• Rates of clinician delivering cessation assistance other than advice as assessed by parent surveys at 1 week and 12 months after clinic visit [ Designated as safety issue: No ]
  
• Rates of 7-day abstinence as confirmed biochemically at 3 and 12 months after clinic visit [ Designated as safety issue: No ]
  

• Rates of clinician asking about parental smoking as assessed by parent surveys at 1 week and 12 months after clinic visit [ Designated as safety issue: No ]
  
• Rates of clinician advising parents to quit as assessed by parent surveys at 1 week and 12 months after clinic visit [ Designated as safety issue: No ]
  
• Rates of clinician counseling parents about institution of rules prohibiting smoking in the home and car as assessed by parent surveys at 1 week and 12 months after clinic visit [ Designated as safety issue: No ]
  
• Percentage of parental smokers who have 7-day abstinence at both 3 and 12 months after clinic visit [ Designated as safety issue: No ]
  
• Percentage of parental smokers reported quit attempts lasting at least 24 hours as assessed by parent surveys at 1 week, 3 months, and 12 months after clinic visit [ Designated as safety issue: No ]
  
• Percentage of parental smokers using pharmacotherapy (i.e., gum, patch, lozenge, inhaler, nasal spray, or bupropion) for smoking cessation as assessed by parent surveys at 1 week, 3 months, and 12 months after clinic visit [ Designated as safety issue: No ]
  
• Percentage of parental smokers who received telephone counseling or other services as assessed by parent surveys at 1 week, 3 months, and 12 months after clinic visit [ Designated as safety issue: No ]
  
• Percentage of parental smokers who instituted home and car smoking bans, as assessed by parent surveys at 1 week, 3 months, and 12 months after clinic visit [ Designated as safety issue: No ]
  
• Percentage of parental smokers who expose children to second-hand smoke as assessed by parent surveys at 1 week, 3 months, and 12 months after clinic visit [ Designated as safety issue: No ]
  
• Practice implementation of tobacco control office system as assessed by process survey of clinicians and key office staff at baseline and then at 6 weeks and 6 months after completion of enrollment [ Designated as safety issue: No ]
  

OBJECTIVES:

• To compare the effectiveness of the Clinical Effort Against Secondhand Smoke (CEASE) intervention vs no intervention in increasing clinicians' delivery of evidence-based parental smoking cessation assistance in pediatric healthcare settings.
• To compare the effectiveness of this intervention vs no intervention on parental smoking behaviors.
• To test the level of systematic practice implementation of the intervention using existing validated measures in an Implementation Process Survey (IPS).
• To evaluate, in an exploratory fashion, additional key implementation step measures mapped from the five A's (Ask, Advise, Assess, Assist, Arrange) to see how well they predict tobacco control service delivery in pediatric healthcare settings.
• To use process results from the IPS (i.e., previously validated and exploratory measures) to improve the adoption, implementation, and maintenance of the intervention in this study.

OUTLINE: This is a multicenter study. Participants are stratified according to practice. Participants are randomized to 1 of 2 intervention arms.

• Arm I (Clinical Effort Against Secondhand Smoke [CEASE] intervention): The CEASE intervention incorporates a number of materials into the operations of the pediatric practice, including baseline questionnaires that screen for parental tobacco use and readiness to quit smoking, enroll in quitline counseling, or explore pharmacotherapy; a label that affixes to the child's problem list in the medical record, documenting parental smoking status and indicating the patient's secondhand exposure, thus encouraging continuity of cessation support in cross-coverage situations; and decision support for clinicians that prompts delivery of exposure-reduction counseling and distribution of motivational-messaging handouts (i.e., halflets) to parents for education, skills training, and psychosocial support. Parental messaging elements include strategies or methods for quitting, collaborative goal setting, identifying personal barriers to quitting, and focused strategies for reducing secondhand-smoke exposure of the patient. Additional intervention materials include a HIPAA-compliant form for enrolling the smoker in counseling through the telephone quitline; pre-printed, practice-embossed prescription pads for prescribing over-the-counter nicotine-replacement therapy when desired by the smoker; pharmacotherapy posters in pediatric patient examination rooms to inform parental smokers and assist clinicians in discussing tobacco dependence treatment; and a simple implementation guide to support integrating the parent, clinician, and practice levels of the intervention.

The CEASE intervention also incorporates telephone counseling after the pediatric healthcare visit to ensure that parents receive professional, ongoing smoking-cessation counseling. Parental smokers undergo follow-up telephone surveys at 1 week, 3 months, and 12 months for evaluation of content of tobacco control delivered during the visit; use of messaging materials, medications, and telephone counseling sessions; current smoking status; and rules about smoking in the home and car. If the parent has had a 7-day quit at the 12-month follow-up, the parent is also asked to provide a saliva sample for cotinine analysis to confirm nonsmoking status.

• Arm II (control): Participants complete a questionnaire at baseline and then telephone interviews at 1 week, 3 month, and 12 months. If the parent has had a 7-day quit at the 12-month follow-up, the parent is also asked to provide a saliva sample for cotinine analysis to confirm nonsmoking status.

In both arms, participating practitioners and key office staff complete Implementation Process Surveys at baseline and at 6 weeks and 6 months.