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Secondhand Smoke Exposure Among Children

NPs & PAs play key roles in prevention.

Secondhand smoke (SHS), also known as environmental tobacco smoke, is a combination of sidestream smoke from burning tobacco products and mainstream smoke exhaled by a smoker.1 Tobacco is the most preventable cause of disease, disability and death in the United States.2 In 2006, a report3 from the U.S. surgeon general's office concluded that on average, children are exposed to more SHS than adults and that no safe level of exposure to SHS exists. More recently, the CDC2 estimated that 88 million nonsmoking Americans, including 54% of children between the ages of 3 and 11 years, are exposed to SHS.

A study conducted by Dake, et al4 found that 80% of pediatricians believed SHS in the home has a considerable effect on children's health. However, only 39% considered smoking cessation counseling to be of "significant value." Therefore, pediatricians, nurse practitioners, physician assistants and other healthcare providers are in a unique position to decrease SHS exposure among children by discussing smoking cessation with parents. Parents visit a pediatrician's office more often than their own healthcare provider, with an average of four pediatric visits per year and 10 within the first two years of a child's life.1 Each patient visit is an opportunity to reinforce health-promoting behaviors such as smoking cessation.

Alarming Statistics

The U.S. surgeon general's office3 has determined that maintaining a 100% smoke-free indoor air environment is the only way to completely protect nonsmokers from SHS. Ventilation attempts such as opening windows, turning on fans or air conditioning systems, and rolling down windows in vehicles do not completely eliminate the risk of SHS exposure.5

Adult smoking is a pediatric issue. The American Academy of Pediatrics6 has stated that a "tobacco-free environment is imperative, because tobacco is a major health hazard to infants, children, adolescents and their families." More than 5,000 children die as a result of tobacco exposure, which represents three times the number of deaths caused by all childhood cancers combined.7 The prevalence of U.S. children living in homes with a smoker is estimated to be 43%, with state-specific estimates of exposure ranging from 12% to 34%.8 An estimated 15 million U.S. children and adolescents are exposed to cigarette smoke.8 Unless smoking cessation interventions are implemented, smoking-related morbidity and mortality among children exposed to SHS will continue to increase.

Approximately $4.6 billion per year is spent on direct medical costs for children exposed to SHS in the United States.9 Sudden infant death syndrome (SIDS), bronchitis, pneumonia, colds, otitis media, asthma and other infections are child health risks associated with SHS.5 As a result of SHS exposure among children 18 years and younger, 150,000 to 300,000 new cases of pneumonia and bronchitis develop annually.9 More than 200,000 cases of childhood asthma are directly associated to parental smoking.9 SIDS secondary to SHS exposure has been documented.1


Healthcare professionals play a significant role in assisting patients to overcome barriers to smoking cessation and supporting preventive health behaviors and practices. Barriers to addressing smoking cessation with parents include lack of time, lack of confidence, concern about negative reactions of parents, and lack of reimbursement.7

To effectively implement strategies and promote health and well-being, healthcare professionals need to become familiar with the barriers smokers encounter when attempting to quit smoking. According to U.S. Public Health Service clinical treatment guidelines for cessation,10 the likelihood of cessation rises the more often a smoker speaks with healthcare providers. Many patients seek guidance and support from healthcare providers.

Barriers to smoking cessation are multifactorial and include intrapersonal, interpersonal and environmental components.11-16 Intrapersonal, interpersonal and environmental barriers are influenced by one another. If proper and effective interventions are to be created, considerations must be given to these many diverse barriers to smoking cessation.

Glover et al11 conducted a study examining the association between preadolescent exposure to SHS in automobiles and the prevalence of early age smoking. Data from a student survey were used to investigate smoking status and reported exposure to smoking in cars. Log binomial regression analyses were used to investigate if reported exposure to SHS in cars was associated with smoking prevalence. Findings from this study concluded that exposure to smoking in cars and homes was significantly associated with increased risk of initiated smoking (RR 1.87, 95% CI 1.43-2.44, and RR 1.5, 95% CI 1.13-1.97, respectively). Exposure to smoking in cars was substantially associated with risk of current smoking (RR 3.21, 95% CI 1.45-7.08).

Keeping preadolescents from initiating smoking behavior will prevent them from having to quit smoking in the future. Many people who smoke state that they wish they had never started. Adults who refrain from smoking around their children will decrease the likelihood of their children smoking. Healthcare providers who educate patients and parents about specific types of behaviors associated with smoking will help preadolescents refrain from this type of behavior. This will further help prevent children from emulating unhealthy behaviors such as smoking.

Intrapersonal Barriers

Intrapersonal barriers, also known as psychologic barriers, are values, behaviors, beliefs, perceptions or attitudes.5 For smoking, examples include lack of knowledge, limited access to resources and quit support, addiction to nicotine, low self-esteem, and absence of self-control.

Bryant et al12 explored barriers and facilitators to smoking cessation among socially underprivileged people. The study identified several barriers to a commitment to smoking cessation: lack of confidence in ability to quit smoking, fear of weight gain, poor knowledge, belief in smoking benefits on stress relief, and uncertainty about quit support. Social and environmental smoke exposure in the patient's family, friends or community, along with the cost of nicotine replacement medication, were significant barriers cited by people in this study.

Once aware of the intrapersonal barriers faced by a patient, the healthcare provider can be more prepared with personalized interventions. If the barrier is cost of nicotine replacement medication, the healthcare provider can dispense medication samples or prescription discount cards. If the patient is unaware of available community resources, the provider can make them aware of what is available in the area or even over the Internet.

Interpersonal Barriers

The Health Promotion Model states that interpersonal influences are cognitions related to the behaviors, beliefs or attitudes of others.17 Healthcare providers, peers, family members and significant others are primary sources of interpersonal influences on health-promoting behaviors.17 Social interaction, lack of support from others, household partners refusing to quit, and disapproval by relatives are examples of interpersonal barriers.5

Moss et al13 investigated the reaction of parents toward pediatricians who addressed parental smoking in the outpatient setting. This study expanded on their previous findings by gathering attitudinal data from a large sample of parents from multiple and geographically diverse settings, and with a higher rate of smoking. This study found that 3% of parents believed their smoking status was not the pediatrician's business, 8% felt it did not matter whether or not the pediatrician asked, and 89% felt it was part of the pediatrician's job to inquire about smoking status.

When compared with nonsmokers, fewer smokers had positive attitudes (81% vs. 91%, p = .002); and highly educated parents were more strongly positive about being asked (91% vs. 83%, p = .006). Of the n = 187 smokers in the study, 95% said they would welcome or feel alright about the physician's concern advising them to quit and 57% stated they would like help from the pediatrician's office.13

Moss and colleagues13 argue that healthcare providers should seize every opportunity to ask about smoking status and encourage smoking cessation at every encounter. It is vital for all healthcare providers to inquire about smoking cessation at every well child visit.

Environmental Barriers

Environmental barriers are influences within the environment or the actual environment where SHS exposure occurs. Environments that allow SHS can be responsible for a number of smoking cues, such as observations of lit cigarettes and the smell of tobacco smoke, which can promote tobacco cravings among smokers.14 Seeing other people smoking is another environmental cue that contributes to the temptation to smoke among people who have recently quit smoking.15 Lack of access to outside and weather are commonly reported physical environmental factors.16

Jones et al18 explored home smoking behaviors, motivators and barriers to smoke-free homes among a group of disadvantaged caregivers of young children and identified the positive levers that healthcare professionals can utilize when supporting smoking behavior change. The study determined that knowledge among caregivers seemed limited and confused. Caregivers were aware of the general risk of SHS, but only a small number could actually associate SHS with particular diseases and chronic conditions in children.

Caregivers living in difficult and multifaceted circumstances experience substantial barriers to creating a smoke-free home. Some of the barriers in this study were life stressors, smoking habit, unwillingness to go outside to smoke, leaving a child alone while outside, unsafe surroundings, and weather.18 The study also determined that house décor and smell was a stronger motivator for change than concern for children's health, signifying that discernible evidence of harm caused by SHS among children might help encourage caregivers to create a smoke-free home. Since healthcare providers are part of a patient's external environment, they have the ability to influence their patients and individualize treatment interventions.


After reviewing evidence-based literature on barriers to SHS exposure prevention among children, it is apparent that exposure to SHS has many adverse and detrimental health effects. Most patients are aware of how smoking affects their own health, but not everyone realizes they are harming innocent bystanders when they smoke. Even when smokers are aware of the effects of SHS, many continue to smoke. Daily barriers to smoking cessation are multidimensional and can be intrapersonal, interpersonal, environmental or any combination of these - increasing the difficulty in achieving smoking cessation. These barriers change over time and smoking cessation interventions need to change as well.

Changing barriers create a unique situation for healthcare providers, offering the opportunity to individualize treatment with each patient. Having thorough knowledge of these barriers will guide healthcare providers in assisting patients in adopting health-promoting behaviors such as smoking cessation. Interventions involving health-promoting behaviors are essential or children exposed to SHS will continue to be at risk for health related illnesses. Understanding barriers and associated behaviors will help healthcare providers individualize interventions and help patients commit to a plan of action. Discussing smoking cessation at every visit, regardless of the setting or practice, is imperative to preventing the long-term health consequences SHS exposure among children.


1. Treyster Z, Gitterman B. Second hand smoke exposure in children: environmental factors, physiological effects, and interventions within pediatrics. Rev Environ Health. 2011;26(3):187-195.

2. Centers for Disease Control and Prevention. Tobacco Use. Targeting the nation's leading killer.

3. US Public Health Service Office of the Surgeon General. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report Of the Surgeon General. Rockville, Md.: US Department of Health and Human Service; 2006.

4. Dake J, et al. Pediatricians' practices regarding smoking cessation among parents of their children. AM J Health Behav. 2006;30(5):503-512.

5. Agbola A, et al. Searching the evidence: what are the barriers to preventing secondhand smoke exposure among children? Unpublished manuscript. School of Nursing, Spalding University, Louisville, KY. 2012.

6. Committee on Substance Abuse. Tobacco's toll: implications for the pediatrician. Pediatrics. 2001;107(4):794-798.

7. Winckoff JP, et al. State-of-the art interventions for office-based parental tobacco control. Pediatrics. 2005;115(3):750-760.

8. Hovell M, et al. Effect of counselling mothers on their children's exposure to environmental tobacco smoke: randomised control trial. BMJ. 2000;321(7257):337-342.

9. Jarvie JA, Malone RE. Children's secondhand smoke exposure in private homes and cars: an ethical analysis. Am J Public Health. 2008;98(12):2140-2145.

10. US Department of Health and Human Services. Treating Tobacco Use and Dependence: 2008 Update.

11. Glover M, et al. Driving kids to smoke? Children's reported exposure to smoke in cars and early smoking initiation. Addict Behav. 2011;36(11):1027-1031.

12. Bryant J, et al. Developing cessation interventions for the social smoker and community service setting: a qualitative study of barriers to quitting among disadvantaged Australian smokers. BMC Public Health. 2011;11(1):493-500.

13. Moss D, et al. Accessing adult smokers in the pediatric setting: What do parents think? Nicotine Tob Res. 2006;8(1):67-75.

14. Cagguila AR, et al. Cue dependency of nicotine self-administration and smoking. Pharmacol Biochem Behav. 2001;70(4), 515-530.

15. Schiffman S, et al. Temptations to smoke after quitting: a comparison of lapsers and maintainers. Health Psychol. 1996;15(6):455-461.

16. Herbert RJ, et al. 'Do it for the kids': barriers and facilitators to smoke-free homes and vehicles. Pediatr Nurs. 2011;37(1):23-29.

17. Pender N, et al. Individual Models to Promote Health Behavior. In: Health Promotion in Nursing Practice. 5th ed. Upper Saddle River, NJ: Prentice Hall: 55.

18. Jones LL, et al. The motivators and barriers to a smoke-free home among disadvantaged caregivers: identifying the positive levers for change. Nicotine Tob Res. 2011;13(6):479-486.

Bridget McKinley is a family nurse practitioner at Heartland Patient Care in Elizabethtown, Ky. Susan Hampton is a family nurse practitioner who lives in Louisville, Ky. Katie Hagan is a family nurse practitioner at First Urology in Louisville, Ky. Victoria Agbola is a family nurse practitioner at Occupational Physician Services in Louisville, Ky. Jennifer Vertrees is a family nurse practitioner at Lincoln Trail Medical Associates in Radcliff, Ky. Ann Lyons is a professor of nursing at Spalding University in Louisville, Ken. Nancy Kern is an assistant professor at Spalding University. The authors have completed disclosure statements and report no relationships related to this article.



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