Dr. K. R. Thankappan and P. Sreedevi
In India it is estimated that there are nearly 275 million (35 percent) tobacco users. Close to half (48%) of men and one fifth of women in India use some form of tobacco. Among the five greatest risk factors of mortality, tobacco use is world’s leading single preventable cause of death. When smokers smoke in their homes there is a major risk of other household members suffering due to second hand smoke related illness.

Tobacco Use in Kerala
According to Global Adult Tobacco Survey 2010 report, among the total adult population in Kerala 35.5% males and 8.5% females currently use some form of tobacco. Although the smoking prevalence among female population is low in Kerala, the threat for the health and well being of women and children from the secondhand smoke exposure, especially within the home is very high.

In Kerala, 42% of adults are exposed to secondhand smoke at home. There are at least 250 chemicals in secondhand smoke from cigarettes/bidis that are known to be toxic or carcinogenic. When non smokers are exposed to second hand smoke, they inhale many of the same cancer causing chemicals that smokers inhale. Research has shown the harms of secondhand smoke to women and children including spontaneous abortion, low birth weight, poor lung function, and respiratory ailments. It is scientifically documented that smoke from a cigarette can remain in the air for 2-4 hours and the residue from smoke seeps into the house curtains and cushions and other cloth items negatively affecting everyone staying in the home.

Smoke Free Home Initiatives by the Project Quit Tobacco India
To address the issue of protecting women and children from secondhand smoke in homes, which is a critical public health issue, Project Quit Tobacco India (QTI) has developed a smoke free homes initiative in rural communities in Kerala. This pioneering project is implemented through women’s groups like Kerala Mahila Samakhya Society and Kudumbasree which play a significant role in community level activities. The goal of ‘Smoke-free Household’ movement envisages that as all homes in a community collectively decide that they will not allow smoking inside any of the homes in their area. The movement has been successfully implemented in the selected communities/wards of Nellanadu Grama panchayat in Trivandrum district.

Before introducing the concept of ‘Smoke-free home’, a community level household survey was conducted to assess women’s and children’s exposure to secondhand smoke both in indoor and outdoor places. In the survey it was identified that more than 70% smokers are smoking inside the home and their family members are inhaling the smoke. Majority of women are aware that second hand smoke is bad for health even though they do not know the specific health problems it can cause and personally disapprove of smoking in the home but most of them feel powerless to do anything about it. Very few homes have rules against the smoking inside the home. Women feel embarrassed or are shy to tell a guest not to smoke in the home. Eighty per cent of men, including those who smoke, expressed support for a community wide smoke free home policy.

As the first step for developing smoke free homes, a meeting was organized with elected Panchayat members and discussed about the objectives of this activity. The second step was to raise consciousness about the harm of secondhand smoke in the community. This was done with the support of the members of Kudumbasree and Mahila Samakhya to organize discussions on the problem of second hand smoke in the home and to provide education to the community about the harms of SHS to non smokers, especially to women and children. For ensuring the sustainability of this movement, a panchayat level resource team was formed and the team was provided training support on the linkages between tobacco and health. The resource team consisted of Health Inspectors, Junior Health Inspectors, Junior Public Health Nurses, Asha Workers, Anganwadi Teachers, Kudumbasree/Mahila Samakhya members etc.

The third step was to organize meetings with men and women to conduct health education campaigns in the community to introduce the concept and the need of ‘smoke free homes’. All households in the community were given information stickers to be placed on the front door of their house stating that this is a smoke free home. Community members also had to place posters and banners in public places showing that this is a smoke free home community. Health education classes were organized in schools for students and they were also involved in the movement by taking part in the education program on second hand smoke. The students also involved in poster contests and they reminded their fathers and other men in their homes not to smoke in the home. The fourth step was a community-wide meeting where people came together to sign a formal declaration which says that in this community there is no smoking inside homes.

After this intervention program a survey was done to assess the impact of the program in the area. The post intervention survey results showed that the proportion of households having rules about no smoking inside the home increased from 20% in the baseline to 60%.  67% of smokers stopped smoking inside the home as a result of the intervention program.

In India smoking in public places is prohibited by law and as a result many smokers are shifting their location of smoking to their homes. Women are either hesitant or helpless to oppose men even though they dislike smoking. Nellanadu experience has shown that if the whole community raises the voice against smoking inside the home and organize it as a community based movement it will be more acceptable and effective. The ‘Smoke-free Home’ movement is now progressing in Muhamma Grama Panchayat in Alappuzha District, Njarakkal Grama Panchayat in Ernakulam District.