Clinical Effort Against Secondhand Smoke Exposure (CEASE)

Helping parents quit smoking tobacco is a national priority. When parents and legal guardians (hereafter called parents) quit smoking, their life expectancy increases by an average of over 10 years, future poor pregnancy outcomes related to tobacco use are eliminated, and the odds of the children becoming adult smokers decreases. Further, children may no longer be exposed to high levels of tobacco smoke, decreasing the risk of all diseases caused by tobacco smoke exposure and yielding fewer missed school days. Helping parents quit also improves the financial resources of poor families, decreases the risk of developmental delays, and lowers the risk of house fires. Parents who smoke are often medically underserved, visiting their child's health care provider more often than they see their own clinician, if they even have one. Despite this extraordinary opportunity for intervention, child health care settings deliver effective tobacco dependence treatment to parents less than 3% of the time. Routinely delivered tobacco control assistance to parents in this context would provide a major health benefit to the nation and specifically help vulnerable populations who suffer the majority of the 480,000 preventable tobacco-related deaths and $300 billion in attributable costs annually in the United States. Programs and services related to helping parents quit smoking and reducing children's secondhand smoke exposure has been a priority for several groups, including the American Academy of Pediatrics. Pediatricians can become partners in supporting parents in tobacco cessation, not only to reduce the negative effects of parental smoking on children's health but also to reduce the likelihood that these children will smoke when they get older.
 

Clinical Effort Against Secondhand Smoke Exposure (CEASE) aims to increase delivery of tobacco cessation interventions to parents. CEASE is an intervention that trains pediatric care practices to modify their systems so they can routinely address family smoking behavior and help families establish rules for smoking at home and in cars. Through CEASE, child health care offices are trained to change their office systems to address parental tobacco use, connect smokers with free cessation resources, and prescribe medications for smoking cessation.

The first step, delivered by front desk staff, takes place before the child and parent(s) enter the exam room. Upon arrival for the child's visit, the parent receives a screening intake survey (on paper or an iPad) to screen for household tobacco use. If the parent indicates that he or she is a smoker, he or she receives the CEASE Action Sheet, which asks the parent if he or she is interested in getting information on a free telephone quitline or receiving nicotine replacement therapy (NRT). If the parent expresses interest in the tobacco cessation quitline, the front desk staff give the parent a quitline fax referral form, help the parent complete it, and fax the form to the free tobacco cessation quitline. During the visit, the clinician reviews the CEASE Action Sheet, gives brief counseling to encourage the parent to quit smoking, helps the parent to set a quit date, supports the parent in establishing rules for a tobacco-free home and car, and provides the parent with a prescription for nicotine replacement therapy (gum and patch).

Health care practices interested in receiving CEASE training identify a practice leader to receive training on integrating the three steps into routine practice. The practice leader training is conducted by telephone and is also accessible as a self-guided video on the CEASE website. A second training is conducted 1‒2 weeks later by conference call with the practice leader and all other office staff to participate in role-playing activities and address any barriers or concerns regarding implementation. A sustainability training is conducted 6‒9 months after implementation.

-- 2-3 minutes for the provider to give brief counseling to the parent during the pediatric visit

-- 60 minutes for individual training for the practice leader

-- Group training for all practice staff: 60 minutes of training to provide an overview and 60-90 minutes of training using videos and role playing to focus on the Ask, Assist, and Refer process

-- 120 minutes monthly for ongoing telephone support to sustain program implementation

-- Email support as needed, including when practice materials (such as quitline forms) have changed

-- 60 minutes for sustainability training for practice staff 6-9 months after initial implementation

Optional

-- Online eQIPP training through the American Academy of Pediatrics' PediaLink training platform

The intervention targets pediatric health care providers.

The intervention is designed for implementation in clinical pediatric health care practices.

Required resources to implement the program include the following:
-- CEASE Action Sheet
-- CEASE Training Manual
-- CEASE Implementation Guide
-- CEASE Training DVD/Video

Optional materials
-- Clinician NRT Frequently Asked Questions
-- CEASE website
-- Asthma Poster
-- Third-hand Smoking Poster
-- No Smoking Sign Poster
-- Medical Records Review Sheet
-- Quick Training Manual
-- CEASE At A Glance

Program products developed after study completion
-- Electronic cigarette information
-- eQIPP course
-- Sample Disease Registry Report
-- Sample Intake Survey Report
-- Tobacco Disease Registry Guide
-- CEASE Comic Strip
-- Clinician Training Manual for the iPad

For costs associated with this program, please contact the developer, Jonathan Winickoff. (See products page on the EBCCP website for developer contact information.)
 

A cluster randomized controlled trial conducted in 20 pediatric practices in 16 states across the United States, assessed the percentage of parents who received tobacco control assistance from their child's pediatric care provider that participated in either CEASE or usual care. The 20 participating practices were part of Pediatric Research in Office Settings (PROS), a research network of the American Academy of Pediatrics that includes over 700 practices. All PROS practices that met the following criteria were invited to participate: (1) had a minimum of 3 practitioners, (2) were not part of a medical school or parent university, (3) saw at least a minimum of 50 patients per day, and (4) saw at least 10 patients per day with one or more parent smokers. Practices were randomized to receive the CEASE intervention (n=10) or usual care (n=10). Usual care practices received no training, but practice staff in this group were aware that they were participating in the comparison arm in the study. Baseline data over a 3-day period were collected to determine the smoking prevalence of parents at each practice. These data, along with data on the number of providers in each practice, were used to assign practices to the CEASE intervention or usual care through stratified random sampling. All study procedures were approved by the institutional review boards of the American Academy of Pediatrics and Massachusetts General Hospital and by individual practice institutional review boards, if required.

Each study site aimed to recruit a sample of 100 parents exiting their child's pediatrics office to result in a total of 2,000 study participants. Parents aged 18 years and older who smoked within the past 7 days and who had a child under age 18 were eligible to participate. A 14-item screening questionnaire was given to parents to collect data on demographics, reason for the visit, parent smoking rules in the home and car, and parent smoking behavior. Parents were also asked about the tobacco control assistance they received during the visit. Follow-up data were collected from the parents through a telephone survey 12 months after their exit interview. During the call, parents were asked about their current tobacco use behavior, smoking rules in the home and car, and any visits to their child's pediatrics office in the past 12 months. Parents who reported that they had at least one office visit in the past 12 months were asked about the tobacco control assistance they received during the visit. A saliva sample was requested from parents who reported cessation of tobacco use.

A total of 1,980 parents participated in the study (999 parents in the CEASE group and 981 parents in the usual care group). The average age of parents was 30 years, and 78% of parents in the study were mothers. In the CEASE group, the participants were 73% White, 11% African American, 8% Hispanic, 4% Native Hawaiian or other, 3% more than one race, and <1% Asian. In the usual care group, the participants were 62% White, 20% African American, 14% Hispanic, 3% more than one race, 1% Native Hawaiian or other, and <1% Asian. Among the 1,355 parents who completed the 12-month telephone survey, the average age was 31 years, and 81% were mothers.

The outcome assessed was the percentage of parents who received tobacco control assistance, first at the initial visit and second during the following 12-month period. Parents were considered to have received tobacco control assistance if they said "yes" to any of the following questions: Did your provider "discuss medicine to help you quit smoking (e.g., nicotine replacement gum, patch, lozenge, or other medicine)," "discuss methods and strategies (other than medicine) to help you quit smoking" or "suggest you use a telephone quitline or other program to help you quit smoking"?

• At the exit interview, 42.5% of parents in the intervention group reported receiving at least one form of tobacco control assistance during the initial office visit compared with 3.5% of parents in the usual care group (p<.001).

• At the 12-month follow-up, among parents who reported having at least one subsequent office visit over the 12-month period, 54.7% of parents in the intervention group reported receiving at least one form of tobacco control assistance compared with 19.2% of parents in the usual care group (p<.001). 

Additional Findings

• At the 12-month follow-up, parents who received any tobacco control assistance (in the intervention group) were more likely to have quit smoking than parents who did not receive any assistance (in the intervention and usual care groups) (p=.016). However, no statistically significant difference in quit rates were found between the CEASE and usual care groups.