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

描述(申请人提供)：儿童二手烟暴露(SHSE)是一个重要的、复杂的公共健康问题，与癌症和心血管疾病风险因素以及许多其他健康后果有关，包括哮喘、中耳炎、SID和牙齿携带。随着许多地区实施公共场所禁烟，减少家庭水平的吸烟(家庭和汽车)已成为保护儿童免受SHSE影响的最后一道干预堡垒。此外，在低收入、医疗服务不足的社区减少SHSE已成为一项公共卫生优先事项，因为这些人群承担的SHSE发病率负担增加。鉴于有证据表明，单一层面的方法(例如，家庭禁烟令，简单的提供者建议)不足以解决这一多方面确定的问题，该提案将测试在SHSE发病率风险最高的社区进行的全面、多层面的干预。建议的干预模式整合了跨越诊所、家庭和社区服务水平的策略。虽然特定的组成部分是以证据为基础的，但所提出的模型是新颖的，并与NIH通过测试多水平干预来推进行为变化科学的路线图一致。我们建议在费城低收入社区的4个儿科诊所提供基于临床工作的针对二手烟暴露的质量改进(CQI)干预措施，以解决儿童SHSE问题。然后，我们将把来这些诊所就诊的466名符合条件的吸烟父母随机分为基于建立无烟家庭的家庭规则(FRESH)的家庭层面的行为咨询干预(CQI+BC)或家庭层面的注意控制干预(CQI+A)。CQI+BC将发生SHSE的地方(家庭/汽车)的行为咨询(例如，强化技能培训、支持)与社区级服务的导航相结合，以促进免费尼古丁戒断药物的获取和有效使用。参与者将在治疗前、治疗3个月结束和12个月随访时完成评估。主要目的是检验这样一种假设，即相对于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/天的更大减少。第二个目的是检验这一假设，即相对于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。我们还将测试社会支持、应对技能和自我效能感在CQI+BC对吸烟结果的影响中的中介作用的假设，并探索其他吸烟者、尼古丁依赖程度和抑郁/焦虑症状是否会削弱治疗效果。拟议的方法可能比现有的单水平方法更有效，因为综合干预水平相互加强，有可能对结果产生协同效应。除了改善病人护理外，这一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，这些人群将从这一方法中受益最大。调解人和主持人AIMS的调查结果将通过确定干预如何和对谁起作用，为这一领域的理论和未来方向提供信息。

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.