Exposure to environmental tobacco smoke (ETS) is a major cause of morbidity and mortality among US children, as demonstrated by numerous studies that show that ETS exposure in children is associated with multiple childhood illnesses including asthma, bronchiolitis, acute otitis media (1–3), and sudden infant death syndrome (4–5). Children under the age of 15 years make more than 23 million annual visits to emergency departments (ED), with approximately 3% of those visits for asthma (6). Parental smoking results in annual direct medical expenditures of $4.6 billion and loss of pediatric life costs of $8.2 billion (7). Approximately 38% of US children younger than 6 years live in a home with at least 1 smoker (8). Adult smoking prevalence varies inversely with educational level and household income (9). Thus, the majority of children exposed to ETS are from low-income families.
As part of Healthy People 2010, there is a mandate to health care providers, including those in the ED, to protect nonsmokers from ETS exposure and to provide smoking cessation help to smokers (10). In response to this, the Society for Academic Emergency Medicine’s Public Health and Education Task Force has submitted several objectives related to health promotion in the ED setting which include an increase to 75% of the proportion of emergency care providers who advise cessation and refer patients to smoking cessation programs (11). In recent years, the ED has been examined as a potential site for identifying smokers and providing smoking education. These studies have shown a prevalence of smoking among ED patients of up to 41%, with greater than two thirds of these patients reporting that they want to quit (12–13). The pediatric ED is an underused forum for educating parents about the effects of ETS on their children and providing smoking cessation advice. Such education may be particularly valuable when parents bring their children into the ED for smoking-related illnesses such as recurrent otitis media or wheezing; such times may represent “teachable moments,” which can enhance subsequent counseling (14).
The purpose of this survey was to determine smoking habits, levels of nicotine addiction, readiness to quit, and beliefs about the effects of ETS exposure of parents of children with bronchiolitis and asthma who present to a pediatric ED.
This was a cross-sectional prevalence study of parents or legal guardians of children with asthma or bronchiolitis presenting to a pediatric ED. The Institutional Review Board at our institution approved the protocol prior to study initiation.
Study Setting and Population.
This study was conducted in the Children’s Hospital Medical Center ED in Cincinnati, Ohio, which has an annual patient census of approximately 82,000. All parents or legal guardians of children between the ages of 0 and 18 years who were given the diagnosis of asthma, reactive airway disease, bronchiolitis, or wheezing were eligible for inclusion into the study. Only 1 parent or legal guardian per family was surveyed, regardless of the number of eligible children or smokers in the family. If a child had multiple visits, caregivers were only interviewed once. Parents of patients who required intubation during their ED visit or had a history of chronic lung disease (other than asthma) or heart disease were excluded from the study.
Survey Content and Administration.
We administered a closed-question, written survey to a convenience sample of eligible parents for a period of 3 months (January 17 to April 17, 2000). The survey was conducted only during hours when the principal investigator or a dedicated trained research associate was available. The survey was conducted during weekdays between 8 am and 4 pm, 1 day per week, between 4 pm and 12 am, 1 to 2 days per week, and between 11 pm and 8 am twice a month. The survey contained 30 items, including demographics and, among smokers, an assessment of the parents’ current smoking habits. Nicotine dependence was determined by the Fagerstrom Test for Nicotine Dependence (FTND) (15), which is a series of 6 questions about smoking habits. The FTND gives a score of 0 to 10; a score above 4 was used to identify patients with moderate to high nicotine dependence. The FTND accurately and reliably measures nicotine dependence (15–17). In parents who were smokers, the questions also addressed their beliefs about the effects of ETS on their wheezing child, their intentions to quit, former advice about the effects of ETS from private physicians, and knowledge about illnesses to which ETS exposure may contribute.
Data were analyzed using the Statistical Software Package for the Social Sciences (SPSS) 10.0 for Windows. To test the associations between demographic characteristics of patients and smoking rates, the χ2 test or Fisher exact test for categoric data, and the unpaired t test for continuous variables were used. Results were interpreted in a 2-tailed manner and were considered statistically significant if P < 0.05.
Response Rate and Sample Characteristics.
The total patient census in our ED during the study period was 21,952. There were 251 eligible patients identified by the principal investigator or research associate, and 249 parents (99.2%) agreed to participate. Our surveyed sample of parents/legal guardians had a mean age (±SD) of 30.0 (±8.9) years and an age range of 15 to 67 years. Most respondents were female (88%) and unmarried (57.4%). Slightly over half (50.6%) were nonwhite. Only 36.6% of the sample were educated beyond high school; 66.3% were employed with 51% having an annual income of $0 to $25,000 (Table 1).
The self-reported smoking prevalence was 41% (95% CI = 32–51). As shown in Table 2, smoking prevalence among parents of wheezing children varied according to education, income, and race, but not according to gender, age, or employment status.
Readiness to Quit and Nicotine Dependence.
Of the 102 smokers in the sample, 84 (82.4%, 95% CI = 73–88) reported that they wanted to quit; 78 (76.5%, 95% CI = 68–84) stated that they wanted to quit within the next month. A small percentage (21%, 95% CI = 14–30) had tried smoking cessation in the past, but 66% (95% CI = 56–74) reported that they would be interested in joining a smoking cessation program/trying a smoking cessation aid or medication. Forty nine percent (95% CI = 39–59) scored above 4 on the Fagerstrom test and were considered nicotine-dependent.
Smoking Location, Health Care Provider Education, and Knowledge of Effects of ETS among Smokers.
The majority of smokers admitted to smoking around their children (66.7%, 95% CI = 57–75), and only 33 of the 102 smokers (32.4%, 95% CI = 24–42) reported that they smoke outside of the house only. Most parents reported that they had received counseling from their pediatricians about the effects of ETS (81.4%, 95% CI = 72–87). Many parents knew that ETS may contribute to the development of the following illnesses: colds/upper respiratory tract infections - 77.5%, otitis media - 68.6%, pneumonia - 50%, wheezing/asthma attacks - 86.3%, and SIDS - 31.4%.
The results of this survey provide important baseline information about the demographic characteristics and attitudes about smoking cessation of urban parents of children presenting to the ED with bronchiolitis or asthma. It is well known that children with asthma who are exposed to ETS have a decrease in pulmonary function, an increase in airway reactivity, an increase in the frequency of ED visits for treatment of acute asthma exacerbations (18), and an impaired recovery after hospitalization for asthma (19). This study shows that a large proportion of parents of children with illnesses that are clearly exacerbated by cigarette smoke do smoke, are nicotinedependent, and want to quit smoking. This group has also been educated by their children’s pediatricians about the effects of ETS exposure on their children. Despite the desire to quit and prior education by other health care providers, only 21% of this population had tried smoking cessation in the past. However, 66% of the smokers reported that they would be interested in trying a smoking cessation program. In the ED setting, health care providers have the unique opportunity to potentially influence smoking parents at a time when they perceive that their child is in need of immediate medical care. If ways could be found not only to educate parents about the effects of their smoking on their child’s health but also to provide parents with affordable smoking cessation sessions or smoking cessation aids, parents might take the appropriate steps to change their smoking habits once they have left the ED. The ED visit may be an ideal time to influence their behavior and may help them take the first steps to smoking cessation and elimination of ETS from their homes.
Some may argue that the ED is not the appropriate setting to provide health promotion counseling. Former Surgeon General Dr. Joycelyn Elders is a strong proponent of such smoking-related counseling in the ED since we do not yet have a health care system that provides all Americans with access to effective and quality preventive services outside of hospital EDs (14). Ways to provide smoking counseling by minimal-contact health care providers as part of routine practice need to be investigated. The role of the emergency physician in providing not only medical care to acutely ill and injured patients, but also health promotion counseling, has been examined and debated in numerous recent studies. The ED has been examined as a potentially successful forum for screening, counseling, and delivery of public health services such as immunizations, Pap tests, blood lead-level testing, and alcohol abuse reduction (20–26).
The results of this survey show some similarities to the results of 2 previous surveys done in the general ED setting (12,13). In a survey of adult patients presenting to an urban ED, the prevalence of smoking and moderate to high nicotine addiction was also high, at 41 and 42%, respectively, with 68% of smokers surveyed wanting to quit (12). In a similar survey of adult patients in a suburban ED, the smoking prevalence was lower at 21%; however, moderate to high nicotine addiction rates were high at 46%, and 69% wanted to quit (13). The current study targeted parents of children with asthma and bronchiolitis and showed a high smoking prevalence of 41%, and an equally high rate of moderate to severe nicotine addiction of 49%. Parents had an even stronger interest in quitting compared to the prior adult ED studies, with 82% reporting that they wanted to quit and 77% reporting that they wanted to quit within the next month. The increased interest in quitting in this population of adults may be because they were interviewed during a “teachable moment,” when they were more aware that their smoking might affect not only their own health, but also their child’s.
Since emergency physicians who work with wheezing pediatric patients come in contact with a large number of parents who smoke and who may be interested in both reduction of their children’s exposure to ETS and smoking cessation, the argument is strong for emergency physicians to deliver advice to parents on ETS exposure reduction and smoking cessation. It is possible that intervention by emergency physicians may have an impact on the smoking habits of these parents, and future trials of such interventions are warranted.
Our study has some important limitations. This survey was a convenience sample, so parents surveyed may not represent a uniform sample of all parents of children with asthma or bronchiolitis. Most of the respondents were female, so male smokers were not adequately represented in this sample. In addition, this survey was limited to an urban, hospital-based ED, and the parents surveyed may have a below-average socioeconomic status; thus, the results may not be generalizable to other populations. However, we found similarities in the prevalence of smoking and nicotine-addicted parents in our population compared to other studies of urban and suburban populations (12,13). The sample of smokers in our population also had similar educational level, employment, and marital status compared to the sample in the Lowenstein et al. study (12), which was performed in the ED of an urban teaching hospital similar to our setting.
The pediatric ED may provide health care providers with opportunities to counsel parents of children with smoking-related illnesses and perhaps non-smoking-related illnesses, such as trauma or neurologic disorders, with smoking cessation advice and ETS exposure information. Future studies need to be conducted to determine the best ways to provide such education to parents.
1. Hinton AE. Surgery for otitis media with effusion in children and its relationship to parental smoking
. J Laryngol Otol 1989; 103:559–561.
2. Etzel RA, Pattishall EN, Haley NJ, et al. Passive smoking
and middle ear effusion among children in day care. Pediatrics 1992; 90:228–232.
3. Owen MJ, Baldwin CD, Swank PR, et al. Relation of infant feeding practices, cigarette smoke exposure, and group child care to the onset and duration of otitis media with effusion in the first two years of life. J Pediatr 1993; 123:702–711.
4. Klonoff-Cohen HS, Edelstein SL, Lefkowitz ES, et al. The effect of passive smoking
and tobacco exposure through breast milk on sudden infant death syndrome. JAMA 1995: 273:795–798.
5. Carroll JL, Siska ES. SIDS: Counseling parents to reduce the risk. Am Fam Physician 1998; 57:1566–1572.
6. Freid VM, Makuc DM, Rooks RN. Ambulatory health care visits by children: Principal diagnosis and place of visit. National Center for Health Statistics. Vital Health Stat 1998; 13:1–22.
7. Aligne CA, Stoddard JJ. Tobacco and children. An economic evaluation of the medical effects of parental smoking
. Arch Pediatr Adolesc Med 1997; 151:648–653.
8. Gergen PJ, Fowler JA, Maurer KR, et al. The burden of environmental tobacco smoke exposure on the respiratory health of children 2 months through 5 years of age in the United States: Third national health and nutrition examination survey, 1988 to 1994. Pediatrics 1998; 101:E8.
9. Centers for Disease Control. Cigarette smoking
among adults–United States, 1995. MMWR Morb Mortal Wkly Rep 1997;46:1217–1220.
10. US Department of Health and Human Services. Healthy People 2010 (Conference Edition, in Two Volumes). Washington, DC: January 2000.
12. Lowenstein SR, Tomlinson D, Koziol-McLain J, et al. Smoking
habits of emergency department patients: An opportunity for disease prevention. Acad Emerg Med 1995; 2:165–171.
13. Richman PB, Dinowitz S, Nashed A, et al. Prevalence of smokers and nicotine-addicted patients in a suburban emergency department. Acad Emerg Med 1999: 6:807–810.
14. Elders MJ. Smoking
cessation efforts. Acad Emerg Med 1995; 2:161–162.
15. Fagerstrom KO, Heatherton TF, Kozlowski LT. Nicotine addiction and its assessment. Ear Nose Throat J 1990; 69:763–765.
16. Fagerstrom KO, Schneider NG. Measuring nicotine dependence: A review of the Fagerstrom Tolerance Questionnaire. J Behav Med 1989; 12:159–182.
17. Fagerstrom KO. Measuring degree of physical dependence to tobacco smoking
with reference to individualization of treatment. Addict Behav 1978; 3:235–241.
18. Chilmonczyk B, Salmun L, Megathlin K, et al. Association between exposure to environmental tobacco smoke and exacerbations of asthma
in children. N Engl J Med 1993; 328:1665–1669.
19. Abulhosn RS, Morray BH, Llewellyn CE, et al. Passive smoke exposure impairs recovery after hospitalization for acute asthma
. Arch Pediatr Adolesc Med 1997; 151:135–139.
20. Cunningham SJ. Providing immunizations in a pediatric emergency department: Underimmunization rates and parental acceptance. Pediatr Emerg Care 1999; 15:255–259.
21. Polis MA, Davey VJ, Collins ED, et al. The emergency department as part of a successful strategy for increasing adult immunization. Ann Emerg Med 1988; 17:1016–1018.
22. Hogness CG, Engelstad LP, Linck LM, et al. Cervical cancer screening in an urban emergency department. Ann Emerg Med 1992; 21:933–939.
23. Mandelblatt J, Freeman H, Winczewski D, et al. Implementation of a breast and cervical cancer screening program in a public hospital emergency department. Cancer Control Center of Harlem. Ann Emerg Med 1996; 28:493–498.
24. Wiley 2nd, JF Bell LM, Rosenblum LS, et al. Lead poisoning: Low rates of screening and high prevalence among children in inner-city emergency departments. J Pediatr 1995; 126:392–395.
25. Orava S, Brogan Jr, GX Mofenson H, et al. Evaluation of two strategies for complying with state-mandated lead screening in the emergency department. Acad Emerg Med 1999; 6:849–851.
26. Maio RF. Alcohol and injury in the emergency department: Opportunities for intervention. Ann Emerg Med 1995; 26:221–223.