BMJ  2007;335:553 (15 September), doi:10.1136/bmj.39301.497593.55 (published 9 September 2007)

Research

Smoking in the home after the smoke-free legislation in Scotland: qualitative study

¹ Public Health Sciences, Division of Community Health Sciences, University of Edinburgh, Medical School, Edinburgh EH8 9AG , ² Nursing Studies, School of Health in Social Science, University of Edinburgh, Medical School, ³ Scottish Centre for Social Research, Edinburgh EH3 9AW

Abstract

Objective To explore the accounts of smokers and non-smokers (who live with smokers) of smoking in their homes and cars after the Scottish smoke-free legislation; to examine the reported impact of the legislation on smoking in the home; and to consider the implications for future initiatives aimed at reducing children's exposure to secondhand smoke in the home.

Design and setting A qualitative cross sectional study involving semistructured interviews conducted across Scotland shortly after the implementation of the legislation on 26 March 2006.

Participants A purposively selected sample of 50 adults (aged 18-75) drawn from all socioeconomic groups, included smokers living with smokers, smokers living with non-smokers, and non-smokers living with smokers.

Results Passive smoking was a well recognised term. Respondents had varied understandings of the risks of secondhand smoke, with a few rejecting evidence of such risks. Children, however, were perceived as vulnerable. Most reported that they restricted smoking in their homes, with a range of restrictions across social classes and home smoking profiles. Spatial, relational, health, and aesthetic factors influenced the development of restrictions. Children and grandchildren were important considerations in the development and modification of restrictions. Other strategies were also used to militate against secondhand smoke, such as opening windows. The meaning of the home as somewhere private and social identity were important underlying factors. Respondents reported greater restrictions on smoking in their cars. There were diverse views on the smoke-free legislation. Few thought it had influenced their smoking in the home, and none thought it had affected how they restricted smoking in their homes.

Conclusions These data suggest two normative discourses around smoking in the home. The first relates to acceptable social identity as a hospitable person who is not anti-smoker. The second relates to moral identity as a caring parent or grandparent. Awareness of the risks of secondhand smoke, despite ambivalence about health messages and the fluidity of smoking restrictions, provides clear opportunities for public health initiatives to support people attain smoke-free homes.

Introduction

Exposure to secondhand smoke is an important cause of premature mortality and morbidity,^{1 2 3} and children are more vulnerable than adults to the effects on health.^{3 4 5 6} They may have little control over their environment and exposure to secondhand smoke. In 2003, over 80% of children aged 8-15 years in Scotland reported being exposed to secondhand smoke, most commonly in their own homes.⁷ Around 40% lived in a home with at least one smoker, and this was highest among low income households. While the proportion of homes in Scotland with smoking restrictions has increased over recent years,⁷ the 2005 health education population survey found that that less than half (42%) had total smoking bans,⁸ though considerably more (75%) did not allow smoking in the car (S Haw, personal communication, 2007).

Reducing children's exposure to secondhand smoke in the home is an important public health issue, which could also contribute to reducing inequalities in health. Interventions have involved media campaigns or brief, usually single, counselling sessions with parents and have had little success.^{9 10} This is perhaps not surprising as we know little about why people do or do not restrict smoking in their homes and the enablers and barriers to reducing children's exposure in the home.⁴ While household restrictions are associated with the presence of children, especially young children, and non-smokers in the home,¹¹ the internal family processes that facilitate or hinder the adoption and enforcement of smoking restrictions in the home remain unknown.^{9 12} We know even less about influences on smoking restrictions in cars.^{4 13}

There has been little qualitative research on this issue, but two studies involving disadvantaged parents in Liverpool and Australia have generated insights about the range of social, physical, and economic factors that parents perceive as barriers to reducing their children's exposure to secondhand smoke in the home.^{14 15 16} These include difficulties associated with the supervision of children, lack of appropriate space to smoke outside the home, a desire to smoke in comfort or privacy, concerns about the negative reactions of family and friends, and the lack of support from partners and friends. In addition the Liverpool study found that while mothers thought that babies should not be exposed to secondhand smoke and reported strategies to deal with this, few had continued these into infancy.^{15 16} Also, knowledge about passive smoking was limited with several participants unconvinced about the links with childhood illnesses including asthma. These two studies were somewhat limited in that they involved only disadvantaged smokers who had preschool children^{15 16} and who wanted to increase home restrictions and lived in high rise accommodation.¹⁴ We need to extend research to include smokers and non-smokers who live with smokers across all socioeconomic groups. We also need to explore whether national tobacco control policies, notably smoke-free legislation, impact on attitudes and behaviours around smoking in the home.

The introduction of the comprehensive legislation on smoke-free public places in Scotland in March 2006¹⁷ provided a unique opportunity to explore the social meaning of restrictions in the home, in particular the different understandings informing these restrictions and the impact of the legislation on people's attitudes and behaviours around smoking in the home. The legislation was expected to reduce children's exposure to secondhand smoke in public places.¹⁸ However, it was not known whether this would also affect their exposure in the home, though research on the impact of such legislation in California, Australia, and Ireland found associated increases in restrictions in homes.^{11 19 20 21}

We carried out a qualitative study in Scotland conducted shortly after the introduction of the legislation. We explored the accounts of smokers and non-smokers (who live with smokers) of the strategies that they use to regulate smoking in their homes and cars after the implementation of the legislation; examined the reported impact of the legislation on smoking in the home to identify potential enablers and barriers to reducing exposure in the home; and considered the implications for future initiatives aimed at reducing children's exposure to secondhand smoke in the home.

Methods

Study design and participants
We carried out qualitative semistructured interviews with 50 smokers and non-smokers who lived with smokers across Scotland. Respondents were purposively recruited from Wave 10 (September-November 2005) of the health education population survey.¹⁸ To examine the diversity of smoking patterns in households and contrasting social positions, we sampled on three characteristics: composition of smokers in the household, socioeconomic group (AB (professional, managerial and technical), C (skilled non-manual and manual), D (partly skilled and unskilled)), and sex. We aimed to recruit equal numbers of men and women across all three socioeconomic groups, though weighted for those in socioeconomic group D, with similar numbers from three household configurations: smokers living alone or with other smoker(s), smokers living with any non-smoker, and non-smokers living with any smoker (table).

View this table: [in this window] [in a new window]   Details of participants interviewed about smoking in their homes

 
Respondents who had indicated that they were interested in participating in future research received a letter about the study from the British Marketing Research Bureau, which conducted the health education population survey, and were given the opportunity to opt out. The bureau then passed details of the remaining respondents to the research team. We invited 106 people to take part in the study by letter, with an information sheet and opt-out form. Thirty declined, 11 were ineligible because of changed personal circumstances (such as no longer living in Scotland), 10 could not be contacted by telephone, and one did not attend the interview. Fifty from the 54 remaining were interviewed, with four discounted when the target sample size was achieved. Respondents were informed that they could withdraw from the study at any stage, and confidentiality and anonymity were assured. Written informed consent was obtained from each respondent at the start of interview.

Interviews
The interviews were conducted between June and September 2006 in respondents' homes and lasted 40-90 minutes. After piloting, we developed interview topic guides for the three types of participant: smoker living alone or with another smoker, smoker living with a non-smoker, and non-smoker living with a smoker. Respondents used a day grid to describe a typical day in relation to smoking or exposure to smoke. The day grid was an adapted version of the "life grid," which has been used in previous qualitative research to collect contextualised smoking data from interviewees.^{22 23} Smokers identified times and places when they smoked. Non-smokers identified when and where they were exposed to smoke, with further contextual information obtained through probing. All respondents were asked to describe any smoking restrictions in their home or car, how they had developed and were maintained, and what might lead to breaches. Respondents were then asked what they understood by passive smoking and whether they thought any people were more at risk. The end of the interview focused on respondents' views about and experiences of the smoke-free legislation and whether this had affected smoking in their home or their social life. Finally, respondents were shown a standard "no smoking" sign and materials from the Glasgow "breathe easy" smoke-free homes initiative and asked for their views about displaying such materials in their home or car.

Analysis
We fully transcribed the tape recorded interviews and analysed transcripts thematically, moving from initial descriptive codes to more conceptual analytical coding. All the authors were involved in the analysis, with at least two reading each transcript and agreeing on coding categories and themes. A modified grounded theory approach was taken whereby themes were revised iteratively as the fieldwork and analysis progressed.²⁴ The analytical procedure was supported by the use of NVivo to aid data retrieval and close analysis. Comparisons were made across interviews and within themes to explore analytical categories rigorously.

Results

Knowledge and understanding of risks of secondhand smoke
Passive smoking was a well recognised term, though respondents' understanding of and views about the health risks varied. Most (36) indicated that they believed that exposure to secondhand smoke represented some form of risk. While some accounts included knowledge about specific health effects, others were less certain. A smaller group of respondents (eight), all smokers, were more ambivalent about whether secondhand smoke was generally a health risk, yet reported a reluctance to expose children or grandchildren to secondhand smoke. A few respondents (six), all but one of whom were smokers, stated firmly that they did not believe that passive smoking was a health risk (box 1). Smokers who lived only with smokers or on their own were less likely than other respondents to believe that secondhand smoke was a health risk. There was no apparent difference in acceptance of risk by socioeconomic group.

Box 1 Knowledge and understandings of risks of secondhand smoke "I think passive smoking is quite dangerous, I do. People say, I have read it, it is actually more dangerous than a smoker, like getting passive smoking, because it is no good for you. It is obviously going into your lungs as well" 19 year old woman, former smoker (socioeconomic group D) Interviewer: "Do you think passive smoking affects other people?" Respondent: "Most probably, yes." Interviewer: "Could you say why?" Respondent: "No, I just think it must probably, but I couldn't say how" 40 year old woman, smoker (D) "My wife has been in, that is since she was 15, she has been [smoked] in front of and I don't see any problems . . . I don't know whether it is bad for the [grand]child, but I am not going to take the chance" 47 year old man, smoker (D) "Well they say it does, but I don't believe that is true. It is just one of these things I don't believe, they say people die from passive smoking, I don't accept it" 69 year old man, former smoker (C) "I couldn't put an age on it because I don't think they should, even if they are older it has a less effect, then it is bad for them to see other people doing it because it means they want to do it themselves or they might want to try it" 49 year old woman, non-smoker (C)

Respondents drew on personal experiences around the visible effects of secondhand smoke on themselves and others, their knowledge about the health effects of active smoking and external sources of information including recent media campaigns on secondhand smoke, other media coverage, and health professionals' advice in assessing the health risks. Many thought that children were particularly at risk because they were still developing and had smaller lungs. Children with respiratory diseases, notably asthma, were viewed by some as being even more at risk. There were diverse views concerning when "vulnerable" children became less vulnerable or invulnerable older children or adults (see box 1). As the quotes illustrate, the respondents often used probabilistic language when discussing risk. In contrast, some smokers who did not think that passive smoking was a health risk thought that it was the responsibility of non-smokers to choose whether they were exposed to secondhand smoke.

Restrictions in the home
Patterns of restrictions
There was a range of restrictions across all the household smoking profiles and socioeconomic groups. These restrictions were primarily spatial in nature—that is, respondents described specific rooms or locations inside or outside the home where smoking was or was not permitted. There were four different styles of restriction: a total ban inside the home (n=9); smoking allowed in one specific room or at an outside door (n=10); smoking allowed in several rooms (n=25); no restrictions (n=6) (box 2). Smokers who lived only with smokers or on their own were more likely to report having no restrictions, and respondents from socioeconomic group D were least likely to have a total ban. In homes with partial restrictions there were differences in the types of rooms where smoking was or was not permitted. Bedrooms were mostly viewed as no smoking areas, with the kitchen also viewed by some, but not all, as inappropriate to smoke in. Children's bedrooms were generally considered out of bounds, although bedrooms of adult smokers' were not always restricted.

Box 2 Patterns of home restrictions "I wouldn't even think about having a fag in the house, [name of daughter] comes first in that respect" 27 year old woman, smoker (D) "There is a back door, there is a garden, this is where [kitchen] we should smoke and we don't allow [smoking] anywhere else in the house" 40 year old woman, smoker (AB) Interviewer: "Is there anywhere that you wouldn't smoke?" Respondent: "Shower [laughs]" 46 year old man, smoker (D) "If we have got people here who don't smoke, we will be less inclined to smoke, certainly smoke less or maybe not at all" 59 year old man, smoker (AB) "Sometimes if somebody else was smoking in here [living room], it is not fair for him [son] and he will say, ‘Can I smoke?' . . . But he usually goes outside, he sometimes gets a treat when [my friend] is in, that is the only time he gets a treat" 54 year old woman, non-smoker (C)

Most respondents reported that they were concerned with the smell of tobacco smoke in their home and described actions to reduce or manage smoke or exposure in their homes. These included opening windows, lighting candles, using air fresheners, opening or closing doors, restricting where they smoked in a room, and smoking only after the children had gone to bed.

Although these general patterns provide an overall sense of the type of restrictions, if any, imposed within the home, the richer contextual data gathered in the interviews suggested some flexibility in the management of such limits. All respondents with partial or no restrictions described how they would temporarily modify these in particular circumstances. For example, partial restrictions would become stricter in the presence of children and grandchildren. Some also spoke of restrictions changing if adult visitors were non-smokers (restrictions stricter) or smokers (restrictions relaxed) (see box 2). In addition, respondents reported that during occasional social events, such as a party, smoking restrictions might be relaxed.

How and why restrictions were developed
Respondents often had more than one reason for having restrictions on smoking, including aesthetic and health reasons. Aesthetic concerns were mostly about the smell of smoke but also about smoke staining decor and impregnating upholstery. Moving house or decorating a room had triggered some to increase restrictions (box 3). Health reasons related mainly to concerns about not exposing children and grandchildren and, in a few cases, adult non-smokers to the health risks of smoke. Respondents also expressed concern about smoking in front of children, thus acting as a role model. Children were seen as being dually vulnerable—to the health risks of secondhand smoke and of becoming future smokers (box 3). The birth of a baby or grandchild was mentioned by several as having trigged or tightened restrictions. Some also talked about pressure from children not to smoke, or from other family members not to smoke in front of their children and an increasing awareness of the health effects of secondhand smoke. For example, several grandparents talked about how they had become increasingly aware of the risks compared with when they brought up their own children. Other less common health reasons included concerns around hygiene (such as not smoking while preparing food) and safety. Others talked about how respecting others' views, particularly family and friends, affected when and where they did or did not restrict smoking. New relationships and break-ups could also generate change, depending on the smoking status and views of the new or former partner. A few respondents found it difficult to give reasons for their restrictions as they had become taken for granted in their daily lives.

Box 3 How and why restrictions were developed "Although I smoke, I am really against the smell of smoke in a house. I feel it attaches itself easily to soft furnishings" 40 year old woman, smoker (AB) Respondent: "To smoke in front of young children nowadays? No, I would not advise it because they pick it up, the smoking, the habit, they see you doing it." Interviewer: "Are there any other reasons why you don't smoke in certain rooms?" Respondent: "No, just because of that, I respect her [wife who had quit smoking]" 55 year old man, smoker (C) "My daughter spoke about ‘We are starting a family,' and I said, ‘Well for a better environment for them,' I says, ‘Right, we will try and enforce this and we will try and go outside,' and we have stuck to it" 50 year old man, smoker (D) "We know now, my mother didn't know, but we know now that it is not good for kids to be in a smoky environment, so I just don't bother doing it" 60 year old woman, smoker (D)

Most respondents presented these changes as being unproblematic, with little tension or conflict over decision making. Indeed, even when talking about being pressured by their children, this was seen as legitimate behaviour that they had to take seriously and respond to appropriately. No respondents reported that the smoke-free legislation had had an affect on their restrictions in the home.

Meaning of the home and smoker identity
From discussions about the reasons for restrictions, respondents' reactions to "no smoking" materials, and the smoke-free legislation, two factors emerged as important in how such restrictions were managed or moderated. These related to the meaning of the home and social identity. The home was seen as being a private space, a place of relaxation and comfort, in contrast with workplaces and other public places. This seemed to bring with it notions of choice about when and where they smoked in the home and about how others should respect their views, just as they respected other people's views about what happened in their homes. This discourse of privacy and individual choice associated with behaviour in one's own home also had a social dimension in that smokers and some former smokers expressed concern about how they would be perceived by family and friends if they further restricted smoking. Concerns pivoted around being regarded as being anti-smoker (rather than anti-secondhand smoke), unfriendly, inhospitable, inconsiderate, and hypocritical, particularly if they smoked. The smoke-free legislation was not presented as having moderated these concerns.

Most smokers were not positive about putting up "no smoking" materials in their homes. Some expressed no need as they said visitors knew whether they could smoke or not and they preferred to talk about such restrictions rather than put up signs, which were usually perceived as inappropriate for the home setting. Some, however, thought that they might be valued by children in trying to persuade their parents to stop smoking. Non-smokers were generally more positive about displaying such materials. Some had already displayed them in their home or had seen them in other homes (box 4).

Box 4 The meaning of the home "I don't think I would like to have them [materials] in my house. It starts to look like, not a house, and looks like a public area . . . If I went to a non-smoker's house and they didn't like me smoking in the house that would be fine, I would go for five minutes and leave. That's their prerogative, it is their space, they can do whatever they like in it and I would never invade that. If I seen them [materials], I would probably would be ‘I get the picture, you don't want me here,' so I would bale out" 47 year old man, smoker (D) Interviewer: "What would you feel about having materials like this in your home?" Respondent: "Kids' bedrooms, yeah, no problem, but that would be it, sorry [laughs]." Interviewer: "Why is that?" Respondent: "Because I smoke, and this is the only place that I can actually smoke in peace without being told where to go, where not to go. So the kids' bedrooms, not a problem, the sitting room, no, the kitchen, no" 42 year old woman, smoker (C)

Beyond the home: smoking restrictions in cars
Forty respondents had access to a car, with those in socioeconomic group D having least access. More respondents, including smokers, reported that they had total (n=16) or partial (n=19) restrictions on smoking in their car. In addition, several said that partial restrictions could increase in the presence of children and non-smoking adults. No respondents in socioeconomic group D reported having total restrictions. The reasons for restrictions were similar to those in the home, with concerns around exposing children to secondhand smoke and aesthetic reasons (such as smell, burning upholstery). In addition, some respondents highlighted concerns about the impact of a more confined space. A few respondents did not smoke or allow smoking when driving as they found it distracting. Two respondents reported that their vehicles had become smoke-free after the legislation as they also used them for work. Smoking restrictions in the car seemed to be more robust than in the home, suggesting that the car occupies an intermediary position between public and private space; its confined nature also seemed to encourage stronger rules (box 5).

Box 5 Smoking restrictions in the car "In the car it is more confined, if you are having your cigarette, then you're re-inhaling your smoke . . . We have a lot of friends and of course the kids come and we take them places and I really would not want them putting in a car filled with stale cigarette smoke. So if you like, it is more for other people than for us" 44 year old woman, smoker (C) "I think it's a control thing, I don't like other people smoking and smoke goes into my face whilst I am driving. It was years ago, I had got a brand new car, when I was in the army, someone smoked and put a burn mark in my chair and that was it and I thought, ‘No, enough is enough' " 30 year old man, smoker (C) "I can't smoke and drive anyway, I need both hands" 42 year old woman, smoker (C)

Impact of the smoke-free legislation
Respondents expressed various views about the smoke-free legislation, mostly positive. As might be expected nearly all non-smokers were pleased with the legislation. Many smokers, however, were also enthusiastic, particularly those from socioeconomic group D (box 6). While most respondents highlighted positive effects (such as less smoky pubs, fewer children becoming future smokers, improving Scotland's health), some were more ambivalent, with a few (all smokers) totally against the legislation. Negative views related primarily to the way the legislation had happened (such as inadequate opportunities for consultation) and thinking that the legislation had gone too far (such as breaching civil liberties, the "nanny" state). Several smokers thought that pubs should be either smoking or non-smoking to give choice over which type of premises people visited (box 6).

Box 6 Impact of the smoke-free legislation "I love it really, because in work I would be so among smoke, it was unbelievable, even when I was having my dinner and that" 23 year old woman, non-smoker (C) "To start with, I thought it was out of order, like the smoking ban. But see now, I think it's the best thing they could have done really. It is, because I've noticed a big difference when I've been in a pub and all that" 23 year old woman, smoker (D) "You can't enjoy a cigarette when you are out socialising, you can't stand in a bus shelter and have a cigarette when you are waiting for a bus, you can't smoke at an airport, I mean it is ridiculous. If there was a referendum, ask us what we wanted, but don't tell us" 41 year old woman, smoker (C) "It should have come in years ago, maybe if this law had come in years ago there would be a lot less smokers than now, and I mean from the younger kids that are smoking now" 38 year old man, smoker (C) "Probably no. Probably, I just smoke the way I've always smoked" 42 year woman, smoker (D) "There hasn't been any difference whatsoever in terms of my habits and the exposure" 36 year woman, non-smoker (AB) "I don't smoke as much in the pub now, so yes, I probably do smoke a bit more in the house" 39 year old man, smoker (D)

Most smokers thought that there had been little or no change in their level of smoking in the home since the legislation. The legislation had had little impact because their workplaces were already smoke-free, they did not go out much socially, or reductions in smoking had been easily accommodated. Several spoke about increased feelings of stigma when smoking in public and therefore the increased importance of being able to smoke in private, in one's home, away from the public gaze. None of the non-smokers reported that their exposure to secondhand smoke in the home had increased. A few smokers expressed some sense that they had increased their smoking in the home or car, but this was mostly phrased in uncertain terms with words such as maybe or probably. They were also unsure about the level of any increase (see box 6).

Discussion

Growing awareness about the health risks of secondhand smoke combined with more established concerns about minimising the negative aesthetic aspects of smoking, notably the smell, have led to increasing restrictions on smoking in homes and cars.³ We found that the strategies that people report they use to regulate smoking in their homes and cars are more complex and fluid than might be suggested by national survey data. Although all respondents said that they restricted smoking in their home at some time, many described how spatial restrictions on smoking, where smoking was limited to certain rooms or locations, were temporarily modified in some circumstances.

Respondents' accounts seemed to be underpinned by normative discourses of acceptable moral and social identities. An acceptable social identity pivoted around being seen to be a "considerate" smoker or non-smoker^{12 25} who would appropriately modify their behaviour or restrictions for family and friends or on certain special occasions. This also related to concerns about being seen as friendly, hospitable, and not "anti-smoker." Moral identities were constructed around being a caring parent, grandparent, or adult.¹⁶ The presence of children, including grandchildren (many grandparents provided child care), was cited as the main reason for both total bans and temporarily increasing restrictions. Similarly, the presence of children or non-smokers was given as a reason by many smokers for not smoking in their car. In addition to concerns about reducing children's exposure to the possible health risks of secondhand smoke were considerations about the future consequences of children seeing adultssmoke. The desire to be seen to act in socially and morally acceptable ways, however, seemed to be tempered by, and at times conflicted with, other imperatives and needs. These included the need to smoke, the desire to smoke in comfort and private (particularly given the recent legislation on smoking in public places), understandings of the risks of secondhand smoke, and social norms, particularly the perceived expectations and smoking behaviour of family and friends.

Given the enormous amount of media coverage leading up to the smoke-free legislation, which included major advertising campaigns by the Scottish Executive and substantial free media coverage,²⁶ we thought that people would have been more knowledgeable about the risks of secondhand smoke. While some respondents were convinced that secondhand smoke was a health risk, particularly for children, others were much less certain, and some indicated a level of resistance to such messages. This is perhaps not surprising given that evidence and education about the health risks of secondhand smoke is relatively recent compared with that on active smoking. Indeed several older respondents referred to how they had unknowingly exposed their children to secondhand smoke several decades previously. It is also perhaps not surprising that some smokers might resist or contest messages that could have consequences for their smoking, home lives, and routines. This may be a particularly important coping strategy where smokers feel unable to reduce children's exposure in the home, for example, disadvantaged mothers caring for toddlers in restricted circumstances.¹⁵ Ambivalence about health messages needs also to be understood as a more general phenomenon, relating less to ignorance of health risks but more to a generalised distrust of scientific knowledge and resistance to externally imposed restraints on individual behaviours.

Strengths and limitations
One strength of our study was the diverse range of respondents in terms of age, socioeconomic group, location, and household smoking profile. This meant that it was not possible to explore in depth the views and experiences of certain groups who may face particular challenges around addressing secondhand smoke in the home,¹⁶ those living in homes where space is restricted or lack outside space,¹⁴ or those with different ethnic and cultural understandings around smoking and secondhand smoke.²⁷ Another limitation was the retrospective nature of the study, which may have made it difficult for respondents to assess the impact of the legislation on their knowledge, attitudes, and behaviour. It may also be that such changes take longer to occur than the period covered in this study.

Implications
Reducing secondhand smoke in the home and car requires a coordinated approach involving national and local action aimed at reducing smoking among adults and protecting children and non-smokers from secondhand smoke in smoking homes.^{6 28} Evidence from other countries indicates that comprehensive smoke-free legislation can contribute to achieving these aims.^{3 21 29} Our findings indicate that smoking restrictions in the home are shaped by a range of sociocultural influences and other factors that create opportunities and challenges, enablers, and barriers for future public health initiatives on this issue (box 7). Such initiatives could include media campaigns and tailored advice and support for individuals, particularly parents, grandparents, and other carers, from health and other professionals on how to develop more effective smoke-free strategies in the home and car.⁶

Box 7 Enablers and barriers to creating smoke-free homes Enablers include: The increasing level of restrictions and the reported modification of partial or no restrictions in some circumstances The higher level of restrictions in cars Increasing awareness of the risks of secondhand smoke, particularly in relation to children Concerns about children and grandchildren not becoming smokers Desire to be seen as behaving in morally and socially acceptable ways Other attempts, both aesthetic and health related, to moderate or remove the perceived negative aspects of smoke in the home Social norms about the unacceptability of smoking in the home among family and friends, including pressure from children Barriers include: Limited understanding of and resistance to messages about the health risks of secondhand smoke Beliefs about the effectiveness of ways of removing or managing secondhand smoke in the home The need to smoke and smoker identity The home (and car) perceived as a private space, protected from public controls and sanctions Social norms among family and friends about the acceptability of smoking in the home

What is already known on this topic Exposure to secondhand smoke is an important cause of morbidity in children, and the main source of exposure is in the home Little is known about why people do or do not restrict smoking in their homes and the enablers and barriers to reducing children's exposure in the home What this study adds Most people restrict smoking in their home but the extent and likely effectiveness vary. Spatial, health, relational, and aesthetic factors are influential and protection of children and grandchildren is a priority There were diverse views about the smoke-free legislation; few thought it had influenced their smoking in the home Awareness of the risks of secondhand smoke, despite ambivalence about health messages and the fluidity of smoking restrictions, provides opportunities for public health initiatives to support people to achieve smoke-free homes

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We thank Irene Miller and Fiona Rait, who undertook some of the interviews; Agnes McGowan, who provided "breathe easy" materials; and Sally Haw for advice and support. We also thank all the respondents for giving their time to this study.

Contributors: AA, SC-B, CM, and DR designed the study. AA wrote the first draft of the paper and is guarantor. RP undertook most of the interviews. All authors were involved in the data analysis and contributed to the paper.

Funding: NHS Health Scotland and the Scottish Executive. The views expressed in this paper are those of the authors and not necessarily those of the funders.

Competing interests: None declared.

Ethical approval: The study complied with the code of practice on ethical standards for social research involving human respondents operating in public health sciences at Edinburgh University.

Provenance and peer review: Non-commissioned; peer reviewed.

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(Accepted 31 July 2007)

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