Smoke Signals

More than 2.5 million Americans have died from smoking without ever having picked up a smoking habit. They just happened to live or work with someone who did.

That’s according to a report from the US Office of the Surgeon General. The smoke that emanates from a lit cigarette contains more than 4,000 chemicals, including 70 known carcinogens.

Secondhand smoke (SHS) disproportionately affects vulnerable populations, particularly low-income children, according to the most recent surgeon general’s report on smoking. Despite the millions of dollars and media impact of antitobacco campaigns, more than 1 million American children will suffer from health problems, ranging from asthma symptoms to hospitalization, brought on by secondhand smoke each year. In the United States, the surgeon general’s office estimates that secondhand smoke results in more than $10 billion per year in costs related to medical care, illness, and death. The World Health Organization estimates that, if unchecked, tobacco-related deaths will increase to more than 8 million per year by 2030.

But while many psychological scientists are testing new behavioral interventions to mitigate the dangerous health effects of cigarette smoking, one researcher is involved in work that focuses more on the bystanders than on the smoker.

Working as part of an interdisciplinary team, public health and behavioral scientist Melbourne Hovell, San Diego State University professor of health promotion and behavioral science, is working with engineers, epidemiologists, and environmental scientists to develop antitobacco interventions that have never been tried before. These interventions use new technology and techniques to target the myriad cultural, social, and physical factors that keep people smoking. By modifying some of these factors and alerting smokers to the impact their puffing has on bystanders, Hovell hopes to keep kids safe from SHS.

Changing Behavior Through Culture

Hovell’s research suggests that in order to squelch dangerous SHS exposure, designers of interventions have to acknowledge the interlocking environmental, physical, cultural, financial, and social factors that lead people to smoke in the first place. Warnings about the health consequences of smoking simply are not enough to change most people’s behaviors.

Hovell’s work utilizes the Behavioral Ecological Model (BEM), which accounts for the many layers of reinforcements for smoking, including social pressure and physiological reactions to nicotine.

“We began looking at what is missing from the operant model in applied science, and what we determined is we really don’t have a good understanding of how social support and social networks operate,” said Hovell. “We also tend to do little about the many industries that promote smoking and do so as if it were harmless, including exposure of children and other vulnerable populations.”

Scientists have used the BEM to identify the impact culture has on smoking habits.

Working with Hovell, behavioral health scientist Yoon Ju Song studied South Koreans who had immigrated to the United States. Smoking can be an important social component of business transactions in South Korea: Businessmen will exchange tobacco and smoking accessories with their associates and coworkers as a standard part of the business relationship. But in the 2004 study, Song and her colleagues found that smoking rates were much lower among a sample of South Korean men living in California compared with men living in Seoul. Based on telephone surveys, Song found that about 30% of South Korean immigrants living in California said they were smokers, compared with about 60% of the men surveyed in Seoul.

The researchers attributed the apparent shift in smoking habits among male South
Korean immigrants  to the difference in business culture between
California and South Korea. California’s health-conscious atmosphere was far less tolerant of smoking anywhere, including business settings. Thus, what had been an essential part of business-related socializing in South Korea could potentially compromise the men’s standing in California.

When Song examined the same smoking trends among women, she found that South Korean women living in California had higher smoking rates than those living in South Korea, where they are socially prohibited from smoking. By comparing the two cultures, she demonstrated male-specific improvements in smoking patterns among South Korean immigrants but increased harm in female South Korean immigrants compared with their male counterparts. These results show that the “engineering of culture” can make a marked difference in smoking.

Smoke_signals_webCoaching Kids to Help Themselves

Rather than testing interventions aimed at discouraging parents from smoking around children or at smoking cessation, Hovell and colleagues have focused on preventing SHS exposure (SHSe) by teaching children to avoid it themselves. “In previous trials for families with children with asthma, we noted that some children who attended parent coaching sessions reported that they left the room when a smoker lit a cigarette, or they asked an adult not to smoke in the house,” Hovell writes in an article published in the journal Chest. “These observations raised the question of whether children could be coached to protect themselves from SHSe.”

Hovell designed an intervention that not only empowered the child to avoid dangerous SHS, but also used feedback as a powerful way to change smokers’ behavior — a key component of BEM interventions.

For the trial, children ages 8–13 who lived with a smoker were provided with a combination of face-to-face coaching and feedback on their body’s exposure to smoke. When a child breathes in tobacco smoke, his or her body begins to metabolize or break down the nicotine contained in the smoke, creating a nicotine byproduct called cotinine. Cotinine levels in urine can be tested to provide a reliable measure for nicotine exposure.

After eight in-home sessions over 5 months, the children covered topics with their coaches such as how to talk to adults about smoking indoors and health problems from SHS. As behavior-shaping procedures, coaches provided praise and points when children reported taking steps — such as  leaving a room when someone started smoking or asking a parent to step outside to smoke — to avoid SHS.

Importantly, during the coaching sessions children were also shown charts illustrating their cotinine levels, with 10 levels ranging from “very dangerous” to “fantastic.” When kids successfully met their goals for reducing their cotinine levels, they received positive reinforcement consisting of points and small prizes. Reduced cotinine levels signaled that the child was successfully implementing behaviors to avoid SHSe.

Over the course of the intervention, the coaching group showed a significant decrease — more than twofold — in both urine cotinine concentration and reported cigarette exposure compared with a control group.

While these results showed promise, Hovell suggested that continued, reliable social reinforcement was necessary in order for the intervention to be truly effective. This reinforcement might be accomplished, he said, by including antitobacco counseling as a standard part of health care visits. Parents and children would receive at least some counseling when they visited doctors, dentists, and other health care workers.

Ideally, this counseling would allow parents and children revisiting the same health facilities year after year the opportunity for built-in, reinforcing feedback on their progress. Real-time feedback also might be a means of sustaining change in smoking practices and protecting children from SHSe.

Real-Time Feedback

Until now, it may have been too difficult and expensive to provide children and families with the long-term counseling or coaching that could truly help them eliminate tobacco from their homes. However, an interdisciplinary research team is working with Hovell to use cutting-edge technology to provide an option for long-term interventions. The approach is based on the hypothesis that people may be more likely to stop smoking in their homes when given immediate feedback on how tobacco smoke soils the air their families breathe.

Combining behavioral science with environmental engineering, Hovell worked with San Diego State University adjunct professor Neil E. Klepeis to pilot test a new technique using real-time data. Based on a small pilot study published in the journal PLOS ONE, the team found that providing people with live information about the air quality in their homes could be a game changer in reducing exposure to SHS.

Hovell is now the principal investigator for an NIH randomized trial stemming from the pilot study. “We’re looking to see if we can get people to smoke only outside the home. The way we do that is by putting two monitors in the home that collect this real-time data,” explained Hovell. “One is in the child’s room, and one is in an area with a lot of smoking, usually the living room. What we see is when somebody lights up in the family room, within a few seconds the monitor in the child’s room is registering smoke even though it’s invisible by the time it reaches the child.”

For the pilot study, the team modified commercially available air-quality monitors to include a “behavioral module” that provides feedback (lights and sounds) in real time as a smoker lights a cigarette in the home. When concentrations of particles in the air hit dangerous levels, the portable air-quality monitor triggers warning signals nearly instantaneously.

As particles from the tobacco smoke reach dangerous levels, the system emits a beeping sound to alert individuals. An LED light also helps provide live feedback about particles in the air via a traffic-light-style display system: green when particle thresholds are at a healthy low level, flashing yellow as healthy levels are first exceeded, and a large red “X” pattern when a second threshold is exceeded.

This direct feedback can help people identify the best strategies for preventing SHS in their homes. For example, someone may think that smoking in the bedroom with the door closed is preventing smoke from entering the rest of the house. But the real-time feedback system can instantly show whether tobacco smoke particles are actually infiltrating another room. Feedback about these dynamics teaches parents that smoking anywhere in the home will expose their children to SHS and its toxic constituents.

Additionally, a small laptop computer collects the real-time data and relays it to the research office as it is collected. This information allows researchers to check and fix equipment when there are problems, and it allows intervention specialists to contact the family when especially high levels of smoke are apparent in the child’s room.

Another advantage of this type of portable feedback system is its suitability for diverse homes and situations. The makeups of families participating in the pilot research widely differed, ranging from a one-smoker family already interested in reducing SHS to a two-smoker family in which one smoker fully intended to continue smoking as usual. The families lived in homes with different layouts that required individualized strategies for mitigating smoking without intensive behavioral interventions from a coach or counselor.

Providing families with nearly instantaneous feedback may help them better recognize and adapt their behaviors to minimize child SHSe. The study is still ongoing, but of the three families that piloted the system, two showed signs of changing their smoking behavior by opening windows or doors, smoking outdoors, or smoking less as a result of the intervention, resulting in decreases in SHS levels in their homes. With the expanded study, Hovell expects similar results.

Hovell is also looking at the effects of adding a positive-reinforcement condition in the form of a financial incentive as part of the expanded trial. “We will be testing a positive-reinforcement version where we add to the original lights and sound a blue-light condition which will signal the period between smoking events,” Hovell says. “The longer that period between smoking events takes place, the longer the blue light stays on and the more that families earn.”

The 50th anniversary US surgeon general’s report on tobacco notes the tremendous changes in the perception of smoking that have been accomplished over the past 50 years: “Americans’ collective view of smoking has been transformed from an accepted national pastime to a discouraged threat to individual and public health.”

By using science-based interventions to decrease the number of smokers worldwide, behavioral researchers are making dramatic improvements in public health across the globe.

“There were few psychologists in public health when I started the behavioral science public health program at San Diego State in 1982,” says Hovell, “and now we have deans and many faculty around the country. All schools of public health now require behavioral science specialists, and this has led to many more psychologists joining the ranks of schools of public health as leading faculty.” Hovell believes that the addition of psychologists to public health fields will enrich the behavioral and social sciences and allow psychologists an opportunity to extend interventions typically designed to impact individuals or small groups to large groups and whole populations.


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Hovell, M. F., & Hughes, S. C. (2009). The behavioral ecology of secondhand smoke exposure: A pathway to complete tobacco control. Nicotine & Tobacco Research, 11(11), 1254–1264. doi: 10.1093/ntr/ntp133

Hovell, M. F., Wahlgren, D. R., Liles, S., Jones, J. A., Hughes, S. C., Matt, G. E., … Ding, D. (2011). Providing coaching and cotinine results to preteens to reduce their secondhand smoke exposure. Chest, 140(3), 681–689. doi: 10.1378/chest.10-2609

Klepeis, N. E., Hughes, S. C., Edwards, R. D., Allen, T., Johnson, M., Chowdhury, Z., … Hovell, M. F. (2013). Promoting smoke-free homes: A novel behavioral intervention using real-time audio-visual feedback on airborne particle levels. PLOS ONE, 8(8). doi: 10.1371/journal.pone.0073251

Rosen, L. J., Myers, V., Hovell, M. F., Zucker, D., & Noach, M. B. (2014). Meta-analysis of parental protection of children from tobacco smoke exposure. Pediatrics, 133(4), 698–714. doi: 10.1542/peds.2013-0958

Song, Y. J., Hofstetter, C. R., Hovell, M. F., Paik, H. Y., Park, H. R., Lee, J., & Irvin, V. (2004). Acculturation and health risk behaviors among Californians of Korean descent. Preventive Medicine, 39, 147–156. doi: 10.1016/j.ypmed.2004.01.013

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