Second-hand smoke: how damaging is it to health?

VOL: 101, ISSUE: 25, PAGE NO: 50

Jennifer Percival, RN, RM, RHV, Dip Counselling, FETC, is RCN tobacco education project manager

Bridget Queally, RN, RM, is counselling psychologist and stop-smoking specialist - Wellingborough, Northants Heartlands Primary Care Trust

In the 20th century, over half the English population smoked, but this figure has now dropped to a quarter (Office for National Statistics, 2003). A combination of scientific evidence, health education campaigns and larger warnings on cigarette packets has contributed to achieving this change. Public opinion has also shifted dramatically, and most people now accept that being a smoker is damaging to health.

In the 20th century, over half the English population smoked, but this figure has now dropped to a quarter (Office for National Statistics, 2003). A combination of scientific evidence, health education campaigns and larger warnings on cigarette packets has contributed to achieving this change. Public opinion has also shifted dramatically, and most people now accept that being a smoker is damaging to health.

In 1992, the World Health Organization International Agency for Research and Cancer classified second-hand smoke as being 'carcinogenic' to humans (WHO International Agency for Research on Cancer, 2002). Following this report, New York became one of the first cities in the world to introduce a comprehensive ban on smoking in public places to protect employees. In the UK, however, many employees, including nurses, are still routinely exposed to tobacco smoke in the workplace.

Several countries have enacted legislation to make all public places smoke-free. These include Ireland, Italy, Norway, Sweden, Thailand, Vietnam, Bhutan, and several Canadian and American States. Many more countries are now considering introducing similar laws.

In Ireland, all workplaces, including public houses, became smoke-free in March 2004. According to research published this year (Irish Office of Tobacco Control, 2005) 98 per cent of the Irish public believe that workplaces are healthier since the introduction of the law, and 93 per cent think the introduction of the law was a good idea. Forecasts of a slump in trade in public houses have not been borne out.

Second-hand smoke and passive smoking
Second-hand smoke (that which is inhaled by those who are not actively smoking - passive smokers) is made up of two types of smoke: smoke from the burning cigarette (side-stream smoke) and the smoke exhaled by active smokers (exhaled mainstream smoke). Side-stream smoke accounts for most of the tobacco smoke in a room where people have been smoking. It comes from cigarettes smouldering in ashtrays at low temperature, where they produce higher levels of dangerous compounds than when actively smoked (Action on Smoking and Health (ASH), 2001). Second-hand smoke is a complex mixture of more than 4,000 chemical compounds, including at least 40 known carcinogens. This smoke also contains carbon monoxide, a gas that inhibits the blood's ability to carry oxygen to the brain and heart.

Second-hand smoke is likely to be even more dangerous than inhaled smoke. The number of toxic substances in second-hand smoke is often more than the number that a smoker inhales.

Effect of second-hand smoke on health
Some of the immediate effects of second-hand smoke include eye irritation, headache, cough, sore throat, dizziness and nausea. Adults with asthma can experience a significant decline in lung function when exposed to second-hand smoke, and it may induce asthma in children whose parents smoke (Scientific Committee on Tobacco and Health, 2004).

A major review by the government-appointed Scientific Committee on Tobacco and Health (SCOTH) in 1998 concluded that second-hand smoke is a cause of lung cancer and ischaemic heart disease in adult non-smokers.

In 2004, SCOTH noted that the conclusions of its initial report still stand. The report confirmed that non-smokers exposed to second-hand smoke face a 24 per cent increased risk of lung cancer and a 25 per cent increased risk of heart disease. The report attracted widespread media coverage and concluded that 'it is evident that no infant, child or adult should be exposed to second-hand smoke. Second-hand smoke represents a substantial public health hazard'.

Many adults cannot cope with exposure to second-hand smoke. The National Asthma Campaign found that 82 per cent of people with asthma (four million people) reported that other people's smoke made their asthma worse and they felt that the government is not doing enough to protect them (Ulrik and Lange, 2001). The ASH website carries a complete summary of the UK and international evidence: www.ash.org.uk

Second-hand smoke and children
The General Household Survey found that 42 per cent of children in the UK are exposed to tobacco smoke at home (Office for National Statistics, 1999).

Children are at particular risk from exposure to second-hand smoke, and the Scientific Committee on Tobacco and Health (2004) found evidence that strongly links second-hand smoke with an increased risk of pneumonia and bronchitis, asthma attacks, middle ear disease, reduced lung function and sudden infant death syndrome in children.

The Royal College of Physicians estimates that each year in Britain, 17,000 children under the age of five were admitted to hospital because of illness caused by their parents smoking (Royal College of Physicians, 1992). An NHS leaflet, P is for Protecting Children from Second-hand Smoke, gives tips on ways people can help children be smoke-free (see Footnote).

Advising smokers after pregnancy - Midwives and health visitors routinely give advice to pregnant women to help them stop smoking (Percival, 2005). Infants of mothers who smoke are three times more likely to die of sudden infant death syndrome than infants who are not so exposed (US Department of Health and Human Services, 2001). Advice in the postnatal period needs to focus on helping smokers develop strategies to protect a newborn child from exposure to second-hand smoke.

Keeping children smoke-free - Many new parents will have family and friends who smoke and may never have thought about going to a smoke-free place and/or asking friends and family to smoke outside or away from their baby/child. Nurses could ask pregnant women, carers and relatives about the plans they have made to keep their children smoke-free. The point of these discussions is to encourage and empower parents to decide the changes they could make (Box 1). Many primary care trusts have Smoke-free Home schemes, which help nurses raise these issues.

The UK political debate on second-hand smoke

The chief medical officer's call in 2003 for a complete ban on smoking in public places (Department of Health, 2003) was ignored by the government, but Choosing Health: making healthy choices easier (DoH, 2004) supported legislation to restrict smoking in most public places in England and Wales, but also proposed exemptions for private clubs and pubs that do not serve prepared food. These proposals do not come into force until 2007.

The issue of exposure to second-hand smoke at work has recently been examined. Jamrozik (2005) estimated that exposure to second-hand smoke in the workplace causes about 700 deaths each year across the UK, which is three times the number of people killed in all industrial accidents in this country. The figures include the death of one hospitality worker a week.

In Scotland, the Scottish Executive has announced a decision to legislate for a comprehensive ban on smoking in public places by 2006. If passed it will apply almost everywhere, apart from oil rigs, psychiatric and care homes and prison cells. The Scottish health minister, Andy Kerr, has said nothing less than blanket restrictions will help to address the health problems caused by smoking.

The National Assembly for Wales has voted overwhelmingly in favour of new powers to end smoking in all workplaces and enclosed public places in Wales. The call goes further than the UK government's proposed legislation, announced in the Queen's Speech. The endorsement of the recommendations of the Assembly's own committee, could result in a ban on smoking in all enclosed public places within the next two to three years.

Smoking in the NHS?
New proposals were announced in Choosing Health (DoH, 2004) to make the NHS completely smoke-free by December 2006. A policy guidance document has been published by the Health Development Agency (2005a) as well as a supporting document called The Case for a Completely Smoke-free NHS in England (Health Development Agency, 2005b).

Some nurses have expressed concerns about the implications of the NHS ban, believing that it is cruel to deprive people of cigarettes when they are in hospital. The NHS has strict policies on drug and alcohol use and provides drugs to manage symptoms associated with dependency and withdrawal; for example, methadone is prescribed for patients addicted to heroin. In the same way, it is essential that the NHS offers nicotine-replacement therapy and support to stop smoking to all smokers on admission to hospital. It could be argued that allowing people to continue the habit that contributes to their deteriorating health is unacceptable when treatment options exist.

Can nurses in primary care be protected from second-hand smoke?
The primary care sector remains outside the legislation proposed in Choosing Health (DoH, 2004). Given the dangers of exposure to second-hand smoke and the wide variation of current practice among staff in dealing with it, there is a need for national guidance from the RCN for NHS organisations on how they can best protect the health and well-being of community staff.

Many community nurses are regularly exposed to second-hand smoke, and although they view this exposure as a problem, very few nurses feel they can do anything about it. Most nurses would not ask a patient to refrain from smoking, believing they have no right to tell people what to do in their own home, or because they fear negative repercussions.

Are there ways to reduce community nurses' exposure to second-hand smoke?
As the public becomes aware of the dangers of second-hand smoke, community staff need to start to ask patients for a smoke-free working environment. Most people receiving care are already happy to do things to help staff undertake their duties; for example, putting their pets in another room or turning the television off. If they have never been asked before to provide a smoke-free environment, it might not have occurred to them to do so.

As most home visits are now pre-booked, community nurses could ask their patients to provide a smoke-free room for the duration of the visit. In the case of patients refusing, the nurses could ask the patients if they could attend the health centre instead for their care. If this were impractical/impossible, the next step would be to ask the patients what they could do to offer the community nurses protection from breathing in smoke during home visits.

The role of the nurse manager
Nurse managers could draw up policies to protect staff from exposure to second-hand smoke. In Scotland, guidelines for local authorities (NHS Health Scotland et al, 2004) state that if employees bring to the attention of their line manager/supervisor that they are experiencing adverse medical effects of second-hand smoke at work, all reasonable steps should be taken to reduce their risk. The authority's human resources policy should provide guidance on the actions to be taken. Failure to take reasonable action when it is foreseeable that the employee could suffer injury would make the authority liable to prosecution under health and safety legislation and employment law. Measures that a manager could consider are listed in Box 2.

Conclusion
It is to be hoped that smoke-free working and public places will one day become the norm across the UK. As members of the public - and as nurses - it is essential to lobby the government to take the necessary action to achieve this as soon as possible.

Footnote
An NHS leaflet, P is for Protecting Children from Second-hand Smoke, is free, along with Second hand Smoking campaign posters from the NHS Smoking Helpline: telephone 0800 169 0 160.