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11 global burden of adverse child health. Arch Dis Child: first published as 10.1136/archdischild-2017-313680 on 3 April 2018. Downloaded from Tobacco control policies in relation In line with evidence from studies in adults,12 smoke-free laws had the largest to child health and perinatal benefit when comprehensively applied (ie, covering a wide range of public places).10 health outcomes Smoke-free legislation appears to exert its effect through reducing SHS exposure Jasper V Been,1,2,3 Aziz Sheikh3,4 among children and pregnant women, reducing parental smoking prevalence and changing social norms, for example, resulting in many people making their Burden of tobacco-related harm of tobacco use and SHS exposure, prohib- homes smoke free.5 6 Furthermore, recent The global epidemic of tobacco use iting smoking in public places and in cars evidence from the UK indicates that continues to cause a considerable burden and reducing parental smoking through implementation of smoke-free legislation of premature death and disease.1 2 World- decreasing the attractiveness of tobacco may help reduce smoking initiation at wide, over 1 billion people are regular products via price increases and marketing school age.13 smokers, and the societal costs of smoking restrictions. To facilitate governments in applying what has been set out in the have been estimated at over £1 trillion/ Taxation and other policies year.1 3 Tobacco is relevant to child health widely endorsed international Framework Tobacco taxation is the most effective in various ways. Unborn children may be Convention for Tobacco Control (FCTC) 1 tool to reduce smoking prevalence, and exposed to tobacco when their mothers treaty, the WHO has formulated six key through doing so it has been shown to smoke, are exposed to secondhand smoke (groups of) tobacco control policies that 10 benefit perinatal and child health. For (SHS) or use smokeless tobacco products. participating countries need to implement, example, consistent reductions in infant Antenatal tobacco smoke exposure can represented by the MPOWER acronym mortality were demonstrated following lead to birth defects, preterm birth, intra- (box 1).1 Ample evidence now supports 4–6 tobacco tax/price increases in the USA, uterine growth restriction and stillbirth. the considerable impact of such policies 14–16 Canada and the European Union. After birth, exposure to SHS increases the on reducing tobacco use and improving Improvements in child health have also risks of neonatal and infant death, otitis population health,8 9 including that of been demonstrated after implementa- media with effusion, respiratory tract children. tion of other tobacco control policies in infections (RTIs), meningococcal disease 10 the USA : governmental provision of and asthma attacks.5 6 Furthermore, early- Impact of tobacco control on smoking cessation services has been asso- life tobacco smoke exposure increases 17 child health ciated with a reduction in severe RTIs, the likelihood that the child will become Smoke-free legislation and there was a reduction in low birth- a smoker later in life. In this paper, we A recent systematic review identi- weight babies following an increase in the discuss how tobacco control measures 18 fied 35 well-designed studies from legal age for cigarette purchasing. may improve early life health outcomes North America, Europe and China and highlight key knowledge gaps. assessing the impact of smoke-free legis- 10 Knowledge gaps

lation on child health. Meta-anal- http://adc.bmj.com/ Controlling the tobacco epidemic yses indicated that implementation of Impact of novel policies Based on international treaties, in partic- smoke-free policies was associated with Now that MPOWER’s impact is well 8–10 ular, the Convention of the Rights of the sizeable reductions in adverse early-life established, there is a need to formally Child, there is consensus that every child health outcomes, including preterm birth assess the effectiveness of newer tobacco should have the right to grow up free from (–3.8%, 95% CI –6.4% to –1.2%), severe control efforts in promoting population the adverse health effects of tobacco.7 asthma attacks (–9.8%, 95% CI –16.6% to health, including that of children. This includes legislation to reduce SHS expo- Children, particularly when young, are –3.0%) and severe lower RTIs (–18.5%, on 13 July 2018 by guest. Protected copyright. entirely dependent on decisions made 95% CI –32.8% to –4.2%).10 These effects sure in outdoor public places frequented by adults in relation to tobacco and SHS are important given that preterm birth and by children, such as playgrounds, school exposure. Tobacco control policies can RTIs are the primary contributors to the grounds and parks, and also in enclosed help guide these decisions, for example, private spaces such as cars. Smoking by informing the public about the dangers in cars results in very high exposure to Box 1 mpower tobacco control harmful tobacco combustion products, 1 and prohibiting smoking in private—in Division of Neonatology, Department of Paediatrics, measures advocated by the WHO Erasmus MC – Sophia Children’s Hospital, Rotterdam, addition to public—vehicles can effec- The Netherlands tively reduce children’s SHS exposure.19 20 2 ►► M: monitor tobacco use and Department of Obstetrics and Gynaecology, Erasmus Adolescents may in addition benefit from MC – Sophia Children’s Hospital, Rotterdam, The prevention policies policies to reduce the attractiveness of Netherlands ►► P: protect people from tobacco smoke 3 smoking, such as banning the display Usher Institute of Population Health Sciences and (eg, smoke-free legislation) Informatics, The University of Edinburgh, Edinburgh, UK of tobacco products in shops and intro- 4 ►► O: offer help to quit tobacco use Division of General Internal Medicine and Primary ducing plain packaging. In New Zealand, Care, Brigham and Women’s Hospital/Harvard Medical ►► W: warn about the dangers of tobacco the display ban was followed by a reduc- School, Boston, Massachusetts, USA ►► E: enforce bans on tobacco tion in smoking experimentation and advertising, promotion and Correspondence to Dr Jasper V Been, Division of initiation among youth.21 Introduction of Neonatology, Department of Paediatrics, Erasmus MC sponsorship plain packaging in Australia was followed – Sophia Children’s Hospital, 3000CB Rotterdam, The ►► R: raise taxes on tobacco. Netherlands; j.​ ​been@er​ asmusmc.​nl by a stronger-than-anticipated response

Been JV, Sheikh A. Arch Dis Child Month 2018 Vol 0 No 0 1 Copyright Article author (or their employer) 2018. Produced by BMJ Publishing Group Ltd (& RCPCH) under licence. Leading article

among adolescents in terms of initia- While they may confer benefit as a harm the public health relevance of recognising Arch Dis Child: first published as 10.1136/archdischild-2017-313680 on 3 April 2018. Downloaded from tion and quitting behaviour.22 Additional reduction approach among established and addressing such tactics. studies in other countries where similar smokers, evidence from the USA suggests policies were recently implemented, such that ENDS can be a gateway to smoking as the UK, are needed to support these among youth.28 ENDS have caused harm Tobacco endgame In recent years, policy development has initial observations. Impact assessment is via explosion on a number of occasions, progressed from thinking about how furthermore needed of policies prohib- and unintentional ingestion of nicotine to control the impact of the tobacco iting flavoured tobacco products; such refill liquids can cause serious harm among epidemic towards pursuing a tobacco-free products are particularly appealing to toddlers. Although ENDS avoid inhalation society within a specific timeframe.33 An youth, who wrongfully tend to perceive of harmful combustion products, research excellent overview of promising policies them as being less harmful than non-fla- has raised concerns over their impact 23 28 that fit this ‘tobacco endgame’ concept voured products. on health. More research is needed, was recently provided by McDaniel and including on the potential health impact colleagues.33 Examples include reducing of secondhand aerosol exposure and of Tobacco control in low-and middle- the nicotine content of tobacco products using ENDS during pregnancy. Mean- income countries (LMICs) to make them less addictive and prohib- while, it is prudent to regulate ENDS in A particularly pressing issue is the lack of iting features designed to mask the harsh- similar ways as combustibles and restrict studies assessing the child health impact ness of tobacco smoke inhalation, such as 10 their promotion to youth. Comprehensive of tobacco control policies in LMICs. additives and filters. Cigarette use may reports on ENDS are available for back- Tobacco companies are increasingly 28 29 be regulated via issuing smokers’ licences ground reading. targeting LMICs, which are already expe- with age restrictions and purchase limits riencing the largest burden of tobacco-re- or via provision of cigarettes on prescrip- 2 lated premature mortality and morbidity. Implications for policy and tion, provided only after prior cessation Studies assessing the effectiveness of practice attempts have failed. Other approaches tobacco control policies in LMICs are Translating evidence into policy include restricting the number of outlets therefore urgently needed. Partnerships Considering the large evidence base or licences to sell tobacco products and between institutions from high-income supporting the effectiveness of tobacco introducing quota on cigarette production countries and LMIC partners, supported control in reducing smoking prevalence, and import. Additional and potentially by initiatives such as the Global Chal- SHS exposure and related harms and the more forward-thinking policies are likely lenges Research Fund, offer the opportu- ratification of the FCTC by 181 countries, to be developed in the near future, and nity to address this knowledge gap. it is of significant concern that MPOWER there is a need to assess their potential to policies are only fully implemented by benefit population health, including that Thirdhand smoke (THS) a minority of countries.1 To accelerate of children. The potential effects of THS are likely to the global adoption of effective tobacco have been underestimated so far. THS are control measures, it is essential that Conclusion tobacco smoke constituents that remain research findings are successfully commu- Children benefit substantially from poli- on surfaces that have been exposed, nicated to policymakers. Researchers in cies to reduce smoking and SHS exposure. such as clothes, hair and skin, and also the field should be aware of their respon-

Governments should accelerate the global http://adc.bmj.com/ curtains, walls and floors. Children may sibility in this regard and seek opportuni- uptake of such policies while the effective- experience potential harm from THS via ties to engage with policymakers and the ness of novel approaches is scientifically inhalation, dermal absorption or inges- media so as to help shape evidence-based 30 assessed so that protection from tobac- tion. Its lingering nature was highlighted policy in the future. Additionally, advo- co-related harm is further optimised for in a recent study demonstrating relevant cacy by health professionals has helped some of the most vulnerable members of THS exposure in a significant propor- accelerate implementation of smoke-free society. tion of non-smokers up to 2 months after public places as well as smoke-free cars in

31 on 13 July 2018 by guest. Protected copyright. moving into a house previously owned by the UK, providing an example for other 24 Contributors JVB drafted the manuscript; AS smokers. Environmental THS pollution countries where such policies are currently supervised the writing. is present in homes of families with young lacking. 25 Funding JVB is funded by personal fellowships from infants and even in a neonatal intensive the Netherlands Lung Foundation (4.2.14.063JO) and care environment, including on incuba- Tackling tobacco industry involvement the Erasmus MC. AS is supported by the Farr Institute and the Asthma UK Centre for Applied Research. tors and parents’ hands despite hand- It is important to be aware of the tobacco washing.26 Smoking outside is ineffective Competing interests None declared. 25 industry’s role in frustrating the policy in preventing THS exposure in the home process towards effective tobacco control Provenance and peer review Commissioned; or in normalising the risk of respiratory externally peer reviewed. 27 as well as their tactics to reduce the effec- symptoms among children. Research tiveness of such policies. As an example, is needed to further assess the potential evidence from the UK indicates that the harms associated with childhood THS industry responds to tobacco tax increases exposure, as well as to assess the effective- 6 by lowering the price of the cheapest ciga- ness of efforts to eliminate exposure. rette brands, allowing smokers to switch to budget cigarettes and through doing so Open Access This is an Open Access article distributed e-Cigarettes sustain their addiction.32 A recent study in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits Electronic nicotine delivery systems across 23 European Union countries others to distribute, remix, adapt, build upon this work (ENDS) are upcoming on the tobacco found that this approach is associated with non-commercially, and license their derivative works on market and are causing much debate. increased infant mortality,16 highlighting different terms, provided the original work is properly

2 Been JV, Sheikh A. Arch Dis Child Month 2018 Vol 0 No 0 Leading article

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