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Creating smoke-free homes for children

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Discussing passive smoking with parents is not always easy. A tool has been developed to equip nurses with the knowledge and confidence to tackle the issue


This article describes a tool that was designed to help nurses deliver health education on the subject of passive smoking. The tool is based on a Scottish study, which encouraged mothers to identify their own strategies for reducing smoking in the home in order to protect their children from being exposed to second-hand smoke. It is designed to give nurses and other health professionals who work with families and children the knowledge, skills and confidence they need to raise the issue of second-hand smoke with parents and help them to find their own solutions to reducing smoking in the home. This article also takes into consideration the implications for nursing practice that relate to raising the issue of exposing children to second-hand smoke with parents and carers.

Citation: Shaw A et al (2013) Creating smoke-free homes for children. Nursing Times; 109: 10, 28-30.

Authors: April Shaw is senior researcher, Action on Health Scotland; Deborah Ritchie is senior lecturer in health promotion and mental health, School of Health in Social Science, University of Edinburgh; Rachel O’Donnell is policy and research manager, Action on Health Scotland; Amanda Amos is professor of health promotion, UK Centre for Tobacco Control Studies, Centre for Population Health Sciences, University of Edinburgh; Lynsey M Mills is research assistant; Sean E Semple is senior lecturer in environmental and occupational medicine; Stephen W Turner is clinical senior lecturer; Inga S Wilson is research fellow, all at Division of Applied Health Sciences, University of Aberdeen.


Reducing exposure to second-hand tobacco smoke (SHS, Box 1) is a major health priority for many countries and has led to widespread legislation regarding smoking in public places. Everyone involved in the welfare of children should understand the importance of protecting them from exposure to SHS in the home and in the car.

The home remains an important source of SHS exposure for many children and they are particularly vulnerable to the adverse health effects of it (Royal College of Physicians, 2010). Younger children, and infants in particular, have little control over their environment and are often unable to remove themselves from SHS exposure in the home (Ashley and Ferrence, 1998). Educating parents about the issue is a significant public-health challenge for nurses who work with families. Primary healthcare staff (such as practice nurses and health visitors) and specialist nurses (paediatric and respiratory nurses) are in a prime position to do this.

Children’s SHS exposure in the home has been linked to various childhood health problems (RCP, 2010). Children exposed to SHS have an increased risk of respiratory infections, wheeze, asthma, middle-ear disease and sudden infant death syndrome. Those living in disadvantaged areas have the highest levels of SHS exposure, reflecting higher parental smoking rates and fewer restrictions on smoking in the home (Akhtar et al, 2009). While parents wish to protect the health of their children, several qualitative studies have found that social, economic and environmental circumstances can make it difficult for them to reduce SHS exposure in the home (Graham, 2012; Phillips et al, 2007; Robinson and Kirkcaldy, 2007). Furthermore, children who grow up with parents and siblings who smoke around them are almost twice as likely as other children to become smokers themselves, thus perpetuating the association between smoking and health inequalities (RCP, 2010).

Encouraging parents and carers to adopt smoke-free policies in their homes is an important complement to general population strategies to protect the health of children. Nurses should consider the range of factors that may affect smoking restrictions in the home, such as lack of suitable outside space to smoke, leaving children unsupervised, negotiating smoking restrictions with other smokers and smoking as a way to cope with stress (Phillips et al, 2007). Nevertheless, nurses are in a unique position to help parents and can draw on their nursing experience with families to identify when parents are most likely to be ready to make the necessary changes to smoking behaviours in the home that will lead to positive health benefits for their children.

To date, interventions aimed at reducing SHS exposure have shown some level of effectiveness (Wilson et al, 2012; Baxter et al, 2011; Priest et al, 2008). Parents with a pre-existing concern over SHS exposure and child health may be more motivated to change their smoking practices within the home, even if they are unable to quit smoking (Baxter et al, 2011). Nurses are particularly well placed to identify children most vulnerable to the health risks of SHS exposure.

Raising the issue with parents

Many health professionals may not feel confident about raising the issue of SHS in the home, perhaps assuming it might damage their relationships with parents and carers. The Reducing Families’ Exposure to Second-hand Smoke in the Home (REFRESH) How to Guide - Creating a Smoke-free Home ( was developed to provide information on SHS that will enable nurses, health visitors and other health professionals to raise the issue with confidence and inform parents of the risks of SHS on their children’s health in a sympathetic and non-judgemental manner. The guide was developed from the learning of the REFRESH project, which used an innovative intervention that measured air quality in the homes of smoking mothers and gave them personal feedback alongside a motivational interview (Wilson et al, 2012).

The REFRESH project team’s survey of over 300 practitioners who worked with families and children (including over 170 nurses and health visitors) identified a need for standardised information on SHS and its effects on child health (Shaw et al, 2010). The How to Guide has drawn on the findings from the survey, as well as the experiences of the field researchers and mothers who took part in the study, and was developed with critical input from parents, healthcare staff, early-years workers and second-hand smoke coordinators.

This peer-developed resource offers advice to nurses and health professionals working with families and children on how to raise the issue of SHS in the home. It contains information on SHS and its health effects, hints and tips that nurses can pass on to parents about how to create a smoke-free home, and information on the benefits of reducing their smoking in the home.

The REFRESH flowchart (Fig 1) illustrates the four-stage process nurses can follow to raise the issue with parents:

  • Assess;
  • Ask;
  • Advise; and
  • Act.

The decisional balance exercise (Box 2) can be used to help parents identify their own solutions for reducing SHS exposure in the home. REFRESH participants found the exercise helpful for identifying current and future restrictions; it also encouraged discussion around the challenges and actions they could take to overcome these. An approach that is both empathetic and sympathetic, which acknoledges the difficulties parents might face may encourage them to discuss the barriers they have met and reveal some of the ways in which they overcame them.


Nurses have a pivotal role in promoting the health of children and families, particularly when the poor health consequences associated with exposure to SHS are so significant for children. We cannot assume parents who smoke are resistant to information on SHS exposure. In fact, when health professionals raise the issue of SHS in the home, it may be the first time a parent has been given information on its health effects or the way SHS particles can travel throughout a home. Access to this information may encourage parents to think differently about their smoking behaviours in their home in order to protect their children.

Professionals working with families and children may sometimes feel uncomfortable about raising the issue of creating a smoke-free home with parents or carers. Nevertheless their unique relationship with parents and their understanding of the social context of their lives mean nurses are in an ideal position to motivate and provide parents with appropriate information about the health benefits of smoke-free homes and cars. In addition, they can draw on their nursing experience to ascertain when parents are likely to be receptive to changing smoking behaviours in the home that will lead to positive health benefits for their children.

Implications for nursing practice

  • There are serious, preventable health risks from exposure to SHS, particularly for children. Nurses have a key role in reducing children’s SHS exposure to by helping parents create a smoke-free home.
  • Nurses need to recognise the social context of mothers’ lives so that they can identify and address some of the barriers to smoking cessation.
  • The decisional balance exercise helps parents to set goals for reducing their child’s exposure to smoke in the home.
  • The REFRESH How to Guide helps nurses to empower parents to make positive changes to smoking behaviours in their home.

Key points

  • Nurses have a key role in reducing children’s exposure to second-hand smoke (SHS) by helping parents create a smoke-free home
  • Nurses need to recognise the barriers that can prevent parents from stopping smoking around their children
  • The key to success lies in empowering parents to find their own solutions to the problem of SHS exposure
  • The decisional balance exercise helps people weigh up the pros and cons and come to a sensible decision
  • Nurses can draw on their experience to ascertain when parents are likely to be receptive to changing smoking behaviours in the home
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