Reducing Secondhand Smoke Exposure of Children Undergoing Surgery David O. Warner, MD; Erin B. Campbell, MEd; Julie C. Hathaway, MS; Yu Shi, MD, MPH; Randall Flick, MD; Tracey E. Harrison, MD; Richard F. Hinds, RRT; Robert C. Klesges, PhD; Kristin S. Vickers, PhD, LP Objective: To determine the attitudes and beliefs of both parents and surgical clinicians regarding interventions to reduce secondhand smoke (SHS) exposure in children undergoing surgery. Methods: Structured interviews were conducted with 25 parents of children scheduled for elective procedures and 10 surgical clinicians. Results: Major themes identified in parent interviews included: (1) parents are receptive to learning about the surgical risks posed by SHS exposure; (2) many are already attempting to reduce SHS exposure, and; (3) parents are more

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pproximately 25% of children in the United States live with at least one person who smokes cigarettes, and thus, are exposed to secondhand smoke (SHS).1 These children are at increased risk for many conditions, including allergies, asthma, upper and lower respiratory infections, sudden infant death syndrome, behavioral problems, and neurocognitive deficits.2,3 For children requiring surgery, those exposed to SHS are at risk to develop pulmonary complications around the time of operation, including bronchospasm and laryngospasm.4-7 Efficacious tobacco interventions have been designed to help parents reduce the exposure of their children to SHS, but like many other behavioral interventions, have proven to be David O. Warner, Professor of Anesthesiology, Mayo Clinic, Rochester, MN. Erin B. Campbell, Consultant, Campbell Consulting/University of Minnesota, Bozeman, MT. Julie C. Hathaway, Patient Education Specialist, Section of Education, Mayo Clinic, Rochester, MN. Yu Shi, Research Fellow, Mayo Clinic, Rochester, MN. Randall Flick, Associate Professor of Anesthesiology and Pediatrics, Mayo Clinic, Rochester, MN. Tracey E. Harrison, Assistant Professor of Anesthesiology, Mayo Clinic, Rochester, MN. Richard Hinds, Clinical Specialist Respiratory Research, Mayo Clinic, Rochester, MN. Robert C. Klesges, Professor of Preventive Medicine, University of Tennessee, Memphis, TN. Kristin S. Vickers, Associate Professor of Psychology, Mayo Clinic, Rochester MN. Correspondence Dr Warner; [email protected]

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accepting of SHS mitigation procedure than a recommendation to quit smoking. Clinicians were receptive to addressing perioperative SHS exposure. Conclusions: Both parents and clinicians are receptive to clinician-delivered interventions to reduce the SHS exposure of children scheduled for elective surgery. Key words: tobacco use interventions, key informant interviews, pediatric surgery, surgical risk, qualitative methods Am J Health Behav. 2014;38(6):924-932 DOI: http://dx.doi.org/10.5993/AJHB.38.6.14

challenging to implement in clinical practice.2,8,9 Visits of children to healthcare providers may represent a teachable moment to address parents’ smoking, especially when effects of SHS on child health are emphasized.10 Because of the immediate potential consequences of SHS to the risk of anesthesia and surgery in children, the scheduling of children for elective surgery and other procedures that require general anesthesia may represent a particularly good opportunity to intervene in parents who smoke. Indeed, we have shown that such scheduling may prompt parents to make an attempt to quit smoking, but that they find it difficult to achieve long term abstinence.11 No parental tobacco use intervention has been developed yet or tested for smokers with children undergoing elective surgery. Prior to developing a tobacco use intervention that could reduce perioperative SHS exposure in children undergoing surgery, formative research is needed to identify the unique barriers and facilitators for such interventions in this setting. The present study was conducted to determine the attitudes and beliefs of both parents and surgical clinicians regarding interventions to reduce secondhand smoke exposure in the perioperative period surrounding elective pediatric surgery. A qualitative research approach was chosen as these methods are recommended for collecting

Warner et al data sensitive to the unique personal experiences, perceptions, and behaviors of individuals.12 Two qualitative studies were conducted at Mayo Clinic, Rochester, Minnesota (USA) as components of this formative research: (1) interviews with cigarettes smokers who have children scheduled for elective procedures; and (2) key informant interviews with surgical providers who care for these children (anesthesiologists and surgeons). METHODS Participants Two categories of participants were recruited at Mayo Clinic in Rochester, Minnesota (USA). Parents. These individuals included current cigarette smokers (defined as daily smoking) with a child scheduled for elective surgery. On a convenience basis, potential participants were identified either at the pre-surgical office visit or in the presurgical area on the day of surgery according to responses to an item (“Does anyone smoke within the home? [no/yes]”) in the patient-provided information gathered during every clinical encounter. Parents who answered yes and responded affirmatively to an offer by clinical personnel to learn more about the study were then contacted by a study coordinator and offered participation. Thirty-four parents consented to an interview to be held at a later date. One of these later declined further participation and 8 could not be reached. Thus, a total of 25 parents completed the qualitative interviews, with most of these occurring over the telephone. Some parents expressed a desire to be interviewed with their spouse or partner. Consequently, 8 parents were interviewed with their spouse/partner (ie, 4 interviews included 2 parents simultaneously, with responses recorded separately for each parent). Clinicians. These subjects consisted of clinicians who work in a pediatric surgical setting. An email describing the study and inviting participation was sent to anesthesiologists, surgeons, and clinical nurse practitioners who regularly provide care to patients in the perioperative period (approximately 25 individuals). Four anesthesiologists, 4 surgeons, and 2 nurse practitioners agreed to participate. The number of patients and clinicians was chosen based on what was determined to be feasible within the time and budgetary constraints of the mechanism funding this work. Participants received modest remuneration ($20 USD) for their participation.

ture the thoughts and feelings of parents within the context of a child undergoing surgery, we attempted to schedule parents to complete study interviews the day of or near the day of surgery. The first interview conducted with the first participant involved an unstructured conversation format, with no formal interview guide. This first unstructured conversation included discussion of this parent’s smoking behavior, barriers to quitting smoking, willingness to engage in a conversation with a healthcare provider about reducing her child’s environmental smoke exposure, willingness to discuss smoking at the time of a child’s surgery, and the challenges of maintaining a smoke-free home when many friends and relatives also smoke cigarettes. Based on the initial conversation with the first parent interviewed, a semi-structured qualitative interview guide was developed (Table 1) for use in subsequent interviews. The interview assessed parental smoking status, knowledge of environmental smoke in general and around the time of surgery in particular, and prior experience with recommendations to reduce a child’s environmental smoke exposure around the time of surgery. The interviewer then read the following recommendation: Secondhand smoke exposure is a health risk in general and a risk factor for complications around the time of surgery. For example, one study showed that a high level of secondhand smoke exposure doubled the risk of pulmonary – or lung related - complications in children undergoing surgery. We know from the science of how people heal after surgery that the most important healing happens the first week after surgery. The best way to reduce your child’s exposure to smoke is for you to quit smoking. Specifically, Dr. XX recommends no smoke exposure one week before surgery and one week after surgery. It’s best if you quit for good, or at least eliminate your child’s exposure to smoke the week before and after surgery.

Procedure Because individual interviews tend to be more useful for evoking personal experiences and perspectives on sensitive topics 12,13 they were chosen over group interviews. They also were logistically more feasible for patients given the time constraints of the perioperative period. Parent interviews. Because we wanted to cap-

This message thus presents options of: (1) parental abstinence, or, in those not willing to make a quit attempt, (2) employing SHS mitigation procedures (eg, indoor smoking banseg). The interviewer then asked parents for their opinions of the recommendation, their emotional response to the recommendation, what they would have done if given that recommendation before their child’s surgery, and several questions about best format and delivery of the recommendation. Parents also were asked about their knowledge of ways to reduce a child’s environmental smoke exposure and interest in learning more about such strategies. A total of 15 parents (6 of them interviewed as couples) completed interviews following this interview guide. To assess parent receptivity to a stronger quit smoking message, for a second group of parents the interview guide was modified, such that the

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Table 1 Questions Included in Parent Interview Guide 1.

What do you know about secondhand smoke and surgery? Has anyone given you recommendations to quit or limit smoking near your child around the time of his/her surgery? (Probes: Who? What was the recommendation? What did you do in response to that recommendation?) May I read to you the recommendation that Dr. XX would like to share with families, based o on his review of the research about environmental smoke (secondhand smoke) and surgery?



Secondhand smoking is a health risk in general and a risk factor for respiratory complications around the time of surgery. One study showed that a high level of secondhand smoke exposure doubled the risk of pulmonary complications in children undergoing surgery. From the science of how people heal after surgery, the most important healing happens the first week. Specifically, Dr. XX recommends no smoke exposure one week before surgery and one week after surgery. It’s best if you quit for good, or at least eliminate the child’s exposure to smoke the week before and after surgery. *

2. 3. 4. 5.

What are your thoughts on that information and recommendation? Describe any emotional reaction to this recommendation. What would have happened if someone gave you that recommendation before your child’s surgery? How should this recommendation be delivered? (probes: by whom, when, how, what format, preferred content, preferred length of material or time)

*The last sentence (“…or at least eliminate the child’s exposure to smoke) was not included in the 2nd and 3rd version of the interview guide.

last sentence of the recommendation became as follows: Specifically, Dr. XX recommends that you quit smoking altogether or at least for one week before your child’s surgery and one week after surgery. Thus, this revised recommendation no longer included the option of employing SHS mitigation procedures (ie, “or at least eliminate your child’s exposure to smoke the week before and after surgery”) and instead only emphasized maintaining abstinence. A total of 5 parents (3 interviewed individually and 2 interviewed as a couple) were interviewed with the interview guide using this quit smoking recommendation. Due to the interviewer sensing more resistance (see results) from parents with this second interview guide, it was revised again to “warm up” the introduction so that the first question was not about parental smoking status. Instead the interviewer gave a longer description of her role, and some general information about qualitative interviewing. This additional neutral content was meant to help build rapport so that the interviewer could further assess whether it was the initial question about smoking status that some parents were reacting to, or whether there was more negativity associated with the stronger quit smoking message. A third group of 5 parents completed individual interviews with this third version of the interview guide. The quit smoking recommendation was exactly the same in the second and third versions of the inter-

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view guide (ie, no mention of reducing smoke exposure, emphasis only on quitting smoking). Clinician interviews. The 10 individual qualitative interviews conducted with clinicians followed a single semi-structured interview guide (Table 2). All parent and clinician interviews were conducted by experienced qualitative researchers who have no affiliation with the clinical area where patients were recruited. Parent interviews required approximately 30 minutes, and interviews with couples required approximately 45 minutes. Clinician interviews required approximately 20 minutes. All interviews were audio recorded and transcribed verbatim. Qualitative Analysis The iterative process of qualitative analysis began simultaneously with data collection, with interviewers comparing field notes and discussing possible themes. Three study co-investigators with experience in qualitative data analysis collaborated in the development of a coding strategy and independently coded interviews using methods of content analysis (ie, systematic process of sorting and coding information based on themes.14,15 Predominant themes (ie, the personal opinions, experiences, or concerns repeated across multiple parents) were identified and specific quotes that seemed to represent each theme were selected. Investigators coded the sections of the transcripts directly following the recommendation to reduce smoke exposure or quit smoking according to parent motivation for change by coding “change talk.”16 Statements were coded to indicate the parent seemed to be

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Table 2 Questions Included in Clinician Interview Guide 1. 2. 3. 4. 5. 6. 7. 8.

What do you know about how secondhand smoke exposure affects children undergoing anesthesia and surgery? Do you currently ask the parents of children undergoing surgery about tobacco use? Please explain. Do you recommend to parents of the children undergoing surgery that they quit smoking or take other measures to reduce their children’s secondhand smoke exposure around the time of surgery? (Probes: How? How often? If no, would you be willing to do so?) Do you think it is part of your responsibility to help parents reduce the child’s secondhand smoke exposure around the time of the child’s surgery? (Probes: Please explain) How might parents respond if you talked with them about their smoking? What do you think about talking to parents about how their smoking is a risk for their child around the time of surgery and recommending they change their behavior the week before and week after surgery? (Probe: What approach could work best?) How much do you know about strategies that parents can use to reduce secondhand smoke exposure? What resources would help you talk to parents about how their smoking is a risk for their child around the time of surgery?

preparing for change (ie, preparatory change statements reflecting desire, ability, reasons or needs for behavior change), or were committing to change (action words/verbs that communicate an intention to change, such as “I’m going to cut down”), statements that show the parent is already taking steps toward change (“I’ve already started using the nicotine patches”). In addition to coding for preparing for change and commitment to change, investigators coded for resistance (“sustain talk”), which are arguments against change or for the status quo.17 Based on the type and frequency of their change talk, the analysts then categorized parents as “preparing to change,” “committing to change,” or “resisting change” (statements against change and for the status quo). When discrepancies in coding occurred, the 3 analysts met and reviewed the qualitative data in question within the full uncoded interview transcript, to improve understanding of the parent’s meaning through examination of the verbalizations within the original context of the interview conversation. Data from the couple interviews were coded together typically and considered as combined/overlapping data instead of considering the text as independent, unique data, except in the cases when the individuals clearly expressed differing opinions. QSR’s NVivo 9 (QSR International, Doncaster, Victoria, Australia; NVivo 2010) qualitative data software analysis program was used to facilitate data coding and sorting. RESULTS Parent Interviews A total of 13 mothers and 12 fathers (age 35 ± 7 [M±SD] years) completed the interviews. Four predominant themes emerged from these interviews. Data supporting the fourth theme were analyzed separately for each of the 3 versions of the interview guide. The other themes emerged from data that were consistent across all interviews. Parent Theme 1: Parents are receptive to learning about the risks of SHS exposure to

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their child’s surgery. Parents expressed consistent receptivity to the idea of receiving information about SHS and their child’s surgery. Most parents knew nothing about the potential acute risks produced by SHS exposure to their child’s surgery. Parents were specifically asked if they had an emotional reaction to the information about SHS health risks or to the thought of having a conversation about SHS in this setting. Parents did not express distress or offense at the idea of receiving this information, though some acknowledged that there may be more emotion and distraction on the actual day of surgery, depending on the severity of medical concern (eg, I think it would be a stronger reaction on the day of because you are already stressed out, worried about your child going into surgery. Because whether they call it a minor surgery or not, there is no such thing as a minor surgery.) Overall, however, parents expressed belief that the information about risks associated with SHS around the time of surgery should be given to parents. Parent Theme 2: Many parents are already attempting to reduce SHS exposure, and protecting their children from SHS health risks is a motivator. A majority of parents (17 of 25; 68%) stated that they employed at least one strategy to limit SHS exposure, including no smoking policies in homes and cars or a dedicated room for smoking. Responses reflect existing active attempts to limit SHS. For example, I don’t smoke inside or in vehicle or in the house around my child. Of course, when I’m outside, he wants to be close to me and so, I’m sure he at least smells it. And that’s what I tell him, if he smells it, he’s too close. Parent Theme 3: Parents have preferences for how information about SHS should be de-

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Table 3 Parent Motivation for Change Group A (N = 15)

Groups B and C (N = 10)

Preparing to change

6 (40%)

1 (10%)

Committing to change

6 (40%)

4 (40%)

0

4 (40%)

Change Talk Category (N, %)

p .03*

Resisting change

* Fisher’s Exact Test. All groups were advised to quit smoking. Group A was also provided with the option of implementing secondhand smoke mitigation procedures; Groups B and C were not. Column percentages do not equal 100% because some interviews did not include change talk or the content was too ambiguous to categorize.

livered around the time of a child’s surgery. Parents would prefer that the recommendation to quit smoking or reduce smoke exposure be delivered by a senior clinician directly involved in the surgical process. Most specifically mentioned that the surgeon or anesthesiologist should deliver this message (eg, “People would respect what the surgeon says.” “Better to have someone related to surgery itself.”) Some mentioned that having a clinician deliver the message at the time of the pre-surgical consult would make the most sense. There was minimal enthusiasm for having other allied health professionals (such as a patient educator) deliver this message. Parents also emphasized that the delivery style and tone of the message is important. They specified that the recommendation to quit smoking or reduce smoke exposure must be presented in a nonjudgmental manner and without shaming or lecturing the parent. For example: I think it’s good to provide that education to the parents. I think it’s OK to let them know why it’s crucial and this is the reason why it’s crucial. But at the same time, it needs to be relayed in a sensitive manner. And maybe just explain more about it being a disease and that you understand that it’s hard for people to just quit. I just think that people need to be more empathetic toward the smoker.” Finally, most parents preferred this conversation to be brief and to the point. Preferences for educational strategies were elicited. As mentioned previously, parents described already having motivation and some experience with reducing SHS exposure, and thus, emphasized interest in specific strategies for more effective SHS mitigation. Though some mentioned a video format as preferable for this educational content, the majority thought brief written parent education material (pamphlet) would be most useful. Suggested content for a written material included a rationale for protecting children from smoke around the time of surgery (specific surgical risks associated

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with SHS), the specific recommendation to quit or eliminate SHS exposure the week before and week after surgery, and effective strategies for limiting SHS exposure. Whereas some suggested quit smoking resources should be included, the majority suggested the emphasis should be on what a parent can do to help their child around the time of surgery, with less emphasis on personally quitting smoking. Parent Theme 4: Parents are more accepting of a recommendation to limit SHS exposure than a recommendation to quit smoking. Although parents were generally accepting about receiving information about how SHS exposure increases surgical risks, parents differed in their responses to a recommendation to make a change to eliminate SHS exposure. The first 15 parents interviewed were asked about the recommendation to limit SHS smoke exposure for one week before and after surgery either by quitting smoking completely or instituting SHS mitigation measures. Parents expressed receptivity to this recommendation and all made statements suggestive of their desire to make or attempt change; none expressed resistance to change or argued for the status quo. For example, when queried about what they would do if they received this recommendation, responses included, Well, I completely agree with it and …I’m going to take that suggestion to heart” and “If they would have told me that, I’d do anything for [my son]. So, I would have quit for those 2 weeks. The subsequent interviews using the 2nd (5 parents) and 3rd (5 parents) versions of the interview guide asked parents to react to the recommendation that they quit smoking completely for at least for one week before and after their child’s surgery, without mentioning another SHS mitigation option. Parents had more varied reactions to this recommendation compared with the parents interviewed with the first version of the interview script. Of the 10 parents interviewed with the quit smoking recommendation, 4 (40%) parents expressed

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Table 4 Practices and Attitudes of Clinicians Do you currently ask the parents of the children undergoing surgery about their tobacco use? Consistently

10%

Representative comments

Sometimes

50%

I almost always do, for ear tube patients. For other surgeries, I don’t typically.

No

40%

If you smell it on them. Parents who smoke all the time have it on their fingers, their face, have a look to them. I’m usually right, when it’s obvious.

Do you recommend to the parents of the children undergoing surgery that they quit smoking or take other measures to reduce their children’s secondhand smoke exposure around the time of surgery? Consistently

0%

Sometimes

70%

No

30%

Representative comments I guess in certain cases. If strongly smelling of tobacco smoke and I think that that intervention would clear up their problem in lieu of surgery, then I do have a conversation with them about it. I don’t always think that parents are really honest and forthright about the tobacco smoke exposure either so I think that a lot of times that they claim that they don’t smoke around the child or they smoke only outside, that’s probably a little bit of stretching of the truth. I should, and in fact, when some children have reactive airway disease unexplained based their procedure or what we did for them, I don’t even consider it and I should…I think that just having that recommendation, talking to the parents, and I think that sometimes we take it for granted that parents know that them smoking directly affects the child. I think most parents reconcile with that by saying, “Oh, I never smoke in the house.”

Do you think it is part of your responsibility to help parents reduce the secondhand smoke exposure of their children around the time of surgery? Consistently

100%

Sometimes

0%

No

0%

Representative comments I feel it is the surgeon’s direct responsibility to warn parents/caregivers about the dangers of second hand smoke and to do some mitigation at around the time of surgery, yes. I think it is. And, now that I’m thinking more about it, I think that I should be doing more to deal with that subject. My feeling is that any opportunity there is to help people stop smoking and also to benefit the health of children in general, we should take every opportunity available.

overt resistance to the recommendation. However, these same parents expressed some motivation toward limiting SHS exposure. For example, when queried about what they would do if they received this recommendation, responses included:

To improve understanding of how parent motivation for change differed across the 3 interview guides, analysts coded all parent interviews for “change talk.” Based on the type and frequency of

their change talk, the analysts categorized parents as “preparing to change,” “committing to change,” or “resisting change” (Table 3). The distribution of change talk categories differed significantly among those receiving the 1st and 2nd or 3rd version of the guide. The 1st interview guide, which presented the option of implementing other SHS mitigation strategies instead of maintaining abstinence, elicited stronger “change talk” with 100% of parents making statements suggesting they were preparing for and/or committing to behavior change related to smoking/smoke exposure. Parents receiving the 2nd or 3rd version of the interview guide, which did not include options other than abstinence, were more likely to express barriers to quitting smoking or argue against the recommendation (arguing against change or for the status quo). Some parents explained that their resistance to a quit smoking message was related to their readiness to

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I probably won’t do it, no. I’d probably continue smoking. But, like I said, I wouldn’t do it around him, obviously,” and “I probably would have left there upset and walked out of there thinking, ‘Oh, it’s just another thing to blame smoking on.’ It just seems that everything gets blamed on smoking a cigarette. And I probably wouldn’t have taken them too seriously.

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Reducing Secondhand Smoke Exposure of Children Undergoing Surgery quit smoking overall; for those who are not ready to quit, reducing smoke exposure presents a more realistic behavioral target. Clinician Interviews Each of the 10 clinicians interviewed expressed belief that protecting children from SHS around the time of surgery is important; representative quotes include: I feel it is the surgeon’s direct responsibility to warn parents/caregivers about the dangers of second hand smoke and to do some mitigation at around the time of surgery,” and “my feeling is that any opportunity there is to help people stop smoking and also to benefit the health of children in general, we should take every opportunity available. Clinicians believed that parents would generally be receptive to smoking risk reduction conversations prior to surgery because of parental motivation to help improve the child’s health. Although all these clinicians feel that addressing SHS exposure in their patients is their responsibility, few consistently ask or advise parents about this topic (Table 4). One barrier to clinician involvement was limited knowledge about this topic (eg, “Boy, honestly, I know very little about how [SHS] affects kids undergoing surgery or anesthesia. I’m not aware of any information on that.”) Though clinicians were willing to learn more about SHS risk reduction and to help communicate recommendations to parents, there was an implicit theme that providers were concerned about doing this the right way. Some also mentioned their own emotional barriers to having these types of conversations with parents I just find it extremely hard to do. It’s also a very difficult time for parents. We often have the parent come back to the operating room to see what their kid is going through and almost 100% of parents walk out of the operating room in tears. And, laying more on them right at that time is really not a caring thing to do. It’s a time they might take it to heart, but still, I’ve tried to think about why is it so hard for me to do that. Putting a guilt trip on them at the time when I am trying to establish a therapeutic approach is difficult. Others asked for training on how deliver a message that would be comfortable for the provider and the parent, some specifically recommending a video that demonstrates a helpful encounter. For example, I think that it is important to appreciate the right way of presenting a material. I think like having a video--it’s a good way for clinicians. And just on the how to present information. So, I guess what I’m trying to say, just because you have

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that information doesn’t mean that the clinician would know how to actually present it. I would like to see how someone who has thought about this says it right. Clinicians were accepting of training on how to facilitate a conversation about reducing the child’s smoke exposure around the time of surgery, but most emphasized that the training must be brief and convenient to access (“Because our time is so short already…something we could do on our own, maybe a web-based module.” “Easiest to do would be web-based stuff.” “An email with a link to a 7-minute video”). DISCUSSION This formative qualitative study provides insight into the attitudes and practices of both parents and providers regarding reducing SHS exposure of children in the perioperative period, insights that can be used to craft interventions. The implications of SHS exposure for child health are well documented.2,3 A variety of strategies for reducing such exposure have been proposed and tested, including interventions with individual parents designed to help them quit (the most effective means to reduce SHS exposure) or implement SHS mitigation strategies.2,18 Systematic reviews show that such interventions are efficacious,2,8,9,18 albeit with modest effect sizes, but implementation has proven to be difficult in real-world settings.19,20 Many interventions take advantage of clinical encounters such as hospitalization of the child,21 although there is little evidence that these are more efficacious than interventions provided in community settings.22 In addition to effects on chronic health, multiple studies show that SHS exposure poses acute perioperative risk, providing an additional impetus to intervene.4-7,23 Because risk is proportional to the level of SHS exposure as quantified by urinary cotinine levels,6 reduction of exposure, even if only around the time of surgery, has the potential to improve surgical outcomes, although this has not been directly evaluated. Thus, interventions in the setting of child surgery may provide a unique opportunity given that potential health benefit is more immediate, and that even a temporary reduction in SHS exposure may be beneficial. We have shown that the scheduling of child surgery indeed prompts parental quit attempts, but that such attempts do not achieve prolonged abstinence11 – indicating that an efficacious intervention for this setting is needed. This formative work identified several prominent themes from both parents and clinicians to guide the development of an intervention. First, although parents are aware that SHS exposure poses general health risks, they are not aware of risks specific to the perioperative period, and want to be informed. This is consistent with the findings of our analogous formative work used

Warner et al to craft an intervention for adult smokers facing surgery,24 and consistent with the emphasis of prior SHS interventions in the setting of child illness. Any concerns that clinicians may have regarding whether parents view this as an appropriate topic for conversation in this setting can thus be alleviated. Second, parents are well-informed about the general threat of SHS exposure to child health, and most are already taking steps to address their child’s SHS exposure. This is consistent with a 2010 survey of Minnesota households indicating that 58% of smokers reported that their homes were smoke free.25 Our interviews did not explore what measures they were currently taking, or knowledge regarding the effectiveness of strategies. Prior studies suggest that belief that SHS exposure harms health is not associated with smoking bans in house or car,26 so that just knowing about potential for harm may not be enough to motivate action. However, our results suggested that learning of the risk of SHS exposure specific to the perioperative period would motivate initiation or strengthening of measures to reduce such exposure. Third, parents expressed definite preferences for how clinicians address SHS. There was a strong preference for the attending surgeon and anesthesiologist to raise this issue and explain its significance, perhaps reflecting the trust placed in these personnel by parents willing to allow surgery. Again, this is consistent with our prior work in adult smokers facing surgery.24 They are not opposed to others also providing information, but involvement of the surgeon or anesthesiologist is crucial to emphasize its importance. Parents also want specifics regarding what they can do, with the focus on what will help the child (eg, how to create a healthy environment of the child around the time of their surgery), rather than shaming the parent. Indeed, parents were concerned that messages not be delivered in a lecturing manner or seeming to imply judgment from the clinician, especially at this inherently stressful time. These preferences reflect a fourth major theme – whether clinicians should insist on quitting, or whether it is useful to present other options to mitigate SHS exposure. The focus of most prior interventions is on getting parents to quit, which is understandable as this is the most effective way of reducing SHS exposure. But for some parents, the strong recommendation in the 2nd and 3rd interview scripts that the parent quit smoking altogether or at least for the week before and after surgery was met with parent expressions of barriers to smoking cessation. Inclusion of other options to reduce SHS exposure allowed parents instead to argue in the direction of change by stating that they think reducing smoke exposure is important and that they are already taking steps to do so. This more positive conversation seemed more motivating to parents, and consequently, there may be better

adherence to recommendations. Finally, even though the clinicians interviewed had knowledge deficits regarding both the importance of SHS exposure to risk and tobacco control measures27 there was strong support for their involvement in interventions in this setting – if it is done in the “right way.” Even those who expressed some discomfort with having this conversation expressed interest, which may imply that it would be important to address self-efficacy for intervening. Consistent with these expressions, we have demonstrated in adult smokers that anesthesiologists with minimal prior experience can be engaged in brief tobacco control interventions,28,29 with only brief education in how to do so. Limitations of this study include the potential selection bias in the parents and clinicians agreeing to be interviewed, who may be more motivated to talk about smoking and consider making change. Parents interviewed were ones who were white, non-Hispanic, with access to healthcare at a major academic medical institution. Additional study of the receptivity of parents to an intervention designed to reduce child smoke exposure could be strengthened by including parents of diverse background, including socio-economic, education and health literacy, severity of surgical risk, culture/ race, and age. In conclusion, both parents and clinicians are receptive to the concept of clinician-delivered interventions to reduce the SHS exposure of children scheduled for elective surgery. Based on the themes identified in this formative work, development and validation of such an intervention is ongoing.

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Human Subjects Statement This study was approved by the Mayo Clinic Institutional Review Board (#09-003810), and written informed consent was obtained from each participant. Conflict of Interest Statement The authors report no financial conflicts of interest. Acknowledgements This work was supported by an award (#082437 CIA) from the Flight Attendant Medical Research Institute. References

 1. Soliman S, Pollack HA, Warner KE. Decrease in the prevalence of environmental tobacco smoke exposure in the home during the 1990’s in families with children. Am J Public Health. 2004;94(2):314-320.  2. Gehrman CA, Hovell MF. Protecting children from environmental tobacco smoke (ETS) exposure: a critical review. Nicotine Tob Res. 2003;5(3):289-301.  3. Kallio K, Jokinen E, Raitakari OT, et al. Tobacco smoke exposure is associated with attenuated endothelial function in 11-year old healthy children. Circulation. 2007;115(25):3205-3212.

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