An automated text system at pediatric clinics helped 3.9% more mothers quit smoking

Forty percent of American children are exposed to secondhand smoke. Their parents visit pediatricians multiple times a year. Those visits - focused on the child's health - represent an untapped opportunity to reach the adult doing the most damage.

A team at Children's Hospital of Philadelphia decided to exploit that opportunity with as little human effort as possible.

Building a system that runs itself

The intervention, published in Pediatrics, was built on a simple premise: if you embed tobacco screening and cessation support directly into the electronic health record workflow, you can reach smoking parents at scale without asking already-stretched clinical staff to do anything extra. No additional training. No new protocols for nurses to memorize. No counseling sessions to schedule.

The automated system screened parents during routine pediatric visits, assessed motivation to quit, and connected interested parents directly to evidence-based cessation treatments - all through the existing EHR infrastructure. It built on the Clinical Effort Against Secondhand Smoke Exposure (CEASE) framework, which targets parental smoking during pediatric primary care.

"We've created a system that removes the traditional barriers, such as provider time, prescribing challenges, and workflow burden," said lead author Brian Jenssen, assistant professor of pediatrics at the University of Pennsylvania Perelman School of Medicine and a pediatrician at CHOP.

What 55,000 parents showed

The researchers conducted a retrospective analysis of a cluster-randomized trial across 12 pediatric practices between June 2021 and August 2024. Six practices received the full automated system. Six implemented screening only, with no follow-up. The analysis included data from more than 55,000 parents.

Among mothers who smoked, cessation rates were 3.9 percentage points higher in the intervention group compared to controls. Among fathers, there was no difference.

A 3.9% absolute increase does not sound dramatic. But context changes the math. Millions of parents who smoke attend pediatric visits annually in the United States. "Even a small but noticeable decrease in smoking can translate to tens of thousands of additional individuals who quit each year, which protects hundreds of thousands of children from secondhand smoke exposure," said co-senior author Alexander Fiks, director of Clinical Futures and the Possibilities Project at CHOP.

Why mothers but not fathers

The sex difference in the results is notable and unexplained by the study itself. The system reached both parents. Only mothers responded. Several hypotheses are plausible. Mothers may be more frequently the parent accompanying children to pediatric visits, making them more engaged with the health messaging. The framing - protecting your child's health - may resonate differently with mothers and fathers. Or the result may reflect broader patterns in smoking cessation research, where women and men respond differently to different types of interventions.

The study did not investigate mechanisms behind the sex difference, and the authors do not speculate extensively. It is a gap that future work will need to address, particularly if the system is to be optimized for the roughly half of smoking parents it currently does not appear to reach.

Scaling without adding burden

The study's most practically relevant finding may not be the cessation rate but the implementation model. The system required no additional staff training, no new clinical workflows, and no extra time per visit. It was embedded in existing EHR infrastructure and ran essentially on autopilot.

That matters because the biggest barrier to smoking cessation interventions in primary care has never been evidence. We know what works: counseling combined with pharmacotherapy. The barrier is capacity. Physicians do not have time to add a tobacco conversation to every visit. Nurses are already overloaded. Referral systems add friction that most patients never overcome.

By automating the entire chain - from screening to motivation assessment to treatment connection - the CHOP system sidesteps the capacity problem entirely. If a pediatric health system can implement this with minimal disruption, the only remaining question is whether it will.

The study was supported by National Institutes of Health grant R01-CA245145.