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

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

Disease Burden of SHS OutcomeAnnual excess number due to SHS in U.S. Episodes of childhood asthma202,300 Doctor visits for childhood otitis media790,000 Deaths due to SIDS430 Deaths due to ischemic heart disease46,000 (22,700 to 69,500) Lung cancer deaths3400 Source: International Agency for Research on Cancer & CA EPA, Air Resources Board, 2005

Exposure to SHS in the U.S. Detectable serum cotinine declined from 83.9% of nonsmokers ( ) to 46.4% ( ) 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 African Americans more likely to have detectable serum cotinine in ; 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, and , MMWR, 2008; 57(27):

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

Prevalence of Household Smoking Bans Nationwide 78.1% of households had total bans in % 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

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

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

New Project NCI funding (State and Community Tobacco Control Policy and Media Research-U01) Builds on work of CPCRN 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 organizations in four states State tobacco control programs in four states

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

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

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

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

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

Client Calls 2-1-1Screen Random Sample for Eligibility Enroll / Obtain Verbal Consent and Baseline Data Over Phone Block Randomization by Smoking StatusControl GroupIntervention Group Flow of Efficacy Trial

Flow of Intervention Study (Cont’d) Both GroupsCollect 3 month follow-up data by phone Collect 6 month follow-up by phone and assess air nicotine in random sample of homes Collect 9 month follow-up data by phone

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

Secondary Outcomes (Smokers) Smoking status Cessation attempts Cigarette consumption

Dissemination Plans Develop an implementation toolkit for SFH intervention Conduct a national grants program to encourage adoption among 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

Examples of Dissemination Questions What factors affect the uptake of the SFH intervention by 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 centers? What factors are associated with program maintenance?

Ideas for Dissemination Research?