The motivators and barriers to a smoke-free home among disadvantaged caregivers: identifying the positive levers for change

Association between exposure to tobacco information through mass media, smoking households and secondhand smoke exposure in adolescents: Survey data from South Korea

INTRODUCTION

To explore the current situation of exposure of Korean adolescents to secondhand smoke (SHS) in households our study aimed to determine the relationship between family member smoking status, exposure to tobacco information through mass media, and household SHS exposure.

METHODS

The present study uses pooled data from the Korean adolescent health behavior online survey conducted in 2015, 2018 and 2021, with 157944 participants. The regression models were used to explore the association between the smoking status of households, and exposure to tobacco information through mass media, and household SHS exposure in adolescents, controlling for potential confounding factors.

RESULTS

SHS exposure duration of Korean adolescents in households was 0.88 days per week. The households with smokers including the father (β=1.087; 95% CI: 1.0-1.126), mother (β=1.461; 95% CI: 1.379- 1.543), siblings (β=0.545; 95% CI: 0.493-0.597), grandparents (β=0.224; 95% CI: 0.174-0.272), and other relatives (β=0.170; 95% CI: 0.126-0.214), showed a positive association with SHS exposure in adolescents within the household. At the same time, information about anti-smoking ads on television (β= -0.042; 95% CI: -0.069 - -0.015) and public transportation (β= -0.031; 95% CI: -0.054 - -0.010), showed a negative association with SHS exposure in adolescents. However, broadcasts, online, and newspaper non-smoking ads were not associated with SHS exposure (p>0.05). In addition, regression models revealed that exposure to cigarette advertising in magazines (β=0.131; 95% CI: 0.097-0.166), networks (β=0.151; 95% CI: 0.127-0.175), convenience stores (β=0.061; 95% CI: 0.035-0.087), and supermarkets (β=0.133; 95% CI: 0.108-0.158) is associated with SHS exposure in adolescents. Finally, our study showed stronger ties between SHS exposure, family smoking, and tobacco ads in girls. The link between maternal smoking, supermarket ads, and adolescent SHS exposure intensified in 2021 compared to 2015.

CONCLUSIONS

Family and media were identified as potential factors associated with SHS exposure in adolescents. Therefore, publicity and education regarding household SHS hazards, and smoking bans in media, can be helpful in protecting adolescents from SHS.

Household smoking impact on the oral health of 5- to 7-years-old children

BACKGROUND

Children's exposure to secondhand smoke, particularly by their parents, could adversely affect their oral health. Thereby, this study aimed to assess the oral health status of children subjected to household smoking and the impact of smoking patterns on the severity of oral health deterioration.

METHODS

A total of 210 healthy children were enrolled in this case-control study and allocated into children subjected to household smoking (HS) and control groups. Participants' guardians were asked to complete a questionnaire regarding sociodemographic characteristics and parental smoking habits. All participants were subjected to clinical dental examination to assess dental caries (ICDAS), hypomineralized primary molars (HSPM), and gingival status (GI). Stimulated saliva samples were collected to assess saliva composition and characteristics. Urine samples were collected and analyzed for cotinine concentration. Data were analyzed using SPSS (v.25) software at a test value of p ≤ 0.05. The t-student test was used to find significant differences between participants' age, gingival index score, saliva pH, flow rate, sIgA, and cotinine level. The Chi-square test was used to test for the significance of parental employment, number of rooms, gender, sweets consumption, brushing frequency, and HMPM. The correspondence analysis was used to test for significance of parents' levels of education, type of house ventilation, ICDAS score, smoking form, frequency, and smoking pattern. The correlation between cotinine level and sIgA was tested for association using Bivariate correlation test.

RESULTS

The HS group showed a significantly increased risk for dental caries (p < 0.000), HSPM lesions (p = 0.007), and GI score (p < 0.000). A significant reduction in salivary flow rate, saliva pH, and sIgA were evident in HS group (p < 0.000). Parental consumption of more than 20 cigarettes/day was accompanied by increased dental caries activity (p < 0.000) and higher risk for increased severity of gingival inflammation (p < 0.000) of children in the HS group. Children of parents who smoke cigarettes and use the hubble/bubble anywhere in the house found to have greater distribution of HSPM (p < 0.000). Reduced sIgA values were found to be significantly associated with increased cotinine concentrations in HS children (p < 0.000).

CONCLUSIONS

Frequent exposure to household smoking could be associated with an increased risk of dental caries progression, enamel hypomineralization, gingival inflammation, and saliva characteristics changes in children.

Lung Effects of Household Air Pollution

Biomass fuel smoke, secondhand smoke, and oxides of nitrogen are common causes of household air pollution (HAP). Almost 2.4 billion people worldwide use solid fuels for cooking and heating, mostly in low- and middle-income countries. Wood combustion for household heating is also common in many areas of high-income countries, and minorities are particularly vulnerable. HAP in low- and middle-income countries is associated with asthma, acute respiratory tract infections in adults and children, chronic obstructive pulmonary disease, lung cancer, tuberculosis, and respiratory mortality. Although wood smoke exposure levels in high-income countries are typically lower than in lower-income countries, it is similarly associated with accelerated lung function decline, higher prevalence of airflow obstruction and chronic bronchitis, and higher all-cause and respiratory cause-specific mortality. Household air cleaners with high-efficiency particle filters have mixed effects on asthma and chronic obstructive pulmonary disease outcomes. Biomass fuel interventions in low-income countries include adding chimneys to cookstoves, improving biomass fuel combustion stoves, and switching fuel to liquid petroleum gas. Still, the impact on health outcomes is inconsistent. In high-income countries, strategies for reducing biomass fuel-related HAP are centered on community-level woodstove changeout programs, although the results are again inconsistent. In addition, initiatives to encourage home smoking bans have mixed success in households with children. Environmental solutions to reduce HAP have varying success in reducing pollutants and health problems. Improved understanding of indoor air quality factors and actions that prevent degradation or improve polluted indoor air may lead to enhanced environmental health policies, but health outcomes must be rigorously examined.

Factors related to caregivers' risk perception of secondhand smoke exposure on children's health

INTRODUCTION

Home is one of the main places for children’s secondhand smoke (SHS) exposure. The implementation of smoke-free rules at home might be influenced by caregivers’ risk perception of SHS exposure. This study aimed to analyze factors related to caregivers’ risk perception of SHS exposure in children.

METHODS

We conducted a cross-sectional telephone survey among a representative sample of 2411 parents or legal guardians of children aged <12 years in Spain in 2016. The main study variable was caregivers’ healthrisk perception of SHS exposure on children. We investigated correlates of risk perception using multivariate Poisson regression models with robust variance.

RESULTS

Overall, 59.6% reported SHS exposure negatively affects children’s health a lot, while 34.1% that it affects quite a bit, and 5.5% and 0.8% a little bit or not at all, respectively. The factors associated with a higher caregivers’ risk perception were high education level (adjusted prevalence ratio, APR=1.11; 95% CI: 1.01–1.24), living in a non-smoking family unit (APR=1.17; 95% CI: 1.07–1.27), in a home with smoke-free rules (APR=1.34; 95% CI: 1.19–1.51), and with girls only (APR=1.14; 95% CI: 1.06–1.22).

CONCLUSIONS

Caregivers’ risk perception of SHS exposure is influenced by social determinants and smoking habits in family units. These findings support the need for interventions with a social equity perspective to reduce children’s SHS exposure.

Protecting Children From Tobacco Smoke Exposure: A Randomized Controlled Trial of Project Zero Exposure

INTRODUCTION

Young children are vulnerable to harm from tobacco smoke exposure (TSE). This study assessed the effect of Project Zero Exposure-an intervention program designed to help parents protect children from TSE-on children's exposure.

METHODS

Randomized controlled trial of a home-based, theory-driven intervention. Parents of young children (<8 y) in families with a smoking parent were eligible. The intervention included feedback on child TSE (hair nicotine), and home air quality (PM2.5), with motivational interviewing. Families were randomized to: intervention group (IG, N = 69), regular control group (RCG, N = 70), or to a secondary enhanced control group, (ECG, N = 20). Child hair samples were taken at baseline and follow-up. We report on child TSE in the IG versus RCG at six months.

RESULTS

Most enrolled families completed the trial (IG: 98.6%[68/69], RCG: 97.1%[68/70]). Log hair nicotine (LHN [ng/mg]) decreased in both the IG (Baseline: -1.78 ± 1.91, Follow-up: -2.82 ± 1.87, p = .003) and RCG (Baseline: -1.79 ± 1.54, Follow-up: -2.85 ± 1.73, p = .002), but did not differ between groups at study end (p = .635). Three of five parentally-reported outcomes showed improvement over time in the IG, and one in the RCG. Among IG participants, 90% found hair nicotine feedback useful.

CONCLUSIONS

No difference between the intervention and control groups was found on the objective biomarker, LHN. Child TSE decreased during the trial in intervention and control groups. Trial participation, which included hair nicotine monitoring, may have contributed to decreasing exposure in both groups. Concurrent control group improvements may partially explain lack of proven intervention benefit. Biomarker monitoring warrants further investigation for reduction of child TSE.

IMPLICATIONS

Project Zero Exposure is an intervention program designed to help parents protect their children from TSE. Results from the randomized controlled trial of the program showed no difference between groups at study end, but a clear and substantial reduction in child exposure to tobacco smoke from beginning to end of the trial, in both intervention and control groups. Biomarker monitoring, a key element of the trial, was used with all participants. Biomarker monitoring of child exposure to tobacco smoke may help parents become aware of their child's exposure and better protect them, and should be explored as a means to reduce child TSE. Clinical Trial Registration: NCT02867241.

Exploring stakeholder views on intervening in hospital around childhood secondhand smoke exposure (Precedent): a protocol for a qualitative study

INTRODUCTION

Secondhand smoke exposure (SHSe) in childhood is linked with increased morbidity and mortality. Hospital or secondary care contact may present a 'teachable moment' to provide parents with support to change their home smoking behaviours to reduce children's SHSe. There is a lack of robust qualitative evidence around parents and healthcare professionals (HCPs) views on using this teachable moment to successfully initiate behavioural change. We aim to identify and understand what is important to stakeholders with a view to informing the development of a support package to help parents change their home smoking behaviours.

METHODS AND ANALYSIS

This qualitative study will be theoretically underpinned by the Capability, Opportunity and Motivation Behaviour (COM-B) model of behavioural change. It will involve semistructured interviews and/or discussion groups with up to 20 parents who smoke and up to 25 HCPs. Stakeholders will be recruited from a single National Health Service children's hospital in England. Interviews and/or discussion groups will be audio recorded, transcribed and anonymised. The transcripts and any field notes will be analysed using the framework method. Initially, we will apply COM-B to the data deductively and will then code inductively within each domain.

ETHICS AND DISSEMINATION

The protocol for this study received a favourable outcome from the East Midlands Leicester Central Research Ethics Committee (19/EM/0171). Results will be written up as part of a PhD thesis, submitted for publication in peer-reviewed journals and presentation at conferences.

TRIAL REGISTRATION NUMBER

ISRCTN40084089.

Stigma and Smoking in the Home: Parents' Accounts of Using Nicotine Replacement Therapy to Protect Their Children from Second-Hand Smoke

Evidence and campaigns highlighting smoking and second-hand smoke risks have significantly reduced smoking prevalence and denormalised smoking in the home in Scotland. However, smoking prevalence remains disproportionally high in socioeconomically disadvantaged groups. Using stigma as a theoretical lens, this article presents a thematic analysis of parents' accounts of attempting to abstain from smoking at home, using nicotine replacement therapy (NRT), in disadvantaged areas of Edinburgh and the Lothians. Smoking stigma, particularly self-stigma, underpinned accounts, with two overarching themes: interplaying barriers and enablers for creation of a smoke-free home and reconceptualisation of the study as an opportunity to quit smoking. Personal motivation to abstain or stop smoking empowered participants to reduce or quit smoking to resist stigma. For those struggling to believe in their ability to stop smoking, stigma led to negative self-labelling. Previously hidden smoking in the home gradually emerged in accounts, suggesting that parents may fear disclosure of smoking in the home in societies where smoking stigma exists. This study suggests that stigma may act both as an enabler and barrier in this group. Reductions in smoking in the home were dependent on self-efficacy and motivations to abstain, and stigma was entwined in these beliefs.

Reducing Secondhand Smoke Exposure Among Nonsmoking Pregnant Women: A Systematic Review

Introduction

Exposure to secondhand smoke (SHS) in pregnancy leads to an increased risk of stillbirths, congenital malformations, and low birth weight. There is a lack of evidence about how best to achieve reductions in SHS exposure among nonsmoking pregnant women. This work systematically reviews individual or household interventions to reduce pregnant women’s exposure to SHS.

Methods

MEDLINE, EMBASE, and CINAHL databases were searched from their dates of inception to April 17, 2019. Studies were included if: participants were nonsmoking pregnant women; involved an intervention to reduce SHS exposure or encourage partner quitting; and measured SHS exposure of pregnant women and/or recorded quit rates among partners. The UK National Institute for Health & Care Excellence (NICE) Quality Appraisal checklist was used to determine internal and external validity.

Results

Nine studies met the inclusion criteria. Educational interventions were primarily targeted at the pregnant woman to change her or others’ behavior, with only two studies involving the partner who smoked. Intervention delivery was mixed, spanning brief discussions through to more involving sessions with role play. The effective interventions involved multiple follow-ups. There was no standardized method of assessing exposure to SHS. Many of the included studies had moderate to high risk of bias.

Conclusion

There is mixed evidence for interventions aimed at reducing pregnant women’s exposure to SHS, though multi-component interventions seem to be more effective. The effectiveness of family-centered approaches involving creating smoke-free homes alongside partner smoking cessation, perhaps involving pharmacological support and/or financial incentives, should be explored.

Implications

• Measures to protect nonsmoking pregnant women from SHS tend to place the responsibility for “avoidance” on the woman.

• There is little work that seeks to involve the smoking partner or other smokers in protecting pregnant women from SHS.

• Interventions to create smoke-free homes and/or smoking partner cessation need to be developed: pharmacological and financial support should be explored.

Fathers' Views and Experiences of Creating a Smoke-Free Home: A Scoping Review

Enabling parents to create a smoke-free home is one of the key ways that children's exposure to second-hand smoke (SHS) can be reduced. Smoke-free home interventions have largely targeted mothers who smoke, and there is little understanding of the barriers and facilitators that fathers experience in creating a smoke-free home. Systematic searches combining terms for fathers, homes, and SHS exposure were run in April 2019 in Web of Science's Citation Indices, PsycINFO, and PubMed for English-language studies published since 2008. The searches identified 980 records for screening, plus 66 records from other sources. Twelve studies reported in 13 papers were included in this scoping review. Eight of the studies were conducted in Asian countries (five in China, one in India, one in Japan, and one in Iran), three were conducted in Canada, and one in Turkey. Findings were extracted in verbatim text for thematic analysis. The review identified that attitudes and knowledge, cultural and social norms, gender power relations, and shifting perceptions and responsibilities related to fatherhood can impact on fathers' views of their role in relation to creating and maintaining a smoke-free home. There were too few published studies that had assessed smoke-free home interventions with fathers to draw conclusions regarding effective approaches. Research is clearly needed to inform our understanding of fathers' roles, successes and challenges in creating and maintaining a smoke-free home, so that father-inclusive rather than mother-led interventions can be developed to benefit entire households and improve gender equity as well as health.

Understanding behaviour change in context: examining the role of midstream social marketing programmes

This research examines how midstream social marketing programmes that adopt a relational and community-based approach create opportunities for individuals to make incremental changes to health behaviour. Specifically, it applies Bourdieusian theory to explore how interactions between community healthcare workers (CHWs) and members of the public generate impetus for change and foster individual agency for improved health. Qualitative interviews were carried out with members of the public and CHWs engaged in a Smokefree home and cars initiative. The findings suggest that although CHWs are challenged by resource constraints, their practices in working with individuals and families build trust and enable dialogue that bridges smoking-related health insight with home logics. These interactions can promote individual agency with a transformative effect through small changes to smoking-related dispositions, norms and practices. However, tensions with the habitus of other household members and other capital deficits can inhibit progress towards embedding new practices. The study concludes that interventions built upon community relationships show potential for addressing limitations of information-focused campaigns but there is a need to also respond to key social structures relating to the field of action for new health dispositions to become embedded in practice.

Secondhand smoking, knowledge/attitudes and socioeconomic status among married Bangladeshi women: a cross-sectional study

BACKGROUND

There is a paucity of research on knowledge/attitudes regarding the dangers of exposure to secondhand smoking (SHS) among women. The relationship between exposure to SHS, socioeconomic status (SES) and knowledge/attitudes regarding the risks of SHS has often been ignored. We therefore aimed to examine (1) whether SES and exposure to SHS were independently associated with knowledge/attitudes regarding the risks of SHS; and (2) whether women with low SES and exposure to SHS were uniquely disadvantaged in terms of deficient knowledge and more dismissive attitudes towards the risks of SHS.

DESIGN AND SETTING

Cross-sectional study in the Rajshahi district, Bangladesh.

METHODS

A total of 541 women were interviewed. Knowledge of and attitudes towards the risks of SHS were the outcomes of interest.

RESULTS

A majority of the respondents were exposed to SHS at home (49.0%). Only 20.1% had higher levels of knowledge, and only 37.3% had non-dismissive attitudes towards the risks of SHS. Participants in the low SES group and those exposed to SHS had lower odds of higher knowledge and their attitudes towards the risks of SHS were more dismissive. Regarding deficient levels of knowledge and scores indicating more dismissive attitudes, women in the low SES group and who were exposed to SHS were not uniquely disadvantaged.

CONCLUSIONS

Exposure to SHS and low SES were independently associated with deficient knowledge and scores indicating more dismissive attitudes. Regarding knowledge/attitudes, the negative effect of exposure to SHS extended across all socioeconomic backgrounds and was not limited to women in either the low or the high SES group.

Patterns of parents' perspectives on protecting young children from secondhand smoke exposure: A Q-methodology study

AIMS

To identify and describe the various patterns of parents' perspectives on avoiding secondhand smoke exposure.

DESIGN

Q methodology was applied to investigate the parental perspectives of 50 parents.

METHODS

The study was implemented from September-December 2016. Forty-two Q-statements were constructed based on the literature related to parental attitudes and prevention practices regarding preventing young children from experiencing secondhand smoke exposure. A series of Q-sorts was performed by the participants to rank the statements into a Q-sort grid. PQMethod 2.35 software was used to perform principal component analysis to identify different patterns of parents' perspectives.

RESULTS

Five patterns of shared perspectives, which accounted for 62% of the total variance, were derived from the analysis: (a) lack of confidence to confront smokers in non-smoking areas; (b) awareness of health hazards but not ready to take preventive actions; (c) emphasis on parental responsibility and behavioural guidance; (d) awareness of health rights protected by legislation; and (e) strong willingness to take protective actions.

CONCLUSION

Our findings revealed the shared perspectives of five groups of parents. The exploration of clusters of parents could assist healthcare professionals in acknowledging parents' tendencies related to attitudes and responses towards secondhand smoke exposure.

IMPACT

Using a forced distribution through the Q-sorting technique, the particular perspective patterns of parents' experiences would be captured. These findings can serve as a useful guide for researchers and practitioners to develop tailored intervention programs for parents with the purpose of reducing secondhand smoke exposure in young children.

Secondhand smoke knowledge, sources of information, and associated factors among hospital staff

Purpose

To evaluate knowledge of secondhand smoke (SHS) risks, sources of information, and associated factors and behaviors among hospital staff.

Methods

We conducted a cross-sectional survey using a 40-item self-administered questionnaire among 328 employees at a university hospital. The questions on representative diseases related to SHS were used to measure the degree of knowledge of SHS. Multiple regression analysis was used to determine the correlation between SHS knowledge scores and variables.

Results

Females had better SHS knowledge scores than males, regardless of smoking status (p<0.05). SHS knowledge was positively correlated with cessation education in males, non-smokers, and the total sample (β = 3.950, 2.356, and 2.684, respectively, p<0.05). It was correlated with the experience of any SHS exposure-related symptoms in males, non-smokers, and the total sample (β = 3.950, 2.356, and 2.684, respectively, p<0.05) and discomfort when exposed to SHS in non-smokers and the total sample (β = 0.670 and 0.821, respectively, p<0.05).

Conclusion

SHS knowledge is high among females, when hospital staff are educated about SHS risks, and when they have experienced any SHS exposure-related symptoms or felt uncomfortable when exposed to SHS. SHS risk education is an effective tool to increase SHS knowledge in hospital staff.

In-Home Secondhand Smoke Exposure Among Urban Children With Asthma: Contrasting Households With and Without Residential Smokers

CONTEXT

Secondhand smoke exposure (SHSe) affects up to half of all children in the United States. Many studies have identified factors associated with in-home SHSe, but few have contrasted these factors between households with and without residential smokers. In the latter case, exposure occurs from only external sources that enter the home, such as visitors or environmental incursion.

OBJECTIVE

Among children with SHSe at home, to examine demographic and psychosocial differences between households with and without residential smokers.

DESIGN

Baseline analysis of an observational cohort.

SETTING

Baltimore City, Maryland.

PARTICIPANTS

A total of 157 children with asthma, aged 5 to 12 years.

MEASURES

At-home airborne nicotine, caregiver-reported depression, asthma-related quality of life, functional social support, and demographics. Univariable comparisons were performed between SHS-exposed households with and without residential smokers. Multivariable logistic regression models were fit to examine associations between measured factors and absence of residential smokers.

RESULTS

Children (78.3%) had at-home SHSe. Of these, 40.7% lived in households without residential smokers. Compared with households with residential smokers, these caregivers endorsed stronger beliefs in SHS harms and also worse functional social support and asthma-related stress, despite no differences in asthma morbidity. In adjusted models, SHS-exposed children with caregivers in the lowest tertile of functional social support (adjusted odds ratio, 3.50; 95% confidence interval, 1.12-10.99), asthma-related quality of life (2.90; 1.06-7.95), and those living alone (5.28; 1.26-22.15) had at least twice higher odds of having exclusively external SHSe than the highest tertile (P trends < .05).

CONCLUSIONS

In-home SHS exposure remains alarmingly high in urban environments. However, a substantial proportion of this exposure appears to be occurring only from external sources that enter the home. Caregivers in these homes had higher desire but lower agency to avoid SHSe, driven by lack of functional support and physical isolation. Public policies targeting these factors may help remediate exposure in this especially vulnerable population.

Parental Perceptions and Misconceptions of Child Tobacco Smoke Exposure

Introduction

Forty percent of young children worldwide are exposed to the harmful effects of tobacco smoke, predominantly by parental smoking. Little is known about why parents regularly expose their children to these risks; perhaps parents underestimate the degree of exposure. Qualitative methods were used to investigate parental perceptions of tobacco smoke exposure.

Methods

Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel. Parents were asked to explain what "exposure to smoking" meant. Thematic analysis was performed, a conceptual model of perceptions was built, and misconceptions were identified.

Results

Parents reported that exposure occurs when smoke or smokers are visible, when smoke can be smelled, felt, or inhaled, or when it "reaches" an individual. Conversely, some believed that exposure does not occur in the absence of odor, visible smoke, or smokers or if smoking occurs outdoors or in indoor ventilated environments. Proximity in space and time affected perceptions of exposure; some parents believed that smoke does not spread far but dissipates rapidly. There was some uncertainty regarding whether or not exposure was occurring.

Conclusions

Awareness of child exposure to tobacco smoke among parents in this study was based on sensory perceptions in the context of the physical environment. The limited capacity of humans to perceive tobacco smoke can lead to misconceptions about exposure. In order to protect children, parents must be convinced that exposure can occur even in situations where they are unable to sense it.

Implications

Parents use sensory perceptions (sight, smell, and feel) in the context of the physical environment to assess whether or not their children are exposed to tobacco smoke. Because 85% of smoke is invisible and the sense of smell is unreliable, assessments based on sensory perceptions cannot provide accurate information about the presence of tobacco smoke. In order to protect children, parents must be convinced that exposure can occur even in situations where they are unable to sense it. The scientific information summarized here about exposure in common situations should be useful in persuading parents to protect their children.

Clinical Trial Registration

This study is registered as a Phase I study which is part of a larger research endeavor entitled: A program to protect young children from tobacco smoke exposure. Registration number: NCT01335178.

Developing an Awareness Campaign to Reduce Second Hand Smoke Among Disadvantaged Families-A Participatory M-Health Approach

Children from disadvantaged families are particularly exposed to second hand smoke in their home environment. Using a mixed methods participatory approach, we aimed at identifying suitable media channels and appropriate content for a campaign increasing caregivers' knowledge about the risks of second hand smoke (SHS) exposure for their children and appropriate measures for exposure reduction. In the first phase of the mixed method design, we evaluated knowledge and norms about children's SHS and perceived barriers for avoiding it. To this end, we conducted 26 one-to-one interviews with smoking caregivers of children below the age of six years. Subsequently, we developed and illustrated core messages and identified appropriate communication channels. These were evaluated in focus group discussions by 20 of the 26 interview participants. After a final revision, 121 caregivers evaluated the campaign via an online questionnaire. Online social networks were identified as the most suitable media channel. For these, we developed animated photos with voiceovers addressing the potential consequences of SHS for children. The overall rating of the campaign messages was promising. Participants confirmed that it was important to address the issue in social media. However, sharing the pictures was considered unlikely due to the sensitive topic of the campaign, while the importance of doctors or scientists being recognizable as a source was highlighted. Employing a participatory approach, we developed an m-health campaign, which can now be disseminated in social networks to reach the target population. The effectiveness of the campaign should be evaluated.

Coaching to create a smoke-free home in a brief secondhand smoke intervention

Few community interventions exist to reduce secondhand exposure to tobacco smoke in the home. This study presents the coaching process of a larger intervention to promote smoke-free homes across an efficacy and 2 effectiveness trials. It furthers assesses the coaching call's reach and participants' satisfaction with the call across three intervention sites. The sources of the data were from baseline and 3-month follow-up surveys, coaching forms or online tracking system and interviews with coaches. Reach for the coaching call across trials was fairly high from 72% to 92%. Overall, the majority of participants were highly satisfied with the intervention (M = 3.76) and found it useful in creating a smoke-free home (M = 3.63). Common goals set were changing the environment to support a home smoking ban (e.g. putting up signs, removing ashtrays) (82%) or picking a date (60%). Challenges to a smoke-free home were consistent with other literature on barriers related to household smoking restrictions, including need for assistance in quitting, outside weather and smokers who do not want to quit. Additional research is needed to explore differential reach and reactions to the coaching call as it is disseminated and the impact of coaching call on the outcome of a smoke-free home.

A randomised controlled trial of a complex intervention to reduce children's exposure to secondhand smoke in the home

Objectives

Exposing children to secondhand tobacco smoke (SHS) causes significant harm and occurs predominantly through smoking by caregivers in the family home. We report a trial of a complex intervention designed to reduce secondhand smoke exposure of children whose primary caregiver feels unable or unwilling to quit smoking.

Design

An open-label, parallel, randomised controlled trial.

Setting

Deprived communities in Nottingham City and County, England

Participants

Caregivers resident in Nottingham City and County in England who were at least 18 years old, the main caregiver of a child aged under 5 years living in their household, and reported that they were smoking tobacco inside their home.

Interventions

We compared a complex intervention combining personalised feedback on home air quality, behavioural support and nicotine replacement therapy for temporary abstinence with usual care.

Main outcomes

The primary outcome was change in air quality in the home, measured as average 16–24  hours levels of particulate matter of  < 2.5  µm diameter (PM_2.5), between baseline and 12 weeks. Secondary outcomes included changes in maximum PM_2.5, proportion of time PM_2.5 exceeded WHO recommended levels of maximum exposure of 25  µg/mg³, child salivary cotinine, caregivers’ cigarette consumption, nicotine dependence, determination to stop smoking, quit attempts and quitting altogether during the intervention.

Results

Arithmetic mean PM_2.5 decreased significantly more (by 35.2 %; 95%  CI 12.7% to 51.9 %) in intervention than in usual care households, as did the proportion of time PM_2.5 exceeded 25  µg/mg³, child salivary cotinine concentrations, caregivers’ cigarette consumption in the home, nicotine dependence, determination to quit and likelihood of having made a quit attempt.

Conclusions

By reducing exposure to SHS in the homes of children who live with smokers unable or unwilling to quit, this intervention offers huge potential to reduce children’s’ tobacco-related harm.

Trial registration number

ISRCTN81701383.

This trial was funded by the UK National Institute for Health Research (NIHR): RP-PG-0608-10020

Environmental Tobacco Smoke Exposure and Smoke-Free Rules in Homes among Socially-Disadvantaged Populations in Poland

This study aims to examine the prevalence of exposure to environmental tobacco smoke (ETS) in homes among socially-disadvantaged populations in Poland, along with the prevalence and correlates of voluntary implementation of smoke-free home rules. Data concerning 1617 respondents from a cross-sectional study completed in the Piotrkowski District were used, which was part of the "Reducing Social Inequalities in Health" program. Overall, 19.4% of the respondents declared exposure to ETS at home. In the non-smokers group, 15.5%, including 6.6% males and 18.3% females, were exposed to ETS in their place of residence (p < 0.0001). Complete smoke-free rules were adopted by 22.1% of the study participants. Two factors, smoker status and lack of ETS-associated health risk awareness, were found to be significantly associated with no adoption of total smoking bans at home. Socially-disadvantaged non-smokers, especially females from rural areas in Poland, still constitute a large population exposed to ETS in their homes-a challenge from the perspective of public health. Focused efforts are required to address social norms around exposing others to ETS.

Using e-cigarettes in the home to reduce smoking and secondhand smoke: disadvantaged parents' accounts

Electronic cigarettes (e-cigarettes) are subject to considerable public health debate. Most public health experts agree that for smokers who find it particularly challenging to quit, e-cigarettes may reduce harm. E-cigarette use in the home may also reduce children's secondhand smoke (SHS) exposure, although e-cigarette vapour may pose risks. This is the first qualitative study to explore disadvantaged parents' views and experiences of e-cigarettes in relation to reducing SHS exposure in the home. Interviews with 25 disadvantaged parents from Edinburgh who smoked and had children aged 1-3 were conducted in 2013, with 17 re-interviewed in 2014. Accounts of e-cigarette perceptions and use were analysed thematically. E-cigarettes were seen by some as potentially valuable in helping quitting or reducing smoking in difficult circumstances, and protecting children from SHS when smoking outside is constrained. However, parents raised concerns about safety issues and continuing their nicotine addiction. In relation to children, concerns included possible health effects of the vapour, children playing with them and role-modelling e-cigarette use. While significant concerns remain about e-cigarettes, for some parents who find it challenging to quit or safely leave their children to smoke outside, e-cigarettes may offer potential for reducing the harm to them and their children.

Protecting children from secondhand smoke: a mixed-methods feasibility study of a novel smoke-free home intervention

BACKGROUND

Globally, 40 % of children under 14 years are regularly exposed to secondhand smoke (SHS), typically in their homes. There is limited evidence of the effectiveness of interventions to reduce children's SHS exposure, and so the aim of this study was to test the feasibility and acceptability of a novel intervention to help parents and carers (caregivers) to reduce their children's exposure to SHS at home.

METHODS

A novel multi-component intervention to support caregivers to reduce their children's SHS exposure at home was tested in a two-phase feasibility study. The 12-week intensive intervention delivered in the home consisted of three components: behavioural support, nicotine replacement therapy (NRT) for temporary abstinence and feedback on levels of SHS exposure in the form of children's salivary cotinine (phase 1) or home air quality (PM2.5) (phase 2). Participants were caregivers who smoked inside their homes and had at least one child under the age of 5 years living with them the majority of the time. Mixed-methods were used to explore the acceptability and feasibility of the intervention as well as processes, particularly around recruitment and retention, for an exploratory efficacy trial.

RESULTS

Twelve caregivers completed the study, all received personalised feedback on SHS exposure and behavioural support to help them to make their homes smoke-free and the majority at least tried NRT. Saliva cotinine results were variable in phase 1, and therefore, measures of PM2.5 were used for feedback in phase 2. Behavioural support was well received with personalised feedback reported as being the key motivator for initiating and maintaining behaviour change.

CONCLUSIONS

Recruiting disadvantaged caregivers was labour intensive, but once recruited, this novel intervention was both feasible and acceptable in supporting caregivers to reduce their children's exposure to SHS at home. It is appropriate to test the efficacy of this novel intervention in an exploratory randomised controlled trial.

TRIAL REGISTRATION

This is not applicable for the current study; however, a registered exploratory randomised controlled trial linked to this manuscript is currently ongoing (ISRCTN81701383).

Disadvantaged Parents' Engagement with a National Secondhand Smoke in the Home Mass Media Campaign: A Qualitative Study

Mass media campaigns can be effective in tobacco control but may widen health inequalities if they fail to engage disadvantaged smokers. This qualitative study explored how parents with young children living in disadvantaged circumstances engaged with a national campaign which aimed to raise awareness of the importance of smokefree homes. Individual semi-structured interviews were carried out with 17 parents before and after the Scottish 2014 “Right Outside” mass media campaign. A conceptual framework exploring meaningful exposure (recall and understanding), motivational responses (protecting children from secondhand smoke (SHS)) and opportunities to act (barriers) was used to thematically analyse the findings. Campaign recall and engagement, and motivation to protect children were high. Parents identified with the dramatized scenario and visual impact of SHS harm to children in the TV advertisement. Some reported changed smoking practices. However, supervising young children in limited accommodation when caring alone constrained opportunities to smoke outside. Instead, parents described actions other than smoking outside that they had taken or were planning to take to create smokefree homes. Mass media campaigns using emotive, real-life circumstances can be effective in engaging parents about SHS. However, the behavioural impact may be limited because of difficult home environments and circumstances.

Barriers and motivators to reducing secondhand smoke exposure in African American families of head start children: a qualitative study

OBJECTIVE

To identify barriers and motivators for reducing secondhand smoke exposure (SHSe) for families of African-American, low-income, urban children.

METHOD

Audiotaped intervention sessions of 52 African-American caregivers of Head Start children who reported being a smoker and/or had at least one smoker in the home were randomly sampled from a larger trial examining the effectiveness of a motivational-interviewing intervention in reducing child's SHSe. Counseling sessions were qualitatively coded to identify barriers and motivators to implementing a home smoking ban or quitting smoking.

RESULTS

African-American families identified several themes that were either or both barriers and motivators for SHSe reduction, including: asking others not to smoke, other family living in the home, neighborhood safety, absence of childcare, cost/availability of cessation tools, physician support and prevention of health problems.

DISCUSSION

Urban, low-income African-American families face numerous barriers to reducing SHSe. Families were able to identify many motivators for reducing SHSe, suggesting an awareness of the importance for SHSe reduction but uncertainty in their confidence to change behaviors. Counseling should include tailoring to be most effective in supporting health behavior change. Greater emphasis on motivators is needed, such as low-cost/free cessation tools, engagement from physicians and greater involvement of extended family members.

Radon, Secondhand Smoke, and Children in the Home: Creating a Teachable Moment for Lung Cancer Prevention

OBJECTIVE

This study determined whether having minor children in the home was associated with the teachable moment (TM) constructs of lung cancer worry, perceived risk, health-related self-concept, and the novel construct of synergistic risk.

DESIGN AND SAMPLE

Secondary data analysis of baseline data from a randomized controlled trial of an intervention to reduce home exposure to radon and secondhand smoke (SHS). Quota sample of adults recruited at a Central Kentucky academic medical center (N = 556).

MEASURES

Survey items assessed lung cancer worry, perceived risk, synergistic risk perception, and health-related self-concept.

RESULTS

The presence of children in the home was not a significant predictor of any construct needed to create a TM for lung cancer prevention. Individuals with children living in the home were more likely to be younger, a racial/ethnic minority, a current smoker, and live with a smoker compared to those without children in the home.

CONCLUSIONS

There is a critical need to raise parental awareness on child health inequities related to the home exposure to radon and SHS. Public health nurses can create TMs for lung cancer prevention through greater awareness of the risks posed by radon and SHS along with promoting home testing and low-cost resources to reduce risk.

Cost Analysis of Motivational Interviewing and Preschool Education for Secondhand Smoke Exposures

INTRODUCTION

This study determines if expenditures associated with implementing a combined motivational interviewing (MI) and Head Start-level education program (MI+Education), as compared to education alone, yield cost savings to society.

METHODS

Post hoc cost analyses were applied to a randomized controlled-trial of MI among predominantly African American, low-income caregivers of 330 Baltimore City Head Start students who reside with a smoker. The primary outcome was the cost savings of MI+Education from averted direct secondhand smoke exposure (SHSe)-related acute healthcare events and inferred indirect costs (work days lost, transportation and reduction in cigarettes smoked). The net direction of savings was defined by the sum of averted direct and indirect costs of the MI+Education intervention at 3, 6 and 12 months, benchmarked against the Education alone cohort at the equivalent time periods.

RESULTS

The costs saved by the MI+Education intervention, relative to Education alone, resulted in savings at solely the 12-month follow-up time point. Significant savings were appreciated from averted emergency department (ED) visits at 12 months ($4410; 95% simulation interval [SI]: $2241, $6626) for the MI+Education group. The total savings at 12 months ($2274; 95% SI: -3916, $8442) could not overcome additional program costs of implementing MI to Head Start-level education ($13 695; 95% SI: $11 250, $16 034).

CONCLUSIONS

This study is the first to examine the cost of either intervention on SHSe-attributed pediatric healthcare costs from a population level relevant for federal and community decision makers. Intervention costs could not be offset by short-term savings but a trend towards positive savings was appreciated 1 year after implementation.

IMPLICATIONS

Behavioral interventions are effective in reducing SHSe in children. However, many of these interventions are not implemented in community settings due to lack of resources and money. Behavioral strategies may be a cost-saving addition to the national initiatives to create smoke-free home environments. The long-term benefits of MI, as evidenced from cost savings from averted ED visits, appeared to show MI+Education to be a robust long-term strategy. The decrease of acute healthcare services at 12 months may be informative for policy decision makers seeking to allocate limited resources to reduce the usage of costly ED services and hospital readmissions.

Smoke-free homes: what are the barriers, motivators and enablers? A qualitative systematic review and thematic synthesis

OBJECTIVE

To thematically synthesise primary qualitative studies of the barriers, motivators and enablers of smoke-free homes (SFHs).

DESIGN

Systematic review and thematic synthesis.

DATA SOURCES

Searches of MEDLINE, EBM Reviews (Cochrane Database of Systematic Reviews), PsycINFO, Global Health, CINAHL, Web of Science, Informit and EMBASE, combining terms for families, households and vulnerable populations; SFH and secondhand smoke; and qualitative research, were supplemented by searches of PhD theses, key authors, specialist journals and reference lists.

STUDY SELECTION

We included 22 articles, reporting on 18 studies, involving 646 participants.

INCLUSION CRITERIA

peer-reviewed; English language; published from 1990 onwards (to week 3 of April 2014); used qualitative data collection methods; explored participants' perspectives of home smoking behaviours; and the barriers, motivators and enablers to initiating and/or maintaining a SFH.

DATA EXTRACTION

1 of 3 authors extracted data with checking by a second.

DATA SYNTHESIS

A thematic synthesis was performed to develop 7 core analytic themes: (1) knowledge, awareness and risk perception; (2) agency and personal skills/attributes; (3) wider community norms and personal moral responsibilities; (4) social relationships and influence of others; (5) perceived benefits, preferences and priorities; (6) addiction and habit; (7) practicalities.

CONCLUSIONS

This synthesis highlights the complexity faced by many households in having a SFH, the practical, social, cultural and personal issues that need to be addressed and balanced by households, and that while some of these are common across study settings, specific social and cultural factors play a critical role in shaping household smoking behaviours. The findings can inform policy and practice and the development of interventions aimed at increasing SFHs.

TRIAL REGISTRATION NUMBER

CRD42014014115.

'Only Fathers Smoking' Contributes the Most to Socioeconomic Inequalities: Changes in Socioeconomic Inequalities in Infants' Exposure to Second Hand Smoke over Time in Japan

BACKGROUND

Exposure to second hand smoke (SHS) is one of the major causes of premature death and disease among children. While socioeconomic inequalities exist for adult smoking, such evidence is limited for SHS exposure in children. Thus, this study examined changes over time in socioeconomic inequalities in infants' SHS exposure in Japan.

METHODS

This is a repeated cross-sectional study of 41,833 infants born in 2001 and 32,120 infants born in 2010 in Japan from nationally representative surveys using questionnaires. The prevalence of infants' SHS exposure was determined and related to household income and parental education level. The magnitudes of income and educational inequalities in infants' SHS exposure were estimated in 2001 and 2010 using both absolute and relative inequality indices.

RESULTS

The prevalence of SHS exposure in infants declined from 2001 to 2010. The relative index of inequality increased from 0.85 (95% confidence interval [CI], 0.80 to 0.89) to 1.47 (95% CI, 1.37 to 1.56) based on income and from 1.22 (95% CI, 1.17 to 1.26) to 2.09 (95% CI, 2.00 to 2.17) based on education. In contrast, the slope index of inequality decreased from 30.9 (95% CI, 29.3 to 32.6) to 20.1 (95% CI, 18.7 to 21.5) based on income and from 44.6 (95% CI, 43.1 to 46.2) to 28.7 (95% CI, 27.3 to 30.0) based on education. Having only a father who smoked indoors was a major contributor to absolute income inequality in infants' SHS exposure in 2010, which increased in importance from 45.1% in 2001 to 67.0% in 2010.

CONCLUSIONS

The socioeconomic inequalities in infants' second hand smoke exposure increased in relative terms but decreased in absolute terms from 2001 to 2010. Further efforts are needed to encourage parents to quit smoking and protect infants from second hand smoke exposure, especially in low socioeconomic households that include non-smoking mothers.

The effectiveness of tobacco control television advertisements in increasing the prevalence of smoke-free homes

BACKGROUND

There is considerable evidence that tobacco control mass media campaigns can change smoking behaviour. In the UK, campaigns over the last decade have contributed to declines in smoking prevalence and been associated with falls in cigarette consumption among continuing smokers. However, it is less evident whether such campaigns can also play a role in changing smokers' behaviour in relation to protecting others from the harmful effects of their smoking in the home. We investigated whether exposure to English televised tobacco control campaigns, and specifically campaigns targeting second hand smoking, is associated with smokers having a smoke-free home.

METHODS

We used repeated cross-sectional national survey data on 9872 households which participated in the Health Survey for England between 2004 and 2010, with at least one adult current smoker living in the household. Exposure to all government-funded televised tobacco control campaigns, and to those specifically with a second hand smoking theme, was quantified in Gross Rating Points (GRPs), an average per capita measure of advert exposure where 100 GRPs indicates 100 % of adults exposed once or 50 % twice. Our outcome was self-reported presence of a smoke-free home (where no one smokes in the home on most days). Analysis used generalised additive models, controlling for individual factors and temporal trends.

RESULTS

There was no association between monthly televised campaigns overall and the probability of having a smoke-free home. However, exposure to campaigns specifically targeting second hand smoke was associated with increased odds of a smoke-free home in the following month (odds ratio per additional 100 GRPs, 1.07, 95 % CI 1.01 to 1.13), though this association was not seen at other lags. These effects were not modified by socio-economic status or by presence of a child in the home.

CONCLUSIONS

Our findings provide tentative evidence that mass media campaigns specifically focussing on second hand smoke may be effective in reducing smoking in the home, and further evaluation of campaigns of this type is needed. General tobacco control campaigns in England, which largely focus on promoting smoking cessation, do not impact on smoke-free homes over and above their direct effect at reducing smoking.

"I don't mind damaging my own body" a qualitative study of the factors that motivate smokers to quit

Background

Although smoking prevalence in England has declined, one in five adults smoke. Smokers are at increased risk of a number of diseases, including COPD which affects an estimated 1.5 million people in England alone. This study aimed to explore issues relating to smoking behaviour and intention to quit that might be used to inform the development of cessation interventions. Issues explored included knowledge of smoking related disease, with a particular emphasis on Chronic Obstructive Pulmonary Disease (COPD). Understanding around risk of disease, including genetic risk was explored, as were features of appropriate and accessible cessation materials and support.

Methods

Semi-structured interviews and focus groups were conducted with a total of 30 individuals of which 17 were smoking cessation clients and 13 were professionals working within health care settings relevant to supporting smokers to quit. A largely purposive approach was taken to sampling, and data were analysed using the constant comparative method.

Results

Knowledge of the smoking related disease COPD was limited. Smokers’ concerns around risk of disease were influenced by their social context and were more focussed on how their smoking might impact on the health of their family and friends, rather than how it might impact on them as individuals. Participants felt the provision of genetic risk information may have a limited impact on motivation to quit. Genetic risk was considered to be a difficult concept to understand, particularly as increased risk does not mean an individual will definitely develop disease. In terms of cessation approaches, the use of visual media was consistently supported, as was the use of materials that linked directly with life experiences. Images of children inhaling second hand smoke for example, had a particular impact.

Conclusions

Public health messages around the risks of smoking and approaches to quitting should continue to have an emphasis on the dangers that an individual’s smoking has on the lives of the people around them. More work also needs to be done to raise awareness around both the risk of COPD in smokers and the impact this disease has on quality of life and life expectancy.

Reducing environmental tobacco smoke exposure of preschool children: a randomized controlled trial of class-based health education and smoking cessation counseling for caregivers

OBJECTIVES

To assess counseling to caregivers and classroom health education interventions to reduce environmental tobacco smoke exposure of children aged 5-6 years in China.

METHODS

In a randomized controlled trial in two preschools in Changsha, China, 65 children aged 5-6 years old and their smoker caregivers (65) were randomly assigned to intervention (n = 33) and control (no intervention) groups (n = 32). In the intervention group, caregivers received self-help materials and smoking cessation counseling from a trained counselor, while their children were given classroom-based participatory health education. Children's urinary cotinine level and the point prevalence of caregiver quitting were measured at baseline and after 6 months.

RESULTS

At the 6-month follow-up, children's urinary cotinine was significantly lower (Z = -3.136; p = 0.002) and caregivers' 7-day quit rate was significantly higher (34.4% versus 0%) (p < 0.001; adjusted OR = 1.13; 95% CI: 1.02-1.26) in the intervention than control group.

CONCLUSIONS

Helping caregivers quitting smoke combined with classroom-based health education was effective in reducing children's environmental tobacco smoke exposure. Larger-scale trials are warranted.

Predictors of children's secondhand smoke exposure at home: a systematic review and narrative synthesis of the evidence

BACKGROUND

Children's exposure to secondhand smoke (SHS) has been causally linked to a number of childhood morbidities and mortalities. Over 50% of UK children whose parents are smokers are regularly exposed to SHS at home. No previous review has identified the factors associated with children's SHS exposure in the home.

AIM

To identify by systematic review, the factors which are associated with children's SHS exposure in the home, determined by parent or child reports and/or biochemically validated measures including cotinine, carbon monoxide or home air particulate matter.

METHODS

Electronic searches of MEDLINE, EMBASE, PsychINFO, CINAHL and Web of Knowledge to July 2014, and hand searches of reference lists from publications included in the review were conducted.

FINDINGS

Forty one studies were included in the review. Parental smoking, low socioeconomic status and being less educated were all frequently and consistently found to be independently associated with children's SHS exposure in the home. Children whose parents held more negative attitudes towards SHS were less likely to be exposed. Associations were strongest for parental cigarette smoking status; compared to children of non-smokers, those whose mothers or both parents smoked were between two and 13 times more likely to be exposed to SHS.

CONCLUSION

Multiple factors are associated with child SHS exposure in the home; the best way to reduce child SHS exposure in the home is for smoking parents to quit. If parents are unable or unwilling to stop smoking, they should instigate smoke-free homes. Interventions targeted towards the socially disadvantaged parents aiming to change attitudes to smoking in the presence of children and providing practical support to help parents smoke outside the home may be beneficial.

Increased knowledge of the effects of smoking and second-hand smoke encourages smoke-free homes

Objective

To establish the drivers for smoke-free homes among current daily smokers.

Design

A cross-sectional study employing interviews (adults) and self-completed surveys (schoolchildren).

Sample

Children aged 12 and 14 in schools in four cities in China, India, Mexico and England. Adults in the community.

Measurements

Knowledge, attitude, beliefs and behaviour relevant to second-hand smoke in home.

Intervention

None.

Results

A total of 8994 adults and 14,756 children were surveyed. Knowledge of some of the effects of tobacco is high, but other effects are poorly understood in all cities. In Thiruvananthapuram, there is a lack of awareness of the addictiveness of tobacco, and Hangzhou has poor knowledge in general.

Conclusions

Messages about reducing tobacco usage are effective in support of smoke-free homes in the city with poorest knowledge (Hangzhou) but other factors are more important where knowledge is high.

Protecting children from smoking in the home: an ethics of care perspective

Community nurses are uniquely placed to help protect child health by facilitating the creation of smoke-free homes. However, there are a number of perceived barriers that may concern community nurses in their role of supporting parents in the creation of smoke-free homes, particularly those faced by disadvantaged parents. Arguments against intervening within the private domain of the home focus on concerns about protecting parents' autonomy to smoke within their own home and the potential for stigmatising parents who smoke, particularly mothers. Drawing on an ethics of care perspective, the authors propose an alternative perspective to the intervention in private settings. An ethics of care perspective may help to justify and encourage parents and community nurses to work in partnership to create a healthy environment for children and decrease the likelihood of children becoming smokers in the future.

Smoke-free homes, strength of smoke-free law, and children in the home

INTRODUCTION

Secondhand smoke (SHS) is a leading cause of childhood illness and premature death, especially in rural areas. The study examined the relationship of having a smoke-free home, strength of smoke-free law (SFL) in the county of residence, having one or more minor children in the home, rural/urban location, and demographics.

METHODS

An Internet-based panel survey was administered to Kentucky residents from 2007 to 2012. Sample size ranged from 400 to 513 per year; N = 2,653 total. Most were female, aged 35-54, had at least some college education, and lived in a smoke-free home. Almost half lived in a county with a comprehensive SFL; 14% lived in a county with a moderate or weak law.

RESULTS

Multivariate logistic regression revealed that the significant predictors of a smoke-free home included having education beyond high school, being a nonsmoker, living in an urban county, and having a year of participation in the survey. Controlling for smoking status and other personal characteristics, those who responded to the survey in the last 2 years of administration were more likely to have a smoke-free home compared to the reference year of 2007. Respondents living in urban counties were nearly 2 times more likely to report a smoke-free home than rural dwellers.

CONCLUSIONS

Smoke-free homes in urban areas, where SFLs may be the norm, may be more typical than in rural communities. Public awareness campaigns and education about the benefits of smoke-free homes is needed, especially in rural areas, targeting smokers, those with less education, and those with children living in the home.

Factors associated with parental smoking in the presence of school-aged children: a cross-sectional study

Background

In 2009, the Tobacco Hazards Prevention Act (Taiwan) was amended to more effectively restrict smoking in indoor public places and workplaces in Taiwan. However, the lack of prohibitions for smoking in private homes may place family members at increased risk for exposure to environmental tobacco smoke (ETS). The aim of our study was to determine the factors associated with parental smoking in the presence of children at home.

Methods

In 2010, we performed a cross-sectional study of factors associated with parental smoking in the presence of children at home in Taiwan using self-administered questionnaires. Quota sampling was used to select five primary schools from four different regions of Taiwan. Parents were surveyed to identify parental smokers and 307 parental smokers were selected for participation in our study. Questionnaire data regarding parental smoking in the presence of children at home and related interactions among family members were analyzed. Hierarchical logistic regression was used to determine the best-fit model for examining the relationships among the variables related to parental smoking in the presence of children at home.

Results

Two-thirds of parents who smoked reported smoking in the presence of their children. The results of the hierarchical logistic regression analysis identified the smokers’ compliance with their family’s antismoking responses, mutual agreement with smoking bans, daily smoking, smoking more than 20 cigarettes per day, the education level of the parental smoker, and the annual family income as determinants of smoking in the presence of children at home.

Conclusions

Households with smoking parents should be targeted for interventions to encourage the adoption and enforcement of home smoking bans. Educational interventions that promote smoke-free homes for children and provide support to help parents stop smoking are critical factors in reducing the frequency of children’s ETS exposure in the home.

How do policy advisors and practitioners prioritise the protection of children from secondhand smoke exposure in a country with advanced tobacco control policy?

OBJECTIVES

The aim is to extend understanding of the policy and practice discourses that inform the development of national tobacco control policy to protect children from secondhand smoke exposure (SHSE) in the home, particularly in a country with successful implementation of smoke-free public places legislation. The Scottish experience will contribute to the tobacco control community, particularly those countries at a similar level of tobacco control, as normalising discourses about protecting children from SHSE are becoming more widespread.

DESIGN

Case study design using qualitative interviews and focus groups (FGs) with policy makers, health and childcare practitioners during which they were presented with the findings of the Reducing Families' Exposure to Secondhand Smoke (REFRESH) intervention and discussed the implications for their policy and practice priorities.

SETTING

Scotland, UK PARTICIPANTS: Qualitative interviews and FGs were conducted with 30 policy makers and practitioners who were purposively recruited.

RESULTS

Participants accepted the harm of SHSE to children; however, action is limited by political expedience due to-the perception of a shift of the public health priority from smoking to alcohol, current financial constraints, more immediate child protection concerns and continuing unresolved ethical arguments.

CONCLUSIONS

In a country, such as Scotland, with advanced tobacco control strategies, there continue to be challenges to policy and practice development in the more contentious arena of the home. Children's SHSE in their homes is unequivocally accepted as an important health priority, but it is not currently perceived to be a top public health priority in Scotland.

The role of nicotine replacement therapy for temporary abstinence in the home to protect children from environmental tobacco smoke exposure: a qualitative study with disadvantaged smokers

BACKGROUND

Nicotine replacement therapy (NRT) has recently been licensed to help smokers to abstain from smoking for short time periods and recent studies have shown that 8-14% of smokers are regularly using NRT to cope when they cannot or are not allowed to smoke. These data suggest that, potentially, NRT for temporary abstinence might be an acceptable method to help smoking caregivers, who are not able to stop smoking completely, to avoid smoking whilst inside their home in order to protect their children from the harms of environmental tobacco smoke (ETS). The aim of this study was therefore to explore the concept of using NRT for temporary abstinence in the home, to protect children from exposure to ETS.

METHODS

Qualitative in-depth interviews were conducted with thirty six disadvantaged smoking parents who were currently, or had recently stopped smoking in the home with at least one child under the age of five. Parents were recruited from Children's Centres and Health Visitor Clinics in Nottingham, UK. Interviews were audio recorded and transcribed verbatim. Data were coded and analysed thematically to identify emergent main and subthemes.

RESULTS

Overall, participants responded negatively to the concept of attempting temporary abstinence in the home in general and more specifically to the use of NRT whilst at home to reduce children's exposure to ETS. Many parents would prefer to either attempt cutting down or quitting completely to make a substantial effort to change their smoking behaviour. There was limited interest in the use of NRT for temporary abstinence in the home as a first step to quitting, although some parents did express a willingness to use NRT to cut down as a first step to quitting.

CONCLUSION

Disadvantaged smoking parents were reluctant to initiate and maintain temporary abstinence with or without NRT as a way of making their homes smoke free to protect their children's health. More education about the specific risks of ETS to their children and the utility of NRT for use in the home might be needed to have a public health impact on children's health.

Space and power: young mothers' management of smoking in extended families in China

Multigenerational co-residence is a widespread phenomenon in China but there is little knowledge about the impact of power dynamics on smoking behaviors among extended family residents. Using a gender lens, this ethnographic study explored how young mothers in extended families in mainland China managed the smoking of their husbands and other family members. Analysis of data resulted in a model of 'two units-three domains' to reflect gendered relationships between young mothers and other family members, and young mothers' participation in family management. Exploration of the mothers' efforts to deal with household smoking using the model provided an explanation for why the young mothers had limited control over household space and could only impose partial restrictions on home smoking in the extended family.

'I'm not doing this for me': mothers' accounts of creating smoke-free homes

This article explores mothers' narratives of changing home smoking behaviours after participating in an intervention (Reducing Families' Exposure to Smoking in the Home [REFRESH]) aimed at reducing families' exposure to secondhand smoke (SHS) in homes in Scotland. An analysis of qualitative findings illuminates quantitative changes in levels of SHS exposure. Prospective quantitative and qualitative data were drawn from 21 smoking mothers with at least one child under 6 years. Quantitative change was measured by home air quality, i.e. fine particulate matter <2.5μg (PM(2.5)). These measurements guided the organization of mothers into categories of change (smoke-free home at baseline [SFB], smoke-free home at final, some change and no change [NC]). Qualitative data from 17 mothers with non-SFB were analysed thematically within and across these categories. Three comparative case studies illustrate the varying changes made, barriers to change and how mothers valued such changes. The outcomes varied post-intervention, with homes smoke-free, partially smoke-free or making NC. The changes in home smoking behaviour were incremental, yet beneficial to reducing SHS exposure, and related to the nature of the restrictions and personal circumstances in the home pre-intervention. Across all change categories, mothers valued the changes they had made and expressed an intention to increase the changes.

Children, smoking households and exposure to second-hand smoke in the home in rural Australia: analysis of a national cross-sectional survey

OBJECTIVES

This paper aimed to explore the association between rurality and (1) household smoking status and (2) home second-hand smoke exposure, in households with children aged 0-14 years.

DESIGN

Cross-sectional study.

SETTING

Households across Australia.

PARTICIPANTS

Households across the country were randomly selected to provide a nationally representative sample. Respondents were persons aged 12 years or older in each household who were next going to celebrate their birthday.

PRIMARY OUTCOME MEASURES

Household smoking status and smoking inside the home.

METHODOLOGY

The 2010 Australian National Drug Strategy Household survey data were analysed to explore the prevalence of household smoking and home second-hand smoke exposure in rural and urban households with children. Multivariable logistic regression was used to explore the association of rurality with household smoking and with home second-hand smoke exposure, controlling for potential confounders.

RESULTS

Households with children were more likely to be smoking households (35.4%, 95% CI 34.2% to 36.5%) than households without children (32.1%, 95% CI 31.3% to 32.8%). Both household smoking (43.6% (95% CI 41.5% to 45.7%) vs 31.4% (95% CI 30.0% to 32.8%)) and home second-hand smoke exposure (8.0% (95% CI 6.8% to 9.1%) vs 5.2% (95% CI 4.5% to 5.8%)) were significantly more common for rural children. In multivariate analyses controlling for confounding factors, rurality remained associated with smoking households (OR 1.21, 95% CI 1.07 to 1.37), whereas it did not remain associated with children's home second-hand smoke exposure (OR 1.07, 95% CI 0.85 to 1.35). Larger household size, low socioeconomic status and being a single-parent household were the main drivers of home second-hand smoke exposure.

CONCLUSIONS

The proportion of smoking households with children, and the number of children regularly exposed to second-hand smoke in their homes remain important public health concerns. Smoking cessation support and tobacco control policies might benefit from targeting larger and/or socioeconomically disadvantaged households including single-parent households.

Evaluation of a programme to increase referrals to stop-smoking services using Children's Centres and smoke-free families schemes

AIMS

To assess the feasibility and effectiveness of a new service using referral liaison advisers to increase the number of referrals of parents/carers at selected Children's Centres to National Health Service (NHS) Stop Smoking Services (SSS) and/or smoke-free families schemes (SFS).

DESIGN

This mixed-methods pilot study collected numerical data on indicators of smoking behaviours and carried out face-to-face and telephone interviews.

SETTINGS

Thirteen Children's Centres in Liverpool and Nottingham using local providers of smoking cessation services, from September 2010 to April 2011.

PARTICIPANTS

Parents and carers registered with, and staff working for, Children's Centres.

MEASURES

Number of smokers referred to smoking cessation services and/or smoke-free family schemes and the views of service providers and users on the new service.

FINDINGS

In Liverpool, 181 referrals to NHS SSS were made from 331 identified smokers (54.7%); extrapolated to 12 months, this represents a 182% increase in referrals from baseline and a similar extrapolation indicates a 643% increase from baseline of referrals to smoke-free families schemes. There were no reliable baseline data for Nottingham; 31 referrals were made (30.7% of smokers) to SSS and 44 referrals to SFS from 52 contacts (84.6%). The interviews highlighted the need for sustained personal contact with parents/carers to discuss smoking behaviours and concerns and their willingness to be referred to SFS as part of caring for their child.

CONCLUSIONS

Routine recording of smoking status and appropriate follow-up by trained staff in Children's Centres can lead to significant numbers of clients attending stop-smoking services, although relatively few stop smoking.

REFRESH--reducing families' exposure to secondhand smoke in the home: a feasibility study

OBJECTIVE

To study a novel intervention (REFRESH) aimed at reducing children's exposure to secondhand smoke (SHS) in their homes.

DESIGN

A randomised feasibility study.

SETTING

Aberdeen City and Aberdeenshire.

PARTICIPANTS

A total of 59 smoking mothers with at least one child younger than 6 years. Participation took place between July 2010 and March 2011.

INTERVENTION

Four home visits over a 1-month period, which involved two 24-h measurements of home air quality (PM2.5) and a motivational interview to encourage changes to smoking behaviour within the home in order to reduce child SHS exposure. The enhanced group received their air quality data as part of their motivational interview at visit 2; the control group received that information at visit 4.

MAIN OUTCOME MEASURES

The main outcome measures were comparisons of the data from visits 2 and 4 on the 24-h average concentration of PM2.5, the peak concentration of PM2.5, the percentage of time when household PM2.5 concentrations exceeded a health-based threshold of 35 μg/m(3) and child's salivary cotinine (in nanograms per millilitre). The views of the mothers from the enhanced group about their understanding of the intervention and the measures used were also analysed to assess the acceptability and utility of the intervention.

RESULTS

Of the recruited 54 participants, 48 completed the study: 27 from the control group and 21 from the enhanced group. Both groups experienced reductions in PM2.5 concentrations. When testing paired samples for the enhanced group, there was a significant difference (p<0.05) between visit 2 and visit 4 values for maximum PM2.5 (p=0.006) and for percentage of time over 35 μg/m(3) (p=0.017), with average PM2.5 approaching significance (p=0.056). There was no significant difference for salivary cotinine. The qualitative findings showed that mothers were able to understand the data they were shown and were shocked by the values measured in their homes despite being aware of the effects of SHS exposure. They appreciated the intervention taking place in their homes as it allowed them to have personalised data. Many mothers described how they had changed their smoking behaviours in their home and in particular were motivated to protect their own children as a result of the knowledge they had gained.

CONCLUSIONS

Providing mothers who smoke with personalised results about the indoor air quality of their homes along with a motivational interview is feasible and has an effect on improving household air quality. Participants found the intervention understandable and acceptable. Taken overall, the results suggest that a future large-scale trial using measurements of indoor air quality as part of a complex intervention to reduce children's SHS exposure should be explored.

Assessing the knowledge of the potential harm to others caused by second-hand smoke and its impact on protective behaviours at home

BACKGROUND

Smokers' knowledge of the risks of second-hand smoke (SHS) and the role this plays in implementing behaviours to reduce the SHS exposure of others have not been thoroughly explored. Mass media health promotion is used to promote behaviour change partly by providing information on the consequences of behaviour. In England, between 2003 and 2006, frequent mass media campaigns highlighted the toxicity of SHS.

OBJECTIVES

To examine peoples' knowledge of SHS-related illnesses in England over time, identify the determinants of good knowledge and to assess its importance in predicting SHS-protective behaviours.

METHODS

Statistical analysis of repeat cross-sectional data (1996-2008) from the Omnibus Survey to explore the trends and determinants of knowledge of SHS-related illnesses and the determinants of SHS-protective behaviours.

RESULTS

Only 40% of smokers had 'good' knowledge of SHS-related illnesses compared with 65% of never smokers. Knowledge increased markedly when frequent SHS-related mass media campaigns (2003-06) ran, compared with earlier years (1996-2002). Smokers with better knowledge were more likely to have smoke-free homes [odds ratio (OR): 1.10, 1.04-1.16] and abstain from smoking in a room with children (OR: 1.11, 1.09-1.14).

CONCLUSIONS

The low levels of knowledge of some SHS-related conditions, especially among smokers, and the relationship between knowledge and SHS-protective behaviours, suggest that greater efforts to educate smokers about the risks associated with SHS are worthwhile.