3. Reducing exposure to second-hand smoke

The aim: to continue to reduce significantly the number of people who are exposed to second-hand smoke across all communities in Scotland.

Scotland's smoke-free law has made an important difference both to our health and to our understanding of the effects of second-hand smoke.  There is huge public support for the law, and for initiatives to reduce second-hand smoke exposure in homes and cars.  Although children's exposure has reduced, 27% of primary school children reported being exposed to smoke in their own home in 2007.  Children from the poorest backgrounds are most likely to be at risk.

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Short term measures

• We must ensure that the smoke-free law continues to be enforced effectively.  We need to explore the best way to extend smoke-free provision to cover areas currently exempt by law (mental health settings, prisons).
• We need effective social marketing campaigns which link into local initiatives on the dangers of smoking in the home and in vehicles.
• We must develop and evaluate new interventions to reduce smoking in the home in Scotland, and training relevant professionals in delivering these.
• We need a consultation on introducing legislation to ban smoking in vehicles.
• We must develop robust intermediate and endpoint targets to reduce second-hand smoke exposure in the home and in vehicles, in order to support awareness raising work and work in communities.

Medium term measures

• We must ensure that all Scottish health and education services have smoke-free grounds.
• We need to be realistic about the difficulties some people have.  We must promote effective harm reduction strategies, including the use of nicotine replacement for temporary abstinence, to protect children from exposure to second hand smoke in the home.

Long term measures

• In the long term we must consider further evidence-based measures to protect people from second-hand smoke

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SHORT TERM

• We must ensure that the smoke-free law continues to be enforced effectively.  We need to explore the best way to extend smoke-free provision to cover areas currently exempt by law (mental health settings, prisons).

Rationale:

Smoke-free legislation in Scotland has been a resounding success, which has proved popular, achieved widespread compliance, improved indoor air quality and reduced second-hand smoke exposure. The law is currently well enforced, but in order to continue to reap the benefits of smoke-free legislation, targeted Government funding must continue for both national and local level enforcement activities.

Prisons, and designated rooms in psychiatric hospitals and units, care homes and police stations currently remain exempt from the legislation. But the avoidable involuntary exposure to second-hand smoke which occurs in these contexts remains preventable, and could be resolved by relatively simple revisions of the relevant regulations. This would bring them in line with current legislation and provide those who reside and work in these settings with adequate protection from second-hand smoke.

Smoking is an often neglected issue in people with mental health problems. Partnership Action on Tobacco and Health's (PATH) 2010 mapping report of existing smoke-free provisions within residential mental health services in Scotland notes a significant positive shift in attitude amongst psychiatric and health service, influenced by an increased awareness of tobacco, the benefits of stopping smoking and the purpose of tobacco policies. Recently, Health Scotland, on behalf of the Scottish Government, published implementation guidance on how mental health services can move towards being smoke-free.

Evidence base:

Lincoln. T Scott Chavez, R and Langmore-Avila, E (2005). US experience of smoke-free prisons. British Medical Journal 331: 1473.

ASH. Essential Information on Smoke-free Prisons (July 2010).

The Research Shop. Achieving Smoke-free Mental Health Services in Scotland: Analysis of Consultation Responses. June 2009. NHS Health Scotland.

• We need effective social marketing campaigns which link into local initiatives on the dangers of smoking in the home and in vehicles.

Rationale:

Social marketing campaigns have an important role to play in promoting smoke-free homes. They should raise awareness of the risks and encourage adults to make practical and appropriate choices.  Key stakeholders in Scotland agree that a tiered media campaign should be implemented, and that social marketing in consultation with local work should be encouraged.  There is currently minimal activity on this front in Scotland, and to achieve these goals a long-term funding strategy must be agreed in the short term.

Evidence base:

Gordon R, McDermott L, Stead M and Angus K (2006). The effectiveness of social marketing interventions for health improvement: What's the evidence. Public Health, 120: 1133-1139.

Borland R et al (2006). Determinants and consequences of smoke-free homes: Findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 15 (Supplement 3): iii42-iii50.

Evans WD et al. (2006). Media and secondhand smoke exposure: results from a national survey. American Journal of Health Behaviour. Jan-Feb: 30 (1): 62-71.

Alwan N et al. (2010). Children's exposure to second-hand smoke in the home: a household survey in the North of England. Health and Social Care in the Community 18 (3): 257-263.

• We must develop and evaluate new interventions to reduce smoking in the home in Scotland, and training relevant professionals in delivering these.

Rationale:

There are currently significant gaps in research with regard to effective interventions aimed at reducing smoking in the home. The NHS Health Scotland report on the National Smoking in the Home Seminar held in Glasgow in 2008 recognised that the development of the evidence base for local effectiveness is essential. It recommended that smoke-free homes initiatives in Scotland should be adapted in local communities and made subject to action research..

Worldwide research tends to focus on knowledge and attitudes, and there is little clarity at local level about the benefits of smoke-free homes initiatives, or about whether the stepped/incremental approach is the most effective method of tackling the issue.  These are other relevant issues are currently being examined in Scotland by ASH Scotland's Big Lottery funded REFRESH project, findings of which should be monitored closely in order to guide future action. 

Evidence base:

Gehrman, C. A. and Hovell, M. F. (2003). Protecting children from environmental tobacco smoke (ETS) exposure: a critical review. Nicotine and Tobacco Research 5: 289-301.

Hacker, J and Wigg, E (2010) Evaluation of a three-stage, community Smoke-free Homes Project. Health Education 10 (3).

Hovell, M. and Daniel, J. (2005) Defining residential tobacco home policies: a behavioural and cultural perspective. Archives of Disease in Childhood

Hovell, M.F., Zakarian, J.M., Matt, G.E., Liles, S., Jones, J.A., Hofstetter, Larson, C.R., Benowitz, S.N., (2009) Counselling to reduce children's secondhand smoke exposure and help parents quit smoking: A controlled trial Nicotine and Tobacco Research Advance Access published on October 29, 2009 Nicotine Tob Res 2009 11: 1383-1394; doi:10.1093/ntr/ntp148

Priest N, Roseby R,Waters E, Polnay A, Campbell R, Spencer N,Webster P, Ferguson-Thorne G. (2008) Family and carer smoking control programmes for reducing children’s exposure to environmental tobacco smoke. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD001746. DOI: 10.1002/14651858.CD001746.pub2.

Taylor L, Wohlgemuth C, Warm D, Taske N, Naidoo B, Millward L, (2005) Public Health interventions for the prevention and reduction of exposure to second-hand smoke: a review of reviews Evidence briefing. National Institute for Clinical Excellence

• We need a consultation on introducing legislation to ban smoking in vehicles.

Rationale:

Second-hand smoke exposure in vehicles is an acute problem for children and young people who have little control over their exposure levels. Adults whose health is already compromised by respiratory or heart disease are also particularly vulnerable, as are pregnant women.

Studies (including one conducted in Scotland) have examined the extent of child passenger exposure to SHS, typically concluding that the concentration of particulate matter in cars where smoking takes place exceeds healthy guidance limits and is likely to be harmful to respiratory health. This includes experimental conditions involving ventilation (e.g. opening windows or running air conditioning).

One means of preventing this risk is to ban smoking in vehicles where children are present (as the British Lung Foundation are currently campaigning for in the UK).  Currently, work vehicles are required to be smoke-free by law in Scotland, but compliance with this requirement may be less than complete, and enforcement is challenging. The issue of legislation to ban smoking in vehicles is a highly complex one.  International practice and research evidence(pdf) both require careful scrutiny alongside issues including public opinion and enforcement in order to determine the most effective way to further reduce exposure to second-hand smoke in this context.

Recently, the Governments in both Ireland and Wales have announced they are considering measures to further restrict smoking in vehicles. At Westminster, MP Alex Cunningham recently won a vote to introduce a private member's bill with similar effect.

Laws requiring cars to be smoke-free when children are present have been adopted in South Australia, Tasmania, New South Wales, Victoria, Queensland and Western Australia. Eight of Canada's thirteen provinces and territories have laws in force which prohibit smoking in vehicles carrying children. In the USA, five states have laws requiring vehicles carrying children to be smoke-free and bills are currently before several other U.S. state legislatures. Mauritius, South Africa and Bahrain have also recently enacted similar laws. The child age at which smoke-free car laws apply differs between jurisdictions. As yet there is no available evidence on the enforcement of smoke-free car laws or levels of compliance. Go here to access ASH Scotland's overview of smoke-free car laws in other parts of the world, outlined in our wider briefing paper on second-hand smoke in cars.

Evidence base:

Hitchman SC et al. (2010) Support and correlates of support for banning smoking in cars with children: findings from the ITC Four Country Survey. European Journal of Public Health Jul 14

Hitchman SC et al. (2010) Predictors of smoking in cars with nonsmokers: findings from the 2007 Wave of the International Tobacco Control Four Country Survey. Nicotine and Tobacco Research 12 (4): 374-380.

Leatherdale ST, Smith P and Ahmed R (2008). Youth exposure to smoking in the home and in cars: how often does it happen and what do youth think about it? Tobacco Control 17 (2): 86-92.

Semple S, Apsley A, Galea K, MacCalman L. Smoking in cars: A project report from the Scottish Centre for Indoor Air. Scottish Centre for Indoor Air. 19 November 2010.

Thomson G et al. (2010) A qualitative case study of policy maker views about the protection of children from smoking in cars. Nicotine and Tobacco Research 12 (9): 970-977.

Tapp D and Thomson G. (2009) Smoke-free cars in New Zealand: rapid research among stakeholders on attitudes and future directions. New Zealand Medical Journal 122 (1303): 54-66.

• We must develop robust intermediate and endpoint targets to reduce second-hand smoke exposure in the home and in vehicles, in order to support awareness raising work and work in communities.

Rationale:

The ideal solution to protecting children from second-hand smoke exposure is parental (and other adult) cessation. If this cannot be achieved in the short term, then the next best option is to minimise the exposure to children that arises from smoking by parents and other household members in the home. Encouraging the implementation of comprehensive smoke free policies in the home and in vehicles are important complements to general population strategies aimed at reducing smoking prevalence.

In England, as part of the previous government's tobacco control strategy, the Department of Health set an aspiration to increase to two-thirds the proportion of homes where parents smoke but that are entirely smoke-free indoors by 2020.The effect this has in reducing children's second-hand smoke exposure will be validated by assessing cotinine levels in children, as in the annual Health Survey for England.  It is yet to be seen whether this ambition will be taken forward by the new coalition government. 

In Scotland, there are no current Government targets to reduce SHS exposure in the home and in vehicles. In addition, we have limited information on the extent of current child exposure to tobacco smoke in homes and vehicles in Scotland. This limits our ability to effectively measure progress. Better prevalence data would assist advocates and policymakers in determining the full extent of the problem, and could also highlight areas where exposure is highest. Setting targets would signal that the Government places a high priority on reducing levels of SHS exposure in children in Scotland.

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MEDIUM TERM

• We must ensure that all Scottish health and education services have smoke-free grounds.

Rationale:

Research in Wales has shown that schools that have the most rigorous policies on tobacco and a strong anti-smoking ethos have significantly lower levels of smoking than other schools, even allowing for sociocultural factors.

Ensuring that all Scottish education services have smoke-free grounds sends a powerful message to children and young people that smoking is no longer a social norm, and encourages them not to start smoking. It also contributes to the development of health promoting schools and strongly reinforces schools' health education programmes.

Ensuring that all health services in Scotland have smoke-free grounds also communicates a strong message about the dangers of smoking and second-hand smoke. Health care settings have a duty of care to staff and to patients, and should play an exemplary role in making smoke-free grounds the norm.

Allowing patients to smoke while in hospital puts them at increased risk of complications and delays their recovery. Completely smoke-free grounds creates a smoke-free environment for people trying to stop smoking and removes triggers that cause many to smoke or relapse to smoking. Some health boards have already taken this step; others can learn from their experience. Effective communication and appropriate (but not heavy-handed) enforcement seems to be key in making grounds smoke-free.

Evidence base:

Bruce G. Smoking cessation in hospital. Nusing Times. 26 June 2008.

Kia AM et al. (2008). Smoke free health care: an organisational change to increase effective intervention for tobacco. New South Wales public health bulletin 19 (3-4): 60-64.  

Parle D, Parker S, Steeves D (2005). Making Canadian healthcare facilities 100% smoke-free: a national trend emerges. Healthcare quarterly (Toronto, Ont.) 8 (4): 53-7, 2.

Nagle AL, Schofield MJ and Redman S. 1996. Smoking on hospital grounds and the impact of outdoor smoke-free zones. Tobacco Control 5; 199-204.

Williams SC et al (2009). The adoption of smoke-free hospital campuses in the United States. Tobacco Control 18: 451-458.

Moore L, Roberts C and Tudor-Smith C (2001). School smoking policies and smoking prevalence among adolescents: multilevel analysis of cross-sectional data from Wales. Tobacco Control. 10: 117-23.

• We need to be realistic about the difficulties some people have.  We must promote effective harm reduction strategies, including the use of nicotine replacement for temporary abstinence, to protect children from exposure to second hand smoke in the home.

Rationale:

For some people, quitting is not an option, and smoking outdoors can be difficult if you have no access to safe outdoor space. Innovative interventions are required to help reduce the barriers to initiating and maintaining smoke-free homes. The use of Nicotine Replacement Therapy (NRT) as a harm reduction option to support temporary abstinence has not been studied extensively, but could be particularly relevant for smokers who are heavily addicted to nicotine. The recent extension of the UK licence for use of some forms of NRT for temporary abstinence from smoking, and/or cutting down cigarette consumption offers this new opportunity to use an effective treatment to promote smoke-free homes and reduce children's exposure to SHS. Research work piloting NRT use in homes is underway and its outcomes should be carefully monitored.

Evidence base:

Jones TE and Williams J. (2010). Craving Control using NRT in a teaching hospital. Internal Medicine Journal. Mar 18 (Epub ahead of print)

Hammond D et al. (2008). Smokers' use of nicotine replacement therapy for reasons other than stopping smoking: findings from the ITC Four Country Survey. Addiction 103 (10): 1696-1703.

Royal College of Physicians. Harm reduction in nicotine addiction. Report of the Tobacco Advisory Group. London: RCP, 2007.

Passive smoking in children. A report by the Tobacco Advisory Group of the Royal College of Physicians. London: RCP. March 2010.

Le Houezec J and Säwe U (2003). Smoking reduction and temporary abstinence: new approaches for smoking cessation. Journal des maladies vasculaires 28 (5): 293-300

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In the long term we must consider further evidence-based measures to protect people from second-hand smoke.

Rationale:

SHS exposure is a completely preventable health risk factor, and there is no known safe level of SHS exposure. Article 8 of the Framework Convention on Tobacco Control (FCTC) calls for the expansion of smoke-free places at the national and other jurisdictional levels in signatory countries to protect people from SHS hazards. In 2007, the Conference of the Parties to the FCTC drew up Guidelines on Protection from Exposure to Tobacco Smoke to assist parties in meeting their obligations under Article 8 and to identify key elements of legislation necessary to effectively protect people from exposure to SHS.

A number of principles are outlined which should guide implementation of Article 8, including that the protection of people from exposure to tobacco smoke should be strengthened and expanded, if necessary; such action may include new or amended legislation, improved enforcement and other measures to reflect new scientific evidence and case-study experience.

There is public support for more comprehensive tobacco control policies and a strong ethical justification for additional measures aimed at reducing exposure to second-hand smoke. In order to make advances and substantially reduce exposure to second-hand smoke in Scotland, new approaches are required to tackle this complex issue. Future work should focus especially on and directly involve communities with the highest smoking rates in order to have the greatest impact on rates of exposure to second-hand smoke.