Protecting children from secondhand smoke at home a

Protecting children from secondhand smoke at home: a feasibility study of a novel intervention Dr Laura Jones University of Birmingham & UKCTCS 27 th June 2013

Acknowledgements Co authors • John Marsh • Tim Coleman • Ann Mc. Neill • Sarah Lewis Nottingham SFH Team • Jacqueline Purdy • Alex Larwood New Leaf support • Jane Hassall • Julie Greenwood • Indu Hari • Michelle Battlemuch This talk summarises independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (RP-PG-0608 -10020). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

Extent of the problem • 600, 000 global deaths directly related to SHS exposure per year – 165, 000 of these are children • 40% of children worldwide are exposed to SHS mainly in domestic settings • Over half (52%) of children in UK households who live with at least one smoker are regularly exposed to SHS at home • Every day in the UK, around 26 children are taken to hospital with SHS related problems

SHS exposure: health risks • SHS health risks well established and documented • We know why children’s exposure to SHS should be a public health priority • However – We know less about why children are exposed to SHS at home – Or how we can help families to reduce or prevent children’s exposure to SHS

What does the current evidence base tell us? Cochrane SHS Systematic Review 2008 – 36 studies (11 showed significant effect) – Conclusion: “At present, there is insufficient evidence to recommend one particular strategy to reduce the prevalence of SHS exposure in children” SFH Narrative Synthesis 2011 – 12 studies (2 showed significant effect) – Conclusion: “mixed evidence for the effectiveness of interventions to reduce parental environmental tobacco smoke in early infancy” Priest et al. (2008); Baxter et al. (2011)

What else do we know? • Promoting caregiver quitting • Promoting smokefree homes – Requires substantial behaviour change – Parents may face significant barriers

Nottingham SFH studies Overall aim: to develop an intervention to reduce children’s exposure to domestic SHS 1. Interview study one - 36 semi-structured interviews with families 2. Interview study two - 29 semi-structured interviews with HCPs 3. Feasibility trial - two phase study 4. Exploratory randomised controlled trial

Feasibility study • • Aim: to test the feasibility and acceptability of the intervention Primary outcome • • • Biochemically validated change in SHS exposure Secondary outcomes • • • Self-reported changes in home smoking Cigarette consumption/quit attempts Use of NRT for TA • • • Recruitment pathways Retention/attrition Effectiveness of different components Main trial design

Feasibility study • Two phases with protocol review • Phase 1: Sept 2011 to Feb 2012 • Phase 2: March to August 2012 • Recruitment via Children’s Centres • Six families recruited into each phase • Typical study participant: • Single female aged 26 years • Two children • Socially disadvantaged

What did the intervention look like initially? 12 week home based intensive intervention 1. 2. 3. 4. Behavioural and emotional support Educational materials (SFH pack) Impact feedback (child’s salivary cotinine) Nicotine replacement therapy

Feasibility study – phase 1 Visit 1 (Baseline) Intervention Visit 1 a (1 -2 wks) Behavioural support NRT Questionnaire Outcomes Urine & saliva sample Recruitment evaluation interview Visit 2 (4 wks) Visit 3 (8 wks) Visit 4 (12 wks) Behavioural support NRT NRT Cotinine feedback Questionnaire Urine & saliva sample 12 weeks Visit 4 a (13 -14 wks) Evaluation interview

Protocol review • Behavioural support – Timing and intensity of visits • Feedback – Saliva vs. urine – Cotinine vs. air monitoring • Educational materials • NRT – Provision of sample bags

Revised intervention 12 week home based intensive intervention 1. Behavioural and emotional support 2. Impact feedback (home air quality PM 2. 5) 3. Nicotine replacement therapy

Feasibility study – phase 2 Visit 1 (Baseline) Visit 2 (1 wk) Behavioural support Intervention NRT PM 2. 5 feedback Questionnaire Outcomes Saliva sample PM 2. 5 data Visit 3 (4 wks) Behavioural support NRT Questionnaire Saliva sample 12 weeks Visit 4 (7 wks) Visit 5 (12 wks) Behavioural support NRT PM 2. 5 feedback Questionnaire Saliva sample PM 2. 5 data Visit 5 a (13 -14 wks) Questionnaire Saliva sample PM 2. 5 feedback Evaluation interview

9: 57 11: 18 12: 39 14: 00 15: 21 16: 42 18: 03 19: 24 20: 45 22: 06 23: 27 0: 48 2: 09 3: 30 4: 51 6: 12 7: 33 8: 54 10: 15 11: 36 12: 57 14: 18 15: 39 17: 00 18: 21 19: 42 21: 03 22: 24 23: 45 1: 06 2: 27 3: 48 5: 09 6: 30 7: 51 9: 12 ug/m 3 Home air quality data 800 700 600 500 Baseline 400 Week 7 Week 12 300 200 100 0 Time

Key findings • Personalised feedback was ranked as the most important component followed by behavioural support • Saliva results highly variable but no change over time (21 ng/ml at baseline vs. 20 ng/ml at week 12) • Average 24 hour PM 2. 5 reduced by 49% between baseline and week 12 • 50% self-reported SFH at week 12 • 100% self-reported that complete indoor ban for visitors at week 12 • Most families reported cutting down (by ~43%) and small number made a quit attempt

Views on taking part “I think the best outcome is I don’t really smoke so much. I smoke only when I’m not at home which is a lot better” “It was told in a decent way, I was never once made to feel bad or like they was disgusted in what I was doing or anything like that, that was the nice part about it because you wasn't. . . singled out and made to look a certain, you know how some people can single you out, “you're a smoking mum”, makes you feel a bit like bad”

Views on taking part “It’s [intervention] definitely encouraged me to [make home smoke-free] without a doubt. Seeing the results of the graph was the most shocking, that basically smoking outside of the room it’s still that much comes back in the room, it is similar to smoking in the room” “…I just didn’t realise that I did have the strength to actually do it, and it was so easy just to, like, take smoking outside, but some people don’t think like that and I think even though I’ve surprised myself, even when we had the snow, I was still smoking outside, even though it was hard, but I thought, no, I’ve done it for so long, why, just because it’s snow[ing] why am I going to bring the smoke in the house and that”

Summary • Children’s exposure to SHS still a significant public health concern • Starting to understanding better why children are exposed to SHS at home and how we can help • Nottingham SFH intervention is both feasible and acceptable • Evidence for initial effectiveness • Main RCT started November 2012

A few final thoughts…we can make a difference

l. l. jones@bham. ac. uk