PERSONAL PRACTICE

Modifying parental smokinghabits e why and how?Steve Turner

Chest infections

Asthma

Ear infections

Re

spo

nd

en

ts a

gre

ein

g t

ha

t E

TS

ex

po

sure

incr

ea

sed

a c

hil

d’s

ris

k f

or

illn

ess

(%

)

100

75

50

25

0

Introduction

Exposure to second hand smoke (SHS) is associated with several

adverse health outcomes in children. Removing children from

SHS exposure is a priority shared by policy makers and health-

care professionals alike. In addition to the burden of childhood

illnesses, the children of parents who smoke are also at increased

risk for becoming smokers in adulthood and this puts the young

individual at increased risk for conditions likely to shorten their

life span, e.g. malignancies, myocardial infarction, chronic

obstructive pulmonary disease and stroke. Parents love their

children and endeavour to provide a safe and healthy environ-

ment for their offspring and smokers know that SHS exposure is

harmful to children (Figure 1) but approximately 40% of children

in the UK continue to be exposed to SHS by their parents.

Exposure of children to SHS is an issue involving a complex

blend of addiction, social pressures and health outcomes. The

aims of this review are (i) to provide clinicians with an up-to-date

brief of what is known about modifying children’s exposure to

SHS, (ii) a summary of what remains to be understood about SHS

exposure and (iii) to provide clinicians with practical advice on

approaching parent who smoke.

What is known about parental smoking?

Approximately three quarters of mothers who smoke and have

children who attend hospital have tried to quit in the past and

a similar proportion is either contemplating or prepared to quit.

Smoking mothers are up to six times more likely to have

a partner who smokes compared to non-smoking mothers and

therefore interventions aimed at reducing SHS should be directed

beyond the child’s mother. One study found evidence to suggest

that having an ill child in hospital presented a “teachable

moment” where by parents are more likely to quit, but this has

not been replicated elsewhere. Coming to hospital with an ill

child is a stressful business and might be exactly the wrong time

to raise the subject of cessation, and this has been our anecdotal

experience. Having completed a semi-qualitative/epidemiolog-

ical study we saw that many parents who smoked were prepared

to quit and expressed an interest in smoking cessation. We were

heartened by this and undertook a feasibility study to recruit

parents attending hospital outpatients onto a smoking cessation

programme; of the 250 parents approached, 80 were smokers

Steve Turner MD MRCP FRCPCH is a Senior Lecturer in Child Health at the

University of Aberdeen School of Medicine and the Department of Child

Health, Royal Aberdeen Children’s Hospital, Foresthill, Aberdeen AB25

2ZG, UK. Conflict of interest: none.

PAEDIATRICS AND CHILD HEALTH 20:9 447

and of these only one was enrolled. Engaging parents in smoking

cessation in the child health setting is a big challenge and

perhaps should be done at home rather than in the hospital

setting.

What remains to be understood

In a perfect world

In a perfect world, the interventions which are effective in adults

who wish to quit smoking would be effective parents (who are

adults after all) but life is rarely straightforward! The brief

interventions which are effective in changing smoking behav-

iour, for example handing out an information leaflet, are not

effective when given to parents in the child health setting. In

a randomized control trial on Tayside, parents of 500 children

were given a brief intervention, warned of the harmful effects

of passive smoke exposure on children and followed up after

12 months. On review, 98% of parents continued smoking, the

children’s SHS exposure (urinary cotinine) was unchanged

between the intervention and control groups and the authors

suggest that the brief intervention might even have entrenched

smoking habits in some parents. A second randomized controlled

trial, also of almost 500 parents, involved a brief intervention in

the form of a 15 min interview but this did not alter quit rates or

daily cigarette consumption. A recent Cochrane review identified

36 intervention studies aimed at reducing children’s SHS expo-

sure, including 19 studies from the USA where the findings may

not necessarily be transferable to the UK. In only 11 studies did

the intervention reduce SHS exposure of children compared to

controls; often SHS exposure was reduced in both groups. The

more successful studies tended to include intensive counselling,

for example three 45 min interviews and four follow-up tele-

phone calls. One American study where parents were random-

ized to receive seven counselling sessions over 3 months

reported a 50% reduction in urinary cotinine 12 months after

entering the study; importantly this study changed the children’s

Non-

smokers

Ex-

smokers

‹ 20

cigarettes/

day

› 20

cigarettes/

day

Figure 1 The proportion of adults who agree that environmental tobacco

smoke (ETS) exposure is a risk for children’s chest infections, asthma and

ear infections. Figure made from raw published data.

� 2010 Elsevier Ltd. All rights reserved.

Smoking behaviours which do not reduce children’s

PERSONAL PRACTICE

SHS exposure by modifying mother’s smoking practices but not

by significantly altering the mother’s own cotinine.

exposure to second hand smoke3

Idealism versus pragmatism

� Opening windows or doors

� Smoking less

� Not smoking in front of the children

� Smoking in different rooms

� Smoking out of the window

� Smoking outside in front of an open door

� Smoking under the kitchen extractor fan

� Air purifiers

Table 2

Whilst idealists might focus on motivating parents to quit

smoking, pragmatists might argue that in the child health setting

the focus should be reducing the child’s SHS exposure by

whatever means. One method for reducing children’s SHS

exposure is to introducing a smoke-free home, i.e. all residents

and visitors do not smoke in the house, but these can be difficult

to establish (Table 1). Smoke-free homes are becoming more

acceptable in the UK where the proportion rose from 21% to 37%

between 1996 and 2007. Importantly, smoke-free homes are

effective in reducing children’s SHS exposure (Figure 2) and can

be introduced as part of an acceptable change in behaviour.

Many households continue to permit smoking indoors but

restrict this activity to certain rooms but this behaviour does not

reduce children’s SHS exposure (also see Table 2). Whereas SHS

exposure in the home is usually chronic but relatively low, SHS

exposure in cars can be brief but relatively high and introducing

a smoke-free car may also reduce SHS exposure, although the

evidence for this is lacking. What is known is that SHS exposure

in cars can be unsafe for children. In summary, what is known is

that children’s SHS exposure can be reduced and this requires

fairly intensive counselling but not necessarily parents quitting.

What is not known about second hand smoke exposure?

Although the presumption is that SHS is harmful to children,

supportive evidence can only arise from intervention studies and

there are surprisingly little data upon which to promote SHS

avoidance. In fact, at the time of writing, there are only two

published studies (both from USA) which have reported the

impact of reduced SHS exposure on children’s health. In the first

study, parents of 87 asthmatic children were randomized to

receive standard asthma education or standard education plus

three smoking counselling sessions (including a video titled

“Poisoning Our Children”); over the following 12 months, the

enhanced intervention was associated with reduced visits to the

doctor or hospital with acute asthma. The enhanced intervention

was not associated with a significant reduced SHS exposure, as

evidence by urinary cotinine, but the study was underpowered to

detect a difference. In the second study, 133 mothers who

smoked and who had asthmatic children were randomized to

receive either smoking cessation advice or advice which focused

on the child’s risk from SHS (including giving mothers their

child’s measured nicotine exposure). Both arms of the study

received three interviews at home and a 5e10 min follow-up

Factors that might prevent mothers from introducingsmoke-free homes

� Partner, relations (e.g. grandparents) and visitors continue to

smoke indoors

� Inability to leave child unsupervised while smoking outside

� It can be cold and wet when smoking outside

� Addiction to tobacco

Table 1

PAEDIATRICS AND CHILD HEALTH 20:9 448

telephone consultation. The children’s nicotine exposure fell five

fold in those whose mothers were given smoking cessation

advice and by only 20% in the other group. Children’s asthma

symptoms improved significantly in both groups although at the

end of the study, somewhat surprisingly, only those children

whose mothers were given risk reduction advise had less asthma

symptoms. This study perhaps asks more questions than it

answers but it suggests that an intervention which takes place in

the home (and not hospital), which focuses on the child’s

exposure (and not mother quitting) and where biofeedback (e.g.

nicotine) may be effective in improving children’s health. There

is indirect evidence that reduced SHS exposure yields health

benefits for children provided by studies in pregnant women

where smoking cessation interventions are associated with

increased birth weight. Despite the absence of overwhelming

evidence, the precautionary principle* empowers policy makers

and clinicians to tell parents that SHS exposure is harmful.

What is a safe exposure?

The exposureeresponse relationship between SHS and child

health is also not described but evidence from studies of foetuses

and adults with cardiovascular disease suggests that the relation-

ship is not linear and passes through zero (Figure 3). The rela-

tionship between birth weight and maternal daily cigarette intake

is linear below five to eight cigarettes and flattens out thereafter. A

similar relationship is described for adult cardiovascular risk and

indoor air pollution, where SHS is a major contributor. The prac-

tical relevance of these observations is that reducing SHS exposure

from a high to intermediate value may not translate into greatly

reduced child health outcomes (Figure 3); there is almost certainly

no safe level of SHS exposure.

In the future, what is needed is (i) a better understanding of

how to engage parents in reducing their child’s SHS exposure and

(ii) a better understanding of the exposureeresponse slope

between SHS and health outcomes.

* Where an action or policy has suspected risk of causing harm to the

public or to the environment, in the absence of a scientific consensus that

harm would not ensue, the burden of proof falls on those who would

advocate taking the action.

� 2010 Elsevier Ltd. All rights reserved.

Geometric mean children’ssalivary cotinine (ng/ml)

Non-smoking

household

Smoke-free house

(1 smoker)

Smoke-free house

(2 smokers)

Non-smoke-free

house (1 smoker)

Non-smoke-free

house (2 smokers)

0 1 2 3

Figure 2 Salivary cotinine (an index of second hand smoke exposure) in

children where a smoke-free house was and was not introduced. Figure-

made from raw published data.

PERSONAL PRACTICE

Approaching the parent who smokes

There is a rather thin evidence base to guide clinicians through

the challenging waters of reducing children’s SHS exposure.

Inevitably there is a need for more research, and these studies are

under way. For the present, there is an American consensus

statements to which the reader could refer [Winickoff 2005] and

a few points for child health workers to consider:

1. The focus for advice should be on reducing the child’s

exposure and not parental smoking cessation since not all

SHS exposure comes from parents. A smoke-free house (and

probably also smoke-free car) is effective in reducing chil-

dren’s SHS exposure.

2. Clinicians could make themselves aware of local NHS

smoking cessation services and perhaps arrange an educa-

tional meeting. The NICE guideline states that “All health

He

alt

h o

utc

om

e

Second-hand smoke exposure

Figure 3 A model which summarizes the potential relationship, and its

uncertainties, between health outcome and exposure to second hand

smoke inferred from outcomes described in foetuses and adults.

PAEDIATRICS AND CHILD HEALTH 20:9 449

professionals, such as hospital clinicians, pharmacists and

dentists, should refer people who smoke to an intensive

support service (for example, NHS Stop Smoking Services)”.

3. Interventions by persons trained in motivational interview-

ing are more likely to be effective but are more time-

consuming than brief interventions. Medical and nursing

staff involved in respiratory paediatrics might benefit their

patients from undergoing relevant training.

A

FURTHER READING

Akhtar PC, Currie DB, Currie CE, et al. Changes in child exposure to

environmental tobacco smoke (CHETS) study after implementation of

smoke-free legislation in Scotland: national cross sectional survey.

Br Med J 2007; 335: 15.

BMA Board of science. Breaking the cycle of children’s exposure to

tobacco smoke, http://www.bma.org.uk/ap.nsf/AttachmentsByTitle/

PDFbreakingthecycle/$FILE/Breakingcycle.pdf; 2007.

Borrelli B, McQuaid EL, Novak SP, et al. Motivating Latino caregivers of

children with asthma to quit smoking: a randomised trial. J Consult

Clin Psychol 2010; 78: 34e43.

Department of Health. Smoking kills: a white paper on tobacco. London:

Stationary Office, 1998.

Dolan-Mullen P, Ramirez G, Groff JY. A meta-analysis of randomized trials

of prenatal smoking cessation interventions. Am J Obstet Gynaecol

1994; 171: 1328e34.

Emmons KM, Hammond SK, Fava JL, et al. A randomized trial to reduce

passive smoke exposure in low-income households with young chil-

dren. Pediatrics 2001; 108: 18e24.

England LJ, Kendrick JS, Wilson HG, et al. Effects of smoking reduction

during pregnancy on the birth weight of term infants. Am J Epidemiol

2001; 154: 694e701.

Gilman SE, Rende R, Boergers J, et al. Parental smoking and adolescent

smoking initiation: an intergenerational perspective on tobacco

control. Pediatrics 2009; 123: e274e81.

Groner JA, Ahijevych K, Grossman LK, et al. The impact of a brief inter-

vention on maternal smoking behavior. Pediatrics 2000; 105: 267e71.

Hebel JR, Fox NL, Sexton M. Doseeresponse of birth weight to various

measures of maternal smoking during pregnancy. J Clin Epidemiol

1988; 41: 483e9.

Hovell MF, Zakarian JM, Matt GE, et al. Effect of counselling mothers on

their children’s exposure to environmental tobacco smoke: rando-

mised controlled trial. Br Med J 2000; 321: 337e42.

Irvine L, Crombie IK, Clark RA, et al. Advising parents of asthmatic children

on passive smoking: randomised controlled trial [see comment]. Br

Med J 1999; 318: 1456e9.

Jarvis MJ, Mindell J, Gilmore A, et al. Smoke-free homes in England:

prevalence, trends and validation by cotinine in children. Tob Control

(Online Ahead of Publication) 2009; 18: 491e5.

Miller M, Gow D, Tappin D, et al. Smoking habits of parents attending

a children’s hospital. Arch Dis Child 2007; 92: 1118e9.

NICE. Brief interventions and referral for smoking cessation in primary

care and other settings, http://www.nice.org.uk/nicemedia/pdf/PH001_

smoking_cessation.pdf; 2006.

Office for National Statistics. Smoking-related behaviour and attitudes,

http://www.statistics.gov.uk/downloads/theme_health/smoking2008-

9.pdf; 2008e9.

� 2010 Elsevier Ltd. All rights reserved.

Practice points for reducing children’s second handsmoke exposure

� Preventing exposure is probably the single most effective

method of improving a child’s health in the short, medium and

long term.

� The focus should be on reducing the child’s exposure and not

primarily parents quitting.

� Clinicians should be more aware of local smoking cessation

services.

� Brief, single interventions are less successful in changing

parents smoking behaviour compared with a series of meet-

ings between parent and trained advisor.

PERSONAL PRACTICE

Phillips R, Amos A, Ritchie D, et al. Smoking in the home after the smoke-

free legislation in Scotland: qualitative study. Br Med J 2007; 335: 15.

Pope 3rd CA, Burnett RT, Krewski D, et al. Cardiovascular mortality and

exposure to airborne fine particulate matter and cigarette smoke:

shape of the exposureeresponse relationship. Circulation 2009; 120:

941e8.

Priest N, Roseby R, Waters E, et al. Family and carer smoking control

programmes for reducing children’s exposure to environmental

tobacco smoke. Cochrane Database Syst Rev 2008; 4.

Roseby R, Waters E, Polnay A, et al. Family and carer smoking control

programmes for reducing children’s exposure to environmental

tobacco smoke. Cochrane Database Syst Rev 2003; 3.

Spencer N, Blackburn C, Bonas S, et al. Parent reported home smoking

bans and toddler (18e30 month) smoke exposure: a cross-sectional

survey. Arch Dis Child 2005; 90: 670e4.

Strachan DP, Cook DG. Health effects of passive smoking. 1. Parental

smoking and lower respiratory illness in infancy and early childhood.

Thorax 1997; 52: 905e14.

Wilson SR, Yamada EG, Sudhakar R, et al. A controlled trial of an envi-

ronmental tobacco smoke reduction intervention in low-income chil-

dren with asthma. Chest 2001; 120: 1709e22.

Winickoff JP, Hibberd PL, Case B, et al. Child hospitalization: an oppor-

tunity for parental smoking intervention. Am J Prev Med 2001; 21:

218e20.

PAEDIATRICS AND CHILD HEALTH 20:9 450

Winickoff JP, Hillis VJ, Palfrey JS, et al. A smoking cessation intervention

for parents of children who are hospitalized for respiratory illness: the

Stop tobacco outreach program. Pediatrics 2003; 111: 140e5.

Winickoff JP, Berkowitz AB, Brooks K, et al. State-of-the-art interventions

for office-based parental tobacco control. Pediatrics 2005; 115:

750e60.

� 2010 Elsevier Ltd. All rights reserved.