Mark Wallace-Bell, PhD, RGN, CPsychol
Lecturer in Tobacco Addiction, Centre for Addiction Studies, St George’s Hospital Medical School, University of London
Before the 1970s it was thought that only active smokers were at risk of developing cancers of the lung, heart disease and other smoking-related illnesses. More recently the evidence has been building, with several major reports and reviews supporting the argument, that passive smoking is dangerous to adult and child health (US National Research Council, 1986; US DHHS, 1986; Hackshaw et al, 1997).Other studies have shown that passive smokers can develop cancer of the lung (Rapti et al, 1999; Zhong et al, 1999), heart disease (He et al, 1999) and other smoking-related disease by being regularly exposed to environmental tobacco smoke (ETS).ETS is a complex mixture of more than 4000 chemical compounds, including at least 40 known carcinogens. It also contains carbon monoxide, a gas that inhibits the blood’s ability to carry oxygen to body tissues, including vital organs.
When a cigarette is smoked, about 85% of the smoke from a cigarette rises into the air. This ‘side-stream’ smoke contains higher levels of many carcinogens - carbon monoxide, nicotine and ammonia - than ‘main-stream’ smoke.Main-stream smoke is smoke that smokers have inhaled into their lungs and then exhaled into the atmosphere. This is harmful to the non-smoker and, like side-stream smoke, contributes to the harm done to passive smokers from second-hand smoke.
Although difficult to measure, passive smoking can be detected in non-smokers by measuring the levels of cotinine present in their saliva or urine (Jarvis et al, 2001). Cotinine is a biomarker of nicotine and is present in children and adults who are exposed to second-hand smoke (Hecht et al, 2001). Many studies have found high levels of cotinine in children who live in smoky homes (Royal College of Physicians, 1992).Women and children may face the greatest risk from second-hand smoke, and the poorest are most affected. Smoking prevalence is higher in lower socioeconomic groups, so the number of poor children exposed to smoking in the home is greater. Poor people are also more likely to live in crowded accommodation and have existing disease that is exacerbated by ETS (Samet and Yang, 2001). In many European countries there is growing public support for control of ETS, and around 80% have some form of regulation.
Risks of ETS in adults
Adult non-smokers are at risk from ETS, whether they work alongside smokers who are permitted to smoke in the workplace, live with a smoker, or go to social environments, such as pubs and restaurants. The harm done to adults by ETS can be chronic if smokers make no effort to smoke outside or reduce the amount of ETS their non-smoker partner or family member inhales.Environmental smoke causes the same serious conditions as active smoking. Cancer of the lung is by far the greatest risk that passive smokers face, as well as coronary heart disease and reduced lung function.
Risks of ETS in children
Children, particularly very young ones, are especially at risk from the harm done by ETS, as they usually have no say in when or where the smoker smokes.Tobacco smoke in the home is an important source of exposure because children spend most of their time at home and indoors. They are far less likely to be able to leave a smoke-filled room if they want to: babies cannot ask, some children may not feel confident about raising the subject and others may not be allowed to leave even if they do ask.Studies in the 1990s showed that many European children live in smoky homes, from a quarter in Finland to two-thirds in the Netherlands (Royal College of Physicians, 1992). Children in smoky homes are also more prone to respiratory problems. Smokers’ children are also more prone to middle ear infections (RCP, 1992).
Nurses and the risks of passive smoking
There is a unique risk to community-based health workers who are caring for smokers in their homes or in community contexts. At a recent RCN congress the issue of whether patients who smoke in their homes before or during visits could harm district nurses was raised. The resolution was put forward by the RCN’s District Nurses’ Forum, with the chair of the forum arguing that the issue was one of health and safety at work.Delegates overwhelmingly voted not to campaign for the rights of nurses to work in a smoke-free environment - most argued that it was an infringement of the human rights of patients to try to restrict their smoking in their own homes. Psychiatric nurses pointed out that it was important that their patients felt as relaxed as possible during treatment, and that this might occasionally require them to smoke.
How ETS harms family life
Passive smoking poses a serious health risk for children, but even ‘minor illnesses’ such as coughs and colds, which can be made worse by passive smoking, can disrupt family life.
Coughs and colds
- Colds: adults may need time off work if the child is very ill or others become infected- Coughs: a child with a bad cough can stop everyone sleeping, disrupting work and school.
Middle ear infections - ‘glue ear’ or otitis media
- Pain: the child may become irritable and difficult to soothe- Poor hearing: a temporarily partially deaf child may not hear instructions and seem difficult- Longer-term hearing loss - children with poor hearing tend to develop more slowly and fall behind at school, or may have behaviour problems- Need for operation - surgery can be frightening for child and parent and disruptive to the family. The child may also regress to tantrums or bedwetting.
- Need to avoid triggers - even moderate asthma may limit family life, and some control methods are expensive
- Wheezing - chest discomfort and wheezing cause anxiety for both child and parents
- Need for drug treatment - some asthma drugs, particularly steroids, can damage children’s health and growth- Need for hospital treatment - A&E attendance or admission may be frightening for the child and parent and disrupt family life- May be life-threatening.
- Serious illness - the child may become physically weak or perhaps fall behind socially or at school
- Coughing - disruptive for household members
- Need for hospital treatment - frightening for child and parent and may disrupt household and the child’s development
- May be life-threatening.
Options for risk reduction - at home
There are many options for reducing smoke exposure. The initial suggestions given here may simply reduce immediate asthma risk, while later methods can substantially reduce smoke exposure. Clients may benefit greatly from careful practical discussion of their best options, which include:
Reducing smoke levels in the room - Simple changes can avoid the highest levels of exposure. For example, holding cigarettes away from a child’s face or smoking as far away from children as possible.
Improving ventilation - Ventilation can help reduce the immediate impact of smoke. Smokers may choose the following options:
- Using a fan to direct smoke away from children
- Opening a window so that smoke is directed outwards
- Using an extractor fan
- Smoking in another room - choosing a room away from children’s play or sleep areas
- Keeping doors shut between children and people who are smoking
- Ventilating the room during and after smoking.
Parents must, of course, consider younger children’s safety when smoking away from them. Some families can afford a ‘baby alarm’ system to check on what is happening, but it may be helpful to discuss realistic options with those who cannot.
Creating smoke-free areas - This can be a good way of clarifying guidelines for family and visitors. Popular choices include:
- Making children’s bedroom(s) smoke free
- Making all bedrooms smoke free
- Making the upper floor smoke free
- Making the kitchen smoke free
- Smoking in the living room only
- Smoking in individual bedrooms only.
Smoking outside only is the safest option, but may not be practical or comfortable.
Options for risk reduction - out and about
Nearly all public places now provide a smoke-free area or are completely smoke free. Yet raising the issue while visiting friends or family can be tricky. Society tends to focus on smoking as a personal choice rather than as a shared risk. It may help clients if you emphasise that they are not trying to get others to stop but to think about the best times and places to smoke.In a car - High levels of tobacco toxins can build up inside a closed car. Apart from the long-term risk to their health this poses, children are also more likely to get car sick. Options could include:
- Keeping the car ventilation on
- Opening the window slightly
- Stopping for cigarette breaks, which is often the only practical solution.
Transport and public places
Most public places and transport services are either completely smoke free or offer a smoke-free area. Families with children with asthma may need to choose seating furthest away from any smoking area. Drivers of public service vehicles should not smoke while carrying passengers, but some private services may not observe the same rules.
In other enclosed areas
Children’s activities are sometimes held in leisure centres or community halls. These may have no policy on smoking, or guidelines may be ignored, sometimes even by staff members. Parents and carers may feel torn about how to protect their children without causing offence. They could first raise the issue with other parents or carers, then approach the group leader or another responsible staff member. The organisation may then need to review guidelines, or consider the placing of no-smoking signs, to help resolve the problem for all users of the centre.
Forty-two per cent of UK children live in a household where at least one person smokes; 17 000 children under the age of five are admitted to hospital every year with illnesses resulting from passive smoking which affects their development and long-term health (RCP, 1992). Parents must recognise that passive smoking causes ill-health in children and that they have a responsibility not to inflict harm.
From the empirical evidence it is clear that passive smoking is a major risk to all those exposed to it. It causes lung cancer and heart disease and can exacerbate existing disease in children and adults. Although the level of exposure required to bring about disease is not yet known, there is a growing evidence base that suggests there is a clear dose-related causal relationship between exposure to ETS, morbidity and mortality.It is important that all health professionals aim to seek to eliminate this risk or at least adopt a harm-reduction approach. This requires an appreciation of the existing evidence and a realisation that passive smoking affects patients and carers alike.
Reflect on your attitudes towards passive smoking:
- When did you last give advice on this to a client who smokes?
- List the reasons why you do or do not feel able to give such advice.
- Reflect on the particular risks to children exposed to passive smoking
- Do you give advice to parents regarding their children’s exposure to smoke?
- Do you know the options for risk reduction you could recommend?
As a community nurse, how would you deal with being exposed to clients smoking in their home?- How would you educate clients on risk reduction?
ASH. (2002)Passive Smoking: The impact on children. One of a wide range of ASH publications. For a complete list contact ASH, or see www.ash.org.uk.
ASH. (2002)Passive Smoking: A summary of the evidence. See www.ash.org.uk
ASH/Health Development Agency. (2001)Smoking and Health Inequalities. London: Health Development Agency. See www.ash.org.uk
ASH/Health Development Agency. (2001)Smoking, Low Income and Health Inequalities. See www.ash.org.uk
Royal College of Physicians. (2000)Nicotine Addiction in Britain. A report of the Tobacco Advisory Group of the Royal College of Physicians. London: RCP.
US Department of Health and Human Services. (2001)Women and Smoking. A major research review, including reproductive outcomes. Summaries and full text at www.cdc.gov/tobacco/sgr_forwomen.htm.
World Health Organization. (2001)Women and the Tobacco Epidemic. Geneva: WHO.Next month: the psychological aspects of nicotine addiction.
Hackshaw, A.K., Law, M.R., Wald, N.J. (1997) The accumulated evidence on lung cancer and environmental tobacco smoke. British Medical Journal 315: 980-988.
He, J., Vupputuri S., Allen, K. et al. (1999)Passive smoking and the risk of coronary heart disease: a meta-analysis of epidemiological studies. New England Journal of Medicine 340: 920-926.
Hecht, S.S., Ye, M., Carmella, S.G. et al. (2001)Metabolites of a tobacco-specific lung carcinogen in the urine of elementary school-aged children. Cancer Epidemiology Biomarkers and Prevention 10: 11, 1109-1116.
Jarvis, M., Goddard, E., Higgins, V. et al. (2001)Children’s exposure to passive smoking in England since the 1980s: cotinine evidence from population surveys. British Medical Journal 321: 343-345.
Rapti, E., Jindal, S.K., Gupta, D., Boffetta, P. (1999)Passive smoking and lung cancer in Chandigarh, India. Lung Cancer 23: 3, 183-189.
Royal College of Physicians. (1992)Smoking and the Young. London: RCP.
Samet, J.M., Yang, G. (2001)Passive smoking, women and children. In: World Health Organization. Women and the Tobacco Epidemic. Geneva: WHO.
US Department of Health and Human Services. (1986)The Health Consequences of Involuntary Smoking. A report of the US Surgeon General. Washington, DC: US DHSS.
US National Research Council. (1986)Environmental Tobacco Smoke: Measuring exposures and assessing health effects. Washington, DC: US National Research Council.
Zhong, L., Goldberg, MS., Gao, Y.T., Fin, F. (1999)A case-control study of lung cancer and environmental tobacco smoke among non-smoking women living in Shanghai, China. Cancer Causes Control 10: 6, 6-16.