Awareness and knowledge of risk

Poor awareness and knowledge of the risks from SHS was identified as a barrier.12 ,15 ,16 ,28 ,29 ,34–37 ,39–45 Conversely, awareness and knowledge of the risks acted as a motivator, with some participants ‘aware’35 and ‘mindful’40 of the dangers of exposing others, particularly children, to SHS. Exposure was reported as ‘deadly’ and ‘dangerous’,41 with household members aware that exposure ‘present[ed] a risk’34 which motivated them to make changes to their home smoking behaviours.12 ,39 While exposure to SHS was largely recognised as being harmful, the specific risks associated with exposure,12 ,16 ,29 ,39 ,45 the continuing risks in childhood or later,12 ,29 ,36 ,39 ,41 ,45 and the risks in pregnancy29 ,39 were often not appreciated or acknowledged. Health messages were considered to lack specificity in relation to risks associated with exposure,12 ,39 and some participants expressed desire NOT to know as it would make them feel worse about exposing their children to SHS.12

Risk perception and acceptable risk

Caregivers were engaged in a process of weighing up risks of SHS exposure with other risks to their children's health and well-being, within the construct of good parenting.12 ,16 ,29 ,30 ,32–35 ,39 ,42 ,43 ,45 This sometimes acted as a barrier to creating a SFH. Their choice to expose children was articulated as ‘…the rational option’ and within this context presented as an acceptable level of risk.34 On the one hand, there were risks of SHS exposure, sometimes perceived as transitory (‘…only half an hour’39) and limited,34 ,39 and on the other hand perceived risks of leaving a child unsupervised, with the associated ‘…near and present harms’16 such as falling or being harmed by a sibling.34 Although one participant felt that ‘smoking in front of a child is just “not a rational” decision’.42

This perception changed over time and made maintenance of a SFH difficult in the longer term. When children were new-born, the risk from SHS exposure was perceived to be greater, and the risk of leaving them unsupervised lower. The rigidity of rules to keep the home smoke-free commonly relaxed as a child in the household grew older12 ,29 ,30 ,35 ,39 ,43 ,45 as first they were considered to be more physiologically ‘robust’ and able to better tolerate SHS,12 ,29 ,30 ,35 ,45 and second physical separation between smoker and inquisitive mobile toddler wanting to be with a caregiver became more difficult.12 ,16 ,32 ,35 ,43 For some households, restricted outside space, for example, in a high rise flat with no balcony12 ,16 ,32 ,33 ,42 ,43 limited caregivers choices for smoking away from children while closely supervising them, forming an important additional context for some of this balancing. The gradual transition back to smoking near or around children within the home appeared to happen without discussion or negotiation.12 ,39

SHS exposure risk was also compared with other risks such as pollution12 ,34 ,45 or weather34 ,43 which were perceived as more harmful to children's health and well-being and provided a justification of why exposing children to SHS was ‘…safe enough’ or ‘…not that bad’.34

Knowledge of effective strategies

Strategies to reduce exposure to SHS were frequently inadequate, reflecting poor knowledge of, or misconceptions around, effective approaches.12 ,15 ,16 ,29 ,30 ,33–37,39 ,42–45 For example, caregivers restricted smoking to one room, increased ventilation, used air fresheners, asked or expected children to move away from the smoke, or smoked near an open window, believing that the actions taken were adequate12 ,29 ,33 ,36 ,37 ,39 ,42 ,45 and that only ‘visible smoke’ was harmful.29 ,42 ,45 The belief that these actions were sufficient to reduce harm undermined motivation to make the home completely smoke-free.33 ,45

Denial of/challenges to risk messages

Some participants denied the risks of SHS exposure.12 ,15 ,29 ,34–36 ,38 ,42 ,43 ,45 In one article, participants cited role models (such as doctors) smoking or government messages as evidence of lack of risk.45

Participants’ lived experience of the lack of (longer term) risk of SHS exposure where ‘…adverse health effects from smoking are seen as a possibility rather than a certainty’38 or an immediate risk was found to be related to their assessing the risk to their own children as minimal.12 ,15 ,34–36 ,38 ,43 ,45 This assessment also related to participants contesting healthcare professionals’ views and public health messages when children were outwardly well.12 ,29 ,43 This included suspicions that negative health effects were exaggerated by the media and healthcare professionals.45 Some caregivers articulated the need for ‘proof’ that their smoking was harming their children,34 ,43 even when their children were suffering from respiratory diseases associated with SHS exposure.12 ,34 ,42 Some participants expressed active resistance in defying ‘…government dogma’ about SFHs38 by continuing to smoke in the home, and asking that their freedom to smoke be respected.38

Protecting others’ health

Recognition of the harms of SHS was reported to be a motivator for change, with one of the most frequently cited motivators for the initiation and maintenance of home smoking rules being to protect the health of others.12 ,15 ,16 ,28 ,29–36 ,38 ,39–46 This included unborn babies,30 children,12 ,15 ,16 ,29–32 ,34 ,35 ,38–46 grandchildren,15 ,36 ,40 ,46 sick adults,28 ,41 adults36 ,43 and non-smokers.33 ,35 ,40

The desire to protect children was perhaps unsurprising given that the majority of studies explored home smoking behaviours with mothers/parents and the perception that ‘protecting children from SHS in the home [is] generally being seen as more important than protecting adults’.46 While protecting children in general was a motivating factor, the level of motivation for change was heightened when a baby was new-born.15 ,28 ,29 ,30 ,31 ,39–42 This was apparent even if mothers had smoked previously around their children; the new baby prompted further positive attempts at change. Grandparents and other relatives were also motivated to moderate their home smoking behaviours due to the presence of a new baby;40 on request of their children who were thinking of starting a family15 or considering leaving their child in the care of their parents.40

Three articles31 ,39 ,40 indicated that significant changes to home smoking behaviours were typically only triggered by the physical presence of the baby in the house rather than during the pregnancy (‘none of the participants had considered the need for pregnant women to avoid smoky places or people who were smoking’39) indicating a lack of awareness of risk. These same participants reported that they ‘strongly and unequivocally supported the principle that new-born babies should not be exposed to cigarette smoke’,39 suggesting differences in risk perceptions between unborn and new-born babies and that this may influence motivation for change.

Motivation for creating a SFH was also triggered by a child being (newly) diagnosed with a SHS-related illness such as asthma, or if exposure to SHS within the home had or could exacerbate current health conditions.12 ,28 ,34 ,41 ,42 ,44 However, Poland reported that few participants ‘undertook restrictions pre-emptively in the absence of [child respiratory problems]’ and that in some cases ‘ample evidence of harm’ was insufficient to motivate change.42

Protecting personal health

While household members, both smoking and non-smoking, were predominantly motivated to protect the health of others, a small number reflected, often hypothetically, that stopping smoking in the home may improve their own personal health.12 ,28 ,36 ,45

How social norms contribute to lack of agency

Studies reporting how social norms contribute to an individual's lack of agency to make changes in household smoking were from communities where a high value was placed on social relationships, and where smoking functioned as a shared activity and was a positive glue in social relationships, work/business relationships, and at family events and celebrations.16 ,29 ,30 ,31 ,36 ,38 ,45 The articles highlighted that in some cultures and subcultures, it remained normal to smoke, and that in societies where smoking is becoming increasingly denormalised, smoking is not denormalised everywhere. They demonstrate that social expectations of behaviour within a culture (eg, associated with politeness/hospitality with visitors)29 ,45 can prevent household members from challenging others’ smoking behaviours and thus result in a lack of agency to initiate or maintain a SFH. These expectations included ideologies about ‘womanly behaviours’36 such as the good/dutiful daughter in law or wife. This subtheme therefore linked closely to gender imbalance.

Gender imbalances

While 18 articles included men as participants,12 ,15 ,28–33,35–37 ,39–42 ,44–46 the focus in most of the studies was on women's experiences. Gender imbalance was visible through women's (mainly) lack of agency in effecting change in male smoking behaviours in their households.12 ,29 ,31 ,36 ,38 ,40 ,45

Structural factors

Lack of agency was also explained by individuals living in someone else's home—usually adult children living with parents/in-laws or other extended family.12 ,15 ,16 ,28 ,30–32 ,34–36 ,38–42 ,44 This situation arose, for example, in Chinese households where couples lived with the husband's parents.36 Lack of agency in this situation related to how challenging a father-in-law over his smoking inside the house would breach the traditional role of being a good daughter-in-law and be viewed as a transgression of ‘filial piety’36 disrupting an essential commitment to the maintenance of family harmony. In other articles, adult household members faced barriers to change relating to their younger generational status31 ,32 ,41 ,42 or the fact that they were unable to make a significant financial contribution to the household and therefore had no voice/power,31 although this was not universal.36

Lack of agency was exacerbated by overcrowding (more smokers) and unemployment (spending more time in the home).31 ,42 It was also intensified by fluid and unstable household composition where other adults regularly moved in and out.12 ,42 Some caregivers felt that they lacked agency to enforce rules about home smoking as they were reliant on others for economic, social, emotional and practical support (such as childcare provision) which they felt may have been compromised if rules had been enforced.12 ,31 ,36 ,38 ,40 ,44

Conversely, leveraging the structural agency invested in the roles (and therefore rights) of primary caregiver/mother, home owner/head of household and non-smoker enabled the making and enforcing of home smoking restrictions. Referencing the presence of their children, and their role as primary caregiver to protect their children, provided some mothers with the necessary power base to introduce and enforce rules around home smoking.16 ,30 ,31 ,34 ,36 ,39 ,40 ,41

Leveraging the authority and rights invested in a home owner/head of household role was linked to respect for those roles (see ‘social relationships and influence of others’ theme).28 ,30 ,34 ,39 ,41 ,42 Some articles included observations about the role of non-smoking household members, where those individuals referenced their rights as non-smokers not to be subjected to SHS, enabling them to enforce household smoking rules.41 ,42 This included children.15 ,35 ,40 ,42 Invoking the mothering/home owner/non-smoker roles in these ways was most effective in contexts where not smoking around others was normalised.

Agency as a barrier was more commonly coded in articles where there was no SFL at the time of data collection but was still common across articles where there was SFL. This was rooted in continued normalisation of smoking in some communities and households and the importance of smoking as social glue, living in someone else's home, and persistent gender inequalities.

Personal skills/attributes

Having a strong personality, willpower, tenacity, assertiveness, self-discipline and willingness and energy to change including a preparedness to jeopardise family relationships were all described as enabling household members to initiate and enforce household smoking rules.16 ,28 ,31 ,34 ,40 ,43 Conversely, the absence of personal qualities and skills such as motivation, assertiveness and negotiation contributed to lack of agency.31 ,40

Community norms

Restrictions on smoking in public places was found to be associated with changing community norms regarding exposing others to tobacco smoke.15 ,28 ,42 Norms regarding not smoking near others, particularly children, operated at three levels: the neighbourhood, household and individual—to enable initiation or maintenance of SFHs. Norms of not smoking near children, or not smoking indoors, shared by friendship groups or neighbourhoods facilitated SFHs.15 ,28 ,29 ,31 ,35 ,39 ,40 ,42 At the household level, some articles found that well-established rules regarding not smoking inside the home were perceived as normal, and not questioned, both in smoking and non-smoking households.28 ,34 ,41 ,42 Some participants had extended their own rules restricting smoking inside their homes to other people's homes, thus modelling this behaviour and supporting restrictions elsewhere.15 ,35 ,40 This was sometimes couched in moral terms—of being a ‘good’ smoker, considerate of others35 ,40 and respectful of the children.31

Being a responsible parent

The desire to perceive themselves and to be perceived by others as a responsible, risk averse, self-disciplined parent acted as a motivator for households, in particular mothers, to change their home smoking behaviours.12 ,15 ,28–30 ,34–37 ,39 ,40 ,44 ,45 For smoking caregivers, the perceived ideal was for them to have a completely SFH; however, for those who were unable to achieve this, they employed risk reduction strategies30 ,34–37 ,39 to reduce exposure to an ‘acceptable level’.34

Smoking near children was ‘not a clear cut issue’35 for families and this ‘risk management’ allowed them to position themselves as ‘morally responsible’,35 ‘caring’15 and ‘considerate’42 parents. Any inconvenience to the smoker as a result of making their home smoke-free or in the employment of risk reduction strategies was reportedly outweighed by their ‘moral and caring obligations’43 as a parent, and the overriding motivation to protect their children from harm. Linked with being a responsible parent was an underlying concern that children exposed to smoking at home would model smoking behaviour.12 ,15 ,28 ,29 ,35 ,40 ,44 ,45

Being a responsible parent was never coded as a barrier to SFHs but was coded as an enabler in articles where there was SFL at the time of data collection. This finding was reversed in articles where there was no SFL at the time of data collection. Similarly, smoking being normalised and acting as a barrier to a SFH was less evident in articles after implementation of SFL. These findings suggest that SFL may impact on behaviour to create and maintain a SFH via mechanisms of new community norms around smoking near children and constructs around good/considerate parenting.

Guilt

Intricately woven into the narratives around being a responsible parent were the feelings of guilt about being a smoker and exposing others, in particular children, to SHS.12 ,32 While for some, guilt was a catalyst for change, for others even having acknowledged that smoking may be harmful to their children, the feelings of guilt did not alter home smoking behaviours.29

Avoiding stigma

Households were motivated to make smoke-free rules driven by a desire to live in a clean, odour-free environment, which was linked to a perceived stigma attached to the smell of smoke.12 ,15 ,28–30 ,35–37 ,40–42 ,44 ,45 Households were motivated to restrict smoking in the home due to the perception that having a home which showed signs of smoke exposure (eg, nicotine stains) and which smelled of smoke was ‘socially unacceptable’40 and that there was ‘stigma’35 associated with having a smoky home, furnishings and clothing. While household décor was described by one article as the ‘biggest emerging motivator’,12 this was not demonstrated across the articles within the current synthesis, rather it was the smell of smoke, which was ‘instrumental’41 in the initiation of both discussions about, and the implementation of, home smoking restrictions.

Maintaining social relationships

In some situations, norms regarding social relationships prevented people from restricting smoking by others.12 ,15 ,16 ,28 ,29 ,31–33 ,36 ,38 ,42 ,44 ,45 For example, many participants, but not all, were unwilling to or uncomfortable asking visitors not to smoke inside.12 ,15 ,16 ,28 ,29 ,31 ,32 ,33 ,38 ,44 ,45 This was considered to contravene etiquette, be ungracious, embarrassing, and carried fear of offending and of being rejected. The fear of rejection related to social identity as a smoker within an environment where smoking was normalised,15 and for some a fear of being seen as a hypocrite (for smoking themselves).12 ,38 In situations where smoking visitors were allowed to smoke inside the home, the maintenance of the social relationship was prioritised over protection of the child/ren given the brief transitory nature of most visitors. While concerns regarding etiquette in relation to visitors smoking were common, in some settings,29 ,36 ,45 this was much more fundamental than a ‘social nicety’; it was about the need to preserve social bonds, respect the status of others and to adhere to fundamental cultural practices. It was also expressed as ‘respecting others need to smoke’.31 ,42 ,44

Negative social impacts of SFH rules was more commonly identified in articles before SFL but only coded in one article after implementation of SFL. This was also the case for feeling upset or bad or awkward about asking visitors not to smoke inside.

Influence of others

Other people, in particular family members, had the potential to influence home smoking behaviours in both positive and negative ways.15 ,16 ,28–31 ,34–37 ,39–45 In households with at least one adult non-smoker, it was reported that in some cases the smoker themselves initiated changes;42 however, frequently it was the non-smoker who instigated discussions41 about home smoking and, in some cases, ‘demand[ed]’ that home smoking be restricted.42 Children and grandchildren also played a role by expressing their dislike of smoking30 ,40 ,41 which helped to motivate behaviour change.

Smoking household members’ and visitors’ acceptance of and compliance with household smoking rules was enabled by the normality and assumed nature of protecting others from SHS, particularly children,28 ,31 ,35 ,39–42 and (for visitors) an expectation of respect15 ,28 ,30 ,34 ,39–41 or asking for respect28 ,44 for household rules and rule-makers. Several articles reported smoking household members not being affected or bothered by abiding by SFH rules,15 ,16 ,28 ,34 ,37 ,43 although some compliance was accompanied by reluctance,28 ,40 ,41 or driven by fear of reprisal.28 ,40

Positive influences on smoking household members’ compliance with SFH rules included other members providing smokers with support and encouragement in their efforts to comply with rules28 ,40 ,43 and children as ‘active agents’35 asking for and policing SFH rules based on concerns for their parents’ and their own health.15 ,35 ,40 ,42 Some studies reported non-smoking household members supporting other non-smoking members in attempting to create or maintain a SFH,36 ,42 although these supporters were not necessarily reliable allies.36 These observations were predominantly reported for households with a mix of smokers and non-smokers. In one article, households with a single smoker or single parent households had more stringent restrictions.42

Lack of support from household members was a barrier to implementing changes to home smoking behaviours.16 ,28 ,29 ,31 ,40 ,41 ,43 ,45 Healthcare professionals, in particular doctors, were cited as a motivating factor and that receiving advice, in the form of a recommendation,28 ,34 ,41 or as an explicit instruction28 ,41 not to smoke in the home around children prompted discussions, and in some cases behaviour change. These discussions typically occurred when a family presented at the clinic with a child who had a potentially SHS-related illness or an exacerbation in a chronic condition linked to SHS exposure.

Perceived benefits of smoking

The perceived benefits of smoking acted as a barrier to establishing a SFH.12 ,15 ,16 ,29–36 ,38 ,39 ,42 Benefits of smoking in the context of ‘relationships with others’ has been discussed earlier, but other personal/individual benefits were described including perceiving smoking as a reward or treat,32 ,33 ,34 a consolation,33 an aid to relaxation,15 ,16 ,29 ,32–34 ,36 or concentration.29 Having to go outside would detract from these perceived benefits. These benefits were described (by some mothers) within the context of balancing their own coping, with caring for children and good parenting. On one hand, smoking was constructed as reflecting an ethic of ‘…caring for self’35 providing mothers with ‘me time’,34 a “‘little luxury’ of having a ‘moment's peace’”34 and important emotional and social support from socialising with others who were smokers.16 ,31 ,34 ,38 Mothers described this as beneficial to the family in ‘coping’34 and facilitating their good parenting, for example, managing stress and preventing them from shouting at their children.12 ,30 ,33 ,34 ,39 ,42 This was linked to addiction and the need to smoke.

Perceived benefits of having a SFH

The initiation of a SFH was associated with unanticipated or unexpected benefits,28 ,30 ,37 ,40 ,42 ,43 and these benefits were ‘self-reinforcing’37 in helping participants to maintain their smoke-free rules. For some household members, the initiation of a SFH helped them to cut down on the amount they smoked. It was rationalised that having to go outside ‘postponed’ or delayed smoking,42 thus helping to remove the ‘autonomic nature of smoking’;37 as well as being ‘inconvenient’.37 The positive reinforcement of cutting down helped motivate household members to maintain their smoke-free rules. In addition to helping to reduce their daily cigarette consumption, the initiation of a SFH may help some household members to quit smoking12 ,28 ,30 ,42 which would in turn help to support longer term maintenance. For example, in the Jones et al12 article, participants who did not have SFHs reported that they were motivated to make their home completely smoke-free as it was perceived that it ‘could be a manageable first step in the complex process of quitting’ and that successfully implementing and maintaining strict home smoking rules might ‘empower’ them to make further positive changes to their smoking behaviours.

Five articles28 ,34 ,37 ,40 ,42 reported other potential benefits to the initiation of a SFH, for example, that smoking outside helped facilitate ‘personal’42 or ‘quiet’40 ,42 time for the smoker with some reporting that they actively used smoking outside as a ‘barrier’ or to ‘isolate’ themselves from others.42 These benefits helped to motivate household members to maintain their smoke-free rules.

Personal preferences

The personal dislike of and aversion to the smell of smoke (including among non-smokers and ex-smokers, and children) motivated establishment of SFHs.30 ,36 ,40–42 ,45 In addition, some smokers who had grown up in smoking households had made a conscious decision to make their own home smoke-free as an adult given their aversion to SHS and the lack of choice around exposure as a child.41 ,44 Others followed the SFH example set by their own parents.41

However, some participants were not willing to make a SFH. This was expressed in two ways: as not wanting to establish a SFH in my home, or in my home. The first set of observations included participants’ determination to be in control of their own home/private space and able to do what they wanted there. This related to smokers’ ‘decision-maker’ status in the household,35 ,41 an expectation that others would respect their freedom or need to smoke, and a lack of self-consciousness, or concern for others’ needs/wants about smoking.15 ,31 ,33 ,38 ,42 ,45 The second and linked set of observations were about participants’ perceptions of the meaning and identity of their home as somewhere private, comforting, relaxing and as the last place where you can choose to smoke uncriticised.15 ,33 ,38 In some articles, the identity of the home constructed in this way was linked to participants’ not having ever thought about establishing a SFH.41 ,45

Priorities

The transience and general chaos of some participants’ home lives contributed to a situation in which initiating and maintaining a SFH did not feature, or did not take precedence over other priorities, which were often the product of very difficult social and economic circumstances.12 ,16 ,32 ,42

Addiction/habit

Addiction and habit were raised as barriers to having a SFH in 13 articles.12 ,15 ,28 ,31–35 ,39 ,41–43 ,45 Addiction was presented as a general impediment to initiating a SFH15 ,32 ,33 ,41 or was used to justify breaking existing rules.28 ,35 ,39 ,45 A small number of articles included examples of participants articulating that their nicotine addiction affected their rational decision-making and capacity to convert understanding of risk and their good intentions into action.34 ,35 For some respondents, quitting smoking was seen as a pre-requisite for a SFH, and their inability to quit due to their addiction was therefore constructed as a barrier.32 ,34 Smoking indoors was reported as ‘habitual’ behaviour and something that they had always done and were unwilling to change,12 ,32 ,41 ,42 ,45 or as an ingrained habit associated with other behaviours such as computer use, watching TV or after a meal,12 ,32 ,41 both of which acted as a barrier to creating a SFH. The habitual and normalised use of smoking for stress management presented a major impediment to both the initiation and maintenance of SFH.12 ,28 ,31–34 ,39 Smoking was described as an entrenched-coping mechanism, a familiar comforter and an automatic response to stress.

Practical issues

Having to go outside to smoke was reported as a barrier to initiating and maintaining a SFH, whereas for others this was a motivator as described above.12 ,15 ,16 ,28 ,29 ,31–33 ,36–39 ,41–45 It was commonly viewed by participants as an inconvenience and was linked to wanting to smoke in comfort12 ,15 ,31–33 ,41 and having to dress children for going outside.32 ,43 Adverse weather posed a significant disincentive to smoking outside acting as a barrier to maintaining a SFH and driving the fluid application of household smoking rules,12 ,16 ,28 ,29 ,31–33 ,37 ,39 ,42–44 as did unpleasant or unsafe surroundings.12 ,16 Several articles included observations about the impact of limited or no private outside space on participants’ capacity (including motivation) to establish a SFH.12 ,16 ,32 ,33 ,42 ,43 Four articles28 ,36 ,42 ,45 reported that households were prompted to initiate home smoking bans as they were concerned about the safety of smoking inside, particularly in bedrooms,36 and the potential increased risk of fires and cigarette-related accidents. Changes in the household composition such as a partner moving in or out, a child taking up residence, or a relative moving in acted as a natural catalyst for reflection and potential changes in home smoking behaviours.28 ,31 ,41 ,42

Practical strategies

Strategies to enable making a SFH suggested by participants included environmental changes such as removing ashtrays and displaying ‘no smoking’ signs.29 ,30 ,38 ,42 ,44 Homes with access to suitable, secure outdoor spaces supported people's attempts to have a SFH,16 ,28 ,37 ,42 with some people designating a comfortable, covered outdoor space for smoking.28 ,37 Other practical strategies included ensuring appropriate clothing for smoking outside was easily accessible,32 letting children play outside while adults smoked,16 ,34 ,43 or changing habits to incorporate smoking into routine outdoor activities such as putting out the garbage.32 Intrapersonal strategies included smokers quitting or reducing smoking; becoming informed about the risks of SHS to increase resolve; and seeing this change as an opportunity and looking for solutions, rather than seeing it as a problem.32 Negotiating with other household members to make the decision and implement it28 ,32 ,42 ,45 and engaging others (especially non-smokers) for support,32 enabled implementation, as did having one unchanging rule which applied to everyone28 ,30 ,34 ,41 and clear and consistent messages.40 ,42 ,44 There were mixed views on whether to implement a SFH gradually (eg, partial bans first then a full ban) or abruptly, with both reported as successful approaches.32 ,42 ,43 ,45 Tobacco control policies that reduced smoking were also considered to support the establishment of SFH.15 ,45