Triple Tobacco Screen Opportunity to Help Families Become Smokefree

Abstract

Background

American Academy of Pediatrics policy recommends that pediatricians document environmental tobacco smoke (ETS) exposure of a child at every visit. The extent to which pediatricians adhere to this policy, however, is unknown.

Purpose

The goal of the study was to examine the extent to which pediatricians screen parents for tobacco use and home- and car-related smoking rules. Further, the potential association between factors associated with pediatrician inquiry into parental tobacco use and rules is examined.

Methods

Post-visit exit interviews were conducted in ten pediatric practices between June 2009 and March 2011 with parents whose children had been seen by a healthcare provider. Parents were considered to have been given the “triple tobacco screen” if they reported being asked by a pediatric healthcare provider about their smoking behavior, smokefree home rules, and smokefree car rules. Bivariate analysis and multivariable logistic regression was done to explore factors associated with parents being given any component of the triple tobacco screening. Data were analyzed between March 2012 and February 2013.

Results

Of 9145 parents interviewed, 20% of the parents reported being asked at least one question from the triple tobacco screen, and only 9% reported being asked all three questions. Overall, 17% of parents reported being asked about their smoking status, 16% about smokefree home rules, and 11% about smokefree car rules. Few smoking parents (23%) and fewer nonsmoking parents (19%) were screened about their tobacco use and behavior.

Conclusions

Pediatricians infrequently addressed ETS exposure of children among parents who do and do not smoke. Substantial missed opportunities may exist to counsel smokers and reduce ETS exposure of children in the most common exposure locations—the home and car.

Background

Adverse health effects of childhood environmental tobacco smoke (ETS) exposure include upper respiratory infections,^1–4 sudden infant death syndrome,^5,6 and severity of asthma symptoms.⁷ Pediatric office visits provide teachable moments for pediatricians to encourage parents to quit smoking and provide their children with a smokefree environment.^8,9 An American Academy of Pediatrics (AAP) policy recommends that pediatricians place high priority on tobacco control goals to improve children’s health, which includes addressing smoking with families, assisting families in becoming tobacco free, and adopting smokefree home and car policies.¹⁰ This paper examines the extent to which pediatricians screen parents for their smoking status, and for smokefree home and car rules, using survey data collected from parents exiting their child’s pediatrician’s office. Further, the potential association between factors associated with pediatrician inquiry into parental tobacco use and home and car smoking rules is also examined.

Methods

Data collected at ten pediatric research in office settings¹¹ pediatric practices located in eight states (Alaska, Connecticut, Missouri, New Mexico, Pennsylvania, South Carolina, Tennessee, Virginia) were analyzed. Practices enrolled in the study at different time points and data were collected between June 2009 and March 2011. The study protocol was approved by the IRBs of AAP and Massachusetts General Hospital, and individual practice IRBs as required. Data were analyzed between March 2012 and February 2013.

At each practice, post-exit interviews were conducted with parents at the end of their child’s visit. Parents were eligible to enroll in the study if they reported being a smoker. All parents exiting the practice were screened until approximately 100 parents were enrolled from that practice. To determine if the “triple tobacco screen” was administered during their visit, parents were asked: “At any time in your visit today did anyone ask if you”: (1) smoke cigarettes; (2) have a smokefree home; (3) have a smokefree car.

Data Analysis

Rates of asking “triple tobacco screen” components were examined. Chi-squared tests were used to assess bivariate associations between screening by the pediatrician and parent, child and visit characteristics. Variables that were significant in the bivariate analysis were included in a multivariate model while adjusting for parental age, gender, education, and race. Single imputation was employed to retain cases missing values for any predictors in the model. A generalized linear mixed model was used that adjusted for clustering within practice using GLLAMM.¹² Adjusted risk ratios (ARRs) and 95% CIs were calculated for each variable from the final model. All p-values are two-sided and were considered significant at <0.05. All analyses were conducted using Stata statistical software, version 10.

Results

Of 9145 parents screened, 81% were women; 64% attended some college, and 59% were white (Table 1). Overall, 20% of parents reported being asked at least one question from the triple tobacco screen; 9% were asked all three questions; 17% were asked about self-smoking; 16% were asked about smokefree home rules; and 11% about smokefree car rules. Among parents screened for tobacco use, the most common pattern was to be asked about all three sources (45%); followed by parental smoking plus home ETS (21%); and parental smoking only (19%).

Table 1.

Factors associated with being screened for environmental tobacco smoke exposure (N=9145)

Characteristic	n (%)	Asked about any exposure, n=1802 (20%); n (%)	Not asked about any exposure, n=7343 (80%), n (%)	p-value
Age, years				<0.001*
≤30	3409 (37)	876 (26)	2533 (74)
>30	5697 (62)	922 (16)	4775 (84)
Gender				0.625
Male	1709 (19)	344 (20)	1365 (80)
Female	7436 (81)	1458 (20)	5978 (80)
Race and Ethnicity				<0.001*
Hispanic (any race)	1457 (16)	314 (22)	1143 (78)
White, non-Hispanic	5369 (59)	776 (14)	4593 (86)
Black or African-American, non-Hispanic	1700 (19)	579 (34)	1121 (66)
Other	523 (6)	117 (22)	406 (78)
Education				<0.001*
<High school	517 (6)	131 (25)	386 (75)
High school graduate	2716 (30)	614 (23)	2102 (77)
Some college	2674 (29)	554 (21)	2120 (79)
College graduate	3224 (35)	499 (15)	2725 (85)
Smoking status
Smoker	1542 (17)	352 (23)	1190 (77)	0.001*
Nonsmoker	7597 (83)	1450 (19)	6147 (81)
Youngest child’s age, years				<0.001*
<1	2389 (26)	716 (30)	1673 (70)
1–4	3177 (35)	569 (18)	2608 (82)
5–9	1872 (20)	289 (15)	1583 (85)
≥10	1632 (18)	212 (13)	1420 (87)
Child’s insurance coverage				<0.001*
Medicaid	3467 (38)	839 (24)	2628 (76)
Private insurance	4773 (52)	722 (15)	4051 (85)
Other/self-pay	849 (9)	227 (27)	622 (73)
Reason for visit				<0.001*
Well-child	3802 (42)	1196 (31)	2606 (69)
Sick child	5343 (58)	606 (11)	4737 (89)

Note: Boldface indicates significance.

^*p<0.05

In both bivariate (Table 1) and multivariable analyses, having a child aged <1 year (ARR=1.43; 95% CI=1.29, 1.58); bringing in the child for a well visit (ARR=2.53; 95% CI=2.29, 2.81); and being a smoker (ARR=1.19; 95% CI=1.06, 1.35) were associated with greater likelihood of being asked any component of the triple tobacco screen. Parents aged >30 years (ARR=0.87; 95% CI=0.78, 0.97) and white parents (ARR=0.89; 95% CI=0.79, 1.00) were less likely to be asked any component of the triple tobacco screen.

Discussion

Few parents (approximately one in six) were screened for their smoking status, and fewer were screened for smokefree home and car rules. Screening for parental tobacco use is important because pediatricians can only offer assistance when they know a health issue exists. Parents of infants were more likely to be screened for ETS exposure than were those of older children.

A possible explanation for pediatrician focus on infants is that infants are likely to spend the most time in close proximity to their parents and hence are considered to be at higher risk from ETS. According to the 2006 Surgeon General’s report, almost 60% of U.S. children aged 3–11 years are exposed to tobacco smoke.¹³ Parent age and race were also found to influence whether pediatricians screen parents for tobacco use. These findings reinforce the importance of screening all parents for tobacco use irrespective of their child’s age, and their own age and race, in order to avoid missing opportunities to identify children exposed to tobacco smoke.

Pediatricians had greater than twofold higher rates of tobacco screening during well-child visits. There maybe more time available to discuss tobacco use at well-child visits. However, extending intervention to sick visits would be a good strategy, as parents may be more receptive to any advice that will help eliminate a risk factor of their child’s disease.¹⁴

Most parents who smoke (77%) are not screened for tobacco use. One reason that questions about smoking may not have been raised at a particular visit is that they had been raised at a previous visit, yet there remain substantial missed opportunities to counsel smokers and reduce ETS exposure of children in their most common exposure locations. Even when exposure was addressed, all three exposure sources were addressed less than half the time, even though studies have shown that many people with smokefree homes do not have smokefree cars, suggesting that parents may not recognize ETS in cars as an important exposure source for their children.^15–17

In light of the AAP guidelines recommending that ETS exposure be addressed and documented at every clinical encounter, it is concerning that only 20% of parents reported any discussion of such exposure at the visit. It has been shown that repeated tobacco cessation counseling is one of the three most important and cost-effective preventive services that can be provided in a medical office.¹⁸ Because pediatricians are in a unique position to address children’s exposure, they should ensure that their offices facilitate delivery of evidence-based tobacco treatment for all smoking parents. Although most pediatricians do not have time to spend the majority of a clinical encounter on the parent’s smoking, brief interventions are effective, and complementary strategies such as referring parents to the state’s quitline will maximize the chances of parental smoking cessation.^8,9,19,20 It is beyond the scope of this paper to discuss ways of optimizing triple tobacco screen in pediatric practices,^20,21,22 but online courses are available to help pediatric offices effectively implement tobacco control strategies in their daily delivery of care by using existing available resources.²³

A limitation of the study is that the results are based on parental self-report and thus, subject to recall and response bias. However, the administration of the survey in-person and immediately after the visit, and the use of a large sample size across eight states, allows greater confidence in the accuracy of the results.

Substantial missed opportunities may exist to counsel smoking parents and reduce ETS exposure of children. Pediatricians could help protect children from this toxic exposure if they knew which children were exposed to tobacco smoke. This study highlights the need for systematic screening of parents for tobacco use so that available systems of care can then be deployed to help them with smoking cessation and establishing smokefree homes and cars.