Twenty practices were recruited from Pediatric Research in Office Settings (PROS), the practice-based research network of the American Academy of Pediatrics. Practices were randomized with 10 to the intervention arm and 10 to the control arm. The study participants were smoking parents who accompanied a child to an office visit. Eligibility criteria specified that participants be a parent or legal guardian of the child, over age 18, and English speaking, as well as having reported: “smoked a cigarette, even a puff, in the past 7 days.” The data for this analysis was collected as part of a larger study testing a pediatric-office based tobacco control program for families called CEASE (Clinical Effort Against Secondhand Smoke Exposure). The program includes training and materials to support the establishment of smoke-free home and car rules and smoking cessation, including connecting smoking parents to free cessation services and pre-printed nicotine replacement therapy prescription pads. The study protocol was approved by the Institutional Review Boards of the American Academy of Pediatrics and Massachusetts General Hospital.
At each control and intervention practice, one or more research assistants were stationed at the exit and administered a screening questionnaire to all adults after their child’s visit. If the parent was eligible, the research assistant obtained informed consent. Parents were offered enrollment into the study after the completion of a baseline screening questionnaire. Parents who enrolled received 5 US dollars for completing the survey. Screening continued until 100 parents had been enrolled at each practice. Data collection was conducted after the introduction of the intervention; parents seen in invention practices may have been exposed to various aspects of the intervention, including educational materials such as posters and handouts, practice materials asking about smoking, and/or assistance in cessation from clinicians.
Screening questions assessed parental smoking status (“Have you smoked a cigarette, even a puff, within the past 7 days?”), readiness to quit smoking (“Are you seriously planning to quit smoking within the next 30 days?”), demographic factors (parent’s age, gender, race and ethnicity, and level of education), age of the youngest child at the visit, the reason for the visit (routine, sick, follow-up, or other), and child’s insurance status (private insurance, Medicaid, self-pay, or other).
Parents who enrolled in the study also completed an enrollment survey that asked questions about recent quit attempts (“During the past 3 months, have you stopped smoking for more than one day because you were trying to quit smoking?”) and frequency of smoking (“Do you now smoke cigarettes every day or some days?”). Parents who smoked were categorized as daily or nondaily smokers and an average number of cigarettes smoked daily per 30 days was computed. The enrollment survey also asked whether parents received assistance for cessation (“During your visit today, did a doctor, nurse, or other health care provider discuss medicine to help you quit smoking, for example, nicotine replacement gum, patch or lozenge, or other medicine”) or (“discuss methods and strategies, other than medication, to help you quit smoking?”), and (“During your visit today, did anyone suggest you use a telephone ‘Quitline’ or other program to help you quit smoking?”). Enrolled parents were read statements of rules about smoking in the home. If the response choice was “No one is allowed to smoke anywhere,” the parent was categorized as having a strict rule against smoking in the home.
Role conflict was assessed with the question, “Please tell me how strongly you agree or disagree with the statement: ‘My being a smoker gets in the way of my being a parent.’ (Answer choices were: “Strongly agree, Agree, Disagree, Strongly disagree.”) The concept was adapted from a study  that used five questions to separately assess parent identity and smoker identity. For this study, it was not possible to use all of the questions from the previous study due to the length of the survey.
Anecdotal evidence from survey respondents revealed that parents had different interpretations of the question. Some interpreted it as referring to conflict between smoking and parental duties (also known as roles) while others interpreted it as referring to conflict in one’s perception or self-definition (identity) as a parent. For the purpose of this paper, the term ‘role’ will be used. Qualitative work would have to be undertaken to clarify how respondents understood the question as it relates to their role or their identity.
The primary variable of interest was parent/smoker role conflict. For analysis, responses were dichotomized as “Strongly Agree” or “Agree” versus “Disagree” or “Strongly Disagree”. Using bivariate analysis, we examined the association between role conflict and other parent/children characteristics assessed in the baseline survey. These included the child’s age, insurance, and reason for the visit, and the parent’s age, sex, race, education, smoking behavior (daily vs. nondaily, cigarettes smoked per month, quit attempt within the past 3 months, and intention to quit in the next 30 days), home smoking policy, and report of whether they had received smoking cessation assistance from the child healthcare provider at the visit. To better describe the role conflict variable, variables that were significantly associated with role conflict at the p ≤ 0.10 level were entered into a multivariable logistic regression model to determine what factors were associated with conflict. An analogous strategy was used to determine whether role conflict was independently associated with intention to quit in the next 30 days. Both bivariate and multivariable analyses were conducted using logistic regression models with Generalized Estimating Equations (GEE) techniques to account for physician clustering. Adjusted Odds Ratio (aOR) with 95% Confidence Interval (CI) and p values are reported for all multivariable analyses. A two-tailed p < .05 was considered statistically significant. All analyses were conducted using SAS version 9.3 (The SAS Institute, Inc, Cary NC).