Published Article Puts Forward Idea of Banning Smoking in Homes with Children

For the first time (to the best of my knowledge), a published article in a peer-reviewed journal has put forward the idea of banning smoking in the home, in order to protect children from secondhand smoke exposure (see: Ferrence R. Passive smoking and children [editorial]. BMJ 2010; 340:c1680 [published March 24, online]).

While there have been previous published articles calling on a ban on smoking in vehicles with children and there have been unpublished articles calling on bans on smoking in homes with children, this is the first published article to call on a ban on smoking in homes with children.

Ferrence puts forward the argument for banning smoking in homes with children as follows: "With increasingly comprehensive restrictions in public spaces, both indoors and out, we are beginning to tackle protection in children’s home environments—homes, multi-unit dwellings, and family vehicles. The arguments for increasing protection for children in these spaces are strong. The home is the major source of exposure, children are more vulnerable than adults, and restrictions in homes reduce the likelihood that adolescents will start to smoke and progress to regular smoking. Smoking in enclosed spaces persists over time, and the hazard increases when nicotine residues react with ambient nitrous acid, found indoors and in vehicles, to form potent carcinogens. Heavy metals, such as cadmium and lead, are also deposited on furniture, carpets, and clothing, so infants and children continue to be exposed when active smoking has ceased. Limiting smoking to outdoors can reduce indoor exposure considerably, but outdoor exposures can be substantial, and residues are carried back inside on hands and clothing."

She then defends the idea of banning smoking in homes with children as follows: "We now have major inconsistencies in our approach to protecting children from passive smoke. It is acceptable to ban smoking in some home environments, such as family vehicles, multi-unit dwellings, and child protection and custody settings, but providing legal protection for children in detached homes and intact families is not viewed as "an effective or ethically justifiable approach"; moreover, "legislation . . . would be difficult to design, implement and enforce." Yet, legal bans have broad public support; in Ontario, Canada, for example, 78% of adults surveyed in 2008 expressed support for bans on smoking in homes with children. There are other examples of laws that set a social norm for behaviour. At least 25 countries have introduced a full ban on corporal punishment for children. In Sweden, there are no legal penalties for spanking children, and most who violate the law are referred for counselling. A similar approach could be used for passive smoke."

The Rest of the Story

Is this serious? Mandated counseling for parents who smoke?

Should we also have mandated counseling for parents who bring their kids to Burger King or McDonald's four days a week? How about counseling for parents who let their kids play video games all day and get no exercise? Counseling for parents who use wood stoves and expose their kids to dangerous particulate matter, anyone? (Remember that "Particulates formed from incompletely-burned wood carry toxic substances such as creosols, aldehydes and phenols into the lungs, as well as carcinogens such as benzopyrene, dibzezanthracenes and dibenzocarbazoles).

The analogy that Ferrence uses demonstrates a lack of differentiation of risk versus harm. Hitting a child causes harm. Exposing a child to secondhand smoke, while it may bother us to think about, increases the risk of illness but does not represent direct and immediate harm. It is critical to make that distinction in order to be able to judge whether it is justified to interfere with parental autonomy by banning particular parental behaviors.

We ban physical abuse against children because it causes harm. The justification for interfering with parental autonomy is the need to prevent harm to the child. We don't ban taking a kid to McDonald's because while it is very unhealthy and increases the risk for disease, it does not represent direct harm.

Moreover, we need to also differentiate whether there is an intent to harm the child. A parent who hits their kid intends to cause pain. The harm is intentional. However, a parent who chooses to heat the home with a wood stove may be increasing their children's risk of illness, but they are not doing it intentionally. This, along with the distinction between risk and harm, explains why interference with parental autonomy in the case of hitting a kid is justified, but in the case of letting a kid go to a tanning salon is not.

What I find most interesting in Ferrence's editorial is the apparent class issue. Parents who smoke (largely from a population which is less educated - smoking is inversely correlated with level of education) need to undergo counseling while parents who expose their kids every day to dangerous particulate matter from wood-burning stoves (likely a population with higher educational background) do not.

Why the singling out of smoking as the one health risk that parents cannot expose their children to, while not regulating any of the other myriad health risks to which parents expose their children?

This is a dangerous line that has been crossed in this editorial. Once we argue that it is justified to interfere with parental autonomy in order to regulate health risks to which parents expose their children, then it is justified to control parental behavior in a whole host of areas, from what they feed their kids to the type of appliances they have in the home to the activities they allow their children to take part in.

Perhaps the most striking thing about the editorial is the complete lack of any consideration of the values of parental autonomy and privacy and an explicit justification for over-riding those values in order to protect children from an increased risk of disease.