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Prevalence of passive smoking in infancy in the Netherlands
Patient Education and Counseling 39 (2000) 149–153 www.elsevier.com / locate / pateducou
Prevalence of passive smoking in infancy in the Netherlands Mathilde R. Crone*, Remy A. Hirasing, Rudy J.F. Burgmeijer TNO Prevention and Health, P.O. Box 2215, 2301 CE Leiden, The Netherlands Received 28 June 1998; received in revised form 6 January 1999; accepted 7 February 1999
Abstract The objective of the study was to assess the prevalence of passive smoking in infancy. This was done by self-report questionnaires completed by parents who attended the well-baby clinic in the period February–May 1996. A total of 2720 questionnaires were spread among parents with babies between 1 and 14 months: smoking and non-smoking parents. The questionnaires contained questions on smoking habits, smoking at home, smoking in presence of the baby. A total of 1702 parents filled in and returned the questionnaire (63%); 24% of the mothers and 33% of their partners smoked. In 44% of the families, one or more persons smoked; 22% of the mothers and 26% of the partners smoked at home. In 39% of the families, one or both parents smoked at home; 42% of the babies were exposed to tobacco smoke in the living-room, 8% were exposed in the car, and 4% during feeding. In cases where only the mother smoked, 13% of the infants were exposed to tobacco smoke during feeding. In the families where only the partner smoked, the babies were predominantly exposed to smoke in the car (18%). If both parents smoked, the child was most frequently exposed to tobacco smoke in the living-room (73%). It can be concluded that health workers, nurses, pediatricians and family physicians should be advised to inform parents systematically of the harmful effects of passive smoking in infancy. If parents are unable or unwilling to stop smoking, it is important to advise them to refrain from smoking in the presence of the baby. 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Passive smoking; Infancy; Prevalence
1. Introduction Smoking is the major cause of premature death in developed countries. Active smoking can cause cardiovascular diseases and lung carcinoma [1]. To a lesser extent, other diseases are also related to active smoking, examples being other forms of cancer, *Corresponding author. Tel.: 1 31-71-5181899. E-mail address: [email protected] (M.R. Crone)
0738-3991 / 00 / $ – see front matter PII: S0738-3991( 99 )00016-6
chronic respiratory illnesses, low birth weight and high perinatal mortality among infants [2]. In recent years, several studies have been performed on passive smoking among adults, pregnant women and children. Passive smoking in infancy also seems to be an important risk factor for a variety of diseases, for example, respiratory illness [3]. Long-term passive smoking can induce a predisposition towards chronic respiratory illness [4]. Furthermore, passive smoking in infancy can also cause
2000 Elsevier Science Ireland Ltd. All rights reserved.
150
M.R. Crone et al. / Patient Education and Counseling 39 (2000) 149 – 153
otitis media with effusion [5]. Due to a reduction of other major risk factors (like prone sleeping), 60% of sudden infant deaths are now associated with passive smoking [6]. The objective of the present study was to assess the prevalence of smoking among parents and others in the presence of babies.
educational attainment of the parents and divided into three groups: Lower SES, primary and junior education; middle SES, secondary education; higher SES, vocational colleges and university. The results were analysed using the statistical program SPSSX. Means and x 2 were calculated. A difference was considered statistically significant when a , 0.05.
2. Methods The study was set up as a cross-sectional design. The research population consisted of infants who had attended a well-baby clinic between February and May 1996. In the Netherlands well-baby clinics are run by home-care associations and they are attended by 95–98% of all infants. The infants in the study were aged between 1 and 14 months. Sixteen home-care associations were asked to participate in the study, one from each of the four main cities of the Netherlands (Amsterdam, Rotterdam, The Hague and Utrecht) and one from each province. Eventually 14 organisations participated, four from the main cities and ten provincial associations. Each organisation was asked to select five well-baby clinics at random, which subsequently received 40 questionnaires. The first 40 parents who visited the well-baby clinic and agreed to take part in the study – both smoking and non-smoking parents were asked to complete a structured questionnaire. Parents were excluded in case they could not read or write the Dutch language. The reason for this was that the questionnaire was in Dutch and the information material for parents will first be developed in the Dutch language. The questionnaire contained questions concerning smoking habits: smoking at home by the parents or by others (friends, family) and smoking behaviour in the presence of the baby. The parents were asked about smoking in the presence of the child in the living-room, in the children’s bedroom, in the car and during feeding. Furthermore, it contained questions about smoking before and during pregnancy. The parents were asked to complete the questionnaire at home and return it in a free-post envelope. Parental age was classified into six groups: below 20, 20–24, 25–29, 30–34, 35–39 and 40 or older. Socio-economic status was measured by the
3. Results A total of 2720 parents were asked to participate and complete the questionnaire; 1702 parents (63%) returned the questionnaire. Ninety-one per cent of the questionnaires were completed by the mother, 9% by the father. This is the reason why this article only presents the results reported by the mothers (n 5 1551). The average age of the children was 6 months. The average age of the mothers was 31 and the average age of the partners was 33. The average age of the mothers was higher than the average age of mothers of children born in the Netherlands [7]. This difference was significant ( x 2 5 73.8, P 5 0.000). Sixty-one per cent of the mothers had a middle or high socio-economic status. This is significantly different from overall distribution of the socio-economic status of women in the Netherlands ( x 2 5 42.4, P 5 0.000) [8].
3.1. Smoking before and during pregnancy Six months prior to pregnancy, 30% of the women questioned smoked; 5% stopped smoking before becoming pregnant and another 4% stopped smoking during pregnancy. A total of 21% of the mothers therefore smoked during pregnancy. After the birth, 3% started smoking again after an average of 1 month.
3.2. Smoking Twenty four per cent of the mothers and 33% of their partners smoked (Table 1). A total of 44% of the babies were exposed to one or more smokers in the family. The questionnaire also asked if friends and family smoked: the reason is that they also can be the cause of second-hand smoking by the child.
M.R. Crone et al. / Patient Education and Counseling 39 (2000) 149 – 153 Table 1 Percentage of smoking mothers and partners Cigarettes / day
Mothers (%, n 5 1551)
Partners (%, n 5 1503)
Non-smoker ,5 5–14 15 or more
76 5 14 5
67 8 18 7
Eighty five per cent of the mothers stated that family (i.e. mother, father, sister, etc. of the respondent or partner) and friends smoked. Mothers and partners with a lower socio-economic status smoked more often (mother x 2 5 79.06, P 5 0.000; partner x 2 5 74.62, P 5 0.000). When both the mother and partner smoked, they smoked between five and 15 cigarettes a day on average.
3.3. Smoking at home Thirty nine per cent of the mothers said they and / or their partners had smoked at home in the past 7 days. Eleven per cent of the mothers who smoked (2% of the total population) and 18% of the partners who smoked (7% of the total population) did not smoke at home. Eighteen per cent of the family who smoked and 13% of friends who smoked refrained from smoking at home. Smoking at home was more frequent among mothers and partners with a lower Table 2 Prevalence of smoking at home by mothers and partners Cigarettes / day indoors
Mothers (%, n 5 1551)
Partners (%, n 5 1503)
Non-smokers No indoor smokers ,5 5–14 . 15
76 2 5 14 3
67 7 12 13 1
151
socio-economic status (mother x 2 5 26.01, P 5 0.002; partner x 2 5 44.06, P 5 0.000). Mothers smoked more cigarettes and more frequently at home than the partners (Table 2).
3.4. Smoking in the presence of the baby Twenty three per cent of the smoking mothers said they never smoked in the presence of the baby. On average, 42% of the families smoked in the livingroom in the presence of the infant. In Table 3, smoking in the presence of the child was divided into two groups: one group with smoking mothers and one group with non-smoking mothers. In the families where the mother smoked, the baby was most frequently exposed to tobacco smoke in the livingroom, in the car, in the child’s bedroom and during feeding. In all, 53% of smoking mothers and 35% of the non-smoking mothers said that they aired the livingroom after smoking there. In the car, 73% of the smoking mothers and 60% of non-smoking mothers said they opened the window when smoking in the presence of the baby.
4. Discussion The response in this study was 63%. This is lower than in comparative studies. Little is known about the non-response group, but dropouts are usually considered as smokers in the literature. Therefore, it is not possible to exclude the possibility of bias in the results. On average, the mothers in this study were significantly older than mothers of new-born babies in the Netherlands [7]. On average they had received more education than women in the Netherlands as a whole [8]. Another Dutch study showed that smok-
Table 3 Prevalence of smoking in presence of the baby in the 7 days before completing the questionnaire if mother did or did not smoke Smoking in the presence of the baby in:
Mother smoker (%, n 5 373)
Mother non-smoker (%, n 5 1142)
Total (%, n 5 1515)
The car The child’s bedroom The living-room During feeding
12 0.4 72 9
4 0 32 2
8 0 42 4
152
M.R. Crone et al. / Patient Education and Counseling 39 (2000) 149 – 153
ing decreases with increasing age and more education [9]. This could mean that the results of the present study are an underestimate and that smokers are not fully represented. The prevalence of smoking among mothers (24%) was lower than in a 1992 study in one province of the Netherlands (28%) [10]. The percentage of women who smoked 6 months before pregnancy corresponds closely to the average percentage of smoking women in the Netherlands in 1996 (30 vs. 32%) [11]. The percentage of women smoking during pregnancy is lower than those who stated that they smoked before pregnancy and this corresponds to findings from other studies [9,10]. A reason for the difference between the prevalence of smoking before and during pregnancy may be that mothers are more or less aware of the consequences of smoking for the unborn child. In the Netherland, the Dutch Foundation of Smoking and Health has already took the initiative to develop an information program to prevent smoking in pregnancy and, at the moment, the University of Maastricht is evaluating a programme which focuses not only on the pregnant woman but also on her partner. This existing antismoking information for pregnant women is a possible explanation for the fact that the percentage of women who smoke after pregnancy is higher than during pregnancy but lower than just before pregnancy or 6 months before pregnancy. After the birth, some mothers return to their old smoking habits. They seem to find it important for the health of the unborn child to refrain from smoking during pregnancy, but this consideration ceases to apply after the birth of the child and the mothers start smoking again. The existing information given to parents focuses only on smoking during pregnancy and not on smoking in presence of the young child. In a study among health workers in the Netherlands, a majority stated that they did nothing or little about passive smoking in infancy, although a large majority did think it was their task to inform parents about the health effects of passive smoking. Two major impediments for paying attention to passive smoking were the lack of time and the lack of material [12]. The objective of the present study was to achieve a better insight into the prevalence of passive smoking in infancy. Mothers were therefore asked about smoking habits at home and in the presence of
the child. This study shows that, in 44% of households, children were exposed to one or two smokers. This percentage is also lower than the one found in the 1992 study (50%) [10]. Mothers smoked less often than their partner but, when they did, they smoked relatively more often at home than their partners. They also smoked more cigarettes at home than their partners. This difference may be explained by the fact that the mothers in the study had less frequently a full-time job than their partners and therefore spent more time at home (6% of the mothers had a full-time job, as opposed to 86% of their partners). In the 7 days before the respondents completed the questionnaire, 42% of the infants had been exposed to smoke in the living-room; 8% of the babies had been exposed to tobacco smoke in the car and 4% had been exposed during feeding. These percentages of smoking in the car and during feeding were 12% and 9%, respectively, for the smoking group. The physical proximity of the child to the smoking source during feeding and the high concentration of smoke in a car lead to an increased risk exposure. Feeding may be a time of relaxation for the mother or the parents what is associated with smoking a cigarette without realising the possible negative consequences for the child. Passive smoking has been shown to be harmful to health. It can therefore be expected that exposure to tobacco smoke at a very young age contributes to an increased incidence of health problems immediately or later. The possible harm depends on the number of cigarettes smoked, the physical proximity of the smoking source, the size of the room, the ventilation and the size of the apartment. The literature does not state a threshold above which there will be harm to the child.
5. Practical implications The knowledge that passive smoking can have consequences to the health of children and the finding that infants are exposed to one or more smokers in 44% of the Dutch households lead to the recommendation that parents should be advised about the harmful effects of passive smoking for their child. Health workers, nurses, pediatricians and
M.R. Crone et al. / Patient Education and Counseling 39 (2000) 149 – 153
family physicians should inform parents systematically about health risks as a consequence of smoking habits and especially about smoking in the presence of the baby. A recommendation is that material for parents and health workers should be developed to make it possible to inform parents systematically and efficiently on passive smoking. One aspect of the information should be that if parents are unwilling or unable to stop smoking, it is important to refrain from smoking in the presence of the child. Smoking during feeding and in the car should be discouraged. Before developing material for advising parents about the possible consequences of smoking in the presence of children, it is important to know more about the factors that influence smoking in the presence of the child. Why do parents smoke or allow smoking in the presence of the child? Are there some factors (attitudes, personal efficacy or subjective norm) that have a particular influence on this behaviour? An understanding of these factors will make it possible to provide effective information. At the same time, information for health workers should be developed, so that they can improve their skills in giving advice to parents about passive smoking.
Acknowledgements This study was supported by the Dutch ‘Praeventie Fonds’ foundation (Grant 28-2726).
References [1] United States Environmental Protection Agency (EPA). Respiratory health effects of passive smoking, Washington, DC: EPA, December 1992.
153
[2] The Royal College of Physicians of London. Smoking and the young: a report of a working party of the Royal College of Physicians of London, Sudbury: Lavenham, 1993. [3] Bakoula CG, Kafritsaa YL, Kavadias GD, Lazopoulou DD, Theodoridou MC, Maravelias KP, Matsaniotis NS. Objective passive smoking indicators and respiratory morbidity in young children. Lancet 1995;346:280–1. [4] Lindfors A, Wickman M, Hedlin G, Pershagen G, Rietz H, Nordvall SL. Indoor environmental risk factors in young asthmatics: a case control study. Arch Dis Child 1993;73:408–12. [5] Ey JL, Holberg CJ, Aldous MB, Wright AL, Martinez FD, Taussig LM. Passive smoke exposure and otitis media in the first year of life. Pediatrics 1995;95:670–7. [6] Blair PS, Fleming PJ, Bensley D, Smith I, Bacon C, Taylor E, Berry J, Golding J, Tripp J. Smoking and the sudden infant death syndrome: results from 1993–1995 case-control study for confidential inquiry into still-births and deaths in infancy. Br Med J 1996;313:195–8. [7] Centraal Bureau voor de Statistiek (CBS. Live births by age of the mother per municipality, 1994. In: Maandstatistiek van de bevolking, 1996, p. 96. [8] Centraal Bureau voor de Statistiek (CBS. Population aged 15–64 years by educational attainment, sex and age, 1992, Vademecum Gezondheidstatistiek, 1994. [9] Verkerk PH, van Noord-Zaadstra BM. Leefstijl, omgevingsfactoren, uitkomsten van zwangerschap en gezondheid (Lifestyle, environmental factors: results of pregnancy and health), Leiden: NIPG-TNO, 1991. [10] Hirasing RA, Gena SAD, Simon JG, Kossen-Boot H, Meulmeester JF, van den Oudenrijn C. Roken in aanˆ onder consulwezigheid van zuigelingen; een enquete tatiebureau-ouders (Smoking in presence of infants). Ned Tijdschr Geneeskd 1994;38:1422–6. [11] Dutch Foundation on Smoking and Health (STIVORO. Annual Report, STIVORO, 1997. [12] Crone MR, Hirasing RA, Herngreen WP, Burgmeijer RJF. Preventie van passief roken door zuigelingen (Prevention of passive smoking in infancy). Tijdschr Jeugdgezondheidsz 1995;27(4):59–62.
Prevalence of passive smoking in infancy in the Netherlands Mathilde R. Crone*, Remy A. Hirasing, Rudy J.F. Burgmeijer TNO Prevention and Health, P.O. Box 2215, 2301 CE Leiden, The Netherlands Received 28 June 1998; received in revised form 6 January 1999; accepted 7 February 1999
Abstract The objective of the study was to assess the prevalence of passive smoking in infancy. This was done by self-report questionnaires completed by parents who attended the well-baby clinic in the period February–May 1996. A total of 2720 questionnaires were spread among parents with babies between 1 and 14 months: smoking and non-smoking parents. The questionnaires contained questions on smoking habits, smoking at home, smoking in presence of the baby. A total of 1702 parents filled in and returned the questionnaire (63%); 24% of the mothers and 33% of their partners smoked. In 44% of the families, one or more persons smoked; 22% of the mothers and 26% of the partners smoked at home. In 39% of the families, one or both parents smoked at home; 42% of the babies were exposed to tobacco smoke in the living-room, 8% were exposed in the car, and 4% during feeding. In cases where only the mother smoked, 13% of the infants were exposed to tobacco smoke during feeding. In the families where only the partner smoked, the babies were predominantly exposed to smoke in the car (18%). If both parents smoked, the child was most frequently exposed to tobacco smoke in the living-room (73%). It can be concluded that health workers, nurses, pediatricians and family physicians should be advised to inform parents systematically of the harmful effects of passive smoking in infancy. If parents are unable or unwilling to stop smoking, it is important to advise them to refrain from smoking in the presence of the baby. 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Passive smoking; Infancy; Prevalence
1. Introduction Smoking is the major cause of premature death in developed countries. Active smoking can cause cardiovascular diseases and lung carcinoma [1]. To a lesser extent, other diseases are also related to active smoking, examples being other forms of cancer, *Corresponding author. Tel.: 1 31-71-5181899. E-mail address: [email protected] (M.R. Crone)
0738-3991 / 00 / $ – see front matter PII: S0738-3991( 99 )00016-6
chronic respiratory illnesses, low birth weight and high perinatal mortality among infants [2]. In recent years, several studies have been performed on passive smoking among adults, pregnant women and children. Passive smoking in infancy also seems to be an important risk factor for a variety of diseases, for example, respiratory illness [3]. Long-term passive smoking can induce a predisposition towards chronic respiratory illness [4]. Furthermore, passive smoking in infancy can also cause
2000 Elsevier Science Ireland Ltd. All rights reserved.
150
M.R. Crone et al. / Patient Education and Counseling 39 (2000) 149 – 153
otitis media with effusion [5]. Due to a reduction of other major risk factors (like prone sleeping), 60% of sudden infant deaths are now associated with passive smoking [6]. The objective of the present study was to assess the prevalence of smoking among parents and others in the presence of babies.
educational attainment of the parents and divided into three groups: Lower SES, primary and junior education; middle SES, secondary education; higher SES, vocational colleges and university. The results were analysed using the statistical program SPSSX. Means and x 2 were calculated. A difference was considered statistically significant when a , 0.05.
2. Methods The study was set up as a cross-sectional design. The research population consisted of infants who had attended a well-baby clinic between February and May 1996. In the Netherlands well-baby clinics are run by home-care associations and they are attended by 95–98% of all infants. The infants in the study were aged between 1 and 14 months. Sixteen home-care associations were asked to participate in the study, one from each of the four main cities of the Netherlands (Amsterdam, Rotterdam, The Hague and Utrecht) and one from each province. Eventually 14 organisations participated, four from the main cities and ten provincial associations. Each organisation was asked to select five well-baby clinics at random, which subsequently received 40 questionnaires. The first 40 parents who visited the well-baby clinic and agreed to take part in the study – both smoking and non-smoking parents were asked to complete a structured questionnaire. Parents were excluded in case they could not read or write the Dutch language. The reason for this was that the questionnaire was in Dutch and the information material for parents will first be developed in the Dutch language. The questionnaire contained questions concerning smoking habits: smoking at home by the parents or by others (friends, family) and smoking behaviour in the presence of the baby. The parents were asked about smoking in the presence of the child in the living-room, in the children’s bedroom, in the car and during feeding. Furthermore, it contained questions about smoking before and during pregnancy. The parents were asked to complete the questionnaire at home and return it in a free-post envelope. Parental age was classified into six groups: below 20, 20–24, 25–29, 30–34, 35–39 and 40 or older. Socio-economic status was measured by the
3. Results A total of 2720 parents were asked to participate and complete the questionnaire; 1702 parents (63%) returned the questionnaire. Ninety-one per cent of the questionnaires were completed by the mother, 9% by the father. This is the reason why this article only presents the results reported by the mothers (n 5 1551). The average age of the children was 6 months. The average age of the mothers was 31 and the average age of the partners was 33. The average age of the mothers was higher than the average age of mothers of children born in the Netherlands [7]. This difference was significant ( x 2 5 73.8, P 5 0.000). Sixty-one per cent of the mothers had a middle or high socio-economic status. This is significantly different from overall distribution of the socio-economic status of women in the Netherlands ( x 2 5 42.4, P 5 0.000) [8].
3.1. Smoking before and during pregnancy Six months prior to pregnancy, 30% of the women questioned smoked; 5% stopped smoking before becoming pregnant and another 4% stopped smoking during pregnancy. A total of 21% of the mothers therefore smoked during pregnancy. After the birth, 3% started smoking again after an average of 1 month.
3.2. Smoking Twenty four per cent of the mothers and 33% of their partners smoked (Table 1). A total of 44% of the babies were exposed to one or more smokers in the family. The questionnaire also asked if friends and family smoked: the reason is that they also can be the cause of second-hand smoking by the child.
M.R. Crone et al. / Patient Education and Counseling 39 (2000) 149 – 153 Table 1 Percentage of smoking mothers and partners Cigarettes / day
Mothers (%, n 5 1551)
Partners (%, n 5 1503)
Non-smoker ,5 5–14 15 or more
76 5 14 5
67 8 18 7
Eighty five per cent of the mothers stated that family (i.e. mother, father, sister, etc. of the respondent or partner) and friends smoked. Mothers and partners with a lower socio-economic status smoked more often (mother x 2 5 79.06, P 5 0.000; partner x 2 5 74.62, P 5 0.000). When both the mother and partner smoked, they smoked between five and 15 cigarettes a day on average.
3.3. Smoking at home Thirty nine per cent of the mothers said they and / or their partners had smoked at home in the past 7 days. Eleven per cent of the mothers who smoked (2% of the total population) and 18% of the partners who smoked (7% of the total population) did not smoke at home. Eighteen per cent of the family who smoked and 13% of friends who smoked refrained from smoking at home. Smoking at home was more frequent among mothers and partners with a lower Table 2 Prevalence of smoking at home by mothers and partners Cigarettes / day indoors
Mothers (%, n 5 1551)
Partners (%, n 5 1503)
Non-smokers No indoor smokers ,5 5–14 . 15
76 2 5 14 3
67 7 12 13 1
151
socio-economic status (mother x 2 5 26.01, P 5 0.002; partner x 2 5 44.06, P 5 0.000). Mothers smoked more cigarettes and more frequently at home than the partners (Table 2).
3.4. Smoking in the presence of the baby Twenty three per cent of the smoking mothers said they never smoked in the presence of the baby. On average, 42% of the families smoked in the livingroom in the presence of the infant. In Table 3, smoking in the presence of the child was divided into two groups: one group with smoking mothers and one group with non-smoking mothers. In the families where the mother smoked, the baby was most frequently exposed to tobacco smoke in the livingroom, in the car, in the child’s bedroom and during feeding. In all, 53% of smoking mothers and 35% of the non-smoking mothers said that they aired the livingroom after smoking there. In the car, 73% of the smoking mothers and 60% of non-smoking mothers said they opened the window when smoking in the presence of the baby.
4. Discussion The response in this study was 63%. This is lower than in comparative studies. Little is known about the non-response group, but dropouts are usually considered as smokers in the literature. Therefore, it is not possible to exclude the possibility of bias in the results. On average, the mothers in this study were significantly older than mothers of new-born babies in the Netherlands [7]. On average they had received more education than women in the Netherlands as a whole [8]. Another Dutch study showed that smok-
Table 3 Prevalence of smoking in presence of the baby in the 7 days before completing the questionnaire if mother did or did not smoke Smoking in the presence of the baby in:
Mother smoker (%, n 5 373)
Mother non-smoker (%, n 5 1142)
Total (%, n 5 1515)
The car The child’s bedroom The living-room During feeding
12 0.4 72 9
4 0 32 2
8 0 42 4
152
M.R. Crone et al. / Patient Education and Counseling 39 (2000) 149 – 153
ing decreases with increasing age and more education [9]. This could mean that the results of the present study are an underestimate and that smokers are not fully represented. The prevalence of smoking among mothers (24%) was lower than in a 1992 study in one province of the Netherlands (28%) [10]. The percentage of women who smoked 6 months before pregnancy corresponds closely to the average percentage of smoking women in the Netherlands in 1996 (30 vs. 32%) [11]. The percentage of women smoking during pregnancy is lower than those who stated that they smoked before pregnancy and this corresponds to findings from other studies [9,10]. A reason for the difference between the prevalence of smoking before and during pregnancy may be that mothers are more or less aware of the consequences of smoking for the unborn child. In the Netherland, the Dutch Foundation of Smoking and Health has already took the initiative to develop an information program to prevent smoking in pregnancy and, at the moment, the University of Maastricht is evaluating a programme which focuses not only on the pregnant woman but also on her partner. This existing antismoking information for pregnant women is a possible explanation for the fact that the percentage of women who smoke after pregnancy is higher than during pregnancy but lower than just before pregnancy or 6 months before pregnancy. After the birth, some mothers return to their old smoking habits. They seem to find it important for the health of the unborn child to refrain from smoking during pregnancy, but this consideration ceases to apply after the birth of the child and the mothers start smoking again. The existing information given to parents focuses only on smoking during pregnancy and not on smoking in presence of the young child. In a study among health workers in the Netherlands, a majority stated that they did nothing or little about passive smoking in infancy, although a large majority did think it was their task to inform parents about the health effects of passive smoking. Two major impediments for paying attention to passive smoking were the lack of time and the lack of material [12]. The objective of the present study was to achieve a better insight into the prevalence of passive smoking in infancy. Mothers were therefore asked about smoking habits at home and in the presence of
the child. This study shows that, in 44% of households, children were exposed to one or two smokers. This percentage is also lower than the one found in the 1992 study (50%) [10]. Mothers smoked less often than their partner but, when they did, they smoked relatively more often at home than their partners. They also smoked more cigarettes at home than their partners. This difference may be explained by the fact that the mothers in the study had less frequently a full-time job than their partners and therefore spent more time at home (6% of the mothers had a full-time job, as opposed to 86% of their partners). In the 7 days before the respondents completed the questionnaire, 42% of the infants had been exposed to smoke in the living-room; 8% of the babies had been exposed to tobacco smoke in the car and 4% had been exposed during feeding. These percentages of smoking in the car and during feeding were 12% and 9%, respectively, for the smoking group. The physical proximity of the child to the smoking source during feeding and the high concentration of smoke in a car lead to an increased risk exposure. Feeding may be a time of relaxation for the mother or the parents what is associated with smoking a cigarette without realising the possible negative consequences for the child. Passive smoking has been shown to be harmful to health. It can therefore be expected that exposure to tobacco smoke at a very young age contributes to an increased incidence of health problems immediately or later. The possible harm depends on the number of cigarettes smoked, the physical proximity of the smoking source, the size of the room, the ventilation and the size of the apartment. The literature does not state a threshold above which there will be harm to the child.
5. Practical implications The knowledge that passive smoking can have consequences to the health of children and the finding that infants are exposed to one or more smokers in 44% of the Dutch households lead to the recommendation that parents should be advised about the harmful effects of passive smoking for their child. Health workers, nurses, pediatricians and
M.R. Crone et al. / Patient Education and Counseling 39 (2000) 149 – 153
family physicians should inform parents systematically about health risks as a consequence of smoking habits and especially about smoking in the presence of the baby. A recommendation is that material for parents and health workers should be developed to make it possible to inform parents systematically and efficiently on passive smoking. One aspect of the information should be that if parents are unwilling or unable to stop smoking, it is important to refrain from smoking in the presence of the child. Smoking during feeding and in the car should be discouraged. Before developing material for advising parents about the possible consequences of smoking in the presence of children, it is important to know more about the factors that influence smoking in the presence of the child. Why do parents smoke or allow smoking in the presence of the child? Are there some factors (attitudes, personal efficacy or subjective norm) that have a particular influence on this behaviour? An understanding of these factors will make it possible to provide effective information. At the same time, information for health workers should be developed, so that they can improve their skills in giving advice to parents about passive smoking.
Acknowledgements This study was supported by the Dutch ‘Praeventie Fonds’ foundation (Grant 28-2726).
References [1] United States Environmental Protection Agency (EPA). Respiratory health effects of passive smoking, Washington, DC: EPA, December 1992.
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