Intended for healthcare professionals

Letters

Smoking by parents of asthmatic children

BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7210.644 (Published 04 September 1999) Cite this as: BMJ 1999;319:644

Sensitive counselling may still be worth while

  1. John Kemm, consultant in public health medicine (John.Kemm{at}wales.gsi.gov.uk)
  1. Llanishen, Cardiff CF14 5EZ
  2. Department of Epidemiology and Public Health, Ninewells Hospital and Medical School, Dundee DD1 9SY

    EDITOR—Reducing exposure of asthmatic children to parental smoking is important, but without more information the paper by Irvine et al provides no foundation for evidence based practice.1 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 et al 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.2 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.

    I would also question whether the intervention was in accord with best practice. The use of a research nurse unknown to the family and apparently unconnected with the patient's practice does not use the practice-patient relationship. The use of the phrase “telling patients what to do” in the discussion raises concern about the 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.

    References

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    Authors' reply

    1. Linda Irvine, research fellow (lirvine{at}eph.dundee.ac.uk),
    2. Iain K Crombie, reader,
    3. Roland A Clark, consultant respiratory physician,
    4. Peter W Slane, general practitioner
    1. Llanishen, Cardiff CF14 5EZ
    2. Department of Epidemiology and Public Health, Ninewells Hospital and Medical School, Dundee DD1 9SY

      EDITOR—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 et al.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 contact with the parents was about one hour, although the actual intervention took around 10 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.

      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 to 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 before the start of the study. We were satisfied that parents were given sufficient information.

      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 effect of counselling smokers at every opportunity.4

      Finally, he 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. The size and complexity of the study and the large number of practices involved made it impracticable for the intervention to be delivered by practice staff Furthermore, we believe that the quality of large trials depends on rigorous data collection by staff dedicated to the project. We remain confident that our study showed that a brief intervention given to parents is of no benefit to children with asthma.

      References

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      4. 4.