Exposing the Evidence- women and secondhand smoke in Europe.

Authors

Amanda Amos

Sarah Sanchez

Mariann Skar

Patti White

This report has been supported by the European Commission and produced in partnership by the Advisory Board for the International Network of Women Against Tobacco – Europe (INWAT-Europe) and the European Network for Smoking Prevention (ENSP).

Acknowledgements: We thank Magda Cedzynska,Norma Cronin, Kirill Danishevski, Sally Haw, Martina Poetschke-Langer, Pepa Pont, Sylviane Ratte andDarina Sedlakova, for their valuable contributions as key informants from their countries and Lorraine Greaves of the British Columbia Centre of Excellence for Women’s Health in Canadafor her expert guidance in reviewing the Key Informant questionnaire and draft report. Thanks also to Ute Mons for help with additional questions on German survey data.We thank Michael Forrest from ENSPfor cheerfully coordinating information requests and providing working documents on secondhand smoke.We are also grateful to the INWAT-Europe Advisory Board for their contribution in developing the recommendations and conclusions for this report.

© INWAT-Europe and ENSP 2008

Table of Contents

Executive Summary

1. Introduction

2. Research Methods

2.1 Literature review

2.2 Key informant interviews

2.3 INWAT-EuropeSeminar

2.4 Limitations of information sources

3. Findings from the literature review and key informant interviews

3.1 Health effects of secondhand smoke

3.1.1 Introduction – evidence of harm

3.1.2 Deaths attributable to SHS exposure

3.1.3 Cancer

3.1.4 Cardiovascular disease

3.1.5 Respiratory effects in adults

3.1.6 Reproductive and developmental effects

3.2 Sources and levels of exposure to secondhand smoke

3.2.1 Introduction – gendered occupational and domestic lives

3.2.2 Smoking in the home

3.2.3 Smoking in the car

3.2.4 Smoking in public places including workplaces

3.3 Reducing exposure to secondhand smoke

3.3.1 Facilitators of and barriers to reducing smoking in the home and car

3.3.2 Public opinion on smoke-free public places

3.3.3 Smoke-free legislation and restrictions on smoking in public places

3.3.4 Impact of smoke-free legislation on public places on smoking in the home

3.3.5The effectiveness of interventions to reduce SHS exposure in the home

and car

4. Conclusions

5. Recommendations

6 References

Appendix I – Interview Schedule for Key Informants

Appendix II - European Trends in Smoke-Free Provisions

Appendix III – March 2008 Seminar Participants

Executive Summary

  • Although it has been firmly established that secondhand smoke (SHS) is a pollutant that causes serious illnesses that sometimes lead to death, few studies have taken sex into account in their data analysis. Even fewer have examined gendered influences or how interactions of sex and gender affect the complex issues of SHS exposure and measures to reduce it.
  • A study of deaths caused by SHS exposure in 28 western European countries estimated that of 79,000 deaths in 2002; 72,000 resulted from SHS exposure at home. The remaining 7,000 were caused by exposure at work.
  • SHS exposure can cause lung cancer and coronary heart disease and is linked to a number of other conditions in adults including respiratory problems and, in women, breast and cervical cancer.
  • Exposure to SHS has a clear and marked impact on children, who are particularly susceptible because of their small lungs and airways and increased frequency of breathing compared to adults. In infants, SHS exposure is a cause of sudden infant death syndrome and low birth weight.Children exposed to secondhand smoke are at increased risk for acute respiratory illness, impaired lung function in childhood and adulthood, middle ear disease, and more severe asthma.
  • Although in Europemen are more likely than women to be in paid employment, many women have occupations, such as those in the hospitality industry (restaurants, bars, etc.) where they may be likely to be exposed to SHS. Women also make up the vast majority of those employed in private houses where they may have no protection from SHS exposure.
  • The majority of women in Europe, regardless of whether they also have paid employment, continue to be responsible for most domestic work and child care; several studies have shown that mothers’ smoking is more important than that of fathers in determining children’s exposure to SHS.
  • Women themselves bear a disproportionate health burden from SHS exposure in the home. One recent estimate from Scotland is that three in every four deaths among non-smokers caused by SHS exposureoccur among women. In most European countries, smoking prevalence is still higher among men than among women.
  • Increasing attention is being paid to smoking in the car, especially in the presence of children. Smoking in the car is becoming less common in the EU as a whole, and about half of smokers report having smoking restrictions in the car, compared to about one in five having restrictions at home. According to survey data, women smokers are less likely than men to smoke in the car either when travelling alone or with non-smokers.
  • Socio-economic status has an important impact on levels of exposure to SHS for both children and adults. Survey data from several countries show that smoking in the home is more common in lower socio-economic households and smoking restrictions are more likely to be found in higher-income households. Parents and carers (such as grandparents) living in disadvantaged circumstances can face additional challenges and dilemmas in protecting children from SHS in the home. For example, families may be living in cramped circumstances or in high-rise housing where they may not have the space to step safely outside the home to smoke. Many women are also concerned that it may not be safe to leave young children on their own, even for the short time it takes to smoke a cigarette.
  • Smoke-free legislation in public places has been shown to contribute to increasing voluntary restrictions in the home. Those jurisdictions that have implemented smoke-free public places legislation have found it to be workable and popular. The period of introduction of legislation can be a crucial time to increase knowledge about SHS and to encourage people to extend the public protection into their private spaces. Europe could take a lead from countries like New Zealand and Australia that are developing mass media campaigns that take a non-guilt inducing approach to urge parents to protect their children from SHS.
  • It is clear from this report and other studies that preventing exposure to SHS is a key aspect of combating the tobacco epidemic and preventing its spread to future generations. What also continues to be clear is how much a comprehensive tobacco control strategy is needed in every country, as the elements of prevention and cessation of tobacco use support each other. This is the basis of the Framework Convention on Tobacco Control (FCTC) which will serve as a guideline on tobacco control to Europe and the rest of the world. The FCTC also underlines the necessity to incorporate sex and gender perspectives into tobacco control measures.
  • Currently there is very limited sex and gender specific information on SHS exposure both within and across European countries and few, if any, programmes have been developed to take a gender-sensitive approach to address the issue in both public and private spaces. INWAT Europe calls on national, regional and local decision makers, health and other professionals, non-governmental organisations, including women’s groups and national and international research and development funding bodies to take action to address this urgent need.

1. Introduction

Secondhand smoke (SHS),increasingly recognised as an important cause of death and disease,has been classified as a carcinogen by the International Agency for Research on Cancer (IARC)[1] and the US Environmental Protection Agency [2]. Since the 1980s, following Hirayama[3]and others’ ground breaking research on the impact of SHS exposure in non-smoking women, evidence on the health effects, sources and levels of exposure as well asinitiatives to address the issue havebeen increasing. SHS harms women and men, girls and boys; though the nature and scale of the impact of SHS exposure on health is likely to vary by sex, socio-economic status, place of work, age and country, reflecting both biological differences and gender and socio-cultural factors which influence frequency and intensity of exposure to SHS. The WHOFramework Convention on Tobacco Control (FCTC)[4]Article 4.2.d states that tobacco controlpolicy measures, including protection from SHS, must address gender-specific risks. However, few studies on SHS have taken account of sex in their data analyses, and even fewer have examined gendered influences, or the interactions of sex and genderrelated to the complex issues surrounding SHS exposure and reduction[5]. Sex refers to the biological differences that distinguish females and males including anatomy, physiology, genes and hormones[6].In relation to smoking this would include differences in smoking patterns and trends, health impact, addiction (e.g.effect of nicotine metabolism) and cessation (e.g.effect of the menstrual cycle)[7]. Gender refers to the array of socially constructed roles and relationships, personality traits, attitudes, behaviours, values, relative power and influence that society ascribes to the two sexes on a differential basis6For example, there are gender differences around the meanings, role and function of smoking[8].

In 2005, INWAT Europe held an Expert Seminar on Women and Secondhand Smoke in Europein Barcelona5. This highlighted both the importance of this issue for European women’s health and the need to develop a better understanding of the gendered nature of the issue in order to develop more effective interventions and programmes to reduce SHS exposure. This report builds on the findings of the Expert Seminar by examining exposure to SHS in Europe from a sex and gender perspective. The specific aims of the report are to analyse the available evidence on SHS, including health effects, place and levels of exposure and the impact of interventions such as smoke-free legislation,to inform and progress effective gender-sensitive action on this issue in Europe.

The report presentsand considers several different types of evidence and information. These include:

  • a literature review of recent expert reports and reviews, papers in peer reviewed journals, ‘grey’ literature including survey reports from different countrieswith a specific focus on identifying sex and gender differences.
  • interviews with key informants working in tobacco control in eight countries from across Europeto provide an up-to-date view of the current situationin the region.
  • a seminar where members of the INWAT-Europe Advisory Board drew on the findings of the literature review and the interviews to develop recommendations for gender-sensitive action at the national and European levels.

The report and its findings are of importance for both the European tobacco control community and the European women’s health movement. We hope that byshowing the necessity of taking gender-sensitive approaches to addressing SHS, it willcontribute to and support the increasing momentum in Europe toward creating more effective smoke-free policies inboth public and private spaces.

2. Research Methods

2.1 Literature review

The literature review focused on four topics: the health effects of SHS;place, sources and levels of exposure to SHS in homes, cars and public places; levels of and support for restrictions on SHS including legislation governing public places and voluntary restrictions in the home; the effectiveness of interventions and restrictions including legislation. In particular the review focused what the literature revealed about sex and gender influences, factors and differences, and their relevance for girls and women in Europe. It also aimed to identify gaps in the research and evidence.

The starting point for this review wasthe recent publication of key reports, reviews and European surveys which wholly or partly focused on SHS undertaken by IARC1the US Surgeon General[9], the British Medical Association[10] the Smokefree Partnership[11], the Global Youth Tobacco Survey[12] and the European Commission[13][14]. The material in these reports wassupplemented and updated with information collected from journal articles and ‘grey’ literature.

  • Journal articles- relevant articles published in English between January 2003 and June 2007 were identified using online versions of Medline and PsychINFO with the key words "Second hand smoke" and Women, "Environmental Tobacco Smoke" and Women, “Second hand Smoke” and Children, “Environmental Tobacco Smoke” and Children, “Second hand smoke” and gender and “Environmental Tobacco Smoke” and gender. Articles which fell outside the focus of the review,for example studies validating testing method using animals,were eliminated.
  • During the time of this project, the conference Towards a Smoke-Free Society took place in Edinburgh, Scotland in September 2007. This conference showcased the results of the evaluation of the implementation of the Scottish smokefree legislation (which came into force on 26 March 2006)as well as SHS research from other countries. The Scottish research was the most comprehensive evaluation of national smokefree legislation ever undertaken. Three studies published in the British Medical Journal to coincide with the conference[15][16][17] were added to the literature review.
  • Grey literature- this included reports and other relevant information published by countries and organisations in Europe. This literature was identified in two ways. First, representatives of national coalitions which belong to the General Assembly of the European Network for Smoking Prevention (ENSP) were emailed and asked to send any relevant information. Second, key informants (see below) were asked to identify any relevant reports or information from their countries.

2.2 Key Informant Interviews

Semi-structured interviews were carried out with key informantsin order to construct a current picture of the situationon women, gender and SHSin a range of European countries. Eight countries were selected to represent different stages of the tobaccoepidemic[18]as well aslevels of smokefree policy development including legislation and smokefree homes initiatives (Table 1). The key informants were restricted to eight because of limited project resources. They came from seven EU countries and Russia. As well as having some of the highest male smoking rates in the world, Russiawas included to reflect the challenges faced by some of the Commonwealth of Independent States (CIS) countries. (These are the former Soviet Union countries that are not now part of the European Union.) Key informants were selected by the research team in consultation with the INWAT-Europe Advisory Board. The key informants had diverse roles in tobacco control and were based inNGOs, research centres, national and regional authorities.While each informant could not represent the views of the whole tobacco control community in acountry, they provided useful insights and additional sources of information.

Table 1 The key informants

Country / Key Informant /

Position / Affiliation

France / Sylviane Ratte / National Cancer Institution, Prevention Department, Tobacco Control Union
Germany / Martina Pötschke-Langer / Head of the Cancer Prevention Unit and the WHO Collaborating Centre for Tobacco Control, German Cancer Research Centre
Ireland / Norma Cronin / Health Promotion Manager, Tobacco Control
Irish Cancer Society, Dublin
Poland / Magda Cedzynska / Cancer Centre, Institute of Oncology, Epidemiology and Prevention Department, Warsaw

Russia

/ Kirill Danishevski / Executive Director of the Open Health Institute, Moscow
Scotland / Sally Haw / Principal Public Health Advisor, NHSHealthScotland, Edinburgh*
Slovakia / Darina Sedlakova / Head of the WHO Country Office in Slovakia
Spain / Pepa Pont / Head of the Health EducationUnit,Health Promotion Service, General Direction of Public Health and Sanitation of the Region of Valencia

*Due to the extensive research conducted in Scotland, it was chosen to represent the UK.

The key informants were initially approached by email and asked to participate in the study. The interviews were conducted by telephone and lasted approximately one hour. The interview questionnaire (Appendix I)was developed by the research team and reviewed by the INWAT-Europe Advisory Board and Lorraine Greaves of the British Columbia Centre of Excellence for Women’s Health. The interviews covered the following topics:current and recent work and activities addressing SHS including legislation, media campaigns and research; SHS in the home and in public places particularly in relation to girls and women;national data on SHS exposure; SHS as a national priority.

The interviews were conducted between December 2007 and March 2008. All interviews except for one were conducted in English. The interview with the key informant from Spain was conducted in Spanish and subsequently translated into English. Notes of the key informant’s responses were taken during the course of each interview. Subsequently, participants reviewedthese notes for accuracy and to add any additional relevant information. The notes of the interviews were analyzed by the research team to identify key themes and issues in particular, commonalities and differences between countries.Finally, key informants were given the opportunity to comment on a draft version of the report including the draft recommendations.