Abstract
Background
Identifying behavioral pathways to smoking cessation in high-risk populations, such as low-income maternal smokers, could reduce tobacco disparities. The previous “BLiSS” multilevel intervention trial demonstrated efficacy of the BLiSS intervention in facilitating low-income maternal smokers’ bioverified abstinence. This present study examined four putative pathways measured at 3-month end of treatment (Time 2) that could account for the observed intervention effect on smoking abstinence through 12 months (Time 2 – Time 3).
Methods
Nutritionists in community clinics delivering safety net nutrition promotion programs across Philadelphia, Pennsylvania, USA, were trained by trial principal investigators to deliver a brief tobacco intervention informed by the American Academy of Pediatrics best practice guidelines (“Ask, Advise, Refer [AAR]”). After referral, 396 eligible participants were randomized to either a multimodal behavioral intervention (AAR + MBI) or a parallel attention control (AAR + control). Random effects regression analysis tested mediation.
Results
Elimination of children’s tobacco smoke exposure (TSE) at Time 2 was the only significant mediator of longitudinal smoking abstinence through Time 3. AAR + MBI mothers were more likely to eliminate their children’s TSE by Time 2 (OR = 2.11, 95%CI 1.30, 3.42), which was significantly associated with Time 3 abstinence (OR = 6.72, CI 2.28, 19.80). Modeling showed a significant total effect of AAR + MBI on abstinence (OR = 6.21, CI 1.86, 20.71), a direct effect of AAR + MBI on abstinence (OR = 4.80, CI 1.45, 15.94) and an indirect effect through TSE elimination (OR = 1.29, CI 1.06, 1.57).
Conclusions
Integrating smoking cessation interventions with counseling prior to the quit attempt that is designed to facilitate adoption of smokefree home policies and efforts to eliminate children’s TSE could enhance the likelihood of long-term abstinence in populations of smokers with elevated challenges quitting smoking.
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References
Babb, S., Malarcher, A., Schauer, G., Asman, K., & Jamal, A. (2017). Quitting smoking among adults — United States, 2000–2015. MMWR Morbidity and Mortality Weekly Report, 65(52), 1457–1464. https://doi.org/10.15585/mmwr.mm6552a1.
Baig, S., Byron, M., Boynton, M., & Ribisl, K. (2017). Communicating about cigarette smoke constituents: An experimental comparison of two messaging strategies. J Beh Med, 40, 352–359. https://doi.org/10.1007/s10865-016-9795-x.
Centers for Disease Control and Prevention (US). (2020). Smoking & tobacco use: Data and statistics. %0A. https://www.cdc.gov/tobacco/%0Adata_statistics/index.htm.
Chan, A. W. K., Pristach, E. A., Welte, J. W., & Russell, M. (1993). Use of the TWEAK Test in Screening for Alcoholism/ Heavy drinking in three populations. Alcoholism: Clinical and Experimental Research, 17(6), 1188–1192. https://doi.org/10.1111/j.1530-0277.1993.tb05226.x.
Chin, S. M., Lepore, S. J., Collins, B. N., Dumenci, L., & Rincon, M. A. (2023). Validation and Psychometric Properties of the Tobacco urge management scale (TUMS). International Journal of Environmental Research and Public Health, 20(8), 5453. https://doi.org/10.3390/ijerph20085453.
Clawson, A., McQuaid, E. L., Dunsiger, S., Bartlett, K., & Borrelli, B. (2018). The longitudinal, bidirectional relationships between parent reports of child secondhand smoke exposure and child smoking trajectories. Journal Of Behavioral Medicine, 41, 221–231. https://doi.org/10.1007/s10865-017-9893-4.
Cohen, S., & Lichtenstein, E. (1990). Partner behaviors that support quitting smoking. Journal Of Consulting And Clinical Psychology, 58(3), 304–309.
Collins, B. N., & Lepore, S. J. (2017). Babies living Safe & Smokefree: Randomized controlled trial of a multilevel multimodal behavioral intervention to reduce low-income children’s tobacco smoke exposure. Bmc Public Health, 17(1), https://doi.org/10.1186/s12889-017-4145-7.
Collins, B. N., Lepore, S. J., Winickoff, J. P., Nair, U. S., Moughan, B., Bryant-Stephens, T., Davey, A., Taylor, D., Fleece, D., & Godfrey, M. (2018). An office-initiated multilevel intervention for tobacco smoke exposure: A randomized trial. Pediatrics, 141(6):e20180894. https://doi.org/10.1542/peds.2018-0894.
Collins, B. N., Lepore, S. J., Winickoff, J. P., & Sosnowski, D. W. (2020). Parents’Self-efficacy for Tobacco Exposure Protection and Smoking Abstinence Mediate Treatment Effects on Child Cotinine at 12-Month Follow-up: Mediation Results from the Kids Safe and Smokefree Trial. Nicotine & Tobacco Research: Official Journal of the Society for Research on Nicotine and Tobacco, 22(11):1981–1988. https://doi.org/10.1093/ntr/ntz175.
Collins, B. N., Nair, U. S., Davis, S., & Rodriguez, D. (2019). Increasing Home Smoking Restrictions boosts Underserved Moms’ Bioverified quit Success. American Journal of Health Behavior, 43(1), 50–56. https://doi.org/10.5993/AJHB.43.1.5.
Collins, B. N., Nair, U. S., DiSantis, K. I., Hovell, M. F., Davis, S. M., Rodriguez, D., & Audrain-McGovern, J. (2020). Long-term results from the FRESH RCT: Sustained reduction of children’s Tobacco smoke exposure. American Journal of Preventive Medicine, 58(1), https://doi.org/10.1016/j.amepre.2019.08.021.
Collins, B. N., Lepore, S. J., & Egleston, B. L. (2022). Multilevel intervention for low-income maternal smokers in the Special Supplemental Nutrition Program for Women, Infants, and children (WIC). American Journal Of Public Health, 112(3), 472–481.
DiClemente, C. C. (1981). Self-efficacy and smoking cessation maintenance: A preliminary report. In Cognitive Therapy and Research (Vol. 5, Issue 2). https://doi.org/10.1007/BF01172525.
Fagerström, K. (2012). Determinants of tobacco use and renaming the FTND to the Fagerström test for cigarette dependence. Nicotine Tobacco Research Official Journal of the Society for Research on Nicotine and Tobacco, 14 SRC, 75–78.
Fichtenberg, C., & Glantz, S. A. (2002). Effect of smoke-free workplaces on smoking behaviour: Systematic review. Bmj, 325(7357), 188. https://doi.org/10.1136/bmj.325.7357.188.
Fiore, M., Jaen, C., Baker, T., & Bailey, W. (2008). A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report. American Journal Of Preventive Medicine, 35(2), 158–176. https://doi.org/10.1016/j.amepre.2008.04.009.
Fuemmeler, B., Behrman, P., & Taylor, M. (2017). Child and family health in the era of prevention: New opportunities and challenges. J Beh Med, 40, 159–174. https://doi.org/10.1007/s10865-016-9791-1.
Gambino, J., Moss, A., Lowary, M., Kerby, G., Winickoff, J. P., Klein, J. D., Hovell, M., & Wilson, K. M. (2021). Tobacco smoke exposure reduction Strategies—Do they work? Academic Pediatrics, 21(1), 124–128. https://doi.org/10.1016/j.acap.2020.02.022.
Gwaltney, C. J., Metrik, J., Kahler, C. W., & Shiffman, S. (2009). Self-efficacy and smoking cessation: a meta-analysis. Psychol Addict Behav, 23(1), 56–66. https://doi.org/10.1037/a0013529.
Homa, D., Neff, L., King, B., & Caraballo, R. (2015). Vital Signs: Disparities in Nonsmokers’ Exposure to Secondhand Smoke—United States, 1999–2012. MMWR, 64(4): 103–108.
Hopkins, D., Razi, S., Leeks, K., Kalra, G., Chattapadhyay, S., Soler, R., & Services, T. F. (2010). Smokefree policies to reduce tobacco use: a systematic review. Am J Prev Med, 38(2), S275–289. https://doi.org/10.1016/j.amepre.2009.10.029.
Jamal, A., Phillips, E., Gentzke, A. S., Homa, D. M., Babb, S. D., King, B. A., & Neff, L. J. (2018). Current cigarette smoking among adults — United States, 2016. MMWR Morbidity and Mortality Weekly Report, 67(2), 53–59. https://doi.org/10.15585/mmwr.mm6702a1.
Lepore, S. J., Collins, B. N., Coffman, D. L., Winickoff, J. P., Nair, U. S., Moughan, B., Bryant-Stephens, T., Taylor, D., Fleece, D., & Godfrey, M. (2018). KKids safe and smokefree (KiSS) multilevel intervention to reduce child tobacco smoke exposure: LongInternational Journal of Environmental Research and Public Health, 15(6),1239. https://doi.org/10.3390/ijerph15061239.
Lepore, S. J., Collins, B. N., & Sosnowski, D. W. (2019). Self-efficacy as a pathway to long-term smoking cessation among low-income parents in the multilevel kids safe and smokefree intervention. Drug and Alcohol Dependence, 204, 107496. https://doi.org/10.1016/j.drugalcdep.2019.05.027.
Lepore, S. J., Collins, B. N., Killam, W., & Barry, B. (2021). Supportive accountability and mobile app use in a tobacco control intervention targeting low-income minority mothers who smoke: An observational study. JMIR MHealth and UHealth, 9, e28175. https://doi.org/10.2196/28175.
Mahabee-Gittens, E. M., Collins, B. N., Murphey, S. A., Woo, H., Chang, Y., Dempsey, J., Weiley, V., & Winickoff, J. P. (2014). The parent-child dyad and parents who quit smoking successfully. Journal of Preventive Medicine, 47(5):596–603. https://doi.org/10.1016/j.amepre.2014.07.010.
Merianos, A. L., Jandarov, R. A., Choi, K., & Mahabee-Gittens, E. M. (2019). Tobacco smoke exposure disparities persist in U.S. children: NHANES 1999–2014. Preventive Medicine, 123, 138–142. https://doi.org/10.1016/j.ypmed.2019.03.028.
Messer, K., Mills, A. L., White, M. M., & Pierce, J. P. (2008). The effect of smoke-free Homes on Smoking Behavior in the U.S. American Journal of Preventive Medicine, 35(3), 210–216. https://doi.org/10.1016/j.amepre.2008.05.023.
Mills, A. L., Messer, K., Gilpin, E. A., & Pierce, J. P. (2009). The effect of smoke-free homes on adult smoking behavior: A review. Nicotine & Tobacco Research, 11(10), 1131–1141. https://doi.org/10.1093/ntr/ntp122.
O’Connell, K. A., Hosein, V. L., Schwartz, J. E., & Leibowitz, R. Q. (2007). How does coping help people resist lapses during smoking cessation? Health Psychology: Official Journal of the Division of Health Psychology American Psychological Association, 26(1), 77–84. https://doi.org/10.1037/0278-6133.26.1.77.
Pizacani, B., Maher, J. E., Rohde, K., Drach, L., & Stark, M. (2012). Implementation of a smoke-free policy in subsidized Multiunit Housing: Effects on Smoking Cessation and Secondhand smoke exposure. Nicotine & Tobacco Research, 14(9), 1027–1034. https://doi.org/10.1093/ntr/ntr334.
Russell, M., Martier, S., Sokol, R., Jacobson, S., Jacobson, J., & Bottoms, S. (1994). Screening for pregnancy risk-drinking: Tweaking the tests. Alcoholism, Clinical And Experimental Research, 18(5), 1156–1161. https://doi.org/10.1111/j.1530-0277.1994.tb00097.x.
Samoilenko, M., & Lefebvre, G. (2021). Parametric-Regression-Based causal mediation analysis of Binary Outcomes and Binary Mediators: Moving beyond the rareness or commonness of the Outcome. American Journal Of Epidemiology, 190(9), 1846–1858.https://doi.org/10.1093/aje/kwab055.
Scheffers-van Schayck, T., Tuithof, M., Otten, R., Engels, R., & Kleinjan, M. (2019). Smoking behavior of women before, during, and after pregnancy: Indi-cators of smoking, quitting, and relapse. European Addiction Research, 25(3), 132–144. https://doi.org/10.1159/000498988.
Shiffman, S. (1984). Coping with temptations to smoke. Journal of Consulting and Clinical Psychology, 52(2), 261–267. https://doi.org/10.1037/0022-006X.52.2.261.
Shrout, P. E., & Bolger, N. (2002). Mediation in experimental and nonexperimental studies: New procedures and recommendations. Psychological Methods, 7(4), 422–445. https://doi.org/10.1037/1082-989X.7.4.422.
Titus, A., Kalousova, L., Meza, R., Levy, D., Thrasher, J., Elliott, M., & Fleischer, N. (2019). Smoke-free policies and smoking cessation in the United States, 2003–2015. Int J Env Res Pub Health, 16(17), 3200. https://doi.org/10.3390/ijerph16173200.
Vidrine, J., Kypriotakis, G., & Li, L. (2015). Mediators of a smoking cessation intervention for persons living with HIV/AIDS. Drug And Alcohol Dependence, 147, 76–80. https://doi.org/10.1016/j.drugalcdep.2014.12.003.
Voorhees, C., Ye, C., Carter-Pokras, O., MacPherson, L., Kanamor, M., Zhang, G., Chen, L., & Fiedler, R. (2011). Peers, tobacco advertising, and secondhand smoke exposure influences smoking initiation in diverse adolescents. American Journal Of Health Promotion : Ajhp, 25(3), e1–11. https://doi.org/10.4278/ajhp.090604-QUAN-180.
Westmaas, J. L., Bontemps-Jones, J., & Bauer, J. E. (2010). Social support in smoking cessation: reconciling theory and evidence. Nicotine Tob Res, 12(7), 695–707. https://doi.org/10.1093/ntr/ntq077.
Yuan, N. P., Nair, U. S., Crane, T. E., Krupski, L., Collins, B. N., & Bell, M. L. (2019). Impact of changes in home smoking bans on tobacco cessation among quitline callers. Health Education Research, 34(3), 345–355. https://doi.org/10.1093/her/cyz008.
World Health Organization (2021). Tobacco Fact Sheet. https://www.who.int/%0Anews-room/fact-sheets/detail/tobacco.
Acknowledgements
The authors thank Dr. Linda Kilby, executive director of NORTH, Inc., the nonprofit that manages the Philadelphia WIC program and Melissa Godfrey, MPH (Project Manager) for their contributions to this complex trial. They were integral partners in facilitating the implementation of the multilevel BLiSS intervention, assessment, and data management protocols.
Funding
This study was supported by grants CA188813 and P30CA006927 from the National Cancer Institute, National Institutes of Health.
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B.N. Collins drafted the article. Collins and S.J. Lepore developed the study and analytic conceptualization, operationalized and designed the BLiSS intervention components, and oversaw the operations of the BLiSS trial. Collins developed and oversaw the telehealth smoking intervention, interventionist training, supervision and fidelity monitoring protocols. Lepore designed the nutrition intervention protocol and oversaw assessment, data management and data quality assurance protocols. B. Egleston finalized the analytic strategy and conducted data analyses. All authors collaboratively interpreted the results and contributed to, and approved, the final version of this article.
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The Temple University Institutional Review Board reviewed and approved the human subjects research protocols. The trial also utilized a Data Safety Monitoring Board of pertinent experts who monitored trial progress to ensure the safety of trial participants and integrity of the data. The study was performed in accordance with the ethical standards described in the 1964 Declaration of Helsinki and its later amendments and comparable ethical standards.
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All participants completed informed consent procedures and signed informed consent forms prior to enrollment.
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This trial is registered in clinicaltrials.gov (NCT02602288).
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Collins, B.N., Lepore, S.J. & Egleston, B.L. Eliminating children’s tobacco smoke exposure: a pathway to bioverified abstinence among low-income maternal smokers in the Babies Living Safe and Smokefree (BLiSS) trial. J Behav Med 46, 1042–1048 (2023). https://doi.org/10.1007/s10865-023-00423-9
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DOI: https://doi.org/10.1007/s10865-023-00423-9