Lung cancer is the leading cause of cancer death in the U.S.; an estimated 222,500 new cases and 155,870 deaths were projected in 2017 (National Cancer Institute, n.d.). Smoking is the leading cause of lung cancer, followed by radon (U.S. Department of Health and Human Services [HHS], 2005) and secondhand smoke (SHS) exposure (HHS, 2006). Radon-related lung cancers are more likely in those with a smoking history (National Research Council, 1999).
Environmental risks are inversely related to income (Evans & Kantrowitz, 2002). Nearly one half of those living in multi-unit housing report that SHS enters their living space from elsewhere (Hewett, Sandell, Anderson, & Niebuhr, 2007). Further, socioeconomic status (SES) disparities are associated with lack of action to reduce environmental risks. A family of lower SES is less likely to adopt a smoke-free (SF) home than a family of higher SES (Norman, Ribisl, Howard-Pitney, & Howard, 1999; Wakefield et al., 2000), and a family of lower SES is more likely to live in a rental property.
Landlords often fear that SF policies will hurt their business, expecting higher vacancy, turnover, and tenant complaints (Cramer, Roberts, & Stevens, 2011; Hewett et al., 2007; Snyder, Vick, & King, 2016; Stein et al., 2016). Similarly, lower income individuals (Halpern & Warner, 1994; Hill, Butterfield, & Larsson, 2006; Wang, Ju, Stark, & Teresi, 1999) are least likely to initiate protective radon behaviors. Although radon test kits are relatively inexpensive and are often available for free, primary care providers do not routinely recommend radon testing.
Report-back is a cueing event that might motivate individuals to take action such as adopting a SF home (McBride, Emmons, & Lipkus, 2003; McBride et al., 2008). Report-back is effective in conveying exposure data (Altman et al., 2008), even with low-SES groups, and prompting action to reduce household exposures (Adams et al., 2011). When individuals are provided with evidence of high radon, they are more likely to mitigate (Duckworth, Frank-Stromborg, Oleckno, Duffy, & Burns, 2002; Riesenfeld et al., 2007; Wang et al., 1999).
This exploratory study evaluated the impact, feasibility, and acceptability of a dual home screening and personalized environmental report-back intervention (Hahn et al., 2014) to prompt action to reduce home exposure to radon and SHS in a sample of renters. We hypothesized that, over time, renters who received free in-person home test kits, report-back, and a brief problem-solving intervention would be more ready to take action to reduce radon and SHS exposure, and would have lower radon and SHS levels in their homes.
Design and Sample
This study was a prospective, quasi-experimental one-group design using quota sampling. Half of eligible renters had at least one smoker living in the home. Participants were eligible to participate if they were at least 21 years, had access to a telephone, had not tested their home for radon within two years, and did not own their home. We recruited participants in primary care clinics at an academic medical center from January-May 2013. Nearly all (97%) eligible renters participated. All 47 participants were assigned to receive the intervention; 23 reported at least one smoker lived in their home. Semistructured interviews were conducted to determine feasibility and acceptability of the intervention.
The Freedom from Radon Exposure and Smoking in the Home (FRESH) intervention (Hahn et al., 2014) creates a teachable moment (Lawson & Flocke, 2009; McBride et al., 2003) for lung cancer risk reduction by motivating participants to 1) simultaneously test their homes for radon and SHS (cueing event) and 2) take action by participating in a personalized environmental report-back and brief problem-solving conversation via telephone.
First, we provided free home test kits in person at enrollment, including print and audiovisual instructions on how to deploy and return the kits. Next, if at least one home test value was high, we delivered the personalized intervention (Fiore et al., 2008; Rollnick, Mason, & Butler, 2010) based on stage of readiness to take action (Weinstein & Sandman, 2002) and on observed radon and airborne nicotine values. If radon values were high, we followed the U.S. Environmental Protection Agency (U.S. EPA) radon measurement protocol (U.S. EPA, 2010, 2012) and recommended their landlord contact a certified radon professional for further assessment and mitigation.
If renters provided permission for us to contact their landlord, we offered a voucher covering 30% of the radon mitigation cost, up to $600. If airborne nicotine levels were high, we suggested participants institute and enforce a SF-home policy. If tobacco smokers lived in or visited the home, we provided a brief intervention on quitting (Fiore et al., 2008) and referral to the telephone quit line (1-800-QUIT-NOW). We also provided information to share with their landlords to dispel perceived barriers to adopting a SF-property policy (American Nonsmokers' Rights Foundation, 2014; National Center for Healthy Housing, 2009). If both values were low, we mailed a results letter.
Participants completed online or paper and pencil surveys at baseline, and at 3-, 9-, and 15-months postintervention; escalating payments ranged from $10-$40 for completing surveys. Renters were asked to deploy radon and SHS test kits in the home for 6 days at baseline and at 15 months postintervention, and were paid $20 for each pair of returned kits. Unless a participant withdrew, we invited them to complete follow-up surveys and end-of-study home testing even if they had missed prior surveys. All participants were invited to take part in semistructured telephone interviews at end of study.
Home radon and SHS levels were assessed using short-term radon test kits (Air Chek, Inc.) and passive airborne nicotine samplers (Hammond & Leaderer, 1987; Ogden & Maiolo, 1992). We used the U.S. EPA action level of [greater than or equal to] 4.0 pCi/L to determine whether home radon was "high" or "low." Similarly, we used the cutoff of [greater than or equal to] 0.1 [micro]g/[m.sub.3] (Eisner, Katz, Yelin, Hammond, & Blanc, 2001; Sockrider, Hudmon, Addy, & Dolan Mullen, 2003) to denote "high" versus "low" air nicotine.
Stage of action between baseline and 3 months postintervention was assessed for home radon testing, home airborne...