Flanders-Stepans M Wilhelm S L & Dolence K Essay

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Flanders-Stepans, M., Wilhelm, S.L., & Dolence, K. (2006). Smoking Hygiene: Reducing Infant Exposure to Tobacco. Biological research for Nursing, 8(2), 104-114.

Considering the title of the work, one would believe that the problem statement would explain ways to reduce infant exposure; when in fact the article commences by explaining the large monetary burden that smoking related issues has brought about in the medical field. The article then begins to explain the correlation that exists between the smoking pattern of the mother and the level of exposure to Environmental Tobacco Smoke (ETS). Finally, it is explained that a strong correlation has been made between breastfeeding and reduced ETS; however it is also stated that in fact a child is more likely to have elevated levels & symptoms associated with ETS if the breastfeeding mother is a smoker. It is also stated that there is a distinct correlation between the smoking pattern of the mother and the ETS of the child. This ETS can lead to breathing issues i.e. respiratory viral bronchitis, acute otitis media, asthma, and loss of infant life.

Comments -- The problem statement was short and only partially related to the topic stated for the article. The problem is explained and there is a brief description of a possible solution and aid in this issue. Though it would have been more explicative to describe in more detail what ways are effective in reducing ETS, while explaining the background to this issue further into the reading. The problem does tie into the title of the work, while giving some aspects as to what caused the issues in the first place. Lastly, it would be useful to provide more information regarding why breastfeeding and not some other method. However, there is educational significance associated with the title and problem statement.


The purpose of this study was to affirm that an intervention would cause a positive impact on the effects associated with children's ETS. It is believed that if mothers are given information regarding the negative effects that smoking has on infants that this will decrease the ETS and will affect children's health in a positive manner. The researchers utilized Neuman's system model to examine the problem of infant ETS.

Comments -- The purpose was clearly stated, there is an agreement with the problem and the title. The researcher insured that the study was limited to their capabilities and available resources. The purpose agrees with problem in that a correlation does exist between child exposure and maternal smoking patterns.


The objective of this study was to evaluate the feasibility of determining the effects of a smoking hygiene intervention on infants of breastfeeding mothers who smoke cigarettes.

Comments -- The researcher's objective was answerable, and they chose to test using questionnaires and home visits. The hypothesis was testable and served to help explain the problem.

Review of Literature

The researchers provided an overview of the available literature in ETS related issues as it pertained to the objectives of the current study completed. The review of literature was rather detailed. However, there were a limited number of current works utilized in the study i.e. after the year 2000. Section titles were (1) Health Consequences of ETS Exposure -- explaining that each year the known effects from ETS continues to increase. This exposure leads to increased risk for health problems like bronchitis etc.; (2) Breastfeeding and Smoking -- in this literature it is explained that there is a belief that breastfed infants of smoking mothers can have urinary cotinine levels 10 times higher than those of bottle fed infants of smoking mothers.; (3) Physiological Effects and Measures of Exposure to ETS -- this section sought out to confirm that children with ETS in closer proximity can and will often display more symptoms and issues than children not in this same environment. Infants whose mothers smoke close by and/or in an enclosed space with them, especially in a motor vehicle, experience higher levels of exposure, which are reflected by higher levels of cotinine in their urine; and (4) Intervention Research -- this section showed that akin to previous research done very little difference was seen between testing and controlled groups. Reference citations appeared concise and used appropriate APA style. Theoretical reasoning was included and similar studies were cited.


An experimental design with repeated measures was used. A convenience sample of 35 mother-infant dyads from seven sites was recruited and randomly assigned to the intervention or control group. Of the 27 dyad completing the survey, 16 were in the experimental group and 11 were in the control group.

New mothers who met the eligibility criteria received information related to the study and an invitation to participate within 24 hours after delivery. Staff nurses at the hospital provided this information to the mothers. If a mother indicated an interest in the study, the staff nurse contacted the research assistant for the region. The research assistants then contacted interested women in the hospital, explained the risks and benefits of the study, and answered questions. Written consent was obtained, and the mother-infant pairs were randomly assigned to the intervention or comparison group using a predetermined randomization schedule. The mothers completed the demographic and smoking habits questionnaires at that time. Questions about maternal smoking behavior during pregnancy were included in the demographic questionnaire. The research assistants also, at this time, arranged to make home visits for both the intervention and the control groups when the infants were 2, 3, and 5 weeks old.

At the home visits, the research assistance collected infant urine and maternal breast milk samples. During each visit, mothers were asked about infant health (wheezing or "whistling in the chest," cough upper respiratory infection [cold], ear infection, pneumonia, bronchitis, and hospitalization). The women were also asked to complete questionnaires about smoking hygiene and smoking habits during the home visits. Timing of collection of these questionnaires was dependent upon whether the mother was in the intervention or control group.

Comments -- The research design was sufficient and the data gathering procedures were explained. The instrument was described in detail and the sample appears to be adequate. However, a bigger sample could have proven to be beneficial in this research. The researchers explained the situation clearly and reviewed the statistical techniques completely.


The results indicate that although 35 mother-infant pairs were recruited into the study, only 27 completed the study. Discrepancies in degree of freedom were due to missing data. There were no differences between the maternal intervention and control group in family income, age, marital status, years of education, or number of cigarettes smoked during pregnancy at week 2 & 5. Although there were no differences between the two groups in number of cigarettes smoked at any data point, women in both groups smoked twice as much at 2 & 5 weeks after delivery than during pregnancy. Nearly half of the mothers had a family income of less that $19,000 per year. The average mother was in her mid-twenties and had a high school education.

There were limitations in the study primarily having a small sample size. In addition, the data collectors were not blind to the group assignment. Lastly, members of the intervention group did not do everything they were suppose to do and there was little uniformity over how data was collected as well as problems with lack of adherence to the smoking hygiene intervention.

Comments -- The findings were objectively reported; in addition there do not appear to be any errors associated with this report. The researchers explain that there was very little difference between the two groups. In addition repeated-measures ANOVA indicated no significant difference for nicotine present in infant urine of the control and intervention groups. The research also shows in its findings that there was no significant difference associated with nicotine levels in the breast milk of the mothers in the control and intervention group.


There was a summary of everything from the introduction right through the hypothesis and procedures. Tables were included to support the documentation.


There was a conclusion included for the objective and the basis for that conclusion was stated. The conclusion was logically stated and related to the logic included.


As stated in the research article though the smoking hygiene intervention did not result in a reduction in levels of infant exposure to ETS, researchers should continue to explore ways to reduce this risk to infant health. Although it is difficult to change the behavior of an individual there may be other methods that prove useful in bringing about a change and effecting ETS in a positive manner. Another recommendation would be to increase the sample size, though it is obvious that results may have provided the same results; there could have been enough of a change in data to offer some insight to any aspects of the intervention method that may, by itself or enhanced prove beneficial in decreasing ETS.

It would have proven more beneficial to have more…[continue]

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