Brief Interventions to Create Smoke-Free Home Policies in
Low-Income HouseholdsCam Escoffery, PhD, MPH
Michelle C. Kegler, DrPH, MPH
Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University
Secondhand Smoke (SHS)
EPA Class A CarcinogenCauses Premature Death in Nonsmokers
Lung cancerHeart disease
Especially Harmful to Children Increases occurrence of severe asthma and
SIDSEar infections
Disease Burden of SHS
Outcome Annual excess number due to SHS in U.S.
Episodes of childhood asthma 202,300
Doctor visits for childhood otitis media 790,000
Deaths due to SIDS 430
Deaths due to ischemic heart disease 46,000 (22,700 to 69,500)
Lung cancer deaths 3400
Source: International Agency for Research on Cancer & CA EPA, Air Resources Board, 2005
Exposure to SHS in the U.S.
Detectable serum cotinine declined from 83.9% of nonsmokers (1988-1994) to 46.4% (1999 -2004) in U.S. population (≥ 4 years of age) Children aged 4-11 had the smallest decline in exposure to
SHS (60.5%) with detectable serum cotinine in 1999-2004 African Americans more likely to have detectable serum
cotinine in 1999-2004; 70.5% compared to 43.0% in non-Hispanic whites and 40.0% in Mexican Americans
Note: cotinine is the primary proximate metabolite of nicotine and is an objective biomarker of exposure
Source: CDC. Disparities in secondhand smoke exposure-United States, 1988-1994 and 1999-2004, MMWR, 2008; 57(27):744-747.
Smoke-Free Home
Private sphere equivalent of a clean indoor air ordinance Household smoking bans are usually unwritten rules Voluntary in nature
Total ban definition (Smoke-Free Home): Smoking is not allowed anywhere inside the home
Partial ban definition: Smoking allowed in some places or at some times
Prevalence of Household Smoking Bans
Nationwide 78.1% of households had total bans in 2008 84.7% of non-smokers report a ban 45.0% of smokers report a ban
Socioeconomic and demographic factors Higher SES had more bans African Americans less likely to have bans than
other racial and ethnic groups Presence of children likely to increase ban
adoptionSource: CDC, 2009
Rationale for Intervention
Smoke-free homes: Reduce exposure to secondhand smoke in
adult nonsmokers and children May help smokers to quit May disrupt the smoking initiation process
Smoke-Free Home Interventions To Date
Tobacco control movement focused on policy approach to multi-family dwellings
Smoke-free home efforts part of comprehensive tobacco control and tend to include awareness via media campaigns and smoke-free home pledges (not typically evaluated as stand-alone interventions)
Intervention research often clinic-based, relatively intensive and/or emphasizes cessation
Community Guide concluded “insufficient evidence” for community education to promote smoke-free homes
New Project
NCI funding (State and Community Tobacco Control Policy and Media Research-U01)
Builds on work of CPCRN 2-1-1 work group Key partners include:
University of North Carolina-Chapel Hill (Williams & Ribisl)
University of Texas-Houston (Mullen & Fernandez)
Washington University-St. Louis (Kreuter)
Emory University and Tobacco Technical Assistance Consortium-Atlanta
2-1-1 organizations in four states State tobacco control programs in four states
Study Aims
Formative research on intervention materials and key messages
Conduct an efficacy trial of the SFH intervention in the Atlanta area 2-1-1
Conduct effectiveness studies in North Carolina and Houston
Disseminate the intervention
Formative Research Plans
Focus groups (2 with smokers and 2 with nonsmokers)Key messagesRelevance, cultural appropriateness of
materialsInterviews with 2-1-1 callers (n=20)Interviews with 2-1-1 line agents (n=10)
Intervention Components
At 2 week IntervalsMailing of Smoke-free Homes Kit (5-step
guide, pledge, sign, challenges and solutions, reasons to go smoke-free)
Telephone counseling to motivate & address barriers
Mailing of photonovellaMailing of newsletter, stickers
and third hand smoke info
Model of Behavior ChangeBrief Intervention to Create Smoke-free Home Policies in Low-Income
Households
Intervention Strategies
Intervention Components
1.Mailing 1: A five step guide to making your home smoke-free; Reasons to have a smoke-free home (SFH); Facts about SHS and SFHs; Pledge; Signs
2.Brief telephone counseling
3.Mailing #2: Challenges and Solutions Booklet; Photo –novella
4.Mailing #3: Newsletter; Thirdhand smoke fact sheet; SFH stickers
Intervention Components
1.Mailing 1: A five step guide to making your home smoke-free; Reasons to have a smoke-free home (SFH); Facts about SHS and SFHs; Pledge; Signs
2.Brief telephone counseling
3.Mailing #2: Challenges and Solutions Booklet; Photo –novella
4.Mailing #3: Newsletter; Thirdhand smoke fact sheet; SFH stickers
Change Process
Intervention Targets
•Behavioral Capability•Self-efficacy•Outcome expectations for SFH•Smoking behavior
Intervention Targets
•Behavioral Capability•Self-efficacy•Outcome expectations for SFH•Smoking behavior
Change Strategies
•Persuasion•Role modeling•Goal setting•Environmental cues•Reinforcement
Change Strategies
•Persuasion•Role modeling•Goal setting•Environmental cues•Reinforcement
Stage of Change
Pre-contemplation
Contemplation
Preparation (Step 1-Decide)
Stage of Change
Pre-contemplation
Contemplation
Preparation (Step 1-Decide)
Discuss with household members (Step 2)
•Barriers•Negotiation•Support
Discuss with household members (Step 2)
•Barriers•Negotiation•Support
Set date/Go smoke-free(Step 3 and 4)•Cues
Set date/Go smoke-free(Step 3 and 4)•Cues
Maintain smoke-free home(Step 5)
Maintain smoke-free home(Step 5)
Eligible Participants for Trials
Current smoker or live with a smoker Allow at least some smoking in the home Live with a nonsmoker or child Speak English Expect to live in the same household for the
next six months, and not be in crisis
Flow of Efficacy Trial
Flow of Intervention Study (Cont’d)
Outcomes
Primary OutcomesPresence of a self-reported banAir nicotine in sub-sample
Secondary OutcomesWeekly and daily SHS exposureSelf-efficacy to restrict smoking in the homeBeliefs about SHS
Secondary Outcomes (Smokers)
Smoking status Cessation attempts Cigarette consumption
Dissemination Plans
Develop an implementation toolkit for SFH intervention
Conduct a national grants program to encourage adoption among 2-1-1 systems nationwide
Use TTAC infrastructure to disseminate SFH intervention to tobacco control community
Adapt and pilot SFH intervention in other populations and/or channels that reach low-income populations
Examples of Dissemination Questions
What factors affect the uptake of the SFH intervention by 2-1-1 centers?
What factors (e.g., organizational, external forces) influence quality implementation of the intervention?
What is the extent of fidelity to the core elements in implementation or of adaptation?
Is the SFH intervention sustained over time in the 2-1-1 centers? What factors are associated with program maintenance?
Ideas for Dissemination Research?