The smoking habits of adults are taking a deadly toll on children.

By Liz Finch

More than a decade ago, the US Surgeon General reported that “involuntary smoking,” or exposure to secondhand smoke, could cause lung cancer in healthy nonsmokers. But that was apparently just the tip of the iceberg. Studies have since shown that environmental tobacco smoke (ETS) is capable of wreaking all kinds of damage on people’s health.

According to the American Lung Association (ALA), every time someone smokes, poisons such as benzene, formaldehyde, and carbon monoxide are released into the air. Even after visible smoke is gone, airborne chemicals can still be found at high levels. In fact, ETS is packed with more than 4,000 chemicals, including 200 that are poisonous and another 43 that are carcinogenic, and it has higher concentrations of such compounds than the smoke inhaled through a pipe or cigarette. ETS has therefore been classified by the Environmental Protection Agency (EPA) as a Group A carcinogen, or a known cause of cancer in humans. It is responsible for approximately 3,000 lung cancer deaths and 37,000 heart disease deaths annually among nonsmokers.

Yet in spite of this compelling information, approximately half of all homes in the United States still have at least one smoker living in them today. That means a large number of people are regularly exposed to ETS, including children, whose delicate systems and rapid breathing lead them to absorb even higher amounts of second-hand smoke by-products. The youngest members of society, then, are also the greatest victims of second-hand smoke intake.

The Facts About Environmental Tobacco Smoke

Research has determined that in healthy children under 18 months of age, ETS can cause pneumonia, ear infections, bronchitis, coughing, wheezing, and increased mucus production. It can lead to a buildup of fluid in the middle ear (otitis media), the most common cause of hospitalization of children for an operation. Each year, ETS is a culprit in 150,000 to 300,000 lower respiratory tract infections in infants and children under 18 months of age, which results in 7,500 and 15,000 hospitalizations annually. Second-hand smoke also has been linked to slower growth, adverse neurobehavioral effects, upper respiratory tract infections (colds and sore throats), unfavorable cholesterol levels, initiation of atherosclerosis (heart disease), sudden infant death syndrome (SIDS), cancers, and leukemia in childhood.

Though the source of the second-hand smoke can be family friends visiting the home, day care workers who “only smoke outside,” or even strangers in public places, most often the person exposing a baby or child to ETS—and the one exposing them to the greatest amount of ETS—is mom or dad.

“Parental smoking is a terrible problem,” says Lisa Latts, MD, MSPH, associate medical director of Blue Cross/Blue Shield, Denver, and an internist in prenatal care. “Children who have a parent smoking in the home are hospitalized three times more commonly than those without smoking parents, and babies with parents smoking have a 300% increased risk of death from SIDS.”

Latts says the highest health risks come if the mother smokes both during and after her pregnancy. The nationwide incidence of smoking during pregnancy is 20% to 25%, though within the Medicaid population, Latts says it can be as high as 40%.

The chemicals in tobacco are easily absorbed through the bloodstream, and pass through the uterus to the fetus. Such prenatal exposure to ETS can lead to complications such as preterm labor, stillbirth, low birth weight, and birth defects of the heart, brain, and face. Intrauterine exposure to carbon monoxide and nicotine helps cause deficiencies in physical growth, intellectual development, and behavior in children of smoking mothers. Nursing mothers who smoke also can pass harmful chemicals from tobacco to their infants in breast milk.

Though Latts says approximately a quarter of all pregnant mothers quit smoking because they know that it is bad for their baby, approximately 70% of those will relapse within a year of giving birth.

“They don’t realize how harmful it is to have smoking in the house,” she says. “Even if it is only dad who is smoking, or if the parents are smoking outside, that represents an increased risk of respiratory infection, earaches, and asthma in their kids.”

A 1992 EPA report said that exposure to ETS is causally associated with additional episodes and increased severity of symptoms in children with asthma, and that it worsens the conditions of 200,000 to 1,000,000 asthmatic children in the United States. ETS is also a risk factor in new cases of asthma in children who have not previously displayed symptoms. Smoking by pregnant women predisposes premature babies to respiratory distress syndrome.

The Institute of Medical Statistics and Epidemiology, Benjamin Franklin University Hospital, Berlin, recently studied 342 children to assess the effects of prenatal and postnatal ETS exposure on specific sensitization to food allergens and inhalant allergens during the first 3 years of life. The study, published in the March 1999 issue of Allergy, showed that by the age of 3, children who were prenatally and postnatally exposed to tobacco smoke had a significantly higher risk of sensitization to food allergens than unexposed children. Children who were postnatally exposed to a smoking mother also had a 2.2 times higher risk of sensitization than unexposed children.

In older children, ETS combined with allergy increases the risk of acute respiratory tract infections above that due to ETS alone. “The number of new episodes and duration of otitis media with effusion in young children are positively correlated with ETS exposure,” says a study by the Department of Environmental Medicine, National Institute of Public Health, Oslo, Norway. The study also showed that infants with low birth weight had a high risk of recurrent otitis media during the first year of life when the mother was a heavy smoker. It named passive smoking as an additional risk factor in meningococcal disease and tuberculosis in young children.

The effects of ETS on health only progress as children get older. A 1994 study in the ALA’s American Journal of Respiratory and Critical Care Medicine looked at the lung function of 8,700 children aged 6 to 18 raised in smoking and nonsmoking households, and found that children whose mothers smoked had significant deficits in lung function—deficits due primarily to tobacco exposure in the womb and prior to the age of 6.

Two years later, the same journal conducted a study of 11,500 elementary school children in 1996 and found that those currently exposed to second-hand smoke at home were 70% more likely to have wheezing with colds, 60% more likely to go to emergency departments for wheezing, and 40% more likely to have persistent wheezing, compared with children living in homes without second-hand smoke.

The negative effects of ETS on children who live with parents who smoke continue to linger even after the child has grown up and left the home. “Environmental Tobacco Smoke: Hazard to Children,” a statement by the American Academy of Pediatrics (AAP) Committee on Environmental Health, cited studies linking parental smoking to two nonrespiratory hazards: one that found a correlation with an unusually high cholesterol levels in nonsmoking teenagers, the other that found a link between heightened risk of leukemia and lymphoma in adulthood and exposure to maternal smoking before the age of 10.

A recent Ohio State University study showed that college students exposed to high levels of ETS while growing up maintained higher blood pressure, mean arterial pressure, and heart rate at rest and during psychological stress compared to students who grew up with low levels of ETS. The effects tended to be “small but long-lasting,” according to associate professor Catherine Stoney, who coauthored the study with psychology graduate student Lisa Manzi Lentino and Karen Emmons of the Dana Farber Cancer Institute and Harvard School of Public Health in Boston.

Since a consistently elevated heart rate, blood pressure, and arterial pressure put stress on the body, and the negative effects are cumulative, the researchers concluded that “20 to 30 years down the line these students might be at risk for hypertension, which puts them at risk for heart disease.”

In addition to increased risks of night cough, respiratory infections, allergies, and asthma, a slew of studies show the impact of ETS on children can be deadly. The September 1995 issue of Environmental Health Perspective included a study by the Epidemiology and Biostatistics Program, National Cancer Institute, Rockville, Md, which found that some exposure to secondhand smoke may contribute to cancers that develop later in life. In the study, ETS was also found to be a likely contributor to the approximately 8,000 cancers diagnosed annually in American children up to 14 years of age. Leukemia and brain tumors are the most common childhood malignancies, accounting for 30% and 20% of new cases, respectively.

Oslo’s Department of Environmental Medicine study also found clear, dose-related associations between maternal smoking and infant death, with the strongest relationship being when the mother smoked during as well as after pregnancy.

The results of a study on SIDS conducted at the Johns Hopkins Children’s Center, Baltimore, were published in the April 1998 issue of American Family Physician. Though the study acknowledged that the cause of SIDS is still unknown, it also linked exposure of infants to cigarette smoke as a contributing factor. Most important, the journal credited public education campaigns informing parents of the dangers of smoking around their children as an integral factor in the reduced incidence of SIDS.

Education Is Key

“The only way to reduce exposure [to ETS] is through public education,” says Katherine Pruitt, manager of environmental health programs at the ALA in Washington, DC, which works closely with the EPA’s indoor environmental division. Both organizations have spent the last decade focusing on educating the public about children being exposed to second-hand smoke, specifically in the home and in day care, areas not really touched by regulation.

“A lot of work needs to be done in education, and it’s difficult to reach smokers with health messages,” Pruitt says. “We are always trying to help smokers come to a place where they’re ready to quit, and we never attack them about it. We just try to make it clear that we’re talking about protecting their children. But that takes skill. It’s hard to listen to this kind of information about your kids and not feel threatened about your own behavior.”

To help reach smokers with this message, the ALA has just completed production of an educational guide for health educators, and local lung associations are already active in programs that educate daycare providers about second-hand smoke.

“Many states have laws banning smoking from child care settings, but not all,” Pruitt says. “Even when we don’t have to worry about smoking in centers, a lot of providers are giving care in their homes, and smoking in the environment is more of an issue. Providers smoke when they’re not at the center, and parents smoke when they drop off their kids.”

Some lung associations are also working with the US Department of Agriculture’s Woman Infant Children (WIC) nutritional program on providing education, or with HeadStart programs in their area. Though by law HeadStart facilities are required to be smoke-free, Pruitt says the ALA still finds they are a good place to focus because they serve people with a high smoking rate.

Latts thinks another potentially very successful approach is to focus on educating patients in physicians’ offices, particularly in the offices of pediatricians, and she is planning an initiative to do just that.

“We can get people to stop smoking only when we start addressing it through every part of the health care delivery system: through the primary care physician, the pediatrician, the pharmacist, the dentist,” Latts says. “We’ve got to cover it as a benefit in health care.”

One physician-based program is currently on trial at Ohio State University, Columbus Children’s Hospital, in Columbus. “Promoting Smoke-Free Families in a Pediatric Health Care Setting” is funded by the Robert Wood Johnson Foundation as part of its Addressing Tobacco in Managed Care program. Gina French, MD, medical director of the primary care center at the hospital, says the program focuses on approaches for physicians to assist adults in stopping smoking, using clinical guidelines put out by the Agency for Health Care Policy and Research.

“They are simple things that, oddly enough, we don’t do right now,” she says. “For example, it’s been proven that if a physician asks patients not to smoke, it increases the rate of cessation. If a physician tells them to quit, that further increases the rate of cessation. So there are a number of ways to assist in cessation, and each one incrementally increases the likelihood of success.”

French also notes another recent pilot program presented through Columbus Medical Foundation where physicians gave out patches to help patients quit smoking and arranged for them to get brief counseling—but only if the patients were willing to state a quit date and if they had children at home under 1 year old, or if their kids clearly had diseases poorly affected by smoke.

“Physicians understand smoking is not good for children, but they don’t understand how they can help,” French says. “They don’t understand how difficult it can be to quit nicotine, and I think we need to educate them a little more about addiction.”

The good news is that national surveys are beginning to show that most nonsmokers and even a large number of smokers believe people should not smoke when they are around nonsmokers. But when you factor in socioeconomic status and education level, a lot of people still do not know how devastating smoking can be to their children.

New public health campaigns are still urgently needed to discourage smoking in the presence of young children because without such education, parents who smoke around their children are not only impacting their health, but also teaching them a deadly habit. In more disturbing facts uncovered by researchers, it has been shown that children who watch their parents smoke are at increased risk of becoming smokers themselves, and the younger a child starts smoking, the more likely it is that he or she will become a regular smoker. Most sobering of all: even without the additional damage wrought by ETS, 40% of smokers will ultimately die of tobacco-related diseases.


Liz Finch is a contributor to RT. For more information, contact [email protected]