Abstract
Little is known about the implementation of voluntary policies in the homes of Black/African American women smokers who live in rural areas where health care access is limited. This paper examines 1) the sample’s prevalence of comprehensive smoke-free rules; 2) sociodemographic, social, and smoking characteristics of women by home rule type; and 3) the association of social indicators with the outcome complete ban on smoked tobacco use in the home (n=191). Families Rising to Enforce Smokefree Homes collected baseline data from 2019-2021 prior to randomization to an intervention that aimed to increase comprehensive smokefree policies in the homes African American women living in the rural Delta region of Arkansas. The primary outcome was implementation of a complete ban on all smoked tobacco products anywhere inside the home. Results showed that 26% of women had a rule that completely banned all smoked tobacco products in the home. Women who reported having no ban were more likely to be employed part-time (50.0%), while women with a partial (66.9%) or complete ban (60.0%) were more likely to not currently work for pay. Women who indicated that they just meet basic expenses and meet needs with little left had significantly lower odds of having a complete ban on smoked tobacco in the home than women who indicated that they live comfortably. Perceived financial security may be a motivating factor that helps women keep their homes free from all smoked tobacco products (# NCT03476837).
Keywords: cigarettes, cigars, social deprivation, black, women, smoking, rural, policies, smoking rules, secondhand smoke
INTRODUCTION
Disparities in secondhand smoke exposure among children and racialized groups have persisted for more than three decades in the United States (1,2). U.S. national data show that among non-smokers, secondhand smoke exposure is nearly twice as high among young children compared to adults (1) and high among children in rural areas (3). Secondhand smoke exposure is twice as high among Black/African American people compared to other racialized and ethnic groups for whom data are reported (1,2). Nearly 38% of children aged 3-11 in 2013/14 (1) and 41.5% of Black/African American non-smokers were exposed to secondhand smoke in 2017/18 (2).
Further, people who live in poverty and have less than a high school education are more than twice as likely to have been exposed to secondhand smoke than people who live at or above poverty or have attained a bachelor’s degree or higher (1). Forty-eight percent of non-smokers who live in poverty and 31% of non-smokers with less than a high school education were exposed to secondhand smoke in 2013/14 (1). Data are not often reported by the intersection of race, age, geography and socioeconomic indicators. One study found that serum cotinine levels in children of parents in rural Appalachia were higher than parents reported rates of smoking (4). Rural residents are more likely to allow cigarette smoking in the presence of children in their homes and cars (5). It is possible that Black/African American children who live in low resource rural communities have disproportionately higher rates of secondhand smoke exposure than their comparative groups.
Multiple factors could potentially explain long-standing disparities in secondhand smoke exposure. At the individual level, living with a smoker increases the risk for exposure. U.S. data show that 73% of non-smokers exposed to secondhand smoke lived with a smoker (1). Smoking is higher in rural areas (6). Children who live in small rural areas (2500 to 9,999 people) are more likely to live with a smoker (35.0%) than children in urban areas (24.4%) (3,7). At the interpersonal level, residents who live in rural areas have limited access to health care providers and health systems (8), thus limiting their access to preventive health messages. People who live in multiunit housing may have a lower prevalence of smokefree rules than people living in single family housing (9). As a result, even if a residence has a smokefree rule, attached residences may not be smokefree.
At the community level, high smoking prevalence may increase exposure to secondhand smoke. In 2020, 20.5% of Arkansan adults reported that they smoked cigarettes compared to 15.5% of adults in in the US (10). At the policy/societal level, data show that only 0.5% of Arkansans compared to 61% of all Americans are protected by comprehensive smokefree policies in workplaces, bars, and restaurants (11). Arkansas ranks amongst the lowest states (40th) in non-smoking regulations (11). Only three cities, Fairfield Bay, Helena-West Helena, and Wooster have 100% comprehensive smokefree coverage (11). Studies also show that voluntary smokefree policies that completely ban cigarette smoking in the home are low in Black/African American, low-income, and rural households (12-15).
Multiple factors at the individual, interpersonal, community and policy levels can prolong health disparities caused by secondhand smoke. Secondhand smoke exposure among non-smokers causes cancer, heart disease, and stroke among adults, and sudden infant death syndrome, respiratory infections, ear infections, and asthma attacks in infants and children (16). Black/African American and socioeconomic disadvantaged people suffer disproportionately from tobacco-caused illnesses and deaths (16,17). Comprehensive smokefree home policies (i.e., free from cigarette, cigar, electronic cigarettes, IQOS, hookah, and pipe smoke) could protect diverse groups from tobacco smoke and reduce longstanding health and social disparities.
In 2019, Families Rising to Enforce Smokefree Homes (FRESH) began recruiting Black/African American women smokers who live in low resource rural counties to participate in a small scale randomized controlled trial that aimed to increase comprehensive smokefree policies in the home (clinical trial # NCT03476837). This paper examines 1) the sample’s prevalence of comprehensive smoke-free rules; 2) sociodemographic, social, and smoking characteristics of women by home rule type; and 3) the association of social indicators with the outcome complete ban on smoked tobacco use in the home (n=191).
METHODS
Study Setting
In 2019-2021, baseline data were collected among Black/African American women who were current cigarette and/or little cigar/cigarillos smokers (LCCs). The FRESH study aimed to increase comprehensive smokefree policies in the home as a primary outcome and smoking cessation as a secondary outcome. Women smokers were recruited from Lee and Phillips counties located in the rural Delta region of Arkansas where the social, economic, and political conditions are similar to those observed in other Tobacco Nation states (18). Tobacco Nation states have smoking prevalence rates that exceed the national average, residents are less financially well-off, health outcomes and access to care are poor, and these states have poor policies to protect the public from secondhand smoke and encourage quitting (18).
In 2021, of the 8,600 residents in Lee County, 54.4% of residents were Black/African American, 58.7% had broadband internet, 9.4% did not have health insurance, 36.8% lived below the poverty level, the median household income was $29,681 (19), 12.3% of residents were unemployed, and 29% received support from the Supplemental Nutrition Assistance Program (SNAP) (20). Of the 16,568 residents in Phillips County, 62.3% of residents were Black/African American, 65.4% had broadband internet, 9.0% did not have health insurance, 22.1% lived below the poverty level, the median household income was $29,320 (19), 13% of residents were unemployed, and 40% received support from SNAP (20). Additional details on the study setting are reported elsewhere (21).
Eligibility and Recruitment
Women eligible to participate in the study: 1) self-identified as Black/African American; 2) were aged 18-50; 3) resided in Lee or Phillips counties; 4) spoke English; 5) provided written informed consent; 6) had a working phone, home address, and email; 7) were the primary caregiver (birth parent, guardian) of at least one child aged 6 months to 14 years old; 8) were the primary decision maker in the home; 9) smoked cigarettes and/or LCCs for at least 1 year and in the past 30 days; and 10) were of low income as defined by any indicator (e.g., Medicaid; Earned Income Tax Credit; Children’s Health Insurance Plan (ARKids); subsidized housing; child care subsidies; food stamps). Women with carbon monoxide levels lower than 5 parts per million (ppm) were excluded from the study.
Research staff used word-of-mouth, radio and newspaper advertisements, flyers, in-person and physically distanced community events (i.e., food distribution with local food banks) to recruit study participants. Trained research staff screened women by telephone or in-person to determine eligibility. Eligible participants were emailed a consent form prior to enrolling in FRESH study and completing the baseline survey online. In December of 2021, our recruitment was completed resulting in 192 study participants. The study was approved by the Institutional Review Board of the University of Arkansas for Medical Sciences (UAMS) (#207306, approved on 22 November 2017) and has met the requirements for human subjects safety and privacy.
Procedures for Survey Administration
Trained research staff administered baseline surveys in the home or at an agreed upon location using computer-based or online self-administered surveys. Staff were available by phone or email to answer participant’s questions. Written informed consent was obtained in accordance with UAMS Institutional Review Board policies. All participants received a $30 reloadable research gift card (i.e., ClinCard) and a one-page fact sheet about quitting smoking when they complete the baseline survey.
Measures
Sociodemographic Characteristics.
Baseline measures are summarized below and in tables 1 and 2. Data were collected on the participant’s age, race, Hispanic ethnicity, sexual orientation, body mass index (BMI), marital status, employment status, insurance status, currently enrolled in college/university degree program, educational attainment, annual household income, overall financial situation (22), receipt of SNAP benefits in the past year, and the number of children in the household by age.
Table 1.
Participant characteristics of Black/African American women smokers by home smoking rule type (N = 191).
| Home smokefree rule on all smoked tobacco products |
|||||
|---|---|---|---|---|---|
| Total N=191 |
Complete ban (n=50) 26.2% |
Partial ban (n=121) 63.4% |
No ban (n=20) 10.5% |
p | |
| Participant characteristics | % (n) or M (SD) |
% (n) or M (SD) |
% (n) or M (SD) |
% (n) or M (SD) |
|
| Age in years (M, SD) | 33.6 (8.9) | 35.4 (8.8) | 33.1 (8.7) | 32.0 (10.2) | .22 |
| Race identify with most | .10 | ||||
| Black/African American | 95.8 (182) | 100.0 (49) | 95.0 (115) | 90.0 (18) | |
| Biracial/multiracial (yes) | 4.2 (8) | 0 | 5.0 (6) | 10.0 (2) | |
| Hispanic ethnicity (yes)a | 1.0 (2) | 2.0 (1) | 0.8 (1) | 0 (0) | .60 |
| Sexual orientation | .45 | ||||
| Heterosexual/straight | 75.8 (144) | 69.4 (34) | 78.5 (95) | 75.0 (15) | |
| Gay/lesbian/bisexual/other | 24.2 (46) | 30.6 (15) | 21.5 (26) | 25.0 (5) | |
| Body mass index (M, SD) | 32.2 (9.4) | 32.8 (9.2) | 32.0 (9.9) | 31.5 (7.2) | .84 |
| Marital status | .85 | ||||
| Married | 22.1 (42) | 22.5 (11) | 22.3 (27) | 20.0 (4) | |
| Living with partner | 16.3 (31) | 18.4 (9) | 14.1 (17) | 25.0 (5) | |
| Never married | 48.4 (92) | 42.9 (21) | 51.2 (62) | 45.0 (9) | |
| Widowed/divorced/separated | 13.2 (25) | 16.3 (8) | 12.4 (15) | 10.0 (2) | |
| Employment status | |||||
| Full-time | 20.9 (40) | 22.0 (11) | 20.7 (25) | 20.0 (4) | .0040 |
| Part-time | 17.8 (34) | 18.0 (9) | 12.4 (15) | 50.0 (10) | |
| Do not currently work for pay | 61.3 (117) | 60.0 (30) | 66.9 (81) | 30.0 (6) | |
| Insurance status | .21 | ||||
| Insured | 80.4 (152) | 85.7 (42) | 76.7 (92) | 90.0 (18) | |
| Uninsured | 19.6 (37) | 14.3 (7) | 23.3 (28) | 10.0 (2) | |
| Enrolled in college/university degree program | .70 | ||||
| Yes | 16.2 (31) | 20.0 (10) | 14.9 (18) | 15.0 (3) | |
| No | 83.8 (160) | 80.0 (40) | 85.1 (103) | 85.0 (17) | |
| Education attainment | .40 | ||||
| Less than high school | 26.2 (50) | 34.0 (17) | 24.8 (30) | 15.0 (3) | |
| High school or GED | 49.7 (95) | 48.0 (24) | 50.4 (61) | 50.0 (10) | |
| Some college or associate degree | 24.1 (46) | 18.0 (9) | 24.8 (30) | 35.0 (7) | |
| Annual household income | .89 | ||||
| <$10K | 65.5 (125) | 66.0 (33) | 64.5 (78) | 70.0 (14) | |
| ≥$10K | 34.6 (66) | 34.0 (17) | 35.5 (43) | 30.0 (6) | |
| Overall financial situation | .0017 | ||||
| Live comfortably | 37.2 (71) | 58.0 (29) | 27.3 (33) | 45.0 (9) | |
| Meet needs with little left | 26.7 (51) | 12.0 (6) | 33.9 (41) | 20.0 (4) | |
| Just meet basic expenses | 25.1 (48) | 14.0 (7) | 29.8 (36) | 25.0 (5) | |
| Don’t meet basic expenses | 11.0 (21) | 16.0 (8) | 9.1 (11) | 10.0 (2) | |
| Received SNAP benefits in past year | .70 | ||||
| Yes | 83.8 (160) | 80.0 (40) | 85.1 (103) | 85.0 (17) | |
| No | 16.2 (31) | 20.0 (10) | 14.9 (18) | 15.0 (3) | |
| Children in household | |||||
| Under aged 18 | 96.9 (186) | 98.0 (49) | 96.7 (117) | 95.0 (19) | .67 |
| Aged 18 and older | 3.1 (6) | 2.0 (1) | 3.3 (4) | 5.0 (1) | |
Notes: Baseline data were collected among Black/African American women who smoke (cigarettes/little cigars and cigarillos) in Lee and Phillips counties in Arkansas from 2019-2022. M=mean, SD=standard deviation, GED=general education diploma.
Comprehensive smoke-free rule is defined as, no one is allowed to smoke cigarettes, cigars, hookah, IQOS, pipes, and electronic cigarettes anywhere inside the home versus at least 1 tobacco product is allowed in some places/at some times or anywhere in the home.
P-values are reported for ANOVA, Wald χ2 or Fisher’s exact test.
Only 2 women reported Hispanic ethnicity.
Table 2.
Smoking characteristics of Black/African American women smokers by home smoking rule type (N = 191).
| Home smokefree rule for all smoked tobacco products |
|||||
|---|---|---|---|---|---|
| Total | Complete ban (n=50) 26.2% |
Partial ban (n=121) 63.4% |
No ban (n=20) 10.5% |
p | |
| Smoking characteristics | % (n) or M (SD) |
% (n) or M (SD) |
% (n) or M (SD) |
% (n) or M (SD) |
|
| Current cigarette use (yes) | 77.5 (148) | 84.0 (42) | 75.0 (90) | 75.0 (15) | .43 |
| # of cigarettes smoked per day (Median, IQR) | 8.0 (10.0) | 7.5 (7.5) | 7.0 (10.0) | 10.0 (9.0) | .46 |
| # of days smoked cigarettes in past 30 days | 20.9 (10.3) | 18.8 (9.9) | 22.2 (10.3) | 18.6 (11.2) | .16 |
| Current LCC use (yes) | 39.5 (75) | 26.5 (13) | 41.3 (50) | 60.00 (12) | .0282 |
| # of LCCs smoked per day | 5.6 (6.0) | 8.0 (8.0) | 4.8 (5.5) | 6.8 (5.1) | .19 |
| # of days smoked LCCs in past 30 days | 12.0 (10.9) | 7.7 (9.5) | 13.4 (11.4) | 10.9 (9.2) | .22 |
| Current regular/premium cigar use (yes) | 25.7 (49) | 20.0 (10) | 23.1 (28) | 55.0 (11) | .0059 |
| Usually smoke menthol (yes) | 90.6 (135) | 90.5 (38) | 90.1 (82) | 93.3 (14) | 1.00 |
| Usually smoke menthol LCCs (yes) | 24.3 (18) | 30.8 (4) | 22.5 (11) | 25.0 (3) | .85 |
| # of cigarette smokers in home | .95 | ||||
| 1 Smoker (women caregiver only) | 63.2 (120) | 63.3 (31) | 60.8 (73) | 75.0 (15) | |
| 2 Smokers in home | 26.3 (50) | 24.5 (12) | 28.3 (34) | 20.0 (4) | |
| 3 Smokers in home | 7.9 (15) | 10.2 (5) | 7.5 (9) | 5.0 (1) | |
| ≥4 Smokers in home | 2.6 (5) | 2.0 (1) | 3.3 (4) | 0 (0) | |
| # of people who smoked in presence in past 7 days, Median (IQR) | 1.0 (1.0) | 1.00 (2.0) | 1.00 (1.0) | 2.00 (1.5) | .06 |
| Mean | 1.7 (1.9) | 1.3 (1.6) | 1.8 (2.0) | 2.15 (1.8) | |
| Current hookah use (yes) | 4.7 (9) | 2.0 (1) | 5.8 (7) | 5.0 (1) | .58 |
| Current e-cigarette use (yes) | 5.8 (11) | 6.0 (3) | 4.1 (5) | 15.0 (3) | .15 |
| Current IQOS use (yes) | 0.5 (1) | 0 (0) | 0.8 (1) | 0 (0) | 1.0 |
| Current pipe use (yes) | 0 (0) | - | - | - | |
| Current smokeless tobacco use (yes) | 2.1 (4) | 0 (0) | 2.5 (3) | 5.0 (1) | .27 |
| Time to first cigarette ≤ 5 min of waking | 50.3 (75) | 52.4 (22) | 48.4 (44) | 60.0 (9) | .68 |
| Ever tried to quit cigarettes (yes) | 53.7 (79) | 47.6 (20) | 58.9 (53) | 40.0 (6) | .26 |
| Past year cigarette quit attempt (yes) | 54.6 (42) | 65.0 (13) | 51.0 (26) | 50.0 (3) | .54 |
| # of past year cigarette quit attempts | .22 | ||||
| 1 | 42.9 (18) | 38.5 (5) | 42.3 (11) | 66.7 (2) | |
| 2-3 | 50.0 (21) | 53.9 (7) | 53.9 (14) | 0 (0) | |
| ≥4+ | 7.1 (3) | 7.7 (1) | 3.9 (1) | 33.3 (1) | |
| Intention to quit cigarettes in next 30 days | .0548 | ||||
| Yes | 17.2 (25) | 31.0 (13) | 11.4 (10) | 13.3 (2) | |
| No | 62.8 (91) | 57.1 (24) | 63.6 (56) | 73.3 (11) | |
| I don’t know | 20.0 (29) | 11.9 (5) | 25.0 (22) | 13.3 (2) | |
| Time to first LCC ≤ 5 min of waking | 29.7 (22) | 38.5 (5) | 22.5 (11) | 50.0 (6) | .13 |
| Ever tried to quit cigars (yes) | 22.8 (13) | 25.0 (3) | 28.1 (9) | 7.7 (1) | .45 |
| Past year cigar quit attempt (yes) | 23.1 (3) | 0 (0) | 22.2 (2) | 100.0 (1) | .16 |
Notes: Baseline data were collected among Black/African American women who smoke (cigarettes/little cigars and cigarillos) in Lee and Phillips counties from 2019-2022.
Comprehensive smoke-free rule is defined as, no one is allowed to smoke cigarettes, cigars, hookah, IQOS, pipes, and electronic cigarettes anywhere inside the home versus at least 1 tobacco product is allowed in some places/at some times or anywhere in the home.
M=mean, SD=standard deviation, IQR=interquartile range, LCC=little cigar or cigarillo P-values are reported for ANOVA, Wald χ2 or Fisher’s exact test.
<.05
<.01
<.001
Tobacco Use Characteristics.
We measured current tobacco use status for cigarettes, LCCs, regular/premium cigars, hookah, electronic cigarettes (e-cigarettes), IQOS, and pipes. We also measured cigarette/cigar smoking frequency and intensity, number of smokers in the household, number of people who smoked in the presence of the participant in the past 7 days, nicotine dependence, and quitting behaviors.
Current cigarette and cigar users.
Participants who indicated that they had smoked at least 100 cigarettes in their lifetime were asked, “Do you currently smoke cigarettes every day, some days, or not at all?” Current cigarette smokers were women who smoked “every day” or “some days”. Ever smokers of a filtered little cigar or cigarillo (LCC) were asked, “Do you now use little cigars or cigarillos every day, some days, or not at all?” Current LCC smokers were women who smoked every day or some days.
Current use of e-cigarettes, hookah, pipes, and smokeless tobacco.
We assessed current use (every day or some days) of other tobacco products including premium/large cigars, hookah, pipe tobacco, IQOS/heated tobacco, e-cigarettes and smokeless tobacco.
Cigarette and cigar smoking intensity was measured by asking current smokers the number of cigarettes smoked per day in the past 30 days. Cigarette smoking frequency was measured by asking current smokers the number of days they smoked in the past 30 days. Similar question was used to asses cigar smoking frequency and intensity.
Menthol cigarette smoking status.
Current cigarette smokers were asked about the usual type of cigarette they smoked (menthol, non-menthol, or no usual type).
Menthol LCC smoking status.
Current LCC smokers were asked what flavor of LCC they usually smoke (e.g., menthol or mint, clove, spice or nut, tobacco, fruit, chocolate, vanilla or cream, an alcoholic drink, beverages, coffee/tea, candy, desserts, other sweet flavor, some other flavor, I don’t use a flavor, and don’t know).
Smoking in the household.
We assessed number of people in the household who smoke and number of people who smoked in the study participant’s presence in the past 7 days.
Nicotine dependence.
We measured nicotine dependence to cigarettes and LCC separately using time to first cigarette and LCC within 5 minutes of waking (i.e., how soon after waking do you smoke your first cigarette/cigar after waking (within 5 minutes, 6-30 minutes, 31-60 minutes, or after 60 minutes).
Quitting cigarettes and cigars.
Cigarette and cigar smokers were asked whether they had ever tried to quit smoking cigarettes or cigars completely (yes/no). Among smokers who ever tried to quit cigarette/cigar smoking, we assessed past year cigarette/cigar quit attempts and the number of cigarette quit attempts in the past year. All cigarette smokers were also asked whether they planned on quitting cigarette smoking within the next 30 days (yes/no/I don’t know).
Motivation to Keep Home Smokefree.
Participants were asked if anyone had ever tried to implement a comprehensive smokefree policy in the home that included all smoked tobacco products (i.e., cigarettes, cigars, hookah, IQOS, pipes, and e-cigarettes; yes/no response option). Participants were asked about their motivation to adopt a rule that keeps their home free from all tobacco smoke and how confident they were that they could keep their home free from all tobacco smoke (1=strongly agree – 5=strongly disagree).
Comprehensive Smokefree Rule in the Home.
To assess the extent to which participants implemented a comprehensive smokefree policy in the home, we asked, “Which statement best describes the rules about smoking in the home?” for each tobacco product. Response options included ‘no one is allowed to smoke [the tobacco product] anywhere inside the home (bedroom, kitchen, bathroom, closet, dining room, living room, halls, den, etc.’; ‘[Tobacco product] smoking is allowed in some places or at some times inside the home’; and ‘[Tobacco product] smoking is permitted anywhere inside the home’. We created a composite measure using the response for each tobacco product resulting in a single measure of a comprehensive smokefree rule in the home: those who reported that no one is allowed to smoke any of the tobacco products anywhere inside the home were considered to have a complete ban; those who reported that smoking/use of at least one tobacco product is allowed in some places or at some times in the home were considered to have a partial ban; and those who reported that smoking/use of all products were permitted anywhere in the home were considered to have no ban.
Data Analysis.
A total of 192 participants completed the baseline study survey as of December 2021. One participant was excluded from analyses due to missing data on smokefree policies. Analyses were conducted in SAS 9.4 (23). We conducted univariate and bivariate analyses (Wald χ2, Fishers exact, ANOVA, and Mann Whitney U tests) to compare the sociodemographic and tobacco user characteristics by comprehensive smokefree rule status. Multivariable multinomial logistic regression and 95% confidence intervals (CI) were used to assess the relationship between the outcome of comprehensive smokefree rule status (reference group=complete ban) and 3 socio-economic indicators (overall financial situation, educational attainment (dichotomized to less than high school education vs. all else), employment status (dichotomized to do not currently work for pay vs. all else, SNAP status, income, financial situation). Multinomial regression models adjusted for age and for all analyses. A p-value <.05 was considered statistically significant.
RESULTS
Participant Characteristics.
Table 1 shows the characteristics of women smokers by home smoking rule type. Overall, 26.2% of the sample had a complete ban, 63.4% had a partial ban, and 10.5% had no ban on smoking cigarettes, cigars, hookah, IQOS, pipes, and e-cigarettes in the home. The mean participant age was 33.6 years old and over 95% of participants identified as non-Hispanic Black/African American, 1% identified as Hispanic, 24.2% identified as a sexual minority, 48.4% were never married, 61.3% did not currently work for pay, 19.6% were uninsured, 16.2% were currently enrolled in a college/university degree program, 26.2% had less than a high school education, 65.5% had an annual household incomes less than $10,000, 37.2% indicated that they lived comfortably, and nearly 84% had received SNAP benefits in the past year.
We found statistically significant differences in comprehensive smokefree rule status by employment status and overall financial situation. Women who reported having no ban were more likely employed part-time (50.0%), while women with a partial (66.9%) or complete ban (60.0%) were more likely to not currently work for pay. Women with a complete (58.0%) or no ban (45.0%) were more likely to live comfortably compared to women with a partial ban (27.3%). No associations were found between comprehensive smokefree rule status and age, race, ethnicity, sexual orientation, BMI, marital status, insurance status, currently enrolled in a college/university degree program, educational attainment, annual household income, receipt of SNAP benefits, or age of children in the household.
Motivation to Keep Home Smokefree.
Only 31.6% of women smokers in the study reported that anyone had ever tried to establish a smokefree rule that included all smoked tobacco products (cigarettes, cigars, e-cigarettes, hookah, IQOS, pipe). Additionally, 47.9% of women smokers agreed/strongly agreed that they were motivated to adopt a rule that keeps their home free from all tobacco smoke and 46.6% agreed/strongly agreed that they were confident that they could keep their home free from all tobacco smoke (data not shown).
Tobacco Use Characteristics.
Table 2 shows the smoking characteristics of women smokers by home smoking rule type. Overall, 77.5% of women smoked cigarettes, smoked a median of 8.0 cigarettes per day, smoked on average 20.9 days per month, and 90.6% smoked menthol cigarettes. Of participants, 39.5% smoked LCCs, smoked on average 5.6 LCCs per day and 12.0 days in the past 30 days; and 24.3% smoked menthol LCCs. Nearly 37% of participants reported at least 2 smokers in the household. Current use of other tobacco products was low (<6%). Moreover, 50.3% of women smoked their first cigarette and 29.7% smoked their first LCC within the first 5 minutes of waking. About 54% had ever tried to quit cigarettes, of whom 54.6% had tried to quit in the past year. Nearly 60% of women tried to quit 2 or more times in the past year. Only 17% of cigarette smokers intended to quit smoking cigarettes in the next 30 days. Similarly, only 22.8% of cigar smokers reported ever trying to quit cigars, 23.1% of whom tried to quit in the past year.
Women with no home ban were significantly more likely to use LCCs (60.0% vs. 26.5%, 41.3%) and regular/premium cigars (55.0% vs. 20.0%, 23.1%) compared to women with a partial or complete ban. Women with a complete ban were more likely to intend to quit cigarettes in the next 30 days (31.0% vs. 11.4%-13.3%) compared to women with a partial or no ban. No other differences were found by smoking characteristics.
Multinomial Logistic Regression of Social Factors and the Outcome Comprehensive Smokefree Rule Status.
Table 3 presents multivariable multinomial logistic regression results. Compared to women who reported that they live comfortably, women whose overall financial situation just meets their basic needs (AOR: 4.21 [95% CI: 1.61, 11.04]) or meets their needs with a little left (AOR: 6.01 [95% CI: 2.19, 16.53]) had higher odds of having a partial ban than a complete ban after adjusting for age, educational attainment, and employment status.
Table 3.
Age-adjusted multinomial regression model of overall financial situation and comprehensive smoke-free rule in the homes of Black/African American women smokers (N=191)
| Outcome: Comprehensive Smoke-free rule in the home (ref= Complete ban) | ||
|---|---|---|
| Partial ban | No ban | |
| Predictors | AOR (95% CI) | AOR (95% CI) |
| Overall Financial Situation | ||
| Don’t meet basic expenses | 1.03 (0.35, 3.03) | 1.06 (0.18, 6.37) |
| Just meet basic expenses | 4.21 (1.61, 11.04) | 2.13 (0.53, 8.65) |
| Meets needs with a little left | 6.01 (2.19, 16.53) | 1.64 (0.37, 7.40) |
| Live comfortably | ref | ref |
| Less than High School Education | ||
| Yes | 0.84 (0.38, 1.83) | 0.45 (0.11, 1.83) |
| No | ref | ref |
| Do not currently work for pay | ||
| Yes | 1.81 (0.41, 3.90) | 0.35 (0.11, 1.13) |
| No | ref | ref |
| Age | 0.98 (0.94, 1.02) | 0.98 (0.92, 1.04) |
Notes: Baseline data were collected among Black/African American women who smoke (cigarettes/LCCs) in Lee and Phillips counties from 2019-2022.
Comprehensive smoke-free rule is defined as, no one is allowed to smoke cigarettes, cigars, hookah, IQOS, pipes, and e-cigarettes anywhere inside the home versus at least 1 tobacco product is allowed in some places/at some times or anywhere in the home.
AOR=adjusted odds ratio, CI=confidence interval. Boldface indicates statistical significance at the α=.05 level
DISCUSSION
To our knowledge, this is the first paper to specifically examine the prevalence of comprehensive smokefree home rules among Black/African American women living in low resource rural areas. Women in our sample had low prevalence of having a complete ban on tobacco products in the home. Women who were full-time or part-time or unemployed were significantly more likely to have a partial than complete or no ban. Logistic regression analyses showed that women who just meet basic need or meet need with little left were significantly less likely to have a complete ban on the use of all smoked tobacco products in the home than women who said they lived comfortably.
About 46% of Arkansas have a smokefree home rules (24) and national data showed that about 34.6% of Black/African American people have smokefree home rules (25). Further, Black/African American people are less likely to have smokefree rules in the home than Whites (24). In homes where there is a low prevalence of a smokefree rule, children could have higher exposure to secondhand smoke than children where smokefree rules are more prevalent. It is unclear if exposure to secondhand smoke has increased in the homes of Black/African American people during the COVID-19 pandemic, thereby putting the children at greater risk for exposure.
This study found that cigar smokers of any type were significantly more likely to have partial than complete or no ban on all smoked tobacco products. Although not reported in this paper, our analyses showed that women were more likely to have a complete ban on cigar use in the home than cigarettes (55% vs. 32%). These data suggest that women had stronger motivation to ban products that they were less likely to use. Cigarette prevalence was higher in our sample.
It is important to note that women in the sample were from low resource communities. The concept of “living comfortably” does not imply that the women were not poor. Low-income women are a diverse group. Some may access resources from government supported (e.g., SNAP) and non-government supported resources (e.g. family, friends, churches, foodbanks) that help them to “live comfortably” in their deprived social circumstances. Perceptions of “live comfortably” may vary by the amount and type of additional resources received.
Williams et al. found that the subjective measure of financial situation may be a robust predictor for self-reported health status and BMI among young adults than other standard measures like household income (22). The measure of self-rated financial status can useful in understanding the adoption of self-protective behaviors, whereas measures of annual household income can help us understand resources that reside within a household.
Strengths and Limitations
Baseline data from this study were collected as part of an NIH-funded, randomized community-based intervention trial. These data were collected prior to randomization. We were not able to validate household smoking using saliva samples due to the onset of the COVID-19 pandemic. Some of the cell sizes were small, but this study provides novel data on the implementation of comprehensive smokefree policies in the homes of rural Black/African American women smokers living in low resource counties. Data may be generalizable to other Black/African American women smokers who live in similar rural, low resource counties. Because women in our sample were severely socioeconomically disadvantaged, it was difficult to identify variations in socioeconomic deprivation. We did not measure home policies related to marijuana smoking.
CONCLUSION
This study highlights disparities in home smoking bans. Although health workforce shortages are common in rural areas, health providers can provide strong motivational messages to quit when they have contact with patients. Such actions may influence the implementation of complete home bans. Comprehensive smokefree policies are needed at the state level to protect residents in Tobacco Nation states. Finally, there is a need to determine how changes in social indicators (e.g. poverty, financial security) and structural factors might influence the implementation of smokefree rules, quitting, and improve the wellbeing of historically marginalized communities.
Highlights.
Only 26% of women in rural areas had a rule that completely banned all smoked tobacco products in the home.
Cigar smokers were significantly more likely to have a partial than complete ban on all smoked tobacco products.
Greater perceived financial security was associated with a higher prevalence of having a complete smoking ban in the home.
Perceived financial security may be a motivating factor that helps women keep their homes smokefree.
Acknowledgements
The authors would like to thank all of the community participants, volunteers, and community partners who helped with or participated in the FRESH Study. We thank the Arkansas Foodbank for providing food to clients during the pandemic when food security rates dramatically increased. We thank all of the former staff, Candice Lewis, Latonya Rucker, Joseph Su, Ping Ching Hsu, Maggie Kulik, and Richard Tatum for assisting with the development of the survey and collection of the data. We appreciate the support from the UAMS Translational Research Institute for conducting community review groups to inform various components of this study. We acknowledge the existence of persistent poverty, oppression, and structural and systemic racism and discrimination that influence smoking and impact access to timely health care in rural low resource geographic regions.
Disclosure of Funding Source and Conflicts of Interest
Research reported in this paper was supported by the National Institutes of Health, National Institute on Minority Health and Health Disparities (U54 MD002329). This project was solely support by resources provided by the grant. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. None of the authors have any perceived or real conflicts of interest or partnerships with commercial interests.
Footnotes
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