Multilevel tobacco intervention in community clinics for underserved families

 描述(申请人提供)：儿童二手烟暴露(SHSE)仍然是可避免的发病率/死亡率的主要原因，与哮喘、中耳炎、小岛屿发展中国家、行为问题以及癌症和心血管疾病的风险有关。解决SHSE是一项公共卫生优先事项，特别是在低收入、幼儿中--这是一个与烟草相关的风险和负担过高的群体。社区诊所(例如，妇女、婴儿和儿童[WIC])可以覆盖到这一人群。WIC解决SHSE的标准做法包括向父母提供最低限度的自助建议，这是一种效果不佳的方法。临床实践指南(“AAR”)建议医生“询问”父母有关儿童高血压的情况，“建议”他们关于危害，并“建议”吸烟者接受强化的循证治疗，以解决吸烟的多种决定因素。因此，我们建议测试一种多层次、多模式的治疗模式，该模式将遵循AAR指南的系统级WIC干预与更密集的、个人级别的多模式行为干预(MBI)相结合，后者将电话减量和戒烟咨询与NCI的Quitpal移动应用程序和尼古丁替代疗法(NRT)的使用指导相结合。我们将培训费城WIC诊所的工作人员，以实施AAR，并将自动传真转介到 审判。然后，我们将随机选择372名符合条件的父母接受AAR+MBI或AAR+CTL(注意力控制干预)。所有参与者都将接受AAR，因为它是一种易于采用的、潜在的社区诊所护理标准。主要目的是验证这样一个假设，即与AAR+CTL相比，AAR+MBI将导致儿童可替宁(SHSE生物标记物)和治疗3个月结束和12个月随访时每天报告的香烟暴露量更大的下降。第二个目的是验证这样的假设，即AAR+MBI与AAR+CTL相比，在3个月和12个月的父母中，BIOVIZATED的7天点患病率将会更高。我们将检验社会支持、催促应对技能、自我效能感和保护行为在AAR+MBI对吸烟结果的中介作用的假设，并探索其他住宅吸烟者、尼古丁依赖程度、抑郁/焦虑症状、体重担忧、干预剂量和怀孕状况是否对治疗效果起到中介作用。我们的模型平衡了必要的干预强度和在服务不足的社区中已经可用的可行成分(Quitline、NRT、Quitpal)，从而促进了未来的传播。与NCI Quitline和许多州服务不同，MBI遵循最佳实践指南，并且不会增加临床负担。它还可以改善服务不足的高危人群获得和参与循证治疗的机会。该项目具有很高的影响潜力：它将产生一种新颖、有效的多层次模式来解决儿童自闭症这一重大问题。 次级目标的结果将通过确定模型如何工作以及为谁工作来为科学和理论提供信息。未来的拆卸研究可以评估干预组件的正交性和协同性。

 DESCRIPTION (provided by applicant): Children's secondhand smoke exposure (SHSe) remains a leading cause of avertible morbidity/mortality, with links to asthma, otitis, SIDS, behavior problems and risk of cancer and cardiovascular disease. Addressing SHSe is a public health priority, particularly in low-income, young children-a group with excess tobacco-related risk and burden. Community clinics (e.g., Women, Infants and Children [WIC]), can reach this population. WIC's standard practice for addressing SHSe includes minimal self-help advice to parents, an approach with inadequate efficacy. Clinical practice guidelines ("AAR") recommend that practitioners "Ask" parents about child SHSe, "Advise" them about harms, and "Refer" smokers to intensive evidence-based treatments that address multiple determinants of smoking. Thus, we propose to test a multilevel, multimodal treatment model that combines a system-level WIC intervention following AAR guidelines with a more intensive, individual-level multimodal behavioral intervention (MBI) that integrates telephone SHSe reduction and cessation counseling with coaching on NCI's QuitPal mobile app and nicotine replacement therapy (NRT) use. We will train staff in Philadelphia WIC clinics to implement AAR with auto-fax referral to the trial. We will then randomize 372 eligible parents to receive AAR+MBI or AAR+CTL (attention control intervention). All participants will receive AAR because it is an easily adoptable, potentil standard of care in community clinics. The primary aim is to test the hypothesis that AAR+MBI compared to AAR+CTL will result in greater reductions in child cotinine (SHSe biomarker) and reported cigarettes exposed/day at 3-month end of treatment and 12-month follow-up. A secondary aim is to test the hypothesis that AAR+MBI vs. AAR+CTL will result in higher bioverified 7-day point prevalence quit rate among parents at 3- and 12-months. We will test the hypothesis that social support, urge coping skills, self-efficacy, and SHSe protective behaviors mediate effects of AAR+MBI on smoking outcomes and explore whether other residential smokers, level of nicotine dependence, depressive/anxious symptoms, weight concerns, intervention dosage, and pregnancy status moderate treatment effects. Our model balances necessary intervention intensity with feasible components (quitline, NRT, QuitPal) already available in under- served communities, thereby facilitating future dissemination. Unlike the NCI Quitline and many state services, the MBI follows best practice guidelines and does so without increasing clinic burden. It also can improve an underserved, high-risk population's access to and engagement in evidence-based treatment. This project has high impact potential: it will result in a novel, efficacious multilevel model for tackling the significant problem of child SHSe. Secondary aims results will inform science and theory by identifying how and for whom the model works. Future dismantling research can assess orthogonal and synergistic effects of intervention components.