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）是一个重要的、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有关，包括哮喘、中耳炎、小岛屿发展中国家（SIDS）和龋齿。随着许多地区实行公共场所禁烟，减少家庭吸烟（家庭和汽车）已成为保护儿童免受SHSe侵害的最后堡垒。此外，减少低收入、医疗服务不足社区的SHSe已成为公共卫生的优先事项，因为这些人群承担的SHSe发病率负担增加。鉴于有证据表明，单层面的方法（例如，家庭禁烟，简短的提供者建议）不足以解决这个多因素决定的问题的许多方面，本提案将在具有最高SHSe发病率风险的社区中测试全面的，多层次的干预措施。所提出的干预模式整合了跨诊所、家庭和社区服务水平的策略。虽然具体的组成部分是基于证据的，但所提出的模型是新颖的，与NIH通过测试多层次干预来推进行为改变科学的路线图是一致的。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努力对抗二手烟暴露（CEASE）的临床水平质量改善（CQI）干预来解决儿童二手烟中毒问题。然后，我们将466名到这些诊所就诊的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）的家庭级行为咨询干预（CQI+BC）或家庭级注意力控制干预（CQI+ a）。CQI+BC将发生重度吸烟（家庭/汽车）的行为咨询（例如，强化技能培训和支持）与社区服务导航相结合，以促进获得和有效使用无成本的尼古丁戒断药物。参与者将在治疗前、治疗结束3个月和12个月随访时完成评估。主要目的是验证相对于CQI+A， CQI+BC会导致儿童可丁宁（SHSe生物标志物）和报告卷烟暴露量的更大减少的假设。第二个目的是测试假设，相对于CQI+A， CQI+BC将导致更高的可替宁验证，7天点患病率戒烟率的父母。我们还将检验社会支持、应对技能和自我效能介导CQI+BC对吸烟结果影响的假设，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。拟议的方法可能比现有的单一层次方法更有效，因为综合干预水平相互加强，可能对结果产生协同效应。除了改善患者护理外，该模式还具有很大的传播潜力和公共卫生影响，因为它减少了与烟草有关的健康和成本负担，而目标人群将从该方法中获益最多。通过确定干预如何以及对谁起作用，中介和调节目标的发现将为该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.