Advising parents of asthmatic children on passive smoking: randomised controlled trial
BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7196.1456 (Published 29 May 1999) Cite this as: BMJ 1999;318:1456
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Editor,
Irvine et al report a randomised controlled study on the effects of
advising parents of asthmatic children on passive smoking (1).
They identified that it is as yet unproved whether the risks from
passive smoking are
appreciated. They then went on to conclude from their study that a brief
intervention has no
significant effect on parental smoking habits.
We are concerned that firstly there appeared to be an information
overload presented
to the parents, during a single session, with no measure of comprehension
and recall.
Secondly, leaflets were sent to the parents involved with no apparent
consideration of
the issue of literacy.
Without these measures in place it is difficult to assess
appreciation of passive
smoking risks and the effectiveness of the intervention they describe.
The results are not unexpected. There have been several studies in
the past that have
shown brief interventions to be ineffective. In this study, however,
Irvine et al did identify
some individuals who displayed a change in their habit. It may therefore
have been more
useful to have analysed subset data in an attempt to elicit the factors
that were important in
influencing these changes. This could then have been used to direct
further in depth studies.
Competing Interests : none
1 Irvine L. et al, Advising Parents of Asthmatic Children on Passive
Smoking: randomised controlled trial.
Competing interests: No competing interests
I read with interest this admirable concept of informing parents
about their child`s medical condition and indeed the risks of any
treatment or not to their health and wellbeing. Perhaps Mr Carroll would
like to pin this advice on his hospital`s notice board so that other
colleagues can share in his wisdom.
Ironic when you consider the ongoing government inquiry into whether
parents were misled and uninformed about the research projects their
children were used in without their knowledge at his hospital!
We will be cautiously hopeful that a change in culture is on the
horizon for those parents unfortunate enough to need the services of the
paediatric department when thier child is sick. Information from those
clinicians treating ones child is vital to encourage trust and
understanding between the doctor and parent who should be working together
to help the child recover from whatever misfortune they find themselves
in.
Competing interests: No competing interests
The subject of the paper by Irvine et al [1] is important but without
more information the paper provides no foundation for evidence based
practice. The reader can safely conclude that something made no difference
but is given no useful description of what that something was. The paper
supplies only two of the five elements that Windsor, Boyd and Orleans [2]
suggest as an adequate description of an intervention namely counselling
content, theoretical framework from which methods are derived, duration of
each patient contact, frequency of intervention components and training of
intervention counsellors. It is sad that journals which take commendable
steps to ensure that the outcomes are adequately reported still do not
apply similar standards to the reporting of the intervention [3].
A further cause for concern is the context of the study. What was the
nature of the families' consent? If they were given adequate information
it is likely that the control group was appreciably contaminated and if
they were not the ethics of the study are debatable. What previous advice
and support had been given to these families? I hope we can assume that
all practices in the study routinely advised all such parents of the
possible connection between their smoking and their child's asthma in
which case the additional intervention sounds marginal.
One has to ask whether the intervention was in accord with best
practice. The use of a research nurse unknown to the family and apparently
unconnected with the patients practice does not utilise the practice
patient relationship. The use of the phrase "telling patients what to do"
in the discussion raises concern as to counselling style.
Certainly we need more effective methods of helping smokers cut back
or quit and the intervention used in this study was apparently
ineffective. However this paper should not be interpreted as indicating
that sensitive counselling by primary care teams of parents who smoke and
have asthmatic children is not worth while.
John Kemm
Consultant in Public Health Medicine
Llanishen
Cardiff CF14 5EZ
References
1 Irvine L,Crombie IK, Clark RA, Slane PW, Feyerabend C, Goodman KE,
Cater JI Advising parents of asthmatic children on passive smoking:
Randomised controlled trial. BMJ (1999) 318 1456-1459
2 Windsor RA, Boyd NR and Orleans CT A meta evaluation of smoking
cessation intervention research among pregnant women: improving the
science and art. Health Education Research (1998) 13 419-438.
3 Speller V, Learmonth A and Harrison D The search for evidence of
effective health promotion. BMJ (1997) 315, 361-363.
Competing interests: No competing interests
Doctors are ethically bound to inform parents about risks
EDITOR – I was saddened if not wholly surprised to find that advice
to parents about the detrimental effects of passive smoking on their
asthmatic children did not seem to influence their behaviour (1). The
authors of the paper correctly identified that further intervention may be
required in order to protect children’s health but went on to conclude
that the ‘parent’s smoking needs to be addressed as a separate issue from
the child’s health’.
Not only is this not always possible, I firmly believe that doctors
are duty bound to inform parents fully about their children’s medical
condition. The GMC guidance on good medical practice states that ‘..you
must give patients the information they ask or need about their condition,
its treatment and prognosis. You should provide this information to those
with parental responsibility where the patients are under 16 years old and
lack the maturity to understand what their condition or its treatment may
involve, provided you judge it to be in the child’s best interests to do
so’ (2). I acknowledge that many parents will choose to ignore the advice
of doctors, even when it is clear they are damaging their children’s
health, however, they cannot be allowed to do so from a position of
ignorance.
Will Carroll Specialist Registrar in Paediatrics
Department of Paediatrics, City General Hospital, Stoke-on-Trent.
1. Irvine L, Crombie IK, Clark RA, Slane PW, Feyerabend C, Goodman
KE, Cater JI. Advising parents of asthmatic children on passive smoking:
randomised controlled trial. BMJ 1999;318:1456-1459.
2. General Medical Council July 1998. ‘Good Medical Practice.’
All correspondence should be sent to:
Dr Will Carroll, 23 Ash Tree Hill, Cheadle, Stoke-on-Trent, ST10 1UQ.
Competing interest: none
Conflict of interest: none.
Competing interests: No competing interests
Authors' response
We have read the responses to this paper with interest and will try
to address all the points made and clarify by giving more details.
Dr Carroll feels doctors are ethically bound to tell parents about
the risks of passive smoking and quotes the GMC guidance on good medical
practice which states that "you must give patients the information they
ask or need about their condition, its treatment and prognosis". We do
not dispute that parents should be given relevant information but what
patients do not need is an intervention which is at best ineffective and
may even be counterproductive. We have only suggested that trying to
persuade parents to stop smoking at a consultation about their child’s
asthma may not be appropriate. It is up to doctors to decide, given the
clinical circumstance, what actions are warranted.
Dr Kemm raised several important issues. He was concerned that the
intervention was not described in enough detail. The extent of reporting
was restricted by the word limit but we take this opportunity to give more
details. The intervention was designed so that it could be easily used in
the clinical situation, if found to be effective. It was brief, based on
the method first described by Russell.[1] Parents were visited once and
the nature of the intervention is described in the paper. Information
given at the time of the consultation was reinforced in leaflets. The
duration of the contact with the parents was approximately one hour
although the actual intervention took around ten minutes. The
intervention was delivered by research nurses, who were not trained
counsellors. This was intentional, the purpose of the study being to test
an intervention which could be delivered by any nurse.
Dr Kemm was also concerned about the ethics of our study. Providing
enough information about a study to obtain informed consent without
contaminating the control group is a problem for all studies designed to
change behaviour. Parents were told that the study was being carried out
to look at ways of reducing passive smoking in children with asthma and
gave written consent of participation. However the full details of the
study design were not disclosed. The issue of informed consent was
discussed in detail with the Tayside Committee on Medical Ethics prior to
the start of the study. We were satisfied that parents were given
sufficient information.
Dr Kemm assumes that clinicians routinely advise all parents of the
possible connection between their smoking and their child’s asthma.
Several studies have shown that many clinicians do not give such advice
routinely,[2,3] and some are uncertain about the impact of counselling
smokers at every opportunity.[4]
Finally, Dr Kemm queried the use of research nurses unknown to the
study participants. The alternative, using practice staff to deliver the
intervention was not a realistic option. Due to the size and complexity
of the study and the large number of GP practices involved, it would have
been impractical for the intervention to be delivered by practice staff.
Further, we believe that the quality of large trials is dependent upon
rigorous data collection by staff dedicated to the project. We remain
confident that our study showed that brief intervention on parents is of
no benefit to children with asthma.
The main concern of the medical students from Newcastle was the
nature of the leaflets given to the parents. Describing the design and
content of the leaflets was beyond the scope of the paper, again due to
the word restriction. The leaflets were based on the intervention with
much of the information which was given orally repeated in the three
leaflets. The leaflets were illustrated and the limited text was in large
print, consisting of short sentences and commonly used words. The only
medical term was the word asthma. We were satisfied that the parents
would understand the content of the leaflets as they had already read the
information leaflets and completed the consent forms.
Information overload is a problem in consultations between patients
and doctors. We were aware that the consultations were long
(approximately one hour) and involved several components (obtaining
informed consent from the parents and children, administering the
questionnaire, collecting saliva samples and then further discussion on
passive smoking with the intervention group). To reinforce the
intervention, the information was repeated in the leaflets, the first of
which was left with the parents on the day of the initial home visit. We
did not try to measure comprehension or recall of the information given,
but used an objective measure, salivary cotinine, to determine whether the
intervention had any impact on passive smoking by the children one year
later. Twelve parents reported stopping smoking and this was confirmed by
salivary cotinine levels in only ten. We explored the histories of these
parents but the numbers were insufficient to be analysed as a subset.
1. Russell MAH, Wilson C, Taylor C, Baker CD. Effects of general
practitioners' advice against smoking. BMJ 1979;2: 231-235.
2. Goldstein MG, Niaura R, Willey-Lessne C, DePue J, Eaton C, Rakowski W,
et al. Physicians counseling smokers. Arch Intern Med 1997;157 1313-1319.
3. Frankowski BL, Weaver SO, Secker-Walker RH. Advising Parents to Stop
Smoking: Pediatricians’ and Parents' Attitudes. Pediatrics 1993;91 (2):
296-300.
4. Coleman T, Wilson A. Anti-smoking advice in general practice
consultations: general practitioners' attitudes, reported practice and
perceived problems. British Journal of General Practice 1996;46 (403): 87-
91.
Competing interests: No competing interests