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Counseling Smoking Parents of Young Children
Comparison of Pediatricians and Family Physicians
Eliseo J. Pérez-Stable, MD;
Maria Juarez-Reyes, MD, PhD;
Celia P. Kaplan, DrPH, MA;
Elena Fuentes-Afflick, MD, MPH;
Virginia Gildengorin, PhD;
Susan G. Millstein, PhD
Arch Pediatr Adolesc Med. 2001;155:25-31.
ABSTRACT
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Background Secondhand smoke is a major cause of morbidity in young children, and
exposure to smoking parents is the principal source. Physician visits for
young children present an opportunity to effect behavioral change among smoking
parents.
Objective To survey pediatricians and family physicians in their knowledge and
practice of smoking cessation counseling with parents.
Design Cross-sectional mail survey.
Setting Urban California.
Participants Pediatricians and family physicians in urban areas of California, younger
than 65 years, practicing in an ambulatory setting, and randomly selected
from the American Medical Association Physician Masterfile.
Main Outcome Measures Reported frequency of asking about tobacco use, using cessation counseling
techniques with smokers, and perceived barriers to providing cessation services.
Results Of the 1000 mailed surveys, 899 were eligible and 499 (56% response
rate) were returned and completed. A higher proportion of pediatricians compared
with family physicians were women (44% vs 29%; P<.01)
and nonwhite (44% vs 32%; P = .01). Family physicians
compared with pediatricians were more likely to report referring a parent
to a smoking cessation program (41% vs 30%), giving pamphlets on smoking cessation
(40% vs 28%), asking for a quit date (41% vs 18%), scheduling a follow-up
visit to discuss quitting (27% vs 5%), and recommending nicotine replacement
therapy (41% vs 13%) (for each comparison, P<.001).
Pediatricians were more likely to report recording in the medical record smoking
by a parent as a problem for the child (65% vs 48%; P<.001),
but a higher proportion of pediatricians perceived that parents would ignore
the advice (39% vs 24%; P<.001) and lacked interest
in quitting smoking (45% vs 27%; P<.001). Pediatricians
were more likely to agree that they lacked smoking cessation counseling skills
(26% vs 7%; P<.001). Multivariate models showed
that pediatricians were less likely to report performing 5 of 14 smoking cessation
techniques in at least 50% of smoking parents.
Conclusions Pediatricians appear to lack training to implement smoking cessation
counseling with smoking parents. Physicians in private practice are less likely
to counsel smoking parents. Educational interventions for pediatricians are
needed to decrease secondhand smoke exposure for young children.
INTRODUCTION
SECONDHAND SMOKE exposure is associated with a significant increase
in morbidity and mortality among children, especially those younger than 5
years.1, 2, 3 In 1986,
an estimated 53% to 76% of households contained one adult resident who smokes
and up to 12 million children aged 5 years and younger were exposed to environmental
tobacco smoke.4 In California, 35% of children
aged 5 years and younger were exposed to environmental tobacco smoke for an
average of about 4 hours per day.3
Based on the data supporting implementation of clinician-mediated interventions
to promote smoking cessation among adults,5
the National Cancer Institute developed a program that targets clinicians
caring for children.6 The strategy to incorporate
primary care clinicians in a public health approach to smoking cessation has
been strengthened by the development of evidence-based guidelines.7 However, in contrast to the data on physicians caring
for adults, there are limited studies8, 9, 10, 11, 12
that have evaluated the effectiveness of this program or the usefulness of
interventions focused on decreasing secondhand smoke exposure for children.
Several studies have evaluated whether pediatric clinicians are able
to assist parents to quit smoking and help decrease secondhand smoke exposure
for young children. In a survey13 of residents
in the 3 primary care specialties, only 32% of pediatric residents reported
any training in smoking cessation counseling and most scored significantly
lower compared with family medicine and primary care internal medicine residents.
Two surveys14, 15 of practicing
pediatricians in Maine and Vermont showed that 91% to 94% advise smoking parents
to quit, spending an average of 4 to 5 minutes doing so, but only about 10%
recorded the information in the medical record. However, less than half of
these pediatricians talked to most parents about the effects of smoking on
their children.14, 15 Secondhand
smoke was addressed by the Vermont pediatricians by advising parents to smoke
away from children (77%), to reduce consumption of cigarette use (40%), and
to set a quit date (22%).15
Parents of young children visit pediatricians more often than any other
physician, and these visits are an opportunity to effect behavioral change
among smoking parents.14, 15 Pediatric
clinicians may be uniquely positioned to counsel these adults to quit smoking,
but they must be comfortable with the topic. To evaluate and compare the knowledge,
attitudes, and practices with respect to counseling parents of children younger
than 5 years about secondhand smoke, we conducted a survey of California pediatricians
and family physicians. We selected family physicians as a comparison group
who also take care of children,16 but would
be expected to use the smoking cessation techniques from adult practice. We
specifically asked about the physicians' practice in delivering smoking cessation
interventions to these parents and the perceived barriers in counseling parents
to quit smoking. Our ultimate goal is to develop and implement an educational
intervention directed at pediatricians and family physicians to promote smoking
cessation among smoking parents of young children.
PARTICIPANTS AND METHODS
SAMPLE
From the 1997 American Medical Association Physician Masterfile data
set for California, we selected a stratified random sample of 1000 pediatricians
or family physicians, aged 65 years or younger, practicing in urban areas
of California. After the surveys were returned, we retained data only for
physicians who continued to be clinically active, saw patients aged 18 years
and younger, and spent time practicing in ambulatory care settings.
QUESTIONNAIRE
We developed the survey to ascertain how often physicians assess smoking
behavior of parents, their practices regarding counseling smoking parents
to quit, and perceived barriers to the delivery of smoking cessation counseling
to these parents. Physicians were asked to estimate the percentage of parents
or accompanying adults who were asked, during a routine visit, if they smoke
tobacco regularly; if they or anyone else smoke in the home; and whether a
smoking parent smokes in front of their child outside the home. Physicians
were asked to estimate the frequency (0%-100% of the time) they provided 14
possible smoking cessation practices during routine visits.
The 14 practices were as follows: discussing a child's health risk from
secondhand smoke, advising a smoking parent to quit, counseling on the health
risks of smoking, recording smoking in the medical record as a health problem
for the child, telling parents that smoking is a bad example for the child,
increasing the motivation of a parent to quit smoking, referring parents to
their personal physician for smoking cessation counseling, referring parents
to a smoking cessation program, providing pamphlets on self-help smoking cessation,
asking parents if they are willing to set a quit date, prescribing or recommending
use of nicotine replacement therapy to quit, asking a nurse in the office
to counsel parents to quit smoking, scheduling a follow-up visit or telephone
call to discuss quitting, and telephoning parents to discuss progress with
quitting. Four of these 14 practices have been central components in randomized
trial studies that have demonstrated increased abstinence among smoking patients
when clinicians used these practices. These effective practices included setting
a quit date, prescribing nicotine replacement therapy, scheduling a follow-up
visit or telephone call, and providing nurse-mediated counseling in the office.7
Respondents were also asked to estimate the amount of time spent counseling
smoking parents on tobacco cessation in categories of minutes (0, 1-2, 3-5,
6-10, and  11 minutes). Finally, we asked the respondents about their level
of agreement with 9 perceived barriers to the delivery of these smoking cessation
services (eg, If I ask all parents whether they smoke tobacco, it would anger
parents). The questionnaire also contained items about the respondents' demographics,
history of smoking cigarettes, medical education history, and type of practice.
The questionnaire was developed by the investigators (E.J.P.-S., M.J.-R.,
C.P.K., E.F.-A., and S.G.M.), designed for self-administration, pretested
with 10 practicing pediatricians, and revised before it was distributed. There
were 31 questions, and it took an average of 10 minutes to complete.
PROCEDURE
The survey packets included a cover letter with contact telephone numbers,
letters of support from professional organizations, the questionnaire, a self-addressed
return envelope, and a $5 bill. Mailings began in November 1997, followed
by a second mailing in January 1998. We attempted to call or fax messages
to physicians' offices to confirm receipt of the packet only after the first
mailing. All procedures were approved by the University of California, San
Francisco, Committee on Human Research.
DATA ANALYSIS
Data analyses were managed using SAS statistical software.17
Univariate analyses compared proportions or categorical data by the  2 test and continuous variables by the t test.
Categories of response were collapsed for comparison purposes. A multivariate
logistic regression model was constructed to compare pediatricians with family
physicians on their responses to the questionnaire and to compare all physician
respondents by type of practice (private vs other). Responses to questions
on use of cessation techniques with parents were dichotomized to 50% or more
of the time they were implemented compared with less than 50%. Responses to
the questions on perceived barriers to the delivery of smoking cessation services
to parents were dichotomized to "agree a lot" and "agree some" compared with
"agree a little" and "agree not at all." The outcome variables were as follows:
asking parents about smoking in the house, spending an average of 3 minutes
or more counseling a smoking parent to quit, examining 14 behaviors regarding
the management of parents who smoke, and determining the level of agreement
with 9 perceived barriers to implement smoking cessation services. The main
predictor variable was physician specialty (pediatrician or family physician).
The multivariate model adjusted for physician sex, age (continuous), ethnicity
(white vs other), birthplace (United States vs other), percentage of patients
seen who were aged 5 years or younger (continuous), percentage of work time
spent in ambulatory care settings (continuous), year graduated from medical
school (before 1970 vs after), location of medical school (United States vs
other), type of practice setting (private, academic, community clinic, or
managed care), and smoking status (ever vs never).
RESULTS
From the original sample of 1000 physicians, 101 surveys were returned
and were determined to be ineligible because of current practice (retired,
no ambulatory care, or no children seen), specialty criteria, or an undeliverable
address. From the sample of 899 remaining and presumed eligible respondents,
we received 499 completed questionnaires, for a response rate of 56%. Comparison
of respondents with nonrespondents among presumed eligible participants showed
no significant differences by physician sex (P =
.32), specialty (P = .26), ethnicity (P = .30), and age (P = .53).
In Table 1, the demographic
and practice characteristics of the sample are shown. A higher percentage
of pediatricians compared with family physicians were women and born outside
the United States. No significant differences were found in the age distribution,
proportion of former smokers, and distribution of the sample by type of practice.
As expected, pediatricians reported a significantly higher percentage of patients
seen who were younger than 5 years, but there were no differences in the amount
of time reported spent in ambulatory practice. Only 12 respondents were current
smokers.
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Table 1. Demographic and Practice Characteristics of Pediatricians
and Family Physicians Responding to the Survey in California, 1997 to 1998*
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ASKING PARENTS ABOUT SMOKING
Table 2 shows responses
to questions about smoking to parents of children aged 5 years and younger.
Nearly two thirds of pediatricians and family physicians indicated asking
parents about smoking. Parents who smoked were queried about smoking in the
home more often by pediatricians than by family physicians. However, only
about half of the parents were asked about smoking in front of their child
in other situations (eg, in the car) by pediatricians or family physicians.
Less than half the time did physicians ask about a nonparental adult smoking
in any room within the home.
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Table 2. Physician Questions About Smoking to Parents of Children Aged
5 Years or Younger by Specialty, California, 1997 to 1998*
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SMOKING CESSATION COUNSELING PRACTICES
A significantly (P<.01) higher proportion
of family physicians reported spending 3 minutes or more counseling a smoking
parent to quit, but more than half of all physicians reported spending an
average of only 1 to 2 minutes counseling (Figure 1). About 1 of 6 pediatricians and 1 of 11 family physicians
reported spending no time at all counseling parents to quit smoking.
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Physicians' time spent counseling a smoking parent to quit.
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Table 3 shows the physician-reported
delivery of smoking cessation interventions for smoking parents of young children
compared by specialty. Pediatricians were significantly more likely to record
parental smoking in the medical record as a problem for the child and discuss
a child's health risk from secondhand smoke. Physicians from both specialties
reported similar rates of providing general advice to quit, increasing motivation
to quit, counseling parents on the health risks of smoking, telling parents
that smoking is a bad example for their children, and making a referral back
to the personal physician. Family physicians were significantly more likely
than pediatricians to have reported using 7 of the 14 practices at least half
the time. Four of the 14 practices have been central components in randomized
trial studies that have demonstrated increased abstinence among smoking patients
when clinicians used these practices. These effective practices included setting
a quit date, prescribing nicotine replacement therapy, scheduling a follow-up
visit or telephone call, and providing nurse-mediated counseling in the office.
Family physicians and pediatricians reported using these 4 strategies less
than half the time, even though pediatricians were significantly less likely
to have reported using each of these. Referral to a smoking cessation program
and providing self-help cessation materials were reported to occur less than
half the time by physicians from both specialties, but pediatricians were
significantly less likely to have reported these practices. There were no
differences by specialty in the practice of referring to the parent's personal
physician.
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Table 3. Physician Smoking Cessation Practices Delivered to Smoking
Parents of Children Aged 5 Years and Younger During Routine Office Visits
by Specialty, California, 1997 to 1998*
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PERCEIVED BARRIERS TO DELIVERY OF SMOKING CESSATION SERVICES
Responses to possible barriers to delivery of smoking cessation services
to smoking parents of young children are compared by specialty in Table 4. Most respondents did not agree
a lot or some with any of the possible barriers. Compared with family physicians,
a significantly higher percentage of pediatricians perceived that counseling
parents to quit smoking was not effective because parents would ignore the
advice or lacked interest in quitting or because the pediatrician lacked smoking
cessation counseling skills. Only 20% to 24% of physicians considered parental
anger or adequate reimbursement to be barriers, but nearly twice as many agreed
that time would be a concern.
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Table 4. Physicians' Perceived Barriers to the Delivery of Smoking
Cessation Services to Smoking Parents With Children Aged 5 Years and Younger,
California, 1997 to 1998*
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RESULTS OF MULTIVARIATE ANALYSIS
Multivariate logistic regression models compared family physicians with
pediatricians in their reported use of smoking cessation practices with parents
at least half the time during a routine office visit. The comparisons were
adjusted for potential confounding variables (Table 5). Results of the models showed that pediatricians were significantly
less likely to have reported use of 5 of the 14 practices that promote smoking
cessation in parents at least half the time (Table 5). Pediatricians were significantly less likely than family
physicians to report spending 3 minutes or more counseling smoking parents
to quit. Pediatricians were also significantly less likely to indicate use
of the effective practices, such as referring to a cessation program, asking
about willingness to set a quit date, scheduling a follow-up visit, or recommending
or prescribing nicotine replacement therapy.
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Table 5. Multivariate Model of Predictors of Physician Use of Smoking
Cessation Techniques by Physician Specialty*
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In the same multivariate logistic regression model, other predictors
were associated with the outcomes of physician use of smoking cessation techniques.
Physicians in private practice, compared with those in all other settings,
were less likely to report referring patients to a smoking cessation program
(odds ratio [OR], 0.53; 95% confidence interval [CI], 0.35-0.80) or having
nursing staff counsel a smoking parent on cessation (OR, 0.48; 95% CI, 0.26-0.89).
Older age among physicians was associated with decreased likelihood to ask
parents if they smoke in front of the child outside the home, advising parents
to quit smoking, and motivating parents to quit. Physicians born in the United
States (OR, 0.50; 95% CI, 0.27-0.93) were less likely to report counseling
smoking parents for 3 minutes or more. Physicians who graduated from US medical
schools were less likely to report referring patients to their nursing staff
for cessation counseling (OR, 0.26; 95% CI, 0.12-0.59) and giving cessation
pamphlets (OR, 0.54; 95% CI, 0.29-0.96).
Comparison of pediatricians and family physicians by agreement with
the 9 perceived barriers showed that only 1 was statistically significant
(P<.001). Pediatricians were more likely to agree
a lot or some that asking parents about tobacco use would "not be effective
since I lack smoking cessation skills" (OR, 3.12; 95% CI, 1.55-6.30). Physicians
in private practice, compared with those in all other settings, were more
likely to agree that asking about tobacco use would be time-consuming (OR,
1.96; 95% CI, 1.12-3.43) and not effective because parents lack interest in
quitting smoking (OR, 1.81; 95% CI, 1.01-3.23).
COMMENT
This survey compares reported behavior among pediatricians and family
physicians toward assessment of secondhand smoke, counseling parents who smoke,
and perceived barriers to delivery of smoking cessation interventions. Pediatricians
were significantly less likely than family physicians to have reported spending
3 or more minutes counseling a smoking parent, referring a parent to a smoking
cessation program, asking for a quit date from the parent, scheduling a follow-up
visit to discuss smoking cessation, increasing motivation for a parent to
quit, and prescribing nicotine replacement therapy. The odds of pediatricians
compared with family physicians reporting these practices varied from 0.14
for prescribing nicotine replacement therapy and scheduling a follow-up visit
to 0.45 for referring a parent to a smoking cessation program. Furthermore,
pediatricians clearly perceived a lack of smoking cessation counseling skills
as a barrier to even asking parents about tobacco use. These findings identify
a potential gap for pediatricians in addressing secondhand smoke exposure
for young children given that the principal contributor in most homes relates
to parental smoking.
Our study found that family physicians were more likely to report routine
counseling of smoking parents of young children. A possible explanation for
these findings is that family physicians see adults and as a result have received
more training in smoking cessation counseling. The fact that these family
physicians would also be the primary care physician for the parents means
that they should respond to the questions as they would for their patients.
However, one third of the time these family physicians would refer a smoking
parent to his or her personal physician, indicating that the respondent was
not the primary physician. Furthermore, based on the physicians' reports,
only 40% of the time did parents receive smoking cessation pamphlets from
family physicians. We would have expected this percentage to be much higher
if the parents were the respondent's patients. Thus, the specialty differences
observed are not entirely explained by the likelihood that family physicians
were also the parent's physician.
We also found that physicians in private practice settings were less
likely to report referring parents to a smoking cessation program or asking
nursing staff to counsel on cessation. The development and implementation
of educational interventions for clinicians to decrease secondhand smoke exposure
among young children will require attention to the needs and reality of physicians
in private practice.
Overall, most physicians in this study reported asking questions about
parental smoking in the home, discussing risks of secondhand smoke, counseling
parents on the health risks of smoking, and trying to motivate parents to
quit. However, less than half indicated that they had referred parents to
a cessation program, given a pamphlet on smoking cessation, asked about willingness
to set a quit date, scheduled follow-up visits, or recommended use of nicotine
replacement therapy in their efforts to help a smoking parent quit. These
data reflect a lack of physician participation in smoking cessation activities
and are consistent with other data on the frequency of cessation counseling
of adults in the ambulatory setting.
Since less than half of adults are advised to quit by their own primary
physicians, pediatricians may have the opportunity to address this important
issue with a smoking adult during pediatric care. The National Cancer Institute
Physicians' Guide to Smoking Cessation includes a section on smoking prevention,
and this was cosponsored by the American Pediatrics Association. The American
Pediatrics Association has made efforts at disseminating these skills through
trainers, but a formal evaluation has not been conducted. Pediatricians have
not been targeted for tobacco control physician-mediated interventions with
a smoking parent of a young child. Despite this, pediatric residents who were
taught smoking cessation counseling techniques performed as well as those
in other primary care specialties.18 Data collected
from pediatricians and parents indicate that counseling about smoking prevention
and cessation and about the harms of secondhand smoke would be welcomed and
considered important.19, 20 Barriers
to counseling about smoking cessation for parents reported by pediatricians
include the perception that techniques are ineffective, feeling ill at ease
about giving this advice, lack of time, and fear that parents may feel this
is intrusive.13, 15, 21
In one survey of parents,20 only 15% reported
their smoking was "none of the doctor's business," but more than half believed
that talking about smoking was "part of the pediatrician's job."
A recent study22 from Scotland found
that an educational intervention with smoking parents of asthmatic children
(age range, 2-12 years) had no effect on smoking at 1 year of follow-up. Based
on studies in adult medical practices, active involvement of clinicians, use
of medical record reminders,23 and promotion
of nicotine replacement therapy as a pharmacological adjunct to smoking cessation
counseling24 should be routine practice for
physicians in contact with smoking parents in pediatric settings. Thus, given
the evidence on the feasibility and effectiveness of training clinicians to
assist their patients to quit smoking, pediatric clinicians are uniquely positioned
to counsel a smoking parent on cessation.
Two randomized trials to evaluate interventions to decrease secondhand
smoke exposure in infants have been conducted. A home-based nurse-delivered
intervention was evaluated in 933 infants, of whom 25.2% had smoking mothers.25 Among the 121 infants of smoking mothers who completed
the study, infants in the intervention group were exposed to 5.9 fewer cigarettes
per day and had a lower prevalence of persistent respiratory tract symptoms
even though there was no difference in the urinary cotinine level between
infants in the intervention and control groups.25
The second study26 randomized 49 pediatric
practices to receive a 45-minute training intervention on brief counseling
for new mothers on the first 4 well-child visits. The intervention intended
to decrease secondhand smoke and was compared with a hospital packet containing
written information received by all mothers. Pediatricians were taught to
deliver a 2-minute intervention with an emphasis on counseling smoking mothers
(42.5% of the study sample) to quit. At 6 months of follow-up, smoking mothers
in the intervention group had higher quit rates (5.9% vs 2.7%) and lower relapse
rates (45% vs 55%), providing evidence that a brief intervention can have
a positive impact on maternal smoking.26
We found that most physicians in our study did not agree with any of
the 8 barriers to delivery of smoking cessation services. Pediatricians were
less convinced that parents would be interested in quitting and more concerned
about parents ignoring their advice. However, 26% agreed that they lacked
smoking cessation counseling skills, compared with only 7% of family physicians.
Based on these findings, training pediatric clinicians to assist smoking parents
to quit seems feasible and should become a priority for residency programs.
Our study has important limitations. First, we obtained a response rate
of 56%, which may introduce bias even though a comparison of available demographics
did not show significant differences between respondents and nonrespondents.
Moreover, this level of response rate is comparable to other physician surveys.27 Second, all the responses are self-reported behavior
or estimates and none were validated with intermediate outcomes or surveys
of patients' parents. However, physicians are more likely to overestimate
the frequency of prevention activities in practice and thus our data probably
represent a best-case scenario. An intervention study should incorporate a
validation component to evaluate physician self-report. Finally, these physicians
reside in California, where there has been an active antismoking campaign
for about 10 years, and their sensitivity and responses to these questions
may be affected by the general change in societal norms on tobacco.
In conclusion, our study confirms that pediatricians and family physicians
are not taking full advantage of an important opportunity to decrease secondhand
smoke exposure in their young patients. Training pediatricians and family
physicians in smoking cessation counseling techniques and motivating them
to use these with smoking parents may help reduce secondhand smoke exposure
among children. Enhancing the practice environment to facilitate smoking cessation
counseling of parents of young children, increasing referrals to smoking cessation
programs, and teaching all clinicians how to recommend nicotine replacement
therapy and other pharmacological adjunctive therapy for nicotine addiction
are additional practices that may reduce secondhand smoke exposure for children.
AUTHOR INFORMATION
Accepted for publication August 22, 2000.
This study was supported by grant 6RT-0368, pediatrician training to
prevent children's tobacco exposure, from the University of California Tobacco-Related
Disease Research Program.
From the Division of General Internal Medicine, Department of Medicine
(Drs Pérez-Stable, Juarez-Reyes, and Kaplan), the Medical Effectiveness
Research Center for Diverse Populations (Drs Pérez-Stable, Juarez-Reyes,
Kaplan, Fuentes-Afflick, and Gildengorin), the Comprehensive Cancer Center
(Drs Pérez-Stable and Kaplan), the Department of Pediatrics (Drs Fuentes-Afflick
and Millstein), the Department of Epidemiology and Biostatistics (Dr Fuentes-Afflick),
and the Division of Adolescent Medicine (Dr Millstein), University of California,
San Francisco.
Corresponding author: Eliseo J. Pérez-Stable, MD, Division
of General Internal Medicine, University of California, San Francisco, 400
Parnassus Ave, Room A-405, Box 0320, San Francisco, CA 94143-0320 (e-mail: eliseops{at}medicine.ucsf.edu).
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