Asking the Right Questions About Secondhand Smoke

Abstract

Introduction

Despite knowledge about major health effects of secondhand tobacco smoke (SHS) exposure, systematic incorporation of SHS screening and counseling in clinical settings has not occurred.

Methods

A three-round modified Delphi Panel of tobacco control experts was convened to build consensus on the screening questions that should be asked and identify opportunities and barriers to SHS exposure screening and counseling. The panel considered four questions: (1) what questions should be asked about SHS exposure; (2) what are the top priorities to advance the goal of ensuring that these questions are asked; (3) what are the barriers to achieving these goals; and (4) how might these barriers be overcome. Each panel member submitted answers to the questions. Responses were summarized and successive rounds were reviewed by panel members for consolidation and prioritization.

Results

Panelists agreed that both adults and children should be screened during clinical encounters by asking if they are exposed or have ever been exposed to smoke from any tobacco products in their usual environment. The panel found that consistent clinician training, quality measurement or other accountability, and policy and electronic health records interventions were needed to successfully implement consistent screening.

Conclusions

The panel successfully generated screening questions and identified priorities to improve SHS exposure screening. Policy interventions and stakeholder engagement are needed to overcome barriers to implementing effective SHS screening.

Implications

In a modified Delphi panel, tobacco control and clinical prevention experts agreed that all adults and children should be screened during clinical encounters by asking if they are exposed or have ever been exposed to smoke from tobacco products. Consistent training, accountability, and policy and electronic health records interventions are needed to implement consistent screening. Increasing SHS screening will have a significant impact on public health and costs.

Introduction

Reducing secondhand tobacco smoke (SHS) exposure is a public health priority. More than 58 million non-smokers are exposed to secondhand smoke¹ and 41 000 adult and 900 infant deaths annually are attributable to SHS in the United States.² Adults who are exposed to SHS have increased rates of coronary heart disease, stroke, and lung cancer; additionally babies die of sudden unexplained infant death syndrome, prematurity, low birthweight, and other conditions.^3,4SHS exposure has been shown to cause a host of health problems, including increased asthma, respiratory infections, ear infections, and sinusitis.³ SHS exposure is also associated with increased health care utilization among both adults and children.^5,6 Since its 2008 Update, the US Public Health Service clinical practice guidelines have recommended SHS screening and counseling as part of primary care health visits.⁷ The American Academy of Pediatrics, reviewing more recent evidence, also strongly recommends counseling to keep children’s environments free from tobacco smoke.⁸ Despite numerous US Surgeon General reports and warnings about the health hazards of exposure to SHS³ many physicians still do not routinely ask questions or offer counseling about such exposure during health visits.^9,10

Research shows that a majority of primary care providers report encouraging parents to limit their children’s SHS exposure and keep their homes and cars smoke free.¹¹ However, surveys of inpatient adult cardiology patients show low rates of SHS exposure screening by clinical staff.¹² When parents are surveyed, only half report having been asked by their children’s physicians about household smoking status or SHS exposure,¹³ undermining smoking cessation efforts directed to parents.

The Flight Attendant Medical Research Institute (FAMRI) is a foundation formed through a court order, which was part of the settlement of a 1991–1997 class action suit on behalf of non-smoking flight attendants against the tobacco industry, seeking damages for the harms caused by their exposure to SHS in airline cabins. FAMRI sponsors scientific and medical research for the early detection, prevention, treatment, and cure of diseases and medical conditions caused by exposure to tobacco smoke. FAMRI’s goals include research to encourage clinicians to “ask the right questions” about SHS exposure. To better understand the low rates of SHS exposure screening, FAMRI sponsored a Delphi Panel in 2018 to develop consensus about the most appropriate screening questions for SHS exposure, and around the opportunities and barriers to clinicians’ implementation of systematic SHS screening during medical intake and clinical encounters.

Methods

We convened a panel of experts and conducted a modified Delphi process as part of a FAMRI-sponsored meeting on asking the right questions about secondhand tobacco smoke exposure in clinical care. Delphi techniques combine quantitative and qualitative research methods to reach consensus based on opinions of informed experts and other stakeholders.¹⁴ These methods require participants in a modified Delphi process to answer questionnaires in multiple rounds. After each round, a facilitator summarizes the responses and shares them in an anonymized summary with the group members. In each following round, individuals again separately answer key questions, considering and potentially revising their responses based on the summary of others’ prior responses. Subsequent rounds continue and eventually lead to a convergence of agreed-upon responses. These methods are designed to minimize some of the limitations of other group opinion assessment strategies, (eg, pressure to conform to a stated attitude, or the potential for a dominant respondent to impact or influence other group members before all opinions are expressed.¹⁵)

Tobacco control researchers and other key stakeholders were identified through professional networks. A 21-member panel of physicians, researchers, and FAMRI stakeholders gathered in Chicago, Illinois in November 2017 for a consensus meeting and the start of a three-round modified Delphi panel.

Prior to the Delphi meeting, a four-member planning committee developed discussion questions based on a review of the literature and input from other panel members. Meeting presentations explored existing evidence and ongoing efforts to improve electronic health record (EHR) documentation and clinical screening for SHS exposure in children and adults, and introduced the modified Delphi methods planned for the study. Our committee proposed three or four rounds, depending on whether the group reached satisfactory consensus.

In Round 1, panel members were asked to write individual responses to the four questions: (1) What is (are) the appropriate and/or standardized screening question(s)?; (2) What are the top priorities to advance the goal of asking the right questions about SHS exposure?; (3) What are the main barriers to succeeding in achieving those priorities (scientific evidence, social strategies, political will)?; and (4) How should those barriers be approached (who, what actions)? The answers to the questions were transcribed, summarized and sent to panel members for priority ranking.

In Round 2, the panelists discussed the group’s answers to the four questions during a conference call. Subsequently, responses for questions 2–4 were reviewed and individually ranked by panel members in order of priority using a five-point Likert scale, where five represented the highest priority. Rankings for these responses were again collated, and average scores and variances were calculated. Similar responses were consolidated and reviewed by panel members to ascertain agreement or differences.

In Round 3, panel members individually finalized and confirmed the importance of the top responses to questions 2–4.

Results

The panel was composed of physicians, researchers, and members of the FAMRI board of trustees. The eight physicians on the panel included both clinicians, researchers, and informatics experts, and were from diverse specialties, including pulmonology/critical care (MWG, RWV), general internal medicine (NAR), adolescent medicine (JDK), general pediatrics (WGA, BJ), hospital medicine (RB) and family medicine (AG). Five panelists were non-clinician tobacco control researchers (MEC, TLC, ALH, MFH, SM). Seven panelists were FAMRI trustees, four of whom were non-smoking former flight attendants affected by tobacco smoke-related conditions who were members of the original class action lawsuit that led to FAMRI’s formation (LB, KJ, LR, PLY); three were lawyers, including two former class counsel for the flight attendant class in the litigation (JO, SR, SMR), and one was the FAMRI executive director (EAK).

For question 1, all members of the panel agreed that the main question that should be asked is whether an individual is, or has ever been, exposed to SHS. Twenty panel members suggested that the question be followed up by details that include when, where, how much, and by whom. Eight respondents suggested that the initial questions be posed in the following way “Are you exposed to tobacco smoke, and if so, how? Are you exposed to secondhand tobacco smoke or are you a smoker?” Three individuals suggested that the questions be kept simple. The panel reached consensus on separate questions for adults and for children. For children, the recommendation was to ask parents or guardians of children: “Does the child spend time or live with anyone who smokes/uses any kind of tobacco product?” For older school-aged children, adolescents and adults, the recommended questions are: “Are you exposed to smoke from cigarettes or other tobacco products?” and, if YES: In the last month, have you been exposed to smoke from cigarettes or other tobacco products at home, in a car, at school, at after school activities, sports arenas, etc.?

These questions and additional follow-up queries recommended for both adults and children are shown in Figure 1.

Figure 1.

SHS questions recommended for adults and children.

Questions 2, 3, and 4 yielded 15, 16, and 20 responses, respectively. Response rankings, averages, and variances are shown in Supplementary Table 1. Responses with high average ratings of importance and low variance indicate both strong and consistent agreement among the panel members. Similarly, items with low endorsement and low variance also reflect agreement, whereas higher scores and larger variance suggest diverse opinions about the item’s importance across panel members. Similar responses were combined into broader themes. As shown in Figure 2, the panel identified three specific recommendations regarding asking the right questions (question 2): agree on simple questions, gain stakeholder buy-in to change EHRs, and make data available for future research. Major barriers to success identified in question 3 were resistance to change, lack of EHR requirements to incorporate questions about SHS exposure, difficulties changing training curricula, lack of funding, and lack of awareness. Finally, the panel agreed on two main ways to overcome these barriers in question 4: compiling existing evidence to engage stakeholders and promoting best practices for reduction of SHS exposure.

Figure 2.

Recommendations for questions and barriers identified by the panel.

Discussion

All panelists agreed that physicians should ask about their patients’ exposure to SHS in various settings, including specifically assessing childhood SHS exposure among all pediatric patients. This finding is consistent with prior research with primary care providers; clinicians (and particularly child health providers) consistently recognize the importance of tobacco and SHS interventions, and endorse encouraging smokers to keep their homes and cars smoke-free to limit children’s or other family members’ SHS exposure.¹¹

However, finding ways to implement the increased surveillance is not simple. Multiple recommendations as well as barriers to implementation were identified. Although overcoming the barriers that prevent physicians from asking these questions has been a long-term goal, the consensus of the Delphi panel was that substantial work remains to be done.

Although screening for tobacco use has increased in recent years,¹⁶ many tobacco control efforts focus primarily on smoking cessation, or treatment of tobacco addiction, and not on elimination of SHS exposure, even though some smokers are more motivated by the impact of SHS exposure on their loved ones than the effects of tobacco on their own health.¹⁷ One way to overcome this barrier is to train clinicians so that SHS screening becomes routine. But fewer than half of medical students report having the skills to counsel patients about SHS exposure and only 12% report observing faculty members discuss SHS exposure with patients.¹⁸ SHS exposure training should begin in medical and other health professions schools and must continue through post-graduate training for all disciplines and specialties.

In addition to increased training for individual clinicians, practice-level systems change can have a large impact on SHS exposure screening and counseling. The Clinical Effort Against Smoking Exposure intervention has increased physician counseling about SHS, and increased identification of families who have rules regarding smoking in the home and car, places where SHS exposure is likely to occur.¹⁹ The Kids Safe and Smokefree Multilevel Intervention to Reduce Child Tobacco Smoke Exposure has also shown positive results.²⁰ Similar content might be expanded to adult medicine practices, to increase the impact of individual SHS exposure interventions for all family members. Nursing and other clinical staff may also be underutilized in the effort to increase SHS exposure screening. Research has shown that just under half of pediatric nurses routinely ask about smoking in the home during inpatient encounters.²¹ However, when screening questions were added to nurse intake forms, the majority of inpatient adult and pediatric patients were screened.²²

Given increasing demands on clinicians and clinical encounters, institutional-level changes to streamline screening and counseling may have the most impact on these processes. Several studies have shown that embedding SHS exposure questions into the EHR increases the quality and standardizes the delivery of SHS interventions in practice.^23,24 Pediatric nurses also have been able to increase parent smoker referrals to cessation quit-lines when this was able to be accomplished through the EHR.²⁵ Changes to EHRs to prompt physicians to ask about SHS exposure increase screening for SHS exposure and engage more parent smokers in treatment, and also increase counseling and quit-line referral for parents who smoke.^26–30 However, implementing these changes requires significant buy-in from clinician leaders, EHR software providers, practice managers, and others.

In addition, merely including a screening question in the EHR will not guarantee that clinicians will ask it. One option is to make the question a forced requirement, which may require changes in payer, hospital, and/or practice policies. Expanding existing quality and accountability measures (such as those required in the Centers for Medicare and Medicaid Services Meaningful Use program,³¹ HEDIS,³² or others) to include SHS exposure metrics should be explored. Recent investments, such as the National Cancer Institute Cancer Center Cessation Initiative have demonstrated how a modest investment has the potential to engaging groups of clinical leaders and establishing standards for EHRs; ³³ however, these sites have been convened around cessation protocols for cancer patients, and are still considering whether or not to include SHS questions in their standards. Given the potential cost of inaction, and the potential benefits of SHS exposure reduction,^5,34 appropriate advocacy is needed to encourage policy makers to make such changes.

A strength of the Delphi technique is that it can be used to identify consensus of group opinion in a way that encourages honest input, free from peer pressure, and reduces “bandwagon” or “groupthink” effects as well as off topic discussions.³⁵ Our study is limited in that our Delphi panel started with an in-person meeting, rather than through fully anonymous surveys, and thus may have been more susceptible to groupthink effects. However, some of this was mitigated by asking panelists for written responses to questions rather than solely gathering opinions through group discussion. Respondents may not have fully discriminated between priorities and barriers to their achievement; however, the responses reflect their attitudes and beliefs, especially those items that consistently received both high endorsement and low standard deviation, reflecting their near universal endorsement.

Our study findings may also be limited by participants’ shared background in tobacco control and SHS. All of the participants in our panel had experience and expertise working on tobacco control and SHS-related illnesses and, therefore, may have prioritized tobacco cessation and SHS exposure screening and interventions above other risk factors. The participants also may have had an expectation that primary care providers would share their view that reducing SHS exposure is a high priority, and this may be why convincing clinicians about the importance of SHS interventions was not identified as a priority. In addition, the panel did not specifically consider the importance of assessing childhood exposure to SHS among adult patients. Although SHS exposure during childhood can have long-term health consequences,^36,37 the relevance of early family exposure questions during adulthood was neither explicitly nor thoroughly explored. The panel also did not address interventions to try to motivate smokers to protect non-smokers that they may have contact with; while protecting others, especially children, is a powerful motivation for smokers to change their behaviors, further exploration of specific motivation for smokers behavior change was beyond the scope of our study, which was primarily focused on clinicians asking about SHS exposure.

The use of a wide, heterogeneous group is recommended, especially with regard to Delphi techniques addressing health care, to avoid reaching a false consensus; ³⁵ thus, our inclusion of a diverse group of experienced stakeholders was an advantage. The physicians on the panel brought a real-world understanding of the factors that drive clinical encounters. The FAMRI Flight Attendant trustees and the FAMRI ED shared their experience as health care consumers who had been exposed to and affected by SHS. Former class counsel for the flight attendants’ class brought their historical perspective of this issue from the litigation filed in 1991. Clinician informatics experts provided a sense of what is feasible with regard to making systemic changes in EHRs.³⁵

In summary, this study provides guidance on ways to assess both pediatric and adult patients for SHS exposure, and identifies ways to address broader implementation of systematic screening and counseling into clinical systems and EHRs in order to improve the delivery of this care. To minimize an additional burden being imposed on clinical care by the SHS screening questions, these and other newer evidence-based guideline recommendations should be integrated into currently used smoking questions. SHS measures and interventions affect the health of the entire population, compared to some priorities (eg, pack-year assessment for lung cancer screening) which stratify screening choices for a smaller population at risk. However, to minimize burden and maximally benefit population health, implementation of SHS recommendations should be coordinated with the National Cancer Institute’s Cancer Center Cessation Initiative, which is committed to streamlining clinical workflows to address quality of care for smoking-related questions efficiently and effectively.³³

Assessing pediatric and adult patients for SHS exposure is both important and feasible. However, additional research is needed to testing the proposed screening questions in diverse populations and various adult and pediatric primary care settings. In addition, dissemination and implementation studies are needed to assess ways in which implementation of these recommendations might best impact practice change and individual behavior change to best protect vulnerable children and adults from SHS exposure.

Successful and impactful SHS screening will rely on standard questions and implementation of the right screening questions into EHR systems. Although incorporating these systems changes will require support from stakeholders at all levels, doing so would have a significant impact on the burden of diseases across the lifespan for non-smokers exposed to secondhand smoke.

Funding

This work was supported by the Flight Attendant Medical Research Institute.

Declaration of Interests

We have no conflicts of interest to disclose.