The barriers, motivators and
enablers of smoke-free
homes: qualitative
systematic review and
synthesis
Laura Jones, Jo Longman, John Wiggers, Jude
Robinson & Megan Passey
Global SHS exposure




40% of children, 33% non-smoking males and
35% of non-smoking females
600 000 annual deaths: 28% children, 26% men
and 47% women
Countries with SFL – exposure in homes and cars
Countries without SFL – exposure in homes and
workplaces
Oberg et al. 2011
SHS intervention evidence
Child focussed
 Mixed evidence for effectiveness of
SHS/SFH interventions
 Need for more research

SHS qualitative evidence
Promote caregiver quitting
 Promote smoke-free homes

– Some caregivers are successful, others find
it very difficult

Qualitative evidence base exploring
caregivers’ home smoking behaviours and
experiences – yet to be synthesised
Jones et al. 2011; Robinson et al. 2010, 2009. 2007a, 2007b; Phillips et al. 2007, Blackburn et al. 2003
Review questions
(1) What are the barriers to, enablers and
motivators of initiating and maintaining a
smoke-free home?
(2) Do the barriers, enablers and motivators
to creating smoke-free homes differ by
context?
PROSPERO protocol registration: CRD42014014115
Methods: search & extraction

Systematic search for relevant qualitative
and mixed-methods peer reviewed
publications in English (1990-2014)

Study data extracted via proforma

Data managed using NVivo

Critical appraisal using modified CASP
Methods: thematic synthesis

Line by line coding; comparing & grouping
of codes; descriptive themes; analytical
themes (Thomas & Harden 2008)
Eight papers (36%) independently coded
 Final codebook applied across all papers
 Descriptive and analytic themes (ongoing)
developed within team

Results: included papers
Bottorff 2010; British
Columbia Canada
Phillips 2007; Ritchie 2009;
Robinson 2011; Wilson 2013;
Scotland
Coxhead 2006; Holdsworth 2008;
Robinson 2007, 2008, 2009; Jones
Herbert 2011; PEI Canada
2011; England
Poland 2009; Toronto Canada
Yousey 2007;
Colorado USA
Mao 2013; Mainland China
Kegler 2007, Escoffery 2009;
Georgia USA
 22 studies from 18 datasets (2 studies
extended original dataset)
 4 Australia; 3 Canada; 2 China; 10 UK; 3 USA
 646 participants: 633 caregivers & 13 HCPs
 58 FGs; 474 interviews; 2 expert panels;
observations
 14 high quality; 8 low quality
Abdullah 2012; Jiangsu
China
Roberts 2000;
South Australia
Hill 2003; Victoria
Australia
Jochelson
2003, Gould
2013; NSW
Australia
Results: theme summary
BARRIERS
ENABLERS
MOTIVATORS
Influence of others
Agency
SHS awareness &
health protection
Knowledge &
perception of SHS
risk & risk reduction
Practicalities
Being a good parent
Practicalities &
strategies
Perceived benefits
of smoking
Benefits of having a
SFH
Lifestyle choice
Personal attributes
Priorities
Social norms around
SHS
Addiction/habit
Desire to live in a
clean, odour free
and safe
environment
Household changes
Barriers
Influence of
others
Indoor smoking by others was often not
challenged because of the need or desire
to preserve social and relational bonds
with the smoker (Bottorff 2001, Mao
2013, Jones 2011, Robinson 2008, Yousey
2007).
Knowledge &
perception
of SHS risk &
risk reduction
Exposure to SHS was recognised as being
harmful; however, the specific risks and
the continuing risks as the child aged
(Abdullah 2012, Jochelson 2003, Jones
2011, Kegler 2007, Mao 2013, Robinson
2007 & 2009) were often not appreciated
or acknowledged.
Addiction/habit
“I try to avoid smoking at home, but
sometimes I really cannot help myself and
start smoking in front of my child. I really
need some help” (Abdullah 2012)
Enablers
Influence of
others
Smoking household members’ and visitors’
acceptance of and compliance with
household smoking rules was facilitated by
the normality and assumed nature of
protecting others from SHS, particularly
children (Bottorff 2001, Escoffery 2009,
Holdsworth 2008, Kegler, Robinson 2009 &
2011, Poland 2009)
Agency
“If I don’t want people to smoke around
my kids I tell them. It’s my house and my
kids” (Coxhead 2006)
Social norms
around SHS
“It’s not something that’s even discussed
anymore, it’s just…automatically assumed
that you don’t smoke in the house”
(Poland 2009)
Motivators
SHS awareness &
health protection
Caregivers were ‘aware’ (Holdsworth
2008) and ‘mindful’ (Robinson 2011) of
the dangers of exposing others, in
particular children, to SHS.
Desire to live in a
clean, odour free
& safe
environment
Homes which showed signs of smoke
exposure (e.g. nicotine stains) and which
smelled of smoke were perceived as
‘socially unacceptable’ (Robinson 2011)
and associated with ‘stigma’ (Holdsworth
2008)
Benefits of
having a SFH
“It makes me smoke less having to go
outside… [I] tend not to go out as much
and smoke” (Escoffery 2009)
Evidence base limitations
Cross-sectional
 Retrospective
 Hypothetical rather than experiential
 Authors are not explicit about participants’
home smoking rules
 Focussed on reducing children’s SHS
rather than SFH

Current evidence gaps
Home smoking rules during pregnancy &
early post natal period
 The male voice
 Other adults (vulnerable/sick)
 Learning from ‘successful’ smoke-free
households
 Other countries, in particular, those with
high tobacco consumption

Implications for policy & practice
Power of social norms
 Clarity & consistency of SHS risk
messages
 Complete ban (where achievable)
 SF households rather than individuals
 Strengths based approach – harnessing
motivation

Funding



National Health and Medical Research Council of
Australia Early Career Fellowship (APP1072213)
Cancer Institute New South Wales Early Career
Fellowship (13/ECF/1-11)
Wellcome Trust and University of Birmingham
ISSF Mobility Scholarship
L.L.Jones@bham.ac.uk
0121 414 3024
Presentation References

Baxi R, Sharma M, Roseby R, Polnay A, Priest N, Waters E et al. Family and carer
smoking control programmes for reducing children's exposure to environmental
tobacco smoke. Cochrane Database Syst Rev. 2014;3:CD001746.

Baxter S, Blank L, Everson-Hock ES, Burrows J, Messina J, Guillaume L, et al. The
effectiveness of interventions to establish smoke-free homes in pregnancy and in the
neonatal period: a systematic review. Health Educ Res. 2011;26(2):265-82.

Blackburn C, Spencer N, Bonas S, Coe C, Dolan A, & Moy R. Effect of strategies to
reduce exposure of infants to environmental tobacco smoke in the home: Cross
sectional survey. BMJ, 2003;327:257.

Thomas J & Harden A. Methods for the thematic synthesis of qualitative research in
systematic reviews. BMC Med Res Methodol. 2008;10(8):45.

Jones LL, Atkinson O, Longman J, Coleman T, McNeill A, Lewis SA. The motivators
and barriers to a smoke-free home among disadvantaged caregivers: identifying the
positive levers for change. Nicotine & tobacco research . 2011;13(6):479-86.

Oberg M, Jaakkola MS, Woodward A, Peruga A, Pruss-Ustun A. Worldwide burden of
disease from exposure to second-hand smoke: a retrospective analysis of data from
192 countries. Lancet. 2011;377(9760):139-46
Presentation References

Phillips R, Amos A, Ritchie D, Cunningham-Burley S, Martin C. Smoking in the home
after the smoke-free legislation in Scotland: qualitative study. BMJ.
2007;335(7619):553-7.

Robinson J & Kirkcaldy AJ. Disadvantaged mothers, young children and smoking in
the home: Mothers’ use of space within their homes. Health and Place.
2007a;13:894–903.

Robinson J & Kirkcaldy AJ. ‘You think that I’m smoking and they’re not’: Why mothers
still smoke in the home. Social Science and Medicine, 2007b;65:641–652.

Robinson J, Kirkcaldy AJ. 'Imagine all that smoke in their lungs': parents' perceptions
of young children's tolerance of tobacco smoke. Health Educ Res. 2009 Feb;24(1):1121.

Robinson J, Ritchie D, Amos A, Cunningham-Burley S, Greaves L, Martin C. ‘Waiting
until they got home’: Gender, smoking and tobacco exposure in households in
Scotland. Soc Sci Med. 2010;71(5):884-90.

Rosen LJ, Myers V, Hovell M, Zucker D, Ben Noach M. Meta-analysis of parental
protection of children from tobacco smoke exposure. Pediatrics. 2014;133(4):698714.
Review References

Abdullah AS, Hua F, Xia X, Hurlburt S, Ng P, MacLeod W, Siegel M, Griffiths S, Zhang
ZY: Second-hand smoke exposure and household smoking bans in Chinese families:
a qualitative study. Health & Social Care in the Community 2012, 20(4):356-364.

Bottorff JL, Johnson JL, Carey J, Hutchinson P, Sullivan D, Mowatt R, Wardman D: A
family affair: Aboriginal women's efforts to limit second-hand smoke exposure at
home. Canadian Journal of Public Health 2010, 101(1):32-35.

Coxhead L & Rhodes T. Accounting for risk and responsibility associated with smoking
among mothers of children with respiratory illness. Sociology of Health and Illness,
2008, 28(1): 98–121.

Escoffery C, Kegler MC, Butler S: Formative research on creating smoke-free homes
in rural communities. Health Education Research 2009, 24(1):76-86.

Gould GS, Munn J, Avuri S, Hoff S, Cadet-James Y, McEwen A, Clough AR: "Nobody
smokes in the house if there's a new baby in it": Aboriginal perspectives on tobacco
smoking in pregnancy and in the household in regional NSW Australia. Women and
Birth 2013, 26(4):246-253.

Holdsworth C & Robinson JE. "I've never ever let anyone hold the kids while they've
got ciggies”: moral tales of maternal smoking practices. Sociology of Health & Illness
2008, 30(7): 1086-1100.
Please note that only the first author was cited in the slides
Review References

Jochelson T, Hua M et al. Knowledge, attitudes and behaviours of caregivers
regarding children's exposure to environmental tobacco smoke among Arabic and
Vietnamese-speaking communities in Sydney, Australia. Ethnicity & Health. 2003,
8(4): 339-351

Jones LL, Atkinson O, Longman J, Coleman T, McNeill A, Lewis SA. The motivators
and barriers to a smoke-free home among disadvantaged caregivers: identifying the
positive levers for change. Nicotine & tobacco research . 2011;13(6):479-86.

Kegler,M & Escoffery M. A qualitative study of how families decide to adopt household
smoking restrictions. Family & Community Health, 2007, 30(4): 328-341.

Mao A. Space and power: Young mothers' management of smoking in extended
families in China. Health & Place. 2013, 21: 102-109.

Poland, B., D. Gastaldo, et al. (2009). "The interpersonal management of
environmental tobacco smoke in the home - a qualitative study." Critical Public
Health. 2009, 19(2): 203-221.

Robinson J. “Trying my hardest”: The hidden social costs of protecting children from
environmental tobacco smoke. International Review of Qualitative Research. 2008, 1,
173–194.
Please note that only the first author was cited in the slides
Review References

Robinson J & Kirkcaldy A. Disadvantaged mothers, young children and smoking in the
home: Mothers' use of space within their homes. Health & Place. 2007, 13(4): 894903.

Robinson J & Kirkcaldy A "Imagine all that smoke in their lungs”: parents' perceptions
of young children's tolerance of tobacco smoke. Health Education Research. 2009,
24(1): 11-21.

Robinson J, Ritchie D, et al. Volunteered, negotiated, enforced: family politics and
the regulation of home smoking. Sociology of Health & Illness. 2011, 33(1): 66-80.

Yousey, Y. "Family attitudes about tobacco smoke exposure of young children at
home. American Journal of Maternal-Child Nursing. 2007, 32(3): 178-183.
Please note that only the first author was cited in the slides