Half of the children worldwide are estimated to live with adult smokers at home1. As such, children’s exposure to environmental smoke remains a public health problem. The likelihood of this exposure is associated with epidemiological characteristics such as economic difficulties, belonging to social minorities, and residing in urban areas2,3.

Susceptibility to the deleterious effects of secondary and tertiary tobacco smoke exposure is higher in early childhood, due to frequent hand-to-mouth contact with objects, clothes, or carpets contaminated with derivatives of tobacco combustion, as well as immature hepatic metabolism and a higher respiratory rate than adults2,3. This leads to a decrease in lung development associated with an increased risk of respiratory infection, exacerbation of bronchial asthma4,5, lung cancer in adulthood6, and sudden infant death1. Therefore, tobacco exposure in early childhood increases morbidity and mortality7. Furthermore, parental smoking habits are associated with an increased likelihood of future smoking habits in their children8.

Any contact with pediatric healthcare services may provide an opportunity to raise awareness, educate and promote parental smoking cessation to improve the current and future well-being of their children. This study aims to know parental smoking habits and their availability for a brief intervention for smoking cessation in the context of pediatric hospitalization or hospital outpatient consultation.


We conducted a prospective study between January 2020 and October 2021 using a convenience sample of parents/ caregivers of children hospitalized or observed in a pediatric consultation at a level two hospital in the central region of Portugal. Upon obtaining written informed consent, parents were asked to fill in a survey questionnaire (Supplementary file Questionnaires 1 and 2) regarding their age, sex, marital status, education level, personal and partner employment status, smoking habits, exposure to smoking during pregnancy, motivation to quit smoking, age and sex of the child, and motive for observation or hospitalization. Smoking dependence was assessed using a short version of the Fagerström test for nicotine dependence9, which defines the degree of dependence as mild, moderate, or severe, through the question: ‘How long after waking up do you smoke your first cigarette?’ with responses 1st cigarette in the first 30 minutes of the day (severe), 1st cigarette between the first 30 to 60 minutes of the day (moderate), and 1st cigarette after the first 60 minutes of the day (mild).

We interpreted as motivation for smoking cessation the positive and simultaneous answer to two questions: ‘Have you made any attempt to quit smoking in the last year?’ and ‘Do you intend to quit smoking within one month?’.

The model of Prochaska and Di Clemente10 describes five stages of change in smoking cessation: pre-contemplation, contemplation, preparation, action, and maintenance. A positive and simultaneous answer to the aforementioned questions has been used as an indication of a probable phase of preparation for smoking cessation.

All parents/caregivers of children hospitalized or seen in a pediatric consultation were consecutively included, with those whose questionnaires were incompletely answered being excluded.

Statistical analysis

The descriptive analysis of the variables under study consisted of obtaining frequencies and percentages for categorical variables and means with standard deviation for quantitative variables. The association between reason for hospitalization or consultation and the different variables under analysis were assessed using Fisher’s exact test and Wilcoxon’s test. Statistical analysis was conducted using SPSS® Statistics software, version 27.0 for Mac®, and R version 4.2.2.


A total of 133 surveys were included in the study, 39 (29%) from parents/caregivers present during hospitalization and 94 (71%) from those observed during consultations. Most surveys were answered by the maternal figure, either during hospitalization or outpatient consultation (89.7% and 90.4%, respectively). Sociodemographic and smoking characteristics of parents are presented in Table 1.

Table 1

Sociodemographic and smoking characteristics of parents

CharacteristicsHospitalization (N=39)Outpatient consultation (N=94)
Age (years), mean ± SD35.74 ± 8.4939.04 ± 6.88
Marital status
Other (civil union, widowed)0023.422
Education level
Up to 9th Grade25.61038.336
Up to 12th Grade30.81234.032
Higher education43.61727.726
Employment status
Partner employment status
Current smoker
Presence of smoker cohabitant
Age began smoking habits, mean ± SD15.57 ± 2.9917 ± 3.3
Average tobacco consumption (cigarettes/day)9.859.856.926.92
Duration of smoking habit (years), mean ± SD3.59 ± 8.3520 ± 5.63
Short version Fagerström dependence test
1st cigarette in the first 30 minutes of the day14.3123.13
1st cigarette between the first 30 to 60 minutes of the day57.1453.87
1st cigarette after the first 60 minutes of the day28.6223.13
Smoking locations
At home14.3115.42
In the car0015.42
Motivation to quit smoking
Attempts to quit smoking in the previous year85.7638.55
Intention to quit smoking in one month57.1446.26
Positive answer to both questions57.1423.03

Respiratory illness was the most frequent cause of hospitalization (73.1%), while 61.7% of children observed in an outpatient consultation unit had a previous history of respiratory symptoms (Table 2).

Table 2

Children’s personal and clinical characteristics

CharacteristicsHospitalization (N=39)Outpatient consultation (N=94)
Age (years), mean ± SD3.1 ± 4.17 ± 5.1
Reason for hospitalization
Respiratory illness73.119
Neurologic illness7.72
Gastrointestinal illness7.72
Other (ENT, urinary, endocrinological)11.53
Previous wheezing episodes, age (years)26.625
>5 to 10164
Recurrent acute otitis media1716
Recurrent acute tonsilitis13.813


In the study sample, the number of children exposed to tobacco smoke were 8 (20.5%) of inpatients and 45 (47.9%) of outpatients. In total, 39.8% of children were exposed to tobacco smoke at some point in their lives, a figure in line with previous studies11.

Among smoking parents who answered the survey, 35% (n=3 inpatient, and n=4 outpatient) were potentially in the preparation phase for smoking cessation. After identifying this preparation phase, the D-day to stop smoking should be scheduled and pharmacological, behavioral, and emotional support should be offered.

Motivation to quit smoking relates inversely with nicotine dependence12. Most respondents (57.1% in the inpatient and 53.8% in the outpatient clinic) had moderate nicotine dependence, so availability for smoking cessation should be considered an opportunity not to be missed.

Availability and motivation for smoking cessation may be related to child disease and higher frequency of respiratory pathology in pediatric age. Our results support this hypothesis, as a higher percentage of parents were motivated for smoking cessation during hospitalization, probably also due to the greater severity of the underlying clinical condition.

Smoking cessation is the best strategy to obtain health gains in the short-term13 and in a more cost-effective manner14. Clinical Effort Against Secondhand Smoke Exposure (CEASE) has been shown to yield satisfactory results in Pediatrics when aimed to reduce parental smoking prevalence15,16. Approaching parents in this context may lead to greater openness and a unique opportunity to maximize the chances of smoking cessation and, consequently, reduce the rate of children exposed to tobacco smoke.


As limitations of this study, we note that a convenience sample was used. Nonetheless, since we used a consecutive sampling of hospital patients, we believe to have obtained a more reliable approximation to the target population, considering we intend to implement a hospital smoking cessation program directed at parents of children who are hospitalized or evaluated at the outpatient clinic. We also note, as a possible sampling bias, the voluntary nature of the survey, which may have led to more frequent answers from non-smoking parents or from those more aware of the secondary effects of smoking. A social desirability bias may have also been present due to the subject of the survey and the way smoking is frowned upon in Portugal. Finally, during the data collection period we observed a higher rate of admissions due to respiratory illness, which may have influenced the results. The study period included part of the COVID-19 pandemic, so the authors consider that the total number of responses obtained was influenced by this fact due to less mental and emotional availability for the families of patients to collaborate with this study.


Pediatric consultations and pediatric hospitalizations provide excellent opportunities to implement awareness-raising measures and brief smoking cessation interventions aimed at smoking parents.