Abstract
Environmental tobacco smoke exposure is an important health risk for small children. The development, spread and evaluation of a national child health-centre-based counselling method targeting environmental tobacco smoke is described. The work progressed in six steps. In a first step, accomplished in 1994, it was found that child health nurses used a limited repertoire of techniques and were dissatisfied with their discussion on tobacco smoke. In a second step, routine recording of parental smoking status was introduced at all child health centres. In a third step, a counselling method based on Bandura's self-efficacy concept was developed, ‘smoke-free children’. In a fourth step, smoke-free children was tested by 28 nurses in 128 families. At follow-up discussions, all parents said that they now smoked outdoors and that they had cut down on their smoking. In a fifth step, the national dissemination of smoke-free children was studied. A manual and a videotape were launched in 1995, supported by a newsletter and 10 regional conferences in the following years. In January 1997, 36% of the child health nurses in Sweden (three counties excluded) stated that they used the method. Training of county instructors did not seem to have improved dissemination. In a sixth step, routinely collected information on parental smoking in Stockholm county on infants born 1995–1997 was used to study the effect. Little change in smoking rates between two consecutive years was found before the introduction of smoke-free children. Yet, after training of the child health nurses, the annual decrease was 1.7% in a pilot area and later, in remaining parts of the county, 2.7%. Thus, answers to two crucial questions were given: first, that the method seemed to affect parental behaviour; and secondly, that the training of county instructors might not have affected the dissemination of smoke-free children.
INTRODUCTION
Environmental tobacco smoke exposure is an important health risk, especially for small children. Children of smoking parents are more prone to respiratory infections, ear infections, asthma and allergies (Couriel, 1994) and the risk of sudden infant death is increased (Gilbert, 1994). Environmental tobacco smoke exposure is a preventable problem. If adults, especially parents, limit their smoking to areas that children do not frequent, children will be protected from tobacco smoke.
In Sweden, a quarter of all children is growing up in households with at least one daily smoking parent (Lund et al., 1998). In 43% of these households, the parents state that they regularly expose their children to tobacco smoke. In Norway, smoking in the presence of children occurs in 70% of smoking households with infants (Eriksen and Bruusgaard, 1995). Clearly, there is ample scope for improvement.
A suitable setting in Sweden for preventive efforts in this field are the child health centres. During the first year of a child's life, 99% of all parents visit a child health nurse on 15–20 occasions and a child health physician three times. The nurse is supposed to discuss smoking habits with the parents. Yet, these discussions have obviously not led to a smokeless environment for the children.
The aim of this study is to describe the development, spread and evaluation of a child health-centre-based counselling method targeting environmental tobacco smoke, which was carried out in Sweden from 1994 to 1999.
Setting
The first steps were undertaken in two pilot areas: (i) the south-western health district in Stockholm county with a total population of 0.3 million, ~3500 newborns each year and 60 nurses working at 24 child health centres; and (ii) two towns in northern Sweden with a total population of 100 000. The population in the south-western health district is socially disadvantaged compared with the county as a whole.
The dissemination of the smoke-free children method was studied in Sweden, with 8 million inhabitants in total, ~100 000 newborns each year and 2732 child health centres. Sweden is divided into 25 counties, each with ~0.3 million total population and ~100 child health nurses. Each county has an elected board of health that is responsible for both curative and preventive medical services in the county. All counties have a chief medical officer appointed to supervise child health centres and co-ordinate child health nurses. The child health centres are either integrated into the Primary Care Centres, which are managed by nurses and general practitioners (75% of all child health centres) or, mainly in the cities, separated into special units.
The process was initiated by the board of health in the south-western health district in Stockholm county, one of the pilot areas, and supported by the Swedish National Institute of Public Health and the Swedish Cancer Society, both financially and with marketing efforts.
METHODS
The work progressed in six steps.
Step 1: establishment of readiness for change in the child health organization—survey of child health nurses' present practices, 1994
The introduction of an improved counselling method requires a readiness for change among staff, i.e. the child health nurses. Moreover, the assumption that the present counselling routines were ineffective had to be confirmed. Therefore, in a first step, the child health nurses' current smoking discussion practices and their attitudes to these practices were charted. Fifteen nurses in one of the pilot areas were interviewed (Arborelius, 1996). Most nurses said that they were anxious not to blame parents; therefore, half of them had chosen a passive stance. Some nurses were more active and offered advice to the parents, either by providing information or by encouraging parents to change their behaviour. A few nurses appeared to reproach smoking parents. None of the nurses reported satisfaction with their current method. Such a limited repertoire of techniques has been demonstrated to be ineffective in other studies of medical professionals' lifestyle discussions and has led to dissatisfaction with their efforts (Arborelius and Bremberg, 1994). Thus, the prospects for introduction of improved methods seemed to be promising since the methods used were probably ineffective and not well liked.
Step 2: establishment of routines for surveillance of progress—introduction of routine recording of smoking status at child health centres, 1994–1995
The ultimate aim was to decrease Swedish children's exposure to environmental tobacco. Progress in this direction had to be assessed in order to adjust the intervention. Therefore, a population-based surveillance system had to be set up. That had to be done before the introduction of new interventions.
At all child health centres, details on important health-related factors, e.g. breast feeding, were already collected from all parents. This information was noted in the records and, in some cases, also compiled into county and national statistics. Since almost all infants visit a child health centre, information from these centres reflects the situation in the total population.
Accordingly, routines for recording smoking status were introduced in Stockholm county in 1994 and gradually afterwards in the remaining parts of Sweden. Ideally, details of exposure to tobacco smoke would be recorded. Such information, however, is difficult to validate. Moreover, we found no way of reliably quantifying such information in a national routine recording system. Therefore, the smoking status of the infant's parents was noted instead. Since 1994, this information has been recorded at infant age 0–4 weeks, and since 1995 it has also been recorded at infant age 8 months.
There was an additional motive for this recording. The interviews indicated that nurses often had mixed feelings towards smoking discussions. Routine recording of smoking status might help the nurse bring up the issue in a non-obtrusive way.
Step 3: development of a new counselling method—‘smoke-free children’, 1995
A crucial step was to develop a counselling method that was expected to be both effective and apt for the Swedish child health centres. In 1995, we were only aware of four controlled studies of methods that aimed at reducing tobacco smoke exposure of infants, by searching on Medline [key words: infant and (smoking cessation or tobacco smoke pollution)] or otherwise. In a first study, physicians telephoned mothers to report urine cotinine levels of their infants and to explain its meaning (Chilmonczyk et al., 1992). Cotinine is a break-down product of nicotine. No effect was found. In a second study, one well-child visit was prolonged with a brief session on smoking (Eriksen et al., 1996). Again, no effect was found. In a third study, paediatricians gave advice to mothers at well-care visits (Severson et al., 1997). The intervention reduced smoking and relapse at 6-month follow-up, but not 12 months later. In these studies, 103, 2901 and 443 and smoking families, respectively, were enrolled. Thus, the lack of effects was not due to low number of observations. Yet, in a fourth study by Greenberg et al. of a nurse-based intervention, significant differences were demonstrated between experiment and control groups at a 12-month follow-up, both with regard to infant exposure to tobacco smoke and parental smoking (Greenberg et al., 1994).
Later, after 1995, three relevant studies were published. Groner et al. reported no effect of a smoking cessation intervention in a hospital setting where mothers were targeted (Groner et al., 2000). Yet, Wahlgren et al. found that behavioural counselling to smoking mothers was effective in reducing children's exposure to smoking (Wahlgren et al., 1997). Their findings were later confirmed in an additional study where children's tobacco exposure was assessed with the biological marker cotinine (Hovell et al., 2000). The behavioural counselling methods used by Wahlgren, Hovell et al. and Greenberg et al. were similar.
Thus, in 1995, the most promising approach seemed to be Greenberg et al.'s counselling method. Greenberg et al. build their method on Bandura's self-efficacy concept, i.e. an individual's beliefs in one's capabilities to organize and execute the courses of action required to produce the given goal (Bandura, 1997). A large number of studies indicate that if self-efficacy concerning a specific type of behaviour is enhanced, then the possibility of behavioural change is increased (Conner et al., 1995; Bandura, 1997). It has been demonstrated previously that parental self-efficacy for the reduction of tobacco smoke exposure might be enhanced (Strecher et al., 1993). Consequently, a counselling method designed for Swedish child health centres was developed, based on Bandura's self-efficacy concept. It was named ‘smoke-free children’. It was intended to enhance parental self-efficacy concerning the ability to arrange a tobacco smoke-free environment for the child, which would in turn be expected to result in less tobacco smoke exposure for the child and probably also in less parental smoking. The parents' own smoking per se was, however, not focused. Instead, discussions dealt with tobacco smoke exposure of the child from any source. Additional knowledge of the health damaging effects of tobacco smoke was not expected to affect behaviour (Conner et al., 1995). Thus, no information about the effects of tobacco smoke on the child was given unless the parent asked for it.
The discussions were outlined to take place within the framework of ordinary visits at child health centres on two to three occasions, as follows.
Initial discussion
Asking what the parents themselves know about passive smoking; and
suggesting that the parents should chart how much tobacco smoke there is in the child's environment.
First follow-up
Using the parents' own survey as a starting point, asking what the parents think of their current smoking habits, and inviting their suggestions for possible changes.
Second follow-up
Supporting any attempts on the part of the parents to change their smoking habits, and discussing any problems which have arisen.
According to published studies, many women who stop smoking during pregnancy resume this habit during the first year of the life of their child (Cnattingius et al., 1992; Secker-Walker et al., 1995). Therefore, all mothers were asked about their smoking by the start of pregnancy. This was done in connection with the routine recording of smoking habits by age 0–4 weeks of the child. Mothers who said that they had quit smoking during pregnancy were offered support by the child health nurse.
Step 4: pilot test of smoke-free children, 1995–1996
The practicality and the outcome of the counselling method were assessed in a pilot test. Twenty-eight child health nurses received instruction and training in smoke-free children over two half-day sessions, which included video recordings and role plays.
Step 5: dissemination of smoke-free children, including training of county instructors, 1995–1999
Since the counselling method seemed to work in the pilot test, the sponsors thought that smoke-free children was ready for national dissemination in June 1995. The sponsor organizations did not deem a formal evaluation necessary. Thus, any analysis of effectiveness had to be carried out later, when dissemination was already underway.
Therefore, at this point in time, problems connected with national implementation were focused on instead of the method's effectiveness. Educational methods often fail since they are not implemented as planned (Basch et al., 1985). This problem had to be counteracted during the dissemination phase that was now due. First, a coordinated plan for marketing was laid out. A detailed manual for child health nurses and a pamphlet for the parents was printed. A videotape for nurses that demonstrated the method was also produced. Samples of this material were sent to the coordinating child health nurse in each county for ordering. A newsletter was also sent to the coordinating child health nurse for distribution to each nurse. In 1996 and 1997, three and four additional newsletters, respectively, were distributed in the same way. From the latter part of 1995 to 1997, 10 regional seminars for child health nurses were also arranged.
Secondly, a more costly, yet potentially more effective method for dissemination was also employed: personal instruction of each child health nurse, followed by supervision. The value of the addition of personal instruction was studied in a controlled trial. The 25 counties in Sweden were divided into two groups: one control group of counties that were only offered the general marketing of the method, and one experimental group of counties where the child health nurses received personal instruction on one occasion from one or two county instructors. The experimental group consisted of 11 random counties; four rural and seven dominated by towns. The control group was formed from an equal number of comparable counties. The three counties with cities, including Stockholm county, were excluded. In the experimental group, county instructors were trained in 1996. After their own training they were expected to train all child health nurses in their own county. The use of smoke-free children among child health nurses was studied in the whole of Sweden in January 1997. Later in 1997, the remaining control counties also received county instructors.
Step 6: study of the effects on parental smoking using routinely collected data, 1994–1999
Due to consideration of the sponsors, the counselling method had to be disseminated before the effectiveness of the methods to be used had been determined. The routine surveillance system that was set up in 1995, however, permitted comparisons between the use of the counselling method and the rates of infant family smoking in different districts. Such comparisons might clarify the effect of the counselling method.
The surveillance system started to be used for children born in 1994 in Stockholm county. The counselling method was first introduced in the main pilot area, the south-western health district, where the nurses were trained in smoke-free children in 1996. In the remaining parts of the county, the training of nurses started 1 year later, i.e. in 1997. Thus, comparisons might be made between the rate of smoking before and after the introduction of smoke-free children, both in the pilot area and in the remaining parts of the county.
Smoking data was available for infants born in 1995, 1996 and 1997 for an average of 9.9, 9.4 and 9.3% of the total population, respectively (see Table 2). Routinely collected information on the percentage of pregnant women who smoked at registration at antenatal clinics during the year preceding the birth of their infants was also used (Swedish National Board of Health, 1999).
RESULTS
Steps 1–4
The nurses' views on smoke-free children, and their reported use of the counselling method, were assessed by interviews 3–4 months after the first course was completed, and again 6 months later. All 28 nurses reported on both occasions that they were satisfied with smoke-free children and that they used it with smoking parents, and nearly all said that it greatly facilitated their discussions of parental smoking habits. They found it advantageous to start with the parents' points of view and to concentrate on the child's exposure to tobacco smoke instead of the parents' smoking.
The outcome of the nurses' counselling was assessed for a 6-month period. In their routine work, the nurses completed a form for each family for when they had brought up discussions on smoking. In this form, the outcome of the discussions was described according to the scheme outlined in step 3.
Twenty-six nurses (26/28) reported the use of smoke-free children in 138 families over the 6-month period. In 110 families, one or both parents smoked, and in the remaining 28 families, the children were subjected to passive smoking from other persons. In total, 275 discussions were documented on the forms. An initial discussion was recorded in all 138 families, a first follow-up discussion in 86/138, a second follow-up in 40/138 and a third follow-up in 40/138. The main reason for lack of follow-up discussions was a late start of the family in the study within the 6-month assessment period. In addition, in some families, nurses did not deem it appropriate to bring up the smoking issue on the second and third follow-up.
The environmental tobacco smoke issue was often brought up with the families on first contact with the child health nurse. Already at the time of this visit, many parents suggested themselves that they should arrange a smoking-free environment for the child. Half of the families were recommended to chart their smoking habits to see how much smoke their child was exposed to.
At the first follow-up discussion, all parents reported that they now smoked outdoors. They all agreed to arrange a smoke-free environment for the child. The goals that parents set for themselves were mainly to continue to smoke outdoors or to smoke elsewhere, but not around the child.
At the second follow-up discussion, only a few parents reported continued exposure of their child to tobacco smoke. The main cause was relatives who smoked; the parents had not managed to persuade them to change their habit. At this follow-up meeting, all parents reported that they had cut down on their smoking. A few (7/40) had stopped smoking entirely or planned to do so.
During the 6-month study period, two-thirds of the nurses in the pilot groups addressed mothers who stopped smoking during pregnancy. Discussions in 28 families were documented. In 16 cases, the nurse followed up the first conversation with further discussions at the child health centre. At the last documented discussion, when the infant was 6 months of age, the majority (25/28) of mothers were still tobacco-free. One mother had a relapse but had managed to quit again. The three women who smoked were all married to smokers.
Thus, the pilot test indicated that the child health nurses had introduced the counselling method into their daily routines. They brought up the environmental tobacco issue with most parents on their first contact with a family. The counselling method, including charting of smoking habits, was often used and most parents reported adjustment of their habits.
Step 5
In 1996, 20 instructors from the 11 selected experimental counties had participated in training sessions. The training sessions covered 2 days, mainly using role-playing exercises and video recordings. The aim of the training was to give the instructors intimate knowledge of smoke-free children and to train child health nurses in the method.
By August 1996 the county instructors had trained almost all child health nurses in two counties (‘ample training’), had trained approximately half of the nurses in three counties (‘some training’), and had only finished planning the training in the remaining seven counties (‘no training’).
In January 1997, a questionnaire was sent from the National Board of Health to all child health nurses in Sweden. We were allowed to include four questions on smoke-free children. The answers from the selected counties, i.e. from all of Sweden excluding the three city counties, were analysed. Questionnaires had been sent to 2228 nurses in these counties. Replies were received from 74%. Only a few questionnaires that were received did not include answers to these four questions.
The results are presented in Table 1. The answers to all four questions indicated no greater use of the method in the counties supported by instructors. Evidently, most nurses had become acquainted with the method without the help of county instructors. In the group of counties with instructors trained in 1996, the answers varied depending on the extent of nurses' training in the county. The percentage of ‘yes’ answers to the question ‘do you use the method for providing children with a smoke-free environment’ in the counties with ‘ample’, ‘some’ and ‘no training’ was 85, 30 and 26%, respectively.
In March 1999, a questionnaire was sent to all chief medical officers of child health in Sweden. A question about the use of smoke-free children was included. The reply rate was 76%, and all respondents stated that the method was used in their county. Thus, during the period 1996–1999 the counselling methods seemed to have been disseminated to major parts of Swedish child health centres. The addition of county instructors did not seem to have conveyed any obvious advantage.
Step 6
In the south-western health district, nurses were trained in the counselling method in 1996. Prior to that year there had been no decrease in mother's smoking between two consecutive years studied (see Table 2). Since 1996, when smoke-free children started to be used, the annual average decrease in parental smoking for all subgroups was 1.6%. The fraction of smokers was significantly lower in the years covered by the intervention compared with the preceding years (p < 0.001 to p < 0.008; χ2 test).
In the remaining parts of Stockholm county, where smoking was less common than in the pilot area, nurses were trained in 1997. Before that year no significant decrease in smoking was detected in parents of 0- to 4-week-old infants. In parents of infants up to 8 months old, smoking decreased by 0.9% between the 2 years studied. This decrease was statistically significant both in mothers and fathers (p = 0.009 and 0.005, respectively; χ2 test). In 1997, when the nurses started to use smoke-free children, the average annual decrease for all subgroups was 2.7%. The fraction of smokers was significantly lower compared with the years preceding the intervention (p < 0.0001).
The comparisons indicate that the introduction of smoke-free children was accompanied by decreasing rates of parental smoking.
DISCUSSION
To achieve the final goal outcome, i.e. decreased exposure of children to environmental tobacco, two aspects were understood as being especially problematic: the effect of the counselling method and its national implementation. Since our limited research resources had to be used for both purposes we could not use the most effective, but also most costly design, the controlled randomized trial. Moreover, the sponsors of the intervention were not ready to postpone the dissemination of smoke-free children until after the analysis of a randomized, controlled trial. If the method is already used routinely, it is hard to carry out such a study. Accordingly, other methods had to be used to establish these parts of the chain of events.
Effect of smoke-free children
The effect of smoke-free children was ascertained in three ways. First, the method was based on the self-efficacy approach. This has been proved to be successful both for behaviour change in general (Conner et al., 1995; Bandura, 1997) and specifically for change of parental smoking habits (Strecher et al., 1993). Secondly, the process was studied in the pilot group where nurses used smoke-free children at child health centres. At the first follow-up discussion, all parents recorded said that they now smoked outdoors, and at the second follow-up discussion, all stated that they had cut down on their smoking. This information suggests that smoke-free children might have caused the planned effects. However, such a conclusion is uncertain since there are several limitations in the process study. There was no control group and not all parents participated in all three discussions. The parents who dropped out might not have altered their smoking habits. Moreover, information was based on reporting of parents through nurses. Both parties might prefer to report a more favourable situation than really occurred.
The third method used to ascertain the effects of smoke-free children was to study the development of parental smoking after the introduction of the method. To do that, the routinely collected information at all child health centres in Stockholm county was used. Only small changes in smoking rates between two consecutive years were found before the introduction of smoke-free children, none in parents of 0- to 4-week-old infants, and a small annual decrease of 0.9% in parents of infants up to 8 months of age. However, after training child health nurses the annual decrease was 1.7% in the pilot area and later, when the method was introduced in the county as a whole, 2.7% in the remaining parts.
These changes could not be explained by the decreasing rates of smokers in early pregnancy in the study areas (Table 2). However, it can not be excluded that smoking decreased faster in the non-pregnant female population than in the pregnant population. If so, the decreases recorded after the introduction of smoke-free children might be ascribed to this trend. Unfortunately, data on smoking in all women with respect to childbearing is only available at a national level (Swedish National Institute of Public Health, 1999). The sample size in these studies (2500 women annually) is smaller and the drop-out rates greater (20%) than in the county recording system for pregnant women. According to the national statistics, the smoking rate in women aged 18–50 years decreased from 28% in 1994 to 25% in 1997. These smoking rates are 2.5 times higher than the rates recorded in the women in this study. The difference is due to both a lower rate of smoking in Stockholm county compared with other parts of Sweden, and to lower rates of smoking in women with small children compared with other women. Thus, the percentage decrease of smoking cannot merely be compared. The annual decrease in smoking, expressed as a fraction of the original percentages of smokers, is a better measure. In the national sample of all women aged 18–50 years, the average annual decrease in smoking calculated in this way was 4% (1/28). After the introduction of smoke-free children in pilot areas, the decrease calculated in this way in mothers of infants aged 0–4 weeks was 19% (2.3/12.3). The reduction in this group of women was 24% (2.4/9.9) after introduction of the method in the remaining parts of Stockholm county. Accordingly, the decreases recorded after the introduction of smoke-free children could not be ascribed to a general trend in the population.
The higher smoking rate in the pilot area and the smaller changes after introduction of the intervention might be due to the socially less advantaged conditions of the population living in this area.
The routinely collected data thus indicate that the introduction of smoke-free children decreased parental smoking rates. However, these data are also based on reports from parents to child health nurses. Accordingly, smoking might be unreported because it is more socially desirable. If so, maternal smoking might be expected to have decreased more than paternal smoking since it is usually mothers who visit child health centres and report to the nurses. Yet, the annual decrease of smoking during the intervention years was somewhat larger for fathers than for mothers. Thus, it is not likely that the effect detected is due to variable rates of reporting.
These three pieces of evidence, the theoretical base, the pilot test and the surveillance data, indicate that the method affected parental smoking behaviour. The quality of evidence is, however, less than what might have been achieved with a randomized controlled trial (RCT). Yet, there are also advantages with the surveillance study method. An RCT is usually carried out under circumstances that are not representative of routine use, since staff are usually better trained and motivated. Therefore an RCT might exaggerate the effects of an intervention. The surveillance method used in this study, however, reflects routine use of the method.
Support of dissemination of the method by county instructors
There was no higher use of smoke-free children in counties provided with county instructors. It is true that by the time of enquiry, not all nurses had probably been trained by the county instructors. It is also true that the fraction of nurses reporting use of the method was higher in counties with ‘ample’ training of nurses. Yet, in the group of counties with trained instructors but where no instruction was given to nurses, the reported use of smoke-free children was less than the average of the total number of nurses studied. Thus, the greater use of the method in the ‘amply’ trained counties is possibly only the result of a greater prior interest in the tobacco issue in these areas.
The questions presented to nurses did not analyse the details of their use of smoke-free children. Thus, it can not be excluded that nurses in counties with instructors followed the manual more closely. However, it is reasonable to assume that there is some relation between careful users of the method and all users. Moreover, when the method was introduced in Stockholm county outside the pilot areas, nurses were given only limited instructor support, in contrast to the test in the pilot areas, which was well supported by instructors. Yet, the decrease in parental smoking was more pronounced in these parts of the county other than that in the pilot area.
In summary, the comparatively costly training by county instructors might not have affected the effective use of smoke-free children. The marketing of printed manuals, pamphlets for the parents, newsletters, videotapes and regional conferences was probably sufficient for the effective dissemination of the method. The manual and the videotape might have been most important for the nurses' trusty use of the method.
Child health nurses' attitudes to smoke-free children in counties with and without county instructors
| Question | Number of nurses answering ‘yes’. The only other alternative was ‘no’ | χ2 tests: probability for demonstrated distribution of ‘yes’ answers in groups A and B | |
|---|---|---|---|
| Nurses in counties with instructors (n = 905) | Nurses in counties without instructors (n = 744) | ||
| Acquaintance with smoke-free children: answer ‘yes’ | 539 (60%) | 473 (64%) | 0.10 |
| Smoke-free children used to provide children with a smoke-free environment | 334 (37%) | 265 (36%) | 0.59 |
| Smoke-free children perceived to facilitate tobacco-prevention work at child health centres | 252 (28%) | 191 (26%) | 0.32 |
| Smoke-free children used to support mothers who stopped smoking during pregnancy | 314 (35%) | 260 (35%) | 0.92 |
| Question | Number of nurses answering ‘yes’. The only other alternative was ‘no’ | χ2 tests: probability for demonstrated distribution of ‘yes’ answers in groups A and B | |
|---|---|---|---|
| Nurses in counties with instructors (n = 905) | Nurses in counties without instructors (n = 744) | ||
| Acquaintance with smoke-free children: answer ‘yes’ | 539 (60%) | 473 (64%) | 0.10 |
| Smoke-free children used to provide children with a smoke-free environment | 334 (37%) | 265 (36%) | 0.59 |
| Smoke-free children perceived to facilitate tobacco-prevention work at child health centres | 252 (28%) | 191 (26%) | 0.32 |
| Smoke-free children used to support mothers who stopped smoking during pregnancy | 314 (35%) | 260 (35%) | 0.92 |
Percentage of smoking parents of infants born in 1994–1997 in the south-western health district (pilot area) and in the entire Stockholm county, by age of infant and statistical tests for differences between outcome in the years preceding and in the years covered by the intervention (χ2)
| Year infants born | Pilot area in Stockholm county | Stockholm county in total excluding the pilot area | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Infant (n) | Infant 0–4 weeks: smokers (%) | Infant 8 months: smokers (%) | No information (average %) | Early pregnancy (%) | Infants (n) | Infant 0–4 weeks: smokers (%) | Infant 8 months: smokers (%) | No information (average %) | |||||
| mother | father | mother | father | mother and father | mother | father | mother | father | mother and father | ||||
| The percentage of smokers at early pregnancy during the year preceding the birth of the child is also given. Years covered by the intervention are marked with italics. | |||||||||||||
| 1994 | 3821 | 12.1 | 22.4 | – | – | – | 19 | 24 202 | 9.8 | 16.9 | – | – | – |
| 1995 | 3554 | 12.3 | 22.5 | 14.6 | 23.0 | 9.7 | 16 | 22 440 | 9.6 | 17.0 | 12.2 | 17.0 | 10.1 |
| 1996 | 3371 | 10.0 | 20.9 | 12.0 | 19.9 | 9.3 | 14 | 21 324 | 9.9 | 17.2 | 11.4 | 16.0 | 9.2 |
| 1997 | 3210 | 9.1 | 19.3 | 11.9 | 19.3 | 8.4 | 14 | 20553 | 7.5 | 14.4 | 9.4 | 14.2 | 8.5 |
| p value (χ2) | 0.0001 | 0.0008 | 0.0001 | 0.0001 | 0.0001 | 0.0001 | 0.0001 | 0.0001 | |||||
| Year infants born | Pilot area in Stockholm county | Stockholm county in total excluding the pilot area | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Infant (n) | Infant 0–4 weeks: smokers (%) | Infant 8 months: smokers (%) | No information (average %) | Early pregnancy (%) | Infants (n) | Infant 0–4 weeks: smokers (%) | Infant 8 months: smokers (%) | No information (average %) | |||||
| mother | father | mother | father | mother and father | mother | father | mother | father | mother and father | ||||
| The percentage of smokers at early pregnancy during the year preceding the birth of the child is also given. Years covered by the intervention are marked with italics. | |||||||||||||
| 1994 | 3821 | 12.1 | 22.4 | – | – | – | 19 | 24 202 | 9.8 | 16.9 | – | – | – |
| 1995 | 3554 | 12.3 | 22.5 | 14.6 | 23.0 | 9.7 | 16 | 22 440 | 9.6 | 17.0 | 12.2 | 17.0 | 10.1 |
| 1996 | 3371 | 10.0 | 20.9 | 12.0 | 19.9 | 9.3 | 14 | 21 324 | 9.9 | 17.2 | 11.4 | 16.0 | 9.2 |
| 1997 | 3210 | 9.1 | 19.3 | 11.9 | 19.3 | 8.4 | 14 | 20553 | 7.5 | 14.4 | 9.4 | 14.2 | 8.5 |
| p value (χ2) | 0.0001 | 0.0008 | 0.0001 | 0.0001 | 0.0001 | 0.0001 | 0.0001 | 0.0001 | |||||
