Thursday, February 09, 2012

CDC Calls for Government Bans on Smoking in Cars With Children

For the first time, the Centers for Disease Control and Prevention (CDC) has called for state and local governments to ban smoking in cars with children present.

In an article published online ahead of print in the journal Pediatrics, researchers from the Office on Smoking and Health at CDC examined trends in the prevalence of self-reported exposure to secondhand smoke (SHS) in cars among youths, based on data from the National Youth Tobacco Survey.

The results and conclusion of the study were as follows: "SHS exposure in cars decreased significantly among U.S. middle and high school students from 2000 to 2009. Nevertheless, in 2009, over one-fifth of nonsmoking students were exposed to SHS in cars. Jurisdictions should expand comprehensive smoke-free policies that prohibit smoking in worksites and public places to also prohibit smoking in motor vehicles occupied by youth."

The Rest of the Story

To the best of my knowledge, this is the first time that CDC has supported government bans on smoking in cars with children present. There is a problem with such policies, however. Secondhand smoke exposure in the home is much more important as a source of childhood morbidity than exposure in cars. First, secondhand smoke exposure in the home is much more prevalent than exposure in cars. Second, the duration of exposure in the home is orders of magnitude higher than that in cars. Thus, the morbidity burden related to secondhand smoke in the home greatly exceeds that related to secondhand smoke exposure in cars. However, the CDC is not recommending a ban on smoking in homes with children.

It seems hypocritical for CDC to suggest that governments should ban smoking in cars to protect children from a major public health hazard, but that governments should not similarly ban smoking in the home. This is especially problematic as a policy stance because the morbidity associated with secondhand smoke in the home dwarfs that related to the usually brief exposure to secondhand smoke that occurs in cars. While children may be exposed to secondhand smoke in cars for thirty minutes or an hour a day, they may well be exposed to tobacco smoke in the home for as much as eight to ten hours a day.

What, then, is the justification for banning smoking in cars but not in the home?

Unfortunately, I have not been able to find such a justification. If one is willing to say that interference with parental autonomy in a private car is justified because of the magnitude of the public health burden associated with smoking in cars, then it is even more true that interference in the home is justified. Therefore, I don't see how the CDC, or any tobacco control group, could justify banning smoking in cars but not in homes with children present. If anything, banning smoking in the home would be more important and easier to justify because the duration of exposure is huge and health effects are much more likely to result.

While the CDC's recommendation that localities ban smoking in cars with children may prevent these youth from exposure during the minutes they are in a car, it will not spare them exposure during the hours upon hours that they are in the home. Thus, these policies are likely to have minimal public health impact (unlike a home smoking ban, which would have a major health impact).

If the CDC and other public health groups are sincere about standing up to protect the health of children, and if they are willing to interfere with parental autonomy in private vehicles by banning smoking in those vehicles, then why are these groups not proposing or supporting bans on smoking in the home? After all, the home - not the car - is the greatest source of secondhand smoke exposure for children who live with smokers.

Those who argue that the worst exposure is in the car are mistaken, as they are confusing concentration of exposure with dose. The dose of exposure is equal to the concentration of exposure multiplied by the duration of exposure:

Dose = Concentration x Duration

While the concentration of secondhand smoke in cars can be very high, the duration of this exposure is short compared to the duration of exposure in the home. And you can bet that if parents are smoking in cars with children, they are most likely also smoking in the home.

By not supporting a ban on smoking in homes with young children, I believe that these politicians, policy makers, and anti-smoking groups are actually being hypocritical and displaying a lack of sincerity, as well as a subordination of public health protection to politics.

My own position is that although smoking in cars with children is unfortunate, the government should not interfere with parental autonomy to make decisions about their children's health risks unless those risks are immediately life-threatening (such as not wearing a seat belt or car seat) or if the behavior causes harm to the child (e.g., abuse or neglect). I do not support smoking bans in the home for this reason. However, I also do not support bans on smoking in cars for the same reason. It would be hypocritical of me to argue for smoking bans in cars with children, but to oppose such policies in homes with children.

Sometimes the most difficult decisions in public health are ones in which we must accept the fact that many parents put their children at risk of health problems. We can still intervene to try to prevent this from happening with educational and persuasion campaigns, but coercive measures that interfere with parental autonomy when the child is not in a situation of direct, life-threatening risk or actual harm are not justified.

While the policy makers and health groups supporting the smoking ban in cars with children are well-intentioned, I believe they are also being insincere in their stated intention of protecting the health of these children. They want to protect them from high, but short-term exposure in cars, but they are perfectly willing to subject those kids to long-term exposure to secondhand smoke in the home.

The problem is that once you regulate the smoking behavior of parents in the presence of their children, you have asserted jurisdiction over the issue. If you fail to ban smoking in the presence of children in the home, you now share responsibility for subjecting children to this exposure. Why? Because you could have acted to prevent such exposure, but you failed to do so.

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