Pediatrician Advice, Family Counseling, & SHS Reduction for Underserved Children

描述（由申请人提供）：儿童二手烟暴露（SHSe）是一个重要而复杂的公共卫生问题，与癌症和心血管疾病风险因素以及许多其他健康后果（包括哮喘、耳炎、SIDS和牙齿携带）有关。随着许多地区采取公共禁烟措施，减少家庭吸烟（家庭和汽车）已成为保护儿童免受SHSe影响的最后干预堡垒。此外，减少低收入，医疗服务不足的社区的SHSe已成为公共卫生的优先事项，因为这些人群承担的SHSe发病率增加的负担。有证据表明，单级方法（例如，家庭吸烟禁令（简短的提供者建议）不足以解决这个多方面的问题，这项建议将测试一个全面的，多层次的干预社区与最高的SHSe发病风险。建议的干预模式整合了诊所，家庭和社区服务水平的战略。虽然具体的组成部分是以证据为基础的，但所提出的模型是新颖的，并且与NIH路线图一致，通过测试多层次干预来推进行为改变科学。 我们建议提供一个诊所级的质量改进（CQI）干预的基础上，针对二手烟暴露的临床努力（CEASE），以解决儿童SHSe在低收入费城社区的4个儿科诊所。然后，我们将466名符合条件的吸烟父母随机访问这些诊所，根据建立无烟家庭的家庭规则（FRESH）或家庭水平的注意力控制干预（CQI+A）进行家庭水平的行为咨询干预（CQI+BC）。CQI+BC合并了行为咨询（例如，在发生SHSe的地方（家庭/汽车）提供强化技能培训，支持），并提供社区服务导航，以促进获得和有效使用免费尼古丁戒断药物。受试者将在治疗前、治疗3个月结束时和12个月随访时完成评估。主要目的是检验以下假设：相对于CQI+A，CQI+BC将导致儿童可替宁（SHSe生物标志物）和报告的香烟暴露/天的更大降低。第二个目的是检验相对于CQI+A，CQI+BC将导致父母中更高的可替宁验证的7天点患病率戒烟率的假设。我们还将检验社会支持、应对技能和自我效能感介导CQI+BC对吸烟结果的影响的假设，并探讨家中其他吸烟者、尼古丁依赖水平和抑郁/焦虑症状是否会减弱治疗效果。拟议的办法可能比现有的单一层次办法更有效，因为综合干预层次相互加强，可能对成果产生协同效应。除了改善患者护理外，这种模式还具有很高的传播潜力和公共卫生影响，因为它减少了目标人群中与烟草有关的健康和成本负担，这些人群将从这种方法中受益最多。从调解人和主持人的目的调查结果将告知理论和未来的方向，在这一领域确定如何和为谁的干预工程。

DESCRIPTION (provided by applicant): Child secondhand smoke exposure (SHSe) is a significant, complex public health problem that is linked to cancer and cardiovascular disease risk factors, and many other health consequences including asthma, otitis, SIDS, and dental carries. With many regions adopting public smoking bans, reducing home-level smoking (homes and cars) has become the last bastion of intervention to protect children from SHSe. In addition, reducing SHSe in low-income, medically-underserved communities has become a public health priority due to the increased SHSe morbidity burden these populations bear. Given evidence that single-level approaches (e.g., home smoking bans brief provider advice) are insufficient to tackle the many facets of this multi- determined problem, this proposal will test a comprehensive, multilevel intervention in communities with the highest SHSe morbidity risks. The proposed intervention model integrates strategies across clinic, family, and community levels of service. While specific components are evidence-based, the proposed model is novel and consistent with the NIH roadmap to advance the science of behavior change by testing multilevel interventions. We propose to provide a clinic-level quality improvement (CQI) intervention based on Clinical Effort Against Secondhand Smoke Exposure (CEASE) to address child SHSe in 4 pediatric clinics in low-income Philadelphia communities. We will then randomize 466 eligible smoking parents visiting these clinics into a home-level behavioral counseling intervention (CQI+BC) based on Family Rules for Establishing Smoke-free Homes (FRESH), or a home-level attention control intervention (CQI+A). CQI+BC merges behavioral counseling (e.g., intensive skills training, support) where SHSe occurs (home/car) with navigation of community-level services to facilitate access to and effective use of no-cost nicotine withdrawal medications. Participants will complete assessments at pre-treatment, 3-month end of treatment, and 12-month follow-up. The primary aim is to test the hypothesis that relative to CQI+A, CQI+BC will result in greater reductions in child cotinine (SHSe biomarker) and reported cigarettes exposed/day. A secondary aim is to test the hypothesis that relative to CQI+A, CQI+BC will result in a higher cotinine-verified, 7-day point prevalence quit rate among parents. We also will test the hypothesis that social support, coping skills, and self-efficacy mediate effects of CQI+BC on smoking outcomes and explore whether other smokers at home, level of nicotine dependence, and depression/anxiety symptoms attenuate treatment effects. The proposed approach is likely to be more effective than existing, single-level approaches because the integrated intervention levels reinforce one another, potentially producing synergistic effects on outcomes. In addition to improving patient care, this model has high potential for dissemination and public health impact by reducing tobacco-related health and cost burdens in target populations that would benefit most from this approach. Findings from mediator and moderator aims will inform theory and future directions in this field by identifying how and for whom the intervention works.