JPediatr(RioJ).2017;93(3):211---213
www.jped.com.br
EDITORIAL
Tobacco
smoke:
it
is
time
for
pediatricians
to
feel
directly
concerned
夽
,
夽夽
Fumac
¸a
de
cigarro:
é
hora
dos
pediatras
perceberem
que
têm
tudo
a
ver
com
isso
Luis
Garcia-Marcos
a,b,∗,
Manuel
Sanchez-Solis
a,baUniversidaddeMurcia,HospitalClínicoUniversitarioVirgendelaArrixaca,UnidadRespiratoria,Murcia,Spain bIMIBBio-HealthResearchInstitute,Murcia,Spain
It has been stated that the epidemic consequences of smoking-associateddiseases rankamongthegreatest pub-lic healthcatastrophesin thepastcentury.1 Manycancers
aswell as chronic diseases have tobaccoas theirspecific anddirectcauseortheirmainriskfactor.Notonlydoactive smokerssufferfromthesediseases,butpassivesmokersdo aswell.
In children, the deleterious effects of tobacco smoke start by the time of conception, as has been demon-strated in acute lymphoblastic leukemia,2 or anorectal
malformations;3 however, without any doubt, they begin
inutero.Forinstance,non-syndromicorofacialclefts4and
likelyothermalformations5arerelatedwithmaternal
smok-ingduringpregnancy,aswellaslowbirthweight.Theresults ofsomestudieshavealertedaboutthepoorerlungfunction ininfantswhosemotherssmokedduringgestation,6a
situa-tionwhichmayberelatedwithincreasedriskofdeveloping asthmalaterinlife.7,8
The list of diseases in which tobacco is a risk factor for morbidity andeven mortality, in children and adoles-cent passive smokers, is long and will likely increase in the future.1,9 Very importantly, children and --- to some
extent---adolescentsdonothavetheopportunityofopting
夽 Please citethisarticle as:Garcia-MarcosL, Sanchez-SolisM.
Tobacco smoke:it is timefor pediatriciansto feel directly con-cerned.JPediatr(RioJ).2017;93:211---3.
夽夽SeepaperbyUrrutia-Pereiraetal.inpages230---7.
∗Correspondingauthor.
E-mail:lgmarcos@um.es(L.Garcia-Marcos).
tosmokeornot,contradictingtheargumentofthetobacco industry,whichstatesthatsmokingisafreechoice.9Thus,
tobaccosmokeexposureisaconcerningandincreasing pedi-atricissue,andrecognizingitasaproblemisveryimportant becauseitrepresentsthefirststeptoeradicatingthisglobal publichealthepidemic.10
TheMPOWERprogramisapolicypackagetoreversethe tobaccoepidemicwithintheTobaccoFreeInitiativeofthe WorldHealthOrganization(WHO),11basedonthemeasures
of the WHO Framework Convention on Tobacco Control, whichhasprovenusefultoreducesmokingprevalence.The programaims toserve asa reference for stakeholders at the country level to help them translate tobacco control policiesintopractice.MPOWERstandsfor Monitor,Protect people,Offerhelp,Warn about thedanger, Enforcebans, andRaisetaxes.The article byUrrutia-Pereiraetal.,12 in
thepresentissue oftheJornaldePediatria,relies onthis strategyof monitoring prevalence and risk factors associ-atedwithsmokingin adolescentslivinginUruguaiana,RS, Brazil.
As in many other places, the prevalence of smoking amongadolescents is high in Uruguaiana. More than 29% of those adolescents included in the study reported hav-ingtriedsmoking;moreworryingly,almost12%arecurrent smokersand,asaconsequence,theyareatriskof becom-ingadultsmokers.Infact,onlyoneinthreebelievetheycan quitsmoking,providedtheywantedto;andupto32%tried tostop smokingcigarettestheprevious year.Onepossible reasonforthehighprevalenceofsmokersistheanswerto ‘‘Is it easy togetcigarettes whenyou want to smoke?’’: 80% of who tried smoking and65% of those whohad not
http://dx.doi.org/10.1016/j.jped.2017.01.001
212 Garcia-MarcosL,Sanchez-SolisM
tried found it is easy to get cigarettes. ‘‘Cigarettes can beeasilyobtained’’isoneofthevariablesassociatedwith smokinginadolescents (OR:3.82). Thus,authorities have a clear opportunity and a great responsibility to enforce bansandraisetaxesinaccordancewiththeMPOWER pro-gram, in ordertomake it more difficult to obtain access tocigarettes. Furthermore,legislation seekingsmoke-free communitiesobtainsadditionalbenefitsinchildren’shealth, suchassubstantialreductionsinpretermbirthsandhospital attendanceforasthmaattacks.13
AnotherinterestingpointofthestudybyUrrutia-Pereira etal.12 is theclear difference of theexposure in passive
smokersbetweenthosewhohavetriedandhavenottried smoking:theauthorsfoundsignificantdifferencesbetween both groups in passive exposure to tobacco ‘‘inside of rooms,’’ ‘‘athome,’’ or ‘‘in cars.’’ It is especially inter-esting that not smoking at home in the previous seven days reduced the risk of being a smoker by 50%, which, together withthe fact that the advice from parents is a protective factor too(OR: 0.67), shows the veryrelevant role of the family in this particular community. Further-more, it is important to underline that interventions to reduceexposuretotobaccosmokeathomehavealowlevel of effectiveness, because although they reduce tobacco smoke pollution, air contamination remains.14 Thus, it is
very important to have a smoke-free home environment priortoanyattemptbytheadolescenttosmoketobacco, in light of the difficulties to clean it afterwards. On the other hand, family interventions to prevent children and adolescentsfrominitiatingtobaccosmokinghavemoderate effectiveness(riskratio:0.76;CI95%:0.68---0.85).15
Theroleofpeers,asinmanystudiesrelatedwith ado-lescence,iscrucialintheinceptionofsmoking.Thehighest independentriskfactorsinthisstudywere‘‘smokingamong theclosestfriends’’and‘‘cigaretteofferedbytheclosest friend’’withoddsratioshigherthan4.0.Ithasbeenshown that the effects of smoking by friendsare even stronger thanthoseof parentalsmoking,aswellasthattheeffect of social networks is stronger for females than for males andfor non-smokers than for smokers.16 The results of a
systematicreview16supportthehypothesisthatpeer
selec-tionandpeerinfluenceareofcrucialimportantinsmoking behavior, and function both in the inception and mainte-nanceofthesmokinghabit.Nevertheless,theinfluenceof thesocialnetworkisnotonlyone-handed:thereisevidence thatadolescentswhoareisolatedaremorelikelytosmoke than those who are group members or leaders.17
School-basedprogramsmustconsiderthesetwotypesofinfluences ofnetworksandprovidenotonlyinformation,butalsoskills tointeractwithpeers.Arecentsystematicreviewand meta-analysistoassesstheeffectivenessofschool-basedsmoking prevention18showedasignificantlong-termeffectofthose
programs, with a mean 12% reduction in starting smok-ing.However,thisefficacydidnotappearinthefirstyear, exceptfor thecase ofcombinedsocialcompetence/social influences programs, which also proved to have higher efficacy than the smoking prevention programs on their own.
Itisdefinitelytimetoconsidertheepidemicoftobacco smokingasadirectconcernfor pediatrician:90% ofadult smokersstartsmokingbeforeageeighteen,1thuswemust
makeallpossibleeffortstopreventitandnotjustrelyonthe
governmentalpolicies.Pediatriciansarethefirstproviders ofhealthinwhichparentstrust:we,aspediatricians,have thegreatopportunityandimmenseresponsibilitytolookat the exposure to tobacco smoke of our patients and initi-atecounselingtopreventit.Briefcounselingbasedonthe ‘‘fiveA’s’’(ask,advise,assess,assist,andarrange follow-up)isthemajorcomponentofcessationcounselingandhas showntoincreasethenumberofattemptstoquitandthe successofthoseattempts.19 However,surveysofmembers
of the AmericanAcademy of Pediatrics (AAP)20 show that
althoughmostpediatricians(>80%)advisedtheiradolescent patientswhosmoketoquit,onlyone-thirddiscussed quit-tingstrategies.Mostlikely,thesituationisnotverydifferent in othercountries.We need tointroduceskills intobacco smokepreventionandinhelpingthosewhosmoketoquitin pediatrician trainingprograms.Itisdefinitelytimetofeel concerned.
Conflicts
of
interest
Theauthorsdeclarenoconflictofinterest.
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