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Evidence-Based Healthcare & Public Health (2005) 9, 383–388

1744-2249/$ - sdoi:10.1016/j.e

www.elsevier.com/locate/ebhph

SYSTEMATIC REVIEW

Domestic smoke alarms

Bazian Ltd

London, UK

D Key points Review of the evidence

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Fires in the home are an important cause ofdeath and injury. T � Smoke alarm promotion strategies have not beenshown in any setting to increase smoke alarmownership or the number of acquired or func-tioning smoke alarms. � A There is insufficient evidence on the effect

of strategies to promote smoke alarm useon fire-related injuries and incidence of fires,but these outcomes are unlikely to improveif interventions do not increase smoke alarmuse.

� There is insufficient evidence on the effective-

ness of smoke alarm promotion strategies deliv-ered in schools and in the community. R

� Further randomised controlled trials (RCTs) are

needed before smoke alarm promotion strate-gies are implemented.

T

Background

In England and Wales, fires in the home cause 500fatalities and 15,000 injuries every year.1 Deathrates are particularly high among the very young,the elderly, the disabled and those with lowsocioeconomic status.2–6 There is some evidenceto suggest that smoke alarms alert occupantsearlier when a fire starts and enable them toescape, reducing the risk of death in a house fire bymore than two-thirds.3

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ee front matter & 2005 Elsevier Ltd. All rights reservhbc.2005.09.009

In this review, we examine the effectiveness ofstrategies to promote smoke alarm or detector usein homes.

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Search strategy

We searched for evidence in June 2005, usingMedline; EMBASE; the Cochrane Library; the Data-base of Abstracts of Reviews of Effectiveness; theHealth Technology Assessment Database and theNHS Economic Evaluation Database.

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Inclusion/exclusion criteria

We included systematic reviews and RCTs. Weincluded any interventions that aimed to increasethe use of a functioning smoke alarm and to reducethe incidence of serious fires, and injury and deathfrom fire. We identified a relevant, high qualitysystematic review (search date September 1998).We then searched for randomised controlled trialspublished since September 1998.

Data extraction and synthesis

We extracted data on the effects of interventionson smoke alarm function and ownership, smokealarms acquired, incidence of serious fires and fire-related injuries. The review is narrative.

ed.

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Results

We identified one systematic review7 and threeadditional RCTs.8–10 The systematic review included11 completed RCTs.11–21

The systematic review aimed to evaluate inter-ventions to promote residential smoke alarm use,assessing their effect on smoke alarm ownershipand continuing operation, fires, burns and other

Table 1 Results of selected RCTs from the systematic re

Key features of study Main outcomes

Watson et al.8 There was no significin functioning smokeownership betweengroups. 91.5% with sconsultation plus fresafety equipment v 8care, OR 1.67, 95% C

Interventions: Safety consultationplus free and fitted fire safetyequipment (stair gates, fire guards,smoke alarms, cupboard and windowlocks); usual care.Setting: General practices in UK.Participants: 3428 families withchildren o5 years of age.Outcome: Ownership of functioningsmoke alarm.

DiGuiseppi et al.9 There was no significin fire-related injuriownership, installatibetween treatmentrelated injuries (all i95% CI 0.9 to 1.9; firownership: RR 1.1, 91.30; fire alarm instwith distribution of79% with no interven(significance not repalarm function: 16%of smoke alarms v 1intervention; attend95% CI 0.96 to 1.3.

Interventions: Distribution of smokealarms (with batteries, fittings andfire safety brochures); nointervention.Setting: Inner London, UK.Participants: Homes.Outcome: Incidence of fires, fire-related injuries; alarm ownership,installation and function.

King et al.10 There was no significin smoke alarm ownedetector function betreatment groups Smownership: OR 1.45,2.22 Smoke alarm fu95% CI 0.79 to 1.30

Interventions: Home visit program(including home safety assessment,home injury package, discountedfire safety items); home safetyassessment and general safetypamphletSetting: 4 hospitals in Canada.Participants: Children o8 years ofage.Outcome: smoke alarm ownership;functioning alarms.

Barone et al.11 There was no significin smoke alarm ownfunctioning smoke atreatment groups. Sownership: 94.1% wipromotion v 89.7% weducation, RR 1.05,1.22.

Interventions: Smoke alarmpromotion (slides and handouts onburn prevention); motor vehiclesafety education and video; bathwater thermometer; hot watergauge; usual safety education.Setting: Not reported.

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fire-related injuries. Studies included in the sys-tematic review and the additional RCTs we identi-fied are described in Table 1. The study populationsincluded parents, pregnant women, schoolchildren,elderly people and residents in council or socialhousing. Nine RCTs were carried out from a clinicalsetting,4,8,10–12,14–15,16,20 four in the home9,17–19

and one in a school.13 Of the four RCTs delivered inthe home, one was delivered in community-wide

view and the additional RCTs.

Key quality issues

ant differencealarm

treatmentafetye and fitted6.5% with usualI 1.21 to 2.32.

Only 35% of eligible participantsenrolled in the trial, which limitsgeneralisability.

ant differencees, fires, alarmon and functiongroups. Fire-njuries): RR 1.3,e alarm5% CI 0.96 toallation: 82%smoke alarms vtionorted); firewith distribution7% with noed fires: RR 1.1,

Most participants lived in councilhomes, which limits generalisability.

ant differencership, or smoketweenoke alarm95% CI 0.94 tonction: OR 1.01,

Control group families were notifiedif they owned smoke detectorswhich were non-functioning. Overallloss to follow up at 1 year was 19%.

ant differenceership orlarms betweenmoke alarmth smoke alarmith usual safety95% CI 0.90 to

27% of parents randomised toallocated classes did not enrol in thetrial

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Table 1 (continued )

Key features of study Main outcomes Key quality issues

Participants: 108 parents of infants. Functioning smoke alarms: 94.1%with smoke alarm promotion v 89.7%with usual safety education, RR1.05, 95% CI 0.90 to 1.22.

Outcome: smoke alarm ownership;functioning alarm.

Clamp et al.12 There was no significant differencein smoke alarm ownership orfunctioning smoke alarms betweentreatment groups. Smoke alarmownership: 98.7% with smoke alarmpromotion v 86.6% with usual safetyeducation, RR 1.14, 95% CI 1.04 to1.25. Functioning smoke alarms:96.4% with smoke alarm promotion v86.6% with usual safety education,RR 1.11, 95% CI 1.01 to 1.22.Acquired smoke alarms: 9.6% withsmoke alarm promotion v 0% withusual care, RR 16.80, 95% CI 0.99 to286.35.

No loss to follow-up.Interventions: Smoke alarmpromotion (general practitionersafety advice and leaflets on smokealarms plus smoke alarms atdiscounted price); usual careSetting: Not reported.Participants: 165 families withchildren o5 years of age.Outcome: smoke alarm ownership;functioning alarm; acquired smokealarms.

Davis et al.13 There was no significant differencein smoke alarm ownership betweentreatment groups. Smoke alarmownership: 70.4% with smoke alarmpromotion v 66.2% with usual lesson,RR 1.08, 95% CI 0.97 to 1.20.

Loss to follow-up: 1% with smokealarm promotion v 0% with usuallessons.

Interventions: Fire safety lessonswith workbook, demonstrations,teacher training and take-homematerials; usual lessons.Setting: Schools.Participants: 41 children in grade 4-6 classes.Outcome: Smoke alarm ownership.

Jenkins et al.14 There was no significant differencein smoke alarm ownership betweentreatment groups. Smoke alarmownership: 72.5% with smoke alarmpromotion v 75.4% with usualdischarge teaching, RR 0.96, 95% CI0.78 to 1.19.

Interventions: Discharge teachingbook about burn care andprevention; usual dischargeteaching.Setting: Paediatric burns unit inCanada.Participants: 141 families ofchildren o17 years of age.Outcome: Smoke alarm ownership.

Kelly et al.15 There was no significant differencein smoke alarm ownership betweentreatment groups. Smoke alarmownership: 14.5% with smoke alarmpromotion v 11.1% with usual wellchild care, RR 1.31, 95% CI 0.49 to3.52.

High loss to follow-up: 35% withsmoke alarm promotion v 37% withusual well child care.

Interventions: Smoke alarmpromotion as part of adevelopmentally orientated childsafety education program, includinghazard assessment and handouts;usual well child care.Setting: Paediatric burns unit inCanada.Participants: 141 families ofchildren o17 years of age.Outcome: Smoke alarm ownership.

Kendrick et al.16 There was no significant differencein smoke alarm ownership orfunctioning smoke alarms betweentreatment groups. Smoke alarmownership: 92.7% with smoke alarmpromotion v 89.5% with usual care,RR 1.04, 95% CI 0.98 to 1.09;

Overall dropout rate was high at34%.Interventions: Smoke alarm

promotion as part of safety advice atchild health surveillanceconsultations; usual care.Setting: 36 general practices in theUK.

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Table 1 (continued )

Key features of study Main outcomes Key quality issues

functioning smoke alarms: 88.7%with smoke alarm promotion v87.0%, RR 1.02, 95% CI 0.96 to 1.08(unpublished data); acquired smokealarms: 5.5% with smoke alarmpromotion v 4.0% with usual care, RR1.38, 95% CI 0.64 to 2.95.

Participants: Children aged 3-12months registered at the generalpractices.Outcome: Smoke alarm ownership;functioning smoke alarms.

Klassen et al.17 There was no significant differencein smoke alarm ownership orfunctioning smoke alarms. Smokealarm ownership: 96.0% with smokealarm promotion v 97.6% with homesafety inspection alone, RR 0.98,95% CI 0.96 to 1.01; functioningsmoke alarms: 89.8% with smokealarm promotion v 89.7% with homesafety inspection alone, RR 1.00,95% CI 0.45 to 2.23; acquired smokealarms: 2.9% with smoke alarmpromotion v 3.0% with home safetyinspection alone, RR 0.97, 95% CI0.47 to 2.02.

High loss to follow-up: 20% withsmoke alarm promotion v 18% withhome safety inspection.

Interventions: Smoke alarmpromotion as part of a home safetyinspection, education, safety devicecoupons; home safety inspectionalone.Setting: Hospital.Participants: 1172 families ofhospitalised children o8 years.Outcome: Smoke alarm ownership;functioning smoke alarms.

Mathews et al.118 There was no significant differencein smoke alarm ownership orfunctioning smoke alarms. Smokealarm ownership: 83.3% with smokealarm promotion v 75.0% with homevisit plus video, handouts andmodeling on language stimulation,RR 1.11, 95% CI 0.74 to 1.68;functioning smoke alarms: 50.0%with smoke alarm promotion v 50.0%with home visit plus video, handoutsand modeling on languagestimulation, RR 1.00, 95% CI 0.45 to2.23; 0% with smoke alarmpromotion v 0% with home visit plusvideo, handouts and modeling onlanguage stimulation, RR notestimated.

Blinding of outcomes assessment notreported.Interventions: Smoke alarm

promotion as part of a safetyinspection, video, handouts, safetyand managing dangerous childbehaviour, hot water thermometers,choke tube; home visit with video,handouts and modeling on languagestimulation.Setting: Clinics and day carecentres.Participants: 26 mothers oftoddlers.Outcome: Smoke alarm ownership;functioning smoke alarms.

Ploeg et al.19 There was no significant differencein smoke alarms acquired betweentreatment groups. Acquired smokealarms: 2.05% with home safetyinspection and safety promotion v0.5% with home visit for influenzavaccine promotion, RR 1.57, 95% CI0.72 to 3.42.

Unpublished data.Interventions: Home safetyinspection and safety promotion;home visit for influenza vaccinepromotion.Setting: Community.Participants: 359 elderly publichealth clients.Outcome: Smoke alarms acquired.

Thomas et al.20 There was no significant differencein smoke alarm ownership betweentreatment groups. Smoke alarmownership: 96.4% with burnprevention lecture, handouts,coupon for an alarm and usual safetyeducation v 84% with usual safetyeducation, RR1.15, 95% CI 0.95 to1.38.

No loss to follow-up.Interventions: Burn preventionlecture, handouts, coupons for analarm and usual safety education;usual safety education alone.Setting: Well-baby classes.Participants: 55 parents.Outcome: Smoke alarm ownership.

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Table 1 (continued )

Key features of study Main outcomes Key quality issues

Williams et al.21 Outcomes data not available. 55% of women attending pre-natalclasses did not enrol in the trialInterventions: Burn prevention

lecture, handouts, motor vehiclesafety education and video and usualsafety education; lecture, handoutsand video on infant stimulation andfeeding with usual safety education;coupons for an alarm and usualsafety education; usual safetyeducation alone.Setting: Pre-natal classes.Participants: 165 pregnant women.Outcome: Smoke alarm ownership.

Domestic smoke alarms 387

A

setting.9 Four RCTs evaluated safety advice as partof routine health surveillance.8,11,15,16 Seven RCTscombined discounted or free smoke alarms withsafety education.8–10,12,16,17,20 Safety educationincluded information on burn prevention, safetyadvice from health professionals, educationalmaterial (handouts and books), home safety checksand first aid training. Five RCTs reported injuryoutcomes,8–10,15,16 but only one RCT specificallyreported fire-related injuries.9 One study reportedfire incidence outcomes.9

Most of the studies were of good quality,although three RCTs had low follow-up rates15–17

and allocation concealment was inadequate or notreported in five.8,9,15,17,19 We were not able to fullyassess the quality of three of the RCTs; one waspublished in abstract form17 and two were uni-versity dissertations.11,13

R Review findings

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Overall, there was no significant difference insmoke alarm ownership, acquired or functioningsmoke alarms between smoke alarm promotionstrategies and control interventions, in anysetting.

ET

� There was insufficient evidence to determine if

smoke alarm promotion strategies reduced fire-related injuries and incidence of fires. Oneadditional RCT found no significant differencein fire-related injuries and fires between dis-tribution of free smoke alarms and no interven-tion, but fire alarm function and ownership didnot differ significantly between interventiongroups.9 If interventions do not increase theuse of smoke alarms, then an effect on injury ordeath is unlikely.

R

Strategies to promote smoke alarm or detectoruse do not increase smoke alarm ownership oracquired or functioning smoke alarms. There isinsufficient evidence about the effect of strategiesto promote smoke alarm use on fire-related injuriesand incidence of fires. There is insufficient evi-dence on the effectiveness of smoke alarm promo-tion strategies delivered in schools and in thecommunity.

Most studies using safety education includedseveral types of interventions, such as informationon burn prevention, safety advice from healthprofessionals, educational material (handouts andbooks), home safety checks, first aid training, fireand prevention brochures and incentives to buysmoke alarms included coupons or smoke alarms atreduced cost. Some of these interventions mayhave had an effect which the studies could notdetect.

Lack of any benefit with smoke alarm or detectorpromotion strategies may be due to people dis-connecting or removing alarm batteries because ofwarnings that batteries are low or to avoid falsealarms from cooking or tobacco smoke. However,the studies included in this review did not assessreasons for why smoke alarms or detectors werenot installed or working. Further RCTs are neededbefore smoke alarm promotion strategies areimplemented.

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References

1. Watson L, Gamble J. Fire statistics: United Kingdom 1998.London: Government Statistical Service. September 1999.(Home office statistical bulletin Issue 15/99). Available at:www.homeoffice.gov.uk/rds/pdfs/hosb1599.pdf (last ac-cessed 11 August 2005)

2. Karter Jr MJ. Fire loss in the United States during 2000.Quincy: National Fire Protection Association; 2001.

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3. Runyan CW, Bangdiwala SI, Linzer MA, Sacks JJ, Butts J. Riskfactors for fatal residential fires. N Engl J Med 1992;327:859–63.

4. Deaths resulting from residential fires and the prevalence ofsmoke alarms. United States. 1991–1995. MMWR MorbMortal Wkly Rep 1998;38:803–6.

5. Ballard JE, Koepsell TD, Rivara FP, et al. Descriptiveepidemiology of unintentional residential fire injuries inKing County, WA, 1984 and 1985. Public Health Rep1992;107:402–8.

6. Patetta MJ, Cole TB. A population-based descriptive study ofhousefire deaths in North Carolina. Am J Public Health1990;80:1116–7.

7. DiGuiseppi C, Higgins JPT. Interventions for promotingsmoke alarm ownership and function. The Cochrane Data-base of Systematic Reviews. 2001, Issue 2. Art No.:CD002246. doi:10.1002/14651858. CD00246

8. Watson M, Kendrick D, Coupland C, Woods A, Futers D,Robinson J. Providing child safety equipment to preventinjuries: randomised controlled trial. BMJ 2005;330:178–83.

9. DiGuiseppi C, Roberts I, Wade A, et al. Incidence of fires andrelated injuries after giving out free smoke alarms: clusterrandomised controlled trial. BMJ 2002;325:995–8.

10. King WJ, Klassen TP, LeBlanc J, et al. The effectiveness of ahome visit to prevent childhood injury. Pediatrics 2001;108:382–8.

11. Barone VJ. An analysis of well-child parenting classes: theextent of parent compliance with health-care recommenda-tions to decrease potential injury of their toddlers.[Dissertation]. Kansas City: University of Kansas; 1988.

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12. Clamp M, Kendrick D. A randomised controlled trial ofgeneral practitioner safety advice for families with childrenunder 5 years. BMJ 1998;316:1576–9.

13. Davis JW. Get fired up: a model for developing Four-H programs(safety) [Dissertation]. Clemson: Clemson University; 1987.

14. Jenkins HML, Blank V, Miller K, Turner J, Stanwick RS. Arandomized single-blind evaluation of a discharge teachingbook for pediatric patients with burns. J Burn Care Rehabil1996;79:49–61.

15. Kelly B, Sein C, McCarthy PL. Safety education in a pediatricprimary care setting. Pediatrics 1987;79:818–24.

16. Kendrick D, Marsh P, Fielding K, et al. Preventing injuries inchildren: cluster randomised controlled trial in primarycare. BMJ 1999;318:980–3.

17. Klassen TP, King WJ, Beaulne G, et al. A randomisedcontrolled trial of a multi-faceted home injury interventionin children following an ED visit [abstract]. Program andAbstracts. 38th Annual Meeting of the Ambulatory PediatricAssociation. New Orleans, LA. May 1–5; 1998:40–41.

18. Mathews JR. An analysis of dangerous behavior in toddlers[Dissertation]. Kansas City: University of Kansas; 1998.

19. Ploeg J, Black ME, Hutchinson BG, et al. Personal, home andcommunity safety promotion with community-dwellingelderly persons: response to a public health nurse interven-tion. Can J Public Health 1994;85:188–91.

20. Thomas KA, Hassanein RS, Christophersen ER. Evaluation ofgroup well-child care for improving burn prevention prac-tices in the home. Pediatrics 1984;74:879–82.

21. Williams GE. An analysis of prenatal education classes: anearly start to injury prevention [Dissertation]. Kansas City:University of Kansas; 1988.

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