Steps Toward Scalability: Illustrations From a Smoke-Free Homes Program.
ABSTRACT: Scalable interventions remain effective across a range of real-world settings and can be modified to fit organizational and community context. "Smoke-Free Homes: Some Things are Better Outside" has been effective in promoting smoke-free home rules in low-income households in efficacy, effectiveness, generalizability, and dissemination studies. Using data from a dissemination study in collaboration with five 2-1-1 call centers in Ohio, Florida, Oklahoma, and Alabama (n = 2,345 households), this article examines key dimensions of scalability, including effectiveness by subpopulation, secondary outcomes, identification of core elements driving effectiveness, and cost-effectiveness. Evaluated by 2-1-1 staff using a pre-post design with self-reported outcomes at 2 months postbaseline, the program was equally effective for men and women, across education levels, with varying number of smokers in the home, and whether children were present in the home or not. It was more effective for nonsmokers, those who smoked fewer cigarettes per day, and African Americans. Creating a smoke-free home was associated with a new smoke-free vehicle rule (odds ratio [OR] = 3.38, confidence interval [CI 2.58, 4.42]), decreased exposure to secondhand smoke among nonsmokers (b = -2.33, p < .0001), and increased cessation among smokers (OR = 5.8, CI [3.81, 8.81]). Use of each program component was significantly associated with success in creating a smoke-free home. Using an intent-to-treat effect size of 40.1%, program benefits from 5 years of health care savings exceed program costs yielding a net savings of $9,633 for delivery to 100 households. Cost effectiveness, subpopulation analyses, and identification of core elements can help in assessing the scalability potential of research-tested interventions such as this smoke-free homes program.
Project description:<h4>Introduction</h4>One-third of Mexican-American children, in addition to nonsmoker adults, are exposed to secondhand smoke at home, yet few interventions target Mexican-American households. An effective, brief English language program, tested with United Way 2-1-1 callers in Atlanta, increased home smoking bans (confirmed by air monitors). Two randomized controlled trials in North Carolina and Texas replicated those results. We explored factors determining adoption and enforcement of smoking bans in Mexican-American households to inform program linguistic and cultural adaptation to broaden program reach and relevance.<h4>Methods</h4>Bilingual interviewers recruited convenience samples of Mexican-American smokers and nonsmokers living with at least one smoker in Houston and San Diego households and asked open-ended questions regarding conditions for implementing home and vehicle smoking bans and conditions for varying acceptance of bans. Investigators independently reviewed English transcripts and completed a descriptive analysis using ATLAS.ti.<h4>Results</h4>Participants (n = 43) were predominantly female (n = 31), current smokers (n = 26), interviewed in Spanish (n = 26), had annual household incomes less than $30000 (n = 24), and allowed smoking inside the home (n = 24). Themes related to difficulty creating and enforcing bans included courtesy, respect for guests and heads of household who smoke, and gender imbalances in decision making. Participants viewed protecting children's health as a reason for the ban but not protecting adult nonsmokers' health.<h4>Conclusion</h4>A dual-language, culturally adapted intervention targeting multigenerational Mexican-American households should address household differences regarding language and consider influences of cultural values on family dynamics and interactions with guests that may weaken bans.<h4>Implications</h4>Qualitative interviews suggested cultural and family considerations to address in adapting a brief evidence-based smoke-free homes intervention for Mexican Americans, including traditional gender roles, unique contexts of multigenerational households, and language preferences. Our work confirms previous research among Latinos regarding importance of common cultural constructs, such as respeto (deference), simpatia (courtesy and agreeability), and familismo (family attachment), which inform behaviors that may impede or facilitate adopting and enforcing home smoking bans. Decision-making gender imbalances, high regard for head-of-household and guest smokers, and less sensitivity to the health of nonsmoker adults compared with children may lead to permission to smoke indoors.
Project description:Smoke-free homes reduce exposure to secondhand smoke, contribute to lower levels of consumption, and help smokers to quit. Even when home smoking rules are established however, they may not be consistently enforced.This study uses data from a randomized controlled trial of a brief intervention to create smoke-free homes among callers to the United Way of Greater Atlanta 2-1-1. Participants with partial or full home smoking bans at 6-month follow-up were asked about enforcement challenges, rooms where smoking occurred, and exceptions to the rules. Air nicotine monitors were placed in a subset of homes.Participants (n = 286) were mostly female (84.6%) and African American (84.9%). Most were smokers (79.0%) and reported at least half of their friends and relatives smoked (63.3%). Among those with a full ban, 4.3% reported their rules were broken very often whereas 52.6% stated they were never broken. Bad weather and parties were the most common exceptions to rules. Among nonsmokers with full bans, 16% reported exposure to secondhand smoke in the home 1-3 days in the past week. In multivariate analyses, having a partial ban, being a nonsmoker, and living with three or more smokers predicted higher levels of enforcement challenges.Findings suggest the majority of households with newly adopted smoke-free rules had no or rare enforcement challenges, but about one-fifth reported their rules were broken sometimes or very often. Interventions to create smoke-free homes should address enforcement challenges as newly adopted rules may be fragile in some households.Interventions that promote smoke-free homes should address enforcement challenges.
Project description:Most households with a smoker do not implement comprehensive smoke-free rules (smoke-free homes and cars), and secondhand smoke (SHS) exposure remains prevalent among children and low-socioeconomic status (SES) populations. This pilot project aimed to assess implementation feasibility and impact of an intervention designed to increase smoke-free rules among socioeconomically disadvantaged households with children. The pilot was implemented through Minnesota's National Breast and Cervical Cancer Early Detection Program (NBCCEDP). NBCCEDPs provide cancer prevention services to low-income individuals experiencing health disparities. We successfully utilized and adapted the Smoke-Free Homes Program (SFHP) to address comprehensive smoke-free rules among households with children. We used two recruitment methods: (a) direct mail (DM) and (b) opportunistic referral (OR) by patient navigators in the NBCCEDP call center. We used descriptive statistics to assess implementation outcomes and hierarchical logistic regression models (HLM) to assess change in smoke-free rules and SHS exposure over the study period. There was no comparison group, and HLM was used to examine within-person change. A total of 64 participants were recruited. Results showed 83% of participants were recruited through DM. OR had a high recruitment rate, and DM recruited more participants with a low response rate but higher retention rate. Among recruited participants with data (n = 47), smoke-free home rules increased by 50.4 percentage points during the study period (p < 0.001). Among recruited participants who had a vehicle (n = 38), smoke-free car rules increased by 37.6 percentage points (p < 0.01) and comprehensive smoke-free rules rose 40.9 percentage points (p < 0.01). Home SHS exposure declined, and within-person increase in smoke-free home rules was significantly related to less home SHS exposure (p < 0.05). It is feasible to adapt and implement the evidence-based SFHP intervention through a national cancer program, but the current pilot demonstrated recruitment is a challenge. DM produced a low response rate and therefore OR is the recommended recruitment route. Despite low recruitment rates, we conclude that the SFHP can successfully increase comprehensive smoke-free rules and reduce SHS exposure among socioeconomically disadvantaged households with children recruited through a NBCCEDP.
Project description:Research has shown that living in a smoke-free home has a positive effect on adolescents' perceived acceptance of smoking. However, the relationship between smoke-free homes and adolescent smoking behaviours remains unclear. The aim of this study was to examine the association between smoke-free homes and smoking susceptibility among high school students, and to determine whether these associations persist when analyses are stratified by familial smoking status.We conducted a random cross-sectional survey (2012/2013 Youth Smoking Survey) of primary, junior and high school students in Canada (n = 47?203). Multivariable logistic regression analyses were used to examine the associations between smoke-free homes and susceptibility to smoking among never-smoking high school students, with and without stratification by familial smoking.Analyses showed that adolescents living in a smoke-free home had reduced odds of being susceptible to smoking (odds ratio [OR] 0.582, 95% confidence interval [CI] 0.428-0.791) compared with their peers living in households where smoking was permitted. When adolescents had other family members who were smokers, having a smoke-free home was not significantly associated with reduced smoking susceptibility (OR 0.878, 95% CI 0.721-1.071).Our results suggest that smoke-free homes may influence future smoking initiation. Optimal success in preventing youth smoking uptake necessitates having a coherent antismoking message between the home smoking environment and familial smoking behaviour.
Project description:We examined homes of hookah-only smokers and nonsmokers for levels of indoor air nicotine (a marker of secondhand smoke) and indoor surface nicotine (a marker of thirdhand smoke), child uptake of nicotine, the carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), and the toxicant acrolein by analyzing their corresponding metabolites cotinine, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) and NNAL-glucuronides (total NNAL) and 3-hydroxypropylmercapturic acid.Data were collected at 3 home visits during a 7-day study period from a convenience sample of 24 households with a child 5 years or younger. Three child urine samples and 2 air and surface samples from the living room and the child bedroom were taken in homes of nonsmokers (n = 5) and hookah-only smokers (n = 19) comprised of daily hookah smokers (n = 8) and weekly/monthly hookah smokers (n = 11).Nicotine levels in indoor air and on surfaces in the child bedrooms in homes of daily hookah smokers were significantly higher than in homes of nonsmokers. Uptake of nicotine, NNK, and acrolein in children living in daily hookah smoker homes was significantly higher than in children living in nonsmoker homes. Uptake of nicotine and NNK in children living in weekly/monthly hookah smoker homes was significantly higher than in children living in nonsmoker homes.Our data provide the first evidence for uptake of nicotine, the tobacco-specific lung carcinogen NNK, and the ciliatoxic and cardiotoxic agent acrolein in children living in homes of hookah smokers. Our findings suggest that daily and occasional hookah use in homes present a serious, emerging threat to children's long-term health.
Project description:This study examined the extent to which delivery of the minimal Smoke-Free Homes intervention by trained 2-1-1 information and referral specialists had an effect on the adoption of home smoking bans in low-income households. A randomized controlled trial was conducted among 2-1-1 callers (n = 500) assigned to control or intervention conditions. 2-1-1 information and referral specialists collected baseline data and delivered the intervention consisting of 3 mailings and 1 coaching call; university-based data collectors conducted follow-up interviews at 3 and 6 months post-baseline. Data were collected from June 2013 through July 2014. Participants were mostly female (87.2%), African American (61.4%), and smokers (76.6%). Participants assigned to the intervention condition were more likely than controls to report a full ban on smoking in the home at both 3- (38.1% vs 19.3%, p = < .001) and 6-month follow-up (43.2% vs 33.2%, p = .02). The longitudinal intent-to-treat analysis showed a significant intervention effect over time (OR = 1.31, p = .001), i.e. OR = 1.72 at 6 months. This study replicates prior findings showing the effectiveness of the minimal intervention to promote smoke-free homes in low-income households, and extends those findings by demonstrating they can be achieved when 2-1-1 information and referral specialists deliver the intervention. Findings offer support for this intervention as a generalizable and scalable model for reducing secondhand smoke exposure in homes.
Project description:Exposure to second-hand smoke (SHS) is associated with various ill-health outcomes for children and adults. Barriers to creating a smoke-free home (SFH) are well-documented. Feasible and effective interventions to create smoke-free homes for disadvantaged households are lacking. Interventions that include providing parents with objective information about the impact of smoking on air quality in their home may be particularly effective. This study describes the development of a novel, theory- and evidence-based smoke-free homes intervention using objectively-assessed air quality feedback. The intervention was developed using the six-step Intervention Mapping (IM) protocol. Findings from literature reviews, focus groups with parents, interviews with health/care professionals, and expert panel discussions shaped intervention content and materials. Findings highlighted the importance of parents receiving personalised information on second-hand smoke levels in their home. Professionals considered the use of non-judgemental language essential in developed materials. Previous literature highlighted the need to address home smoking behaviour at a household rather than individual level. The AFRESH intervention is modular and designed to be delivered face-to-face by healthcare professionals. It includes up to five meetings with parents, two sets of five days' air quality monitoring and personalised feedback, and the option to involve other household members in creating a smoke-free home using educational, motivational, and goal setting techniques. Further research is needed to evaluate the acceptability and effectiveness of the AFRESH intervention and which specific groups of parents this intervention will most likely benefit. IM was a useful framework for developing this complex intervention. This paper does not present evaluation findings.
Project description:BACKGROUND:Second-hand smoke (SHS) is a serious health hazard costing 890,000 lives a year globally. Women and children in many economically developing countries are worst affected as smoke-free laws are only partially implemented and homes remain a major source of SHS exposure. There is limited evidence on interventions designed to reduce SHS exposure in homes, especially in community settings. Following a successful pilot, a community-based approach to promote smoke-free homes in Bangladesh, a country with a strong commitment to smoke-free environments but with high levels of SHS exposure, will be evaluated. The study aims to assess the effectiveness and cost-effectiveness of a community-based intervention, Muslims for better Health (M4bH), with or without Indoor Air Quality (IAQ) feedback, in reducing non-smokers' exposure to SHS in the home. METHODS/DESIGN:Based on behaviour-change theories, M4bH and IAQ feedback are designed to discourage people from smoking indoors. M4bH consists of a set of messages couched within mainstream Islamic discourse, delivered weekly by faith leaders (imams and khatibs) in mosques over 12?weeks (one message each week). The messages address key determinants of current smoking behaviours including lack of knowledge and misconceptions on specific harms associated with SHS exposure. IAQ feedback consists of personalised information on IAQ measured by a particulate matter (PM2.5) monitor within the home. Following adaptation of M4bH and IAQ feedback for the Bangladeshi context, a three-arm cluster randomised controlled trial will be conducted in Dhaka. Forty-five mosques and 1800 households, with at least one smoker and one non-smoker, will be recruited. Mosques will be randomised to: M4bH and IAQ feedback; M4bH alone; or usual services only. The primary outcome is 24-h mean household concentration of indoor fine particulate matter (PM2.5) at 12?months post randomisation. Secondary outcomes are 24-h mean household PM2.5 at 3 months post randomisation, frequency and severity of respiratory symptoms, health care service use and quality of life. A cost-effectiveness analysis and process evaluation will also be conducted. DISCUSSION:The MCLASS II trial will test the potential of a community-based intervention to reduce second-hand smoke exposure at home and improve lung health among non-smokers in Bangladesh and beyond. TRIAL REGISTRATION:ISRCTN, ISRCTN49975452 . Registered on 11 January 2018.
Project description:National surveys are commonly used to monitor the rates of smoke-free homes and public attitudes toward smoking bans. The study explored the difference in the estimates corresponding to two survey modes-personal interviews and phone interviews-among single-parent households. Data from the Tobacco Use Supplement to the Current Population Survey administered in 2010-11 and 2014-15 were used in a stratified fashion. The rate of smoke-free homes was lower for personal interviews (79% in 2010-11 and 82% in 2014-15) than for phone interviews (85% in 2010-11 and 90% in 2014-15). Even after controlling for several factors, personal interviews corresponded to lower odds of having a smoke-free home relative to phone interviews (OR=0.7, CI=0.6:0.9 in 2010-11; OR=0.5, CI = 0.4:0.6 in 2014-15). The survey mode should be included in the analyses when estimating the rates of smoke-free homes and other smoking-related attitudes, because different survey modes could be associated with different response bias.
Project description:We examined the effectiveness of state cigarette price and smoke-free homes on smoking behaviors of low-income and high-income populations in the United States.We used the 2006-2007 Tobacco Use Supplement to the Current Population Survey. The primary outcomes were average daily cigarette consumption and successful quitting. We used multivariable regression to examine the association of cigarette price and smoke-free home policies on these outcomes.High state cigarette price (pack price???$4.50) was associated with lower consumption across all income levels. Although low-income individuals were least likely to adopt smoke-free homes, those who adopted them had consumption levels and successful quit rates that were similar to those among higher-income individuals. In multivariable analysis, both policies were independently associated with lower consumption, but only smoke-free homes were associated with sustained cessation at 90 days.High cigarette prices and especially smoke-free homes have the potential to reduce smoking behaviors among low-income individuals. Interventions are needed to increase adoption of smoke-free homes among low-income populations to increase cessation rates and prevent relapse.