Deborah Ritchie

Smoking in the home after the smoke-free legislation in Scotland: qualitative study

Objective To explore the accounts of smokers and non-smokers (who live with smokers) of smoking in their homes and cars after the Scottish smoke-free legislation; to examine the reported impact of the legislation on smoking in the home; and to consider the implications for future initiatives aimed at reducing childrens exposure to secondhand smoke in the home. Design and setting A qualitative cross sectional study involving semistructured interviews conducted across Scotland shortly after the implementation of the legislation on 26 March 2006. Participants A purposively selected sample of 50 adults (aged 18-75) drawn from all socioeconomic groups, included smokers living with smokers, smokers living with non-smokers, and non-smokers living with smokers. Results Passive smoking was a well recognised term. Respondents had varied understandings of the risks of secondhand smoke, with a few rejecting evidence of such risks. Children, however, were perceived as vulnerable. Most reported that they restricted smoking in their homes, with a range of restrictions across social classes and home smoking profiles. Spatial, relational, health, and aesthetic factors influenced the development of restrictions. Children and grandchildren were important considerations in the development and modification of restrictions. Other strategies were also used to militate against secondhand smoke, such as opening windows. The meaning of the home as somewhere private and social identity were important underlying factors. Respondents reported greater restrictions on smoking in their cars. There were diverse views on the smoke-free legislation. Few thought it had influenced their smoking in the home, and none thought it had affected how they restricted smoking in their homes. Conclusions These data suggest two normative discourses around smoking in the home. The first relates to acceptable social identity as a hospitable person who is not anti-smoker. The second relates to moral identity as a caring parent or grandparent. Awareness of the risks of secondhand smoke, despite ambivalence about health messages and the fluidity of smoking restrictions, provides clear opportunities for public health initiatives to support people attain smoke-free homes.

But it just has that sort of feel about it, a leper—Stigma, smoke-free legislation and public health

INTRODUCTION The Scottish smoke-free legislation has had considerable success, with high compliance resulting in significant health benefits and the increased denormalization of smoking. International literature on the impact of smoke-free legislation has mostly focused on the success of such policies. Relatively little consideration has been given to the potentially negative, albeit unintended, consequences of smoke-free policies within different social and cultural contexts, in particular the increased stigmatization of smokers. METHODS A 3-wave longitudinal qualitative study in 4 localities in Scotland using repeat in-depth interviews. Participants comprised a panel of 40 current and recent ex-smokers, interviewed before and after implementation of the legislation in 2 socioeconomically advantaged and 2 disadvantaged localities in Scotland. RESULTS Smokers perceived the smoke-free legislation to have increased the stigmatization of smoking. By separating, albeit temporarily, those who were smoking from those who were not had led to increased felt stigma. This had led to a social milieu that fostered self-labeling and self-stigmatization by smokers of their own smoking behavior, even when they were not smoking. While there was little reported direct discrimination, there was a loss of social status in public places. Smokers attempted to ameliorate stigmatization by not smoking outside, reducing going out socially, joining in the stigmatization of other smokers, and/or acknowledging the benefits of smoke-free environments. DISCUSSION The unintended negative consequences of smoke-free legislation for some suggest that tobacco control strategies need to consider how smokers who experience increased stigma are supported by public health to address their smoking while continuing to create smoke-free environments.

REFRESH—reducing families' exposure to secondhand smoke in the home: a feasibility study

Objective To study a novel intervention (REFRESH) aimed at reducing childrens exposure to secondhand smoke (SHS) in their homes. Design A randomised feasibility study. Setting Aberdeen City and Aberdeenshire. Participants A total of 59 smoking mothers with at least one child younger than 6 years. Participation took place between July 2010 and March 2011. Intervention Four home visits over a 1-month period, which involved two 24-h measurements of home air quality (PM2.5) and a motivational interview to encourage changes to smoking behaviour within the home in order to reduce child SHS exposure. The enhanced group received their air quality data as part of their motivational interview at visit 2; the control group received that information at visit 4. Main outcome measures The main outcome measures were comparisons of the data from visits 2 and 4 on the 24-h average concentration of PM2.5, the peak concentration of PM2.5, the percentage of time when household PM2.5 concentrations exceeded a health-based threshold of 35 μg/m3 and childs salivary cotinine (in nanograms per millilitre). The views of the mothers from the enhanced group about their understanding of the intervention and the measures used were also analysed to assess the acceptability and utility of the intervention. Results Of the recruited 54 participants, 48 completed the study: 27 from the control group and 21 from the enhanced group. Both groups experienced reductions in PM2.5 concentrations. When testing paired samples for the enhanced group, there was a significant difference (p<0.05) between visit 2 and visit 4 values for maximum PM2.5 (p=0.006) and for percentage of time over 35 μg/m3 (p=0.017), with average PM2.5 approaching significance (p=0.056). There was no significant difference for salivary cotinine. The qualitative findings showed that mothers were able to understand the data they were shown and were shocked by the values measured in their homes despite being aware of the effects of SHS exposure. They appreciated the intervention taking place in their homes as it allowed them to have personalised data. Many mothers described how they had changed their smoking behaviours in their home and in particular were motivated to protect their own children as a result of the knowledge they had gained. Conclusions Providing mothers who smoke with personalised results about the indoor air quality of their homes along with a motivational interview is feasible and has an effect on improving household air quality. 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 to reduce childrens SHS exposure should be explored.

The social context of change in tobacco consumption following the introduction of ‘smokefree’ England legislation: A qualitative, longitudinal study

Legislation implemented in England on 1st July 2007 to prohibit smoking in enclosed public places aimed primarily to limit exposure to second-hand smoke, thereby reducing smoking-related morbidity and mortality. We conducted a qualitative study between April 2007 and December 2008 in six contrasting localities in two metropolitan areas in the north and south of England, which examined the impact of the legislation on individuals, families and communities. Using a multi-level longitudinal case study design, we collected data at community and individual levels, from three months prior to the legislation to a year after its enactment through a range of methods, including semi-structured interviews with panel informants and observations in locality settings. Drawing on theoretical understandings of the relationship between structure, agency and practice, this paper examines the social and cultural contexts of change in tobacco consumption. Observations in a variety of community settings identified reduced smoking in public places post-legislation. More than half of panel informants reported decreased consumption at one year post-legislation; a minority had quit, maintained or increased their smoking levels. The dominant pattern of reduced consumption was attributed primarily to constraints imposed by the legislation. This suggests that the law may have provided an impetus for some smokers to cut down or quit. Smoking behaviour was, however, strongly influenced by the social networks in which smokers were embedded, indicating that, while individuals had the power to act, any changes they made were largely shaped by social structural factors. Our findings support the need for a comprehensive tobacco control strategy that takes account of the complex array of contextual factors that constrain and enable smoking.

Public places after smoke-free—A qualitative exploration of the changes in smoking behaviour

The social context of smoking behaviours is explored after the introduction of Scottish smoke-free legislation. A longitudinal qualitative study was conducted in four contrasting localities. Whilst post-legislation changes in smoking behaviour were evident in all four localities, they were most apparent in the disadvantaged localities. Changes in the patterns of smoking were linked to the ways in which people interacted in social contexts and how people re-negotiated habitual smoking behaviours in public spaces. Pre-legislation differences in the communities appeared to influence the extent of these changes. Cultural and social contexts are important in shaping smoking behaviours and locating change within public places.

Covert observation in practice: lessons from the evaluation of the prohibition of smoking in public places in Scotland.

BackgroundA ban on smoking in wholly or substantially enclosed public places has been in place in Scotland since 26th March 2006. The impact of this legislation is currently being evaluated in seven studies, three of which involve direct observation of smoking in bars and other enclosed public places. While the ethical issues around covert observation have been widely discussed there is little practical guidance on the conduct of such research. A workshop was therefore convened to identify practical lessons learned so far from the Scottish evaluation.MethodsWe convened a workshop involving researchers from the three studies which used direct observation. In addition, one of the fieldwork managers collected written feedback on the fieldwork, identifying problems that arose in the field and some solutions.ResultsThere were four main themes identified: (i) the difficulty of achieving and maintaining concealment; (ii) the experience of being an observer; (iii) the risk of bias in the observations and (iv) issues around training and recruitment. These are discussed.ConclusionCollecting covert observational data poses unique practical challenges, in particular in relation to the health and safety of the researcher. The findings and solutions presented in this paper will be of value to researchers designing similar studies.

Volunteered, negotiated, enforced: family politics and the regulation of home smoking

The protection of children from secondhand smoke in their homes remains a key objective for health agencies worldwide. While research has explored how parents can influence the introduction of home smoking restrictions, less attention has been paid to the role of wider familial and social networks as conduits for positive behaviour changes. In this article we explore how people living in Scotland have introduced various home smoking restrictions to reduce or eliminate childrens exposure to tobacco smoke, and how some have gone on to influence people in their wider familial and social networks. The results suggest that many parents are willing to act on messages on the need to protect children from smoke, leading to the creation of patterns of smoking behaviour that are passed on to their parents and siblings and, more widely, to friends and visitors. However, while some parents and grandparents apparently voluntarily changed their smoking behaviour, other parents found that they had to make direct requests to family members and some needed to negotiate more forcefully to protect children, albeit often with positive results.

The re-shaping of the life-world: male British Bangladeshi smokers and the English smoke-free legislation

Objective. To explore how male Bangladeshi smokers adapted to the English smoke-free legislation. Design. We draw on data derived from the Evaluation of Smoke-free England (ESME), a qualitative, longitudinal study conducted between 2007 and 2008 in two English metropolitan areas. Repeat interviews (n=34) were conducted before and after the legislation with 15 male Bangladeshi panel informants and from two focus groups: one with Bangladeshi men and the other with Bangladeshi women. Results. Bangladeshi smokers who participated in this study had largely accommodated to the smoke-free legislation and most had reduced their consumption of cigarettes, albeit to a modest degree. However, at the same time some Bangladeshi smokers appeared to have increased their use of shisha, a popular alternative method of smoking tobacco in this community. Smoke-free legislation also had an impact on the social and cultural forces that shape smoking behaviour in this group. In particular, family homes continued to be a key space where tobacco is consumed, although the legislation may have helped to shift the balance in favour of forces that oppose smoking and against enduring cultural pro-smoking norms. Smoking in public was also less socially acceptable, especially in the vicinity of local mosques and at community events. In some older groups, however, smoking remains a deeply embedded social habit which can undermine smokers’ efforts to quit. Conclusion. For maximum impact, tobacco control interventions aimed at whole populations may need to be supplemented by culturally sensitive measures in local areas where there is a high concentration of Bangladeshi people. Similar considerations may apply to other minority communities with a high prevalence of smoking.

Parenting support for families with young children- a public health user-focused study undertaken in a semi-rural area of Scotland

AIMS AND OBJECTIVES To work with parents and public health nurses (health visitors), to identify and design a range of public health interventions to provide support to parents of young children. BACKGROUND In the UK, only vulnerable families are now eligible for pro-active health visiting interventions on an individual family basis beyond the early days. Public health approaches are recommended for the majority of families who are not eligible for one-to-one professional support. DESIGN Focus groups were carried out with parents of young children, health visitors and other professionals working with them. METHODS The study was carried out in a semi-rural area of Scotland, consisting of a small town, and the surrounding rural area, including one area of deprivation. The area is served by a team consisting of six health visitors and one health assistant, based in two health centres in the area. Nineteen parents, five members of the health visiting team and 11 other professionals from health, education and social work took part via an invitation to contact the research team. RESULTS The needs of parents identified by both parents and professionals could best be met by social support, with skilled facilitation and suitable resources. The resolution of tensions between caseload-based and population-based health visiting, as well as the management of the tensions inherent in these changes, seems to be vital in order to implement these approaches. Many parents would like information made available online. CONCLUSIONS Services to support families with young children need to be designed from the perspectives of parents and their needs. RELEVANCE TO CLINICAL PRACTICE Services need to be set up in partnership with parents to provide them with information and access to peer and professional support, using public health approaches. Multiagency working, including among senior managers, may be the most effective way of providing this support.

An interview study of pregnant women who were provided with indoor air quality measurements of second hand smoke to help them quit smoking

BackgroundMaternal smoking can cause health complications in pregnancy. Particulate matter (PM2.5) metrics applied to second hand smoke (SHS) concentrations provide indoor air quality (IAQ) measurements and have been used to promote smoking behaviour change among parents of young children. Here, we present the qualitative results from a study designed to use IAQ measurements to help pregnant women who smoke to quit smoking.MethodsWe used IAQ measurements in two centres (Aberdeen and Coventry) using two interventions: 1. In Aberdeen, women made IAQ measurements in their homes following routine ultrasound scan; 2. In Coventry, IAQ measurements were added to a home-based Stop Smoking in Pregnancy Service. All women were invited to give a qualitative interview to explore acceptability and feasibility of IAQ measurements to help with smoking cessation. A case study approach using grounded theory was applied to develop a typology of pregnant women who smoke.ResultsThere were 39 women recruited (18 in Aberdeen and 21 in Coventry) and qualitative interviews were undertaken with nine of those women. Diverse accounts of smoking behaviours and experiences of participation were given. Many women reported changes to their smoking behaviours during pregnancy. Most women wanted to make further changes to their own behaviour, but could not commit or felt constrained by living with a partner or family members who smoked. Others could not envisage quitting. Using themes emerging from the interviews, we constructed a typology where women were classified as follows: ‘champions for change’; ‘keen, but not committed’; and ‘can’t quit, won’t quit’. Three women reported quitting smoking alongside participation in our study.ConclusionsPregnant women who smoke remain hard to engage,. Although providing IAQ measurements does not obviously improve quit rates, it can support changes in smoking behaviour in/around the home for some individuals. Our typology might offer a useful assessment tool for midwives.