Reducing Underserved Children's Exposure to Tobacco Smoke: A Randomized Counseling Trial With Maternal Smokers

Am J Prev Med. 2015 Oct;49(4):534-44. doi: 10.1016/j.amepre.2015.03.008. Epub 2015 May 28.


Introduction: Addressing maternal smoking and child tobacco smoke exposure is a public health priority. Standard care advice and self-help materials to help parents reduce child tobacco smoke exposure is not sufficient to promote change in underserved populations. We tested the efficacy of a behavioral counseling approach with underserved maternal smokers to reduce infant's and preschooler's tobacco smoke exposure.

Design: A two-arm randomized trial: enhanced behavior counseling (experimental) versus enhanced standard care (control). Assessment staff members were blinded.

Setting/participants: Three hundred randomized maternal smokers were recruited from low-income urban communities. Participants had a child aged <4 years exposed to two or more maternal cigarettes/day at baseline.

Intervention: Philadelphia Family Rules for Establishing Smoke-free Homes (FRESH) included 16 weeks of counseling. Using a behavioral shaping approach within an individualized cognitive-behavioral therapy framework, counseling reinforced efforts to adopt increasingly challenging tobacco smoke exposure-protective behaviors with the eventual goal of establishing a smoke-free home.

Main outcome measures: Primary outcomes were end-of-treatment child cotinine and reported tobacco smoke exposure (maternal cigarettes/day exposed). Secondary outcomes were end-of-treatment 7-day point-prevalence self-reported cigarettes smoked/day and bioverified quit status.

Results: Participation in FRESH behavioral counseling was associated with lower child cotinine (β=-0.18, p=0.03) and reported tobacco smoke exposure (β=-0.57, p=0.03) at the end of treatment. Mothers in behavioral counseling smoked fewer cigarettes/day (β=-1.84, p=0.03) and had higher bioverified quit rates compared with controls (13.8% vs 1.9%, χ(2)=10.56, p<0.01). There was no moderating effect of other smokers living at home.

Conclusions: FRESH behavioral counseling reduces child tobacco smoke exposure and promotes smoking quit rates in a highly distressed and vulnerable population.

Trial registration: This study is registered at NCT02117947.

Publication types

  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural

MeSH terms

  • Child, Preschool
  • Cotinine / urine
  • Directive Counseling / methods*
  • Female
  • Humans
  • Infant
  • Maternal Behavior
  • Philadelphia / epidemiology
  • Smoking / epidemiology
  • Smoking Cessation / statistics & numerical data
  • Tobacco Smoke Pollution / analysis
  • Tobacco Smoke Pollution / prevention & control*
  • Vulnerable Populations / statistics & numerical data*


  • Tobacco Smoke Pollution
  • Cotinine

Associated data