Editorials

Protecting children from passive smoking

The risks are clear and a comprehensive strategy is now needed

Papers pp 333, 337, 343

Environmental tobacco smoke is a serious health risk to children. Regulatory measures to protect children, such as eliminating smoking in day care settings, schools, and public places, do not address their main source of exposure to tobacco smoketheir homes. Formal structures for protecting children in the home are usually only used in certain circumstances involving custody and adoption,¹ and legislation to ban smoking in homes is unlikely, so other strategies to reduce children's exposure to environmental tobacco smoke must be put in place.

In this issue of the BMJ, three separate but thematically related papers provide support for a comprehensive approach to protect children from environmental tobacco smoke.^2-4 Jarvis et al report that much of the reduction in exposure among English children aged 11-15 that occurred between 1988 and 1998 was due to reduced prevalence of parental smoking, as well as reduced smoking in the home (p 343).² Thus public education and programmes directed at reducing exposure in the home need to be combined with policies and programmes for the public aimed at preventing smoking and encouraging smokers to give up.

In California, where a comprehensive approach to tobacco control is well under way, Hovell et al found a major effect of behavioural counselling on childhood exposure in an ethnically diverse, low income population, indicating that specific interventions of this type can be successful (p 337).³ Wakefield et al report that a ban on smoking in the home significantly reduced initiation and prevalence of smoking among students aged 14-17 in the United States (p 333).⁴ Smaller effects were seen for partial restrictions. School bans that were enforced and restrictions in public places were also associated with lower smoking rates. These findings indicate other potential benefits, beyond physical protection from environmental tobacco smoke, which accrue from more restrictions on smoking. Not only do children model their behaviour on that of adults ^{5 6} but parental and societal attitudes toward tobacco use, as shown by bans on smoking in homes, schools, and public places, may also reduce the number of adolescents who take up smoking.

While a comprehensive approach is needed, this does not negate the need for focused interventions. The findings of Hovell et al show the potential of more focused techniques that impact directly on smoking parents.³ In our jurisdiction (Ontario, Canada) attitudes of the public, both smokers and non-smokers, towards smoking in the home in the presence of children increasingly favour restrictions, suggesting that the climate is right for behavioural interventions aimed at parents.⁷

The time is also right for interventions aimed at health professionals, in particular, family physicians and paediatricians. Recent revisions to the Ontario Child and Family Services Act require that physicians report their suspicions to the Children's Aid Society if they suspect physical harm or even a risk of harm resulting from failure to protect the child or a pattern of neglect.⁸ While reporting is difficult for physicians in cases of abuse and even more so when there is risk of abuse, it is likely to be particularly difficult with smoke exposure, since smoking in the presence of others is still considered acceptable by most of society. Nevertheless, such requirements may sensitise physicians to the need to intervene in cases of exposure to environmental tobacco smoke by giving advice to parents, including help in smoking cessation. Furthermore, they make clear the urgency of specific interventions to prepare physicians for this role and help them in carrying it out.

Increasing the scope and effectiveness of smoking restrictions in public places and workplaces will continue to be a cornerstone of any comprehensive strategy. Recent studies have highlighted the important part that household and workplace restrictions play in promoting sustained smoking cessation, and by extension, reducing the exposure of children to secondhand smoke. ^{9 10} Other strategies, such as price increases, reduced availability of tobacco products, and mass media interventions, are also crucial.

As more is learnt about strategies to control tobacco and how they interact, it is clear that no one strategy will work alone. The indirect effects of a particular strategy may be just as important as the direct ones. The protection of children from passive smoking cannot be separated from the larger issue of reducing the harm caused by tobacco products in the population as a whole. The need for a comprehensive strategy to address this major public health problem is now readily apparent. The addition of these new studies strengthens the rationale for a comprehensive framework to protect children's health and prevent their recruitment to smoking in adolescence.

Roberta Ferrence, director. 

Ontario Tobacco Research Unit, Toronto, ON, Canada M5S 2S1 (roberta.ferrence{at}utoronto.ca)

Mary Jane Ashley, professor. 

Department of Public Health Science, University of Toronto, Toronto, ON, Canada M5S 1A8