The barriers, motivators and enablers of smoke-free

homes: qualitative systematic review and

synthesis

Laura Jones, Jo Longman, John Wiggers, Jude Robinson & Megan Passey

Global SHS exposure

40% of children, 33% non-smoking males and 35% of non-smoking females

600 000 annual deaths: 28% children, 26% men and 47% women

Countries with SFL – exposure in homes and cars Countries without SFL – exposure in homes and

workplaces

Oberg et al. 2011

SHS intervention evidence

Child focussed Mixed evidence for effectiveness of

SHS/SFH interventions Need for more research

SHS qualitative evidence

Promote caregiver quitting Promote smoke-free homes

– Some caregivers are successful, others find it very difficult

Qualitative evidence base exploring caregivers’ home smoking behaviours and experiences – yet to be synthesised

Jones et al. 2011; Robinson et al. 2010, 2009. 2007a, 2007b; Phillips et al. 2007, Blackburn et al. 2003

Review questions

(1) What are the barriers to, enablers and motivators of initiating and maintaining a smoke-free home?

(2) Do the barriers, enablers and motivators to creating smoke-free homes differ by context?

PROSPERO protocol registration: CRD42014014115

Methods: search & extraction

Systematic search for relevant qualitative and mixed-methods peer reviewed publications in English (1990-2014)

Study data extracted via proforma

Data managed using NVivo

Critical appraisal using modified CASP

Methods: thematic synthesis

Line by line coding; comparing & grouping of codes; descriptive themes; analytical themes (Thomas & Harden 2008)

Eight papers (36%) independently coded Final codebook applied across all papers Descriptive and analytic themes (ongoing)

developed within team

Results: included papers

Roberts 2000; South Australia

Hill 2003; Victoria Australia

Jochelson 2003, Gould 2013; NSW Australia

Bottorff 2010; British Columbia Canada

Herbert 2011; PEI Canada

Abdullah 2012; Jiangsu China

Poland 2009; Toronto Canada

Coxhead 2006; Holdsworth 2008; Robinson 2007, 2008, 2009; Jones 2011; England

Phillips 2007; Ritchie 2009; Robinson 2011; Wilson 2013;

Scotland

Kegler 2007, Escoffery 2009; Georgia USA

Mao 2013; Mainland ChinaYousey 2007; Colorado USA

22 studies from 18 datasets (2 studies extended original dataset)

4 Australia; 3 Canada; 2 China; 10 UK; 3 USA 646 participants: 633 caregivers & 13 HCPs 58 FGs; 474 interviews; 2 expert panels;

observations 14 high quality; 8 low quality

Results: theme summaryBARRIERS ENABLERS MOTIVATORS

Influence of others

Agency

Knowledge & perception of SHS

risk & risk reduction

SHS awareness & health protection

Perceived benefits of smoking

Addiction/habit

Lifestyle choice

Priorities

Practicalities

Social norms around SHS

Personal attributes

Practicalities & strategies

Desire to live in a clean, odour free

and safe environment

Benefits of having a SFH

Household changes

Being a good parent

Barriers

Exposure to SHS was recognised as being harmful; however, the specific risks and the continuing risks as the child aged (Abdullah 2012, Jochelson 2003, Jones 2011, Kegler 2007, Mao 2013, Robinson 2007 & 2009) were often not appreciated or acknowledged.

Knowledge & perception of SHS risk & risk reduction

“I try to avoid smoking at home, but sometimes I really cannot help myself and start smoking in front of my child. I really need some help” (Abdullah 2012)

Addiction/habit

Indoor smoking by others was often not challenged because of the need or desire to preserve social and relational bonds with the smoker (Bottorff 2001, Mao 2013, Jones 2011, Robinson 2008, Yousey 2007).

Influence of others

Enablers

“If I don’t want people to smoke around my kids I tell them. It’s my house and my kids” (Coxhead 2006)

Agency

“It’s not something that’s even discussed anymore, it’s just…automatically assumed that you don’t smoke in the house” (Poland 2009)

Social norms around SHS

Smoking household members’ and visitors’ acceptance of and compliance with household smoking rules was facilitated by the normality and assumed nature of protecting others from SHS, particularly children (Bottorff 2001, Escoffery 2009, Holdsworth 2008, Kegler, Robinson 2009 & 2011, Poland 2009)

Influence of others

Motivators

Homes which showed signs of smoke exposure (e.g. nicotine stains) and which smelled of smoke were perceived as ‘socially unacceptable’ (Robinson 2011) and associated with ‘stigma’ (Holdsworth 2008)

Desire to live in a clean, odour free & safe environment

Caregivers were ‘aware’ (Holdsworth 2008) and ‘mindful’ (Robinson 2011) of the dangers of exposing others, in particular children, to SHS.

SHS awareness & health protection

“It makes me smoke less having to go outside… [I] tend not to go out as much and smoke” (Escoffery 2009)

Benefits of having a SFH

Evidence base limitations

Cross-sectional Retrospective Hypothetical rather than experiential Authors are not explicit about participants’

home smoking rules Focussed on reducing children’s SHS

rather than SFH

Current evidence gaps

Home smoking rules during pregnancy & early post natal period

The male voice Other adults (vulnerable/sick) Learning from ‘successful’ smoke-free

households Other countries, in particular, those with

high tobacco consumption

Implications for policy & practice

Power of social norms Clarity & consistency of SHS risk messages Complete ban (where achievable) SF households rather than individuals Strengths based approach – harnessing

motivation

Funding

National Health and Medical Research Council of Australia Early Career Fellowship (APP1072213)

Cancer Institute New South Wales Early Career Fellowship (13/ECF/1-11)

Wellcome Trust and University of Birmingham ISSF Mobility Scholarship

L.L.Jones@bham.ac.uk0121 414 3024

Presentation References Baxi R, Sharma M, Roseby R, Polnay A, Priest N, Waters E et al. Family and carer

smoking control programmes for reducing children's exposure to environmental tobacco smoke. Cochrane Database Syst Rev. 2014;3:CD001746.

Baxter S, Blank L, Everson-Hock ES, Burrows J, Messina J, Guillaume L, et al. The effectiveness of interventions to establish smoke-free homes in pregnancy and in the neonatal period: a systematic review. Health Educ Res. 2011;26(2):265-82.

Blackburn C, Spencer N, Bonas S, Coe C, Dolan A, & Moy R. Effect of strategies to reduce exposure of infants to environmental tobacco smoke in the home: Cross sectional survey. BMJ, 2003;327:257.

Thomas J & Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008;10(8):45.

Jones LL, Atkinson O, Longman J, Coleman T, McNeill A, Lewis SA. The motivators and barriers to a smoke-free home among disadvantaged caregivers: identifying the positive levers for change. Nicotine & tobacco research . 2011;13(6):479-86.

Oberg M, Jaakkola MS, Woodward A, Peruga A, Pruss-Ustun A. Worldwide burden of disease from exposure to second-hand smoke: a retrospective analysis of data from 192 countries. Lancet. 2011;377(9760):139-46

Presentation References

Phillips R, Amos A, Ritchie D, Cunningham-Burley S, Martin C. Smoking in the home after the smoke-free legislation in Scotland: qualitative study. BMJ. 2007;335(7619):553-7.

Robinson J & Kirkcaldy AJ. Disadvantaged mothers, young children and smoking in the home: Mothers’ use of space within their homes. Health and Place. 2007a;13:894–903.

Robinson J & Kirkcaldy AJ. ‘You think that I’m smoking and they’re not’: Why mothers still smoke in the home. Social Science and Medicine, 2007b;65:641–652.

Robinson J, Kirkcaldy AJ. 'Imagine all that smoke in their lungs': parents' perceptions of young children's tolerance of tobacco smoke. Health Educ Res. 2009 Feb;24(1):11-21.

Robinson J, Ritchie D, Amos A, Cunningham-Burley S, Greaves L, Martin C. ‘Waiting until they got home’: Gender, smoking and tobacco exposure in households in Scotland. Soc Sci Med. 2010;71(5):884-90.

Rosen LJ, Myers V, Hovell M, Zucker D, Ben Noach M. Meta-analysis of parental protection of children from tobacco smoke exposure. Pediatrics. 2014;133(4):698-714.

Review References

Abdullah AS, Hua F, Xia X, Hurlburt S, Ng P, MacLeod W, Siegel M, Griffiths S, Zhang ZY: Second-hand smoke exposure and household smoking bans in Chinese families: a qualitative study. Health & Social Care in the Community 2012, 20(4):356-364.

Bottorff JL, Johnson JL, Carey J, Hutchinson P, Sullivan D, Mowatt R, Wardman D: A family affair: Aboriginal women's efforts to limit second-hand smoke exposure at home. Canadian Journal of Public Health 2010, 101(1):32-35.

Coxhead L & Rhodes T. Accounting for risk and responsibility associated with smoking among mothers of children with respiratory illness. Sociology of Health and Illness, 2008, 28(1): 98–121.

Escoffery C, Kegler MC, Butler S: Formative research on creating smoke-free homes in rural communities. Health Education Research 2009, 24(1):76-86.

Gould GS, Munn J, Avuri S, Hoff S, Cadet-James Y, McEwen A, Clough AR: "Nobody smokes in the house if there's a new baby in it": Aboriginal perspectives on tobacco smoking in pregnancy and in the household in regional NSW Australia. Women and Birth 2013, 26(4):246-253.

Holdsworth C & Robinson JE. "I've never ever let anyone hold the kids while they've got ciggies”: moral tales of maternal smoking practices. Sociology of Health & Illness 2008, 30(7): 1086-1100.

Please note that only the first author was cited in the slides

Review References

Jochelson T, Hua M et al. Knowledge, attitudes and behaviours of caregivers regarding children's exposure to environmental tobacco smoke among Arabic and Vietnamese-speaking communities in Sydney, Australia. Ethnicity & Health. 2003, 8(4): 339-351

Jones LL, Atkinson O, Longman J, Coleman T, McNeill A, Lewis SA. The motivators and barriers to a smoke-free home among disadvantaged caregivers: identifying the positive levers for change. Nicotine & tobacco research . 2011;13(6):479-86.

Kegler,M & Escoffery M. A qualitative study of how families decide to adopt household smoking restrictions. Family & Community Health, 2007, 30(4): 328-341.

Mao A. Space and power: Young mothers' management of smoking in extended families in China. Health & Place. 2013, 21: 102-109.

Poland, B., D. Gastaldo, et al. (2009). "The interpersonal management of environmental tobacco smoke in the home - a qualitative study." Critical Public Health. 2009, 19(2): 203-221.

Robinson J. “Trying my hardest”: The hidden social costs of protecting children from environmental tobacco smoke. International Review of Qualitative Research. 2008, 1, 173–194.

Please note that only the first author was cited in the slides

Review References

Robinson J & Kirkcaldy A. Disadvantaged mothers, young children and smoking in the home: Mothers' use of space within their homes. Health & Place. 2007, 13(4): 894-903.

Robinson J & Kirkcaldy A "Imagine all that smoke in their lungs”: parents' perceptions of young children's tolerance of tobacco smoke. Health Education Research. 2009, 24(1): 11-21.

Robinson J, Ritchie D, et al. Volunteered, negotiated, enforced: family politics and the regulation of home smoking. Sociology of Health & Illness. 2011, 33(1): 66-80.

Yousey, Y. "Family attitudes about tobacco smoke exposure of young children at home. American Journal of Maternal-Child Nursing. 2007, 32(3): 178-183.

Please note that only the first author was cited in the slides