Disparities in secondhand smoke exposure among children and racialized groups have persisted for more than three decades in the United States (Tsai et al., 2018; Brody et al., 2021). U.S. national data show that among non-smokers, secondhand smoke exposure is nearly twice as high among young children compared to adults (Tsai et al., 2018) and high among children in rural areas (American Lung Association, 2012). Secondhand smoke exposure is twice as high among Black/African American people compared to other racialized and ethnic groups for whom data are reported (Tsai et al., 2018; Brody et al., 2021). Nearly 38% of children aged 3–11 in 2013/14 (Tsai et al., 2018) and 41.5% of Black/African American non-smokers were exposed to secondhand smoke in 2017/18 (Brody et al., 2021).

Further, people who live in poverty and have less than a high school education are more than twice as likely to have been exposed to secondhand smoke than people who live at or above poverty or have attained a bachelor's degree or higher (Tsai et al., 2018). Forty-eight percent of non-smokers who live in poverty and 31% of non-smokers with less than a high school education were exposed to secondhand smoke in 2013/14 (Tsai et al., 2018). Data are not often reported by the intersection of race, age, geography and socioeconomic indicators. One study found that serum cotinine levels in children of parents in rural Appalachia were higher than parents reported rates of smoking (Yeramaneni et al., 2019). Rural residents are more likely to allow cigarette smoking in the presence of children in their homes and cars (McMillen et al., 2004). It is possible that Black/African American children who live in low resource rural communities have disproportionately higher rates of secondhand smoke exposure than their comparative groups.

Multiple factors could potentially explain long-standing disparities in secondhand smoke exposure. At the individual level, living with a smoker increases the risk for exposure. U.S. data show that 73% of non-smokers exposed to secondhand smoke lived with a smoker (Tsai et al., 2018). Smoking is higher in rural areas (Doogan et al., 2017). Children who live in small rural areas (2500 to 9999 people) are more likely to live with a smoker (35.0%) than children in urban areas (24.4%) (American Lung Association, 2012; U.S. Department of Health and Human Services et al., 2011). At the interpersonal level, residents who live in rural areas have limited access to health care providers and health systems (U.S. Department of Health and Human Services, 2022), thus limiting their access to preventive health messages. People who live in multiunit housing may have a lower prevalence of smokefree rules than people living in single family housing (Nguyen et al., 2016). As a result, even if a residence has a smokefree rule, attached residences may not be smokefree.

At the community level, high smoking prevalence may increase exposure to secondhand smoke. In 2020, 20.5% of Arkansan adults reported that they smoked cigarettes compared to 15.5% of adults in in the US (Americans Health Rankings, 2021). At the policy/societal level, data show that only 0.5% of Arkansans compared to 61% of all Americans are protected by comprehensive smokefree policies in workplaces, bars, and restaurants (American Nonsmokers' Rights Foundation, 2019). Arkansas ranks among the lowest states (40th) in non-smoking regulations (American Nonsmokers' Rights Foundation, 2019). Only three cities, Fairfield Bay, Helena-West Helena, and Wooster have 100% comprehensive smokefree coverage (American Nonsmokers' Rights Foundation, 2019). Studies also show that voluntary smokefree policies that completely ban cigarette smoking in the home are low in Black/African American, low-income, and rural households (Gilpin et al., 1999; Okah et al., 2002; Kegler and Malcoe, 2002; Berg et al., 2006).

Multiple factors at the individual, interpersonal, community and policy levels can prolong health disparities caused by secondhand smoke. Secondhand smoke exposure among non-smokers causes cancer, heart disease, and stroke among adults, and sudden infant death syndrome, respiratory infections, ear infections, and asthma attacks in infants and children (U.S. Department of Health and Human Services, 2006). Black/African American and socioeconomic disadvantaged people suffer disproportionately from tobacco-caused illnesses and deaths (U.S. Department of Health and Human Services, 2006; U.S. Department of Health and Human Services, 1998). Comprehensive smoke-free home policies (i.e., free from cigarette, cigar, electronic cigarettes, IQOS, hookah, and pipe smoke) could protect diverse groups from tobacco smoke and reduce longstanding health and social disparities.

In 2019, Families Rising to Enforce Smokefree Homes (FRESH) began recruiting Black/African American women smokers who live in low resource rural counties to participate in a small scale randomized controlled trial that aimed to increase comprehensive smokefree policies in the home (clinical trial # NCT03476837). This paper examines 1) the sample's prevalence of comprehensive smoke-free rules; 2) sociodemographic, social, and smoking characteristics of women by home rule type; and 3) the association of social indicators with the outcome complete ban on smoked tobacco use in the home (n = 191).