1. FRESH: Freedom from Radon Exposure and Smoking in the Home Ellen J. Hahn, PhD, RN, FAAN College of Nursing Clean Indoor Air Partnership University of Kentucky

2. Disclosure The project described is supported by Award Number R01ES021502-03 (9/1/12-5/31/17) from the National Institute of Environmental Health Sciences. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Environmental Health Sciences or the National Institutes of Health.

3. In Memoriam….”I just did not know” Lois, a never smoker, died from radon-induced lung cancer, September 2013

4. Clean Indoor Air Partnership Our Mission To reduce tobacco use and exposure to secondhand smoke and radon through research, community engagement, and policy surveillance and development in treatment and prevention. www.ciap.uky.edu Find kysmokefree on twitter and facebook

6. FRESH Freedom from Radon Exposure and Smoking in the Home Can Dual Home Screening Reduce Exposure?

7. Tobacco Smoke ◦ 85% lung cancer cases caused by tobacco smoke. ◦ 3,000 lung cancer deaths per year among nonsmokers from secondhand smoke Radon ◦ 20,000 lung cancer deaths per year from radon exposure (only 2,100-2,900 among never smokers) ◦ Of those exposed to at least 4 pCi/L of radon, the risk of developing lung cancer is estimated at 62/1,000 for smokers and 7/1,000 for nonsmokers. ◦ Most never smokers with lung cancer are women. Tobacco, Radon, & Lung Cancer

8. Soil gas infiltration primary source of indoor radon exposure. Most radon-induced lung cancers are associated with low to moderate radon concentrations. When radon gas is inhaled, alpha particles are emitted by the radon decay products (Po and Pb), leading to significant DNA damage. Radon decay products create Pb-210, a semi- stable isotope of lead (half-life 22 yrs) Radon and Lung Cancer

9. Purposes of the Study Test the effects of FRESH on:  (a) home exposure to SHS and radon and the likelihood of taking action among homeowners.  (b) Teachable Moment psychosocial factors Examine the differential effects of home smoking on taking action. Explore impact of FRESH on renters Identify factors associated with use of monetary incentive for radon mitigation (simulated tax credit)

10. Create a Teachable Moment! Adapted from the Teachable Moment model (McBride et al., 2003)

11. FRESH: Dual Home Screening for Lung Cancer Prevention Pilot Funding from Markey Cancer Center/KLCRP, UK College of Nursing, UK Got Grants Program Brief, home screening and environmental feedback intervention (FRESH) 50 parents recruited in pediatrician’s office and received free home radon and air nicotine kits. 2-month follow up survey National Institute of Environmental Health Sciences (NIEHS) National Institute of General Medical Sciences (NIGMS) R01ES021502-03 (9/1/12-5/31/17) Hahn, E.J., Rayens, M.K., Kercsmar, S.E., Adkins, S.M., Wright, A.P., Robertson, H.E., Rinker, G. (2014). Dual home screening and tailored environmental feedback to reduce radon and secondhand smoke: An exploratory study. Journal of Environmental Health, 76(6):156-61.

12. Study Design RCT with stratified sampling to ensure equal proportion of those exposed to SHS in the home Recruit homeowners (n = 520) and renters (n = 46) at UK Family Medicine Clinic & Pharmacy Baseline electronic survey ($10) Intervention Free home test kits for radon and SHS Environmental feedback intervention post-results (8- 10 weeks post-enrollment) Follow up online surveys to assess behavior change (3-9-15 mos; $20-$30-$40) 17-month home testing

13. Dual Home Screening Radon Test KitSecondhand Smoke Test Kit

14. Environmental Feedback Intervention Tailored based on one of four conditions ◦ high radon/high SHS (radon = > 4 pCi/L; SHS = > 0.1 μ g/m 3 ) ◦ high radon/low SHS ◦ low radon/high SHS ◦ low radon/low SHS Brief problem solving via phone ◦ Readiness stage assessment, stage-tailored queries to enhance self-efficacy, motivation, & behavior change ◦ Follow-up queries using 5Rs Relevance, Risks, Rewards, Roadbocks, Repetition ◦ Stage-tailored goals and actions to reduce risk Mailed packet with results and educational materials

15. Data Gathering and Keeping Participants Engaged

18. Sample Characteristics (N = 387) Group p Renters (n = 47) Treatment homeowners (n = 168) Control homeowners (n = 172) Mean (SD); range or n (%) Mean (SD); range or n (%) Mean (SD); range or n (%) Age 42.5 (14.7); 21-8453.5 (12.8); 25-8152.3 (13.0); 24-80<.001 Gender Male Female 18 (38.3%) 29 (61.7%) 66 (39.3%) 102 (60.7%) 58 (33.7%) 114 (66.3%).55 Race White Other 33 (70.2%) 14 (29.8%) 147 (87.5%) 21 (12.5%) 148 (87.1%) 22 (12.9%).009 Education Less than college graduate College graduate 31 (66.0%) 16 (34.0%) 52 (31.1%) 115 (68.9%) 42 (24.4%) 130 (75.6%) <.001 Note. Renter group younger, less likely to be White, and less educated than both homeowner groups. Recruitment ongoing through March 2015.

19. Percent who Tested at Baseline Note. Renters and Treatment homeowners were provided free test kits and paid to test for both

20. Median Test Results by Group Group p Renter Treatment homeowner Control homeowner n Median (IQR); range n Median(IQR); range n Median (IQR); range Radon25 2.40 (0.55- 3.30); 0.0-68.0 127 2.30 (0.70- 4.55); 0.30-25.20 56 3.55 (1.55- 7.80); 0.30-35.00.018 SHS260.03 (0.02- 5.76); 0.02-17.15 1230.02 (0.02- 0.03); <0.01-11.15 250.02 (0.02- 0.03); 0.02-11.47.032 p from Kruskal-Wallis test Note. Controls who tested had higher radon levels than renters or treatment homeowner participants. Renters had higher air nicotine levels than the homeowner groups.

21. Probability of testing at baseline for both radon and secondhand smoke (n = 384) Estimated Odds Ratio (OR) 95% Confidence Interval for OR p Age 1.02 1.00-1.04.067 Gender Male vs. Female 1.48 0.88-2.25.14 Race: White vs. Other 1.11 0.55-2.25.78 Education College graduate vs. Other 2.11 1.17-3.81.013 Smoking Smoker vs. Non-smoker 1.32 0.72-2.41.37 Group Renter vs. Control Treatment homeowners vs. Control 19.00 11.21 10.63-34.01 4.87-25.80 <.001

22. Preliminary Results Sample Characteristics: ◦ Renters were younger, less likely to be White, and less educated than both homeowner groups. Test Results: ◦ Renters had higher air nicotine levels than either homeowner group.

23. Likelihood of Testing Participants with higher education were more likely to test. Likelihood to test did not vary by whether or not there was a smoker in the home. Renters and homeowners were more likely to test for radon and SHS compared to controls. ◦ Renters & homeowners were provided free test kits and were paid to test.

24. What Can You Do? Promote Tobacco Treatment ◦ 1-800-QUIT-NOW Promote Smoke-free Homes & Public Housing ◦ At least 30 ft. away from entryways, doors, windows. Promote Tobacco-free Campuses ◦ All products, all the time, everywhere Promote Lung Cancer Awareness Month Support Local and State Smoke-free Policies Promote Home Radon Testing Support Radon Policy Change

27. Exposure to Radon in Kentucky

29. Questions? For more information, contact us: ◦ 859-323-4587 ◦ UKFRESH@LSV.UKY.EDU UKFRESH@LSV.UKY.EDU