CANCER PREVENTION INSTITUTE OF CANADA

Last updated: 15-Jan-2007

Interventions to Reduce ETS Exposure in Children and Public Places

This subsection will focus on the new and important field of children’s exposure to ETS. Due to the well-documented risks of environmental tobacco smoke (ETS),[1],[2] reducing exposure to ETS in public places and family settings is a widespread public health goal. Many players are involved with the effort to reduce such exposure, including researchers, clinicians, midwives, community and hospital nurses, health departments and tobacco control agencies and organizations.

Children are thought to be particularly vulnerable and have received special attention with regard to ETS. Parental smoking, for instance, is a common but preventable source of childhood morbidity and mortality.[3],[4] A 1998 study revealed that almost half of Canadian children are exposed to ETS in the home.[5] Of particular concern in some jurisdictions is the uneven distribution of ETS exposure, being higher in children of low-income, less-educated parents.[6]

As with other arenas of tobacco control, ETS exposure in childhood can be reduced through community programs, individual interventions and wider policy shifts. There are complexities involved with measuring trial outcomes. The choice of methods are: self-reported rates of smoking around children (which can be unreliable), reading smoke or chemical levels in the environment (e.g., a room which the child frequents), or detecting biochemical by-products of ETS (e.g., urinary cotinine) in the body. The latter method is subject to less reporting bias, but the validity of the particular chemical chosen and the accuracy of testing remain as ongoing areas of research.[7],[8],[9]

Community-based Interventions

Obviously, children of all ages can benefit to some extent from tobacco bans in workplaces (see above) and, more significantly, from similar programs in public places which they might frequent (see below). Research on other community interventions has been extremely limited; after eliminating two heterogeneous projects based in elementary schools, there was only one study in the entire Cochrane review in this area.[10]

School-based Interventions

School smoking bans were covered earlier, in the section on reducing smoking initiation. As was noted there, enforcement, or at least the perception of enforcement, seems to be the key to compliance.

Theoretically, it is possible that children can take responsibility to either influence their parent’s smoking or to move themselves to a smoke-free environment. Only one study from 1993 in China has focused on motivating children in a school setting to create change at home (with some success observed.).[11]

Home-based Interventions

The majority of the programs have been aimed at influencing the behaviour of parents directly, with those and other carers recruited mostly through contact with the healthcare system. (Note: the topic of smoking cessation among pregnant women will be covered in a separate subsection.) Smokers have three options to reduce ETS for their children: quit smoking, reduce smoking or change smoking location (sometimes called avoidance); a combination of the approaches also can be used.

There is limited literature on adult-focused programs. A 2001 review by Emmons et al. rated a mere 5 studies as meeting its stringent requirements, with only one of those recording positive results (as self-reported by carers).[12] The relevant Cochrane review (2004) accessed three times the number of studies, but recorded a similar low rate of success in reducing children’s ETS exposure (see details on a key project below).[13] The successful programs involved intensive counselling. Brief interventions were less effective than in projects which focused on adult smoking cessation. There is greater support for concentrating on changes in participants’ attitude and behaviours rather than merely transferring knowledge.

Interventions in the Well Child Healthcare Setting

Opportunistic interventions can be targeted at parents or other carers in the “well child healthcare setting,” e.g., maternity hospitals, immunization clinics and routine health checks. Only one positive study fit this category according to Cochrane, namely Project KISS (Keeping Infants Safe From Smoke). In the paper, Emmons and colleagues (2001) report a significant decline in nicotine levels in the home of the intervention group at 3 and 6 month follow-up, though there was no effect on parental smoking rates. This apparently was the first study that had been effective in reducing objective measures of ETS exposure in households with healthy children.[14] The intervention consisted of a 30- to 45-minute motivational interviewing session at the participant’s home with a trained health educator and 4 telephone follow-ups.

Interventions in the Ill Child Healthcare Setting

Sometimes opportunistic interventions can be targeted at parents of children with health problems such as respiratory illness. Two projects demonstrated modest improvements in ETS exposure, one with asthmatic children and one with a sample drawn from a supplemental nutrition program.[15],[16] Again, intensive counselling was the focus of the intervention, and the outcome measure was reduced smoking in the presence of children (self-reported).

Regulatory and Economic Interventions

Smoking bans in public places has been an issue in B.C. since 1992 when the Capital Region banned smoking in all workplaces except restaurants and long-term care facilities. Since then the policy has expanded to other municipalities and begun to cover the excluded locations. While the main purpose of smoking bans is the protection of non-smokers from ETS, a side effect, as noted earlier, is the potential to reduce consumption in smokers and possibly increase cessation rates.[17]

Several studies have shown that assertive requests to refrain from smoking directed at individual smokers (in, for example, offices and businesses) can be a very effective addition to the presence of no-smoking signs.[18] Such a strategy is unlikely to be acceptable as a formal public health intervention,[19] though it may continue to grow as an informal social control mechanism (i.e., passers-by taking matters into their own hands) as health concerns and non-smokers’ rights continue to be promoted.

The most significant interventions are likely still to come in the area of ETS (it is notable that apparently the most recent successful clinical project is 5 years old). Apart from more research in order to identify effective interventions, fuller progress on ETS exposure in children may finally require the kind of diffuse “social norm” shifts that now exist in other spheres, e.g., the growing stigma surrounding any pregnant mother who smokes. This does not mean that proactive regulation will not play a role. A possibility which remains to be tested is targeted legislation, such as the proposal by the Ontario Medical Association to ban smoking in cars where children are passengers.[20]

Comprehensive Strategies

All the results included in the relevant Cochrane review were from uncontrolled before and after studies.[21] The conclusion from the 11 included studies is that, when carefully planned and resourced, multi-component strategies can reduce smoking within public places. Most of the studies dated from the 1980s or earlier. This seems to be an area of little current research interest, perhaps because ban policies (including legislation) have been largely successful, at least in offices and institutions. It has reached the point where, even in the absence of rigorous testing of effectiveness (e.g., evaluating compliance rates), bans in many public places in developed countries are considered a social norm, where there is even informal “policing” by people being affected by an adjacent smoker.

[2] He J, Vupputuri S, Allen K et al. Passive smoking and the risk of coronary heart disease. A meta-analysis of epidemiologic studies New England Journal of Medicine 1999; 340: 920-6.

[3] Roseby R, Waters E, Polnay A et al. Family and carer smoking control programmes for reducing children's exposure to environmental tobacco smoke Cochrane Tobacco Addiction Group Cochrane Database of Systematic Reviews, 2004.

[4] World Health Organization. International Consultation on Environmental Tobacco Smoke (ETS) and Child Health. 1999.

[5] Ashley MJ, Ferrence R. Reducing children’s exposure to environmental tobacco smoke in homes: issues and strategies Tobacco Control 1998; 7: 61-5.

[6] Emmons KM, Wong M, Hammond K et al. Intervention and policy issues related to children’s exposure to environmental tobacco smoke Preventive Medicine 2001; 32: 321-31.

[7] Hovell MF, Zakarian JM, Wahlgren DR et al. Reported measures of environmental tobacco smoke exposure: trials and tribulations Tobacco Control 2000; 9(Suppl 3): 22-8.

[8] Bono R, Vincenti M, Schiliro T et al. Cotinine and N-(2-hydroxyethyl)valine as markers of passive exposure to tobacco smoke in children Journal of Exposure Analysis & Environmental Epidemiology 2004 [E-published ahead of print].

[9] Sexton K, Adgate JL, Church TR et al. Children's exposure to environmental tobacco smoke: using diverse exposure metrics to document ethnic/racial differences Environmental Health Perspectives 2004; 112(3): 392-7.

[10] Roseby R, Waters E, Polnay A et al. Family and carer smoking control programmes for reducing children's exposure to environmental tobacco smoke Cochrane Tobacco Addiction Group Cochrane Database of Systematic Reviews. 3, 2004.

[11] Zhang D, Qiu X. School-based tobacco-use prevention--People's Republic of China, May 1989-January 1990 Morbidity and Mortality Weekly Report 1993; 42(19): 370-1, 377.

[12] Emmons KM, Wong M, Hammond K et al. Intervention and policy issues related to children’s exposure to environmental tobacco smoke Preventive Medicine 2001; 32: 321-31.

[13] Roseby R, Waters E, Polnay A et al. Family and carer smoking control programmes for reducing children's exposure to environmental tobacco smoke Cochrane Tobacco Addiction Group Cochrane Database of Systematic Reviews. 3, 2004.

[14] Emmons KM, Hammond SK, Fava JL et al. A randomized trial to reduce passive smoke exposure in low-income households with young children Pediatrics 2001; 108(1): 18-24.

[15] Hovell MF, Zakarian JM, Matt GE et al. Decreasing environmental tobacco smoke exposure among low income children: preliminary findings Tobacco Control 2000; 9(Suppl 3): 70-71.

[16] Wahlgren DR, Hovell MF, Meltzer SB et al. Reduction of environmental tobacco smoke exposure in asthmatic children. A 2-year follow-up Chest 1997; 111(1): 81-8.

[17] Stephens T, Pederson LL, Koval JJ et al. The relationship of cigarette prices and no-smoking bylaws to the prevalence of smoking in Canada American Journal of Public Health 1997; 87(9):1519-21.

[18] Leedom C, Persuad D, Shovein J. The effect on smoking behaviour of an assertive request to refrain from smoking International Journal of Addictions 1986; 21: 1113-7.

[19] Serra C, Cabezas C, Bonfill X et al. Interventions for preventing tobacco smoking in public places Cochrane Tobacco Addiction Group Cochrane Database of Systematic Reviews. 3, 2004.

[20] Source: http://www.no-smoking.org/oct04/10-14-04-5.html (accessed October 2004).

[21] Serra C, Cabezas C, Bonfill X et al. Interventions for preventing tobacco smoking in public places Cochrane Tobacco Addiction Group Cochrane Database of Systematic Reviews. 3, 2004.