Family Rules About Exposure to Environmental Tobacco Smoke

Families, Systems, & Health 2005, Vol. 23, No. 1, 3–16

Copyright 2005 by the Educational Publishing Foundation 1091-7527/05/$12.00 DOI: 10.1037/1091-7527.23.1.3

Family Rules About Exposure to Environmental Tobacco Smoke SARA A. PYLE, MA C. KEITH HADDOCK, PHD NORMAN HYMOWITZ, PHD JOSEPH SCHWAB, MD SARAH MESHBERG, BA

the parents and the presence of smokers in the home were related to fewer home smoking rules. Implications for communitybased interventions on the dangers of ETS are discussed.

Environmental tobacco smoke (ETS) is detrimental to the health of children. It is important for families to implement rules that limit the exposure of children both within the home and in the community. The current study used a diverse sample of participants from pediatric clinics in a large metropolitan area to explore what restrictions families place on tobacco use in their home and in the community (e.g., restaurants, trains). In general, minority ethnic groups were less likely than their Caucasian peers to limit exposure to ETS outside of the home, even when income and education were taken into account. Income and education had a consistent inverse relationship to the endorsement of home smoking rules. It was not surprising that smoking status of

xposure to environmental tobacco smoke (ETS), or secondhand smoke, is detrimental to health and has been related to higher rates of stroke, heart disease, and lung cancer (Brownson, Eriksen, Davis, & Warner, 1997; He et al., 1999). The evidence of the negative effects of ETS is so well established that the U.S. Environmental Protection Agency classified ETS as a Class A environmental carcinogen in 1993 (U.S. Environmental Protection Agency, 1993). ETS has been found to be particularly harmful to the health of children (DiFranza & Lew, 1996; Stoddard & Gray, 1997). It has been associated with higher incidence of lower respiratory tract infections (e.g., bronchitis, pneumonia) as well as middle ear diseases and worsening of asthma in children (World Health Organization, 1999). Anderson and Cook (1997) reported a strong relationship between maternal smoking and an increased risk of sudden infant death syndrome. Because of the negative health effects of ETS on chil-

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Sara A. Pyle, MA, and C. Keith Haddock, PhD, Department of Psychology, University of Missouri— Kansas City, and Mid America Heart Institute, Saint Luke’s Hospital; Norman Hymowitz, PhD, Joseph Schwab, MD, and Sarah Meshberg, BA, Department of Psychiatry, University of Medicine and Dentistry of New Jersey, New Jersey Medical School. This research was supported by National Institute of Child Health and Development Grant 5-RO1 HD040683-03 to Norman Hymowitz, PhD. Correspondence concerning this article should be addressed to C. Keith Haddock, PhD, Department of Psychology, University of Missouri, 4825 Troost, Suite 124, Kansas City, MO 64110. E-mail: haddockc@ umkc.edu

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PYLE, HADDOCK, HYMOWITZ, SCHWAB, AND MESHBERG

dren, the medical community has been urged to support parents in protecting their children from tobacco smoke (American Academy of Pediatrics Committee on Adolescence, 1987; American Medical Association, 1994). One important source of children’s exposure to ETS is in the home. Thus, examining family rules for creating a smoke-free home has become a priority for tobacco control researchers. Gilpin, Farkas, Emery, Ake, and Pierce (2002) found that 73.7% of adults in California reported having a smoke-free home in 1999. Studies from other locations have reported smoke-free home rates as low as 34.6% (Ashley et al., 1998). When homes were stratified by the smoking status of parents, only 40.0% of current smokers had smoke-free homes, whereas 61.4% of never smokers and 77.8% of former smokers from the same sample reported having a smoke-free home (Hymowitz et al., 2003). An apparent interaction exists between home smoking rules and smoking status, as smokers who live in a home with smoking restrictions report more quit attempts than those with no restrictions (Farkas, Gilpin, Distefan, & Pierce, 1999). Some trends exist in the endorsement of home smoking rules. For instance, African Americans tend to be the ethnic group least likely to endorse rules in homes and cars (Gilpin, White, Farkas, & Pierce, 1999; Norman, Ribisl, Howard-Pitney, & Howard, 1999). Findings have been mixed in regard to the relationship between smoking rules and both gender and age (Gilpin et al., 1999; Norman et al., 1999). Although not all families require their home to be entirely smoke free, they often enforce rules that limit exposure for children within the home. Families might have a designated smoking area or might not allow smoking in a child’s room. Among adolescents who reported having a family member who smoked, 22.0% reported that their family had established designated smoking areas (Ashley et al., 1998). In a

survey of Australian families, Borland, Mullins, Trotter, and White (1999) reported that 53.0% of their respondents discouraged visitors from smoking in their home and that respondents with children were more likely than respondents with no children to request that smoking remain outside of the house. Limited research is available that has explored the endorsement of family rules that protect children from ETS in enclosed areas outside the home. In a survey of Californians regarding protecting children from ETS in motor vehicles, 66.0% of respondents reported a total smoking ban in their vehicles, 16.0% reported limiting smoking, and 18.0% reported no limitations on smoking in the car (Norman et al., 1999). Similarly, a survey conducted in Australia found that 77.0% of car owners indicated that they allow no smoking (Walsh, Tzelepis, Paul, & McKenzie, 2002). Rules regarding limiting exposure in the car are of particular interest given the concentrated levels of pollution within a small, enclosed area (Zhou, Li, Zhou, & Haug, 2000). Studies of family rules protecting children from ETS in other venues are lacking. Although previous research has explored the prevalence of smoke-free homes and smoke-free cars, little is known about the types of rules parents impose on themselves and others limiting exposure to ETS within the home and in the community. This study provides a more comprehensive analysis of how families protect children from ETS both inside the home and in other venues. On the basis of the previous research, we posit that there are trends in the rates of home smoking rules and rules in the community in terms of ethnicity, income, education, and smoking status. Participants in this study are a diverse cohort of parents seeking care at pediatric offices in New Jersey and New York. Factors related to the endorsement of rules limiting ETS both inside and outside the home are explored. Results are stratified

HOME SMOKING RULES

by both gender and ethnicity to examine the relationship each characteristic has with endorsement of smoking restrictions. METHOD Description of the Larger Study The Pediatric Resident Training on Tobacco Project (Haddock, Pyle, Hymowitz, Schwab, & Burd, in press; Hymowitz, Schwab, Haddock, Burd, & Pyle, 2004; Hymowitz, Schwab, Haddock, Pyle, et al., in press; Hymowitz, Schwab, Haddock, Pyle, & Meshberg, in press) is a group-randomized trial of the effectiveness of pediatric residents’ training on tobacco cessation and prevention. Participants in the current study were parents and guardians of patients seen at 15 pediatric residency training programs in the New York–New Jersey metropolitan area. Participants were approached about participation while waiting for their child’s or children’s appointment with their pediatrician. Human participant approvals were granted by the University of Medicine and Dentistry of New Jersey, the University of Missouri—Kansas City, and each of the residency training sites.

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Participants Participants were 1,770 parents and guardians completing baseline surveys for the parent study. The mean age of parents and guardians was 29.9 years (range ⫽ 15 to 72 years). Eighty-six percent of the participants were female. The parents and guardians reported diverse ethnic backgrounds, with 90.0% of respondents classifying themselves as a member of an ethnic minority group. Of those who classified themselves as minorities, 39.6% reported African American ethnicity, 40.1% reported Hispanic ethnicity, and 3.7% reported Asian ethnicity. The remainder of the parents who classified themselves as a minority (6.6%) were classified as “other” because of the small numbers within ethnic categories. Table 1 provides the distribution of income and education by ethnic group. Measures All parents and guardians were approached while in their pediatrician’s office, were asked to consent to participation in the study, and were given for completion a consent form approved by the institu-

Table 1 Distribution of Income and Educational Level by Ethnic Group Ethnic group Variable

White

African American

Hispanic

Asian

Other

% of total n Income level per year (%) Less than $10 $10–$20 $21–$40 $41–$60 More than $60 Education level (%) Less than 8th grade Some high school High school graduate Some college College graduate

10.3 163

39.4 624

39.9 632

3.8 61

6.6 105

18.4 20.9 22.7 12.9 25.2

28.0 29.8 31.6 8.3 2.2

40.5 31.0 21.7 5.4 1.4

24.6 39.3 26.2 6.6 3.3

30.5 23.8 35.2 6.7 3.8

2.9 8.6 29.1 27.4 32.0

1.0 18.5 39.1 31.7 9.7

9.9 29.7 30.4 22.2 7.7

6.2 9.2 32.3 16.9 35.4

3.5 20.9 27.0 28.7 20.0

Note. Income levels are presented in thousands of dollars.

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tional review board. A 69-question Pediatric Clinic Tobacco Survey was developed for the current study. The survey included demographic information such as age, gender, ethnicity, level of education, marital status, and income. Family tobacco use and personal tobacco use were assessed (i.e., cigarettes, cigars, pipes, and smokeless tobacco). Participants were asked, “Did you ever smoke cigarettes?” as well as “Do you currently smoke cigarettes?” Questions assessing family tobacco use were, “Does your spouse/mate smoke cigarettes?” and “What is the number of household members who smoke cigarettes?” To assess family rules about smoking, we asked parents to identify from a list of possible rules which family smoking restrictions were in place within their family (e.g., “Only adults can smoke,” “Adults can smoke, but not around children,” “No smoking is allowed in my home”). We also assessed attempts to reduce exposure to ETS outside of the home by asking what other rules about smoking the family follows (e.g., “Do not allow smoking in the car,” “Ask people not to smoke in their presence,” “Usually sit in ‘no smoking’ sections of restaurants”). Questions were developed by a team of established tobacco researchers on the basis of previous literature and have been used in a variety of studies (e.g., Hymowitz, Schwab, & Eckholdt, 2001; Hymowitz et al., 2003). Participants were then asked whether they had witnessed any tobacco interventions from their pediatrician (e.g., “Did your child’s doctor ever ask you if you smoke?” “Did your child’s doctor ever offer to help you quit smoking?” “Did your child’s doctor ever talk to you about environmental tobacco smoke?”). Approach to Analysis We examined the relationship between endorsing rules limiting ETS and potential predictors using exploratory univariate logistic regression models. First, we considered demographic characteristics (e.g., eth-

nicity, level of education, income). We examined ethnicity with Caucasians serving as the referent group. Reported levels of income were dichotomized to be either more or less than $41,000 per year, on the basis of the median incomes reported by the 2001 U.S. Census (U.S. Census Bureau, 2001). Next, we considered parental and family smoking behaviors. Current smokers were used as the referent group and were compared with both former smokers and individuals who reported never smoking. Family smoking was assessed with questions about whether the spouse in the home smokes and the number of individuals living in the home who smoke as well as the total number of people in the home. Finally, we examined the influence of the pediatrician’s intervention on limiting ETS exposure, on the basis of participants’ response to the question, “Has your doctor ever discussed the health hazards of environmental tobacco smoke?” RESULTS Tables 1 and 2 contain frequencies of endorsement for rules limiting exposure to ETS both inside and outside the home when stratified by demographic characteristics. In general, families with an income over $41,000 per year endorsed rules limiting exposure within the home less frequently than did those with lower incomes, but they reported having an entirely smoke-free home and reported limiting exposure outside the home at higher rates than those in the lower income bracket. Former and never smokers were similar in their responses regarding limiting exposure both within and outside the home. Those who reported having a spouse who smokes endorsed rules limiting exposure inside the home at higher rates than those whose spouse does not smoke. However, those with a spouse who smokes reported having a smoke-free home at a lower rate than those whose spouse does not smoke. Rates for endorsing rules limiting exposure outside the home were similar for those

26.6 19.8 44.7 18.5 14.4 38.1 16.4

27.2 18.8 43.8 21.1 13.1 38.4 15.1

Rules in the home

44.3 65.1 32.6 50.6 37.9 50.0 47.0 43.0 46.3

46.1 63.8 38.9 49.9 44.3 51.6 46.6 46.7 47.0

23.5 29.8

16.4 32.5 30.8

18.8 31.7

26.8 46.2

32.3 40.7

23.3 42.8 42.1

31.8 41.1

39.0 42.7

Ask people not to smoke in the presence of my children

57.1 56.1

53.5 56.3 57.5

53.4 57.7

55.9 69.9

Ask people to smoke outside, not in the house

Rules outside the home

62.0 26.3

62.4 30.6 26.4

44.2 31.2

37.2 19.9

Adults can smoke, but not around young children

No smoking Usually sit in allowed in nonsmoking sections Sit in nonsmoking the car of restaurants sections of trains

22.9 16.6

22.6 14.4

Adults can smoke in certain rooms or at certain times

Note. Values represent the percentage of respondents who answered “yes” regarding each rule. yr ⫽ year.

Income Under $41,000/yr (n ⫽ 1,353) $41,000/yr or more (n ⫽ 181) Education Less than high school (n ⫽ 449) High school graduate or more (n ⫽ 1,235) Smoking status Current smoker (n ⫽ 349) Former smoker (n ⫽ 281) Never smoker (n ⫽ 1,042) Spouse who smokes Yes (n ⫽ 384) No (n ⫽ 1,260)

Predictor

Income Under $41,000/yr (n ⫽ 1,353) $41,000/yr or more (n ⫽ 181) Education Less than high school (n ⫽ 449) High school graduate or more (n ⫽ 1,235) Smoking status Current smoker (n ⫽ 349) Former smoker (n ⫽ 281) Never smoker (n ⫽ 1,042) Spouse who smokes Yes (n ⫽ 384) No (n ⫽ 1,260)

Predictor

Only adults are allowed to smoke

Table 2 Demographic Factors and Family Rules Regarding Exposure to Environmental Tobacco Smoke

76.3 55.5

75.4 60.9 55.3

58.8 61.5

61.3 64.2

Do not smoke around small children or infants

41.3 68.7

36.1 65.7 70.3

57.6 64.5

60.3 74.1

No smoking is allowed in the home

HOME SMOKING RULES 7

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who had a spouse who smokes and those who did not. Factors Related to Rules in the Home Figure 1 presents the frequency of endorsement of home smoking rules. Approximately 60.0% of all families reported hav-

ing a smoke-free home, whereas slightly over 20.0% allow adults to smoke in the home. Over 50.0% ask people to smoke outside rather than in their home, whereas about 35.0% allow smoking in the home but not around young children. Table 3 presents the odds ratios (ORs)

Figure 1. Home smoking rules stratified by ethnicity.

HOME SMOKING RULES

and confidence intervals (CIs) for the univariate logistic regressions examining potential predictors of the adoption of home smoking rules. For ethnicity, income and level of education were included as covariates to adjust the analysis for these factors. In general, Asian participants were least likely to establish home smoking rules. African Americans, Hispanics, and Asian Americans were less likely than Caucasians to endorse the rule that only adults are allowed to smoke in the home (African Americans, OR ⫽ 0.617, CI ⫽ 0.40, 0.95; Hispanics, OR ⫽ 0.405, CI ⫽ 0.26, 0.63; Asian Americans, OR ⫽ 0.285, CI ⫽ 0.12, 0.69). Similarly, they were less likely than Caucasians to endorse the rule that adults can smoke, but not in the home (African Americans, OR ⫽ 0.612, CI ⫽ 0.40, 0.94; Hispanics, OR ⫽ 0.526, CI ⫽ 0.34, 0.82; Asian Americans OR ⫽ 0.884, CI ⫽ 0.10, 0.66). Those reporting “other” as their ethnicity did not differ significantly from Caucasians on endorsement of any rules. Hispanics were more than twice as likely as their Caucasian peers to have a smoke-free home (OR ⫽ 2.232, CI ⫽ 1.50, 3.33). However, no other ethnic group differed significantly from Caucasians. Income was consistently associated with home smoking rules. Those families with a higher income were less likely to endorse rules that only restricted smoking but were more likely to have a totally smoke-free home (OR ⫽ 1.880, CI ⫽ 1.33, 2.66). Education showed a similar trend, with those having a high school education or more being more likely to maintain a smoke-free home (OR ⫽ 1.338, CI ⫽ 1.08, 1.67) and those with less than a high school education being more likely to endorse rules that allow smoking in the home with restrictions. Former and never smokers were less likely than current smokers to endorse rules that allowed smoking in their home. For instance, never smokers were more than five times less likely to endorse allowing adults to smoke in their home (OR ⫽

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0.194, CI ⫽ 0.14, 0.26). In addition, both former smokers (OR ⫽ 3.390, CI ⫽ 2.44, 4.71) and never smokers (OR ⫽ 4.180, CI ⫽ 3.24, 5.40) were almost four times as likely as current smokers to have a completely smoke-free home. Having more smokers in the home was related to an increased likelihood of endorsing rules allowing restricted smoking. In particular, having more household members who smoke was related to an increased likelihood of allowing only adults to smoke (OR ⫽ 2.477, CI ⫽ 2.15, 2.86), allowing adults to smoke in certain rooms or at certain times (OR ⫽ 2.095, CI ⫽ 1.83, 2.40), and allowing adults to smoke, but not around young children (OR ⫽ 2.895, CI ⫽ 2.50, 3.35). Similarly, having more smokers in the home was associated with a decreased likelihood that the family requires people to smoke outside (OR ⫽ 0.898, CI ⫽ 0.81, 1.00) or has an entirely smoke-free home (OR ⫽ 0.383, CI ⫽ 0.33, 0.44). Similar trends were found for those who reported having a spouse who smokes. The total number of people in the home (regardless of their smoking status) was not associated with home smoking rules other than a rule allowing adults to smoke, but not around young children (OR ⫽ 1.076, CI ⫽ 1.02, 1.12). Having had a pediatrician discuss the health hazards of smoking in the presence of children was significantly associated with limiting ETS exposure but not with having a smoke-free home. Pediatric intervention was associated with allowing only adults to smoke (OR ⫽ 1.888, CI ⫽ 1.43, 2.49), allowing adults to smoke in certain rooms or at certain times (OR ⫽ 1.803, CI ⫽ 1.37, 2.37), and allowing adults to smoke, but not around young children (OR ⫽ 1.902, CI ⫽ 1.49, 2.43). Factors Related to Rules Outside the Home Figure 2 presents the frequency of endorsement of smoking rules outside the home. Less than half of the participants

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Table 3 Factors Related to Family Rules in the Home Regarding Exposure to ETS Rules in the home

Predictor Ethnicity pa Caucasian African American OR CI Hispanic OR CI Asian American OR CI Other OR CI Income p Under $41,000/yr $41,000/yr or more OR CI Education p Less than high school High school graduate or more OR CI Smoking status p Current smoker Former smoker OR CI Never smoker OR CI Reported having a spouse who smokes p OR CI No. household members who smoke p OR CI

Only adults are allowed to smoke ⬍.001 1.000

Adults can smoke in certain rooms or at certain times .005 1.000

Adults can smoke, but not around young children .070 1.000

Ask people to smoke No smoking outside, not is allowed in the house in the home .153 1.000

⬍.001 1.000

0.617* 0.40, 0.95

0.612* 0.40, 0.94

1.489 0.97, 2.28

0.930 0.63, 1.36

1.052 0.71, 1.55

0.405** 0.26, 0.63

0.526* 0.34, 0.82

1.191 0.77, 1.83

1.092 0.74, 1.61

2.232** 1.50, 3.33

0.285* 0.12, 0.69

0.258* 0.10, 0.66

0.884 0.43, 1.80

0.556 0.30, 1.03

1.604 0.84, 3.07

0.649 0.36, 1.19 ⬍.009 1.000

0.892 0.50, 1.60 .047 1.000

0.920 0.51, 1.67 .001 1.000

1.033 0.61, 1.75 .001 1.000

1.509 0.88, 2.60 .001 1.000

0.578* 0.37, 0.89 .001

0.668* 0.44, 1.01 .003

0.419** 0.29, 0.61 .001

1.832** 1.32, 2.55 .114

1.880** 1.33, 2.66 .009

1.000

1.000

1.000

1.000

1.000

0.621** 0.48, 0.80 .001 1.000

0.681* 0.53, 0.88 .001 1.000

0.572** 0.46, 0.71 .001 1.000

1.190 0.96, 1.48 .439 1.000

1.338* 1.08, 1.67 .001 1.000

0.342** 0.24, 0.49

0.281** 0.20, 0.41

0.266** 0.19, 0.37

1.120 0.82, 1.53

3.390** 2.44, 4.71

0.194** 0.14, 0.26

0.209** 0.16, 0.27

0.216** 0.17, 0.28

1.262 0.92, 1.49

4.18** 3.24, 5.40

.001 3.514** 2.72, 4.55

.001 3.122** 2.42, 4.03

.001 4.575** 3.60, 5.82

.722 1.043 0.83, 1.31

.001 0.320** 0.25, 0.41

.001 2.477** 2.15, 2.86

.001 2.095** 1.83, 2.40

.001 2.895** 2.50, 3.35

.040 .898* 0.81, 1.00

.001 0.383** 0.33, 0.44

HOME SMOKING RULES

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Table 3 (Continued) Rules in the home

Predictor Pediatrician has discussed health hazards of ETS p OR CI No. people in the home p OR CI

Adults can smoke in Only adults certain rooms are allowed or at certain to smoke times

Adults can smoke, but not around young children

Ask people to smoke No smoking outside, not is allowed in the house in the home

.001 1.888** 1.43, 2.49

.001 1.803** 1.37, 2.37

.001 1.902** 1.49, 2.43

.057 1.265 0.99, 1.61

.291 0.876 0.69, 1.12

.971 0.999 0.96, 1.05

.898 1.003 0.96, 1.05

.001 1.076** 1.03, 1.12

1.000 1.000 0.96, 1.04

.075 0.967 0.93, 1.00

Note. The referent group is designated by an OR of 1.000. Outcomes were coded as 1 ⫽ yes, 0 ⫽ no. ETS ⫽ environmental tobacco smoke; OR ⫽ odds ratio; CI ⫽ confidence interval; yr ⫽ year. a Income level and ethnicity were included as covariates. * p ⬍ .05. ** p ⬍ .001.

forbid smoking in their car or usually sit in the nonsmoking section of restaurants. Less than 30.0% sit in the nonsmoking section of trains, whereas nearly 40.0% ask others to not smoke around their children. Approximately 60.0% of respondents disallow smoking around young children or infants. Table 4 presents the ORs and CIs for logistic regression analyses examining predictors of family rules outside the home. Analyses involving ethnicity were adjusted for income level and education. Compared with Caucasian participants, Asian Americans (OR ⫽ 0.359, CI ⫽ 0.19, 0.69) reported being much less likely to choose the nonsmoking section of restaurants. African Americans and Hispanics were more likely to ask people not to smoke in the presence of their children (African Americans, OR ⫽ 1.642, CI ⫽ 1.11, 2.44; Asian Americans, OR ⫽ 1.775, CI ⫽ 1.19, 2.65). Higher education and income were found to be associated with restricting smoking in the car (education, OR ⫽ 1.564, CI ⫽ 1.26, 1.95; income, OR ⫽ 2.058, CI ⫽ 1.50, 2.83), sitting in the nonsmoking section of restaurants (education, OR ⫽ 2.119,

CI ⫽ 1.69, 2.66; income, OR ⫽ 2.345, CI ⫽ 1.70, 3.23), and sitting in the nonsmoking section of trains (education, OR ⫽ 2.000, CI ⫽ 1.53, 2.61; income, OR ⫽ 2.346, CI ⫽ 1.71, 3.21). Although there was no association between smoking status and having a smokefree car, smoking status was associated with all other rules outside the home. Both former and never smokers were more likely than their currently smoking peers to sit in the nonsmoking section of restaurants (former smokers, OR ⫽ 1.636, CI ⫽ 1.19, 2.25; never smokers, OR ⫽ 1.452, CI ⫽ 1.13, 1.86) and trains (former smokers, OR ⫽ 2.450, CI ⫽ 1.68, 3.58; never smokers, OR ⫽ 2.264, CI ⫽ 1.66, 3.10). Former smokers (OR ⫽ 2.462, CI ⫽ 1.75, 3.47) and never smokers (OR ⫽ 2.398, CI ⫽ 1.82, 3.16) were also more likely than their smoking peers to ask people not to smoke in the presence of their children. Having more smokers in the home was associated with failing to choose the nonsmoking section of restaurants (OR ⫽ 0.754, CI ⫽ 0.67, 0.85) and trains (OR ⫽ 0.616, CI ⫽ 0.53, 0.72). Choosing not to ask people to smoke out of the presence of chil-

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Figure 2. Smoking rules outside the home stratified by ethnicity.

dren was related to the number of smokers in the home (OR ⫽ 0.710, CI ⫽ 0.62, 0.81) as well as the presence of a spouse who smokes (OR ⫽ 0.695, CI ⫽ 0.55, 0.89). The number of people in the home (regardless of their smoking status) was only associ-

ated with not having a smoke-free car (OR ⫽ 0.950, CI ⫽ 0.91, 0.99). Pediatric intervention regarding the health hazards of ETS was also associated with an increased likelihood of limiting exposure outside of the home in terms of hav-

HOME SMOKING RULES

ing a smoke-free car (OR ⫽ 1.389, CI ⫽ 0.84, 1.03), sitting in the nonsmoking section of trains (OR ⫽ 1.321, CI ⫽ 1.02, 1.72), asking people not to smoke in the presence of children (OR ⫽ 1.327, CI ⫽ 1.04, 1.69), and not smoking around small children or infants (OR ⫽ 1.615, CI ⫽ 1.25, 2.08). DISCUSSION This study examines family rules regarding exposure to ETS both within the home and in enclosed areas outside the home in a large, ethnically diverse sample from New Jersey and New York. Unfortunately, 40.0% of homes and more than 50.0% of family cars likely expose children to ETS, a Class A carcinogen. Fewer than half of the parents consistently choose to sit in the smoke-free section of restaurants and trains, and less than half of parents ask others not to smoke in the presence of their children. Families that were from an ethnic minority background, were less educated, and were poorer were the most likely to have rules that increase the likelihood their children will be exposed to ETS. It is not surprising that both the smoking status of the parent and the number of smokers in the home also increased the likelihood of children being exposed to ETS at home and in enclosed spaces outside the home. Clearly, public health efforts designed to help parents protect their children from ETS should be bolstered. The percentage of smoke-free homes found in this study (60.0%) was considerably less than that found for homes in California (73.7%; Gilpin et al., 2002). This is likely due to the fact that both low-income and minority ethnic status were overrepresented in this population. However, given that the California survey targeted a representative sample of all California homes, whereas this study targeted parents, the results are unfortunate. The rate of parents allowing smoking in their family cars is even more disturbing. Whereas 66.0% of Californians (Norman et al., 1999) and 77.0% of Australians (Walsh et al., 2002)

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were found to ban smoking in their cars in previous surveys, less than 50.0% of participants in this study ban smoking in their car. Thus, a large percentage of children from homes represented in this study are likely exposed to ETS both at home and in the family car. This study adds to the current literature by examining whether children are exposed to ETS in other important venues, such as in restaurants and trains. Regardless of ethnic background or the smoking status of the parent, few families attempt to protect their children from ETS in these settings. In fact, less than 40.0% of all respondents ask others not to smoke around their children. Thus, this research suggests that public health efforts to ban smoking in public, enclosed spaces is needed to protect children from ETS. Otherwise, most children will be exposed to tobacco smoke and will be at risk for diseases caused by ETS. Limitations to the current study exist. For instance, the survey was a self-report, and responses were limited by social desirability. Furthermore, the survey was administered to parents and guardians who were bringing their children to the pediatrician mostly because of illness. Because it is known that exposure to ETS contributes to a variety of illnesses in children (DiFranza & Lew, 1996), it is possible that the children being seen in a clinic are there because of their high exposure to ETS, which could account for the low rates of endorsement of rules. Participants’ answers and their recall of pediatric intervention might have been influenced by the type of illness (e.g., respiratory) the child was experiencing, and data were not collected regarding this. Although the sample may not be reflective of the population of parents as a whole, it is likely representative of those parents physicians are most likely to treat and be able to influence. Another possible limitation is the survey instrument used. Because of the nature of the setting and participants (e.g., the survey was administered to low-income pa-

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Table 4 Family Rules Outside the Home Regarding Exposure to ETS Rules outside the home

Predictor Ethnicity pa Caucasian African American OR CI Hispanic OR CI Asian American OR CI Other OR CI Income p Under $41,000/yr $41,000/yr or more OR CI Education p Less than high school High school graduate or more OR CI Smoking status p Current smoker Former smoker OR CI Never smoker OR CI Spouse who smokes p OR CI No. household members who smoke p OR CI

No smoking allowed in the car .126 1.000

Usually sit in nonsmoking section of restaurants .036 1.000

Sit in nonsmoking section of train .135 1.000

Ask people not to smoke in the presence of my children .021 1.000

Do not smoke around small children or infants .118 1.000

1.080 0.74, 1.58

0.841 0.57, 1.23

0.730 0.49, 1.08

1.643* 1.11, 2.44

1.078 0.74, 1.58

1.258 0.86, 1.85

0.755 0.51, 1.11

0.738 0.50, 1.10

1.775* 1.19, 2.65

1.142 0.78, 1.58

0.717 0.39, 1.34

0.359* 0.19, 0.69

0.479 0.24, 0.95

0.909 0.47, 1.76

0.588 0.32, 1.09

0.818 0.48, 1.38 .001 1.000

0.808 0.48, 1.37 .001 1.000

0.579 0.30, 0.94 .001 1.000

1.571 0.92, 2.68 .340 1.000

0.819 0.49, 1.38 .442 1.000

2.058** 1.50, 2.83 .001

2.345** 1.70, 3.23 .001

2.346** 1.71, 3.21 .001

1.164 0.85, 1.59 .001

1.132 0.82, 1.56 .305

1.000

1.000

1.000

1.000

1.000

1.564** 1.26, 1.95 .173 1.000

2.119** 1.69, 2.66 .003 1.000

2.000** 1.53, 2.61 .001 1.000

1.492* 1.19, 1.88 .001 1.000

1.121 0.90, 1.40 .001 1.000

1.343 0.98, 1.84

1.636* 1.19, 2.25

2.450** 1.68, 3.58

2.462** 1.75, 3.47

0.508** 0.36, 0.71

1.099 0.86, 1.40

1.452* 1.13, 1.86

2.264** 1.66, 3.10

2.398** 1.82, 3.16

0.403** 0.31, 0.53

.925 0.989 0.79, 1.25

.270 0.878 0.70, 1.11

.016 0.725 0.56, 0.95

.003 0.695* 0.55, 0.89

.001 2.578** 1.99, 3.34

.154 0.928 0.84, 1.03

.001 0.754** 0.67, 0.85

.001 0.616** 0.53, 0.72

.001 0.710** 0.62, 0.81

.001 1.760 1.53, 2.02

HOME SMOKING RULES

15

Table 4 (Continued) Rules outside the home

Predictor Pediatrician has discussed health hazards of ETS p OR CI No. people in the home p OR CI

No smoking allowed in the car

Usually sit in Sit in Ask people not Do not smoke nonsmoking nonsmoking to smoke in around small section of section of the presence children or restaurants train of my children infants

.007 1.389* 1.09, 1.77

.137 1.200 0.94, 1.53

.039 1.321* 1.02, 1.72

.023 1.327* 1.04, 1.69

.001 1.615** 1.25, 2.08

.010 0.950* 0.91, 0.99

.001 0.911 0.87, 0.95

.001 0.924 0.88, 0.97

.020 0.953 0.91, 0.99

.056 0.964 0.93, 1.00

Note The referent group is designated by an OR of 1.000. Outcomes were coded as 1 ⫽ yes, 0 ⫽ no. ETS ⫽ environmental tobacco smoke; OR ⫽ odds ratio; CI ⫽ confidence interval; yr ⫽ year. a Income level and ethnicity were included as covariates. * p ⬍ .05. ** p ⬍ .001.

tients in pediatric clinics), it was not possible to recontact participants to establish consistency reliability. Also, because the items were not thought to be measuring one latent factor, internal consistency reliability was not determined. However, given the strong theoretical and empirical background of the items and the large sample used in the study, we are convinced that the data are a useful reflection of how parents establish rules about tobacco exposure for their family. In summary, a large proportion of family rules regarding exposure to ETS allow the children to be exposed to tobacco smoke. The results identify the positive impact physician intervention can have on family rules regarding ETS, which highlights the importance of family physicians and pediatricians educating parents about the hazards of ETS and methods to minimize their children’s exposure to this important health threat. REFERENCES American Academy of Pediatrics Committee on Adolescence. (1987). Tobacco use by children and adolescents. Pediatrics, 79, 479 – 481. American Medical Association. (1994). Ameri-

can Medical Association guidelines for adolescent preventive services (GAPS). Baltimore: Williams and Wilkins. Anderson, H., & Cook, D. (1997). Passive smoking and sudden infant death syndrome: Review of the epidemiological evidence. Thorax, 52, 1003–1009. Ashley, M., Cohen, J., Ferrence R., Bull, S., Bondy, S., Poland, B., & Pederson, L. (1998). Smoking in the home: Changing attitudes and current practices. American Journal of Public Health, 88, 797– 800. Borland, R., Mullins, R., Trotter, L., & White, V. (1999). Trends in environmental tobacco smoke restrictions in the home in Victoria, Australia. Tobacco Control, 8, 266 –271. Brownson, R., Eriksen, M., Davis, R., & Warner, K. (1997). Environmental tobacco smoke: Health effects and policies to reduce exposure. Annual Review of Public Health, 18, 163–185. DiFranza, J., & Lew, R. (1996). Morbidity and mortality in children associated with the use of tobacco products by other people. Pediatrics, 97, 560 –568. Farkas, A. J., Gilpin, E. A., Distefan, J. M., & Pierce, J. P. (1999). The effects of home smoking restrictions on quitting behaviours. Tobacco Control, 8, 261–265. Gilpin, E., Farkas, A., Emery S., Ake, C., & Pierce, J. (2002). Clean indoor air: Advances in California, 1990 –1999. American Journal of Public Health, 92, 785–792. Gilpin, E., White, M., Farkas A., & Pierce, J.

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(1999). Home smoking restrictions: Which smokers have them and how they are associated with smoking behavior? Nicotine and Tobacco Research, 1, 153–162. Haddock, C. K., Pyle, S. A., Hymowitz, N., Schwab, J. & Burd, K. (in press). Which pediatric residents assist and arrange follow-up for patients and parents who use tobacco? Journal of Adolescent Health. He, J., Vupputuri, S., Allen S., Prerost, M., Hughes, J., & Whelton, P. (1999). Passive smoking and the risk of coronary heart disease—a meta-analysis of epidemiological studies. New England Journal of Medicine, 340, 920 –926. Hymowitz, N., Schwab, J., & Eckholdt, H. (2001). Pediatric residency training on tobacco. Pediatrics, 108, E8. Retrieved April, 12, 2004, from http//www.pediatrics.org/cgi/ content/full/108/1e8 Hymowitz, N., Schwab, J., Haddock, C. K., Burd, K. M., & Pyle, S. (2004). The Pediatric Residency Training on Tobacco Project: Baseline findings from the resident tobacco survey and observed structured clinical observations. Preventive Medicine, 39, 507–516. Hymowitz, N., Schwab, J., Haddock, C. K., Pyle, S. A. & Meshberg, S. (in press). The Pediatric Resident Training on Tobacco Project: Baseline findings from the patient tobacco survey. Preventive Medicine. Hymowitz, N., Schwab, J., Haddock, C. K., Pyle, S. A., Moore, G., & Meshberg, S. (in press). The Pediatric Resident Training on Tobacco Project: Baseline findings from the parent/ guardian tobacco survey. Preventive Medicine.

Hymowitz, N., Schwab, M., McNerney, C., Schwab, J., Eckholdt, H., & Haddock, K. (2003). Postpartum relapse to cigarette smoking in inner city women. Journal of the National Medical Association, 95, 461– 474. Norman, G., Ribisl, K., Howard-Pitney, B., & Howard, K. (1999). Smoking bans in the home and car: Do those that need them have them? Preventive Medicine, 29, 581–589. Stoddard, J., & Gray, B. (1997). Maternal smoking and medical expenditures for childhood respiratory illness. American Journal of Public Health, 87, 205–209. U.S. Census Bureau. (2001). Income 2001. Retrieved June 26, 2003, from http://www .census.gov/hhes/income/income01/inctab1 .html U.S. Environmental Protection Agency. (1993). Respiratory health effects of passive smoking: Lung cancer and other disorders (NIH Publication No. 93–3605). Washington, DC: U.S. Environmental Protection Agency and the National Institutes of Health. Walsh, R., Tzelepis, F., Paul, C., & McKenzie, J. (2002). Environmental tobacco smoke in homes, motor vehicles and licensed premises: Community attitudes and practices. Australian and New Zealand Journal of Public Health, 26, 536 –542. World Health Organization. (1999). Tobacco free initiative. International consultation on environmental tobacco smoke (ETS) and child health. Geneva, Switzerland: Author. Zhou, R., Li, S., Zhou, Y., & Haug, A. (2000). Comparison of environmental tobacco smoke concentrations and mutagenicity for several indoor environments. Mutation Research, 465, 191–200.