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

Effectiveness of a Telephone Counseling Intervention in Reducing Passive Smoking Among Children

Legislative smoking bans that prohibit smoking in public places have successfully reduced passive smoking in public areas. However, smokers only partially adhere to smoking restrictions in their homes. Young children are particularly vulnerable to exposure to tobacco smoke because they spend more time at home. In this study, we designed an intervention program based on an empowerment theory to reduce passive smoking among children. The priority participants were nonsmoking mothers living with smokers who smoke in the presence of children. The aim of this randomized control trial study was to examine the effectiveness of this intervention in reducing children's exposure to tobacco smoke at home. The intervention group received tailored educational brochures and two follow-up counseling telephone calls at 2 and 8 weeks, which provided resources to support the mothers to increase their knowledge, skill, and self-confidence in promoting behavior shaping of smokers. The control group received only tailored educational brochures. We found the intervention group demonstrated a higher rate of maternal actions to reduce their children's exposure to smoke and a higher rate than the control group of attempts to avoid smoking in the presence of children at the 16-week follow-up. These results suggest that the intervention helped reduce passive smoking among children. These findings highlight the need to empower and train mothers to help them develop rules for smoking at home. These interventions could be applied in the home of children who live with smokers who are unable or unwilling to quit smoking.

Perception of harm is strongly associated with complete ban on in-home cannabis smoking: a cross-sectional study

BACKGROUND

Perception of health risk can influence household rules, but little is known about how the perception of harm from cannabis secondhand smoke (cSHS) is related to having a complete ban on in-home cannabis smoking. We examined this association among a nationally representative sample of United States adults.

METHODS

Respondents were 21,381 adults from the cross-sectional Marijuana Use and Environmental Survey recruited from December 2019-February 2020. Perceived harm of cSHS exposure (extremely harmful, somewhat harmful, mostly safe, or totally safe) and complete ban of cannabis smoking anywhere in the home (yes or no) were self-reported. Logistic regression for survey-weighted data estimated covariate-adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association between perceived harm of cSHS and complete ban on in-home cannabis smoking. Stratified subgroup analyses (by cannabis smoking status, cannabis use legalization in state of residence, and children under age 6 living in the home) were conducted to quantify effect measure modification of the association between perception of harm and complete ban.

RESULTS

A complete ban on in-home cannabis smoking was reported by 71.8% of respondents. Eight percent reported cSHS as "totally safe"; 20.5% "mostly safe"; 38.3% "somewhat harmful"; and 33.0% "extremely harmful". Those who reported cSHS as "extremely harmful" had 6 times the odds of a complete ban on in-home cannabis smoking (OR = 6.0, 95%CI = 4.9-7.2) as those reporting smoking as "totally safe". The odds of a complete ban were higher among those reporting cSHS as "somewhat harmful" (OR = 2.6, 95%CI = 2.2-3.1) or "mostly safe" (OR = 1.4, 95%CI = 1.2-1.7) vs those reporting cSHS as "totally safe". In each subgroup of cannabis smoking status, state cannabis use legalization, and children under the age of 6 living in the home, perceived harm was associated with a complete ban on in-home cannabis smoking.

CONCLUSIONS

Our study demonstrates perceiving cSHS as harmful is strongly associated with having a complete in-home cannabis smoking ban. With almost a third of US adults perceiving cSHS as at least "mostly safe", there is strong need to educate the general population about potential risks associated with cSHS exposure to raise awareness and encourage adoption of household rules prohibiting indoor cannabis smoking.

Prevalence and factors associated with second hand smoke exposure among a sample of pregnant women in Cairo, Egypt

PURPOSE

This study estimated the prevalence of and factors associated with secondhand smoke (SHS) exposure, and assessed attitudes and knowledge about SHS among pregnant women in Cairo, Egypt.

METHODS

Pregnant women in the third trimester were recruited to participate in a survey assessing tobacco smoking and SHS exposure during their current pregnancy. Participants were recruited from three antenatal clinics in Cairo, Egypt, from June 2015 to May 2016. We examined differences in sociodemographic characteristics and SHS exposure, attitudes, and knowledge by smoking/SHS status. We used multivariable ordinary least squares regression to examine the association between husbands' smoking and pregnant women's mean daily hours of SHS exposure, adjusting for women's smoking status, age group, education, and urban (vs. suburban/rural) residence.

RESULTS

Of two hundred pregnant women aged 16-37 years, about two-thirds (69%) had a husband who smoked tobacco. During their current pregnancy, most women reported being non-smokers (71%), and 38% of non-smokers reported being SHS-exposed. Non-smokers exposed to SHS tended to live in more rural areas and have husbands who smoked in the home. In adjusted analyses, having a husband who smoked was significantly associated with a greater mean number of hours of SHS exposure per day exposed, and this difference was driven by husbands who smoked in the home (p < 0.001). Women in the SHS-exposed group were less likely than other groups to agree that SHS exposure was harmful to their own or their future child's health; however, all groups agreed that SHS was harmful to newborn health.

CONCLUSION

Among our sample of pregnant women in Cairo, Egypt, there was a high rate of SHS exposure as well as misconceptions about the safety of SHS exposure to a developing fetus. Our findings suggest a need for targeted education and gender-sensitive messaging about SHS exposure, along with improved enforcement of existing tobacco control policies.

Barriers and Enablers to Implementing a Smoke-free Home and Car During Pregnancy: A Qualitative Study Among Expectant Israeli Fathers

INTRODUCTION

Secondhand smoke exposure during pregnancy is a significant cause of negative health effects. This study aims to identify barriers and facilitators for implementing a smoke-free home and car among expectant Israeli fathers.

AIMS AND METHODS

Twenty-four qualitative semistructured telephone interviews were audio-recorded, transcribed, and analyzed according to a reflexive and collaborative thematic approach. Inclusion criteria were being male, Hebrew speaker, age ≥18 years, smoking at least one cigarette a day, and living with their nonsmoking pregnant spouse. The Capability, Opportunity and Motivation for Behavior (COM-B) model was used as a theoretical model for analysis.

RESULTS

Participants reported feeling a strong responsibility for their pregnant spouse's comfort and health, stating that they are doing the best they can to reduce their spouse's secondhand smoke exposure (Motivation). Participants had a low level of knowledge about specific secondhand smoke health consequences, effective strategies to reduce secondhand smoke exposure, with incorrect perceptions about what constitutes exposure (Capability). Couple relationships were not affected by the husband's smoking habits, and participants expressed mutual consideration and understanding (Opportunity). Participants also expressed positive attitudes regarding smoke-free home and car implementation but emphasized that any changes have to be their own decision (Motivation).

CONCLUSIONS

The present study identified principal Capability, Opportunity and Motivation barriers and facilitators that influence Israeli expectant fathers' decision to implement a smoke-free home and car. Those findings will inform the development of a digital behavioral intervention targeting expectant fathers to reduce prenatal secondhand smoke exposure.

IMPLICATIONS

Secondhand smoke exposure during pregnancy is a significant cause of negative health effects. Interventions among expectant fathers that focus on creating a smoke-free home and car may be effective because pregnancy has been identified as a "window of opportunity" that generates a strong motivation and creates a sense of urgency to change smoking behavior, while being considered more achievable than smoking cessation. Interventions might be effective if they focus on strengthening the parental responsibility among expectant fathers and emphasize the benefits of a smoke-free home and car, while maintaining male autonomy and increasing skills to effectively implement a smoke-free home and car.

Use of nicotine replacement therapy to reduce children's exposure to second-hand smoke in the home: a qualitative pilot study involving local community pharmacies

BACKGROUND

In Scotland, and in several other countries, most second-hand smoke exposure now occurs in low-income households, where housing constraints and sole parenting often make it harder to create a smoke-free home. This pilot study provided people who smoke with a free 12-week supply of nicotine replacement therapy through local community pharmacies to reduce smoking indoors.

METHODS

Twenty-five parents/caregivers who smoked in the home and cared for children at least weekly were recruited via Facebook during the COVID-19 pandemic. Air quality (PM2.5) was monitored in participant homes for seven days before their first pharmacy visit and 12 weeks later. Qualitative interviews (N = 14) were conducted with 13 participants who completed the study and one who withdrew part-way through. The interviews explored views/experiences of using nicotine replacement therapy to help create a smoke-free home. Another participant took part in a shorter telephone discussion at their request, with detailed notes taken by the interviewer, because of their speech disorder.

RESULTS

Three participants reported smoking outdoors only, one of whom subsequently quit smoking. Six participants reported reduced cigarette consumption by 50% in the home, four reported no (sustained) reduction and one reported increased smoking indoors. Self-reported outcomes were not always consistent with PM2.5 readings. Participants' experiences of accessing nicotine replacement therapy through community pharmacies varied. Some suggested ongoing support to use nicotine replacement products could better assist behavioural change, and that access could be streamlined by posting products to the home. Several suggested that focusing on changing home smoking behaviours using nicotine replacement therapy might facilitate a future quit attempt.

CONCLUSION

Access to free nicotine replacement therapy for temporary use indoors may support some people who smoke to reduce children's exposure to second-hand smoke. Our findings confirm the need to modify the intervention before undertaking a definitive trial to assess the effectiveness of this approach. This work is now underway.

Tobacco smoke incursion into private residences in Israel: a cross-sectional study examining public perceptions of private rights and support for governmental policies

BACKGROUND

Tobacco smoke incursion (TSI) into private residences is a widespread problem in many countries. We sought to assess the prevalence of self-reported TSI and public attitudes about TSI in Israel, a country with a relatively high smoking prevalence and high population density.

METHODS

We conducted a random digit dial survey among residents in Israel (N = 285) in 2017, which examined the frequency, source, correlates of, and attitudes towards TSI and potential regulatory options. The cooperation rate was 63.9%.

RESULTS

Among respondents, 44.7% reported ever experiencing home TSI, with higher exposure among residents of multi-unit housing (MUH) (MUH versus private homes: aOR (Adjusted Odds Ratio): 3.60, CI (Confidence Interval): [1.96, 6.58], p < .001). Most respondents (69.8%), including nearly half of smokers, prioritized the right of individuals to breath smoke-free air in their apartments over the right of smokers to smoke in their apartments. Women and non-smokers were more likely to support the right to breathe smoke-free air (Women versus men: aOR: 2.77 CI: [1.48, 5.16], p = .001; Nonsmokers versus smokers: aOR: 3.21 CI [1.59, 6.48], p = .001). However, only about a quarter (24.8%) of respondents who ever experienced TSI raised the issue with the neighbor who smoked, the neighbor's landlord, or the building committee. The vast majority (85.2%) of all respondents, including three-quarters of smokers, supported smoke-free legislation for multi-unit housing (MUH), with those ever-exposed to TSI and non-smokers more likely to support legislation (ever-exposed versus never-exposed aOR = 2.99, CI [1.28, 6.97], p = 0.011; nonsmokers versus smokers aOR = 3.00, CI [1.28, 7.01], p = 0.011).

CONCLUSIONS

Among study participants, tobacco smoke incursion was a common, yet unwelcome experience. Most respondents believed that the right to breathe smoke-free air in one's apartment superseded that of neighbors to smoke anywhere in their home, and most supported legislation to prevent TSI. Though further study is needed to understand better TSI and effective methods for its prevention, our findings suggest that policy interventions, including legal action at the level of the Supreme Court and/or the Knesset, are needed. Regulation, policy initiatives and campaigns to denormalize smoking in proximity to other people and private residences globally could reduce the scope of this widespread problem, protect individuals from home TSI, and improve population health.

Perspectives of older women in the Netherlands: identifying motivators and barriers for healthy lifestyles and determinants of healthy aging

BACKGROUND

Women have a higher life expectancy than men but experience more years with physical disabilities in daily life at older ages, especially women with a migration background. This pinpoints older women as an important target group for strategies that stimulate healthy lifestyle, which benefits healthy aging. Our study investigates motivators and barriers for healthy lifestyles and perspectives on determinants of healthy aging of older women. This provides essential information for developing targeted strategies.

METHODS

Data was collected by semi-structured digital interviews from February till June 2021. Women aged 55 years and older living in the Netherlands (n = 34) with a native Dutch (n = 24), Turkish (n = 6) or Moroccan (n = 4) migration background were included. Two main subjects were investigated: (1) motivators and barriers on their current lifestyles regarding smoking, alcohol consumption, physical activity, diet and sleep and (2) perspectives on determinants of healthy aging. Interviews were analyzed using Krueger's framework.

RESULTS

Personal health was the most common motivator for a healthy lifestyle. In addition, peer pressure and being outdoors were specific motivators for physical activity. Bad weather conditions and personal dislike to be active were specific barriers. The social environment, personal preferences and personal belief to compensate with other healthy lifestyle behaviors were barriers for low alcohol consumption. Personal preferences (liking unhealthy food and not making time) were the main barriers for a healthy diet. Sleep was not perceived as a form of lifestyle behavior, but rather as a personal trait. Since there were no smokers, specific barriers were not mentioned. For Turkish-Dutch and Moroccan-Dutch women, additional barriers and motivators were culture and religion. These were strong motivators to abstain from alcohol consumption and smoking, but a barrier for a healthy diet. With regard to perspectives on determinants of healthy aging, positive views on aging and being physically active were perceived as most important. Women often wanted to increase their physical activity or healthy diet to stimulate healthy aging. Among Turkish-Dutch and Moroccan-Dutch women, healthy aging was also perceived as something in the hands of God.

CONCLUSIONS

Although motivators and barriers for a healthy lifestyle and perspectives on healthy aging vary for distinct lifestyles, personal health is a common motivator across all lifestyles. Having a migration background added culture and religion as distinct barriers and motivations. Strategies to improve lifestyle among older women should therefore have a tailored, culture sensitive approach (if applicable) for distinct lifestyle factors.

Low-dose computed tomography for lung cancer screening in Anhui, China: A randomized controlled trial

Background

Lung cancer is the leading cause of cancer-related death worldwide, with risk factors such as age and smoking. Low-dose computed tomography screening can reduce lung cancer mortality. However, its effectiveness in Asian populations remains unclear. Most Asian women with lung cancer are non-smokers who have not been screened. We conducted a randomized controlled trial to evaluate the performance of low-dose computed tomography screening in a Chinese population, including high-risk smokers and non-smokers exposed to passive smoking. The baseline data are reported in this study.

Methods

Between May and December 2019, eligible participants were randomized in a ratio of 1:1:1 to a screening (two arms) or control cohort. Non-calcified nodules/masses with a diameter >4 mm on low-dose computed tomography were considered positive findings.

Results

In total, 600 patients (mean age, 59.1 ± 6.9 years) underwent low-dose computed tomography. Women accounted for 31.5% (189/600) of patients; 89.9% (170/189) were non-smokers/passive smokers. At baseline, the incidence of lung cancer was 1.8% (11/600). The incidence of lung cancer was significantly lower in smokers than in female non-smokers/passive smokers (1.0% [4/415] vs. 4.1% [7/170], respectively; P=0.017). Stage 0-I lung cancer accounted for 90.9% (10/11) of cases.

Conclusions

We demonstrate the importance of including active smokers and female non-smokers/passive smokers in lung cancer screening programs. Further studies are needed to explore the risk factors, and long-term cost-benefit of screening Asian non-smoking women.

Clinical trial registration

http://chictr.org.cn/showproj.aspx?proj=39003, identifier ChiCTR1900023197.

Barriers and facilitators of digital interventions use to reduce loneliness among older adults: a protocol for a qualitative systematic review

INTRODUCTION

Digital interventions are considered as a potential solution to loneliness in older adults. However, this type of intervention has had limited acceptance among older adults (aged ≥60 years). To ensure the use of digital interventions in older adults, possible barriers and facilitating factors should be better understood from the user's perspective. We aim to systematically examine the barriers and facilitators to the implementation of digital interventions designed to reduce loneliness in older adults by identifying, evaluating and synthesising qualitative studies.

METHODS AND ANALYSIS

A comprehensive search of qualitative studies for barriers and facilitators for use of digital interventions will be conducted in the following databases: PubMed, MEDLINE, CINAHL, Embase, Scopus, Cochrane Library and Web of Science. Studies reported in English will be considered for this review. Grey literature will not be included. Two reviewers (HZ and XL) will independently screen the literatures, and any differences will be solved by turning to the third reviewer (JN). The Joanna Briggs Institute (JBI) Qualitative Research Critical Appraisal Checklist will be used by two reviewers to independently assess the validity of the methods used. Relevant data about the populations, context, culture, geographical location, study methods and barriers and facilitators to the implementation of digital interventions will be extracted using the JBI standardised data extraction tool. JBI meta-aggregation methods will be implemented to synthesise the data, which will generate themes and categories based on the data. The final synthesis will establish confidence levels using the JBI ConQual approach.

ETHICS AND DISSEMINATION

The protocol does not require ethical approval. The data are based on published scientific databases. The results will be disseminated through journal articles and scientific conference presentations (if feasible).

PROSPERO REGISTRATION NUMBER

CRD42022328609.

Examining Psychosocial Correlates of a Home Smoking Ban Among Low-income Smokers: Analysis of Social Support, Unmet Social Needs, Perceived Stress, and Depressive Symptoms

Home smoking bans reduce exposure to second-hand smoke. Understanding how psychosocial factors are related to having a home smoking ban may lead to better interventions for populations less likely to have home smoking bans, including low-income smokers. In this study, we used baseline data from 1,944 participants in a randomized trial of low-income smokers in Missouri to explore psychosocial correlates of a total home smoking ban. Using logistic regression, we examined associations between psychosocial variables (social support, unmet social needs [e.g., food, housing], perceived stress, and depressive symptoms) and a total home smoking ban. 72% of participants were female, and 58% were Black/African American; 26% reported a home smoking ban. In unadjusted and adjusted models, greater social support was associated with greater likelihood of a home smoking ban. Stress was negatively associated with a ban in adjusted models only. The fact that most participants did not have a home smoking ban highlights the need for further intervention in this population. Results suggest links between social support and having a home smoking ban, although effect sizes were small. Smoke-free home interventions that increase social connectedness or leverage existing support may be especially effective. Tobacco control planners may also consider partnering with agencies addressing social isolation.

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.

Pregnant Women's Perception of Secondhand Smoke Exposure

BACKGROUND

Birth outcomes including low birth weight, preterm birth, and delayed infant neurodevelopment are associated with secondhand smoke exposure while pregnant. The purpose of the study was to explore pregnant women's perspectives on secondhand smoke exposure to understand their experience and inform recommendations.

STUDY DESIGN AND METHODS

Qualitative semistructured interviews were conducted with 15 secondhand smoke-exposed pregnant women in the United States.

RESULTS

Four primary themes were identified: feeling powerless, trapped, and discomfort; enhancing women's self-advocacy and initiative; having conflicting feelings about secondhand smoke exposure; and desiring professional advice and education. Women expressed concern about prenatal secondhand smoke exposure, although they felt unable to request that people refrain from smoking in their presence or personal space. Women's strategies to minimize secondhand smoke exposure often involved their own social isolation. Women described sources of support, educational needs, and desire for practical advice in secondhand smoke avoidance.

CLINICAL IMPLICATIONS

Findings underscore the role of nurses working with pregnant women living with household members who smoke to educate women about secondhand smoke risks and strategies for avoidance and to enhance women's self-confidence in advocating for themselves to reduce their exposure.

Healthcare Professionals' Knowledge, Attitudes and Counselling Practice Regarding Prevention of Secondhand Smoke Exposure Among Pregnant Women/Children in Assiut, Egypt

Objectives and Methods: A cross sectional study of HCPs working in public MCH clinics in Assiut city was conducted to explore their knowledge, attitudes and counselling practices regarding prevention of SHS exposure among pregnant women and children. Descriptive and regression analyses were performed. Results: 367 HCPs participated in the study, 12% of whom were smokers. The majority were nurses (45%). A considerable proportion of HCPs reported being exposed to SHS in workplace (70%) and home (52%). About half HCP reported high SHS knowledge (56%), supportive attitude towards preventing SHS exposure (53%), and having good counselling practice regarding SHS exposure (52%). Being a GP and serving urban communities were significantly associated with high knowledge. Being female, serving a rural population, receiving training on smoking cessation services, not being exposed to SHS at home, and having a supportive attitude towards prevention of SHS exposure were significantly associated with good counselling practice. Conclusion: Awareness, attitudes and counselling practice of HCPs should be improved. Training for HCPs and enforcement of smoke free polices are needed to improve awareness and facilitate changes in social norms.

"Everything the hujur tells is very educative but if I cannot apply those in my own life then there is no meaning": a mixed-methods process evaluation of a smoke-free homes intervention in Bangladesh

BACKGROUND

Second-hand smoke exposure from tobacco significantly contributes to morbidity and mortality worldwide. A cluster RCT in Bangladesh compared a community-based smoke-free home (SFH) intervention delivered in mosques, with or without indoor air quality (IAQ) feedback to households to no intervention. Neither was effective nor cost-effective compared to no intervention using an objective measure of second-hand smoke. This paper presents the process evaluation embedded within the trial and seeks to understand this.

METHODS

A mixed method process evaluation comprising interviews with 30 household leads and six imams (prayer leader in mosque), brief questionnaire completed by 900 household leads (75% response), fidelity assessment of intervention delivery in six (20%) mosques and research team records. Data were triangulated using meta-themes informed by three process evaluation functions: implementation, mechanisms of impact and context.

RESULTS

IMPLEMENTATION: Frequency of SFH intervention delivery was judged moderate to good. However there were mixed levels of intervention fidelity and poor reach. Linked Ayahs (verses of the Qur'an) with health messages targeting SHS attitudes were most often fully implemented and had greatest reach (along with those targeting social norms). Frequency and reach of the IAQ feedback were good.

MECHANISMS OF IMPACT

Both interventions had good acceptability. However, views on usefulness of the interventions in creating a SFH were mixed. Individual drivers to behaviour change were new SFH knowledge with corresponding positive attitudes, social norms and intentions. Individual barriers were a lack of self-efficacy and plans.

CONTEXT

Social context drivers to SFH intervention implementation in mosques were in place and important. No context barriers to implementation were reported. Social context drivers to SHS behaviour change were children's requests. Barriers were women's reluctance to ask men to smoke outside alongside general reluctance to request this of visitors. (Not) having somewhere to smoke outside was a physical context (barrier) and driver.

CONCLUSIONS

Despite detailed development and adaption work with relevant stakeholders, the SFH intervention and IAQ feedback became educational interventions that were motivational but insufficient to overcome significant context barriers to reduce objectively measured SHS exposure in the home. Future interventions could usefully incorporate practical support for SFH behaviour change. Moreover, embedding these into community wide strategies that include practical cessation support and enforcement of SFH legislation is needed.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN49975452.

Association between secondhand smoke exposure in pregnant women and their socioeconomic status and its interaction with age: a cross-sectional study

Background

Existing evidence highlights that exposure to secondhand smoke (SHS) is a risk factor for pregnant women’s health and is possibly affected by individual characteristics. This study aimed to explore the effect of individual socioeconomic status (SES) on SHS exposure among pregnant women in the third trimester and the interaction effect of age.

Methods

A total of 678 nonsmoking pregnant women with a median age of 29.0 years from 14 communities in a medium-sized city were recruited for this survey. Exposure to SHS was defined as the self-reported smoking habit of a spouse/partner. Individual SES characteristics consisted of marital status, educational attainment, employment and per capita monthly income.

Results

There were 238 (35.1%) participants who suffered from SHS exposure. Compared to the pregnant women who were employed, those who were unemployed were more likely to suffer from SHS exposure (OR = 1.572, 95% CI: 1.013–2.441). Participants who had a high school or technical secondary school education were more likely to be exposed to SHS than those with a college education or above (OR = 1.601, 95% CI: 1.029–2.449). Advanced age was a protective factor for participants with a college education or above (OR = 0.939, 95% CI: 0.884–0.997), but age increased the risk of SHS exposure among women who had unstable marriages (OR = 1.256, 95% CI: 1.019–1.549).

Conclusion

Exposure to SHS was very common among pregnant women in the third trimester. Pregnant women with a low SES and an older age should be considered a key population for the implementation of public health interventions.

Muslim Communities Learning About Second-hand Smoke in Bangladesh (MCLASS II): a combined evidence and theory-based plus partnership intervention development approach

Introduction

Deaths from second-hand smoke (SHS) exposure are increasing, but there is not sufficient evidence to recommend a particular SHS intervention or intervention development approach. Despite the available guidance on intervention reporting, and on the role and nature of pilot and feasibility studies, partial reporting of SHS interventions is common. The decision-making whilst developing such interventions is often under-reported. This paper describes the processes and decisions employed during transitioning from the aim of adapting an existing mosque-based intervention focused on public health messages, to the development of the content of novel community-based Smoke-Free Home (SFH) intervention. The intervention aims to promote smoke-free homes to reduce non-smokers’ exposure to SHS in the home via faith-based messages.

Methods

The development of the SFH intervention had four sequential phases: in-depth interviews with adults in households in Dhaka, identification of an intervention programme theory and content with Islamic scholars from the Bangladesh Islamic Foundation (BIF), user testing of candidate intervention content with adults, and iterative intervention development workshops with Imams and khatibs who trained at the BIF.

Results

It was judged inappropriately to take an intervention adaptation approach. Following the identification of an intervention programme theory and collaborating with stakeholders in an iterative and collaborative process to identify barriers, six potentially modifiable constructs were identified. These were targeted with a series of behaviour change techniques operationalised as Quranic verses with associated health messages to be used as the basis for Khutbahs. Following iterative user testing, acceptable intervention content was generated.

Conclusion

The potential of this community-based intervention to reduce SHS exposure at home and improve lung health among non-smokers in Bangladesh is the result of an iterative and collaborative process. It is the result of the integration of behaviour change evidence and theory and community stakeholder contributions to the production of the intervention content. This novel combination of intervention development frameworks demonstrates a flexible approach that could provide insights for intervention development in related contexts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01100-5.

Residential secondhand smoke in a densely populated urban setting: a qualitative exploration of psychosocial impacts, views and experiences

Background

People remain exposed to secondhand smoke, a serious health hazard, inside their home as households face challenges in setting no-smoking rules or are exposed to secondhand smoke drifting in from neighbouring homes. This study explores the psychosocial impacts, views, and experiences with residential secondhand smoke in a densely populated urban setting. 

Methods

In-depth online or face to face interviews with 18 key informants who had been involved in public discourse, policy, advocacy or handling complaints related to residential secondhand smoke, 14 smokers, and 16 non-smokers exposed to secondhand smoke inside their home. All participants were residents of Singapore, a densely populated, multi-ethnic city-state. Interview transcripts were coded in NVivo using a deductive and inductive coding process.

Findings

Secondhand smoke has wide-reaching impacts on physical and psychosocial wellbeing, even if smokers tried to minimise secondhand smoke. Feelings of anxiety and stress are generally tied to feeling discomfort in one’s personal space, a perceived lack of control over the situation, resentment towards smokers, and concerns over the health effects. Family, community, and cultural dynamics add complexities to tackling the issue, especially in patriarchal households. Secondhand smoke exposure from neighbours is considered a widespread issue, exacerbated by structural factors such as building layout and the COVID-19 pandemic. Resolving the issue amicably is considered challenging due to the absence of regulations and a reluctance to stir up conflict with neighbours. While smokers took measures to reduce secondhand smoke, these were described as ineffective by other participants. Smokers appeared to have contrasting views from other participants on what it means to smoke in a socially responsible manner.

Conclusion

Given the wide-reaching psychosocial impacts of residential secondhand smoke, there is a case for stronger interventions, especially in densely populated urban settings where it is more difficult to avoid.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13561-7.

What Helps and What Hinders the Creation of a Smoke-free Home: A Qualitative Study of Fathers in Scotland

INTRODUCTION

Few studies have explored fathers' views and experiences of creating a smoke-free home, with interventions largely targeting mothers. This study aimed to identify barriers and facilitators to fathers creating a smoke-free home, to inform future intervention development.

METHODS

Eighteen fathers who were smokers and lived in Scotland were recruited from Dads' community groups, Early Years Centres and through social media advertising. Semi-structured interviews explored their views and experiences of creating a smoke-free home. A theory-informed thematic analysis using the COM-B model highlighted ways in which capability, opportunity, and motivations shaped fathers' home smoking behaviors.

RESULTS

Several fathers understood the health risks of second-hand smoke exposure through public health messaging associated with recent smoke-free legislation prohibiting smoking in cars carrying children. Limited understanding of effective exposure reduction strategies and personal mental health challenges reduced some fathers' ability to create a smoke-free home. Fathers were keen to maintain their smoke-free home rules, and their motivations for this largely centered on their perceived role as protector of their children, and their desire to be a good role model.

CONCLUSIONS

Fathers' abilities to create a smoke-free home are shaped by a range of capabilities, opportunities, and motivations, some of which relate to their role as a father. Establishing a fuller understanding of the contextual and gender-specific factors that shape fathers' views on smoking in the home will facilitate the development of interventions and initiatives that fathers can identify and engage with, for the broader benefit of families and to improve gender equity and health.

IMPLICATIONS

Our findings can inform future development of father-centered and household-level smoke-free home interventions. They identify fathers' views and experiences and help reframe smoking in the home as a gendered family-wide issue, which is important in building consensus on how best to support parents to create a smoke-free home. Our findings highlight the need for additional research to develop understanding of the ways in which gender-related aspects of family structures, heterosexual relationships, and child living arrangements influence home smoking rules and how to tailor interventions accordingly.

Prevalence and trends in tobacco use, secondhand smoke exposure at home and household solid fuel use among women in 57 low- and middle-income countries, 2000-2018

BACKGROUND

Tobacco use, secondhand smoke (SHS) exposure and household solid fuel use in women of reproductive age can cause morbidity and mortality for both women and offspring.

OBJECTIVES

We aimed to determine the prevalence of tobacco use, SHS exposure at home and household solid fuel use among women in low- and middle-income countries (LMICs) and their secular trends between 2000 and 2018.

METHODS

We used the most recent data from the Demographic and Health Surveys in 57 LMICs (n = 1,598,111) that were completed between 2010 and 2018 to assess the prevalence of tobacco use, SHS exposure at home and household solid fuel use among women of reproductive age (15-49 years). We also used data from 41 selected LMICs that had data from two or more surveys completed between 2000 and 2018 to assess secular trends in the prevalence of tobacco use and household solid fuel use among women.

RESULTS

In 2010-2018, the overall prevalence of tobacco use, daily SHS exposure at home and household solid fuel use among women in 57 LMICs was 3.2% (95 %CI = 3.1-3.3), 23.0% (22.8-23.2), and 65.6% (65.3-65.9), respectively. The prevalence of tobacco use was lower among pregnant women than non-pregnant women (2.1% vs. 3.3%), but the prevalence of daily SHS exposure at home (24.4% vs. 22.8%) and household solid fuel use (69.1% vs. 65.3%) was higher among pregnant women than non-pregnant women. About 16% of the women presented two or three simultaneous risk factors. Between 2000 and 2018, the prevalence of tobacco use decreased in 24 (64.9%) of 37 countries, and the prevalence of household solid fuel use decreased in 20 (50.0%) of 40 countries.

CONCLUSIONS

Tobacco use among women was much low in LMICs, but SHS exposure at home was more common. Although the prevalence of household solid fuel use decreased over time in most LMICs, these recent estimates remained unacceptably high.

Tobacco-related risk perceptions, social influences and public smoke-free policies in relation to smoke-free home restrictions: findings from a baseline cross-sectional survey of Armenian and Georgian adults in a community randomised trial

OBJECTIVES

Given high prevalence of smoking and secondhand smoke exposure in Armenia and Georgia and quicker implementation of tobacco legislation in Georgia versus Armenia, we examined correlates of having no/partial versus complete smoke-free home (SFH) restrictions across countries, particularly smoking characteristics, risk perceptions, social influences and public smoking restrictions.

DESIGN

Cross-sectional survey study design.

SETTING

28 communities in Armenia and Georgia surveyed in 2018.

PARTICIPANTS

1456 adults ages 18-64 in Armenia (n=705) and Georgia (n=751).

MEASUREMENTS

We used binary logistic regression to examine aforementioned correlates of no/partial versus complete SFH among non-smokers and smokers in Armenia and Georgia, respectively.

RESULTS

Participants were an average age of 43.35, 60.5% women and 27.3% smokers. In Armenia, among non-smokers, having no/partial SFHs correlated with being men (OR=2.63, p=0.001) and having more friend smokers (OR=1.23, p=0.002); among smokers, having no/partial SFHs correlated with being unmarried (OR=10.00, p=0.001), lower quitting importance (OR=0.82, p=0.010) and less favourable smoking attitudes among friends/family/public (OR=0.48, p=0.034). In Georgia, among non-smokers, having no/partial SFHs correlated with older age (OR=1.04, p=0.002), being men (OR=5.56, p<0.001), lower SHS risk perception (OR=0.43, p<0.001), more friend smokers (OR=1.49, p=0.002) and fewer workplace (indoor) restrictions (OR=0.51, p=0.026); among smokers, having no/partial SFHs correlated with being men (OR=50.00, p<0.001), without children (OR=5.88, p<0.001), daily smoking (OR=4.30, p=0.050), lower quitting confidence (OR=0.81, p=0.004), more friend smokers (OR=1.62, p=0.038) and fewer community restrictions (OR=0.68, p=0.026).

CONCLUSIONS

Private settings continue to lack smoking restrictions in Armenia and Georgia. Findings highlight the importance of social influences and comprehensive tobacco legislation, particularly smoke-free policies, in changing household smoking restrictions and behaviours.

TRIAL REGISTRATION NUMBER

NCT03447912.

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.

Socioeconomic inequalities in secondhand smoke exposure before, during and after implementation of Quebec's 2015 'An Act to Bolster Tobacco Control'

BACKGROUND

To better understand whether tobacco control policies are associated with changes in secondhand smoke (SHS) exposure across socioeconomic groups, we monitored differences in socioeconomic inequalities in SHS exposure in households and private vehicles among youth and adults before, during and after adoption of Quebec's 2015 An Act to Bolster Tobacco Control.

METHODS

Using data from the Canadian Community Health Survey, we examined the prevalence of daily exposure to SHS in households and private vehicles among youth (ages 12 to 17) and adults (ages 18+) across levels of household education and income (separately) in 2013/2014, 2015/2016 and 2017/2018. We tested differences in the magnitude of differences in outcomes over time across education and income categories using logistic models with interaction terms, controlling for age and sex.

RESULTS

We detected inequalities in SHS exposure outcomes at each time point, most markedly at home among youth (OR of SHS exposure among youth living in the 20% poorest households vs the 20% richest=4.9, 95% CI 2.7 to 6.2). There were decreases in SHS exposure in homes and cars in each education/income group over time. The magnitude of inequalities in SHS exposure in homes and cars, however, did not change during this period.

CONCLUSIONS

The persistence of socioeconomic inequalities in SHS exposure despite implementation of new tobacco control laws represents an increasingly worrisome public health challenge, particularly among youth. Policymakers should prioritise the reduction of socioeconomic inequalities in SHS exposure and consider the specific needs of socioeconomically disadvantaged populations in the design of future legislation.

'Stretched thin with little children' - smoking perceptions and experiences of families seeking help with parenting

Cigarette smoking is the leading preventable cause of poor pregnancy outcomes. Pregnancy is a trigger for smoking cessation yet, up to 50% of parents will relapse in the early years of their child's life. This study explored the smoking-related perceptions and experiences of 11 parents seeking professional help with the care and parenting of babies and toddlers using semi-structured interviews. Inductive thematic analysis identified three themes: parenting as a change catalyst, smoking as a parenting challenge and smoking as a coping strategy. Becoming a parent is a catalyst to reduce the associated risks and stigma associated with smoking, but maintaining rules and boundaries can be perceived as a further burden for parents who are struggling to care for their infant. When faced with difficulties with parenting, parents may revert to smoking as a coping strategy. Based on these study findings, interventions targeting gender norms may be useful in addressing smoking cessation.

Exploring the Barriers to and Motivators for Using Digital Mental Health Interventions Among Construction Personnel in Nigeria: Qualitative Study

Background

Work-related stress in the construction industry increases the prevalence of depression and anxiety among personnel. In low-resource settings such as Nigeria, construction personnel face high demands and severe working conditions but only have a few services to address their mental health needs. With emerging research showing that digital interventions can be used to self-manage mental health across diverse settings, there may be new opportunities to support construction personnel in the construction industry.

Objective

This study aims to determine the use of digital interventions for mental health management among construction personnel in Nigeria and to explore the factors that facilitate or impede the use of these interventions.

Methods

This qualitative study explored the perspectives of a convenience sample of 62 construction personnel. The data were subjected to inductive content analysis.

Results

A total of 6 barrier and 3 motivator themes were identified and categorized into 2 groups. The barrier themes were subcategorized into barriers to adoption and barriers to persistent use, whereas the motivator themes were subcategorized into intrinsic and extrinsic motivators. Lack of awareness and knowledge about the interventions may constitute a barrier to adoption and use. Participants frequently reported concerns regarding their effectiveness and usability.

Conclusions

This study provides an understanding of the design needs required to facilitate sustained self-management of mental health based on the experiences and expectations of construction personnel with digital interventions.

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.

"Ask Parents What They Want to Do" - Mothers Seeking Help with Parenting and Their Perspectives on Barriers and Potential Enablers for Help with Smoking Cessation: A Qualitative Study

PURPOSE

To describe parents' perceptions of opportunities and barriers to smoking cessation in early parenting and the support needed to achieve this.

DESIGN AND METHODS

A qualitative approach, using semi-structured interviews with mothers, and inductive thematic analysis.

RESULTS

Barriers to cessation intervention included readiness to quit, lack of knowledge, and the shame and stigma of seeking help. Mothers' perceived opportunities for support from early parenting services included approaches to effecting change, leveraging opportunities to explore smoking cessation, and tailoring interventions to family strengths, with a focus on promoting attachment.

CONCLUSIONS

Mothers may be struggling with parenting, but are also open to opportunities to explore smoking behaviours and intervention. Nurses and other health care professionals working in this setting may be well situated to support parents with their decisions to consider smoking cessation and avoid smoking relapse.

PRACTICE IMPLICATIONS

The findings can assist nurses and other early parenting service clinicians to consider their approach to parents who continue to smoke or are at risk of smoking relapse.

'They only smoke in the house when I'm not in': understanding the limited effectiveness of a smoke-free homes intervention

Background

Children’s second-hand smoke (SHS) exposure in the home is highest in socio-economically disadvantaged areas. Personalized household air-quality measurements can promote changes in smoking that reduce SHS exposure. The ‘First Steps 2 Smoke-free’ (FS2SF) intervention is the first to trial this approach delivered as part of health professionals’ routine work. This paper reports the findings of qualitative interviews with participants that explored their experiences of the intervention and why outcomes varied.

Methods

120 women were recruited from the NHS First Steps Programme, which supports disadvantaged mothers. They received either personalized feedback on their home air quality and advice on reducing SHS or standard SHS advice. Qualitative interviews with 15 mothers were analyzed thematically using the Capability, Opportunity, Motivation, Behaviour (COM-B) model.

Results

The intervention increased women’s capability to change home-smoking behaviour, through increasing awareness and salience of SHS risks to their children, and motivation to act. However, taking effective action was constrained by their limited social and environmental opportunities, including others’ smoking in the home.

Conclusions

The FS2SF intervention was ineffective as it was unable to fully address the precarious, complex life circumstances that make creating a smoke-free home particularly difficult for women experiencing intersecting dimensions of disadvantage.

Parental health risk perceptions and preventive measures related to Children's second-hand cigarette smoke exposure in Malaysia

Background

Secondhand smoke (SHS) exposure can affect physical development in children. An understanding of parental risk perception of SHS could guide efforts to develop measures for prevention of SHS exposure among children. This study aimed to assess parental risk perceptions of SHS and action taken by parents to minimise SHS exposure in their children.

Methods

This cross-sectional nationwide study conducted in 2018 recruited convenience sample of 289 parents with children up to age 12 at public areas. Parents were asked to rate the risk level from 1 (no risk) to 5 (extremely high risk) by looking at photographs of an adult smoking in the presence of a child in 8 different situations. The implementation of smoking restriction rules was assessed. Mean scores were calculated with higher scores representing higher risk perception of SHS to child’s health. Linear regression analysis was used to determine factors associated with the level of parental risk perception of SHS exposure to their children’s health.

Results

A total of 246 parents responded. Their mean age was 35 years (SD 6.4). The majority were mothers (75.6%), Malays (72.0%) and had tertiary education level (82.5%), and non-smoker (87.1%). The mean age of respondents’ youngest child was 3 years (SD 3.1). The risk perception level was high [mean scores: 4.11 (SD: 0.82)]. Most parents implemented household (65.0%) and car (68.3%) smoking restriction rules. Lower levels of risk perception were observed among participants who were current smokers (p < 0.001), lived with a smoker (p < 0.001), allowed household smoking with an open window (p = 0.027).

Conclusion

Most parents perceived that risks of SHS exposure to their children were high but only two-thirds of them had set rules prohibiting smoking. Health policymakers should pay attention to factors associated with lower risk perception among parents.

Trial registration

This study was approved by the Medical Research Ethics Committee, Ministry of Health Malaysia (Registration Number: NMRR-18-3299-44967).

What is a public health approach to substance use? Protocol for a qualitative systematic review

INTRODUCTION

The concept of a 'public health approach' to substance use is frequently but inconsistently invoked. This inconsistency is reflected in public policy, with governments using the term 'public health approach' in contradictory ways. This aim of this study is to clarify what is meant and understood when the term 'public health approach' is used in the context of substance use.

METHODS AND ANALYSIS

We will conduct a systematic search of Medline, Embase, Scopus, CINAHL, PsycINFO, Sociological Abstracts and PAIS Index. Eligible articles will be from peer-reviewed journals, in English, with full text available. There will be no limits on year of publication. Substance use must be the primary topic of the article. Editorials, commentaries and letters to the editor will be included, but not commentaries on other articles, unless the definition of a public health approach is central to the commentary. Data selection and collection will be conducted independently by two researchers, with a third separately resolving any disagreement. To answer the research question, we will extract authors' definitions of a public health approach to substance use as well as any descriptions of the central principles, characteristics and components of such an approach. To synthesise the data, we will employ thematic synthesis. Coding will be conducted by one researcher and verified by a second; two researchers will then group the codes into themes using an inductive process. Finally, the full research team will develop a set of analytic themes, which will be presented as a narrative.

ETHICS AND DISSEMINATION

Ethics approval is not needed since the research will only involve published work. Our findings will be disseminated in a peer-reviewed journal and, if possible, at conferences.

PROSPERO REGISTRATION NUMBER

CRD42021270632.

Home Tobacco Use Policies and Exposure to Secondhand Tobacco Smoke: Findings from Waves 1 through 4 of the Population Assessment of Tobacco and Health (PATH) Study

BACKGROUND

The 2006 Surgeon General's Report recommended the elimination of smoking in homes as an effective protective measure against the harmful effects of secondhand tobacco smoke exposure. This study aims to examine trends in the prevalence and levels of the adoption of home tobacco use policies specifically for cigarettes, e-cigarettes, smokeless tobacco, and the relationships between home tobacco use policies and self-reported exposure to secondhand tobacco smoke.

METHODS

This study utilizes data from Wave 1 (2013-2014) through Wave 4 (2016-2018) of the Population Assessment of Tobacco and Health (PATH) Study, a large prospective cohort study of youths and adults in the United States which collected information about both smoke-free and tobacco-free home policies. We present the weighted, population-based, self-reported prevalence of home tobacco use policies overall and by product, and the average number of self-reported hours of secondhand smoke (SHS) exposure by levels of home tobacco policy and by survey wave. In addition, we examine the characteristics of those who adopted (by yes or no) a home tobacco use ban between survey waves.

RESULTS

We found a high prevalence of completely tobacco-free home policies (69.5%). However, 10.6% of adults allow the use of any type of tobacco product inside their homes, and 19.8% have a policy allowing the use of some types of tobacco products and banning the use of others. Adults with a complete tobacco use ban inside their homes were more likely to be nonusers of tobacco (79.9%); living with children in the home (71.8%); at or above the poverty level (70.8%); non-white (76.0%); Hispanic (82.7%); and aged 45 or older (71.9%). The adoption of 100% tobacco-free home policies is associated with a 64% decrease in secondhand smoke exposure among youths and a 69% decrease in exposure among adults.

CONCLUSIONS

Most US adults have implemented tobacco-free home policies; however, there is still exposure to SHS in the home, for both adults and children, particularly in the homes of tobacco users. Additional research should investigate tobacco-free home policies for different types of products and what effect they have on future tobacco use behaviors.

'I Was Smoking a Lot More during Lockdown Because I Can': A Qualitative Study of How UK Smokers Responded to the Covid-19 Lockdown

This study explored how Covid-19 lockdown restrictions affected people’s daily smoking routines and behaviours, including adherence and modifications to pre-established smoking restrictions in the home. Semi-structured telephone interviews were conducted with smokers and non-smokers from smoking households 19 to 27 weeks after the first full UK lockdown ended in May 2020. A non-probability purposive sample representing 25 adults aged 21 or over living in households with at least 1 smoker were recruited to the study. A quota sampling strategy was used, according to age, gender, smoking status, family status, household composition, householder access to outdoor space, and change to work-life status. Most participants found lockdown increased the amount of time spent at home, where stresses associated with confinement, curtailment of social routines, removal of barriers and distractions to smoking due to home working, and feelings of boredom all contributed to increased smoking. Fewer factors were identified as reducing smoking during lockdown. Prominent examples included disruption to habitual smoking patterns and distraction from smoking associated with spending more time doing outdoor activities. Pressures placed on physical space and lack of privacy due to the confinement at home were responsible for displacement of smoking within the home, leading to breaking of smoke-free rules and family tensions, and in some cases to greater awareness amongst parents that their children smoked. Changes in daily routines associated with lockdown affected and displaced smoking behaviour both positively and negatively. Health improvement interventions could seek to harness positive changes in smoking associated with any future lockdown approaches. New home-working norms highlight the need for employers to support staff to reduce their smoking and to remain smoke-free.

Experiences and views of women, children, and professionals regarding second-hand smoke exposure prevention in Middle Eastern countries: a qualitative systematic review protocol

OBJECTIVE

This systematic review aims to identify and explore the experiences and views of women, children, and professionals regarding second-hand smoke exposure prevention in the home, workplace, school, personal vehicles, and public places in Middle Eastern countries.

INTRODUCTION

Exposure to second-hand smoke is a significant public health problem globally, but particularly in Middle Eastern countries. Whilst many Middle Eastern countries have implemented tobacco-control programs and have legislation that bans smoking in public places, the legislation is not always comprehensively implemented or enforced. Therefore, women and children continue to be exposed to second-hand smoke in public and private settings.

INCLUSION CRITERIA

This review will consider studies that include the views and experiences of any of the following three groups: (i) women (including pregnant women and mothers), (ii) children (primary and secondary school age), and (iii) professionals (including health professionals and policy makers), regarding the prevention of second-hand smoke exposure in women and children in Middle Eastern countries.

METHODS

MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Scopus, and sources of gray literature will be searched for eligible studies. Databases will be searched from their inception dates and no language restrictions will be applied. Two reviewers will independently screen studies and assess methodological quality and extract data from the included studies following JBI systematic review guidelines. The JBI process of meta-aggregation will be used to identify categories and synthesize findings. The ConQual approach will be used to assess confidence in the findings.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO (CRD42019137006).

Small-Area Estimation of Smoke-Free Workplace Policies and Home Rules in US Counties

INTRODUCTION

The workplace and home are sources of exposure to secondhand smoke, a serious health hazard for nonsmoking adults and children. Smoke-free workplace policies and home rules protect nonsmoking individuals from secondhand smoke and help individuals who smoke to quit smoking. However, estimated population coverages of smoke-free workplace policies and home rules are not typically available at small geographic levels such as counties. Model-based small-area estimation techniques are needed to produce such estimates.

METHODS

Self-reported smoke-free workplace policies and home rules data came from the 2014-2015 Tobacco Use Supplement to the Current Population Survey. County-level design-based estimates of the two measures were computed and linked to county-level relevant covariates obtained from external sources. Hierarchical Bayesian models were then built and implemented through Markov Chain Monte Carlo methods.

RESULTS

Model-based estimates of smoke-free workplace policies and home rules were produced for 3134 (of 3143) US counties. In 2014-2015, nearly 80% of US adult workers were covered by smoke-free workplace policies, and more than 85% of US adults were covered by smoke-free home rules. We found large variations within and between states in the coverage of smoke-free workplace policies and home rules.

CONCLUSIONS

The small-area modeling approach efficiently reduced the variability that was attributable to small sample size in the direct estimates for counties with data and predicted estimates for counties without data by borrowing strength from covariates and other counties with similar profiles. The county-level modeled estimates can serve as a useful resource for tobacco control research and intervention.

IMPLICATIONS

Detailed county- and state-level estimates of smoke-free workplace policies and home rules can help identify coverage disparities and differential impact of smoke-free legislation and related social norms. Moreover, this estimation framework can be useful for modeling different tobacco control variables and applied elsewhere, for example, to other behavioral, policy, or health related topics.

Systematic Review of Behaviour Change Techniques within Interventions to Reduce Environmental Tobacco Smoke Exposure for Children

Children are particularly vulnerable to environmental tobacco smoke (ETS). There is no routine support to reduce ETS in the home. We systematically reviewed trials to reduce ETS in children in order to identify intervention characteristics and behaviour change techniques (BCTs) to inform future interventions. We searched Medline, EMBASE, CINAHL, PsycINFO, ERIC, Cochrane Central Register of Controlled Trials, and Cochrane Tobacco Addiction Group Specialised Register from January 2017 to June 2020 to update an existing systematic review. We included controlled trials to reduce parent/caregiver smoking or ETS in children <12 years that demonstrated a statistically significant benefit, in comparison to less intensive interventions or usual care. We extracted trial characteristics; and BCTs using Behaviour Change Technique Taxonomy v1. We defined "promising" BCTs as those present in at least 25% of effective interventions. Data synthesis was narrative. We included 16 trials, of which eight were at low risk of bias. All trials used counselling in combination with self-help or other supporting materials. We identified 13 "promising" BCTs centred on education, setting goals and planning, or support to reach goals. Interventions to reduce ETS in children should incorporate effective BCTs and consider counselling and self-help as mechanisms of delivery.

Supporting Parents Living in Disadvantaged Areas of Edinburgh to Create a Smoke-Free Home Using Nicotine Replacement Therapy (NRT): A Two-Phase Qualitative Study

Exposure to second-hand smoke (SHS) in the home is largely associated with socio-economic disadvantage. Disadvantaged parents face specific challenges creating a smoke-free home, often caring for children in accommodation without access to outdoor garden space. Existing smoke-free home interventions largely fail to accommodate these constraints. Innovative approaches are required to address this inequality. In this two-phase study, we engaged with parents living in disadvantaged areas of Edinburgh, Scotland, to explore tailored approaches to creating a smoke-free home and develop and pilot-test an intervention based on their views and preferences. In Phase 1, qualitative interviews with 17 parents recruited from Early Years Centres explored alternative approaches to smoke-free home interventions. In Phase 2, an intervention based on parents’ views and preferences was pilot-tested with parents recruited through Early Years and Family Nurse Partnership centres. Seventeen parents took part in an interview to share their views/experiences of the intervention. Data from both study phases were thematically analysed. Phase 1 findings suggested that parents associated nicotine replacement therapy (NRT) with quit attempts but supported the idea of NRT use for temporary abstinence to create a smoke-free home, viewing this as a safer option than using e-cigarettes indoors. In Phase 2, 54 parents expressed an interest in accessing NRT to create a smoke-free home, 32 discussed NRT product choice during a home visit from a smoking adviser, and 20 collected their free NRT prescription from the pharmacy. NRT was used for up to 12 weeks in the home, with ongoing advice available from pharmacy staff. During qualitative interviews (n = 17), parents self-reported successfully creating a smoke-free home, quitting smoking, and reduced cigarette consumption, often exceeding their expectations regarding changes made. The intervention was acceptable to parents, but the multi-step process used to access NRT was cumbersome. Some participants were lost to this process. Parents living in disadvantaged circumstances may benefit from access to NRT for temporary abstinence in the home to assist them to protect their children from SHS exposure. Further research using a more streamlined approach to NRT access is required to determine the feasibility and cost-effectiveness of this approach.

Engaging with Aboriginal Shire Councils in remote Cape York communities to address smoke-free environments

The high prevalence and health effect of tobacco smoking and secondhand smoke exposure among Aboriginal and Torres Strait Islander people is well known. Due to its significance, the responsibility of tackling smoking among Aboriginal and Torres Strait Islander people should not remain solely with health service providers. The creation of supportive environments and collaboration beyond the health sector are critical elements of comprehensive primary health care practised by Aboriginal Community Controlled Health Services. This paper discusses how Apunipima Cape York Health Council worked with three Aboriginal Shire Councils to create more smoke-free places, using local working groups, information sessions and community-based health promotion. The flexibility and the time allocated to the engagement process with councils, community leaders, organisations and community members were important. All three communities acknowledged the benefits of role modelling and working together to improve health, with addressing tobacco smoking seen as 'everyone's business' and 'not just service providers'. Aboriginal Shire Councils can play a critical role, in partnership with Aboriginal Community Controlled Health Services, in creating healthy places that enable healthy choices.

A Scoping Review of Foci, Trends, and Gaps in Reviews of Tobacco Control Research

INTRODUCTION

The burden of disease associated with tobacco use has prompted a substantial increase in tobacco-related research, but the breadth of this literature has not been comprehensively examined. This review examines the nature of the research addressing the action areas in World Health Organization's Framework Convention on Tobacco Control (FCTC), the populations targeted and how equity-related concepts are integrated.

METHOD

A scoping review of published reviews addressing tobacco control within the primary prevention domain. We searched PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Educational Resources Information Centre, and PsycInfo from 2004 to 2018.

RESULTS

The scoping review of reviews offered a "birds-eye-view" of the tobacco control literature. Within the 681 reviews meeting inclusion criteria, there was a strong focus on smoking cessation targeting individuals; less attention has been given to product regulation, packaging, and labeling or sales to minors. Equity-related concepts were addressed in 167/681 (24.5%); few were focused on addressing inequity through structural and systemic root causes.

CONCLUSION

This analysis of foci, trends, and gaps in the research pursuant to the FCTC illustrated the particular action areas and populations most frequently addressed in tobacco control research. Further research is needed to address: (1) underlying social influences, (2) particular action areas and with specific populations, and (3) sustained tobacco use through the influence of novel marketing and product innovations by tobacco industry.

IMPLICATIONS

This scoping review of the breadth of tobacco control research reviews enables a better understanding of which action areas and target populations have been addressed in the research. Our findings alongside recommendations from other reviews suggest prioritizing further research to support policymaking and considering the role of the tobacco industry in circumventing tobacco control efforts. The large amount of research targeting individual cessation would suggest there is a need to move beyond a focus on individual choice and decontextualized behaviors. Also, given the majority of reviews that simply recognize or describe disparity, further research that integrates equity and targets various forms of social exclusion and discrimination is needed and may benefit from working in collaboration with communities where programs can be tailored to need and context.

Measuring for change: A multi-centre pre-post trial of an air quality feedback intervention to promote smoke-free homes

INTRODUCTION

Second-hand smoke exposure in the home is a serious cause of ill-health for children. Behaviour change interventions have been developed to encourage parents to keep homes smoke-free. This study evaluates a novel air quality feedback intervention using remote air quality monitoring with SMS and email messaging to promote smoke-free homes among families from deprived areas.

METHODS

This paper presents a pre-post study of this intervention. Using internet connected monitors developed with the Dylos DC1700, daily SMS and weekly email feedback provided for 16 days to participants recruited in four European countries. Participants were recruited based on their stage of change, in order to target those most able to achieve smoke-free homes. The primary outcome measure was median change in mean fine particulate matter (PM_2.5) concentration between baseline and follow-up periods, while secondary outcome measures included change in time over the World Health Organisation (WHO) guideline limit for PM_2.5 exposure over 24 h (25 µg/m³) in those periods and the number of homes where PM_2.5 concentrations reduced. Telephone interviews were conducted with participants in Scotland post-intervention to explore intervention experience and perceived effectiveness.

RESULTS

Of 86 homes that completed the intervention study, 57 (66%) experienced pre-post reductions in measured PM_2.5. The median reduction experienced was 4.1 µg/m³ (a reduction of 19% from baseline, p = 0.008). Eight homes where concentrations were higher than the WHO guideline limit at baseline fell below that level at follow-up. In follow-up interviews, participants expressed positive views on the usefulness of air quality feedback.

DISCUSSION

Household air quality monitoring with SMS and email feedback can lead to behaviour change and consequent reductions in SHS in homes, but within the context of our study few homes became totally smoke-free.

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.

"I can't stand it…but I do it sometimes" parental smoking around children: practices, beliefs, and conflicts - a qualitative study

Background

Many parents continue to smoke around their children despite the widely known risks of children’s exposure to tobacco smoke. We sought to learn about parental smoking behavior around children from parents’ perspective.

Methods

Semi-structured interviews were conducted with 65 smoking parents or partners of smoking parents of children up to age 7, to learn about home smoking rules, behaviours performed to try to protect children, and smoking-related conflicts, from parents’ perspective. Interviews were recorded and transcribed and thematic analysis performed. Recruitment was challenging due to the sensitive nature of the topic.

Results

Many parents described smoking around their children in certain areas of the home, outdoors, and in what they consider to be open or ventilated areas. Participants emphasized efforts to protect their children and described various mitigating practices but held mixed views as to their effectiveness. Parents had different conceptions of which areas or distances were considered ‘safe’. Many smoking parents described conflicts both internal and with other family members regarding the protection of children. Some parents who continue to smoke around their children despite understanding the health risks felt powerless to effect change, as well as being uncertain as to the effectiveness of their protective strategies; others were aware but reluctant to change.

Conclusion

Findings shed light on some of the difficulties faced by smoking parents and obstacles to maintaining a smoke-free environment for their children, providing insight for the type of information and support required to help parents better protect their children from exposure to tobacco smoke. Awareness of health risks associated with secondhand smoke was demonstrated, yet parents in smoking families were confused regarding which rules and behaviours best protect children from exposure to tobacco smoke. Parents were sometimes aware that their smoking ‘rules’ and mitigating practices were limited in their effectiveness. Guidelines should be provided explaining how and when exposure occurs and how to keep children safe.

Moderators of Establishing a Smoke-Free Home: Pooled Data from Three Randomized Controlled Trials of a Brief Intervention

Interventions to create smoke-free homes typically focus on parents, involve multiple counseling sessions and blend cessation and smoke-free home messages. Smoke-Free Homes: Some Things are Better Outside is a minimal intervention focused on smokers and nonsmokers who allow smoking in the home, and emphasizes creation of a smoke-free home over cessation. The purpose of this study is to conduct moderator analyses using pooled data from three randomized controlled trials of the intervention conducted in collaboration with 2-1-1 contact centers in Atlanta, North Carolina and Houston. 2-1-1 is a strategic partner for tobacco control as it connects over 15 million clients, largely socio-economically disadvantaged, to social and health resources each year. A total of 1506 2-1-1 callers participated across the three intervention trials. Outcomes from 6 months intent-to-treat analyses were used to examine whether sociodemographic variables and smoking-related characteristics moderated effectiveness of the intervention in establishing full home smoking bans. Intervention effectiveness was not moderated by race/ethnicity, education, income, children in the home or number of smokers in the home. Smoking status of the participant, however, did moderate program effectiveness, as did time to first cigarette. Number of cigarettes per day and daily versus nondaily smoking did not moderate intervention effectiveness. Overall, the intervention was effective across socio-demographic groups and was effective without respect to daily versus nondaily smoking or number of cigarettes smoked per day, although smoking status and level of nicotine dependence did influence effectiveness.

Primary Care Healthcare Professionals' Knowledge, Attitudes, and Practices Towards Promoting the Reduction of Children's Secondhand Smoke Exposure: A Mixed-Methods Review and Synthesis

INTRODUCTION

Secondhand smoke exposure (SHSe) leads to increased mortality and morbidity. Primary care healthcare professionals (HCPs) are well placed to support patients to reduce SHSe. This paper explores HCPs': (1) knowledge around SHSe; (2) current practices to promote SHSe reduction; (3) beliefs and experiences regarding delivering interventions to reduce SHSe; and (4) identified factors that influence the delivery of SHSe-related interventions.

METHODS

Six electronic databases were searched for relevant literature published January 1980-February 2016. 17 quantitative and 3 qualitative studies were included in this mixed-methods review. Data synthesis followed the method outlined by the Joanna Briggs Institute. This segregated approach involved independent syntheses of the quantitative and qualitative data followed by an overall mixed-methods synthesis.

RESULTS

Primary care HCPs had a basic understanding of the risks associated with SHSe but required training to help them intervene. It was more common for HCPs to ask about SHSe or provide advice than to act to facilitate SHSe reduction. SHSe was viewed as an issue of high importance and considered relevant to the role of the primary care HCPs. However, barriers such as the priority given to the issue and the desire to protect the professional relationship with patients prevented HCPs from intervening around SHSe.

CONCLUSIONS

Primary care HCPs require training, guidance, and support to enable them to intervene and support patients to effectively reduce SHSe.

IMPLICATIONS

This review used rigorous methods to explore the current, global literature on how children's exposure to secondhand smoke is being addressed in primary care settings. The review findings highlight healthcare professionals' need for further training and support, which would enable them to better translate their knowledge of the risks associated with secondhand smoke exposure into actual clinical practices. The review identified a lack of practical action taken to address secondhand smoke exposure, even once it has been identified as an issue.

Opportunities for Tailored Support to Implement Smoke-Free Homes: A Qualitative Study among Lower Socioeconomic Status Parents

With the aim of preventing children from being exposed to secondhand smoke, we examined to which level lower socio-economic status (SES) households had implemented home smoking rules and the factors that hampered parents in their process of change toward a complete smoke-free home (SFH). We conducted a qualitative study including semi-structured in-depth interviews with 14 parents of young children living in a lower SES neighborhood of a provincial town in the Netherlands. Interview transcripts were subjected to a qualitative content analysis. Three distinct levels of SFH implementation emerged: complete SFH, flexible SFH, and partial SFH. Differences between parents at these three levels essentially concerned: (1) the role of child-related moral considerations in their motivation for an SFH; (2) whether they felt they had the agency to set and enforce home smoking rules; (3) the difficulties they experienced in changing their smoking habit from smoking indoors to smoking outdoors. Parents also had different opinions about the role their children could play in facilitating the parental process of change. We conclude that the current level of SFH implementation may serve as a starting point for developing tailored interventions. Such interventions should probably address other factors than the commonly used awareness–knowledge–commitment approach.

Development of a Smoke-Free Homes Intervention for Parents: An Intervention Mapping Approach

Exposure to second-hand smoke (SHS) is associated with various ill-health outcomes for children and adults. Barriers to creating a smoke-free home (SFH) are well-documented. Feasible and effective interventions to create smoke-free homes for disadvantaged households are lacking. Interventions that include providing parents with objective information about the impact of smoking on air quality in their home may be particularly effective. This study describes the development of a novel, theory- and evidence-based smoke-free homes intervention using objectively-assessed air quality feedback. The intervention was developed using the six-step Intervention Mapping (IM) protocol. Findings from literature reviews, focus groups with parents, interviews with health/care professionals, and expert panel discussions shaped intervention content and materials. Findings highlighted the importance of parents receiving personalised information on second-hand smoke levels in their home. Professionals considered the use of non-judgemental language essential in developed materials. Previous literature highlighted the need to address home smoking behaviour at a household rather than individual level. The AFRESH intervention is modular and designed to be delivered face-to-face by healthcare professionals. It includes up to five meetings with parents, two sets of five days' air quality monitoring and personalised feedback, and the option to involve other household members in creating a smoke-free home using educational, motivational, and goal setting techniques. Further research is needed to evaluate the acceptability and effectiveness of the AFRESH intervention and which specific groups of parents this intervention will most likely benefit. IM was a useful framework for developing this complex intervention. This paper does not present evaluation findings.

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.