Passive smoking and children’s health: New evidence and call for action

Royal College of Physicians Founded London Fellows & Members in 80 countries Set medical standards through training, exams, and advice to government Strong interest in public health

Tobacco & Royal College of Physicians Long history of involvement in tobacco control 1962 report “Tobacco or Health” Smoking and the young (1992) Nicotine addiction in Britain (2000) Forty Fatal Years (2002) Going smoke-free (2005) Harm reduction in nicotine addition (2007)

Smoke-free legislation in the UK: In place since 2006 (Scotland), 2007 (England, NI, Wales) Amongst the most comprehensive in Europe All enclosed workplaces including all bars and restaurants No smoking rooms allowed Includes residential mental health settings Includes work vehicles Young Offender institutions Partial exemptions for adult prisons and some residential facilities

The impact of UK smoke-free legislation: Highly effective and popular Has generated marked improvements in health, particularly heart disease Legislation does not extend into the home This is where the majority of exposure, and particularly of children, occurs This report explores the extent of and possible policy responses to the problem of passive smoking in children

Children’s exposure to passive smoke

Trend in passive exposure of children over time

Effect of parent and carer smoking

Children living in smoke-free homes in England

Key Points: Main determinants of exposure are: – Whether parents and carers smoke – Whether smoking is allowed in the home Homes usually smoke-free if parents don’t smoke 2 million children live in homes that allow smoking Exposure highest in the young and socio-economically disadvantaged

Maternal active and passive smoking: Effects on fetal health

Effect of active smoking during pregnancy Each year in the UK, smoking during pregnancy causes around: 5000 miscarriages 300 perinatal deaths 2200 premature births 19,000 low birth weight Smoking in pregnancy also increases risk of birth defects: Heart (15-50% increase in risk) Missing/deformed limbs or digits (30-50% increase in risk) Face: cleft lip/palate (35% increase in risk)

Effect of passive smoking in pregnancy General consistency with active smoking studies Clear evidence on low birth weight and premature births Some direct evidence on birth defects (e.g. of the face, cleft lip/palate)

Passive smoking and children’s health

Sudden infant death syndrome 3-fold increase with mother smoking More than doubling with father or other household member smoking Lower respiratory infection 54% increase in risk from household smoking Mostly bronchiolitis (2.5-fold increase in risk from mother smoking) Middle ear infection 35% increase in risk from household smoking Stronger effects on disease requiring surgery

Wheeze 65% or more increase with mother smoking Up to 37% increase with household smoking Asthma 50% increase in asthma at school age by household smoking Approx 2 fold increase in asthma in under 3’s if mother smokes in pregnancy Meningitis Twice as likely if one or more parents smoke

Parental and sibling smoking and smoking uptake in children

Smoking uptake 62% increase if one parent smoked – Stronger for mother than father Nearly 3 fold increase if both parents smoked More than doubling in risk if sibling smoked Any household smoking increased risk by 92%

Key points: Smoking in pregnancy causes significant harm to the unborn child Passive smoking in pregnancy is common and has similar, though less strong effects, particularly on birth weight and facial defects Passive smoking significantly increases risk of sudden infant death, lung infections, asthma, wheeze, meningitis and ear disease in children Effects typically stronger for mother smoking after birth Significant impact on risk of smoking uptake in children

Economic impact

Excess disease in children – UK general practice activity Excess UK cases Excess UK consultations Lower respiratory tract infections < 2 years20,50026,000 Middle ear infections 0-16 years121,400160,200 Wheeze < 2 years7,20010,300 Asthma 3-4 years1,7007,600 Asthma 5-16 years13,70099,000 Meningitis 0-16 years Total165,100303,900

Excess Disease – Hospital Admissions in England Excess admissions Lower respiratory tract infections < 2 years3,361 Middle ear infections 0-16 years2,517 Wheeze < 2 years938 Asthma 3-4 years236 Asthma 5-16 years1,211 Meningitis 0-16 years231 Total8,494

Other excess disease Approximately 40 UK cases of sudden infant death Approximately 25,000 UK children start smoking before age 16 – 50% chance of death caused by smoking – Average loss of 10 years life expectancy

Primary care costs (UK) Additional 300,000 consultations £9 million €10.5m Asthma/wheeze treatments£0.7 million €0.84m Hospital Costs (UK) Additional admissions million £13.6 million €16.5m

Long term costs from uptake of smoking Total excess health care cost of – £48 million over 60 years* €58m *(discounted at 3.5% p.a.) Productivity losses due to absenteeism and ill health estimated at: – £63 to £72 million over lifetime** €79 to €87m **(discounted at 3.5% p.a.)

Key points: Each year in children in the UK, passive smoking causes approximately – 165,000 new cases of disease – 300,000 GP consultations – 9500 hospital admissions – 40 sudden infant deaths – 25,000 new smokers by age 16 – National Health Service costs of £23.3 million (€27m) per annum Lifetime discounted health care costs £48 million (€58m) Wider economic costs of up to £72 million (€87m) due to future lost productivity All of this disease and cost is avoidable

Ethical issues

A general duty on adults to protect children from smoke Preventing direct harm – Not exposing children to smoke – Not giving children tobacco products Preventing or limiting “role modelling” – Not smoking around children in “safe” (i.e. open) environments – Limiting media exposures to (positive) smoking messages Making tobacco sales less visible, and making packaging less attractive

Key points: General duty of parents and all adults to protect children from Tobacco smoke Tobacco smoking Tobacco products and imager y Restrictions appropriate where they can work Smoking in cars Tobacco promotion, sale and imagery in media Looked-after children Rights of the child should be paramount UN Convention on the Rights of the Child

Public opinion on smoke-free policy

Legislation at work: Growing support

Increasingly, smokers support smokefree

Smoke-free homes

Better understanding of the risks

Support for stronger action: Cars

Support for stronger action: Outdoors

Key points: Support is high and rising, particularly among smokers Attitudes are underpinned by growing belief that passive smoking is harmful and that smoke-free rules improve health There is a substantial support for measures to include private and to protect children

Recommendations for action

1.Reduce the number of parents and younger adult smokers

Measures to reduce smoking in young adults Cost: increase real cost, reduce illicit supply Retail availability: licensing, location, opening hours Promotion: Point of Sale display, smoking in media, generic packs Health promotion: Media campaigns and health warnings Cessation: improve coverage and design of services Harm reduction: promote alternative nicotine sources

2. Prevent exposure to smoke Smoke-free homes: – mass media campaigns – health warnings – behavioural interventions – nicotine substitution Smoke-free cars: – Prohibit smoking in vehicles

3. Prevent exposure to smoking Change social acceptability of smoking in public, particularly around children Mass media campaigns to explain policy Prevent exposure to tobacco products and brands in shops, films, TV, other media Extend smoke-free regulations to include places frequented by children

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