Parents Smoking in Their Cars With Children Present
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ARTICLE
Parents Smoking in Their Cars With Children Present
AUTHORS: Emara Nabi-Burza, MBBS, MS,a,b Susan Regan, WHAT’S KNOWN ON THIS SUBJECT: Tobacco smoke exposure is
PhD,c Jeremy Drehmer, MPH,d Deborah Ossip, PhD,e Nancy associated with increased morbidity in children, and exposure in
Rigotti, MD,b,c Bethany Hipple, MPH,a,b Janelle Dempsey, cars can be particularly intense. The American Academy of
BA,a,b Nicole Hall, MS,a,b Joan Friebely, EdD,a,b Victoria Pediatrics policy statement recommends that pediatricians assist
Weiley, MIS,d and Jonathan P. Winickoff, MD, MPHa,b,f families in adopting smoke-free car policies.
aCenter for Child and Adolescent Health Research and Policy,
Massachusetts General Hospital for Children, Boston, WHAT THIS STUDY ADDS: In this study, few smoking parents had
Massachusetts; bTobacco Research and Treatment Center, and
cGeneral Medicine Division, Massachusetts General Hospital, a strictly enforced smoke-free car policy. Low rates of pediatric
Boston, Massachusetts; dPediatric Research in Office Settings, health care providers addressing smoking in the car highlights
and fAAP Richmond Center of Excellence, American Academy of the need for improved pediatric interventions to protect children
Pediatrics, Elk Grove Village, Illinois; and eUniversity of Rochester from tobacco smoke toxins.
Medical Center, Rochester, New York
KEY WORDS
parents, pediatrics, secondhand smoke, smoking in car, tobacco
control, tobacco smoke
ABBREVIATIONS
AAP—American Academy of Pediatrics
abstract
CI—confidence interval OBJECTIVE: To determine prevalence and factors associated with
OR—odds ratio
PROS—Pediatric Research in Office Settings
strictly enforced smoke-free car policies among smoking parents.
TSE—tobacco smoke exposure METHODS: As part of a cluster, randomized controlled trial addressing
Dr Nabi-Burza conceived of and designed this article, drafted the parental smoking, exit interviews were conducted with parents whose
manuscript and revised it, and takes full responsibility for the children were seen in 10 control pediatric practices. Parents who
final submission; Dr Regan advised on and conducted data
analyses and participated in the interpretation of results; Dr smoked were asked about smoking behaviors in their car and receipt
Winickoff conceived of and conducted the larger trial as the of smoke-free car advice at the visit. Parents were considered to have
principal investigator; and all coauthors had full access to all of a “strictly enforced smoke-free car policy” if they reported having
the data in the study and made substantial intellectual
contributions to the conception and design, analysis and
a smoke-free car policy and nobody had smoked in their car within
interpretation of data, editing the manuscript, and approving the past 3 months.
the final version for publication.
RESULTS: Of 981 smoking parents, 817 (83%) had a car; of these, 795
This trial has been registered at www.clinicaltrials.gov parents answered questions about their car smoking policy. Of these
(identifier NCT00664261).
795 parents, 29% reported having a smoke-free car policy, and 24% had
www.pediatrics.org/cgi/doi/10.1542/peds.2012-0334
a strictly enforced smoke-free car policy. Of the 562 parents without
doi:10.1542/peds.2012-0334
a smoke-free car policy, 48% reported that smoking occurred with
Accepted for publication Aug 20, 2012 children present. Few parents who smoke (12%) were advised to have
Address correspondence to Jonathan P. Winickoff, MD, MPH, a smoke-free car. Multivariable logistic regression controlling for
Center for Child and Adolescent Health Research and Policy,
Massachusetts General Hospital for Children, 15 Floor, Suite
parent age, gender, education, and race showed that having a younger
1542A, 100 Cambridge St, Boston, MA 02114. E-mail: child and smoking #10 cigarettes per day were associated with
jwinickoff@partners.org having a strictly enforced smoke-free car policy.
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). CONCLUSIONS: The majority of smoking parents exposed their children
Copyright © 2012 by the American Academy of Pediatrics to tobacco smoke in cars. Coupled with the finding of low rates of
FINANCIAL DISCLOSURE: The authors have indicated they have pediatricians addressing smoking in cars, this study highlights the
no financial relationships relevant to this article to disclose.
need for improved pediatric interventions, public health campaigns,
(Continued on last page) and policies regarding smoke-free car laws to protect children from
tobacco smoke. Pediatrics 2012;130:e1471–e1478
PEDIATRICS Volume 130, Number 6, December 2012 e1471
Downloaded from www.aappublications.org/news by guest on February 2, 2021According to the 2010 Surgeon Gen- a typical smoky bar.22 These findings related to parents enforcing a strict
eral’s report, there is “no safe level” of led the British Medical Association to smoke-free car policy. Identifying and
tobacco smoke exposure (TSE)1; thus, urge the government to ban smoking in understanding these characteristics will
implementing 100% smoke-free policies cars at all times to protect people from help design better smoking cessation
is the only way to protect children and the risk of TSE.23 interventions for pediatric offices that
their families against the harms of TSE. Despite the proven harms of TSE,6,7 identify children at risk and reduce TSE
Tobacco smoke is a well-documented many parents overlook its dangers and in children as early as possible.
toxic air contaminant that contributes smoke in their cars, thus exposing
to increased morbidity and mortality their children to high concentrations of METHODS
in children. It leads to a greater likeli- secondhand smoke. Furthermore, third-
We analyzed baseline data collected at
hood of lower respiratory infections,2–4 hand smoke toxins, defined as residual
pediatric practices enrolled in the
sudden infant death syndrome,5,6 and tobacco smoke contamination that re- control arm of a cluster, randomized
ear infections,7 and it increases the mains after the cigarette is extinguished, controlled trial, Clinical Effort Against
severity of asthma symptoms.8,9 In have also been shown to remain on Secondhand Smoke Exposure. This trial
1992, the US Environmental Protection surfaces wherever cigarettes are tested the implementation of an in-
Agency concluded that TSE is a “group smoked, including in cars.12,24–26 In tervention to address parental tobacco
A” carcinogen, a substance that has addition, studies have shown that use in the pediatric office setting. The
been established as a definitive cause smoking initiation early in life is as- study was conducted in partnership
of cancer in humans.10 sociated with having been exposed to with the Pediatric Research in Office
An estimated 88 million nonsmoking tobacco smoke in cars, adding to the Settings (PROS),41 which is the practice-
Americans, including 54% of children importance of implementing strict based research network of the AAP.
aged 3 to 11 years, were exposed to smoke-free car policies.27 Twenty practices were recruited and
tobacco smoke in 2007 and 2008.11 In The best way to protect children from randomized, 10 each to the intervention
children aged #18 months, TSE is re- the harms of TSE is for parents to quit and control arms. The 10 control prac-
sponsible for an estimated 150 000 to smoking, but even parents who can- tices were located in 8 states (AK, CT,
300 000 new cases of bronchiolitis and not quit can reduce their children’s MO, NM, PA, SC, TN, and VA). Participants
pneumonia annually and ∼7500 to exposure by implementing 100% were eligible to enroll in the study if
15 000 hospitalizations annually in the smoke-free home and car policies.28 they had accompanied a child to the
United States.10 Homes have tradition- The pediatric health care setting pro- office visit, had smoked at least a puff of
ally been considered the main indoor vides a unique teachable moment to a cigarette in the past 7 days, were the
source of tobacco smoke contaminants motivate and help parents quit smok- parent or legal guardian of the child
for children,12,13 but recent studies ing.29–33 American Academy of Pediat- seen that day, were at least 18 years old,
have shown that private passenger rics (AAP) guidelines also recommend and spoke English. The study protocol
vehicles (hereafter referred to as cars) that pediatricians assist families with was approved by the institutional re-
are an important domestic environ- tobacco-use prevention and treat- view boards of the AAP and Massachu-
ment with the potential for elevated ment.34 Although some researchers setts General Hospital and by individual
levels of tobacco smoke contamination have examined smoking in cars,35–37 no practice institutional review boards
under normal conditions of use.14–18 previous studies have examined rates where required.
These studies demonstrated that con- of counseling for smoke-free cars in
centrations of PM2.5 (particulate mat- the immediate context of a pediatric Participant Enrollment
ter with a diameter ,2.5 mm) can visit, and few have studied the corre- At each practice, 1 or more research
exceed the limits recommended by the lates of parental smoking in cars.35–40 assistants were stationed at the exit
US Environmental Protection Agency19 The primary aims of the current study and administered a screening ques-
and World Health Organization20 in cars were to determine the prevalence of tionnaire to all adults (smoking and
where people smoke. Even with venti- parents smoking in their cars with nonsmoking) at the end of their child’s
lation, tobacco smoke pollution levels children present and to determine how visit. If the adult was eligible, the re-
in cars remain high,21 and at least 1 often pediatric health care providers search assistant obtained written in-
study has demonstrated that air qual- advise parents to have smoke-free formed consent and administered a
ity in a car with a window partially or cars. Further aims included identi- baseline enrollment survey to the
completely down is similar to that of fying parent and child characteristics parents/legal guardians (hereafter
e1472 NABI-BURZA et al
Downloaded from www.aappublications.org/news by guest on February 2, 2021ARTICLE
referred to as parents). These enrolled smoked anywhere in your home, even Bivariate analyses were conducted by
parents received $5 in cash for com- a puff?” using x 2 tests to explore the associa-
pleting the baseline enrollment survey. Parents were asked a series of ques- tion between parent and child charac-
Screening continued until 100 eligible tions to determine if smoking behaviors teristics and having a strictly enforced
parents were enrolled at each practice. or policies were discussed during their smoke-free car policy. Parents were
The screening questionnaire was used visit at the pediatric office: “At any time excluded from the bivariate and mul-
to gather demographic information: in your visit today did anyone ask if tivariate analyses who did not answer
parent’s age, gender, race and ethnic- you”: (1) smoke cigarettes; (2) have questions about smoking policy in their
ity, and level of education (high school a smoke-free car; or (3) have a smoke- car. Parent’s age, gender, education,
or less versus some college or college free home. In addition, enrolled parents and race were included in the logistic
graduates); the age of the youngest were asked if, during their visit, their regression model as control variables
child present at the visit; reason for the child’s health care provider advised along with other variables that were
visit (routine well-child visit, sick visit, them to: (1) stop smoking; (2) have significant at P , .05 in the bivariate
or other reason); and how the visit was a smoke-free car; or (3) have a smoke- analysis and had theoretical plausibil-
paid for (private insurance, Medicaid, free home. ity. Odds ratios (ORs) and 95% confi-
self-pay, or some other method). The dence intervals (CIs) were reported for
baseline enrollment survey assessed each variable from the final model. In
Statistical Analysis the multivariable model, robust SEs
smoking behaviors in more detail, in-
cluding the parent’s smoking level The primary study outcome was having were used to adjust for clustering of
(cigarettes per day) and readiness to a “strictly enforced smoke-free car parents within practices. In explor-
quit. policy.” Parents were considered to atory analyses, we tested interactions
have a strictly enforced smoke-free car between the parent demographic var-
Enrolled parents who reported having
policy if they reported having a smoke- iables and the other significant pre-
a car were asked several items focused
free car policy and that no one had dictors. We present a final model that
on smoking behavior and policy. Parents includes significant interaction terms.
smoked in their car for the past 3
were asked to select the statement that
best described their car smoking policy:
months. Analyses were limited to Model fit was assessed with the C sta-
parents who reported having a car tistic. All P values are 2-sided, and they
(1) no one is allowed to smoke in my car;
(2) people are allowed to smoke in my
that they owned or traveled in fre- were considered significant at ,.05. All
quently. To study any association be- analyses were conducted by using
car; or (3) other. Car smoking behavior tween parental smoking behaviors at Stata version 10 (Stata Corp, College
was assessed according to the question: home and in the car, we also looked at Station, TX).
“In the past 3 months, has anyone the number of parents who had a
smoked in your car, even a puff?” If the “strictly enforced smoke-free home
parent reported that smoking was RESULTS
policy.” Parents were considered as
allowed in their car, the research as- having a strictly enforced smoke-free Of the total 981 parents who were en-
sistant asked this additional question: home policy if they reported having rolled in 10 PROS control practices, 817
“How often do people smoke in your car a smoke-free home policy and that no reported having a car. The majority
when there is a child present?” The one had smoked in their home for the (70%) of the parents were in the age
answer options were never, rarely, past 3 months. To examine counseling group 25 to 44 years, 77% were females,
sometimes, or often. of parents about having smoke-free mostly mothers (98% vs 2% legal
Parents were also asked questions cars, a stratified analysis was con- guardians), and 68% were non-Hispanic
about their home smoking behaviorand ducted on the parents who reported whites. Many parents (42%) had only a
policy. Parents were asked to select the smoking in their cars with children high school degree, and 16% had com-
statement that best described their present, and we examined the per- pleted college. Most of the children (60%)
home smoking policy: (1) no one is centage of providers who gave advice were covered by Medicaid (Table 1).
allowed tosmoke anywhere;(2) smoking regarding having a smoke-free car at Of the 817 parents who reported having
is permitted in some places or at some that day’s visit. Furthermore, we ex- a car, 795 answered questions about
times; or (3) smoking is permitted amined the association between the their car smoking policy. Of these 795
anywhere. Home smoking behavior was age of the child and the type of visit parents, 73% reported that someone
assessed according to the question with pediatricians addressing smoke- had smoked in their car in the past 3
“During the past 3 months, has anyone free cars with parents. months (Table 2). Fewer than 1 in 3
PEDIATRICS Volume 130, Number 6, December 2012 e1473
Downloaded from www.aappublications.org/news by guest on February 2, 2021TABLE 1 Parent Characteristics (N = 817) parents who had a smoke-free car sociated with having a strictly enforced
Variable N (%) policy reported that it was violated in smoke-free car policy. Having another
Age, y the past 3 months. Of the 562 parents smoker at home was associated with
18–24 190 (23) who did not report having a smoke-free a lower likelihood of having a strictly
25–44 573 (70)
car policy, 48% reported that smoking enforced smoke-free car policy. We
45–64 54 (7)
Gender occurred with children present in the did not find any association between
Male 185 (23) car. parent’s age, race and ethnicity, edu-
Female 632 (77)
Race and ethnicity Approximately one-fifth of all enrolled cation, and intention to quit smoking
Hispanic (any race) 106 (13) parents reported being asked by a pe- with having a strictly enforced smoke-
White 554 (68) diatric health care provider about their free car policy. In the multivariable lo-
Black or African American 118 (14)
smoking status (Table 2). Only 14% of gistic regression model (Table 4), we
Others 39 (5)
Education smoking parents reported being asked confirmed that factors associated with
,High school 99 (12) if they had a smoke-free car, and even greater likelihood of having a strictly
High school graduate 346 (42)
fewer (12%) reported being advised to enforced smoke-free car policy were
Some college 240 (29)
College graduate 130 (16) have a smoke-free car policy by a pe- having a child ,1 year old versus $1
Other smokers in home diatric health care provider. Of those year (OR: 1.64 [95% CI: 1.14–2.34]) and
Yes 474 (58) who smoked with children present in parents smoking #10 cigarettes per
No 343 (42)
Youngest child’s age, y the car, only 5% were counseled about day versus .10 cigarettes per day (OR:
,1 214 (26) having a smoke-free car. Of those who 3.59 [95% CI: 2.45–5.26]). Having an-
1–4 288 (35) were advised to have a smoke-free car other smoker in the home versus not
5–9 158 (19)
$10 147 (18)
policy, 54% identified the reason for the having another smoker at home was
Child’s insurance coverage visit as a routine well-child visit and associated with a lower likelihood of
Medicaid 488 (60) 34% as a sick visit. having a strictly enforced smoke-free
Private insurance/HMO 257 (31)
Other/self-pay 72 (9) Bivariate analysis (Table 3) showed that car policy (OR: 0.56 [95% CI: 0.35–0.89]).
HMO, health maintenance organization. having a child ,1 year old and smok- The model fit was acceptable with a C
ing fewer cigarettes per day were as- statistic of 0.70.
parents (29%) reported having a In the exploratory analyses, we arrived
smoke-free car policy, and only 24% at a final model after considering all
TABLE 2 Parental Smoking Behavior in Cars possible interactions between the 4
reported having a strictly enforced and Pediatrician Assistance (N = 795)
smoke-free car policy, which is less parent demographic variables (age,
Variable N (%)
than one-half the parents who reported gender, race, and education) and the
Parents’ smoking behavior in
having a strictly enforced smoke-free 3 significant predictors of car policy
their cars
home policy (57%). There was some Someone smoked in their 580 (73) (child’s age, number of cigarettes
geographic variability in the number of car in the past 3 mo smoked per day by the parent, and
Have a smoke-free car policy
parents reporting strictly enforced having another smoker at home). Par-
Yes 233 (29)
smoke-free car policies across the 8 No 562 (71) ent gender and education interacted
states. It ranged from 16% in Virginia Smoked with child present 268a (48) with child’s age: parents of children
(mean of 3 practices) to 39% in Con-
in the car aged ,1 year were more likely to have
Have a strictly enforced 187 (24)
necticut; the other states were as fol- smoke-free car policy strict smoke-free car policies if they
lows: Tennessee, 17%; Missouri, 23%; Pediatrician assistance were female (OR: 3.00 [95% CI: 1.22–
Asked about smoking status 169 (21) 7.38], P = .016) or college educated (OR:
New Mexico, 24%; Pennsylvania, 28%; Asked about smoke-free car 116 (14)
South Carolina, 31%; and Alaska, 33%. Advised about a smoke-free car 101 (12) 2.42 [95% CI: 1.21–4.83], P = .013). Strict
Eighty-two percent of parents who Type of visit smoke-free car policies were more
Routine well-child visit 55 (54) common when parents were both light
reported having a strictly enforced
Sick visit 34 (34)
smoke-free car policy also reported Other reason 12 (12) smokers (smoked #10 cigarettes per
having a strictly enforced smoke-free Youngest child’s age, y day) and college educated (OR: 2.88
home policy. However, the majority ,1 36 (36) [95% CI: 1.24–6.66], P = .013). No other
1–4 40 (40)
(66%) of those with a smoke-free home 5–9 15 (15) interactions were statistically signifi-
policy do not have a strictly enforced $10 10 (9) cant. The model fit was acceptable with
smoke-free car policy. Almost 1 in 5 a N = 562 (parents who allow smoking in their car). a C statistic of 0.71.
e1474 NABI-BURZA et al
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TABLE 3 Strictly Enforced Smoke-Free Car Policy by Parent and Child Characteristics (N = 795) smoked per day by the parent39 and
Characteristic Have a Strictly Do Not Have a Strictly P Value lower parental education39,40 were as-
Enforced Smoke-Free Enforced Smoke-Free sociated with increased TSE of children
Car, n = 187 (24%) Car, n = 608 (76%)
in cars. In our study, we found that
Smoking-related characteristics
No. of cigarettes per day
parents who smoke more cigarettes
1–10 159 (31) 359 (69) ,.001 per day had lower odds of having
.10 28 (10) 249 (90) a strictly enforced smoke-free policy in
Quit readiness
their car. Although it is important to
Consider quitting in 6 mo 133 (23) 441 (77) .96
Seriously planning to quit in 30 d 90 (26) 254 (73) .07 intervene with all parents regarding
Strictly enforced smoke-free home policy strict smoke-free car policies, it is
Yes 153 (34) 298 (66) ,.001
possible that parents who smoke fewer
No 34 (10) 310 (90)
Demographic characteristics cigarettes may have less difficulty ab-
Age, y staining when driving and could be
18–24 58 (31) 131 (69) .03 more receptive to advice from a health
25–44 119 (22) 434 (78)
$45 10 (19) 43 (81) care provider. In our exploratory anal-
Gender yses, we also found that college-
Male 40 (23) 137 (77) .74 educated parents of children aged ,1
Female 147 (24) 471 (76)
Race/ethnicity year were more likely to have strict
Hispanic (any race) 28 (27) 74 (73) .64 smoke-free car policies. This finding
White 122 (22) 426 (78) challenges the assumption that more
Black or African American 27 (25) 80 (75)
Other 10 (26) 28 (74)
educated parents who smoke protect
Education children of all ages from TSE and
,High school 17 (18) 79 (83) .36 highlights the need to address having
High school graduate 77 (23) 256 (77)
Some college 56 (24) 179 (76)
strict smoke-free car policies with all
College graduate 36 (28) 93 (72) parents regardless of their education
Other smokers in home level.
Yes 91 (20) 373 (80) .002
No 96 (29) 235 (71) Most parents who had a strictly en-
Youngest child’s age, y forced smoke-free car policy had a
,1 66 (32) 141 (68) ,.001 strictly enforced smoke-free home pol-
1–4 84 (30) 202 (71)
5–9 19 (12) 133 (88) icy, and few parents who reported
$10 16 (11) 125 (89) having a strictly enforced smoke-free
Child’s insurance coverage car policy did not have a strictly
Medicaid 106 (22) 367 (78) .20
Private insurance/HMO 68 (27) 183 (73) enforced smoke-free home policy.
Other/self-pay 13 (18) 58 (82) However, 2 of 3 parents with strict
HMO, health maintenance organization. smoke-free home policies did not have
strict smoke-free car policies, suggest-
ing that parentsmay not recognize TSEin
DISCUSSION home was associated with decreased cars as an important exposure source
odds of having a strictly enforced for their children. The association be-
In this large sample of parents who
smoked and visited a pediatrician, few smoke-free car policy. Few parents who tween having a younger child and car
parents reported having a strictly en- smoked were advised by a pediatric smoking policy may reflect parental
forced smoke-free car policy, and ap- health care provider to have a smoke- belief that TSE is more harmful to
proximately one-half of those without free car. younger children versus older children.
policies smoked in their cars with Studies have shown that smoking 1 These findings reinforce the importance
children present. Having a child aged cigarette in a confined space such as of educating parents about the dangers
,1 year and being a lighter smoker inside a car creates unsafe levels of of TSE to all children, irrespective of
(#10 cigarettes per day) were associ- respiratory suspended particles.15 Pre- location and age.
ated with greater odds of having vious research conducted in Greek To our knowledge, no study has looked
a strictly enforced smoke-free car and German populations has shown at the rate at which pediatric health
policy. Having another smoker in the that increased numbers of cigarettes care providers ask about and advise
PEDIATRICS Volume 130, Number 6, December 2012 e1475
Downloaded from www.aappublications.org/news by guest on February 2, 2021TABLE 4 Multivariable Logistic Regression counseling given to parents if .50% of lem of childhood TSE in cars exists in
Showing Odds of Having a Strictly
Enforced Smoke-Free Car Policy
the total visit time is spent on coun- the United States. In future studies,
(N = 793) seling parents about tobacco use.42 The biomarkers of TSE could be used to
Variable OR (95% CI) pediatrician may also be in the best quantify degree of exposure in the sub-
Youngest child’s age position to advocate for the children’s sample of children who have smoking
,1 y 1.64 (1.14–2.34) ** need to breathe clean air given that the bans at home and are exposed to tobacco
$1 y 1.0a parents expect to hear about health smoke only in cars. To determine health
No. of cigarettes per day
Light smoker (#10 3.59 (2.45–5.26) *** issues that affect their child in this outcomes of children exposed to tobacco
cigarettes per day) context. Home TSE has been a more smoke only in cars, longitudinal follow-up
Heavy smoker (.10 1.0a traditional focus of pediatric tobacco of children who were and were not ex-
cigarettes per day)
control counseling, but children may posed to tobacco smoke only in cars will
Other smoker in home
Yes 0.56 (0.35–0.89)* spend a considerable amount of time in be helpful.
No 1.0 a their family’s car. Action to protect
Adjusted for parent age, education, and race and gender,
CONCLUSIONS
children from TSE in cars could pro-
none of which was statistically significantly related to hav-
ing a strictly enforced smoke-free car policy. ceed on multiple levels which include This research highlights the magnitude
a Reference group.
developing and testing interventions of the problem of parents exposing their
* P , .05;
** P , .01; that address parental smoking in the children to tobacco smoke in cars.
*** P , .001. pediatric health care setting and de- Strict 100% smoke-free car policies
veloping public health campaigns at would help reduce TSE of children and
the population level to educate smok- aid in protecting them from its harmful
parents to enforce smoke-free car ers about the dangers of TSE and em- health effects. Pediatricians can help
policies. Bringing their children to the phasize the need for smoke-free cars protect children from TSE in cars by
pediatric office for a visit may create for children. A recent study conducted prioritizing addressing tobacco use
a teachable moment for parental in 4 countries showed that the majority with parents and advising them to have
smoking cessation and for addressing of smokers supported a ban on smok- strict smoke-free car policies. US pe-
TSE.31 Most of the parents with whom ing in cars with children, with 60% of diatricians can also advocate for their
smoking was addressed reported patients by presenting the case to
US smokers supporting the ban.43
bringing their children in to the pedi- lawmakers and/or lobbyists for in-
Levels of support were higher in Aus-
atric office for routine well-child visits. troducing legislation that protects
tralia (83%), the United Kingdom (75%),
Although there may be more time children from TSE in cars as has been
and Canada (74%). Pediatricians can
available to discuss tobacco use at done in some states and in the United
advocate for smoke-free cars and help
routine well-child visits, extending in- Kingdom.23 Finally, given the low rates
develop new legislative approaches to
tervention to sick visits might enhance of clinical intervention on this issue,
protect children from TSE in cars. Op-
parental receptivity to advice, which pediatricians might concurrently con-
portunities may also exist in adult
might help to eliminate a risk factor (ie, sider supporting broader health pro-
medicine, obstetrics, and in hospitals
TSE) for their child’s disease. Although motion campaigns that address the
to address TSE of children and other
some pediatric offices have systems to dangers of parental smoking in cars.
vulnerable individuals.44
prompt clinicians to screen for paren-
tal tobacco use, few systematically use Although the study surveys were ad- ACKNOWLEDGMENTS
the full range of evidence-based to- ministered in-person and directly after We especially appreciate the efforts of
bacco control techniques to reduce TSE clinic visits, the results are based on the PROS practices and practitioners.
of children and even fewer include re- parental self-report and thus are sub- The pediatric practices or individual
ducing the intense TSE in cars. Child- ject to recall and response bias. Results practitioners who enrolled participants
hood TSE in confined spaces should be likely provide a lower-end estimate of in the larger study are listed here ac-
considered an intervention priority in true childhood TSE in cars. Also, the cording to AAP chapter: Alaska: Anchor-
the pediatric setting because children’s results are based on cross-sectional age Pediatric Group, LLC (Anchorage);
exposure to TSE is involuntary, and no survey data, and we therefore cannot Connecticut: Hospital of Saint Raphaels
one other than the child’s health care determine causality. Despite these (New Haven); Illinois: Community Health
provider may have the opportunity to limitations, the use of a large sample Improvement Center (Decatur); Mary-
advocate for smoke-free cars. Most size across 8 states allows greater land:CambridgePediatricsLLC(Waldorf);
health care plans pay for tobacco confidence in reporting that the prob- Massachusetts: Quabbins Pediatrics
e1476 NABI-BURZA et al
Downloaded from www.aappublications.org/news by guest on February 2, 2021ARTICLE
(Ware), RiverBend Medical Group– Oklahoma: Shawnee Medical Center Falls); Tennessee: Raleigh Group PC
Springfield Office (Springfield); Missouri: Clinic (Shawnee); Oregon: Siskiyou Pedi- (Memphis); Virginia: Pediatrics of
Priority Care Pediatrics LLC (Kansas atric Clinic LLP (Grants Pass); Pennsyl- Kempsville PC (Virginia Beach), River-
City); New Mexico: Las Vegas Clinic for vania: Pennridge Pediatric Associates side Pediatric Center (Newport News),
Children and Youth; PA (Las Vegas); (Sellersville); South Carolina: Inlet The Clinic (Richlands); and West Virginia:
Ohio: Bryan Medical Group (Bryan), Pediatrics (Murrells Inlet); South Da- Shenandoah Community Health Center
The Cleveland Clinic Wooster (Wooster); kota: Avery McGreevy Clinic (Sioux (Martinsburg).
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(Continued from first page)
FUNDING: Supported by the National Institutes of Health National Cancer Institute grant R01-CA127127 (to Dr Winickoff), the National Institute on Drug Abuse, and
the Agency for Healthcare Research and Quality. This study was also partially supported by a grant from the Flight Attendant Medical Research Institute to the AAP
Julius B. Richmond Center, and the Pediatric Research in Office Settings Network receives core funding from theHealth Resources and Services Administration’s
Maternal and Child Health Bureau (HRSA 5-UA6-10-001) and the American Academy of Pediatrics. The funders had no role in the design or conduct of the study;
collection, management, analysis, and interpretation of the data; or preparation, review, and approval of the manuscript. Funded by the National Institutes of
Health (NIH).
e1478 NABI-BURZA et al
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Emara Nabi-Burza, Susan Regan, Jeremy Drehmer, Deborah Ossip, Nancy Rigotti,
Bethany Hipple, Janelle Dempsey, Nicole Hall, Joan Friebely, Victoria Weiley and
Jonathan P. Winickoff
Pediatrics 2012;130;e1471
DOI: 10.1542/peds.2012-0334 originally published online November 12, 2012;
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Downloaded from www.aappublications.org/news by guest on February 2, 2021Parents Smoking in Their Cars With Children Present
Emara Nabi-Burza, Susan Regan, Jeremy Drehmer, Deborah Ossip, Nancy Rigotti,
Bethany Hipple, Janelle Dempsey, Nicole Hall, Joan Friebely, Victoria Weiley and
Jonathan P. Winickoff
Pediatrics 2012;130;e1471
DOI: 10.1542/peds.2012-0334 originally published online November 12, 2012;
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