536288 research-article2014
SJP0010.1177/1403494814536288Smoking and SHS exposure in DenmarkB. Ádám
Scandinavian Journal of Public Health, 2014; 42: 473–475
Debate Article
Should we bother with second-hand smoke exposure if smoking is on track? A poorly explored discrepancy in Denmark
BALÁZS ÁDÁM Unit for Health Promotion Research, Institute of Public Health, University of Southern Denmark, Esbjerg, Denmark
Abstract The recognition of the serious health-damaging effects of tobacco smoke exposure has initiated several preventive programmes on the national and international levels worldwide. In the last decade, a considerable decrease in the prevalence of active smoking was observed in Denmark, changing the country from a poor to a favourable position in comparison to other EU countries. However, second-hand tobacco smoke exposure, especially in homes, still ranks Denmark among the problematic countries in Europe. This poorly recognised and studied discrepancy calls for further research and effective targeted interventions on population level. Key Words: tobacco smoke, active smoking, second-hand tobacco smoke exposure, Denmark, anti-smoking policy, targeted intervention, behaviour change
Introduction It is common sense by now that tobacco smoke exposure has a crucial role in the development of various acute and chronic diseases. Active smoking is one of the most significant preventable causes of ill health worldwide. Nevertheless, health can be damaged not only by active smoking but also by exposure to environmental tobacco smoke (ETS) in the vicinity of smokers, especially in indoors [1]. It is also known that the health effects of second-hand tobacco smoke (SHS) exposure pose high disease burden either on exposed individuals or on society as a whole [2]. One would think that the extent of the problem of active smoking and SHS exposure go hand in hand, that is societies where the smoking rate is low in international comparison have a low prevalence of SHS exposure, too. However, it is not necessarily always the case.
show that the prevalence of smoking has been decreasing considerably in the past decade. In a 2002 comparison, Denmark had the third highest smoking rate in the EU after the United Kingdom and France with 42.6% of active smokers [3]. But according to the last Eurobarometer survey on smoking in 2012, the prevalence rate of smokers decreased to 26%, placing Denmark in a midfield position among EU countries [4]. The favourable improvement is also underpinned by OECD and domestic data [5]. According to the last National Health Survey in 2010, 22.7% of males and 19.3% of females smoke daily, giving a total smoking rate of 20.9% [6], although some population groups can be characterised with a substantially higher smoking rate. A recent study found 44% daily smokers among Danish seafarers [7].
Decreasing smoking rate in Denmark
Problem with second-hand tobacco smoke exposure in Danish homes
Public health professionals agree that the problem of smoking is being resolved in Denmark. Recent data
Information about SHS exposure in Denmark, however, indicates a position that is not in accord with
Correspondence: Balázs Ádám, Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, PO Box 17666, Al Ain, United Arab Emirates. E-mail: [email protected] (Accepted 25 April 2014) © 2014 the Nordic Societies of Public Health DOI: 10.1177/1403494814536288
Downloaded from sjp.sagepub.com at University of Haifa Library on May 27, 2015
474 B. Ádám the country’s European rank in smoking; this is especially true for tobacco smoke exposure in homes. Comprehensive nationwide data on SHS exposure in private settings are available from EU sources. According to the 2010 “Tobacco” issue of Eurobarometer, smoking is prohibited only in 51% of Danish homes [8]. In 49% of homes smoking is permitted, and in almost half of them (22% in total) smoking is allowed everywhere in the house. This figure is the fourth worst in the EU, after Greece, Spain and Cyprus. The unfavourable position of Denmark is also confirmed by a pervious Eurobarometer analytical report from 2009 that identifies 23% of the Danish population exposed to ETS at home every day or almost every day. Among smokers the highest ETS exposure rate at home is found in Bulgaria (38%), followed by Denmark and the Czech Republic (35%). On the other hand, neighbouring Nordic countries, like Sweden and Finland, are among those at the lower end of the distribution [9]. Previous studies could reveal similar differences between Nordic countries [10,11]. Domestic data on home ETS exposure in Denmark are limited and typically are topic or region specific; even so, they can point to the same problem. The Smoke-free Newborn Study showed that 23% of pregnant women were exposed to ETS at home and more than half of them were exposed in other places during the late 90s in Denmark [12]. In 2010, 27% of those living in multiunit dwellings with children reported ‘neighbour smoke’ exposure [13]. From the same year, the Health Profiles of the Capital Region of Denmark reports that in 10.9% of households with children smoking takes place indoors, but the rate is as high as 25.2% in the lowest education group of parents [14]. In contrast, 1% of Swedish parents reported that they smoke at home, according to the children’s environmental health survey 2011 [15]. What should be done? The discrepancy between Denmark’s international position regarding smoking and SHS exposure is remarkable, although it seems to have been overlooked by the public health community. The figures indicate that while both experts and the public are satisfied with the recent achievements of reduced smoking prevalence, ETS exposure in homes remains a crucial issue in Denmark that requires further research to describe underlying causes and to determine adequate actions. The Danish anti-smoking regulation in force is the Smoke-free Environments Act, which was enacted in 2007. It prohibits smoking in indoor public places and workplaces as a general rule; however, it has exceptions that make Danish regulation one of the
most permissive in Europe, even after the tightening that was put in effect on 15 August 2012. The law still allows employers to provide employees with smoking rooms and cubicles in the workplace, and permits smoking on ships in rooms that serve as a private dwelling for one person at a time. The regulation, as well as the above figures, reflects the liberal Danish standpoint about the right to smoke. It is proven that banning smoking in closed public places has a direct positive effect on ETS exposure in such environments but can only indirectly influence smoking at home. Nonetheless, home ETS exposure is a significant issue in many regards. Non-smokers exposed to SHS at home can experience various health effects [1]. Studies so far have mostly focused on the ETS exposure of children who may face longterm health consequences resulting in large disease burden; however, non-smoking adults’ ETS exposure should not be neglected, too. All exposed individuals have the right to a healthy life but such provision in the case of home ETS exposure is cumbersome since it cannot be regulated in the same way as smoking in public places due to legal considerations. The only targeted solution remains to deliver effective health promotion interventions that aim not only at smoking cessation but also at persuading people not to smoke at home. Although some health counselling trials reported limited effectiveness, intensive intervention based on behaviour change with components maximising motivation not only for quitting but ceasing smoking at home can be a way forward [16,17]. The structured integration of information from measurement-based quantitative risk assessment and from risk perception into the risk communication process of counselling can provide a so far rarely studied but promising solution [18,19]. Further research is called for to explore the causes of the unfavourable public health situation of SHS exposure in homes in Denmark and to work out effective means for its management. Acknowledgement I acknowledge the possibility to work on this topic and contribute to the development of the Danish Centre for Risk and Safety Management while employed by the Centre of Maritime Health and Society of the University of Southern Denmark. Conflict of interest None declared. Funding This research received no specific grant from any funding agency in the public, commercial or not-forprofit sectors.
Downloaded from sjp.sagepub.com at University of Haifa Library on May 27, 2015
Smoking and SHS exposure in Denmark 475 References [1] U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeons General. Atlanta GA: U.S. DHHS, CDC, Office on Smoking and Health; 2006. [2] Öberg M, Jaakkola MS, Woodward A, et al. Worldwide burden of disease from exposure to second-hand smoke: A retrospective analysis of data from 192 countries. Lancet 2011;377:139–46. [3] European Commission. Smoking and the Environment: Actions and Attitudes. Special Eurobarometer 183. Brussels: EC; 2003. [4] European Commission. Attitudes of Europeans towards Tobacco. Special Eurobarometer 385. Brussels: EC, 2012. [5] Organisation for Economic Co-operation and Development. OECD Health Data 2012. How Does Denmark Compare. Paris: OECD, 2012. [6] National Board of Health. Danish National Health Survey 2010. Available at: http://www.sundhedsprofil2010.dk/ (accessed July 2013) [7] Hjarnø L, Leppin A. A risky occupation? (Un)healthy lifestyle behaviors among Danish seafarers. Health Promot Int. Epub ahead of print 28 April 2013. DOI:10.1093/heapro/dat024. [8] European Commission. Tobacco. Special Eurobarometer 332. Brussels: EC, 2010. [9] European Commission. Survey on Tobacco. Analytical report. Special Eurobarometer 332. Brussels: EC, 2009. [10] Lund KE, Skrondal A, Vertio H, et al. Children’s residential exposure to environmental tobacco smoke varies
0
greatly between the Nordic countries. Scand J Soc Med 1998;26:115–20. [11] Franklin KA, Gíslason T, Omenaas E, et al. The influence of active and passive smoking on habitual snoring. Am J Respir Crit Care Med 2004;170:799–803. [12] Hegaard HK, Kjaergaard H, Møller LF, et al. The effect of environmental tobacco smoke during pregnancy on birth weight. Acta Obstet Gynecol Scand 2006;85:675–81. [13] Køster B, Brink AL and Clemmensen IH. ‘Neighbour smoke’—exposure to secondhand smoke in multiunit dwellings in Denmark in 2010: A cross-sectional study. Tob Control 2013;22:190–3. [14] Pisinger C, Hammer-Helmich L, Andreasen AH, et al. Social disparities in children’s exposure to second hand smoke at home: A repeated cross-sectional survey. Environ Health 2012;11: 65. [15] Institute of Environmental Medicine. Environmental Health Report 2013. Stockholm: Karolinska Institute, 2013. [16] Gehrman CA, Hovell MF. Protecting children from environmental tobacco smoke (ETS) exposure: A critical review. Nicotine Tob Res 2003;5:289–301. [17] Rosen LJ, Noach MB, Winickoff JP, et al. Parental smoking cessation to protect young children: A systematic review and meta-analysis. Pediatrics 2012;129:141–52. [18] Hovell MF, Zakarian JM, Matt GE, et al. Counseling to reduce children’s secondhand smoke exposure and help parents quit smoking: A controlled trial. Nicotine Tob Res 2009;11:1383–94. [19] Wilson I, Semple S, Mills LM, et al. REFRESH—reducing families’ exposure to secondhand smoke in the home: a feasibility study. Tob Control 2013;22(5):e8.
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SJP0010.1177/1403494814536288Smoking and SHS exposure in DenmarkB. Ádám
Scandinavian Journal of Public Health, 2014; 42: 473–475
Debate Article
Should we bother with second-hand smoke exposure if smoking is on track? A poorly explored discrepancy in Denmark
BALÁZS ÁDÁM Unit for Health Promotion Research, Institute of Public Health, University of Southern Denmark, Esbjerg, Denmark
Abstract The recognition of the serious health-damaging effects of tobacco smoke exposure has initiated several preventive programmes on the national and international levels worldwide. In the last decade, a considerable decrease in the prevalence of active smoking was observed in Denmark, changing the country from a poor to a favourable position in comparison to other EU countries. However, second-hand tobacco smoke exposure, especially in homes, still ranks Denmark among the problematic countries in Europe. This poorly recognised and studied discrepancy calls for further research and effective targeted interventions on population level. Key Words: tobacco smoke, active smoking, second-hand tobacco smoke exposure, Denmark, anti-smoking policy, targeted intervention, behaviour change
Introduction It is common sense by now that tobacco smoke exposure has a crucial role in the development of various acute and chronic diseases. Active smoking is one of the most significant preventable causes of ill health worldwide. Nevertheless, health can be damaged not only by active smoking but also by exposure to environmental tobacco smoke (ETS) in the vicinity of smokers, especially in indoors [1]. It is also known that the health effects of second-hand tobacco smoke (SHS) exposure pose high disease burden either on exposed individuals or on society as a whole [2]. One would think that the extent of the problem of active smoking and SHS exposure go hand in hand, that is societies where the smoking rate is low in international comparison have a low prevalence of SHS exposure, too. However, it is not necessarily always the case.
show that the prevalence of smoking has been decreasing considerably in the past decade. In a 2002 comparison, Denmark had the third highest smoking rate in the EU after the United Kingdom and France with 42.6% of active smokers [3]. But according to the last Eurobarometer survey on smoking in 2012, the prevalence rate of smokers decreased to 26%, placing Denmark in a midfield position among EU countries [4]. The favourable improvement is also underpinned by OECD and domestic data [5]. According to the last National Health Survey in 2010, 22.7% of males and 19.3% of females smoke daily, giving a total smoking rate of 20.9% [6], although some population groups can be characterised with a substantially higher smoking rate. A recent study found 44% daily smokers among Danish seafarers [7].
Decreasing smoking rate in Denmark
Problem with second-hand tobacco smoke exposure in Danish homes
Public health professionals agree that the problem of smoking is being resolved in Denmark. Recent data
Information about SHS exposure in Denmark, however, indicates a position that is not in accord with
Correspondence: Balázs Ádám, Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, PO Box 17666, Al Ain, United Arab Emirates. E-mail: [email protected] (Accepted 25 April 2014) © 2014 the Nordic Societies of Public Health DOI: 10.1177/1403494814536288
Downloaded from sjp.sagepub.com at University of Haifa Library on May 27, 2015
474 B. Ádám the country’s European rank in smoking; this is especially true for tobacco smoke exposure in homes. Comprehensive nationwide data on SHS exposure in private settings are available from EU sources. According to the 2010 “Tobacco” issue of Eurobarometer, smoking is prohibited only in 51% of Danish homes [8]. In 49% of homes smoking is permitted, and in almost half of them (22% in total) smoking is allowed everywhere in the house. This figure is the fourth worst in the EU, after Greece, Spain and Cyprus. The unfavourable position of Denmark is also confirmed by a pervious Eurobarometer analytical report from 2009 that identifies 23% of the Danish population exposed to ETS at home every day or almost every day. Among smokers the highest ETS exposure rate at home is found in Bulgaria (38%), followed by Denmark and the Czech Republic (35%). On the other hand, neighbouring Nordic countries, like Sweden and Finland, are among those at the lower end of the distribution [9]. Previous studies could reveal similar differences between Nordic countries [10,11]. Domestic data on home ETS exposure in Denmark are limited and typically are topic or region specific; even so, they can point to the same problem. The Smoke-free Newborn Study showed that 23% of pregnant women were exposed to ETS at home and more than half of them were exposed in other places during the late 90s in Denmark [12]. In 2010, 27% of those living in multiunit dwellings with children reported ‘neighbour smoke’ exposure [13]. From the same year, the Health Profiles of the Capital Region of Denmark reports that in 10.9% of households with children smoking takes place indoors, but the rate is as high as 25.2% in the lowest education group of parents [14]. In contrast, 1% of Swedish parents reported that they smoke at home, according to the children’s environmental health survey 2011 [15]. What should be done? The discrepancy between Denmark’s international position regarding smoking and SHS exposure is remarkable, although it seems to have been overlooked by the public health community. The figures indicate that while both experts and the public are satisfied with the recent achievements of reduced smoking prevalence, ETS exposure in homes remains a crucial issue in Denmark that requires further research to describe underlying causes and to determine adequate actions. The Danish anti-smoking regulation in force is the Smoke-free Environments Act, which was enacted in 2007. It prohibits smoking in indoor public places and workplaces as a general rule; however, it has exceptions that make Danish regulation one of the
most permissive in Europe, even after the tightening that was put in effect on 15 August 2012. The law still allows employers to provide employees with smoking rooms and cubicles in the workplace, and permits smoking on ships in rooms that serve as a private dwelling for one person at a time. The regulation, as well as the above figures, reflects the liberal Danish standpoint about the right to smoke. It is proven that banning smoking in closed public places has a direct positive effect on ETS exposure in such environments but can only indirectly influence smoking at home. Nonetheless, home ETS exposure is a significant issue in many regards. Non-smokers exposed to SHS at home can experience various health effects [1]. Studies so far have mostly focused on the ETS exposure of children who may face longterm health consequences resulting in large disease burden; however, non-smoking adults’ ETS exposure should not be neglected, too. All exposed individuals have the right to a healthy life but such provision in the case of home ETS exposure is cumbersome since it cannot be regulated in the same way as smoking in public places due to legal considerations. The only targeted solution remains to deliver effective health promotion interventions that aim not only at smoking cessation but also at persuading people not to smoke at home. Although some health counselling trials reported limited effectiveness, intensive intervention based on behaviour change with components maximising motivation not only for quitting but ceasing smoking at home can be a way forward [16,17]. The structured integration of information from measurement-based quantitative risk assessment and from risk perception into the risk communication process of counselling can provide a so far rarely studied but promising solution [18,19]. Further research is called for to explore the causes of the unfavourable public health situation of SHS exposure in homes in Denmark and to work out effective means for its management. Acknowledgement I acknowledge the possibility to work on this topic and contribute to the development of the Danish Centre for Risk and Safety Management while employed by the Centre of Maritime Health and Society of the University of Southern Denmark. Conflict of interest None declared. Funding This research received no specific grant from any funding agency in the public, commercial or not-forprofit sectors.
Downloaded from sjp.sagepub.com at University of Haifa Library on May 27, 2015
Smoking and SHS exposure in Denmark 475 References [1] U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeons General. Atlanta GA: U.S. DHHS, CDC, Office on Smoking and Health; 2006. [2] Öberg M, Jaakkola MS, Woodward A, et al. Worldwide burden of disease from exposure to second-hand smoke: A retrospective analysis of data from 192 countries. Lancet 2011;377:139–46. [3] European Commission. Smoking and the Environment: Actions and Attitudes. Special Eurobarometer 183. Brussels: EC; 2003. [4] European Commission. Attitudes of Europeans towards Tobacco. Special Eurobarometer 385. Brussels: EC, 2012. [5] Organisation for Economic Co-operation and Development. OECD Health Data 2012. How Does Denmark Compare. Paris: OECD, 2012. [6] National Board of Health. Danish National Health Survey 2010. Available at: http://www.sundhedsprofil2010.dk/ (accessed July 2013) [7] Hjarnø L, Leppin A. A risky occupation? (Un)healthy lifestyle behaviors among Danish seafarers. Health Promot Int. Epub ahead of print 28 April 2013. DOI:10.1093/heapro/dat024. [8] European Commission. Tobacco. Special Eurobarometer 332. Brussels: EC, 2010. [9] European Commission. Survey on Tobacco. Analytical report. Special Eurobarometer 332. Brussels: EC, 2009. [10] Lund KE, Skrondal A, Vertio H, et al. Children’s residential exposure to environmental tobacco smoke varies
0
greatly between the Nordic countries. Scand J Soc Med 1998;26:115–20. [11] Franklin KA, Gíslason T, Omenaas E, et al. The influence of active and passive smoking on habitual snoring. Am J Respir Crit Care Med 2004;170:799–803. [12] Hegaard HK, Kjaergaard H, Møller LF, et al. The effect of environmental tobacco smoke during pregnancy on birth weight. Acta Obstet Gynecol Scand 2006;85:675–81. [13] Køster B, Brink AL and Clemmensen IH. ‘Neighbour smoke’—exposure to secondhand smoke in multiunit dwellings in Denmark in 2010: A cross-sectional study. Tob Control 2013;22:190–3. [14] Pisinger C, Hammer-Helmich L, Andreasen AH, et al. Social disparities in children’s exposure to second hand smoke at home: A repeated cross-sectional survey. Environ Health 2012;11: 65. [15] Institute of Environmental Medicine. Environmental Health Report 2013. Stockholm: Karolinska Institute, 2013. [16] Gehrman CA, Hovell MF. Protecting children from environmental tobacco smoke (ETS) exposure: A critical review. Nicotine Tob Res 2003;5:289–301. [17] Rosen LJ, Noach MB, Winickoff JP, et al. Parental smoking cessation to protect young children: A systematic review and meta-analysis. Pediatrics 2012;129:141–52. [18] Hovell MF, Zakarian JM, Matt GE, et al. Counseling to reduce children’s secondhand smoke exposure and help parents quit smoking: A controlled trial. Nicotine Tob Res 2009;11:1383–94. [19] Wilson I, Semple S, Mills LM, et al. REFRESH—reducing families’ exposure to secondhand smoke in the home: a feasibility study. Tob Control 2013;22(5):e8.
Information for Authors
55
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10
1. Ownership of copyright by the Nordic Societies of Public Health ensures maximum protection against infringement of copyright protected material through breach of copyright or piracy anywhere in the world. 2. It also ensures that requests by third parties to reprint or reproduce a contribution, or part of it in any format, are handled efficiently in accordance with our general policy which encourages dissemination of knowledge inside the framework of copyright.
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