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

Babies Living Safe and Smokefree (BLiSS) Intervention Reduces Children's Tobacco Smoke Exposure Directly and Indirectly by Improving Maternal Smokers' Urge Management Skills and Exposure Protection Behaviors

Children's tobacco smoke exposure (CTSE) is a public health concern, particularly in low-income and minority communities. Interventions to reduce CTSE have had modest success, and so research must identify mechanisms to improve intervention efficacy. This study investigated mediators of CTSE reduction in an intervention designed to facilitate CTSE protection and maternal smoking abstinence. We analyzed data from the Babies Living Safe and Smokefree (BLiSS) trial, which evaluated the efficacy of a multilevel behavioral smoking intervention initiated in community clinics serving low-income mothers. We estimated direct and indirect effects to evaluate the role of two mediators of the intervention on CTSE at post-intervention follow-up: mothers' skills in managing smoking urges and their protective behaviors to shield children from TSE. CTSE was measured using mothers' reports and child cotinine (a CTSE biomarker). The BLiSS intervention was linked to statistically significant lower longitudinal reported CTSE directly and indirectly by increasing mothers' urge management skills and CTSE protection behaviors (p-values < 0.05). The intervention was not directly linked to child cotinine. However, evidence of a statistically significant indirect effect (p-value = 0.028) suggested that the intervention reduced longitudinal child cotinine levels by increasing CTSE protection behaviors. Two non-program factors, nicotine dependence and total smokers in the home, also increased child cotinine and reported CTSE (p-values < 0.001). Interventions that improve maternal smokers' urge management skills and CTSE protections can mitigate CTSE. In addition, it is essential to target barriers to CTSE reduction, such as nicotine dependence levels and the presence of other smokers in the home.

Evaluating the effectiveness of Smoke-Free Home SafeCare, an integrated intervention, among families at risk for secondhand smoke exposure and child maltreatment in the United States: a study protocol for a hybrid type 1 trial

BACKGROUND

Secondhand smoke exposure (SHS) and child maltreatment (CM) are preventable yet have negative lifelong impacts on health. When considered together, the risk for negative health outcomes may be compounded, especially for people living in low-resource settings. Evidence-based interventions exist for preventing CM and reducing SHS among families with low resources; however, no programs jointly target SHS exposure and maltreatment risk.

METHODS

This study is a hybrid type 1 trial to examine the effectiveness of a systematically braided intervention to target CM risk and SHS in the home. Fifty SafeCare Providers will be randomized to deliver either standard SafeCare (i.e., the SafeCare model alone; active treatment control; n = 25) or Smoke-Free Home SafeCare (SFHSC; treatment condition; n = 25), the braided intervention that includes both SafeCare and the Smoke-Free Homes: Some Things are Better Outside intervention to N = 500 families. Aim 2 is to assess family-level outcomes. The primary outcome is a full home smoking ban, validated by air nicotine monitors; secondary outcomes include parenting and smoking outcomes. Aim 3 is to evaluate process and implementation outcomes, including cost-benefit. We will use multilevel models and ROC analyses to evaluate and validate the primary outcome. We will use tests of non-inferiority to evaluate secondary outcomes. Cost-effectiveness analyses will be used to assess cost-benefit of SFHSC.

DISCUSSION

This study will be the first to document the outcomes of a multi-component intervention to address cumulative risk factors that impact cancer risk among children whose parents are at risk or involved in child-protective services. Integrating an evidence-based intervention that targets SHS exposure in the home with a broadly disseminated CM prevention intervention may be a sustainable way to help reduce the compounded effects of SHS in the home and CM.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT05000632. Registered on August 11, 2021.

Cancer health awareness through screening and education: A community approach to healthy equity

BACKGROUND

The Cancer Health Awareness through screeNinG and Education (CHANGE) initiative delivers cancer awareness education with an emphasis on modifiable risk factors and navigation to screening for prostate, breast, and colorectal cancers to residents of public housing communities who experience significant negative social determinants of health.

METHODS

Residents of five communities participated. Community advisory board members were recruited and provided feedback to local environmental change projects, recruitment, and community engagement at each site. At each site, four education sessions were provided by trained facilitators on cancer risk factors and etiology, racial disparities, eligibility for cancer screening, and participation in clinical trials. Attendance, knowledge, attitudes and beliefs about cancer, and height, weight, and waist circumference were measured at baseline and 1-week post-CHANGE sessions.

RESULTS

90 residents (60% 65 and older years old, 33% male, 60% High School education, 93% AA) participated in the program. 95% completed post-intervention evaluation. Participants were eligible for breast (n = 12), prostate (n = 15), and colorectal screening (n = 25) based on American Cancer Society guidelines, and 22 for tobacco cessation; 21 participants accepted navigation assistance for these services. At post-test, participants significantly increased in knowledge and behaviors around obesity/overweight risk for cancer, nutrition, and physical activity. Colorectal, prostate, and breast cancer knowledge scores also increased, but were not significant.

CONCLUSIONS

CHANGE participants demonstrated improved health knowledge and intentions to improve their modifiable health behaviors. Participants reported being motivated and confident in seeking preventive care and satisfaction with community engagement efforts. Replication of this project in similar communities may improve knowledge and health equity among underserved populations.

Smoke-free home restrictions in Armenia and Georgia: motives, barriers and secondhand smoke reduction behaviors

BACKGROUND

Promoting smoke-free homes (SFHs) in Armenia and Georgia is timely given high smoking and secondhand smoke exposure (SHSe) rates and recent national smoke-free policy implementation. This study examined theoretical predictors (e.g. motives, barriers) of SFH status, and among those without SFHs, past 3-month SFH attempts and intent to establish SFHs in the next 3 months.

METHODS

Multilevel logistic regression analyzed these outcomes using 2022 survey data from 1467 adults (31.6% past-month smokers) in Armenia (n = 762) and Georgia (n = 705). Correlates of interest included SHSe reduction behaviors and SFH motives and barriers; models controlled for country, community, age, sex, smoking status and other smokers in the home.

RESULTS

In this sample, 53.6% had SFHs (Armenia: 39.2%; Georgia: 69.2%). Among those without SFHs, one-fourth had partial restrictions, no smokers in the home and/or recent SFH attempts; 35.5% intended to establish SFHs; and ∼70% of multiunit housing residents supported smoke-free buildings. We documented common SHSe reduction behaviors (opening windows, limiting smoking areas), SFH motives (prevent smell, protect children/nonsmokers) and barriers (smokers' resistance). Correlates of SFHs were being from Georgia, other smokers in the home, fewer SHSe reduction behaviors, greater motives and fewer barriers. Among participants without SFHs, correlates of recent SFH attempts were other smokers in the home, greater SHSe reduction behaviors and SFH motives, and fewer barriers; correlates of SFH intentions were being female, greater SHSe reduction behaviors, greater motives, and fewer barriers.

CONCLUSIONS

SFH interventions should address motives, barriers and misperceptions regarding SHSe reduction behaviors. Moreover, smoke-free multiunit housing could have a great population impact.

Theory-based correlates of cannabis use and intentions among US and Israeli adults: a mixed methods study

BACKGROUND

In the US and Israel, non-medical ('recreational') cannabis use is illegal at the national level; however, use rates are high and decriminalization and legalization is spreading. Thus, theory-based intervention efforts, especially for youth prevention, are crucial.

METHODS

This mixed-methods study of adults in the US (n = 1,128) and Israel (n = 1,094) analyzed: 1) cross-sectional survey data (Fall 2021) to identify theory-based correlates (risk perceptions, social norms) of past-month cannabis use, next-year use intentions, and intentions to use in the home or among children if non-medical cannabis was legal, using multivariable regression; and 2) qualitative interviews regarding perceptions of cannabis policies and use (US n = 40, Israel n = 44).

RESULTS

16.7% reported past-month use; 70.5%, 56.3%, and 82.6% indicated "not at all likely" regarding next-year use and use in the home and among children if legal. Lower perceived risk and greater social norms were associated with past-month use, greater use intentions, and greater intentions to use in the home or among children. Past-month use was more prevalent among US (vs. Israeli) participants (22.0% vs. 11.2%); however, in multivariable regression controlling for past-month use, being from Israel was associated with greater use intentions (next-year; in the home/among children). Qualitative themes indicated: concerns about use (e.g., increasing use, health risks, driving-related risks) and legalization (e.g., impact on society/economy, marketing), and perceived benefits of use (e.g., medical) and legalization (e.g., access/safety, economic, individual rights).

CONCLUSIONS

Despite differences in cannabis perceptions and use across countries, perceived risk and social norms are relevant intervention targets regardless of sociopolitical context.

Promoting Smoke-Free Environments: The Impact of Thirdhand Smoke Awareness on Smoking Bans at Home

OBJECTIVE

A creating smoke-free home is a way to protect a vulnerable group from being exposed to secondhand smoke in the home, such as children, infants, and non-smokers. Studies reported an intervention for promoting a smoke-free home by using secondhand smoke messages and smoking cessation messages. However, the thirdhand smoke (THS) message has rarely been found. Therefore, this study aimed to explore the prevalence and correlations of smoking bans in homes.

METHODS

Secondary data from a community-based cross-sectional design survey was used for this study. Smoking ban status was defined as a smoking ban or no smoking ban. We used multiple logistic regression to test the association between factors and smoking ban status. An adjusted odd ratio and 95% confidence interval were reported.

RESULTS

Of the 882 participants included in this analysis, 38.66% (95%CI: 35.43, 41.97) had a smoking ban at home. A multiple logistic regression analysis showed that participants who believe that secondhand or THS harms children had a greater correlation with developing a smoking ban in the home compared with those who did not believe (odd ratio: 3.94, 95% confidence interval: 2.35, 6.60 and odd ratio:4.22, 95% confidence interval:2.6, 6.86, respectively).

CONCLUSION

This study found that the belief that thirdhand smoke and secondhand smoke exposure harm children. The smoke-free home message's relevance to the harms of thirdhand smoke exposure should be adapted to be promoted, especially in homes.

Systematic braiding of Smoke-Free Home SafeCare to address child maltreatment risk and secondhand smoke exposure: findings from a pilot study

BACKGROUND

Exposure to secondhand tobacco smoke (SHS) and child maltreatment are preventable threats to child health. Few evidence-based interventions target both SHS and child maltreatment risk. The purpose of this paper is to describe the systematic braiding process of two evidence-based programs to address child SHS in the home and maltreatment perpetration risk, and present results from the formative work and pilot study.

METHODS

The first 4 steps of the systematic braiding process were completed, including the following: (1) the identification of core elements of both programs, (2) the development of an initial draft of the braided curriculum (Smoke-Free Home SafeCare - SFH-SC), (3) an acceptability and feasibility pilot of SFH-SC with caregivers of young children who reported a smoker living in the home (N = 8), and (4) feedback collection on the braided curriculum from SafeCare Providers (N = 9).

RESULTS

Experts identified common pedagogical and theoretical underpinnings for the two programs and braided Smoke-Free Homes: Some Things Are Better Outside into two SafeCare modules. Caregiver feedback from the pilot demonstrated that participants were engaged with SFH-SC and felt supported and comfortable discussing SHS intervention content with the SFH-SC Provider. Caregiver self-reports indicated a slight increase in smoke-free home rules from baseline to follow-up and a notable reduction in parent stress on the Parent Stress Index of 5.9 points (SD = 10.2). SafeCare Provider feedback following intensive review of the curriculum indicated high feasibility for SFH-SC delivery.

CONCLUSIONS

Parent and Provider findings suggest SFH-SC is a viable intervention that has potential to reduce the public health impact of SHS and child maltreatment for at-risk families.

PROTOCOL

The protocol for the pilot is not published elsewhere; however, the full protocol for the hybrid trial can be found here: https://clinicaltrials.gov/ct2/show/NCT05000632 .

TRIAL REGISTRATION

NCT, NCT05000632. Registered 14 July 2021, there is not a separate registration number for the pilot.

Evaluation of a 2-1-1 Telephone Navigation Program to Increase Cancer Control Behaviors: Results From a Randomized Controlled Trial

PURPOSE

To evaluate the effectiveness of a telephone navigation intervention for increasing use of cancer control services among underserved 2-1-1 callers.

DESIGN

Randomized controlled trial.

SETTING

2-1-1 call centers in Houston and Weslaco, Texas (located in the Rio Grande Valley near the Mexican border).

PARTICIPANTS

2-1-1 callers in need of Pap test, mammography, colorectal cancer screening, smoking cessation counseling, and/or HPV vaccination for a daughter (n = 1,554). A majority were low-income and described themselves as Black or Hispanic.

INTERVENTION

Participants were randomly assigned to receive either a cancer control referral for the needed service(s) with telephone navigation from a trained cancer control navigator (n = 995) or a referral only (n = 559).

MEASURES

Uptake of each individual service and any needed service.

ANALYSIS

Assessed uptake in both groups using bivariate chi-square analyses and multivariable logistic regression analyses, adjusted for sociodemographic covariates. Both per-protocol and intent-to-treat approaches were used.

RESULTS

Both interventions increased cancer control behaviors. Referral with navigation intervention resulted in significantly greater completion of any needed service (OR = 1.38; p = .042), Pap test (OR = 1.56; p = .023), and smoking cessation counseling (OR = 2.66; p = .044), than referral-only condition. Other outcomes showed the same trend although the difference was not statistically significant: mammography (OR = 1.53; p = .106); colorectal cancer screening (OR = 1.80; p = .095); and HPV vaccination of a daughter (OR = 1.61; p = .331).

CONCLUSION

Adding cancer control referrals and navigation to an informational service like the 2-1-1 program can increase overall participation in cancer control services.

Smoke-Free Home Intervention in Permanent Supportive Housing: A Multifaceted Intervention Pilot

INTRODUCTION

Smoke-free homes (SFHs), the voluntary adoption of home smoking restrictions, are associated with reduced secondhand smoke exposure. However, SFHs are uncommon in permanent supportive housing (PSH) for formerly homeless adults, who have fivefold higher smoking rates than the general population. We pilot-tested a brief intervention to increase voluntary adoption of SFHs among PSH residents in the San Francisco Bay Area.

AIMS AND METHODS

We pilot-tested a brief intervention to increase voluntary adoption of SFHs among PSH residents in the San Francisco Bay Area. Rest of the methods, PSH residents (n = 100) and staff (n = 62) from 15 PSH sites participated in the intervention between October 2017 and February 2018. Research staff provided counseling to PSH residents on how to adopt an SFH and trained PSH staff on how to counsel residents on smoking cessation. The primary outcome was self-reported voluntary adoption of an SFH for ≥90 days, and the secondary outcome was carbon monoxide-verified PPA at 6-month follow-up. PSH staff completed the Smoking Knowledge, Attitudes, and Practices survey at baseline and 3-month follow-up.

RESULTS

At 6 months, 31.3% of PSH residents had adopted an SFH (vs. 13.0% at baseline) and 16.9% reported carbon monoxide-verified PPA. A positive attitude toward an SFH policy was associated with increased odds of SFH adoption (adjusted odds ratio = 8.68, 95% confidence interval: 2.42, 31.17). Voluntary SFH adoption was associated with increased PPA (adjusted odds ratio = 26.27, 95% confidence interval: 3.43, 201.30). PSH staff reported improved attitudes toward and self-efficacy in delivering cessation care, and decreased barriers to discussing smoking cessation among PSH residents between baseline and 3-month follow-up.

CONCLUSIONS

In this single-arm study, a brief intervention increased SFH adoption and PPA among PSH residents.

IMPLICATIONS

To date, few interventions have addressed SFHs and their association with tobacco use among PSH residents. A "ground-up" approach that relies on buy-in from residents and that promotes voluntary SFHs is an innovative way to increase smoke-free living environments in PSH. This approach could pave a pathway for smoke-free policy implementation in these sites. PSH can play a role in reducing the burden of tobacco use by empowering its residents to adopt voluntary SFHs, which could increase smoking cessation among residents.

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.

Disseminating a Smoke-free Homes Program to Low Socioeconomic Status Households in the United States Through 2-1-1: Results of a National Impact Evaluation

INTRODUCTION

Given homes are now a primary source of secondhand smoke (SHS) exposure in the United States, research-tested interventions that promote smoke-free homes should be evaluated in real-world settings to build the evidence base for dissemination. This study describes outcome evaluation results from a dissemination and implementation study of a research-tested program to increase smoke-free home rules through US 2-1-1 helplines.

METHODS

Five 2-1-1 organizations, chosen through a competitive application process, were awarded grants of up to $70 000. 2-1-1 staff recruited participants, delivered the intervention, and evaluated the program. 2-1-1 clients who were recruited into the program allowed smoking in the home, lived in households with both a smoker and a nonsmoker or child, spoke English, and were at least 18 years old. Self-reported outcomes were assessed using a pre-post design, with follow-up at 2 months post baseline.

RESULTS

A total of 2345 households (335-605 per 2-1-1 center) were enrolled by 2-1-1 staff. Most participants were female (82%) and smokers (76%), and half were African American (54%). Overall, 40.1% (n = 940) reported creating a full household smoking ban. Among the nonsmoking adults reached at follow-up (n = 389), days of SHS exposure in the past week decreased from 4.9 (SD = 2.52) to 1.2 (SD = 2.20). Among the 1148 smokers reached for follow-up, 211 people quit, an absolute reduction in smoking of 18.4% (p < .0001), with no differences by gender.

CONCLUSIONS

Among those reached for 2-month follow-up, the proportion who reported establishing a smoke-free home was comparable to or higher than smoke-free home rates in the prior controlled research studies.

IMPLICATIONS

Dissemination of this brief research-tested intervention via a national grants program with support from university staff to five 2-1-1 centers increased home smoking bans, decreased SHS exposure, and increased cessation rates. Although the program delivery capacity demonstrated by these competitively selected 2-1-1s may not generalize to the broader 2-1-1 network in the United States, or social service agencies outside of the United States, partnering with 2-1-1s may be a promising avenue for large-scale dissemination of this smoke-free homes program and other public health programs to low socioeconomic status populations in the United States.

Use of Telephone and Digital Channels to Engage Socioeconomically Disadvantaged Adults in Health Disparities Research Within a Social Service Setting: Cross-Sectional Study

Background

Engaging socioeconomically disadvantaged populations in health research is vital to understanding and, ultimately, eliminating health-related disparities. Digital communication channels are increasingly used to recruit study participants, and recent trends indicate a growing need to partner with the social service sector to improve population health. However, few studies have recruited participants from social service settings using multiple digital channels.

Objective

This study aimed to recruit and survey 3791 adult clients of a social service organization via telephone and digital channels. This paper aimed to describe recruitment outcomes across five channels and compare participant characteristics by recruitment channel type.

Methods

The Cancer Communication Channels in Context Study recruited and surveyed adult clients of 2-1-1, a social service–focused information and referral system, using five channels: telephone, website, text message, web-based live chat, and email. Participants completed surveys administered either by phone (if recruited by phone) or on the web (if recruited from digital channels, ie, website, text message, Web-based live chat, or email). Measures for the current analysis included demographic and health characteristics.

Results

A total of 3293 participants were recruited, with 1907 recruited by phone and 1386 recruited from digital channels. Those recruited by phone had a moderate study eligibility rate (42.23%) and the highest survey completion rate (91.24%) of all channels. Individuals recruited by text message had a high study eligibility rate (94.14%) yet the lowest survey completion rate (74.0%) of all channels. Sample accrual goals were achieved for phone, text message, and website recruitment. Multivariable analyses found differences in participant characteristics by recruitment channel type. Compared with participants recruited by phone, those recruited from digital channels were younger (adjusted odds ratio [aOR] 0.96, 95% CI 0.96-0.97) and more likely to be female (aOR 1.52, 95% CI 1.23-1.88), married (aOR 1.52, 95% CI 1.22-1.89), and other than non-Hispanic black (aOR 1.48, 95% CI 1.22-1.79). Those recruited via phone also were more likely to have more than a high school education (aOR 2.17, 95% CI 1.67-2.82), have a household income ≥US $25,000 a year (aOR 2.02, 95% CI 1.56-2.61), and have children living in the home (aOR 1.26, 95% CI 1.06-1.51). Additionally, participants recruited from digital channels were less likely than those recruited by phone to have public health insurance (aOR 0.75, 95% CI 0.62-0.90) and more likely to report better overall health (aOR 1.52, 95% CI 1.27-1.83 for good-to-excellent health).

Conclusions

Findings indicate the feasibility and utility of recruiting socioeconomically disadvantaged adults from the social service sector using multiple communication channels, including digital channels. As social service–based health research evolves, strategic recruitment using a combination of traditional and digital channels may be warranted to avoid underrepresentation of highly medically vulnerable individuals, which could exacerbate disparities in health.

Moderators of Establishing a Smoke-Free Home: Pooled Data from Three Randomized Controlled Trials of a Brief Intervention

Interventions to create smoke-free homes typically focus on parents, involve multiple counseling sessions and blend cessation and smoke-free home messages. Smoke-Free Homes: Some Things are Better Outside is a minimal intervention focused on smokers and nonsmokers who allow smoking in the home, and emphasizes creation of a smoke-free home over cessation. The purpose of this study is to conduct moderator analyses using pooled data from three randomized controlled trials of the intervention conducted in collaboration with 2-1-1 contact centers in Atlanta, North Carolina and Houston. 2-1-1 is a strategic partner for tobacco control as it connects over 15 million clients, largely socio-economically disadvantaged, to social and health resources each year. A total of 1506 2-1-1 callers participated across the three intervention trials. Outcomes from 6 months intent-to-treat analyses were used to examine whether sociodemographic variables and smoking-related characteristics moderated effectiveness of the intervention in establishing full home smoking bans. Intervention effectiveness was not moderated by race/ethnicity, education, income, children in the home or number of smokers in the home. Smoking status of the participant, however, did moderate program effectiveness, as did time to first cigarette. Number of cigarettes per day and daily versus nondaily smoking did not moderate intervention effectiveness. Overall, the intervention was effective across socio-demographic groups and was effective without respect to daily versus nondaily smoking or number of cigarettes smoked per day, although smoking status and level of nicotine dependence did influence effectiveness.

Adaptation of a brief smoke-free homes intervention for American Indian and Alaska Native families

BACKGROUND

The goal of adaptation is to maintain the effectiveness of the original intervention by preserving the core elements that account for its success while delivering an intervention that is tailored to the new community and/or cultural context. The current study describes the process of adapting an evidence-based smoke-free homes (SFH) intervention for use in American Indian/Alaska Native (AI/AN) households.

METHODS

We followed a systematic adaptation process. We first assessed the community through focus groups coordinated in collaboration with tribal partners. Because our team included the original developers of the intervention, the steps of understanding the intervention, selecting the intervention and consulting with experts were simplified. Additional steps included consulting with stakeholders through a national work group and collaboratively deciding what needed adaptation.

RESULTS

A number of key themes pertinent to the adaptation of the SFH intervention were identified in the focus groups. These included the gravity of messaging about commercial tobacco use; respect, familialism, and intergenerationalism; imagery, including significant symbolism, colors, and representative role models; whether and how to address traditional tobacco; and, barriers to a SFH not adequately addressed in the original materials.

CONCLUSIONS

Adaptation of an intervention to create smoke-free homes in AI/AN families necessitated both surface structure changes such as appearance of role models and deep structure changes that addressed core values, and beliefs and traditions.

A cross-sectional study of the relationship of proximal smoking environments and cessation history, plans, and self-efficacy among low-income smokers

Introduction

Proximal environments could facilitate smoking cessation among low-income smokers by making cessation appealing to strive for and tenable.

Aims

We sought to examine how home smoking rules and proximal environmental factors such as other household members' and peers' smoking behaviors and attitudes related to low-income smokers' past quit attempts, readiness, and self-efficacy to quit.

Methods

This analysis used data from Offering Proactive Treatment Intervention (OPT-IN) (randomized control trial of proactive tobacco cessation outreach) baseline survey, which was completed by 2,406 participants in 2011/12. We tested the associations between predictors (home smoking rules and proximal environmental factors) and outcomes (past-year quit attempts, readiness to quit, and quitting self-efficacy).

Results

Smokers who lived in homes with more restrictive household smoking rules, and/or reported having 'important others' who would be supportive of their quitting, were more likely to report having made a quit attempt in the past year, had greater readiness to quit, and greater self-efficacy related to quitting.

Conclusions

Adjustments to proximal environments, including strengthening household smoking rules, might encourage cessation even if other household members are smokers.

Steps Toward Scalability: Illustrations From a Smoke-Free Homes Program

Scalable interventions remain effective across a range of real-world settings and can be modified to fit organizational and community context. "Smoke-Free Homes: Some Things are Better Outside" has been effective in promoting smoke-free home rules in low-income households in efficacy, effectiveness, generalizability, and dissemination studies. Using data from a dissemination study in collaboration with five 2-1-1 call centers in Ohio, Florida, Oklahoma, and Alabama (n = 2,345 households), this article examines key dimensions of scalability, including effectiveness by subpopulation, secondary outcomes, identification of core elements driving effectiveness, and cost-effectiveness. Evaluated by 2-1-1 staff using a pre-post design with self-reported outcomes at 2 months postbaseline, the program was equally effective for men and women, across education levels, with varying number of smokers in the home, and whether children were present in the home or not. It was more effective for nonsmokers, those who smoked fewer cigarettes per day, and African Americans. Creating a smoke-free home was associated with a new smoke-free vehicle rule (odds ratio [OR] = 3.38, confidence interval [CI 2.58, 4.42]), decreased exposure to secondhand smoke among nonsmokers (b = -2.33, p < .0001), and increased cessation among smokers (OR = 5.8, CI [3.81, 8.81]). Use of each program component was significantly associated with success in creating a smoke-free home. Using an intent-to-treat effect size of 40.1%, program benefits from 5 years of health care savings exceed program costs yielding a net savings of $9,633 for delivery to 100 households. Cost effectiveness, subpopulation analyses, and identification of core elements can help in assessing the scalability potential of research-tested interventions such as this smoke-free homes program.

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.

Implementing an Evidence-based Tobacco Control Program at Five 2-1-1 Call Centers: An Evaluation Using the Consolidated Framework for Implementation Research

Introduction

The Smoke-Free Homes (SFH) Program is an evidence-based intervention offered within 2-1-1 information and referral call centers to promote smoke-free homes in low-income populations. We used the Consolidated Framework for Implementation Research to conduct a mixed-methods analysis of facilitators and barriers to scaling up SFH to five 2-1-1 sites in the United States.

Methods

Data were collected from staff in 2015-2016 via online surveys administered before (N = 120) and after SFH training (N = 101) and after SFH implementation (N = 79). Semi-structured telephone interviews were conducted in 2016 with 25 staff to examine attitudes towards SFH, ways local context affected implementation, and unintended benefits and consequences of implementing SFH.

Results

Post-implementation, 79% of respondents reported that SFH was consistent with their 2-1-1's mission, 70% thought it led to more smoke-free homes in their population, 62% thought it was easy to adapt, and 56% thought participants were satisfied. Composite measures of perceived appropriateness of SFH for 2-1-1 callers and staff positivity toward SFH were significantly lower post-implementation than pre-implementation. In interviews, staff said SFH fit with their 2-1-1's mission but expressed concerns about intervention sustainability, time and resources needed for delivery, and how SFH fit into their workflow.

Conclusions

Sites' SFH implementation experiences were affected both by demands of intervention delivery and by SFH's perceived effectiveness and fit with organizational mission. Future implementation of SFH and other tobacco control programs should address identified barriers by securing ongoing funding, providing dedicated staff time, and ensuring programs fit with staff workflow.

Implications

Smoke-free home policies reduce exposure to secondhand smoke. Partnering with social service agencies offers a promising way to scale up evidence-based smoke-free home interventions among low-income populations. We found that the SFH intervention was acceptable and feasible among multiple 2-1-1 delivery sites. There were also significant challenges to implementation, including site workflow, desire to adapt the intervention, time needed for intervention delivery, and financial sustainability. Addressing such challenges will aid future efforts to scale up evidence-based tobacco control interventions to social service agencies such as 2-1-1.

Educational attainment & quitting smoking: A structural equation model approach

In the United States, disparities in smoking prevalence and cessation by socioeconomic status are well documented, but there is limited research on reasons why and none conducted in a national sample assessing multiple potential mechanisms. We identified smoking and cessation-related behavioral and environmental variables associated with both educational attainment and quitting success. We used a structural equation model of cross-sectional data from respondents ≥25 years from the United States 2010-2011 Tobacco Use Supplement-Current Population Survey. Quitting success was defined as former (n = 2607) versus continuing smokers (n = 7636); categories of educational attainment were ≤high school degree, some college/college degree, and advanced degree. Results indicated that using nicotine replacement therapy (NRT) >1 month and having a home smoking restriction were associated with both educational attainment and quitting success. Those with lower educational attainment versus those with an advanced degree were less likely to report using NRT >1 month (≤high school: β = -0.50, p < 0.001; college: β = -0.24, p = 0.019). Use of NRT >1 month, in turn, was positively associated with quitting success (β = 0.25, p < 0.001). Those with lower educational attainment were also less likely to report a home smoking restriction (≤high school: β = -0.42, p < 0.001; college: β = -0.21, p = 0.009). Having a home smoking restriction was positively associated with quitting success (β = 0.50, p < 0.001). Results were similar with income substituted for education. Using NRT >1 month and having a home smoking restriction are two strategies that may explain the association between low education and lower cessation success; these strategies should be further tested for their potential ability to mitigate this association.

Cessation and reduction in smoking behavior: impact of creating a smoke-free home on smokers

The aim of this study was to assess the effect of a creating a smoke-free home (SFH) on cessation and reduction of cigarette smoking on low-income smokers. This secondary data analysis uses data from study participants who were originally recruited through 2-1-1 information and referral call centers in Atlanta (Georgia, 2013), North Carolina (2014) and the Texas Gulf Coast (2015) across three randomized controlled trials testing an intervention aimed at creating SFHs, pooling data from 941 smokers. Participants who reported adopting a SFH were more likely to report quitting smoking than those who did not adopt a SFH. This was true at 3-month follow-up and even more pronounced at 6-month follow-up and persisted when considering only those who consistently reported no smoking at 3 and 6 months. Among those who did not stop smoking, the number of cigarettes per day declined significantly more and quit attempts were more frequent for those who created a SFH compared with those who did not. Findings suggest that creating a SFH facilitates cessation, reduces cigarette consumption and increases quit attempts. Future studies should assess the long-term impact of SFHs on sustaining cessation.

Household Implementation of Smoke-Free Rules in Homes and Cars: A Focus on Adolescent Smoking Behavior and Secondhand Smoke Exposure

PURPOSE

This study addresses the dearth of population-based research on how comprehensive household smoke-free rules (ie, in the home and car) relate to tobacco use and secondhand smoke (SHS) exposure among adolescents.

DESIGN

Analysis of 2014 Minnesota Youth Tobacco Survey.

SETTING

Representative sample of Minnesota youth.

PARTICIPANTS

A total of 1287 youth who lived with a smoker.

MEASURES

Measures included household smoke-free rules (no rules, partial rules-home or car, but not both-and comprehensive rules), lifetime and 30-day cigarette use, 30-day cigarette and other product use, and SHS exposure in past 7 days in home and car.

ANALYSIS

Weighted multivariate logistic, zero-inflated Poisson, and zero-inflated negative binomial regressions were used.

RESULTS

Compared to comprehensive rules, partial and no smoke-free rules were significantly and positively related to lifetime cigarette use (respectively, adjusted odds ratio [AOR] = 1.80, 95% confidence interval [CI] = 1.24-2.61; AOR = 2.87, 95% CI = 1.93-4.25), and a similar significant pattern was found for 30-day cigarette use (respectively, AOR = 2.20, 95% CI = 1.21-4.02; AOR = 2.45, 95% CI = 1.34-4.50). No smoke-free rules significantly predicted using cigarettes and other tobacco products compared to comprehensive rules. In both descriptive and regression analyses, we found SHS exposure rates in both the home and car were significantly lower among youth whose household implemented comprehensive smoke-free rules.

CONCLUSIONS

Comprehensive smoke-free rules protect youth from the harms of caregiver tobacco use. Relative to both partial and no smoke-free rules, comprehensive smoke-free rules have a marked impact on tobacco use and SHS exposure among youth who live with a smoker. Health promotion efforts should promote comprehensive smoke-free rules among all households and particularly households with children and adolescents.

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.

Family and carer smoking control programmes for reducing children's exposure to environmental tobacco smoke

BACKGROUND

Children's exposure to other people's tobacco smoke (environmental tobacco smoke, or ETS) is associated with a range of adverse health outcomes for children. Parental smoking is a common source of children's exposure to ETS. Older children in child care or educational settings are also at risk of exposure to ETS. Preventing exposure to ETS during infancy and childhood has significant potential to improve children's health worldwide.

OBJECTIVES

To determine the effectiveness of interventions designed to reduce exposure of children to environmental tobacco smoke, or ETS.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register and conducted additional searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Education Resource Information Center (ERIC), and the Social Science Citation Index & Science Citation Index (Web of Knowledge). We conducted the most recent search in February 2017.

SELECTION CRITERIA

We included controlled trials, with or without random allocation, that enrolled participants (parents and other family members, child care workers, and teachers) involved in the care and education of infants and young children (from birth to 12 years of age). All mechanisms for reducing children's ETS exposure were eligible, including smoking prevention, cessation, and control programmes. These include health promotion, social-behavioural therapies, technology, education, and clinical interventions.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies and extracted data. Due to heterogeneity of methods and outcome measures, we did not pool results but instead synthesised study findings narratively.

MAIN RESULTS

Seventy-eight studies met the inclusion criteria, and we assessed all evidence to be of low or very low quality based on GRADE assessment. We judged nine studies to be at low risk of bias, 35 to have unclear overall risk of bias, and 34 to have high risk of bias. Twenty-one interventions targeted populations or community settings, 27 studies were conducted in the well-child healthcare setting and 26 in the ill-child healthcare setting. Two further studies conducted in paediatric clinics did not make clear whether visits were made to well- or ill-children, and another included visits to both well- and ill-children. Forty-five studies were reported from North America, 22 from other high-income countries, and 11 from low- or middle-income countries. Only 26 of the 78 studies reported a beneficial intervention effect for reduction of child ETS exposure, 24 of which were statistically significant. Of these 24 studies, 13 used objective measures of children's ETS exposure. We were unable to pinpoint what made these programmes effective. Studies showing a significant effect used a range of interventions: nine used in-person counselling or motivational interviewing; another study used telephone counselling, and one used a combination of in-person and telephone counselling; three used multi-component counselling-based interventions; two used multi-component education-based interventions; one used a school-based strategy; four used educational interventions, including one that used picture books; one used a smoking cessation intervention; one used a brief intervention; and another did not describe the intervention. Of the 52 studies that did not show a significant reduction in child ETS exposure, 19 used more intensive counselling approaches, including motivational interviewing, education, coaching, and smoking cessation brief advice. Other interventions consisted of brief advice or counselling (10 studies), feedback of a biological measure of children's ETS exposure (six studies), nicotine replacement therapy (two studies), feedback of maternal cotinine (one study), computerised risk assessment (one study), telephone smoking cessation support (two studies), educational home visits (eight studies), group sessions (one study), educational materials (three studies), and school-based policy and health promotion (one study). Some studies employed more than one intervention. 35 of the 78 studies reported a reduction in ETS exposure for children, irrespective of assignment to intervention and comparison groups. One study did not aim to reduce children's tobacco smoke exposure but rather sought to reduce symptoms of asthma, and found a significant reduction in symptoms among the group exposed to motivational interviewing. We found little evidence of difference in effectiveness of interventions between the well infant, child respiratory illness, and other child illness settings as contexts for parental smoking cessation interventions.

AUTHORS' CONCLUSIONS

A minority of interventions have been shown to reduce children's exposure to environmental tobacco smoke and improve children's health, but the features that differentiate the effective interventions from those without clear evidence of effectiveness remain unclear. The evidence was judged to be of low or very low quality, as many of the trials are at a high risk of bias, are small and inadequately powered, with heterogeneous interventions and populations.

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.

Coaching to create a smoke-free home in a brief secondhand smoke intervention

Few community interventions exist to reduce secondhand exposure to tobacco smoke in the home. This study presents the coaching process of a larger intervention to promote smoke-free homes across an efficacy and 2 effectiveness trials. It furthers assesses the coaching call's reach and participants' satisfaction with the call across three intervention sites. The sources of the data were from baseline and 3-month follow-up surveys, coaching forms or online tracking system and interviews with coaches. Reach for the coaching call across trials was fairly high from 72% to 92%. Overall, the majority of participants were highly satisfied with the intervention (M = 3.76) and found it useful in creating a smoke-free home (M = 3.63). Common goals set were changing the environment to support a home smoking ban (e.g. putting up signs, removing ashtrays) (82%) or picking a date (60%). Challenges to a smoke-free home were consistent with other literature on barriers related to household smoking restrictions, including need for assistance in quitting, outside weather and smokers who do not want to quit. Additional research is needed to explore differential reach and reactions to the coaching call as it is disseminated and the impact of coaching call on the outcome of a smoke-free home.