Promoting smoke-free homes through biomarker feedback documenting child exposure to tobacco toxins: Protocol for a randomized clinical trial

Janet Leigh Thomas, Meredith Schreier, Xianghua Luo, Sue Lowry, Deborah Hennrikus, Lawrence An, David W. Wetter, Jasjit S. Ahluwalia

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Background: Exposure to secondhand smoke (SHS) early in life increases the risk of sudden infant death syndrome (SIDS), asthma, and respiratory illnesses. Since children’s primary exposure to SHS occurs in the home, these most vulnerable members of our society are not fully protected by recent increases in the adoption of smoking bans in public spaces. Although exposure to SHS is a quickly reversible cause of excess morbidity, few low-income homes strictly enforce smoking restrictions. Objective: This study aims to test a novel approach to motivate the adoption of home smoking restrictions and to eliminate child SHS exposure by providing parents with objective data documenting home SHS exposure and “biomarker feedback” of child ingestion of tobacco toxins, that is, objective, laboratory-based results of assays performed on child urine, documenting levels of nicotine; cotinine; and NNAL (4-[methylnitrosamino]-1-[3-pyridyl]-1-butanol), which is a metabolite of the known tobacco carcinogen NNK (4-[methylnitro-samino]-1-[3-pyridyl]-1-butanone). Methods: From 2011 to 2013, 195 low-income, female smokers with children aged ≤10 years residing in their homes were recruited into a two-arm randomized clinical trial. Participants were assigned to one of two groups: biomarker feedback (n=98) and health education (n=97). In-home assessments were administered at baseline, week 16, and week 26. Children’s home SHS exposure and nicotine, cotinine, and NNAL levels from urine samples, measured through a passive nicotine dosimeter and a surface sample of residual tobacco smoke (ie, thirdhand smoke), were collected at all three time points. Primary outcome was dosimeter-verified, self-reported complete home smoking restrictions at 6 months after randomization. Secondary outcomes included parental self-report of smoking behavior change and child urine tobacco toxin (biomarker) change. Results: Data collection and analyses are complete, and the results are being interpreted. Conclusions: The study protocol describes the development of a novel community-based controlled trial designed to examine the efficacy of biomarker feedback documenting home and child exposure to SHS on parental smoking behavior change.

Original languageEnglish (US)
Article numbere12654
JournalJMIR Research Protocols
Issue number10
StatePublished - Oct 1 2019

Bibliographical note

Funding Information:
We would like to thank our community partner and participants, without whom this work would not have been possible. We would also like to thank the staff and students for their assistance with the implementation of this project. This work was supported by the University of Minnesota Center for Health Equity (JA, Principal Investigator, 1P60MD003422, National Institute on Minority Health and Health Disparities). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.


  • Biomarker feedback
  • Cessation
  • Randomized clinical trial
  • Second hand smoke

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