Traditional methods aimed at the reduction of secondhand smoke (SHS) exposure often employ modalities that are difficult to adopt and sustain. For those limited caretakers who may be able to abstain from smoking, there is adequate proof in the literature that smoke exposures continue to occur among children with asthma from other household members or visitors who are smoking in the home setting. What is not known are effective ways to reduce SHS exposure in low-income households of children with asthma? The primary objective of the project, which is aligned with the NIEHS mission of exploring the role of the environment in health outcomes, is to determine the effectiveness of financial incentives in reducing SHS exposure in the homes of preschool children with uncontrolled asthma. This grant application applies a contingency management schema, using concepts from behavioral economics and psychology, to modify the smoking behaviors of caregivers. This could occur directly by altering smoking behavior of the caretaker and/or indirectly through their ability to regulate cigarette smoking in the home by household members and visitors. The rationale for the proposed research is that individuals are more likely to alter their behavior if properly incentivized. Maternal caretakers, who ideally act in an altruistic manner toward their children, will be motivated by the incentives to reduce indoor SHS exposures generated by themselves or by others in the home setting. Modifying behaviors through modest financial incentives may also have the potential to be a highly cost-effective modality to address the rising healthcare costs among SHS-associated pediatric asthma cases. This goal will be achieved by pursuit of the following aims: 1) Qualitative assessment of barriers and the characteristics of incentive plans that could enhance the adoption of home smoking bans and 2) Quantitative determination of the effectiveness of financial incentives in reducing home SHS exposure and asthma-related health outcomes. Focus group discussions, consisting of caregivers of preschool asthmatic children, will be used in the first aim to identify the barries and possible means by which to overcome those obstacles in the enforcement of a home smoking ban - the findings of which will inform the design of future studies. A two-arm randomized-control trial will be employed in the second aim over a 6-month time interval. Both study groups will receive encouragement to implement a home smoking ban plus an offer of standard smoking cessation treatment for the primary caregiver. The experimental group will receive in addition the opportunity to earn 6 monthly financial incentives based on reduction in SHS exposures in the target asthmatic preschool child as verified by salivary cotinine levels. The knowledge derived from the pilot study will be used to gauge feasibility and further inform the design of future research using financial incentives for SHS reduction. Thus, the study opens a new avenue for use of contingency management in the service of environmental asthma research.

Public Health Relevance

Environmental determinants may account for US$2-4 billion in asthma healthcare expenditures every year in the United States. Secondhand smoke exposure is one of the most common and potentially modifiable environmental triggers for asthma. Financial incentivization may serve as an effective modality to enforce a smoke-free home environment with potential down-stream benefits on improved asthma control and subsequent reduced healthcare utilization.

National Institute of Health (NIH)
National Institute of Environmental Health Sciences (NIEHS)
Mentored Patient-Oriented Research Career Development Award (K23)
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Special Emphasis Panel (ZES1)
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Finn, Symma
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Johns Hopkins University
Schools of Medicine
United States
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Tower, Craig; Butz, Arlene; Lewis-Land, Cassia et al. (2018) Exploring the barriers and incentive architecture for modifying smoke exposures among asthmatics. J Asthma :1-11
Jassal, Mandeep S; Butz, Arlene (2018) The case for exploring the usage of employee wellness programs for pediatric asthma control. J Asthma :1-3