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Background: Provider adherence to best practice guidelines (ask, advise, refer [AAR]) for addressing child tobacco smoke exposure (TSE) motivates parents to reduce TSE. However, high-risk, vulnerable populations of smokers may require more intensive treatment. We hypothesized that a pragmatic, multilevel treatment model including AAR coupled with individualized, telephone-based behavioral counseling promoting child TSE reduction would demonstrate greater child TSE reduction than would standard AAR., Methods: In this 2-arm randomized controlled trial, we trained pediatric providers in systems serving low-income communities to improve AAR adherence by using decision aid prompts embedded in routine electronic health record assessments. Providers faxed referrals to the study and received ongoing AAR adherence feedback. Referred participants were eligible if they were daily smokers, >17 years old, and spoke English. Participants were randomly assigned to telephone-based behavioral counseling (AAR and counseling) or nutrition education (AAR and attention control). Participants completed prerandomization and 3-month follow-up assessments., Results: Of providers, >80% ( n = 334) adhered to AAR procedures and faxed 2949 referrals. Participants ( n = 327) were 83% women, 83% African American, and 79% low income (below poverty level). Intention-to-treat logistic regression showed robust, positive treatment effects: more parents in AAR and counseling than in AAR and attention control eliminated all sources of TSE (45.8% vs 29.9%; odds ratio 1.99 [95% confidence interval 1.44-2.74]) and quit smoking (28.2% vs 8.2%; odds ratio 3.78 [95% confidence interval 1.51-9.52])., Conclusions: The results indicate that the integration of clinic- and individual-level smoking interventions produces improved TSE and cessation outcomes relative to standalone clinic AAR intervention. Moreover, this study was among the first in which researchers demonstrated success in embedding AAR decision aids into electronic health records and seamlessly facilitated TSE intervention into routine clinic practice., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Purpose: National guidelines recommend adolescents achieve 60 minutes of moderate-to-vigorous physical activity (MVPA)/day, yet few adolescents meet these guidelines., Methods: We piloted a novel quasi-randomized physical activity intervention to promote adolescent's use of their surrounding built environment among 30 intervention and 30 control overweight/obese adolescents aged 10-16 years living in greater Boston from 2013 to 2015. Location-specific MPVA was measured by accelerometry and global positioning system for three one-week periods (Time 1 [T1], Time 2 [T2], and Time 3 [T3]). One month after T1, intervention participants received individualized counseling on how to use their surrounding built environment to increase MVPA, and control participants received standard-of-care lifestyle modification counseling; both groups received their T1 physical activity data. T2 assessment occurred the week after the counseling visit and T3 assessment 3-4 months later. The main outcome was change in average daily minutes of MVPA; the secondary outcome was meeting national MVPA guidelines. Multivariable modeling accounted for covariates (baseline MVPA, body mass index, age, sex, race/ethnicity) and clustering by study group and town., Results: Among the 60 adolescents recruited, 55 (92%) completed data collection. Short-term (T2) intervention effects included increased average MVPA of +13.9 minutes intervention versus -.6 minutes control (p < .0001). Differential increase in mean daily MVPA was sustained at T3 (9.3 minutes more in intervention group; p = .0006). The proportion of adolescents in the intervention group who achieved 60 minutes/day of MVPA increased from 11% (T1) to 21% (T2), whereas declining (7%-0%) among controls., Conclusions: Individualized counseling about the built environment can help increase MVPA among overweight and obese adolescents., Competing Interests: The authors report no potential, perceived, or real conflicts of interest. The study sponsor had no role in the study design, data collection, analysis, or interpretation, in writing the report, or in the decision to submit the manuscript. Dr. Oreskovic wrote the first draft of the manuscript., (Copyright © 2016 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Secondhand smoke (SHS) exposure of children due to parental tobacco use is a particularly prevalent health issue and is associated with adverse health outcomes. Following the US Clinical Practice guidelines, pediatricians in the United States deliver 5A's (ask, advise, assess, assist, and arrange) counseling to smoking parents which has proven to be effective. We examined Chinese pediatricians' adherence to the clinical practice guidelines for smoking cessation (i.e. 5A's counseling practices) with smoking parents, and identified factors associated with these practices., Methods: A cross-sectional paper-and-pencil survey of pediatricians was conducted in twelve conveniently selected southern Chinese hospitals. Factors associated with any of the 5A's smoking cessation counseling practices were identified by logistic regression., Results: Of respondents (504/550), only 26 % routinely provided 5A's smoking cessation counseling to smoking parents. More than 80 % of pediatricians didn't receive formal training in smoking cessation and had not read China smoking cessation guidelines; 24 % reported being "very confident" in discussing smoking or SHS reduction with parents. Pediatricians who had never smoked (OR: 2.29, CI:1.02-5.12), received training in smoking cessation (OR: 2.50, CI:1.40-4.48), had read China smoking cessation guidelines (OR: 2.17, CI:1.10-4.26), and felt very (OR: 7.12, CI:2.45-20.70) or somewhat (OR: 3.05, CI:1.11-8.37) confident in delivering cessation counseling were more likely to practice 5A's. Pediatricians who reported "it is hard to find a time to talk with parents" (OR: 0.32, CI: 0.11-0.92) or "lack of a standard of care requiring pediatricians to provide smoking cessation or SHS exposure reduction intervention" (OR: 0.45, CI: 0.21-0.98) as a barrier were less likely to follow the 5A's guidelines., Conclusions: Smoking cessation counseling to address parental smoking is infrequent among Chinese pediatricians. There is a need to develop and test intervention strategies to improve the delivery of 5A's smoking cessation counseling to parental smokers.

Background: Secondhand Smoke (SHS) exposure is a leading cause of childhood illness and premature death. Pediatricians play an important role in helping parents to quit smoking and reducing children's SHS exposure. This study examined Chinese pediatricians' attitudes and practices regarding children's exposure to SHS and clinical efforts against SHS exposure., Methods: A cross-sectional survey of pediatricians was conducted in thirteen conveniently selected hospitals in southern China, during September to December 2013. Five hundred and four pediatricians completed self-administered questionnaires with a response rate of 92%. χ² tests were used to compare categorical variables differences between smokers and non-smokers and other categorical variables., Results: Pediatricians thought that the key barriers to encouraging parents to quit smoking were: lack of professional training (94%), lack of time (84%), resistance to discussions about smoking (77%). 94% of the pediatricians agreed that smoking in enclosed public places should be prohibited and more than 70% agreed that smoking should not be allowed in any indoor places and in cars. Most of the pediatricians thought that their current knowledge on helping people to quit smoking and SHS exposure reduction counseling was insufficient., Conclusions: Many Chinese pediatricians did not have adequate knowledge about smoking and SHS, and many lacked confidence about giving cessation or SHS exposure reduction counseling to smoking parents. Lack of professional training and time were the most important barriers to help parents quit smoking among the Chinese pediatricians. Intensified efforts are called for to provide the necessary professional training and increase pediatricians' participation in the training.

Background: Assisting smoking parents to quit smoking and eliminating the secondhand smoke (SHS) exposure of their children is a global health priority. Engaging healthcare workers in developing countries to address this priority has been a challenge. This study intends to explore issues around current practice related to SHS exposure assessment and counseling and identify barriers to SHS exposure reduction counseling in the Chinese pediatric setting., Methods: We conducted qualitative interviews (11 focus groups discussions (FGDs) with pediatricians, 6 FGDs with pediatric nurses and 11 in-depth interviews (IDIs) with hospital administrators) among 101 health-care professionals (HCP) from 5 hospitals in four major cities of Guangxi Province, China. All FGDs/ IDIs were audio recorded and analysed thematically., Results: The findings suggest that few Chinese pediatricians routinely address the SHS exposure of children in their usual practice. All HCPs felt the need for clinical interventions to promote SHS exposure reduction for children. Primary barriers to SHS exposure reduction counseling in the Chinese pediatric setting included: lack of skills and training in tobacco use reduction and cessation counseling; time constraints and heavy workloads, uncertainty about the usefulness of smoking cessation interventions and lack of hospital-wide systems requiring pediatricians to record tobacco use or SHS exposure information. Ideas for overcoming these barriers were building capacity of pediatricians, collaboration with international organization to initiate training, engaging top level leaders in the effort and ensuring financial resources to support the program., Conclusions: This study among hospital administrators and service providers in China demonstrated a high level of interest in delivering SHS exposure reduction interventions in the pediatric setting. The findings can inform the creation and delivery of clinical interventions in China to promote SHS exposure reduction to children in the pediatric setting.

Objective: To assess the impact of an electronic health record (EHR) modification and brief clinician training on tobacco smoke exposure (TSE) management in pediatric primary care., Methods: Within a teaching hospital-based, urban primary care setting, we modified the EHR to include TSE screening prompts, decision support, educational literature, and simplified referral to the state quit line (QuitWorks). A brief training was conducted for the 48 clinic physicians (34 residents and 14 attendings). We collected cross-sectional, independent, random samples of EHR data from well-child visits for children ≤12 years old seen 3 months before (2024 visits) and 3 months after (1895 visits) the intervention and pooled client data from QuitWorks to evaluate TSE screening, counseling, and quit-line referrals. A needs assessment questionnaire examined preintervention attitudes and practice around TSE management; follow-up questionnaires explored satisfaction and subjective changes in skills., Results: The baseline needs assessment revealed that although most clinicians agreed that it is appropriate for pediatricians to conduct TSE screening, counseling, and referral during well-child visits, only about half screened, 42% counseled, and 28% routinely offered to refer smoking parents. In pre-post analyses of 117 and 112 EHR-documented positive screens, the intervention was associated with a 16-fold greater likelihood of counseling among positive screens (adjusted odds ratio 16.12; 95% confidence interval 7.28, 35.68). Referrals to QuitWorks increased from 1 before to 31 after the intervention., Conclusions: Implementation of EHR modifications and a brief training to support TSE management was associated with higher rates of counseling and quit-line referrals for parents who smoke., (Copyright © 2014 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: To identify individual- and system-level predictors and barriers associated with US pediatric nurses' routine counseling about child secondhand smoke exposure for parents of hospitalized children., Methods: In 2008, members of the Society of Pediatric Nurses completed a questionnaire assessing demographic, hospital systems, and work attitudes related to the following outcomes: asking about child secondhand smoke exposure, informing about sources of secondhand smoke exposure, counseling about the dangers of secondhand smoke exposure, and advising a smoke-free home policy., Results: Of 1475 eligible nurses, 888 completed the survey. We found that 39% asked, 43% informed, 29% counseled, and 25% advised parents. Nurses working in hospitals with mandatory prompts in the medical record to assess child secondhand smoke exposure, the availability of written materials for parent smokers, and regular secondhand smoke counseling training for nurses had increased odds of routinely engaging parents in secondhand smoke reduction best practices. Nurses reported parents' resistance to discussions about smoking, short hospital stays, and non-standardized care as the most common barriers to counseling parents., Conclusion: System supports in hospitals significantly increases the odds of nurses engaging in child secondhand smoke reduction practices. Strengthening existing systems and introducing new policies are critical for nurses' engagement of parents in discussions about reducing child secondhand smoke exposure., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Young children can be protected from much of the harm from tobacco smoke exposure if their parents quit smoking. Some researchers encourage parents to quit for their children's benefit, but the evidence for effectiveness of such approaches is mixed., Objective: To perform a systematic review and meta-analysis to quantify the effects of interventions that encourage parental cessation., Methods: We searched PubMed, the Cochrane Library, Web of Science, and PsycINFO. Controlled trials published before April 2011 that targeted smoking parents of infants or young children, encouraged parents to quit smoking for their children's benefit, and measured parental quit rates were included. Study quality was assessed. Relative risks and risk differences were calculated by using the DerSimonian and Laird random-effects model., Results: Eighteen trials were included. Interventions took place in hospitals, pediatric clinical settings, well-baby clinics, and family homes. Quit rates averaged 23.1% in the intervention group and 18.4% in the control group. The interventions successfully increased the parental quit rate. Subgroups with significant intervention benefits were children aged 4 to 17 years, interventions whose primary goal was cessation, interventions that offered medications, and interventions with high follow-up rates (>80%)., Conclusions: Interventions to achieve cessation among parents, for the sake of the children, provide a worthwhile addition to the arsenal of cessation approaches, and can help protect vulnerable children from harm due to tobacco smoke exposure. However, most parents do not quit, and additional strategies to protect children are needed.

Objective: Given the central role played by pediatric nurses in intake assessment, discharge planning, and education for families of hospitalized pediatric patients, a child's hospitalization may provide a unique opportunity for counseling parents about smoking. We sought to determine if hospital policies can support nurses in effectively counseling parents about smoking., Design and Sample: We conducted a national survey of pediatric staff nurses and administrators/educators who were members of the Society of Pediatric Nurses in 2008 (n=888) to explore counseling practices for tobacco control., Measures: Questionnaires included data on demographics, personal and work environment characteristics, hospital policy characteristics, work attitudes and barriers and the main outcome--5As for smoking cessation counseling--Ask, Advise, Assess, Assist, and Arrange., Results: Overall, routine screening for household smokers was most common (43%), followed by advice to quit (25%), assessing willingness to quit (19%), assisting with a quit plan (6%), and arranging follow-up contact (3%). Nurses working in hospitals with admission assessments specifically asking about household members who smoke were 7 times more likely than those without such assessments to routinely ask about smoking (OR: 7.2, 95% CI: 4.9-10.5)., Conclusion: Future research should test the efficacy of developing comprehensive hospital-wide policies to deliver smoking cessation for parents during a child's hospitalization., (© 2011 Wiley Periodicals, Inc.)

Background: Comprehensively assessing care quality with electronic medical records (EMRs) is not currently possible because much data reside in clinicians' free-text notes., Methods: We evaluated the accuracy of MediClass, an automated, rule-based classifier of the EMR that incorporates natural language processing, in assessing whether clinicians: (1) asked if the patient smoked; (2) advised them to stop; (3) assessed their readiness to quit; (4) assisted them in quitting by providing information or medications; and (5) arranged for appropriate follow-up care (i.e., the 5A's of smoking-cessation care)., Design: We analyzed 125 medical records of known smokers at each of four HMOs in 2003 and 2004. One trained abstractor at each HMO manually coded all 500 records according to whether or not each of the 5A's of smoking cessation care was addressed during routine outpatient visits., Measurements: For each patient's record, we compared the presence or absence of each of the 5A's as assessed by each human coder and by MediClass. We measured the chance-corrected agreement between the human raters and MediClass using the kappa statistic., Results: For "ask" and "assist," agreement among human coders was indistinguishable from agreement between humans and MediClass (p>0.05). For "assess" and "advise," the human coders agreed more with each other than they did with MediClass (p<0.01); however, MediClass performance was sufficient to assess quality in these areas. The frequency of "arrange" was too low to be analyzed., Conclusions: MediClass performance appears adequate to replace human coders of the 5A's of smoking-cessation care, allowing for automated assessment of clinician adherence to one of the most important, evidence-based guidelines in preventive health care.

Objective: To assess the perceived preparedness of residents in adult primary care specialties to counsel patients about preventive care and psychosocial issues., Design: Cross-sectional national mail survey of residents (63% response rate)., Participants: Nine hundred twenty-eight final-year primary care residents in Internal Medicine (IM), family practice (FP), and Obstetrics/Gynecology (OB/GYN) at 162 U.S. academic health centers., Measurements: Residents self-rated preparedness to counsel patients about smoking, diet and exercise, substance abuse, domestic violence, and depression., Results: Residents felt better prepared to counsel about smoking (62%) and diet and exercise (53%) than about depression (37%), substance abuse (36%), or domestic violence (21%). In most areas, females felt better prepared than males. Rates of counseling preparedness varied significantly by specialty after adjustment for gender, race, medical school location, and percent of training spent in ambulatory settings. FP residents felt better prepared than OB/GYN residents to counsel about smoking, diet and exercise, and depression, while OB/GYN residents felt better prepared to address domestic violence than IM or FP residents. IM residents' perceptions of preparedness were between the other 2 specialties. Proportion of training spent in ambulatory settings was not associated with residents' perceived preparedness., Conclusions: Physicians completing residencies in adult primary care did not feel very well prepared to counsel patients about preventive and psychosocial issues. Significant differences exist among specialties, even after adjusting for differences in time spent in ambulatory settings. Increasing residency time in ambulatory settings may not alone be sufficient to ensure that residents emerge with adequate counseling skills.

Objective: To evaluate the feasibility of implementing a smoking cessation intervention for parents at the time of the pediatric visit., Methods: A prospective cohort of smoking parents whose child was seen in an outpatient pediatric practice was offered the Stop Tobacco Outreach Program, which includes 3 brief counseling sessions, written materials, free nicotine replacement therapy (NRT), proactive referral to a free state telephone quitline, and fax referral to the parents' primary clinician. The primary outcome was completion of all three counseling sessions. Other outcomes were quit attempts, cessation, NRT use, state quitline use, and household smoking assessed at 2-month follow-up., Results: One hundred fifty-eight smoking parents met eligibility criteria and 100 (63%) enrolled in the study. Of the 100 enrollees, 81% completed all three counseling sessions and 78% accepted free NRT at the time of enrollment. At 2-month follow-up, of the 100 enrollees, 56% reported making a quit attempt of >or=24 hours, 18% reported 7-day tobacco abstinence, 34% used NRT, and 42% received additional counseling from the state telephone quitline. The mean number of cigarettes smoked inside the home and car declined over 2 months (home, 5.1 vs 1.4; and car, 2.5 vs 1.4)., Conclusions: This study demonstrates the feasibility of engaging parents in a smoking cessation intervention at the time of a child's clinic visit. This approach may be an effective way to reach smokers who otherwise are unlikely to access smoking cessation interventions. High rates of program enrollment, use of NRT, and completion of telephone counseling in this study support the hypothesis that a child's clinic visit is a teachable moment to address parental smoking cessation.

Objective: To assess the frequency of clinician-reported delivery of counseling for avoidance of child environmental tobacco smoke (ETS) exposure and tobacco use at periodic well-child visits and at illness visits for asthma and otitis media (OM)., Methods: Combined data from the National Ambulatory Medical Care Survey and the outpatient portion of the National Hospital Ambulatory Medical Care Survey from 1997 to 1999 were analyzed. The frequency of pediatric visits (