A Qualitative Study Among Mexican Americans to Understand Factors Influencing the Adoption and Enforcement of Home Smoking Bans

Abstract

Introduction

One-third of Mexican-American children, in addition to nonsmoker adults, are exposed to secondhand smoke at home, yet few interventions target Mexican-American households. An effective, brief English language program, tested with United Way 2-1-1 callers in Atlanta, increased home smoking bans (confirmed by air monitors). Two randomized controlled trials in North Carolina and Texas replicated those results. We explored factors determining adoption and enforcement of smoking bans in Mexican-American households to inform program linguistic and cultural adaptation to broaden program reach and relevance.

Methods

Bilingual interviewers recruited convenience samples of Mexican-American smokers and nonsmokers living with at least one smoker in Houston and San Diego households and asked open-ended questions regarding conditions for implementing home and vehicle smoking bans and conditions for varying acceptance of bans. Investigators independently reviewed English transcripts and completed a descriptive analysis using ATLAS.ti.

Results

Participants (n = 43) were predominantly female (n = 31), current smokers (n = 26), interviewed in Spanish (n = 26), had annual household incomes less than $30000 (n = 24), and allowed smoking inside the home (n = 24). Themes related to difficulty creating and enforcing bans included courtesy, respect for guests and heads of household who smoke, and gender imbalances in decision making. Participants viewed protecting children’s health as a reason for the ban but not protecting adult nonsmokers’ health.

Conclusion

A dual-language, culturally adapted intervention targeting multigenerational Mexican-American households should address household differences regarding language and consider influences of cultural values on family dynamics and interactions with guests that may weaken bans.

Implications

Qualitative interviews suggested cultural and family considerations to address in adapting a brief evidence-based smoke-free homes intervention for Mexican Americans, including traditional gender roles, unique contexts of multigenerational households, and language preferences. Our work confirms previous research among Latinos regarding importance of common cultural constructs, such as respeto (deference), simpatia (courtesy and agreeability), and familismo (family attachment), which inform behaviors that may impede or facilitate adopting and enforcing home smoking bans. Decision-making gender imbalances, high regard for head-of-household and guest smokers, and less sensitivity to the health of nonsmoker adults compared with children may lead to permission to smoke indoors.

Introduction

Secondhand smoke exposure (SHSe) in the home is an important public health problem for Mexican Americans, the largest Hispanic/Latino (hereafter referred to as Latinos), subgroup (64%) in the United States.¹ Between 2011 and 2012, 6.2 million Mexican Americans older than 3 years were involuntarily exposed to secondhand smoke, and nearly one-third of Mexican-American children were exposed in their homes.² The substantial health burden of SHSe has made this a public health priority. SHSe increases children’s risk for bronchitis, pneumonia, ear infection, and aggravated asthma-related problems.³ Among adults, SHSe causes heart disease–related death (more than 41000 deaths annually) and lung cancer (3400 deaths annually) and increases stroke risk by 20%–30%.^3,4

Mexican Americans born in the United States now outnumber those foreign-born, and the smoking risk profile is changing within this growing population. At present, smoking among Latinos is more common among men, lower income groups, less educated, U.S.-born, and younger ages. ^5–8 Studies indicate that with increasing acculturation, smoking rates rise among females; however, the smoking–acculturation link is unclear for males.^6,9 The shift in smoking behaviors is already evident among Latino adolescents, who have higher smoking rates than other ethnic groups.¹⁰ A potentially important influence on the younger population is the tobacco industry itself, which targets Latinos with brands such as “Rio” and “Dorado.”¹¹

In the United States, common characteristics of people exposed to secondhand smoke in the home include lower education and socioeconomic position, being Black, younger ages, and living in a home without smoking rules.^12,13 Although more Latinos report having smoke-free home rules compared with non-Latino Whites (87.7% vs. 80.9%), more Latinos without household rules reported SHSe in the previous 7 days (47.8% vs. 40.9).¹⁴ This discrepancy suggests inconsistency in ban enforcement.

Smoke-free home interventions in the general population have substantially reduced home SHSe, especially for people at high risk for health complications.^15–18 Few interventions, however, have focused on home smoking bans in Mexican-American households.^19–23 Almost all Latino-focused intervention research has targeted families with children who have health problems, such as asthma.^22,24,25 To reach the growing population of underserved Mexican Americans, community-based intervention research with scalable prevention programs is needed.

The community-based “Smoke-Free Homes: Some Things are Better Outside” is an evidence-based program that targets low-income households comprising nonsmokers residing with smokers who smoke inside the home. Guided by social cognitive theory and the transtheoretical model, this program targets theory-related behavioral determinants and uses methods and practical strategies such as persuasion, role modeling, goal setting, written and oral reinforcement, and environmental cues.^26,27 Program materials follow a five-step guide that includes how to (1) decide to make the home smoke free, (2) discuss a ban with family members and visitors who smoke, (3) plan for challenges and identify solutions to enforce bans, (4) make the home smoke free, and (5) maintain the smoke-free home. The materials were delivered in three mailings, and one 15- to 20-minute coaching call following the first mailing was conducted with the household member recruited from the 2-1-1 call (either the smoker or nonsmoker).

Three separate randomized controlled trials demonstrated the effectiveness of the “Smoke-Free Homes” program on increasing home smoking bans among low-income, predominately female smokers, and African Americans.¹⁸ Each trial was conducted in partnership with the United Way 2-1-1 information and referral system, including an efficacy trial in Atlanta¹⁸ (with self-reported home smoking bans validated by home nicotine monitors) and two effectiveness trials, one in North Carolina²⁸ followed by one in the Texas Gulf Coast 2-1-1 center.²⁹

To increase reach and effectiveness of the Smoke-Free Homes program among the growing Mexican-American population, we conducted this qualitative study to understand the need for linguistic and cultural adaptation. Nationally, the 2-1-1 network covers 93% of the population and provides health and human services in multiple languages, including Spanish.³⁰ This national telephone helpline offers great potential to reach underserved Mexican Americans to deliver the intervention. However, more research is needed to understand factors influencing creation and enforcement of smoke-free home bans within Mexican-American households. The goal of this qualitative research study was to explore factors determining smoke-free home ban adoption and enforcement, with particular attention to the potential influence of Mexican-American cultural norms and values. Ultimately, a systematic approach to adapting the Smoke-Free Homes program for Mexican Americans will build on this research to broaden program reach and potentially increase the program’s relevance.

Methods

The Consolidated Criteria for Reporting Qualitative Research guided this report.³¹ The University of Texas Health Science Center at Houston and San Diego State University Institutional Review Boards approved the study.

Participants and Recruitment

We recruited convenience samples of Mexican-American smokers and nonsmokers living in households with and without full or partial smoking bans from residents of Houston, Texas, or the San Diego-Tijuana, Mexico, border area to represent different experiences and perspectives. Eligibility criteria were being Latino, 18 years or older and living with at least one person with the opposite smoking status or being a caregiver of children who visits the household regularly, and having no other study participant in the same household.

We used convenience sampling methods to recruit participants in community settings during a 6-week period in 2013. To increase efficiency of enrollment, both recruitment sites targeted large Latino communities where researchers have previous experience and could work within well-established community partnerships. The Houston site, for example, worked with trained 2-1-1 Texas Helpline bilingual information and referral specialists who delivered the original Smoke-Free Homes program to recruit low-income, Latino English- and Spanish-speaking 2-1-1 callers. The Houston staff also recruited in community settings (eg, Mexican-American neighborhood grocery stores) through flyers and in person. San Diego research assistants leveraged their community-based research experience in the Latino community using previous recruitment methods, including word-of-mouth and online networking. Overall, the majority of participants were identified through community recruitment methods, with only seven participants recruited through the 2-1-1 helpline. Participants chose the interview location: 15 took place over the telephone, 17 in participants’ homes, and 11 in public locations. Participants received $20 gift card compensation for their time.

Data Collection

Bilingual, first-generation or immigrant, Latina research assistants assisted in modest adaptations and translation into Spanish of the brief questionnaire and interview guide that the original Smoke-Free Homes program used for formative research with English speakers.^32,33 The structured interview guide facilitated a more deductive approach and included probes to understand the influence of factors based on social cognitive theory and the behavioral-ecological model. Factors explored included social norms, beliefs, and attitudes regarding barriers and facilitators to creating smoke-free home and vehicle rules and knowledge about second- and thirdhand smoke.^32,33 We did not directly ask about cultural values but rather followed a more inductive approach to allow these constructs to emerge and described how they related to different topics. The research assistants helped translate the interview guide, including forward translation from English to Spanish. Using standard translation techniques to ensure clarity and preserve conceptual meaning, the Spanish guide was back translated and compared with the original guide to ensure meaning was retained. (In-depth interview guides are available from the corresponding author).

Before conducting the interviews, we obtained written consent (in-person) or oral consent (when obtained by telephone). Consent was obtained in participants’ preferred languages, and once obtained, interviewers asked closed-ended questions about sociodemographic characteristics, smoking status/history, household composition, and household/vehicle smoking rules. Open-ended questions prompted the sharing of experiences and views on each topic, such as “What are some times or situations when it might be hard for a smoker to go outside to smoke?” and “What, if anything, might convince you to totally ban smoking in your home?” Interviews were audio recorded, and an independent company transcribed each in the language used and then translated Spanish text to English. Interviewers checked the translation of their own interviews for accuracy against the Spanish transcripts. Supplementary observations written by the interviewers at the conclusion of each interview helped with interpretation of emotion and emphasis of responses.

Analysis

We analyzed quantitative data using SPSS and conducted qualitative data content analysis using ATLAS.ti.³⁴ Investigators (LSS and PDM) reviewed the English transcripts to identify codes that were then placed into a priori and emergent categories: behaviors (including nonsmokers’ actions or inactions banning indoor or in-vehicle smoking, and smokers’ responses to bans); beliefs (about SHSe and health); knowledge (about smoking laws and second- and thirdhand smoke); other (barriers or facilitators to implementing indoor or in-vehicle smoking bans); and attitudes, including respeto as an emergent theme, where we accumulated all codes that could have been in other groups but that specifically described related attitudes. Categories were further examined at a case level to develop a simplified framework with two overarching categories, conditions for implementing bans and conditions for the varying acceptance of bans, followed by the a priori subcategories represented by the concepts facilitators for bans and enforcement, and barriers to bans, as well as context (eg, smoking status). Within these categories, we described themes that emerged (Supplementary Figure 1, a simplified emergent themes framework related to conditions for implementing bans). Although we observed numbers of respondents by themes, we did not use numbers to represent the “strength” of findings but rather considered the entire range of responses and viewed each response as representing a larger group.

Results

Participant Characteristics

We interviewed 43 participants, roughly half from each site (Table 1). The majority were female (n = 31), current smokers (n = 26), interviewed in Spanish (n = 26), and had annual household incomes less than $30000 (n = 24). About half (n = 24) said they allowed smoking inside their homes; 20 of the 39 vehicle owners allowed smoking in their vehicles.

Table 1.

Sociodemographic and Smoking-Related Characteristics of Participants, N = 43

	N	Participant’s smoking status
		Current smoker	Nonsmokera
		(n = 26)	(n = 17)
Site
Houston	22	10	12
San Diego	21	16	5
Gender
Female	31	17	14
Male	11	9	2
Missing	1	0	1
Age (Mean ± SD)	41 (15.03)	41 (16.46)	40 (12.86)
Education
Less than high school	12	6	6
High school graduate/GED or higher	30	20	10
Missing	1	0	1
Household income
Less than $30000	24	13	11
$30000 or higher	16	11	4
Missing/Don’t know	3	2	1
Interview language
Spanish	26	17	9
English	17	9	8
Home smoking rule
No ban	10	5	5
Total ban	19	12	7
Partial ban	14	9	5
Smoking in vehicle
No ban	9	5	4
Total ban	19	12	7
Partial ban	11	7	4
No vehicle	3	2	1
Missing	1	0	1
Quit smoking for >1 day in past 12 monthsb
Yes	17	15	2
No	15	11	4
Live with other people
Yes	41	24	17
Noc	2	2	0
Family/friends sometimes smoke inside your home
Yes	13	5	8
No	30	21	9
Family/friends sometimes smoke in your vehicle
Yes	21	13	8
No	22	13	9

^aSix self-identified nonsmokers with history of smoking.

^bTotal smoking quit attempts in the past 12 months.

^cCaretakers of children in their home.

There were participants who spoke only Spanish or who spoke only English, as well as dual-language participants who switched between the two languages. Research staff also noted that participants interviewed in either language frequently used words or phrases from the other language to elaborate or clarify answers. Two participants changed languages for the open-ended questions, and we classified them by the language to which they switched. As one aspect of acculturation, this variation of language use may indicate a range of acculturation, including biculturalism.³⁵

Below we present the emergent themes, organized by the a priori overarching categories (conditions for implementing bans and conditions for varying acceptance of bans). Within these categories, we further organized findings by a priori concepts represented by the subcategories potential facilitators for bans and enforcement, barriers to bans, and context.

Conditions for Implementing Bans

Facilitators for banning smoking in homes included respect for children, preferences of heads of household, initiation or support of the ban by a smoker, concern about health risks of secondhand smoke, and dislike of the lingering odor of smoke on clothes or in the home (thirdhand smoke). These themes also related to strategies for enforcing smoke-free home rules.

Potential Facilitators for Bans and Enforcement: Participants With Bans

Respeto was a primary theme related to smoke-free home rules and enforcement for both male and female smokers and nonsmokers. This theme also highlights the importance of heads of household. Participant A, a young adult female smoker, described the rationale for their smoke-free home:

We choose not to let people smoke in our house because it is my mom’s house so whatever she agrees on that’s it--that’s the rule. Out of respect, I guess, for non-smokers.

Interviewees with smoking bans also indicated the need for courteous communication strategies to show sensitivity for the smoker. A female smoker with a ban provided indirect enforcement when she explained to visitors that it would be better not to smoke because her nephews have problems with the smoke. Another example of a more passive enforcement approach was Participant B, a female smoker, who described redirecting a visitor.

They asked if I had a lighter, and I could tell they wanted to smoke. I told them, “No, I don’t have a lighter in here. I might have one in my car. Let’s go outside so you can smoke outside. We don’t smoke in the home.”

Strong support of a rule by the smoker in the house was important, as was the smoker’s position. When Participant C, a male smoker, was asked about making the smoke-free home decision, he explained, “I am the one who makes the decisions because I am the head of the household.” He described changing his smoking habits to smoke outside when his wife moved in with him, possibly indicating awareness of SHSe hazards to the nonsmoker and desire to protect his wife, although not full awareness of smokers’ own risks, “…secondhand smoke is worse than the [cigarette] you smoke.” He also described a confident approach to enforcing a smoke-free home rule that he paired with maintaining fellowship with the smoker rather than isolating him.

No, it wouldn’t be hard. I would just say, “Hey, we don’t smoke here, please, outside. I am going with you.”

Protecting children also helped to enforce a smoking ban, as exemplified by Participant B a woman with a smoke-free home rule who cited her nephews’ problem with smoke.

I think if I didn’t have children they would be like, “Come on. Why? It is just smoke. You smoke, too, so what.” They wouldn’t understand it as well, I don’t think. Some people wouldn’t care if I didn’t have kids but since I have kids they are okay.

Conditions for Varying Acceptance of Bans

Smoker-specific barriers to bans included inconvenience or discomfort associated with smoking outside, attitudes regarding having a right to smoke in one’s home, deference regarding smoker behavior, lack of knowledge regarding second- and thirdhand smoke, belief that the smoker would have to quit to have a home smoking ban, and smokers’ breaking rules (both overtly and covertly). Nonsmokers’ deference to smokers’ preferences and inclination to avoid conflict, particularly if the smoker paid the household bills, fostered reluctant acceptance of smoking in the home.

Potential Barriers to Bans: Participants With Partial or No Ban

Reasons for inconsistent bans included smokers’ discomfort or inconvenience with smoking outside; guests’ request to smoke inside, particularly at parties; and intergenerational groups where norms may conflict. Participant D, a female smoker in Houston, described discomfort as a main barrier.

Well, in the winter no one goes out to smoke, so I smoke here inside because you freeze out there if you go out.

Participant E, a female smoker who lives with her husband who also smokes, described the inconvenience of smoking outside.

Well, because, like I said, I am an adult and I like to smoke, and I like to be inside my house … because there [are] people who smoke and, for instance, go to the patio or go out to the street or go to the garage, and I am not in those conditions. I, if I am doing something here in the kitchen … I smoke my cigarette here.

Participants also identified social gatherings as situations that lead to modifying smoking rules, including lifting bans for company. One young female participant described, “Just holidays; we have huge parties. Yeah, it’s like a free for all.” She described more tolerance of smoking in the home because it is normal in certain situations, like when she visits her grandparents who smoke inside their own home.

Participant F, a Spanish-speaking, male nonsmoker, described deference for visitors who smoke.

It’s important if you have visitors or friends or family in your house; it’s important for them to know that they shouldn’t be smoking too much, but it’s also not the intention to make them feel uncomfortable or make them feel bad, so yes, it is important to make them see, but you shouldn’t insist. [So] banning, no, because I don’t want to prohibit something from someone. I would prefer to make that person aware that it’s doing them harm, so that they can then make a decision.

Participant B, a wife who smokes, explained her deference to her husband who also smokes.

When he was around, yes he did smoke in the home. Not a lot, I mean it would be like, he knew it was a rule that I didn’t allow but at the same time, he was the one who paid the majority of the bills and he was the father of my children and he would every once in a while go behind my back and still smoke.

Situational context also seemed to guide household rules. Participant E, a smoker and grandmother with no smoking ban, described a partial rule that depended on others’ preferences or presence of a child.

[I]f I ask him not to smoke inside my home, there is a reason, because everybody knows that here it is allowed to smoke, but if I ask, it is because the children are there or because there is people who don’t like other people to smoke.

Conflict also arose when an older child became a smoker and exposed nonsmoker family members. Several mothers of adults or adolescent boys described their inability to enforce a ban in this parent (nonsmoker)–child (smoker) relationship. Participant G, a Spanish-speaking nonsmoker mother, described communication problems with her adolescent son who smokes when she is not at home.

Well, I tell him…it makes me sick, it makes your sister sick, but he doesn’t stop. I say please, I don’t care if you smoke outside, you’re the one that’s hurting us, but he gets mad, and now I don’t know how to talk to him.

From the smoker’s perspective, if the parent enforcer of the ban was not at home, they might sneak an indoor cigarette (in a well-ventilated part of the home). Participant H is a female Spanish-speaking smoker, who pays the rent and lives with her nonsmoker mother.

I was lying down, happily listening to music, there wasn’t anyone around, I was alone. It was the perfect moment for a cigarette for me, so to have stopped and gone out to smoke, that would have killed that mood.

Participant H also described use of electronic cigarettes³⁶ as a strategy to reduce SHSe to nonsmokers, particularly in situations where it was not possible to smoke.

If I’m alone, I’ll smoke. If there are minors or people that don’t smoke, then no, I have an electronic cigarette for anxiety.

Context: Awareness of Risks and Thirdhand Smoke, The “Smell” Factor

Participants had varied knowledge of secondhand smoke and knew less about thirdhand smoke. They conveyed more awareness of the lingering smell than knowledge of its persistence and its health effects. Smokers and nonsmokers, with and without bans, described using deodorizers and scents. Several female smokers with no household ban described how they tried to get rid of the smell. Participant D said, “When people come to my house they feel the smell. That’s why I spray scents all over. One should always smoke outside.” Participant I said, “Because in the house I have deodorizers in every outlet, I’m very obsessive about smell and even though I know I smell, if I get to my house and it smells like cigarettes, I won’t tolerate it.”

Context: Landlord Bans

Landlord smoking bans did not necessarily result in a home smoking ban. Participant J is a female Spanish-speaking smoker.

The thing is that in some occasions, I mean, yes sometimes we open the window and when there is nobody around, we can smoke a cigarette but throwing the smoke outside, otherwise, the siren rings.

Vehicle Bans

Having a vehicle smoking ban was more important for some smokers than having a home ban. The motivation was not necessarily related to health as Participant K, a male Spanish-speaking smoker reported.

Like a couple of friends have tried to smoke in my car, but I don’t let them. I told them not to. No. Nobody’s allowed to smoke in my car. Because—well—I just don’t want my seats to get burned. Yeah, with a cigarette or I don’t want ashes everywhere or the smell.

Discussion

We have found that Mexican Americans who participated in our study have many barriers and facilitators in common with other populations. Similar to previous research results in non-Latino populations, facilitators for creating household smoking bans include awareness of the health impact of home SHSe, especially on children, a health diagnosis exacerbated by SHSe, and not liking the smell.^18,32,33 We also found other commonly reported barriers to creating bans, such as weather, parties with smokers present, smokers’ resisting bans, and feelings about smoker’s rights influenced by their household or guest status.^32,37

In addition, we observed the importance of cultural factors that affected participants’ interpersonal behaviors around adopting and enforcing home smoking bans. The importance of Latino culture to household smoking behaviors has been described in other Latino-specific, secondhand smoke–related research.^19,38,39 In our interviews, participants expressed discomfort asking guests or heads of household to smoke outside, and women in particular expressed reluctance to ask smokers in these positions to go outside. Cultural norms, including agreeability, courtesy, and respect, especially with regard to age, male gender, or household provider gave rise to different sub-behaviors, such as deference to smokers, and underscored the importance of family and cultural context when understanding household behavior.

Mexican-American cultural beliefs and norms that emerged and seemed to influence adopting and enforcing home smoking bans included simpatia, respeto, and familismo.⁴⁰Simpatia is a construct that emphasizes agreeability and courtesy.²⁴ Favoring courtesy and a desire to accommodate visitors and other family members was commonly cited as a reason to allow smoking in the home, despite one’s own preferences for rules or intent to have a ban. A high regard for the elders, visitors, and heads of household all reflect the importance of respeto and may relate to a sub-behavior of deference to others.^40,41 Women in our sample expressed passivity with regard to men (partners) living in the home, reflecting traditional gender roles. In a social context, some men also showed deference to smokers’ needs and had more confidence enforcing bans as the protector of others. Within multigenerational households, in addition to men, older family members were comfortable enforcing bans, as it was natural for them to assert household rules in general. This assertion of authority, however, may not apply to mothers of teenage smokers.

Familismo, generally described in terms of the importance family attachments and needs over individual needs,⁴² also influenced attitudes about smoke-free home rules, with adults feeling protective especially of children over adults.^40,43 However, participants described situations when the family’s preferences conflicted with powerful, culturally related social norms to accommodate others, including friends and even strangers who presumed freedom to smoke in the home.²⁵ In these situations, the sense of courtesy and respect, particularly when accommodating visitors or the elders, led to exceptions and tolerance of indoor smoking.

Our findings are similar to those of previous research conducted among Latino multiunit housing residents to inform an intervention to decrease smoking inside multiunit housing.^38,39 Among multiunit housing residents, the authors describe the influences of respeto, simpatia, and personalismo, as in friendliness, as barriers to enforcing bans, particularly with regard to asking the elders or neighbors who smoke to refrain from smoking.³⁸ Another study based on Latino residents in multiunit apartment housing described the dual role of familismo (a facilitator to asking someone not to smoke around young children), while also reflecting cultural values of simpatia and respeto, when describing participants not wanting to disrupt relationships with neighbors.³⁹

Smokers’ strong influence may present barriers to smoke-free home rules in the general population, but in multigenerational, Mexican-American homes, passivity and courtesy and respect for heads of household, the elders or male smokers pose unique challenges to creating and enforcing bans. In some situations, conflict avoidance may have played a role in subsuming one’s own preference to protect children in order to accommodate an adult smoker (guest or more senior family member). Passive ways of asking visitors not to smoke, such as the original Smoke-Free Homes program’s stickers and signs to declare the home smoke free, would be particularly appropriate. Messages for these stickers and signs could be adapted for Mexican Americans to help avoid social discomfort or embarrassment caused by directly asking visitors to smoke outside. Persuasive messages could also reflect courtesy and focus on protecting the family health, drawing on familismo.

Messages emphasizing familismo could also be strengthened by extending understanding of SHSe risks to children to understanding the risks to adults. Use of stickers and signs with messages that reflect a rationale for protecting adult household members and visitors could help alleviate potential social distress caused by asking visitors or more senior family members not to smoke in the home. Culturally adapted messages could reflect sensitivity to the needs for others, such as, Respeta mi familia, mis amigos, nuestra salud, y nuestra casa (Respect me, my family, my friends, our health and our home).

Multigenerational households, and households with nonfamily members living together, create a unique environment in which to negotiate household rules. Twenty-two percent of Latinos live in multigenerational households, 48% of whom live with three generations.⁴⁴ Solutions for these households must acknowledge the role of cultural factors with regard to traditional gender roles and esteem for the elders, as well as deference to main income earners. In households with less-acculturated older family members and where men and adolescents are more likely to smoke than women, the nonsmoker woman may not feel empowered to challenge the smokers. To support the nonsmoker household member, specific scenarios and story lines will need to be created. For example, one scenario could address the challenges faced by nonsmoker mothers negotiating with more acculturated adolescent smokers. An adapted coaching call strategy should anticipate more ambivalence, and additional coaching calls may be helpful. Including more than one household member in the program may help facilitate dialogue. Such calls could target the most influential household member to increase support of a ban. Broadening contact with other family members may also help move the household incrementally toward a full ban. Future adaptation work could examine the potential of providing an additional coaching call to provide more tailored support to other household members

One limitation to our work is the conduct of interviews with only one person from each household, limiting us to that participant’s perspective. Future directions for qualitative research should include independently and confidentially interviewing at least two adults (one smoker and one nonsmoker) from the same household. This approach would enable researchers to capture the degree of concordance and difference in perceptions of household smoking bans/nonbans and smoking behavior.

The current research helps underscore contexts and factors influencing behaviors which may be culturally bound. Our findings also provide insight into cultural narratives that researchers must understand to help Mexican-American families acquire strategies and skills to implement and enforce bans. Findings from this work will inform our future adaptation of the Smoke-Free Homes program efforts to increase reach and potentially effectiveness for Mexican Americans. Such efforts will use IM Adapt,^45,46 based on intervention mapping, a systematic approach to designing or adapting theory and evidence-based interventions.⁴⁷ To plan intervention adaptation, we will use a multistep approach building on these qualitative data to design messages, scenarios, and images that would be tested for acceptability and impact in more representative samples. Future smoke-free home interventions targeting Mexican Americans should select methods to influence the cultural norms that focus on the value of protecting the family overall, to increase norms to protect nonsmoker adults, and to develop intervention approaches to help nonsmokers overcome social norms of deference to smokers that may weaken bans.

Supplementary Material

Supplementary Figure 1 can be found online at http://www.ntr.oxfordjournals.org

Funding

This research was supported by the National Cancer Institute’s State and Community Tobacco Control Research Initiative (U01CA154282; MCK, PI). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute or the National Institutes of Health.

Declaration of Interests

None declared.