Smoke-Free Homes

Overview

Smoke-Free Homes (SFH): Some Things Are Better Outside is an evidence-based program designed to promote home smoking bans to reduce secondhand smoke exposure in the home. By providing interactive print materials, practical tools, and coaching, this brief program supports families in establishing a healthier smoke-free environment for everyone.

Why Smoke-Free Homes Matters

Secondhand smoke exposure is harmful at any level, and the home is now a primary source of exposure for many. Nonsmoking adults and children who live in a household where smoking is allowed indoors can experience significant exposure to secondhand smoke. Secondhand smoke can cause coronary heart disease, lung cancer, and stroke in nonsmoking adults. In children, it can lead to impaired lung function, respiratory infections, middle ear disease, sudden infant death syndrome (SIDS), and worsened asthma.

Program & Materials

The Smoke-Free Homes program consists of four components— three mailings of print materials and a one-on-one coaching call. Each mailing includes easy-to-understand, interactive print materials that help families learn about secondhand smoke and take concrete steps toward a smoke-free home. The materials are educational in nature and include fact sheets, a challenges and solutions booklet, a photo story illustrating aspects of creating a smoke-free home, a newsletter, helpful reminders and visual cues, such as a pledge, signs, window clings, stickers, and more.

The materials are supplemented by a brief one-on-one coaching call (approximately 10–20 minutes). During the call, a trained coach walks participants through the 5-Steps to creating a smoke-free home, helps them problem-solve barriers, and reinforces their goals. Together, these components support participants as they work through the 5-Step process for creating and keeping a smoke-free home. The program is delivered in 2-week intervals over a 6-week period.

Research

Smoke-Free Homes has been tested and adapted across multiple research settings and populations, including healthcare, community-based organizations, and 2-1-1 settings. Following qualitative interviews to better understand family dynamics and decision-making around household smoking restrictions, we conducted a pilot test of the intervention. This work informed a randomized controlled trial in collaboration with United Way of Greater Atlanta 2-1-1. Line agents recruited 498 participants from the metro-Atlanta area to participate in the study. The primary outcome was the implementation of a smoking ban in the home and the resulting reduction in secondhand smoke exposure. Data were collected at baseline and at three- and six-month follow-ups. A randomly selected subsample received an air nicotine monitor at the three-month follow-up to provide an objective measure of nicotine levels in the home and validate participants’ self-reported smoke-free home status.

We then conducted an effectiveness trial in North Carolina in partnership with a 2-1-1 agency delivering the intervention, followed by a second effectiveness trial in Texas. Results from both trials similarly demonstrated the success of the Smoke-Free Homes program in helping households establish smoke-free home rules.

Building on these findings, we conducted a national grants program to disseminate the research-tested program through five 2-1-1 systems across the United States. The goal was to accelerate the dissemination of the intervention while systematically studying its implementation and effects across diverse 2-1-1 systems and communities. This work provided an opportunity to learn how Smoke-Free Homes could be adapted and delivered in real-world settings while maintaining the core elements of the evidence-based program.

Findings

Smoke-Free Homes was successfully tested in three randomized controlled trials in Atlanta, North Carolina, and Texas. It has been disseminated across the U.S. through 2-1-1’s and community-based organizations and clinics. It has shown to be cost effective, with a healthcare cost yielding net savings of $9,633 per 100 households. The program is listed on the National Cancer Institute's Evidence-Based Cancer Control Programs (EBCCP) and has been shown to be effective across multiple populations and settings.

This phase of the Smoke-Free Homes Project was funded through the National Cancer Institute’s State and Community Tobacco Control Research Initiative, Cooperative Agreement # U01 CA154282.

Study Adaptations

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Various adaptations of the Smoke-Free Homes program have been developed to meet the needs of diverse populations. Learn about other iterations below:

An enhanced (or expanded) version of Smoke-Free Homes: Some Things are Better Outside was integrated into clinical practice to increase smoking cessation success among patients of Federally Qualified Health Centers (FQHC). The program was designed to create personal smoke-free environments, including homes and vehicles, to reduce situational and environmental cues to smoke, reduce opportunities and places to smoke, increase self-efficacy for quitting, and increase motivation to quit.

In collaboration with Albany Area Primary Health Care, CareConnect Health, East Georgia Health Care, Community Health Care Systems, Athens Neighborhood Health Center, and First Choice Primary Care, this study’s aims were to:

Adapt an effective Smoke Free Homes program for integration into the 5A approach for tobacco cessation in primary care settings that serve socio-economically disadvantaged patients, specifically FQHCs.
Partner with FQHCs in rural Georgia to conduct a randomized controlled trial to test the efficacy of integrating a robust SFHs intervention into the 5A approach for tobacco cessation among FQHC patients.
Conduct a process evaluation of the expanded intervention to assess implementation outcomes, cost and scalability potential.

This latest research has the potential to create additional smoke-free environments to reduce secondhand smoke exposure among nonsmokers and children, and become an effective model for increasing cessation among socioeconomically disadvantaged patients seen at FQHCs.

This study is funded by the National Cancer Institute.

The Emory Prevention Research Center (EPRC), the Inter-Tribal Council of Michigan (ITCM), and Great Plains Tribal Health (GPTH) are working together to refine and test an adapted version of an evidence-based Smoke-Free Homes intervention in tribal communities. The Inter-Tribal Council of Michigan (ITCM) represents 12 federally recognized tribes in Michigan; Great Plains Tribal Health Board (GPTH) represents 17 sovereign American Indian nations within a four-state area (North Dakota, South Dakota, Nebraska, and Iowa), plus a service area.

Using a participatory approach operationalized through a Steering Committee with shared decision-making, our aims are to:

Pre-test and refine the adapted Smoke-Free Homes: Respect our Past, Protect our Future intervention to ensure cultural appropriateness for specific tribal partners.
Evaluate the impact of the adapted intervention on establishment of smoke-free home rules among American Indian households using a randomized wait-list controlled trial with three- and six-month follow-up, and explore its impact on smoke-free vehicles, cessation attempts, smoking cessation, and support for smoke-free tribal housing.
Conduct a mixed methods process evaluation of the intervention to assess reach, adoption, implementation, contextual influences, and maintenance potential from tribal, organizational and participant perspectives.
Assess changes in community readiness to address smoke-free multi-unit tribal housing.

This research builds on a successful collaboration with the potential to create an innovative and effective model for promoting smoke-free homes and reducing secondhand smoke exposure in rural tribal communities.

This research is funded by the National Cancer Institute.

The Emory Prevention Research Center (EPRC), in partnership with George Washington University, Georgia National Center for Disease Control and Public Health, Armenia National Institute of Health, and the American University of Armenia, is working to expand the Smoke-Free Homes: Some Things Are Better Outside program to families in the countries of Georgia and Armenia.

This work builds on the Georgia & Armenia Teams for Healthy Environments & Research (GATHER), a collaboration that established community coalitions to address chronic diseases and their risk factors in low- and middle-income countries (LMICs). Through GATHER, local partners developed the infrastructure needed to implement and sustain evidence-based public health programs within their communities.

Tobacco use and secondhand smoke exposure are significant public health concerns in both Georgia and Armenia. Smoking rates are among the highest in the region, and approximately 61% of homes allow smoking indoors, making the home the primary source of secondhand smoke exposure for children and other nonsmoking household members. By adapting and implementing the Smoke-Free Homes program in these countries, this project aims to help families create healthier home environments while building local capacity to deliver evidence-based programs that can be sustained over time.

GATHER II aims to:

Adapt the Smoke-Free Homes program to be culturally appropriate for families in Armenia and Georgia and develop in-country capacity for program delivery. Activities include translating and adapting the Smoke-Free Homes materials, including program content and imagery. As well as, conducting focus groups with adult smokers and nonsmokers to refine the program based on community feedback.
Leverage community coalitions to identify effective strategies for recruiting eligible participants who allow smoking in the home and partnering with national Quitline staff to deliver the program.
Through these efforts, EPRC and its partners are expanding access to an evidence-based program while strengthening the infrastructure needed to support tobacco control and improve population health in low- and middle-income countries.
This research is funded by the National Institute of Health.

Key Publications

Bundy LT, Haardörfer R, Kegler MC, Owolabi S, Berg CJ, Escoffery C, Thompson T, Mullen PD, Williams R, Hovell M, Kahl T, Harvey D, Price A, House D, Booker BW, Kreuter MW. Disseminating a smoke-free homes program to low socioeconomic status households in the United States through 2-1-1: Results of a national impact evaluation. Nicotine Tob Res. 2020; 22(4):498-505.
Kegler MC, Haardörfer R, Melanson T, Allen L, Bundy LT, Kreuter MW, Williams RS, Hovell MF, Mullen PD. Steps toward scalability: Illustrations from a smoke-free homes program. Health Educ Behav. 2019;46(5):773-781.
Anderson KM, Kegler MC, Bundy LT, Henderson P, Halfacre J, Escoffery C. Adaptation of a brief smoke-free homes intervention for American Indian and Alaska Native families. BMC Public Health. 2019 23;19(1):981.
Haardörfer R, Kreuter M, Berg CJ, Escoffery C, Bundy LT, Hovell M, Mullen PD, Williams R, Kegler MC. Cessation and reduction in smoking behavior: impact of creating a smoke-free home on smokers. Health Educ Res. 2018;33(3):256-259.
Williams RS, Stollings JH, Bundy Ł, Haardörfer R, Kreuter MW, Mullen PD, Hovell M, Morris M, Kegler MC. A minimal intervention to promote smoke-free homes among 2-1-1 callers: North Carolina randomized effectiveness trial. PLoS One. 2016;11(11):e0165086.
Mullen PD, Savas LS, Bundy ŁT, Haardörfer R, Hovell M, Fernández ME, Monroy JA, Williams RS, Kreuter MW, Jobe D, Kegler MC. Minimal intervention delivered by 2-1-1 information and referral specialists promotes smoke-free homes among 2-1-1 callers: A Texas generalisation trial. Tob Control. 2016;25(Suppl 1):i10-i18.
Kegler MC, Bundy L, Haardörfer R, Escoffery C, Berg C, Yembra D, Kreuter M, Hovell M, Williams R, Mullen PD, Ribisl K, Burnham D. A minimal intervention to promote smoke-free homes among 2-1-1 callers: A randomized controlled trial. Am J Public Health. 2015;105(3):530-7.
Kegler MC, Escoffery C, Bundy L, Berg CJ, Haardörfer R, Yembra D, Schauer G. Pilot study results from a brief intervention to create smoke-free homes. J Environ Public Health. 2012;2012:951426.

Contact

For more information about Smoke-Free Homes, please contact: Shadé Owolabi at shade.o.owolabi@emory.edu