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National Cancer Institute

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

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

Organization: Emory University

Grant Number: 1U01CA154282

Principal Investigator: Michelle Kegler

Note: The descriptions in this section were provided by the principal investigator and are not maintained or updated by NCI.

Co-Investigators
Carla Berg, Emory University
Cam Escoffery, Emory University
Rebecca Williams, University of North Carolina at Chapel Hill
Patricia Mullen, University of Texas
Matthew Kreuter, Washington University in St Louis
Kurt Ribisl, University of North Carolina at Chapel Hill
Maria Fernandez, University of Texas

Project Website: Sample intervention materials can be ordered at http://smokefreehomes.emory.edu/. exit disclaimer This site also hosts a training on smoke-free homes for foster care parents.

Study Summary
Dr. Kegler and her research team have helped to fill an important gap in tobacco control research by testing a large-scale, non–clinic-based, brief intervention to create smoke-free home policies through use of the existing national 211 infrastructure.

Research Aims and Methods                                                                     

  • Conduct formative research on intervention messages and materials for promoting smoke-free homes in low-income populations, applicable to both smokers and nonsmokers as household change agents.
  • Conduct a randomized control trial in the Atlanta 211 service area to evaluate the efficacy of a brief intervention to create smoke-free homes among 211 callers.
  • Conduct replication studies in Houston and North Carolina 211 systems to test the effectiveness of the intervention in varied populations and tobacco control climates.
  • Disseminate the research-tested smoke-free homes intervention to public health programs and practitioners.

Target Population: Low-income families with at least one smoker and one nonsmoker in the household

Key Findings

  • The Atlanta Efficacy Trial (n = 498) was the first of three trials designed to show the efficacy of the brief Smoke-Free Homes: Some Things are Better Outside Program with information and referral specialists from United Way of Greater Atlanta 211 recruiting callers and collecting baseline information while trained university staff delivered the program. The intervention consists of three mailings and one coaching call delivered at 2-week intervals. Results of this study demonstrated a successful intervention program with significantly more intervention group participants banning smoking in the home (40% vs. 25.2%) than control participants at 6-month follow-up (p = .0003). Self-reported smoke-free home bans were validated via air nicotine monitoring.
  • The North Carolina Effectiveness Trial (n = 500) examined the delivery of the Smoke-free Homes Program by trained information and referral specialists from North Carolina 211 and its effect on the adoption of home smoking bans. Intervention group participants were more likely to report a full ban on smoking in the home at 6-month follow-up (43.2% vs. 33.2%, p = .02) as compared to control participants. This replication study supports prior findings of the effectiveness of the minimal intervention to promote smoke-free homes in low-income households, in this case when 211 information and referral specialists delivered the intervention.
  • The Texas Generalization Trial was the second replication study (n = 508) testing the Program’s generalizability in a new context and more diverse population. Call specialists from the 211 Texas/United Way Helpline Gulf Coast recruited callers and delivered the Smoke-Free Homes Program. At 6-month follow-up, 63% of intervention participants had established a home smoking ban compared to 38% of controls (p < .0001). Results of this replication add further evidence that the Program is generalizable to low-income households, including English-speaking Hispanics in Texas.
  • All three studies showed a significant impact in longitudinal intent-to-treat analyses. Related sensitivity analyses in which households with enforcement challenges were classified as failures also showed a significant effect. Among participants who smoked, all three studies showed significant reductions in number of cigarettes smoked per day.
  • In the Atlanta trial, about half of households with newly established smoke-free home rules reported that they were never broken, with the rest reporting that rules were rarely, occasionally, or frequently broken. Violations occurred most frequently because of parties and guests visiting, and smoking occurred most frequently in bathrooms.
  • The project team also administered a National Grants Program with competitively selected 211 centers (Akron, Cleveland, Orlando, Tulsa, and nine centers in Alabama) to adopt, implement, and evaluate the Smoke-Free Home Program. The goal of the National Grants Program was to accelerate dissemination of the Smoke-Free Homes intervention while systematically studying its implementation and effects in diverse 211 systems across the United States.

Key Implications

  • A simple intervention that encourages and supports household members in adopting a smoke-free home rule is successful in a range of contexts. The intervention works when either a smoker or a nonsmoker is the change agent, and also whether children are present in the household or not.
  • The majority of the U.S. population now has smoke-free homes rules, thus this program is easiest to implement in communities with pockets of high smoking rates and/in systems where screening for smoke-free home rules can be routinized into ongoing practices, with referrals to the program for those who allow smoking in the home.
  • 211 systems are innovative partners for tobacco control efforts that are attempting to reach a low-income population.

Original Abstract
The burden of tobacco use falls disproportionately on low-income populations, through high rates of primary smoking and exposure to secondhand smoke. The remarkable progress in creating smoke-free environments in the U.S. over the past two decades has left smokers' homes as a significant source of exposure to secondhand smoke for both children and nonsmoking adults. Intervention research that identifies effective and practical strategies for reaching the minority of households that still allow smoking in the home has considerable potential to reduce exposure to secondhand smoke, but suitable channels to reach low-income families are limited. The proposed research will develop, evaluate and disseminate a brief smoke-free homes intervention through the established national infrastructure of 2-1-1 call centers. 2-1-1 is a nationally designated 3-digit telephone exchange, similar to 9-1-1 for emergencies or 4-1-1 for directory assistance, that links callers to community-based health and social services. Most 2-1-1 callers are low income. The proposed research has four specific aims: 1) Conduct formative research on intervention messages and materials for promoting smoke-free homes in low-income populations, applicable to both smokers and nonsmokers as household change agents; 2) Conduct a randomized controlled trial in the Atlanta 2-1-1 service area to evaluate the efficacy of a brief intervention to create smoke-free homes among 2-1-1 callers; 3) Conduct replication studies in Houston and North Carolina 2-1-1 systems to systematically test the intervention in varied populations and tobacco control climates; and 4) Disseminate the research tested smoke-free homes intervention through a national grants program to 2-1-1 systems and through the Tobacco Technical Assistance Consortium's linkages to the state and local tobacco control infrastructure in the U.S.