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.

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.

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.

Do partial home smoking bans signal progress toward a smoke-free home?

Understanding who establishes partial home smoking bans, what these bans cover, and whether they are an intermediate step in going smoke-free would help to inform smoke-free home interventions. Participants were recruited from United Way of Greater Atlanta's 2-1-1 contact center. Data were collected at baseline, 3 and 6 months via telephone interview. Participants (n = 375) were mostly African American (84.2%) and female (84.3%). The majority (58.5%) had annual household incomes <$10,000. At baseline, 61.3% reported a partial smoking ban and 38.7% reported no ban. Existence of a partial ban as compared with no ban was associated with being female, having more than a high school education, being married and younger age. Partial bans most often meant smoking was allowed only in designated rooms (52.6%). Other common rules included: no smoking in the presence of children (18.4%) and smoking allowed only in combination with actions such as opening a window or running a fan (9.8%). A higher percentage of households with partial bans at baseline were smoke-free at 6 months (36.5%) compared with households with no bans at baseline (22.1%). Households with partial smoking bans may have a higher level of readiness to go smoke-free than households with no restrictions.