeI Do Not Know HowI Forget to Do SoI Do Not Think the Caregiver Wants My HelpI Do Not Think It Is My Responsibility to HelpI Do Not Think My Help Will Be EffectiveThe EHR Does Not Allow for ThisNo Barriers
Ask about TSE 11 19 46 17 18 54 11 39 
Counsel a caregiver who wants to quit smokingc 22 18 31 20 41 19 23 33 37 14 
Refer a caregiver to local cessation resourcesc 10 44 14 11 15 25 32 36 18 20 17 
Prescribe pharmacotherapy to a caregiverc 72 19 17 55 11 11 17 12 
Follow-up with a caregiver after hospitalization regarding quit attemptc,d 86 10 — — — — — — — — 
BehaviorHospitalist or Inpatient Team Frequency of Behavior Completion (%)aBarriers to Behavior Completion (%)b
I or We Never Do This≤25% of the Time26%–50% of the Time51%–75% of the Time76%–99% of the TimeI or We Always Do ThisI Do Not Have TimeI Do Not Know HowI Forget to Do SoI Do Not Think the Caregiver Wants My HelpI Do Not Think It Is My Responsibility to HelpI Do Not Think My Help Will Be EffectiveThe EHR Does Not Allow for ThisNo Barriers
Ask about TSE 11 19 46 17 18 54 11 39 
Counsel a caregiver who wants to quit smokingc 22 18 31 20 41 19 23 33 37 14 
Refer a caregiver to local cessation resourcesc 10 44 14 11 15 25 32 36 18 20 17 
Prescribe pharmacotherapy to a caregiverc 72 19 17 55 11 11 17 12 
Follow-up with a caregiver after hospitalization regarding quit attemptc,d 86 10 — — — — — — — — 

EHR, electronic health record; —, not applicable.

a

Teammates included hospitalist attending physician, resident physician, medical student, physician assistant or nurse practitioner, bedside nurse, social worker, respiratory therapist, pulmonologist, and nurse case manager.

b

Respondents were able to select >1 barrier for each of the listed behaviors; percentages do not add to 100.

c

P < .001 for this behavior compared with the behavior “ask about TSE.”

d

Barriers to following-up with caregivers after hospitalization were not examined in the survey.

When asked if the following respiratory diagnoses would make hospitalists more likely to ask about TSE, 82% of respondents selected asthma, 69% selected bronchiolitis, 61% selected chronic lung disease of prematurity or bronchopulmonary dysplasia, and 33% selected pneumonia. Teams were more likely to counsel a caregiver to quit smoking for patients with asthma (85%), bronchiolitis (55%), chronic lung disease of prematurity or bronchopulmonary dysplasia (64%), and pneumonia (29%).

Some hospitals had smoking support systems in place, although some respondents were not aware of any at their institution (Table 1). Most respondents (83%) wanted to learn more about smoking cessation, especially counseling (54%) and prescribing pharmacotherapy (54%). Online modules (46%) or webinars (25%) were the most preferred educational methods.

In this study, we confirmed our hypothesis that pediatric hospitalists would frequently ask about TSE and recommend quitting but would less frequently assist caregivers in smoking cessation or prescribe NRT. Consistent education on the physical and psychological impact of SHS and THS, as well as appropriate methods for supporting cessation, is lacking from medical school to residency and beyond.19  Improved education may contribute to increasing the likelihood of hospitalists asking about TSE and supporting caregivers in quitting smoking when their child is hospitalized for any diagnosis, not just respiratory diagnoses, aligning with recommendations to do so at every patient encounter.68  Acknowledging that even brief counseling interventions can be beneficial, almost two-thirds of the respondents in this study spend <5 minutes providing counseling. This can be easily incorporated into hospitalization, regardless of diagnosis. Employing multiple team members can contribute to cessation rates and “denormalize” tobacco use.20 

Several studies have revealed success in organizing TSE screening and cessation counseling in inpatient settings, including use of electronic medical record prompts. This may lessen the common barrier of forgetting to complete steps in cessation counseling, which was seen in this study.16,2123  Support systems did not consistently appear in the institutions represented herein, nor were hospitalists always aware of available resources.

Free public cessation programs, such as quitlines in all US states and Canadian provinces, make referral to local resources quick and easy, but almost half of respondents did not identify them as available to their patients’ families.24,25  Awareness of these programs should be targeted in continuing medical education and public health campaigns.

Prescription of NRT increases quit rates and is within the realm of the pediatrician’s practice because it directly impacts their patients. Most parents accept prescriptions from pediatricians.9,26  Inpatient teams, with multiple types of members and hospital-based support systems, can achieve the effective steps “ask [about tobacco use], assist [with counseling and/or NRT], and refer [to local resources]”27  and provide postdischarge follow-up. These multiple elements during and after hospitalization can increase quit rates; the US Department of Health and Human Services advises that all smokers who receive cessation intervention be contacted afterward to assess treatment success and strategize against challenges.6 

This study was performed in a network of pediatric hospitalists and is thereby limited in its generalizability. However, the geographic and practice diversity of the respondents, as well as their ranges in age and training experiences, provides an important insight into the practices of pediatric hospitalists. Given a low response rate, the possibility of nonresponse bias exists in this voluntary survey. In addition, electronic cigarettes were not investigated given inconsistencies in data on their use in smoking cessation at the time of survey administration.

Although many pediatric hospitalists and inpatient teams ask caregivers about tobacco use, most are not providing evidence-based interventions to advocate for their patients’ health by routinely and consistently asking about TSE and recommending cessation with both resource provision and pharmacotherapy prescription. Hospitals and health systems should support simple solutions, such as electronic referrals to state quitlines as well as comprehensive cessation programs for caregivers of hospitalized children, to reduce TSE and its related harms. Ongoing education to develop physician knowledge and comfort in cessation counseling and use of pharmacotherapy is imperative.

We thank the members of the Trust Fund of the Alumnae/i Association of Women’s Medical College and Medical College of Pennsylvania and the Pediatric Research in Inpatient Settings Network for their support and the Sections of Hospital Medicine at St Christopher’s Hospital for Children and Children’s Hospital Colorado for their encouragement and feedback, their participation in focus groups, and their assistance in our survey design.

The funder or sponsor did not participate in the work.

Dr Dickinson conceptualized and designed the study, led focus groups, interpreted the data, and drafted and revised the manuscript; Drs Thompson and Wilson helped design the study, participated in focus groups, reviewed the data, and reviewed and revised the manuscript; Dr Gracely helped design the study, performed the statistical analysis, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.

FUNDING: Supported by the Mary DeWitt Pettit, MD, Fellowship of the Trust Fund of the Alumnae/i Association of Women’s Medical College and Medical College of Pennsylvania.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: Dr Wilson is deputy editor of Hospital Pediatrics; and Drs Dickinson, Thompson, and Gracely have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.