Assessing reinforcing versus aversive consequences in a real-time secondhand smoke intervention.

Few studies have examined the relative effectiveness of reinforcing versus aversive consequences at changing behavior in real-world environments. Real-time sensing devices makes it easier to investigate such questions, offering the potential to improve both intervention outcomes and theory. This research aims to describe the development of a real-time, operant theory-based secondhand smoke (SHS) intervention and compare the efficacy of aversive versus aversive plus reinforcement contingency systems. Indoor air particle monitors were placed in the households of 253 smokers for approximately three months. Participants were assigned to a measurement-only control group (N = 129) or one of the following groups: 1.) aversive only (AO, N = 71), with aversive audio/visual consequences triggered by the detection of elevated air particle measurements, or 2.) aversive plus reinforcement (AP, N = 53), with reinforcing consequences contingent on the absence of SHS added to the AO intervention. Residualized change ANCOVA analysis compared particle concentrations over time and across groups. Post-hoc pairwise comparisons were also performed. After controlling for Baseline, Post-Baseline daily particle counts (F = 6.42, p = 0.002), % of time >15,000 counts (F = 7.72, p < 0.001), and daily particle events (F = 4.04, p = 0.02) significantly differed by study group. Nearly all control versus AO/AP pair-wise comparisons were statistically significant. No significant differences were found for AO versus AP groups. The aversive feedback system reduced SHS, but adding reinforcing consequences did not further improve outcomes. The complexity of real-world environments requires the nuances of these two contingency systems continue to be explored, with this study demonstrating that real-time sensing technology can serve as a platform for such research.

Randomised controlled trial of real-time feedback and brief coaching to reduce indoor smoking.

BACKGROUND: Previous secondhand smoke (SHS) reduction interventions have provided only delayed feedback on reported smoking behaviour, such as coaching, or presenting results from child cotinine assays or air particle counters. DESIGN: This SHS reduction trial assigned families at random to brief coaching and continuous real-time feedback (intervention) or measurement-only (control) groups. PARTICIPANTS: We enrolled 298 families with a resident tobacco smoker and a child under age 14. INTERVENTION: We installed air particle monitors in all homes. For the intervention homes, immediate light and sound feedback was contingent on elevated indoor particle levels, and up to four coaching sessions used prompts and praise contingent on smoking outdoors. Mean intervention duration was 64 days. MEASURES: The primary outcome was 'particle events' (PEs) which were patterns of air particle concentrations indicative of the occurrence of particle-generating behaviours such as smoking cigarettes or burning candles. Other measures included indoor air nicotine concentrations and participant reports of particle-generating behaviour. RESULTS: PEs were significantly correlated with air nicotine levels (r=0.60) and reported indoor cigarette smoking (r=0.51). Interrupted time-series analyses showed an immediate intervention effect, with reduced PEs the day following intervention initiation. The trajectory of daily PEs over the intervention period declined significantly faster in intervention homes than in control homes. Pretest to post-test, air nicotine levels, cigarette smoking and e-cigarette use decreased more in intervention homes than in control homes. CONCLUSIONS: Results suggest that real-time particle feedback and coaching contingencies reduced PEs generated by cigarette smoking and other sources. TRIAL REGISTRATION NUMBER: NCT01634334; Post-results.

Indoor cannabis smoke and children's health.

Cannabis use is increasing and cannabis is typically consumed by smoking. This study explored how indoor secondhand cannabis smoke (SCS) was associated with child health. As part of a larger trial, air particle monitors were placed in 298 homes of families with at least one cigarette smoker and one child under 14 years old in San Diego County, California. Assessment included past 7-day indoor cigarette and cannabis use, the youngest child's exposure to cigarette smoke, and 5 smoke-related past-year child health outcomes: emergency department use for coughing/difficulty breathing; physician diagnosis of ear infection, bronchitis/bronchiolitis, asthma, or eczema/atopic dermatitis. An ordinal measure of adverse health outcomes (0, 1, or ≥2) was regressed on reported indoor cannabis smoking-the main measure of exposure (yes/no). Of 221 parents/guardians asked about cannabis use, 192 (86.9%) provided all required data, and 29 (15.1%) reported indoor cannabis smoking; reports were supported by air particle data. Homes without indoor smoking had lower average 7-day particle concentrations (1968 particles/0.01ft3) than homes with cannabis smoking only (3131 particles/0.01ft3), cigarette smoking only (3095 particles/0.01ft3), or both cigarette and cannabis smoking (6006 particles/0.01ft3). Odds of reporting a greater number of adverse health outcomes were 1.83 (95% CI = 0.89-3.80, p = 0.10) times higher for children of families with indoor cannabis smoking vs families without cannabis smoking, after controlling for exposure to cigarette smoke and other covariates. Our results do not indicate a statistically significant association. However, the magnitude of the (non-significant) association between indoor cannabis smoking and adverse health outcomes warrants more studies.

Screening for Pregnancy Status in a Population-Based Sample: Characteristics Associated with Item Nonresponse.

OBJECTIVES: Population-based recruitment of a cohort of women who are currently pregnant or who may become pregnant in a given timeframe presents challenges unique to identifying pregnancy status or the likelihood of future pregnancy. Little is known about the performance of individual eligibility items on pregnancy screeners although they are critical to participant recruitment. This paper examined the patterns and respondent characteristics of key pregnancy screener items used in a large national study. METHODS: Cross-sectional analyses were conducted. Descriptive statistics and multivariable logistic regression models were used to examine nonresponse patterns to three questions (currently pregnant, trying to get pregnant and able to get pregnant). The questions were asked of 50,529 women in 17 locations across the US, as part of eligibility screening for the National Children's Study Vanguard Study household-based recruitment. RESULTS: Most respondents were willing to provide information about current pregnancy, trying, and able to get pregnant: 99.3% of respondents answered all three questions and 97.4% provided meaningful answers. Nonresponse ranged from 0.3 to 2.5% for individual items. Multivariable logistic regression results identified small but statistically significant differences in nonresponse by respondent age, marital status, race/ethnicity-language, and household-based recruitment group. CONCLUSIONS FOR PRACTICE: The high levels of response to pregnancy-related items are impressive considering that the eligibility questions were fairly sensitive, were administered at households, and were not part of a respondent-initiated encounter.

Randomized Trial to Reduce Air Particle Levels in Homes of Smokers and Children.

INTRODUCTION: Exposure to fine particulate matter in the home from sources such as smoking, cooking, and cleaning may put residents, especially children, at risk for detrimental health effects. A randomized clinical trial was conducted from 2011 to 2016 to determine whether real-time feedback in the home plus brief coaching of parents or guardians could reduce fine particle levels in homes with smokers and children. DESIGN: A randomized trial with two groups-intervention and control. SETTING/PARTICIPANTS: A total of 298 participants from predominantly low-income households with an adult smoker and a child aged <14 years. Participants were recruited during 2012-2015 from multiple sources in San Diego, mainly Women, Infants and Children Program sites. INTERVENTION: The multicomponent intervention consisted of continuous lights and brief sound alerts based on fine particle levels in real time and four brief coaching sessions using particle level graphs and motivational interviewing techniques. Motivational interviewing coaching focused on particle reduction to protect children and other occupants from elevated particle levels, especially from tobacco-related sources. MAIN OUTCOME MEASURES: In-home air particle levels were measured by laser particle counters continuously in both study groups. The two outcomes were daily mean particle counts and percentage time with high particle concentrations (>15,000 particles/0.01 ft3). Linear mixed models were used to analyze the differential change in the outcomes over time by group, during 2016-2017. RESULTS: Intervention homes had significantly larger reductions than controls in daily geometric mean particle concentrations (18.8% reduction vs 6.5% reduction, p<0.001). Intervention homes' average percentage time with high particle concentrations decreased 45.1% compared with a 4.2% increase among controls (difference between groups p<0.001). CONCLUSIONS: Real-time feedback for air particle levels and brief coaching can reduce fine particle levels in homes with smokers and young children. Results set the stage for refining feedback and possible reinforcing consequences for not generating smoke-related particles. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT01634334.

And She's Buying a Stairway to Health: Signs and Participant Factors Influencing Stair Ascent at a Public Airport.

Several studies have demonstrated that point-of-choice prompts modestly increase stair use (i.e., incidental physical activity) in many public places, but evidence of effectiveness in airport settings is weak. Furthermore, evaluating the effects of past physical activity on stair use and on point-of-choice prompts to increase stair use is lacking. The purpose of this study was to evaluate the influence of sign prompts and participant factors including past physical activity on stair ascent in an airport setting. We used a quasi-experimental design, systematically introducing and removing sign prompts daily across 22 days at the San Diego International Airport. Intercept interviewers recruited stair and escalator ascenders (N = 1091; 33.0% interview refusal rate) of the only stairs/escalators providing access to Terminal 1 from the parking lot. A 13-item questionnaire about demographics, physical activity, health behavior, and contextual factors provided data not available in nearly all other stair use studies. We examined the effects of signs and self-reported covariates using multivariable logistic regression analyses, and tested whether physical activity and other covariates modified the intervention effect. Adjusting for all significant covariates, prompts increased the odds of stair use (odds ratio 3.67; p < .001). Past participation in vigorous physical activity increased the odds of stair use by 1.62 (p = 0.001). None of the covariates moderated the intervention effect. In conclusion, vigorous physical activity and correlates of physical activity were related to stair use in expected directions, but did not modify the effect of the intervention. This indicates that the effects of point-of-choice prompts are independent of past physical activity, making them effective interventions for active adults and the higher risk population of inactive adults. Signs can prompt stair use in an airport setting and might be employed at most public stairs to increase rates of incidental physical activity and contribute to overall improvements in population health.

Fine particles in homes of predominantly low-income families with children and smokers: Key physical and behavioral determinants to inform indoor-air-quality interventions.

Children are at risk for adverse health outcomes from occupant-controllable indoor airborne contaminants in their homes. Data are needed to design residential interventions for reducing low-income children's pollutant exposure. Using customized air quality monitors, we continuously measured fine particle counts (0.5 to 2.5 microns) over a week in living areas of predominantly low-income households in San Diego, California, with at least one child (under age 14) and at least one cigarette smoker. We performed retrospective interviews on home characteristics, and particle source and ventilation activities occurring during the week of monitoring. We explored the relationship between weekly mean particle counts and interview responses using graphical visualization and multivariable linear regression (base sample n = 262; complete cases n = 193). We found associations of higher weekly mean particle counts with reports of indoor smoking of cigarettes or marijuana, as well as with frying food, using candles or incense, and house cleaning. Lower particle levels were associated with larger homes. We did not observe an association between lower mean particle counts and reports of opening windows, using kitchen exhaust fans, or other ventilation activities. Our findings about sources of fine airborne particles and their mitigation can inform future studies that investigate more effective feedback on residential indoor-air-quality and better strategies for reducing occupant exposures.

Association Between Parental Barriers to Accessing a Usual Source of Care and Children's Receipt of Preventive Services.

OBJECTIVES: Preventive health services are important for child development, and parents play a key role in facilitating access to services. This study examined how parents' reasons for not having a usual source of care were associated with their children's receipt of preventive services. METHODS: We used pooled data from the 2011-2014 National Health Interview Survey (n = 34 843 participants). Parents' reasons for not having a usual source of care were framed within the Penchansky and Thomas model of access and measured through 3 dichotomous indicators: financial barriers (affordability), attitudes and beliefs about health care (acceptability), and all other nonfinancial barriers (accessibility, accommodation, and availability). We used multivariable logistic regression models to test associations between parental barriers and children's receipt of past-year well-child care visits and influenza vaccinations, controlling for other child, family, and contextual factors. RESULTS: In 2014, 14.3% (weighted percentage) of children had at least 1 parent without a usual source of care. Children of parents without a usual source of care because they "don't need a doctor and/or haven't had any problems" or they "don't like, trust, or believe in doctors" had 35% lower odds of receiving well-child care (adjusted odds ratio = 0.65; 95% CI, 0.56-0.74) and 23% lower odds of receiving influenza vaccination (adjusted odds ratio = 0.77; 95% CI, 0.69-0.86) than children of parents without those attitudes and beliefs about health care. Financial and other nonfinancial parental barriers were not associated with children's receipt of preventive services. Results were independent of several factors relevant to children's access to preventive health care, including whether the child had a usual source of care. CONCLUSIONS: Parents' attitudes and beliefs about having a usual source of care were strongly associated with their children's receipt of recommended preventive health services. Rates of receipt of child preventive services may be improved by addressing parents' attitudes and beliefs about having a usual source of care. Future studies should assess causes of these associations.

Feasibility Pilot of a Randomized Faith-Based Intervention to Reduce Secondhand Smoke Exposure Among Korean Americans.

INTRODUCTION: Interventions are needed to prevent exposure to secondhand smoke (SHS), which persists in certain immigrant enclaves, including Koreans in the United States. A faith-based and culturally acceptable intervention was developed and pilot tested in collaboration with Korean churches to address SHS exposure among people of Korean descent. METHODS: A pilot cluster randomized intervention trial was conducted with 11 Korean churches in southern California and 75 Korean adults who were exposed to SHS. Study participants received a multicomponent intervention, which consisted of motivational interviewing by telephone and educational materials tailored with related biblical messages; the intervention was bolstered by church-based group activities and environmental cues. The control group received the same type and frequency of intervention components, but the components related only to fruit and vegetable consumption. Data were collected on the feasibility of the intervention and study procedures. SHS exposure and awareness and knowledge of SHS exposure were assessed by telephone interviews at baseline and follow-up. RESULTS: At follow-up, a larger percentage of the intervention group than the control group reported correct SHS knowledge and disapproval of SHS. The intervention group's SHS exposure was reduced by 8.5 cigarettes per week (vs a reduction of 1 cigarette per week among the control group). CONCLUSIONS: Initial findings are promising for improving knowledge, attitudes, and protective behaviors surrounding SHS exposure. Results suggest that a faith-based intervention for Korean Americans who are exposed to SHS is feasible, acceptable, and potentially effective in reducing their exposure to SHS.

Faith-based intervention to increase fruit and vegetable intake among Koreans in the USA: a feasibility pilot.

OBJECTIVE: In the USA, adults of Korean descent tend to eat fewer vegetables than adults in South Korea. The present pilot study examined the feasibility of developing and implementing a faith-based intervention to improve knowledge, attitudes and intake of fruit and vegetables (F&V) for Koreans in the USA. DESIGN: Feasibility pilot using a cluster-randomized intervention trial design. The multicomponent intervention included motivational interviewing sessions by telephone and church-based group activities. SETTING: Eleven of the largest Korean churches in Southern California. SUBJECTS: Adults (n 71) from the eleven Korean churches. RESULTS: Feasibility was demonstrated for the study procedures, including recruitment of churches and individual participants. Allocating time throughout the study for church collaboration and having a study church coordinator to coordinate multiple churches were crucial. Participants' attendance at church activities (89 %) and participation by pastors and fellow churchgoers exceeded expectations. Participants' use of intervention materials was high (94 % or above) and satisfaction with coaching sessions was also high (75 % or above). Having a centralized coach trained in motivational interviewing, instead of one at each church, proved practical. Pilot results are promising for F&V knowledge, attitudes and behaviours. The intervention group improved knowledge and intake of the recommended amounts of F&V, above that of the control group. CONCLUSIONS: This pilot suggests that Koreans in the USA can be reached through their church and that a faith-based intervention study can be implemented to increase F&V intake. Preliminary results for the intervention appear promising but further research is needed to properly evaluate its efficacy.

Developing and Selecting Auditory Warnings for a Real-Time Behavioral Intervention.

Real-time sensing and computing technologies are increasingly used in the delivery of real-time health behavior interventions. Auditory signals play a critical role in many of these interventions, impacting not only behavioral response but also treatment adherence and participant retention. Yet, few behavioral interventions that employ auditory feedback report the characteristics of sounds used and even fewer design signals specifically for their intervention. This paper describes a four-step process used in developing and selecting auditory warnings for a behavioral trial designed to reduce indoor secondhand smoke exposure. In step one, relevant information was gathered from ergonomic and behavioral science literature to assist a panel of research assistants in developing criteria for intervention-specific auditory feedback. In step two, multiple sounds were identified through internet searches and modified in accordance with the developed criteria, and two sounds were selected that best met those criteria. In step three, a survey was conducted among 64 persons from the primary sampling frame of the larger behavioral trial to compare the relative aversiveness of sounds, determine respondents' reported behavioral reactions to those signals, and assess participant's preference between sounds. In the final step, survey results were used to select the appropriate sound for auditory warnings. Ultimately, a single-tone pulse, 500 milliseconds (ms) in length that repeats every 270 ms for 3 cycles was chosen for the behavioral trial. The methods described herein represent one example of steps that can be followed to develop and select auditory feedback tailored for a given behavioral intervention.

Promoting smoke-free homes: a novel behavioral intervention using real-time audio-visual feedback on airborne particle levels.

Interventions are needed to protect the health of children who live with smokers. We pilot-tested a real-time intervention for promoting behavior change in homes that reduces second hand tobacco smoke (SHS) levels. The intervention uses a monitor and feedback system to provide immediate auditory and visual signals triggered at defined thresholds of fine particle concentration. Dynamic graphs of real-time particle levels are also shown on a computer screen. We experimentally evaluated the system, field-tested it in homes with smokers, and conducted focus groups to obtain general opinions. Laboratory tests of the monitor demonstrated SHS sensitivity, stability, precision equivalent to at least 1 µg/m(3), and low noise. A linear relationship (R(2) = 0.98) was observed between the monitor and average SHS mass concentrations up to 150 µg/m(3). Focus groups and interviews with intervention participants showed in-home use to be acceptable and feasible. The intervention was evaluated in 3 homes with combined baseline and intervention periods lasting 9 to 15 full days. Two families modified their behavior by opening windows or doors, smoking outdoors, or smoking less. We observed evidence of lower SHS levels in these homes. The remaining household voiced reluctance to changing their smoking activity and did not exhibit lower SHS levels in main smoking areas or clear behavior change; however, family members expressed receptivity to smoking outdoors. This study established the feasibility of the real-time intervention, laying the groundwork for controlled trials with larger sample sizes. Visual and auditory cues may prompt family members to take immediate action to reduce SHS levels. Dynamic graphs of SHS levels may help families make decisions about specific mitigation approaches.

Sensitivity to secondhand smoke exposure predicts future smoking susceptibility.

OBJECTIVE: Susceptibility to cigarette smoking in tobacco-naive youth is a strong predictor of smoking initiation. Identifying mechanisms that contribute to smoking susceptibility provide information about early targets for smoking prevention. This study investigated whether sensitivity to secondhand smoke exposure (SHSe) contributes to smoking susceptibility. PARTICIPANTS AND METHODS: Subjects were high-risk, ethnically diverse 8- to 13-year-old subjects who never smoked and who lived with at least 1 smoker and who participated in a longitudinal SHSe reduction intervention trial. Reactions (eg, feeling dizzy) to SHSe were assessed at baseline, and smoking susceptibility was assessed at baseline and 3 follow-up measurements over 12 months. We examined the SHSe reaction factor structure, association with demographic characteristics, and prediction of longitudinal smoking susceptibility status. RESULTS: Factor analysis identified "physically unpleasant" and "pleasant" reaction factors. Reported SHSe reactions did not differ across gender or family smoking history. More black preteens reported feeling relaxed and calm, and fewer reported feeling a head rush or buzz compared with non-Hispanic white and Hispanic white counterparts. Longitudinally, 8.5% of subjects tracked along the trajectory for high (versus low) smoking susceptibility. Reporting SHSe as "unpleasant or gross" predicted a 78% reduction in the probability of being assigned to the high-smoking susceptibility trajectory (odds ratio: 0.22 [95% confidence interval: 0.05-0.95]), after covariate adjustment. CONCLUSIONS: Assessment of SHSe sensitivity is a novel approach to the study of cigarette initiation etiology and informs prevention interventions.

Providing coaching and cotinine results to preteens to reduce their secondhand smoke exposure: a randomized trial.

BACKGROUND: Secondhand smoke exposure (SHSe) poses health risks to children living with smokers. Most interventions to protect children from SHSe have coached adult smokers. This trial determined whether coaching and cotinine feedback provided to preteens can reduce their SHSe. METHODS: Two hundred one predominantly low-income families with a resident smoker and a child aged 8 to 13 years who was exposed to two or more cigarettes per day or had a urine cotinine concentration ≥ 2.0 ng/mL were randomized to control or SHSe reduction coaching groups. During eight in-home sessions over 5 months, coaches presented to the child graphic charts of cotinine assay results as performance feedback and provided differential praise and incentives for cotinine reductions. Generalized estimating equations were used to determine the differential change in SHSe over time by group. RESULTS: For the baseline to posttest period, the coaching group had a greater decrease in both urine cotinine concentration (P = .039) and reported child SHSe in the number of cigarettes exposed per day (child report, P = .003; parent report, P = .078). For posttest to month 12 follow-up, no group or group by time differences were obtained, and both groups returned toward baseline. CONCLUSIONS: Coaching preteens can reduce their SHSe, although reductions may not be sustained without ongoing counseling, feedback, and incentives. Unlike interventions that coach adults to reduce child SHSe, programs that increase child avoidance of SHSe have the potential to reduce SHSe in all settings in which the child is exposed, without requiring a change in adult smoking behavior.

Sensitivity to secondhand smoke exposure predicts smoking susceptibility in 8-13-year-old never smokers.

PURPOSE: To investigate the sensitivity to secondhand smoke exposure (SHSe) in preteens aged 8-13 years who have never smoked, and to determine whether it predicts smoking susceptibility. METHODS: We assessed the sensitivity to SHSe using reactions commonly used for the assessment of sensitivity to the first-smoked cigarette (e.g., feeling dizzy), and investigated the factor structure of these reactions for the purpose of data reduction. We examined the association of each reaction measure and summary score with demographic characteristics and smoking susceptibility, using logistic regression and ordinal logistic regression. RESULTS: One factor was identified that captured the physical and/or unpleasant reactions. Older preteens and preteens with more highly educated parents reported fewer reactions to SHSe. More African American preteens reported feeling relaxed or calm compared with all other racial/ethnic groups. Experiencing physical and/or unpleasant reactions to SHSe predicted lower risk for smoking susceptibility. CONCLUSIONS: This was the first study to extend analytical methodology for sensitivity to active smoking to sensitivity to SHSe in youth who had never smoked. Results suggest a desensitization process with age and lower sensitivity to some reactions in preteens from more highly educated households. Preteens who have more aversive experiences with SHSe tend to be less susceptible to smoking than those who experience fewer aversive reactions. Assessment of sensitivity to SHSe is a novel approach to the study of cigarette use etiology and may contribute to better prediction of smoking initiation.

Cultural and social network predictors of drinking among Korean American women.

This study estimated the association of cultural and social mechanisms with Korean American women's drinking behaviors. Data were drawn from telephone interviews with 591 Korean women selected from a random sample of households in California with Korean surnames during 2007. About 62% of eligible respondents completed the interview. Respondents reported any lifetime drinking (yes/no), drinking volume (typical number of drinks consumed on drinking days), level of acculturation, and described their social network by assessing who encouraged or discouraged drinking (drinking support) or drank (drinking models). Multivariable regressions were used for analyses. About 70% (95% confidence interval [95%CI]:, 67, 74) of Korean American women reported any lifetime drinking and current drinkers drank 1.18 (95%CI: 1.07, 1.28) drinks on drinking days. Acculturation was not significantly associated with any lifetime drinking or drinking volume, whereas models and support for drinking were statistically significantly associated with a higher probability of any lifetime drinking and drinking more on drinking days. Each additional encourager, or one or fewer discourager, for drinking in women's social networks was associated with a 2% (95%CI: 1, 3) higher probability of any lifetime drinking and drinking 0.25 (95%CI: -0.53, 1.18) more drinks on drinking days. Each additional drinker in women's networks was associated with a 4% (95%CI: 1, 8) higher probability of any lifetime drinking and drinking 0.26 (95%CI: -0.05, 0.60) more drinks on drinking days. Korean American women's drinking appears to be strongly related to their social networks, although how women take on traits of their new environment was not.

Reactions to secondhand smoke by nonsmokers of Korean descent: clash of cultures?

Koreans hail from a culture where men's smoking and secondhand smoke (SHS) exposure were the norm. Little is known about how nonsmokers of Korean descent respond to smokers in the United States. In 2007-2008, trained moderators conducted eight focus groups with nonsmokers (n = 47) of Korean descent in San Diego. Participants discussed their personal experiences and views concerning SHS. Most participants detected SHS quickly and disliked the smell. Their reactions differed by gender, age, and how well they knew the smoker. Reactions ranged from passive (e.g., tolerating SHS or staring) to assertive (moving or asking the smoker to stop smoking). Younger participants were more tolerant than older participants. Participants appeared caught between two cultures. Despite high awareness, they struggled with how to avoid SHS in a manner befitting of their social status and Korean values. Culturally sensitive programs are needed for immigrants such as Koreans in the United States.

Smoking on both sides of the pacific: home smoking restrictions and secondhand smoke exposure among Korean adults and children in Seoul and California.

INTRODUCTION: This study, informed by ecological frameworks, compared the prevalence, predictors, and association of home smoking restrictions with secondhand smoke exposure (SHSe) between Koreans in Seoul, South Korea, and Korean Americans in California, United States. METHODS: A cross-sectional survey was drawn from telephone interviews with Korean adults in Seoul (N = 500) and California (N = 2,830) during 2001-02. Multivariable regressions were used for analyses. RESULTS: Koreans, compared with Korean Americans, had significantly fewer complete home smoking bans, 19% (95% CI: 16-23) versus 66% (95% CI: 64-68), and were more likely to not have a home smoking restriction, 64% (95% CI: 60-69) versus 5% (95% CI: 4-6). Home smoking restrictions were associated with lower home SHSe; however, the impact was consistently larger among Korean Americans. Households with more SHSe sources were less likely to have the strongest home smoking restrictions, where the difference in complete bans among Korean Americans versus Koreans was largely among those at low risk of SHSe, 82% (95% CI: 76-86) versus 36% (95% CI: 17-57), while high-risk Korean American and Koreans had similar low probabilities, 10% (95% CI: 7-13) versus 7% (95% CI: 3-13). CONCLUSIONS: Consistent with ecological frameworks, exposure to California's antismoking policy and culture was associated with stronger home smoking restrictions and improved effectiveness. Interventions tailored to Korean and Korean American SHSe profiles are needed. Behavioral interventions specifically for high-risk Korean Americans and stronger policy controls for Koreans may be effective at rapidly expanding home smoking restrictions.

Secondhand smoke avoidance by preteens living with smokers: to leave or stay?

INTRODUCTION: Secondhand smoke (SHS) is hazardous to children's health. Designing interventions to reduce exposure requires understanding children's behavior in the presence of smokers, yet little is known about this behavior. PURPOSE: To determine whether children's avoidance of SHS is associated with lower exposure and to explore predictors of avoidance based on a behavioral ecological model. METHOD: Preteens aged 8-13 (N=358) living with a smoker identified their primary source of SHS exposure, and reported whether they left (avoided exposure) or stayed the last time they were exposed to that person's smoke. The SHS avoidance measure was validated by examining associations with SHS exposure. Multiple Logistic Regression was used to determine predictors of SHS avoidance. RESULTS: Based on urine cotinine and reported exposure, preteens who left the presence of SHS had lower exposure than those who stayed. Preteens were more likely to leave SHS if they were less physically mature, had not tried smoking, had a firm commitment not to smoke, did not assist family smoking, had family/friends who discouraged breathing SHS, or had friends who disliked smoking. DISCUSSION: Most SHS exposure reduction interventions have targeted changes in smokers' behavior. Reductions can also be achieved by changing exposed nonsmokers' behavior, such as avoiding the exposure. Future studies should measure young people's SHS avoidance and test interventions to increase their avoidance practices.

It's others, not the police: smoking, reprimand, and fines among adults of Korean descent in California.

OBJECTIVE: This study assesses the association of immediate social and legal reprimand and current smoking status among Californians of Korean descent. DESIGN: Data were drawn from a population-based probability sample using a telephone survey conducted by bilingual, professional interviewers (N = 2085). About 85.0% of eligible respondents completed interviews and 86.3% of participants preferred to be interviewed in Korean. MAIN OUTCOME MEASURE: Smoking status was measured using Centers for Disease Control and Prevention criteria, ever smoked 100 cigarettes and currently smoke every day or some days. RESULTS AND CONCLUSION: Reports of immediate criticism by others in several settings was associated with nonsmoking, but likelihood of immediate legal penalties was unrelated. Participants were far less likely to expect legal than social sanction. Results were replicated after controlling for reinforcers of smoking and ecologically relevant variables including models of smoking, primary group social support for smoking, acculturation, sex, acculturation by sex (male) interaction, age, and education. It may be efficacious to target public health interventions encouraging appropriate social sanctions of smoking in public among persons of Korean descent, and to encourage strict enforcement of legal penalties for smoking in public places.