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?