Second-hand tobacco smoke and...

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Second-hand tobacco smoke and children

Children’s Health and the Environment

CHEST Training Package for the Health Sector

TRAINING FOR HEALTH CARE PROVIDERSTRAINING FOR HEALTH CARE PROVIDERS

<<NOTE TO USER: Please add details of the date, time, place and sponsorship of the meeting for which you are using this presentation.>>First draft prepared by Stephan Boese-O’Reilly, Thomas Lob-Corziliusand Wojciech Hanke, based on material prepared by Wolf-Ruediger Horn, Ursel Heudorf, Sabine Schmidt, Annette Bornhaeuser, Martina Poetschke-Langer and Leda Nemer

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Learning objectivesLearning objectives

Definition of secondDefinition of second--hand tobacco smokehand tobacco smoke

Health relevanceHealth relevance

Epidemiology of secondEpidemiology of second--hand tobacco smokehand tobacco smoke

Environmental history and diagnosticsEnvironmental history and diagnostics

Primary preventionPrimary prevention

Smoking and breastfeedingSmoking and breastfeeding

Secondary preventionSecondary prevention

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Second-hand tobacco smoke and childrenDefinition of second hand tobacco smokeDefinition of second hand tobacco smoke

Second-hand tobacco smoke:Inhalation of tobacco smoke in the airComprises 80–85% of the sidestream smoke coming from the burning tip of the cigarette The second-hand tobacco smoke is up to 10 times more burdened than the mainstream smoke, such as with carcinogenic substances

SecondSecond--hand tobacco smoke is a new technical term for what was hand tobacco smoke is a new technical term for what was previously called environmental tobacco smokepreviously called environmental tobacco smoke

Ref.: Courage C.M.: Environmental tobacco smoke. In: Children’s health and environment: A review of evidence - a joint report from the European Environment Agency and the WHO Regional Office for Europe. Edited by: Giorgio Tamburlini, Ondine S. von Ehrenstein, Roberto Bertollini. WHO Regional Office for Europe, ISBN 92-9167-412-5, Copenhagen 2002, http://www.euro.who.int/ecehrome. Page: 142: “Environmental tobacco smoke (SHTS) is an aged, diluted mixture of mainstream smoke, that is smoke exhaled by smokers, and sidestream smoke, that is smoke emitted from the burning tip of the cigarette. The inhalation of ETS is known as ‘involuntary smoking’ or ‘passive smoking’. More than 4 000 compounds have been identified in laboratory-based studies as components of mainstream smoke and at least 42 of these were classed as carcinogenic to laboratory animals, many of them known or suspected human carcinogens (NRC, 1986).”

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Second-hand tobacco smoke and childrenTobacco smoke Tobacco smoke –– windows of exposurewindows of exposure

Prenatal exposurePrenatal exposureActively smoking or passively exposed mother is exposing the unborn child via the umbilical cord

Passive childhood exposurePassive childhood exposureA smoking mother exposes the child via breast-milkSmoking household members expose the child via indoor air

Active smokingActive smokingSome teenagers are starting to smoke in the early years of life

In the US, it has been estimated that 43% of children aged 2 months to 11 years live in a home with at least one person that smokes. The prevalence of passive infant smoking was reported to be around 40% also in Europe. (Samet,2001 )

Ref.: Samet JM, Yang G. Passive smoking, women and children. In Samet JM, Yoon SY (eds). Women and the Tobacco Epidemic. Challenges for the 21st Century. The World Health Organization in collaboration with the Institute for Global Tobacco Control and the Johns Hopkins School of Public Health, Geneva, 2001.

It seems that based on statistical data, the number of adult smokers in Europe is showing a decreasing trend. In addition, regulation onsmoking is being implemented in Europe with the aim to reduce numbers of smokers. However it is also observed that the number of smoking women in reproductive age is not decreasing or is even increasing. Large differences in smoking prevalence exist between countries and in different environments (urban vs rural, socioeconomicclasses, etc) (Samet,2001).

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Second-hand tobacco smoke and childrenToxic and carcinogenic substances in tobacco smokeToxic and carcinogenic substances in tobacco smoke

Toxic substances:Toxic substances:Carbon monoxideNitrogen dioxideAmmonia

Carcinogenic substances:Carcinogenic substances:FormaldehydePhenolsAcrylaldehydeQuinolineBenzene HydrazineBenzo-a-pyrene 2-Toluidine2-Naphthylamine4-AminodiphenolN-NitrosodimethylamineN-NitrosopyrrolidineCadmiumNickelPolonium-210

Martina Poetschke-Langer (ed): Tobacco prevention and control (No 2): Passive smoking in Germany, 2003, Germany Cancer Research Institute and WHO Collaboration Centre for Tobacco Control (www.dkfz.de): List after US-EPA and IARC (page 11)

Picture: CDC Media Campaign Resource Center. Copyright WHO: www.who.int/features/2003/08/en/

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Second-hand tobacco smoke and childrenTobacco smoke Tobacco smoke –– exposure dataexposure data

-- 43% of children in the United States live in a home with at leas43% of children in the United States live in a home with at least one smokert one smoker

-- The prevalence of passive infant smoking is about 40% in EuropeThe prevalence of passive infant smoking is about 40% in Europe

-- The proportion of adult smokers in Europe is decreasingThe proportion of adult smokers in Europe is decreasing

-- Regulations on smoking have been implemented in Europe to reduceRegulations on smoking have been implemented in Europe to reduce the the numbers of smokersnumbers of smokers

-- The number of women The number of women of reproductive age who smoke is increasingof reproductive age who smoke is increasing

-- The smoking prevalence differs greatly between countries and in The smoking prevalence differs greatly between countries and in different different environments (urban versus rural,environments (urban versus rural, socioeconomicsocioeconomic classes, etc.)classes, etc.)

-In a study by Samet, the prevalence of passive infant smoking in Europe was reported to be around 40%. (Samet, 2001 )

-It seems that based on statistical data, the number of adult smokers in Europe is showing a decreasing trend.

-In addition, regulation on smoking is being implemented in Europe with the aim to reduce numbers of smokers.

-However it is also observed that the number of smoking women in reproductive age is not decreasing or is even increasing.

-Large differences in smoking prevalence exist between countries and in different environments (urban vs rural, socioeconomic classes, etc) (Samet,2001).

Ref.: Samet JM, Yang G. Passive smoking, women and children. In Samet JM, Yoon SY (eds). Women and the Tobacco Epidemic. Challenges for the 21st Century. The World Health Organization in collaboration with the Institute for Global Tobacco Control and the Johns Hopkins School of Public Health, Geneva, 2001.

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Prenatal exposure to second-hand smoke in some countries in

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70

Switzerland

Sweden

Norway

Netherlands

Ireland

Greece

Germany

England (Avon)

England (Mainland)

Denmark

Czech Republic

Belgium

Smoking rates in pregnant women (%)

Exposure to Environmental Tobacco Smoke in Europe – A review.Olenka BrynczkaWorld Health Organization Regional Office for Europe, Bonn 2003www.euro.who.int/air

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Exposure to second-hand smoke at 0Š4 years in selected European countries

0

4

8

12

16

20

24

28

32

36

40

Czech

Rep

ublic

Denmark

Englan

d

Netherl

ands

Nordic

coun

tries*

Sweden

(Stoc

kholm

)

Sweden

(Öste

rgötla

nd)

%


Nordic countries = Denmark, Finland, Iceland, Norway, Sweden

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Exposure of children 4Š13 years old to second-hand smoke at home in selected European countries

05

101520253035404550556065707580

Englan

d

France

Greece

German

y

Irelan

d

Poland

Switzerl

and

%


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Exposure of children 13Š17 years old to second-hand smoke at home in selected European countries

05

1015202530354045505560657075

Czech

Rep

ublic

German

y (Eas

t)

Irelan

dLa

tvia

Lithu

ania

Poland

(Rura

l)

Poland

(Urba

n)

Russia

n Fed

eratio

n

Ukraine

%


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Smoking trends in the WHO European RegionSmoking trends in the WHO European Region

38% male smokers and an increasing gap between east and west38% male smokers and an increasing gap between east and west

Eleven Member States have prevalence rates exceeding 50%; four MEleven Member States have prevalence rates exceeding 50%; four Member ember States have prevalence rates of less than 30%States have prevalence rates of less than 30%

Nearly 23% female smokers and a narrowing eastNearly 23% female smokers and a narrowing east--west gapwest gap

The smoking prevalence among young people is about 27The smoking prevalence among young people is about 27––30%, with an upward 30%, with an upward trend generally (and a potential slight decline in the past few trend generally (and a potential slight decline in the past few years, such as in years, such as in Germany)Germany)

A rising trend among adolescent girls, who have the highest inciA rising trend among adolescent girls, who have the highest incidence of smoking dence of smoking initiationinitiation

Smoking in the WHO European Region still remains at a rate that Smoking in the WHO European Region still remains at a rate that could have could have direct and indirect devastating public health effects for Europedirect and indirect devastating public health effects for Europe

Exposure to Environmental Tobacco Smoke in Europe – A review.Olenka BrynczkaWorld Health Organization Regional Office for Europe, Bonn 2003www.euro.who.int/air* Very slow downward trend in some regions possible in the last few years, e.g Germany

WHO Europe consists of 52 Member States and goes from Western Europe to the Newly Independent States (including Uzbekistan).

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Second-hand tobacco smoke and childrenMaternal smoking and prenatal exposureMaternal smoking and prenatal exposure

Scientifically provenScientifically proven⇓ birth weight, birth length, head circumference⇑ risk of sudden infant death syndrome due to possible changes in the “arousal” centre⇑ miscarriage⇑ stillbirth

⇑ risk of SIDS Surgeon General⇓ birth weight, birth length, head circumference Windham GC, Hopkins B, Fenster L, Swan SH: Prenatal active or passive tobacco smoke exposure and the risk of preterm delivery or low birth weight. Epidemiology 2000,11,427-33⇑ miscarriageRef.: Tuormaa, T.E., The adverse effects of tobacco smoking on reproduction and health: A review from the literature, Nutr Health, Vol10, pp. 105–20, 1995. Cited after Giorgio Tamburlini, Ondine S. von Ehrenstein, Roberto Bertollini. WHO Regional Office for Europe, ISBN 92-9167-412-5, Copenhagen 2002, http://www.euro.who.int/ecehrome ⇑ still birthRef.: Di Franza and Lew, 1995 after Courage C.M.: Environmental tobacco smoke. In: Children’s health and environment: A review of evidence - a joint report from the European Environment Agency and the WHO Regional Office for Europe. Edited by: Giorgio Tamburlini, Ondine S. von Ehrenstein, Roberto Bertollini. WHO Regional Office for Europe, ISBN 92-9167-412-5, Copenhagen 2002, http://www.euro.who.int/ecehrome.

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Second-hand tobacco smoke and childrenMaternal smoking and prenatal exposureMaternal smoking and prenatal exposure

Under investigation:Under investigation:⇑ risk of birth defects⇓ pulmonary growth and maternal smoking (in utero exposure > postnatal)⇑ childhood cancer⇑ preterm birth⇑ neurobehavioural abnormalities⇓ IQ

We identified more than 30 studies on the association between exposure to maternal tobacco smoke during pregnancy and cancer in childhood. We combined their results in meta-analyses based on a random effects model. The results of the meta-analyses suggest a small increase in risk of all neoplasm's [relative risk (RR) 1.10; 95% confidence interval (CI), 1.03-1.19; based on 12 studies] ... The results on exposure to paternal tobacco smoke suggest an association with brain tumours (RR 1.22; CI, 1.05-1.40; based on 10 studies) and lymphomas (RR 2.08; CI, 1.08-3.98; 4 studies

Ref.: Paolo Boffetta, Jean Trédaniel, and Antonia Greco: Risk of Childhood Cancer and Adult Lung Cancer after Childhood Exposure to Passive Smoke: A Meta-Analysis. Environ Health Perspect 108:73-82 (2000). http://ehpnet1.niehs.nih.gov/docs/ 2000/108p73-82boffetta/ page 108: „).“

Smoking in late pregnancy is linked to lower IQ in offspringhttp://bmj.bmjjournals.com/cgi/content/full/330/7490/499?ehom

BMJ 2005;330:499 (5 March), doi:10.1136/bmj.330.7490.499

Mothers who smoke in late pregnancy risk having children with lowerintelligence. Young men whose mothers smoked 20 or more cigarettes a day hadIQs that were on average 6.2 points below those of sons of non-smokers,research has found (Paediatric and Perinatal Epidemiology 2005;19:4-11).The more cigarettes a woman smoked, the greater the risk. The association

was as strong in children with high social status as in low statusoffspring.

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Second-hand tobacco smoke and childrenMaternal smoking Maternal smoking ––

more smoke, less babymore smoke, less baby

NonsmokerNonsmoker 11––5 cigarettes per day 5 cigarettes per day >20 cigarettes per day>20 cigarettes per day

⇓ birth weight or ‘More smoke less baby’: 19 studies ⇒ consistent slight effect of SHTS exposure on birth weight–- pooled weight decrement of 31g (95%CI (-42, -20))⇑ risk (about 20%) intrauterine growth restriction (IUGR) ⇒ smaller birth weight than expected based on pregnancy duration

Ref.: California Environmental Protection Agency. Health effects of exposure to environmental tobacco smoke. San Francisco (CA): California Environmental Protection Agency 1997Windham GC, Hopkins B, Fenster L, Swan SH: Prenatal active or passive tobacco smoke exposure and the risk of preterm delivery or low birth weight. Epidemiology 2000,11,427-33

Ref.:Martina Poetschke-Langer (ed): Tobacco prevention and control (No 2): passive smoking in Germany, 2003, Germany Cancer Research Institute and WHO Collaboration Centre for Tobacco Control (www.dkfz.de): page 17

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Second-hand tobacco smoke and childrenSmoking parents Smoking parents ––

sudden infant death syndromesudden infant death syndrome

Sudden infant death syndrome is defined as a sudden, unexpected Sudden infant death syndrome is defined as a sudden, unexpected death of an infant without any evidence of a fatal illness at audeath of an infant without any evidence of a fatal illness at autopsytopsyPostulated mechanisms in relation to exposure to secondPostulated mechanisms in relation to exposure to second--hand hand tobtobacco smoke:acco smoke:

Second-hand tobacco smoke promotes direct irritation of the airways and respiratory infection Exposure to nicotine may alter the infant’s response to hypoxia (abnormal control of cardiorespiratory activity)Exposure to nicotine may alter the infant’s catecholamine metabolism

SIDS is defined as a sudden, unexpected death of an infant, without evidence any fatal illness at autopsy. After congenital anomalies, SIDS is the most common cause of death among infants 1 month to 1 year old in the US, accounting for 5 417 deaths in 1990. Active maternal smoking during pregnancy is established risk factor of SIDSRole of paternal smoking – elevated risk of SIDS while accounting for maternal smoking in 3 out of 6 studies.

California Environmental Protection Agency (1997) states that current studies support an elevated risk of SIDS associated with postnatal ETS exposure, independent of maternal smoking during pregnancy.

Postulated mechanisms in relation to SHTS exposure:

•SHTS promotes direct irritation of the airways and respiratory infection• Exposure to nicotine may alter infant’s response to hypoxia (abnormal control of cardio-respiratory activity)•Exposure to nicotine may alter infant’s catecholamine metabolism

Ref.: Nicholl J, O’Cathian A:Antenatal Smoking, postnatal passive smoking and the sudden infant death syndrome, In:Prsillo D, Alberman E, eds. Effects of smoking o the fetus, neonate and child. Oxford: Oxford University Press, 1992:138-49; Klonoff-Cohen HS, Edelstein SL: A case-control study of routine and death scene sleep position and sudden infant death syndrome in southern California JAMA 1995,273,790-794; Blair PS, Fleming Pj, Bensley D, Smith I, Bacon C, Taylor E: Smoking and the sudden infant death syndrome: results of 1993-5 case-control study for Confidential Inquiry into Stillbirths and Deaths in Infancy. BMJ 1996, 313, 195-198

Slotkin TA, Lappi SE, Lin J, Sundwell HW: Nicotine attenuates the ventilatory response to hypoxia in the developing lamb. Pediatric Research 1995, 37, 652-660

.

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Second-hand tobacco smoke and childrenMaternal smoking Maternal smoking ––

sudden infant death syndromesudden infant death syndrome

Exposure to second-hand tobacco smoke

Pooled odds ratio

95% confidence

interval Prenatal maternal smoking (unadjusted) 2.77 2.45Š3.13

Prenatal maternal smoking (adjusted) 2.08 1.83Š2.38

Postnatal maternal smoking (after controlling for prenatal smoking) 1.94 1.55Š2.43

Prenatal and postnatal maternal smoking and risk of sudden infant death sudden infant death syndromesyndrome (meta-analysis of 39 studies)

Most studies found dose-response relationships with both prenatal and postnatal maternalsmoking.

Studies controlled for maternal factors (age, parity); infant factors (sex, birth weight, gestational age), socioeconomic status (ethnicity, social class, education) and infant care practices (breastfeeding, sleeping position, wrapping), prenatal maternal smoking (4 studies)

OR = odds ration, CI = confidence interval

Ref.: Anderson HR, Cook DG: Passive smoking and sudden infant death syndrome: review of epidmiologic evidence. Thorax 1997, 52, 1003-9

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Second-hand tobacco smoke and childrenSmoking parentsSmoking parents

Scientifically proven:Scientifically proven:⇑ 94% sudden infant death syndrome⇑ 60% acute respiratory illnesses⇑ 24–40% chronic respiratory symptoms ⇑ 21% asthma and exacerbation of asthma symptoms⇓ growth in lung functioning⇑ 50% recurrent otitis media (repeated ear infection)

•94% increase in Sudden Infant Death Syndrome (SIDS) (Anderson HR, Cook DG: Passive smoking and sudden infant death syndrome: review of epidemiologic evidence. Thorax 1997, 52, 1003-9)

•60% increase in acute respiratory illnesses (ARI) ( Strachan DP, Cook DG: Parental smoking and lower respiratory illness in infancy and early childhood. Thorax 1997, 52, 905-14)•24-40% increase in chronic respiratory symptoms ( Cook DG, Strachan DP: Health effects of passive smoking 3. Parental smoking and prevalence of respiratory symptoms and asthma in school age children. Thorax 1997, 52, 1081-94)•21% increase in asthma and exacerbation of asthma symptoms (Cook DG, Strachan DP: Health effects of passive smoking 3. Parental smoking and prevalence of respiratory symptoms and asthma in school age children. Thorax 1997, 52, 1081-94)•reduced lung function growth (Surgeon General 1986 US Department of Health and Human Services. The health consequences of involuntary smoking. A Report of the Surgeon General. Washington, DC: US Government Printing Office; 1986)•⇑ 50% recurrent otitis media (Strachan DP, Cook DG. Parental smoking, middle ear disease and adenotosillectomy in children, Thorax 1997; 53:50-6

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Second-hand tobacco smoke and childrenSmoking parents Smoking parents ––neurodevelopmentneurodevelopment

Under investigation:Under investigation:Neurobehavioural deficitsNeurodevelopmental deficitsChildhood cancer

Studies on behavioural and neuro-developmental deficits in children exposed to SHTS are difficult to interpret influence of uncontrolled (parental intelligence, home environment, environmental and personal exposures, child rearing practices, depression, other characteristics of smokers) imprecision in measurement of smoking exposure. McCartney JS, Fried PA, WatkinsonB: Central auditory processing in school-age children prentatally exposed to cigarette smoke. Neurotoxicol Teratol 16,269-276, 1994

Eskenazi B, Trupin LS: Passive and active maternal smoking during pregnancy, as measured by serum cotinine, and postnatal smoke exposure. II. Effects on neurodevelopment at age 5 years. Am J Epidemiol 142(9Suppl):S19-29(1995)

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respiratory symptoms in children respiratory symptoms in children • The first reports of an effect of parental smoking on children’s respiratory symptoms were published in the early 1970s

• Risk if either parent smokes (meta-analysis of 60 studies)

Respiratory symptoms

Number of studies Odds ratio

95% confidence

interval Wheezing 41 1.24 1.17Š1.31

Cough 34 1.40 1.27Š1.53

Phlegm 7 1.35 1.13Š1.62

Breathlessness 6 1.31 1.08Š1.59

The measures of effect were lower for one parent smoking and higher for both parents smoking.

The effect of maternal smoking was stronger than paternal smoking. This can be due to a higher exposure of the child to maternal than to paternal smoking, because mothers are more often at home, or because the mother also smoked in pregnancy, so the effect foundcould be due to prenatal exposure rather than to exposure duringchildhood.

The increased risk found in households where the father but not the mother smoked supports an effect of SHTS exposure independent of in utero exposure.

Conclusions of California EPA (1997) : There is sufficient evidence that ETS exposure at home is causally associated with chronic respiratory symptoms (cough, phlegm or wheezing) in children, particularly infants and young children. California Environmental Protection Agency. Health effects of exposure to environmental tobacco smoke. San Francisco (CA): California Environmental Protection Agency 1997

Ref.:Cook DG, Strachan DP: Parental smoking and prevalence of respiratory symptoms and asthma in school age children, Thorax 1997; 52:1081-94

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Second-hand tobacco smoke and childrenSmoking parents Smoking parents ––asthma in childrenasthma in children

21% 21% increaseincrease in clinically diagnosed asthma among children with in clinically diagnosed asthma among children with either parent being a smoker either parent being a smoker Developing asthma or wheezing is more related to maternal than Developing asthma or wheezing is more related to maternal than paternal smokingpaternal smokingThe effect was stronger for the first 5The effect was stronger for the first 5––7 years of life than for school 7 years of life than for school ageage

Meta-analysis (37 studies):-Clinically diagnosed asthma: odds ratio OR = 1.44 (95%CI (1.27-1.64))

Meta-analysis (25 studies):-The pooled odds ratio for either parent smoking: odds ratio OR = 1,21 (95%CI (1.1-1.34))

Incidence of asthma or wheezing was related to maternal smokingEffect was stronger for the first 5-7 years of life than school age

ETS increases airway hyper responsiveness.

Martinzez FD, Wright AL., Taussig LM et al.: Asthma and wheezing in the first six years of life. The Group Health Medical Associates N Engl J Med. 1995, 332, 133-138.

While exposure to ETS increases the risk of sensitization to food allergens in the first few years of life it does not appear to increase the sensitivity to inhalant allergens.

Kulig M et al.: Effect of re- and postnatal tobacco smoke exposure on specificsensitization to food and inhalant allergens during the first 3 years of life. Allergy 1999, 54, 220--228

Strachan, D. P. and Cook, D. G.; Health Effects of Passive Smoking .5. Parental Smoking and Allergic Sensitisation in Children; Thorax; 53 (2) p.117-123, 1998

Likewise exposure to ETS is not associated with increase in IgE in children Gergen, P. J.; Environmental Tobacco Smoke As a Risk Factor for Respiratory Disease in Children; Respir.Physiol; 128 (1) p.39-46, 2001

OR = odds ratio, CI = confidence interval

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prognosis of asthmaprognosis of asthma

Disease severity increasedDisease severity increased, as assessed by:, as assessed by:Frequency and intensity of asthma attacksNumber of emergency room visits during a yearUse of asthma medicationOccurrence of severe asthma attacks (requiring intubation)

Ref.: Cook DG, Strachan DP, Carey IM: Health effects of passive smoking: 9. Parental smoking and spirometric indices in children. Thorax 1998, 53, 884-93.California Environmental Protection Agency. Health effects of exposure to environmental tobacco smoke. San Francisco (CA): California Environmental Protection Agency 1997Jaakkola JJ, Jakkolla MS. Effects of environmental tobacco smoke on the respiratory health of children, Scand J Work Environ Health 2002; 28(suppl 2): 71-83

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Second-hand tobacco smoke and childrenTobacco smoke Tobacco smoke –– childrenchildren’’s lungs lung

In early childhood (up to 3 years) lung development is completedIn early childhood (up to 3 years) lung development is completedwith the formation of alveoliwith the formation of alveoliGrowth in lung functioning parallels the change in height Growth in lung functioning parallels the change in height throughout childhoodthroughout childhoodSecondSecond--hand tobacco smoke increases the risk of respiratory hand tobacco smoke increases the risk of respiratory infections, which may adversely affect lung functioninginfections, which may adversely affect lung functioningIn In uteroutero exposure to maternal smoking may have lasting effects on exposure to maternal smoking may have lasting effects on the airways of the lungthe airways of the lungLung functioning declines with active smoking among older Lung functioning declines with active smoking among older childrenchildren

Ref.:Surgeon General 1986 US Department of Health and Human Services.The health consequences of involuntary smoking. A Report of the Surgeon General. Washington, DC: US Government Printing Office; 1986US Environmental Protection Agency. Respiratory health effects of passive smoking: lung cancer and other disorders. Washington, DC: US Government Printing Office; 1992; EPA/600/006FCalifornia Environmental Protection Agency. Health effects of exposure to environmental tobacco smoke. San Francisco (CA): California Environmental Protection Agency 1997

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Second-hand tobacco smoke and childrenLung functioningLung functioning

Spirometry parameter

Decrement ml/year

95% confidence interval

FEV1 Š3.8 Š6.4 to Š1.2

FVC Š2.8 Š5.5 to 0

FEF25Š75 Š14.3 Š29.0 to Š0.3

8706 schoolchildren (6–18 years) were followed annually: small reductions in lung functioning through adolescence were associated with both current and preschool exposure to maternal smoking

• Maternal smoking is a stronger determinant of lung functioning than the smoking of the father or other household members

• Exposure in utero? • Closer contact of the child with the mother?

• Second-hand tobacco smoke more strongly affected FEV1 among boys than girls

Ref.: Wang X, Wypij D, Gold Dr: A longitudinal study of the effects of parental smoking on pulmonary function in children 6-18 years. Am J Respir Critical Care Med. 1994, 149, 1420-5

FEV1, FVC and FEF25-75 are lung function parametersCI = confidence interval

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Second-hand tobacco smoke and childrenAcute respiratory illnessesAcute respiratory illnesses

SecondSecond--hand tobacco smoke particles are small and can penetrate hand tobacco smoke particles are small and can penetrate the airways and alveoli of the lungthe airways and alveoli of the lungThe gaseous components of secondThe gaseous components of second--hand tobacco smoke may hand tobacco smoke may adversely affect lung defences, with effects adversely affect lung defences, with effects oon:n:

CiliaMacrophage functionImmune response

SeSecondcond--hand tobacco smoke may increase the severity of acute hand tobacco smoke may increase the severity of acute respiratory illnesses by irritating and inflaming the lungsrespiratory illnesses by irritating and inflaming the lungs

Ref.:Surgeon General 1986 US Department of Health and Human Services.The health consequences of involuntary smoking. A Report of the Surgeon General. Washington, DC: US Government Printing Office; 1986US Environmental Protection Agency. Respiratory health effects of passive smoking: lung cancer and other disorders. Washington, DC: US Government Printing Office; 1992; EPA/600/006FScientific Committee on Tobacco and Health, HMSO. Report of the Scientific Committee on Tobacco and Health. The Stationery Office, London, 1998, 011322124X

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Second-hand tobacco smoke and childrenAcute respiratory illnessesAcute respiratory illnesses

Results of epidemiological studiesResults of epidemiological studies⇑⇑ 60% if either parent smokes60% if either parent smokes⇑⇑ 70% if only the mother smokes70% if only the mother smokes⇑⇑ 30% if another household member smokes30% if another household member smokes

Each year children younger than 18 months in the United States Each year children younger than 18 months in the United States have 150have 150 000 to 200000 to 200 000 cases of lower respiratory tract illness 000 cases of lower respiratory tract illness related to secondrelated to second--hand tobacco smoke, about 5% of which require hand tobacco smoke, about 5% of which require hospitalization hospitalization

Meta-analysis (36 studies):-Either parent smoking: odds ratio OR = 1.6 (95%CI (1.4 –1.7))-Maternal smoking only: odds ratio OR = 1.7 (95%CI (1.6 – 1.9))-Other household member smoking: odds ratio OR = 1.3 (95%CI (1.2 – 1.4))

Ref.: Strachan DP, Cook DG: Parental smoking and lower respiratory illness in infancy and early childhood. Thorax 1997, 52, 905

ETS particles are small and can penetrate the airways and alveoli of the lung.Gaseous components of ETS may adversely affect lung defences (effects on cilia, macrophage function, immune responses).

ETS may increase ARI severity through irritation and inflammation of the lung. (Surgeon General 1986, US EPA 1992, UK Scientific Committee on Tobacco and Health 1998)

Risk of ARI from SHTS is highest in the first year of life, and remains elevated until about the age of 3 years.Direct effects of ETS exposure on the risk of ARI in young children’s, independent of in utero exposure to ETS. The effects of ETS on the susceptibility to infections can be protected, at least to some extent, by breastfeeding the child for a lengthy period.

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Second-hand tobacco smoke and childrenAcute and chronic middle ear diseaseAcute and chronic middle ear disease

Eustachian tube dysfunction is central to the development of Eustachian tube dysfunction is central to the development of middle ear diseasemiddle ear diseaseSecondSecond--hand tobacco smoke may contribute to hand tobacco smoke may contribute to eustachianeustachian tube tube dysfunction through:dysfunction through:

⇓ mucociliary clearance⇑ adenoidal hyperplasia⇑ mucosal swelling⇑ frequency of upper respiratory tract infections

Parental smoking is linked with middle ear disease among childreParental smoking is linked with middle ear disease among children n anand is likely to be a caused is likely to be a cause

Ref.: Scientific Committee on Tobacco and Health, HMSO. Report of the Scientific Committee on Tobacco and Health. The Stationery Office, London, 1998, 011322124X

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neurobehaviouralneurobehavioural and and neurodevelopmentalneurodevelopmental deficitsdeficits

Biological plausibility of exposure to secondBiological plausibility of exposure to second--hand tobacco smoke hand tobacco smoke causing adverse causing adverse neurodevelopmentalneurodevelopmental effectseffects

Second-hand tobacco smoke exposure may be potentially more hazardous than in utero exposure to maternal smokingInhalation exposure provides a higher dose than transplacentalexposure

ChiChildhood may be the critical period for ldhood may be the critical period for neurodevelopmentalneurodevelopmentaleffects of smokingeffects of smokingChildren have a longer duration of exposure than do foetusesChildren have a longer duration of exposure than do foetusesAnimal experiments Animal experiments –– brain development is altered by postnatal brain development is altered by postnatal but not prenatal exposure to secondbut not prenatal exposure to second--hand tobacco smokehand tobacco smoke

Ref.:Eskenazi, B. and Castorina, R.; Association of Prenatal Maternal or Postnatal Child Environmental Tobacco Smoke Exposure and Neurodevelopmental and Behavioral Problems in Children; Environ.Health Perspect.; 107 (12) p.991-1000, 1999.

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Second-hand tobacco smoke and childrenNeurodevelopmentNeurodevelopment

Poorer academic performance in relation to paternal, maternal orPoorer academic performance in relation to paternal, maternal or household household smoking has been reported at the time of a followsmoking has been reported at the time of a follow--up during childhoodup during childhoodOne study controlled for maternal smoking during pregnancyOne study controlled for maternal smoking during pregnancyClearly worse performance on a range of cognitive, perceptual, cClearly worse performance on a range of cognitive, perceptual, central auditory entral auditory and linguistic abilities was associated with postnatal exposure and linguistic abilities was associated with postnatal exposure in three of six in three of six studies that controlled for prenatal maternal smokingstudies that controlled for prenatal maternal smokingChildren of mothers who smoked only after pregnancy performed soChildren of mothers who smoked only after pregnancy performed somewhat mewhat worse than children of mothers who smoked only during pregnancyworse than children of mothers who smoked only during pregnancyCognitive abilities (reading and math) were reduced among childrCognitive abilities (reading and math) were reduced among children 6en 6––16 years 16 years old if exposed to secondold if exposed to second--hand tobacco smoke (adjusted data)hand tobacco smoke (adjusted data)

Ref.: Poorer academic performance in relation to paternal, maternal or household smoking was reported at the time of a follow-up during childhood (Rentekallio1983, Bauman 1989, Byrd 1994).Only one study (Rentekallio 1983) controlled for maternal smoking during pregnancy.

Clear decrement in performance on a range of cognitive, perceptual, central auditory and linguistic abilities associated with postnatal exposure was observed in three (Bauman 1991,Eskenazi 1995, Fried 1997) out of six studies that controlled for prenatal maternal smoking.

Children of mothers who smoked only after pregnancy performed somewhat worse than children of mothers who smoked only during pregnancy (Bauman 1989, Eskenazi 1995).Eskenazi, B. and Castorina, R.; Association of Prenatal Maternal or Postnatal Child Environmental Tobacco Smoke Exposure and Neurodevelopmental and Behavioral Problems in Children; Environ.Health Perspect.; 107 (12) p.991-1000, 1999.Rentekallio P:A follow-up study up to the age of 14 of children whose mothers smoked during pregnancy. Acta Paediatr Scand 72:747-753, 1983Bauman KE, Koch GG, Fisher LA: Family cigarette smoking and test performance by adolescents. Health Psychol 8, 97-105, 1989 , Byrd RS, Weitzman ML; Predictors of early grade retention among children in the United States. Pediatrics 93,481-487, 1994Bauman KE, Flewelling Rl, LaPrelle J: Parental cigarette smoking and cognitive performance of children. Health Psychol 10, 282-288,1991.Eskenazi B, Prehn AW, Christianson RE: Passive and active maternal smoking as measured by cotinine; the effect on birth weight Am J Public Health 1995, 85, 395-8.Fried PA, Watkinson B, Siegel LS: Reading and Language in 9- to 12- year olds prenatally exposed to cigarettes and marijuana. Neurotoxicol Teratol 20,293-306, 1997

Yolton K, Dietrich K, Auinger P, Lanphear B P, Hornung R: Exposure to Environmental Tobacco Smoke and Cognitive Abilities among U.S. Children and Adolescents. Environ Health Perspect113:98–103 (2005): Children aged 6 to 16 showed reduced cognitive abilities in an inverse association with ETS exposure.

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Second-hand tobacco smoke and childrenParental smoking Parental smoking ––childhood cancerchildhood cancer

Paternal tobacco smokePaternal tobacco smoke⇑ 22% increase in the risk of brain tumour⇑ 200% increase in the risk of lymphomaThe results on exposure to tobacco smoke from maternal smoking before or after pregnancy are too sparse to allow for conclusion

Brain tumours among the children of Brain tumours among the children of nonsmokingnonsmoking women exposed women exposed to tobacco smoke from the husbandto tobacco smoke from the husband’’s smoking: s smoking:

⇑ 80% increase for early pregnancy exposure⇑ 70% increase for late pregnancy

Paternal tobacco smoke-Brain tumours (10 studies): relative risk RR = 1.22 (95%CI (1.05-1.40)) -Lymphomas (4 studies): relative risk RR = 2.08 (95%CI (1.08-3.98))

Brain tumours among children of non-smoking women exposed to tobacco smoke from the husband’s smoking:

-For early pregnancy: relative risk RR = 1.8 (95%CI (1.2-2.5))-For late pregnancy: relative risk RR = 1.7 (95%CI (1.2-2.6))

Ref.: Boffetta, P., Tredaniel, J., and Greco, A.; Risk of Childhood Cancer and Adult Lung Cancer After Childhood Exposure to Passive Smoke: A Meta-Analysis; Environmental Health Perspectives.; 108 (1) p.73-82, 2000

More than 30 studies on the association between exposure to maternal tobacco smoke during pregnancy and cancer in childhood were identified. The results of the meta-analyses suggest a small increase in risk of all neoplasm's [relative risk (RR) 1.10; 95% confidence interval (CI), 1.03-1.19; based on 12 studies] ... The results on exposure to paternal tobacco smoke suggest an association with brain tumours (RR 1.22; CI, 1.05-1.40; based on 10 studies) and lymphomas (RR 2.08; CI, 1.08-3.98; 4 studies).“Ref.: Paolo Boffetta, Jean Trédaniel, and Antonia Greco: Risk of Childhood Cancer and Adult Lung Cancer after Childhood Exposure to Passive Smoke: A Meta-Analysis. Environ Health Perspect 108:73-82 (2000). http://ehpnet1.niehs.nih.gov/docs/ 2000/108p73-82boffetta/ page 108:

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Second-hand tobacco smoke and childrenEnvironmental history and diagnostic proceduresEnvironmental history and diagnostic procedures

HistoryHistoryTaking the history is essential to recognize the problem and to advise parentsQuestions on smoking habits in the family should be asked at the very first consultation (such as other questions about family, home and pets)

Diagnostic proceduresDiagnostic proceduresNo routine diagnostic procedures are necessaryFor scientific purposes, cotinine analysis of urine or serum can be used to document exposure

Picture: TFI/WHO www.who.int/tobacco/health_priority/en/

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Example: the US National Cancer InstituteExample: the US National Cancer Institute’’s ask, advice, assist s ask, advice, assist and arrange model for physicianand arrange model for physician--based smoking cessation based smoking cessation

Ask parents about smoking at evAsk parents about smoking at every opportunityery opportunityI’ve noticed that your daughter has had a large number of respiratory problems. Do you or your spouse smoke cigarettes?How many cigarettes do you smoke each day?

Advise parents to stop smokingAdvise parents to stop smokingAs your child’s paediatrician, I must advise you to stop smoking, both for your own health and that of your son.One of the best ways for you to help your daughter is to quit smoking.Are you willing to attempt to quit smoking?

Risa Jean Stein, Christopher Keith Haddock, Kristin Koetting O’Byrne, Norman Hymowitz and Joseph Schwab: The Pediatrician’s Role in Reducing Tobacco Exposure in Children. Pediatrics 2000;106(5). URL: http://www.pediatrics.org/ cgi/content/full/106/5/e66: page 111:“The National Cancer Institute’s 4-A Approach to Physician-Based Smoking Cessation

As an example from the U.S. the 4 A Approach to Physician Based Smoking Cessation is given. It is a very directive way of interaction.

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Second-hand tobacco smoke and childrenThe US National Cancer InstituteThe US National Cancer Institute’’s ask, advice, assist and s ask, advice, assist and

arrange model for physicianarrange model for physician--based smoking cessationbased smoking cessation

Assist the parent in quittingAssist the parent in quittingLet’s set a quit date in the next couple of weeks.Here are some materials from the National Cancer Institute that many smokers have found helpful.Let’s talk about some medications that might help you to quit.

Arrange followArrange follow--up visits with the parentup visits with the parentI’d like us to arrange an appointment a week after your quit day.My nurse will be calling you next week to ask you about your quit day.

Risa Jean Stein, Christopher Keith Haddock, Kristin Koetting O’Byrne, Norman Hymowitz and Joseph Schwab: The Pediatrician’s Role in Reducing Tobacco Exposure in Children. Pediatrics 2000;106(5). URL: http://www.pediatrics.org/ cgi/content/full/106/5/e66: page 111:“The National Cancer Institute’s 4-A Approach to Physician-Based Smoking Cessation

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Second-hand tobacco smoke and childrenSuccessful national actions to tackle Successful national actions to tackle

secondsecond--hand tobacco smokehand tobacco smoke•• Introduce or strengthen legislation to make all public places Introduce or strengthen legislation to make all public places

smokesmoke--free, including public transport and workplacesfree, including public transport and workplaces•• Ban smoking indoors and outdoors in all educational Ban smoking indoors and outdoors in all educational

institutions, health care delivery and at all public events, institutions, health care delivery and at all public events, indoors and outdoorsindoors and outdoors

•• Ban or severely restrict smoking in restaurants and bars to Ban or severely restrict smoking in restaurants and bars to protect owner, employees and clientsprotect owner, employees and clients

•• Classify tobacco smoke as a carcinogen to protect the rights Classify tobacco smoke as a carcinogen to protect the rights of workersof workers

•• Labels on cigarettes should occupy a large part of the Labels on cigarettes should occupy a large part of the packagepackage

•• Ban selling to childrenBan selling to children•• Ban tobacco advertisingBan tobacco advertising

Source: European Strategy for Tobacco Control, WHO Europe, Copenhagen 2002The European Region of WHO, with only 15% of the world’s population, faces nearly one third of the worldwide burden of tobacco related diseases. At the end of the 1990s tobacco products were responsible for 1.2 million deaths (14% of all deaths), and unless more effective measures are implemented it is estimated that they will cause 2 million deaths (20% of all deaths) each year by 2020. While it has fallen from 45% to 30% over the past 30 years and has currently stabilized, smoking prevalence in the European Region still remains at a level that is devastating for public health and future generations. The negative trends in smoking prevalence among young people, women and lower socioeconomic groups, as well as the gap in tobacco control policies between Member States, are of a particular concern. To strengthen action and sustain progress, at the WHO European Ministerial Conference for a Tobacco-free Europe (Warsaw, 18–19 February 2002) Member States committed themselves to developing the European Strategy for Tobacco Control (ESTC) and declared their strong support for a comprehensive Framework Convention on Tobacco Control.The ESTC sets out strategic directions for action in the Region, to be carried out through national policies, legislation and international cooperation. The ESTC recognizes that Member States and the European Community, when applicable, will have to adopt different sets of measures, based on their concrete needs, resources, and the stage they have reached with their tobacco control policy, according to a realistic time frame. The measures included in the Strategy cover the areas of reducing the demand for tobacco products (price and taxation, smoke-free environments, bans on advertising, promotion and sponsorship, information, training and public awareness, smoking cessation, product control and consumer information) and the supply of such products (illicit trade, availability to young people, tobacco subsidies). The ESTC also sets out recommendations regarding monitoring, evaluating and reporting on tobacco use and tobacco control policies. Finally the ESTC specifies mechanisms, tools and milestones for international cooperation; these include Region-wide political commitment, strengthening national capacity, promoting international coordination, and information exchange, technical cooperation and monitoring.

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Second-hand tobacco smoke and childrenRecommended interventionsRecommended interventions

(Strong evidence)(Strong evidence)Smoking bans and restrictionsSmoking bans and restrictionsIncreasing unit price for tobacco productsIncreasing unit price for tobacco productsMassMass--media educational campaign media educational campaign when combined with other when combined with other interventionsinterventions

(Insufficient evidence (Insufficient evidence –– more studies needed)more studies needed)Community education to reduce exposure to Community education to reduce exposure to secondsecond--hand tobacco hand tobacco smokesmoke in the homein the home

Ref: Guide to Community Preventive Services

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Second-hand tobacco smoke and childrenPrimary preventionPrimary prevention

Start very early (during and before pregnancy) Start very early (during and before pregnancy) ⇒⇒ gynaecologists gynaecologists and midwifesand midwifesWithin the family, Within the family, ““strengthen the parentsstrengthen the parents””

Education style, consumption Education style, consumption style, communication and style, communication and stress management have to be stress management have to be consideredconsideredUse the high acceptance of the Use the high acceptance of the doctor doctor –– patient patient –– parent parent contact to sensitize for the contact to sensitize for the dangers of active and passive dangers of active and passive smokingsmoking

Picture: CDC Media Campaign Resource Center. Copyright: WHO. www.who.int/features/2003/08/en/Martina Poetschke-Langer (ed): Tobacco prevention and control (No 2): Passive smoking in Germany, 2003, Germany Cancer Research Institute and WHO Collaboration Centre for Tobacco Control (www.dkfz.de):

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Second-hand tobacco smoke and childrenPaediatricians as faithful partnersPaediatricians as faithful partners

72% of 105 interviewed parents had thought about the risks of 72% of 105 interviewed parents had thought about the risks of secondsecond--hand tobacco smokehand tobacco smoke75% thought that asthma and allergies can be triggered by 75% thought that asthma and allergies can be triggered by secondsecond--hand tobacco smokehand tobacco smokeGeneral practitioners talked to 46% of all parents about smokingGeneral practitioners talked to 46% of all parents about smoking, , but only 15% of the paediatricians did sobut only 15% of the paediatricians did soOnly 8% of all parents of children with asthma indicate that theOnly 8% of all parents of children with asthma indicate that thepaediatrician talked with them about their smoking habits and paediatrician talked with them about their smoking habits and asthmaasthmaParents consider a clear medical opinion and positive requests tParents consider a clear medical opinion and positive requests to o reduce smoking as helpful (12%), a bit helpful (44%) and not reareduce smoking as helpful (12%), a bit helpful (44%) and not really lly helpful (44%)helpful (44%)DoctorDoctor--hopping did not occur as a result of medical advicehopping did not occur as a result of medical advice

Ref.: Szczepanski, R., Hillen, P.: Minderung der Passivrauchexpositionvon Kindern - elterliches Verhalten, Aenderungsmöglichkeiten und deren Determinanten (Minimising passive smoke exposure of children – possibilities to change and their determinants). Pneumologie 53, 37-42Risa Jean Stein, Christopher Keith Haddock, Kristin Koetting O’Byrne, Norman Hymowitz and Joseph Schwab: The Pediatrician’s Role in Reducing Tobacco Exposure in Children. Pediatrics 2000;106(5). URL: http://www.pediatrics.org/ cgi/content/full/106/5/e66: Page106: „Pediatricians have a unique and important role to play in the prevention and treatment of childhood and adolescent tobacco use, the protection of patients from the harmful effects of environmental tobacco smoke, and the encouragement of smoking cessation among parents.However, because recent research indicates that physician training in tobacco dependence is woefully weak and lacks a model for training, this article constructs a useful approach to this problem. ... Acomprehensive model is presented for training pediatricians in the areas of reducing infant and child exposure to environmental tobacco smoke, preventing youth smoking initiation, and providing smoking cessation assistance for adolescents and parents.

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Second-hand tobacco smoke and childrenPrimary preventionPrimary prevention

PreventivPreventive guidelines for paediatricians are very helpful:e guidelines for paediatricians are very helpful:German guidelines for advice on second-hand tobacco smoke for paediatriciansModules should be used during regular contacts, such as check-ups, mainly in the first year of life for breastfeeding women and/or for fathers

Main mesMain message: constructive, positive climate makes giving advice sage: constructive, positive climate makes giving advice to parents easierto parents easierAvoid negative comments and positively support all behavioural Avoid negative comments and positively support all behavioural changes, such as during pregnancychanges, such as during pregnancy

Ref.: Horn, W.R.: Beratungsleitfaden zur Tabakprävention in Kinder- und Jugendarztpraxen erarbeitet. Kinder- und Jugendarzt 32,Supp.10, 2001Ref.: Risa Jean Stein, Christopher Keith Haddock, Kristin Koetting O’Byrne, Norman Hymowitz and Joseph Schwab: The Pediatrician’s Role in Reducing Tobacco Exposure in Children. Pediatrics 2000;106(5). URL: http://www.pediatrics.org/ cgi/content/full/106/5/e66: page 108:“Strategies for Reducing SHTS Exposure Among Children•Initial SHTS interventions•Identify sources of SHTS exposure for the child.•Provide general information regarding the negative health effects of SHTS.•Review strategies and potential barriers for reducing the child’s exposure to SHTS.•Suggest that parents discuss strategies to reduce the child’s SHTS exposure with other caretakers.•Interventions at follow-up visits•Further identify sources of SHTS exposure, reinforce possible reductions brought about by the parents, and problem-solve barriers encountered in their endeavors.•Provide additional information about the health consequences•of SHTS.•Assess parental smoking cessation efforts.”

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Second-hand tobacco smoke and childrenSmoking and breastfeedingSmoking and breastfeeding

The National Commission for Breastfeeding in Germany recommends The National Commission for Breastfeeding in Germany recommends to advise to advise smoking breastfeeding women as follows.smoking breastfeeding women as follows.Smoking should be avoided during the months of breastfeedingSmoking should be avoided during the months of breastfeedingA breastfeeding woman who does smoke should try continuously to A breastfeeding woman who does smoke should try continuously to reduce the reduce the number of cigarettes smokednumber of cigarettes smokedOnly if consumption is massive can the appropriateness of breastOnly if consumption is massive can the appropriateness of breastfeeding be feeding be questioned due to the possibility of retarding the growth of thequestioned due to the possibility of retarding the growth of the childchildGiven the possibility of passive uptake of smoke particles, peopGiven the possibility of passive uptake of smoke particles, people should never le should never smoke near a childsmoke near a childThe burden of breastThe burden of breast--milk with a few harmful substances can be reduced by the milk with a few harmful substances can be reduced by the mother through special smoking breaks before breastfeedingmother through special smoking breaks before breastfeeding

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Second-hand tobacco smoke and childrenHealth relevance:Health relevance:

what could be avoidedwhat could be avoided

Children whose mothers smoke have an estimated 70% more Children whose mothers smoke have an estimated 70% more respiratory problems than children whose mothers do not smokerespiratory problems than children whose mothers do not smokePneumonia and hospitalization is 38% more frequent among Pneumonia and hospitalization is 38% more frequent among children in the first year of life when the mother smokeschildren in the first year of life when the mother smokesInfant mortality was 80% higher among children born to women Infant mortality was 80% higher among children born to women smoking during pregnancy than among the children of nonsmokerssmoking during pregnancy than among the children of nonsmokersAn estimated 20% of all infant deaths could be avoided if all An estimated 20% of all infant deaths could be avoided if all pregnant smokers stopped by the 16th week of gestationpregnant smokers stopped by the 16th week of gestationInfants of mothers who smoke have almost five times the risk of Infants of mothers who smoke have almost five times the risk of sudden infant death syndrome versus infants of mothers who do sudden infant death syndrome versus infants of mothers who do not smokenot smoke

Page is copied from indoor air training package

Smoke released from cigarettes, cigars and pipes, composed of more than 3800 different substances. Particulate matter is 2-3 times higher in homes of smokers. Exposure may occur at home, school, child care settings, relatives´ home and others. Important to reduce second-hand smoke justifies prohibiting smoke at home, schools and child care settings.Etzel, Indoor Air Pollutants in Homes and Schools. Pediatric Clinics of North America (2001) 48 (5): 1153Wisborg, Exposure to tobacco smoke in utero and the risk of stillbirth and death in the first year of life, Am J Epidemiol. (2001)154(4):322The authors examined the association between exposure to tobacco smoke in utero and the risk of stillbirth and infant death in a cohort of 25,102 singleton children of pregnant women scheduled to deliver at Aarhus University Hospital, Aarhus, Denmark, from September 1989 to August 1996. Exposure to tobacco smoke in utero was associated with an increased risk of stillbirth (odds ratio = 2.0, 95% confidence interval: 1.4, 2.9), and infant mortality was almost doubled in children born to women who had smoked during pregnancy compared with children of nonsmokers (odds ratio = 1.8, 95% confidence interval: 1.3, 2.6). Among children of women who stopped smoking during the first trimester, stillbirth and infant mortality was comparable with that in children of women who had been nonsmokers from the beginning of pregnancy. Conclusions were not changed after adjustment in a logistic regression model for the sex of the child; parity; or maternal age, height, weight, marital status, years of education, occupational status, and alcohol and caffeine intake during pregnancy. Approximately 25% of all stillbirths and 20% of all infant deaths in a population with 30% pregnant smokers could be avoided if all pregnant smokers stopped smoking by the sixteenth week of gestation.

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Prevent teenagers from starting to smokePrevent teenagers from starting to smoke

Primary prevention: do not start to smokePrimary prevention: do not start to smokeSecondary prevention: smoking teenagers need support and Secondary prevention: smoking teenagers need support and advice to stop smokingadvice to stop smoking

Special projects for target groups (children and teenagers) are rare:

In Germany the programme Just Be Smoke-free for teenagers and adolescents is promoted by the German Professional Association of Children’s and Young People’s Physicians and the German Medical Association (www.justbesmokefree.de))Space for other local examples:

Picture: WHOMore national programs need to be added here (see line on slide)

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The German approach The German approach –– based on paediatriciansbased on paediatricians’’ experienceexperience

Advise parents to stopAdvise parents to stop smoking indoors foreversmoking indoors forever“As your child’s paediatrician, I must advise you to stop indoor smoking for the benefit of your child”“One of the best ways for you to help your child is to quit smoking”

Advise parents to not smoke in the car Advise parents to not smoke in the car Assist the parent in not smoking indoorsAssist the parent in not smoking indoorsArrange followArrange follow--up visits with the parentup visits with the parent

“I’d like to have another appointment with you in a week”“My nurse will be calling you next week to ask you about your experience”

The German Paediatric Association has a guideline for paediatricians on SHTS, based on material from Martina Poetschke-Langer (ed): Tobacco prevention and control (No 2): Passive smoking in Germany, 2003, Germany Cancer Research Institute and WHO Collaboration Centre for Tobacco Control (www.dkfz.de):

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The German approach The German approach –– use regular checkuse regular check--upsups

Avoid accusation Avoid accusation –– support every positive change, such as during support every positive change, such as during pregnancypregnancyDuring every first visit, ask about smoking habitsDuring every first visit, ask about smoking habitsPromote healthy surroundings Promote healthy surroundings –– clean airclean airIf parents are motivated to reduce or stop smoking, support themIf parents are motivated to reduce or stop smoking, support them with with practical tipspractical tipsReassure parents at the following appointments Reassure parents at the following appointments Admire small changes as well, such as smoking outdoors onlyAdmire small changes as well, such as smoking outdoors onlyTalk to parents about their model role Talk to parents about their model role –– smoking parents are more likely smoking parents are more likely to have smoking childrento have smoking childrenIf parents regress, offer more support, such as nicotine replaceIf parents regress, offer more support, such as nicotine replacement ment therapytherapyIf children have repeated airway problems, mainly asthma, ask agIf children have repeated airway problems, mainly asthma, ask again ain about secondabout second--hand tobacco smokehand tobacco smoke

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Health and environment professionals play a critical roleHealth and environment professionals play a critical role

Health promotion in general has to be at least as attractive forHealth promotion in general has to be at least as attractive forphysicians as early diagnosis and treatment of diseasesphysicians as early diagnosis and treatment of diseases

But changes are usually only possible in small But changes are usually only possible in small stepsstepsNot only the smoker but also a hesitating Not only the smoker but also a hesitating physician or insecure outpatient or hospital physician or insecure outpatient or hospital staff have to be respected with their identity staff have to be respected with their identity and then motivated and trained and then motivated and trained Change the framework conditions:Change the framework conditions:

Stop the promotion of tobacco productsIncrease the price of tobacco productsRestrict sale of cigarettes to teenagersProtect nonsmokers

Picture: WHORef.: Risa Jean Stein, Christopher Keith Haddock, Kristin Koetting O’Byrne, Norman Hymowitz and Joseph Schwab: The Pediatrician’s Role in Reducing Tobacco Exposure in Children. Pediatrics2000;106(5). URL: http://www.pediatrics.org/ cgi/content/full/106/5/e66: page 115:

Pediatric Interventions for the Prevention of Tobacco Use•Office and setting factors•Model a tobacco-free lifestyle•Provide a tobacco-free office environment•Place anti-tobacco messages (eg, posters, pamphlets) in office•Seek continuing medical education on tobacco-use prevention•Encourage parents to create a tobacco-free home environment•Countering social influences•Reinforce abstinence from all tobacco products•Teach about the immediate negative consequences of tobacco use•Provide counter advertising education•Teach tobacco refusal techniques•Community-based interventions•Participate in organizations attempting to reduce tobacco use•Disseminate tobacco-use prevention messages in local media•Participate in school-based prevention programs•Policy interventions•Provide expert testimony to legislative bodies•Lobby legislators to support tobacco-use prevention efforts•Support initiatives to increase excise taxes on tobacco products•Encourage enforcement of laws designed to prevent tobacco sales to minors

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Second-hand tobacco smoke and childrenChildrenChildren’’s and adolescentss and adolescents’’ complex environmentcomplex environment

HAZARDSChemical

MEDIAAir, placenta, breast-milk

SETTINGSRural vs urbanHomeSchoolPlaygroundStreetWorkplaceCar (inside)

ACTIVITIESLearning, working, eating, drinking, sleeping, breathing, playing

Photograph courtesy of US Center for the Evaluation of Risks to Human Reproduction, National Institute of Environmental Health Sciences logologo

OUTCOME EFFECTSInfectionGrowthAirwaysBrainSudden infant death

syndrome

SUSCEPTIBILITYFoetusNewbornChildren

In this summary slide, we see the complexity of the issues related to children’s environmental health. Hazards (physical, chemical, biological – in many cases favored by social factors) are introduced into environmental media (water, air, food, soil objects, toys) with variable efficiency in different settings (urban and rural: home, school, field, playground, street, workplace). A child’s activities brings him into contact with these hazards. <<READ SLIDE>>Depending upon the individual susceptibility of the child based upon age, general health and social supports, the exposure may cause harm from subtle changes in function to death. Children’s environmental health is the field which synthesizes these complexities and attempts to make fundamental changes to improvechildren’s environments and prevent environmental illnesses.

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Critical role of health and environment professionalsCritical role of health and environment professionals

Diagnose and treatDiagnose and treatPublish and researchPublish and researchSentinel casesSentinel casesCommunityCommunity--based based interventionsinterventionsEdEducateucate

Patients and familiesColleagues and students

AdAdvocatevocateProvide a role modelProvide a role model

Health and environment professionals have a critical role to play in maintaining and stimulating changes that will restore and protect children’s environmental health. While the human genome project is very important and scientifically exciting, we all know that genes express themselves within an environment and understanding gene-environment interactions is what will keep our children healthy. So, as we look to our political and personal lives to support sustainable development, we can look to our practices for ways to enhance the environmental health of our patients. All of us can do something. At the one on one patient level we can include environmental etiologies in our differential diagnoses and in our preventive advice. We can be dissatisfied with the diagnosis of “idiopathic” and look hard for potential environmental causes of disease and disability. We can publish sentinel cases and develop and write up community based interventions. We can educate our patients, families, colleagues and students didactically. Finally, we must all become vigorous advocates for the environmental health of our children and future generations. It’s not enough to be an informed citizen, we need to write letters and articles, testify in hearings, approach our elected officials with education and positive messages, avoiding "scares" and "alarmism" but providing the evidence for action and clear remedial/preventive proposals. And, we must all recognize that as professionals with understanding of both health and the environment, we are powerful role models. Our choices will be noticed: they should be thoughtful and sustainable.

Pic: Norwegian campaign for non smoking www.kreftforeningen.no

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Poster contest by HRIDAY with support from the WHO Regional Office for South-East Asia

We hold our future in our handsWe hold our future in our handsand it is our childrenand it is our children

I end with this beautiful reminder to us from a child in India, We must recognize the risks to our children and assume our responsibilities of preventing them, because we hold our future in our hands—and it is our children.Thank you.

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This report was produced by a contractor for Health & Consumer Protection Directorate General and represents the views of thecontractor or author. These views have not been adopted or in any way approved by the Commission and do not necessarilyrepresent the view of the Commission or the Directorate General for Health and Consumer Protection. The EuropeanCommission does not guarantee the accuracy of the data included in this study, nor does it accept responsibility for any use madethereof.

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