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Home smoking policies in urban households with children and smokers
Preventive Medicine 62 (2014) 30–34
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Home smoking policies in urban households with children and smokers Amy Bleakley a,⁎, Michael Hennessy a, Giridhar Mallya b, Daniel Romer a a b
Annenberg Public Policy Center at the University of Pennsylvania, 202 S. 36th Street, Philadelphia, PA 19104, USA Philadelphia Department of Public Health, Philadelphia, PA, USA
a r t i c l e
i n f o
Available online 24 December 2013 Keywords: Secondhand smoke Home smoking bans Urban
a b s t r a c t Objective. We identified household, child, and demographic characteristics associated with not having a smoking ban and having a rule about smoking in the presence of children in an urban population. Method. We conducted a cross-sectional random digit dial telephone survey (n = 456) of Philadelphia parents in June 2012. Results. Forty-eight percent of homes reported a full smoking ban. In homes that allowed smoking, over half allowed smoking in front of children. Cigarettes smoked in the home decreased as the restrictiveness of the bans increased. Multinomial logistic regression analyses showed that compared to having a full ban, banning smoking only in the presence of children was associated with being African-American, having a child N 5 years old, and having an asthma-free child. These characteristics, as well as having both parents as smokers and not having an outdoor space, were also associated with not having any restrictions. Conclusion. It is possible that households attempt to reduce home smoking by limiting smoking in the presence of children. Health communication messages should be used to inform families about the lingering effects of SHS in the home even when smoking does not occur in the presence of a child. © 2014 Elsevier Inc. All rights reserved.
Introduction As defined by the Centers for Disease Control and Prevention, secondhand smoke (SHS) is “a mixture of gases and fine particles that includes smoke from a burning cigarette, cigar, or pipe tip; smoke that has been exhaled or breathed out by the person or people smoking”(Centers for Disease Control and Prevention, 2013). As such, SHS exposure is a health hazard for children and adults (Brownson et al., 1997; Eriksen et al., 1988) and higher levels of SHS exposure are found in minority or lower socioeconomic households in urban areas (Centers for Disease Control and Prevention, 2008; Hopper and Craig, 2000). Infants and children are at particular increased risk of respiratory and other health problems when exposed to SHS (Ferrence and Ashley, 2000; Hovell et al., 2000; Kawachi, 2005), and because of this risk, intervention research has investigated methods of reducing their exposure (Emmons et al., 2001). At the household level, the focus has been on household bans or restrictions on indoor smoking (Gilpin et al., 1999; Hovell and Daniel, 2004; Sockrider et al., 2003; Spencer et al., 2005; Wewers and Uno, 2002; Yousey, 2006). Household smoking restrictions are associated with reduced exposure to SHS among children and adult non-smokers (Pizacani et al., 2003; Wakefield et al., 2000a) as well as quit attempts (Pizacani et al., 2004) and delayed smoking onset in children (Wakefield et al., 2000b). ⁎ Corresponding author at: 202 S. 36th Street, Philadelphia, PA 19147, USA. E-mail address: [email protected] (A. Bleakley). 0091-7435/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ypmed.2013.12.015
Despite half of U.S. households with smokers and children having a full smoking ban (Mills et al., 2011), children continue to be particularly vulnerable to SHS. Smoking in the home is the greatest source of SHS exposure among children (Ashley and Ferrence, 1998) and children from urban households are typically exposed to more SHS than other children (Halterman et al., 2006; Weaver et al., 1996). For example, urban children frequently live in multi-unit housing with close proximity to their neighbors, whose smoking may put other residents at risk (Winickoff et al., 2010). Awareness that SHS is harmful to one's health and the presence of a child in the home (Mills et al., 2011; Norman et al., 1999; Pizacani et al., 2003) are associated with having household restrictions. AfricanAmerican households, households with older children, and Hispanic and white households with high smoking prevalence are less likely to have home smoking bans (Mills et al., 2011). Studies have shown that while parents have knowledge about the potentially harmful effects of SHS on children, emotional and/or financial stressors prevent the adoption of full smoking bans (Halterman et al., 2007; Halterman et al., 2010). However, partial smoking bans which allow household smoking in certain rooms or under certain circumstances are not as effective as full bans in reducing children's exposure to SHS (Wakefield et al., 2000a). To learn more about these different types of household smoking policies, we conducted a survey with urban parents who either smoke or live with a smoker to determine household, child, and demographic characteristics associated with having a full household smoking ban and having a rule about smoking in the presence of children. We also
A. Bleakley et al. / Preventive Medicine 62 (2014) 30–34
examined how these policies are related to the number of cigarettes smoked in the home. Methods A telephone survey in May/June 2012 was conducted with 456 Philadelphia parents or caregivers from homes with at least one smoker and a child 13 years or younger living in the home. We focused on families with children 13 years old and younger because younger children are more vulnerable to SHS (see Ashley and Ferrence, 1998). The sample was randomly drawn from a list of households in Philadelphia County identified as including a child under the age of 13 (n = 217) and through a random digit dialing (RDD) sample drawn from phone numbers with Philadelphia County telephone exchanges from predominantly low-income sections of the city (n = 123). We drew from low-income exchanges specifically because tobacco use is higher in lower socioeconomic groups (Hill et al., 2013). In addition, a random sample was drawn from a pool of respondents who completed a RDD survey of Philadelphia County smokers between 2010 and 2012 and who indicated the presence of a child in their household (n = 116). The combination of approaches was necessary because of the low incidence of the target population. The response rate for this study was 25.3%; the average survey length was 18 min. Unless otherwise noted, all results in this report are weighted. ⁎The study was approved by the institutional review boards at the University of Pennsylvania and the Philadelphia Department of Public Health. Measures Smoking policies in the home Two questions on the survey asked about home smoking rules. The first was: Which of the following best describes your household's rules about smoking? (a) Smoking is allowed in all parts of the home (no ban), (b) Smoking is allowed in some parts of the home (partial ban), and (c) Smoking is not allowed in any part of the home (full ban). A small number of respondents (n = 6, unweighted) answered that there were no smoking rules, and these were classified as response (a). If respondents indicated having either no ban or a partial ban, they were asked a second item asked about smoking in the presence of children: In your home, is smoking in the presence of children always allowed, sometimes allowed, or never allowed? If the respondent stated that there was no household rule about smoking in the presence of children (n = 8, unweighted), the item was coded as “always allowed”. From these two items we created a new variable to reflect the combined presence of these rules to indicate a child's level of protection from SHS. Based on their distribution, the variable had three categories: (1) full smoking ban, (2) no smoking in the presence of children (in the absence of a full ban), and (3) no ban/smoking allowed in the presence of children. Child and household characteristics The independent variables included the presence of a child in the home that was b5 years old and if the child in the home had ever been diagnosed with asthma. We also measured household characteristics such as the number of smokers in the household, the number of rooms in the home, access to a private outdoor space (e.g., a balcony, patio), and the relationship of the smoker(s) in the home to the child (mother, father, both, or other). For smokers who reported that they ⁎ The sample was weighted to (1) adjust for bias stemming from the propensity to complete a second survey in households re-contacted based on responses to the previous smoking survey; (2) adjust for differences in the probability of selection between listed households and the RDD sampling frame; (3) correct for the oversampling of lowincome exchanges; and (4) balance the sample to known household estimates in Philadelphia County and households of smokers with children.
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smoked at least 100 cigarettes in their lifetime and smoked at any time during the past 30 days, we asked how many cigarettes they smoked on a typical day [M: 9.8 cigarettes, 95% CI: 8.8–10.7]. Note that to reduce respondent bias, the smoking self-reports were collected before the information on the two types of household smoking restrictions. Additional covariates Other covariates were exposure to ads on television or radio about SHS in the last month (never, rarely, sometimes, often) as well as how many of their friends were smokers (none, only some, more than half, or all of them). Knowledge about the effects of SHS was measured using a 4-item scale with responses from 1 to 5 (strongly disagree to strongly agree). The items were “SHS is a cause of”: lung cancer in a non-smoker; asthma in children; low birth weight in babies; ear infections in children and babies. Prior to answering these knowledge items, respondents were given the following definition of SHS: “By secondhand smoke we mean smoke from cigarettes or other tobacco products that could be inhaled by people who are not smoking.” Standard demographic data were also collected. Statistical analysis Descriptive analyses were conducted on all variables to determine the prevalence of relevant child, household, and demographic characteristics as well as the home smoking policies. We created bar graphs to illustrate the mean number of cigarettes smoked in the home by the type of household smoking ban. Multinomial logistic regression was used to identify correlates of having a child-ban and not allowing smoking in the presence of children. For the odds ratios, the referent category was those parents with a full ban, which we compared to those homes that either (1) banned smoking in the presence of children, or (2) that had no ban on smoking. All analyses were weighted and were conducted using Stata 11.0. Results Sample The child, household, and demographic characteristics of the respondents are shown in Table 1. The sample was largely AfricanAmerican and female. Fifty percent of the caregiving respondents were mothers, 18.4% fathers, 26.1% grandparents, and the remaining 5.6% were another relative (e.g., a sibling). In general, knowledge about the effects of SHS was high especially regarding its role in lung cancer in non-smokers and asthma in children (Table 1). Household smoking policies About 48% (47.9%) of households reported a full ban which prohibited smoking in any part of the home. In contrast, 10% of households allowed smoking in all parts of the home and 42.1% allowed smoking in some parts of the home. Of those homes without a full ban (n = 212), 45.8% reported that smoking in the presence of children was never allowed, 43.6% reported it was sometimes allowed, and 10.7% stated it was always allowed. The cross-tabulation of these two items regarding smoking in the home (Table 2) indicates that the major difference between the two rules was attributable to households in which smoking was only allowed in some parts of the home. About 24% of households reported never allowing smoking in the presence of children but still allowed smoking somewhere in the home. Thus, the combination of these two policies was as follows: full smoking ban (47.9%), no smoking in the presence of children in the absence of a full ban (24.1%), and smoking allowed in the presence of children (28%).
A. Bleakley et al. / Preventive Medicine 62 (2014) 30–34
Table 1 Descriptive statistics (weighted) on correlates of household smoking bans (weighted; n = 456), Philadelphia, PA, June 2012.
Marital status (married versus other) Child characteristics Child is under 5 years old Child ever diagnosed with asthma Household characteristics Number of smokers in household Number of rooms Outdoor space Smokers in the home Mother Father Both parents Other (e.g., sibling, aunt, grandparent) Exposure to anti-smoking PSAs in the last month Never Rarely Sometimes Often Knowledge about effects of SHS [1 Strongly disagree–5 Strongly agree] Causes lung cancer in a non-smoker Causes asthma in children Causes ear infections in children and babies Causes low birth weight in babies Norms Friends of the respondents who are smokers None Only some More than half All of them
Unweighted n
39.5% 51.0% 9.5% 75.5% 77.5% 44.03 [42.45, 45.62] 36.5%
216 201 33 275 333 456
43.3% 37.0%
178 161
1.79 [1.68,1.89] 5.88 [5.65,6.10] 89.3%
456 456 427
36.3% 16.0% 22.0% 25.7%
154 96 99 107
10.9% 22.6% 25.7% 40.8%
59 111 119 166
3.90 [3.76, 4.04] 3.95 [3.81, 4.09] 3.75 [3.60, 3.90] 3.43 [3.30, 3.56]
456 456 456 456
12.6% 57.7% 22.4% 7.3%
68 281 83 24
10
% or mean [CI]
8.76
5
Race White Black Other Income (less than $60,000 per year) Female Age
13.3
225
1.8
0
Demographics and other correlates
15
32
Full Ban
No smoking around children Smoking allowed
Fig. 1. Number of cigarettes smoked in the home (all smokers) by type of household smoking ban (weighted), Philadelphia, PA, June 2012.
Correlates of household smoking policies Results of the multinomial logistic outcome on the combined presence of smoking policies in the home are in Table 3. Having a child b5 years old and having a child diagnosed with asthma were each negatively associated with having a ban on smoking in front of children compared to homes with a full ban. That is, homes with older children and asthma-free children were more likely to have such a ban. In addition, African-American households were more likely than white households to have a ban about smoking in front children. There were similar patterns with regard to not having any restrictions. African-American households and homes in which both parents were smokers were more likely to allow smoking in the presence of children (no ban), compared to those with a full ban. These homes were also less likely to have a child b5 years old, have a child with asthma, or have a private outdoor space. Discussion
Cigarette consumption in the home by household smoking policy For the three categorizations described above we examined the mean number of cigarettes smoked in the home by all smokers living in the home. As shown in Fig. 1, the number of cigarettes smoked decreased as the restrictiveness of the bans increased: households with full ban restrictions reported smoking the fewest cigarettes. Differences between the groups in the number of cigarettes smoked were statistically significant. The relationship between cigarettes smoked in the home and ban restrictiveness was the same even when the respondent was not a smoker (n = 165), although the overall estimates of cigarettes smoked in the home were higher (Full ban M = 2.96, CI −1.33, 7.26; No smoking around children M = 9.63, CI 4.77, 14.49; Smoking allowed M = 15.86, CI 2.05, 29.7).
Respondents from our sample of Philadelphia parents reported a full smoking ban in about 48% of households, which is lower than national estimates (Zhang et al., 2012). Most of the time (72%), children were somewhat protected either through a full ban or a ban on smoking in front of children. However, among homes that allowed smoking (i.e., did not have a full ban), over half allowed smoking in front of children. The restrictiveness of the household bans was related to the number of cigarettes smoked in the home. That is, full household smoking bans were associated with fewer cigarettes smoked in the home compared to a ban on smoking in front of children or no ban at all. Less restrictive smoking policies that did not allow smoking in the presence of children but allowed it otherwise in the home were more common in African-American households; African American homes were also more likely than white homes not to have a smoking policy at all, a
Table 2 General and child-specific household smoking policies (weighted; n = 448), Philadelphia, PA, June 2012. Household smoking policy Smoking in presence of child
Smoking is always allowed in home no ban
Smoking is allowed in some parts of home partial ban
Smoking is never allowed in home full ban
Total
Always allowed Sometimes allowed Never allowed Total
3.5% (15)a 6.0% (20)c 0.5% (5)e 10.0% (40)
2.1% (9)b 16.4% (62)d 23.6% (99)f 42.1% (170)
0% (0) 0% (0) 47.9% (238)g 47.9% (238)
5.6% (24) 22.4% (82) 72.0% (342) 100% (448)
Notes: Percentages are proportions of total households. Unweighted n in parentheses. Cells a + b + c + d = Smoking allowed in front of children; Cells e + f = No smoking in front of children; Cell g = Full ban.
A. Bleakley et al. / Preventive Medicine 62 (2014) 30–34 Table 3 Results of multinomial logistic regression (weighted) on household smoking bans (n = 414), Philadelphia, PA, June 2012. Referent: Full ban
Demographics Race White Black Other Income Gender Age Marital status (married or other) Child characteristics Child is under 5 years old Child ever diagnosed with asthma Household characteristics Number of smokers in household Number of rooms Outdoor space available Smokers in the home Father Mother Both parents Other (e.g., sibling, aunt, grandparent) Exposure to anti-smoking PSAs On television or radio Knowledge about effects of SHS Causes lung cancer Causes asthma Causes ear infections in kids Causes low birth weight Norms Friends of the respondents who are smokers
Smoking allowed in No smoking in presence of children presence of children OR [95% CI] OR [95.% CI]
1.0 [Reference] 8.65 [3.11,24.08] 0.82 [.128,5.29] 0.86 [.66,1.12] 1.38 [.56,3.41] 0.97 [.94,1.01] 2.02 [.79,5.14]
1.0 [Reference] 7.08 [2.92, 17.16] 3.83 [1.05, 14.02] 0.88 [.70, 1.10] 1.07 [.44, 2.59] 0.98 [.95, 1.01] 1.57 [.69, 3.59]
0.32 [.16, .65] 0.36 [.17, .76]
0.38 [.17, .82] 0.44 [.19, 1.00]
1.46 [.92, 2.30] 1.00 [.83, 1.21] 0.46 [.10, 2.06]
1.24 [.74, 2.08] 0.99 [.80, 1.23] 0.24 [.06, .98]
1.0 [Reference] 1.89 [.60, 5.93] 2.26 [.59, 8.7] 1.51 [.43, 5.32]
1.0 [Reference] 2.48 [.78, 7.92] 3.34 [1.01, 11.02] 1.00 [.26, 3.70]
1.04 [.73, 1.50]
0.91 [.64, 1.29]
0.98 [.63, 1.52] 0.81 [.56, 1.19] 1.20 [.87, 1.67] 0.86 [.57, 1.30]
0.71 [.48, 1.04] 0.92 [.62, 1.37] 1.37 [.98, 1.92] 0.75 [.52, 1.08]
1.38 [.91, 2.09]
1.37 [.85, 2.19]
pattern that was also observed in households in which both parents were smokers or did not have an outdoor space available.
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There are limitations to this study. Because the survey is crosssectional we are unable to determine if the ban results in fewer cigarettes smoked in the home or if bans are more likely to be implemented in homes with lighter or less addicted smokers. Most research in this area has been cross-sectional in nature and thus unable to discern directionality (Pizacani et al., 2008), although some evidence does suggest that bans result in less home smoking (Hennessy et al., in press). We were also unable to compare levels of actual SHS exposure in children based on the different types of household bans. The response rate for the survey, at 25.3%, is slightly lower than other phone surveys with adults (e.g., the Behavioral Risk Factor Surveillance System Survey, 2012, for Pennsylvania was 37.8%) thus selection bias may have affected our findings. And although the sample was weighted to reflect the population of Philadelphia parents with children younger than 13 years, the multi-approach sampling strategy used (because of the low incidence of our target population) may have limited generalizability. Finally, although most of the respondents (70%) were smokers themselves, when the respondent was not the smoker s/he was reporting on the cigarettes smoked in the home by the smoker(s) in the household. Most likely they are underestimates, given that smokers may smoke in the home when the respondent did not observe their behavior. Conclusion These findings demonstrate that while the characteristics associated with the implementation of full smoking bans in a large urban area with high smoking prevalence are consistent with national trends, AfricanAmerican households, those with children older than 5 years of age, and those with asthma-free children are more likely to have childcentric bans or no bans at all. In addition, when smoking is allowed in front of children, it is also more likely to occur in homes when parents are both smokers and when there is not an outdoor space available. The number of cigarettes smoked at home decreased with the restrictiveness of the ban. Health communication messages should be used to inform families about the lingering effects of SHS smoke in the home even when smoking does not occur in the presence of a child.
Implications for practice, policy, and research Conflict of interest statement
Previous research in both adult households (Pizacani et al., 2003, 2008) and households with children (Gonzales et al., 2006; Mills et al., 2011; Norman et al., 1999) focused on select child and household characteristics associated with full smoking bans. In our research, we identified factors associated with households that have partial child-centric bans or no bans at all. Our findings suggest that there is potential for intervention in homes with a child-centric smoking ban. What distinguishes these households from full-ban households may be their beliefs about the effectiveness of not smoking in front of children. Intervention and health communication messages should increase awareness about how smoke lingers and drifts in the physical environment. In addition, promotion of smoking in outdoor spaces may be successful. Most households in our sample had access to an outdoor space, which was strongly associated with having a full ban. Finally, messages highlighting SHS risks to older and non-ill children may also be important in motivating caregivers to adopt full bans (Gould et al., 2013). Although this study did not explore the reasons for implementing a smoking ban, there is evidence that suggests the health of their children is a dominant theme in families who adopt household smoking policies (Kegler et al., 2007). Many interventions to promote cessation among parents have used child protection as its main focus (Rosen et al., 2012). For those families without a full ban, not smoking in the presence of children may represent a middle ground. It would be useful to understand why these families stop short of implementing a full ban. Additional research should examine whether parents believe that their children are protected from the effects of SHS if they are not present during the act of smoking.
The authors declare that there is no conflict of interest.
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Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed
Home smoking policies in urban households with children and smokers Amy Bleakley a,⁎, Michael Hennessy a, Giridhar Mallya b, Daniel Romer a a b
Annenberg Public Policy Center at the University of Pennsylvania, 202 S. 36th Street, Philadelphia, PA 19104, USA Philadelphia Department of Public Health, Philadelphia, PA, USA
a r t i c l e
i n f o
Available online 24 December 2013 Keywords: Secondhand smoke Home smoking bans Urban
a b s t r a c t Objective. We identified household, child, and demographic characteristics associated with not having a smoking ban and having a rule about smoking in the presence of children in an urban population. Method. We conducted a cross-sectional random digit dial telephone survey (n = 456) of Philadelphia parents in June 2012. Results. Forty-eight percent of homes reported a full smoking ban. In homes that allowed smoking, over half allowed smoking in front of children. Cigarettes smoked in the home decreased as the restrictiveness of the bans increased. Multinomial logistic regression analyses showed that compared to having a full ban, banning smoking only in the presence of children was associated with being African-American, having a child N 5 years old, and having an asthma-free child. These characteristics, as well as having both parents as smokers and not having an outdoor space, were also associated with not having any restrictions. Conclusion. It is possible that households attempt to reduce home smoking by limiting smoking in the presence of children. Health communication messages should be used to inform families about the lingering effects of SHS in the home even when smoking does not occur in the presence of a child. © 2014 Elsevier Inc. All rights reserved.
Introduction As defined by the Centers for Disease Control and Prevention, secondhand smoke (SHS) is “a mixture of gases and fine particles that includes smoke from a burning cigarette, cigar, or pipe tip; smoke that has been exhaled or breathed out by the person or people smoking”(Centers for Disease Control and Prevention, 2013). As such, SHS exposure is a health hazard for children and adults (Brownson et al., 1997; Eriksen et al., 1988) and higher levels of SHS exposure are found in minority or lower socioeconomic households in urban areas (Centers for Disease Control and Prevention, 2008; Hopper and Craig, 2000). Infants and children are at particular increased risk of respiratory and other health problems when exposed to SHS (Ferrence and Ashley, 2000; Hovell et al., 2000; Kawachi, 2005), and because of this risk, intervention research has investigated methods of reducing their exposure (Emmons et al., 2001). At the household level, the focus has been on household bans or restrictions on indoor smoking (Gilpin et al., 1999; Hovell and Daniel, 2004; Sockrider et al., 2003; Spencer et al., 2005; Wewers and Uno, 2002; Yousey, 2006). Household smoking restrictions are associated with reduced exposure to SHS among children and adult non-smokers (Pizacani et al., 2003; Wakefield et al., 2000a) as well as quit attempts (Pizacani et al., 2004) and delayed smoking onset in children (Wakefield et al., 2000b). ⁎ Corresponding author at: 202 S. 36th Street, Philadelphia, PA 19147, USA. E-mail address: [email protected] (A. Bleakley). 0091-7435/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ypmed.2013.12.015
Despite half of U.S. households with smokers and children having a full smoking ban (Mills et al., 2011), children continue to be particularly vulnerable to SHS. Smoking in the home is the greatest source of SHS exposure among children (Ashley and Ferrence, 1998) and children from urban households are typically exposed to more SHS than other children (Halterman et al., 2006; Weaver et al., 1996). For example, urban children frequently live in multi-unit housing with close proximity to their neighbors, whose smoking may put other residents at risk (Winickoff et al., 2010). Awareness that SHS is harmful to one's health and the presence of a child in the home (Mills et al., 2011; Norman et al., 1999; Pizacani et al., 2003) are associated with having household restrictions. AfricanAmerican households, households with older children, and Hispanic and white households with high smoking prevalence are less likely to have home smoking bans (Mills et al., 2011). Studies have shown that while parents have knowledge about the potentially harmful effects of SHS on children, emotional and/or financial stressors prevent the adoption of full smoking bans (Halterman et al., 2007; Halterman et al., 2010). However, partial smoking bans which allow household smoking in certain rooms or under certain circumstances are not as effective as full bans in reducing children's exposure to SHS (Wakefield et al., 2000a). To learn more about these different types of household smoking policies, we conducted a survey with urban parents who either smoke or live with a smoker to determine household, child, and demographic characteristics associated with having a full household smoking ban and having a rule about smoking in the presence of children. We also
A. Bleakley et al. / Preventive Medicine 62 (2014) 30–34
examined how these policies are related to the number of cigarettes smoked in the home. Methods A telephone survey in May/June 2012 was conducted with 456 Philadelphia parents or caregivers from homes with at least one smoker and a child 13 years or younger living in the home. We focused on families with children 13 years old and younger because younger children are more vulnerable to SHS (see Ashley and Ferrence, 1998). The sample was randomly drawn from a list of households in Philadelphia County identified as including a child under the age of 13 (n = 217) and through a random digit dialing (RDD) sample drawn from phone numbers with Philadelphia County telephone exchanges from predominantly low-income sections of the city (n = 123). We drew from low-income exchanges specifically because tobacco use is higher in lower socioeconomic groups (Hill et al., 2013). In addition, a random sample was drawn from a pool of respondents who completed a RDD survey of Philadelphia County smokers between 2010 and 2012 and who indicated the presence of a child in their household (n = 116). The combination of approaches was necessary because of the low incidence of the target population. The response rate for this study was 25.3%; the average survey length was 18 min. Unless otherwise noted, all results in this report are weighted. ⁎The study was approved by the institutional review boards at the University of Pennsylvania and the Philadelphia Department of Public Health. Measures Smoking policies in the home Two questions on the survey asked about home smoking rules. The first was: Which of the following best describes your household's rules about smoking? (a) Smoking is allowed in all parts of the home (no ban), (b) Smoking is allowed in some parts of the home (partial ban), and (c) Smoking is not allowed in any part of the home (full ban). A small number of respondents (n = 6, unweighted) answered that there were no smoking rules, and these were classified as response (a). If respondents indicated having either no ban or a partial ban, they were asked a second item asked about smoking in the presence of children: In your home, is smoking in the presence of children always allowed, sometimes allowed, or never allowed? If the respondent stated that there was no household rule about smoking in the presence of children (n = 8, unweighted), the item was coded as “always allowed”. From these two items we created a new variable to reflect the combined presence of these rules to indicate a child's level of protection from SHS. Based on their distribution, the variable had three categories: (1) full smoking ban, (2) no smoking in the presence of children (in the absence of a full ban), and (3) no ban/smoking allowed in the presence of children. Child and household characteristics The independent variables included the presence of a child in the home that was b5 years old and if the child in the home had ever been diagnosed with asthma. We also measured household characteristics such as the number of smokers in the household, the number of rooms in the home, access to a private outdoor space (e.g., a balcony, patio), and the relationship of the smoker(s) in the home to the child (mother, father, both, or other). For smokers who reported that they ⁎ The sample was weighted to (1) adjust for bias stemming from the propensity to complete a second survey in households re-contacted based on responses to the previous smoking survey; (2) adjust for differences in the probability of selection between listed households and the RDD sampling frame; (3) correct for the oversampling of lowincome exchanges; and (4) balance the sample to known household estimates in Philadelphia County and households of smokers with children.
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smoked at least 100 cigarettes in their lifetime and smoked at any time during the past 30 days, we asked how many cigarettes they smoked on a typical day [M: 9.8 cigarettes, 95% CI: 8.8–10.7]. Note that to reduce respondent bias, the smoking self-reports were collected before the information on the two types of household smoking restrictions. Additional covariates Other covariates were exposure to ads on television or radio about SHS in the last month (never, rarely, sometimes, often) as well as how many of their friends were smokers (none, only some, more than half, or all of them). Knowledge about the effects of SHS was measured using a 4-item scale with responses from 1 to 5 (strongly disagree to strongly agree). The items were “SHS is a cause of”: lung cancer in a non-smoker; asthma in children; low birth weight in babies; ear infections in children and babies. Prior to answering these knowledge items, respondents were given the following definition of SHS: “By secondhand smoke we mean smoke from cigarettes or other tobacco products that could be inhaled by people who are not smoking.” Standard demographic data were also collected. Statistical analysis Descriptive analyses were conducted on all variables to determine the prevalence of relevant child, household, and demographic characteristics as well as the home smoking policies. We created bar graphs to illustrate the mean number of cigarettes smoked in the home by the type of household smoking ban. Multinomial logistic regression was used to identify correlates of having a child-ban and not allowing smoking in the presence of children. For the odds ratios, the referent category was those parents with a full ban, which we compared to those homes that either (1) banned smoking in the presence of children, or (2) that had no ban on smoking. All analyses were weighted and were conducted using Stata 11.0. Results Sample The child, household, and demographic characteristics of the respondents are shown in Table 1. The sample was largely AfricanAmerican and female. Fifty percent of the caregiving respondents were mothers, 18.4% fathers, 26.1% grandparents, and the remaining 5.6% were another relative (e.g., a sibling). In general, knowledge about the effects of SHS was high especially regarding its role in lung cancer in non-smokers and asthma in children (Table 1). Household smoking policies About 48% (47.9%) of households reported a full ban which prohibited smoking in any part of the home. In contrast, 10% of households allowed smoking in all parts of the home and 42.1% allowed smoking in some parts of the home. Of those homes without a full ban (n = 212), 45.8% reported that smoking in the presence of children was never allowed, 43.6% reported it was sometimes allowed, and 10.7% stated it was always allowed. The cross-tabulation of these two items regarding smoking in the home (Table 2) indicates that the major difference between the two rules was attributable to households in which smoking was only allowed in some parts of the home. About 24% of households reported never allowing smoking in the presence of children but still allowed smoking somewhere in the home. Thus, the combination of these two policies was as follows: full smoking ban (47.9%), no smoking in the presence of children in the absence of a full ban (24.1%), and smoking allowed in the presence of children (28%).
A. Bleakley et al. / Preventive Medicine 62 (2014) 30–34
Table 1 Descriptive statistics (weighted) on correlates of household smoking bans (weighted; n = 456), Philadelphia, PA, June 2012.
Marital status (married versus other) Child characteristics Child is under 5 years old Child ever diagnosed with asthma Household characteristics Number of smokers in household Number of rooms Outdoor space Smokers in the home Mother Father Both parents Other (e.g., sibling, aunt, grandparent) Exposure to anti-smoking PSAs in the last month Never Rarely Sometimes Often Knowledge about effects of SHS [1 Strongly disagree–5 Strongly agree] Causes lung cancer in a non-smoker Causes asthma in children Causes ear infections in children and babies Causes low birth weight in babies Norms Friends of the respondents who are smokers None Only some More than half All of them
Unweighted n
39.5% 51.0% 9.5% 75.5% 77.5% 44.03 [42.45, 45.62] 36.5%
216 201 33 275 333 456
43.3% 37.0%
178 161
1.79 [1.68,1.89] 5.88 [5.65,6.10] 89.3%
456 456 427
36.3% 16.0% 22.0% 25.7%
154 96 99 107
10.9% 22.6% 25.7% 40.8%
59 111 119 166
3.90 [3.76, 4.04] 3.95 [3.81, 4.09] 3.75 [3.60, 3.90] 3.43 [3.30, 3.56]
456 456 456 456
12.6% 57.7% 22.4% 7.3%
68 281 83 24
10
% or mean [CI]
8.76
5
Race White Black Other Income (less than $60,000 per year) Female Age
13.3
225
1.8
0
Demographics and other correlates
15
32
Full Ban
No smoking around children Smoking allowed
Fig. 1. Number of cigarettes smoked in the home (all smokers) by type of household smoking ban (weighted), Philadelphia, PA, June 2012.
Correlates of household smoking policies Results of the multinomial logistic outcome on the combined presence of smoking policies in the home are in Table 3. Having a child b5 years old and having a child diagnosed with asthma were each negatively associated with having a ban on smoking in front of children compared to homes with a full ban. That is, homes with older children and asthma-free children were more likely to have such a ban. In addition, African-American households were more likely than white households to have a ban about smoking in front children. There were similar patterns with regard to not having any restrictions. African-American households and homes in which both parents were smokers were more likely to allow smoking in the presence of children (no ban), compared to those with a full ban. These homes were also less likely to have a child b5 years old, have a child with asthma, or have a private outdoor space. Discussion
Cigarette consumption in the home by household smoking policy For the three categorizations described above we examined the mean number of cigarettes smoked in the home by all smokers living in the home. As shown in Fig. 1, the number of cigarettes smoked decreased as the restrictiveness of the bans increased: households with full ban restrictions reported smoking the fewest cigarettes. Differences between the groups in the number of cigarettes smoked were statistically significant. The relationship between cigarettes smoked in the home and ban restrictiveness was the same even when the respondent was not a smoker (n = 165), although the overall estimates of cigarettes smoked in the home were higher (Full ban M = 2.96, CI −1.33, 7.26; No smoking around children M = 9.63, CI 4.77, 14.49; Smoking allowed M = 15.86, CI 2.05, 29.7).
Respondents from our sample of Philadelphia parents reported a full smoking ban in about 48% of households, which is lower than national estimates (Zhang et al., 2012). Most of the time (72%), children were somewhat protected either through a full ban or a ban on smoking in front of children. However, among homes that allowed smoking (i.e., did not have a full ban), over half allowed smoking in front of children. The restrictiveness of the household bans was related to the number of cigarettes smoked in the home. That is, full household smoking bans were associated with fewer cigarettes smoked in the home compared to a ban on smoking in front of children or no ban at all. Less restrictive smoking policies that did not allow smoking in the presence of children but allowed it otherwise in the home were more common in African-American households; African American homes were also more likely than white homes not to have a smoking policy at all, a
Table 2 General and child-specific household smoking policies (weighted; n = 448), Philadelphia, PA, June 2012. Household smoking policy Smoking in presence of child
Smoking is always allowed in home no ban
Smoking is allowed in some parts of home partial ban
Smoking is never allowed in home full ban
Total
Always allowed Sometimes allowed Never allowed Total
3.5% (15)a 6.0% (20)c 0.5% (5)e 10.0% (40)
2.1% (9)b 16.4% (62)d 23.6% (99)f 42.1% (170)
0% (0) 0% (0) 47.9% (238)g 47.9% (238)
5.6% (24) 22.4% (82) 72.0% (342) 100% (448)
Notes: Percentages are proportions of total households. Unweighted n in parentheses. Cells a + b + c + d = Smoking allowed in front of children; Cells e + f = No smoking in front of children; Cell g = Full ban.
A. Bleakley et al. / Preventive Medicine 62 (2014) 30–34 Table 3 Results of multinomial logistic regression (weighted) on household smoking bans (n = 414), Philadelphia, PA, June 2012. Referent: Full ban
Demographics Race White Black Other Income Gender Age Marital status (married or other) Child characteristics Child is under 5 years old Child ever diagnosed with asthma Household characteristics Number of smokers in household Number of rooms Outdoor space available Smokers in the home Father Mother Both parents Other (e.g., sibling, aunt, grandparent) Exposure to anti-smoking PSAs On television or radio Knowledge about effects of SHS Causes lung cancer Causes asthma Causes ear infections in kids Causes low birth weight Norms Friends of the respondents who are smokers
Smoking allowed in No smoking in presence of children presence of children OR [95% CI] OR [95.% CI]
1.0 [Reference] 8.65 [3.11,24.08] 0.82 [.128,5.29] 0.86 [.66,1.12] 1.38 [.56,3.41] 0.97 [.94,1.01] 2.02 [.79,5.14]
1.0 [Reference] 7.08 [2.92, 17.16] 3.83 [1.05, 14.02] 0.88 [.70, 1.10] 1.07 [.44, 2.59] 0.98 [.95, 1.01] 1.57 [.69, 3.59]
0.32 [.16, .65] 0.36 [.17, .76]
0.38 [.17, .82] 0.44 [.19, 1.00]
1.46 [.92, 2.30] 1.00 [.83, 1.21] 0.46 [.10, 2.06]
1.24 [.74, 2.08] 0.99 [.80, 1.23] 0.24 [.06, .98]
1.0 [Reference] 1.89 [.60, 5.93] 2.26 [.59, 8.7] 1.51 [.43, 5.32]
1.0 [Reference] 2.48 [.78, 7.92] 3.34 [1.01, 11.02] 1.00 [.26, 3.70]
1.04 [.73, 1.50]
0.91 [.64, 1.29]
0.98 [.63, 1.52] 0.81 [.56, 1.19] 1.20 [.87, 1.67] 0.86 [.57, 1.30]
0.71 [.48, 1.04] 0.92 [.62, 1.37] 1.37 [.98, 1.92] 0.75 [.52, 1.08]
1.38 [.91, 2.09]
1.37 [.85, 2.19]
pattern that was also observed in households in which both parents were smokers or did not have an outdoor space available.
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There are limitations to this study. Because the survey is crosssectional we are unable to determine if the ban results in fewer cigarettes smoked in the home or if bans are more likely to be implemented in homes with lighter or less addicted smokers. Most research in this area has been cross-sectional in nature and thus unable to discern directionality (Pizacani et al., 2008), although some evidence does suggest that bans result in less home smoking (Hennessy et al., in press). We were also unable to compare levels of actual SHS exposure in children based on the different types of household bans. The response rate for the survey, at 25.3%, is slightly lower than other phone surveys with adults (e.g., the Behavioral Risk Factor Surveillance System Survey, 2012, for Pennsylvania was 37.8%) thus selection bias may have affected our findings. And although the sample was weighted to reflect the population of Philadelphia parents with children younger than 13 years, the multi-approach sampling strategy used (because of the low incidence of our target population) may have limited generalizability. Finally, although most of the respondents (70%) were smokers themselves, when the respondent was not the smoker s/he was reporting on the cigarettes smoked in the home by the smoker(s) in the household. Most likely they are underestimates, given that smokers may smoke in the home when the respondent did not observe their behavior. Conclusion These findings demonstrate that while the characteristics associated with the implementation of full smoking bans in a large urban area with high smoking prevalence are consistent with national trends, AfricanAmerican households, those with children older than 5 years of age, and those with asthma-free children are more likely to have childcentric bans or no bans at all. In addition, when smoking is allowed in front of children, it is also more likely to occur in homes when parents are both smokers and when there is not an outdoor space available. The number of cigarettes smoked at home decreased with the restrictiveness of the ban. Health communication messages should be used to inform families about the lingering effects of SHS smoke in the home even when smoking does not occur in the presence of a child.
Implications for practice, policy, and research Conflict of interest statement
Previous research in both adult households (Pizacani et al., 2003, 2008) and households with children (Gonzales et al., 2006; Mills et al., 2011; Norman et al., 1999) focused on select child and household characteristics associated with full smoking bans. In our research, we identified factors associated with households that have partial child-centric bans or no bans at all. Our findings suggest that there is potential for intervention in homes with a child-centric smoking ban. What distinguishes these households from full-ban households may be their beliefs about the effectiveness of not smoking in front of children. Intervention and health communication messages should increase awareness about how smoke lingers and drifts in the physical environment. In addition, promotion of smoking in outdoor spaces may be successful. Most households in our sample had access to an outdoor space, which was strongly associated with having a full ban. Finally, messages highlighting SHS risks to older and non-ill children may also be important in motivating caregivers to adopt full bans (Gould et al., 2013). Although this study did not explore the reasons for implementing a smoking ban, there is evidence that suggests the health of their children is a dominant theme in families who adopt household smoking policies (Kegler et al., 2007). Many interventions to promote cessation among parents have used child protection as its main focus (Rosen et al., 2012). For those families without a full ban, not smoking in the presence of children may represent a middle ground. It would be useful to understand why these families stop short of implementing a full ban. Additional research should examine whether parents believe that their children are protected from the effects of SHS if they are not present during the act of smoking.
The authors declare that there is no conflict of interest.
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