The question about whether young people should be subject to passive smoking (or “second hand smoke” (SHS)) soon resolves an issue of the rights of the child or the responsibilities of the parent. A person may wish to exert autonomy over their desire to have a cigarette, but does his or her child have an overriding right not to be subject of that smoke? As is usual with the law, the judgment crucially deciding upon conflicting interests, and balancing their decisions to make an apt decision. Ethicists have long wondered who exactly confers these rights, how are they defined and on what basis (Hall, 2005)

In fact, it is tempting to believe that UK health policy exists in a total vacuum, when it comes to the outside world. This is in fact not true, because the UK is a signatory to the United Nations Convention on the Rights of the Child (UNCRC). Although UN Conventions do not have  ‘the force of law’, countries do report at regular intervals to the relevant UN Committee on their progress in implementation. From a legal point, it is noteworthy that the UNCRC does not have the same force as the Human Rights Act, although it is widely quoted in policy documents (Hagger, 2005). The concept of “rights’” cannot change human behaviour, but it “adds an element of accountability and a legal framework that can be used to make governments wake up to their obligations to make things happen’”. (Hall, 2005)

It is therefore nonetheless encouraging that one of that the UK’s leading lung charities seems to be very serious about children and lung health.

One of their election points, in relation to the British Lung Foundation’s “Children’s Charter”, argues the following:

The BLF therefore believes that parents and carers should be given opportunities to learn how to keep young lungs healthy and that children should have the right to enjoy a smoke free environment both inside and outside of the home.

In some ways, this is reminiscent of the NHS Patient Charter, which had its oft-exhausted list of inherent strengths and weaknesses. Christine Farrell has done a very considerabke review of the NHS Charter process (Farrell, 1999). The weaknesses of the Charter were seen by patients and staff as falling within three categories although staff were much more vocal in their criticisms than patients and carers. The problem areas were categorized into three groups:

1. problems with standards and rights;

(From this point of view, it is worth noting therefore the phrasing of “opportunities to learn how…” is not trivial, given the previous problems in how people understand standards and rights. NHS staff and patients have in the past commented on the lack of clarity and the confusion about what was a “standard’ and what was a “right”. This is an issue much discussed in the literature too (Hogg, 1994;  Bynoe, 1996).)

2. difficulties with monitoring;

3. patient expectations raised too high.

Smoking, lung disease and policy

A very recent study has looked in fact at the relationship between childhood environmental tobacco smoke (ETS) exposure and the development of subsequent lung disease (Lovasi et al. 2010) Mechanical stress to alveolar walls, the little units which make up our lungs, may cause progressive damage after an early-life insult such as exposure to environmental tobacco smoke. Childhood ETS exposure was assessed retrospectively as a report of living with one or more regular indoor smokers. Childhood ETS exposure was associated with detectable differences on computed tomography scans of adult lungs of nonsmokers.

Indeed, young children who are exposed to tobacco smoke are in general significantly more likely to develop health problems during childhood and in later life. who are exposed to second-hand smoke (Health Care Commission (2006), ATS (1999). Although parental smoking is the commonest source of ETS exposure to children, children are also unfortunately exposed to ETS in schools, restaurants, public places and public transport vehicles.

Apart from containing thousands of chemicals, the particle size in the ETS is much smaller than the main stream smoke, and therefore has a greater penetrability in the airways of children. Exposure to ETS has been shown to be associated with increased prevalence of upper respiratory tract infections, wheeze, asthma and lower respiratory tract infections. Therefore, arguably, an increased awareness of the harmful effects of ETS on children’s health is warranted for formulating health policy overall (Cheraghi and Salvi, 2009). Furthermore, specifically, environmental tobacco smoke exposure carries a number of risks for the developing lung of the fetus, infant and child. (Wallace, 2009)

Despite the recent campaigns to eliminate smoking and hinder the detrimental effects of passive smoking , actual smoking rates still increase worldwide. Several physiological systems, with the respiratory being the primary, are disrupted by PS and progressively deteriorate through chronic exposures. This is of particular importance in children, given that respiratory complications during childhood can be transferred to adulthood, lead to significantly inferior health profiles. (Metsios, Flouris, and Koutedakis 2009).

SHS exposure is a known cause of disease among non-smokers, contributing to lung cancer, heart disease, and sudden infant death syndrome, as well as other diseases. Yet thousands of children remain unprotected from exposure to SHS in private homes and cars. New initiatives targeting SHS in these spaces have raised ethical questions about imposing constraints on private behaviours (Jarvis and Malone, 2008) In the countries where the smoke free legislation was successfully implemented (Ireland, Italy, Scotland) there is evidence of reduced prevalence of the smoking induced diseases, especially acute coronary attacks (Kemp, 2009).

Summary

One would, arguably, want to follow one’s intuitions and to see a society where children’s lungs are not damaged to the actions of their parents or adults generally. However, the whole issue brings up the added problems of whether second-hand smoke or passive smoking does without doubt cause lung problems (is science infallible?) and, as a country, whether we can do anything other than ‘encourage opportunities’ rather than to ‘enforce rights’. It is not an electoral issue, however, and nor is it likely to become one. It might become, on the other hand, a very campaigning issue for charities such as the British Lung Foundation and the British Heart Foundation.

References

Bynoe, I. (1996), Beyond the Citizen’s Charter. New Directions for Social Rights, Institute for Public Policy Research, London.

Cheraghi, M, Salvi, S. Environmental tobacco smoke (ETS) and respiratory health in children.  Eur J Pediatr. 2009 Aug;168(8):897-905. Epub 2009 Mar 20.

Farrell, C. The Patient’s Charter: a tool for quality improvement? International Journal of Health Care Quality Assurance 12/4 [1999] 129-134

Guyer, B, Ma, S, Grason, H, Frick, KD, Perry, DF, Sharkey, A, McIntosh, J.  Early childhood health promotion and its life course health consequences. Acad Pediatr. 2009 May-Jun;9(3):142-149.e1-71.

Hall, DMB. Children, rights, and responsibilities. Arch Dis Child 2005;90:171–173. doi: 10.1136/adc.2004.053017

Health Care Commission report, Clearing the Air 2006

Hogg, C. (1994), Working with Users: Beyond the Patient’s Charter, Health Rights, London.

Jarvis, JA, Malone, RE.  Children’s secondhand smoke exposure in private homes and cars: an ethical analysis. Am J Public Health. 2008 Dec;98(12):2140-5. Epub 2008 Oct 15.

Kemp, FB.  Smoke free policies in Europe. An overview.  Pneumologia. 2009 Jul-Sep;58(3):155-8.

Lovasi, GS, Diez Doux AV, Hoffman, EA, Kawut, SM, Jacobs, DR Jnr., Barr, RG. Association of environmental tobacco smoke exposure in childhood with early emphysema in adulthood among nonsmokers: the MESA-lung study. Am J Epidemiol. 2010 Jan 1;171(1):54-62. Epub 2009 Nov 25.

Metselos, GS, Flouris, AD, Koutedakis, Y.  Passive smoking, asthma and allergy in children. Inflamm Allergy Drug Targets. 2009 Dec;8(5):348-52.

The American Thoracic Society (1999) Pulmonary rehabilitation, American Journal of Respiratory and Critical Care Medicine

Wallace, J,  The respiratory effects of tobacco smoke exposure on the fetus and child. S D Med. 2009;Spec No:11-2.