Women of Algiers in their Room, by Eugene Delacroix, 1834.

Hookahs in Art. http://www.discoverhookah.com/store/pages.php?pageid=9

Second & Third-Hand Smoke Exposure in Private Homes: Current & Future Clinical

Interventions & Ecological Contexts

The Johns Hopkins University3/28/11

The Behavioral Ecological Model

Based on Biology/Ecology– Selection of Species– Selection of Behavior– Principles of Learning Across All Animal Species– Emphasizes Environment Determinants

Based on Principles of Learning– Contingencies of Reinforcement—incentives or rewards– Hierarchical & interacting contingencies– Meta-and Macro-contjngencies– Motivating operations or Moderating Factors

The Problem with Behavior

• It is a stream• It’s a stream interacting with the environment • The entire environment is also a stream• Neither will hold still• It’s very hard to measure a stream• It’s almost impossible to measure multiple streams • Measuring Streams is prerequisite to Modifying behavior • Measuring Multiple behaviors from multiple people

residing in multiple social networks are the streams to be targeted by behavioral science

Social Networks Defined by Contingencies

Cascading & Interlocking Contingencies

Mom asks Dad to Smoke outside

A B C

Counselor prompts

C

A

B

B

Dad smokesoutside A

C

Avoids Criticism; protects child

Cascading & Interlocking Contingencies

Asks Visitors Not to smoke

A B C

Legislative Bans

C

A

B

B

Boss smokesoutside A

C

Thanks/avoids Criticism

BEHAVIORAL COUNSELING PROGRAM

•Parents contract to reduce their child’s ETS Exposure

•Short-term goals

•Self-monitoring

•Positive feedback

•Problem-solving brainstorming

•Recruitment of social contingencies

•4-14 sessions in the home and by phone

~ The Role of Clinicians ~

•Nonsmoker Models

•Deliver Tobacco Control Services

•Contract with parents and other family members

•Address ETS as Lead contamination

•Promote Policies for reimbursement of tobacco control services

•Promote Laws restricting ETS exposure community-wide

•Most providers do few of these

Cross Validity of Measures

Contamination: Exposure:

Child Urine Cotinine ------.65------- Indoor Air Nicotine | | | | | | __________ | | .63 _________\___ | .62 | / \ | | .71 .41 | | / \ | Reported Indoor ------.78--------- Reported Smoking in Smoking presence of the child

Results of Overall Trial*Results of Overall Trial*L

og

cig

aret

tes

pe

r w

ork

/wee

kday

0

0.5

1

1.5

2

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30

Month in Study

Usual TreatmentMonitoringCounseling

CounselingEnds

MaterialsDistributed

*Published in Chest, 1997;111:81-88

Results: Cotinine (geometric means)

Intervention Phase• Group by time (linear) interaction

significant (p<.05)

Follow-up Phase• Group by time interaction nonsignificant

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

2.0

Urine Cotinine(ng/ml)

0 1 2 3 4 5 6 7 8 9 10 11 12 13

Months

Coaching

Control

Intervention Phase Follow-up Phase

AsthmaEduc.

Base-line

Pre-test

Post-test F.U. F.U. F.U.

ETS Coaching

Healthy Tots: SHSe and Cessation Counseling

Project Sirocco: Counseling and Cotinine Feedback

for preteens

General schematic of Thirdhand smoke (THS) formation and reactions on indoor

surfaces

THS Exposure in Homes of Smokers and Nonsmokers

No Exposure: Nonsmoking Parents, no known exposure of child

Indirect: Smoking parents, no indoor smoking at home

Direct: Smoking parents, indoor smoking at home

Matt, G.E., et al. (2004). Households contaminated by environmental tobacco smoke: sources of infant exposures. Tobacco Control, 13, 29–37.Chudler, E.H. (2004). Nicotine, Secondhand Smoke and Infants. Smoking outside the home still exposes infants to nicotine. http://faculty.washington.edu/chudler/shs.html.

KBB Value in $

Adjusted Asking Price in $

Nonsmoker Car & Seller

Smoker Seller Smoker

CarSmoker

Car & Seller

2003 Av 8,629 9,273 8,903 8,788 8,437

% Loss vs. Referent Referent 4% 5.2% 9.0%

Cascading Contingencies can Change cultures

G. Matt et al

Cascading & Interacting Contingencies

Parents DecontaminatesHome

A B C

C

A

B

B

DecontaminatesHome A

C

Sells for > $

Dr Explains Cotinine

Real Time Telemetry and Feedback: SHS exposure

Figure 3

Legislative and other Policies: Macro-contingencies that may alter clinical

metacontingencies

Tobacco Module #1 Prescription

Dose Effect – Tobacco-Use Incidence and Anti-Tobacco Prescriptions

0-1 RX 2-3 RX 3-6 RX 7-8 RX 0

2

4

6

8

10

12

14

1614.3

12.7

10.810

% Smoking Incidence

% Smoking Incidence

* *

* Significant differences between group that received 0-1 prescription.

Proportion of participants who initiated tobacco use stratified by experimental group

and “friends who think smoking is cool”

Study Sites

DAILY SHS EXPOSURE

0

10

20

30

40

50

60

70

80

Home Workplace Car Otherplaces

Anywhere

San Diego Tijuana GDL

Social Criticism in Public Places

73.7

54.3

47.2

70.6

47.7

33.2

85.7

69.665.8

88.7

72.464.2

9387.8

93.4

0

10

20

30

40

50

60

70

80

90

100

Workplaces Restaurants Transportation Schools Health Ctrs.

San Diego Tijuana Guadalajara

Percentage of respondents who considered it VERY LIKELY TO BE CRITICIZED for smoking inside public places

Secondhand smoke avoidance by preteens:To leave or stay?

Tobacco Contingencies for Avoidance Behavior

Adjusted Odds Ratio

Home Smoking Ban

None or partial 1.00

Complete 1. 56

Family Discouraged SHSe

No 1.00

Yes 1.44

Friends Discouraged SHSe

No 1.00

Yes 1.73

Friends Decline Smoking

No 1.00

Yes 1.52

Conclusions: Anti-tobacco cultures are contagious

• Differences in social criticism of tobacco varying by proximity,

• Differences in Home bans differ by proximity to California

• Workplace bans moderate city effects on home bans

• Suggests that the exposure to the California anti-tobacco culture is changing the culture of Tijuana.

What do we think?

• Counseling can decrease SHSe • Context Enhances or weakens counseling• Measurement reactivity weakens g x t sign• SHSe & THSe requires changes in Social

Networks, including Providers• Real time Feedback may enhance SHSe and

THSe control• Cascading Contingencies Change Cultures

Waterpipe Use among the Youth

Soweid, RA. (2005). Lebanon: waterpipe line to youth. Tobacco Control, 14(6):363-4.

A young female is smoking the waterpipe in a public pool area in Lebanon.