Running head: SECONDHAND SMOKE EXPOSURE FOR CHILDREN IN URBAN

Secondhand Smoke Exposure for Children in Urban Families

by
Angela Long

Presented to
Dr. Nayna Philipsen, JD, PhD, RN

In partial fulfillment of the requirements of

Urban Family Theory and Research
Nurs 512

Coppin State University

Helen Fuld School of Nursing
Masters in Nursing Family Nurse Practitioner

April 23, 2013

SECONDHAND SMOKE EXPOSURE FOR CHILDREN IN URBAN

Children Exposed to Secondhand Smoke by Families Have Increased Emergency Room Visits
and Health Issues
Introduction
Thousands of children in Maryland live with parents or family members that smoke in
their homes. Secondhand smoke is known to release hundreds of chemicals that are toxic to the
human body (Oberg, Woodward, Jaakkola, Peruga, & Pruis-Ustun, 2010, p. 2). These children
whose parents smoke in the home, suffer from many more health issues and have an increased
number of emergency room visits than children who live in a home that have family members or
parents that do not smoke.
Children that live with parents or family members that smoke in the home often have
severe asthma and allergies that are made worst or exacerbated by secondhand smoke. These
children suffer from multiple emergency room visits and multiple hospitalizations.

Many

research studies have been conducted to identify the health issues that are associated with
secondhand smoke, but the public still are not following the CDC and WHO suggestions and
recommendations to not smoke around children. More research needs to be performed so that
more of the statistics can be collected and analyzed to better help us, the healthcare providers,
educated and learn how to take care of these children that are living with this deadly exposures
that can 100% be prevented. The people that are supposed to love children the most are their
parents and caregivers, but these are the people that are causing children more trips to the
emergency room and more health issues. Children from urban low income families have a higher
rate of families that smoke in the homes and have more health issues and higher number of ER
visits. The literature lacks the information and data on urban families, most of the current
research does not separate out the families by income or location or race. Most of the literature
and research available focuses on education that needs to be provided but there is very little
available that states what this secondhand smoking is costing us in healthcare costs. The

SECONDHAND SMOKE EXPOSURE FOR CHILDREN IN URBAN

unnecessary economic burden has not been addressed. Another issues that needs to be addressed
is this a crime? Are these parents and caregivers knowing hurts their children, should they be
charged with a crime? These parents and caregivers are causes these innocent children the pain
and life time health issues that have to be dealt with forever. Is this a crime? Or should this be a
crime?
The purpose of the review of literature is to identify why secondhand smoke exposure is
dangerous and even deadly for children. The review of literature will identify the dangers of
secondhand smoke and what health issues are associated with secondhand smoke.
The Review of the Literature
Secondhand smoke
According to Been, tobacco kills more than five million people a year, making it the
leading preventable cause of death worldwide (Been, Nurmatov, Van Schayck, & Sheikh, 2013,
p. 1). Secondhand smoke kills 600,000 a year which includes 165, 000 children who die, which
are totally preventable deaths (Been et al., 2013, p. 1). Worldwide at least 40% of children are
exposed to secondhand smoke (Been et al., 2013, p. 2). It is estimated that 40 to 67% of inner
city children with asthma live with at least one family member that smokes in the home, with
even higher rate for children who live in poverty (Butz et al., 2011, p. 449)
Younger children are at greater risk from secondhand smoke exposure because then can
spend up to 90% of their time in the home (Butz et al., 2011, p. 455). According to Butz, 70% of
smokers desire to quit, only 34% attempt to quit and only 10% are successful each year (Butz et
al., 2011, p. 455). Quit rates are the lowest in less educated adults and in higher poverty areas
such as the inner city and urban areas (Butz et al., 2011, p. 456).
Health issues

SECONDHAND SMOKE EXPOSURE FOR CHILDREN IN URBAN

According to the World Health Organization, there is strong evidence that secondhand
smoke causes lung cancer, ischemic heart disease and asthma in adults (Oberg et al., 2010, p.
13). Secondhand smoke also cause low birth weight , preterm delivery, childhood chronic
respiratory infection symptoms, lower respiratory illness in young children, asthma exacerbation,
middle ear effusion and infections in younger children, reduced pulmonary functioning and
sudden infant death syndrome known as SIDS (Oberg et al., 2010, p. 13).
Secondhand smoke exposure in children has been associated with an increased risk for
development and severity of asthma and difficulty in managing asthma symptoms. Even with
parental awareness that secondhand smoke exposure exacerbates the symptoms, parents still
continue to smoke ignoring the medical providers education and recommendations for their
childs health (Butz et al., 2011, p. 449).
Caregivers
Families and caregivers sometimes state that routine daily stress, habit or depression
prevents them from cessation of smoking even when education and smoking cessation is offered
free of charge. Caregivers and parents often state they primarily smoke in their bedroom 57%,
kitchen 30%, or family /TV room 27% (Butz et al., 2011, p. 5).
A Family Theoretical Framework
George P. Murdock was born 1897, died 1985 was an American anthropologist who
specialized in comparative ethnology and social theory (White, 2000, p. 1). Murdocks family
theory defined the family and how it functions in society. The Nuclear Family is defined as The
family is a social group characterized by common residence, economic cooperation and
reproduction. It contains adults of both sexes, at least two of whom maintain a socially approved
sexual relationship, and one or more children, own or adopted, of the sexually cohabiting adults."
(Murdock, 1949, p. 2). Any of the following are not considered a family: Lone parents and their
children would not be seen as families because they do not contain two or more adults in an

SECONDHAND SMOKE EXPOSURE FOR CHILDREN IN URBAN

approved sexual relationship. Childless heterosexual couples, married or cohabiting, would not
be seen as families. Gay and lesbian couples, cohabiting or civil partnered, with or without
children would not be seen as families. Friendship groups sharing a household would not be
described as families.
The nuclear family exists as a distinct and strongly functional group in every society and
that it performs four functions fundamental to human social life (Murdock, 1949, p. 2). Sexual,
economic, reproductive and educational are the four functions of a family. Most of the families
that will be studied in this survey will not meet this definition of family. Most of the families that
live in poverty and in urban areas do not meet the four functions that Murdock defines in order to
be a successful families, this in part could be one of the answers for why these families cannot
quit smoking in their homes. These families often state stress caused by economic issues keep
them from smoking, and the medical world always states that these families need more
education. These are two of the four fundamental functions that Murdock stresses in his theories.
Roys Adaptation Model
According to Long (2013), Roys Adaptation Model was written and published by Sister
Callista Roy in 1968, which she presented as a framework to be used for nursing practice,
research and education (Alligood & Tomey, 2010, p. 336). Roys framework is used around the
world in nursing schools, and as framework that is used for research and journal articles in five
different continents (Alligood & Tomey, 2010, p. 340). Roys model seeks to explain and
describe the central concept of adaptation.

Roys adaptation model allows nurses to use a six

step nursing process (Alligood & Tomey, 2010, p. 345).

The first function of the nursing process is to assess the behaviors that are part of the four
adaptive modes (Alligood & Tomey, 2010, p. 345). The second step is to assess the focal,
contextual or residual stimuli (Alligood & Tomey, 2010, p. 345). Next come up with nursing
diagnoses that clearly define the adaptive state (Alligood & Tomey, 2010, p. 345). The fourth

SECONDHAND SMOKE EXPOSURE FOR CHILDREN IN URBAN

step in the process is to set clear goal that promote adaptation (Alligood & Tomey, 2010, p. 345).
Next implement nursing interventions aimed at the current nursing diagnoses of step 2 (Alligood
& Tomey, 2010, p. 345). Lastly step six is to evaluate the outcomes, see what adaptive goals
were met (Alligood & Tomey, 2010, p. 345).
Roys adaptation model has four adaptive modes. The four concepts explain how
everything in life is centered around change or adaptation, The physiological mode identities
basic needs such as oxygenation, nutrition, elimination, activity and rest, protection, senses, fluid
and electrolytes and acid base balance, neurological function and endocrine function(Alligood &
Tomey, 2010, p. 355). The second mode is self-concept which is concerned with psychic and
spiritual integrity (Alligood & Tomey, 2010, p. 355). The third mode is interdependence which
is concerned with the relationship and nurturing of others (Alligood & Tomey, 2010, p. 355).
The last mode or concept is role function which is concerned with social integrity (Alligood &
Tomey, 2010, p. 355)
Roy has a list of many scientific and philosophical assumptions. Some of the major
scientific assumptions are awareness of self and environment is rooted in thinking and feeling,
thinking and feel is a human action, humans by their decisions are accountable for the
integration of the creative process, and integration of human and environment meanings result
in adaptation (Alligood & Tomey, 2010, p. 341). Some of Roys philosophical assumptions are
that people have mutual relationships with the world and god, people use human abilities of
awareness, enlightenment and faith, and the people are accountable for deriving, sustaining and
transforming the universe (Alligood & Tomey, 2010, p. 341).
The context for use of the theory is clearly described by the six steps of the nursing
process that Roy has outlined. The concepts of the four adaptive modes are used in each step of
the nursing process to create a goal that must be met. The theory is a broad middle range theory

SECONDHAND SMOKE EXPOSURE FOR CHILDREN IN URBAN

that is easily adaptive that is why it has been used by many nursing schools, in nursing practice
and for education and research.
Roys framework uses concepts that are theoretically and operationally defined. System
is defined as a set of parts connected to function as a whole and operationally defined as a
whole that has inputs, outputs, control and feedback processes (Alligood & Tomey, 2010, p.
337). Roy defines focal, contextual and residual stimuli as major concepts. She also defines
coping processes, innate coping mechanisms, acquired coping mechanisms, adaptive responses
and ineffective responses as major concepts (Alligood & Tomey, 2010, p. 338). Roy thoroughly
defines the four adaptive modes repeatedly . The physiological adaptive mode refers to a way a
person responds or adapts to the internal and external environment (William F. Connell School of
Nursing, 2013, p. 2). These physiological needs are oxygenation, nutrition, elimination, activity
and rest, protection, senses, fluid and electrolyte and acid-base balance, neurological function,
endocrine function (Alligood & Tomey, 2010, p. 356).
The adaptation model is a great theory that can be used for all of family situations. The
family adapts to its own situation. The children adapt to being exposed to secondhand smoke,
most not ever knowing any different. The children adapt to their external environments.
This study is a quasi-experimental study. Future studies can be performed by having more
than one hospital in different areas and different cities take the same questionnaire. The
information can be compared to other cities to see if the problem is truly a problem that needs to
be addressed in inner cities and urban areas or if it is a global issue.
Hypotheses
Children that live with families that smoke in their homes, that are exposed to
secondhand smoke have an increased number of emergency room visits per year and have an
increased number of health issues or illness. Children that live in homes where there is no smoke

SECONDHAND SMOKE EXPOSURE FOR CHILDREN IN URBAN

exposure have a decreased number of emergency room visits and a smaller number of health
issues and illnesses.
Theoretical definitions
Children
Child is a human between the age of birth and full grown and children is the plural of
child (Butz et al., 2011, p. 2).
Families
Family has many definitions one being written by Murdock, The family is a social group
characterized by common residence, economic cooperation and reproduction. It contains adults
of both sexes, at least two of whom maintain a socially approved sexual relationship, and one or
more children, own or adopted, of the sexually cohabiting adults." (Murdock, 1949, p. 2).
Another being family is a basic social unit consisting of parents and their children, considered
as a group, whether dwelling together or not: the traditional family or a social unit consisting of
one or more adults together with the children they care for: a single-parent family
Secondhand smoke exposure
Secondhand smoke exposure can be described as a form of side stream smoke emitted
into the environment from the smoldering of cigarettes and other tobacco products between puffs
and from the mainstream smoke exhaled by the smoker (Oberg, Woodward, Jaakkola, Peruga, &
Pruis-Ustun, 2010, p. 2). Other terms that are used interchangeable for secondhand smoke are
passive smoking and involuntary smoking according to the World Health Organization (Oberg et
al., 2010, p. 2).
Emergency room visits
Emergency room visit is any visit to an hospital that is unplanned to receive acute care
for an emergent issue that cannot wait to be seen by primary care medical provider by an

SECONDHAND SMOKE EXPOSURE FOR CHILDREN IN URBAN

appointment. The Emergency room is open 24 hours a day seven days a week and no
appointment is necessary.
Health issues
Health is a measure of quality of life that is difficult to define. The World Health
Organization defined health as a "state of complete physical, mental, and social well-being and
not merely the absence of disease or infirmity"(Oberg et al., 2010, p. 10). Such as health issues
can be defined as disruption of normal state of physical, mental and social well-being.
Operational Definitions
Children
Children are those age from 1 to 17 years old for the purpose of this study, seen in local
community hospital emergency room.
Families
Families are anyone that a child lives with who is a caregiver such as mother , father,
aunt, uncle, grandmother, grandfather, foster parent, stepmother or father, or any adult caregiver.
Secondhand smoke
Secondhand smoke is any exposure in a home to someone who smokes cigarettes in the
presences of a child.
Emergency room visit
Emergency room visit is any visit to the emergency room for the child referred to in the
questionnaire
Health issues
Health issues are any past or present medical diagnoses ever made for the child referred
to in the questionnaire. Anything that the referred to child has been treated for such as asthma,
upper respiratory infections, ear infections, strep throat , urinary infections and so on.

SECONDHAND SMOKE EXPOSURE FOR CHILDREN IN URBAN

10

Secondhand Smoke Assessment Tool

Secondhand Smoke Questionnaire
1. Smoking status of parent
2. Hours of childs SHS at home

total
home

parent or family
parent or family

3. Cigarettes per day smoked

total

parent or family

4. Cigarettes per day smoked in home

home

parent or family

5. Total number of Emergency Room visits

total

child

total

child

this year for child

6. Health issues this child has been diagnosed
within the past year
Secondhand smoke exposure questionnaire is adapted from a questionnaire that
has been used in current research with permission from http://group.bmj.com/group/rightslicensing/permissions. This questionnaire is a smaller scaled down questionnaire to limit the
amount of information collected to only answer the specific question asked by the two variables
identified in this paper. The questionnaire can be handed out to every pediatric ER patient for a
two week period. If the hospital sees 80 to 100 children a day and at least half of the families
complete the questionnaire then we will collect at least a minimum of 700 questionnaires, which
is an acceptable sample size.
The accuracy of these questions is valid and reliable. Families are asked to answer these
questions, and they are considered reliable when the information correctly identifies those
children that are truly exposed to secondhand smoke, the number of emergency room visits and
the accurate health issues that the child faces. The family member present can reliably answer
questions for any family member who lives in the house that smokes such as a spouse, aunt,
uncle or grandparent. The questionnaire is so simple that even older children can complete the
questions with accuracy. The accuracy and reliability only decreases when the child lives or

SECONDHAND SMOKE EXPOSURE FOR CHILDREN IN URBAN

11

shares time in more than one home, such as divorced parents. The parent or family member
completing the questionnaire might not give the correct information about the childs second
living environment.
This questionnaire can be handed out to parents of patients at a local community pediatric
emergency room and asked to fill out this simple survey to help us learn what education the
community needs about smoking. The parents will be informed that the survey has been
approved by the IPR board at the hospital and does not affect the care they will receive today; it
is only for informational purposes only.

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References
Alligood, M. R., & Tomey, A. M. (2010). Nursing theorists and their work (7th Ed.). Maryland
Heights, Missouri: Mosby Elsevier.
Avil-Tang, E., Elf, J., Cummings, M., Fong, G., Hovell, M., Klein, J., ... Samet, J. (2012,
September 4). Assessing secondhand smoke exposure with reported measures. Tobacco
Control BMJ Publishing, 1-8. http://dx.doi.org/10.1136/tobaccocontrol-2011-050296
Batscheider, A., Zakrzewska, S., Heinrich, J., Teuner, C., Menn, P., Bauer, C., ... Koletzko, S.
(2012). Exposure to second-hand smoke and direct healthcare costs in children-results
from two German birth cohorts, GINIplus and LISAplus. BMC Health Services Research,
12(344), 1-11. Retrieved from http://www.biomedical.central.com/1472-6963/12/344
Been, J. V., Nurmatov, U., Van Schayck, C. P., & Sheikh, A. (2013, Janurary 17). The impact of
smoke-free legislation on fetal, infant and child health: a systematic review and metaanalysis protocol. BMJ Open, 3(1), 1-5. http://dx.doi.org/10.1136/bmjopen-2012-002261
Butz, A., Breysse, P., Rand, C., Curtin-Brosnan, J., Eggleston, P., Diette, G., ... Matsui, E. (2011,
May). Household smoking behavior: effects on indoor air quality and health of urban
children with asthma. Matern Child Health Journal, 15(4), 460-468.
http://dx.doi.org/10.1007/s10995-010-0606-7
Butz, A. M., Halterman, J. S., Bellin, M., Tsoukleris, M., Donithan, M., Kub, J., ... Bollinger, M.
E. (2011). Factors associated with second-hand smoke exposure in young inner-city
children with asthma. Journal of Asthma, 48(1), 449-457.
http://dx.doi.org/10.3109/02770903.2011.576742
Chen, Q., Just, A. C., Miller, R. L., Perzanowski, M. S., Goldstein, I. F., Perera, F. P., & Whyatt,
R. M. (2012, May). Using latent class growth analysis to identify childhood wheeze
phenotypes in an urban birth cohort. National Institutes of Health, 108(5), 311-315.
http://dx.doi.org/10.1016/j.anai.2012.02.016

SECONDHAND SMOKE EXPOSURE FOR CHILDREN IN URBAN

13

Chen, Y., Hsiao, F., Miao, N., & Chen, P. (2013, ). Janurary 7. International Journal of
Environmental Research and Piblic Health, 10, 192-209.
http://dx.doi.org/10.3390/ijerph10010192
Friebly, J., Rigotti, N., Chang, Y., Hall, N., Weiley, V., Dempsey, J., ... Winickoff, J. (2013).
Paretn smoker role conflict and planning to quit smoking: a cross-sectional study. BMC
Public Health, 13(164), 1-7. Retrieved from http://www.biomedcentral.com/14712458/13/164
Geerts, C. C., Bots, M. L., Van Der Ent, C. K., Grobbee, D. E., & Uiterwaal, C. S. (2012,
December 6). Parental smoking and vascular damage in their 5 year old children.
Pediatrics Official Journal of the American Academy of Pediatrics, 129(1), 44-54.
http://dx.doi.org/10.1542/peds.2011-0249
Long, A. (2013, Janurary ). Theory Evaluation . Coppin State University, unpublished.
Murdock, G. P. (1949). Social structure. New York: Macmillian.
Oberg, M., Woodward, A., Jaakkola, M., Peruga, A., & Pruis-Ustun, A. (2010). Global estimate
of the burden of disease from second-hand smoke. World Health Organization, 1-81.
Retrieved from http://www.who.int
Tanako, K., & Miyake, Y. (2011). Association between prenatal and postnatal tobacco smoke
exposure and allergies in young children. Journal of Asthma, 48(1), 458-463.
http://dx.doi.org/10.3109/02770903.2011.578314
White, D. R. (2000). Murdock, George Peter. American National Biography Online. Retrieved
from http://www.anb.org/articles/14/14-01020.html
William F. Connell School of Nursing. (2013). The roy adapation model. Retrieved from
http://www.bc.edu/schools/son/faculty/featured/theorist/roy_adaptation_model.html

SECONDHAND SMOKE EXPOSURE FOR CHILDREN IN URBAN

14

Woodgate, R. L., & Kreklewetz, C. M. (2012). Youths narratives about family members
smoking: parenting the parent-its not fair. BMC Public Health, 12, 1-13. Retrieved from
http://www.biomedcentral.com/1471-2458/12/965