Reducing Families' Exposure to Second-hand Smoke in the Home (REFRESH)

1. Reducing Families' Exposure to Second-hand Smoke in the Home (REFRESH) A collaborative study by the University of Aberdeen, ASH Scotland and the University of Edinburgh.

2. Intervention Premise Reduce children’s exposure by creating a smoke-free home Emphasis of the study was NOT cessation Intervention aimed at changing smoking behaviours around children

3. Intervention Based on evidence showing effectiveness of interventions with longer & more involved contact with parent(s) Lack of Community / Home based interventions Aimed at mothers who smoke who have children aged 1-5 years Mothers given personalised feedback on the levels of SHS in their home

4. Study design • Intervention tested by comparing 2 groups Enhanced Enhanced 24 hours 24 hours 4 weeks Further interview Personal air quality levels discussed Visit 2 Visit 4 Visit 1 Visit 3 Saliva sample Air monitor set-up Saliva sample Air monitor set-up Motivational interview Air quality feedback Standard No air quality feedback

5. Recruitment • SPCRN identified smoking mothers from Aberdeen city and shire from different levels of socioeconomic deprivation through GP records • Mothers were sent a letter and returned a reply slip if interested • 1693 invited  59 agreed to take part (3.5%) • Randomised to Standard or Enhanced group

6. Areas of smoking prevalence across Aberdeen

7. Air quality measurements • Measured using a SidePak • Measured levels of fine particulate matter • (PM2.5)/smoke over 24 hours. • Health-based guideline of 35µg/m3 averaged over 24h

8. Air quality feedback

9. Your Maximum (372) Amount above unhealthy level Your Average (57)

10. REFRESH Intervention Description of air quality measures and current ‘unhealthy’ guidelines Feedback of personal air quality measures Discussion about existing knowledge of SHS health effects and personal experiences Decisional balance: Pros & cons of current restrictions and future restrictions Focus on ways to overcome difficulties mentioned in cons for future restrictions Potential challenges from others in the home or support they can provide What they would like to achieve before the next visit Practical tips on how to achieve these changes

11. Main outcomes PM2.5 data • Average over 24 hours • Maximum • % time over 35 µg/m3 Children’s salivary cotinine Qualitative results from interviews

12. Average PM2.5

13. Average PM2.5

14. Maximum PM2.5 Significant difference for maximum p = 0.006 N=26 N=20

15. Maximum PM2.5 Significant difference for maximum p = 0.006 N=26 N=20

16. % time over 35µg/m3 Significant difference for % of time over p= 0.017

17. % time over 35µg/m3 Significant difference for % of time over p= 0.017

18. Salivary Cotinine

19. Salivary Cotinine

20. Summary of part 2 • Recruitment a challenge • Intervention reduced PM2.5 • Borderline reduction in exposure • How was is received/perceived?

21. Findings from interviews with the Enhanced group • Intervention was acceptable • Willingness to engage • Eagerness to share experience • Information used to make informed decisions • Not a lecture

22. Quotes about intervention acceptability • “I showed them. I showed them the chart, you know, the graph. I showed them how high it was, and some of them was like – you’re joking? And I was like no, that’s why I’m in the kitchen. I says – so if that’s what’s going about in the air, can you imagine what’s inside the kids. And they were quite happy enough to go in the kitchen.” (32, SIMD 1, visit 4) • “Basically it isn’t a lecture. You’re not trying to put me off smoking if you like; you’re just giving me the evidence to make up my own mind.” (35, SIMD 5, visit 4) • “So my idea is that you’ve came here to highlight what we didnae (didn’t) really know and then it’s up to us, like you’ve said from day one, you’re not here to preach or tell us what to do. You’re here to give us results and then say, here you go, it’s up to us to decide what we’re going to do about it.” (45, SIMD 4, visit 4)

23. Findings from interviews with the Enhanced group Valued the additional information • Learning about PM2.5 • Length of time SHS stays in the air and how far it can travel, even after a cigarette is extinguished

24. Quotes about learning and valuing information “It’s given me more knowledge and understanding about secondhand smoke and about how much it actually travels and how long it lasted for as well. So it has increased my knowledge and I can use that for what’s best for (my child) as well.” (25, SIMD 2, visit 4) “ Because what we’ve found out there, like I say, we wouldn’t have known. Like I say I wouldn’t have known even those levels. You just assume that because you smoke outside, everything’s fine.” (34, SIMD 5, visit 4) “I just wouldn’t have thought it would be that. Because I don’t sit here and smoke, I didn’t think it would be that at all.” (23, SIMD 1, visit 2) “For me you were showing how to give my family a healthier life and how high the levels actually are. Cause I’m guessing that a lot of people don’t know. Unless it’s sitting there in front of you on a graph, you don’t.” (23, SIMD 1, visit 4)

25. Findings from interviews with the Enhanced group • Motivators and mechanisms of change • Reaction to PM2.5 was ‘shock’ • Existing behaviour thought to be enough to protect children • Important that information was personalised • Graph acted as reminder and tool for sharing information • Primary motivation was child’s heath

26. Quotes about mechanisms of change “Seeing the results made a big difference. It was like a shock because I didn’t realise. Like I don’t sit here and smoke in front of (my child), I do it in the kitchen, but for the readings to be high like that when I’m not like anywhere near it, if you know what I mean, it’s like a shock factor to realise what it can do. So I think that’s the best thing that like helped me.” (23, SIMD 1, visit 4) “To be done in your own house is more recognisable than to be told in a community centre or a church or even a doctor’s surgery. For it to be done in your own home and for you to know that the level of smoke is so high and you’re putting your children at risk of asthma, emphysema, all kinds of things, it’s quite shocking.” (37, SIMD 2, visit 4) “But at the end of the day I would just have to stick to it because it’s (my child’s) health that it’s coming down to. I’ve made my decision for myself to smoke but it’s not fair that I’m putting my smoke on him, my health problems on him. I just have to keep thinking, it’s not for me, it’s for (my child).” (23, SIMD 1, visit 2)

27. Strengths & Limitations Strengths • Longitudinal study • Real life setting • Several objective measures of child’s SHS exposure • Several types of feedback provided • Quantitative & qualitative elements Limitations • Only 1 month follow-up • Recruitment was very low; 3% • Difficulty obtaining saliva sample from youngest children • Difficult to extract respiratory health data from GP records – not used as an outcome measure

28. Conclusions Providing mothers who smoke with personalised results about the indoor air quality of their home along with a motivational interview is feasible and has an effect on improving measures of air quality after one month. Knowledge about PM2.5 and SHS exposure among smoking mothers of young children is limited. Increasing mothers awareness of the risks related to these can be shocking, but providing personalised data with immediate support to find solutions to their envisaged barriers is empowering in supporting them in reducing SHS in their homes. Participants found the intervention understandable and acceptable. Taken overall, the results suggest that a future large-scale trial using measurements of indoor air quality as part of a complex intervention should be explored.