Call to ban smoking in cars

The dangers of exposing children to cigarette smoke were widely reported today. Many newspapers have focussed on a call for smoking to be banned in all vehicles, parks and play areas, as an extension of the current smoking ban. The news follows a report by the Tobacco Advisory Group of the Royal College of Physicians, stating its recommendations for reducing the effects of passive smoking in children. The proposals have won the support of the government’s chief medical officer Sir Liam Donaldson, who is quoted in The Times :

“The report is a very valuable addition to the evidence base that will be considered as part of the Department of Health's review of the existing smoke-free legislation in England three years after it came into force, to be carried out later this year.”

The report also gives estimates of the cost of passive smoking to the health of the nation’s children and to the NHS. Professor John Britton, head of the college's Tobacco Advisory Group and lead author of the report, said: “This report isn't just about protecting children from passive smoking, it's about taking smoking completely out of children's lives.”

What is the basis for these current reports?

On behalf of the Royal College of Physicians, and funded by Cancer Research UK, the UK Centre for Tobacco Control Studies has published a report entitled Passive Smoking and Children .

The researchers have conducted a systematic review of the evidence in an attempt to quantify the health effects and costs of second-hand smoke exposure to children. A previous report in 2002 was instrumental in introducing the 2007 smoking ban in all public places. The aim of the group is to “keep up the momentum” of reducing harm from second-hand smoke exposure, particularly where children are concerned, and hopefully create a “smoke-free future”.

What follows is a condensed summary of the main findings.

What is the current situation?

In 2003, 11,000 deaths were attributed to passive smoking, an estimated 10,700 of which were related to smoke exposure in the home.
Smoke-free legislation was first introduced in the UK in Scotland in March 2006; in Wales and Northern Ireland in April 2007; and in England in July 2007. The island Crown Dependencies of Guernsey and Jersey became smoke-free in 2006 and 2007, and finally the Isle of Man in March 2008. The legislation covers all enclosed premises where people work and/or the public has access, which includes public transport and work vehicles.
Currently exempt from the legislation are private dwellings (with the exception of those used for childminding or private lessons), residential institutions (hotels, hostels and guest houses which are allowed designated spaces), certain specified workplaces where smoke-free requirements are impractical (offshore locations, specialist tobacconists), Crown bodies and property, and recognised diplomatic premises.
Since the smoking ban, observational studies have demonstrated a large reduction in smoke levels in indoor public areas, salivary cotinine content (a breakdown product of tobacco) in bar staff, reduction in respiratory symptoms of bar workers, and reduction in hospital admissions for coronary heart disease.
Data from household surveys have noted a decline in smoking rates, e.g. the Scottish Household Survey noted a decline in smoking prevalence over the years immediately before and after the legislation was introduced, from 26.2% in 2005 to 25.0% in 2006 and 24.7% in 2007.
There has been some failure in compliance in certain areas, e.g. commercial vehicles, where enforcement is difficult, and in major public entertainment venues such as sports grounds and music festivals.
Other highlighted problem areas are those places exempt from legislation, in particular private vehicles where smoke levels can be very high. Also, in areas under legislation, smokers still congregate around entrances and exits of places which are not substantially enclosed and are hence still exposed to the smoke.
New approaches are therefore considered necessary to address these problems.

Where are children particularly exposed to second-hand smoke?

The most important determinants of passive smoke exposure in children are whether parents or carers smoke, and whether smoking is allowed in the home.
Children who live in homes where someone smokes on most days are exposed to about seven times more smoke than children who live in smoke-free homes. Someone smokes on most days in the home in 88% of households where both parents smoke; 81% of homes where only the mother smokes; and 65% of homes were only the father smokes.
Compared to children whose parents do not smoke, passive smoke exposure in children is typically three times greater if the child’s father smokes; over six times greater if the mother smokes; and nearly nine times greater if both parents smoke.
Compared to more socio-economically privileged children, those from disadvantaged backgrounds are more likely to be exposed to smoke, which is attributed to heavier smoking inside the family home and in other places visited by the children.
However, the overall level of passive smoke exposure in children has fallen substantially over recent years, probably due to the reduction in both smoking prevalence and the prevalence of parents/carers who will smoke in the home with their child.

What are the health effects of second-hand smoke exposure in children?

Passive smoking from the mother’s smoke increases the risk of a child having a chest infection by about 60% (50% when they face exposure from any other family member). Most of this risk increase is for bronchiolitis (infection and inflammation of the small airways of the lung, which affects mostly babies under one), which is about 2.5 times more common in babies whose mothers smoke. Overall, about 20,500 new cases of chest infection in children under three are believed to be caused by passive smoking.
Passive smoking (from the mother in particular) increases the risk of wheezing at all ages (risk increase 65% to 77% depending on the age of the child).
Passive smoking by school-aged children increases the risk of asthma by about 50%, although associations are not as clear as for wheeze or infection. Overall passive smoking is believed to be responsible for 22,600 new cases of wheeze and asthma in UK children every year.
Passive smoking increases the risk of ear infection and subsequent problems by about 35% for household smoking and about 46% for smoking by the mother. Overall, about 121,400 new cases of middle ear disease in children (of all ages) per year are believed to be caused by passive smoking.
Passive smoking more than doubles the risk of bacterial meningitis (responsible for an estimated 200 cases per year).
Overall, the researchers estimate that passive smoking contributes to 300,000 GP consultations and 9,500 hospital admissions of children per year in the UK, all of which are avoidable.

In addition to the disease effects of passive smoking, children whose parents or siblings smoke are 90% more likely to start smoking themselves. Approximately 23,000 15-year-olds in England and Wales every year are believed to start smoking as a result of smoke exposure in the home. Although exposure to smoke outside of the home will have some influence, the effect is considered to be less.

What are the dangers to the unborn child?

Smoking by the expectant mother is believed to be responsible for up to about 5,000 miscarriages, 300 infant deaths around the time of birth, 2,200 premature births and 19,000 babies being born of low birthweight in the UK each year.
Smoking by the expectant mother affects the baby’s growth and development, and increases their risk of being born small for gestational age and of low birthweight (typically reducing weight by about 250grammes). It has also been linked to increased risk of the baby being born with abnormalities of the heart, limbs, and face (e.g. cleft lip and palate).
Maternal passive smoking is believed to reduce birthweight by about 30–40g, and may also have small effects on the risk of prematurity and being small for gestational age.
Maternal passive smoking is also believed to have similar, but smaller effect on the fertility of the mother and general health of the baby and risk of congenital abnormalities, though evidence for this is inconclusive.
Maternal passive smoking is therefore a cause of potentially significant health impact to the unborn baby, effects that could be avoided by no smoke exposure.
Subsequently living in a household in which one or more people smoke more than doubles the risk of sudden infant death syndrome (cot death), and is believed to be the cause of 40 such deaths in the UK every year.

What are the costs of smoke exposure to children?

Passive smoking is estimated to be responsible for a yearly cost of £9.7 million in GP visits and asthma treatments, and £13.6 million in hospital admissions in the UK.
Providing asthma drugs up to the age of 16 for all children who develop asthma each year as a result of passive smoking would cost the UK approximately £4 million.
The future treatment costs of smokers who take up smoking as a consequence of exposure to parental smoking could be as high as £5.7 million a year, or £48 million over 60 years.
In addition to this there may be an annual cost of £5.6 million in terms of lost productivity due to smoking-related absence and smoking breaks in the workplace, which translates to £72 million over a lifetime career.

What are the recommendations of the report?

The report concludes that a quarter of the population are still exposed to smoke, either in the home or in the workplace. Due to the known health hazards of passive smoking there is increased support for smoke-free legislation, among both smokers and non-smokers. Most importantly, 80% of children are aware that smoke exposure is dangerous to them. Surveys have found that half of children with a parent who smokes report that they are exposed to it in the home, and a third report that they are exposed to it in the car. It is reported that many people would now support the further extension of the smoking ban to include smoking in front of children, in front of buildings and in private cars.

The report concludes that adults, and the government, have a duty to avoid exposing children to smoke. Current legislation only protects children in public places, when smoking in the home is still common. Extending current smoke-free legislation to include all public places visited by children, whether or not enclosed as currently defined in law, would prevent much of this exposure, and this could also be extended to cover private vehicles.

However, they conclude that actually preventing smoking in the private home would be difficult to implement and enforce. The report says that mass-media campaigns and health warnings are probably the most effective method of increasing awareness of the hazards of passive smoking and the need to make homes completely smoke-free.