This study was one of the first to qualitatively examine smoking practices in the home, perceived benefits of or motivators for establishing smoke-free homes, the process of establishing smoke-free home policies, and difficulties in enforcing or exceptions made in enforcing existing rules regarding smoking in the home in Shanghai, China. The most notable contributions to the literature were findings regarding how the rule was established; that is, what interpersonal processes occurred within household members leading to the adoption (or not the adoption) of smoke-free homes or smoking rules.
In regard to reasons for establishing a smoke-free home, the current findings are also consistent with prior research indicating that concern about the health impact of SHS was the most important reason for establishing a smoke-free home in Shanghai [10] and in other countries [13]. The other common reasons also resonate with prior quantitative findings indicating that child-related factors and cleanliness are important motivators [10,13]. In addition, there were mixed attitudes regarding the potential for promoting harm reduction or cessation as a result of implementing such a policy. Given some doubt among participants, this might be an important intervention message. In fact, studies have confirmed that a complete smoke-free home versus a home with some level of restrictions is more effective in increasing the likelihood of making quit attempts among the smokers [16]. Moreover, smokers who live in a smoke-free home have been shown to be more likely to have made a quitting attempt and maintain abstinence compared to smokers without a smoke-free home, indicating that smoke-free home policies act as a part of effective cessation support systems [16].
In terms of the interpersonal processes in the household resulting in the implementation of a smoke-free policy, women were seen as critical change agents. Despite prior research documenting that authoritative attitudes of husbands or father-in-laws were barriers to women influencing such policy adoption [9,11], the current study documented that women did have the authority to influence this matter, which was similarly found in research regarding the interpersonal processes that lead to the adoption of smoke-free homes in the U.S. [13]. Women in this study most commonly endorsed the idea and had the authority in many cases to make the decision to implement them. However, there were some situations where this was not the case and the discussion to implement a smoke-free policy was quite sensitive. Many participants who had a smoke-free policy had adopted it early on in their relationship. Thus, early relationship years or during the beginning of the marriage may be a critical intervention window for addressing smoke-free homes. This also coincides with an important opportunity prior to beginning the family in which men might be particularly invested in the health of their home and family. The one child family planning policy in China promotes the value and status of children at home, which is a good opportunity to advocate for having a smoke-free home policy in families with children. Moreover, studies suggested that the lack of smoke-free home policies, even in homes without smoking parents, may weaken communication of parental antismoking values, while implementing smoke-free homes (despite the smoking status of the parents) might dissuade youth smoking [17]. This is in line with other research documenting the importance of parental attitudes toward smoking rather than their actual smoking behavior in terms of the impact on youth smoking initiation [18]. Furthermore, studies have confirmed that a complete smoke-free home versus a home with some level of restrictions is more effective in reducing the likelihood of adolescents smoking [16]. These findings and prior research might help address the interpersonal issues related to persuading smokers to commit to a smoke-free policy rather than ignore the request or lapse into smoking in the home after agreeing to the policy, which were prominent themes of husbands’ reactions to the policy in the current study and in prior research [13].
Our findings indicated several issues with enforcement. In terms of where smoking was most commonly allowed, our findings were similar to prior quantitative findings indicating that, among participants with no or partial smoke-free policies, the most common places where smoking was allowed included the living room, kitchen, and bathroom [10]. Moreover, there were enforcement challenges in terms of several harm reduction behaviors, such as smoking near windows or by fans in order to reduce the impact of SHS exposure. Prior research has also found that the misconception regarding these harm reduction behaviors is prevalent in China [19]. Guests visiting, social gatherings, and family relationships also were reported as particular challenges in enforcement, which is highly related to the cultural context of smoking in China. That is, prior research has highlighted the identification of smoking as a symbol of personal freedom, the importance of tobacco in social and cultural interactions, and the importance of tobacco to the economy in China [19].
It was also interesting to note that, as children aged, some smokers were less vigilant about protecting them from SHS. In fact, prior research has found that having children under 18 years old was not associated with having a complete smoke-free home policy, which is consistent with other studies [10,16,17]. People tend to believe that older children may not be sensitive to SHS. Educational outreach should grasp these opportunities and focus on the information that SHS is dangerous to all nonsmokers of all ages, including older children and adolescents.
Finally, the impact of addiction on the feasibility of establishing and enforcing a smoke-free home policy in this context was important to note. The wave 3 International Tobacco Control survey in China conducted in 2009 found that 96% of adult smokers were daily smokers, and adult male daily smokers in China smoked an average of 17 cigarettes per day [20]. Thus, implementing a smoke-free home policy in this context might be challenging, particularly if homes do not have highly accessible outdoor areas where smokers can go to smoke.
This study has important implications for research and practice. Research is needed to refine measures regarding interpersonal interactions that facilitate or impede the adoption of smoke-free home policies. Moreover, intervention strategies targeting the motivators for implementing smoke-free policies to promote their adoption (e.g., health of family and children) and targeting the challenges in adopting and enforcing them (e.g., weather, concerns during social gatherings, less concern about the impact of SHS on older children) should be developed and tested to identify ways to reduce SHS exposure among youth in China. In particular, it may be beneficial to address the interpersonal processes to aid women and children in their communication with smokers in the home regarding SHS exposure and smoke-free homes in order to maximize the effectiveness of these opportunities. In practice, clinicians should promote smoke-free homes in the practice setting, particularly among youth who have specific vulnerabilities that could be exacerbated by SHS such as asthma. The school setting may also be a place where children can be educated about the harms of SHS exposure and may be empowered as change agents in their home. As in other countries, prevalence of smoke-free homes is also likely to rise as smoke-free public places become more common [21].
Limitations
This study has some limitations. First, this was a qualitative study of 30 male smokers and female nonsmokers with young children in Shanghai, China. Thus, findings from this small sample may not generalize to other adults in Shanghai or China more broadly. In addition, the interviews may not have yielded exhaustive information regarding the constructs and processes investigated; thus, additional qualitative and quantitative research is need to confirm and elaborate on these findings.