‘Waiting until they got home’: Gender, smoking and tobacco exposure in households in Scotland

Social Science & Medicine 71 (2010) 884e890

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Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed

‘Waiting until they got home’: Gender, smoking and tobacco exposure in households in Scotlandq Jude Robinson a, *, Deborah Ritchie b, Amanda Amos c, Sarah Cunningham-Burley d, Lorraine Greaves e, Claudia Martin f a

The Health and Community Care Research Unit (HaCCRU), University of Liverpool, Thompson Yates Building, The Quadrangle, Brownlow Hill, Liverpool L69 3GB, United Kingdom Nursing Studies, School of Health in Social Science, Medical School, University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, United Kingdom UK Centre for Tobacco Control Studies, Centre for Population Health Sciences, Medical School, University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, United Kingdom d Centre for Population Health Sciences, Medical School, University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, United Kingdom e British Columbia Centre of Excellence for Women’s Health, Canada f Scottish Centre for Social Research, 73 Lothian Road, Edinburgh EH3 9AW, United Kingdom b c

a r t i c l e i n f o

a b s t r a c t

Article history: Available online 20 May 2010

The introduction in March 2006 of legislation banning smoking in public places in Scotland raised concerns that smokers would smoke more at home and so increase the exposure of those living with them to tobacco smoke. Drawing on interviews from two qualitative studies conducted after the implementation of the legislation, this article uses a gendered analysis to explore where and why smokers, who lived with non-smokers including children, continued to smoke in their homes. Although very few people attributed any increased home smoking to being a direct consequence of the legislation, many who already smoked there continued, and most women reported little or no disruption to their home smoking post-legislation. Also, because of the changing social environment of smoking, and other life circumstances, a minority of women had increased their levels of home smoking. Compared to the men in these studies, women, particularly those who didn’t work outside the home, had restricted social lives and thus were less likely to have smoked in public places before the legislation and spent more time socialising in the homes of other people. In addition, women with children, including women who worked outside their homes, were more likely to spend sustained periods of time caring for children compared to fathers, who were more likely to leave the home to work or socialise. Although home smoking was linked to gendered caring responsibilities, other issues associated with being a smoker also meant that many women smokers chose to keep smoking in their homes. Ó 2010 Elsevier Ltd. All rights reserved.

Keywords: Scotland Gender Smoking Second-hand smoke Tobacco control UK

Introduction Despite overall declining smoking rates in developed countries, levels of smoking remain high in the poorest communities, linked to multiple social and economic disadvantages, ill health, and poor lifeexpectancy (Graham, Inskip, Francis, & Harman, 2006; Marsh & McKay, 1994). As smoking relates to embedded cultural and social norms within communities and households (Poland, 2000), some

q Both studies and the GBA were funded by NHS Health Scotland. The views expressed in this paper are those of the authors and not necessarily those of the funder. We would like to thank all those who participated in the studies; Richard Phillips for his work on the Homes study; the interviewers Irene Miller, Fiona Rait, and Fenella Hayes; and Sally Haw for her advice and support. * Corresponding author. Tel.: þ44 151 794 5288; fax: þ44 151 794 5434. E-mail address: [email protected] (J. Robinson). 0277-9536/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2010.04.031

groups, particularly people living in poverty and disadvantage, remain ‘hard to reach’ (Parry, Bancroft, Gnich, & Amos, 2001). Indeed, research suggests that although population based interventions, such as media campaigns and legislation, may change wider social attitudes towards smoking, they do not necessarily reduce health inequalities (Thomson, Wilson, & Howden-Chapman, 2006). Furthermore, research into the introduction of comprehensive tobacco control policies indicate that women and girls, particularly those on low incomes, may be adversely affected, leading to a call for the development of gender-sensitive policies (Dedobbeleer, Béland, Contandriopoulos, & Adrian, 2004; Greaves & Jategaonkar, 2006). Gender has been identified as a key determinant of smoking behaviour, with teenage girls in many developed countries more likely to take up smoking than teenage boys, and women who have children more likely to smoke than women without children (Dedobbeleer et al., 2004; Graham, 1994, 2003; Greaves & Jategaonkar, 2006).

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One of the concerns about the introduction of legislation to ban smoking in public places in Scotland was that levels of home smoking would increase, leading to increased exposure of household members to second-hand smoke. An early study by Borland, Mullins, Trotter, and White (1999) found that the introduction of workplace restrictions in the state of Victoria, Australia, did not increase household smoking, and a more recent study in Ireland and the UK found reduced levels of smoking (Hyland et al., 2008). However these studies also found that there was less of a reduction in exposure in households where both adults smoked. Research has consistently found that children who live with non-smokers experience the highest reductions in exposure to second-hand smoke as a result of smoke-free policy initiatives, whereas there is comparatively little change for children who live with smokers (Akhtar, Currie, Currie, & Haw, 2007; Borland et al., 1999; Jarvis et al., 2000). Notably, in Scotland exposure declined significantly post-legislation for children whose parents were non-smokers or where only the father smoked but not where both parents or only the mother smoked (Akhtar et al., 2007). The exposure of children to tobacco smoke has been linked not only to poor health outcomes in childhood and an increased risk of developing life-threatening conditions in later life (Cook & Strachan, 1998; Muller, 2007; Strachan & Cook, 1998), but also to poor performance at school and other cognitive and behavioural problems (Eskenazi & Castorina, 1999). Therefore it is important to understand why some parents continue to smoke in their homes in order to develop more effective initiatives on reducing children’s exposure to second-hand smoke, particularly the most disadvantaged children whose parents are most likely to smoke and whose homes have fewer smoking restrictions (Muller, 2007). Sociological perspectives in smoking research have highlighted the personal, emotional and structural barriers smokers experience when attempting to quit smoking (Graham et al., 2006). Some smokers have described how smoking supports them to perform particular daily tasks, such as getting up in the morning, as a reward for cleaning the house, or by helping them think over issues at work (McKie, Laurier, Taylor, & Lennox, 2003). Structural barriers relate to aspects of people’s wider social environments, such as limitations of poverty, low literacy or the built environment. For example some parents of young children have limited choices regarding their smoking. In one study, they felt unable to move their smoking outside to protect their children as they were concerned about leaving babies and young children unsupervised in their homes, even for short periods (J. Robinson & Kirkcaldy, 2007). Research suggests that changing smoking behaviours are linked to gender (Bottorff et al., 2006; Dedobbeleer et al., 2004), and that the barriers to quitting smoking, or smoking outside the home, are experienced differently by mothers and fathers, reflecting the gendered roles of caring embedded within social relationships (Graham, 1994; Greaves & Jategaonkar, 2006; Greaves, Kalaw, & Bottorff, 2007; Royce, Corbett, Sorensen, & Ockene, 1997; Thompson, Parahoo, McCurry, O’Doherty, & Doherty, 2004). In the UK, smoking rates are highest for people living on a low income, such as manual workers and those who are unemployed. Furthermore, more people aged 20e35 years are more likely to smoke, and smoke more, than people in younger or older age groups, which is also the time when many people are involved in the bearing and caring for children (S. Robinson & Lader, 2007). Therefore, it is likely that the introduction of smoking legislation will affect different people in different ways, including their levels and patterns of home smoking (Graham, 1993; Greaves, Vallone, & Velicer, 2006; Lader, 2006; Marsh & McKay, 1994). In considering the social context of smoking, Poland (2006) identifies the study of relative power as a key dimension for researching the how and the why of smoking behaviours. Drawing on the accounts of people

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who still smoke in their homes, and are living with non-smokers, in this article we apply a gender analysis to further explore who, when and why people still expose other adults and children to secondhand smoke in home environments, and how this intersects with changing public health policy and shifting social attitudes.

Research design and methods In March 2006, the Scottish Government introduced legislation to ban people smoking in enclosed public places. NHS Health Scotland commissioned two qualitative studies to explore the impact of the legislation at both individual and community levels. ‘Evaluation of the Smoke-free legislation in Scotland: Qualitative Community Study’ (Martin, Ritchie, & Amos, 2008) was a longitudinal study that used semi-structured in-depth interviews to explore participants’ changing smoking behaviours, including their understanding of, and exposure to, second-hand smoke at four points prior to and after the smoking legislation. Participants described their smoking behaviour in a typical 24 h period using an adapted version of the ‘life grid’ (the day grid) which annotated the number of cigarettes smoked over the course of a day in terms of when, where and in what social context smoking occurred (Bancroft, Wiltshire, Parry, & Amos, 2003). The research took place in four socially and economically contrasting areas in Scotland. Data were collected between October 2005 and March 2007. In the Qualitative Study of Smoking in the Home (Amos, Philips, Ritchie, Cunningham-Burley, & Martin, 2008; Phillips, Amos, Ritchie, Cunningham-Burley, & Martin, 2007), participants took part in semi-structured interviews in their homes post-legislation to discuss their daily patterns of smoking (using the day grid), attitudes towards smoking and second-hand smoke, and whether they had introduced any home smoking restrictions. Data were collected between June and September 2006. Narrative accounts in the interviews and the day grids in both studies were independently scrutinised by the researchers to ascertain each participant’s tobacco consumption. Any disagreements were re-examined until a consensus was reached. For the thematic analysis, a modified grounded theory approach was taken. The interviews were read by all the researchers, descriptive indexing structures developed and the data then coded using QSR N6. Comparisons were made across interviews and within themes to explore analytical categories rigorously. Both studies complied with the Code of Practice on Ethical Standards for Social Research Involving Human Participants operating in Public Health Sciences at the University of Edinburgh. Participants were informed that they could withdraw from the study at any stage. Confidentiality and anonymity were assured. These two studies produced internationally unique datasets, which included post-legislation depth interviews with a total of 85 smokers and non-smokers, living in socially and economically diverse areas in Scotland. The studies found that there were high levels of compliance with the legislation although a number of people, particularly older people, talked about how their social lives had been disrupted, and overall patterns of home smoking remained unchanged. In order to further explore the complexity of these data sets, a subsequent wave of analysis was undertaken with a reflexive team, where ideas and assumptions were discussed through face to face meetings and telephone conferences (Barry, Britten, Barber, Bradley, & Stevenson, 1999). The team was composed of members of the original research team and widened to include two new members (JR and LG). This re-analysis of each transcript from each of the two studies aimed to identify gendered factors, differences and issues to explore how they relate to, and perhaps clarify, other findings from the research (Johnson, Greaves, & Repta, 2007). Specifically, the team looked for implications or evidence of

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gendered roles, responsibilities, relationships or power differentials on the patterns and levels of home smoking in both women and men. The opportunity to engage in a deeper level of analysis, specifically to look at gender is not often given to researchers, who may need to undertake a time-limited analysis of often large volumes of data, requiring them to develop analytical approaches to identify themes that cross-cut age, ethnicity and gender. This analysis started with a period of orientation with the data sets, based on a careful reading, and re-reading of all the transcripts. This enabled the identification of tentative themes through a constant questioning of the data using a gender lens and by comparing cases, and scrutinising any negative cases. At key stages in the further data analysis, members of the reflexive research team discussed and commented on the scope of the analytical approach and content of the emerging findings. By revisiting the data and looking at how gender intersected with multiple factors relating to the lives of the men and women in the two studies, we were able to locate how their gender influenced the participant’s view of their lives, their smoking and themselves, and how this shaped and at times appeared to control other aspects of their lives, such as their work, family relationships, household responsibilities and wider social opportunities. Data relating to gender, particularly for a study that was not set up to specifically explore these issues, proved to lie deep within the transcripts, and at times were elusive and embedded in discussions of other issues. Nevertheless, the presence of the gendered nature of smoking behaviours mediated by age and social relationships was evident in both studies. The original analysis of the data sets had identified that many adults reported that they had altered their smoking behaviours in the presence of non-smokers, particularly children and the majority reported that when they smoked at home, they now took their smoking outside (Phillips et al., 2007). Although the reported consumption of the total number of cigarettes smoked decreased for the home smokers in both studies following the introduction of the smoke-free legislation, with some smokers quitting altogether, we noted this reduction in total consumption was largely due to people stopping or reducing their smoking in public places. Relatively few people decreased the number of cigarettes they smoked at home, although many had moved their smoking ‘outside’ their home in recent years, and smoked in their garden or areas directly adjacent to their house or flat, yet for a minority of people, their reported levels of home smoking increased. To further explore the links between gender and home smoking we focused on the 30 people, 14 from the Community Study and 16 from the Smoking in the Home study, of working age, who lived with at least one non-smoker, including children, and who still smoked in their homes (Table 1). All of the participants were from a white background, which is consistent with the demographics of the areas in the study. Ages in the sub-sample ranged from 23 to 63 years, with 14 of the participants aged 40 and 49 years (6 men and 8 women), with 4 women and 2 men aged over 50 years. Two men and 2 women were under

30 years, with the remaining 4 men and 2 women aged between 30 and 39 years of age. Findings One of the most notable findings from the gender based analysis of those who still smoked inside their homes was the lack of impact the smoke-free legislation had on the lives of most female home smokers. Of the 30 people who smoked in their homes and lived with a non-smoker, 18 were women and 12 were men, and more of the women lived with children (11 out of 18) compared to the men (6 out of 12). Although the numbers are too small to be representative, a greater number of women from disadvantaged backgrounds reported that they smoked in their homes in front of non-smokers than women from more affluent backgrounds (11 compared to 7). However, while the number of men in both studies was lower, there was no distinction between socio-economic groups, with 6 men from affluent backgrounds and 6 from disadvantaged backgrounds smoking in their homes in front of non-smokers. This suggests that gender is likely to cross-cut other factors, such as social class, in different ways, resulting in gendered behavioural patterns. While it is difficult to accurately estimate cigarette consumption from self-reported data and participants were not consistent about how they talked about their smoking, over half of the participants from this sub-sample (17 out of 30 people) described smoking over 20 cigarettes a day, here designated as ‘heavy smokers’ (8 women and 9 men), with 2 of the 17 people (both male) reporting smoking over 40 and over 60 cigarettes a day. Five were identified as ‘moderate smokers’, smoking between 11 and 19 cigarettes a day, including 3 men and 2 women. Eight women but no men reported smoking 10 or fewer cigarettes a day and were designated ‘light smokers’. Patterns of smoking within households varied, depending on whether people lived with other people and their smoking status. Of the 20 households where children were present, 17 included single parents (5 women and 1 man who acted as the parttime carer of his children), or 2 or more smoking adults. Only in 3 households with children was the smoker the only adult who smoked (2 men and 1 woman). Eleven of the 17 people who lived with children were heavy smokers (5 men and 6 women), 2 were moderate smokers, with 4 women designated light smokers. In 10 households without children smokers smoked. A further analysis of the accounts given by people who still smoked in their homes enabled the identification of their characteristics and life circumstances, and a clearer picture to be drawn as to how gender and social relationships intersect as part of wider social and cultural influences on smoking behaviours in households with non-smoking adults and children. While the issues presented are not clear cut, as people do not neatly fall into categories or groups, this analysis does highlight some of the factors that may sustain home smoking, even if the individual is motivated to stop smoking in the presence of their child. In the following

Table 1 Women and men home smokers of working age, living with non-smokers, who smoke in their homes. Socio-economic background Community study

Smoking in homes

Women who smoke indoors in households with only adult non-smokers Women who smoke indoors in households with children Men who smoke indoors in households with adult non-smokers Men who smoke indoors in households with children Women who smoke indoors in households with non-smokers Women who smoke indoors in households with children Men who smoke indoors in households with adult non-smokers Men who smoke indoors in households with children Total

Advantaged

Dis-advantaged

Total

2 3 2 1 0 2 1 2 13

3 1 0 2 2 5 3 1 17

5 4 2 3 2 7 4 3 30

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presentation of the key findings, data extracts preceded by ‘SH’ denote the Smoking in Homes study and ‘CS’ the Community Study, and ‘H’, ‘M’ and ‘L’ after the number code designates the participant as either a ‘Heavy’, ‘Moderate’ or ‘Light’ smoker. Smoking and paid work Several home smokers undertook paid work outside their homes, although men were more likely to work full-time and regular hours than women, who tended to work shorter hours and part-time. Both men and women reported smoking less at work as a direct result of the smoking legislation, as they had reduced opportunities to smoke. This man describes how he had adjusted his smoking in advance of the legislation, and so tended to use the same opportunities he had to smoke outside his workplace: I never smoked at my work anyways and 9 times out of 10 I’m working outside in the car park there so you can always have a cigarette, not like I’m smoking in the workplace (CS14H) While women similarly linked a reduction in the number of cigarettes they smoked to being in paid employment, unlike the men, they spontaneously contrasted their limited ‘work’ smoking to their heavier ‘home’ smoking, and reflected on how ‘being busy’ or occupied determined their cigarette consumption, rather than the introduction of the legislation. One woman, who lived with her smoking husband and cared for her daughter who had Down’s Syndrome, was made redundant soon after the legislation was introduced. She described how she now smoked more at home, as despite being a heavy smoker, her work had successfully restricted her smoking in a way that home did not: Well I wasn’t working everyday but when I was working it was maybe like four hours in the morning, or three in the afternoon which I would never smoke during those hours, whereas now I am. I am smoking maybe every hour! (CS13H) Another woman, also a heavy smoker, had decreased her overall smoking by undertaking paid employment as a dinner lady, as before she worked she smoked almost continuously in her home: RES: I don’t know, I seem to be busier at school I don’t have time. Now it’s maybe even ‘til half past 3 when the boss has gone into [a] meeting and then I don’t have another one ‘til I get home INT: Right RES: So you can see why I didn’t want [to stay at home], 24 hours I was smoking. (CS6H) Overall, the women home smokers who worked stated that they found it easy not to smoke during their breaks at work, but found it very hard to limit their smoking once they were at home, with weekends representing a real problem for some. One working woman with 3 children who worked during the week described how she smoked more at weekends:

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INT: Why do you try and do that? RES: Just for something. if you are sitting in front of the television I would smoke more than I would normally smoke during the day, instead of having one an hour, it could be one every 45 minutes or something. So I try and stretch it out. (SH14406H) Women seemed to be very aware of the link between levels of smoking while spending time in a home environment compared to a working environment. One woman linked her home smoking to her experiences of working outside the home, which suggests that although workplace restrictions and the physical and mental activity involved in paid work may reduce smoking at work, the overall pressure on women as they manage competing demands of work and home mean that they may use their homes to smoke to relieve pressures they are experiencing at work: If you’re stressed, you know you come home from work and if you’ve been stressed, if you’ve had a stressful day it’s nice to sit down with a cup of tea and a cigarette and that’s it. (CS12L) In contrast to the women, who welcomed the opportunity to smoke less, one man, who described himself as smoking over 60 cigarettes a day, reported making changes to his work that effectively sustained his smoking: RES: I dinnae work nights now. INT: Oh right, oh you’ve given that up now? RES: Aye, I work during the day, work outside I can smoke till my heart’s content. INT: So when did you give up the night portering job? RES: Two month ago. INT: And why did you give that up? RES: Well they were wanting me to change hours and all the rest of it and well basically you just couldnae smoke either. (CS26H) That most men in this sub-sample found ways to maintain their pre-legislation patterns of consumption of cigarettes suggests that men and women were reacting to the legislation in subtly different ways, with women tending to use the time at work to reduce rather than maintain their smoking in ways that they found more difficult when they were at home.

Restricted and unrestricted lives and home smoking Men who smoked in the home talked about how they were able to adapt to the changing social landscape by changing their smoking behaviours: I don’t think it changes, if you really want to have a big drink when you’re in the mood for a big drink, then you have a big drink it won’t affect just because you can’t smoke or you’re smoking less. (CS34M)

I would say probably [smoking] more because I am doing nothing, so I am constantly. I don’t know, I can’t even think to every hour, I would say practically every half hour during the weekend, aye I am really bad at the weekend, where I’m like, where it would be constantly lighting up. (SH14319H)

These accounts by men contrasted with those of women, who associated their unchanged smoking behaviours with their more restricted and limited working and social lives, which centred on their home and the homes of friends and relatives. This mother who cared for her 4 year old daughter at home described how she smoked once her child had gone to bed:

A common theme across the accounts from working women in both studies was that they had to deliberately keep busy to stop themselves smoking almost continuously when they were at home:

I’m usually quite busy during the day so I dinnae really like sit down, I’ve only got a few hours like but ‘em, no I don’t really smoke much during the day, I don’t like smoking when [name of child] is at nursery and smelling of smoke around kids. (CS29T3L)

RES: I sometimes find I do things to slow the smoking down, you know I will get up and go and maybe clean the bathroom for a bit, come back and then.

She associated smoking with her social identity and related her home smoking solely to the lack of opportunities to socialise and to smoke outside:

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. smoking is like my adult thing for me, my wee treat, because I dinnae go out, I dinnae socialise, I dinnae drink, I dinnae go to pubs and clubbing every week-end so my smoking is like my wee thing, do you know what I mean? (CS29L) She positioned her smoking as a reasonable response to the competing needs of being a caring mother and a person in her own right, and having given up much of her social life to care for her child, was not prepared to give up her smoking. Other women also seemed to have little opportunity to go out, for example this mother of 3 children under 16 who lived with her partner, who also smoked, had gradually restricted her social life in response to her caring and working responsibilities: To the pubs I go out less, but now with my sister’s business and that and me helping her out and that and working for her, I am hardly ever down the town, it’s not very often, and it’s just a case of. I used to like going walking around the town and that, but now I don’t do it, I just like going down for what I want and then back up again. (SH14319H) That it is the gendered role of caring and lack of occupation that sustains higher levels of home smoking, not the sex of the person doing it, is supported by the account of a man who cared for his 9 year old son while his wife continued to work. Like the women in this study, he expressed his increased home smoking as a response to a restricted social life and lack of physical and mental occupation during the day: There is two aspects to it, one it’s not so much in the summer months but in the winter months, it kills my appetite, it stops me snacking last thing at night which is a tendency to do, just boredom. So that’s a way of killing the appetite and also there is a kind of, I recognise now that there’s an award feature in other words, I have done my bit for the day, kids in bed, dog is walked. I suppose I could have a drink instead but it tends to be the sort of reward at the end of the day. (SH11019M) Patterns of spending time at home rather than at work meant that one woman, who smoked more than 40 a day, and had recently become unemployed, was smoking more: I’m not working just now but when I’m in the house myself, I smoke, smoke, smoke. (SH16118H) As the women’s social lives had revolved around their own and other people’s homes for many years, their sustained home smoking cannot be viewed simply a response to the changing policy landscape or shifting social practices. However while personal preference could explain why some women chose to socialise in private places, the association between spending time at home and taking on the caring responsibilities for their children, described by both single parents and women in relationships, offers a more persuasive argument. Even in families with two parents, caring roles and responsibilities could impact on home smoking. A 33 year old man, living with a wife and baby, was a heavy smoker prior to legislation and spent most evenings at the pub. Although he reported spending more time at home post-legislation, he smoked outside, or through an open window if his child was asleep in their room, and reported that he had reduced his smoking. However he contrasted his own changed behaviour with that of his wife, who remained a heavy smoker and still smoked indoors, although not directly in front of their child. Interestingly, in his view, her smoking hadn’t changed post-legislation because she didn’t socialise in pubs: RES: No, I’d rather do without rather than, ken, if I’m not in the pub I’ll just sit in the house and drink tea or coffee, I’m not one for

drinking in the house, I don’t really smoke in the house that much either. It’s like 20 fags will do me probably for 2 days instead of like smoking 40 a day. INT: Yes RES: And the wee one’s getting bigger and all so I’m trying not to smoke so much in our house so much. INT: And what about, you said your partner smoked in the house as well RES: Oh she, she’s not changed she’s just as bad. INT: She’s just the same. RES: She’ll not stop. She’ll not even cut down, I’ve tried asking her to do that but she didn’t want to do it. And she even smokes the same places all the time as she did before, it doesn’t really bother her because she’s not much of a drinker. If she was more of a drinker then it would probably have more effect on her, but it’s not changed her at all. (CS22M) This account highlights a number of key issues around the unchanged nature of women’s smoking, compared to that of men. While this father maintains he was not bringing his smoking in to their home post-legislation, he did not appear to have instigated any changes that could positively affect his wife’s behaviour, such as coming home after work to enable her to go out, and just ‘asked’ her to cut down. INT: . you went out every night after work, every day after work, so do you find yourself.? RES: I still do that, yeah. INT: You still do that. So what, do you still go for the same length of time as well? RES: Yeah. (CS022M) By maintaining elements of his social life and keeping his smoking outside his home this man demonstrated his continued ability to detach himself from his caring responsibilities when he wished to. While he could be viewed as a ‘considerate smoker’, his apparent lack of insight into how his behaviour could be contributing to his child’s exposure to smoke, meant that while his child’s exposure had not increased post-legislation, it has not decreased either. Doing without Another way in which women accounted for the lack of impact of the smoking legislation on their lives was linked to their ability to go for long periods without smoking when visiting public places. This woman, while a heavy smoker, described how she waited until she got home before she had a cigarette: I got to cafes and meet friends at least once a week and we go for a cuppa you know. I am not at the pub a great.in fact I think I have probably only been in the pub maybe once since you were last here, except for on holiday. I tend to go to people’s houses, friends’ houses which I did before anyway you know. We go out for a meal occasionally but. I would just have the one and then came home, I just waited until I got home and have a cigarette then. It hasn’t changed. (CS13H) Again the ability to not smoke in public places was linked to being occupied and being in a social, non-smoking environment. However the accounts also included an element of ‘denial’ of a much wanted privilege, and a new construction of self as people with sufficient willpower and self control to abstain from smoking: I don’t really think it has had any impact on me whatsoever, I can go quite long without cigarettes if I want to, so if I am in a restaurant I tend to go the whole night there without having a cigarette. (SH11911M)

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Many of the women appeared resigned to the need to change their smoking behaviours outside their homes, and constructed a positive social identity from being someone who could ‘do without’ and ultimately adapt to the new norms, which appeared to be smoking at home: I have learnt to just work around it. I am not going to let it upset me or not going to start making protests in the street to the government saying I think you should bring back smoking in pubs and all that. You just accept what is happening and you deal with it in other ways. (CS36L) However this was perhaps related to the desire for some women to hide their smoking status in public rather than a desire to cut down their smoking. People who needed to smoke so much that they smoked in public, were contrasted unfavourably with smokers who were controlled enough to wait until they got home: INT: And what happens with cigarettes if you are going for a swim in the mornings? RES: I leave them at home I am very good that way. I always feel quite proud of myself when I come out of the swimming pool, and the last think I want is a cigarette because I feel so clean. I don’t want to tarnish it with a dirty cigarette. My mum as soon as she comes out she has got a cigarette in her mouth right enough. She is terrible. But no.I have one when I get home from the swimming. (CS36L) ‘Waiting until they got home’ was a recurrent theme in the smoking accounts of many women, some of whom were light smokers, suggesting that smoking had become a private activity, rather than a public pastime. If we were out for a meal and staying longer, and having a few more drinks I would go outside and have a cigarette yes. But I mean if we were just out for a meal and coming home, not out for the night as such I would probably just wait until I came home. (CS13H) For this woman, her lived environment was mapped in terms of where she could and couldn’t smoke, essentially into public and private spaces, with home being the one safe secure place where she could now smoke: Well I can’t smoke in work, I can’t smoke in the playground or that, I have to go outside the playground to smoke. You can’t smoke in, well if you go to Safeway, not Safeway, Morrison’s [both supermarkets] to do the shopping, you cannot go for a coffee and a cigarette. Wednesday I was at ASDA’s parked the car, went straight into ASDA’s, there’s a restaurant in there but what’s the use of going to the restaurant so I was in there about an hour and a half I think shopping. Never bought any messages [groceries] mind just clothes. And I had one when I got home ‘cos just walking out and getting in the car packing messages didn’t have time, drove home and had a fag when I got home. So it does stop the likes of me smoking. I can’t say that it bothers us that much until I get home and know I can smoke (CS6H) Therefore although many women reported that they had moderated their outdoor smoking in response to the legislation and the changing social context, other factors such as their caring responsibilities, personal identity and social lives meant that their homes remained the place where they still smoked. Although their total cigarette consumption may have reduced, there was the suggestion in their accounts that some cigarettes that might have previously been smoked in public, were now ‘saved’ for consumption in private, with the home representing a ‘safe’ smoking environment.

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Discussion Overall, although many of the men and women in these two studies described how they had altered their smoking patterns as the result of changing social norms and the introduction of the smoke-free legislation, the majority of women who lived with nonsmokers reported that their home smoking remained largely unchanged. This suggests that while the de-normalisation of smoking in public places protects the majority of non-smokers, there is disadvantaged minority of non-smokers, particularly children, for whom little has changed (Chapman & Freeman, 2008; Greaves & Jategaonkar, 2006; Thomson, Wilson, & Howden, 2006). Some women reported that they smoked more in their homes postlegislation, but this was often linked to other factors, such as a change in their family circumstances or employment, which only served to emphasise how little impact the legislation had on them overall. Smoking indoors for women was also linked to the lack of opportunities to smoke in public places post-legislation, cross-cut by a lack of opportunity to smoke outside their homes due to caring and working responsibilities (Graham, 2003; Hattery, 2001; J. Robinson & Kirkcaldy, 2007), which meant that increasingly some women were more likely to ‘do without’ cigarettes when outside their homes and wait until they got home to smoke a cigarette. While this did not increase their total consumption of cigarettes, and may even have led to an overall decrease in the total number of cigarettes they smoked, it meant that for these women, their home had become their preferred site for smoking, which is likely to make it harder for future public health initiatives to influence their behaviour. Compared to the men in these two studies, the women who still smoked in their homes described having limited social contact with the wider social world, and even the women who worked did not often socialise outside their homes. This resonates with previous research that found that women and are more likely to be home and community orientated, even if they do undertake some paid work outside the home (Finch & Mason, 1992). This may account for why changing social norms around home smoking may not have had the same impact on all households, as while some women were unhappy about using their homes to smoke and were concerned about how much more they tended to smoke than at other times, others were more relaxed about their home smoking and valued their opportunity to smoke in a comfortable environment. Research has highlighted the balancing act that many women perform in maintaining their dual roles as paid workers and carers for children (Daly & Rake, 2003; Hattery, 2001), yet aspects of gender, work and caring, particularly relating to social exclusion, remain under researched (Lister, 2004). In these two studies from Scotland, the majority of the working women who cared for children reported although they had cut down their smoking during working hours, their levels of home smoking remained as high as before the introduction of the legislation. In contrast, the men in these studies tended to continue to smoke during working hours as they had before, but were less likely to smoke in their homes in front of non-smokers. While the number of men and women from these two studies who smoke at home is limited, these results suggest that research needs to examine more closely the relationship between paid work and smoking, and the work of caring. Research suggests that the link between gender and workplace smoking restrictions and home smoking is complex, but knowledge is currently limited by the presentation of research data, where data from men and women are combined. For example, an influential study that linked workplace restrictions to the introduction of home smoking bans gave only aggregate data, and so there was no indication as to whether it was male and/or female workers that made these changes (Borland et al., 1999). Similarly the work by

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Hyland et al. (2008) on the impact of smoking legislation on home smoking data presented only aggregate data. However a study by Gritz et al. (1998) in the US looked more specifically at men and women’s smoking, and found that although some women and men did reduce their smoking in response to workplace restrictions, this finding did not relate corresponding reductions in home smoking. Similarly another US study also found that women’s smoking prevalence was less affected than men’s by the introduction of workplace restrictions (Farrelly, Evans, & Sfekas, 1999). These patterns of behaviour suggest that although women may respond positively to the introduction of workplace restrictions, they may be unable or unwilling to decrease their levels of home smoking. Therefore the links between gender and public and workplace smoking bans needs to be further explored, as an overall reduction in smoking may still mean that smoking occurs in the home, and a link between workplace smoking bans and home smoking restrictions does not tell us whether it is men or women (or both) who are making them. The findings from the Scottish studies suggest that while the de-normalisation of smoking in public places has been beneficial for many non-smokers, there is a disadvantaged minority of nonsmokers (including children) who live with smokers, for whom little has changed. The link between the maintenance of caring responsibilities and home smoking in the literature is well established (Graham, 2003; Graham et al., 2006), and the findings from these two studies highlight that little has changed for some women. Although the data from the Scottish Community Study indicates an overall reduction in the number of cigarettes smoked, the reduction tends to be in the number of cigarettes smoking in public places, rather than in the home. Gender interacts with smoking behaviour in various ways, but a key finding is how postlegislation, some men are able to maintain their detachment from their family life, which while it prevents their smoking from being brought inside, also prevents anything changing for their families who remain inside the home. In summary, there needs to be a deeper understanding of how and why women and men still smoke in their homes, in single and two parent families, and clearer messages to all smoking adults, particularly the parents of children, as to how they could act to protect their children, which may involve co-operatively supporting their partner to smoke outside, rather than simply taking their own smoking outside.

References Akhtar, P. C., Currie, D. B., Currie, C. E., & Haw, S. J. (2007). Changes in child exposure to environmental tobacco smoke (CHETS) study after implementation of smoke-free legislation in Scotland: national cross sectional survey. British Medical Journal, 335, 545e549. Amos, A., Philips, R., Ritchie, D., Cunningham-Burley, S., & Martin, C. (2008). Qualitative study of smoking in the home: Final report. Edinburgh: University of Edinburgh. Bancroft, A., Wiltshire, S., Parry, O., & Amos, A. (2003). “It’s like an addiction first thing. afterwards it’s like a habit”: daily smoking behaviour among people living in areas of deprivation. Social Science & Medicine, 56(6), 1261e1267. Barry, C. A., Britten, N., Barber, N., Bradley, C., & Stevenson, F. (1999). Using reflexivity to optimize teamwork in qualitative research. Qualitative Health Research, 9(1), 26e44. Borland, R., Mullins, R., Trotter, L., & White, V. (1999). Trends in environmental tobacco smoke restrictions in the home in Victoria, Australia. Tobacco Control, 8(3), 266e271. Bottorff, J. L., Kalaw, C., Johnson, J. L., Stewart, M., Greaves, L., & Carey, J. (2006). Couple dynamics during women’s tobacco reduction in pregnancy and postpartum. Nicotine & Tobacco Research, 8(4), 499e509. Chapman, S., & Freeman, B. (2008). Markers of the denormalisation of smoking and the tobacco industry. Tobacco Control, 17(1), 25e31. Cook, D. G., & Strachan, D. P. (1998). Parental smoking, bronchial reactivity and peak flow variability in children [Review]. Thorax, 53(4), 295e301. Daly, M., & Rake, K. (2003). Gender and the welfare state. Cambridge: Polity.

Dedobbeleer, N., Béland, F., Contandriopoulos, A.-P., & Adrian, M. (2004). Gender and the social context of smoking behaviour. Social Science & Medicine, 58(1), 1e12. Eskenazi, B., & Castorina, R. (1999). Association of prenatal maternal or postnatal child environmental tobacco smoke exposure and neurodevelopmental and behavioral problems in children. Environmental Health Perspectives, 107(12), 991e1000. Farrelly, M. C., Evans, W. N., & Sfekas, A. E. S. (1999). The impact of workplace smoking bans: results from a national survey. Tobacco Control, 8(3), 272e277. Finch, J., & Mason, J. (1992). Negotiating family responsibilities. London: Tavistock. Graham, H. (1993). When life’s a drag. London: HMSO. Graham, H. (1994). Gender and class as dimensions of smoking behaviour in Britain: insights from a survey of mothers. Social Science & Medicine, 38(5), 691e698. Graham, H. (2003). Disadvantaged lives and women’s smoking: patterns and policy levers. MIDIRS Midwifery Digest, 13(2), 152e156. Graham, H., Inskip, H. M., Francis, B., & Harman, J. (2006). Pathways of disadvantage and smoking careers: evidence and policy implications, 60(Suppl. 2), ii7eii12. Greaves, L., & Jategaonkar, N. (2006). Tobacco policies and vulnerable girls and women: toward a framework for gender sensitive policy development. Journal of Epidemiology and Community Health, 60, 57e65. Greaves, L., Kalaw, C., & Bottorff, J. L. (2007). Case studies of power and control related to tobacco use during pregnancy. Women’s Health Issues, 17(5), 325e332. Greaves, L., Vallone, D., & Velicer, W. (2006). Special effects: tobacco policies and low socioeconomic status girls and women. Journal of Epidemiology and Community Health, Vol. 60(ii), 1e2. Gritz, E., Thompson, B., Emmons, K., Ockene, J., McLerran, D., & Nielsen, I. (1998). Gender differences among smokers and quitters in the working well trial. Preventive Medicine, 27, 553e561. Hattery, A. (2001). Women, work, and family: Balancing and weaving. London: Sage. Hyland, A., Higbee, C., Hassan, L., Fong, G. T., Borland, R., Cummings, K. M., et al. (2008). Does smoke-free Ireland have more smoking inside the home and less in pubs than the United Kingdom? Findings from the international tobacco control policy evaluation project. The European Journal of Public Health, 18, 63e65. Jarvis, M., Goddard, E., Higgins, V., Feyerabend, C., Bryant, A., & Cook, D. G. (2000). Children’s exposure to passive smoking in England since the 1980s: cotinine evidence from population surveys [Papers]. British Medical Journal, 321, 343e345. Johnson, J., Greaves, L., & Repta, R. (2007). Better science with sex and gender: A primer for health research. Vancouver: Women’s Health Research Network. Lader, D. (2006). Smoking-related behaviour and attitudes. Newport: Office for National Statistics. Lister, R. (2004). Poverty. Cambridge: Polity Press. Marsh, A., & McKay, S. (1994). Poor smokers. London: PSI. Martin, C., Ritchie, D., & Amos, A. (2008). Evaluation of the smoke-free legislation in Scotland: Qualitative community study. Edinburgh: Scottish Centre for Social Research. McKie, L., Laurier, E., Taylor, R. J., & Lennox, A. S. (2003). Eliciting the smoker's agenda: implications for policy and practice. Social Science & Medicine, 56(1), 83e94. Muller, T. (2007). Breaking the cycle of children’s exposure to tobacco smoke. London: British Medical Association. Parry, O., Bancroft, A., Gnich, W., & Amos, A. (2001). Nobody home? Issues of respondent recruitment in areas of deprivation. Critical Public Health, 11(4), 305e317. Phillips, R., Amos, A., Ritchie, D., Cunningham-Burley, S., & Martin, C. (2007). Smoking in the home after the smoke-free legislation in Scotland: qualitative study. British Medical Journal, 335, 553e557. Poland, B. (2000). The ‘considerate’ smoker in public space: the micro-politics and political economy of ‘doing the right thing’. Health Place, 6(1), 1e14. Poland, B., Frohlich, K., Haines, R., Mykhalovskiy, E., Rock, M., & Sparks, R. (2006). The social context of smoking: the next frontier in tobacco control? Tobacco Control, 15, 59e63. Robinson, J., & Kirkcaldy, A. (2007). Disadvantaged mothers, young children and smoking in the home: mothers’ use of space within their homes. Health & Place, 13(4), 894e903. Robinson, S., & Lader, D. (2007). Smoking and drinking among adults. Newport: Office for National Statistics. Royce, J. M., Corbett, K., Sorensen, G., & Ockene, J. (1997). Gender, social pressure, and smoking cessations: the community intervention trial for smoking cessation (COMMIT) at baseline. Social Science & Medicine, 44(3), 359e370. Strachan, D., & Cook, D. (1998). Parental smoking and childhood asthma: longitudinal and case-control studies [Review]. Thorax, 53(3), 204e212. Thompson, K., Parahoo, K., McCurry, N., O’Doherty, E., & Doherty, A. (2004). Women’s perceptions of support from partners, family members and close friends for smoking cessation during pregnancyecombining quantitative and qualitative findings. Health Education Research, 19, 29e39. Thomson, G., Wilson, N., & Howden-Chapman, P. (2006). Population level policy options for increasing the prevalence of smokefree homes. Journal of Epidemiology and Community Health, 60, 298e304.