Smoke-free homes: outcomes of a local service development.
This paper aims to determine the impact of a smokefree homes initiative in Doncaster. An evaluation was conducted via a self-reported semi-structured questionnaire and telephone survey in 2006. Numbers and types of smoke-free homes promises, self-reported smoking restrictions in the home and factors associated with smoke-free homes were measured. A total of 825 smoke-free home promises were received, of which 567 (69%) were 'gold', 221 (27%) 'silver' and 37 (4%) 'bronze'. Of these promises, 523 (63%) were from smokers.
Non-smokers (95%) and smokers who had just stopped (91%) were more likely to opt in for a gold promise when compared to smokers (52%, p<0.001). Over half of smokers who opted for the gold promise reported not allowing smoking in the house (57%, p<0.001). Of 82 responses at follow up, 41 (50%) reported smoking outside the house or in the street. Engaging families in the implementation of smoke-free homes is an effective measure to reduce household second-hand smoke exposure. Further research is required to assess the long-term feasibility, sustainability and cost per quitter.
Smoking, smoke-free homes, health inequalities, second-hand smoke, tobacco control
In 1998, the editors of Tobacco Control predicted that protecting children from exposure to second-hand smoke (SHS) was likely to become increasingly important among children and young people over the next decade. (1) Due to the profound impact that SHS has on child health, they recommended that homes with children should become smoke free. The US Environmental Protection Agency launched a campaign in 2001 to protect children from SHS through a smoke-free home pledge, estimating that 12 million children in the US were exposed to SHS in their homes, leading to ear infections, pneumonia and asthma. (2) In 2003, the Department of Health launched a TV campaign in the England called 'Smoking Kids', which placed children's exposure to SHS firmly on the public health agenda. Approximately 50% of all children in the UK are exposed to SHS in the home. (3,4)
Children and infants are more vulnerable to SHS than adults because they have smaller airways and faster breathing rates, so inhale more dust containing SHS particulates--perhaps 40 times more per body weight than adults. Infants also have greater hand-object-mouth contact, so absorb proportionately more chemicals found in SHS through ingestion and inhalation. (5-8)
Studies evaluating the implementation of smoke-free policies in California, Australia and Ireland highlight a growing movement toward smoke-free societies and the impact of reducing SHS in the home. (9-11)
However, there is little evidence to support whether smoke-free homes interventions are effective in reducing SHS exposure, why individuals make their homes smoke free, factors associated in decision-making and associated social benefits. Research suggests that a co-ordinated approach should be considered in order to benefit from potential synergies across interventions. (12,13) Evidence provides some qualitative insight into how wider health determinants act as barriers to people making their homes smoke free. (14,15) Evidence is needed for how smoke-free homes initiatives can be translated into practice, identify why smoke-free policies are implemented in the home, and whether there are any social benefits. (16)
What is already known on this topic
* SHS contains over 4000 harmful chemicals including over 50 carcinogens, and the main source of exposure to children is in the home and car
* Exposure to SHS is an important cause of morbidity and mortality in non-smoking adults and children
* Although little is known about why people restrict smoking at home, there is growing evidence that people do undertake measures to reduce the harm from SHS for the sake of their children.
The Smoke Free Homes project
Doncaster, South Yorkshire has a higher smoking prevalence (33%) than the national average (25%), mainly within its most deprived neighbourhoods. (17) Maternal smoking poses a greater risk for infant mortality, low birthweight, decreased lung function and sudden infant death syndrome, (18,19) but abstinence among adults reduces uptake among young people. (20-22)
The Smoke Free Homes project in England was originally developed and implemented in the Yorkshire and Humber region in 2002 by West Yorkshire Smoking and Health (WYSH). The Tobacco Control Alliance--Smoke Free South Yorkshire agreed to coordinate and roll out a similar intervention in Doncaster using the WYSH model, which incorporates the following principles:
* Negotiated goals
* Signing a contract
* Positive messages about the immediate benefits of smoking restrictions
* Reinforcement from health workers.
The Smoking Cessation Service, Doncaster Metropolitan Council, South Yorkshire Fire Service, Sure Start and two midwives were resourced and provided with motivational interviewing training to deliver smoke-free homes in 13 Neighbourhood Renewal Strategy (NRS) areas. Ethical approval was not required because this was a local service development evaluation.
Preliminary data collection
A series of promotional events, including road shows, were held to raise awareness of smoke-free homes. Members of the public were randomly selected and informed of the smoke-free homes promise through routine contact by frontline staff. Smokers and non-smokers who wished to ban smoking in their household were included as long as they were aged between 16 and 65 years and lived within identified NRS areas. They were asked if they would like to make their home smoke free, and provided with a leaflet that offered a choice of three promises:
* Gold--to make the home completely smoke free at all times
* Silver--to allow smoking in one well ventilated room only, and never smoke in the presence of children
* Bronze--to never smoke in the presence of children.
Respondents where asked to complete a tearoff slip and return it to frontline staff. A Freepost system was also offered in case they preferred to return responses at a later date. The slips gathered preliminary information, such as smoking status, where smoking was currently allowed (one room, everywhere and nowhere), number of children in the household, promise type, and whether or not they were willing to be contacted in the future. They were collated at two-week intervals, and a gold, silver or bronze certificate was posted to promise-makers along with a goodie bag.
Follow-up data collection
All respondents were asked for consent and informed of their right to withdraw during the follow up, which was conducted in April 2006 using either a postal semi-structured questionnaire or telephone survey. Confidentiality and anonymity were maintained throughout. Questions asked included type of promise, smoking status, ease of keeping the promise, motivation to keep the promise, feelings after making the promise, where they now smoked and what smoke-free homes resources where useful. Self-reporting was utilised as a valid measure of assessing smoking status. (23-28)
A Microsoft Excel spreadsheet was used to input data from the tear-off slips and follow-up questionnaires. Statistical significance was tested for using SPSS statistical software. (29) Chi-square tests were performed to compare smoking status (smoker, non-smoker or just stopped) with promise type, where smoking was allowed and likelihood of changing smoking behaviour. Subanalyses were produced within each category versus smoking status. However, due to the small sample size there were instances where only the smoking category could be reported on. Chi square was used to test the null hypotheses--that there was no association between smoking status and other factors.
A total of 825 slips were received between December 2005 and March 2006, covering 823 children. This comprised 567 (69%) gold, 221 (27%) silver and 37 (4%) bronze promises. Of these, 523 (63%) were received from smokers--271 (52%) gold, 206 (39%) silver and 46 (9%) bronze.
Smoking status versus other factors
Non-smokers (286/301, 95%) and smokers who had just quit (10/11, 91%) were more likely to opt for the gold promise than smokers (271/523, 52%) (Pearson chi square=166.7, df=4, p<0.001). Respondents in all three categories showed a greater tendency to opt for the gold promise.
Non-smokers were less likely to allow smoking anywhere (159, 84.1%) compared to smokers (415, 30.4%) and those who had just stopped (253, 27.3%) (Pearson chi square=227.7, df=4, p<0.001). No substantial differences were observed between smokers and those who had just stopped.
Non-smokers were least likely to change their smoking status (286, 89%). Smokers (212, 41%) were more likely to report changing their smoking status, as were those who had just stopped (7, 64%) (Pearson chi square=85.2, df=2, p<0.001).
The chi-square tests all rejected the null hypothesis that there was no association between smoking status versus other factors.
Sub-analyses of smoking status
Due to the low numbers of non-smokers and smokers who had just stopped, only the findings from smokers can be reported. Tests were carried out to identify any association between smokers and promise type, where smoking was allowed and change in smoking status. The chi-square tests rejected the null hypothesis that there was no association between smokers and other factors.
Smokers versus promise type versus where smoking was allowed: Of smokers who opted for the gold promise, 154 (57%) reported not allowing smoking anywhere at home, with 81 (30%) allowing it in one room and 36 (13%) everywhere (Pearson chi square=198.6, df=4, p<0.001).
Of silver promise smokers, 1 (0.5%) reported not allowing smoking anywhere at home, with 134 (65%) allowing it in one room and 71 (34%) everywhere (Pearson chi square=198.6, df=4, p<0.001).
Of bronze promise smokers, 4 (9%) reported not allowing smoking anywhere at home, with 18 (39%) allowing it in one room and 24 (52%) everywhere (Pearson chi square=198.6, df=4, p<0.001).
The results suggest that smokers who opted for gold were more likely not to allow smoking anywhere in the home. The null hypothesis--that there was no association between smoking status and where smoking was allowed--was rejected.
Smokers versus promise versus change in smoking status: A total of 117 (43%) smokers who opted for the gold promise reported to have changed their smoking status as a result, compared to 154 (57%) who reported no change in smoking status (Pearson chi square=6.5, df=2, p<0.001).
Of silver promise smokers, 71 (35%) reported to have changed smoking status as a result, while 135 (66%) reported no change (Pearson chi square=6.5, df=2, p<0.001).
Of bronze promise smokers, 24 (52%) reported to have changed smoking status as a result, with 22 (48%) reporting no change (Pearson chi square=6.5, df=2, p<0.001).
The results suggest that bronze promise smokers were more likely to change their smoking status than silver or gold.
Referral to smoking cessation
Of the 523 smokers who signed up to a smoke-free home promise, 270 (52%) were referred through Doncaster's Stop Smoking Service, 65 (12%) set a quit date and 31 (6%) had quit successfully at four weeks.
Although 755 (90%) respondents consented to participate in the follow up, only 230 were randomly selected and contacted due to constraints of time, cost and staff availability. This included 22 non-smokers who never allowed smoking in their home and 208 smokers who had just stopped and reported making some change to their smoking behaviour at home.
Of 81 participants asked to return the postal questionnaire, eight (10%) were returned, and of 149 contacted for the telephone survey, 74 (50%) responded--a total of 82 (36%) follow-up responses.
Motivational factors to keep promise
The most common motivations for respondents to keep their promises were reported to be 'health of children', 'cleaner house or decoration' and 'children' (see Table 1).
Feeling after making promise
After making the promise, 16 (19.5%) respondents reported feeling healthy or health conscious, 14 (17%) caring about health of others, 14 (17%) responsible, 12 (15%) a good parent and nine (11%) a 'sense of achievement' (see Table 2). This highlights the social benefits of the intervention. In addition, 46 (55%) requested a free fire safety risk assessment.
Where do you now smoke?
When asked where they now smoked, 41 (50%) stated 'outside the house' or 'in the street', followed by 14 (17%) smoking in one room only (see Table 3).
The results suggest that smokers implement different restrictions in relation to their smoking status, where they currently allow smoking, promise type and whether they make changes to where smoking is allowed. The gold promise seems to provide the best incentive for smokers to change their smoking status and where smoking is allowed, and to implement a total ban on smoking in the home. The majority of smokers in the follow up reported that they implemented smoking restrictions at home for the health of their children and a cleaner house. This is supported by wider evidence that protecting children's health, advice from physicians and the smell of smoke are key factors for household smoking bans. (31,32)
Providing options through the WYSH model seemed to play an important role in promoting household smoking restrictions, though a number of factors should be considered. Restricting smoking in one room does not eliminate SHS exposure, and a commitment to a completely smoke-free home would therefore be needed to remove absolute risk--the gold promise. (32) Providing a silver or bronze option might give a misleading message regarding the risks associated with SHS exposure. This is particularly true when discussing SHS exposure during pregnancy.
This intervention highlighted the benefits that a smoke-free homes initiative can have, even prior to the implemention of smoke-free legislation. Despite expectations that smoke-free laws might increase the number of people who smoke in their homes, there is no substantial evidence to validate this.33 Smokers who lived under a total household smoking ban had an odds ratio of 1.65 (CI=95%, 1.43 to 1.91) of abstaining for at least six months compared with smokers with no smoking restrictions at home. (34) They were also four times more likely to report an attempt to quit smoking within 12 months than smokers with no household smoking restrictions. In addition, smoking restrictions in the home have been associated with reduced experimentation with tobacco among young people, and are considered to be an important measure to reduce intergenerational smoking. (35)
Engaging families in a smoke-free homes initiative is an effective measure to reduce SHS exposure in the home. Of 82 responses at follow up, 41(50%) reported to either smoke outside the home or in the street. The health of children was reported to be an important factor in implementing smoking restrictions at home, with other stated benefits including being healthy or health conscious, caring about the health of others, and being responsible and a good parent.
The total cost of running the intervention was estimated to be 8700 [pounds sterling], resulting in 567 (69%) gold promise-makers and 31 (6%) quitters at four weeks. Although quitting was not a primary objective, further research is needed to assess interactions between smoke-free homes and cessation interventions and the cost per quitter.
The small sample of this evaluation restricted the amount of data that could be collected and analysed, and statistical analysis could only be undertaken within the smoking category. Due to a lack of time and funding, it was not possible to follow up qualitatively. Although self-reported surveys among smokers have been shown to be truthful, there may have been some bias due to respondents associating smoking at home and in front of children to be detrimental to good parenting. Smoking in the car was not investigated. The authors also acknowledge that the perceptions of staff and selection may have been biased toward specific clients.
Recommendations for practice
* Promoting completely smoke-free homes is essential for a clear health message about removing the risk of SHS exposure, and a stepped approach may be used to achieve smoke-free homes and cars
* Social implications highlighted by this intervention should be used in future smoke-free homes initiatives alongside social marketing techniques, to help to address how to engage families to overcome emotional barriers, the process of exchange and immediate rewards
* A training pack for frontline staff would assist in ensuring consistency and delivery of key messages, targeting fire services, community nurses, school nurses, nursery nurses, health visitors, children's centre staff and midwives
* On-going campaigns would help to inform families on SHS risks, and provide an opportunity to modify smoking behaviour in the home and disengage smokers from nicotine addiction
* Smoke-free home interventions should also consider short- and long-term implications (four versus 52 weeks) in relation to the cost per quitter
* Cessation interventions should include a smoke-free homes approach to enable smokers to implement both changes simultaneously as a part of best practice.
Engaging families to implement smoke-free homes is an effective measure for reducing SHS exposure at home. A relationship was observed between smoking status against type of promise, where smoking is allowed and likelihood to change smoking status. Smoke-free homes would help to reduce health inequalities through infant mortality and life expectancy at birth. Further research is required to assess long-term feasibility and sustainability of smoke-free home interventions, and to identify the costs per quitter.
* Healthcare and social care professionals and voluntary sector staff have a vital role in providing information to parents about the risks of exposure to SHS
* A smoke-free homes intervention can be effective in reducing home SHS exposure
* Only a pledge to not smoke at all at home will remove absolute risk in this setting
* An effective way for healthcare professionals to promote smoke-free homes might include a step-by-step approach to making the home and car smoke free
* Smoke-free homes initiatives could be utilised as a tool to address the social, health and financial impact associated with tobacco in the community
The authors would like to thank Smoke Free South Yorkshire, Doncaster Metropolitan Council, Doncaster and Rotherham Primary Care Trust, Doncaster NHS Stop Smoking Service, WYSH, Doncaster Sure Start and South Yorkshire Fire Service and the regional tobacco control programme manager.
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Khamis Al-alawy MSc, BSc Tobacco control lead, Rotherham Primary Care Trust
Nicholas Wellington MSc, BSc, BSc Environmental health manager, Doncaster Metropolitan Council
Enis Dalton DipNH, NEBOSH, C&GHS Health education officer, Doncaster Metropolitan Council
Lisa Fendall RM, RGN
Tracey MacDonald RM, RGN Specialist midwives, Doncaster Primary Care Trust
Marcus Williamson PGCPH Public health information analyst, Rotherham Primary Care Trust
Table 1. Motivation to keep promise Motivation Number (n=82) Health of children 21 (26%) Children 10 (12%) Cleaner house or decoration 10 (12%) Smoke Free Homes team or 8 (10%) Stop Smoking Services Other relatives 7 (9%) Partner 6 (7%) Friends 6 (7%) Dangers of SHS 6 (7%) Encouragement to quit smoking 4 (5%) Avoid house fires 4 (5%) Health of other non-smokers 0 Forthcoming legislation 0 National television advertising 0 Other 0 Missing 0 Table 2. Feeling after making promise Feeling Number (n=82) Healthy or health conscious 16 (20%) Responsible 14 (17%) Care about health of others 14 (17%) Good parent 12 (15%) Sense of achievement 9 (11%) Proud 7 (9%) Challenged 5 (6%) Stressed 4 (5%) Other 1 (1%) Missing 0 Table 3. Where they smoke now Location Number (n=82) Outside the house 35 (43%) Just in one room 14 (17%) In the pub 7 (9%) At friends' or relatives' 7 (9%) In the street 6 (7%) At other leisure activities 5 (6%) At work 4 (5%) In the car 4 (5%) Other 0 Missing 0
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|Author:||Al-alawy, Khamis; Wellington, Nicholas; Dalton, Enis; Fendall, Lisa; MacDonald, Tracey; Williamson,|
|Date:||Dec 1, 2008|
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