Can a community-based 'smoke-free homes ...

Journal of Public Health Advance Access published October 7, 2010 Journal of Public Health | pp. 1– 7 | doi:10.1093/pubmed/fdq073

Can a community-based ‘smoke-free homes’ intervention persuade families to apply smoking restrictions at homes? Nisreen Alwan1, Kamran Siddiqi2,3, Heather Thomson3, Joy Lane4, Ian Cameron3 1

Centre for Epidemiology and Biostatistics, Faculty of Medicine, University of Leeds, Room 8.01, Level 8, Worsley Building, Leeds LS2 9JT, UK Nuffield Centre for International Health and Development, University of Leeds, Leeds LS2 9JT, UK Leeds Primary Care Trust, Leeds LS16 6QG, UK 4 Wakefield District Community Healthcare Services, NHS Wakefield, Wakefield WF8 4AY, UK Address correspondence to Nisreen Alwan, E-mail: [email protected] 2 3

Background Children are commonly exposed to second-hand smoke (SHS). The aim of this study is to evaluate the feasibility, acceptability and outcome of Smoke-Free Homes (SFH), a community-based intervention; and assess potential evaluation methods. Methods SFH, designed to encourage families to implement smoking restrictions at home, was delivered over a period of 6 months through schools, healthcare settings and community events in Beeston, South Leeds, UK. It was evaluated using baseline and post-implementation surveys, focus group discussions and promise forms follow-up. Results We surveyed 318 households before, and 217 households after, the intervention. The proportion of all surveyed households reporting being completely smoke free significantly increased from 35% [95% confidence interval (CI) 30, 40] at baseline to 68% (95% CI: 61, 74) 6 months post-implementation (P , 0.0001). Ninety per cent of people, followed-up by telephone 3 months after signing SFH promise form, said they were still keeping their promise. Focus group discussions with children and parents conveyed acceptability of the intervention, in particular, the schools element, where children are encouraged to discuss the concept of SFH with the adults in their households. Conclusions Our study shows that SFH can be implemented effectively and has the potential to improve children’s health through preventing exposure to SHS in the home. Keywords children, communities, tobacco

Introduction Children exposed to second-hand smoke (SHS) have an increased risk of developing adverse health outcomes,1 becoming smokers themselves2 and achieving lower educational attainment.3,4 Children’s exposure to SHS is also associated with increasing health care costs.5 This is of particular relevance to those communities experiencing the worst socioeconomic and health inequalities.6 There is evidence that children in vulnerable populations including ethnic minorities are at greatest risk of SHS exposure.7,8 Low income and single parent families are more likely to have a smoker in the home, have friends who smoke and to live in smaller housing units with limited access to outdoors.9 Approximately, 49% of children from families with a low income live with a smoker compared with 21% children from affluent families, according to a US-based survey.10

Smoke-free legislation in public and work places was introduced in England in July 2007.11 There is some evidence that a smoking ban in public places encourages people to implement smoking restrictions at home as explained by the social diffusion model.12 However, for children, the home is often the most important site for SHS exposure and they may not be direct beneficiaries of this legislation. A crosssectional comparison carried out in the same schools before

Nisreen Alwan, Specialist Registrar in Public Health Kamran Siddiqi, Clinical Senior Lecturer and Consultant in Public Health Heather Thomson, Tobacco Control Lead & Health Improvement Manager Joy Lane, LifeCheck Co-ordinator Ian Cameron, Director of Public Health

# The Author 2010, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved

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Downloaded from jpubhealth.oxfordjournals.org at University of Leeds - Librarian on October 8, 2010

A B S T R AC T

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J O U R NA L O F P U B L I C H E A LT H

Methods SFH intervention and its delivery

The SFH intervention, designed to encourage families to implement smoking restrictions in their homes, was delivered over a period of 6 months by a dedicated SFH team. During this period, the team: (i) Visited primary schools in the area and took children between 9 and 11 years through a series of educational activities using a SFH toolkit. These activities included a class-room presentation, a quiz, a game, role play, poster making and a speech bubble exercise, lasting approximately one and a half hours. Children were given promise forms containing pictorial and written messages on the hazards of SHS, a pictorial step-guide for families to make their homes smokefree, a puzzle to help families learn about the benefits of a smoke-free home and a tear-off slip to make a commitment to impose smoking

restrictions at home. Children were expected to bring this slip back to school and receive a SFH Gold certificate should their home be totally smoke free. (ii) Trained health professionals and other community workers to encourage their clients to impose smoking restrictions at home. (iii) Organized community-based events and provided educational materials to community outlets such as local shops, children’ centres and mosques. Families in the area received a SFH promise form, through all of the above activities. Beeston in South Leeds was selected as the study site. Beeston is ranked among the 5% most deprived super output (census) areas in the UK using the Index of Multiple Deprivation score, with 30% of households receiving one or more forms of council/welfare benefits.18,19,20 It also has a high proportion of black and ethnic minority population, known to have higher rates of smoking compared with the national average.18

SFH: The theoretical framework Providing information: Reinforcing understanding of the harmful effect of second-hand smoke in an easy-to-understand format. Empowerment: Empowering youngsters with the tool of negotiation and encouraging young people to become ‘champions of smoke-free spaces’. Negotiated goals: Giving families a menu of options on how to reduce their children’s exposure to tobacco smoke; letting them decide for themselves which of the options are achievable for the family. Signing a contract: Encouraging parents to sign the ‘Promise’ form and return to the project team increases their commitment and the likelihood of their maintaining smoking restrictions in the home. Positive feedback: Praising parents for the positive consequences of reducing their children’s exposure to SHS increases self-esteem efficacy in making changes in their lives. Immediate benefits: Using the basic principle of social marketing ‘exchange’. People expect to receive a benefit in exchange for giving up something. In this case, in addition to praise and encouragement, families were ‘rewarded’ with a modest ‘goody-pack’. The school toolkit consists of a CD Rom, which has a presentation showing the health impact of SHS, worksheets to reinforce learning, and video of children singing about the hazards of SHS. There is a suggested lesson plan, which equips the children, through discussion, role play and drama, to negotiate with their parents altered smoking habits in the home. There is also a board game about the dangers of SHS.


and after the implementation of smoke-free legislation in Scotland showed little change in reported exposure to SHS in pupils’ own homes or in cars.13 The evidence for the effectiveness of interventions aimed at providing non-smokers and children with a smoke-free home is scarce. A recent Cochrane review analysed several studies on strategies that were aimed at reducing exposure to SHS in the home through smoking restrictions.14 The authors acknowledged that there is insufficient evidence to support one strategy over another and recommend further studies to explore the effectiveness of family-based interventions in establishing a smoke-free environment at home. Smoke-Free Homes (SFH) is an initiative developed by West Yorkshire Smoking & Health (WYSH) in 2003 as an adaptation of ‘Smoke-Free Home Pledge’ launched in America in 2001 by the US Environmental Protection Agency.15 This was aimed to increase awareness of the health hazards of SHS and self-efficacy in being able to restrict smoking in homes using children as the primary change agent. SFH has been adapted in certain other parts of the UK. However, the reported evaluations have been limited. In Doncaster, 69% of households, signing up for SFH, promised to have a complete smoking ban in the house.16 A report from Salford suggested that nearly all smokers who signed up to keep their homes smoke-free were able to maintain their commitment in the following 6 months.17 We report findings of an exploratory study of SFH in a deprived locality in Leeds to (i) test the feasibility and fidelity of SFH; (ii) refine various components of the intervention; and (iii) assess potential methods for its evaluation in a future trial.

CO MMUN I TY-BASED ‘ SMOK E -FRE E H OM ES ’ I N TERVE N TI O N

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Table 1 Evaluation objectives and activities of the SFH community intervention in Leeds Target group Children Parents

Objective

Evaluation activity

Assess knowledge around SHS and attitudes towards

Qualitative evaluation of demonstrations at schools

negotiating with parents around SFH

Focus groups

Assess knowledge around SHS, attitudes towards SFH,

Promise form follow-up: total number of SFH promises

behaviour in initiating and maintaining SFH

Three month follow-up of promise forms Baseline and post intervention community surveys Focus groups

Health professionals

Post training self-administered questionnaire

towards promoting SFH and exploring barriers; Assess

Focus groups

behaviour in promoting SFH

Promise form follow-up: number of SFH promises made through HP

Evaluation methods

The intervention was evaluated using a combination of quantitative and qualitative methods (Table 1). We carried out pre- and post-intervention surveys on a randomly selected household sample in the area to assess the difference in the number and types of smoking restrictions in the homes before and after the intervention. The primary outcome measure was the difference in the proportion of households applying total smoke bans inside the home before and after the implementation of the intervention. Both surveys followed the same methodology in terms of design and data collection and this is described in detail elsewhere.21 A total of 625 houses were approached in the baseline survey, out of which 318 households met the inclusion criteria (of having at least one child under 16 years in the household) and agreed to take part. We conducted a postintervention survey targeting the same addresses which participated in the baseline survey. We anticipated that a considerable proportion of addresses may not have the same residents given the transient nature of the population in that area. Questions about smoking restrictions in the household included asking whether smoking takes place in the presence of children as well as the location where smoking takes place in the house. We also collated and analysed promise form returns to test the fidelity of the intervention. We were interested in the proportion of SFH promises made through the different routes. We conducted a telephone follow-up of the SFH promise forms on all households which provided a telephone number on their returned promise form at least 3 months post signing the forms to assess the level of compliance with household smoking restrictions. Focus group discussions with children, parents and health professionals were carried out to assess acceptability and appropriateness of SFH.

Three focus group discussions were carried out with children aged 9 – 11 years from a local school, local parents/ carers through the area’s Healthy Living (community) Centre and health care professionals from the local health centre. A focus group guide was developed before each session. The average number of participants per group was five. The parents focus group had three parents from households with smokers and no smoking restrictions, and two from SFHs, including one from a household where smoking was allowed in the house prior to the intervention. Analyses

Statistical analysis was performed using Stata (version 10; Stata Corp, College Station, TX, USA). Means and standard deviations are presented for continuous variables. Proportions with 95% confidence intervals (CIs) around proportions are calculated and presented for categorical variables. Equality of proportions for categorical variables was tested using the x2 test and equality of means for continuous variables was tested using the two sample t-test.

Results Prevalence of SFH: pre- and post-intervention household survey

The total number of households included in the pre- and post-intervention household survey were 318 and 217, respectively. Head of household characteristics in both surveys are described in Table 2. Forty-eight pre cent (95% CI: 42, 55) of households in the post-intervention survey had at least one smoker compared with 54% (95% CI: 49, 60) in the baseline survey (P ¼ 0.2). In 68% of households (95% CI: 61, 74), smoking was not allowed anywhere inside the house (SFH) 6 months after the intervention compared with 35% (95% CI: 30, 40) at baseline (P , 0.0001) (Fig. 1).


Assess Knowledge around SHS; Assess attitudes

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Table 2 Household characteristics in the baseline and post-intervention surveys Baseline (n ¼ 318)

Post-intervention (n ¼ 217)

P-value

Head of household mean age in years (95% CI)

37 (35, 38)

37 (35, 39)

0.9

Male head of household (%, 95% CI)

51 (45, 56)

59 (52, 65)

0.07

Unemployed head of household (%, 95% CI)

37 (32, 43)

30 (24, 37)

0.09

Head of household from non-white ethnic background (%, 95% CI)

–

58 (51, 65)

–

A-levela and above qualification for head of household (%, 95% CI)

27 (23, 33)

25 (20, 31)

0.6 0.2

At least one smoker in the household (%, 95% CI)

54 (49, 60)

48 (42, 55)

Smoking not allowed anywhere in the home (SFH) (%, 95% CI)

35 (30, 40)

68 (61, 74)

9 (6, 13)

6 (3, 10)

Smoking allowed anywhere in the home (%, 95% CI)

,0.0001 0.2

12 (9, 16)

23 (17, 29)

,0.001

17 (13, 22)

23 (17, 29)

0.09

n, number of households; CI, Confidence interval. a

National exams at 18 years in England.

In households with at least one smoker (n ¼ 173 at baseline, 105 at 6 months), the proportion with total smoking bans increased from 41% (95% CI: 35, 47) to 48% (95% CI: 38– 58; P ¼ 0.3; Fig. 2). There was also a rise in reporting partial smoking restrictions in the post-intervention survey compared with the baseline survey. Smoking allowed only in a specific room, increased from 12% (95% CI: 9– 16) at baseline to 23% (95% CI: 17 – 29) at 6 months (P ¼ 0.0008). This is similar to reporting that smoking was only allowed in a specific room with the windows open: 17% (95% CI: 13 –22) at baseline and 23% (95% CI: 17 –29) at 6 months (P ¼ 0.09; Table 2). Fifty-two per cent (112) of respondents stated that they directly received a leaflet informing them about the importance of having a SFH in the proceeding 6 months. Forty-eight per cent of respondents received it through the school, 31% through the GP/practice nurse/health centre, 7% through a community event, 5% through the post, 3% from a local shop, 1% through a local mosque/church, 3% reported being given to them by a midwife, 1% by a health trainer and 1% by a health visitor. Only 65 respondents (30%) were able to recall that they or another adult in the household took part in a similar survey 6 months previously. Out of those who did not recall taking part of the baseline survey (n ¼ 152), the proportion of SFH was 66% (95% CI: 58, 74, n ¼ 101) compared with 68% in the overall post intervention survey sample (P ¼ 0.7). SFH promise forms follow-up

Two hundred and fifty-eight signed promise forms were obtained during the duration of the intervention. Of these,

70

Baseline 6 months

60 50 40 30 20 10 0 All households

Households with at least one smoker

Head of hosuehold is a smoker

Fig. 1 Proportion of SFH from surveys conducted before and after the implementation of the SFH community intervention in Beeston, Leeds.

50

Baseline 6 months

45 40 35 30 25 20 15 10 5 0

Not allowed Only in a Only in a Any part of Any part of inside specific room specific room the house the house with with windows windows open open

Fig. 2 Types of smoking restrictions reported in survey households with at least one smoker before and after the implementation of the SFH project in Beeston, Leeds.


Smoking allowed only in a specific room (%, 95% CI) Smoking allowed only in a specific room with windows open (%, 95% CI)


206 (80%) came from the local schools. We conducted telephone interviews with adults in 70 (30%) households 3 months after signing the promise form. Sixty-two (90%) said that they are still keeping their smoke-free promise at the time of the interview. Nine (13%) respondents said that the smoker(s) in the households have cut down on their smoking. When asked about the source of the SFH promise form, 56 (80%) said that they were brought in by their children through their schools, 11 (16%) through community events and 1 (1%) through a health care professional.

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Discussion Main findings of this study

Findings from focus groups discussions

The children’s focus group discussion revealed that some parents of the children included in the group have acted on the SFH message (three out of six households who applied no smoking restrictions in response to the intervention), and some have even stopped smoking altogether. However, they forgot to mail the promise form back. All children felt confident talking to their parents about the harms of SHS and negotiating making their home smoke free: ‘Felt proud to tell mum about what would happen if she continued smoking, but felt bossy because I was telling mum what to do’. The health professionals, in their focus group discussion identified their role as reinforcing the SFH message and directing people to the appropriate channels for more information rather than introducing and discussing the SFH concept themselves due to time restraints in consultation times. They also explored using a smaller, more adult-oriented version of the promise form, in primary care centres. Parents/carers felt that the intervention was generally acceptable: ‘not awkward at all if my children ask me not to smoke at home’. They suggested targeting the parents directly through school sessions as well as children, with an ex-smoker parent participating in the session delivery.

Recommendations from focus group participants: (i) Use two versions of the SFH promise form for different settings (e.g. schools and health centres) rather than one standard form. (ii) Use other methods to evaluate the effectiveness of SFH in addition to the return of promise forms which may underestimate the effectiveness of the intervention. (iii) Jointly target children and parents through school interventions by inviting parents to attend the SFH sessions in schools.

What is already known on this topic

There are fewer community-level interventions identified by the Cochrane systematic review on reducing children’s exposure to environmental tobacco smoke compared with healthcare settings interventions. Many of the studies which reported interventions in the home were targeted at the immediate postnatal period.14 SFH and other similar initiatives to limit children’s exposure to SHS in the home and cars have ethical implications about imposing constraints on private behaviour. In a qualitative study conducted shortly after the smoke-free legislation in Scotland, one of the barriers identified against achieving an SFH was the perception of the home as a private space protected from public controls and sanctions.22 There are existing laws and regulations that protect physical and sexual abuse inside the home and enforce mandatory child restraint in cars. From a legal perspective, parents have the right to raise children without interference except when there is action or inaction that places the children at real risk of serious harm.23 However, creating a norm of unacceptability for childhood SHS exposure may have the same effect as policy and legislation while preserving the private identity of the home. Programmes to counter exposure to SHS in the home are essential ingredients of population-level policies to reduce mortality, morbidity and widening health inequalities associated with passive smoking. Possible interventions include public education, community-level programmes, clinical interventions, policy and advocacy statements and legal and regulatory measures.9 All these need proper monitoring and evaluation mechanisms. Evaluation of community-based programmes has shown variable success.16,24 – 27 However, many of the evaluated programmes focussed on media campaigns and did not use a combination of different approaches as those used in our project including school demonstrations, community events and brief interventions by health professionals.


Our study found that households with total smoking bans almost doubled from 35% at baseline to 68% 6 months after the intervention in the whole survey sample. However, the rise in SFHs was not statistically significant when considering smoking households only (41 –48%). The most effective component of the intervention was the school intervention element judging by the number of promise forms received. There was no evidence of unacceptability of the community-based intervention.

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What this study adds

exposure to SHS (documented by salivary cotinine measurements) and levels of smoking restrictions at home.29 Beeston, similar to many deprived inner city areas in the UK, has a high proportion of transient population. Loss to follow-up in our surveys was due to a high number of families moving house within a period of 6 months. Unlike drug trials, where loss to follow-up is more likely to be due to the side effects or lack of benefit from the drug, our loss to follow-up was unlikely to be due to the reasons related to the outcomes. It is possible though that the transient households lost to follow-up are those who were least likely to take up a SFH policy leading to potential bias. This is supported by the fact that there was a smaller proportion of unemployed, female heads of household and smokers in the follow-up survey sample compared with the baseline survey. However, the differences were not statistically significant (Table 2). Our study provides the basis for carrying out a more robust evaluation of the intervention. Existing research on SFH shows that it has a sound theoretical basis, good feasibility, broad acceptability and potential to improve children’s health. However, the evidence of its cost-effectiveness to support wide adoption is lacking. We propose this as the next step in the evaluation of this scheme.

Limitations of this study

Our study was not a randomized controlled trial and therefore, liable to confounding. It is worth mentioning though that other than the intervention, there were no concurrent national or local policy SFH initiatives or campaigns that could have confounded the changes observed. Given that this was only an exploratory study with limited aims; a controlled trial would have been premature. The postintervention survey targeted the same addresses included in the baseline survey. This could potentially introduce bias in terms of responses to the smoking restriction questions. The respondents may be inclined to give what they perceive as socially or morally acceptable answers. However, 70% of respondents did not recall being asked about smoking restrictions before, indicating that the many of addresses may not have had the same residents after 6 months. Out of those households, 66% applied total smoking restriction bans in their homes, a similar proportion to the overall prevalence in the post intervention survey (68%). This potential for bias applies generally to any self-reporting method in this context. Using an objective measure, for example cotinine levels, to validate change in the exposure to SHS in children at this stage would have overcome this problem. Such a measure would require more resources and would be ideal to use as a primary outcome measure or a validation tool for self-report in a future controlled trial. However, there is evidence of strong association between

Acknowledgments We would like to thank the survey and focus group participants, Shambaleen Panezai for co-ordination of data collection and entry, health trainers: Tony Crawford, Carmen Webbe, Balwinder Kaur, Delia kenley, Naseem Saeed, Lufta Begum, Moninda Toor for data collection and Hannah Winchester for data entry.

Funding This work was supported by NHS Leeds.

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This is a real-life feasibility study of a public health intervention in a deprived multi-ethnic urban area in the UK. It constitutes an exploratory phase preceding the conduct of a cluster randomized controlled trial of the intervention.28 We tested the feasibility and fidelity of the multiple elements of the intervention using a mixture of quantitative and qualitative methods. Our intervention has the strength of combining several elements aimed at different settings and age-groups in the target community including parents/ carers, children, community and healthcare settings. Although the increase in the proportion of smoke-free households where at least one smoker lives was only 7% between the baseline and post-intervention surveys, the Beeston SFH project seems to have encouraged households where regular smoking does not take place to ban smoking inside the home. This is particularly important in an area where the prevalence of smoking is relatively high and children are likely to be exposed to SHS through social interaction even if the adults in the house are non-smokers.


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