Tuesday, 6 August 2013

Second Hand Surveys

Second-hand smoke means other people's tobacco smoke, either from the burning tip of the cigarette or the smoke that is exhaled by the smoker. There is currently a consultation on second hand smoking and an online survey. Here are the questions, and some of my comments
1. Studies show that children who see adults smoking are more likely to smoke. Do you think smoking should be stopped in the following outside areas: (tick all that apply)
Outside eating and drinking areas in pubs and restaurants
Bus stops and taxi ranks
Pedestrian shopping areas
The survey assumes that one of the options would be ticked; it would be helpful not to make that assumption and give an option of "none of these".
In fact, studies are cited frequently without any specific detail as to the study in question, the sample size, replication, etc. There was a study in America in 2005 which reported that "Children whose parents smoked are twice as likely to begin smoking between 13 and 21" A note on the research says that:
"The research is part of the ongoing Seattle Social Development Project supported by the National Institute on Drug Abuse that is tracking the development of positive and antisocial behaviors among 808 individuals. They originally were recruited as fifth-grade students from elementary schools in high-crime Seattle neighborhoods." What is also interesting is that "The study found differences in daily smoking rates both by gender and racial background."
It is perhaps as important to consider gender and racial background, as well as a deprived and poverty-stricken background, but that would probably be politically incorrect in any survey. But context is clearly important and perhaps we also should consider this in Jersey.
Another study looked at 120 children, and was published in "Pediatrics & Adolescent Medicine" This was how the study worked:
"A store stocked with 133 miniature items gave the children choices - including meat, fruit, vegetables, snacks, non-alcoholic drinks, cigarettes, beer and wine. The children could "buy" anything they wanted by filling a small grocery cart and taking it to a small checkout counter. Twenty-eight percent of the children bought cigarettes, and 61 percent bought alcohol. The children whose parents smoked were almost four times more likely to buy cigarettes."
These were children aged between 2 and 6.  The children in the study were mostly white and their parents were mostly college educated. Smoking rates were lower among the parents than in the general population, but alcohol use was fairly high. It was not, by any standards, a random sample. Moreoever, how children behave and mimic adult patterns in play between 2 and 6 is hardly a good predictor of adult behaviour. One might as well suggest that how they handle money at that age is a good predictor of how they will manage their finances in later life.
Australian research, as well as finding some influence from parental smoking, finds that smoking behaviour of the best friend and wider peer group is positively related to uptake of smoking; one Australian study noted a particularly strong association for girls.
This was also the case of a 2010 meta study entitled "Recent Findings on Peer Group Influences on Adolescent Substance Use" which looked over the literature in general and concluded that:
"Our review indicates the following with respect to adolescent smoking: (1) substantial peer group homogeneity of smoking behavior; (2) support for both socialization and selection effects, although evidence is somewhat stronger for selection; (3) an interactive influence of best friends, peer groups and crowd affiliation; and (4) an indirect protective effect of positive parenting practices against the uptake of adolescent smoking."
"Socialization is the tendency for attitudes and behavior to be influenced by the actual or perceived attitudes and behavior (e.g., norms) of ones' friends and the conforming properties of group membership. Selection, on the other hand, is the tendency to affiliate and develop friendships with those who have similar attitudes and common interests"
It in fact notes that by contrast, "Parent influence has frequently been found to be associated with adolescent smoking. However, associations have generally been modes.However, of the few studies that have examined both peer and parent effects, most indicate that peers provide greater influences on adolescent smoking than parents"
This is something which is absent from the survey, perhaps because it is simpler to target parents as role models rather than peer group pressure, where a ban on particular public spaces will only drive the peer group to another location to smoke.
2. How important do you think it is for the States of Jersey to stop children from coming into contact with second-hand smoke?
Very Important
Moderately important
Not important
Don't know,
This question I could only answer "don't know" because there is no quantitative measures or examples given. It is patently obvious that a small amount of second-hand smoke, on a very occasional basis, no more than I might get during the course of a year, walking in public spaces, is qualitatively different in effect from an environment like the traditional old smoky pub, where clothes used to reek of smoke, even if you didn't smoke yourself. There is probably a range, and a threshold at which the tipping point becomes damaging, but the survey just ignores this.
A question which fails to make the distinction is in danger of being like the air traffic policy which grounded all planes after the Icelandic volcanoe erupted; the limits for acceptable amounts of airborne material were so low as to make any flying impossible, and when tested, turned out to be an incorrect judgement.
3. Do you support any of the following? Please tick those which apply.
Do you support any of the following? Please tick those which apply.  
Extending the law to stop smoking in outside public places
Encouraging employers to adopt policies to stop smoking in outside public places
Having voluntary smokefree areas
At the moment, enclosed buildings, where concentrations of smoke can accumulate, have smoking banned. Outdoor places do not. This can lead to problems with alfresco dining, where there is no smoking ban, and enjoyment of a meal might be spoilt by a smoker close by, so some kind of smokefree areas would be helpful, but that is a matter for the proprietors to organise. Smokers have nowhere to go except outside, often in the cold and rain in winter, where they can find enough shelter for a quick smoke. To drive them out of that would seem to be a step too far.
Many countries are actively encouraging people to create smokefree homes to protect children from second-hand smoke and help them to make voluntary changes within their homes.
4. Do you think families with children should be encouraged to create smokefree homes in Jersey?
Don't know
The option of smoke free areas within a home does not seem to have appeared in the survey, and yet surely this would also be a sensible option. After all, a study away from the children, or a utility room area could very well serve to allow individuals to smoke, with little risk of much smoke, if any, making its way into the main living areas where the children are present. The absence of a via media seems foolish, as that is the commonsense approach which I am sure that responsible parents who are smokers adopt.
5. Some countries are thinking about making it illegal to smoke in cars. Would you support a law in Jersey to stop smoking in cars carrying children under 18 years old?
Don't know
This question simply doesn't make sense. Legally, someone who is 18 is not a child. In fact, anyone over the age of 16 is not a child. They may be somebody's child, but in the eyes of the law, they are not a child. This survey seems to be rather slavishly following the Welsh stance.
The literature certainly shows that smoking in cars decreases the air quality in the car (and thereby increases the  risk from passive smoking) considerable. For example:
"A study published by The New Zealand Medical Journal found that smoking in a car with the window open produced air quality five times worse than even on the poorest air quality days in Auckland. Furthermore, it found that air quality was up to 100 times worse with all car  windows closed.
These are studies which are capable of replication, as they don't depend on unknown factors, and they all seem pretty consistent. The question becomes, however, at what age do we bad smoking in cars. At 18, of course, the teenagers themselves could well be smoking passengers. Calling them "children" as the survey question does, confuses genealogy with legality.
A new survey released by the University of Michigan in July 2013 said that more than eight out of 10 American adults support banning smoking in cars carrying children younger than 13 years old. That would seem to be a move to the right direction regarding age. Most of Australia has a smoking ban in cars with minors under the age of 16 which has existed since May 2012. That would seem sensible as after 16, the law deems that once you reach 16 you are classed as an adult with a right to determine what to do 'without parental consent' .

In conclusion, while some steps could be taken to reduce the effect of second-hand smoking, I feel that the way the survey is conducted, with very little scope for options outside of those preset, makes it something of a failure as an instrument to elucidate public reaction.
Moreover, statistically, the existing literature points more towards peer group pressure than parental role models for taking up smoking, and the lack of references in the survey document, or the contextual framework in which studies have been done, means that the questions in this respect are leading questions, making suggestions for which the evidence is, at least, ambivalent.
The same is not true of studies about cars, probably because the number of variables, and the ability to scientifically replicate findings is pretty exact. There it is clear that there is a case for banning smoking in cars with children, but the survey again vitiates its own case by a failure to understand what, in law, a child is. The law forbidding the sale of cigarettes speaks of "persons under the age of 18", just as the law relating to marriage speaks of "persons" of 16 years or older.
While I sympathise with the desire for a reduction in passive smoking, I do think that this survey is flawed both in its structural bias, and in its use of language (e.g. "children" for 17 year olds) . I'm not sure how legitimate the results will be deemed to be, and if the States are trying to elucidate public opinion via a questionnaire, a random sample of the population would yield a much more representative result.

1 comment:

James said...

Of all people I should be one of those who backs limiting smoking: I lost my father (who gave up smoking over 30 years before) to lung cancer in 2011, and I have a long history of chest infections. I do not: I think that the MOH's proposals are dog-whistle politics.

Peer pressure and parental choices may influence the likelihood of someone starting to smoke. But that isn't the same thing as someone continuing to smoke. People continue to smoke because it gives a degree of pleasure and because it is addictive (we are talking about a drug, after all).

The active ingredient in tobacco - nicotine - has certain recognised effects. It rapidly stimulates the production of a variety of neurotransmitters - things like endorphin, which cause feelings of wellbeing, and acetylcholine, which allows better mental focus. It has a recognised effect of reducing appetite.

Recent developments like nicotine gum and patches are well and good, but I would very much like to see evidence that they really replace smoking. It's reckoned that the hit from a puff of smoke takes about seven seconds: if gum or patches can't replicate that, they probably will not work.

I have no evidence whatsoever other than gut feeling, but I suspect that the reduction in smoking in bars may correlate with a more aggressive atmosphere in these places. I also wonder at whether there is a connection between the reduction in smoking and the so-say "obesity epidemic". In braying about "protecting our children from smoke", the MOH may be condemning the rest of us to live in a more violent and unhealthy society. But as you point out the statistical data is severely limited and there are questions around its validity.