Challenges in Enforcing Home Smoking Rules in a Low-Income Population: Implications for Measurement and Intervention Design

Changes in prevalence and socioeconomic inequalities in secondhand smoke exposure in Spanish children, 2016-2019

INTRODUCTION

Children are vulnerable to secondhand smoke (SHS) exposure, especially those with lower socioeconomic status. This study assesses the changes in prevalence and socioeconomic inequalities in SHS exposure in children younger than 12 years old in Spain between 2016 and 2019.

METHODS

We conducted two cross-sectional studies among representative samples of households with children aged <12 years in Spain, in 2016 (n=2411) and 2019 (n=2412). Families were interviewed to assess children's SHS exposure in private settings and outdoor public venues and their adoption of home and car smoke-free rules. We used the education level of the home main earner as a proxy for socioeconomic position. Changes over time in the prevalence and socioeconomic inequalities of SHS exposure and smoke-free rules were estimated through adjusted Poisson regression models with robust variance according to sociodemographic covariates (adjusted prevalence ratios, APRs).

RESULTS

In 2019, 70.5% of children were exposed to SHS in Spain. No changes between 2016 and 2019 were found for overall SHS exposure, exposure at home, and at school entrances. SHS exposure increased at public transport stations (APR=1.24; 95% CI: 1.03-1.49) and outdoor hospitality venues (APR=1.17; 95% CI: 1.07-1.29) while it decreased in cars (APR=0.74; 95% CI: 0.56-0.98) and parks (APR=0.87; 95% CI: 0.77-0.98). Households with lower education level had higher prevalence of SHS exposure at home in 2019 compared with those with university studies (primary: APR=1.30; 95% CI: 1.11-1.51; secondary: APR=1.12; 95% CI: 1.00-1.25) and were less likely to adopt home indoor smoke-free rules (primary: APR=0.88; 95% CI: 0.79-0.99; secondary: APR=0.95; 95% CI: 0.89-1.02). Socioeconomic inequalities in SHS exposure at home persisted between 2016 and 2019 (p>0.05), while decreased in smoke-free rules in cars (p=0.039).

CONCLUSIONS

Reported SHS exposure among children in Spain remained high between 2016 and 2019. Inequalities persisted at home, highlighting the need for measures to reduce such exposure with an equity perspective.

Association Between Area-Level Socioeconomic Deprivation and Diabetes Care Quality in US Primary Care Practices

IMPORTANCE

Diabetes management operates under a complex interrelationship between behavioral, social, and economic factors that affect a patient's ability to self-manage and access care.

OBJECTIVE

To examine the association between 2 complementary area-based metrics, area deprivation index (ADI) score and rurality, and optimal diabetes care.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed the electronic health records of patients who were receiving care at any of the 75 Mayo Clinic or Mayo Clinic Health System primary care practices in Minnesota, Iowa, and Wisconsin in 2019. Participants were adults with diabetes aged 18 to 75 years. All data were abstracted and analyzed between June 1 and November 30, 2020.

MAIN OUTCOMES AND MEASURES

The primary outcome was the attainment of all 5 components of the D5 metric of optimal diabetes care: glycemic control (hemoglobin A1c <8.0%), blood pressure (BP) control (systolic BP <140 mm Hg and diastolic BP <90 mm Hg), lipid control (use of statin therapy according to recommended guidelines), aspirin use (for patients with ischemic vascular disease), and no tobacco use. The proportion of patients receiving optimal diabetes care was calculated as a function of block group-level ADI score (a composite measure of 17 US Census indicators) and zip code-level rurality (calculated using Rural-Urban Commuting Area codes). Odds of achieving the D5 metric and its components were assessed using logistic regression that was adjusted for demographic characteristics, coronary artery disease history, and primary care team specialty.

RESULTS

Among the 31 934 patients included in the study (mean [SD] age, 59 [11.7] years; 17 645 men [55.3%]), 13 138 (41.1%) achieved the D5 metric of optimal diabetes care. Overall, 4090 patients (12.8%) resided in the least deprived quintile (quintile 1) of block groups and 1614 (5.1%) lived in the most deprived quintile (quintile 5), while 9193 patients (28.8%) lived in rural areas and 2299 (7.2%) in highly rural areas. The odds of meeting the D5 metric were lower for individuals residing in quintile 5 vs quintile 1 block groups (odds ratio [OR], 0.72; 95% CI, 0.67-0.78). Patients residing in rural (OR, 0.84; 95% CI, 0.73-0.97) and highly rural (OR, 0.81; 95% CI, 0.72-0.91) zip codes were also less likely to attain the D5 metric compared with those in urban areas.

CONCLUSIONS AND RELEVANCE

This cross-sectional study found that patients living in more deprived and rural areas were significantly less likely to attain high-quality diabetes care compared with those living in less deprived and urban areas. The results call for geographically targeted population health management efforts by health systems, public health agencies, and payers.

Reducing Socioeconomic Disparities in Comprehensive Smoke-Free Rules among Households with Children: A Pilot Intervention Implemented through a National Cancer Program

Most households with a smoker do not implement comprehensive smoke-free rules (smoke-free homes and cars), and secondhand smoke (SHS) exposure remains prevalent among children and low-socioeconomic status (SES) populations. This pilot project aimed to assess implementation feasibility and impact of an intervention designed to increase smoke-free rules among socioeconomically disadvantaged households with children. The pilot was implemented through Minnesota’s National Breast and Cervical Cancer Early Detection Program (NBCCEDP). NBCCEDPs provide cancer prevention services to low-income individuals experiencing health disparities. We successfully utilized and adapted the Smoke-Free Homes Program (SFHP) to address comprehensive smoke-free rules among households with children. We used two recruitment methods: (a) direct mail (DM) and (b) opportunistic referral (OR) by patient navigators in the NBCCEDP call center. We used descriptive statistics to assess implementation outcomes and hierarchical logistic regression models (HLM) to assess change in smoke-free rules and SHS exposure over the study period. There was no comparison group, and HLM was used to examine within-person change. A total of 64 participants were recruited. Results showed 83% of participants were recruited through DM. OR had a high recruitment rate, and DM recruited more participants with a low response rate but higher retention rate. Among recruited participants with data (n = 47), smoke-free home rules increased by 50.4 percentage points during the study period (p < 0.001). Among recruited participants who had a vehicle (n = 38), smoke-free car rules increased by 37.6 percentage points (p < 0.01) and comprehensive smoke-free rules rose 40.9 percentage points (p < 0.01). Home SHS exposure declined, and within-person increase in smoke-free home rules was significantly related to less home SHS exposure (p < 0.05). It is feasible to adapt and implement the evidence-based SFHP intervention through a national cancer program, but the current pilot demonstrated recruitment is a challenge. DM produced a low response rate and therefore OR is the recommended recruitment route. Despite low recruitment rates, we conclude that the SFHP can successfully increase comprehensive smoke-free rules and reduce SHS exposure among socioeconomically disadvantaged households with children recruited through a NBCCEDP.

A Qualitative Study about Creating Smoke-free Home Rules in American Indian and Alaska Native Households

Smoke-free homes can reduce exposure to secondhand smoke (SHS) and support smoking cessation. The current study seeks to understand perspectives, including barriers and facilitators, on smoke-free homes among five American Indian/Alaska Native (AI/AN) communities. Guided by a national work group of tribal partners, ten focus groups were conducted with AI/AN adult smokers and nonsmokers (n = 95) in Alaska, California, Michigan and Oklahoma, stratified by smoking status. The majority of participants lived in single unit detached homes (70.5%). Most of the nonsmokers had a smoke-free home rule (92.9%) and a majority of smokers did as well (64.7%). The most common reasons for smoke-free home rules were protecting children and grandchildren, including children with health problems. Challenges to a smoke-free home included weather and visitors who smoked, along with the inconvenience of going outside, the habit of smoking inside, the need to watch a young child, safety concerns, and smokers who break the rules. Respecting rules and respecting elders emerged as important themes. Traditional use of tobacco in the home was viewed as quite distinct from recreational or everyday use. Over half (58.2%) reported never using tobacco for ceremonial, prayer or traditional reasons in their homes. Given unique considerations for the adoption of smoke-free homes in AI/AN communities, particularly regarding the use of sacred tobacco for traditional, ceremonial, or medicinal purposes, it is important to learn which barriers and facilitators are similar to the general population and which may be unique to tribal communities in the U.S.

A Qualitative Study Among Mexican Americans to Understand Factors Influencing the Adoption and Enforcement of Home Smoking Bans

Introduction

One-third of Mexican-American children, in addition to nonsmoker adults, are exposed to secondhand smoke at home, yet few interventions target Mexican-American households. An effective, brief English language program, tested with United Way 2-1-1 callers in Atlanta, increased home smoking bans (confirmed by air monitors). Two randomized controlled trials in North Carolina and Texas replicated those results. We explored factors determining adoption and enforcement of smoking bans in Mexican-American households to inform program linguistic and cultural adaptation to broaden program reach and relevance.

Methods

Bilingual interviewers recruited convenience samples of Mexican-American smokers and nonsmokers living with at least one smoker in Houston and San Diego households and asked open-ended questions regarding conditions for implementing home and vehicle smoking bans and conditions for varying acceptance of bans. Investigators independently reviewed English transcripts and completed a descriptive analysis using ATLAS.ti.

Results

Participants (n = 43) were predominantly female (n = 31), current smokers (n = 26), interviewed in Spanish (n = 26), had annual household incomes less than $30000 (n = 24), and allowed smoking inside the home (n = 24). Themes related to difficulty creating and enforcing bans included courtesy, respect for guests and heads of household who smoke, and gender imbalances in decision making. Participants viewed protecting children's health as a reason for the ban but not protecting adult nonsmokers' health.

Conclusion

A dual-language, culturally adapted intervention targeting multigenerational Mexican-American households should address household differences regarding language and consider influences of cultural values on family dynamics and interactions with guests that may weaken bans.

Implications

Qualitative interviews suggested cultural and family considerations to address in adapting a brief evidence-based smoke-free homes intervention for Mexican Americans, including traditional gender roles, unique contexts of multigenerational households, and language preferences. Our work confirms previous research among Latinos regarding importance of common cultural constructs, such as respeto (deference), simpatia (courtesy and agreeability), and familismo (family attachment), which inform behaviors that may impede or facilitate adopting and enforcing home smoking bans. Decision-making gender imbalances, high regard for head-of-household and guest smokers, and less sensitivity to the health of nonsmoker adults compared with children may lead to permission to smoke indoors.

Who's still smoking? Disparities in adult cigarette smoking prevalence in the United States

The continuing high prevalence of cigarette smoking among specific subpopulations, many of them vulnerable, is one of the most pressing challenges facing the tobacco control community. These populations include individuals in lower education and/or socioeconomic groups; from certain racial/ethnic groups; in the lesbian, gay, bisexual, and transgender community; with mental illness; and in the military, particularly among those in the lowest pay grades. Although traditional tobacco control measures are having positive health effects for most groups, the effects are not sufficient for others. More attention to and support for promising novel interventions, in addition to new attempts at reaching these populations through conventional interventions that have proven to be effective, are crucial going forward to find new ways to address these disparities. CA Cancer J Clin 2018;68:106-115. © 2018 American Cancer Society.

Tobacco Use Cessation Among Quitline Callers Who Implemented Complete Home Smoking Bans During the Quitting Process

INTRODUCTION

The implementation of a home smoking ban (HSB) is associated with tobacco use cessation. We identified which quitline callers were most likely to report 30-day cessation among those who implemented complete HSBs after enrollment.

METHODS

Our sample consisted of callers to the Arizona Smokers' Helpline who enrolled from January 1, 2011, through July 26, 2015, and who reported no HSB at enrollment and a complete HSB by 7-month follow-up. We used logistic regression to estimate associations between no use of tobacco in the previous 30 days (30-day quit) at 7-month follow-up and demographic characteristics, health conditions, tobacco use, and cessation strategies.

RESULTS

At 7-month follow-up, 65.4% of 399 callers who implemented a complete HSB reported 30-day quit. Lower odds of tobacco use cessation were associated with having a chronic health condition (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.18-0.56) and living with other smokers (OR, 0.46; 95% CI, 0.29-0.73). Higher odds of tobacco cessation were associated with completing 5 or more telephone coaching sessions (OR, 2.48; 95% CI, 1.54-3.98) and having confidence to quit (OR, 2.05; 95% CI, 1.05-3.99). However, confidence to quit was not significant in the sensitivity analysis.

CONCLUSION

Implementing an HSB after enrolling in quitline services increases the likelihood of cessation among some tobacco users. Individuals with complete HSBs were more likely to quit if they did not have a chronic health condition, did not live with another smoker, and were actively engaged in coaching services. These findings may be used by quitlines to develop HSB intervention protocols primarily targeting tobacco users most likely to benefit from them.

The Relationship between Neighborhood Disorder, Social Networks, and Indoor Cigarette Smoking among Impoverished Inner-City Residents

Impoverished urban neighborhoods tend to have higher rates of smoking and higher rates of exposure to secondhand smoke as compared to more affluent neighborhoods. Contextual factors of neighborhood disorder and social network and household composition may have an impact on indoor smoking behaviors. The TIDE study examined psychosocial factors associated with smoking behaviors among impoverished inner-city smokers in Baltimore, Maryland. Among a community-recruited sample of 413 smokers who lived with others, most (73%) reported that they or others smoked in their residence. Cohabitation with children, elderly, and those with asthma and other respiratory condition was not associated with indoor smoking. Neighborhood disorder, the proportion of social network members who smoked with the study participant, and the proportion of household members who smoked were all independently associated with smoking indoors. The study findings suggest the importance of addressing neighborhood and social network factors when developing programs for promoting indoor smoking bans as well as cessation and prevention programs.