Barriers and Motivators for Smoking Cessation Among Caregivers of Inpatient Pediatric Patients Free

This is a secondary analysis of field notes recorded during and after motivational interviews, which served as the intervention, during a randomized controlled trial (registration number NCT02281864). This trial consisted of a smoking cessation motivational interviewing (MI) intervention for the caregivers of inpatients at a 412-bed free-standing pediatric hospital in Aurora, Colorado from December 2014 to April 2018. Enrolled families had children 0 to 17 years of age with at least 1 legal caregiver who currently smoked tobacco and lived at home with the child.

Written consent was obtained for all study procedures. The University of Colorado Institutional Review Board reviewed and approved the study. The study was overseen by a Data Safety Monitoring Committee who raised no concerns.

Motivational interviewing (MI) was used as the intervention arm for this study. MI was used along with the 5A model: ask the caregiver about their smoking habits, assess the caregiver’s readiness to quit or reduce smoke exposure, advise the caregiver on reasons to quit or reduce smoking, assist the caregiver in their cessation or reduction plan through MI sessions and nicotine replacement therapy (NRT), and arrange follow up for the caregiver by referring them either to their local quitline or primary care physician.⁷ 

Caregivers randomly assigned to the intervention arm were asked to participate in at least 1 MI session with a tobacco coach trained in MI techniques. The first MI session was used for this analysis. Caregivers were offered up to 3 motivational interview follow-up sessions via phone once their child discharged from the hospital. Tobacco counselors took notes on the MI sessions using a standardized note-taking form with prompting questions, which focused on the caregivers’ past smoking habits, current smoking habits, future goals, current barriers to quitting or reduction, strategies for obtaining their goals, and motivators for quitting or reduction. The notes were then transcribed into REDCap, a secure, electronic application designed for data capture.¹²  A caregiver survey, distributed at enrollment with both the intervention and control groups before randomization, included questions on demographics and number of smokers in the child’s primary home or homes. The study team regularly reviewed the tobacco counselors’ MI sessions, either by audiotape or by in-person observation of sessions, to ensure standardization of MI across tobacco counselors.

The study cohort was limited to subjects or caregivers who completed the first MI visit. The subjects’ responses (written answers on the note-taking form) to questions related to smoking habits and cessation, which were obtained during MI, were coded by 2 individuals (a senior research coordinator and a pediatric hospitalist) by using basic interpretative qualitative study methodology.¹³  Disagreements were resolved by having a third person (a pediatric pulmonologist) code the subjects’ comments and then having a discussion among all 3 coders take place until consensus was reached. Codes were then categorized by these individuals to identify themes around the barriers and motivators to smoking.

Bivariable analysis of the barriers and motivators (indicated versus not indicated) was performed with χ² tests and Fisher’s exact tests for categorical factors and t-tests for continuous factors. Multivariable logistic regression was used to assess demographic and family characteristics associated with the top barriers and motivators.¹⁴  Predictors included in the multivariable analysis were identified a priori and through clinical and statistical significance in the bivariable analysis. Data were analyzed by using SAS version 9.4 software. All statistical tests were performed with a level of significance of 0.05.

Of 124 subjects randomly assigned to the intervention, 99 (80%) completed their first MI session and were included in this analysis. Twenty-five subjects did not complete the first MI session because of scheduling conflicts and early discharge from the hospital. The average age of the caregiver completing the MI session was 31.6 years; 69% were female caregivers; 31% were male caregivers; the average age of the caregiver’s enrolled child was 4.7 years. Fifty-three percent of the caregivers were White, 25% were Hispanic, 16% were African American, and 6% were of another race or ethnicity. Fifty-six percent of caregivers had some college education or more, and 39% of households had >1 smoker in the home.

The barriers to smoking cessation identified included stress; social influence; emotions driving behavior such as self-reported anxiety, self-reported depression, and anger; personal time when smoking is relaxing; addictive habit; mental preparedness; a means to pass the time; access to cigarettes; and association with consumption of food and drinking (Table 1). Stress (57%) and social influence (37%) were the most prevalent barriers. In bivariable analysis, older age of child (mean [SD]: 8.0 [6.5] years vs 4.5 [4.7] years) and older age of parent (mean [SD] 37.6 [9.8] years vs 31.1 [6.8] years) were associated with emotions driving behavior as a barrier. More parents of boys than girls indicated “personal time during which smoking was relaxing” as a barrier to smoking cessation (35% vs 19%) (Table 2). Predictors included in the multivariable analysis for the barrier of stress were race and ethnicity, sex, relationship to child, number of smokers in home, and age of parent. Predictors included in the multivariable analysis for social influence barriers were race and ethnicity, sex, relationship to child, number of smokers in home, and a rating of the amount of encouragement received from family and friends to stop smoking. Multivariable analysis did not identify any significant predictors of endorsing stress triggers or social influence barriers.

The motivators to smoking cessation identified negative side effects of cigarette smoking, financial concerns, social influence, emotions driving behavior such as stigma of smoking and feelings of guilt while smoking, desire to lead a healthy life, desire to improve the child or family’s well-being, and religious reasons (Table 1). Desire to lead a healthy life (54%) and desire to improve the child or family’s well-being (47%) were the most prevalent motivators. In bivariable analysis, older parent age (mean [SD]: 33.1 [6.8] years vs 30.0 [7.1] years) was associated with the desire to lead a healthy life as a motivator, and younger child age (mean [SD]: 3.2 [4.0] years vs 6.0 [5.3] years) was associated with desire to improve the child or family’s well-being as a motivator (Table 3). Predictors in the multivariable model for the desire to a lead healthy life included relationship to child, education of parent, age of parent, and number of smokers in home. However, none were found significant in the multivariable analysis. Predictors in the multivariable model for the desire to improve the child or family’s well-being included relationship to child, education of parent, number of smokers in home, and age of child. After adjusting for other covariates, fewer smokers in the home and younger age of child were associated with endorsing desire to improve the child or family’s well-being as a motivator (P = .0192 and .0089, respectively) (Table 4).

The most common barriers cited by the caregivers in our study were stress and social influences, and the most common motivators were a desire to lead a healthy life and to improve their child or family’s well-being. Knowing these barriers and motivators, health care providers may be able to improve acceptance of smoking cessation assistance and better tailor motivational messaging to the needs of parents in the inpatient setting.

Fifty-seven percent of caregivers in our sample reported stress as a major barrier to smoking cessation. This is not surprising in the context of a child’s hospitalization and suggests that addressing smoking in a pediatric hospital setting should explicitly address stress reduction techniques. Mindfulness activities, including meditation, have been shown to reduce stress and can increase smoking cessation, even without directly addressing smoking.¹⁵  Recent studies have found that introducing a daily mindfulness activity by using a smartphone app can help reduce overall stress and improve psychosocial well-being.^16,17  Providers may recommend free mindfulness applications available on mobile phones to guide parents through quick 5- to 10-minute breathing exercises to relieve stress. Combining the use of an application along with mindfulness-based stress reduction and mindfulness-based cognitive therapy tools may help reduce daily stress in parents and help them develop new coping strategies.

Providers can help caregivers explore why smoking helped relieve stress: was it having something in their hand to distract them? Or taking a 5-minute break for themselves? Such questioning may help the caregiver eliminate the cigarette from their stress response while keeping other stress-relieving habits, such as taking a 5-minute break and going for a brief walk. This method draws upon the Relaxation Response Resiliency Program (3RP), which integrates mindfulness stress coping strategies with goal-setting techniques over multiple weeks to reach stress management goals.¹⁸  While health care providers in the inpatient setting may not have weeks to work with a caregiver, they can instill relaxation strategies and mindfulness tools to be continued as an outpatient with their primary care provider.

Our subjects explained that it was more difficult for them to quit when they were with other smokers. Ideally, if both caregivers smoke, they should both be encouraged to work toward smoking cessation. Administering dual cessation assistance may not be possible in all situations. If a caregiver wants to quit and their partner does not, providers can help identify other people they are close to who do not smoke and who could provide social support. Helping the caregiver identify situations where they will be with other smokers and develop a proactive strategy to avoid smoking can also foster the self-efficacy needed to quit.

Living a healthier life was the most commonly cited motivator for caregivers in our study. Tools that some caregivers found useful were exercising more and snacking on vegetables when experiencing cravings. Caregivers who were most successful with quitting smoking focused on making small behavior changes one at a time. Once they identified what aspects of their health or family’s well-being that they wanted to improve, they set small obtainable goals to work toward to make the changes. Caregivers also reported healthy cooking as a proactive strategy. Cravings are a major barrier to quitting smoking and leading a healthier lifestyle; our caregivers noted that NRT, hard candy, and locking cigarettes away in a hard-to-reach place were means to help curb their cravings.

The second most common motivator among caregivers was a desire to improve their child or family’s well-being. Although it is a popular reason to quit, it can be tricky to discuss the health risks of smoking while a child is hospitalized, because there may be a perception that the health care provider may be judging the caregivers or focusing on the wrong “problem” at hand, which would be counterproductive. MI techniques, such as asking caregivers what their motivators are and waiting for them to bring up their child’s health, allow for an open, nonjudgmental conversation about smoking health risks without the provider seeming judgmental or taking on a lecturing tone.

Institutions with less funding or resources may find it difficult to implement a cessation program as comprehensive as the one used in this research study. A few main themes from this study’s findings may still apply to almost any hospital-based cessation efforts.

If health care providers wish to change their approach to discussing smoking cessation, they should focus on the following: First, they must implement a system to identify families that have a smoker in the home, which would give health clinicians the opportunity to begin cessation discussions. It is well documented that pediatricians feel like they lack knowledge in smoking cessation; therefore, it is recommended that pediatricians seek training in cessation counseling.^19,20  There are free resources that can offer health care workers the necessary tools and instruction (Table 5). Second, it is critical to discuss smoking during pediatric inpatient stays in an efficient, compassionate way. The updated United States Public Health Service (USPHS) report entitled “Treating Tobacco Use and Dependence: A Clinical Practice Guideline” suggests brief and frequent “5A model” interventions with caregivers who smoke.¹¹  Health care workers can focus on 3 of the 5. In brief conversations with caregivers, they can focus on the following:

• Advise: Provide information to caregivers about SHS exposure and benefits of cessation or reduction of SHS exposure to child

• Assess: Help the caregiver explore their willingness to quit via prompts such as

• “What is motivating you to quit?”

• “What may make it difficult for you to quit/what barriers do you have to quitting?”

• Assist: If the caregiver is interested in quitting, provide them resources, such as referral to the local quitline and self-help materials¹¹ 

As with the intervention used in this study, the USPHS recommends incorporating web-based interventions, local quit programs, and self-help materials into the 5A cessation approach.¹¹  If health care providers understand and discuss barriers and motivators to smoking cessation and the associated resources for quitting, they will be able to better care for their patients and families. As previous research has found, the more benefit-oriented and specific the interventions are to the caregiver the more successful the caregiver will be in their cessation efforts.²¹ 

Limitations of this study included that the MI sessions were not recorded; motivators and barriers were coded by using cessation counselor notes. Multiple tobacco counselors worked on the study from 2014 to 2018, so details of notes and subjects’ responses varied. However, a note template was used for conducting MI sessions helping to encourage uniformity of information across tobacco counselors. The study took place in a single Midwestern state with relatively low tobacco use prevalence, and thus our findings may not be generalizable to other regions or areas with greater prevalence.

The inpatient pediatric setting presents a unique opportunity to provide smoking cessation resources for caregivers. As seen at Colorado Children’s Hospital, caregivers experience distinct motivators and barriers to smoking cessations. By providing motivator and barrier-specific resources to caregivers, health care clinicians may be able to better tailor their cessation assistance efforts to the needs of caregivers. The common themes identified among caregivers were stress as a barrier to cessation and leading a healthier lifestyle as a motivator. This finding is congruent with previous smoking cessation behavioral research.²² Cessation counseling using MI techniques focusing on questions related to parental stress, social influences, healthier lifestyles, and improving child well-being may result in more productive conversations about SHS and more successful parental smoking cessation assistance.