Tobacco smoke pollution is a major cause of disease and death for children in this country. While there has been some progress limiting tobacco smoking pollution (TSP) in public and work places, relatively little attention has focused on improving air quality in homes and private spaces where children receive their greatest exposure to TSP. As a result in the United States each year, children continue to suffer more than 5 million additional episodes of illness leading to nearly 4,000 preventable deaths due to the effects of tobacco smoke pollution (Aligne, 1997; US EPA, 1993; California EPA, 1997; DiFranza, 1996). This proposal represents a developing collaboration between the U.S. Environmental Protection Agency, a large regional health maintenance organization (Health Partners, Minnesota), and an international team of researchers in an innovative effort to change parental smoking behavior in order to reduce children's exposure to TSP. Parental, and especially maternal, smoking in the home is the major source of children's exposure to TSP. All smoking parents should be advised and assisted in quitting. For the majority of smoking parents initially unable or unwilling to quit, efforts should focus on helping them limit their children's exposure to TSP. Promising counseling interventions have been developed to help parents create reduced-smoke and smoke-free environments for their children. Unfortunately, parents' continued smoking commonly results in continued exposure for the child and parents may need additional assistance to create truly smoke-free environments. Since nicotine addiction is often a major force driving continued cigarette use, providing smoking parents an alternative non-polluting source of nicotine (i.e. nicotine gum) for use in the home may help reduce their dependence on cigarettes and their children's TSP exposure. Through a population-based environmental assessment survey of a large health plan's youngest members, we will identify families with infant children exposed to maternal smoking in the home (a marker for higher levels of overall TSP exposure). Smoking mothers will be recruited into a prospective 3 group randomized clinical trial to determine the ability of (1) individualized counseling and (2) individualized counseling plus access to nicotine gum as a substitute for cigarettes in the home to help mothers create smoke-free environments for their children. Specifically, we hypothesize that compared to usual care (advice to quit and written materials promoting a smoke-free environment for children): 1. Providing smoking mothers with individualized counseling focused on TSP reduction will reduce children's exposure to TSP. 2. Providing smoking mothers with individualized counseling focused on TSP reduction plus access to nicotine gum as a substitute for cigarettes in the home will further reduce children's exposure to TSP. 3. Engaging smoking mothers in interventions to reduce children's exposure to TSP will reduce maternal cigarette consumption and increase maternal smoking cessation. In addition, we will explore a secondary set of hypotheses on the relative economic costs and benefits of the study interventions. Specifically, we hypothesize that, if sufficiently effective, the study interventions: (a) will also be a cost-effective (in terms of cost per life year gained) when compared to widely prescribed medical treatments; and (b) will lead to reductions in medical, mortality and morbidity costs that fully or partially offset the costs of the intervention.
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