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Children With Asthma: Smoking by Other Family Members and Friends

Children With Asthma: Smoking by Other Family Members and FriendsThe limitations of infrequent urine cotinine tests as a measure of typical exposure may seem to imply that providing feedback on cotinine levels as part of the intervention is questionable. However, the problems that arise in its use as an outcome measure are primarily due to temporal sampling problems, rather than to any insensitivity or unreliability of the assay in the range of cotinine levels in which we are interested (notwithstanding the complexities of the assays and of nicotine metabolism and excretion). In the present intervention, the results of cotinine measurements were always communicated to the caregiver in conjunction with a review of the parent’s report of the child’s exposure history during the period leading up to that report, which was given on the day the urine sample was taken. In this way, high or low values could be interpreted and discussed, and the parent could be reinforced for a reduction or queried further if there was an apparent discrepancy between the assay value and the reported exposure. In some cases, such queries prompted the recall of previously unreported exposure (eg, that a sister’s boyfriend, a chain smoker, had moved into the home), which then uncovered the need for a new strategy to eliminate exposure. When used in this manner, the cotinine level results had face validity to the parents and nurse educator and were well-accepted. Other family members also appeared to be more readily convinced of the reality and importance of the exposure by the laboratory results than by the caregiver’s assertions. canadian health care mall

Smoking by Other Family Members and Friends
In this population, only about half of the maternal caregivers smoked, and, typically, those who did so were not the only smokers in the home. To reduce exposure, caregivers typically had to negotiate behavior changes by other adults. Some children were exposed when staying in their second (paternal) home but not in the maternal home. Many mothers and their children lived with the mother’s parent(s), who were smokers, and were dependent on them for financial support, shelter, or childcare. Some children lived in homes in which boyfriends, girlfriends, and other acquaintances of family members were present frequently, sometimes for prolonged periods of time, and they lacked authority over these individuals and had limited capacity to monitor their smoking practices when the caregiver was not present. In one instance, the child’s caregiver was the grandmother, who did not smoke but was also the caregiver to two other elderly, physically and emotionally handicapped relatives who both smoked. These caregivers, particularly the younger mothers, typically lacked the skills needed to address these issues effectively. In some cases, older family members discounted their opinions on the relationship of ETS to the child’s asthma. The intervention attempted to develop those skills through modeling and role playing, and it provided additional support using such strategies as a written prescription from the physician that the child was not to be exposed to ETS and by providing “smoke-free zone” window stickers. Where relevant, the nurse invited the (other) smokers to attend the third session and to participate in the education in order to gain their cooperation with a prohibition against smoking in the home, if not in smoking cessation. It was very apparent that, without this tailored assistance, little change was likely to occur. The subjective impression of the nurse educator, as recorded in her progress notes, was that these strategies were very clearly beneficial in a number of instances.