Children Learning About Second-hand Smoke: Cluster randomised-controlled trial

Lead Research Organisation: University of York
Department Name: Health Science

Abstract

Breathing in other people's exhaled smoke is called second-hand smoking. Second-hand smoke (SHS) contains harmful chemicals and is a serious health hazard to non-smokers. SHS is estimated to cost more than 800,000 lives per year, worldwide. Children are worst affected; almost a third of deaths from SHS exposure occur in children. A large proportion of the overall burden of diseases due to SHS in children is due to lung diseases such as asthma and chest infections and lung cancer. SHS exposure can also lead to meningitis in children. Children exposed to SHS are more likely to be hospitalised, fall short of their academic potential and take up smoking themselves as compared to those living in smoke-free environments. Recognising SHS as a public health threat, most countries have introduced bans on smoking in enclosed public spaces, which has significantly reduced adults' exposure to SHS. However, for many children, cars and homes remain the most likely places for them to breathe SHS. The only possible way to protect them from SHS is to make cars and homes completely smoke-free.

For the last few years, we have been working with schools, parents and children to develop and test a school-based intervention called, 'Smoke-Free Intervention (SFI). It consists of six teaching lessons delivered by schoolteachers, four fun activities and one educational take home resource. Teaching lessons help to increase pupils' knowledge about the harms caused by breathing second-hand smoke. Fun activities include storytelling, role-playing, quizzes and games. These activities help to motivate children to act and feel confident in talking to adults to persuade them not to smoke inside homes. The take-home resource helps children to show what they have learned in school and to negotiate with their families to "sign-up" to a voluntary contract to make their homes smoke-free. The results of this work show that it is possible to encourage children to discuss with their families ways of restricting smoking inside their homes. Our pilot study also showed that it is possible to recruit and retain schools and children and collect the necessary data for such studies. Inspired by our pilot work, we now propose a large study in Bangladesh and Pakistan where SHS is a major public health problem and a priority for policy makers. Through our work in these countries for several years, we have established collaborations with schools, local communities and policy makers. We wish to examine how effective SFI is, in reducing children's exposure to SHS in homes. We are also interested to see if SFI can improve children's lung health, academic performance and general quality of life, and if it can reduce their health service use. To provide accurate answers to these important questions, we will recruit a total of 66 schools and 2,636 children between 9-12 years of age. We will randomly allocate schools to two arms: arm 1 and arm 2. School teachers in arm 1 will receive training and resources on SFI. School teachers will then deliver SFI in classrooms to the children. Those in arm 2, will not deliver anything about SHS to the children. They will receive SFI to deliver only after the completion of the trial. We will also use objective measurements including testing children saliva for cotinine (a chemical compound derived from nicotine) to assess whether our intervention has reduced their SHS exposure. We will also record their respiratory symptoms such as coughing and wheezing and measure their lung functions and quality of life. We will undertake these measurements as described above using internationally agreed standards. During the study, we will repeat these assessments at regular intervals. Using economics, we will also assess whether SFI is value for money. We will run discussion groups with some children to ask about their experience of negotiating a smoke-free home; and interview some parents and teachers to investigate the likely obstacles to implementing SFI.

Technical Summary

Second-hand smoke (SHS) exposure costs 800,000 lives a year. Children in developing countries are worst affected as smoke-free laws are only partially implemented. Private homes and cars remain a key source of SHS exposure. There is limited evidence on non-legislative interventions designed to protect children from SHS exposure. Following the success of two feasibility studies and a pilot trial, we plan to evaluate a school-based approach to protect children from SHS exposure in Bangladesh and Pakistan - countries with a strong commitment to smoke-free environments but with high levels of SHS exposure in children.
We aim to assess the effectiveness and cost-effectiveness of a school-based Smoke-Free Intervention (SFI) in reducing children's exposure to SHS and the frequency and severity of respiratory symptoms. SFI, a behavioural intervention, consists of two 45-minute sessions delivered by schoolteachers over two consecutive days in classroom settings. Each session includes classroom presentations, a quiz, interactive games, storytelling and role-play. In our feasibility work, these activities helped children learn negotiation skills and develop confidence in persuading their parents/carers to implement smoking restrictions in their homes.
We will conduct a two-arm cluster randomised controlled-trial in Dhaka and Karachi. We will recruit and randomise 66 schools (2,636 children); half will be allocated to receive SFI (arm 1) and the other half usual education (arm 2). A change in salivary cotinine -a highly sensitive and specific biomarker of SHS exposure- is the primary outcome. Secondary outcomes include frequency and severity of respiratory symptoms, healthcare contacts, school absenteeism, smoking uptake, lung functions and quality of life. An economic and process evaluation will also be conducted. The investigators' expertise and track record within the field is complemented by their extensive links with schools and with policy makers in the two countries.

Planned Impact

CLASS III trial findings are likely to have a big impact: (a) By tackling adult smoking behaviours at homes, we are aiming to improve health outcomes of children in Bangladesh and Pakistan- our study will be one of three MRC-funded studies assessing and demonstrating the effect of modifying smoking behaviours through community-based approaches in South Asia. (b) It will improve the health of the most vulnerable - SHS disproportionately affects women and children with devastating health and economic consequences. If successful and taken up, our intervention would lead to a reduction in the burden of disease among the most vulnerable. (c) Knowledge translation and scaling up into policy and practice - Our research is grounded within implementation science, attempting to answer questions that are highly relevant to programme managers. Being research partners, the findings will be owned by policy makers and advocates in health and education sector, enabling the adoption, scaling up and sustainability of such intervention. (d) A new model of programme implementation - Bangladesh and Pakistan, like many other low- and middle-income countries, lacks infrastructure to provide comprehensive health promotion through their health services. In this study, we will develop knowledge on how best to support local schools in becoming aware, owning and delivering health promotion. (e) Addressing Sustainable Development Goals - By tackling smoking behaviours, our proposal indirectly, creates opportunities for families to have more disposable income (SDG 1) to spend on food (SDG 2), and children's education (SDG 4). Addressing tobacco use is likely to promote gender equality (SDG 5) and maternal and child health (SDG 3) and reduce child mortality (SDG 3). Reduction in tobacco demand also cuts down pesticide use and deforestation leading to environmental sustainability (SDG 13 & 15). Protecting children from second-hand smoking can enhance their educational attainment (SDG 4) leading to improved economy (SDG 8).

Publications

10 25 50

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Huque R (2021) Smoke-free homes: The final frontier in Tobacco Prevention & Cessation

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Khan Z (2021) Population-Level Interventions and Health Disparities: The Devil is in the Detail. in Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco

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Khokhar MA (2020) Smoke-Free Policies in the Global South. in Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco

 
Title CLASS III Second Hand Smoke Awareness Video 
Description CLASS III Second Hand Smoke Awareness Video 
Type Of Art Film/Video/Animation 
Year Produced 2021 
Impact 200 views 
URL https://www.youtube.com/watch?v=2eBM5fGWWV4&t=18s
 
Description Children Learning About Second-hand Smoke: Cluster randomised-controlled trial
Amount £1,239,062 (GBP)
Funding ID MR/T004959/1 
Organisation Medical Research Council (MRC) 
Sector Public
Country United Kingdom
Start 12/2019 
End 05/2023
 
Description The Smoke-free Homes Innovation Network (SHINE)
Amount £9,869 (GBP)
Funding ID ES/V008137/1 
Organisation Economic and Social Research Council 
Sector Public
Country United Kingdom
Start 03/2021 
End 02/2022
 
Description Global Health Respiratory Network 
Organisation Liverpool School of Tropical Medicine
Country United Kingdom 
Sector Academic/University 
PI Contribution My research team contributed to joint papers and also to joint grant applications.
Collaborator Contribution My research partners also contributed to joint papers and new research proposals through this collaboration.
Impact Sheikh A, Campbell H, Balharry D, et al. The UK's Global Health Respiratory Network: Improving respiratory health of the world's poorest through research collaborations. J Glob Health. 2019;9(2):020104. doi:10.7189/jogh.09.020104 Siân Williams, Aziz Sheikh, Harry Campbell, Neil Fitch, Chris Griffiths, Robert S Heyderman, Rachel E Jordan, S Vittal Katikireddi, Ioanna Tsiligianni, Angela Obasi, Respiratory research funding is inadequate, inequitable, and a missed opportunity, The Lancet Respiratory Medicine, Volume 8, Issue 8, 2020,
Start Year 2018
 
Description Global Health Respiratory Network 
Organisation University of Edinburgh
Department Global Public Health Unit
Country United Kingdom 
Sector Academic/University 
PI Contribution My research team contributed to joint papers and also to joint grant applications.
Collaborator Contribution My research partners also contributed to joint papers and new research proposals through this collaboration.
Impact Sheikh A, Campbell H, Balharry D, et al. The UK's Global Health Respiratory Network: Improving respiratory health of the world's poorest through research collaborations. J Glob Health. 2019;9(2):020104. doi:10.7189/jogh.09.020104 Siân Williams, Aziz Sheikh, Harry Campbell, Neil Fitch, Chris Griffiths, Robert S Heyderman, Rachel E Jordan, S Vittal Katikireddi, Ioanna Tsiligianni, Angela Obasi, Respiratory research funding is inadequate, inequitable, and a missed opportunity, The Lancet Respiratory Medicine, Volume 8, Issue 8, 2020,
Start Year 2018
 
Description Smoke-free homes Innovation Network (SHINE) 
Organisation University of Stirling
Country United Kingdom 
Sector Academic/University 
PI Contribution I have contributed to this network by leading a webinar and also by taking part in several meetings in which new research ideas were discussed with respect to funding and publications.
Collaborator Contribution Within this Network, there are opportunities to develop ideas for innovative, systems-based approaches which take into account the wider social, economic and structural barriers that can make it particularly difficult for families to create a smoke-free home. Involving families in the co-design and development of these approaches will help to ensure that ideas for future research, policy and practice are tailored to the needs of people living in socio-economic disadvantage. There has been increased dialogue between researchers and health and social care professionals regarding the development of effective individual and community approaches to creating a smoke-free home in the future. There is also potential to develop an international library of resources for professionals delivering smoke-free homes brief advice/interventions, to support them to raise the issue with family members who smoke, and encourage shared knowledge and learning. Maximising opportunities to learn from international research, policy and practice initiatives is instrumental to future success. Partners seek to co-operate with scientists and policymakers working on smoke-free home measures globally. The Network will establish a fuller understanding of ways that gender-specific factors shape decisions to create and maintain a smoke-free home in the UK, Ireland, and more widely internationally, as research has largely focused on the role and experience of women and mothers as primary caregivers. Acknowledging cultural shifts in gendered roles, fatherhood and family composition will assist in moving beyond stereotypical understandings of roles and responsibilities associated with creating a smoke-free home
Impact O'Donnell R, Semple S, Kroll T & Frazer K (2021) Smoke-free homes Innovation Network (SHINE) Charter: Priorities for future collaboration. Tobacco Control Blog [Blog post] 04.08.2021. https://blogs.bmj.com/tc/2021/08/04/smoke-free-homes-innovation-network-shine-charter-priorities-for-future-collaboration/
Start Year 2021
 
Title Children Learning About Second-Hand Smoking- Smoke Free Homes 
Description The intervention enable teachers to use the guidelines for empowering children (9-12 years) to transform household smoking behaviours for better health. The training manual includes guidelines and resource materials to guide teachers in their teaching of healthy behaviours to empower children as advocates. 
Type Preventative Intervention - Behavioural risk modification
Current Stage Of Development Refinement. Clinical
Year Development Stage Completed 2021
Development Status Under active development/distribution
Clinical Trial? Yes
Impact To be tested in a full scale clinical trial 
 
Description Closing the Gap: Nicotine and Tobacco Research in High-Burden Low-Income Countries 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact More than 300 people attended this preliminary talk during an international meeting. This led to much discussion and follow up collaborations.
Year(s) Of Engagement Activity 2021