The role of nicotine replacement therapy for temporary abstinence in the home to protect children from environmental tobacco smoke exposure: a qualitative study with disadvantaged smokers

Two sets of qualitative in-depth interview data (n=36) were combined in the current study to explore the views of smokers with young children on using NRT to abstain from smoking in the home. One-to-one interviews were chosen in both studies to enable open discussion of anticipated sensitive social and psychological issues [12‐14]. In addition, this allowed the interviewers to offer flexible appointment slots to fit around the participants’ busy family lives. In the first study, 22 smoking families were interviewed between July and September 2009. As described previously [15], recruitment was done via Sure Start Children’s Centres which are located amongst the most socio-economically disadvantaged parts of Nottingham as defined by Index of Multiple Deprivation, and where the smoking rate was up to 48.1% in recent years [16]. In the second study, 14 smoking families were interviewed between October and November 2010. Potential participants were identified through six health visitor clinics, which were randomly selected from the 17 clinics located in areas across Nottingham City where we had not attempted to recruit families for the first study. The inclusion criteria for the participants were: age 16 years and over, self-reported current smoker and currently or recently smoking in the home, caregiver to at least one child under the age of five, and good level of spoken English. We purposively included parents who reported no longer smoking in the home. This was partly because other studies suggest that smoking rules are fluid and therefore self-report of having a smoke-free home may not be valid [12, 14, 17]. Secondly, parents who indeed did manage to establish smoke-free homes could provide invaluable insight into how to successfully implement changes of smoking behaviour in the home. The interviews took place in a private room at the Children’s Centre or the health visitor clinic where the participant accessed services or in the participant’s own home. All participants were offered a £15 retail voucher as an inconvenience allowance and for potentially having to arrange child care. At the end of the interview each participant completed a brief demographic and smoking information questionnaire.

These two interview studies form part of a larger body of research which aims to develop an effective intervention to reduce children’s exposure to domestic ETS. The aim of the first study was to explore home smoking behaviours, the motivators and barriers to smoke-free homes, and to identify the positive levers that health care professionals can utilise when supporting smoking caregivers to change their behaviours. The aim of the second study was to further investigate the specific details of the intervention, in particular, to explore in more detail the use of NRT for temporary abstinence in the home to protect children from ETS. The interview guides were developed from the literature and through discussions with the Children’s Centre and health visitor staff that provided the authors with useful insights into the social challenges facing their clients. The guides were modified further throughout the data collection to incorporate any new themes. Guide modification was facilitated by immediate post-interview de-briefing between the interviewers. The first set of interviews was carried out by both LLJ and OA and the second set of interviews carried out by LLJ and another interviewer. The discussion guide included exploration of topics around previous quit attempts, previous and future use of NRT, the concept of temporary abstinence and the use of NRT for optional temporary abstinence in the home. We anticipated that the concept of temporary abstinence might be challenging for interviewees to understand and therefore invested time and effort during interviews to help the participants comprehend this. Once we were satisfied that participants adequately understood the concept of temporary abstinence, we explored their views and attitudes towards initiating and maintaining optional temporary abstinence in their homes in general, and also to using NRT for optional temporary abstinence in their homes. The participants were also provided with a NRT summary sheet prior to the interview which included a brief description of some NRT products. For those participants who had no previous experience of NRT, we showed them gum and lozenge samples as visual aids. We have previously analysed the first interview study [15] to show that caregivers had some knowledge of the health risks of ETS exposure for their children, but that they did have some confusion about, and resistance to these health messages; in neither study did we provide caregivers with education about health risks but rather we explored their views and attitudes to temporary abstinence and NRT in the context of their existing knowledge and experience. This study was conducted with reference to and adheres to the RATS guidelines for qualitative research [18]. Ethical approval for the first study was sought and gained from the University of Nottingham Medical School Ethics Committee (ref: A/5/2009) and for the second study a favourable opinion was given by the Nottingham Research Ethics Committee 1 (10/H0403/18).

Data analysis was ongoing throughout the period of data collection and regular discussions were held between the interviewers and within the rest of the research team. Each interview was digitally audio-recorded and transcribed verbatim by an external specialist transcription company. Each transcript was carefully checked for transcription errors to ensure data quality. Analysis of the transcripts was facilitated by the use of NVivo software version 8 (QSR International Pty Ltd, Australia). The interviewers independently generated an open coding framework, utilising the six phase process of Braun and Clarke [19]. The interviewers independently reviewed each transcript and initial ideas were noted that identified preliminary codes. These codes were then grouped into potentially relevant themes and discussed between the researchers and with the wider research team. Further analysis clarified the specific nature of each theme leading to the development of names and descriptions. Following the agreement of the themes identified, extracts were taken from the transcripts to exemplify each theme in order to reflect the experiences of the participants.

In total 36 semi-structured interviews were conducted with self-reported smokers. Although all interviewees were current smokers, they reported a variety of smoking behaviours within the home. Of the 36 interviews, 27 were with mothers, one with a grandmother, a resident carer, and eight with fathers. Eighty one per cent were unemployed or considered themselves to be a house-wife. On average, there were two children living in each household (range, one to six), and in 48% of the households there were two or more adult smokers living in the home.

In this manuscript data relating to the following themes are reported:

Overall, most participants were generally negative about the idea of temporary abstinence in the home. Many did not believe that they could successfully avoid smoking inside their homes (Table 1, quotes a-b). These participants could not recognise the benefit of “just” stopping smoking inside their homes and felt that if they were to invest time and effort to change their smoking behaviour they would prefer to stop smoking altogether (Table 1, quote c). Few caregivers voluntarily raised the subject of their children’s health in this context. One participant, who aspired to quit smoking altogether at some point in the future, did suggest that she would consider making her home smoke-free through optional temporary abstinence, but only as a step towards quitting (Table 1, quote d).

Most participants reported previous use of NRT and understood that NRT provides nicotine in a medicinal form rather than from cigarettes which helps to overcome the cravings arising from nicotine withdrawal. However, some were still sceptical about the health advantages of using NRT instead of cigarettes (Table 2, quotes a-b). Many of the previous NRT users reported positive experiences and had managed to stop smoking for periods of time, ranging from days to several years. Those who had relapsed rationalised their negative experiences of NRT in terms of the common side-effects and its ineffectiveness. For instance, some users attributed their failed quit attempts to experiencing persistent cigarette cravings despite using high strength NRT products; others were sceptical about the role of NRT as they felt that their own willpower was the most important factor. The taste of NRT was also a common problem – mostly reported for gum, but also experienced with the lozenge and inhalators (Table 2, quotes c-d).

Exploration of interviewees’ previous experiences of NRT often facilitated lengthy discussions about the potential use of NRT to help the participants make their homes smoke-free. An overwhelming majority of interviewees expressed generally negative attitudes about using NRT to help them to avoid smoking in their homes. One of the participants, a father of one, voluntarily described how he had already managed to initiate and maintain temporary abstinence to make his home completely smoke free by using nicotine gum to control his cravings inside the house, even though he was not familiar with the terminology of temporary abstinence. His reason for stopping smoking inside the house was his son’s health. However, when asked about the potential use of NRT by other smokers to help them stop smoking in the home, he promptly talked about his desire to use NRT to help him stop smoking altogether (Table 3, quotes a-c). Some participants rejected the use of NRT for optional temporary abstinence because they perceived that stopping completely was the only appropriate way to alter their smoking behaviour, reiterating previously expressed negativity about the concept of temporary abstinence itself (Table 4, quotes a-c). Those participants who had already successfully managed to make their homes smoke-free were also unsure about the value of NRT. These families, as a whole household, appeared to prioritise their children’s health over smoking indoors. They felt that understanding the harmful effects of cigarette smoke in the home was a more important factor. For them, access to NRT alone would not be sufficient to motivate families to stop smoking in the home. They suggested that NRT use had to be supplemented by parental education around the benefits of a smoke-free home (Table 4, quotes d-e).

Others were sceptical that using NRT for optional temporary abstinence alone would not address the more important need to change their smoking routine (Table 4, quotes f-h). One of the participants, a single mother, felt that smoking for her was more than just nicotine. She was therefore worried that by substituting cigarettes for NRT she would miss out on the opportunities to have a break and time to herself (Table 4, quote i). A small group of participants, when asked directly, were initially positive about using NRT for optional temporary abstinence, however, none gave detailed suggestions as to why this might be and most only briefly indicated agreement. Those few participants who gave explanations talked about using NRT in the context of quitting or cutting down smoking, rather than optional temporary abstinence. The majority of the participants who rejected the idea of using NRT for optional temporary abstinence, however, reported being very willing to use NRT in more established and traditional ways, for example, for quitting or cutting down to quit (Table 4, quotes j-m). This was despite their previous failed attempts and reported side-effects of NRT.