Secondhand smoke education interventions

Evidence Rating  
Evidence rating: Mixed Evidence

Strategies with this rating have been tested more than once and results are inconsistent or trend negative; further research is needed to confirm effects.

Health Factors  
Date last updated

Secondhand smoke education informs smokers and non-smokers of the dangers of secondhand smoke. These efforts encourage smokers to smoke less in their homes and both smokers and non-smokers to implement home smoking bans, and can incorporate cessation interventions. Education can be delivered through counseling, health care programs, home visiting, informational materials, or media messages. Educational efforts may be implemented alone, combined with biological feedback (e.g., cotinine feedback), or delivered as part of a multi-component intervention1.

Note: The term “tobacco” in this strategy refers to commercial tobacco, not ceremonial or traditional tobacco. County Health Rankings & Roadmaps recognizes the important role that ceremonial and traditional tobacco play for many Tribal Nations, and our tobacco-related work focuses on eliminating the harms and inequities associated with commercial tobacco.

What could this strategy improve?

Expected Benefits

Our evidence rating is based on the likelihood of achieving these outcomes:

  • Reduced exposure to secondhand smoke

What does the research say about effectiveness?

There is mixed evidence about the effects of secondhand smoke education on tobacco use and secondhand smoke (SHS) exposure in the home. Educational interventions have been shown to reduce SHS exposure in some circumstances, but often appear to have no effect on exposure. Additional evidence is needed to confirm effects and understand which specific interventions are effective1, 2.

Intensive parental counseling and motivational interviewing have been shown to reduce children’s SHS exposure in some circumstances, but often have no effect on SHS exposure1, 2, 3. Home visits from counselors or coaches appear to reduce SHS in homes, though some tobacco smoke pollution remains4. Selected interventions for families with infants and small children may also increase home smoking bans and family avoidance of SHS5.

Overall, less intensive interventions, such as brief advice or counseling for family and caregivers, do not appear to affect SHS exposure1. However, select interventions such as the United Way’s Smoke-Free Homes program, a Georgia, Texas, and North Carolina-based effort that includes three mailings and a coaching call, appear to increase home smoking bans and reduce short-term SHS exposure among both smokers and non-smokers, low income families with and without children, and among blacks6, 7, 8, 9 and Latinos6.

A study of asthma education and motivational interviewing for parents of premature infants in a Rochester, NY NICU suggests a combined approach may reduce infant SHS exposure more than education alone, but differences were not sustained over the longer term10. Similarly, a study of families receiving a multi-component intervention to reduce SHS exposure among children undergoing treatment at a pediatric oncology hospital indicates that participating families were more likely to adopt a home smoking ban by three months than peer families. By 12 months, both groups were equally likely to have a ban in place11, 12; however, children did not experience a significant change in cotinine levels (a biomarker of recent SHS exposure) in either group12.

An assessment of a parental counseling intervention for SHS reduction and smoking cessation suggests such interventions can increase short-term tobacco cessation among mothers13, 14. A China-based study suggests that mobile health-based interventions combined with face-to-face counseling and educational materials can increase smoking cessation by fathers and reduce SHS exposure for mothers and newborns15.

How could this strategy impact health disparities? This strategy is rated likely to increase disparities.
Implementation Examples

The Centers for Disease Control and Prevention provides information on the health dangers of secondhand smoke (SHS) for children and offers culturally relevant brochures to encourage parents and guardians to establish home smoking bans16.

Emory University’s Rollins School of Public Health’s Smoke-Free Homes Project provides guidance on how to create a smoke-free home rule; the program partners with social service and public health organizations nationwide to offer smoke-free homes kits and coaching call guides17.

Implementation Resources

ANRF-Smokefree - American Nonsmokers’ Rights Foundation (ANRF). Smokefree lists, maps, and data.

US EPA-Smoke-free homes kit - U.S. Environmental Protection Agency (U.S. EPA). National Service Center for Environmental Publications (NSCEP). Smoke-free homes community action kit.

ALA-Smoke-free housing - American Lung Association (ALA). Smokefree policies in multi-unit housing: Steps for success.


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1 Cochrane-Behbod 2018 - Behbod B, Sharma M, Baxi R, et al. Family and carer smoking control programmes for reducing children's exposure to environmental tobacco smoke. Cochrane Database of Systematic Reviews. 2018;(1):CD001746.

2 Baxter 2011 - Baxter S, Blank L, Everson-Hock ES, et al. The effectiveness of interventions to establish smoke-free homes in pregnancy and in the neonatal period: A systematic review. Health Education Research. 2011;26(2):265-82.

3 Collins 2015 - Collins BN, Nair US, Hovell MF, et al. Reducing underserved children's exposure to tobacco smoke: A randomized counseling trial with maternal smokers. American Journal of Preventive Medicine. 2015;49(4):534-544.

4 Rosen 2015 - Rosen LJ, Myers V, Winickoff JP, Kott J. Effectiveness of interventions to reduce tobacco smoke pollution in homes: A systematic review and meta-analysis. International Journal of Environmental Research and Public Health. 2015;12(12):16043-16059.

5 Brown 2015 - Brown N, Luckett T, Davidson PM, DiGiacomo M. Interventions to reduce harm from smoking with families in infancy and early childhood: A systematic review. International Journal of Environmental Research and Public Health. 2015;12(3):3091-3119.

6 Mullen 2016 - Mullen PD, Savas LS, Bundy ?T, et al. Minimal intervention delivered by 2-1-1 information and referral specialists promotes smoke-free homes among 2-1-1 callers: A Texas generalisation trial. Tobacco Control. 2016;25(Suppl 1):i10-i18.

7 Williams 2016 - Williams RS, Stollings JH, Bundy ?, et al. A minimal intervention to promote smoke-free homes among 2-1-1 callers: North Carolina randomized effectiveness trial. PLOS ONE. 2016;11(11):e0165086.

8 Kegler 2015 - Kegler MC, Bundy L, Haardorfer R, et al. A minimal intervention to promote smoke-free homes among 2-1-1 callers: A randomized controlled trial. American Journal of Public Health. 2015;105(3):530-537.

9 Kegler 2012 - Kegler MC, Escoffery C, Bundy L, et al. Pilot study results from a brief intervention to create smoke-free homes. Journal of Environmental and Public Health. 2012;2012:951426.

10 Blaakman 2015 - Blaakman SW, Borrelli B, Wiesenthal EN, et al. Secondhand smoke exposure reduction after NICU discharge: Results of a randomized trial. American Pediatrics. 2015;15(6):605-612.

11 Nicholson 2015 - Nicholson JS, McDermott MJ, Huang Q, Zhang H, Tyc VL. Full and home smoking ban adoption after a randomized controlled trial targeting secondhand smoke exposure reduction. Nicotine & Tobacco Research. 2015;17(5):612-616.

12 Tyc 2013 - Tyc VL, Huang Q, Nicholson J, et al. Intervention to reduce secondhand smoke exposure among children with cancer: A controlled trial. Psycho-Oncology. 2013;22(5):1104-1111.

13 Hovell 2009 - Hovell MF, Zakarian JM, Matt GE, et al. Counseling to reduce children’s secondhand smoke exposure and help parents quit smoking: A controlled trial. Nicotine & Tobacco Research. 2009;11(12):1383-1394.

14 Liles 2009 - Liles S, Hovell MF, Matt GE, Zakarian JM, Jones JA. Parent quit attempts after counseling to reduce children’s secondhand smoke exposure and promote cessation: Main and moderating relationships. Nicotine & Tobacco Research. 2009;11(12):1395-1406.

15 Yu 2017a - Yu S, Duan Z, Redmon PB, et al. mHealth intervention is effective in creating smoke-free homes for newborns: A randomized controlled trial study in China. Scientific Reports. 2017;7(1):9276.

16 CDC-SHS protection - Centers for Disease Control and Prevention (CDC). Smoking & Tobacco Use: How we can protect our children from secondhand smoke (SHS).

17 Emory-Smoke-Free Homes - Emory University, Rollins School of Public Health. Smoke-Free Homes Project.