Negotiating health: A qualitative analysis of home smoking rules among families with medically vulnerable infants.
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INTRODUCTION: Approximately 5000 child deaths are attributed to secondhand smoke exposure (SHSe) annually, which is three times the number of childhood cancers combined. Infants, medically fragile infants, are highly vulnerable to the harmful effects of SHSe, including respiratory infections and sudden infant death syndrome. While having a home smoking ban may mitigate these risks, implementation remains a challenge for many families. Our primary aim was to explore the familial and sociocultural factors associated with smoking-ban initiation and maintenance in households with medically fragile infants. METHODS: Qualitative interviews were conducted with 20 mothers participating in a behavioral intervention from 2015 to 2016 aimed at reducing SHSe in infants discharged from a large urban, children's hospital in Houston, Texas. Interviews explored family structure, cultural influences, social networks, and smoking history. Thematic analysis was used to identify key themes. RESULTS: Three primary themes emerged: 1) Household structure and power dynamics - mothers in multigenerational homes often lacked authority to enforce smoking bans, especially when the primary authority figure was a smoker; 2) Sole responsibility - mothers felt burdened as the only advocates for SHSe reduction, often without support from other household members; and 3) Variable level of support for SHS bans - while emotional and logistical support was common during infants' hospital stays, this support rarely extended to smoking-related behavior change. Participants felt these factors significantly influenced smoking-ban initiation and sustainability. CONCLUSIONS: Findings underscore the need to move beyond individual-level interventions and engage the broader household context. Intervention sessions should include all household members - particularly individuals who smoke - and incorporate collaborative care models that offer behavioral counseling, pharmacological aids (e.g. nicotine replacement therapy), and real-time feedback technologies. Tailoring interventions to reflect household power structures and support systems may enhance their effectiveness in reducing SHSe and protecting medically vulnerable infants.