Household air pollution (HAP) from solid fuel use affects nearly 3.6 billion people globally, causing 3.2 million deaths annually. Despite extensive research, interventions show limited health benefits, highlighting the need for community-centered approaches that meaningfully engage affected populations in research dissemination and solution co-design. We present a community case study from the Fuel to Pot project (2020–2023), an interdisciplinary study conducted in the informal settlements of Mukuru, Kenya, and Ndirande, Malawi. Following 2 years of participatory research using walking interviews and photovoice, we implemented a cascaded, interactive dissemination model involving sequential community engagement events followed by policymaker discussions. Community dissemination events engaged diverse community members in each location through mobile poster exhibitions featuring local language translations, photovoice images, and simplified data visualizations. Interactive discussions generated contextually relevant recommendations addressing immediate community needs and systemic policy changes. Subsequent policymaker events with key stakeholders further facilitated dialog between community priorities and institutional capacity, strengthening researcher-community-policy relationships. We suggest six principles for community engagement in research dissemination (Engagement, Networks, Accessibility, Capacity strengthening, Trust, and Budgeting) that aim to transform research dissemination from a performative, extractive practice into a collaborative action. This approach enhances the sustainability of interventions, builds local capacity, and addresses ethical imperatives in global and public health research. The principles provide a replicable framework for researchers seeking to move beyond traditional academic dissemination toward more genuine community engagement and the co-creation of effective health interventions.

Background:High levels of smoking among people who experience imprisonment contribute to their high mortality and morbidity rates and to inequalities. Scotland's prisons became smokefree in 2018. However, questions remain about how to prevent high relapse to smoking post release. Objectives:Summarise evidence on supporting people to reduce tobacco-related harms post release. Understand experiences, opportunities and challenges for reducing tobacco-related harms for people leaving smokefree prisons and for families. Feasibility test a household-targeted intervention to support people released from smokefree prisons to reduce tobacco-related harms. Update cost-effectiveness of smokefree prison policy. Partnership-working with key stakeholders. Design and methods:Scoping reviews; qualitative; health economic modelling. Setting/participants:Prisons in Scotland; staff, people in prison, family members. Results:Our scoping reviews show that evidence on interventions to support people leaving smokefree prisons to remain tobacco-free is weak. There is no evidence on smoking rates among people released from smokefree prisons allowing vaping. Significant barriers remain for people from underserved communities to create smokefree homes. Our modelling highlights that offering effective smoking cessation support to people leaving smokefree prisons would be cost saving at both the personal and societal levels. The challenges people face on release from prison and variability in throughcare support often render smoking relapse prevention a low priority for them, their families and service providers. However, in terms of long-term prevention of ill health and premature death, the high rates of relapse to smoking (~50-80%) continue to fuel inequalities. Supporting people leaving smokefree prisons to remain abstinent will help governments to achieve ambitions to create smokefree societies. Progress may be achieved by greater integration of support for tobacco-harm reduction with services addressing interconnected needs, such as harmful use of other substances and underlying mental ill health. Limitations:The extensive impact of coronavirus disease discovered in 2019 in prisons into 2023, alongside challenges due to overcrowding and staffing pressures, limited the opportunities for partnership working and the number of interviews we could conduct. This meant that we were unable to test the feasibility of delivering a household-based intervention to reduce tobacco-related harms in this population. Conclusions:Progress in developing suitable interventions to prevent very high relapse-to-smoking rates following release from smokefree prisons is required. Helping people released from smokefree prisons to remain abstinent from tobacco post release could deliver considerable benefits. However, in the face of substantial challenges, preventing relapse to smoking has become entrenched as a low priority - for many service providers, people leaving smokefree prisons and their families. Greater success in reducing tobacco-related harms among this often-overlooked population may be achieved through more holistic models of service delivery. Aspirations for countries to become tobacco-free may require a rethink of what is needed to support underserved populations in whom smoking remains entrenched. Future work:Further research is required to better understand what approaches are feasible and effective for maintaining smoking abstinence following release from prison, including development and evaluation of integrated/holistic approaches which tackle smoking/vaping behaviours in the context of use of other substances and needs. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR131613.

Solid fuels are still used by over 3 billion people worldwide, including many residents of informal settlements. Most interventions designed to improve people's solid fuel-related health have failed or fallen short of their ambitions. Often, this is because implementers have not fully understood the contexts, cultures and behaviours of the places and people they are working within and with. To address this, our study used a food-energy nexus lens to explore people's experiences of the cooking journey, i.e., decision-making regarding which fuel to use, obtaining fuel and then cooking using that fuel. We videoed 'go along' interviews with residents of two African informal settlements during their cooking journeys. Interviews with 15 participants in Mukuru (Kenya) and 15 in Ndirande (Malawi) were analyzed using thematic analysis. Participants' decision-making regarding fuel use was complex, dynamic (considering short-to-long timescales) and context-specific. Participants were aware of some of the household air pollution (and other solid fuel-related) health risks, though there were some misconceptions. The use of waste materials in solid fuel cooking-particularly during ignition-was common. The 'cooking journey' framing in this study highlighted the range of risks and challenges experienced across the food-energy nexus beyond household air pollution, including terrain, the built environment and gender-based violence. Broader approaches to understanding the contexts, cultures and behaviours of fuel users in informal settlements, such as our 'cooking journey' approach, can support better intervention design, and therefore enable progress towards sustainable development goal 7-access to affordable, reliable, sustainable and modern energy for all.

Abstract Introduction Children’s exposure to second-hand tobacco smoke is a preventable global public health issue, yet there is no consensus on how best to support families to create a smoke-free home. This pilot randomised controlled trial tested the feasibility of use of free nicotine replacement therapy combined with telephone-delivered support to reduce children’s exposure to second-hand smoke in the home, and inform a future full-scale trial. Methods Parents/carers aged 18+ years, who smoke in the home and care for one or more children aged 0-16 years were recruited through existing initiatives and social media. Participants were randomised to either the intervention (Group A) or control (Group B) arm. Group A received free posted-to-home nicotine replacement therapy, alongside fortnightly telephone calls to support smoking abstinence in the home. Group B were signposted to the Scottish Government’s ‘Take it Right Outside’ website which provides interactive advice on creating a smoke-free home. To measure second-hand smoke levels, participants installed an air quality monitor in their living room for 7 days to measure fine particulate matter (PM 2.5 ) at baseline and 12-week follow-up. Results Approximately one-quarter (n=27/100) of the intended sample size was recruited. Median PM 2.5 concentrations reduced in both the intervention (-36μg/m 3 ) and control (-16mg/m 3 ) groups. Retention rates and adherence rates to nicotine replacement therapy were 70% and above, with no risks and/or safety concerns reported, suggesting this approach is feasible and acceptable to participants. The estimated cost of delivering this 12-week intervention was £244 per individual. Conclusions Although recruitment rates were insufficient to recommend progression to a larger trial to test effectiveness of this approach in Scotland, this study could inform trial development in other countries where smoking in the home is commonplace. Insights regarding the alignment of smoke-free home interventions with broader smoking cessation initiatives could inform future policy and public health approaches. What is already known on this topic Children’s exposure to second-hand tobacco smoke (SHS) is a preventable global public health issue, and whilst there is no consensus on how best to support families to create a smoke-free home, the use of nicotine replacement therapy (NRT) for temporary abstinence from smoking in the home has shown promise in UK settings. What this study adds Use of free posted-to-home NRT alongside behavioural support by telephone to reduce children’s exposure to second-hand smoke in the home is feasible in terms of retention rates, NRT adherence, andDthe practicalities of intervention delivery within an established National Health Service. Recruitment to the study was difficult and participation rates were insufficient to inform the development of a future trial to study intervention effectiveness, which likely reflects a Scotland-wide reduction in the proportion of individuals who smoke in the home in the presence of children, and perceived stigma in acknowledging this practice to healthcare staff. How this study might affect research, practice or policy The effectiveness of this approach should be evaluated in countries where smoking in the home is more prevalent, meaning that recruitment is potentially easier, and where NRT is licenced for use. Using NRT for temporary abstinence from smoking in the home creates conditions conducive to subsequent smoking cessation, highlighting the value of integrating smoke-free home interventions within wider tobacco control policies and public health strategies.

Air quality monitoring networks are essential for characterising spatial and temporal patterns in air pollution concentrations that inform the management of population exposure, but are often spatially sparse, limiting their ability to capture hyperlocal variation in air pollution. Lower-cost air quality sensors are increasingly used to address this challenge by complementing regulatory networks where they exist, extending monitoring into under-represented locations where monitoring is sparse, and establishing networks where monitoring is non-existent. However, deploying such sensors in practice frequently requires bespoke, context-responsive system configurations, particularly where access to power and infrastructure is limited. By deploying a lower-cost particulate matter sensor in a high-latitude context characterised by strong seasonal variability, using a customised solar-powered configuration, the paper consolidates practical considerations for the design and deployment of an off-grid air quality monitoring system, highlighting how design decisions, system trade-offs, and deployment processes could be adapted depending on context. While solar-powered systems can support hyperlocal monitoring, performance and scalability are shaped by seasonal variability, energy storage and charge-control limitations, connectivity-related power demand, siting constraints, and resilience to power interruptions. Deployment also highlighted institutional and governance considerations, including permissions, public space management, and ongoing maintenance burden. Synthesised practical considerations and recommendations are presented to inform the design and deployment of autonomous sensor networks capable of supporting hyperlocal air quality assessment, targeted mitigation, and more actionable decision-making.

INTRODUCTION: Tobacco smoking prevalence remains high in disadvantaged populations such as people in prison. Smokefree prisons protect health, however around 90% of people who smoke pre-prison, relapse to smoking shortly after release. If people released from smokefree prisons maintain smoking abstinence this could benefit their health and finances. Knock-on effects of smoking relapse on families could also be avoided. Offering an intervention to reduce relapse to smoking on release has the potential to benefit released people and their families. This study assesses potential costs and outcomes for released people and their families, of introducing a smokefree prison policy and an intervention to reduce post-release smoking relapse. METHODS: Based on the smoking/vaping status of released people we modelled the impact, on costs and outcomes, of four scenarios. We modelled scenarios which varied across two dimensions: (1) whether people were/were not permitted to vape in smokefree prisons, and (2) whether a smoking cessation intervention was offered/was not offered in smokefree prisons. The scenarios reflect different combinations of these factors. We estimated costs and outcomes (benefits) for released people, their partners and children over a lifetime. We included personal costs (vaping and smoking), healthcare and intervention costs, and outcomes included quality of life. RESULTS: For released people, results indicated that not permitting vaping in prison was less costly and more beneficial than when vaping was permitted. Offering a smoking cessation intervention to released people was less costly than not offering a smoking cessation intervention, irrespective of whether vaping was permitted or not. However, whilst offering a smoking cessation intervention was beneficial when vaping was permitted in prison, results are uncertain for the benefits of offering a smoking cessation intervention when vaping is not permitted in prison. Sensitivity analyses indicate uncertainty and show that changing the values for vaping prevalence and smoking relapse rates would change these results. For both partner and child (ren), costs were higher and quality of life lower for those living with released people who relapse to smoking compared to those who vape or neither smoke nor vape. INTERPRETATION: Targeted support for smoking cessation interventions to improve health outcomes for people released from smokefree prison and their families can ultimately contribute to broader public health improvements and improve health in a priority group. There is a need for greater evidence in this area to inform future modelling, particularly on relapse to smoking on release and the long-term effects of vaping. Results indicate uncertainty about the overall value of permitting vaping in smokefree prisons; wider factors associated with not allowing vaping in prisons would need to be assessed in future work. Study findings enhance understanding of the potential cost-effectiveness of smokefree prison policy, highlight uncertainty in some model inputs, and can inform decisions about how value could be maximised.

Air pollution is a key contributor to poor respiratory health, particularly for those susceptible to its effects, such as adolescents whose lungs are still developing. Better understanding of the lived experiences of air pollution and lung health can support the design of policies and other interventions to improve health. The aim of this study was to explore adolescents’ lived experiences of breathing, lung health and air pollution in Nairobi, Kenya. We focused on adolescents who had reported respiratory symptoms and were attending schools in an informal settlement (Mukuru (n=22)) and an adjacent more affluent area (Buruburu (n=16)). We took a mixed-methods approach, combining video-recorded walking interviews with route tracking (GPS) and particulate pollution (PM2.5) measurements along the route. Participants took the interviewer to a space they found it harder to breathe and a space where they found it easier to breathe. Though both settlements had relatively high levels of PM2.5, Mukuru had more ‘hotspots’ of PM2.5, highlighting exposure inequalities for Nairobi residents. There was no significant difference in PM2.5 between spaces considered by interviewees as easier or harder to breathe in. Harder to breathe locations limited people’s activities within those spaces. The concept of ‘breathing well’ went beyond air quality, encompassing cleanliness, population and building density and presence of vegetation, offering potential for urban planning to support better lung health. Avoidance behaviours (for example walking faster) were a common way to reduce exposures. To supplement individual action, policies to reduce place-based inequalities and improve respiratory health for all are urgently needed.

Background The high prevalence of COPD in sub-Saharan Africa is poorly understood. In high-income countries, COPD is the consequence of suboptimal lung growth during childhood and/or accelerated lung function decline in adult life. We have conducted cross-sectional studies to measure the lung function of children and adults in Kenya and to identify associations with age. Methods We performed spirometry in three groups in Kenya: a random sample of schoolchildren in two districts of urban Nairobi and age/sex-stratified representative community samples of adults in Nairobi and rural Machakos. Forced expiratory volume in 1 s (FEV 1 ) and forced vital capacity were expressed as z-scores using race-neutral GLI-Global reference equations. Results The mean (95% CI) FEV 1 z-score in Nairobi schoolchildren (n=2373, median age 10 years (IQR 8–13) 52% girls) was −0.60 (−0.64– −0.55); in Nairobi adults (n=2936, median age 32 years (24–43), 62% female) −0.49 (−0.53– −0.45); and in Machakos adults (n=1607, median age 46 years (35–59), 65% female) −0.67 (−0.72– −0.61). In adults, FEV 1 was negatively associated with age (FEV 1 z-score regression coefficient β −0.005/year (95% CI −0.009– −0.002) p=0.005, and there was a negative interaction between residence in Nairobi and age, β −0.006/year (95% CI −0.011– −0.001), p=0.020. Conclusion The lung function of children and adults in Kenya was lower than predicted by race-neutral Global Lung Function Initiative (GLI)-Global reference equations. In adults, a negative association between lung function and age was greater in urban, than in rural, settings. Further work is required to identify and mitigate relevant influences.

INTRODUCTION Scotland introduced comprehensive smoke-free legislation covering most enclosed public spaces in 2006. Twenty years on, this study examines changes in markers of population level exposure to secondhand tobacco smoke (SHS). METHODS A secondary analysis of Scottish Health Survey data between 1998 and 2024 to examine trends in population exposure to SHS and household rules about smoking indoors. The proportions of non-smoking adults who had measurable cotinine in their saliva were calculated for the period 1998-2024. The geometric mean (GM) concentrations of cotinine levels were calculated using Tobit regression. Data from 2012-2024 on self-reported smoking rules for the home were analyzed. RESULTS Salivary cotinine expressed as a GM fell from 0.464 ng/mL (95% CI: 0.444-0.485) in 1998 to 0.020 ng/mL (95% CI: 0.015-0.028) in 2024: a reduction of 95.7%. The percentage of non-smoking adults who had no measurable cotinine in their saliva increased by six-fold between 1998 (12.5%) and 2024 (77.6%). Most of the change occurred in the immediate aftermath of smoke-free legislation, with both metrics of population exposure to SHS demonstrating little evidence of change between 2011 and 2024. The proportion of households that are smoke-free has increased from 75.2% in 2012 to 90.2% in 2024 but is now ten times more common in the most deprived areas compared to the least deprived. CONCLUSIONS Scotland has sustained large reductions in SHS exposure since smoke-free legislation was introduced twenty years ago in 2006. However, progress evident in the years between 2006 and 2011 has not been maintained: there are still nearly one-quarter of non-smoking adults having measurable exposure to SHS on any given day. Smoking in the home has also reduced, but the level of inequality of this measure has doubled between 2012 and 2024. Public health interventions should consider the remaining workplace and home settings where people experience exposure to SHS.

Effective implementation of evidence-based programmes in real-world settings requires the capacity to adapt programmes and tailor implementation strategies to local contexts. Many primary cancer prevention (PCP) programmes that are effective in controlled settings struggle in routine practice. Although several frameworks outline principles of adaptation and tailoring, practical guidance on how to operationalise these processes remains limited. The PIECES project aims to help address this gap by developing, implementing, and evaluating structured support for tailored implementation of PCP programmes. Within the PIECES project, a toolkit was co-developed with practitioners and researchers to provide theory- and evidence-informed guidance for adapting, tailoring, implementing, and evaluating PCP programmes. The toolkit aims to strengthen implementation competencies through structured planning, collaborative learning, and evidence-informed decision-making. This paper presents the protocol for the PIECES study which evaluates the toolkit’s usability, feasibility, and mechanisms of impact of PCP programmes across diverse healthcare and community settings. The PIECES study uses a multi-site pre-post comparative case study design with a mixed-methods implementation evaluation across 11 sites in Europe and Australia, reflecting variation in organisational structures, resources, and cultural contexts. The primary outcome is change in implementation competencies among toolkit users. Guided by the UK MRC Process Evaluation Framework and Proctor’s implementation outcomes, the process evaluation examines toolkit usability, feasibility, user satisfaction, and perceived impact on implementation processes and outcomes. Quantitative and qualitative data, toolkit log data, and structured field notes will be collected at six-month intervals (2025–2027). In parallel, a realist evaluation will explore how, why, and under what conditions the toolkit supports tailored implementation. Together, these approaches provide complementary descriptive and explanatory insights into the mechanisms and contextual factors shaping tailored implementation of PCP programmes. This study is expected to contribute to implementation science by evaluating a structured, evidence-informed tool designed to strengthen capacity for tailored implementation of PCP programmes. Its multi-country design offers a natural field-laboratory to explore how implementation support tools function across varying contexts. By integrating process and realist evaluation approaches, the study is designed to generate practical and theoretical evidence to inform scalable, context-sensitive strategies and enhance the sustainability and impact of evidence-based prevention efforts. ClinicalTrials.gov ID NCT06718322.

This interactive workshop will explore the role of Patient and Public Involvement (PPI) in research focused on migrant communities. Despite growing evidence on PPI in health research, significant gaps remain, particularly in engaging underrepresented groups. The participation of migrant communities is increasingly recognised as essential, shaped by contemporary political discourse on migration. With over 280 million international migrants worldwide—a diverse population facing substantial inequities—meaningful PPI?engagement is vital to ensure research relevance and inclusivity. Participants will be able to describe key principles of effective PPI in migrant health research. Participants will explore methodologies for meaningful community engagement, using a case study on smoke-free homes in Scottish migrant communities. Participants will be invited to contribute to a network of researchers and community stakeholders committed to inclusive PPI practices. Evidence-based research achieves greater impact when co-produced with the communities it serves. However, structural barriers—such as language, trust, and systemic exclusion—often hinder migrant participation. Effective PPI requires adaptable strategies that address these challenges while valuing lived experience as expertise. This workshop will analyse a case study from a Scottish project on smoke-free homes, illustrating practical approaches to collaborative research design, implementation, and dissemination. The session will highlight the importance of shifting from research conducted for migrant communities to research developed with them. By integrating diverse perspectives, academics and public health professionals can enhance the cultural relevance, equity, and impact of their work. Discussions will address power dynamics, ethical considerations, and methods to sustain long-term community partnerships. This workshop aims to empower researchers to embed migrant voices as active contributors, fostering inclusive practices that improve health outcomes. Through collaborative dialogue, participants will leave equipped to apply PPI principles in their own contexts, ensuring migrant communities shape the research that affects their lives.

INTRODUCTION:Around 80% of the world's smokers live in lower-middle income countries and smoking rates in China, Philippines and Indonesia are very high. Evidence suggests that most people begin smoking or become habitual smokers before reaching adulthood. This highlights the need for a smoking prevention intervention focused on young people. ASSIST (A Stop Smoking In Schools Trial) is a 'peer-led', school-based smoking prevention intervention, shown to be effective in the UK. The aim of the study is to assess the feasibility of conducting a full-scale effectiveness evaluation of an adapted version of the ASSIST intervention in China, Indonesia or the Philippines. However, due to issues with obtaining relevant approvals, China was removed from the trial with the approval of the funder and Trial Steering Committee, and the study will only be completed in Indonesia and the Philippines. METHODS AND ANALYSIS:A feasibility mixed-methods cluster randomised controlled trial in 10 schools (six intervention, four control) in each of the two countries. Participants will be students aged c13-14 in mainstream ('lower secondary') schools. In addition to their usual education on smoking, intervention schools will receive the ASSIST intervention which is based on 'diffusion of innovation' theory, with new norms and behaviours promoted through: (1) peer modelling by locally influential individuals; and (2) information disseminated by them through their social networks. Control schools will continue with their usual education around smoking prevention.The key outcome of the study is whether prespecified progression criteria relating to recruitment, retention, acceptability and feasibility have been met in order to progress to a larger cluster randomised controlled effectiveness trial in one or more of the countries. A mixed-methods process evaluation will assess acceptability, feasibility and fidelity of intervention delivery, exposure to and reach of the intervention. The feasibility of trial processes including outcome measurement will be assessed. An economic evaluation will estimate the costs of the ASSIST intervention. Statistical analyses will focus on feasibility criteria, and qualitative data will be analysed using a framework approach. Outcomes assessed will include self-reported smoking behaviour (own and that of friends and family); vaping and other forms of nicotine use; smoking-related attitudes and knowledge; smoking norms; self-esteem; self-efficacy; (all at baseline and 7 month follow-up) and exhaled carbon monoxide concentration (at follow-up only). ETHICS AND DISSEMINATION:The trial has been approved by the University of Glasgow College of Medical, Veterinary and Life Sciences (MVLS) Ethics Committee (ref: 200210204), the De La Salle University Research Ethics Review Committee (ref: 2023-012C) and the Medical and Health Research Ethics Committee (MHREC); Faculty of Medicine, Public Health and Nursing; Universitas Gadjah Mada (ref: KE/FK/1205/EC/2022). The trial is sponsored by the University of Glasgow (Head of Research Regulation and Compliance-debra.stuart@glasgow.ac.uk). The sponsor will not have input in data collection, management, analysis and interpretation; write up and submissions for publication.The study findings will be disseminated through peer-reviewed publications in expert journals and conference presentations and targeted communications to schools, policymakers and the public. TRIAL REGISTRATION NUMBER:ISRCTN99140476.

Background:Homes are one of the primary locations where people are exposed to second-hand smoke (SHS) in Europe. We describe the prevalence and identify the main determinants of having home-smoking restrictions in 12 European countries. Methods:Cross-sectional survey in 12 European countries conducted in 2017-2018 (TackSHS project). Approximately 1000 participants representing the general population aged ≥15 years of each country were interviewed face to face. Individual- and country-level characteristics were explored through adjusted prevalence ratios (PRs) obtained from multilevel Poisson models with random effects. Results:Among 11 734 participants, 70.2% (95% confidence interval (CI) 69.4-71.0%) had smoke-free homes and 17.5% (95% CI 16.8-18.2%) had partial home-smoking restrictions in place. Prevalence of smoke-free homes ranged from 44.4% in Greece to 84.5% in England. Having a smoke-free home was significantly inversely associated with current (PR=0.60) or former (PR=0.95) smoking and living in a household with one (PR=0.70) or two or more (PR=0.58) people who smoke. It was also significantly associated with being ≥65 years old (PR=1.05), being female (PR=1.07), having a high educational level (PR=1.09) and living with children (PR=1.09). Having a smoke-free home was associated with living in northern Europe, while partial home-smoking restrictions were more likely among respondents from eastern Europe and countries with lower per capita gross domestic product. Conclusions:The prevalence of smoke-free homes in Europe is relatively high, but with large variability across countries. European countries with a lower prevalence of smoke-free homes should implement tailored interventions targeting identified determinants and incorporate the success of other countries.

INTRODUCTION:The harmful health effects of children's exposure to secondhand smoke (SHS) are well established. Most SHS exposure now occurs in the home, in low-income households. Previous research suggests that using nicotine replacement therapy (NRT) in the home can help with temporary smoking abstinence and could reduce smoking indoors. This pilot randomised controlled trial tests the feasibility of providing parents, carers and relatives with posted-to-home nicotine replacement therapy alongside fortnightly telephone support to reduce children's exposure to SHS. METHODS AND ANALYSIS:100 participants are being recruited through existing National Health Service (NHS) Lanarkshire initiatives and social media. Parents/carers who are at least 18 years old, smoke in the home and care for one or more children aged 0-16 years are eligible to take part. Participants are randomised to either the intervention (Group A) or control (Group B) arm. Group A receives NRT posted to their home for 12 weeks free of charge, alongside fortnightly telephone calls and materials to support them in reducing children's exposure to SHS. Group B is signposted to the Scottish Government's 'Take it Right Outside' website which provides interactive advice on creating a smoke-free home. To quantify the child's exposure to SHS, participants instal an air quality monitor to measure fine particulate matter (PM2.5) concentrations in their living room for 7 days at baseline and 12-week follow-up and/or collect and post saliva samples from their youngest child (age 5 or over) for cotinine analysis. Qualitative interviews explore intervention experience, NRT use and adherence and changes to home-smoking behaviours/smoking-related expenditure. Descriptive data analyses will be performed to address the feasibility of recruitment, randomisation, retention and adherence, data collection and intervention delivery. Analysis will also include pre/post changes (paired t-test) in both child's salivary cotinine and PM2.5 levels to provide preliminary data on intervention effectiveness and difference between the intervention and control arms of the study. Health economics and resource use data will be collected and assessed for completeness, to test the process of data collection and estimate mean cost of both study arms. ETHICS AND DISSEMINATION:NHS ethical approval has been obtained by the West of Scotland Research Ethics Service (15 December 2023, ref 23/WS/0153; 13 December 2024, ref AM01). The findings will be disseminated to participants, funders, NHS Lanarkshire and other health services, and in peer-reviewed journals and academic conferences. Findings will inform new approaches that are timely and important, providing valuable evidence to help reduce children's exposure to SHS in the home in Scotland and elsewhere. TRAIL REGISTRATION NUMBER:ISRCTN79307718.

Alcohol per capita consumption (APC; total pure alcohol consumed per person 15 years or older per year) is the primary indicator used to track global progress in reducing harms associated with alcohol use. However, in many low-income and middle-income countries (LMICs), where most of the population abstain from alcohol and risk of alcohol-associated harm is concentrated in a heavy-drinking minority, APC can misrepresent both exposure and risk. This Viewpoint argues for the routine inclusion of drinker-adjusted metrics, specifically litres of alcohol consumed per drinker (alcohol per drinker), alongside the standard APC indicator. By use of data from WHO's Global Information System on Alcohol and Health, we show how alcohol per drinker reveals patterns hidden by population averages, particularly in high-abstention LMICs. For example, South Africa and the UK have similar APC but starkly different alcohol-attributable harm profiles, which are better explained by differences in alcohol per drinker. Although APC remains valuable, relying on this metric alone risks misinterpreting progress and misdirecting policy in contexts where drinking is concentrated among a minority of the population who drink heavily. As global monitoring evolves, we call for the inclusion of additional metrics that better reflect risk in diverse contexts.

INTRODUCTION:Exposure to secondhand tobacco smoke generates a considerable health burden globally. In South-East Asia, most of that burden falls on women and children who are exposed to secondhand smoke (SHS) from male smoking in their home. Interventions to encourage smoke-free homes have tended to target people who smoke individually or within their family unit, although some evidence suggests a community-wide approach holds promise. The aim of this study was to codevelop a toolkit to increase the uptake of smoke-free homes within small village/town communities in Indonesia and Malaysia. METHODS:During 2022/3, the CO-FRESH (COmmunities Facilitating incREasing Smoke-free Homes) study engaged with local community members in three villages in central Malaysia and one subdistrict in Indonesia. This toolkit-development study co-created: (1) online training materials to equip local health professionals to tackle smoking in the home; (2) a local public information campaign on the benefits of a smoke-free home; (3) methods to provide household air quality feedback to highlight the impact of smoking in the home; and (4) information on local services to support families to create smoke-free homes. RESULTS:Communities welcomed the concept of tackling smoking in the home; however, there was limited knowledge about how SHS moved around the home and could enter indoor spaces from outdoor smoking. There were differences in the conceptualisation of what defined a 'smoke-free' home, alongside the delineation of indoor and outdoor spaces within the home setting. In addition, findings of high background air pollution levels mean that household air quality measurement may not be suited to providing SHS information in these communities. CONCLUSIONS:Communities in Malaysia and Indonesia recognised the importance of reducing smoking in the home and welcomed the approach of co-developing community-wide methods of tackling the issue. The CO-FRESH toolkit requires evaluation to determine effectiveness and how it can be implemented at scale.