REFRESH – Reducing Families Exposure to Second Hand Smoke in the Home
Research Report
Project Aims:
Exposure to second-hand tobacco smoke brings real health risks, particularly to
children. Following the ban on smoking in most enclosed public spaces the majority
of exposure now takes place in the home, where legislative bans are not an
appropriate option. Further reducing children’s exposure to second-hand tobacco
smoke relies on encouraging and enabling voluntary action by parents, particularly
with regard to making homes smoke-free.
Funded by the Big Lottery the REFRESH project was a partnership between ASH
Scotland and the Universities of Aberdeen and Edinburgh which ran from to March
2010 to March 2014 with the following aims:
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to investigate the effectiveness and potential of using air quality monitors to
provide tailored feedback to parents who smoke regarding levels of secondhand tobacco smoke in their own home, as a means of engaging and
supporting these parents to take voluntary action to protect their families
through creating smoke-free homes;
to explore the knowledge and views of policy makers at local and national
level with regard to second hand smoke;
to engage with a range of health practitioners to investigate effective action on
their part to support parents who smoke to reduce levels of tobacco smoke in
their homes and to disseminate and encourage good practice; and
to disseminate the findings of the research and hence to ensure that this
enhanced evidence base informs and influences future action on secondhand tobacco smoke and smoke-free homes
Research Elements 1: intervention with mothers who smoke
A randomized feasibility study was carried out with 59 mothers who smoke, each
with at least one child younger than six years. Participation took paces between July
2010 and March 2011.
In each case four home visits took place over a one-month period. These involved
two 24-hour measurements of home air quality by measuring fine airborne
particulate matter (PM2.5) and a motivational interview to encourage changes to
smoking behaviour within the home in order to reduce the child’s exposure to
tobacco smoke. The enhanced group received their air quality data as part of their
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motivational interview after the first two visits and measurements, the control group
received that information a month later, after the second visits and measurements.
Comparisons were made of the PM2.5 data from the initial and follow-on visits, giving
an indication of behaviour change over the intervening month. The views of the
mothers from the enhanced group about their understanding of the intervention and
their response to the air quality feedback were also analysed.
Both the enhanced and control groups registered a decrease in PM2.5 levels over the
month, but with a greater decrease amongst the enhanced group. Mothers
appreciated the intervention and were able to understand the data they were shown
and were shocked by the tobacco smoke levels measured in their homes.
With positive feedback from parents once they are engaged with the intervention, we
sought to explore a new recruitment approach through partnering with the
Greendykes Family Support Centre in Edinburgh. Staff at the centre offered a
REFRESH-style intervention providing air quality monitors to parents who smoke
who were being supported by the service. Results showed that parents welcomed
such an approach coming from family support staff and that the intervention once
again acted as a positive motivation to making their homes smoke-free. Results
indicate that this may be an attractive route for recruiting parents to take part in the
intervention and will be written up for publication in due course.
Wilson I, Semple S, Mills LM, Ritchie D, Shaw A, O'Donnell R, Bonella P, Turner S,
Amos A. REFRESH--reducing families' exposure to secondhand smoke in the
home: a feasibility study. Tob Control. 2013 Sep;22(5):e8.
http://tobaccocontrol.bmj.com/content/early/2012/05/20/tobaccocontrol-2011050212.abstract
Wilson IS, Ritchie D, Amos A, Shaw A, O'Donnell R, Mills LM, Semple SE, Turner
SW. 'I'm not doing this for me': mothers' accounts of creating smoke-free
homes. Health Educ Res. 2013 Feb;28(1):165-78.
http://her.oxfordjournals.org/content/early/2012/07/26/her.cys082.full.pdf
Mills LM, Semple SE, Wilson IS, MacCalman L, Amos A, Ritchie D, O'Donnell R,
Shaw A, Turner SW. Factors influencing exposure to secondhand smoke in
preschool children living with smoking mothers. Nicotine Tob Res. 2012
Dec;14(12):1435-44. http://ntr.oxfordjournals.org/content/14/12/1435
Research Elements 2: interviews with policy advisors and
practitioners
A series of qualitative interviews and focus groups were carried out with 30 policy
makers, health professionals and childcare practitioners, during which they were
presented with the findings of the REFRESH intervention with mothers who smoke
and discussed the implications for their policy and practice priorities.
Participants accepted the harm caused to children by second-hand tobacco smoke,
however action is limited by political expedience due to the perception of a shift of
the public health priority from smoking to alcohol, current financial constraints, more
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immediate child protection concerns and continuing ethical arguments such as
balancing protection of the child while not stigmatizing the parents who smoke.
Overall children’s exposure to second-hand smoke in the home is unequivocally
accepted as an important health priority but it is not currently perceived to be a top
public health priority in Scotland.
Ritchie DD, Amos A, Shaw A, O'Donnell R, Semple S, Turner S, Martin C. How do
policy advisors and practitioners prioritise the protection of children from
secondhand smoke exposure in a country with advanced tobacco control
policy? Tob Control. 2013 Aug 16. doi: 10.1136/tobaccocontrol-2012-050936.
http://tobaccocontrol.bmj.com/content/early/2013/08/16/tobaccocontrol-2012050936.short
Research Elements 3: informing and enhancing practice
A comprehensive literature review was carried out and completed in September
2011 and is available upon request.
Learning from the literature review and the REFRESH research was developed into
a practical 'How To' guide for professionals seeking to engage parents on smokefree homes. A supporting website was set up at www.refreshproject.org A first draft
was circulated for testing and review, receiving positive feedback. A revised and
updated version is now available for general use.
A one-day training course, based on the How To Guide, was developed for voluntary
sector organisations providing family support services. The course was initially
delivered at 8 locations across Scotland, with 85 people attending. Evaluation
feedback indicated that when rating the improvement in knowledge of SHS and
confidence in raising the issue, the average participant moved from 4 to 8 on a 1-10
confidence scale and rated the course 8.5 for how well it had met their needs. The
training sessions will continue to be made available.
A baseline survey of practitioners engaged in work on second-hand smoke was
carried out in 2010 and repeated towards the end of the project in 2013. Responses
in the 2013 follow-up were more positive on practitioner confidence, knowledge and
skills in addressing SHS, more thought that it was part of their role to raise SHS in
the home and more indicated that their workplace provided respondents with advice
or information on SHS and its effects on children’s health.
http://www.ashscotland.org.uk/go-smoke-free/reducing-second-hand-smoke/refreshliterature-review.aspx
http://www.refreshproject.org.uk/wp-content/uploads/2012/02/REFRESH-How-toGuide.2012.pdf
Shaw A, Ritchie D, O'Donnell R, Amos A, Mills LM, Semple SE, Turner SW, Wilson
IS. Creating smoke-free homes for children. Nurs Times. 2013 Mar 1218;109(10):28-30. http://www.nursingtimes.net/nursing-practice/clinicalzones/smoking-cessation/creating-smoke-free-homes-for-children/5055895.article
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Research Elements 4: dissemination
The project Advisory Board agreed a set of recommendations for future policy,
practice and research, which was used as the basis for engagement with
development of the Scottish Government’s new tobacco control strategy.
Published in March 2013 the new strategy showed influence from the REFRESH
project and contained several key commitments in this area:
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advice on creating a smoke-free home should be a feature of all ante- and post-natal
services and adoption, foster, kinship and residential care services;
the setting of the first national target to reduce children’s exposure to second-hand
smoke in the home, now set as a 6% self-reported rate in 2020;
the development of an awareness-raising campaign, now underway following input
from several members of the REFRESH team; and
continued Government support for REFRESH-type interventions.
www.rightoutside.org
www.scotland.gov.uk/Topics/Health/Services/Smoking
Research Conclusions:
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Parents who smoke at home generally take measures to protect their families
but only making the home completely smoke-free is effective.
Parents respond well to personalized feedback on smoke levels found in their
homes and are motivated to make effective changes.
Programmes to reduce tobacco smoke in the home should engage parents
positively and focus on a smoke-free home as the goal.
Air quality monitoring provides an effective means to do this.
Smoke-free homes approaches are complementary to stop smoking
initiatives, often engaging smokers who are not yet ready or willing to quit.
Partnering with professionals with an existing support relationship can be an
effective means to engage parents.
Decision-makers need to be persuaded that smoke-free homes are an
important goal.
Further information:
For more information please contact John Watson, Director of Policy and
Engagement at ASH Scotland.
0131 220 9468 jwatson@ashscotland.org.uk
Signed by John Watson, lead researcher, 7th May 2014
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