A family affair: aboriginal women's efforts to limit second-hand smoke exposure at home.

Bottorff, Joan L. ; Johnson, Joy L. ; Carey, Joanne 等

Exposure to second-hand smoke (SHS) in homes is an important contributor to inequalities in maternal and child health in Aboriginal communities. Although Aboriginal communities have begun to introduce smoke-free public places, significant gaps remain in protection from SHS in reserve communities. (1,2) With over half of the Aboriginal population reporting that they smoke, protection from SHS in homes is particularly a high priority in Aboriginal communities. (3)

Although there has been increasing interest in SHS exposure in homes, (4-9) only one study was found that addressed attitudes toward SHS in Indigenous communities. In this Australian study, smoking cessation was associated with increased motivation to establish smoke-free homes to protect child health. (10) No studies have examined this issue from the point of view of women engaged in childrearing in First Nations communities in Canada. The objective of this study was to explore factors influencing smoking in home environments and First Nations women's efforts to minimize exposure for their children and themselves. Recognizing the difficulties of reducing smoking among disadvantaged smokers, (11,12) finding ways to support smoking bans in homes is important for protecting the health of children and others by reducing exposure to SHS.

METHODS

This research was carried out as part of a larger community-based ethnographic research project that was initiated by community members and involved a collaboration with university-based researchers to identify ways to reduce exposure to SHS.

Study context

The study took place in the northwest region of BC with the Gitxsan First Nations and involved participants from six small reserve communities who identified as Gitxsan and Wet'suwet'en. While there is a 20-year history of individual leaders creating smoke-free spaces in these communities, (13) the issue of smoking in domestic space, as is the case in most communities, is unregulated.

Data collection

Participants were recruited using local media, presentations to community groups and through snowballing. Data were collected over a two-year period (2006-2008) and involved 4 individual semi-structured interviews and 25 focus group discussions (conducted as a series of 2-3 discussions held over several weeks) with 26 women 17-35 years of age who were pregnant or parenting young children. Participants included ex-smokers (n=7), occasional smokers (n=9) and daily smokers (n=10). A focus group with 7 women aged 27-57 who were not primary caregivers of young children was also conducted. Also interviewed were key informants including community leaders in health, education, development and governance (n=15), elders (n=9), middle-aged women (n=7), and youth (n=6). Most interviews were conducted by the community research assistant (RM) who grew up in the area and was a band member. Other members of the research team conducted the remaining interviews. The interview guide included questions about what life was like for women and children in the community, especially in regard to SHS exposure.

Data analysis

An inductive approach was used in which researchers read transcribed data and highlighted key phrases to identify coding categories. Coding was completed using the qualitative software program Nvivo (14) and retrieved for detailed analysis. Findings were shared with individuals and groups in the community during the project to validate and refine interpretations.

RESULTS

There were conflicting reports about how many homes with young children were smoke-free in the study communities. Nevertheless, the women were clearly aware of the importance of protecting children from SHS. Yet despite efforts to educate family and friends, they indicated they were not consistently successful in changing smoking patterns to protect children.

Other parents, they smoke in their house. But they know I'll pack my kids up and leave and they just don't grasp that the thing where you can't smoke in front of them. (28-year-old woman, daily smoker)

Some participants proudly reported that their families were non-smokers or that they had successfully established smoke-free homes. However, challenges in protecting themselves and their children from SHS were experienced. These challenges were not unlike those experienced by other women who lived with smokers. Themes identified that describe these challenges were social dimensions of smoking in extended families, and the structural and relational influences on women's efforts to minimize household SHS to protect children's health.

Social dimensions of smoking in extended families

In the study communities, extended family networks provided a critically important dimension of life. Despite the effects of unemployment, poverty, and collective experiences related to the consequence of residential schools, strong connections within and among families were evident in daily life. These connections were important in fostering involvement in shared activities that supported health (e.g., sharing traditional foods). However, these connections also increased pressures to smoke, particularly in households where smoking was part of everyday interactions, celebrations and other family events. Smoking reflected and strengthened social bonds, and enabled family life by helping individuals manage the stresses of disadvantage as well as shared losses.

Because of who we are as Gitxsan First Nations people and where we are situated and how connected we are to families around our area ... you know everybody comes together.... I mean you go to anybody's home where there's a deceased within that home, you'll find probably 75% of the people that are there to comfort the family are outside the home smoking, right? (Key informant, Community worker)

Many participants remarked they were given their first cigarettes by well-meaning parents or relatives at young ages, and that it was not uncommon for older relatives to share their cigarettes with younger family members. As such, smoking and exposure to SHS both inside and outside the home was a part of life course for most.

Structural influences on women's efforts to minimize household SHS

Housing, economics, and the rural context were key structural factors in the study communities that influenced women's efforts to minimize SHS. The demand for safe and affordable housing far exceeded the supply. As a result, young families, unable to find accommodation to live on their own, shared housing with others. This created a situation where many of the homes were overcrowded, and women felt like guests in the house. Consequently, many felt they had little control over the home environment. As one woman explained:

Yeah, a lot of people are living with their partner's parents and their partner's siblings and maybe their uncle who doesn't have a house right now and, they'll be lots of time, 13, 15 people in a house with 3 bedrooms and you know, it's hard to have a relationship when you have no privacy and it's hard to raise your kids when your parents and aunts and uncles are there telling you how to raise your kids. (Key informant, Community worker)

Other factors also contributed to women's lack of influence in this situation. Many of the women with children were young and lacked support. Some were single mothers; others who were partnered often found themselves on their own for extended periods while their partners worked outside the community. Grandparents were often not available to offer assistance. Furthermore, many of the young women we spoke with did not have the financial resources needed to make significant contributions to rent or other household expenses. As a result, some had limited say about what went on in the home. One of the health care providers described these difficult domestic situations, highlighting that despite efforts to be healthy, young women were at times negatively affected by the home context.

I go out to the family and or to the young mom or couple and inquire if there is a pregnancy there and then we start saying okay, you know what you're not supposed to do during pregnancy and some are really abiding. But, if they're in a home where there's a lot of alcohol and a lot of smoking you know, even though they're trying, they're still inhaling it and sometimes even participating one night or whatever. It still goes on. (Key informant, Health worker)

It was suggested that women required a very strong personality if they were to assert their desire to have a smoke-free home. While many women could not request that smoking be taken outside for their own benefit, the presence of a child sometimes influenced smoking behaviour.

When I was pregnant, they smoked in the house. They asked me if I wanted them to smoke outside but it's their house. I can't just say nope, you gotta smoke outside. I could have and would have but ... it's just didn't feel it was my place to tell them what to do. And once I had a baby they started smoking outside. I think just a week before I think they started smoking outside. (23-year-old woman, occasional smoker)

Sometimes, the women enlisted the help of a partner to convince family members to remove their smoking. This was met with mixed results.

I just tried to get (partner) to talk to them but he said he can't really do anything cause it's their house. And for a while they went in their bedroom but when the door opens just a big cloud of smoke comes out and goes everywhere in the house again. (19-year-old woman, occasional smoker)

High unemployment levels and the rural context meant more people spent time at home. In addition, the climate in this northern community, especially in winter, made smoking outside uncomfortable and unappealing. As a result, some women felt they had to acquiesce and not complain about smoking in the home.

Relational factors influencing women's efforts to minimize household SHS

To protect children's health, the women negotiated competing demands related to preserving family relationships and respecting others' need to smoke. Accordingly some women were unsure about how to bring up the issue of smoking with their partners or family in effective ways. Even the most assertive women had moments when they wavered and allowed guests to smoke in their home because they did not want to be perceived as impolite and ungracious. While some women relied on relatives' smoke-free homes for temporary refuge from smoky family gatherings, not everyone had this option. Others jeopardized family relationships and made personal sacrifices to protect their children from SHS.

Yeah, when it comes to my kids I'll do anything. Tell anybody to go somewhere else. Like it was real hard for my mom 'cause it took us so long just to talk socially. 'Cause I was really pissed off at her 'cause she gave us up. And then for me to ask her to go outside when my son was born was just like chaotic for her. Just put up the nastiest fight ever and then I was just like well, you're gonna smoke in your house? I'm moving out. So we moved out and then she finally got the picture with the rest of my kids. Gotta go outside. (33-year-old woman, daily smoker)

There were also times when young women needed to depend on family members who smoked for child care and in these situations they lacked control over SHS exposure. For example, one elder described how fathers smoked around their infants while their wives were at work.

Success stories

A number of success stories suggested that positive changes were also occurring. Actions by hereditary chiefs and councils to support smoke-free public events that involved children provided a strong demonstration of the importance of protecting child health, and undoubtedly influenced smokers. It was frequently commented that people were observed standing outside their homes and smoking. As one person stated, "I see the young parents standing outside even though it's real freezing cold they smoke outside. It's out of respect for the kids." That a new norm of non-smoking homes may be in the process of emerging in the community was also evident in this comment: "I think I'm pretty much the only one around (laughs) who has smoking in their household." Many of these positive changes had occurred over the course of a generation. Older adults who had smoked in the presence of their children were now creating a smoke-free environment for their children.

Even though my parents smoked with us in the house and now that they have all these grandkids because I gave them three grandkids and my brother gave them three and my sister gave them two. They don't smoke in the house like, my dad goes in his own little cubby hole and stays in there and smokes outside he won't have smoke around them, all of the sudden they got smart after we had kids. (28-year-old woman, daily smoker)

A number of women told stories about how they had successfully asked others not to smoke in front of their children. While on occasion they were met with shock or resistance, this request resulted in a change in practise for some.

Yeah, that's how it was at (name), when he would come in with smoke, I would just tell him straight out, I don't smoke in front of my kids, you're not going to smoke in from of my kids. I go, it's your house but, smoke outside. He was really shocked [RA: Did he do it?] Yeah, he sees us coming, he runs outside and he smokes outside, opens all the windows up. (28-year-old woman, daily smoker)

DISCUSSION

The findings indicate that a growing social norm toward smoke-free homes in the study communities may help to mitigate the challenges women encounter in minimizing SHS exposure. While the women's experiences need to be understood in relation to norms that position smoking as an accepted strategy for reducing stress and promoting socialization, and community values that include a high respect for individual freedoms and reciprocity, our findings show that women's difficulties in establishing and maintaining smoke-free homes are also related to housing shortages, unemployment, dynamics within families and gender roles. Women often lacked the support of family members and control over domestic space. Based on data from Statistics Canada, (15) unemployment rates in the region were high (33-50% for men and 11-41% for women). Others have suggested that low SES girls and women often encounter difficulties in negotiating smoke-free homes. (7,16)

Although the findings cannot be generalized beyond the study communities, insights gained provide useful considerations for addressing SHS in First Nations communities where exposure in homes is influenced by high rates of smoking, shortage of housing, and poverty. Our results support calls for a comprehensive approach to tobacco control in First Nations communities related to the social determinants of health. (17) This study highlights the need to involve stakeholders with responsibilities for band housing and community economic development. Housing policy in part determines family and inter/intra generational dynamics and contributes to exposure to SHS. Women need to be supported in their efforts to decrease SHS in home environments. This can be accomplished through public education initiatives to enhance understanding of the health effects of SHS and extend the responsibility for protecting children from SHS to all those who find themselves in the company of children. Increasing the visibility of smoke-free homes in communities could also help strengthen emerging social norms. Success stories related to smoke-free homes could be publicized to provide models and incentives for others. For example, promoters of the Blue Light Project visited over 800 homes in one Manitoba reserve and gave out over 300 blue lights to those who declared their homes smoke-free. (18) Endorsement of these activities by hereditary chiefs and council members as well as community groups could also support changes. Although women-centred, harm reduction programs designed to encourage low-income mothers to smoke away from their children, such as the STARSS (Start Thinking About Reducing Secondhand Smoke), (19) have been well received, it may be helpful to use such programs in conjunction with other family- and community-oriented interventions in reserve communities.

In conclusion, SHS in households presents a multifaceted challenge to First Nations women who are motivated to protect their health and the health of their children. Increasing the prevalence of smoke-free homes can be supported through housing policies, initiatives that promote a social climate of shared responsibility in establishing smoke-free homes, and continuing efforts to reduce the prevalence of smoking.

Acknowledgements: This study was conducted as part of the Gitxsan TRYAMP (Tobacco Reduction for Young Aboriginal Mothers and Families Project) funded by the Canadian Institutes of Health Research (CIHR) [Project #ACB-77334], and supported by Gitxsan Health Society and Gitsegukla Health Centre. The First Nation Inuit Health Branch of Health Canada provided funding to implement strategies to reduce the effects of SHS and to supplement the costs of research activities. This research was also supported by CIHR and Michael Smith Foundation for Health Research (MSFHR) Postdoctoral Awards to Dr. Hutchinson. We also thank Wanda Williams, Community Health Representative, Gitsegukla Health Programs and Services for her advice and assistance with research activities.

Conflict of Interest: None to declare.

Received: May 19, 2009 Accepted: October 8, 2009

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Joan L. Bottorff, PhD, RN, FCAHS, [1] Joy L. Johnson, PhD, RN, FCAHS, [2] Joanne Carey, MA, [3] Peter Hutchinson, PhD, [4] Debbie Sullivan, BSN, MEd, [5] Roberta Mowatt, [6] Dennis Wardman, MD, FRCPC [7]

Author Affiliations

[1.] Professor, Institute for Healthy Living and Chronic Disease Prevention, University of British Columbia Okanagan, Kelowna, BC

[2.] Professor, School of Nursing, University of British Columbia, Vancouver, BC

[3.] Research Coordinator, Institute for Healthy Living and Chronic Disease Prevention, University of British Columbia Okanagan, Kelowna, BC

[4.] Postdoctoral Fellow, Institute for Healthy Living and Chronic Disease Prevention, University of British Columbia Okanagan, Kelowna, BC

[5.] Community Health Nurse, Gitsegukla Health Programs and Services, Gitsegukla, BC

[6.] Research Assistant, Institute for Healthy Living and Chronic Disease Prevention, University of British Columbia Okanagan, Kelowna, BC

[7.] First Nation Inuit Health Branch, Pacific Region, Health Canada, Vancouver, BC

Correspondence: Dr. Joan L. Bottorff, Institute for Healthy Living and Chronic Disease Prevention, University of British Columbia Okanagan, 3333 University Way, Kelowna, BC V1V 1V7, Tel: 250-807-8627, E-mail: [email protected]