REFRESH – Reducing Families Exposure to Second Hand Smoke in the Home

Research Report

Project Aims:

Exposure to second-hand tobacco smoke brings real health risks, particularly to children. Following the ban on smoking in most enclosed public spaces the majority of exposure now takes place in the home, where legislative bans are not an appropriate option. Further reducing children’s exposure to second-hand tobacco smoke relies on encouraging and enabling voluntary action by parents, particularly with regard to making homes smoke-free.

Funded by the Big Lottery the REFRESH project was a partnership between ASH Scotland and the Universities of Aberdeen and Edinburgh which ran from to March 2010 to March 2014 with the following aims:

-to investigate the effectiveness and potential of using air quality monitors to provide tailored feedback to parents who smoke regarding levels of second-hand tobacco smoke in their own home, as a means of engaging and supporting these parents to take voluntary action to protect their families through creating smoke-free homes;

-to explore the knowledge and views of policy makers at local and national level with regard to second hand smoke;

-to engage with a range of health practitioners to investigate effective action on their part to support parents who smoke to reduce levels of tobacco smoke in their homes and to disseminate and encourage good practice; and

-to disseminate the findings of the research and hence to ensure that this enhanced evidence base informs and influences future action on second-hand tobacco smoke and smoke-free homes

Research Elements 1: intervention with mothers who smoke

A randomized feasibility study was carried out with 59 mothers who smoke, each with at least one child younger than six years. Participation took paces between July 2010 and March 2011.

In each case four home visits took place over a one-month period. These involved two 24-hour measurements of home air quality by measuring fine airborne particulate matter (PM2.5) and a motivational interview to encourage changes to smoking behaviour within the home in order to reduce the child’s exposure to tobacco smoke. The enhanced group received their airquality data as part of their motivational interview after the first two visits and measurements, the control group received that information a month later, after the second visits and measurements.

Comparisons were made of the PM2.5 data from the initial and follow-on visits, giving an indication of behaviour change over the intervening month. The views of the mothers from the enhanced group about their understanding of the intervention and their response to the air quality feedback were also analysed.

Both the enhanced and control groups registered a decrease in PM2.5 levels over the month, but with a greater decrease amongst the enhanced group. Mothers appreciated the intervention and were able to understand the data they were shown and were shocked by the tobacco smoke levels measured in their homes.

With positive feedback from parents once they are engaged with the intervention, we sought to explore a new recruitment approach through partnering with the Greendykes Family Support Centre in Edinburgh. Staff at the centre offered a REFRESH-style intervention providing air quality monitors to parents who smoke who were being supported by the service. Results showed that parents welcomed such an approach coming from family support staff and that the intervention once again acted as a positive motivation to making their homes smoke-free. Results indicate that this may be an attractive route for recruiting parents to take part in the intervention and will be written up for publication in due course.

Wilson I, Semple S, Mills LM, Ritchie D, Shaw A, O'Donnell R, Bonella P, Turner S, Amos A. REFRESH--reducing families' exposure to secondhand smoke in the home: a feasibility study.Tob Control. 2013 Sep;22(5):e8.

Wilson IS, Ritchie D, Amos A, Shaw A, O'Donnell R, Mills LM, Semple SE, Turner SW. 'I'm not doing this for me': mothers' accounts of creating smoke-free homes. Health Educ Res. 2013 Feb;28(1):165-78.

Mills LM, Semple SE, Wilson IS, MacCalman L, Amos A, Ritchie D, O'Donnell R, Shaw A, Turner SW. Factors influencing exposure to secondhand smoke in preschool children living with smoking mothers. Nicotine Tob Res. 2012 Dec;14(12):1435-44.

Research Elements 2: interviews with policy advisors and practitioners

A series of qualitative interviews and focus groups were carried out with 30 policy makers, health professionals and childcare practitioners, during which they were presented with the findings of the REFRESH intervention with mothers who smoke and discussed the implications for their policy and practice priorities.

Participants accepted the harm caused to children by second-hand tobacco smoke, however action is limited by political expedience due to the perception of a shift of the public health priority from smoking to alcohol, current financial constraints, more immediate child protection concerns and continuing ethical arguments such as balancing protection of the child while not stigmatizing the parents who smoke.

Overall children’s exposure to second-hand smoke in the home is unequivocally accepted as an important health priority but it is not currently perceived to be a top public health priority in Scotland.

Ritchie DD, Amos A, Shaw A, O'Donnell R, Semple S, Turner S, Martin C. How do policy advisors and practitioners prioritise the protection of children from secondhand smoke exposure in a country with advanced tobacco control policy?Tob Control. 2013 Aug 16.doi: 10.1136/tobaccocontrol-2012-050936.

Research Elements 3: informing and enhancing practice

A comprehensive literature review was carried out and completed in September 2011 and is available upon request.

Learning from the literature review and the REFRESHresearch was developed into a practical 'How To' guide for professionals seeking to engage parents on smoke-free homes. A supporting website was set up at first draft was circulated for testing and review, receiving positive feedback. A revised and updated version is now available for general use.

A one-day training course, based on the How To Guide, was developed for voluntary sector organisations providing family support services. The course was initially delivered at 8 locations across Scotland, with 85 people attending. Evaluation feedback indicated that when rating the improvement in knowledge of SHS and confidence in raising the issue, the average participant moved from 4 to 8 on a 1-10 confidence scale and rated the course 8.5 for how well it had met their needs. The training sessions will continue to be made available.

A baseline survey of practitioners engaged in work on second-hand smoke was carried out in 2010 and repeated towards the end of the project in 2013. Responses in the 2013 follow-up were more positive on practitioner confidence,knowledge and skills in addressing SHS, more thought that it was part of their role to raise SHS in the home and more indicated that their workplace provided respondents with advice or information on SHS and its effects on children’s health.

Shaw A, Ritchie D, O'Donnell R, Amos A, Mills LM, Semple SE, Turner SW, Wilson IS. Creating smoke-free homes for children.Nurs Times. 2013 Mar 12-18;109(10):28-30.

Research Elements 4: dissemination

The project Advisory Board agreed a set of recommendations for future policy, practice and research, which was used as the basis for engagement with development of the Scottish Government’s new tobacco control strategy.

Published in March 2013 the new strategy showed influence from the REFRESH project and contained several key commitments in this area:

-advice on creating a smoke-free home should be a feature of all ante- and post-natal services and adoption, foster, kinship and residential care services;

-the setting of the first national target to reduce children’s exposure to second-hand smoke in the home, now set as a 6% self-reported rate in 2020;

-the development of an awareness-raising campaign, now underway following input from several members of the REFRESH team; and

-continued Government support for REFRESH-type interventions.

Research Conclusions:

  • Parents who smoke at home generally take measures to protect their families but only making the home completely smoke-free is effective.
  • Parents respond well to personalized feedback on smoke levels found in their homes and are motivated to make effective changes.
  • Programmes to reduce tobacco smoke in the home should engage parents positively and focus on a smoke-free home as the goal.
  • Air quality monitoring provides an effective means to do this.
  • Smoke-free homes approaches are complementary to stop smoking initiatives, often engaging smokers who are not yet ready or willing to quit.
  • Partnering with professionals with an existing support relationship can be an effective means to engage parents.
  • Decision-makers need to be persuaded that smoke-free homes are an important goal.

Further information:

For more information please contact John Watson, Director of Policy and Engagement at ASH Scotland.

0131 220 9468

Signed by John Watson, lead researcher, 7th May 2014

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