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Protecting children from secondhand smoke

Jennifer Percival
RGN RM RHV RCN Tobacco Education Project Manager

The Department of Health's latest antismoking campaign is hard-hitting. To the innocent soundtrack of "Twinkle, twinkle little star" comes the message "If you smoke around children, they smoke too". Every year thousands of children are admitted to hospital because of breathing in other people's smoke. To bring this point home, the film shows children appearing to breathe out tobacco smoke. The advert ends with the line "Protect children, don't make them breathe cigarette smoke". This powerful message has been backed up by billboard posters with the message "If you smoke, I smoke", written in a child's handwriting.
It is estimated that 42% of children live in a house where at least one person smokes, and approximately one-third of current smokers continue to smoke near children(1) - that's over 4 million people. The new Department of Health media campaign aims to raise the public's awareness of the health risks of smoking around children.

Why is secondhand smoke a problem?
Tobacco smoke contains around 4,000 different chemicals in gaseous and particle form, including more than 50 known carcinogens, such as benzo(a)pyrene, chromium, vinyl chloride and benzene.
Secondhand (also called passive) smoke consists of the sidestream smoke from the burning tip of the cigarette plus the mainstream smoke exhaled by the smoker. Sidestream smoke typically makes up nearly 85% of the smoke in a smoky environment. This type of smoke contains much higher concentration of toxins, such as hydrogen cyanide, ammonia and carbon monoxide, than mainstream smoke (see Table 1 for full list of constituents). In America, secondhand tobacco smoke has been classified a carcinogen, like arsenic, asbestos and radon; and it has been classified by the World Health Organization's Inter­national Agency for Research on Cancer as a cause of cancer.

Secondhand smoke and children
Children are particularly affected by the poisons in tobacco smoke because their bodies are still developing. Their bronchial tubes and lungs are smaller and their immune systems less developed, making them more ­vulnerable to infection. Children also breathe faster than adults, taking in proportionally more chemicals than an adult per kg body weight.

The health effects
The1992 Royal College of Physicians' report Smoking and the Young stated that babies and children exposed to passive smoking have a much higher risk of cot death, an increased risk of meningitis and otitis media, and more coughs, colds and wheezes in the first year of life.(2)
The Chief Medical Officer's Annual Report 2002 states that babies and children exposed to a smoky atmosphere are twice as likely to have asthma attacks and chest infections, more likely to need hospital care in their first year of life, and are off sick from school more often.(3) Besides the immediate risk, a child's education can be affected by poor hearing, or by taking time off from school due to frequent respiratory infections.
What is very surprising is that 70% of parents who smoke claim to be unaware of the harmful effects their habit could have on their children,(4) which explains the urgent need for the current mass media campaign.
In summary, smoking near children is a cause of:

  • Cot death - twice as likely for babies of smoking mothers.(5)
  • Respiratory illness, such as bronchitis and ­pneumonia.(5) A child whose parent smokes is approximately twice as likely to need to go to ­hospital because of a serious lung infection during infancy.(6)
  • Asthma attacks and an increased risk of other breathing problems such as wheezing, coughing, phlegm and breathlessness.(5)
  • Acute and chronic middle ear disease in children, which can cause deafness(5) - there is a 40% increase in risk in children exposed to secondhand smoke.(3)

Helping smokers protect children
Smoking is responsible for at least 17,000 admissions to hospital each year of children under the age of 5.(2) Despite this, many health professionals find it hard to discuss the link with parents who smoke. Fear of difficult conversations may stop health professionals from pursuing the topic, even when they observe the impact of secondhand smoke. Parents seeking advice on managing their child's respiratory symptoms may be reluctant to believe that secondhand smoke could be exacerbating the problem. The very serious impact of smoking on children's health presents a good case for using a harm minimisation approach.

Being practical
No one likes being told they have to give up something they feel they need or enjoy. Likewise, content smokers can become very resistant if advised to give up. The answer is to ask adult smokers if they can find ways to keep their children's breathing space smoke-free. To get the best results, avoid discussing cessation. Spend the time helping them decide what changes are practical. An open, nonjudgmental attitude will help you discuss ways they can protect a child from secondhand smoke without having to stop smoking.
Ways to start the conversation may include:

  • What things have you heard about secondhand smoke and children?
  • What do you already do to keep smoke away from your family?
  • How do you manage if the weather is bad?

Try to encourage the smoker to state all possible changes, while you reinforce or support them. If they are planning to smoke indoors, encourage them to keep to one area, well away from children. Suggest tips like opening a window to ventilate the room and ask if this is possible.

Protecting children outside the home
Ask about how they plan to manage when they are away from home. Often people's family and friends will include smokers. The type of questions you could ask are:

  • Do you have family and friends who smoke?
  • Have you asked them about not smoking near your baby/child?
  • What about your childcare arrangements?

If they feel "stuck", suggest they explain their concerns about health and ask for support.

Travelling with children
It is still common to see children strapped "safely" into a car accompanied by smoking adults. Remind smokers that secondhand smoke becomes more concentrated inside a car and is also a frequent cause of travel sickness. Ask:

  • What about smoking in the car or when you go out?
  • What could you do to keep children and smoke separate in these situations?

You could suggest that on shorter trips they smoke before setting off, and on longer trips stop for a smoke outside the car.

Research from other countries
Studies have been undertaken in Sweden and Boston (MA, USA) on the impact of a harm minimisation approach.(7,8) The results of both were very interesting as they showed this method to be effective, both in reducing children's exposure and in changing adults' attitudes.
The Swedish project set out to train 200 public health nurses in a person-centred "Talk technique". Participants learnt how to encourage smoking parents to find their own solutions to enable their children to grow up in a smoke-free environment. On the new birth visit, the nurse provided information and advice on the benefits of keeping the home smoke-free. They did not moralise or discuss the benefits of cessation. At each meeting, the topic of smoking was revisited with the question "How's it going keeping the smoke away from the (baby) children?" In this way the nurse was not judgmental and recognised the parents' right to smoke. All positive changes were congratulated (it takes some effort to always go outside to smoke), and the parents were encouraged to continue for the benefit of their children.
An unexpected result of this initiative was that after 6-9 months of nurse contact many parents spontaneously sought cessation advice. One parent commented: "I've begun to realise smoking is not very good for me, as well as my child."
The Boston study showed that professionals can help parents work towards reducing household passive smoke exposure by using motivational strategies and providing a menu of approaches regardless of whether the parents are ready to stop. A damage limitation approach had positive benefits for the child.
As the Swedish survey showed, adults who make initial changes for the benefit of their children often go on to consider stopping smoking. This is a double bonus and may help to reassure any professionals who worry that they are not taking a hard enough line. With a harm limitation approach, children get to breathe clean air and their parents may actually start thinking for the first time about stopping.

Helping smokers discourage their children from smoking
Many smokers are keen to prevent their children from taking up the habit. Young people usually face pressure to start smoking between the ages of 11 and 14. If they have lived with a smoker they might think smoking is safe. To help parents discourage their children from starting to smoke, suggest they try the following:

  • Explain from personal experience why they wish they hadn't started.
  • Never let children try a cigarette, even as a joke.
  • Tell them how much smoking costs each year.
  • Explain that most smokers want to stop.
  • Discourage family members from smoking near their children.
  • Warn children about withdrawal symptoms, which may include mood swings and irritability.

In summary
It is always worthwhile discussing with your patients who smoke ways in which they can protect their children. In general, taking a soft line is easier and more likely to be accepted by a smoker. By applying the advice in this article, you can and will make a difference to the health of the next generation of children. Good luck!


  1. Office for National Statistics. General household survey 2001. London: ONS; 2001.
  2. Royal College of Physicians. Smoking and the young. London: RCP; 1992.
  3. Department of Health. Chief Medical Officer's Annual Report 2002. London:?Department of Health; 2003. Available from URL:? annualreport2002
  4. Action on Smoking and Health. The impact of passive smoking on children.  Passive smoking - summary of the evidence. London: ASH; 2001.
  5. Department of Health. Report of the Scientific Committee on Tobacco and Health. London: The Stationery Office; 1998.
  6. Li JSM, Peat JK, Xuan W, Berry G. Meta-analysis on the association between environmental tobacco smoke (ETS) exposure and the prevalence of lower respiratory tract infection in early childhood. Pediatr Pulmonol J 1999;27(1):5-13. Available from URL:
  7. Swedish Cancer Society.Smoke-free children - a report: the first 10 years. Stockholm: Swedish Cancer Society; 2003.
  8. Emmons KM, Hammond SK, Fava JL, Velicer WF, Evans JL, Monroe AD. A randomized trial to reduce passive smoke exposure in low-income ­households with young children. Pediatrics 2001;108(1):18-24.

Action on Smoking and Health (ASH) Produces resource - Passive Smoking: the impact on children. Updated July 2002
Department of Health Tobacco Information Campaign NHS Smoking Helpline
T:0800 169 0 169
The helpline is open between 7am and 11pm every day for information, requests and referrals, with unlimited access from 10am to trained advisers giving one-to-one advice and support. Advisers can also send callers a free Giving up for life booklet, which is full of practical tips and advice for giving up, key smoking facts and real-life stories. Professionals can order copies of campaign resources, ­including leaflets on secondhand smoke Local NHS Stop Smoking Services Helpline advisers can refer callers to their local "Stop Smoking" service, offering free face-to-face support and advice near their home. Smokers wishing to quit can also contact NHS Direct or ask their local ­pharmacist about "Stop Smoking" ­services
NHS Resources The NHS leaflets P is for Protecting Babies and Children from Secondhand Smoke and Secondhand Smoke - what it is and what you can do about it, plus a pack of posters, baby bibs, cot stickers and room thermometers, have been produced to support your work with families. They are available free from the NHS Smoking Helpline - 0800 169 0 169