Passive smoking and children

207 Pages·2010·1.239 MB·English

by  Royal College of Physicians of London. Tobacco Advisory Group., Royal College of Physicians of London

Passive smoking
and children
A report by the Tobacco Advisory Group
of the Royal College of Physicians
March 2010
Supported bythe Royal College of Paediatrics and Child Health
With funding from
Acknowledgements
The members of the Tobacco Advisory Group acknowledge with thanks Nicholas
Ridgman and Joanna Reid of the RCP Publications Department for the editing and
production of this report.
This report was made possible by funding from Cancer Research UK, which enabled the
systematic reviews, original analyses of primary care databases, and further analysis of
data from the Health Survey for England to be carried out. Much of the content of the
report was produced by staff and students at the UK Centre for Tobacco Control Studies
(www.ukctcs.org), which is supported by core funding from the British Heart Foundation,
Cancer Research UK, Economic and Social Research Council, Medical Research Council,
and the Department of Health, under the auspices of the UK Clinical Research
Collaboration. Health Survey for England data were available from a study funded by the
Department of Health (England).
The Royal College of Physicians
The Royal College of Physicians is a registered charity that aims to ensure high quality care
for patients by promoting the highest standards of medical practice. It provides and
sets standards in clinical practice and education and training, conducts assessments and
examinations, quality assures external audit programmes, supports doctors in their practice
of medicine, and advises the Government, public and the profession on healthcare issues.
Citation for this report: Royal College of Physicians. Passive smoking and children. A report
by the Tobacco Advisory Group. London: RCP, 2010.
Copyright
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Copyright © Royal College of Physicians 2010
ISBN 978-1-86016-376-0
Royal College of Physicians
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© Royal College of Physicians 2010. All rights reserved.
Contents
Contributors vi
Foreword vii
Members of the Tobacco Advisory Group viii
Preface ix
1 Smoke-free legislation in the UK 1
1.1 Background 1
1.2 Implementation of smoke-free legislation in the UK 2
1.3 Scope of the legislation 2
1.4 Exemptions 2
1.5 Extensions beyond legislative requirements 4
1.6 Evaluation of smoke-free legislation 11
1.7 Gaps and inconsistencies in the legislation 15
1.8 Summary 17
2 Passive smoking in UK children 21
2.1 Introduction 21
2.2 English study data and methods 22
2.3 Smoke-free policy and passive smoke exposure of children 35
in Scotland
2.4 Data from Northern Ireland 36
2.5 Data from Wales 37
2.6 Data from other countries 37
2.7 Summary 37
3 Effects of maternal active and passive smoking on fetal and 40
reproductive health
3.1 Background 40
3.2 Prevalence of smoking among pregnant women 41
3.3 Effects of maternal active smoking on fertility and the fetus 41
3.4 Prevalence of passive smoking among pregnant women 62
3.5 Effects of maternal passive smoking on fertility and the fetus 62
3.6 Bias and confounding in observational studies 71
3.7 Limitations of the studies of maternal passive smoking 72
3.8 Summary 73
4 Health effects of passive smoking in children 79
4.1 Introduction 79
4.2 Methods 80
4.3 Sudden infant death syndrome 81
4.4 Lower respiratory infection 81
© Royal College of Physicians 2010. All rights reserved.
iv Contents
4.5 Wheeze and asthma 83
4.6 Middle ear infection 86
4.7 Lung function 87
4.8 Meningitis 88
4.9 Confounding 90
4.10 Summary 91
5 How much disease in children is caused by passive smoking? 107
5.1 Introduction 107
5.2 Estimates of disease incidence 108
5.3 General practice consultation rates 110
5.4 Disease incidence and socio-economic status 110
5.5 Hospital admissions 110
5.6 Notified cases of meningococcal meningitis 111
5.7 Sudden infant deaths 111
5.8 Attributable fractions for passive smoke exposure 111
5.9 Morbidity and mortality attributable to passive smoking 112
5.10 Association between morbidity and deprivation 115
5.11 Summary 115
6 Effect of parent and sibling smoking on smoking uptake 117
6.1 Introduction 117
6.2 Age and uptake of smoking 117
6.3. Factors influencing smoking uptake 118
6.4 Studies identified 118
6.5 Parental smoking 119
6.6 Sibling smoking 119
6.7 Household smoking 120
6.8 Implications of effect of family smoking on smoking uptake 120
6.9 Number of children who take up smoking as a result of smoking 121
exposure in the home
6.10 Implications for policy 121
6.11 Summary 122
7 The costs of passive smoking in children 127
7.1 Background 127
7.2 Costs in primary care 128
7.3 Hospital costs 129
7.4 Costs of uptake of smoking 131
7.5 Summary 132
8 Public opinion on smoke-free policy 134
8.1 Introduction 134
8.2 Support for smoke-free legislation 135
© Royal College of Physicians 2010. All rights reserved.
Contents v
8.3 Perceived exposure to passive smoke 136
8.4 Perceived health benefits of smoke-free places 137
8.5 Attitudes among smokers 138
8.6 Perceived harms of passive smoke 138
8.7 New social norms 140
8.8 Opinions on smoking outdoors and in vehicles 141
8.9 Where the smoke still lingers 144
8.10 Children’s opinions on smoke-free policy 145
8.11 Summary 145
9 Ethics: children and smoking 147
9.1 Introduction 147
9.2 Protecting children from smoking 148
9.3 Preventing smoking among children 149
9.4 Controlling smoking within the home 153
9.5 Special cases: looked-after children, foster carers and potential 155
adoptive parents
9.6 Children in their home 158
9.7 Children outside the home 159
9.8 Summary 161
10 Strategies to reduce passive smoking in children 163
10.1 Introduction 163
10.2 Reducing the number of parents and carers who smoke 164
10.3 Making homes smoke-free 165
10.4 Passive smoking in cars and other vehicles 171
10.5 Use of medicinal substitution to support smoke-free settings 172
10.6 Summary 173
11 Overview and conclusions 177
11.1 The UK smoke-free legislation 177
11.2 Health effects of passive smoking in children 178
11.3 Passive smoking and smoking uptake in children 180
11.4 The costs of passive smoking 181
11.5 Ethics 181
11.6 Preventing the harm caused by passive smoking in children 181
11.7 Smoke-free vehicles 187
11.8 Smoking in other public places 187
11.9 Public opinion on extensions to smoke-free legislation 188
11.10Summary 188
12 Key conclusions and recommendations 191
© Royal College of Physicians 2010. All rights reserved.
vi
Contributors
Deborah Arnott Chief executive, Action on Smoking and Health, London
Richard AshcroftProfessor of bioethics, Queen Mary, University of London
Fatima BhayatResearch fellow, University of Nottingham
John BrittonProfessor of epidemiology; director, UK Centre for Tobacco Control Studies,
University of Nottingham
Hannah BurkeFoundation year doctor, Nottingham University Hospitals
Yilu ChenLecturer in medical statistics, University of Nottingham
Tim ColemanReader in primary care, University of Nottingham
Derek CookProfessor of epidemiology, St George’s University of London
Martin DockrellDirector of research and policy, Action on Smoking and Health, London
Richard EdwardsProfessor of public health, University of Otago
Anna GilmoreReader in public health, University of Bath; senior lecturer, London School of
Hygiene and Tropical Medicine
Christine GodfreyProfessor of health economics, University of York
Ian GrayPrincipalpolicy officer, Chartered Institute of Environmental Health, London
Allan HackshawDeputy director, Cancer Research UK and University College London Cancer
Trials Centre
Ahmed HashimData analyst, University of Nottingham
Amal Hassanien Masters student, University of Nottingham
Sally HawSenior scientific adviser, Scottish Collaboration for Public Health Research and Policy,
Edinburgh
Yue HuangUK Centre for Tobacco Control Studies Data Analyst, University of Nottingham
Richard HubbardBritish Lung Foundation professor of respiratory epidemiology, University of
Nottingham
Martin JarvisProfessor emeritus of health psychology, University College London
Mirriam Lisa JereMasters student, University of Nottingham
Laura JonesUK Centre for Tobacco Control Studies research fellow, University of Nottingham
Shona KellyLecturer in social epidemiology, University of Nottingham
Jo Leonardi-BeeLecturer in medical statistics, University of Nottingham
Tricia McKeeverAssociate professor of medical statistics, University of Nottingham
Ann McNeillProfessor of health policy and promotion; deputy director, UK Centre for Tobacco
Control Studies, University of Nottingham
Steve ParrottResearch fellow, Department of Health Sciences, University of York
Michelle SimsResearch officer, University of Bath
Lisa Szatkowski UK Centre for Tobacco Control Studies postgraduate research student, University
of Nottingham
Laila TataLecturer in epidemiology, University of Nottingham
Andrea VennAssociate professor of epidemiology, University of Nottingham
© Royal College of Physicians 2010. All rights reserved.
vii
Foreword
I welcome this report from the Royal College of Physicians.
The report quantifies the effects of second-hand smoke on children’s health,
and the related costs, and identifies ways in which smoke-free legislation could
be improved to afford greater protection to children. Most importantly, it calls
for a radical rethink of the acceptability of smoking anywhere in the presence of
children.
One of the biggest impacts of smoking around children is that adult smokers
can be seen as role models, increasing the likelihood that the child will, in due
course, also become a regular smoker. Preventing this means that adults take
responsibility to stop smoking in front of their children at home, or in places
where children may see them smoke.
Success will demand far more radical approaches to tobacco prevention,
particularly in terms of price, mass media campaigns, and the consideration of
generic packaging, and wider smoke-free public policy covering cars, entrances
to public buildings, parks, and other outdoor places frequented by children.
Protecting children is a health priority. Adult smoking behaviour must
radically change to achieve that. This report identifies the reasons why, and what
should be done to achieve it.
The Government continues to implement strong measures and policies to
protect children from second-hand smoke, as featured in the new tobacco
control strategy for England, A smokefree future,* published earlier this year.
In my 2002 annual report,†I highlighted children’s special vulnerability to
second-hand smoke, owing to their smaller lungs and underdeveloped immune
systems, making them more susceptible to respiratory and ear infections
triggered by passive smoking. It was in this report that I first called for a smoking
ban in all enclosed public places, which became law in 2007, and we must ensure
we keep up the momentum, especially where children are exposed, to continue
to reduce the harm of tobacco use in our communities, and create a truly smoke-
free future.
March 2010 Sir Liam Donaldson
Chief Medical Officer
*Department of Health. A smokefree future: a comprehensive tobacco control strategy for England.
London: DH, 2010.
†Department of Health. Annual report of the Chief Medical Officer 2002.London: DH, 2003.
© Royal College of Physicians 2010. All rights reserved.
viii
Members of the Tobacco Advisory Group
of the Royal College of Physicians
John Britton (Chair)
Deborah Arnott
Richard Ashcroft
Paul Belcher
Tim Coleman
Linda Cuthbertson
Anna Gilmore
Christine Godfrey
Allan Hackshaw
Zoe Horwich
Martin Jarvis
Jean King
Ann McNeill
Jennifer Percival
Huw Thomas
Mike Ward
© Royal College of Physicians 2010. All rights reserved.
ix
Preface
In 2003, over 11,000 people in the UK are estimated to have died as a result of
passive smoking.* Although regarded for many years as little more than a
nuisance, exposure to ambient tobacco smoke released directly by burning
tobacco and indirectly by exhalation of smoke by smokers (also variously
referred to as environmental tobacco smoke, second-hand smoke, or tobacco
smoke pollution) is now a recognised cause of significant short- and long-term
harm to others. Many of those adverse health effects were summarised,
particularly in relation to adult exposure, in an earlier Royal College of
Physicians report.†
Increasing awareness of these health risks has led the UK and several other
countries to introduce legislation restricting or prohibiting smoking in enclosed
public places. This legislation has typically been justified by the legal and moral
obligation to ensure safe working environments and, in the UK, to prevent the
600 or so deaths previously estimated to be caused each year by passive smoking
at work.* However, these are the minority of deaths caused by passive smoking,
the bulk of which (an estimated 10,700 deaths in adults in 2003)* arise from
exposure to tobacco smoke in the home.
Passive smoking in the home is also a major hazard to the health of the
millions of children in the UK who live with smokers, and the extent of this
health problem has not, to date, been accurately quantified. In this report, we
therefore use established literature and additional analysis to estimate the
prevalence, determinants and trends in passive smoking exposure, present new
systematic reviews and meta-analyses of the magnitude of the effects of passive
smoking on the main recognised health consequences in children, and estimate
the numbers of cases of illness and death arising from these effects. We also
quantify the effect of exposure to smoking behaviour on the risk of children
starting to smoke, and estimate the number of children who do take up smoking
as a consequence. We then consider the financial cost of the disease burden for
the NHS and wider society arising from all of these exposures. The report also
explores ethical issues relating to passive smoking and children, and public
opinion on measures to prevent passive smoking, concluding with policy options
*Jamrozik K. Estimate of deaths attributable to passive smoking among UK adults: database
analysis. BMJ2005;330:812–17.
†Royal College of Physicians. Going smoke-free: the medical case for clean air in the home, at
work and in public places. A report by the Tobacco Advisory Group. London: RCP, 2005.
© Royal College of Physicians 2010. All rights reserved.
x Preface
that would reduce exposure of children to this significant health hazard and
negative behavioural model.
Governments, and societies, have a duty to ensure that children grow up in a
safe environment, and are protected from explicit or implicit encouragement to
take up hazardous behaviours such as smoking. This report provides some of the
background and policy measures necessary to ensure that that duty is discharged.
I am personally very grateful to John Britton and the other members of the
RCP’s Tobacco Advisory Group, and the many contributors to this report who
have continued the excellent tradition of the RCP in this important area.
March 2010 Professor Ian Gilmore
President, Royal College of Physicians
© Royal College of Physicians 2010. All rights reserved.