Secondhand smoke (SHS) exposure affects approximately 40 percent of the children in the United States, increasing their risk for acute respiratory infections, sudden infant death syndrome, and premature death, while also exacerbating chronic respiratory diseases such as asthma. As a pediatrician, it is astounding to me that this issue still affects so many children given what we know about the related health harms—so I wanted to find a solution.
We know that when a parent quits smoking, they eliminate the majority of their child’s SHS exposure, decrease the risk of their children becoming smokers as adults and increase their own life expectancy. We also know that parents who smoke often don’t receive all the medical care they need, and often don’t have regular contact with an adult healthcare provider. They do however, see their child’s doctor an average of three to four times each year.
This interaction puts pediatricians in a unique position to provide intergenerational family services to address the health needs of parent smokers by educating, motivating and initiating tobacco dependence treatment, while helping to protect children from tobacco and SHS exposure. Research tells us that parents expect pediatricians to ask about their smoking status and are receptive to their help on how to quit. Yet, pediatric healthcare settings very rarely deliver effective tobacco dependence assistance.
Connecting Parents to the Quitline in the Pediatrician’s Office
My colleagues and I set out to determine how we could address this treatment gap by evaluating an innovative strategy combining electronic health records (EHRs) and tobacco counseling services. Guidelines recommend pediatricians provide smoking cessation strategies to parent smokers, including giving information about or telling them to call state tobacco quitlines. However, pediatricians have an increasing number of guidelines, screenings and health issues to address when meeting with families for a short visit, so we created an electronic quitline referral system that was brief and fit within the clinicians’ typical workflow. It was our hope that by reducing the provider burden of providing smoking cessation services we could also increase the likelihood that parents would engage in treatment.
We tested two approaches at a Children’s Hospital of Philadelphia (CHOP) primary care practice in West Philadelphia. Pediatricians gave some parents the quitline phone number and encouraged them to reach out and enroll on their own. Others received an eReferral—a “warm handoff” where a physician sent the parent’s information electronically to the quitline so a quitline representative could call the parent directly to enroll. Pediatricians advised all parents to quit smoking and prescribed nicotine replacement therapy, such as the nicotine patch and nicotine gum, if they were interested.
A Promising Approach
After enrolling more than 480 parents, we found that making an eReferral led to an 8 percent increase in parents enrolling in the quitline, representing a fivefold improvement in enrollment over parents who only received quitline contact information. Conducting the study in a real-world clinical setting shows us that simply telling a parent to quit smoking isn’t enough and leads to only 1 of 50 parents successfully enrolling in treatment. When using an eReferral process, enrollment rates increased to 1 of 10 parents.
What we learned is that by connecting parents who smoke to the quitline through eReferral, pediatric practices may be successful in significantly increasing treatment rates. It’s important work, but it’s also just a first step. While eReferral to the quitline led to 10 percent of parents successfully enrolling, 90 percent of parents still did not engage. Further, we need ongoing efforts that support parents in achieving the ultimate outcome: quitting.
Continued research is key to this effort. My colleagues at PolicyLab at CHOP, and beyond, are working to increase the likelihood that parents will start treatment by leveraging behavioral economics methods to initiate behavior change. What we already know is that multiple quit attempts and sticking with treatment can dramatically increase the likelihood that an individual will quit smoking. Given the widespread benefits of tobacco cessation, we should continue exploring and investing in longer-term follow-up services that keep parents engaged including, but not limited to, reminders to revisit smoking at the next office visit, text messages to check in with parents and reinforce behavior change, telephone outreach, additional in-person services available at the office, or even home visits by a community health worker.
In all, this work reveals how helping parents quit smoking through pediatric settings is possible and should be a policy priority we all strive toward. Pediatricians have the opportunity to protect the health of children by intervening directly with parents—helping ensure that they and their children live healthier, tobacco-free lives.
Dr. Brian Jenssen is a pediatrician at Children’s Hospital of Philadelphia, Assistant Professor within the Department of Pediatrics at the University of Pennsylvania Perelman School of Medicine, a researcher at PolicyLab and Policy Chair of the American Academy of Pediatrics’ Section on Tobacco Control.
Blog last updated: April 13, 2020