The behavioral ecology of secondhand smoke exposure: A pathway to complete tobacco control

Perceptions of Barriers and Facilitators to Reducing Exposure to Secondhand Smoke in the Home: A Qualitative Study With Palestinian-Arab Women in Israel

INTRODUCTION

Smoking is a collective and complex problem in the Palestinian-Arab community in Israel, where women and children are particularly vulnerable to exposure to secondhand smoke (SHS), especially in the home.

AIMS AND METHODS

We undertook this study to better understand women's experiences with SHS exposure in the home and to identify pathways for intervention. Using the grounded theory approach, seven focus groups were conducted with 66 women in different localities across Israel. Purposive and snowball sampling techniques were applied to recruit women who have currently or previously been exposed to smoking in the home. Focus groups were audio-recorded and transcribed verbatim, and data were then coded and analyzed using the constant comparison analysis method to identify emergent themes and subthemes.

RESULTS

Three core themes emerged from the discussions. These include women's perceptions of smoking among men and exposure to SHS in the home, the implications of smoking on spousal and social relationships, and the women's experiences in coping with this situation and their suggestions for interventions. We identified additional sub-themes, including the consequences to women's and children's health, as well as the complex interaction between smoking in the home and women's social position, agency, and home ownership.

CONCLUSIONS

Women exposed to SHS in the home experience consequences that affect their health and their spousal and social relationships. They also face several personal and societal challenges in tackling this issue. Culturally tailored interventions targeting both communities and households can raise awareness and impact smoking behaviors in the home.

IMPLICATIONS

The findings of this study demonstrate the far-reaching consequences of SHS exposure in the home among women who are exposed. The findings contribute to our understanding of smoking contingencies among men and smoking behaviors in the home. This study lays the groundwork for future community and household-based research and interventions. We suggest several critical junctures that may increase response to smoking cessation interventions and to reduce smoking in the home, such as at the time of marriage when the home policy is set, and the adverse effects of exposure on children and other family members, especially those with illness.

Associations of childhood and current secondhand smoke exposure at home with current secondhand smoke exposure at work: A cross-sectional analysis of the Singapore multi-ethnic cohort

INTRODUCTION

Relationships between secondhand smoke exposure (SHSE) in various temporal and physical settings are not fully studied despite its adverse impacts on human health, especially in multi-ethnic Asian populations. We investigated associations of childhood and current SHSE at home (SHSEhome) with current SHSE at work (SHSEwork) in Singapore and its relation to sources of daily smokers at home.

METHODS

This cross-sectional study identified 925 healthy, never smoker working adults from the Singapore Multi-Ethnic Cohort (2004-2010). Firstly, the multiple logistic regression model estimated the adjusted odds ratios (AORs) of SHSEhome. Subsequently, sources of daily smokers entered through an additional model building process using the former as a base.

RESULTS

Current adults (AOR=2.05; 95% CI: 1.28-3.29) and childhood SHSEhome (AOR=1.43; 95% CI: 0.93-2.19) had a positive and no association with current SHSEwork, respectively. These findings persisted when smoker identity-related variables entered the model: child (AOR=3.56; 95% CI: 1.19-10.64) for current daily smokers; father (AOR=2.30; 95% CI: 0.94-5.64) and sibling (AOR=2.97; 95% CI: 1.55-5.68) for childhood. Compared to no childhood SHSEhome, only those living with their fathers and siblings who smoked daily at home had significantly higher odds of reporting current SHSEwork (AOR=3.70; 95% CI: 1.88-7.30).

CONCLUSIONS

Current SHSEhome was a risk factor for current SHSEwork, with risks elevated among those who smoke daily at home and living with their children. Childhood SHSEhome becomes a risk factor when daily household smokers include fathers and siblings. Deformalizing smoking could consider interpersonal dynamics of daily smokers at home with family members in different temporal settings, to reduce SHSEwork.

Validation and Psychometric Properties of the Tobacco Urge Management Scale (TUMS)

BACKGROUND

During quit attempts, smokers must overcome smoking urges triggered by environmental cues and nicotine withdrawal symptoms. This study investigates the psychometric properties of the 12-item Tobacco Urge Management Scale (TUMS), a new measure of smoking urge management behaviors.

METHODS

We analyzed secondary data (n = 327) from a behavioral smoking cessation intervention trial, Kids Safe and Smokefree (KiSS).

RESULTS

Confirmatory factor analysis of the TUMS indicated that a one-factor model and a correlated two-factor model had similar model fit indices, and a Chi-square difference test supported the one-factor model. Further study of the parsimonious one-factor scale provided evidence of reliability and construct validity. Known group validity was evidenced by significantly higher TUMS scores in the KiSS intervention arm receiving urge management skills training than in the control arm (p < 0.001). Concurrent validity was evidenced by TUMS's inverse association with cigarettes smoked per day and positive associations with nonsmoking days, 7-day abstinence, and self-efficacy to control smoking behaviors (p's < 0.05).

CONCLUSION

The TUMS is a reliable, valid measure of smoking urge management behaviors. The measure can support theory-driven research on smoking-specific coping mechanisms, inform clinical practice by identifying coping strategies that might be under-utilized in treatment-seeking smokers, and function as a measure of treatment adherence in cessation trials that target urge management behaviors.

Higher blood cotinine level is associated with worse cognitive functioning in non-smoking older adults

Introduction

Secondhand smoke (SHS) is common in older adults; however, its cognitive effect is unclear. We aimed to examine the association between serum cotinine level and cognitive functioning among non-smoking older adults.

Materials and methods

A total of 2,703 older adults aged 60 and above from the National Health and Nutrition Examination (NHANES) Survey 2011-2014 were included. Serum cotinine level was analyzed in the laboratory. A level ≤10 ng/ml and a response of "no" to the question "Do you currently smoke?" were used to select non-smokers. Cognitive functioning was measured using the Consortium to Establish a Registry for Alzheimer's disease Word Learning subtest (CERAD-WL) immediate and delayed recall tests, the Animal Fluency test (AFT), and the Digit Symbol Substitution test (DSST). Multivariable linear regression models were constructed to examine the association between serum cotinine level quartile and test-specific and global cognition z scores adjusting for age, race/ethnicity, education, depressive symptoms, body mass index, alcohol use, smoking history, prevalent coronary heart disease (CHD), stroke, and systolic blood pressure.

Results

About half of the participants (mean age 70.5 years) were female (53.6%), non-Hispanic White (48.3%), and completed some college and above (50.2%). Multivariate linear regressions with a reference group being those in the 1st quantile (lowest) showed that participants in the 4th quartile (highest) of serum cotinine level had lower immediate recall [β = -0.16, 95% confidence interval (CI) = -0.29, -0.03], AFT (β = -0.19, 95% CI = -0.33, -0.05), DSST (β = -0.27, 95% CI = -0.39, -0.15), and global cognition (β = -0.26, 95% CI = -0.39, -0.14) z scores. Participants in the 3rd quartile had lower immediate recall (β = -0.16, 95% CI = -0.30, -0.02) and global cognition (β = -0.16, 95% CI = -0.29, -0.02) z scores. Participants in the 2nd quartile had lower delayed recall z scores (β = -0.16, 95% CI = -0.29, -0.02).

Conclusion

Higher serum cotinine level was associated with worse cognitive functioning in non-smoking older adults. Prevention and reduction of SHS in older adults may help protect their cognitive functioning.

Multilevel Intervention for Low-Income Maternal Smokers in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

Objectives. To test the efficacy of Babies Living Safe and Smokefree (BLiSS), a multilevel intervention initiated in a citywide safety net health system to improve low-income maternal smokers' abstinence and reduce child tobacco smoke exposure. Methods. This randomized controlled trial in Philadelphia, Pennsylvania (2015-2020), recruited low-income maternal smokers who received a brief smoking intervention (Ask, Advise, Refer [AAR]) from nutrition professionals in the Special Supplemental Nutrition Program for Women, Infants, and Children before randomization to (1) a multilevel intervention (AAR + multimodal behavioral intervention [MBI]; n = 199) or (2) an attention control intervention (AAR + control; n = 197). Results. AAR + MBI mothers had significantly higher 12-month bioverified abstinence rates than did AAR + control mothers (odds ratio [OR] = 9.55; 95% confidence interval [CI] = 1.54, 59.30; P = .015). There were significant effects of time (b = -0.15; SE = 0.04; P < .001) and condition by time (b = -0.19; SE = 0.06; P < .001) on reported child exposure favoring AAR + MBI, but no group difference in child cotinine. Presence of other residential smokers was related to higher exposure. Higher baseline nicotine dependence was related to higher child exposure and lower abstinence likelihood at follow-up. Conclusions. The multilevel BLiSS intervention was acceptable and efficacious in a population that experiences elevated challenges with cessation. Public Health Implications. BLiSS is a translatable intervention model that can successfully improve efforts to address the persistent tobacco-related burdens in low-income communities. Trial Registration. Clinical Trials.gov identifier: NCT02602288. (Am J Public Health. 2022;112(3):472-481. https://doi.org/10.2105/AJPH.2021.306601).

Smoke-Free Air Interventions in Seven Latin American Countries: Health and Financial Impact to Inform Evidence-Based Policy Implementation

INTRODUCTION

Disease burden due to tobacco smoking in Latin America remains very high. The objective of this study was to evaluate the potential impact of implementing smoke-free air interventions on health and cost outcomes in Argentina, Bolivia, Brazil, Chile, Colombia, Mexico, and Peru, using a mathematical model.

AIMS AND METHODS

We built a probabilistic Monte Carlo microsimulation model, considering natural history, direct health system costs, and quality of life impairment associated with main tobacco-related diseases. We followed individuals in hypothetical cohorts and calculated health outcomes on an annual basis to obtain aggregated 10-year population health outcomes (deaths and events) and costs. To populate the model, we completed an overview and systematic review of the literature. Also, we calibrated the model comparing the predicted disease-specific mortality rates with those coming from local national statistics.

RESULTS

With current policies, for the next 10 years, a total of 137 121 deaths and 917 210 events could be averted, adding 3.84 million years of healthy life and saving USD 9.2 billion in these seven countries. If countries fully implemented smoke-free air strategies, it would be possible to avert nearly 180 000 premature deaths and 1.2 million events, adding 5 million healthy years of life and saving USD 13.1 billion in direct healthcare.

CONCLUSIONS

Implementing the smoke-free air strategy would substantially reduce deaths, diseases, and health care costs attributed to smoking. Latin American countries should not delay the full implementation of this strategy.

IMPLICATIONS

Tobacco smoking is the single most preventable and premature mortality cause in the world. The Framework Convention on Tobacco Control, supported by the World Health Organization, introduced a package of evidence-based measures for tobacco control. This study adds quality evidence on the potential health effects and savings of implementing smoke-free air policies in countries representing almost 80% of the Latin America and the Caribbean population.

'Just Drive': An Employee-Based Intervention to Reduce Distracted Driving

Distracted driving is a major danger on today's roadways. Employers play a critical role in developing distracted driving policies and promoting a culture of workplace driving safety. The purpose of this study was to evaluate the effectiveness of an in-person work-based class to reduce distracted driving in participating employees. The "Just Drive-Take Action Against Distraction" class was designed by the UC San Diego Training, Research and Education for Driving Safety (TREDS) program to increase awareness of the dangers of distracted driving and to encourage employees to be safe and responsible drivers, both on and off the job. Participants completed pre- and post-anonymous surveys and, in a subset of attendees, volunteers were contacted via email 3 months post-intervention to complete a driving-behavior survey on Surveymonkey.com. 115 classes for 6896 employees were delivered at 54 agencies in Southern California. A total of 4928 participants completed the pre- and post-survey; 2014 n = 2263 and 2015 n = 2665. The course was found useful (85%) and engaging (85.6%). For non-commercial drivers, 55.6% of participants reported an increase of 80-100% in awareness of the dangers of distracted driving, and 67.2% reported an increase of 80-100% in their motivation to change. For commercial drivers, 71.3% reported a motivation increase of 80-100%. There were significant increases in knowledge for both groups. In the three-month follow-up survey, participants identified multiple positive changes in distracted driving behavior. This 1-h employer-supported intervention demonstrated positive changes in short-term intention and medium-term behaviors.

Parents' Self-efficacy for Tobacco Exposure Protection and Smoking Abstinence Mediate Treatment Effects on Child Cotinine at 12-Month Follow-up: Mediation Results from the Kids Safe and Smokefree Trial

INTRODUCTION

Compared with the general smoking population, low-income smokers face elevated challenges to success in evidence-based smoking cessation treatment. Moreover, their children bear increased disease burden. Understanding behavioral mechanisms related to successful reduction of child tobacco smoke exposure (TSE) could inform future smoking interventions in vulnerable, underserved populations.

METHODS

Smoking parents were recruited from pediatric clinics in low-income communities and randomized into a multilevel intervention including a pediatric clinic intervention framed in best clinical practice guidelines ("Ask, Advise, Refer" [AAR]) plus individualized telephone counseling (AAR + counseling), or AAR + control. Mediation analysis included treatment condition (independent variable), 12-month child cotinine (TSE biomarker, criterion), and four mediators: 3-month end-of-treatment self-efficacy to protect children from TSE and smoking urge coping skills, and 12-month perceived program (intra-treatment) support and bioverified smoking abstinence. Analyses controlled for baseline nicotine dependence, depressive symptoms, child age, and presence of other residential smokers.

RESULTS

Participants (n = 327) included 83% women and 83% African Americans. Multilevel AAR + counseling was associated with significantly higher levels of all four mediators (ps < .05). Baseline nicotine dependence (p < .05), 3-month self-efficacy (p < .05) and 12-month bioverified smoking abstinence (p < .001) related significantly to 12-month child cotinine outcome. The indirect effects of AAR + counseling intervention on cotinine via self-efficacy for child TSE protection and smoking abstinence (ps < .05) suggested mediation through these pathways.

CONCLUSIONS

Compared with AAR + control, multilevel AAR + counseling improved all putative mediators. Findings suggest that fostering TSE protection self-efficacy during intervention and encouraging parental smoking abstinence may be key to promoting long-term child TSE-reduction in populations of smokers with elevated challenges to quitting smoking.

IMPLICATIONS

Pediatric harm reduction interventions to protect children of smokers from tobacco smoke have emerged to address tobacco-related health disparities in underserved populations. Low-income smokers experience greater tobacco-related disease burden and more difficulty with smoking behavior change in standard evidence-based interventions than the general population of smokers. Therefore, improving knowledge about putative behavioral mechanisms of smoking behavior change that results in lower child exposure risk could inform future intervention improvements.

Addressing Ethnic Disparities in Adolescent Smoking: Is Reducing Exposure to Smoking in the Home a Key?

INTRODUCTION

Smoking among New Zealand (NZ) adolescents has declined since 2000, but ethnic disparities remain pronounced. To inform prevention efforts, we investigated exposure to and relative importance of known predictors of adolescent smoking and how these have changed over time, for Māori (NZ's indigenous population) and adolescents overall.

METHODS

We used repeat cross-sectional data, 2003-2015, from a national survey of 14- to 15-year olds (N = 20 443-31 696 per year). For the overall sample and for Māori and non-Māori, we calculated adjusted odds ratios (aORs) to assess the association between regular smoking and risk factors each year: one or more parents smoke, best friend smokes, older sibling(s) smoke, and past week exposure to smoking in the home. We calculated population attributable risk (PAR) for risk factors in 2003 and 2015.

RESULTS

Between 2003 and 2015, aORs for exposure to smoking in the home increased from 1.7 (95% CI 1.6% to 1.8%) to 2.6 (2.1% to 3.1%) overall and from 1.8 (1.6% to 2.1%) to 3.4 (2.5% to 4.5%) for Māori; aORs for "best friend smokes" also increased, while aORs for sibling smoking and parental smoking did not change meaningfully. PAR for exposure to smoking in the home increased from 17% to 31% overall and from 28% to 57% for Māori, while PARs for other risk factors decreased.

CONCLUSIONS

Exposure to smoking in the home has become more strongly associated with adolescent smoking over time and is an increasingly important risk factor at the population level (independent of parental smoking), particularly for Māori.

IMPLICATIONS

Our findings have implications for reducing smoking uptake and ethnic disparities in NZ, and potentially elsewhere, given the similarity in risk factors and trends for adolescent smoking internationally. Our findings suggest that reducing second-hand smoke exposure in homes will likely reduce uptake of smoking. Because Māori children are both more exposed and appear to be more strongly influenced by exposure to smoking in the home, interventions to reduce indoor smoking could have differentially positive effects for Māori. Greater research and policy attention to reducing smoking in homes is warranted.

Long-term Results From the FRESH RCT: Sustained Reduction of Children's Tobacco Smoke Exposure

INTRODUCTION

Standard care interventions to reduce children's tobacco smoke exposure (TSE) may not be sufficient to promote behavior change in underserved populations. A previous study demonstrated the short-term efficacy of an experimental counseling intervention, Family Rules for Establishing Smokefree Homes (FRESH) compared with standard care on boosting low-income children's TSE reduction and maternal smoking at 16-week end of treatment (EOT). This study tested long-term posttreatment efficacy of this treatment through a 12-month follow-up.

STUDY DESIGN

This study was a two-arm RCT.

SETTING/PARTICIPANTS

Maternal smokers (n=300) not seeking cessation treatment were recruited from low-income, urban communities. Participants exposed their <4-year-old children to tobacco smoke daily. Data collection and analyses occurred from 2006 to 2018.

INTERVENTION

The FRESH behavioral intervention included 2 home visits and 7 phone sessions. FRESH used cognitive behavioral skills training, support, problem-solving, and positive social reinforcement to facilitate the adoption of increasingly challenging TSE-protection behaviors. No nicotine-replacement therapy or medication was provided.

MAIN OUTCOME MEASURES

Primary outcomes were child cotinine (TSE biomarker) and reported TSE from EOT through 12 months after treatment. A secondary outcome was bioverified maternal smoking cessation.

RESULTS

Compared with controls, children in FRESH had significantly lower cotinine (β= -0.31, p<0.01) and lower maternal-reported TSE (β= -1.48, p=0.001) through the 12-month follow-up. A significant effect of time (β= -0.03, p=0.003) reflected a posttreatment decrease in cotinine. There was no treatment × time interaction, suggesting the treatment effect at EOT was sustained after treatment. Compared with controls, FRESH mothers maintained significantly higher odds of quitting smoking from EOT through 12-month follow-up (OR=8.87, 95% CI=2.33, 33.75).

CONCLUSIONS

Study results with a sample of underserved maternal smokers demonstrated that the short-term effect of FRESH counseling at 16-week EOT was maintained through 12 months after treatment-for both bioverified child TSE reduction and maternal smoking cessation. Smokers in low-income communities demonstrate elevated challenges to success in standard smoking treatment. FRESH follow-up results suggest the high potential value of more-intensive behavioral intervention for vulnerable smokers.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02117947.

Self-efficacy as a pathway to long-term smoking cessation among low-income parents in the multilevel Kids Safe and Smokefree intervention

BACKGROUND

This study investigated the effects of a multi-level smoking intervention on mediators of long-term abstinence in parental smokers, including smoking cessation self-efficacy, smoking urge coping, and perceived support to quit smoking.

METHODS

This is a secondary analysis of data from a randomized trial that recruited parental smokers from pediatric clinics in low-income communities (N = 327, 83% women, 83% African American, 79% below poverty level). Following clinical practice guidelines for tobacco intervention ("Ask, Advise, Refer" [AAR]), pediatricians asked all parents about child tobacco smoke exposure (TSE), advised about TSE harms and benefits of reducing TSE, and referred smokers to cessation resources. Eligible parents were then randomized to additional telephone-based smoking behavior counseling (AAR + counseling) or nutrition education (AAR + control). Bioverified 7-day point prevalence smoking abstinence and perceived counselor support were assessed at 12-month follow-up; cessation self-efficacy and urge coping were assessed at 3-month follow-up.

RESULTS

Relative to AAR + control, AAR + counseling was associated with higher self-efficacy, urge coping, and perceived support to quit (all p's<.001). Self-efficacy, but no other mediators, had a significant positive effect on 12-month bioverified smoking abstinence (p < .001). The indirect effect of intervention on 12-month abstinence via self-efficacy suggested mediation via this pathway (p = .002).

CONCLUSION

Results suggest that all putative treatment pathways were improved more by the multi-level AAR + counseling than the clinic-level AAR + control intervention. Further, self-efficacy at end-of-treatment prospectively predicted long-term cessation, suggesting that building of self-efficacy through treatment may be key to sustained cessation.

Revealing users' experience and social interaction outcomes following a web-based smoking prevention intervention for adolescents: A qualitative study

BACKGROUND

Tobacco smoking remains a public health problem among adolescents in the United States. While Web-based interventions for smoking prevention have been successful at the individual level, there is still an urgent need to understand their engagement capabilities and their effects at the social level. In the current study, we aimed to (1) learn about adolescents' subjective experience with a Web-based program called a smoking prevention interactive experience (ASPIRE), (2) obtain suggestions for improvement in ASPIRE content, (3) identify psychological outcomes of ASPIRE, and (4) explore outcomes of social interaction.

MATERIALS AND METHODS

After a randomized controlled trial with 110 adolescents, 20 adolescent users of ASPIRE, aged 11-18, were randomly selected to participate in one-on-one interviews at four after-school programs in Houston, Texas. Interviews involved questions concerning adolescents' experience with the intervention. Qualitative data were coded and analyzed using a constant comparison approach for the generation of themes.

RESULTS

Describing their experience with ASPIRE, participants expressed comfort in material that is tailored to their demographic and preferred interactive activities over entertaining videos. Presenting suggestions for improvement, participants mainly reported the need to include gaming features into ASPIRE. Presenting psychological outcomes, they expressed emotional engagement in the program, shifts in attitudes and beliefs, and unwillingness to smoke. Finally, as outcomes of social interaction, participants reported engagement with others in discussions about tobacco and their need to hold smokers accountable for their actions.

CONCLUSIONS

Adolescents' reports moved from their individual experience with ASPIRE to their active interactions with family members and friends and their attempt to persuade others to quit smoking. Future Web-based programs for adolescents may be designed with tailoring and game play in mind, in order to provide mobilization skills and foster social interactions against smoking.

Perspectives of Chinese American smoker and nonsmoker household pairs about the creating smokefree living together program

BACKGROUND

Chinese men smoke at high rates, and this puts household members at risk for tobacco-related diseases. Culturally responsive interventions that provide education and support are needed to promote smokefree living and reduce smoke exposure, particularly for US immigrants who experience changes in smokefree social norms. This qualitative study examines perspectives of Chinese American smoker and nonsmoker household pairs in the Creating Smokefree Living Together program.

METHODS

Four focus groups were conducted with 30 Chinese American participants (15 smokers and 15 nonsmokers) who, in household pairs, completed smokefree education interventions of either brief or moderate intensity. Nearly three-quarters of the smokers continued to smoke after the intervention at the time of focus group participation. All smokers were male, and most household nonsmokers were female spouses. All participants had limited English proficiency. Focus group meetings were recorded, and the recordings were translated and transcribed. Transcripts and field notes were thematically analyzed.

RESULTS

The following themes, shared by smokers and nonsmokers across interventions, were identified: 1) there was a preference for dyadic and group interventions because of the support offered, 2) increased knowledge of the health harms of smoke exposure within a pair improved the nonsmoker's support for smokefree living, 3) learning communication strategies improved household relationships and assertiveness for smokefree environments, 4) biochemical feedback was useful but had short-term effects, and 5) project magnets provided cues to action.

CONCLUSIONS

Involving household partners is critical to smokefree interventions. Simple reminders at home appear to be more powerful than personal biochemical feedback of smoke exposure for sustaining motivation and engagement in ongoing behavioral changes within the household. Cancer 2018;124:1599-606. © 2018 American Cancer Society.

Impact of changes in home smoking bans on tobacco cessation among quitline callers

Home smoking bans may be an effective way to promote tobacco cessation among treatment seeking smokers. Few studies have examined this relationship in a quitline setting. Data were obtained from 14,296 adults who were enrolled in a state quitline between January 2011 and July 2016. This study investigated whether cessation rates varied by changes in home smoking ban implementation between enrollment and 7-month follow-up. The impact of changes in home smoking bans on cessation at follow-up was significantly modified by having other smokers living in the home at follow-up (P < 0.0001). Among callers who did not live with other smokers in the home, the highest odds ratio of 30-day cessation was for callers who reported bans at follow-up only (OR = 10.50, 95%CI: 8.00, 13.70), followed by callers who reported bans at both enrollment and follow-up (OR = 8.02, 95%CI: 6.27, 10.30) and callers who reported bans at enrollment only (OR = 2.06, 95% CI: 1.47, 2.89) compared with callers with no home smoking bans. When callers reported that they lived with other smokers in the home, the effect of home smoking bans on cessation was much smaller. Quitlines should support the implementation of home smoking bans as a part of callers' goal setting activities to achieve tobacco cessation.

Randomised controlled trial of real-time feedback and brief coaching to reduce indoor smoking

BACKGROUND

Previous secondhand smoke (SHS) reduction interventions have provided only delayed feedback on reported smoking behaviour, such as coaching, or presenting results from child cotinine assays or air particle counters.

DESIGN

This SHS reduction trial assigned families at random to brief coaching and continuous real-time feedback (intervention) or measurement-only (control) groups.

PARTICIPANTS

We enrolled 298 families with a resident tobacco smoker and a child under age 14.

INTERVENTION

We installed air particle monitors in all homes. For the intervention homes, immediate light and sound feedback was contingent on elevated indoor particle levels, and up to four coaching sessions used prompts and praise contingent on smoking outdoors. Mean intervention duration was 64 days.

MEASURES

The primary outcome was 'particle events' (PEs) which were patterns of air particle concentrations indicative of the occurrence of particle-generating behaviours such as smoking cigarettes or burning candles. Other measures included indoor air nicotine concentrations and participant reports of particle-generating behaviour.

RESULTS

PEs were significantly correlated with air nicotine levels (r=0.60) and reported indoor cigarette smoking (r=0.51). Interrupted time-series analyses showed an immediate intervention effect, with reduced PEs the day following intervention initiation. The trajectory of daily PEs over the intervention period declined significantly faster in intervention homes than in control homes. Pretest to post-test, air nicotine levels, cigarette smoking and e-cigarette use decreased more in intervention homes than in control homes.

CONCLUSIONS

Results suggest that real-time particle feedback and coaching contingencies reduced PEs generated by cigarette smoking and other sources.

TRIAL REGISTRATION NUMBER

NCT01634334; Post-results.

Facilitators and barriers to smoking cessation among minority men using the behavioral-ecological model and Behavior Change Wheel: A concept mapping study

Background and aim

Universal smoking cessation strategies are not always successful for minorities, among whom smoking is highly prevalent despite high intention to quit. This study identifies facilitators for smoking cessation, as perceived by minority male smokers, that can inform a culturally appropriate national plan for smoking prevention and cessation.

Methods

We conducted in 2013 a three-stage study among Arab minority male current and former smokers (ages 18–64) in Israel, among whom smoking is very high: first, a Concept Mapping (CM) study with 102 and 202 participants in the brainstorming, and sorting and rating phases respectively. Second, we assigned clusters identified in the CM study to contingency levels using the Behavioral Ecological Model (BEM). Third, we classified clusters into intervention functions and policies using the Behavior Change Wheel (BCW).

Findings

The CM study revealed 58 barriers and facilitators for smoking prevention and cessation that were sorted into 11 clusters by the participants. These clusters were analogous to four BEM level contingency of smoking (social, institutional, community and individual). We classified it into two main policy categories, based on the BCW: 1- restructuring the socio-political environment of smoking through affirmative government's policies towards Arab minority in Israel, and 2-developing a culturally appropriate plan for smoking cessation in Arab local authorities including: raising awareness about tobacco hazards; enforcing anti-smoking laws; strengthening community institutional action; providing smoking cessation services; considering raising prices for tobacco products, addressing psychological sources of smoking in Arab men.

Conclusions

Our study revealed barriers, facilitators and contingencies of smoking prevention and cessation with two main policy action items among the Arab minority in Israel: changing the socio-political environment of smoking, and developing a culturally appropriate smoking prevention and cessation national plan. Our study framework can inform policies and culturally appropriate interventions for smoking prevention and cessation in other minorities.

And She's Buying a Stairway to Health: Signs and Participant Factors Influencing Stair Ascent at a Public Airport

Several studies have demonstrated that point-of-choice prompts modestly increase stair use (i.e., incidental physical activity) in many public places, but evidence of effectiveness in airport settings is weak. Furthermore, evaluating the effects of past physical activity on stair use and on point-of-choice prompts to increase stair use is lacking. The purpose of this study was to evaluate the influence of sign prompts and participant factors including past physical activity on stair ascent in an airport setting. We used a quasi-experimental design, systematically introducing and removing sign prompts daily across 22 days at the San Diego International Airport. Intercept interviewers recruited stair and escalator ascenders (N = 1091; 33.0% interview refusal rate) of the only stairs/escalators providing access to Terminal 1 from the parking lot. A 13-item questionnaire about demographics, physical activity, health behavior, and contextual factors provided data not available in nearly all other stair use studies. We examined the effects of signs and self-reported covariates using multivariable logistic regression analyses, and tested whether physical activity and other covariates modified the intervention effect. Adjusting for all significant covariates, prompts increased the odds of stair use (odds ratio 3.67; p < .001). Past participation in vigorous physical activity increased the odds of stair use by 1.62 (p = 0.001). None of the covariates moderated the intervention effect. In conclusion, vigorous physical activity and correlates of physical activity were related to stair use in expected directions, but did not modify the effect of the intervention. This indicates that the effects of point-of-choice prompts are independent of past physical activity, making them effective interventions for active adults and the higher risk population of inactive adults. Signs can prompt stair use in an airport setting and might be employed at most public stairs to increase rates of incidental physical activity and contribute to overall improvements in population health.

Social Environmental Influences on Smoking and Cessation: Qualitative Perspectives Among Chinese-Speaking Smokers and Nonsmokers in California

This qualitative study examines the social environmental influences on smoking and cessation from the perspectives of Chinese smokers and household nonsmokers in California. Seven focus groups were conducted with 63 participants. Three culturally influenced levels of potential intervention emerged from constant comparative analysis. At the individual level, participants focused more on irritating odor than health harms of exposure and had inaccurate beliefs about harms of smoking and cessation. At the relational level, peers kept smokers connected to pro-smoking norms. There was conflict in the home about smoking and failed cessation, but smokers recognized the benefits of cessation for family harmony and children's health. Physicians encouraged cessation but this tended to be insufficient to prompt action unless a smoker felt ill. At the societal level, participants recognized changes in social acceptability and environmental regulation of smoking upon immigration. Better implementation of smokefree policies, plus culturally nuanced strategies for equipping both nonsmokers and smokers to become smokefree, are needed.

Kids Safe and Smokefree (KiSS) Multilevel Intervention to Reduce Child Tobacco Smoke Exposure: Long-Term Results of a Randomized Controlled Trial

BACKGROUND

Pediatricians following clinical practice guidelines for tobacco intervention (“Ask, Advise, and Refer” [AAR]) can motivate parents to reduce child tobacco smoke exposure (TSE). However, brief clinic interventions are unable to provide the more intensive, evidence-based behavioral treatments that facilitate the knowledge, skills, and confidence that parents need to both reduce child TSE and quit smoking. We hypothesized that a multilevel treatment model integrating pediatric clinic-level AAR with individual-level, telephone counseling would promote greater long-term (12-month) child TSE reduction and parent smoking cessation than clinic-level AAR alone.

METHODS

Pediatricians were trained to implement AAR with parents during clinic visits and reminded via prompts embedded in electronic health records. Following AAR, parents were randomized to intervention (AAR + counseling) or nutrition education attention control (AAR + control). Child TSE and parent quit status were bioverified.

RESULTS

Participants (n = 327) were 83% female, 83% African American, and 79% below the poverty level. Child TSE (urine cotinine) declined significantly in both conditions from baseline to 12 months (p = 0.001), with no between-group differences. The intervention had a statistically significant effect on 12-month bioverified quit status (p = 0.029): those in the intervention group were 2.47 times more likely to quit smoking than those in the control. Child age was negatively associated with 12-month log-cotinine (p = 0.01), whereas nicotine dependence was positively associated with 12-month log-cotinine levels (p = 0.001) and negatively associated with bioverified quit status (p = 0.006).

CONCLUSIONS

Pediatrician advice alone may be sufficient to increase parent protections of children from TSE. Integrating clinic-level intervention with more intensive individual-level smoking intervention is necessary to promote parent cessation.

Acrolein Exposure in Hookah Smokers and Non-Smokers Exposed to Hookah Tobacco Secondhand Smoke: Implications for Regulating Hookah Tobacco Products

Introduction

Acrolein is a highly ciliatoxic agent, a toxic respiratory irritant, a cardiotoxicant, and a possible carcinogen present in tobacco smoke including hookah tobacco.

Methods

105 hookah smokers and 103 non-smokers attended exclusively hookah smoking social events at either a hookah lounge or private home, and provided urine samples the morning of and the morning after the event. Samples were analyzed for 3-hydroxypropylmercapturic acid (3-HPMA), a metabolite of acrolein.

Results

Geometric mean (GM) urinary 3-HPMA levels in hookah smokers and non-smokers exposed to secondhand smoke (SHS) increased significantly, 1.41 times, 95% CI = 1.15 to 1.74 and 1.39 times, 95% CI = 1.16 to 1.67, respectively, following a hookah social event. The highest increase (1.68 times, 95% CI = 1.15 to 2.45; p = 0.007) in 3-HPMA post a hookah social event was among daily hookah smokers (GM, from 1991 pmol/mg to 3348 pmol/mg). Pre-to-post event change in urinary 3-HPMA was significantly positively correlated with pre-to-post event change in urinary cotinine among hookah smokers at either location of hookah event, (ρ = 0.359, p = 0.001), and among non-smokers in hookah lounges (ρ = 0.369, p = 0.012).

Conclusions

Hookah tobacco smoke is a source of acrolein exposure. Findings support regulating hookah tobacco products including reducing humectants and sugar additives, which are precursors of acrolein under certain pyrolysis conditions. We suggest posting health warning signs for indoor smoking in hookah lounges, and encouraging voluntary bans of smoking hookah tobacco in private homes.

Implications

Our study is the first to quantify the increase in acrolein exposure in hookah smokers and non-smokers exposed to exclusively hookah tobacco SHS at hookah social events in homes or hookah lounges. Our findings provide additional support for regulating hookah tobacco product content, protecting non-smokers' health by posting health warning signs for indoor smoking in hookah lounges, and encouraging home bans on hookah tobacco smoking to safeguard vulnerable residents.

Levels of Urine Cotinine from Hookah Smoking and Exposure to Hookah Tobacco Secondhand Smoke in Hookah Lounges and Homes

Background

Nicotine, an addictive drug, is present in all forms of tobacco products, including hookah tobacco, which is not yet regulated in the United States.

Objectives

This study aimed to investigate the uptake of nicotine in hookah smokers and non-smokers exposed to secondhand smoke (SHS) at indoor hookah social events in natural settings where hookah tobacco was smoked exclusively.

Patients and Methods

We quantified cotinine, a metabolite of nicotine, in the urine of 105 hookah smokers and 103 non-smokers. Participants provided spot urine samples the morning of and the morning after attending an indoor hookah-only smoking social event at a hookah lounge or in a private home.

Results

Following a social event where exclusively hookah tobacco was smoked, urinary cotinine levels increased significantly 8.5 times (geometric mean (GM): 16.0 ng/mg to 136.1 ng/mg) among hookah smokers, and 2.5 times (GM: 0.4 ng/mg to 1.0 ng/mg) among non-smokers exposed exclusively to hookah tobacco SHS. Among hookah smokers, the highest increase in urinary cotinine levels post a hookah event was found in occasional hookah smokers in which GM levels increased significantly 31.2 times post smoking (from 2.0 ng/mg to 62.3 ng/mg). Reported reasons for preference to smoke hookah at home by hookah smokers who attended a hookah social event in a private home included recreational purposes, socializing with friends and family, ‘Me’ time and relaxing at home, more comfortable to smoke hookah at home, owning a hookah and hookah tobacco, eating and drinking while smoking hookah, and saving money by smoking at home and not going to hookah lounges.

Conclusions

Hookah tobacco smoke is a source of substantial nicotine exposure. Our results call for protecting hookah smokers’ and non-smokers’ health by requiring accurate hookah tobacco labels, raising taxes on hookah tobacco, reducing the spread of hookah lounges, and encouraging voluntary bans on smoking hookah tobacco in private homes.

Minimal intervention delivered by 2-1-1 information and referral specialists promotes smoke-free homes among 2-1-1 callers: a Texas generalisation trial

Background

Replication of intervention research is reported infrequently, limiting what we know about external validity and generalisability. The Smoke Free Homes Program, a minimal intervention, increased home smoking bans by United Way 2-1-1 callers in randomised controlled trials in Atlanta, Georgia and North Carolina.

Objective

Test the programme's generalisability-external validity in a different context.

Methods

A randomised controlled trial (n=508) of English-speaking callers from smoking-discordant households (≥1 smoker and ≥1 non-smoker). 2-1-1 Texas/United Way HELPLINE call specialists serving the Texas Gulf Coast recruited callers and delivered three mailings and one coaching call, supported by an online tracking system. Data collectors, blind to study assignment, conducted telephone interviews 3 and 6 months postbaseline.

Results

At 3 months, more intervention households reported a smoke-free home (46.6% vs 25.4%, p<0.0001; growth model intent-to-treat OR=1.48, 95% CI 1.241 to 1.772, p<0.0001). At 6 months, self-reported full bans were 62.9% for intervention participants and 38.4% for controls (OR=2.19). Texas trial participants were predominantly women (83%), single-smoker households (76%) and African-American (65%); half had incomes ≤US$10 000/year (50%). Texas recruitment was <50% of the other sites. Fewer callers reported having a smoker in the household. Almost twice the callers with a household smoker declined interest in the programme/study.

Conclusions

Our findings in a region with lower smoking rates and more diverse callers, including English-speaking Latinos, support programme generalisability and convey evidence of external validity. Our recruitment experience indicates that site-specific adjustments might improve recruitment efficiency and reach.

Trial registration number

NCT02097914, Results.

An Office-Initiated Multilevel Intervention for Tobacco Smoke Exposure: A Randomized Trial

BACKGROUND

Provider adherence to best practice guidelines (ask, advise, refer [AAR]) for addressing child tobacco smoke exposure (TSE) motivates parents to reduce TSE. However, high-risk, vulnerable populations of smokers may require more intensive treatment. We hypothesized that a pragmatic, multilevel treatment model including AAR coupled with individualized, telephone-based behavioral counseling promoting child TSE reduction would demonstrate greater child TSE reduction than would standard AAR.

METHODS

In this 2-arm randomized controlled trial, we trained pediatric providers in systems serving low-income communities to improve AAR adherence by using decision aid prompts embedded in routine electronic health record assessments. Providers faxed referrals to the study and received ongoing AAR adherence feedback. Referred participants were eligible if they were daily smokers, >17 years old, and spoke English. Participants were randomly assigned to telephone-based behavioral counseling (AAR and counseling) or nutrition education (AAR and attention control). Participants completed prerandomization and 3-month follow-up assessments.

RESULTS

Of providers, >80% (n = 334) adhered to AAR procedures and faxed 2949 referrals. Participants (n = 327) were 83% women, 83% African American, and 79% low income (below poverty level). Intention-to-treat logistic regression showed robust, positive treatment effects: more parents in AAR and counseling than in AAR and attention control eliminated all sources of TSE (45.8% vs 29.9%; odds ratio 1.99 [95% confidence interval 1.44-2.74]) and quit smoking (28.2% vs 8.2%; odds ratio 3.78 [95% confidence interval 1.51-9.52]).

CONCLUSIONS

The results indicate that the integration of clinic- and individual-level smoking interventions produces improved TSE and cessation outcomes relative to standalone clinic AAR intervention. Moreover, this study was among the first in which researchers demonstrated success in embedding AAR decision aids into electronic health records and seamlessly facilitated TSE intervention into routine clinic practice.

Smokers who have children with asthma: Perceptions about child secondhand smoke exposure and tobacco use initiation and parental willingness to participate in child-focused tobacco interventions

OBJECTIVE

This study examined, among parents who smoke and have children with asthma, perceptions about child secondhand smoke exposure (SHSe), child tobacco use (TU) initiation, and parent willingness to participate in child-focused tobacco interventions.

METHODS

Participants were 300 caregivers who smoked and had a child with asthma (aged 10-14). Parents completed an online survey and self-reported perceptions about child SHSe elimination, child TU prevention, and willingness to participate in three types of interventions with and without their child (SHSe reduction intervention, tobacco prevention intervention, and the combination of the two). Correlates of perceptions and willingness were examined.

RESULTS

Parents who were ready to quit smoking and who reported home smoking bans (HSBs) were more motivated to eliminate SHSe (p < 0.05). Being white, younger, ready to quit, and having HSBs were associated with greater confidence to eliminate SHSe (p < 0.05). Parents with HSBs reported higher perceived importance about preventing child TU (p < 0.05). Parents were less confident about preventing male children from using tobacco (p = 0.001). Parents were highly willing to participate in all the described intervention approaches, with or without their child.

CONCLUSIONS

Parents were willing to participate in child-focused tobacco interventions, with or without their child with asthma, including interventions that address both child SHSe and TU prevention. This research demonstrates the acceptability of child-focused tobacco interventions among a high-risk population and may be a foundational step for intervention development.

Developing a Biomarker Feedback Intervention to Motivate Smoking Cessation During Pregnancy: Phase II MAW Study

INTRODUCTION

The prevalence of smoking during pregnancy for Alaska Native (AN) women is more than triple that of non-Native Alaska women. In this qualitative study, we solicited input from AN women and others to determine how best to present findings from an earlier study demonstrating a strong correlation between biomarkers for maternal smoking (cotinine) and neonatal exposure to a tobacco-specific carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) to motivate cessation.

METHODS

We developed a brochure incorporating generalized biomarker information. Using in-depth individual interviews with pregnant and postpartum AN women and partners/family members, we explored applicability and acceptability of the information. Postpartum women, who had participated in the earlier correlation study, additionally received their individual biomarker results. We assessed whether being presented general or individual biomarker information would motivate cessation using content analysis.

RESULTS

We conducted 39 interviews: 16 pregnant women, 12 postpartum women, and 11 partners/family members. Overall, participants agreed the biomarker information was new, but understandable as presented. Postpartum women shared that learning their personal results inspired them to want to quit or cut back smoking while pregnant women indicated the generalized correlation information was less helpful in motivating cessation.

CONCLUSION

Generalized information about fetal exposure to carcinogens may be more effective in motivating pregnant women to quit smoking when combined with individual cotinine testing.

IMPLICATIONS

Using feedback from this study, we refined and are currently evaluating an intervention incorporating generalized correlation information from Phase I and cotinine testing to determine its effectiveness in motivating smoking cessation among pregnant AN women.

Babies Living Safe & Smokefree: randomized controlled trial of a multilevel multimodal behavioral intervention to reduce low-income children's tobacco smoke exposure

Background

Addressing children’s tobacco smoke exposure (TSE) remains a public health priority. However, there is low uptake and ineffectiveness of treatment, particularly in low-income populations that face numerous challenges to smoking behavior change. A multilevel intervention combining system-level health messaging and advice about TSE delivered at community clinics that disseminate the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), combined with nicotine replacement and intensive multimodal, individual-level behavioral intervention may improve TSE control efforts in such high-risk populations.

Methods/Design

This trial uses a randomized two-group design with three measurement points: baseline, 3-month and 12-month follow-up. The primary outcome is bioverified child TSE; the secondary outcome is bioverified maternal quit status. Smoking mothers of children less than 6 years old are recruited from WIC clinics. All participants receive WIC system-level intervention based on the “Ask, Advise, Refer (AAR)” best practices guidelines for pediatrics clinics. It includes training all WIC staff about the importance of maternal tobacco control; and detailing clinics with AAR intervention prompts in routine work flow to remind WIC nutrition counselors to ask all mothers about child TSE, advise about TSE harms and benefits of protection, and refer smokers to cessation services. After receiving the system intervention, mothers are randomized to receive 3 months of additional treatment or an attention control intervention: (1) The multimodal behavioral intervention (MBI) treatment includes telephone counseling sessions about child TSE reduction and smoking cessation, provision of nicotine replacement therapy, a mobile app to support cessation efforts, and multimedia text messages about TSE and smoking cessation; (2) The attention control intervention offers equivalent contact as the MBI and includes nutrition-focused telephone counseling, mobile app, and multimedia text messages about improving nutrition. The control condition also receives a referral to the state smoking cessation quitline.

Discussion

This study tests an innovative community-based, multilevel and integrated multimodal approach to reducing child TSE in a vulnerable, low-income population. The approach is sustainable and has potential for wide reach because WIC can integrate the tobacco intervention prompts into routine workflow and refer smokers to free evidence-based behavioral counseling interventions, such as state quitlines.

Trial registration

Clinicaltrials.gov NCT02602288. Registered 9 November 2015.

Feasibility Pilot of a Randomized Faith-Based Intervention to Reduce Secondhand Smoke Exposure Among Korean Americans

INTRODUCTION

Interventions are needed to prevent exposure to secondhand smoke (SHS), which persists in certain immigrant enclaves, including Koreans in the United States. A faith-based and culturally acceptable intervention was developed and pilot tested in collaboration with Korean churches to address SHS exposure among people of Korean descent.

METHODS

A pilot cluster randomized intervention trial was conducted with 11 Korean churches in southern California and 75 Korean adults who were exposed to SHS. Study participants received a multicomponent intervention, which consisted of motivational interviewing by telephone and educational materials tailored with related biblical messages; the intervention was bolstered by church-based group activities and environmental cues. The control group received the same type and frequency of intervention components, but the components related only to fruit and vegetable consumption. Data were collected on the feasibility of the intervention and study procedures. SHS exposure and awareness and knowledge of SHS exposure were assessed by telephone interviews at baseline and follow-up.

RESULTS

At follow-up, a larger percentage of the intervention group than the control group reported correct SHS knowledge and disapproval of SHS. The intervention group's SHS exposure was reduced by 8.5 cigarettes per week (vs a reduction of 1 cigarette per week among the control group).

CONCLUSIONS

Initial findings are promising for improving knowledge, attitudes, and protective behaviors surrounding SHS exposure. Results suggest that a faith-based intervention for Korean Americans who are exposed to SHS is feasible, acceptable, and potentially effective in reducing their exposure to SHS.

Development of a scale assessing Beliefs About ThirdHand Smoke (BATHS)

BACKGROUND

Similarly to secondhand smoke (SHS), thirdhand smoke (THS) beliefs may be correlated with smoking behaviors and smokefree policies in the home. Thus, there is a need to develop and validate measures to assess beliefs about THS.

METHODS

A list of 19 items related to THS were generated by an expert panel and tested in a pilot study. Based on results from an exploratory factor analysis, two factors emerged: THS persistence in the environment and THS impact on health. The scale was reduced to nine items, which showed no differential item functioning by smoking status or smoking ban status in the home. The nine items and the two factor structure were tested in a validation sample from a smoke-free homes intervention that included THS educational materials.

RESULTS

The 9-item scale showed excellent internal consistency. Confirmatory factor analysis indicated good model fit for the two factor solution in a low-income population. Tests of construct validity indicated differences due to exposure to the smoke-free homes intervention, by smoking status, whether participants own or rent their home, and smoking ban status in the home.

CONCLUSIONS

The BATHS scale offers researchers a valid and reliable tool to assess THS beliefs.

Facilitators and Barriers of Smokers' Compliance with Smoking Bans in Public Places: A Systematic Review of Quantitative and Qualitative Literature

Background: Environmental tobacco smoke (ETS) exposure is associated with an increased risk of many diseases. Many countries have ratified a national smoking ban in public places, but studies on factors related to smoking issues in public places post-ban are lacking. Aim: To identify facilitators and barriers that influenced smokers’ compliance with smoking bans in public places. Methods: Using PubMed, MEDLINE, and the Web of Science database, we conducted a systematic search of English articles published before June 2015 on factors of smokers’ compliance with the smoking bans in public places. Results: A total of 390 references were identified, among which seventeen articles (twelve quantitative studies, two qualitative studies, three mixed-method studies) were included in this review. These studies focused on four types of public places including recreational venues (n = 7), hospital (n = 5), school (n = 4), and workplace (n = 1). Factors at the  individual-, interpersonal-, and organizational-level were identified: at the individual level, nicotine dependence, insufficiency of tobacco-related knowledge, and the negative attitudes towards smoking bans were the most commonly identified barriers; at the interpersonal level, the smoking behaviors of people around, close relatives, and friends’ approval were the main barriers; and at the organizational level, the main barriers were inefficient implementation of the bans and the inconvenience of the designative smoking areas. Conclusions: This synthesis of the literature provided evidence of the identified barriers and facilitators of smokers’ compliance with the smoking bans. It will be beneficial for the policy-maker to consider interventions on multiple levels of factors to overcome the barriers and enhance smokers’ compliance with the smoking bans in public places.

A Minimal Intervention to Promote Smoke-Free Homes among 2-1-1 Callers: North Carolina Randomized Effectiveness Trial

This study examined the extent to which delivery of the minimal Smoke-Free Homes intervention by trained 2-1-1 information and referral specialists had an effect on the adoption of home smoking bans in low-income households. A randomized controlled trial was conducted among 2-1-1 callers (n = 500) assigned to control or intervention conditions. 2-1-1 information and referral specialists collected baseline data and delivered the intervention consisting of 3 mailings and 1 coaching call; university-based data collectors conducted follow-up interviews at 3 and 6 months post-baseline. Data were collected from June 2013 through July 2014. Participants were mostly female (87.2%), African American (61.4%), and smokers (76.6%). Participants assigned to the intervention condition were more likely than controls to report a full ban on smoking in the home at both 3- (38.1% vs 19.3%, p = < .001) and 6-month follow-up (43.2% vs 33.2%, p = .02). The longitudinal intent-to-treat analysis showed a significant intervention effect over time (OR = 1.31, p = .001), i.e. OR = 1.72 at 6 months. This study replicates prior findings showing the effectiveness of the minimal intervention to promote smoke-free homes in low-income households, and extends those findings by demonstrating they can be achieved when 2-1-1 information and referral specialists deliver the intervention. Findings offer support for this intervention as a generalizable and scalable model for reducing secondhand smoke exposure in homes.

Children's Exposure to Secondhand Smoke during Ramadan in Jakarta, Indonesia

Secondhand smoke exposure (SHS) causes a disproportionate health burden for children, yet existing smoke-free laws are often poorly enforced. We monitored air quality while observing children and adult nonsmokers present in public venues during Ramadan, a period of Muslim religious observance marked by family and social gatherings, in Jakarta, Indonesia. A repeated-measures design was used to assess indoor air quality during and after Ramadan in 43 restaurants and in five smoke-free control venues. Fine particulate matter of 2.5 microns or less (PM_2.5) was sampled. The average number of children and active smokers present in each venue was also observed. PM_2.5 levels were significantly higher during Ramadan (mean 86.5 µg/m³) compared with post-Ramadan (mean 63.2 µg/m³) in smoking venues (p = 0.015). During Ramadan, there were more active smokers (p = 0.012) and children (p = 0.051) observed in venues where smoking occurred, compared with the same venues post-Ramadan. Poor enforcement of the smoke-free law in Jakarta has failed to protect children from SHS exposure in public venues during Ramadan. Collaboration between the government, NGOs (such as the Indonesian Cancer Foundation (YKI) and the Smoking Control Foundation (LM3)), religious leaders, and venue owners and managers must be developed to ensure that the comprehensive smoking bans apply to all venues, and that smoke-free laws are enforced.

Understanding motivation to implement smoking bans among mothers with a hospitalized infant

OBJECTIVE

Secondhand smoke exposure (SHSe) poses risks to hospitalized children upon discharge and no uniformly effective interventions have been identified. Understanding change-related processes and social-contextual factors related to motivation for implementing home and car smoking bans may inform interventions to reduce infant SHSe among mothers with a hospitalized infant.

METHODS

In this cross-sectional, secondary analysis, mothers of neonatal ICU infants who reported smoking or living with a smoker (N=205) were assigned to stages of change (pre-contemplation, contemplation, preparation, or action) based on behaviors and intentions for establishing smoking bans in their homes and cars. Processes of change (POC) for SHSe reduction practices, self-efficacy, depressive symptoms, generalized anxiety, and social support for not smoking in the home were examined across all four stages.

RESULTS

The majority of mothers were in the action stage for having a home smoking ban in place (55%); only 35% of participants were in action for a car smoking ban. POC use differed across the stages of change for having a home ban (p=0.004) and car ban (p=0.02), with earlier stages using fewer overall and relatively fewer cognitive/affective processes. Earlier stage women also reported lower self-efficacy to change, less familial and partner support for in-home smoking bans, and more depressive symptoms.

CONCLUSIONS

Novel intervention targets were identified, including cognitive/affective change processes, mental health, and familial/social contingencies for implementing SHSe protective practices. Creative ways in which to affect change at the individual and household level are needed in order to fully address the complexity of child SHSe.

Social disparities in parental smoking and young children's exposure to secondhand smoke at home: a time-trend analysis of repeated cross-sectional data from the German KiGGS study between 2003-2006 and 2009-2012

Background

Children who are exposed to secondhand smoke (SHS) have an increased risk of a wide range of health problems and illnesses. Smoke-free legislation aims to improve indoor air quality and in this way protect the health of people who do not smoke. This paper examines trends in SHS exposure at home among children in Germany since the introduction of smoking bans in public places. Special focus is placed on the importance of the family of origin’s socioeconomic status (SES) and on parental smoking behaviour.

Methods

The analyses are based on two waves of the “German Health Interview and Examination Survey for Children and Adolescents” (KiGGS)—one of which was conducted immediately before the introduction of central smoke-free legislation in the 2003-2006 period, the other approximately 6 years later from 2009 to 2012. A comparison is made between the answers given by the parents of children aged between 0 to 6 (KiGGS baseline study, n = 6680; KiGGS Wave 1, n = 4455). Domestic SHS exposure is covered in the parent interviews by asking whether anyone is allowed to smoke at home in the presence of their child. Parental smoking behaviour is determined separately for mothers and fathers. SES is determined on the basis of the parents’ education, occupational status and income.

Results

The percentage of 0- to 6-year-old children exposed to SHS in the parental home fell from 23.9 to 6.6 % in the period from 2003-2006 to 2009-2012. At the same time, the percentage of children with at least one parent who smokes decreased from 49.8 to 41.8 %. While relative social inequalities in parental smoking behaviour have tended to increase over time, inequalities in domestic SHS exposure have persisted. Children whose parents smoke and children from low-SES families are still most likely to be exposed to tobacco smoke. In both study periods and after statistical adjustment for parental smoking behaviour, children with a low SES had a 6.6-fold higher risk for SHS exposure in the parental home than children from high-SES households.

Conclusions

The results of the KiGGS study show that the proportion of children in Germany who are exposed to SHS at home has declined significantly over the last few years. There is much to suggest that the smoke-free legislation that has been introduced in Germany has led to a heightened awareness of the health risks of SHS both in public and in the private sphere, as well as to a denormalization of smoking. Children whose parents smoke, and among them particularly children from socially disadvantaged families, should be recognised as key target groups when implementing future tobacco-control measures.

Transmission of Smoking across Three Generations in Finland

The influence of parents’ smoking on children’s smoking is well known, but few studies have examined the association between grandparents’ and grandchildren’s smoking. We studied the association between paternal and maternal grandparents’ smoking and their grandchildren’s tobacco use and assessed whether parents’ smoking is a mediator in this process. Data were obtained from a national survey of 12–18-year-old Finns in 2013 (N = 3535, response rate 38%). Logistic regression and mediation analyses were used. Both boys and girls had higher odds for smoking experimentation, daily smoking and other tobacco or tobacco-like product use if their mother, father or any of the four grandparents were current or former smokers. When parents’ and grandparents’ smoking status were included in the same model, grandparents’ smoking generally lost statistical significance. In the mediation analysis, 73% of the total effect of grandparents’ smoking on grandchildren’s daily smoking was mediated through parents’ smoking, 64% on smoking experimentation and 63% on other tobacco or tobacco-like product use. The indirect effect of a mother’s smoking was higher than that of a father’s. To conclude, paternal and maternal grandparents’ smoking increases grandchildren’s tobacco use. The influence is mainly, but not completely, mediated through parents’ smoking.

Compliance with smoke-free policies in korean bars and restaurants in california: a descriptive analysis

BACKGROUND

Compliance with California's smoke-free restaurant and bar policies may be more a function of social contingencies and less a function of legal contingencies. The aims of this study were: 1) to report indications of compliance with smoke-free legislation in Korean bars and restaurants in California; 2) to examine the demographic, smoking status, and acculturation factors of who smoked indoors; and 3) to report social cues in opposition to smoking among a sample of Koreans in California.

MATERIALS AND METHODS

Data were collected by telephone surveys administered by bilingual interviewers between 2007-2009, and included California adults of Korean descent who visited a Korean bar or restaurant in a typical month (N=2,173, 55% female).

RESULTS

1% of restaurant-going participants smoked inside while 7% observed someone else smoke inside a Korean restaurant. Some 23% of bar-going participants smoked inside and 65% observed someone else smoke inside a Korean bar. Presence of ashtrays was related to indoor smoking in bars and restaurants. Among participants who observed smoking, a higher percentage observed someone ask a smoker to stop (17.6%) or gesture to a smoker (27.0%) inside Korean restaurants (N=169) than inside Korean bars (n=141, 17.0% observed verbal cue and 22.7% observed gesture). Participants who smoked inside were significantly younger and more acculturated than participants who did not. Less acculturated participants were significantly more to likely to be told to stop smoking.

CONCLUSIONS

Ten years after implementation of ordinances, smoking appears to be common in Korean bars in California.

Thirdhand smoke contamination in hospital settings: assessing exposure risk for vulnerable paediatric patients

BACKGROUND

Tobacco has regained the status of the world's number two killer behind heart/vascular disease. Thirdhand smoke (THS) residue and particles from secondhand smoke (SHS) are suspected health hazards (eg, DNA damage) that are likely to contribute to morbidity and mortality, especially in vulnerable children. THS is easily transported and deposited indoors, where it persists and exposes individuals for months, creating potential health consequences in seemingly nicotine-free environments, particularly for vulnerable patients. We collected THS data to estimate infant exposure in the neonatal ICU (NICU) after visits from household smokers. Infant exposure to nicotine, potentially from THS, was assessed via assays of infant urine.

METHODS

Participants were mothers who smoked and had an infant in the NICU (N=5). Participants provided surface nicotine samples from their fingers, infants' crib/incubator and hospital-provided furniture. Infant urine was analysed for cotinine, cotinine's major metabolite: trans-3'-hydroxycotinine (3HC) and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), a metabolite of the nicotine-derived and tobacco-specific carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK).

RESULTS

Incubators/cribs and other furniture had detectable surface nicotine. Detectable levels of cotinine, 3HC and NNAL were found in the infants' urine.

DISCUSSION

THS appears to be ubiquitous, even in closely guarded healthcare settings. Future research will address potential health consequences and THS-reduction policies. Ultimately, hospital policies and interventions to reduce THS transport and exposure may prove necessary, especially for immunocompromised children.

Parental receptivity to child biomarker testing for tobacco smoke exposure: A qualitative study

OBJECTIVE

Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their children's exposure. Biomarkers demonstrate exposure and may motivate behavior change, but their acceptability is not well understood.

METHODS

Sixty-five in-depth interviews were conducted with parents of young children, in smoking families in central Israel. Data were analyzed using thematic analysis.

RESULTS

Consent to testing was associated with desire for information, for reassurance or to motivate change, and with concerns for long-term health, taking responsibility for one's child, and trust in research. Opposition to testing was associated with preference to avoid knowledge, reluctance to cause short-term discomfort, perceived powerlessness, and mistrust of research. Most parents expressed willingness to allow measurement by urine (83%), hair (88%), or saliva (93%), but not blood samples (43%); and believed that test results could motivate behavior change.

CONCLUSIONS

Parents were receptive to non-invasive child biomarker testing. Biomarker information could help persuade parents who smoke that their children need protection.

PRACTICE IMPLICATIONS

Biomarker testing of children in smoking families is an acceptable and promising tool for education, counseling, and motivation of parents to protect their children from TSE. Additionally, biomarker testing allows objective assessment of population-level child TSE.

Reducing Underserved Children's Exposure to Tobacco Smoke: A Randomized Counseling Trial With Maternal Smokers

INTRODUCTION

Addressing maternal smoking and child tobacco smoke exposure is a public health priority. Standard care advice and self-help materials to help parents reduce child tobacco smoke exposure is not sufficient to promote change in underserved populations. We tested the efficacy of a behavioral counseling approach with underserved maternal smokers to reduce infant's and preschooler's tobacco smoke exposure.

DESIGN

A two-arm randomized trial: enhanced behavior counseling (experimental) versus enhanced standard care (control). Assessment staff members were blinded.

SETTING/PARTICIPANTS

Three hundred randomized maternal smokers were recruited from low-income urban communities. Participants had a child aged <4 years exposed to two or more maternal cigarettes/day at baseline.

INTERVENTION

Philadelphia Family Rules for Establishing Smoke-free Homes (FRESH) included 16 weeks of counseling. Using a behavioral shaping approach within an individualized cognitive-behavioral therapy framework, counseling reinforced efforts to adopt increasingly challenging tobacco smoke exposure-protective behaviors with the eventual goal of establishing a smoke-free home.

MAIN OUTCOME MEASURES

Primary outcomes were end-of-treatment child cotinine and reported tobacco smoke exposure (maternal cigarettes/day exposed). Secondary outcomes were end-of-treatment 7-day point-prevalence self-reported cigarettes smoked/day and bioverified quit status.

RESULTS

Participation in FRESH behavioral counseling was associated with lower child cotinine (β=-0.18, p=0.03) and reported tobacco smoke exposure (β=-0.57, p=0.03) at the end of treatment. Mothers in behavioral counseling smoked fewer cigarettes/day (β=-1.84, p=0.03) and had higher bioverified quit rates compared with controls (13.8% vs 1.9%, χ(2)=10.56, p<0.01). There was no moderating effect of other smokers living at home.

CONCLUSIONS

FRESH behavioral counseling reduces child tobacco smoke exposure and promotes smoking quit rates in a highly distressed and vulnerable population.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02117947.

Family Beliefs and Behaviors About Smoking and Young Children's Secondhand Smoke Exposure

INTRODUCTION

Home smoking bans (HSBs) reduce children's secondhand smoke exposure (SHSe), a contributor to health disparities. General psychosocial characteristics and SHSe beliefs and behaviors within the family may relate to HSB existence. This study's aim was to identify general psychosocial characteristics and SHSe beliefs associated with HSB presence and lower SHSe among children living with a smoker.

METHODS

Caregivers (n = 269) of Head Start preschool students (age 1-6 years) living with a smoker reported on HSBs, caregiver depressive symptoms and stress, family routines, SHSe beliefs, and household smoking characteristics. SHSe biomarkers included air nicotine in 2 areas of the home and child salivary cotinine.

RESULTS

One-quarter of families reported complete HSBs, and HSBs were more common among nonsmoking (37%) versus smoking caregivers (21%; p < .01). Perceived importance of HSBs differed between nonsmoking (9.7±1.0) versus smoking caregivers (9.1±2.0; p < .01). Smoking caregivers, more smokers in the home, and lower self-efficacy and intent to implement an HSB were consistently associated with lower likelihood of HSB existence and children's higher SHSe. Caregiver SHSe beliefs were more consistently associated with HSBs and SHSe than were general psychosocial factors.

CONCLUSIONS

Despite greater HSB likelihood and higher perceived importance of HSBs among nonsmoking versus smoking primary caregivers, SHSe reduction self-efficacy and intent are protective for Head Start students at high-risk for exposure. Pediatric healthcare providers and early education professionals may be able to support SHSe reduction efforts (e.g., smoking cessation, HSB implementation) and reduce children's SHSe with counseling strategies to address caregivers' HSB self-efficacy, intent, and related behaviors.

Thirdhand Smoke in the Homes of Medically Fragile Children: Assessing the Impact of Indoor Smoking Levels and Smoking Bans

INTRODUCTION

Thirdhand smoke (THS) residue results from secondhand smoke, and is emerging as a distinct public health hazard, particularly for medically fragile pediatric patients living with smokers. THS is difficult to remove and readily reacts with other pollutants to form carcinogens and ultrafine particles. This study investigated THS found in homes of high-risk infants admitted to a neonatal intensive care unit and their association with characteristics (eg, number of household smokers) hypothesized to influence THS.

METHODS

Baseline data from 141 hospitalized infants' homes were analyzed, along with follow-up data (n = 22) to explore household smoking characteristics and THS changes in response to indoor smoking ban policies.

RESULTS

Households with an indoor ban, in which not more than 10 cigarettes/d were smoked, had the lowest levels of THS contamination compared to homes with no ban (P < .001) and compared to homes with an indoor ban in which greater numbers of cigarettes were smoked (P < .001). Importantly, homes with an indoor ban in which at least 11 cigarettes/d were smoked were not different from homes without a ban. The follow-up sample of 22 homes provided initial evidence indicating that, unless a ban was implemented, THS levels in homes continued to increase over time.

CONCLUSIONS

Preliminary longitudinal data suggest that THS may continue to accumulate in homes over time and household smoking bans may be protective. However, for homes with high occupant smoking levels, banning indoor smoking may not be fully adequate to protect children from THS. Unless smoking is reduced and bans are implemented, medically fragile children will be exposed to the dangers of THS.

Benzene uptake in Hookah smokers and non-smokers attending Hookah social events: regulatory implications

BACKGROUND

Benzene is a human hematotoxicant and a leukemogen that causes lymphohematopoietic cancers, especially acute myelogenous leukemia. We investigated uptake of benzene in hookah smokers and non-smokers attending hookah social events in naturalistic settings where hookah tobacco was smoked exclusively.

METHODS

We quantified S-phenylmercapturic acid (SPMA), a metabolite of benzene, in the urine of 105 hookah smokers and 103 non-smokers. Participants provided spot urine samples the morning of and the morning after attending an indoor hookah-only smoking social event at a hookah lounge or in a private home.

RESULTS

Urinary SPMA levels in hookah smokers increased significantly following a hookah social event (P < 0.001). This increase was 4.2 times higher after hookah lounge events (P < 0.001) and 1.9 times higher after home events (P = 0.003). In non-smokers, urinary SPMA levels increased 2.6 times after hookah lounge events (P = 0.055); however, similar urinary SPMA levels were detected before and after home events, possibly indicating chronic exposure to benzene (P = 0.933).

CONCLUSIONS

Our data provide the first evidence for uptake of benzene in hookah smokers and non-smokers exposed to hookah tobacco secondhand smoke at social events in private homes compared with their counterparts in hookah lounges. Hookah tobacco smoke is a source of benzene exposure, a risk factor for leukemia.

IMPACT

Because there is no safe level of exposure to benzene, our results call for interventions to reduce or prevent hookah tobacco use, regulatory actions to limit hookah-related exposure to toxicants including benzene, initiate labeling of hookah-related products, and include hookah smoking in clean indoor air legislation.

Caregivers' interest in using smokeless tobacco products: Novel methods that may reduce children's exposure to secondhand smoke

The study examined caregivers' interest in using potentially reduced exposure tobacco products for smoking cessation, reduction, and to help them not smoke in places such as around their child, as all three methods would potentially lead to reduced secondhand smoke exposure for their children. A sample of 136 caregivers completed carbon monoxide testing to assess smoking status and a brief survey. Few caregivers had ever used potentially reduced exposure tobacco products (<1%), but a majority were interested in trying them as means of smoking reduction (54%), to quit/stay quit from smoking (51%), and to help them not smoke around their child or in the home (55%). Caregivers less motivated to quit smoking and with no home smoking ban were more interested in using potentially reduced exposure tobacco products to help them quit/stay quit from smoking (p < .05).

Changes in and patterns of smoking exposure in an elderly urban population in Beijing: 2001-2010

OBJECTIVE

The study aims to explore the patterns and changes of active and passive smoking in the elderly population.

METHODS

Two cross-sectional surveys with representative samples of urban populations, aged between 60 and 95 years old, were conducted in 2001 and 2010 in Beijing. A current smoker was defined as a person who smoked a tobacco product at the time of the survey, and a passive smoker was defined as a person who had been exposed to smoke exhaled by a smoker for more than 15 minutes per day more than once per week.

RESULTS

A total of 2,277 participants in 2001 and 2,102 participants in 2010 completed the survey. The current smoking prevalence changed slightly in males (24.7 vs. 21.2%, P = 0.081), while the prevalence in females decreased significantly from 8.8% (95% CI: 7.3-10.3%) in 2001 to 4.1% (95% CI: 3.0-5.2%) in 2010 (P<0.001). The prevalence of passive smoking was 30.5% (95% CI: 28.6-32.4%) in 2001 and 30.0% (95% CI: 28.1-32.0%) in 2010. The main source of secondhand smoke switched from a spouse in 2001 to offspring in 2010. This trend was observed in both sexes. Passive smoking in males from a smoking spouse decreased from 5.7% to 2.4% (P<0.001), while that from smoking offspring increased from 7.3 to 14.5% (P<0.001). Passive smoking in females from a spouse decreased from 30.6 to 17.6%, while that from offspring increased from 5.3 to 15.4% (P<0.001).

CONCLUSION

Offspring became the main source of secondhand smoke for the elderly. Our findings demonstrated the importance of implementing smoking prevention programs, to educate older adults who live with a smoking spouse and/or offspring.

Reduction of Secondhand Smoke Exposure in the Cars of Children With Cancer

This study examined whether an intervention designed to reduce secondhand smoke exposure (SHSe) among children being treated for cancer had effects in the specific setting of a motor vehicle. The parents or guardians (n = 71) of children being treated for cancer were randomized to either a behavioral secondhand smoke (SHS) reduction program or a standard care control group. Parental reports of SHSe were collected over the course of 12 months. Younger children were exposed at baseline more than their older counterparts. The greatest initial declines in car exposure were observed among children ≤5 years old in the intervention group compared with same-aged peers in the control group. After the 3-month time point, the control group showed greater reductions in car exposure in comparison with the intervention group. Interventions that teach parents strategies to manage their smoking while driving in their personal vehicles may produce even greater reductions in child exposure and should be developed. Based on the age-specific results reported here, future studies should account for effects of child age and use setting-specific measures of SHS.

A minimal intervention to promote smoke-free homes among 2-1-1 callers: a randomized controlled trial

OBJECTIVES

We tested the efficacy of a minimal intervention to create smoke-free homes in low-income households recruited through the United Way of Greater Atlanta 2-1-1, an information and referral system that connects callers to local social services.

METHODS

We conducted a randomized controlled trial (n=498) from June 2012 through June 2013, with follow-up at 3 and 6 months. The intervention consisted of 3 mailings and 1 coaching call.

RESULTS

Participants were mostly smokers (79.7%), women (82.7%), African American (83.3%), and not employed (76.5%), with an annual household income of $10,000 or less (55.6%). At 6-months postbaseline, significantly more intervention participants reported a full ban on smoking in the home than did control participants (40.0% vs 25.4%; P=.002). The intervention worked for smokers and nonsmokers, as well as those with or without children.

CONCLUSIONS

Minimal intervention was effective in promoting smoke-free homes in low income households and offers a potentially scalable model for protecting children and adult nonsmokers from secondhand smoke exposure in their homes.

Health promotion interventions and policies addressing excessive alcohol use: a systematic review of national and global evidence as a guide to health-care reform in China

AIMS

Steady increases in alcohol consumption and related problems are likely to accompany China's rapid epidemiological transition and profit-based marketing activities. We reviewed research on health promotion interventions and policies to address excessive drinking and to guide health-care reform.

METHODS

We searched Chinese- and English-language databases and included 21 studies in China published between 1980 and 2013 that covered each policy area from the World Health Organization (WHO) Global Strategy to Reduce the Harmful Use of Alcohol. We evaluated and compared preventive interventions to the global alcohol literature for cross-national applicability.

RESULTS

In contrast with hundreds of studies in the global literature, 11 of 12 studies from mainland China were published in Chinese; six of 10 in English were on taxation from Taiwan or Hong Kong. Most studies demonstrated effectiveness in reducing excessive drinking, and some reported the reduction of health problems. Seven were randomized controlled trials. Studies targeted schools, drink-driving, work-places, the health sector and taxation.

CONCLUSIONS

China is the world's largest alcohol market, yet there has been little growth in alcohol policy research related to health promotion interventions over the past decade. Guided by a public health approach, the WHO Global Strategy and health reform experience in Russia, Australia, Mexico and the United States, China could improve its public health response through better coordination and implementation of surveillance and evidence-based research, and through programmatic and legal responses such as public health law research, screening and early intervention within health systems and the implementation of effective alcohol control strategies.

Tobacco use and exposure among youth undergoing cancer treatment

INTRODUCTION

Adolescents with cancer are susceptible to the health consequences associated with secondhand smoke exposure (SHSE) and tobacco use. The present study compared tobacco use, exposure, and risk factors between patients and population peers.

METHOD

Self-reported data on tobacco use, SHSE, and tobacco-related risk factors were drawn from a pediatric oncology hospital and the National Youth Tobacco Survey. Conditional logistic regression was used to estimate odds ratios for patients and control subjects.

RESULTS

Patients were as likely to have tried tobacco and report home SHSE as control subjects. Patients were more likely to report car SHSE, less likely to report that SHSE is harmful, and less likely to report home smoking bans.

DISCUSSION

Patients experienced SHSE, tobacco use, and tobacco-related risk factors at rates greater than or equal to control subjects. These results provide support for consideration of intervention targets, health status, and delivery mechanisms, particularly by health care providers, when developing comprehensive tobacco control strategies.

Changes in and factors affecting second-hand smoke exposure in nonsmoking Korean Americans in California: a panel study

PURPOSE

We evaluated changes in and factors affecting second-hand smoke (SHS) exposure in a panel study of nonsmokers.

METHODS

This study was based on data from a larger study of tobacco use among a representative sample of adults of Korean descent residing in California. Participants included 846 males and 1,399 females who were nonsmokers at baseline (2005-2006) and at follow-up (2007-2009). Participants were selected by probability sampling and were interviewed by telephone.

RESULTS

At baseline, 50.0% were exposed to any SHS, and at follow-up 2 years later, 60.4% were exposed to any SHS (p < .001). SHS exposure at baseline was associated with acculturation, employment, spousal smoking, and having a friend who smoked (p < .001). Employment, spousal smoking, and other family members smoking were associated with SHS at follow-up (p < .001). The odds ratio of SHS in the employed group declined from 2.01 at baseline to 1.53 at follow-up, that of the group having a smoking spouse increased from 1.88 to 2.36, and that of the group having other family members smoking increased from 1.20 to 1.69.

CONCLUSIONS

We showed that SHS exposure increased among Korean American nonsmokers in California, and the most important variables explaining the change in SHS exposure involved smoking among others with whom the subject is associated. These findings could be used as objective evidence for developing public health policies to reduce SHS exposure.