Brief Interventions to Create Smoke-Free Home Policies in Low-Income Households

1. Brief Interventions to Create Smoke-Free Home Policies in Low-Income Households Cam Escoffery, PhD, MPH Michelle C. Kegler, DrPH, MPH Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University

2. Secondhand Smoke (SHS) • EPA Class A Carcinogen • Causes Premature Death in Nonsmokers • Lung cancer • Heart disease • Especially Harmful to Children • Increases occurrence of severe asthma and SIDS • Ear infections

3. Disease Burden of SHS Source: International Agency for Research on Cancer & CA EPA, Air Resources Board, 2005

4. Exposure to SHS in the U.S. • Detectable serum cotinine declined from 83.9% of nonsmokers(1988-1994) to 46.4% (1999 -2004) in U.S. population (≥ 4 years of age) • Children aged 4-11 had the smallest decline in exposure to SHS (60.5%) with detectable serum cotinine in 1999-2004 • African Americans more likely to have detectable serum cotinine in 1999-2004; 70.5% compared to 43.0% in non-Hispanic whites and 40.0% in Mexican Americans Note: cotinine is the primary proximate metabolite of nicotine and is an objective biomarker of exposure Source: CDC. Disparities in secondhand smoke exposure-United States, 1988-1994 and 1999-2004, MMWR, 2008; 57(27):744-747.

5. Smoke-Free Home • Private sphere equivalent of a clean indoor air ordinance • Household smoking bans are usually unwritten rules • Voluntary in nature • Total ban definition (Smoke-Free Home): • Smoking is not allowed anywhere inside the home • Partial ban definition: • Smoking allowed in some places or at some times

6. Prevalence of Household Smoking Bans • Nationwide 78.1% of households had total bans in 2008 • 84.7% of non-smokers report a ban • 45.0% of smokers report a ban • Socioeconomic and demographic factors • Higher SES had more bans • African Americans less likely to have bans than other racial and ethnic groups • Presence of children likely to increase ban adoption Source: CDC, 2009

7. Rationale for Intervention Smoke-free homes: • Reduce exposure to secondhand smoke in adult nonsmokers and children • May help smokers to quit • May disrupt the smoking initiation process

8. Smoke-Free Home Interventions To Date • Tobacco control movement focused on policy approach to multi-family dwellings • Smoke-free home efforts part of comprehensive tobacco control and tend to include awareness via media campaigns and smoke-free home pledges (not typically evaluated as stand-alone interventions) • Intervention research often clinic-based, relatively intensive and/or emphasizes cessation • Community Guide concluded “insufficient evidence” for community education to promote smoke-free homes

9. New Project • NCI funding (State and Community Tobacco Control Policy and Media Research-U01) • Builds on work of CPCRN 2-1-1 work group • Key partners include: • University of North Carolina-Chapel Hill (Williams & Ribisl) • University of Texas-Houston (Mullen & Fernandez) • Washington University-St. Louis (Kreuter) • Emory University and Tobacco Technical Assistance Consortium-Atlanta • 2-1-1 organizations in four states • State tobacco control programs in four states

10. Study Aims • Formative research on intervention materials and key messages • Conduct an efficacy trial of the SFH intervention in the Atlanta area 2-1-1 • Conduct effectiveness studies in North Carolina and Houston • Disseminate the intervention

11. Formative Research Plans • Focus groups (2 with smokers and 2 with nonsmokers) • Key messages • Relevance, cultural appropriateness of materials • Interviews with 2-1-1 callers (n=20) • Interviews with 2-1-1 line agents (n=10)

12. Intervention Components At 2 week Intervals • Mailing of Smoke-free Homes Kit (5-step guide, pledge, sign, challenges and solutions, reasons to go smoke-free) • Telephone counseling to motivate & address barriers • Mailing of photonovella • Mailing of newsletter, stickers and third hand smoke info

13. Intervention Strategies Change Process Model of Behavior ChangeBrief Intervention to Create Smoke-free Home Policies in Low-Income Households • Stage of Change • Pre-contemplation • Contemplation • Preparation (Step 1-Decide) • Intervention Targets • Behavioral Capability • Self-efficacy • Outcome expectations for SFH • Smoking behavior • Intervention Components • Mailing 1: A five step guide to making your home smoke-free; Reasons to have a smoke-free home (SFH); Facts about SHS and SFHs; Pledge; Signs • Brief telephone counseling • Mailing #2: Challenges and Solutions Booklet; Photo –novella • Mailing #3: Newsletter; Thirdhand smoke fact sheet; SFH stickers • Discuss with household members (Step 2) • Barriers • Negotiation • Support • Change Strategies • Persuasion • Role modeling • Goal setting • Environmental cues • Reinforcement • Set date/Go smoke-free • (Step 3 and 4) • Cues • Maintain smoke-free home • (Step 5)

19. Eligible Participants for Trials • Current smoker or live with a smoker • Allow at least some smoking in the home • Live with a nonsmoker or child • Speak English • Expect to live in the same household for the next six months, and not be in crisis

20. Flow of Efficacy Trial

21. Flow of Intervention Study (Cont’d)

22. Outcomes • Primary Outcomes • Presence of a self-reported ban • Air nicotine in sub-sample • Secondary Outcomes • Weekly and daily SHS exposure • Self-efficacy to restrict smoking in the home • Beliefs about SHS

23. Secondary Outcomes (Smokers) • Smoking status • Cessation attempts • Cigarette consumption

24. Dissemination Plans • Develop an implementation toolkit for SFH intervention • Conduct a national grants program to encourage adoption among 2-1-1 systems nationwide • Use TTAC infrastructure to disseminate SFH intervention to tobacco control community • Adapt and pilot SFH intervention in other populations and/or channels that reach low-income populations

25. Examples of Dissemination Questions • What factors affect the uptake of the SFH intervention by 2-1-1 centers? • What factors (e.g., organizational, external forces) influence quality implementation of the intervention? • What is the extent of fidelity to the core elements in implementation or of adaptation? • Is the SFH intervention sustained over time in the 2-1-1 centers? What factors are associated with program maintenance?

26. Ideas for Dissemination Research?