Parental receptivity to child biomarker testing for tobacco smoke exposure: A qualitative study

Highlights

• Most parents are willing to have their children tested for TSE using biomarkers.

• Parents who favor testing desire information for reassurance or motivation.

• Most parents believe testing would motivate behavior change to protect the child.

• Concerns include child's discomfort, mistrust of tests and powerlessness to change.

• TSE biomarker testing is a promising tool for counseling interventions.

Abstract

Objective

Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their children's exposure. Biomarkers demonstrate exposure and may motivate behavior change, but their acceptability is not well understood.

Methods

Sixty-five in-depth interviews were conducted with parents of young children, in smoking families in central Israel. Data were analyzed using thematic analysis.

Results

Consent to testing was associated with desire for information, for reassurance or to motivate change, and with concerns for long-term health, taking responsibility for one's child, and trust in research. Opposition to testing was associated with preference to avoid knowledge, reluctance to cause short-term discomfort, perceived powerlessness, and mistrust of research.

Most parents expressed willingness to allow measurement by urine (83%), hair (88%), or saliva (93%), but not blood samples (43%); and believed that test results could motivate behavior change.

Conclusions

Parents were receptive to non-invasive child biomarker testing. Biomarker information could help persuade parents who smoke that their children need protection.

Practice implications

Biomarker testing of children in smoking families is an acceptable and promising tool for education, counseling, and motivation of parents to protect their children from TSE. Additionally, biomarker testing allows objective assessment of population-level child TSE.

Introduction

Reduction of child exposure to tobacco smoke is an important global health challenge [1], [2], [3], [4], and depends to a large degree on parental beliefs and practices. Worldwide, it is estimated that 40% of children are exposed to tobacco smoke in their homes [5], with most exposure caused by parental smoking. The high prevalence of exposure, combined with well-documented increased health risks [5], leads to a large and entirely preventable population burden. In 2004, 166,000 child deaths and nearly 6 million child lower respiratory infections were attributed to secondhand smoke (SHS) [5]. Exposed infants are at increased risk for sudden infant death syndrome, while exposed children have a higher risk of acute respiratory infections, lower levels of childhood lung function [1], and increased likelihood of developmental and behavioral problems [6].

Despite the broad consensus about the need to protect children from tobacco smoke (US Surgeon General [1], WHO [2], the G8 [3], Healthy Israel 2020 [4]), questions remain about how to reduce smoking around children, in particular in their home environment. Thus, at the individual level, an important challenge is to convey to parents the risk to their children caused by their own or family members’ smoking behaviors, and to persuade them to refrain from smoking in places where children live, study, and play. Another challenge is to obtain accurate population-level data to assess the magnitude of this problem [7], [8], [9]. Monitoring exposure as a means to control population-level risk is common to many public health endeavors, and has been used for other contaminants; for example, lead, allergens, pesticides [10], and mercury levels [11].

Biomarkers are measureable biological substances found in the body, which can be used for quantification of environmental exposures [12]. Biomarkers to assess child tobacco smoke exposure have the potential to persuade adults to stop smoking around children, and to measure population-level exposure. They are advantageous over parental reports, which may be compromised by social desirability bias, or parental unawareness of their child's exposure, as demonstrated by discrepancies between parental reports of exposure and objective markers [13], [14]. Consequently, biomarkers are considered the gold standard for evidence of exposure [1], [15]. Several biomarkers of tobacco smoke exposure (TSE) have been studied. Cotinine, found in urine, blood, hair, saliva, and nails, is most often used, due to its high sensitivity and specificity [16], [17], [18], [19]. There are some differences between the different modalities, for example, cotinine in hair and nails reflects long-term exposure, while cotinine in saliva, serum and urine reflect short-term exposure [7]. Biomarkers can be used for individual feedback, and may persuade parents to protect their children by showing them in a convincing way that exposure, whether secondhand or thirdhand, is occurring. Research has shown that beliefs about thirdhand smoke are related to increased protective behaviors such as enforcing a ‘smoke-free home’ [20]. Several interventions aimed at reducing TSE of children in the home used feedback of biomarkers with varying degrees of success [21], [22], [23], [24], [25].

Despite the potential utility of biomarkers for both behavior-change interventions and monitoring, the topic of parental receptivity to child biomarker testing to assess TSE has received little attention in the research literature. Just two previous studies were found on this topic [26], [27]. One study addressed the willingness of Latino parents to allow hair sampling of their children, and found that over 90% of them were willing to provide child hair samples [26]. A nationally-representative study conducted in the US [27] found that the majority of both smoking and non-smoking parents were willing to have their children tested for TSE. However, these studies addressed only one biomarker, and neither performed an in-depth qualitative investigation of parental attitudes.

This study aimed to explore in-depth the beliefs, attitudes, concerns and preferences about child biomarker testing among parents in whose families smoking occurs, as they relate to behavior change associated with protecting children from TSE.