Treating Parents for Tobacco Use in the Pediatric Setting: The Clinical Effort Against Secondhand Smoke Exposure Cluster Randomized Clinical Trial | Pediatrics | JAMA Pediatrics | JAMA Network
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Farber  HJ, Groner  J, Walley  S, Nelson  K; Section on Tobacco Control.  Protecting children from tobacco, nicotine, and tobacco smoke.  Pediatrics. 2015;136(5):e1439-e1467. doi:10.1542/peds.2015-3110PubMedGoogle ScholarCrossref
US Department of Health and Human Services. The health consequences of smoking: 50 years of progress, a report of the Surgeon General. Published 2014. Accessed July 8, 2019.
Hall  N, Hipple  B, Friebely  J, Ossip  DJ, Winickoff  JP.  Addressing family smoking in child health care settings.  J Clin Outcomes Manag. 2009;16(8):367-373.PubMedGoogle Scholar
US Department of Health and Human Services. The health consequences of involuntary tobacco smoke: a report of the Surgeon General. Published 2006. Accessed July 8, 2019.
Mackay  D, Haw  S, Ayres  JG, Fischbacher  C, Pell  JP.  Smoke-free legislation and hospitalizations for childhood asthma.  N Engl J Med. 2010;363(12):1139-1145. doi:10.1056/NEJMoa1002861PubMedGoogle ScholarCrossref
den Exter Blokland  EA, Engels  RC, Hale  WW  III, Meeus  W, Willemsen  MC.  Lifetime parental smoking history and cessation and early adolescent smoking behavior.  Prev Med. 2004;38(3):359-368. doi:10.1016/j.ypmed.2003.11.008PubMedGoogle ScholarCrossref
Farkas  AJ, Distefan  JM, Choi  WS, Gilpin  EA, Pierce  JP.  Does parental smoking cessation discourage adolescent smoking?  Prev Med. 1999;28(3):213-218. doi:10.1006/pmed.1998.0451PubMedGoogle ScholarCrossref
Bricker  JB, Leroux  BG, Peterson  AV  Jr,  et al.  Nine-year prospective relationship between parental smoking cessation and children’s daily smoking.  Addiction. 2003;98(5):585-593. doi:10.1046/j.1360-0443.2003.00343.xPubMedGoogle ScholarCrossref
Bricker  JB, Leroux  BG, Robyn Andersen  M, Rajan  KB, Peterson  AVJ  Jr.  Parental smoking cessation and children’s smoking: mediation by antismoking actions.  Nicotine Tob Res. 2005;7(4):501-509. doi:10.1080/14622200500186353PubMedGoogle ScholarCrossref
Bricker  JB, Peterson  AVJ  Jr, Sarason  IG, Andersen  MR, Rajan  KB.  Changes in the influence of parents’ and close friends’ smoking on adolescent smoking transitions.  Addict Behav. 2007;32(4):740-757. doi:10.1016/j.addbeh.2006.06.020PubMedGoogle ScholarCrossref
Winickoff  JP, Healey  EA, Regan  S,  et al.  Using the postpartum hospital stay to address mothers’ and fathers’ smoking: the NEWS study.  Pediatrics. 2010;125(3):518-525. doi:10.1542/peds.2009-0356PubMedGoogle ScholarCrossref
Fiore  MC, Jaén  CR, Baker  TB,  et al. Treating tobacco use and dependence: 2008 update, clinical practice guideline. Published May 2008. Accessed July 8, 2019.
Winickoff  JP, Nabi-Burza  E, Chang  Y,  et al.  Implementation of a parental tobacco control intervention in pediatric practice.  Pediatrics. 2013;132(1):109-117. doi:10.1542/peds.2012-3901PubMedGoogle ScholarCrossref
Winickoff  JP, Nabi-Burza  E, Chang  Y,  et al.  Sustainability of a parental tobacco control intervention in pediatric practice.  Pediatrics. 2014;134(5):933-941. doi:10.1542/peds.2014-0639PubMedGoogle ScholarCrossref
Winickoff  JP, Park  ER, Hipple  BJ,  et al.  Clinical effort against secondhand smoke exposure: development of framework and intervention.  Pediatrics. 2008;122(2):e363-e375. doi:10.1542/peds.2008-0478PubMedGoogle ScholarCrossref
Winickoff  JP, Hipple  B, Drehmer  J,  et al.  The Clinical Effort Against Secondhand Smoke Exposure (CEASE) intervention: a decade of lessons learned.  J Clin Outcomes Manag. 2012;19(9):414-419.PubMedGoogle Scholar
Walters  BH, Ossip  DJ, Drehmer  JE,  et al.  Clinician telephone training to reduce family tobacco use: analysis of transcribed recordings.  J Clin Outcomes Manag. 2016;23(2):79-86.PubMedGoogle Scholar
Harris  PA, Taylor  R, Thielke  R, Payne  J, Gonzalez  N, Conde  JG.  Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support.  J Biomed Inform. 2009;42(2):377-381. doi:10.1016/j.jbi.2008.08.010PubMedGoogle ScholarCrossref
19. SmokefreeTXT. Accessed April 1, 2019.
Office of the Legislative Counsel. Compilation of Patient Protection and Affordable Care Act. Published 2010. Accessed April 1, 2019.
Green  ME, Hogg  W, Savage  C,  et al.  Assessing methods for measurement of clinical outcomes and quality of care in primary care practices.  BMC Health Serv Res. 2012;12:214. doi:10.1186/1472-6963-12-214PubMedGoogle ScholarCrossref
Moody-Thomas  S, Celestin  MD  Jr, Tseng  TS, Horswell  R.  Patient tobacco use, quit attempts, and perceptions of healthcare provider practices in a safety-net healthcare system.  Ochsner J. 2013;13(3):367-374.PubMedGoogle Scholar
Pbert  L, Adams  A, Quirk  M, Hebert  JR, Ockene  JK, Luippold  RS.  The patient exit interview as an assessment of physician-delivered smoking intervention: a validation study.  Health Psychol. 1999;18(2):183-188. doi:10.1037/0278-6133.18.2.183PubMedGoogle ScholarCrossref
Hrisos  S, Eccles  MP, Francis  JJ,  et al.  Are there valid proxy measures of clinical behaviour? a systematic review.  Implement Sci. 2009;4:37. doi:10.1186/1748-5908-4-37PubMedGoogle ScholarCrossref
Winickoff  JP, Hillis  VJ, Palfrey  JS, Perrin  JM, Rigotti  NA.  A smoking cessation intervention for parents of children who are hospitalized for respiratory illness: the Stop Tobacco outreach program.  Pediatrics. 2003;111(1):140-145. doi:10.1542/peds.111.1.140PubMedGoogle ScholarCrossref
Winickoff  JP, Buckley  VJ, Palfrey  JS, Perrin  JM, Rigotti  NA.  Intervention with parental smokers in an outpatient pediatric clinic using counseling and nicotine replacement.  Pediatrics. 2003;112(5):1127-1133. doi:10.1542/peds.112.5.1127PubMedGoogle ScholarCrossref
Martinson  BC, Murray  DM, Jeffery  RW, Hennrikus  DJ.  Intraclass correlation for measures from a worksite health promotion study: estimates, correlates, and applications.  Am J Health Promot. 1999;13(6):347-357.Google ScholarCrossref
Prochaska  JO, DiClemente  CC.  Stages and processes of self-change of smoking: toward an integrative model of change.  J Consult Clin Psychol. 1983;51(3):390-395. doi:10.1037/0022-006X.51.3.390PubMedGoogle ScholarCrossref
Prochaska  JO, Velicer  WF.  The transtheoretical model of health behavior change.  Am J Health Promot. 1997;12(1):38-48. doi:10.4278/0890-1171-12.1.38PubMedGoogle ScholarCrossref
McBride  CM, Emmons  KM, Lipkus  IM.  Understanding the potential of teachable moments: the case of smoking cessation.  Health Educ Res. 2003;18(2):156-170. doi:10.1093/her/18.2.156PubMedGoogle ScholarCrossref
Jenssen  BP, Bryant-Stephens  T, Leone  FT, Grundmeier  RW, Fiks  AG.  Clinical decision support tool for parental tobacco treatment in primary care.  Pediatrics. 2016;137(5):e20154185. doi:10.1542/peds.2015-4185PubMedGoogle ScholarCrossref
Winickoff  JP, Tanski  SE, McMillen  RC, Hipple  BJ, Friebely  J, Healey  EA.  A national survey of the acceptability of quitlines to help parents quit smoking.  Pediatrics. 2006;117(4):e695-e700. doi:10.1542/peds.2005-1946PubMedGoogle ScholarCrossref
Nabi-Burza  E, Winickoff  JP, Drehmer  J,  et al Innovations in parental smoking cessation assistance delivered in the child healthcare setting.  Accept Transl Behav Med. 2019;pii:ibz070. doi:10.1093/tbm/ibz070Google ScholarCrossref
Mahabee-Gittens  EM, Dixon  CA, Vaughn  LM, Duma  EM, Gordon  JS.  Parental tobacco screening and counseling in the pediatric emergency department: practitioners’ attitudes, perceived barriers, and suggestions for implementation and maintenance.  J Emerg Nurs. 2014;40(4):336-345. doi:10.1016/j.jen.2013.06.001PubMedGoogle ScholarCrossref
Jamal  A, King  BA, Neff  LJ, Whitmill  J, Babb  SD, Graffunder  CM.  Current cigarette smoking among adults—United States, 2005-2015.  MMWR Morb Mortal Wkly Rep. 2016;65(44):1205-1211. doi:10.15585/mmwr.mm6544a2PubMedGoogle ScholarCrossref
Wang  TW, Asman  K, Gentzke  AS,  et al.  Tobacco product use among adults—United States, 2017.  MMWR Morb Mortal Wkly Rep. 2018;67(44):1225-1232.Google ScholarCrossref
Fisher  ES, McClellan  MB, Bertko  J,  et al.  Fostering accountable health care: moving forward in Medicare, Vol. 28.  Health Aff (Millwood). 2009;28(2):219-231.Google ScholarCrossref
Dilley  JA, Harris  JR, Boysun  MJ, Reid  TR.  Program, policy, and price interventions for tobacco control: quantifying the return on investment of a state tobacco control program.  Am J Public Health. 2012;102(2):e22-e28. doi:10.2105/AJPH.2011.300506PubMedGoogle ScholarCrossref
Original Investigation
August 12, 2019

Treating Parents for Tobacco Use in the Pediatric Setting: The Clinical Effort Against Secondhand Smoke Exposure Cluster Randomized Clinical Trial

Author Affiliations
  • 1Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston
  • 2Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston
  • 3Harvard Medical School, Boston, Massachusetts
  • 4Mongan Institute Health Policy Center, Massachusetts General Hospital, Boston
  • 5Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
  • 6American Academy of Pediatrics, Julius B. Richmond Center of Excellence, Itasca, Illinois
  • 7Department of Pediatrics, University of Illinois at Chicago
JAMA Pediatr. 2019;173(10):931-939. doi:10.1001/jamapediatrics.2019.2639
Key Points

Question  Can the Clinical Effort Against Secondhand Smoke Exposure intervention help parents quit smoking in the context of pediatric practices?

Findings  In this cluster randomized clinical trial, after initial intervention implementation, 44% of parents received cessation assistance in intervention practices, compared with less than 1% in control practices. Over the 2-year study period, intervention practices had a 2.7% decrease in the smoking rate in parents, compared with a 1.1% increase in control practices.

Meaning  In this trial, implementing a program to treat parents for tobacco use within pediatric offices was associated with markedly higher rates of tobacco treatment delivery and a decline in practice-level parent smoking rates compared with a control group of practices that delivered usual care.


Importance  Despite the availability of free and effective treatment, few pediatric practices identify and treat parental tobacco use.

Objective  To determine if the Clinical Effort Against Secondhand Smoke Exposure (CEASE) intervention can be implemented and sustained in pediatric practices and test whether implementing CEASE led to changes in practice-level prevalence of smoking among parents over 2 years.

Design, Setting, and Participants  This cluster randomized clinical trial was conducted from April 2015 to October 2017. Ten pediatric practices in 5 states were randomized to either implement the CEASE protocol or maintain usual care (as a control group). All parents who screened positive for tobacco use by exit survey after their child’s clinical visit 2 weeks (from April to October 2015) and 2 years after intervention implementation (April to October 2017) were eligible to participate. Data analysis occurred from January 2018 to March 2019.

Interventions  The CEASE intervention is a practice-change intervention designed to facilitate both routine screening in pediatric settings of families for tobacco use and delivery of tobacco cessation treatment to individuals in screened households who use tobacco.

Main Outcomes and Measures  The primary outcome was delivery of meaningful tobacco treatment, defined as the prescription of nicotine replacement therapy or quit line enrollment. Furthermore, changes in practice-level smoking prevalence and cotinine-confirmed quit rates over the 2 years of intervention implementation were assessed.

Results  Of the 8184 parents screened after their child's visit 2 weeks after intervention implementation, 961 (27.1%) were identified as currently smoking in intervention practices; 1103 parents (23.9%) were currently smoking in control practices. Among the 822 and 701 eligible parents who completed the survey in intervention and control practices, respectively 364 in the intervention practices (44.3%) vs 1 in a control practice (0.1%) received meaningful treatment at that visit (risk difference, 44.0% [95% CI, 9.8%-84.8%]). Two years later, of the 9794 parents screened, 1261 (24.4%) in intervention practices and 1149 (25.0%) in control practices were identified as currently smoking. Among the 804 and 727 eligible parents completing the survey in intervention and control practices, respectively, 113 in the intervention practices (14.1%) vs 2 in the control practices (0.3%) received meaningful treatment at that visit (risk difference, 12.8% [95% CI, 3.3%-37.8%]). Change in smoking prevalence over the 2 years of intervention implementation favored the intervention (−2.7% vs 1.1%; difference −3.7% [95% CI, −6.3% to −1.2%]), as did the cotinine-confirmed quit rate (2.4% vs −3.2%; difference, 5.5% [95% CI, 1.4%-9.6%]).

Conclusions and Relevance  In this trial, integrating screening and treatment for parental tobacco use in pediatric practices showed both immediate and long-term increases in treatment delivery, a decline in practice-level parental smoking prevalence, and an increase in cotinine-confirmed cessation, compared with usual care.

Trial Registration identifier: NCT01882348