Determinants and consequences of smoke-free homes: findings from the International Tobacco Control (ITC) Four Country Survey

Predictors of quitting smoking behavior: evidence from Pakistan

This study attempts to identify factors that significantly encourage the cessation of smoking in the context of Pakistan. The study distributes a modified questionnaire among 421 respondents (current as well as former smokers) in the capital city of Pakistan, Islamabad. The binary regression method was employed to data for analyzing predictors of making quit attempts and successful smoking cessation. The result indicates that respondents having strong intentions to quit, high socioeconomic status, low nicotine dependency, and past quit attempts, and those having no-smoking friends, are more likely to quit cigarette smoking successfully. On the other hand, factors like social pressure to quit smoking, religious information against smoking, intention to quit smoking, and public regulation on smoking are more likely to encourage smokers to make quit attempts. The study calls for community and school-wide smoking cessation campaigns involving officials, peers and parents, religious leaders, and other influential individuals to inform people about the dangers of smoking. In addition, religious leaders should be encouraged to issue rulings against smoking especially during "Friday Prayer." Furthermore, the government should pronounce more strict and comprehensive regulations on smoking by properly monitoring its implementation to encourage cessation of cigarette smoking.

The association between risk perceptions, anxiety, and self-reported changes in tobacco and nicotine product use due to COVID-19 in May-June 2020 in Israel

BACKGROUND

Early in the COVID-19 pandemic, reports about a possible protective effect of nicotine on COVID-19 conflicted with messaging by public health organizations about increased risks of COVID-19 due to smoking. The ambiguous information the public received, combined with COVID-19-induced anxiety, may have led to changes in tobacco or other nicotine product use. This study examined changes in use of combustible cigarettes (CCs), nargila (hookah/waterpipe), e-cigarettes, and IQOS and home-smoking behaviors. We also assessed COVID-19 related anxiety and perceptions regarding changes in risk of COVID-19 severity due to smoking.

METHODS

We used cross-sectional data from a population telephone survey that was conducted in Israel in the early phase of the COVID-19 pandemic (May-June 2020) and included 420 adult (age 18+) individuals who reported having ever used CCs (n = 391), nargila (n = 193), and/or electronic cigarettes (e-cigarettes)/heated tobacco products (e.g., IQOS) (n = 52). Respondents were asked about the effect that COVID-19 had on their nicotine product use (quit/reduced use, no change, increased use). We assessed changes in product use, risk perceptions, and anxiety using adjusted multinomial logistic regression analyses.

RESULTS

Most respondents did not change their frequency of product use (CCs: 81.0%, nargila: 88.2%, e-cigarettes/IQOS: 96.8%). A small percentage either decreased use (CCs: 7.2%, nargila: 3.2%, e-cigarettes/IQOS:2.4%) or increased use (CCs:11.8%, nargila:8.6%, e-cigarettes/IQOS:+ 0.9%). 55.6% of respondents used a product in the home prior to COVID-19; but during the first lockdown COVID-19 period, a greater percentage increased (12.6%) than decreased (4.0%) their home use. Higher levels of anxiety due to COVID-19 were associated with increased home smoking (aOR = 1.59, 95% CI:1.04-2.42, p = 0.02). Many respondents believed that increased severity of COVID-19 illness was associated with CCs (62.0%) and e-cigarettes/vaping (45.3%), with uncertainty about the association being lower for CCs (20.5%) than for vaping (41.3%).

CONCLUSIONS

While many respondents believed that nicotine product use (particularly CCs and e-cigarettes) was associated with increased risk of COVID-19 disease severity, the majority of users did not change their tobacco/nicotine use. The confusion about the relationship between tobacco use and COVID-19 calls for clear evidence-based messaging from governments. The association between home smoking and increased COVID-19-related stress suggests the need for campaigns and resources to prevent smoking in the home, particularly during times of stress.

A qualitative exploration of the provision and prioritisation of smoking cessation support to patient carers in a paediatric ward in Australia

Background

Hospitalisation of a child is a unique opportunity for health staff to offer smoking cessation support; that is screening for carer smoking status, discussing cessation and providing interventions to carers who smoke. This has the potential to reduce the child’s exposure to second-hand smoke, and in turn tobacco related illnesses in children. However, these interventions are not always offered in paediatric wards. The aim of this study was to explore the provision and prioritisation of smoking cessation support to patient carers in a paediatric ward with a high proportion of Aboriginal patients and carers in a regional area of Australia’s Northern Territory.

Methods

This is a qualitative descriptive study of data collected through semi-structured interviews with 19 health staff. The interviews were audio recorded and transcribed verbatim. Thematic analysis was performed on the transcripts.

Results

We found low prioritisation of addressing carer smoking due to, a lack of systems and procedures to screen for smoking and provide quitting advice and unclear systems for providing more detailed cessation support to carers. Staff were demotivated by the lack of clear referral pathways. There were gaps in skills and knowledge, and health staff expressed a need for training opportunities in smoking cessation.

Conclusion

Health staff perceived they would provide more cessation support if there was a systematic approach with evidence-based resources for smoking cessation. These resources would include guidelines and clinical record systems with screening tools, clear action plans and referral pathways to guide clinical practice. Health staff requested support to identify existing training opportunities on smoking cessation.

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.

Secondhand Smoke Exposure in Lao People's Democratic Republic: Results From the 2015 National Adult Tobacco Survey

Objectives: Second-hand smoke (SHS) exposure causes >600,000 deaths annually worldwide, however, information regarding SHS exposure in Lao People's Democratic Republic (Lao PRD) is limited; we report SHS exposure prevalence at home, inside workplaces, and indoor public spaces in Lao PDR. Methods: Data were from the 2015 Lao National Adult Tobacco Survey, a nationally representative sample of 7,562 participants aged ≥15 years recruited through a stratified 2-stage cluster sampling approach. Results: 88.3% (83.9% of non-smokers) reported SHS exposure at home and 63.0% (54.0% of non-smokers) at workplaces. Among non-smokers, women had greater exposure at home than men (86.6 vs. 77.0%). Lower education levels were associated with exposure at home or the workplace. 99.2% reported SHS exposure at any public place; specifically for restaurants/food stores 57.7%, government offices 56.2%, public transport 31.6%, and health care facilities 11.7%. Conclusion: SHS exposure at home and workplace in Lao PDR is among the highest in South-East Asia. Comprehensive smoke-free policies at government-owned workplaces and facilities, stricter enforcement of these smoke-free policies, and strategies to encourage smoke-free environments at homes and in public places are urgently needed.

Estimating the equity impacts of the smoking ban in England on cotinine levels: a regression discontinuity design

OBJECTIVE

To estimate the equity impacts of the 2007 smoking ban in England, for both smokers and non-smokers.

DESIGN

Doubly robust regression discontinuity analysis of salivary cotinine levels. Conditional average treatment effects were used to estimate differential impacts of the ban by socioeconomic deprivation (based on the Index of Multiple Deprivation). Distributional impacts were further assessed using conditional quantile treatment effects and inequality treatment effects.

SETTING

In 2007, England introduced a ban on smoking in public places. This had little impact on tobacco consumption by smokers but was associated with decreases in environmental tobacco smoke exposure for non-smokers. However, the impact of the ban on socioeconomic inequalities in exposure is unclear.

PARTICIPANTS

766 smokers and 2952 non-smokers responding to the Health Survey for England in 2007.

OUTCOME MEASURE

Levels of salivary cotinine.

RESULTS

Before the ban, socioeconomic deprivation was associated with higher cotinine levels for non-smokers but not for smokers. The ban caused a significant reduction in average cotinine levels for non-smokers (p=0.043) but had no effect for smokers (p=0.817). Reductions for non-smokers were greater for more deprived groups with higher levels of exposure, and there was a significant reduction in socioeconomic-related inequality in cotinine. Across the whole population (both smokers and non-smokers), there was no significant increase in the concentration of cotinine levels among the socioeconomically deprived.

CONCLUSION

The 2007 ban on smoking in public places had little impact on smokers, but was, as intended, associated with reductions in both (1) average levels of environmental tobacco smoke exposure and (2) deprivation-related inequality in exposure among non-smokers.

A breath of fresh air: The effect of public smoking bans on Indigenous youth

In general, past studies have estimated the average effect of public smoking bans on youth, ignoring differences across sub-populations. We extend the literature by considering Indigenous youth, who are a vulnerable and previously unexamined group (however, our analysis excludes First Nations youth who live on reserve). We also consider previously unexamined outcomes among youth: self-assessed health and subjective well-being. Our difference-in-differences estimates from Canada indicate that public bans reduced youth smoking and second-hand exposure in public places, on average. There was no displacement on the extensive margin, but the bans increased the number of people who smoke in the homes of youth, conditional on the presence of smokers in the household. Beyond average effects, however, we find that public bans reduced second-hand exposure in the homes of Indigenous youth (particularly Métis youth), on the extensive and intensive margins. The same youth experienced concurrent improvements in self-assessed health and life satisfaction. We conclude that public bans mitigate disparities in health and well-being between Indigenous and non-Indigenous youth, but the extent varies across Indigenous sub-populations, even within a particular country.

Self-Reported Exposure to Secondhand Smoke and Support for Complete Smoking Bans in Multiunit Housing Among Smokers in the United States, Canada, and the United Kingdom

Introduction

Involuntary exposure to secondhand smoke most frequently occurs at home, which is problematic for residents of multiunit housing (MUH). The primary objective of this study was to estimate the extent of secondhand smoke incursions into the homes of MUH smokers who banned smoking in their homes but lived in buildings where smoking is allowed.

Methods

We used data from Wave 9 of the International Tobacco Control Four Country Survey. We estimated 1) the prevalence of complete smoking bans among smokers living in single-family homes vs MUH in the United States (n = 3,208), Canada (n = 1,592), and the United Kingdom (n = 1,403) from 2013 to 2015; 2) the extent of secondhand smoke incursions into the homes of MUH smokers who banned smoking in their units but lived in buildings that allow smoking; and 3) MUH smokers’ preferences for complete smoking bans in MUH. Weighted multivariable logistic regression estimated the country-specific adjusted prevalence of all outcomes.

Results

Overall, 53.0% of smokers living in single-family homes completely banned smoking in their homes, compared with 44.8% of smokers in MUH. Across all 3 countries, only 27.8% of MUH smokers reported that smoking was completely prohibited in their building. A similar percentage of MUH smokers who banned smoking in their home but lived in buildings allowing smoking reported a secondhand smoke incursion into their home in the United States (29.9%; 95% CI, 20.4%–41.5%), Canada (38.4%; 95% CI, 26.7%–51.6%), and the United Kingdom (24.7%; 95% CI, 15.7%–36.7%). Across all 3 countries, 36.1% (95% CI, 33.4%–38.9%) of smokers in MUH reported they preferred a complete smoking ban in all building areas.

Conclusion

A need remains to educate MUH operators and residents about the benefits of comprehensive smoke-free policies.

Factors associated with indoor smoking at home by adults across Korea: a focus on socioeconomic status

OBJECTIVES

Secondhand smoke is an issue that cannot be ignored due to its various negative effects. Especially, secondhand smoke inside the household is an area where health policy must pay attention as it can affect all age groups. This study aims to identify the factors associated with smoking inside the household focusing on socioeconomic status in Korea.

METHODS

We used data from the Community Health Survey of 2017 and a total of 33,462 participated in the study. Data were analyzed through IBM SPSS version 25.0 to conduct binary logistic regression analysis.

RESULTS

Results indicated that indoor smoking had a significant association with socioeconomic status. This association was more marked in those participants who had low household income or those with elementary school education level or less. Furthermore, the study indicates that when the smoker is a woman, older, has higher stress, and is a heavier smoker, the probability of her smoking inside the house is higher.

CONCLUSIONS

Based on the results, it is meaningful that this study has found the factors of smoking inside household. The result identify the factors associated with indoor smoking at home, and it can be used as baseline data for developing new smoking cessation policies.

Evaluating the impact of the California 1995 smoke-free workplace law on population smoking prevalence using a synthetic control method

The objective of this study is to assess the impact of the California 1995 Smoke-Free Workplace Act (SFWA) on cigarette smoking prevalence in the population. We used survey responses related to cigarette smoking from the Behavioral Risk Factor Surveillance System (BRFSS) from 1990 to 2000. We utilize a synthetic control method which creates a weighted combination of control states to produce a single ‘synthetic’ control group to best approximate the counterfactual trend in California in the absence of the SFWA. Variables known to be associated with smoking were included to weight each state in the pre-intervention period as medians by state and included: distribution of race/ethnicity (White, Black, Asian, Hispanic), sex (Male/Female), marital status (married/unmarried), high school education (yes/no) and employment status (yes/no).

We find evidence that there was a small decrease in population smoking prevalence in California in the year immediately following the SFWA, but this effect was not sustained beyond 1995. We hypothesize that one potential explanation for the lack of prolonged impact on population smoking prevalence is that there are sustained effects from the passage of 1989 California Proposition 99, which enacted an excise tax on tobacco products. Understanding how workplace smoking ban legislation affects population smoking behaviors is necessary to better inform policy development in other states and counties and to improve existing policies. Future work should consider the impact of smoking legislation impacts subgroups of the population by socioeconomic status, occupation or race/ethnicity.

Impact of Cognitive and Social Factors on Smoking Cessation Attempts among US Adult Muslim Smokers

Background

Muslims in the United States (US) exhibit high rates of cigarette smoking. Guided by the Social Cognitive Theory, the study aimed to investigate the associations between the number of serious cigarette smoking cessation attempts and cognitive as well as environmental factors in adult US Muslim smokers.

Methods

This cross-sectional study was based on a convenience sample of adult (≥ 18 years) US Muslim smokers. After receiving IRB approval, data were collected using an on-line survey. Unadjusted Poisson regression followed by adjusted multivariable Poisson regression analyses were conducted to answer the research question.

Results

One hundred thirty-two smokers completed the questionnaire. Smokers reported more serious cigarette smoking cessation attempts if they 1) had more knowledge about the consequences of cigarette smoking cessation, 2) had more positive attitudes regarding quitting, and 3) reported greater religiosity. Additionally, smokers reported fewer serious cigarette smoking cessation attempts if they 1) were employed, 2) affiliated with Sunnah sect, 3) reported better self-assessed health, 4) reported higher perceived value for quitting, and 5) indicated that using tobacco was not allowed inside the home. Only three smokers reported using both prescription medications and counseling to aid with smoking cessation attempts.

Conclusions

Inadequate utilization of pharmaceutical smoking cessation products and provider professional assistance may exacerbate the problems associated with elevated rates of smoking among US Muslim smokers. Knowledge of the consequences, more positive attitudes, and greater religiosity can be influential constructs in future interventions aimed at encouraging smoking cessation attempts in this population.

Factors Associated with Cigarette Smoking Cessation in Lao People's Democratic Republic: Results from the 2015 National Adult Tobacco Survey

Cigarette smoking represents a major public health problem in Lao People's Democratic Republic (Lao PDR). This study aims to examine factors associated with cigarette smoking cessation attempts and intention to quit. Data were from the Lao National Adult Tobacco Survey that consisted of 7562 participants ≥15 years old. Multivariable logistic regression models were used to evaluate the associations, adjusted for sex, age groups, education level, income per day, and smoking frequency. Results show that past quit attempts were associated with visiting a healthcare provider in the past year (adjusted odds ratio [AOR]: 1.74, 95% confidence intervals [CI]: 1.28-2.35), home smoking bans (AOR: 5.52, 95% CI: 2.13-14.33), noticing media-based messages informing the dangers of smoking or encouraging quitting (AOR: 3.25, 95% CI: 2.28-4.63), noticing health warnings on cigarette packages in the past 30 days (AOR: 3.33, 95% CI: 2.21-5.03), and believing that smoking is seriously harmful to their health (AOR: 3.45, 95% CI: 1.24-9.57). The Lao PDR government should continue implementing tobacco control policies that demonstrated associations with cessation attempts or intention to quit, such as smoke-free environments and required health warnings on cigarette packages. Tobacco cessation treatment programs are pressingly needed in Lao PDR.

Trends and patterns of second-hand smoke exposure amongst the non-smokers in India-A secondary data analysis from the Global Adult Tobacco Survey (GATS) I & II

Objectives

The primary objective of the present study was to compare the prevalence and patterns of second-hand smoke (SHS) exposure in the home, workplace, public places, and at all three places amongst the non-smoker respondents between the two rounds of Global Adult Tobacco Survey (GATS) in India. The secondary objectives were to assess the differences in various factors associated with SHS exposure among non-smokers.

Study design

This secondary data analysis incorporated data generated from the previous two rounds of the cross-sectional, nationally representative GATS India, which covered 69,296 and 74,037 individuals aged 15 years and above. Exposure to the SHS at home, workplace, and public places amongst the non-smokers were the primary outcome variables. Standard definitions of the surveys were used.

Results

The overall weighted prevalence of exposure to SHS amongst the non-smokers inside the home and public places reduced. In contrast, the prevalence in the workplace increased marginally in round II compared to I. The proportion of adults who were exposed to SHS at all three places did not change much in two rounds of surveys. A decrease in the knowledge of the respondents exposed to SHS at home and public places was observed about the harmful effects of smoking in round II. Age, gender, occupation, place, and region of respondents were found to be significant determinants of SHS exposure at all the three places on multinomial logistic regression analysis.

Conclusions

The study calls for focused interventions in India and stringent implementation of anti-tobacco legislation, especially in the workplaces for reducing the exposure to SHS amongst the non-smokers and to produce encouraging and motivating results by next round of the survey.

Disseminating a Smoke-free Homes Program to Low Socioeconomic Status Households in the United States Through 2-1-1: Results of a National Impact Evaluation

INTRODUCTION

Given homes are now a primary source of secondhand smoke (SHS) exposure in the United States, research-tested interventions that promote smoke-free homes should be evaluated in real-world settings to build the evidence base for dissemination. This study describes outcome evaluation results from a dissemination and implementation study of a research-tested program to increase smoke-free home rules through US 2-1-1 helplines.

METHODS

Five 2-1-1 organizations, chosen through a competitive application process, were awarded grants of up to $70 000. 2-1-1 staff recruited participants, delivered the intervention, and evaluated the program. 2-1-1 clients who were recruited into the program allowed smoking in the home, lived in households with both a smoker and a nonsmoker or child, spoke English, and were at least 18 years old. Self-reported outcomes were assessed using a pre-post design, with follow-up at 2 months post baseline.

RESULTS

A total of 2345 households (335-605 per 2-1-1 center) were enrolled by 2-1-1 staff. Most participants were female (82%) and smokers (76%), and half were African American (54%). Overall, 40.1% (n = 940) reported creating a full household smoking ban. Among the nonsmoking adults reached at follow-up (n = 389), days of SHS exposure in the past week decreased from 4.9 (SD = 2.52) to 1.2 (SD = 2.20). Among the 1148 smokers reached for follow-up, 211 people quit, an absolute reduction in smoking of 18.4% (p < .0001), with no differences by gender.

CONCLUSIONS

Among those reached for 2-month follow-up, the proportion who reported establishing a smoke-free home was comparable to or higher than smoke-free home rates in the prior controlled research studies.

IMPLICATIONS

Dissemination of this brief research-tested intervention via a national grants program with support from university staff to five 2-1-1 centers increased home smoking bans, decreased SHS exposure, and increased cessation rates. Although the program delivery capacity demonstrated by these competitively selected 2-1-1s may not generalize to the broader 2-1-1 network in the United States, or social service agencies outside of the United States, partnering with 2-1-1s may be a promising avenue for large-scale dissemination of this smoke-free homes program and other public health programs to low socioeconomic status populations in the United States.

Smokefree home rules and cigarette smoking intensity among smokers in different stages of smoking cessation from 20 low-and-middle income countries

Smokefree environment created by smokefree policies is associated with smoking reduction; however, there is paucity of literature on the relationship between smokefree home rules and smoking intensity in low-and-middle income countries (LMICs), and how smokefree policy affects smoking behavior of smokers at different stages of smoking cessation. This study examined the relationship between smokefree home rules and average number of cigarettes smoked per day (CPD) among daily smokers at different stages of the transtheoretical model (TTM) of change. Data from 18,718 current daily cigarette smokers from the Global Adult Tobacco Survey (GATS) conducted from 2011 to 2017 in 20 LMICs were analyzed. Weighted multivariable linear regression analyses were conducted using the log of CPD as the outcome variable with smokefree home rules as the exposure variable, controlling for selected covariates. Approximately 15% of the participants were in precontemplation, 5% were in preparation, 15% lived in partial smokefree homes, and 30% lived in complete smokefree homes. The average number of CPD was 12.3, 12.0, and 10.6 among participants living in homes where smoking was allowed, partial smokefree homes, and complete smokefree homes, respectively. Compared to living in homes where smoking was allowed, living in complete smokefree homes were associated with 22.5% (95%CI = 18.4%-26.5%), 17.9% (95%CI = 8.4%-27.3%), and 29.3% (95% CI = 17.1%-41.5%) fewer CPD among participants in precontemplation, contemplation, and preparation stages, respectively. These findings suggest that complete smokefree home policy will benefit smokers in LMICs irrespective of their intention to quit smoking in addition to protecting non-smokers from secondhand smoke exposure.

It's Just Steam: a qualitative analysis of New Zealand ENDS users' perceptions of secondhand aerosol

Introduction

Many smokers who begin using electronic nicotine delivery systems (ENDS) report vaping in settings where they would not have smoked and believe secondhand aerosol (SHA) is simply steam. However, current understanding of how ENDS users differentiate between secondhand smoke and SHA, or how vaping norms develop, is limited.

Methods

We conducted in-depth, semi-structured interviews with 39 current ENDS users (dual users and former smokers, now exclusive ENDS users) from New Zealand to explore participants’ perceptions of SHA. We probed how these perceptions arose and examined implications for vaping practices and policy. We managed the data using NVivo V.11 and used a thematic analysis approach to interpret the transcripts.

Results

Participants had limited understanding of SHA, its constituents or its possible effects on others. They drew on the absence of harm information, and their sensory experiences and perceptions of others’ views of vaping, to support the conclusion that SHA posed few, if any, risks to bystanders. Yet despite this perception, some felt they should recognise others’ rights to clean air and most would not vape around children to avoid setting an example.

Conclusions

In the absence of trusted information, participants used sensory heuristics to rationalise their ENDS practices. Policy-makers face the challenge of correcting misperceptions about SHA without deterring full transition from smoking to ENDS use. They could consider including vaping in current smoke-free area policies; this measure would signal that SHA is not harmless, and could protect clean-air settings and reduce potential normalisation of vaping among non-smokers.

Rules about smoking and vaping in the home: findings from the 2016 International Tobacco Control Four Country Smoking and Vaping Survey

AIMS

To examine rules about smoking and vaping in the home in relation to beliefs about the relative harm of second-hand vapor (SHV) compared with second-hand smoke (SHS) in four countries: Canada, United States, England and Australia.

DESIGN

Data were available from 12 294 adults (18+) who participated in the 2016 (wave 1) International Tobacco Control Four Country Smoking and Vaping (ITC 4CV1) Survey.

PARTICIPANTS

All participants were current or recent former adult smokers.

MEASUREMENTS

Data were analyzed by weighted logistic regression on rules about smoking and vaping in the home; odds ratios and 95% confidence intervals were reported, adjusted for demographic and behavioral variables.

FINDINGS

Of all respondents, 37.4% allowed smoking inside their home. Among a subset who were current vapers (n = 6135), 60.4% allowed vaping in their homes. After controlling for demographic and behavioral characteristics, beliefs about the harm of SHV compared with SHS was not associated with allowing smoking in the home, but was associated with allowing vaping in the home [odds ratio (OR) = 2.86 in Canada, OR = 1.82 in the United States and OR = 1.68 in England]. Characteristics that were associated with rules about vaping inside the home included daily vaping (OR = 2.95, 2.04-4.26; OR = 7.00, 4.12-11.87; OR = 5.50, 3.40-8.88; OR = 7.78, 1.90-31.80), living with a spouse who vapes (OR = 2.48, 1.54-3.98; OR = 2.69, 1.42-5.11; OR = 4.67, 2.74-7.95; OR = 21.82, 2.16-220.9) and living with children aged under 18 years (OR = 0.50, 0.37-0.68; OR = 0.89, 0.48-1.65; OR = 0.76, 0.53-1.09; OR = 0.26, = 0.11-0.61) in Canada, the United States, England and Australia, respectively. Similar characteristics were associated with rules about smoking inside the home.

CONCLUSIONS

Among current and former smokers in 2016 in Canada, the United States, England and Australia, 37.4% allowed smoking in the home; 60.4% of current vapers allowed vaping. Both concurrent users and exclusive vapers were more likely to allow vaping than smoking inside the home. Allowing vaping inside the home was correlated with the belief that second-hand vapor is less harmful than second-hand smoke.

Uneven Access to Smoke-Free Laws and Policies and Its Effect on Health Equity in the United States: 2000-2019

Tobacco control measures have played an important role in the reduction of the cigarette smoking prevalence among US adults.However, although overall smoking prevalence has declined, it remains high among many subpopulations that are disproportionately burdened by tobacco use, resulting in tobacco-related health disparities. Slow diffusion of smoke-free laws to rural regions, particularly in the South and Southeast, and uneven adoption of voluntary policies in single-family homes and multiunit housing are key policy variables associated with the disproportionate burden of tobacco-related health disparities in these subpopulations.Developing policies that expand the reach of comprehensive smoke-free laws not only will facilitate the decline in smoking prevalence among subpopulations disproportionately burdened by tobacco use but will also decrease exposure to secondhand smoke and further reduce tobacco-caused health disparities in the United States.

Attitudes of Korean smokers towards smoke-free public places: findings from the longitudinal ITC Korea Survey, 2005-2010

OBJECTIVE

Prior to December 2012, restaurants in South Korea were required to implement only partial smoking bans. This study documents the changes in Korean smokers' attitudes towards smoking bans between 2005 and 2010 and explores the effects of anti-smoking advertising as a correlate of support for total smoking bans in public places.

DESIGN

Longitudinal cohort study of Korean adult smokers.

SETTING

The data were derived from three waves (2005, 2008 and 2010) of the International Tobacco Control (ITC) Korea Survey.

PARTICIPANTS

The ITC Korea Survey respondents were a probability-based, nationally representative sample of Korean smokers aged 19 and older. The current analysis includes 995 smokers who participated in Wave 1 (2005), 1737 smokers who participated in Wave 2 (2008) and 1560 smokers who participated in Wave 3 (2010).

PRIMARY AND SECONDARY OUTCOME MEASURES

Changes in respondents' awareness of secondhand smoke (SHS) harm, attitudes towards smoking bans and personal rules for smoking in private homes and/or vehicles were analysed. Correlates of support for smoking bans in public places were examined using generalised estimating equation regression models.

RESULTS

More than 80% of Korean smokers are aware of the harms of SHS. The proportion of smokers who support smoke-free restaurants or smoke-free bars increased twofold between 2005 and 2010. Smokers who were aware of the dangers of SHS were more likely to support a total smoking ban in workplaces. Noticing anti-smoking advertising or information was not significantly associated with support for a total smoking ban in public places.

CONCLUSIONS

Korean smokers became more supportive of smoking bans in public places between 2005 and 2008. These results show that smokers' attitudes towards smoking bans can change with the implementation of smoke-free policies, even in a country that has a high prevalence of smokers.

A cross-sectional study of the relationship of proximal smoking environments and cessation history, plans, and self-efficacy among low-income smokers

Introduction

Proximal environments could facilitate smoking cessation among low-income smokers by making cessation appealing to strive for and tenable.

Aims

We sought to examine how home smoking rules and proximal environmental factors such as other household members' and peers' smoking behaviors and attitudes related to low-income smokers' past quit attempts, readiness, and self-efficacy to quit.

Methods

This analysis used data from Offering Proactive Treatment Intervention (OPT-IN) (randomized control trial of proactive tobacco cessation outreach) baseline survey, which was completed by 2,406 participants in 2011/12. We tested the associations between predictors (home smoking rules and proximal environmental factors) and outcomes (past-year quit attempts, readiness to quit, and quitting self-efficacy).

Results

Smokers who lived in homes with more restrictive household smoking rules, and/or reported having 'important others' who would be supportive of their quitting, were more likely to report having made a quit attempt in the past year, had greater readiness to quit, and greater self-efficacy related to quitting.

Conclusions

Adjustments to proximal environments, including strengthening household smoking rules, might encourage cessation even if other household members are smokers.

Black Light Smokers: How Nicotine Intake and Carcinogen Exposure Differ Across Various Biobehavioral Factors

OBJECTIVE

The study objective was to identify biobehavioral variables associated with greater intake of nicotine and a tobacco carcinogen among Black light smokers who smoke 1 to 10 cigarettes per day (CPD).

METHODS

We analyzed baseline data collected from 426 Black light smokers enrolled in Kick It at Swope III (KIS III), a smoking cessation trial for Black smokers. We examined differences in concentrations of tobacco biomarkers, including urinary total nicotine equivalents (TNE) and total 4-(methylnitrosamino)-1-(3)pyridyl-1-butanonol (NNAL; a human carcinogen), across gender, age, plasma nicotine metabolite ratio (NMR), CPD, and measures of tobacco dependence, including time to first cigarette (TFC), using ANOVA.

RESULTS

Tobacco biomarker levels were significantly higher among those who smoked more CPD (6-10 vs 1-5 CPD) and those with greater reported physical dependence on tobacco. Concurrently, those who smoked 1-5 CPD smoked each cigarette more intensely than those who smoked 6-10 CPD. While we found no gender differences overall, among those who smoked 1-5 CPD, women had higher NNAL levels compared to men. The rate of nicotine metabolism, measured by the nicotine metabolite ratio, was not significantly related to TNE or NNAL levels.

CONCLUSION

Among Black Light smokers, higher cigarette consumption and greater physical dependence-but not rate of nicotine metabolism, menthol use, or socioeconomic status-were associated with greater toxicant exposure and thus a likely increased risk of tobacco-related diseases. The lack of data on light smokers, and specifically on Blacks, make this observation important given the disproportionate burden of lung cancer in this population.

Smoke-Free Ordinances and Policies Protect Youth, but Ordinances Appear to Have Little Impact on Non-Combustible Tobacco Use

Smoke-free ordinances and policies protect youth from exposure to secondhand smoke (SHS) and cigarette use. This study investigated whether smoke-free ordinances also protect youth from the use of other tobacco products. We compared the prevalence of SHS exposure, cigarette smoking, cigar smoking, smokeless tobacco use, and e-cigarette use among high school students living in a municipality with or without a smoke-free ordinance and in homes with and without smoke-free policies. Data were analyzed using the 2017 Mississippi Youth Tobacco Survey (n = 1923). Smoke-free ordinances were found to be associated with lower prevalence of SHS exposure (41.9% vs. 51.5%), cigarette smoking (5.1% vs. 11.4%), and cigar smoking (7.2% vs. 10.9%). There were no differences in smokeless tobacco use (6.6% vs. 6.5%) or e-cigarette use (11.2% vs 12.1%). Smoke-free homes were associated with lower prevalence of SHS exposure (38.0% vs 74.6%), cigarette smoking (4.8% vs. 17.6%), cigar smoking (6.4% vs. 16.4%), smokeless tobacco use (4.9% vs. 13.2%), and e-cigarette use (9.6% vs. 19.5%), p < 0.05 for all comparisons. The results suggest that smoke-free ordinances and policies protect against exposure to tobacco smoke and use of combustible tobacco products, but smoke-free ordinances do not protect from smokeless tobacco and e-cigarette use. Tobacco-free, rather than smoke-free, ordinances might offer more protection.

Voluntary home and car smoke-free rules in Japan: a cross-sectional study in 2015

OBJECTIVES

Recently, the Tokyo Metropolitan Assembly passed an ordinance prohibiting smoking in private homes and cars if children are present. However, no previous study has investigated existing, voluntary home and car smoke-free rules in Japan. Therefore, we examined prevalence and determinants of comprehensive home and car smoke-free rules.

DESIGN

A cross-sectional study.

SETTING

Internet survey data with adjustments using inverse probability weighting for 'being a respondent in an internet survey'.

PARTICIPANTS

5600 respondents aged 15-69 years in 2015 were analysed to estimate weighted percentages and prevalence ratios (PRs) with 95% CIs of having comprehensive home and car smoke-free rules.

MAIN OUTCOME MEASURES

Respondents who answered 'smoking is never allowed' in their home and car were defined as having home and car smoke-free rules.

RESULTS

Overall, 47.0% (95% CI=45.8% to 48.3%) of respondents implemented comprehensive home and car smoke-free rules. People who agreed with 'smoking relieves stress' were less likely to have comprehensive smoke-free rules (PR=0.76, 0.71 to 0.82), especially among ever-users of electronic nicotine delivery systems (PR=0.49, 0.30 to 0.81). Higher education was significantly associated with higher PR for comprehensive smoke-free rules (PR=1.30, 1.19 to 1.41). Living with children was significantly associated with higher PR for smoke-free rules among current smokers than not living with children (PR=2.91, 1.99 to 4.27).

CONCLUSIONS

In Japan, about 50% of respondents had voluntary smoke-free rules in the home and car. Information on current voluntary smoke-free rules will be useful as baseline information on home and car smoke-free status before enforcement of the 2018 Tokyo home and car smoke-free legislation.

Prevalence and correlates of different smoking bans in homes and cars among smokers in six countries of the EUREST-PLUS ITC Europe Surveys

INTRODUCTION

Second-hand smoke exposure has decreased in a number of countries due to widespread smoke-free legislation in public places, but exposure is still present in private settings like homes and cars. Our objective was to describe to what extent smokers implement smoking rules in these settings in six European Union (EU) Member States (MS).

METHODS

A cross-sectional survey was conducted with a nationally representative sample of adult smokers from Germany, Greece, Hungary, Poland, Romania and Spain (ITC six European countries survey, part of the EUREST-PLUS Project). We analysed data from 6011 smokers regarding smoking rules in their homes and in cars with children (no rules, partial ban, total ban). We described the prevalence of smoking rules by EU MS and several sociodemographic and smoking characteristics using prevalence ratios (PR) and 95% confidence intervals (CI) derived from Poisson regression models. \.

RESULTS

In homes, 26.5% had a total smoking ban (from 13.1% in Spain to 35.5% in Hungary), 44.7% had a partial ban (from 41.3% in Spain to 49.9% in Greece), and 28.8% had no-smoking rules (from 20.2% in Romania to 45.6% in Spain). Prevalence of no-smoking rules in cars with children was 16.2% (from 11.2% in Germany to 20.4% in Spain). The correlates of not restricting smoking in homes and cars included: low education (PR=1.51; 95%CI: 1.20-1.90 and PR=1.55; 95%CI: 1.09-2.20), smoking >30 cigarettes daily (PR=1.53; 95%CI: 1.10-2.14 and PR=2.66; 95%CI: 1.40-5.05) and no attempts to quit ever (PR=1.18; 95%CI: 1.06-1.31 and PR=1.28; 95%CI: 1.06-1.54).

CONCLUSIONS

Among smokers in six EU MS, no-smoking rules were more prevalent in homes than in cars with children. Whilst awareness about the health effects of exposure to tobacco smoke on children seemed to be high, more research is needed to better understand the factors that promote private smoke-free environments.

Impact of public smoking bans on children's exposure to tobacco smoke at home: a systematic review and meta-analysis

Backround

Meta-analysis of the impact of public smoking bans on children’s exposure to secondhand smoke (SHS) exposure at home.

Methods

The electronic databases of PubMed, Web of Science, PsycINFo, ASSIA, CINAHL were searched. German public health journals not captured by these databases and grey literature were considered in addition.

Studies were included when they reported children’s SHS exposure at home in relation to smoke-free legislation by measuring exposure before and after the introduction of a public smoking ban. Studies had to provide results on exposure prevalences of children aged below 18 years. Language of publications was restricted to German and English.

Details of the included studies (n = 15) were extracted by one author and checked for accuracy by a second author. Given the exposure prevalences before and after the introduction of a smoke-free legislation, a random-effects meta-analysis of relative risks (RR) was conducted. Results were presented in a forest plot.

Results

Meta-analysis showed that the overall effect was a decreased exposure to SHS in the children’s homes after introduction of a public smoking ban (RR = 0.72; 95% CI = 0.62–0.83). Only two of the 15 studies indicated an increased exposure. Sensitivity analyses considering the type of smoke-free legislation, children’s age group and study quality did not substantially alter the result.

Conclusion

The assumption of a displacement of smoking into homes with children due to smoke-free legislation in public places could not be confirmed. Additional research is needed to analyse long-term trends.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5679-z) contains supplementary material, which is available to authorized users.

Cessation and reduction in smoking behavior: impact of creating a smoke-free home on smokers

The aim of this study was to assess the effect of a creating a smoke-free home (SFH) on cessation and reduction of cigarette smoking on low-income smokers. This secondary data analysis uses data from study participants who were originally recruited through 2-1-1 information and referral call centers in Atlanta (Georgia, 2013), North Carolina (2014) and the Texas Gulf Coast (2015) across three randomized controlled trials testing an intervention aimed at creating SFHs, pooling data from 941 smokers. Participants who reported adopting a SFH were more likely to report quitting smoking than those who did not adopt a SFH. This was true at 3-month follow-up and even more pronounced at 6-month follow-up and persisted when considering only those who consistently reported no smoking at 3 and 6 months. Among those who did not stop smoking, the number of cigarettes per day declined significantly more and quit attempts were more frequent for those who created a SFH compared with those who did not. Findings suggest that creating a SFH facilitates cessation, reduces cigarette consumption and increases quit attempts. Future studies should assess the long-term impact of SFHs on sustaining cessation.

Health Warnings, Smoking Rules, and Smoking Status: A Cross-National Comparison of Turkey and the United States

OBJECTIVES

This study aimed to compare the prevalence of smoking status (i.e., current, former and never) between the United States and Turkey in terms of age and gender, and examine how smoking rules and health warnings are associated with smoking status within and between the two countries.

METHODS

The study used data from the 2012-2013 National Adult Tobacco Survey (U.S. sample, N = 60,196) and the 2012 Global Adult Tobacco Survey (Turkey sample, N = 9,581). SAS PROC SURVEYLOGISTIC with a weighted variable was used to examine the associations between demographics (age, gender and education), smoking rules, health warnings, and smoking status within and between the two countries.

RESULTS

There was an 18% current smoking prevalence among U.S. sample, compared to 27% of the Turkey sample. The U.S. sample had a higher rate of former smoking compared to the Turkey sample (25% vs. 22%). In both countries, being older and male gender predicted former smoking while being younger and female gender predicted never smoking. Having seen a health warning, and not allowing smoking in the vehicle and home positively predicted former and never smoking status. Higher education predicted both smoking statuses in the U.S. only.

CONCLUSIONS

It is important to work with partners particularly in low- and middle-income countries (e.g., Turkey) to combat the global tobacco epidemic. In both counties, cessation endeavors should emphasize a comprehensive understanding of smoking status in terms of smoking rules in personal spaces and health warnings.

Paternal smoking and maternal protective behaviors at home on infant's saliva cotinine levels

BackgroundWe investigated the association between paternal smoking, avoidance behaviors and maternal protective actions and smoke-free home rules with infant's saliva cotinine in Hong Kong.MethodsSix hundred and seventy-five non-smoking mothers (mean age 32.6 years) who attended the maternal-child health clinics with their newborns aged ≤18 months completed a questionnaire about paternal smoking and avoidance behaviors, maternal protective actions, smoke-free rules at home, and infant's second-hand smoke (SHS) exposure. Three hundred and eighty-nine infants provided saliva sample and its cotinine was tested.ResultsThe geometric mean of infant's saliva cotinine was 1.07 ng/ml (95% confidence interval (CI): 0.98, 1.16). Infants living in smoking families with SHS exposure had significantly higher cotinine level than in non-smoking families (adjusted β=0.25, 95% CI: 0.16, 0.33). Paternal smoking near infants (within 1.5 m) was associated with higher cotinine level (adjusted β=0.60, 95% CI: 0.22, 0.98), which was not reduced by avoidance behaviors (e.g., smoking in kitchen or balcony). Even fathers smoking ≥3 m away from infants was associated with higher cotinine level than non-smoking families (adjusted β=0. 09, 95% CI: 0.01, 0.16). Maternal protective actions and smoke-free home rules were not significantly associated with reduced cotinine level.ConclusionPaternal smoking avoidance, maternal protective actions, and smoke-free policy at home did not reduce infant's saliva cotinine.

A Cluster Randomised Controlled Trial of a Brief Child Health Nurse Intervention to Reduce Infant Secondhand Smoke Exposure

Background Exposure to secondhand smoke (SHS) is a significant contributor to ill health in children. A study was undertaken to determine the effectiveness of two brief multi-strategic child health nurse delivered interventions in: decreasing the prevalence of infants exposed to SHS; decreasing the prevalence of smoking amongst parent/carers of infants and increasing the prevalence of household smoking bans. Methods This study was a 3 arm, cluster randomised controlled trial. Clusters were 39 community based well child health clinics in one local area health service. Clinics were stratified according to annual number of client appointments and then randomly assigned in a 1:1:1 ratio, (Intervention 1: Intervention 2: Control), with 13 clinics in each cluster. Parents/carers of infants in the intervention groups received a brief multi-strategic intervention from child health nurses during clinic consultations. Treatment condition 1 included computer delivered risk assessment and feedback and nurse brief advice. Treatment condition 2 included all elements of Treatment condition 1 with the addition of biochemical feedback of infant SHS exposure. Results When compared to the Control group at 12 months, no significant differences in the prevalence of infant exposure to SHS were detected from baseline to follow-up for Treatment condition 1 (OR 1.16, 95 % CI 0.73-1.85, p = 0.53) or Treatment condition 2 (OR 1.30, 95 % CI 0.88-1.92, p = 0.19) Similarly, no significant differences were detected in the proportion of parent/carers who reported that they were smokers (T1:OR 0.95, 95 % CI 0.78-1.15, p = 0.58 and T2:OR 0.97, 95 % CI 0.80-1.18, p = 0.77), or in the proportion of households reported to have a complete smoking ban (T1:OR 1.21, 95 % CI 0.89-1.64, p = 0.23 and T2:OR 1.06, 95 % CI 0.79-1.43, p = 0.68). Conclusions Further research is required to identify effective interventions that can be consistently provided by child health nurses if the potential of such settings to contribute to reductions in child SHS exposure is to be realised.

Acceptance and patterns of personal vaporizer use in Australia and the United Kingdom: Results from the International Tobacco Control survey

BACKGROUND

This study examined the prevalence and correlates of (1) perceived social acceptability of personal vaporizer (PV)/e-cigarette use, and (2) reported vaping in public and private places, in the UK and Australia with different regulatory environments for PVs.

METHODS

Data analyzed come from 2849 smokers and recent ex-smokers in the UK and Australia who participated in the 2014 wave of the International Tobacco Control Survey.

RESULTS

UK respondents were more likely to think vaping is socially acceptable than Australians (56.4% vs. 27.9%; p < 0.001). Having quit smoking, observing vaping in smoke-free (SF) public places, and believing vaping is less harmful than smoking was all significantly associated with greater perceived social acceptability of vaping in both countries. However, vaping status and that of friends and family were more influential in Australia than in the UK. Vaping was reported as much more common in private, than public, settings in both countries. UK vapers were more likely to report vaping in SF public places (OR = 2.66; 95% CI = 1.5-4.7; p < 0.01) and at home (OR = 2.44; 95% CI = 1.5-3.9; p < 0.001), but not in their car when controlling for demographic factors and vaping and smoking status.

CONCLUSION

The acceptability of vaping was greater among those who were more exposed to vaping and not just among those with some personal experience of vaping, suggesting no strong social barriers to increased use. Vaping in SF public places was less common than in homes, and both were more common in the UK than in Australia, suggesting some social constraints on use, particularly in Australia.

Impact of smoke-free housing policy lease exemptions on compliance, enforcement and smoking behavior: A qualitative study

This paper investigates the impacts of smoke-free housing policies on compliance, enforcement and smoking behavior. From 2012 to 2014, we studied two affordable housing providers in Canada with comprehensive smoke-free policies: Waterloo Regional Housing that required new leases to be non-smoking and exempted existing leases, and Yukon Housing Corporation that required all leases (existing and new) to be non-smoking. Focus groups and key informant interviews were conducted with 31 housing and public health staff involved in policy development and implementation, and qualitative interviews with 56 tenants. Both types of smoke-free policies helped tenants to reduce and quit smoking. However, exempting existing tenants from the policy created challenges for monitoring compliance and enforcing the policy, and resulted in ongoing tobacco smoke exposure. Moreover, some new tenants were smoking in exempted units, which undermined the policy and maintained smoking behavior. Our findings support the implementation of complete smoke-free housing policies that do not exempt existing leases to avoid many of the problems experienced by staff and tenants. In jurisdictions where exempting existing leases is still required by law, adequate staff resources for monitoring and enforcement, along with consistent and clear communication (particularly regarding balconies, patios and outdoor spaces) will encourage compliance.

•

Smoke-free housing policy exemptions contribute to continued tobacco smoke exposure.

•

Smoke-free housing policy exemptions contribute to compliance/enforcement issues.

•

Resources for proactive policy enforcement will help to encourage compliance.

Smoke-Free Rules in Homes and Cars Among Smokers and Nonsmokers in Minnesota

We examined prevalence and predictors of comprehensive smoke-free household rules (ie, smoke-free homes and cars) among smokers and nonsmokers in Minnesota. Data came from the 2014 Minnesota Adult Tobacco Survey; weighted analyses consisted of descriptive analyses and multivariate logistic regression analyses. Most adult smokers implemented home-only smoke-free rules (43%) while most nonsmokers implemented comprehensive smoke-free rules (home and car; 85%). Comprehensive smoke-free rules were more common among people with high socioeconomic status (SES), married people, and people who did not live with a smoker; those with a child in the home were more likely to implement smoke-free homes but not smoke-free cars. Public health practitioners should focus on addressing the majority of smokers who do not implement comprehensive smoke-free household rules, such as low-SES populations, and addressing caregivers who do not implement smoke-free car rules.

Interventions to encourage smoke-free homes in remote indigenous Australian communities: a study protocol to evaluate the effects of a community-inspired awareness-raising and motivational enhancement strategy

INTRODUCTION

Rates of secondhand smoke exposure are currently significantly higher among remote indigenous communities in the top end of Australia. By implementing a 'smoke-free home' rule, secondhand smoke exposure can be reduced. Smoke-free homes encourage quit attempts and improve the health of children. The prevalence of indigenous smoking rates in remote, discrete communities in Australia is elevated compared with their non-indigenous counterparts. The primary aim of this project is to examine the feasibility of conducting a health-driven intervention to encourage community members to make their homes a smoke-free zone.

METHODS AND ANALYSIS

This study uses mixed-methods exploratory evaluation design to obtain data from key informants and community householders to assess their willingness to implement a 'smoke-free' rule in their homes. Initial focus groups will provide guidance on intervention content and deliver evaluation procedures and community requirements. A rapid survey will be conducted to ascertain interest from community members in having the project team visit to discuss study objectives further and to have a particle meter (with consent) placed in the house. Focus groups recordings will be transcribed and analysed thematically. Rapid surveys will be analysed using frequency distributions and tabulations of responses.

ETHICS AND DISSEMINATION

The National Health and Medical Research Council guidelines on ethical research approaches to indigenous studies will be adhered to. The James Cook University Human Research Ethics Committee has provided ethics approval.

Recruiting families for an intervention study to prevent second-hand smoke exposure in children

Background

We evaluated the effectiveness of different recruitment strategies used in a study aimed at eliminating/reducing second-hand smoke (SHS) exposure in Dutch children 0–13 years of age with a high risk of asthma.

Methods

The different strategies include: 1) questionnaires distributed via home addresses, physicians or schools of the children; 2) cohorts from other paediatric studies; 3) physicians working in the paediatric field (family physicians, paediatricians and Youth Health Care (YHC) physicians); and 4) advertisements in a local newsletter, at child-care facilities, and day-care centres.

Results

More than 42,782 families were approached to take part in the screening of which 3663 could be assessed for eligibility. Of these responders, 196 families met the inclusion criteria for the study. However, only 58 (one third) could be randomised in the trial, mainly because of no interest or time of the parents. The results showed that recruiting families who expose their children to SHS exposure is very challenging, which may be explained by lack of ‘recognition’ or awareness that SHS occurs in homes. The presence of asthma in the family, respiratory symptoms in the children, and even incentives did not increase parental motivation for participation in the study.

Conclusions

The recruitment process for an intervention program addressing SHS exposure in children was considerably more challenging and time consuming than anticipated. Barriers at both a parents level and a doctor’s level can be discriminated.

Electronic supplementary material

The online version of this article (10.1186/s12887-018-0983-4) contains supplementary material, which is available to authorized users.

Installation Tobacco Control Programs in the U.S. Military

Tobacco use prevalence is unacceptably high in the U.S. military, and the Department of Defense and service branches have implemented tobacco control policies and cessation programs. To explore aspects of programs regarded as exemplary by their services, we visited four installations, nominated by their service's health promotion leaders, and conducted interviews, observations, and focus groups. Installations included Naval Hospital Guam, Tripler Army Medical Center, MacDill Air Force Base, and the Naval Hospital at Marine Corps Air Ground Combat Center Twentynine Palms. The tobacco control managers (TCMs) at the programs studied were all civilian employees, highly motivated and enthusiastic, and had remained in their positions for approximately a decade. Other commonalities included support from command, a "culture" of health, and location in warm climates. Programs varied in their involvement in establishing designated tobacco use areas, and length and requirement of attending cessation classes; however, no evaluation of cessation programs is currently underway. TCMs should be more engaged in policy discussions for the larger installations they serve. A strong policy framework and command support for TCMs will be necessary to achieve the goal of a tobacco-free military.

Correlates of Allowing Alternative Tobacco Product or Marijuana Use in the Homes of Young Adults

BACKGROUND

Given the increases in alternative tobacco product (ATP) and marijuana use, we examined self-reported likelihood of allowing ATP and marijuana use in the home among young adults.

METHODS

We analyzed data from a study of students aged 18 to 25 years (n = 2865) at 7 Georgia colleges and universities. Variables included: personal, household members', and friends' tobacco (cigarettes, little cigars and cigarillos [LCCs], e-cigarettes, hookah) and marijuana use and the perceived harm to health, harm of byproducts, addictiveness, and social acceptability of each. Regression models were specified to examine correlates of the likelihood of allowing use of each product in the home.

RESULTS

Personal use prevalence ranged from 5.5% for e-cigarettes to 12.5% for marijuana. E-cigarettes were most likely to be allowed in the home; cigarettes were least. Regression indicated that others' use and the perceived social acceptability of using each product was correlated with greater likelihood of allowing the use of a product. A greater likelihood of allowing cigarette and LCC use in the home was only associated with cigarette or LCC use, respectively; a greater likelihood of allowing e-cigarette use was associated with current e-cigarette use; greater likelihood of allowing hookah use was associated with using any product except e-cigarettes; and greater likelihood of allowing marijuana use was associated with LCC and marijuana use. Perceived harm to health, byproduct harms, and addictiveness were differentially related to the likelihood of allowing use of different products.

CONCLUSIONS

ATPs and marijuana may undermine efforts to protect against environmental toxins in the home, thus warranting interventions targeting young adults.

Passive Smoking at Home by Socioeconomic Factors in a Japanese Population: NIPPON DATA2010

BACKGROUND

Long-term passive exposure to cigarette smoke has been reported to affect the health of non-smokers. This study aims to investigate the relationships among socioeconomic factors and passive smoking at home in the non-current smokers of a representative sample from a general Japanese population.

METHODS

Data are from NIPPON DATA2010. Among 2,891 participants, 2,288 non-current smokers (1,763 never smokers and 525 past smokers) were analyzed in the present study. Cross-sectional analyses were performed on the relationships among socioeconomic factors and passive smoking at home (several times a week or more) in men and women separately. Socioeconomic factors were employment, length of education, marital status, and equivalent household expenditure. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a multivariable logistic regression model.

RESULTS

The multivariable-adjusted model showed that employed women had a higher risk of passive smoking than unemployed women (OR 1.44; 95% CI, 1.06-1.96). Women with 9 years or less of education had a higher risk of passive smoking at home than women with 13 years and more of education (OR 2.37; 95% CI, 1.49-3.78). Single women had a lower risk of passive smoking at home (OR 0.53; 95% CI, 0.37-0.77) than married women. No significant associations were observed in men.

CONCLUSIONS

An employed status, lower education, and being single were associated with passive smoking at home in the non-current smoking women of a representative Japanese population.

Establishing Smoke-Free Homes in the Indigenous Populations of Australia, New Zealand, Canada and the United States: A Systematic Literature Review

A smoke-free home can have multiple benefits by reducing exposure to secondhand smoke (SHS), supporting quit attempts among active smokers, and discouraging adolescents from taking up smoking. The aim of this review was to summarize the literature on the establishment of smoke-free homes in Indigenous populations and identify the supporting influences and barriers, using the Social Cognitive Theory lens. A search of the Medline, CINAHL, Cochrane Collaboration and PyscINFO databases and manual searches of relevant peer-reviewed literature was completed, focusing on Indigenous populations in developed economies of North America and Oceania. Of 2567 articles identified, 15 studies were included. Ten studies included Indigenous participants only, and of these just three focused entirely on SHS in the home. Knowledge of the harms associated with SHS was the most common theme represented in all the studies. This knowledge fueled parents’ motivation to protect their children from SHS by establishing smoke-free homes. Individuals who approached implementation with confidence, coupled with clear communication about smoke-free home rules were more successful. Barriers included challenges for families with multiple smokers living in the same dwelling. There is limited research regarding managing smoking behaviors in the home among Indigenous populations, even though this approach is a successful catalyst for smoking prevention and cessation. Research to understand the influences that support the establishment of smoke-free homes is required for better-informed intervention studies.

Tobacco Use Cessation Among Quitline Callers Who Implemented Complete Home Smoking Bans During the Quitting Process

INTRODUCTION

The implementation of a home smoking ban (HSB) is associated with tobacco use cessation. We identified which quitline callers were most likely to report 30-day cessation among those who implemented complete HSBs after enrollment.

METHODS

Our sample consisted of callers to the Arizona Smokers' Helpline who enrolled from January 1, 2011, through July 26, 2015, and who reported no HSB at enrollment and a complete HSB by 7-month follow-up. We used logistic regression to estimate associations between no use of tobacco in the previous 30 days (30-day quit) at 7-month follow-up and demographic characteristics, health conditions, tobacco use, and cessation strategies.

RESULTS

At 7-month follow-up, 65.4% of 399 callers who implemented a complete HSB reported 30-day quit. Lower odds of tobacco use cessation were associated with having a chronic health condition (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.18-0.56) and living with other smokers (OR, 0.46; 95% CI, 0.29-0.73). Higher odds of tobacco cessation were associated with completing 5 or more telephone coaching sessions (OR, 2.48; 95% CI, 1.54-3.98) and having confidence to quit (OR, 2.05; 95% CI, 1.05-3.99). However, confidence to quit was not significant in the sensitivity analysis.

CONCLUSION

Implementing an HSB after enrolling in quitline services increases the likelihood of cessation among some tobacco users. Individuals with complete HSBs were more likely to quit if they did not have a chronic health condition, did not live with another smoker, and were actively engaged in coaching services. These findings may be used by quitlines to develop HSB intervention protocols primarily targeting tobacco users most likely to benefit from them.

Restrictions on the use of e-cigarettes in public and private places-current practice and support among adults in Great Britain

Background

Debates around policies regulating e-cigarette use make it important to obtain an overview of current practice, people's attitudes and correlates of policy support. Aims were to assess (i) current practices for e-cigarette use in homes and workplaces; (ii) characteristics associated with allowing e-cigarette use in the home; and (iii) level of, and characteristics associated with, support for extending smoke-free legislation to include e-cigarettes.

Methods

Online survey in 2016, n = 11 389 adults in Great Britain. Descriptives for all measures; multivariable logistic regressions assessed correlates of allowing e-cigarette use and support for extension of legislation.

Results

Most (79%) reporting on workplace policies reported some level of restrictions on e-cigarette use. Small majorities would not allow e-cigarette use in their home (58%) and supported an extension of smoke-free legislation (52%; 21% opposed). Allowing use was less likely and supporting an extension more likely among men, respondents from a higher socio-economic status, ex-smokers, never-smokers, non-users of e-cigarettes and respondents with increased perceived harm of e-cigarettes or nicotine (all P < 0.001). Older respondents were less likely to allow use and to support an extension and Labour voters more likely to allow use.

Conclusions

In Great Britain, the majority of workplaces has policies restricting e-cigarette use. Over half of adults would not allow use of e-cigarettes in their home and support prohibiting the use of e-cigarettes in smoke-free places. Adjusting for socio-demographics, more restrictive attitudes are more common among never-smokers, never-users and those with increased perception of relative harms of e-cigarettes or nicotine as cause of smoking-related illness.

The Relationship between Neighborhood Disorder, Social Networks, and Indoor Cigarette Smoking among Impoverished Inner-City Residents

Impoverished urban neighborhoods tend to have higher rates of smoking and higher rates of exposure to secondhand smoke as compared to more affluent neighborhoods. Contextual factors of neighborhood disorder and social network and household composition may have an impact on indoor smoking behaviors. The TIDE study examined psychosocial factors associated with smoking behaviors among impoverished inner-city smokers in Baltimore, Maryland. Among a community-recruited sample of 413 smokers who lived with others, most (73%) reported that they or others smoked in their residence. Cohabitation with children, elderly, and those with asthma and other respiratory condition was not associated with indoor smoking. Neighborhood disorder, the proportion of social network members who smoked with the study participant, and the proportion of household members who smoked were all independently associated with smoking indoors. The study findings suggest the importance of addressing neighborhood and social network factors when developing programs for promoting indoor smoking bans as well as cessation and prevention programs.

Postdischarge smoking cessation in subgroups of hospitalized smokers: A latent class analysis

BACKGROUND

Hospitalization presents a window of opportunity to treat smoking, and hospital-initiated smoking treatment has demonstrated effectiveness. Despite effective interventions, not all smokers will discontinue use, highlighting the need to better understand which patients achieve cessation. Traditional regression methods may not capture the complexity of inpatient smoker subgroups.

METHODS

Latent class analysis (LCA) was conducted with data from 397 hospitalized adult cigarette smokers enrolled in a randomized trial. Six categorical indicator variables known to impact cessation were selected to estimate subgroups: health conditions (smoking-related disease [SRD], depressive symptoms, positive screen for alcohol problems) and smoking-related variables (time to first cigarette, cigarettes/day, smoking indoors). The probability of achieving biologically verified 7-day tobacco cessation 6 months after discharged was estimated.

RESULTS

A 3-class model best fit the trial data: a Light Smokers subgroup had lower probability for most indicators; a High Health Burden subgroup had high smoking behavior probabilities and similar health problems to the Light Smokers subgroup; and a Heavy Smoking Drinking Depressed subgroup had high nicotine dependence, depressive symptoms, and alcohol misuse probabilities. Probability of biologically verified cessation conditional on class membership was significantly higher (P < .001) for the High Health Burden and the Light Smokers subgroups compared with the Heavy Smoking Drinking Depressed subgroup.

CONCLUSION

Results suggest that subgroups with lower probabilities of alcohol misuse and depression and higher probability of SRD had higher probability of successful cessation after hospital discharge. Hospitalized patients with nicotine dependence combined with behavioral and mental health problems have additional cessation barriers that may require intervention focus.

Predictors of past quit attempts and duration of abstinence among cigarette smokers

Objective: Despite the widespread awareness of the harms of smoking, millions continue to smoke around the world partly due to the difficulty it takes to quit smoking. Identifying the factors associated with making quit attempts is an essential pillar to reach successful quitting. The purpose of this study is to assess the factors associated with the past quit attempts and their past length of abstinence in a Lebanese sample of cigarette smokers.

Methods: This study was conducted between March 2014 and March 2015, involving 382 patients randomly chosen from 5 outpatient clinics in 5 hospitals in Lebanon. A standardized questionnaire was completed including socio-demographic characteristics, smoking behavior, chronic respiratory symptoms, Fagerstrom scale, Mondor scale, packaging perception, quitting behavior and readiness to quit ladder.

Results: Smokers who have chronic allergies (ORa = 2.45, p = 0.03), those who have ever stopped smoking for at least one month due to the warnings implemented on the packages (ORa = 4.6, p < 0.0001) and smokers with an intention to quit in 2 months (ORa = 2.49, p < 0.0001) had significantly more past quit attempts.

Results: Furthermore, longer quit attempts duration (more than 1 month) were significantly associated with low-nicotine dependent smokers (ORa = 0.56, p = 0.02), higher-motivated smokers (ORa = 1.85, p = 0.01), people with chronic allergies (ORa = 2.07, p = 0.02), smokers who have ever stopped smoking for at least one month due to the warnings (ORa = 3.72, p < 0.0001) and those with an intention to quit in 2 months (ORa = 1.98, p = 0.05).

Conclusion: The promoters of smoking cessation services should consider these factors when designing comprehensive tobacco control initiatives and in service planning.

In utero and early childhood exposure to secondhand smoke in Taiwan: a population-based birth cohort study

OBJECTIVES

This study provides secondhand smoke (SHS) exposure data in utero and after birth when children were at 18 months, 36 months and 66 months old, and it identifies risk factors for the early childhood SHS among 18-month-old infants living in smoker and non-smoker households.

STUDY DESIGN

The data come from the Taiwan Birth Cohort Study, a longitudinal survey of a birth cohort born in 2005. This study used the survey wave when children were 18 months old (n=18 845) for statistical analysis of early childhood SHS exposure. Logistic regression was used to identify the risk factors of the SHS exposure.

RESULTS

Approximately 62% of the 18-month-old infants lived in a household with at least one smoker, with the father being the smoker in 84% of those households. Among these infants living in a smoker household, 70% were exposed to SHS and 36% were exposed to heavy SHS in utero, and the prevalence was approximately 66% and 17% after birth for SHS and heavy SHS, respectively. The number and the existence of smokers in the household, parents' smoking status, father's educational attainment and being a first-born baby are strong predictors of early childhood heavy SHS exposure.

CONCLUSIONS

Encouraging families to have a smoke-free home environment, empowering women to ensure their perspectives and rights are embedded into tobacco control efforts and educating families about the health risks from childhood SHS exposure, especially among people living in households with smokers, will protect non-smoking adults and children from SHS exposure.

Secondhand smoke risk perception and smoke-free rules in homes: a cross-sectional study in Barcelona (Spain)

OBJECTIVE

To describe the voluntary adoption of smoke-free homes in Spain among general population and to identify variables associated with its voluntary adoption.

METHODS

Cross-sectional study of a representative sample (n=731) of the adult population (>26 years) of Barcelona, Spain, in 2013-2014. We defined smoking rules inside the households as complete indoor rules (when smoking was not allowed inside the house), and partial or absent indoor rules (when smoking was allowed in some designated places inside the house or when smoking was allowed everywhere) and described them according to the perceived risk of the secondhand smoke (SHS) exposure. We calculated the prevalence and prevalence ratios (PR) according to sociodemographic variables.

RESULTS

57.4% of households had complete indoor smoke-free rules. The prevalence of households with complete indoor rules was higher among women (PRa: 1.15; 95% CI 1.00 to 1.33), married (PRa: 1.18; 95% CI 1.01 to 1.38), never-smokers (PRa: 2.68; 95% CI 2.06 to 3.50) and in households where a minor lived (PRa: 1.40; 95% CI: 1.20-1.65). Believe that breathing tobacco smoke from smokers is dangerous for non-smokers (PRa: 1.77; 95% CI: 1.06-2.97) is associated with the voluntary adoption of complete indoor smoke-free home.

CONCLUSIONS

Risk perceptions of SHS exposure were associated with the voluntary adoption of indoor smoke-free homes.

Children's exposure to secondhand smoke at home before and after smoke-free legislation in Taiwan

INTRODUCTION

In January 2009, Taiwan broadened smoke-free legislation, requiring mass transportation systems, indoor public areas and indoor workplaces with 3 or more people, to become smoke-free. We investigated the secondhand smoke (SHS) exposure at home for children aged 3-11 years in Taiwan before and after the implantation of the legislation.

METHODS

We studied 7911 children from the 2005, 2009 and 2013 National Health Interview Surveys (cross-sectional, nationally representative household surveys). Logistic regression modelling estimated adjusted ORs (AOR) and 95% CIs for children's SHS exposure at home in 2009 and 2013 (2005 as reference) for the overall sample and for each category of household socioeconomic status (SES) and household composition.

RESULTS

Prevalence of children SHS exposure at home decreased from 51% (2005) to 32% (2009) and 28% (2013). Compared to 2005, children in 2009 and 2013 had lower likelihoods of SHS exposure at home with AOR of 0.45 (95% CI 0.41 to 0.51) and 0.41 (95% CI 0.36 to 0.46), respectively. All children had reduced SHS exposure at home after the legislation, irrespective of household SES and compositions. Low household income, low parental education level, living with grandparents or living with other adults was individually associated with increased SHS exposure.

DISCUSSION

The proportion of children exposed to SHS at home in Taiwan declined substantially from 2005 to 2009 after smoke-free legislation, and fell further by 2013, irrespective of SES and household compositions. Still, inequality in SHS exposure at home by SES and household composition warrants future research.

Social Acceptance of Smoking Restrictions During 10 Years of Policy Implementation, Reversal, and Reenactment in the Netherlands: Findings From a National Population Survey

INTRODUCTION

Little is known about the extent to which smoking restrictions are socially accepted in a country such as the Netherlands where smoking restrictions have been implemented and reversed several times. The current study assessed trends as well as factors associated with two indicators of social acceptance of smoking restrictions in the Netherlands: acceptance of smoking in public places and implementation of home smoking bans.

METHODS

We used data from the Dutch Continuous Survey of Smoking Habits (DCSSH) between 2005 and 2014 (n = 182826). The DCSSH is a national population survey with a cross-sectional design in which respondents aged 15 years and older are surveyed weekly.

RESULTS

Acceptance of smoking in public places decreased for six out of eight included venues, with the largest decrease for smoking in restaurants. The decrease in acceptance was larger among younger respondents and smokers. Smoking on terraces was an exception: decrease in acceptance there was larger among older respondents and ex-smokers. Implementation of home smoking bans increased over time. Having implemented a home smoking ban was associated with being male, being younger, having a high socioeconomic status, and being ex- or never smoker.

CONCLUSIONS

Social acceptance of smoking restrictions has increased in the Netherlands, despite a suboptimal implementation process of smoking restrictions. However, there is still potential for improvement as acceptance of smoking is still quite high for some public venues like bars. It is important to strengthen smoking restrictions in order to further denormalize smoking in the Netherlands.

IMPLICATIONS

We examined the extent to which smoking restrictions are socially accepted in the Netherlands where smoking restrictions have been implemented and reversed several times. Acceptance of smoking in public places decreased and implementation of home smoking bans increased between 2005 and 2014. Social acceptance of smoking restrictions increased in the Netherlands despite a suboptimal implementation process of smoking restrictions. However, acceptance of smoking in bars remains relatively high.

A Smoke-Free Community Housing Policy: Changes in Reported Smoking Behaviour-Findings from Waterloo Region, Canada

In 2010, Waterloo Region Housing (Canada) enacted a smoke-free (SF) housing policy that made all new leases in their community-housing portfolio (2722 units) 100 % SF. Existing lease holders were 'grandfathered'-meaning tenants could still smoke in their homes. A survey to measure support for the policy and how the policy had impacted smoking behaviour was delivered to all 2722 households in the Waterloo Region Housing portfolio in 2010 (pre-policy), 2011 and 2013 (post-policy). The proportion of households that completed the survey was 26 % (n = 717) in 2010, 25 % (n = 685) in 2011, and 23 % (n = 619) in 2013. Support for the SF housing policy was 72 % pre-enactment (2010), and increased to 78 % in 2011 and 79 % in 2013; however, most smokers do not support the policy. In 2010, prior to the SF policy, 65 % of tenants who smoke reported someone smoked inside their home; in 2013 this was reduced to approximately half of smokers (52 %). In 2013, 44 % of smokers reported smoking outside more often than before the SF policy was enacted, almost half of tenants with a smoke-free lease (46 %) and more than a third of tenants who have a grandfathered lease (34 %) reported they smoke less since the smoke-free policy. There has been no significant change in the proportion of respondents (>50 %) who reported being exposed to second-hand smoke in their home. This SF housing policy is associated with increased reported outdoor smoking and reduced smoking. Smoke-free policies may support smokers interested in quitting.

Smoke-Free Homes and Youth Smoking Behavior in Italy: Findings From the SIDRIAT Longitudinal Study

INTRODUCTION

Few studies have explored whether smoke-free homes (SFH) can promote reductions of smoking onset in children, particularly in households with smoking parents. The aim of this study was to determine whether youths living in SFH were less likely to progress to smoking.

METHODS

We conducted a longitudinal, 11-year, two-wave study on 778 children aged 6-7 years and 985 adolescents aged 13-14 in 2002. At baseline, youths were asked whether or not adults smoked at home (SFH); at follow-up, in 2012-2014, whether a household smoking ban (HSB) had been implemented during the course of the study. Logistic regression was used to investigate SFH effects on youth smoking behaviors.

RESULTS

Sixty-nine percent of children and 54% of adolescents reported SFH at baseline; 80% of children and 71% of adolescents reported HSB at follow-up. Youths living in non-SFH at baseline were twice as likely to become established smokers at follow-up compared with those living in SFH (children + adolescents: odds ratio [OR] = 1.99; 95% confidence interval [CI] = 1.39-2.94; adolescents: OR = 2.15; 95% CI = 1.36-3.42; children: OR = 1.69; 95% CI = 0.80-3.56), either for youths living with nonsmoking parents at baseline and follow-up (OR for both children and adolescents = 3.06; 95% CI = 1.70-5.51) or for youths with ≥1 smoking parent at baseline and follow-up (OR = 2.12, 95% CI = 1.01-4.46). The effect was greater in youths living in the worst situation (non-SFH at baseline + non-HSB at follow-up) compared with those in the best situation (SFH at baseline + HSB at follow-up; children: OR = 3.20; 95% CI = 1.10-9.35; adolescents: OR = 5.41; 95% CI = 2.66-10.97).

CONCLUSIONS

Household smoke-free policies had a significant impact in protecting youths from becoming established smokers.

IMPLICATIONS

The results of the SIDRIAT longitudinal study showed that youths living in homes where people smoked at baseline were twice as likely to become established smokers 11 years later at follow-up, compared with youths living in SFH. The lower number of established smokers among youths living in SFH at baseline was recorded not only in households with nonsmoking parents but also in those with smoking parents. Implementing a home smoking ban is recommended in all households. Living in homes with no ban may be a risk factor for smoking initiation, which is independent of having smoking parents.

Social disparities in parental smoking and young children's exposure to secondhand smoke at home: a time-trend analysis of repeated cross-sectional data from the German KiGGS study between 2003-2006 and 2009-2012

Background

Children who are exposed to secondhand smoke (SHS) have an increased risk of a wide range of health problems and illnesses. Smoke-free legislation aims to improve indoor air quality and in this way protect the health of people who do not smoke. This paper examines trends in SHS exposure at home among children in Germany since the introduction of smoking bans in public places. Special focus is placed on the importance of the family of origin’s socioeconomic status (SES) and on parental smoking behaviour.

Methods

The analyses are based on two waves of the “German Health Interview and Examination Survey for Children and Adolescents” (KiGGS)—one of which was conducted immediately before the introduction of central smoke-free legislation in the 2003-2006 period, the other approximately 6 years later from 2009 to 2012. A comparison is made between the answers given by the parents of children aged between 0 to 6 (KiGGS baseline study, n = 6680; KiGGS Wave 1, n = 4455). Domestic SHS exposure is covered in the parent interviews by asking whether anyone is allowed to smoke at home in the presence of their child. Parental smoking behaviour is determined separately for mothers and fathers. SES is determined on the basis of the parents’ education, occupational status and income.

Results

The percentage of 0- to 6-year-old children exposed to SHS in the parental home fell from 23.9 to 6.6 % in the period from 2003-2006 to 2009-2012. At the same time, the percentage of children with at least one parent who smokes decreased from 49.8 to 41.8 %. While relative social inequalities in parental smoking behaviour have tended to increase over time, inequalities in domestic SHS exposure have persisted. Children whose parents smoke and children from low-SES families are still most likely to be exposed to tobacco smoke. In both study periods and after statistical adjustment for parental smoking behaviour, children with a low SES had a 6.6-fold higher risk for SHS exposure in the parental home than children from high-SES households.

Conclusions

The results of the KiGGS study show that the proportion of children in Germany who are exposed to SHS at home has declined significantly over the last few years. There is much to suggest that the smoke-free legislation that has been introduced in Germany has led to a heightened awareness of the health risks of SHS both in public and in the private sphere, as well as to a denormalization of smoking. Children whose parents smoke, and among them particularly children from socially disadvantaged families, should be recognised as key target groups when implementing future tobacco-control measures.