Advocacy for Those without a Voice: Helping Parents with Smoking Cessation

Submitted by Karmen Dayhuff

Tags: cessation child children family pediatric pediatrics second-hand smoke smoking smoking cessation

Advocacy for Those without a Voice: Helping Parents with Smoking Cessation

Share Article:

Written by:

Karmen Dayhuff
Christa McAfee
Debra Vincent
Susan Eley

Indiana State University


The purpose of this manuscript is to summarize current research in the area of second-hand smoke exposure in children and smoking cessation interventions for their parents. A literature review was conducted using Academic Search Complete, CINAHL, MEDLINE, PsycARTICLES, PsycINFO, and Biomedical Reference Collection: Basic, and Health Source: Nursing/Academic Edition. Although there are a significant amount of studies demonstrating that second-hand smoke exposure is an avoidable risk factor for respiratory illness in children, there is a definite lack of studies demonstrating specific guidelines for smoking cessation interventions for these parents. Despite a lack of specific smoking cessation intervention guidelines for parents to help decrease second-hand smoke exposure in their children, the 5As are effective evidence based recommendations to utilize at every pediatric office visit in order to promote discussion between parents and care providers.

Common reasons for seeking medical care for children are respiratory illnesses, and a major contributing factor to these illnesses is second-hand smoke exposure (Caponnetto, Polosa, & Best, 2008). Complications linked to second hand smoke exposure also include sudden infant death syndrome, otitis media, respiratory illness and infection (including asthma), and a 20% increased risk for cardiovascular disease (Collins & Ibrahim, 2012). Not only can health complications continue on into adulthood, but second-hand smoke exposure can also increase a child’s risk for tobacco use (Rosen et al., 2011).

The health complications created from second-hand smoke exposure in children also creates a significant economic burden. “According to the World Health Organization (as cited in Rosen et al, 2011), “medical costs of children due to SHS have been estimated at $703-$897 million in the US, $239.5 million in Canada, and $267 million in Britain.” Additionally, as a result of second-hand smoke exposure, children with asthma are at risk for more frequent hospitalizations (Schvartsman et al., 2013) which adds to the economic burden. As part of a recent study funded by the National Institute of Health, it was found that children with asthma exposed to second-hand smoke have twice the risk of hospital readmission compared to children with asthma who are not exposed to second-hand smoke (Howrylak et al., 2014).

Attempts to reduce public second-hand smoke exposure have been successful due to national and local legislation that have banned smoking in public places. Unfortunately, children are still exposed to smoke at home (Lubik, 2011). Given the health and economic burden of exposure to second-hand smoke in children, it is important for nurse practitioners to examine current evidence and develop strategies that promote smoking cessation among parents who smoke. By doing so, health care providers are able to advocate for children who are unable to defend their own health. In children under the age of 18 who are exposed to secondhand smoke, it has been questioned whether or not smoking cessation intervention for parents affect the rate of childhood respiratory illnesses, such as asthma and pneumonia. A potential for positive outcomes in the pediatric patient population exists by educating parents about the detriments of second-hand smoke exposure. One way to inform parents is through written information regarding acute and chronic effects from second-hand smoke and smoking cessation programs. The end goal is to eliminate second-hand smoke exposure to children.

The purpose of this literature review is to summarize current literature regarding second-hand smoke exposure to children, which will aid health care providers when discussing smoking cessation interventions with adults who have children. The review is essential because parents need to be aware of the effects of second-hand smoke and the potential negative impact on their children’s health. Interventions targeted for parents who smoke that highlight the negative effects of smoking and its impact on their children’s health may encourage parental smoking cessation.


Literature Review

A review of literature was conducted using Academic Search Complete, CINAHL, MEDLINE, PsycARTICLES, PsycINFO, and Biomedical Reference Collection: Basic, and Health Source: Nursing/Academic Edition. The search terms included “secondhand smoke exposure,” “children,” “smoking cessation,” and “smoking cessation for parents,” and publication dates were between 2008 and 2014. The search yielded 83 studies. Studies were then chosen according to their relevance to the topic of second-hand smoke exposure in children and smoking cessation for parents.
In a systematic review, Jones et al. (2011) noted a significant increase in the risk of lower respiratory illness in children aged two years and younger who were exposed to all types of second-hand smoke with the highest risk noted in children who resided in a home where both parents smoke. Additionally, Jones et al. (2011) revealed that children contracting bronchiolitis had an increased association with passive maternal smoking. In a study by Martin-Pujol et al. (2013), questionnaires were administered to school aged children to assess second-hand smoke exposure and respiratory symptoms. The questionnaire included four setting selections: home, school, transportation, and leisure time. A little over 75% of the respondents indicated exposure to second-hand smoke in at least one setting. While limitations to this study could be information bias related to self-reporting, a significant association between wheezing and exposure to second-hand smoke was also found.

Evidence based practice (EBP) can lead to positive patient outcomes, and in primary care best practices should be considered when educating parents about smoking cessation. Given the long and short-term implications of children exposed to second-hand smoke, opportunities for parental education regarding the effects of secondhand smoke can be maximized and serve as a motivational factor for smoking cessation. Caponnetto, Polosa and Best (2008) suggest parents are the main source of second-hand smoke exposure in children and recommend to inquire about tobacco use in parents, and offer smoking cessation education and assistance. Evidence has indicated the use of the 5 As (ask, advise, assess, assist, and arrange) in smoking cessation has been found to increase quit attempts and success with cessation (Caponnetto et al., 2008). Caponnetto et al., (2008) illustrate each step of the five As and suggest approaches that can be incorporated into practice. The authors provide examples for each step including helpful ways of initiating questioning in a simple, non-judgmental manner, which can open communication with any individual that may smoke around the child.

Blanch et al. (2013) used a randomized clustered community trial to evaluate the effectiveness of a multi-level school-based intervention to prevent secondhand smoke exposure in children ages 12 to 14. Interventions in the classroom, school, and home were aimed at education regarding the risks of secondhand smoke exposure and ways to prevent secondhand smoke exposure (Blanch et al., 2013). Results of the study demonstrated no overall effectiveness of the interventions in decreasing secondhand smoke exposure. Hovell et al. (2009), examined participating mothers who admitted to smoking around their young children. The participants were randomized into one of two groups: an intervention group who received second-hand smoke exposure counseling and smoking cessation counseling, and a control group who did not receive counseling. The study results demonstrated mothers and families who were counseled regarding smoking cessation and second-hand smoke exposure were three times more likely to quit smoking (although short-term) than the participants in the control group.

Limitations of the Evidence

A significant number of studies exist that support that second-hand smoke is one avoidable risk factor for prevention of childhood respiratory illness (Martin-Pujol et al., 2013). Evidence also supports the use of smoking cessation in parents to reduce this risk factor (Caponnetto et al., 2008). In studies reviewed by Caponnetto et al., (2008), it was identified that there are benefits of implementing smoking cessation counseling to every tobacco user encountered in the clinical setting as recommended by 2008 updated guidelines, Treating Tobacco Use and Dependence.
Potential limitations in reviewed literature include information bias related to self-reporting and use of questionnaires. Self-reporting of information can lead to over self-reporting to glorify symptoms or under-reporting to minimize information (Science Daily, 2011). Self–reporting via questionnaire was mitigated through correlation of responses with salivary or urine cotinine (a byproduct formed after nicotine enters the body) concentration. The correlation between self-reported cessation though questionnaire and cotinine levels demonstrated significant and moderate correlations confirming self-reporting validity (Hovel et al., 2009). Additionally, intervention studies provided quality evidence and high participation follow-up avoided attrition bias commonly seen as a limitation in these types of studies (Blanch et al., 2013).


Application to Family Practice

A significant source of second-hand smoke exposure for children is from caregivers and parents. The 2008 update of Treating Tobacco Use and Dependence recommends addressing and treating every smoker that enters the clinical setting (Caponnetto, 2008). Due to low smoking cessation rates, screening and treating parents who smoke at an early onset has significant clinical implications for children exposed to second-hand smoke and for those that provide their health care (Hovel, 2009).

Early screening at pediatric visits can be accomplished by utilizing the 5 As which include ask, advise, assess, assist, and arrange. Asking can be initiated as a vital sign or be prompted by an electronic health record reminder. Either way, screening parents should be conducted in a manner to encourage parents to discuss tobacco use in the home and enclosed environments such as the car (Caponnetto, 2008). Clear communication about the effects on the childrens’ health can be verbalized with strong advisement to quit. The use of educational materials such as a brochure and a short video demonstrating the effects of second-hand smoke on a childrens’ health could be used for reinforcement of cessation education. Subsequent assessment of parental behavioral change should occur with the goal of providing assistance to facilitate change (Caponnetto, 2008). To help parents in the process of change, counseling and intervention(s) based on readiness to quit should be implemented (Chan et al., 2005). Interventions would include connecting parents with resources such as smoking cessation programs that offer clinical and social support including pharmalogical treatment and problem-solving skills to avoid triggers or urges and promote relapse-prevention (Caponnetto, 2008).

The 2008 update of Treating Tobacco Use and Dependence also recommend telephone quit-lines as an effective smoking cessation intervention because they can reach a broad patient population (U.S. Department of Health and Human Services, 2008). Applying this to practice would suggest offering information in written form, which includes resources such as a telephone quit-line, could promote success in cessation. A more personal intervention might include a telephone follow-up by the provider to add additional support and allow for continued assessment of needs.

Even though exposure to second-hand smoke has decreased in recent years, a significant number of children are still exposed and face the serious health effects. Despite the lack of studies demonstrating specific intervention guidelines for decreasing exposure to second-hand smoke in children, the five As are recommended to be implemented at each pediatric office visit. Future studies might focus on interventions that illustrate the effects of second-hand smoke on children. Ultimately, the use of current recommended interventions can provide positive outcomes and help decrease second-hand smoke exposure in children.


  1. Blanch, C., Fernández, E., Martínez-Sánchez, J. M., Ariza, C., López, M. J., Moncada, A., . . . Nebot, M. (2013). Impact of a multi-level intervention to prevent secondhand smoke exposure in schoolchildren: A randomized cluster community trial. Preventative Medicine, 57(5).
  2. Caponnetto, P., Polosa, R. & Best, D. (2008). Tobacco use cessation counseling of parents. Current Opinion in Pediatrics, 20, 729-733.
  3. Chan, S. S., Lam, T. H., Salili, F, Leung, G. M., Wong, D. C., Botelho, R. J…Lau, Y. L. (2005). A randomized control trial of an individualized motivational intervention on smoking cessation for parents of sick children: A pilot study. Applied Nursing Research, 18(3), 178-181.
  4. Collins, B. N. & Ibrahim, J. (2012). Pediatric second hand smoke exposure: Moving toward systematic multi-level strategies to improve health. Global Heart, 7(2), 161-165.
  5. Collins, B. N., Levin, K. P. & Bryant-Stephens, T. Pediatricians practices and attitudes about environmental tobacco smoke and parental smoking. Journal of Pediatricians, 150(5), 547-552.
  6. Curry, S. J, Ludman, E. J., Graham, E., Stout, J. Grothaus, L. & Lozano, P. (2003). Pediatric-based smoking cessation intervention for low income women: A randomized trial. Archives of Pediatric & Adolescent Medicine, (157)3, 295-302.
  7. Hovell, M. F., Zakarian, J. M., Matt, G. E., Liles, S., Jones, J. A., Hofstetter, C. R., … Benowitz, N. L. (2009). Counseling to reduce children’s secondhand smoke exposure and help parents quit smoking: A controlled trial. Nicotine & Tobacco Research, 11(12), 1383-1394.
  8. Howrylak, J. A., Spanier, A. J., Huang, B., Peake, R.W.A., Kellogg, M. D., Sauers, H., & Kahn, R. S. (2014). Cotinine in children admitted for asthma and readmission. Pediatrics, 133(2), 355-362. Jones, L. J, Hashim, A., McKeever, T., Cook, D. G., Britton, J. & Leonardi-Bee, J. (2011). Parental and household smoking and the increased risk of bronchitis, bronchiolitis, and other lower respiratory infections in infancy: Systematic review and meta-analysis. Respiratory Research, 12(5), 1-11.
  9. Lubik, N. (2011). Smoking and second hand smoke: Global estimate of SHS burden. Environmental Health Perspective, 119(2), A66-A67. Martin-Pujol, A., Fernandez, E., Schiaffino, A., Mondcada, A., Ariza, C., Blanch, C….Martinez-
  10. Sanchez, J.M. (2013). Tobacco smoking, exposure to second-hand smoke, and asthma and wheezing in schoolchildren: a cross-sectional study. Foundations Acta Paediatrica, 102, 305-309.
  11. Rosen, L. J., Guttman, N., Hovell, M. F., Noach, M. B., Winickoff, J. P., Tchernokovski, S., Rosenblum,… Zucker, D. M. (2011). Development, design, and conceptual issues of project zero exposure: A program to protect young children from tobacco smoke exposure. BMC Public Health, 11, 1-11.
  12. Schvartsman, C., Lima Farhat, S. C., Schvartsman, S., & Nascimento Saldiva, P. H. (2013). Parental smoking patterns and their association with wheezing in children. Clinics (Sao Paulo), 68(7), 934-939.
  13. Science Daily. (2011). Avoiding bias in medical literature.
  14. U. S. Department of Health and Human Services. (2008). Treating tobacco use and dependence: 2008 update.