Health Education Research Advance Access published online on January 24, 2008
Health Education Research, doi:10.1093/her/cym095
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Formative research on creating smoke-free homes in rural communities
Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 30322, USA
Correspondence to: * Correspondence to: C. Escoffery. E-mail: cescoff{at}sph.emory.edu
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Abstract |
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The home is a significant place for exposure to secondhand smoke for children and non-smoking adults. This study explored factors that would convince families to adopt household smoking bans and actions to create and maintain smoke-free homes. Interviews were conducted with adults in 102 households in rural Georgia. Participating families had a young adolescent and included households with a mix of smokers and non-smokers and smoking ban status. Families reported they would consider a total ban to protect children from secondhand smoke and protect family members if they got sick. Few described difficulties in enforcement with over half of smokers accepting the rules. Situations that made it hard to enforce restrictions were if there was a visitor who smoked, a smoker who had cravings, and bad weather outside when the smoker desired to smoke. Smokers explained that family members could assist them in quitting by talking to them, not purchasing cigarettes for them, not smoking around them, and supporting them. Ideas for promoting smoke-free homes were having a no smoking sign, saying no to visitors who want to smoke, removing ashtrays, and creating a place outside for smokers. These findings can inform interventions designed to create and maintain smoke-free households.
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Introduction |
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The home is a significant place for exposure to secondhand smoke for children and for non-smoking adults [1–5]. In 2002, 25% of children in the United States lived in a home where a resident or visitor regularly smoked [6]. The 2006 Surgeon General's Report on ‘Health Consequences of Involuntary Exposure to Tobacco Smoke’ states that there is no safe amount of secondhand smoke [7]. Childhood exposure to secondhand smoke is associated with low birth weight, sudden infant death syndrome, ear infections, respiratory tract infections, decreased lung growth and childhood asthma [8, 9]. Non-smokers who are exposed to secondhand smoke in the home have an increased risk of heart disease and lung cancer [10, 11]. Smoke-free homes reduce exposure to secondhand smoke in children and non-smokers [1–4]. The percentage of smoke-free homes increased from 43 to 66% between 1993 and 2002 [7, 12]. A recent report found 72.2% of US households in 2003 reported smoke-free homes [13]. Households with a smoker report lower rates of smoking restrictions [3, 14] and rural, low-income, and African-American households are also less likely to report strict bans [15–18].
There are few rigorously evaluated interventions to reduce secondhand smoke exposure in the home, and intervention results have been mixed. Those that have been tested tend to be clinic based and focus on secondhand smoke reduction in children, often children with asthma [1, 19]. More evaluation research is needed on community-based interventions to reduce secondhand smoke in the home [20]. These interventions to date include smoke-free home pledges [21, 22], mass media campaigns [22, 23], providers’ advice and counseling [24–27]. In addition, formative research on creating and maintaining household smoking bans within various target audiences is needed. At present, relatively little is known about what would convince caregivers of children in homes to adopt a smoke-free home [28].
To assist families in implementing smoke-free homes, an understanding of stages of behavior change is helpful. The transtheoretical model of change identifies five stages of readiness for changing a health behavior: precontemplation, contemplation, preparation, action and maintenance [29, 30]. Different messages and strategies might be relevant at different stages. For example, in precontemplation, household members are not thinking about creating a total smoking ban. Messages for them may need to increase awareness about the risks of secondhand smoke exposure. Members in the preparation stage are intending to create a smoking ban in the next 30 days. Information for them may need to focus on negotiation skills. Those in the action and the maintenance stages may need assistance in enforcing bans.
The purpose of this qualitative study was to conduct formative research to inform smoke-free home interventions. This research is part of a larger study that explored the process families go through in adopting voluntary household smoking restrictions [31]. Specifically, this study explores: (i) the motivating factors that would convince families to adopt stricter household smoking bans and (ii) suggestions for behavioral actions to create and maintain smoke-free homes. The study also explores the impact of bans on smokers. Results from this qualitative study can inform the development of messages and strategies to encourage families to adopt smoke-free homes.
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Methods |
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African American and White caregivers residing in three rural counties in Southwest Georgia were recruited for in-person interviews. Recruitment strategies included newspaper ads, fliers distributed at schools, word-of-mouth and fliers posted around the local community. The inclusion criteria were (i) a parent or caregiver of an adolescent aged 10–14, (ii) an African-American or White household, (ii) at least age 18 and (iv) English speaking. Households were recruited to represent a range of ban status and included households with: no adult smokers, mixed smoking status and all adult smokers. A total of 102 households participated in the study. In 52 households, we interviewed only the primary caregiver, and in 50 households, we interviewed all adult residents.
The interview guide included both open-ended and close-ended questions to assess what factors would convince families to adopt a stricter smoking ban, effects of the ban on smokers, the enforcement of bans and attitudes about smoking in the home. Interviews were conducted from May 2004 to January 2005 in the participants’ homes. Interviewers attended a one-and-a-half day training. Signed informed consent was obtained from all participants, and each participant received $35. The study was approved by Emory University's Institutional Review Board.
Interviews were tape recorded and transcribed verbatim. A codebook of major themes was developed and two coders then coded each transcript independently. Codes were compared and discrepancies were resolved by reaching of consensus. The coded data were entered in the QRS N6 (NUDIST) software for analysis [32]. Matrices were created to facilitate the analysis of themes and the similarities and differences by household smoking restriction and smoking status. For quantitative items in the interview, Epi Info was used for data entry and SPSS version 13.0 was used for data analyses [33]. Fisher exact tests, analysis of variances and chi-square tests assessed differences in household demographic characteristics by ban status.
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Results |
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Homes with a total ban were reported by 35 households (34.0%). Fifty-five households (54.0%) had a partial ban in which smoking was allowed in some places or sometimes and 12 households had no bans (12.0%). On average, homes had 2 adults (SD = 0.6), 2.3 children (SD = 2.3) and 1 smoker (SD = 0.9). Households that had more smokers and fewer children were more likely to report having no smoking ban. Table I presents demographic characteristics of households by smoking restriction.
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What would convince participants to adopt stricter bans
Participants in homes with partial or no bans responded to what might ‘convince’ them to ‘totally’ ban smoking in the home. The two most frequently reported reasons were to protect children from secondhand smoke and to protect a family member if s/he got sick. Other reasons mentioned were personal health, if the smoker quits, concern over a fire occurring, smoking is a bad influence on children, a physician's recommendation to protect children from secondhand smoke exposure and stopping the smoker from smoking. The quotes capturing these themes are presented in Table II.
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For homes with no ban, participants were asked if they would consider a ‘partial ban’ and what would convince them to have one. A few participants mentioned that they would consider a partial ban because they did not want smoke around the children, they were sick or that people around them do not like smoke. When asked what would convince them to have a partial ban, reasons described were someone's health condition such as bronchitis or asthma or if a baby or child is present (Table II).
Enforcement of bans
Difficulty in sticking with the ban
Participants with total or partial bans were asked if it has ever been hard to stick to their home smoking restrictions. Most of them reported that it has not been difficult to stick to the restrictions. About one-fifth of homes with total bans reported that it is hard to enforce. In contrast, no home with partial bans reported difficulty in enforcement. Many felt that people knew not to smoke in their home.
No, not really, because once you know you get used to knowing you got to go out there and do it. You now, it's like, you know it's something you know that you ain't supposed to do and you get caught you'll have to hear that, and if you don't want to hear that you know just don't be coming to the door with them. (White male, partial ban)Everybody know it, by this time, we've been here over 40 years so everybody know it by now that we don't smoke and don't like smoking in the home. (African-American female, partial ban)
What I say goes, no, it hasn't been hard. (African-American female, total ban)
One person commented about the difficulty in enforcing the ban:
There have been difficult times but I never once wanted to back down from it. (White female, total ban)
Some of the few situations when participants reported that it was hard to stick to the smoking restrictions were if there was a visitor to the home who smokes, if the smoker has a craving or if there is bad weather outside when the smoker goes to smoke.
Of course, it has been hard. Like I told you earlier, I've got, I've got relatives and friends that smoke. And, my oldest son, my oldest son, he is a sergeant in the army and he smokes. (African-American male, partial ban)Yes, in certain situations and I wanted to smoke and I want to smoke real bad, I'll fire one up in the—and she's like I smell that smoke. (African-American female, total ban)
Like when it rains or we have company from out of town and stuff like that. It's kind of hard, you know, you tell them, hey, you can't smoke in here and you got to go in the back or front ... (African-American female, total ban)
Asking people not to smoke in their home
Participants were also asked if they had asked someone to not smoke in their home and whether they would consider asking people not to smoke in their home. A majority of participants have ‘actually’ asked a smoker to refrain from smoking in their home. The strongest themes for the decision to ask smokers not to smoke were related to rules existing for no smoking, protecting children from secondhand smoke and personal dislike of smoke.
Well no one else you know is allowed to smoke then why should they be allowed to smoke, same rule goes for everybody. (African-American female)Because I don't want to subject the kids to the secondhand smoke and I don't want the smell in the house and on the clothes and everything else. (White female)
Because I just can't, you know when they come in and go to smoke and then go to talking that smoke burns my eye and I just don't like it, and I just tell them don't smoke in here or put it out you know. (African-American female)
When asked how the smoker reacted when asked not to smoke, most commented that the smoker reacted positively. A few participants stated that the smoker ‘gave the person the look’.
A majority of participants reported that they have been in a situation where they requested that a smoker refrain from smoking. These situations included when visitors did not know the rules, in the presence of children or grandchildren, when a child in the home has asthma, when a person cannot stand smoke or when a person is sick or has allergies. The quotes illustrate these situations:
Yes, yes I have had some people over, and they wanted to light up a cigarette, and I told them I don't have ashtrays in my house, nobody can smoke in my house. I don't have a problem letting them know that, but that did come up and I had to ask them outside, if they plan to smoke they would have to go outside, they couldn't smoke in my house. (African-American female)I've been in a situation where somebody was going to smoke. I said don't smoke the cigarette around my children because I don't like nobody to smoke around my children. (African-American female)
... when [child's name] had asthma real bad I had to say uh huh, you all can't do this anymore, [name's] sister came over and she was smoking and I had to tell her no because he was taking breathing treatments and stuff and he was sick, she just couldn't do it. (White female)
Yes, my smoke don't bother me but it's like the other person's smoke like it balls up in a room and you get more of the smoke than I do, ... and then I get more of the impact than they do. (African-American female)
I was real sick one time, I think I had the flu or pneumonia or something, the smoke kept messing with my breathing, I just felt like running everybody out of the house because all that smoke was getting to me. When you say you can't breathe the smoking don't help. (White female)
The vast majority of participants reported having no problem asking a smoker not to smoke in their home. They explained that it is their home and they set the rules, people should respect other people's wishes and that they are comfortable telling visitors not to smoke. This quote characterizes many of the comments:
It would not be a problem for me. This is where I have to live every day, and you're a guest in my home, and when I go to your house, I should not do anything to offend you. When you come to mine you shouldn't do anything to offend me. (African-American female)
However, a few participants reported that they would feel uncomfortable asking smokers not to smoke because it would hurt their friends’ feelings or make visitors uneasy, they found it difficult to ask their parents or older relatives not to smoke or they are smokers too.
Bad, it makes you feel bad ‘cause you want people to be comfortable when they come to see you but still you hate to hurt their feelings. (White female)Well, when you're younger, people always tell you to be polite to guests, and so you don't want to embarrass the person. So I'd feel awkward because I'm afraid of embarrassing them. (African-American female)
Because, like, if it's my uncle, he smokes and it'll be, it would be real, you know, to me I would feel like it's disrespectful to ask him to go outside and smoke. (African-American female)
I wouldn't ask them not to smoke, but if I had to I'd feel bad .... Because you see that's what I do, and like when I have my company over here you know, I tell them it's all right to smoke. (African-American female)
How the smoking restrictions affect the smoker
Smokers in homes with smoking restrictions were asked how the restrictions affected them. Over half of smokers accepted the rules. Common comments such as ‘it doesn't affect me’, and ‘it's alright’, were given in response to how smoking restrictions impacted smokers. Most smokers reported going outside or on the porch to smoke. They reported that they felt fine with where they go to smoke and did not smoke where they were not allowed to smoke. Each of these is illustrated below:
Oh, it doesn't affect me at all, I'm all right with it, the rules, I'm all right with it. (African-American female, partial ban)I feel OK, I feel it's the right thing to do. (White female, total ban)
Well it really don't affect us because we just, you know, when we want a cigarette we just go outside. (African-American female, partial ban)
Some smokers reported that the rules help them consider quitting or make them smoke less.
It makes me smoke less having to go outside when it's cold or when it's raining or when it's really hot, I tend not to go out as much and smoke ... (White female, total ban)
When asked if smokers ever smoke where they were not allowed to, most said that they did not break the rule. One smoker commented, ‘No, I try to live by that rule’. (African-American female, total ban). Of the smokers asked if any arguments occurred about smoking in the household, none reported any.
In some households, the smokers were not as accepting of the bans. Participants reported that some smokers thought that the bans were inconvenient because smokers had to go outside, expressed feelings of being upset or disliked the bans. Some smokers reported smoking anyway. The following are representative comments regarding smokers’ not approving of the bans:
The rules about where to smoke affect him more because now he's got to get up, and he might even be watching a TV show or whatever and so he's going to have to go get up and go outside to smoke ... so, it affects him more because he might be sitting down relaxing, and all of a sudden he wants a cigarette, he's going to have to get up and go outside to do that. (African-American female, total ban)She gets upset sometimes about it. (African-American female, total ban)
Well, I get some frowns, maybe some kind of little gesture, but it really doesn't matter ....Some of them they might get a little funny look but they understand. (African-American female, partial ban)
It doesn't stop them. (White female, partial ban)
Family discussions with smokers about quitting
In order to understand factors that can influence the maintenance of smoking bans such as number of smokers in the family, we asked smokers if family members ever discussed quitting, the topics of these discussions and how they can assist the smoker in quitting. Smokers were asked if anyone in their home ever talked to them about quitting. Over three-fourths of smokers reported that a family member had discussed quitting with them. The two most common sources of these discussions were their children and spouse. Most conversations centered on the need for the smoker to quit because smoking is not good for them, affects their health and costs money.
My wife and my daughter and my sons .... Well they always say that, you know, I should quit because it's going to kill me and they want me to be around much longer. (African-American male, total ban)Yeah, me and my husband discusses it quite frequently .... We say that we need to stop smoking. It's costing us money, it's bad for the children. Every time the children get sick, you know, it's parts of it's from our cigarette smoke and we know it. But it's just hard (White female, partial ban)
Smokers were also asked to describe what their families could do to help them quit. A fourth of the comments focused on it being up to the smoker to quit and that the family could do nothing.
When it's time for me to do it, I guess I'll do it. You can't make somebody do something they don't want to do .... Nothing, it's got to be my choice, it's got to be me doing it. Ain't nobody else can stop me from doing it. (White female, partial ban)
However, other activities that family members mentioned to help them quit included: talking to the smoker, not purchasing cigarettes for them, not smoking around them, praying for them and supporting them. The following quotes illustrate these activities:
You know, talk to me, try to tell me to stop smoking. (African-American female, total ban).Well, for instance, if I ain't got no money, it don't give me nothing to buy cigarettes, don't even give me a cigarette if I don't have any, stuff like that and keep talking to me, encourage me to quit. (African-American male, partial ban)
They got to stop smoking because if I see them smoking, I'm going to want to smoke (African-American female, partial ban)
Pray along with me. Yeah, do a lot of this talking because I notice my wife talks to me regular about smoking. (African-American male, total ban)
I really don't know, just encourage me stop, because really and truly I don't supposed to be smoking because I had asthma too. (African-American female, partial ban)
Participants who lived with a smoker were asked if they ever talked to them about quitting. About three-fourths of participants had discussed quitting with the smoker. The topics most frequently discussed were how smoking affects health, the need to quit, methods to quit and how smoke smells. The following comments describe the topics discussed:
I talk to her all of the time, tell her to quit smoking, don't smoke, smoking ain't good for you and smoking gives you cancer, it can, it can do all kind of things. It can slow you down. (African-American male, total ban)Just more or less, we need to quit, basically before the kids say we need to quit because neither of us really want none of our kids to grow up smoking either, but when they see us do it they think it's OK and it's something OK to do so that's why we don't want them to do it, so that's pretty much all we discuss is trying to quit for them. (White male, total ban)
Well, I told her try doing something else, try chewing gum or drinking a coke or something like that when you have the urge to smoke (African-American female, total ban)
She knows about the health issues and, you know, all these other things, how it gets in your clothes, and in your hair, and I don't care how much you wash it, you just end up smelling like smoke. (African-American female, partial ban)
Ideas to promote a smoke-free home
When asked about ideas for encouraging people to make their homes smoke free, the most frequently suggested idea was to verbally explain to household members and visitors that the house should be smoke free for their children's health. Other ideas included placing a ‘No Smoking’ sign on the front door of the house, saying no to visitors who want to smoke, removing ashtrays and creating a designated place outside for smokers. These ideas are illustrated below:
Put a sign on the door, I've seen that a lot, this is a smoke free home, this is a smoke free place, this is a smoke free thing, immediately respect it, ... (White male)Maybe a sign, this is a no smoking environment, and if it's a family, if your family comes around you let them know ahead of time you know, just say you have a couple of relatives that smoke and if they're coming around you know you can't smoke here so you better smoke before you get here. (White female)
Take up the ashtrays. (African-American female)
I mean make a little place outside that may be comfortable for, you know if you know people that smoke or have family members or something, someplace that's comfortable so that they might be more inclined to go outside and smoke. (White female)
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Discussion |
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This study is one of the first to explore the factors that motivate rural families to adopt a smoke-free home. According to our study participants who had not yet established a smoke-free home, key motivators for convincing rural parents and caregivers to have a total smoking ban are the protection of children's and their own personal health, preventing another household member from getting ill, a belief that smoking in the home encourages children to start smoking and a doctor's advice. Participants also commented on the following positive outcomes of having a smoke-free home: a healthier place for everyone, particularly children and those with health issues and a home that smells better.
The study findings suggest that messages to convince parents and caregivers who are considering a smoke-free home (preparation stage of change) should incorporate: disadvantages or cons of smoking in the home such as the risk for exposure to secondhand smoke for children and other adults in the home when smoking is allowed and the short-term and long-term consequences of exposure to secondhand smoke for children and non-smokers (e.g. children gets sick or asthma, family members get lung cancer, etc.). Messages should also highlight the numerous, positive benefits of having a smoke-free home such as reduced likelihood that children will start smoking, having a cleaner home and a healthier place. Some of these same motivators have been employed in health education efforts to increase home smoking bans [7, 34, 35]. Specific messages to caregivers about the positive benefits of having a smoke-free home should also emphasize that household smoking restrictions lead to significantly less exposure to secondhand smoke [4].
The results of this study also suggest strategies to create and maintain a smoke-free home, including skills training and environmental supports. Skills training is important to build caregivers’ self-efficacy to adopt and enforce a total ban in the home. Although most participants reported they were comfortable asking smokers to refrain from smoking, a few mentioned some situations that made it difficult to ask people not to smoke such as a visit by an older relative or close friends who smoke. Parents and caregivers should be trained on how to ask family members and visitors to refrain from smoking or to go outside to maintain bans once implemented [1, 36]. Caregivers should also be encouraged to consider situations that may lead to relapses and ways to handle these potential situations in advance. In addition, participants recommended environmental changes to reduce secondhand smoke by removing ashtrays, displaying ‘no smoking’ signs, and encouraging support from household members. Another practical recommendation is to designate a comfortable place for the smoker to smoke outside of the home.
Surprising, this study found that over half of smokers accepted the smoking restrictions in the home and reported no arguments about smoking in the home. They commented that they felt fine with bans and complied with the rules. The social climate is changing so that more smokers are accustomed to not smoking around non-smokers [37]. This finding suggests that many smokers may be following home smoking restrictions just as they are complying with smoke-free policies in restaurants and bars in their communities [38]. Parents and caregivers who are trying to maintain home smoking bans should know that they can enforce their restrictions and may not experience much disagreement from smokers at least with partial bans. Messages about how many smokers are more accepting of smoking bans and how they led to smokers’ refraining from smoking in the home should be delivered to those who want to adopt a smoke-free home.
However, we found some households with smokers who were not accepting of the bans. The barriers cited in this study such as negative smoker's attitudes, feelings that smoking outside was a hassle and lack of acceptance of the rules should be addressed when training families to implement smoke-free home policies. These findings of a portion of smokers’ disapproving of bans, feelings of being inconvenienced and a perceived need to smoke despite restrictions are similar to attitudes found after the implementation of worksite smoking bans [39, 40]. Families with smokers who are adopting smoking bans should advise and help smokers to use methods like 5 D's when they get the urge to smoke (delay, drink water, do something else, deep breathe, discuss with a friend/family member) or plan for alternative activities to cope with these situations [41].
This study also revealed how family members can assist the smoker in quitting. Most household members with total and partial bans in this study reported talking to smokers about quitting. They discussed how smoking affects the smokers’ health, the need to quit, methods to quit and how smoke smells. These actions have the potential to assist smokers in making more quit attempts. Smokers also reported that family members could help by talking to the smoker about quitting, not purchasing cigarettes for them, not smoking around them, praying for them and supporting them. Research has shown that cessation is more successful with partner support [42], social support [43] and family or friend or physician advice [44]. Smokers in this sample also reported that the smoking rules help them consider quitting or make them smoke less. Studies have shown that smoke-free homes can encourage and maintain cessation [45–47]. Therefore, interventions to promote smoke-free homes and encourage cessation should have a family component to assist household members in helping the smoker to quit.
This study has several limitations. Our participants were mostly rural, African-American or White and had a least one child aged 10–14 years. The findings may not be transferable to other types of households or communities. Participants volunteered to be a part of the study and as a result, there may be selection bias. In addition, participants may have responded in a socially desirable manner in describing their attitudes and actions to protect their children from secondhand smoke. Third, we noted some discrepancies in reports of ban status between members of the same household, as found in previous research [48]. In classifying households on this measure, we classified the household based on the least restrictive policy reported.
Future research is needed to develop and test intervention messages around the benefits of smoke-free homes and strategies to create a home smoking ban, such as negotiating between family members and assertiveness training to enforce bans. The current research on intervention strategies to create smoke-free homes has had mixed results [1, 19]. Research can also evaluate the effectiveness of interventions tailored to caregivers by stages of adoption. For example, this research can test the combinations of positive messages about the benefits of a smoke-free home when families are deciding to adopt a ban and environmental changes and skill-building strategies (i.e. negotiating and enforcing a total smoking ban) to create and maintain a smoke-free home.
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National Cancer Institute (R21 CA 098484).
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Conflict of interest statement |
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TopAbstractIntroductionMethodsResultsDiscussionFundingConflict of interest statementAcknowledgementsReferences |
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None declared.
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Acknowledgements |
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The authors wish to thank John Fowler for coordinating data collection in Southwest Georgia, our study participants for their time and the Southwest Georgia Cancer Coalition for their ongoing support of this study.
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References |
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Received on June 21, 2007; accepted on November 20, 2007
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