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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Smoking in the Household.

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Strategy. Clinic-based Counseling + Education Materials (Household)

Approach. Provide in-person counseling + educational materials during visits with a health care provider to reduce child exposure to secondhand smoke in the home

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Overview. Research indicates that counseling parents/caregivers during health visits with their child can be effective in reducing child exposure to secondhand smoke in the home and reducing or eliminating smoking by parents/caregivers. Behavioral counseling and motivational interviewing practices, such as the "Ask Advice Refer (AAR) best practice guidelines endorsed by professional pediatric organizations, can be combined with educational materials. These materials include pamphlets or self-help manuals that promote smoking cessation, smoking bans, and healthy lifestyles, which can reinforce the importance of smoke-free households

Evidence. Moderate Evidence. Strategies with this rating are likely to work...

Access the peer-reviewed evidence through the MCH Digital Library or related evidence source.

Potential Data Sources. Data to support this strategy can be accessed through:

  • Healthcare provider feedback and training data
  • Patient recall and understanding (assessed at follow-up)
  • Integration of secondhand smoke counseling into clinic protocols and Electronic Health Records (EHRs)

Outcome Components. This strategy has shown to have impact on the following outcomes (Read more about these categories):

  • Health and Health Behaviors/Behavior Change. This strategy improves individuals' physical and mental health and their adoption of healthy behaviors (e.g., healthy eating, physical activity).
  • Timeliness of Care. This strategy promotes delivery of healthcare services in a timely manner to optimize benefits and prevent complications.
  • Environmental Health. This strategy improves the impact of physical, chemical, and biological factors in the environment on health.

Detailed Outcomes. For specific outcomes related to each study supporting this strategy, access the peer-reviewed evidence and read the Intervention Results for each study.

Intervention Type. Counseling (Read more about intervention types and levels as defined by the Public Health Intervention Wheel).

Intervention Level. Individual/Family-Focused

Examples from the Field. Access descriptions of ESMs that use this strategy or aligned components.

Sample ESMs. Here are sample ESMs to use as models for your own measures using the RBA framework (see The Role of Title V in Adapting Strategies).

Quadrant 1:
Measuring Quantity of Effort (“What/how much did we do?”)

  • Number of healthcare providers trained in the "Ask Advise Refer" (AAR) guidelines for addressing child tobacco smoke exposure. (Assesses capacity building for effective intervention)
  • Number of Electronic Health Record (EHR) systems updated with AAR prompts. (Measures implementation of system-level support to facilitate consistent screening)

Quadrant 2:
Measuring Quality of Effort (“How well did we do it?”)

  • Percent of child health visits that include AAR-based counseling on secondhand smoke exposure. (Measures adherence to best practices in routine care)
  • Percent of educational materials available in languages reflecting the patient population. (Evaluates responsiveness of resources)

Quadrant 3:
Measuring Quantity of Effect (“Is anyone better off?”)

  • Number of follow-up phone counseling sessions conducted with families. (Shows ongoing support to reinforce intervention)
  • Number of quality improvement cycles conducted to refine counseling and education process. (Measures commitment to ongoing program enhancement)
  • Number of children showing improved respiratory health outcomes correlated with reduced smoke exposure. (Quantifies tangible health benefits for children)
  • Number of healthcare practices adopting comprehensive secondhand smoke exposure prevention protocols. (Measures broader institutional change)

Quadrant 4:
Measuring Quality of Effect (“How are they better off?”)

  • Percent of counseling and education resources allocated to populations affected by secondhand smoke exposure. (Measures resource distribution)
  • Percent of successful follow-up phone counseling sessions conducted with families. (Shows ongoing support to reinforce intervention)
  • Percent reduction in reported secondhand smoke exposure among children of counseled families. (Measures direct program effectiveness on child health)
  • Percent of parents/caregivers reporting quit attempts for successful smoking cessation. (Assesses impact on smoking behavior of caregivers)

Note. When looking at your ESMs, SPMs, or other strategies:

  1. Move from measuring quantity to quality.
  2. Move from measuring effort to effect.
  3. Quadrant 1 strategies should be used sparingly, when no other data exists.
  4. The most effective measurement combines strategies in all levels, with most in Quadrants 2 and 4.

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.

References

1 Lepore, S.J., Collins, B.N., & Egleston, B.L. (2025). Babies Living Safe and Free (BLiSS) intervention reduces children's tobacco smoking exposure directly and indirectly by improving maternal smokers' urge management skills and exposure protection behaviors. International Journal of Environmental Research and Public Health, 22(2), 254.

2 Collins BN, Lepore SJ, Winickoff JP, Nair US, Moughan B, Bryant-Stephens T, Davey A, Taylor D, Fleece D, Godfrey M. (2018). An Office-Initiated Multilevel Intervention for Tobacco Smoke Exposure: A Randomized Trial. Pediatrics. 2018 Jan;141(Suppl 1):S75-S86. doi: 10.1542/peds.2017-1026K.

3 Lepore SJ, Collins BN, Coffman DL, Winickoff JP, Nair US, Moughan B, Bryant-Stephens T, Taylor D, Fleece D, Godfrey M. (2018). Kids Safe and Smokefree (KiSS) Multilevel Intervention to Reduce Child Tobacco Smoke Exposure: Long-Term Results of a Randomized Controlled Trial. International Journal of Environmental Research and Public Health. 2018 Jun 12;15(6). pii: E1239. doi: 10.3390/ijerph15061239.

4 Chellini E, Gorini G, Carreras G, Da noi non si fuma Study Group. The "Don't smoke in our home" randomized controlled trial to protect children from second-hand smoke exposure at home. Tumori Journal 2013;99(1):23–9.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.