Preferred Smoking Cessation Methods for Asian or Pacific Islander Household Smokers Who Live with Hospitalized Children

Abstract

Introduction

A qualitative study was conducted to determine preferred smoking cessation methods among Asian or Pacific Islander (API) smokers who live with hospitalized children. This study occurred in a children's hospital where a new cessation program would be developed.

Methods

Twenty-six API smokers who live with children admitted to the hospital were interviewed and tape-recorded. Responses to survey questions were transcribed, categorized, and analyzed.

Results

73% were interested in quitting, 34% within the next 30 days. Few would independently use the quit-line (31%) or attend group classes (4%). However, if offered during their child's hospitalization, 52% would sign up for individualized counseling and 29% would attend group sessions. Respondents believed advice would be helpful from their physician (71%), child's pediatrician (65%), nurse (64%), respiratory therapist (65%), or smoking cessation counselor (75%).

Conclusions

The majority of API smokers were interested in quitting and receptive to one-on-one counseling. Advice would be helpful from any healthcare professional.

Introduction

Environmental tobacco smoke (ETS) exposure, created by smokers living in households with children, imposes a significant burden on child health and wellness. Tobacco smoke has been identified as a Class A Carcinogen, containing greater than 4000 chemical toxins or intoxicants that contribute to significant illness and disease.¹ It is well established that children who live in households with smokers, compared to children who live in smoke-free homes, suffer more asthma, upper and lower respiratory tract infections, middle-ear disease, pneumonia, and other serious bacterial infections.^2,3 Additionally, studies link ETS to Sudden Infant Death syndrome, low birth weight, spontaneous abortions, as well as adverse neurodevelopmental and behavioral effects.^2–4 Although the smoking prevalence in Hawai‘i is down to 15.4%,⁵ smoking among Asian and Pacific Islanders (API) is disproportionately high at 21% for Native Hawaiians, 30% for Pacific Islanders, and 18% for Filipinos.⁵ Of special concern is data suggesting that 50% of Hawai‘i's children are exposed to daily household smoke and only 13% of households with smokers have rules banning smoking inside the home.⁵ In addition, young adult smokers (ages 18–35), who best represent the subpopulation of parent smokers who put young children at risk for serious illness, have the highest rates of smoking at 19–21%.⁵ Despite the high smoking prevalence, it should be noted that this subpopulation is more likely to try quitting and to be successful than older, more established smokers.^6,7

While it is estimated that 60–85% of young adult smokers make serious attempts to quit smoking each year, the vast majority do so without counseling or pharmacologic aid.^6,7 In fact, national surveys suggest that among smokers who attempt to quit, only 10–40% used behavioral interventions such as group, individual, or telephone counseling.^7,8 Although these surveys do not subcategorize young adult smokers into parent smokers, studies specifically targeting parent smokers report that the majority would accept enrollment into counseling programs offered during their child's health care visits.^9–14 Although the long-term effectiveness of such interventions has not been well established, these findings suggest that a hospitalization could serve as an opportune time to help parents quit smoking.

Of the limited number of studies that have been done in this setting, the newborn nursery and the inpatient pediatric units have been identified as sites where parent smokers have enrolled and subsequently been able to successfully complete a smoking cessation program.^10,11,14 A hospitalization represents a unique intervention opportunity to reach adult smokers. Adults who are in the hospital for either the birth of their child or for an illness are an ideal target group for smoking cessation interventions. Having a hospitalized child can represent a teachable moment for the adult smoker, which may make them more ready to attempt to quit. In addition, adult smokers are a captive audience, and often have long periods of down time when their child is sleeping or otherwise engaged. In this regard, the hospital serves as an opportune site where a smoking cessation intervention could be easily delivered.

To help eliminate ETS among Hawai‘i's children, we sought to develop a hospital-based smoking cessation program for parent smokers at a tertiary care children's hospital in Hawai‘i. Serving as the only pediatric referral center for Hawai‘i and the Pacific Basin, this hospital services a significant number of sick children, predominantly of Asian and Pacific Islander descent. Because the studies described above reflect responses from predominantly Caucasian populations, it is not known if API in Hawai‘i would have similar attitudes and preferred smoking cessation methods. Hence, to improve likelihood of success for our hospital-based program, a qualitative study was conducted to determine smoking attitudes and cessation needs of API smokers in this hospital setting.

Methods

Study Population

This study took place at a children's tertiary care hospital that services pregnant women, newborns, and children. It is the only children's hospital in Hawai‘i and is a referral center for the State of Hawai‘i and the Pacific Basin. This study targeted adult smokers that live with children admitted to this hospital, because this would be the site for implementation of a new smoking cessation program. Smokers were offered participation if they were greater than 18 years old, current smokers, and living in a household with a child or newborn at the time of data collection. Smokers were excluded if they were not of Asian or Pacific Islander ethnicity, did not speak English, were 17 years old or younger, did not live with the hospitalized child, or refused to sign consent.

Recruitment

Approval was obtained from the hospital Institutional Review Board prior to implementation. We used the Electronic Medical Record database to identify all smokers admitted to the hospital. As part of routine care, all triage nurses complete a section on the top portion of the medical record documenting adult household smoking status. Each day during the study period, our project personnel created a list of all rooms with positive smoking status and visited these rooms on random days of the month to offer participation in our study.

Two interviewers with experience in public health and tobacco prevention were trained to interview program participants according to a standardized study protocol. Interviewers visited each pre-identified hospital room, announced that a study was being conducted to learn about smoking cessation needs of adult smokers who live with children, and offered voluntary participation. Interviewers determined if participants met the inclusion criteria described above. Participants were asked if they would answer survey questions and allow the interviewer to tape record the interview. Interviewers explained that the purpose of tape recording was to verify the accuracy of information recorded by interviewers. All subjects were told that their participation or refusal to participate would not affect the healthcare provided to their child. Participants who met inclusion criteria and agreed to voluntarily participate were offered a $10 gift certificate to a local vendor as incentive and compensation for their time. Interviews lasted an average of 15–30 minutes per session; this time was spent solely on completing each questionnaire. Interviewers obtained consent to participate and entered interview information onto a standardized survey.

Study Design

A qualitative study design was used where trained interviewers completed one-on-one interviews with smokers in our target population. Responses were entered onto a standardized survey questionnaire, as well as recorded and transcribed. Items from our survey questionnaire were based on previously validated measures¹⁵ which were tailored to be culturally appropriate for our population and setting. There were 8 categories of questions asked: current smoking habits, previous quit attempts, triggers, barriers, cessation strategies, readiness to quit, home environment, and preferred resources in a hospital setting. There were 45 questions in total. Recruitment continued until consistent themes emerged during the interviews. All recorded responses were reviewed and grouped into categories based on responses. Two independent investigators assigned all responses into categories and compared groupings until 100% consensus was achieved. Frequency of themes was determined, and quotes that best captured these opinions were selected.

Results

Demographics

A total of 26 parent smokers participated in this study (response rate = 100% of all API smokers asked). All participants were either of Asian or Pacific Islander ethnicity. Fifteen (58%) were women; the mean age was 28 years. Mean years of smoking was 11.3, mean age of first cigarette smoked was 15.1, and 73% had made at least one prior quit attempt. Fifty percent of smokers were parents of newborns just delivered; the remainder represented parents of children admitted to the inpatient pediatric ward.

Attitudes About Smoking

Smokers identified stress (46%), boredom (15%), and contact with other smokers (27%) as the most significant triggers for smoking. 73% of respondents were interested in quitting, with only 34% willing to quit within the next 30 days. Factors most helpful to quitting included: family encouragement (24%), avoiding other smokers (24%), and having the right mental attitude (16%). When asked about reasons for failed quit attempts or relapse, smokers attributed stress (38.5%), exposure (15.4%), and cravings/habit (7.7%).

A characteristic response to the top reason for smoking was, “The stress is there, and I smoke to relieve the stress. I would have to find something to replace the habit when stressed.” Many smokers also identified living, working, and socializing with other smokers as a trigger for smoking, as well as a barrier to quitting. Representative attitudes included: “the hardest part to quit smoking is that everyone else I know smokes,” and “it's hard to be around other people that smoke.”

Preferred Cessation Methods

Smokers ready to quit in the next 30 days would use the following cessation methods: nicotine replacement therapy (NRT, 69%), oral medication (42%), the tobacco quit-line (31%), or group cessation classes (4%). If offered during their child's hospitalization, 52% would attend one-on-one counseling while only 29% would attend group sessions. Participants would find advice helpful from: their own physician (71%), their child's pediatrician (65%), a nurse (64%), a respiratory therapist (65%), or a smoking cessation counselor (75%).

Common themes were identified when discussing quitting and motivators for quitting. Many smokers wanted to quit in order to improve the health of their children. Statements included: “my daughter likes to copy it - smoking a cigarette…when she tries to do it, we take it away from her,” “my kids always want me to quit,” and “they learned a lot about [smoking] in school, and they don't like [my smoking].” Regarding preferred cessation methods, smokers who preferred one-on-one interventions felt, “if it were here [in my hospital room] I wouldn't have to go anywhere, and it would be easy. I'm here for some time, so if I can stay in my room or go down the hall, it would be convenient.” Few commented on the use of the tobacco quit line, while those that did stated, “it doesn't help at all, it doesn't help me.”

Discussion

This study was conducted to determine smoking cessation preferences among API parent smokers in a hospital-based setting. Our qualitative findings describe attitudes about smoking and quitting so that a smoking cessation program could be developed that best addressed the needs of this important target population. In addition, findings from our study allowed for comparisons to be made between our local API population and other findings in the literature. Our findings suggest that in our unique setting, over half of parent and household smokers who are ready to quit would participate in a hospital-based smoking cessation program if offered. Our study also suggests that one-on-one counseling during their child's hospitalization would be the preferred smoking cessation program to offer.

This study is unique in that it specifically targets API smokers who are either parents or live in households with children. This represents an important demographic group that has not been well studied, and one that exposes Hawai‘i's children to significant morbidity through daily second hand smoke exposure. As mentioned previously, APIs represent a group with disproportionately high smoking rates in Hawai‘i: 21% for Native Hawaiians, 30% for Pacific Islanders, and 18% for Filipinos.⁵ Furthermore, our hospital-based population of parent and household smokers represents a significant subpopulation that imposes serious risk for adverse health effects to Hawai‘i's most vulnerable children: infants who have just been born, or children who are so acutely ill that they require hospitalization.

A limited number of studies have been reported that describe attitudes and cessation preferences among smokers who live in households with children. While some may argue that a stressful hospital environment may not be an ideal time to offer parents participation in a smoking cessation program, surveys have reported acceptability rates as high as 56–94% for parents to enroll in a smoking cessation program if offered by their child's physician in the outpatient clinic, hospital, newborn nursery, or emergency room.^9,10,13,14 Our study similarly reports a high acceptability rate of 52%, and even further describes that smokers in our target population would find advice helpful not only from their own physician (71%), but their child's pediatrician (65%), a nurse (64%), a respiratory therapist (65%), or a smoking cessation counselor (75%).

Of note, only a small proportion of API respondents in our study reported that they would independently use a telephone quit line program (31%) or be willing to participate in group cessation classes (4%). Interestingly, in a recent national survey, with greater than 75% Caucasian respondents, 64% of parent smokers said that they would accept enrollment in a telephone cessation program if offered by their child's pediatrician.¹⁶ It should be noted that the national average for quit line usage in the United States was 2.8%, with only 6% of all Hawai‘i smokers using the quit line during the year 2007, when this study took place.¹⁷ Interestingly, 29% of our population would be interested in using the quit line if offered during their child's hospitalization.

While one could speculate that differences in acceptability and usage rates could be attributable to differences in ethnicity, geographic location, and culture. Determining these causes is beyond the scope of this study. However, there were many common opinions that provided insight to reasons for wanting to quit smoking and preferred methods for quitting. Several participants commented, “My kids want me to quit. They hear about it in school…and don't like [my smoking].” A few also described being bothered when their children “copy the motion of smoking.” Many participants from our target population reported, “I want to quit for my children” but smoke or have difficulty quitting because “the stress is there, I smoke to relieve the stress. I would need to find something to replace the habit when stressed.” Other representative statements included, “it's hard to be around others that smoke,” “being able to talk to people would help me quit smoking,” and “if it were here [in my hospital room] I wouldn't have to go anywhere, and it would be easy…it would be convenient.”

The effectiveness of hospital-based smoking cessation interventions has been reported to result in long-term quit rates as high as 60–70% among adult hospitalized patients.^18,19 However, it should be noted that a recent Cochrane review concluded that brief interventions that have been identified as successful for adult interventions cannot be extrapolated to adults as parents in child health care settings.²⁰ Our qualitative findings suggest that smokers that are parents have a unique motivation to want to quit; the health of their children. In addition, it would not be unreasonable to speculate that being a caretaker or provider for a child creates a unique stress that smokers without children do not have. These factors support the idea that parent smokers are a unique subgroup of adult smokers whose cessation preferences and potential for success with quitting may differ from the general adult population.

Currently, the long-term effectiveness of interventions aimed at reducing household second hand smoke exposure has not been well established. A recent Cochrane review identified at least four studies that provided evidence for the effectiveness of intensive counseling offered to parent smokers in the clinical setting.²⁰ Although randomized, controlled intervention studies are lacking, our feasibility study is consistent with findings reported by others in the literature; parent smokers are interested and willing to receive help from a health care professional if offered during their child's hospitalization. Finally, it should be remembered that young adult smokers are not only more likely to attempt quitting, but more likely to be successful in quitting.^6,7 Hence, pediatricians and other child health care professionals should be encouraged to routinely offer cessation support to parent and household smokers of their patients.

This study has several limitations. We recognize that a small sample size was used; however, the purpose for this study was to learn through qualitative analysis what smokers in our target population believed would best help them quit. Although we could have interviewed more participants, limiting our data to twenty-six respondents was felt to be adequate to establish common themes among those surveyed.

This study was also limited because the actual breakdown of Asian and Pacific Islander ethnicities was not captured. Although it may have been helpful to break down our participant demographics by specific Asian or Pacific Islander ethnic groups, our sample size was intentionally small; hence the number of participants representing each ethnic group would have been even smaller. Furthermore, many of the studies we reviewed only described ethnicity by Caucasian, non-Caucasian, or Asians. Hence, for comparison purposes, further sub-classification of ethnicity would not have been necessary or useful.

Finally, this study occurred in only one hospital setting, based in the Pacific Ocean, yet uniquely still a part of the United States. Hence, attitudes and beliefs from our API population may not represent cultural attitudes or opinions of parent smokers of API descent on the mainland US, Asia, or even from countries represented in the Pacific Islands. However, this study does add to the literature unique insight about API smokers who care for and live with the most vulnerable and sickest children in Hawai‘i and the Pacific Basin. Future studies should be directed at measuring the effectiveness of interventions that reduce second hand smoke exposure for this vulnerable population.

Conclusion

In summary, our findings suggest that most API smokers who are ready to quit would be amenable to enrolling in a hospital-based smoking cessation program if offered during their child's hospitalization. Parent and household smokers who live with children represent a unique subpopulation of the adult smoking population. Differences in preference for quitting may exist between our API parent smoking population and the general US population. Despite differences, all pediatric health care professionals should be encouraged to routinely and emphatically offer participation to parent smokers during their child's health care visit.