Editor's note: "EFO Research Brief" is a new collaboration between Firehouse.com and the National Fire Academy's Executive Fire Officer Program to highlight the research conducted by students. Each month, we will provide a summation brief of the student's final research capstone spanning multiple fire service topics.  

The increasing prevalence of home oxygen therapy (HOT) fires is significantly adding to our nation’s fire deaths. According to a report produced by the National Fire Protection Association (NFPA), the incidence of home oxygen patients dying in fires involving home oxygen equipment within the United States is more prevalent than previously reported, with one patient dying every four days.

Several states are reporting as much as 40 percent of their fire fatalities are HOT-related fires. Fires involving home oxygen are a significant risk to the safety of firefighters.Two firefighters die each year fighting HOT fires and many more are injured.

“The enrichment of normal room air with oxygen increases the energy, heat release and severity of any fire. What can normally be a fairly nonflammable substance can, in the presence of oxygen, burn with vigor and produce noxious fumes very rapidly," according to Brendon G. Cooper in his research, Home oxygen and domestic fires.

Five firefighters in Tacoma, WA, were injured in a June 2023 fast-moving apartment fire that was later determined to be caused by smoking and home oxygen use.

This problem is not a rare isolated anomaly. “Around 16 million people have been diagnosed with Chronic Obstructive Lung Disease (COPD) in the U.S. (1 in 8 over the age of 45), with millions more undiagnosed. Of these, an estimated 1.5 million require home oxygen therapy” (American Thoracic Society, 2018). Research shows 1.5 million people are prescribed home oxygen. Of that number, “It is difficult to determine how many individuals on HOT continue to smoke. Estimates range from 10-to 50-percent due to the addictive nature of nicotine.”

The research

More troubling is the research from my capstone showing those interviewed believe they have less risk from smoking and supplemental home oxygen use because they are safe smokers. In fact, all but two people believe their home fire risk is higher in normal everyday living without considering the risk of smoking and oxygen.

The failure of smokers who use supplemental home oxygen in recognizing the increased risks of fire should be of concern to the fire service. Almost every HOT fire tracked by the IAFC Home Oxygen Therapy Fire working group shows the fire originating directly on the victim, either face or clothing. These fires burn faster, hotter, and more intense and require rescue at the very early onset.  Fires like the Gabriel House fire in Fall River, Massachusetts, put responding firefighters in a no-win scenario with over 50 people needing rescued by the first arriving 3-person engine crew. Sadly, 10 people perished in this fire and 30 people were injured. To date, this is the worst HOT fire in the U.S.

Research recommendations

The 5 E’s of prevention are education, engineering, enforcement, economic incentives and emergency response. The research shows people addicted to nicotine, despite the risk of experiencing a devastating fire, do not respond to education. In fact, the research shows despite the best messaging from government and health sources pertaining to the dangers of smoking while using HOT, the addiction will drive risky behaviors. The acceptance of risk is exactly why engineered solutions need to be mandated in the U.S.

Recommendation #1: Redesign the oxygen safety education HOT patients receive to make it more effective and repeated.

Recommendation #2: Prioritize development of engineered safety solutions that minimize reliance on human behavior for oxygen fire safety.

Recommendation #3: Develop government policy mandates requiring the use of engineered protections to protect smokers on oxygen from the risks they fail to acknowledge.  

Recommendation #4: Consider implementing a multi-discipline approach to engage individuals who smoke while using oxygen. 

Research by Dr. Clifford Sheckter and Rebecca Coffey, PhD, shows HOT fires have a societal cost of $28.67 billion over 10 years. Mandating engineered solutions to stop HOT fires would provide $305.40 million in savings over that same time period and add 1812 quality life year (QLY) improvements. The Department of Veterans Affairs (VA) has mandated thermal fuse technology for all Veterans since 2018. The Centers for Medicare and Medicaid Services and private insurance carriers have yet to follow suit.

Conclusion

This research has determined that incidents of home oxygen fires occur more often from smoking cigarettes. A research gap exists between smoking and smoking while using home oxygen therapy. The central paradox shows that awareness does not equate to behavior change. Addiction overrides rational decision making to stop smoking while using home oxygen. People justify dangerous behaviors to maintain their level of comfort.

The findings underscore individuals involved in this study hold an incorrect understanding of what happens when oxygen ignites or how quickly fires develop. The research participants predominantly believe their smoking behaviors while using oxygen present less risk than general fire risks anyone faces in their homes. 

This disassociation of risk, in such a vulnerable health compromised population, speaks to the need for developing engineered safety solutions to reduce their fire risk. There are solutions to stop HOT fires. Home Oxygen Therapy fires in this country are occurring more frequently.  The risks associated with these fires remains unrecognized by this population group and the fire service.