A Controlled Trial of an Environmental Tobacco Smoke Reduction Intervention in Low-Income Children With Asthma

doi:10.1378/chest.120.5.1709

Chest

Volume 120, Issue 5, November 2001, Pages 1709-1722

https://doi.org/10.1378/chest.120.5.1709 Get rights and content

Study objectives

To determine the effectiveness of a cotinine-feedback, behaviorally based education intervention in reducing environmental tobacco smoke (ETS) exposure and health-care utilization of children with asthma.

Design

Randomized controlled trial of educational intervention vs usual care.

Setting

The pediatric pulmonary service of a regional pediatric hospital.

Participants

ETS-exposed, Medicaid/Medi-Cal-eligible, predominantly minority children who were 3 to 12 years old and who were seen for asthma in the hospital’s emergency, inpatient, and outpatient services departments (n = 87).

Intervention

Three nurse-led sessions employing behavior-changing strategies and basic asthma education and that incorporated repeated feedback on the child’s urinary cotinine level.

Measurements

The primary measurements were the urinary cotinine/creatinine ratio (CCR) and the number of acute asthma medical visits. The secondary measurements were number of hospitalizations, smoking restrictions in home, amount smoked, reported exposures of children, and asthma control.

Results

The intervention was associated with a significantly lower odds ratio (OR) for more than one acute asthma medical visit in the follow-up year, after adjusting for baseline visits (total visits, 87; OR, 0.32; p = 0.03), and a comparably sized but nonsignificant OR for one or more hospitalization (OR, 0.34; p = 0.14). The follow-up CCR measurement and the determination of whether smoking was prohibited inside the home strongly favored the intervention group (n = 51) (mean difference in CCR adjusted for baseline, −0.38; p = 0.26; n = 51) (60; OR [for proportion of subjects prohibiting smoking], 0.24; p = 0.11; n = 60).

Conclusions

This intervention significantly reduced asthma health-care utilization in ETS-exposed, low-income, minority children. Effects sizes for urine cotinine and proportion prohibiting smoking were moderate to large but not statistically significant, possibly the result of reduced precision due to the loss of patients to active follow-up. Improving ETS reduction interventions and understanding their mechanism of action on asthma outcomes requires further controlled trials that measure ETS exposure and behavioral and disease outcomes concurrently.

Section snippets

Interventions to Reduce ETS Exposure in Children

Legal, regulatory, and taxation changes, antismoking education programs, and smoking cessation assistance that incorporates nicotine replacement therapy have been associated with a reduction in the overall smoking rates in the United States, but reductions in the rates among young women, especially those with less education, have lagged behind those of men.¹³ Attempts to encourage nonvolunteer female smokers of childbearing age, including pregnant women and new mothers, to quit smoking or to

Eligibility:

Eligible children had the following characteristics: (1) age between 3 and 12 years; (2) had been examined because of acute asthma within the preceding year in the ED or urgent-care (Peds Plus) clinics and/or had been admitted to the inpatient service of the Valley Children’s Hospital (VCH) (VCH had been located in Fresno County, CA, until its new facility [in-patient services, ED, and specialty clinics] opened just across the Fresno-Madera County line in September 1998; the Peds Plus

Demographic Characteristics:

The sample consisted of approximately equal numbers of male and female children (Table 1). Approximately 44% of the sample was Hispanic and 38% was black. One third of the primary caregivers (28 of 87 caregivers) had not graduated from high school, and only 3 caregivers were college graduates. None of these demographic characteristics differed significantly between the intervention and control groups.

Smoking Practices:

The primary maternal caregiver (who was not always the child’s natural mother) was a smoker in

Discussion

We found that an educational intervention that emphasized reduction in ETS exposure and that used a variety of motivational, instructional, and other aides to promote behavior change was associated with significantly lower odds of having more than one acute medical visit for asthma (OR, 0.32; p = 0.03 [after controlling for baseline visits]) and also with a nonsignificant trend toward lower odds of hospitalization (OR, 0.34; p = 0.14). Using statistical bootstrap procedures, we confirmed that

Session 1

I.
Introduction
- a.
  Overview of the program
- b.
  Identify problems that the parent has in managing the child’s asthma
II.
Asthma pathophysiology
- a.
  Explain how the lungs and breathing system work
- b.
  Explain how this system is affected during and after an acute asthma episode
- c.
  Explain inflammation and how to prevent and control it
- d.
  Explain the effects of irritants/allergens on the lungs
- e.
  Explain what it means to control asthma: environmental control and medications
- f.
  Parental practice in explaining asthma to someone else
III.
Understand

Acknowledgment

The authors acknowledge the contributions of the participating families and of Patricia Springer, RN, Pediatric Pulmonary Department, Monica Dibble, RRT, RPFT, and Terry Driscoll, RRT, CPFT, of the Pulmonary Function Laboratory, Eldon Swanson, Supervisor of the Immunology Laboratory, and Leo Baranda and Christine Davies of the Information Services Department, all of VCH, Madera, CA, for their assistance with the identification of patients, recruitment and follow-up, laboratory testing, and the

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Cited by (111)

Randomized Trial to Reduce Air Particle Levels in Homes of Smokers and Children
2018, American Journal of Preventive Medicine
Citation Excerpt :
The strategy of reducing exposure has demonstrated efficacy and does not rely on smoking cessation by all household smokers, which is important because the majority of parents do not quit smoking.19,20 A new line of intervention research was launched with the provision of delayed feedback of household nicotine levels to families, and delayed feedback of children’s cotinine levels (a biomarker of SHS exposure) to clinicians and families.21–24 The provision of delayed feedback of particle levels measured over 24 hours total was investigated in two recent studies of households with smokers and children.
Exposure to fine particulate matter in the home from sources such as smoking, cooking, and cleaning may put residents, especially children, at risk for detrimental health effects. A randomized clinical trial was conducted from 2011 to 2016 to determine whether real-time feedback in the home plus brief coaching of parents or guardians could reduce fine particle levels in homes with smokers and children.
A randomized trial with two groups—intervention and control.
A total of 298 participants from predominantly low-income households with an adult smoker and a child aged <14 years. Participants were recruited during 2012–2015 from multiple sources in San Diego, mainly Women, Infants and Children Program sites.
The multicomponent intervention consisted of continuous lights and brief sound alerts based on fine particle levels in real time and four brief coaching sessions using particle level graphs and motivational interviewing techniques. Motivational interviewing coaching focused on particle reduction to protect children and other occupants from elevated particle levels, especially from tobacco-related sources.
In-home air particle levels were measured by laser particle counters continuously in both study groups. The two outcomes were daily mean particle counts and percentage time with high particle concentrations (>15,000 particles/0.01 ft³). Linear mixed models were used to analyze the differential change in the outcomes over time by group, during 2016–2017.
Intervention homes had significantly larger reductions than controls in daily geometric mean particle concentrations (18.8% reduction vs 6.5% reduction, p<0.001). Intervention homes’ average percentage time with high particle concentrations decreased 45.1% compared with a 4.2% increase among controls (difference between groups p<0.001).
Real-time feedback for air particle levels and brief coaching can reduce fine particle levels in homes with smokers and young children. Results set the stage for refining feedback and possible reinforcing consequences for not generating smoke-related particles.
This study is registered at www.clinicaltrials.gov NCT01634334.
Design of a pragmatic trial in minority children presenting to the emergency department with uncontrolled asthma: The CHICAGO Plan
2017, Contemporary Clinical Trials
Citation Excerpt :
Home visits take 60 to 90 min, and occur approximately 2–3 days, 2 weeks, 1 month, 3 month, and 6 months after ED discharge (Table 1). Environmental tobacco smoke was a focus of trigger avoidance because exposure to it is prevalent in this population, increases morbidity due to asthma, and is actionable [25–27]. Emphasis was placed on pest allergens because inner city homes have high levels of exposure to both cockroach and mouse allergen, and both of these are common sensitizers and associated with significant morbidity including respiratory symptoms and healthcare utilization [28–32].
Among children with asthma, black children are two to four times as likely to have an emergency department (ED) visit and die from asthma, respectively, compared to white children in the United States. Despite the availability of evidence-based asthma management guidelines, minority children are less likely than white children to receive or use effective options for asthma care. The CHICAGO Plan is a three-arm multi-center randomized pragmatic trial of children 5 to 11 years old presenting to the ED with uncontrolled asthma that compares: [1] an ED-focused intervention to improve the quality of care on discharge to home, [2] the same ED-focused intervention together with a home-based community health worker (CHW)-led intervention, and [3] enhanced usual care. All children receive spacers for the metered dose inhaler and teaching about its use. The Patient-Reported Outcomes Measurement Information System (PROMIS) Asthma Impact Scale and Satisfaction with Participation in Social Roles at 6 months are the primary outcomes in children and in caregivers, respectively. Other patient-reported outcomes and indicators of healthcare utilization are assessed as secondary outcomes. Innovative features of the CHICAGO Plan include early and continuous engagement of children, caregivers, the Chicago Department of Public Health, and other stakeholders to inform the design and implementation of the study and a shared research infrastructure to coordinate study activities. The objective of this report is to describe the development of the CHICAGO Plan, including the methods and rationale for engaging stakeholders, the shared research infrastructure, and other features of the pragmatic clinical trial design.
Parental receptivity to child biomarker testing for tobacco smoke exposure: A qualitative study
2015, Patient Education and Counseling
Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their children's exposure. Biomarkers demonstrate exposure and may motivate behavior change, but their acceptability is not well understood.
Sixty-five in-depth interviews were conducted with parents of young children, in smoking families in central Israel. Data were analyzed using thematic analysis.
Consent to testing was associated with desire for information, for reassurance or to motivate change, and with concerns for long-term health, taking responsibility for one's child, and trust in research. Opposition to testing was associated with preference to avoid knowledge, reluctance to cause short-term discomfort, perceived powerlessness, and mistrust of research.
Most parents expressed willingness to allow measurement by urine (83%), hair (88%), or saliva (93%), but not blood samples (43%); and believed that test results could motivate behavior change.
Parents were receptive to non-invasive child biomarker testing. Biomarker information could help persuade parents who smoke that their children need protection.
Biomarker testing of children in smoking families is an acceptable and promising tool for education, counseling, and motivation of parents to protect their children from TSE. Additionally, biomarker testing allows objective assessment of population-level child TSE.
Patient- and family-centered care as an approach to reducing disparities in asthma outcomes in urban African American children: A review of the literature
2015, Journal of the National Medical Association
We thank Cathy Eames (Director, Library Services, Detroit Medical Center) for valuable input and assistance with the search strategy. Funding for this research was supported by a grant from Children’s Hospital of Michigan Research Foundation (Principal Investigator: Terrance L. Albrecht, Ph.D.).
Patient- and family-centered care (PFCC) has the potential to address disparities in access and quality of healthcare for African American pediatric asthma patients by accommodating and responding to the individual needs of patients and families.
To identify and evaluate research on the impact of family-provider interventions that reflect elements of PFCC on reducing disparities in the provision, access, quality, and use of healthcare services for African American pediatric asthma patients.
Electronic searches were conducted using PubMed, CINAHL, and Psyclnfo databases. Inclusion criteria were peer-reviewed, English-language articles on family–provider interventions that (a) reflected one or more elements of PFCC and (b) addressed healthcare disparities in urban African American pediatric asthma patients (≤ 18 years).
Thirteen interventions or programs were identified and reviewed. Designs included randomized clinical trials, controlled clinical trials, pre- and post-interventions, and program evaluations.
Few interventions were identified as explicitly providing PFCC in a pediatric asthma context, possibly because of a lack of consensus on what constitutes PFCC in practice. Some studies have demonstrated that PFCC improves satisfaction and communication during clinical interactions. More empirical research is needed to understand whether PFCC interventions reduce care disparities and improve the provision, access, and quality of asthma healthcare for urban African American children.
PubMed, CINAHL, and Psyclnfo
AA—African American: CCT—Controlled clinical trial; ED—Emergency Department; ETS—Environmental tobacco smoke; FCC— Family Centered Care; PFCC—Patient and Family Centered Care; RCT— Randomized, controlled trial
Reducing tobacco smoke exposure in children aged below 4years - A randomized controlled trial
2014, Preventive Medicine
Citation Excerpt :
Employing the CUCL as an outcome measure, the efficacy of the intervention could not be demonstrated. Given that the effect of the setting cannot be separated from the intervention (Gehrman and Hovell, 2003), the comparability of the results with null findings in previous studies using CUCL feedback in settings with children with respiratory illness is limited (Chilmonczyk et al., 1992; McIntosh et al., 1994; Wakefield et al., 2002; Wilson et al., 2001). However, two previous studies that addressed the parents of children below the age of 4 years and that used higher doses of interventions found significant differences in cotinine levels between study groups (Emmons et al., 2001; Hovell et al., 2000).
To explore the reach of a German population-based household sample using proactive recruitment and to test the efficacy of a behavioral change counseling intervention including feedback about children's urine cotinine level (CUCL).
A randomized controlled trial (2008–2010) was conducted in households with at least one child aged below 4 years and at least one current smoker. The study area comprised of 3570 households. A screening assessment was provided in 2641 households; 1282 included one current smoker and 852 completed the study protocol. The intervention group (IG; n = 428) received feedback about CUCL and up to two counseling sessions. The control group (CG; n = 424) received a leaflet. Assessments were provided at baseline and 12-month follow-up. Heckman's selection model analysis was used to consider the detection limit of cotinine in urine (10 ng/ml).
CUCL below the detection limit in the IG was found in 43.2% at baseline and 44.6% at follow-up and in 44.8% of the CG at baseline and 47.2% at follow-up. The CUCL difference between follow-up and baseline was smaller in the CG than in the IG. The effect was not significant.
Data revealed a high reach of the target population but failed to identify an intervention effect.
Clinical Trial Registration www.clinicaltrials.gov (NCT00647413).
Using Randomized Controlled Trials to Estimate the Effect of Community Interventions for Childhood Asthma
2023, Preventing Chronic Disease

View all citing articles on Scopus

: This research was supported by award No. U60/CCU912212 from the US Centers for Disease Control and Prevention and by the Medi-Cal Special Projects Section and Tobacco Control Section, California Department of Health Services.

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Chest

Occupational and Environmental Lung DiseaseA Controlled Trial of an Environmental Tobacco Smoke Reduction Intervention in Low-Income Children With Asthma

Study objectives

Design

Setting

Participants

Intervention

Measurements

Results

Conclusions

Section snippets

Interventions to Reduce ETS Exposure in Children

Eligibility:

Demographic Characteristics:

Smoking Practices:

Discussion

Session 1

Acknowledgment

Am J Obstet Gynecol

Am J Prev Med

Am J Prev Med

Chest

Chest

Respiratory health effects of passive smoking: lung cancer and other disorders: final report

Health effects of exposure to environmental tobacco smoke: final report

Health effects of passive smoking: 10. Summary of effects of parental smoking on the respiratory health of children and implications for research

Thorax

Report of the Scientific Committee on Tobacco and Health: tobacco report; UK

International consultation on environmental tobacco smoke (ETS), and child health proceedings: tobacco free initiative; consultation report

Clearing the air: asthma and indoor air exposures; Committee on the Assessment of Asthma and Indoor Air, Division of Health Promotion and Prevention, Institute of Medicine (IOM)

Cancer prevention, and control program (CPCP): tobacco control in California; who's winning the war?—final report to the California Department of Health Services

Variations in asthma hospitalization and deaths in New York City

Am J Public Health

Changing patterns of asthma hospitalization among children: 1979–1987

JAMA

Surveillance for Asthma: United States, 1960–1995

MMWR Morb Mortal Wkly Rep

Forecasted state-specific estimates of self-reported asthma prevalence: United States, 1998

MMWR Morb Mortal Wkly Rep

Passive smoking among children with chronic respiratory disease

J Asthma

Smoking among women across the life span: prevalence, interventions, and implications for cessation research

Ann Behav Med

Cotinine-assisted intervention in pregnancy to reduce smoking and low birthweight delivery

Br J Obstet Gynaecol

An unsuccessful cotinine-assisted intervention strategy to reduce environmental tobacco smoke exposure during infancy

Am J Dis Child

Trial of an intervention to reduce passive smoking in infancy

Pediatr Pulmonol

Occupational and Environmental Lung Disease
A Controlled Trial of an Environmental Tobacco Smoke Reduction Intervention in Low-Income Children With Asthma