Published on January 27, 2008
Table of Contents Executive Summary p. 1 OMA Recommendations to Protect Children from Exposure to Second-Hand Smoke p. 2 1. Introduction p. 3 2. Second-Hand Smoke and its Impact on Child Health p. 3 2.1 Prenatal Exposure p. 3 2.2 Sudden Infant Death Syndrome (SIDS) p. 3 2.3 Respiratory Illness and Asthma p. 3 2.4 Child Cognition p. 4 2.5 Cancer in Adulthood p. 4 2.6 Heart Disease p. 4 3. Smoking in the Home and in Vehicles p. 4 3.1 Smoking in the Home p. 5 3.2 Smoking in Vehicles p. 6 4. Children in Regulated Care p. 6 4.1 Children in Government Care p. 6 4.2 Private Home Day Cares p. 7 5. Second-hand Smoke and Child Custody Decisions p. 8 6. Public Health Campaigns p. 9 7. Interventions by Health-Care Professionals p. 10 8. Conclusion p. 12 Acknowledgments p. 12 References p. 12 Appendix I • Sample of Smoking Policies from Children’s Aid Societies Agencies in Ontario (p. 17) Appendix II • Smoking Policy for Halton Region Children’s Aid Society – 2004 (p. 17)
Exposure to second-hand smoke: are we protecting our kids? A Position Paper by the Ontario Medical Association Executive Summary exposure to SHS in homes and vehi- cles, and many public settings that T he Ontario Medical Association (OMA) is the children frequent are still not smoke- free. professional association of the province’s Tobacco control efforts across Ontario are increasing with the pas- 25,000 physicians, and represents its members sage of smoking bylaws in a majority of municipalities making public in a variety of clinical, policy and economic areas. places and workplaces smoke-free. The provincial government has also The mission of the Association is to “serve the med- made a strong commitment to imple- ment a comprehensive provincewide ical profession and the people of Ontario in the pur- smoking ban by 2007. Nonetheless, protection for chil- suit of good health and excellence in health care.” dren where they are most commonly exposed remains a concern, and could The OMA has issued statements indi- adult tobacco use is also a child health become a more acute problem if a cating the need to prevent exposure problem. 2, 3 Prenatal and postnatal growing number of parents and care- of children to second-hand smoke exposure to SHS has multiple signifi- givers begin to view their homes and (SHS). cant negative effects on a child’s vehicles as among the few places In its 1996 position paper entitled health during both childhood and where they are able to smoke. “Second-Hand Smoke and Indoor Air subsequent adulthood. SHS exposure is a compelling Quality,” the OMA recommended SHS is known to increase the risk problem for Ontario’s children. It has that all Ontario workplaces and pub- of low birth weight, serve as a trigger now been established that levels of lic places become smoke-free (this for asthma symptoms and lower res- SHS in homes can reach those found paper is posted online at: http://www. piratory infections, and has been in bars. 6 Exposure in vehicles is oma.org/phealth/tobaccomain.htm). associated with sudden infant death known to be especially potent be- Furthermore, it was suggested that syndrome (SIDS), ear infections, and cause of the restricted space.7 an expert advisory group, including an increased risk for development of There is strong evidence that even individuals with expertise in law, cancer and heart disease in adults. though some caregivers practice medicine, civil and individual rights, Furthermore, there is now emerg- indoor smoking bans, significant and ethics, be formed in order to ing evidence that exposure to SHS exposure to SHS can still occur.8, 9 consider the comprehensive control can negatively impact behaviour, Parents who continue to use to- of SHS, including elimination of SHS attention, and cognition.4, 5 bacco in the presence of their chil- in the home.1 A substantial number of children dren — either because they are There is growing awareness that continue to be at risk as a result of unaware of the detrimental health 1 Ontario Medical Review • October 2004 1
OMA Position Paper effects, or are unable to quit because should be dealt with through legisla- can regulate such exposure. of a heavy dependence — need guid- tion. The OMA believes that, if imple- ance and ongoing support to be able The purpose of this document is to mented, the recommendations in this to decrease the exposure of their chil- outline the position of the OMA with report will lead to a significant reduc- dren to SHS. respect to the importance of protect- tion in children’s exposure to SHS. The OMA has a longstanding com- ing children from exposure to SHS. Efforts underpinning the im- mitment to the reduction of SHS This is not only relevant in homes plementation of these recommen- exposure, and it is now time to and vehicles, where children are dations will increase public and address its impact on children in most commonly exposed, but also professional awareness of this impor- home settings. in situations where organizations tant children’s health issue, and pro- Furthermore, evidence makes it such as Children’s Aid Societies mote interventions to eliminate clear that SHS exposure in vehicles (CAS)s, family court, and day cares children’s exposure to SHS. OMA Recommendations to Protect Children from Exposure to Second-Hand Smoke 1. Individuals responsible for the care of children who and public education and awareness programs that are have tried quit methods that were unsuccessful, should currently offered through umbrella agencies such as the be encouraged to use nicotine replacement therapies Home Child Care Association of Ontario (HCCAO). (NRTs) as a way to decrease second-hand smoke (SHS) levels in their homes and cars. Because there is not much 6. The provincial government should amend the Day public information on the use of NRTs for this purpose, a Nurseries Act to ban smoking, and provide enforcement public information campaign should be conducted to to ensure compliance in any homes and/or facilities that recommend and educate parents and caregivers about provide childcare. the use of NRTs to avoid smoking in homes and vehicles. 7. A system which facilitates the dissemination of med- 2. The government should publicly fund NRTs, and the ical and legal information regarding SHS and children Ontario Drug Benefit Plan should include funding NRTs, should be researched by an Expert Panel and then made as is currently done in Quebec. available to lawyers and judges in order to improve their access to necessary information for making decisions 3. Caregivers should not be permitted to smoke in vehi- regarding child welfare in the courts. cles while transporting children, and the provincial gov- ernment should take steps to ensure the protection of 8. The provincial government should provide public children from SHS while traveling in vehicles through health departments with adequate funding to meet their the introduction of legislation banning the use of obligations under the Mandatory Programs and Services tobacco inside vehicles used to transport children. Guidelines, including providing funding for the Breath- ing Space campaign to become provincewide. 4. The Ministry of Children and Youth Services should work closely with the Ontario Association of Children’s 9. Programs should be created to enhance health profes- Aid Societies (OACAS) and the Children’s Aid Societies sionals’ ability to prevent parents from exposing their (CAS)s to develop a uniform smoking policy, and to pro- children to SHS. Effective training programs that allow vide ongoing education and support programs to enable for health professionals to provide brief interventions foster parents to decrease the amount of SHS that chil- should also be offered across all disciplines wherein the dren are exposed to in homes, and prohibit exposure in opportunity exists to interact with parents and their chil- vehicles. dren. This training should become integral at the under- graduate training level, as well as within postgraduate 5. Information about the health effects of SHS should be and continuing education programs for practicing pro- included in professional education, project co-ordination, fessionals. 2 Ontario Medical Review • October 2004 2
OMA Position Paper Introduction children is carried out by foster par- death syndrome, research has also Exposure of children to second-hand ents in homes that have been ap- identified SHS exposure in child- smoke (SHS) in the home is a wide- proved by the government or welfare hood as a risk factor for the develop- spread problem in Ontario. agency.14 ment of cancer and heart disease in In 1999, approximately one in Where the government assumes adult life.16 four Ontario households reported responsibility for any child, this Furthermore, there is now emerg- that at least one person used tobacco should include the responsibility of ing evidence that exposure to SHS inside the home on a daily basis. Half protecting the child from SHS. How- during prenatal and/or postnatal of all households with young chil- ever, at the institutional level, a periods can impact behaviour, atten- dren and tobacco users reported that smoke-free policy continues to be tion, and children’s ability to reason smoking occurred within the home.10 difficult to implement. and understand. 4, 5, 17-20 In 2001, it was reported that daily The Tobacco Control Act protects smoking occurred in 21 per cent of children in licensed day cares from Prenatal exposure homes in Canada with children SHS exposure. However, many On- Despite the well-known risks of smok- under the age of 12 — this means tario children are cared for in private ing during pregnancy, there continues that just over 800,000 children were home day care environments, which to be a population of women who regularly exposed to the hazards of may or may not be regulated by an either use tobacco products through- SHS in their homes.11 agency. out their pregnancies 21 and/or are The Canadian Tobacco Use Moni- Despite the fact that there are exposed to SHS. toring Survey for the first half of 2003 associations that regulate agencies Nicotine can cross the placental reports that 10.6 per cent of Ontario under their membership — thereby barrier, thereby decreasing blood households with children under the providing some form of regulation flow to the fetus, and affecting the age of 14 had someone smoking in for private home childcare — there fetal cardiovascular system, gastroin- the home every day, or almost every remains variability in smoking poli- testinal system, and central nervous day — a decrease from the reported cies among the individual agencies. system.22 14 per cent in 2002.12 There are also caregivers in private Other components of cigarette Within Ontario households sur- homes that do not have membership smoke, such as carbon monoxide, veyed in 2001-2002, those in which under a larger agency, therefore leav- have also been demonstrated to all adults smoked, and children were ing these environments unregulated adversely affect fetal growth, leading present, 64 per cent of residents were for SHS exposure. to low birth weights.23-25 exposed to SHS, compared to 79 per The family court is an arena in cent in homes with no children. In which the presence or absence of Sudden Infant Death Syndrome households where only some adults smoking in the home is receiving in- The relationship of tobacco smoke smoked, and children were present, creasing, but still sporadic, attention exposure and sudden infant death 35 per cent of residents were exposed in child custody cases. Although there syndrome has been extensively stud- to SHS, as opposed to 54 per cent in has been some movement to give cus- ied, and SHS is now a recognized risk homes with no children.13 tody to the non-smoking parent, there factor for SIDS. Exposure to SHS can also occur in is no standard across the province, In addition to maternal tobacco homes and home-like settings other and it may be of benefit to provide use, the impact of tobacco use by than a child’s own home. At this education to legal practitioners about other caregivers in the home must time, there is no provincial umbrella the impact of SHS on child health, also be recognized. of protection from SHS for children and the need to take parental smoking Several studies have established an who are not in their parents’ care. into account in determining what is in association between paternal tobacco Because these children are cared for the best interests of the child.15 use and SIDS, while accounting for in home-like settings, such as foster maternal tobacco use.26-29 It has also care or home-based day cares, regula- been found that the amount of house- tion of SHS exposure is also a chal- Second-hand smoke and its hold SHS exposure can be correlated lenge for these settings. impact on child health to the incidence of SIDS in a dose- Ontario’s new Ministry of Chil- Several comprehensive scientific response relationship.26, 27, 29 dren and Youth Services, established reviews on the health effects of SHS in October 2003, legislates child pro- in children have appeared in the last Respiratory illness and asthma tection in the province. Local CASs decade. Studies on SHS and lower respiratory provide child protection services and It is clear that the impact of SHS illnesses provided some of the first have exclusive responsibility for the on child health is substantial. In evidence of the adverse effects of SHS. provision of services under the Child addition to its impact on respiratory Some of the earliest studies in this and Family Services Act. health (including otitis media), low area showed an association between Ultimately, the actual care of the birth weight, and sudden infant the tobacco use of women during 3 Ontario Medical Review • October 2004 3
OMA Position Paper pregnancy, and subsequent admis- responsiveness shortly after birth has Cancer in adulthood sions of their infants to hospital for shown that infants whose mothers The U.S. EPA 16, 34 and the Interna- bronchitis and pneumonia30, 31 used tobacco during pregnancy have tional Agency for Research on Can- In addition, the number of admis- increased airways responsiveness, cer,50 have both concluded that SHS sions increased with the number of and reduced ventilatory function, is a group A carcinogen (i.e. it causes cigarettes smoked. Since then, the compared with those whose mothers cancer in humans). causative association between SHS do no use tobacco.40, 41 A small number of studies have exposure from both mothers and Second, studies have shown that examined the relationship between fathers, and respiratory illnesses in children with asthma, whose parents exposure to SHS during childhood, infants and children, has been firmly use tobacco products, may have more and cancer risk. Overall, cancer risk is established.31, 32 frequent episodes and more severe greater for individuals with exposure At present, there is an extensive symptoms. to SHS during both childhood and international body of knowledge Exposure to SHS in the home has adulthood than for individuals with highlighting the increased risk of been shown to increase the number exposure during only one period.51 lower respiratory tract infections in of emergency room visits made by When specific cancer types are infants with parents who use tobacco asthmatic children.42, 43 In addition, considered, it has been found that (this includes a report from the Cana- asthmatic children with mothers leukemia and lymphoma among dian Institute for Child Health in who use tobacco products are more adults are significantly related to 2000. 33) A 1992 report by the U.S. likely to use asthma medications.44 In exposure to maternal tobacco use Environmental Protection Agency one intervention study, a reduction before 10 years of age.52 (EPA) estimated 150,000 to 300,000 in smoking by parents resulted in a A study in the New England Journal cases annually in infants and younger decrease in the severity of asthma of Medicine concluded that approxi- children up to 18 months. 34 More symptoms in their asthmatic chil- mately one out of every five instances recently, an analysis that combined dren.45 of lung cancer in non-smokers could data from 39 studies showed a 50 per The relationship between expo- be contributed to childhood SHS cent increase in respiratory illness sure to SHS and diseases of the ear exposure.53 risk if either parent smoked.35 has also been established in several Exposure to SHS is a well-estab- studies. A significant correlation Heart disease lished risk factor for asthma. Statistics between otitis media and SHS expo- A link between heart disease and SHS from the U.S. EPA (1992) estimate sure has been established in pediatric exposure has been substantiated by that 200,000 to 1,000,000 asthmatic patients.46-49 several studies, especially over the children have their condition wors- last five years.54-57 ened by exposure to SHS,34 and recent Child cognition There is strong evidence that research continues to support and A less-known effect of SHS exposure shows involuntary exposure to SHS expand these findings36 (this includes is its impact on cognition. Emerging is a cause of coronary heart disease a study of Canadian school chil- literature on SHS exposure is now morbidity and mortality. dren37). showing an impact on a child’s atten- When researchers looked to child- This disease is one that has led to tion, behaviour, and ability to reason hood exposure to SHS, correlations more and more recommendations to and understand (cognition). were discovered that now identify reduce SHS exposure in the home Children whose mothers did not early exposure as a possible cause of environment. In fact, all recom- use tobacco, but were exposed to SHS premature coronary heart disease.58, 59 mendations for the management of during pregnancy, scored lower in asthma urge reduction of SHS expo- cognitive tests than those children sure in the home. whose mothers were not exposed Smoking in the home and in SHS is known to affect the preva- during pregnancy.17 vehicles lence and severity of asthma symp- Several studies over the last while The health effects of SHS have be- toms. First, SHS is an established have validated a significant relation- come more understood and recog- contributor to the incidence of respi- ship between exposure to SHS and nized over the last 10 years. ratory illnesses, and evidence has attention, behaviour and cognition Despite a growing protection from shown that asthma can arise as a in children.4, 18-20 SHS in Ontario due to the imple- long-term consequence of increased Furthermore, it has now been re- mentation of bylaws, and the pros- occurrence of lower respiratory tract ported that a significant association pect of future implementation of a infection in early childhood, or exists between maternal smoking dur- provincewide smoking ban in public through other pathophysiological ing pregnancy, and symptoms of places and workplaces, there contin- mechanisms, including inflamma- attention deficit hyperactivity disorder ues to be significant sources of SHS tion of the respiratory epithelium.38, 39 (ADHD), which is independent of for children in homes and vehicles. In fact, assessment of airways other factors previously identified.5 Homes which allow smoking are a 4 Ontario Medical Review • October 2004 4
OMA Position Paper significant source of exposure to SHS into the home through windows and the likelihood of having smoking because of the amount of time chil- doors if cigarettes are smoked outside, restrictions to 73 per cent, compared dren spend indoors (especially when and through contaminated clothes, to 60 per cent in homes where all younger), close physical contact with skin and dust carried into the home if adults smoked.74 their caregivers, and prolonged expo- cigarettes are smoked elsewhere.8 Nonetheless, survey results from sure over time. In fact, in homes that Most parents are aware of the Ontario show strong support for vol- include smoking, air pollution can health hazards of SHS exposure, and untary restrictions on SHS expo- reach the levels found in bars.6 make efforts to stop smoking or sure.75-77 In fact, a 1996 report showed Vehicles provide a potent source change their smoking behaviour to 35.4 per cent of the population of SHS because of the restricted area protect their children.66 favoured a legal restriction on smok- within which the smoke is circu- In a major Canadian study com- ing in the home, 77 suggesting that lated.7 missioned by Health Canada in interventions directed at decreasing 1995, it was shown that about 30 per SHS in homes and vehicles in On- Smoking in the home cent of the parent population was tario could be well received. Attention must be directed toward somewhat or very likely to respond This is confirmed by a 2003 On- using prevention/protection mea- to messages about SHS.71 tario survey that showed 87 per cent sures in households with infants and Using data from population-based of respondents agreed that parents younger children because of their surveys of adults in Ontario conduc- should not be allowed to smoke in physical dependence on caregivers, ted in 1992, 1993, 1995, and 1996, homes with small children. When as well as their susceptibility to the trends in attitudes and current prac- asked whether there should be a law effects of SHS. tices concerning smoking in the to prohibit parents from smoking Because of higher respiratory rates, home were determined. Between inside a home if children are living children experience a higher internal 1992 and 1996, the percentage of there, 63 per cent of respondents exposure to SHS.60, 61 A recent study respondents who agreed that parents agreed.12 measuring levels of urinary cotinine spending time at home with small Many of the interventions that — a well-known breakdown product children should not smoke increased have been evaluated and have shown of nicotine— found lower levels in from 51 per cent to 70 per cent. success are targeted at the mother, households where smoking was However, data from the survey in and are more effective if the mother completely banned inside the home. 1996 showed only 20 per cent of is the only individual using tobacco Effective protection cannot be homes with children and any daily in the home. When the mother is not achieved by actions such as opening tobacco users were smoke-free.72 the only smoker, or when she is not a a window, smoking in another room, Despite these changing attitudes smoker herself, the counseling and or using an air purifier.62-67 and behaviours with regard to SHS in changes expected of her become New research has found that chil- the home, challenges and considera- much more difficult to implement. dren exposed to SHS in homes — tions remain. A 1994 Winnipeg study The mother would be expected to regardless of whether or not smoking found that although 90 per cent of influence members of her family to was allowed indoors or restricted to respondents indicated knowledge make changes in their smoking outside — will show levels of expo- regarding the harmful effects of SHS behaviours — this can be difficult, sure higher than children in non- in the home, only 24 per cent imple- and often times impossible.78 smoking homes.68-70 In fact, a child’s mented any SHS controls.73 The size and type of living space, exposure can still be five to seven However, more recent data are single parenting, other household times higher when adults smoke out- encouraging. Another population members who smoke, and lower edu- side compared to smoke-free homes.8 study conducted between May and cation levels are all related to higher In a study published earlier this December 2000 showed 27 per cent levels of SHS exposure.75, 79, 80 year, Matt et al. cite possible reasons of Ontario residents were exposed to In addition, persons of lower socio- for the observed exposure levels in SHS in their homes — 21 per cent on economic status may face a particu- children that live in homes where a daily basis, and six per cent on an larly greater challenge in modifying adults use tobacco outside. Their occasional basis. SHS in their homes if they have fewer findings indicate there are some Homes with adult smokers, and opportunities to smoke away from sources of SHS that parents cannot children present, were more likely to their children, if their homes are easily control through indoor smok- have smoking restrictions in place smaller with fewer rooms, and if they ing bans. In fact, SHS can remain in for family members than homes do not have garages, balconies, or the home even if smoking took place without children (61 per cent com- other places to smoke outdoors.81 days, weeks and months earlier 9 pared to 46 per cent). Having at A 1994 Harvard-based Stop Tobac- through contaminated dust and sur- least one adult non-smoker in a co Outreach Program offered smoking faces, and a smoker’s finger. home where children and other parents of children seen in an outpa- Additionally, SHS can find its way adult smokers are present increased tient pediatric clinic, three brief coun- 5 Ontario Medical Review • October 2004 5
OMA Position Paper seling sessions, written materials, free the access of NRTs. It is not currently ing in cars that have a child in a safety nicotine replacement therapy (NRT), possible to purchase a one-day dose of seat, once the law is enforced.86 proactive referral to a free state tele- NRTs. Individuals must purchase A similar bill was introduced in phone quit line, and fax referral to the NRTs in a one-week supply (approxi- New Hampshire this year.87 parents’ primary clinician. mately $30 per package), making the In June, California moved closer to Of the parents who enrolled in the cost much higher than the purchase becoming the first state to have a ban study, 81 per cent completed all three cost of a single package of cigarettes in force on smoking in vehicles carry- counseling sessions, and 78 per cent (approximately $7.50 in Ontario). ing children by approving a bill via accepted free NRT at the time of Furthermore, the greater expendi- the state’s Senate committee. The bill enrolment. At a two-month follow- ture is problematic for low-income would make it an infraction to smoke up, more than half of the participants individuals who tend to have higher in motor vehicles carrying children had made a serious quit attempt. smoking rates and lower quitting who were under the age of six, or More notably, the mean number of rates.84 weighed less than 60 pounds and cigarettes smoked inside the home In its 1999 paper, the OMA recom- were required by law to ride in child and car declined over two months. mended that the provincial gov- safety seats. The bill would take effect This approach may be effective in ernment and the pharmaceutical January 1, 2006, and require that any reaching smokers who are otherwise industry work together to closely fines generated by the legislation be unlikely to access smoking cessation match the package quantity and cost used for public education programs interventions.82 of NRTs to the package quantity and about the dangers of SHS.88 It is well understood that tobacco cost of tobacco products. In a 1996 Ontario survey, 54.6 per dependence can make the idea of not The OMA again recommends that cent of respondents said they would smoking overwhelming for heavily the government publicly fund NRTs, and support a law prohibiting children’s addicted individuals. that the Ontario Drug Benefit Plan exposure to SHS in vehicles.77 Data In the 1999 OMA paper entitled should include funding for NRTs, as is from a 2003 survey showed a signifi- “Rethinking Stop-Smoking Medica- currently done in Quebec. cant increase in support, with 73.2 tions — Myths and Facts,” NRT use per cent of respondents saying there was suggested for smokers who are Smoking in vehicles should be a law that prohibits par- not able, or willing, to quit smoking Research has shown that SHS can ents from smoking inside a car if chil- in order to help them substantially reach very high levels in vehicles. A dren are present.12 reduce their cigarette consumption. comprehensive study that measured The OMA recommends that care- As a potential side benefit, this type cigarette smoke in vehicles showed givers should not be permitted to smoke of avoidance technique could lead to that while driving with the windows in vehicles while transporting children, eventual quit attempts for these indi- closed, a single smoker can raise the and that the provincial government viduals.83 (This paper is posted online interior carbon monoxide levels sig- take steps to ensure the protection of at: http://www.oma.org/phealth/ nificantly by the third cigarette. children from SHS while traveling in tobaccomain.htm.) Furthermore, blood carboxyhe- vehicles through the introduction of With the compounding issue of moglobin levels of both the individ- legislation banning the use of to- parents being unable to leave chil- ual using tobacco, and the individual bacco inside vehicles used to trans- dren unattended while going outside exposed to SHS (as measured in port children. to smoke, or being unable to avoid breath), increase significantly after smoking during longer car trips, NRT smoking has occurred.7 This, taken in use in the home and in vehicles would relation to the fact that children have Children in regulated care be an effective alternative. much higher respiratory rates and Children in government care The OMA recommends that individ- metabolism than adults, makes SHS In Ontario, the Child and Family uals responsible for the care of children exposure in vehicles a serious prob- Services Act provides the Minister of who have tried quit methods that were lem for children. Children and Youth Services with unsuccessful, should be encouraged to Based on the evidence that expo- guardianship of children who have use NRTs as a way to decrease SHS lev- sure to SHS in a vehicle is 23-times been removed from their parents’ els in their homes and cars. Because more toxic than in a house due to the custody because they are unwilling or there is not much public information on smaller enclosed space, the state of unable to provide a safe environment the use of NRTs for this purpose, a public Colorado drafted a bill that would for their children. information campaign should be con- impose fines on adults caught smok- By acting as temporary guardians, ducted to recommend to, and educate, ing in cars when a child is present.85 the government assumes all of the parents and caregivers about the use of Earlier this year, the state of Georgia responsibilities of natural parents NRTs to avoid smoking in homes and moved to an advanced stage of pro- for the duration a child is in care. vehicles. cess that would allow police to pull Government-approved agencies, and Cost remains a significant barrier to over and fine drivers who are smok- their foster parents, carry out the 6 Ontario Medical Review • October 2004 6
OMA Position Paper actual responsibility of caring for the exposed to it, therefore agencies an increase of 51 per cent and 59 per children. should take that into consideration. cent respectively in foster home and There are currently 52 govern- “There are agencies that advise adoptive home availability since ment-approved Children’s Aid So- parents not to smoke in their homes, March 31, 1998. 92 These increases cieties (CASs) in Ontario, 51 of which and there are others that have poli- could help to allay concerns that are members of the Ontario Associ- cies regarding very young children, or implementation of a comprehensive ation of Children’s Aid Societies children with medical conditions.”90 smoking policy would reduce avail- (OACAS). The OACAS does not, however, ability of foster homes. Using provincial requirements have the authority to enforce a pro- In a ground-breaking decision, the and local guidelines, each CAS is vincewide policy, and its position state of Maine implemented a law in required to conduct an assessment of does not ensure that local agencies October 2003 that prohibits foster potential foster families before the will implement a policy. parents from smoking in their homes placement of a child can occur. Furthermore, individual local when children in their care could be Within the regulations, it is clearly agencies have expressed concerns that exposed to SHS. The original bill, stated that an assessment of the child by refusing potential foster parents which would have also prohibited must be done prior to placement, because of their smoking status, there foster parents from smoking in their and includes assessing the medical could be a further decline of much- cars, was amended because officials needs of the child. needed care for children in crisis.91 thought it was too restrictive.93 In response to a motion that was At the present time, there are sev- In 2003, New York City Mayor passed in 1996 by the Foster Parent eral CASs in Ontario that have smok- Michael Bloomberg made foster par- Society of Ontario, which supported ing policies or positions on smoking ents part of his anti-smoking plat- a ban on smoking in foster homes, in foster homes (see Appendix A, p. form by announcing that foster and the release of a 1996 OMA paper 17). parents who smoke will undergo addressing the harmful effects of For example, the CAS office in extra scrutiny before the city places SHS, a focus group was held at the Kingston asks all foster parents not to children in their homes.94 OACAS in 1997 to discuss smoking smoke in the presence of children in British adoption and fostering in foster homes, and the effects that their care, while the Toronto CAS will agencies implemented guidelines in SHS exposure has on children in not place any children under five in 1993 that ban smokers from adopt- these homes. homes where smoking is allowed, ing or caring for young children. The Participants included experts in but will only prohibit such a place- British Agencies for Adoption and the field, foster parents, and CAS ment of children over the age of five Fostering referred to overwhelming staff. As a result of these meetings, if a child has a medical condition evidence that children younger than and a subsequent survey, it was con- that is exacerbated by exposure to two years of age, and those with res- cluded that SHS in foster homes is a SHS. piratory illnesses, are at particular challenging issue. In order to address Halton CAS includes smoke-free risk from SHS exposure.95 the problem, the OACAS prepared a environments as a consideration for The OMA recommends that the background paper and information approval of a foster home, and open- Ministry of Children and Youth Servi- package about SHS and its detrimen- ing windows or smoking in another ces work closely with the OACAS and tal effect on the health of children, to room do not meet the criteria for a CASs to develop a uniform smoking pol- be distributed to all agencies in the smoke-free environment (See Appen- icy, and to provide ongoing education province.89 dix B, p. 17). and support programs to enable foster The OACAS directs individual Enforcement of Halton CAS smok- parents to decrease the amount of SHS agencies to implement their own ing policy has not required any extra that children are exposed to in homes policies, but does not have a compre- funding and/or staff, and feedback and vehicles. hensive smoking policy for foster has shown little resistance from long- homes because of the great concern time and/or new foster parents. Private home day cares about availability of placements for For the period between April 1, In Ontario, home childcare is pro- the many children in need of care. 2003, and March 31, 2004, it was vided to children in approved private The official position of the OACAS projected that CASs in Ontario would homes other than that of the par- emphasizes the hazards of exposing provide substitute care for 24,578 ent/caregiver, for up to a maximum children to SHS, and encourages the children. It is encouraging to note that of five children under the age of 10. individual agencies to implement between March 31, 1998, and March Standards of care are set by the practices, positions or policies that 31, 2003, there was a 42 per cent in- Ministry of Children’s Services under protect children from SHS in foster crease in the availability of foster the Day Nurseries Act. homes. homes, and a 43 per cent increase in While Ontario’s Tobacco Control “Our position is that SHS is dan- the availability of adoptive homes. Act mandates that all educational gerous, and children shouldn’t be As of March 31, 2004, there was institutions, including licensed day 7 Ontario Medical Review • October 2004 7
OMA Position Paper nurseries, be smoke-free, this cover- giver shall be smoke-free during be affected by her father’s smoking age does not extend to homes in childcare times.” during visitations.102 which private home-based childcare is The OMA recommends that infor- There have since been several cases offered. Government does not provide mation about the health effects of SHS in all levels of the Canadian court policies to protect children in home be included in professional education, system that have made SHS a consid- childcare from exposure to SHS. project co-ordination, and public educa- eration in custody determinations. The Home Child Care Association tion and awareness programs that are In a well-publicized case from of Ontario (HCCAO) estimates that currently offered through umbrella 2002, a father in British Columbia over 80,000 children in the province agencies such as the HCCAO. refused to give signed permission for are being cared for in childcare faci- The OMA recommends that the his former wife to travel outside of lities that are regulated by approxi- provincial government amend the Day Canada with their son because she mately 70 Home Child Care agencies.96 Nurseries Act to ban smoking and pro- would not agree to refrain from smok- These agencies provide assurance vide enforcement to ensure compliance ing in the car. When she finally agreed that legislated standards are met and in any homes and/or facilities that pro- in court to smoke outside the vehicle, maintained in each caregiver’s home. vide childcare. the judge decided the case did not Agencies that are licensed to man- need to be pursued any further.103 age individual home childcare facili- An Ontario Superior Court decision ties are also subject to inspections by Second-hand smoke and child (2002) ordered the removal of a child the Ministry. custody decisions with serious health problems from his While individual agencies may Custody decisions focus on the best mother’s home, and ruled that the have smoking policies in place, they interests of the child, and in doing so, father would become the primary resi- do vary. Most will advise parents of place the needs of children ahead of dential parent because the mother any smoking that occurs in the home parents’ interests.99 refused to stop smoking. The court childcare environment, and will dis- Legislation clearly states that the reached its decision on the basis that tribute information about the bene- physical health of the child is an im- the child’s health was being placed at fits of smoke-free homes.97 However, portant factor in determining a child’s risk when in the care of his mother.104 without a comprehensive smoking best interests, and both provincial Custody hearings provide an policy in place, there is no way to and federal law dictate that judges are opportunity to place the needs and ensure a smoke-free environment for required to make the best interests of well-being of the child at the forefront children in these settings.98 Further- the child a major factor in their deci- of any decision-making. more, there are also several home- sions.15 Therefore, parental smoking When parental smoking is ad- based childcare environments that is an issue that can be considered by dressed, experience has shown that are not part of a larger agency, and the court, and thereby provides an objections may be raised on the basis therefore not regulated. opportunity for intervention with of the addictive nature of smoking. Individual municipalities are respect to restricting a child’s expo- However, a significant number of responsible for managing licensed sure to SHS in the home. court decisions have determined that childcare agencies, thus providing a Children with asthma have been a other addictions place children at valuable opportunity to intervene focus for Canadian cases involving risk, and have subsequently estab- with respect to protecting children access to children, and custody by lished that such addictions could be from second-hand smoke exposure. smoking parents.100, 101 Parents who indicative of lack of parental fitness.100 Childcare centres are eligible to refuse to provide smoke-free environ- The consideration of parental receive subsidization, and must ments for asthmatic children have smoking during custody determina- therefore sign a contract with the been denied access or custody. tions can also serve an important municipalities. A review of custody cases in the educational purpose. For example, in May 2003, the United States from 1997 shows that First, any publicity that comes Region of Waterloo Social Services most decisions favoured protection from such cases is beneficial in edu- revised its contracts for home-based of the child from SHS, and although cating the public about the impact of day care providers who apply for some cases allowed for smoking in SHS on children’s health. subsidization from the Region. other parts of the home, most in- Second, the solutions developed Previously, home-based day care volved a complete ban, including a by some courts show that there are providers in Waterloo were encour- ban in vehicles, that was applicable effective ways to decrease a child’s aged to provide smoke-free spaces to both parents.101 exposure to SHS in the home. during childcare hours. The contract The first Canadian case to consider For example, some courts have or- now includes the following state- parental smoking took place in 1988. dered a restriction of parental smok- ment: “The indoor areas of a care- An Ontario court terminated a father’s ing around children that requires giver’s residence and all indoor places access to his daughter after the child’s parents to be aware of where and where the child attends with the care- asthma and allergies were proven to when they smoke. In most cases, it 8 Ontario Medical Review • October 2004 8
OMA Position Paper implies parents simply have to go seven pubic health units, with subse- from parents and community mem- outside to smoke.99 quent evaluation results showing bers to provide some measure of the Because of an increasing number there was a significant impact on atti- effectiveness of the messages. of court cases that involve parental tudes and behavioural intentions of In order to keep the smoke-free smoking, lawyers and judges have the target audience. Furthermore, the homes message alive in the commu- access to rulings regarding SHS which campaign was shown to increase nity, health units are encouraged to have set legal precedent. However, it awareness of the health-hazards of participate by contributing their own is still essential that awareness of the SHS, as well as the likelihood that funding and resources to supplement health issues be available to these individuals would ask someone who broad media campaigns in their area. decision-makers. smoked to refrain from smoking in In Ontario, the 1997 Public Health The OMA recommends that a system the home.109 Mandatory Health Programs and Servi- which facilitates the dissemination of In response to the evaluation, the ces Guidelines (MHPSG) mandate medical and legal information regarding winter 2003 campaign was expanded programming for boards of health. SHS and children be researched by an to include 23 of Ontario’s 37 health As such, many health units are able expert panel, and then made available to units, thereby allowing for regions in to participate in the campaign be- lawyers and judges in order to improve Ontario with limited funds and cause it meets the initiatives outlined their access to necessary information resources to benefit from a province- for SHS control in the MHPSG. How- regarding child welfare in the courts. wide campaign. The campaign mate- ever, several health units have not rials were translated into French, and participated due to financial and/or a smaller selection was translated other resource shortages during times Public health campaigns into Ojibway, Ojicree, and Cree by of campaign implementation. Research in health promotion has request from Northern communities. In early 2004, the partnering 23 shown that mass media messages, in Numerous municipalities across health units, and Cancer Care On- combination with community-based Ontario have participated in Breath- tario – Prevention Unit, provided in- interventions, can have a great impact ing Space: Community Partners for kind and financial resources to on increasing awareness and encour- Smoke-Free Homes,109 however, not develop and focus test campaign cre- aging behavioural change. However, all boards of health participated in ative addressing hard-to-reach audi- evaluations of community-based pro- the campaign and/or have adequate ences. The partnership has grown to grams have shown both success and resources to administer them. 33 health units, currently seeking failure in being able to decrease SHS A review compiled for Health financial support to fund the imple- in homes and vehicles.105-108 Canada in April 2003 summarized mentation of a provincewide media Breathing Space: Community the effectiveness of the media com- campaign using this new creative.110 Partners for Smoke-Free Homes is a ponent of the campaign. The results The Breathing Space campaign has social marketing campaign meant to were encouraging, and showed an been presented at more than a dozen be delivered by public health units increase in the number of individuals conferences and workshops across across Ontario, along with commu- — from 63 per cent in 2000 to 74 per Ontario, Canada, and internationally. nity-based education, in an effort to cent in 2003 — who would be will- As a result, several Canadian provin- inform people of the dangers of SHS ing to ask someone to smoke outside ces and other countries continue to in homes and vehicles. if children were present. seek information and consultation The campaign focuses on motivat- There was also an increase in from Breathing Space in designing, ing people to make their homes 100 agreement among participants that implementing, and evaluating their per cent smoke-free, with a long-term SHS is a serious health hazard, rising own smoke-free homes initiatives. goal of increasing the proportion of from 74 per cent in 2000 to 88 per- Materials from the campaign are smoke-free homes by 2010. cent in 2003. also valuable in other public educa- Using radio, newspaper and transit The major limitation of this evalu- tion endeavours, and are used in advertising, the messages are delivered ation is that it was restricted to atti- public health programs, including: to a target audience of individuals who tudes and behavioural intentions, Best Start; Healthy Babies, Healthy smoke in the home, or allow smoking and did not measure actual impact Children; Heart Healthy programs; in the home, particularly those with on the prevalence of smoking in Heart Smart; Workplace Wellness children under the age of 18. The cam- homes with children. Days and cessation displays; and paign was conducted in 2000, 2001, Budget constraints are a major health fairs.109 and 2003, with funding support from impediment to being able to mea- The OMA recommends that the the Tobacco Control Programme, sure the overall effectiveness of the provincial government provide public Health Canada, and the Ontario campaign on behaviour change. health departments with adequate fund- Tobacco Strategy of the Ministry of Instead, the boards of health from ing to meet their obligations under the Health and Long-Term Care. participating health units have Mandatory Programs and Services The campaign initially involved relied on word-of-mouth feedback Guidelines, including providing funds 9 Ontario Medical Review • October 2004 9
OMA Position Paper for the Breathing Space campaign to ing interventions during parent-child regarding their practices in advising become provincewide. visits to health professionals — pri- parents about smoking. The campaign should have ade- marily family physicians — must be Using data from the U.S. National quate funding to focus on hard-to- investigated and evaluated. Ambulatory Medical Care Survey reach audiences, and allow for the There are chronic and acute child- between 1997 and 1999, a compre- recommended duration/frequency hood health problems that are linked hensive assessment of the frequency required to have the desired impact to SHS exposure, and it is clear that of clinician-reported delivery of on the public. these interactions provide valuable counseling for avoidance of child Funding should also be available to teachable moments for effecting SHS exposure was conducted during allow for the use of such methods as change, particularly among special- periodic well-child visits and illness repeat surveys to allow for a thorough ists who commonly treat these ill- visits for both asthma and otitis assessment of the campaign’s effective- nesses (e.g., pediatricians, allergists, media. Results collected from 1997 ness in reducing the number of homes respirologists, ear nose and throat to 1999 showed a very low rate of and vehicles that allow smoking. specialists, and emergency room tobacco counseling for well-child vis- physicians — particularly pediatric). its, and for diagnoses affected by Interventions by health-care Successful training and implemen- SHS, with 4.1 per cent at well-child tation of tobacco interventions by visits, 4.4 per cent at illness visits for professionals clinicians should be applied to all asthma, and 0.3 per cent of illness Although there is evidence to support disciplines, especially those that visits for otitis media.117 the incorporation of smoking inter- work closely with children most In a 2003 study from Boston’s ventions by primary care clinicians in adversely affected by SHS exposure, Children’s Hospital, a telephone sur- a public health approach, evalua- including nurses, obstetricians, mid- vey of households (conducted from tions of the effectiveness of these pro- wives, respiratory therapists, pharma- July 2001 to September 2001) col- grams have also shown varied success cists, dentists and psychiatrists. lected data to examine and compare in reducing children’s exposure.111, 112 When Wall and associates focused rates of pediatrician and family prac- These varied findings provide solid on interventions with newborn titioner screening and counseling for evidence of the need for ongoing infants, they saw benefit from the parental tobacco use. research to improve intervention motivation of new mothers to pro- The study found that although attempts and compliance. tect their newborn children.113 there was a higher rate of discussion One of the greatest challenges to Another study by Butz and col- about parental smoking with pedia- success lies in developing strategies leagues — a comparison of SHS tricians versus family practitioners, to address the factors that reinforce among children with chronic respira- fewer than half reported being coun- smoking and SHS exposure, such as t
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