Highlight
This cluster-randomized clinical trial assessed the integration of an automated tobacco cessation tool (eCEASE) into pediatric primary care for parents who smoke, implemented via electronic health records.
The intervention significantly increased parental engagement with cessation treatments including use of nicotine replacement therapy and quitline or text-based support, and prompted more quit attempts and cigarette consumption reduction than usual care.
However, the primary outcome of biochemically verified 7-day tobacco abstinence at 1 year was not significantly different between the intervention and control groups, indicating that additional strategies are needed to improve sustained quitting.
Study Background and Disease Burden
Tobacco use among parents represents a critical public health challenge due to its direct impact on their health and through secondhand smoke exposure risks to children, including respiratory illnesses and sudden infant death syndrome. Despite pediatric visits providing an opportunity to address this issue, tobacco cessation interventions for parents remain underutilized in these settings.
Embedding cessation support directly into pediatric primary care offers a strategic avenue to reduce parental tobacco use and children’s tobacco smoke exposure. The Clinical Effort Against Secondhand Smoke Exposure (CEASE) program aims to leverage electronic health records (EHRs) to deliver systematic, automated cessation interventions. However, evidence regarding the effectiveness of automated interventions integrated into pediatric care remains limited, highlighting an unmet clinical need prompting this cluster-randomized clinical trial.
Study Design
This study was a cluster-randomized clinical trial conducted across 12 pediatric primary care practices in Philadelphia, Pennsylvania, from July 16, 2021, to August 15, 2023. Practices were randomized to either an intervention arm or a control arm, each containing six practices.
Participants were 817 parents who reported using combusted tobacco in the past 7 days and attended their child’s preventive health care visit. The intervention group received eCEASE, an automated EHR-integrated cessation program that proactively offered nicotine replacement therapy (NRT), enrollment in quitline and/or SmokefreeTXT messaging support, and access to tobacco use cessation navigators. In contrast, control group parents received usual care without automated interventions.
All households completed previsit EHR questionnaires regarding tobacco use, enabling identification and targeting of smoking parents. The primary endpoint was biochemically confirmed 7-day abstinence from combusted tobacco at 1-year follow-up. Secondary outcomes included use of NRT, quitline and/or SmokefreeTXT engagement, recent quit attempts, and changes in cigarettes per day and smoking frequency from baseline to 1-year.
Key Findings
Among the 817 enrolled smokers (82.3% females, mean age 36.17 years), follow-up survey completion rates were 90.0% in both intervention (367 of 408) and control groups (368 of 409). The majority were mothers (79.2% in intervention vs 79.7% in control).
The primary outcome—biochemically confirmed 7-day abstinence at 1 year—was 8.3% (34 of 408) in the intervention group versus 6.4% (26 of 409) in controls. The adjusted odds ratio was 1.34 (95% CI, 0.79–2.29), which was not statistically significant, suggesting that the intervention did not substantially increase quit rates compared with usual care.
Secondary outcomes demonstrated marked benefits in the intervention arm. Among respondents completing follow-up, 48.2% used nicotine replacement therapy compared with 16.0% in the control group. Engagement with quitline and/or SmokefreeTXT messaging was 22.8% versus 2.2% respectively. Moreover, 80.1% of intervention participants reported attempting to quit in the last 3 months compared to 70.1% of controls.
Regarding smoking intensity, the intervention group had a greater mean reduction in cigarettes smoked daily (–3.32 vs –1.81) and a more pronounced decrease in the proportion of daily smokers (–35.2% vs –25.8%) relative to controls.
These findings indicate that while the automated intervention enhanced treatment engagement and reduced smoking behaviors, it was insufficient alone to significantly improve long-term abstinence.
Expert Commentary
This trial provides important insights into the challenges of implementing tobacco cessation interventions in pediatric practice settings. The eCEASE system effectively increased parent engagement with evidence-based cessation methods, such as NRT and quitline support, reinforcing the value of automated EHR-based tools for reaching smokers during pediatric visits.
However, the modest and statistically non-significant increase in quit rates at 1 year highlights persistent barriers beyond treatment access, such as motivation, psychosocial factors, and addiction severity, that automated approaches alone may not overcome.
Limitations include reliance on parental self-report for some data, potential variability in intervention fidelity across practices, and the urban Philadelphia setting, which may affect generalizability. Future research should explore integrated multifaceted cessation programs combining automation with tailored counseling, follow-up support, and possibly incentive structures.
The trial’s rigorous design, biochemical verification of abstinence, and high follow-up rates strengthen confidence in findings. Clinician awareness that automated interventions can increase treatment uptake but may require enhancement to improve quit rates is critical.
Conclusion
The cluster-randomized clinical trial demonstrated that integrating an automated tobacco cessation intervention into pediatric primary care significantly increased parental engagement with cessation resources and reduced cigarette consumption but failed to produce a statistically significant improvement in 1-year tobacco abstinence.
Addressing parental tobacco use remains a vital public health goal to protect child health and promote familial well-being. Automated electronic interventions represent a feasible, scalable approach within pediatric settings but should be supplemented with additional supportive strategies to enhance quitting success.
These findings advocate for continued innovation and evaluation of comprehensive, parent-focused tobacco cessation interventions that leverage technology-enhanced delivery while addressing behavioral complexities of smoking addiction.
References
1. Nabi-Burza E, Jenssen BP, Jeffers AM, et al. Automated Tobacco Cessation Intervention for Parents in Pediatric Primary Care: A Cluster-Randomized Clinical Trial. JAMA Netw Open. 2025;8(8):e2529384. doi:10.1001/jamanetworkopen.2025.29384
2. Winickoff JP, Lebowitz M, Rigotti NA. Addressing Tobacco Use in Primary Care Pediatric Settings. Curr Opin Pediatr. 2017;29(2):252-258.
3. American Academy of Pediatrics. Policy Statement: Tobacco Use Prevention and Cessation in Pediatric Settings. Pediatrics. 2015;136(5):e1431-e1444.
