Exposure to second-hand smoke:

ISBN 0-919047-50-5

Table of Contents

Executive Summary p. 1

OMA Recommendations to Protect Children from Exposure to

Second-Hand Smoke p. 2

1. Introduction p. 3

2. Second-Hand Smoke and its Impact on Child Health p. 3

2.1 Prenatal Exposure p. 3

2.2 Sudden Infant Death Syndrome (SIDS) p. 3

2.3 Respiratory Illness and Asthma p. 3

2.4 Child Cognition p. 4

2.5 Cancer in Adulthood p. 4

2.6 Heart Disease p. 4

3. Smoking in the Home and in Vehicles p. 4

3.1 Smoking in the Home p. 5

3.2 Smoking in Vehicles p. 6

4. Children in Regulated Care p. 6

4.1 Children in Government Care p. 6

4.2 Private Home Day Cares p. 7

5. Second-hand Smoke and Child Custody Decisions p. 8

6. Public Health Campaigns p. 9

7. Interventions by Health-Care Professionals p. 10

8. Conclusion p. 12

Acknowledgments p. 12

References p. 12

Appendix I

• Sample of Smoking Policies from Children’s Aid Societies Agencies in Ontario (p. 17)

Appendix II

• Smoking Policy for Halton Region Children’s Aid Society – 2004 (p. 17)

Exposure to second-hand smoke:are we protecting our kids?

A Position Paper by the Ontario Medical Association

The OMA has issued statements indi-cating the need to prevent exposureof children to second-hand smoke(SHS).

In its 1996 position paper entitled“Second-Hand Smoke and Indoor AirQuality,” the OMA recommendedthat all Ontario workplaces and pub-lic places become smoke-free (thispaper is posted online at: http://www.oma.org/phealth/tobaccomain.htm).

Furthermore, it was suggested thatan expert advisory group, includingindividuals with expertise in law,medicine, civil and individual rights,and ethics, be formed in order toconsider the comprehensive controlof SHS, including elimination of SHSin the home.1

There is growing awareness that

adult tobacco use is also a child healthproblem.2, 3 Prenatal and postnatalexposure to SHS has multiple signifi-cant negative effects on a child’shealth during both childhood andsubsequent adulthood.

SHS is known to increase the riskof low birth weight, serve as a triggerfor asthma symptoms and lower res-piratory infections, and has beenassociated with sudden infant deathsyndrome (SIDS), ear infections, andan increased risk for development ofcancer and heart disease in adults.

Furthermore, there is now emerg-ing evidence that exposure to SHScan negatively impact behaviour,attention, and cognition.4, 5

A substantial number of childrencontinue to be at risk as a result of

exposure to SHS in homes and vehi-cles, and many public settings thatchildren frequent are still not smoke-free.

Tobacco control efforts acrossOntario are increasing with the pas-sage of smoking bylaws in a majorityof municipalities making publicplaces and workplaces smoke-free.

The provincial government has alsomade a strong commitment to imple-ment a comprehensive provincewidesmoking ban by 2007.

Nonetheless, protection for chil-dren where they are most commonlyexposed remains a concern, and couldbecome a more acute problem if agrowing number of parents and care-givers begin to view their homes andvehicles as among the few placeswhere they are able to smoke.

SHS exposure is a compellingproblem for Ontario’s children. It hasnow been established that levels ofSHS in homes can reach those foundin bars.6 Exposure in vehicles isknown to be especially potent be-cause of the restricted space.7

There is strong evidence that eventhough some caregivers practiceindoor smoking bans, significantexposure to SHS can still occur.8, 9

Parents who continue to use to-bacco in the presence of their chil-dren — either because they areunaware of the detrimental health

Executive Summary

The Ontario Medical Association (OMA) is the

professional association of the province’s

25,000 physicians, and represents its members

in a variety of clinical, policy and economic areas.

The mission of the Association is to “serve the med-

ical profession and the people of Ontario in the pur-

suit of good health and excellence in health care.”

Ontario Medical Review • October 20041 1

effects, or are unable to quit becauseof a heavy dependence — need guid-ance and ongoing support to be ableto decrease the exposure of their chil-dren to SHS.

The OMA has a longstanding com-mitment to the reduction of SHSexposure, and it is now time toaddress its impact on children inhome settings.

Furthermore, evidence makes itclear that SHS exposure in vehicles

should be dealt with through legisla-tion.

The purpose of this document is tooutline the position of the OMA withrespect to the importance of protect-ing children from exposure to SHS.

This is not only relevant in homesand vehicles, where children aremost commonly exposed, but alsoin situations where organizationssuch as Children’s Aid Societies(CAS)s, family court, and day cares

can regulate such exposure. The OMA believes that, if imple-

mented, the recommendations in thisreport will lead to a significant reduc-tion in children’s exposure to SHS.

Efforts underpinning the im-plementation of these recommen-dations will increase public andprofessional awareness of this impor-tant children’s health issue, and pro-mote interventions to eliminatechildren’s exposure to SHS.

OMA Position Paper

2 2Ontario Medical Review • October 2004

1. Individuals responsible for the care of children whohave tried quit methods that were unsuccessful, shouldbe encouraged to use nicotine replacement therapies(NRTs) as a way to decrease second-hand smoke (SHS)levels in their homes and cars. Because there is not muchpublic information on the use of NRTs for this purpose, apublic information campaign should be conducted torecommend and educate parents and caregivers aboutthe use of NRTs to avoid smoking in homes and vehicles.

2. The government should publicly fund NRTs, and theOntario Drug Benefit Plan should include funding NRTs,as is currently done in Quebec.

3. Caregivers should not be permitted to smoke in vehi-cles while transporting children, and the provincial gov-ernment should take steps to ensure the protection ofchildren from SHS while traveling in vehicles throughthe introduction of legislation banning the use oftobacco inside vehicles used to transport children.

4. The Ministry of Children and Youth Services shouldwork closely with the Ontario Association of Children’sAid Societies (OACAS) and the Children’s Aid Societies(CAS)s to develop a uniform smoking policy, and to pro-vide ongoing education and support programs to enablefoster parents to decrease the amount of SHS that chil-dren are exposed to in homes, and prohibit exposure invehicles.

5. Information about the health effects of SHS should beincluded in professional education, project co-ordination,

and public education and awareness programs that arecurrently offered through umbrella agencies such as theHome Child Care Association of Ontario (HCCAO).

6. The provincial government should amend the DayNurseries Act to ban smoking, and provide enforcementto ensure compliance in any homes and/or facilities thatprovide childcare.

7. A system which facilitates the dissemination of med-ical and legal information regarding SHS and childrenshould be researched by an Expert Panel and then madeavailable to lawyers and judges in order to improve theiraccess to necessary information for making decisionsregarding child welfare in the courts.

8. The provincial government should provide publichealth departments with adequate funding to meet theirobligations under the Mandatory Programs and ServicesGuidelines, including providing funding for the Breath-ing Space campaign to become provincewide.

9. Programs should be created to enhance health profes-sionals’ ability to prevent parents from exposing theirchildren to SHS. Effective training programs that allowfor health professionals to provide brief interventionsshould also be offered across all disciplines wherein theopportunity exists to interact with parents and their chil-dren. This training should become integral at the under-graduate training level, as well as within postgraduateand continuing education programs for practicing pro-fessionals.

OMA Recommendations to Protect Children fromExposure to Second-Hand Smoke

IntroductionExposure of children to second-handsmoke (SHS) in the home is a wide-spread problem in Ontario.

In 1999, approximately one infour Ontario households reportedthat at least one person used tobaccoinside the home on a daily basis. Halfof all households with young chil-dren and tobacco users reported thatsmoking occurred within the home.10

In 2001, it was reported that dailysmoking occurred in 21 per cent ofhomes in Canada with childrenunder the age of 12 — this meansthat just over 800,000 children wereregularly exposed to the hazards ofSHS in their homes.11

The Canadian Tobacco Use Moni-toring Survey for the first half of 2003reports that 10.6 per cent of Ontariohouseholds with children under theage of 14 had someone smoking inthe home every day, or almost everyday — a decrease from the reported14 per cent in 2002.12

Within Ontario households sur-veyed in 2001-2002, those in whichall adults smoked, and children werepresent, 64 per cent of residents wereexposed to SHS, compared to 79 percent in homes with no children. Inhouseholds where only some adultssmoked, and children were present,35 per cent of residents were exposedto SHS, as opposed to 54 per cent inhomes with no children.13

Exposure to SHS can also occur inhomes and home-like settings otherthan a child’s own home. At thistime, there is no provincial umbrellaof protection from SHS for childrenwho are not in their parents’ care.Because these children are cared forin home-like settings, such as fostercare or home-based day cares, regula-tion of SHS exposure is also a chal-lenge for these settings.

Ontario’s new Ministry of Chil-dren and Youth Services, establishedin October 2003, legislates child pro-tection in the province. Local CASsprovide child protection services andhave exclusive responsibility for theprovision of services under the Childand Family Services Act.

Ultimately, the actual care of the

children is carried out by foster par-ents in homes that have been ap-proved by the government or welfareagency.14

Where the government assumesresponsibility for any child, thisshould include the responsibility ofprotecting the child from SHS. How-ever, at the institutional level, asmoke-free policy continues to bedifficult to implement.

The Tobacco Control Act protectschildren in licensed day cares fromSHS exposure. However, many On-tario children are cared for in privatehome day care environments, whichmay or may not be regulated by anagency.

Despite the fact that there areassociations that regulate agenciesunder their membership — therebyproviding some form of regulationfor private home childcare — thereremains variability in smoking poli-cies among the individual agencies.

There are also caregivers in privatehomes that do not have membershipunder a larger agency, therefore leav-ing these environments unregulatedfor SHS exposure.

The family court is an arena inwhich the presence or absence ofsmoking in the home is receiving in-creasing, but still sporadic, attentionin child custody cases. Although therehas been some movement to give cus-tody to the non-smoking parent, thereis no standard across the province,and it may be of benefit to provideeducation to legal practitioners aboutthe impact of SHS on child health,and the need to take parental smokinginto account in determining what is inthe best interests of the child.15

Second-hand smoke and itsimpact on child healthSeveral comprehensive scientificreviews on the health effects of SHSin children have appeared in the lastdecade.

It is clear that the impact of SHSon child health is substantial. Inaddition to its impact on respiratoryhealth (including otitis media), lowbirth weight, and sudden infant

death syndrome, research has alsoidentified SHS exposure in child-hood as a risk factor for the develop-ment of cancer and heart disease inadult life.16

Furthermore, there is now emerg-ing evidence that exposure to SHSduring prenatal and/or postnatalperiods can impact behaviour, atten-tion, and children’s ability to reasonand understand. 4, 5, 17-20

Prenatal exposureDespite the well-known risks of smok-ing during pregnancy, there continuesto be a population of women whoeither use tobacco products through-out their pregnancies21 and/or areexposed to SHS.

Nicotine can cross the placentalbarrier, thereby decreasing bloodflow to the fetus, and affecting thefetal cardiovascular system, gastroin-testinal system, and central nervoussystem.22

Other components of cigarettesmoke, such as carbon monoxide,have also been demonstrated toadversely affect fetal growth, leadingto low birth weights.23-25

Sudden Infant Death SyndromeThe relationship of tobacco smokeexposure and sudden infant deathsyndrome has been extensively stud-ied, and SHS is now a recognized riskfactor for SIDS.

In addition to maternal tobaccouse, the impact of tobacco use byother caregivers in the home mustalso be recognized.

Several studies have established anassociation between paternal tobaccouse and SIDS, while accounting formaternal tobacco use.26-29 It has alsobeen found that the amount of house-hold SHS exposure can be correlatedto the incidence of SIDS in a dose-response relationship.26, 27, 29

Respiratory illness and asthmaStudies on SHS and lower respiratoryillnesses provided some of the firstevidence of the adverse effects of SHS.Some of the earliest studies in thisarea showed an association betweenthe tobacco use of women during

OMA Position Paper


pregnancy, and subsequent admis-sions of their infants to hospital forbronchitis and pneumonia30, 31

In addition, the number of admis-sions increased with the number ofcigarettes smoked. Since then, thecausative association between SHSexposure from both mothers andfathers, and respiratory illnesses ininfants and children, has been firmlyestablished.31, 32

At present, there is an extensiveinternational body of knowledgehighlighting the increased risk oflower respiratory tract infections ininfants with parents who use tobacco(this includes a report from the Cana-dian Institute for Child Health in2000.33) A 1992 report by the U.S.Environmental Protection Agency(EPA) estimated 150,000 to 300,000cases annually in infants and youngerchildren up to 18 months.34 Morerecently, an analysis that combineddata from 39 studies showed a 50 percent increase in respiratory illnessrisk if either parent smoked.35

Exposure to SHS is a well-estab-lished risk factor for asthma. Statisticsfrom the U.S. EPA (1992) estimatethat 200,000 to 1,000,000 asthmaticchildren have their condition wors-ened by exposure to SHS,34 and recentresearch continues to support andexpand these findings36 (this includesa study of Canadian school chil-dren37).

This disease is one that has led tomore and more recommendations toreduce SHS exposure in the homeenvironment. In fact, all recom-mendations for the management ofasthma urge reduction of SHS expo-sure in the home.

SHS is known to affect the preva-lence and severity of asthma symp-toms. First, SHS is an establishedcontributor to the incidence of respi-ratory illnesses, and evidence hasshown that asthma can arise as along-term consequence of increasedoccurrence of lower respiratory tractinfection in early childhood, orthrough other pathophysiologicalmechanisms, including inflamma-tion of the respiratory epithelium.38, 39

In fact, assessment of airways

responsiveness shortly after birth hasshown that infants whose mothersused tobacco during pregnancy haveincreased airways responsiveness,and reduced ventilatory function,compared with those whose mothersdo no use tobacco.40, 41

Second, studies have shown thatchildren with asthma, whose parentsuse tobacco products, may have morefrequent episodes and more severesymptoms.

Exposure to SHS in the home hasbeen shown to increase the numberof emergency room visits made byasthmatic children.42, 43 In addition,asthmatic children with motherswho use tobacco products are morelikely to use asthma medications.44 Inone intervention study, a reductionin smoking by parents resulted in adecrease in the severity of asthmasymptoms in their asthmatic chil-dren.45

The relationship between expo-sure to SHS and diseases of the earhas also been established in severalstudies. A significant correlationbetween otitis media and SHS expo-sure has been established in pediatricpatients.46-49

Child cognitionA less-known effect of SHS exposureis its impact on cognition. Emergingliterature on SHS exposure is nowshowing an impact on a child’s atten-tion, behaviour, and ability to reasonand understand (cognition).

Children whose mothers did notuse tobacco, but were exposed to SHSduring pregnancy, scored lower incognitive tests than those childrenwhose mothers were not exposedduring pregnancy.17

Several studies over the last whilehave validated a significant relation-ship between exposure to SHS andattention, behaviour and cognitionin children.4, 18-20

Furthermore, it has now been re-ported that a significant associationexists between maternal smoking dur-ing pregnancy, and symptoms ofattention deficit hyperactivity disorder(ADHD), which is independent ofother factors previously identified.5

Cancer in adulthoodThe U.S. EPA16, 34 and the Interna-tional Agency for Research on Can-cer,50 have both concluded that SHSis a group A carcinogen (i.e. it causescancer in humans).

A small number of studies haveexamined the relationship betweenexposure to SHS during childhood,and cancer risk. Overall, cancer risk isgreater for individuals with exposureto SHS during both childhood andadulthood than for individuals withexposure during only one period.51

When specific cancer types areconsidered, it has been found thatleukemia and lymphoma amongadults are significantly related toexposure to maternal tobacco usebefore 10 years of age.52

A study in the New England Journalof Medicine concluded that approxi-mately one out of every five instancesof lung cancer in non-smokers couldbe contributed to childhood SHSexposure.53

Heart diseaseA link between heart disease and SHSexposure has been substantiated byseveral studies, especially over thelast five years.54-57

There is strong evidence thatshows involuntary exposure to SHSis a cause of coronary heart diseasemorbidity and mortality.

When researchers looked to child-hood exposure to SHS, correlationswere discovered that now identifyearly exposure as a possible cause ofpremature coronary heart disease.58, 59

Smoking in the home and invehicles The health effects of SHS have be-come more understood and recog-nized over the last 10 years.

Despite a growing protection fromSHS in Ontario due to the imple-mentation of bylaws, and the pros-pect of future implementation of aprovincewide smoking ban in publicplaces and workplaces, there contin-ues to be significant sources of SHSfor children in homes and vehicles.

Homes which allow smoking are a

OMA Position Paper


significant source of exposure to SHSbecause of the amount of time chil-dren spend indoors (especially whenyounger), close physical contact withtheir caregivers, and prolonged expo-sure over time. In fact, in homes thatinclude smoking, air pollution canreach the levels found in bars.6

Vehicles provide a potent sourceof SHS because of the restricted areawithin which the smoke is circu-lated.7

Smoking in the homeAttention must be directed towardusing prevention/protection mea-sures in households with infants andyounger children because of theirphysical dependence on caregivers,as well as their susceptibility to theeffects of SHS.

Because of higher respiratory rates,children experience a higher internalexposure to SHS.60, 61 A recent studymeasuring levels of urinary cotinine— a well-known breakdown productof nicotine— found lower levels inhouseholds where smoking wascompletely banned inside the home.Effective protection cannot beachieved by actions such as openinga window, smoking in another room,or using an air purifier.62-67

New research has found that chil-dren exposed to SHS in homes —regardless of whether or not smokingwas allowed indoors or restricted tooutside — will show levels of expo-sure higher than children in non-smoking homes.68-70 In fact, a child’sexposure can still be five to seventimes higher when adults smoke out-side compared to smoke-free homes.8

In a study published earlier thisyear, Matt et al. cite possible reasonsfor the observed exposure levels inchildren that live in homes whereadults use tobacco outside. Theirfindings indicate there are somesources of SHS that parents cannoteasily control through indoor smok-ing bans. In fact, SHS can remain inthe home even if smoking took placedays, weeks and months earlier9

through contaminated dust and sur-faces, and a smoker’s finger.

Additionally, SHS can find its way

into the home through windows anddoors if cigarettes are smoked outside,and through contaminated clothes,skin and dust carried into the home ifcigarettes are smoked elsewhere.8

Most parents are aware of thehealth hazards of SHS exposure, andmake efforts to stop smoking orchange their smoking behaviour toprotect their children.66

In a major Canadian study com-missioned by Health Canada in1995, it was shown that about 30 percent of the parent population wassomewhat or very likely to respondto messages about SHS.71

Using data from population-basedsurveys of adults in Ontario conduc-ted in 1992, 1993, 1995, and 1996,trends in attitudes and current prac-tices concerning smoking in thehome were determined. Between1992 and 1996, the percentage ofrespondents who agreed that parentsspending time at home with smallchildren should not smoke increasedfrom 51 per cent to 70 per cent.However, data from the survey in1996 showed only 20 per cent ofhomes with children and any dailytobacco users were smoke-free.72

Despite these changing attitudesand behaviours with regard to SHS inthe home, challenges and considera-tions remain. A 1994 Winnipeg studyfound that although 90 per cent ofrespondents indicated knowledgeregarding the harmful effects of SHSin the home, only 24 per cent imple-mented any SHS controls.73

However, more recent data areencouraging. Another populationstudy conducted between May andDecember 2000 showed 27 per centof Ontario residents were exposed toSHS in their homes — 21 per cent ona daily basis, and six per cent on anoccasional basis.

Homes with adult smokers, andchildren present, were more likely tohave smoking restrictions in placefor family members than homeswithout children (61 per cent com-pared to 46 per cent). Having atleast one adult non-smoker in ahome where children and otheradult smokers are present increased

the likelihood of having smokingrestrictions to 73 per cent, comparedto 60 per cent in homes where alladults smoked.74

Nonetheless, survey results fromOntario show strong support for vol-untary restrictions on SHS expo-sure.75-77 In fact, a 1996 report showed35.4 per cent of the populationfavoured a legal restriction on smok-ing in the home,77 suggesting thatinterventions directed at decreasingSHS in homes and vehicles in On-tario could be well received.

This is confirmed by a 2003 On-tario survey that showed 87 per centof respondents agreed that parentsshould not be allowed to smoke inhomes with small children. Whenasked whether there should be a lawto prohibit parents from smokinginside a home if children are livingthere, 63 per cent of respondentsagreed.12

Many of the interventions thathave been evaluated and have shownsuccess are targeted at the mother,and are more effective if the motheris the only individual using tobaccoin the home. When the mother is notthe only smoker, or when she is not asmoker herself, the counseling andchanges expected of her becomemuch more difficult to implement.The mother would be expected toinfluence members of her family tomake changes in their smokingbehaviours — this can be difficult,and often times impossible.78

The size and type of living space,single parenting, other householdmembers who smoke, and lower edu-cation levels are all related to higherlevels of SHS exposure.75, 79, 80

In addition, persons of lower socio-economic status may face a particu-larly greater challenge in modifyingSHS in their homes if they have feweropportunities to smoke away fromtheir children, if their homes aresmaller with fewer rooms, and if theydo not have garages, balconies, orother places to smoke outdoors.81

A 1994 Harvard-based Stop Tobac-co Outreach Program offered smokingparents of children seen in an outpa-tient pediatric clinic, three brief coun-

OMA Position Paper


seling sessions, written materials, freenicotine replacement therapy (NRT),proactive referral to a free state tele-phone quit line, and fax referral to theparents’ primary clinician.

Of the parents who enrolled in thestudy, 81 per cent completed all threecounseling sessions, and 78 per centaccepted free NRT at the time ofenrolment. At a two-month follow-up, more than half of the participantshad made a serious quit attempt.More notably, the mean number ofcigarettes smoked inside the homeand car declined over two months.This approach may be effective inreaching smokers who are otherwiseunlikely to access smoking cessationinterventions.82

It is well understood that tobaccodependence can make the idea of notsmoking overwhelming for heavilyaddicted individuals.

In the 1999 OMA paper entitled“Rethinking Stop-Smoking Medica-tions — Myths and Facts,” NRT usewas suggested for smokers who arenot able, or willing, to quit smokingin order to help them substantiallyreduce their cigarette consumption.As a potential side benefit, this typeof avoidance technique could lead toeventual quit attempts for these indi-viduals.83 (This paper is posted onlineat: http://www.oma.org/phealth/tobaccomain.htm.)

With the compounding issue ofparents being unable to leave chil-dren unattended while going outsideto smoke, or being unable to avoidsmoking during longer car trips, NRTuse in the home and in vehicles wouldbe an effective alternative.

The OMA recommends that individ-uals responsible for the care of childrenwho have tried quit methods that wereunsuccessful, should be encouraged touse NRTs as a way to decrease SHS lev-els in their homes and cars. Becausethere is not much public information onthe use of NRTs for this purpose, a publicinformation campaign should be con-ducted to recommend to, and educate,parents and caregivers about the use ofNRTs to avoid smoking in homes andvehicles.

Cost remains a significant barrier to

the access of NRTs. It is not currentlypossible to purchase a one-day dose ofNRTs. Individuals must purchaseNRTs in a one-week supply (approxi-mately $30 per package), making thecost much higher than the purchasecost of a single package of cigarettes(approximately $7.50 in Ontario).

Furthermore, the greater expendi-ture is problematic for low-incomeindividuals who tend to have highersmoking rates and lower quittingrates.84

In its 1999 paper, the OMA recom-mended that the provincial gov-ernment and the pharmaceuticalindustry work together to closelymatch the package quantity and costof NRTs to the package quantity andcost of tobacco products.

The OMA again recommends thatthe government publicly fund NRTs, andthat the Ontario Drug Benefit Planshould include funding for NRTs, as iscurrently done in Quebec.

Smoking in vehiclesResearch has shown that SHS canreach very high levels in vehicles. Acomprehensive study that measuredcigarette smoke in vehicles showedthat while driving with the windowsclosed, a single smoker can raise theinterior carbon monoxide levels sig-nificantly by the third cigarette.

Furthermore, blood carboxyhe-moglobin levels of both the individ-ual using tobacco, and the individualexposed to SHS (as measured inbreath), increase significantly aftersmoking has occurred.7 This, taken inrelation to the fact that children havemuch higher respiratory rates andmetabolism than adults, makes SHSexposure in vehicles a serious prob-lem for children.

Based on the evidence that expo-sure to SHS in a vehicle is 23-timesmore toxic than in a house due to thesmaller enclosed space, the state ofColorado drafted a bill that wouldimpose fines on adults caught smok-ing in cars when a child is present.85

Earlier this year, the state of Georgiamoved to an advanced stage of pro-cess that would allow police to pullover and fine drivers who are smok-

ing in cars that have a child in a safetyseat, once the law is enforced.86

A similar bill was introduced inNew Hampshire this year.87

In June, California moved closer tobecoming the first state to have a banin force on smoking in vehicles carry-ing children by approving a bill viathe state’s Senate committee. The billwould make it an infraction to smokein motor vehicles carrying childrenwho were under the age of six, orweighed less than 60 pounds andwere required by law to ride in childsafety seats. The bill would take effectJanuary 1, 2006, and require that anyfines generated by the legislation beused for public education programsabout the dangers of SHS.88

In a 1996 Ontario survey, 54.6 percent of respondents said they wouldsupport a law prohibiting children’sexposure to SHS in vehicles.77 Datafrom a 2003 survey showed a signifi-cant increase in support, with 73.2per cent of respondents saying thereshould be a law that prohibits par-ents from smoking inside a car if chil-dren are present.12

The OMA recommends that care-givers should not be permitted to smokein vehicles while transporting children,and that the provincial governmenttake steps to ensure the protection ofchildren from SHS while traveling invehicles through the introduction oflegis lat ion banning the use of to-bacco inside vehicles used to trans-port children.

Children in regulated careChildren in government careIn Ontario, the Child and FamilyServices Act provides the Minister ofChildren and Youth Services withguardianship of children who havebeen removed from their parents’custody because they are unwilling orunable to provide a safe environmentfor their children.

By acting as temporary guardians,the government assumes all of theresponsibilities of natural parentsfor the duration a child is in care.Government-approved agencies, andtheir foster parents, carry out the

OMA Position Paper


actual responsibility of caring for thechildren.

There are currently 52 govern-ment-approved Children’s Aid So-cieties (CASs) in Ontario, 51 of whichare members of the Ontario Associ-ation of Children’s Aid Societies(OACAS).

Using provincial requirementsand local guidelines, each CAS isrequired to conduct an assessment ofpotential foster families before theplacement of a child can occur.

Within the regulations, it is clearlystated that an assessment of the childmust be done prior to placement,and includes assessing the medicalneeds of the child.

In response to a motion that waspassed in 1996 by the Foster ParentSociety of Ontario, which supporteda ban on smoking in foster homes,and the release of a 1996 OMA paperaddressing the harmful effects ofSHS, a focus group was held at theOACAS in 1997 to discuss smokingin foster homes, and the effects thatSHS exposure has on children inthese homes.

Participants included experts inthe field, foster parents, and CASstaff. As a result of these meetings,and a subsequent survey, it was con-cluded that SHS in foster homes is achallenging issue. In order to addressthe problem, the OACAS prepared abackground paper and informationpackage about SHS and its detrimen-tal effect on the health of children, tobe distributed to all agencies in theprovince.89

The OACAS directs individualagencies to implement their ownpolicies, but does not have a compre-hensive smoking policy for fosterhomes because of the great concernabout availability of placements forthe many children in need of care.

The official position of the OACASemphasizes the hazards of exposingchildren to SHS, and encourages theindividual agencies to implementpractices, positions or policies thatprotect children from SHS in fosterhomes.

“Our position is that SHS is dan-gerous, and children shouldn’t be

exposed to it, therefore agenciesshould take that into consideration.

“There are agencies that adviseparents not to smoke in their homes,and there are others that have poli-cies regarding very young children, orchildren with medical conditions.”90

The OACAS does not, however,have the authority to enforce a pro-vincewide policy, and its positiondoes not ensure that local agencieswill implement a policy.

Furthermore, individual localagencies have expressed concerns thatby refusing potential foster parentsbecause of their smoking status, therecould be a further decline of much-needed care for children in crisis.91

At the present time, there are sev-eral CASs in Ontario that have smok-ing policies or positions on smokingin foster homes (see Appendix A, p.17).

For example, the CAS office inKingston asks all foster parents not tosmoke in the presence of children intheir care, while the Toronto CAS willnot place any children under five inhomes where smoking is allowed,but will only prohibit such a place-ment of children over the age of fiveif a child has a medical conditionthat is exacerbated by exposure toSHS.

Halton CAS includes smoke-freeenvironments as a consideration forapproval of a foster home, and open-ing windows or smoking in anotherroom do not meet the criteria for asmoke-free environment (See Appen-dix B, p. 17).

Enforcement of Halton CAS smok-ing policy has not required any extrafunding and/or staff, and feedbackhas shown little resistance from long-time and/or new foster parents.

For the period between April 1,2003, and March 31, 2004, it wasprojected that CASs in Ontario wouldprovide substitute care for 24,578children. It is encouraging to note thatbetween March 31, 1998, and March31, 2003, there was a 42 per cent in-crease in the availability of fosterhomes, and a 43 per cent increase inthe availability of adoptive homes.

As of March 31, 2004, there was

an increase of 51 per cent and 59 percent respectively in foster home andadoptive home availability sinceMarch 31, 1998.92 These increasescould help to allay concerns thatimplementation of a comprehensivesmoking policy would reduce avail-ability of foster homes.

In a ground-breaking decision, thestate of Maine implemented a law inOctober 2003 that prohibits fosterparents from smoking in their homeswhen children in their care could beexposed to SHS. The original bill,which would have also prohibitedfoster parents from smoking in theircars, was amended because officialsthought it was too restrictive.93

In 2003, New York City MayorMichael Bloomberg made foster par-ents part of his anti-smoking plat-form by announcing that fosterparents who smoke will undergoextra scrutiny before the city placeschildren in their homes.94

British adoption and fosteringagencies implemented guidelines in1993 that ban smokers from adopt-ing or caring for young children. TheBritish Agencies for Adoption andFostering referred to overwhelmingevidence that children younger thantwo years of age, and those with res-piratory illnesses, are at particularrisk from SHS exposure.95

The OMA recommends that theMinistry of Children and Youth Servi-ces work closely with the OACAS andCASs to develop a uniform smoking pol-icy, and to provide ongoing educationand support programs to enable fosterparents to decrease the amount of SHSthat children are exposed to in homesand vehicles.

Private home day caresIn Ontario, home childcare is pro-vided to children in approved privatehomes other than that of the par-ent/caregiver, for up to a maximumof five children under the age of 10.

Standards of care are set by theMinistry of Children’s Services underthe Day Nurseries Act.

While Ontario’s Tobacco ControlAct mandates that all educationalinstitutions, including licensed day

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nurseries, be smoke-free, this cover-age does not extend to homes inwhich private home-based childcare isoffered. Government does not providepolicies to protect children in homechildcare from exposure to SHS.

The Home Child Care Associationof Ontario (HCCAO) estimates thatover 80,000 children in the provinceare being cared for in childcare faci-lities that are regulated by approxi-mately 70 Home Child Care agencies.96

These agencies provide assurancethat legislated standards are met andmaintained in each caregiver’s home.

Agencies that are licensed to man-age individual home childcare facili-ties are also subject to inspections bythe Ministry.

While individual agencies mayhave smoking policies in place, theydo vary. Most will advise parents ofany smoking that occurs in the homechildcare environment, and will dis-tribute information about the bene-fits of smoke-free homes.97 However,without a comprehensive smokingpolicy in place, there is no way toensure a smoke-free environment forchildren in these settings.98 Further-more, there are also several home-based childcare environments thatare not part of a larger agency, andtherefore not regulated.

Individual municipalities areresponsible for managing licensedchildcare agencies, thus providing avaluable opportunity to intervenewith respect to protecting childrenfrom second-hand smoke exposure.

Childcare centres are eligible toreceive subsidization, and musttherefore sign a contract with themunicipalities.

For example, in May 2003, theRegion of Waterloo Social Servicesrevised its contracts for home-basedday care providers who apply forsubsidization from the Region.Previously, home-based day careproviders in Waterloo were encour-aged to provide smoke-free spacesduring childcare hours. The contractnow includes the following state-ment: “The indoor areas of a care-giver’s residence and all indoor placeswhere the child attends with the care-

giver shall be smoke-free duringchildcare times.”

The OMA recommends that infor-mation about the health effects of SHSbe included in professional education,project co-ordination, and public educa-tion and awareness programs that arecurrently offered through umbrellaagencies such as the HCCAO.

The OMA recommends that theprovincial government amend the DayNurseries Act to ban smoking and pro-vide enforcement to ensure compliancein any homes and/or facilities that pro-vide childcare.

Second-hand smoke and childcustody decisionsCustody decisions focus on the bestinterests of the child, and in doing so,place the needs of children ahead ofparents’ interests.99

Legislation clearly states that thephysical health of the child is an im-portant factor in determining a child’sbest interests, and both provincialand federal law dictate that judges arerequired to make the best interests ofthe child a major factor in their deci-sions.15 Therefore, parental smokingis an issue that can be considered bythe court, and thereby provides anopportunity for intervention withrespect to restricting a child’s expo-sure to SHS in the home.

Children with asthma have been afocus for Canadian cases involvingaccess to children, and custody bysmoking parents.100, 101 Parents whorefuse to provide smoke-free environ-ments for asthmatic children havebeen denied access or custody.

A review of custody cases in theUnited States from 1997 shows thatmost decisions favoured protectionof the child from SHS, and althoughsome cases allowed for smoking inother parts of the home, most in-volved a complete ban, including aban in vehicles, that was applicableto both parents.101

The first Canadian case to considerparental smoking took place in 1988.An Ontario court terminated a father’saccess to his daughter after the child’sasthma and allergies were proven to

be affected by her father’s smokingduring visitations.102

There have since been several casesin all levels of the Canadian courtsystem that have made SHS a consid-eration in custody determinations.

In a well-publicized case from2002, a father in British Columbiarefused to give signed permission forhis former wife to travel outside ofCanada with their son because shewould not agree to refrain from smok-ing in the car. When she finally agreedin court to smoke outside the vehicle,the judge decided the case did notneed to be pursued any further.103

An Ontario Superior Court decision(2002) ordered the removal of a childwith serious health problems from hismother’s home, and ruled that thefather would become the primary resi-dential parent because the motherrefused to stop smoking. The courtreached its decision on the basis thatthe child’s health was being placed atrisk when in the care of his mother.104

Custody hearings provide anopportunity to place the needs andwell-being of the child at the forefrontof any decision-making.

When parental smoking is ad-dressed, experience has shown thatobjections may be raised on the basisof the addictive nature of smoking.However, a significant number ofcourt decisions have determined thatother addictions place children atrisk, and have subsequently estab-lished that such addictions could beindicative of lack of parental fitness.100

The consideration of parentalsmoking during custody determina-tions can also serve an importanteducational purpose.

First, any publicity that comesfrom such cases is beneficial in edu-cating the public about the impact ofSHS on children’s health.

Second, the solutions developedby some courts show that there areeffective ways to decrease a child’sexposure to SHS in the home.

For example, some courts have or-dered a restriction of parental smok-ing around children that requiresparents to be aware of where andwhen they smoke. In most cases, it

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implies parents simply have to gooutside to smoke.99

Because of an increasing numberof court cases that involve parentalsmoking, lawyers and judges haveaccess to rulings regarding SHS whichhave set legal precedent. However, itis still essential that awareness of thehealth issues be available to thesedecision-makers.

The OMA recommends that a systemwhich facilitates the dissemination ofmedical and legal information regardingSHS and children be researched by anexpert panel, and then made available tolawyers and judges in order to improvetheir access to necessary informationregarding child welfare in the courts.

Public health campaignsResearch in health promotion hasshown that mass media messages, incombination with community-basedinterventions, can have a great impacton increasing awareness and encour-aging behavioural change. However,evaluations of community-based pro-grams have shown both success andfailure in being able to decrease SHSin homes and vehicles.105-108

Breathing Space: CommunityPartners for Smoke-Free Homes is asocial marketing campaign meant tobe delivered by public health unitsacross Ontario, along with commu-nity-based education, in an effort toinform people of the dangers of SHSin homes and vehicles.

The campaign focuses on motivat-ing people to make their homes 100per cent smoke-free, with a long-termgoal of increasing the proportion ofsmoke-free homes by 2010.

Using radio, newspaper and transitadvertising, the messages are deliveredto a target audience of individuals whosmoke in the home, or allow smokingin the home, particularly those withchildren under the age of 18. The cam-paign was conducted in 2000, 2001,and 2003, with funding support fromthe Tobacco Control Programme,Health Canada, and the OntarioTobacco Strategy of the Ministry ofHealth and Long-Term Care.

The campaign initially involved

seven pubic health units, with subse-quent evaluation results showingthere was a significant impact on atti-tudes and behavioural intentions ofthe target audience. Furthermore, thecampaign was shown to increaseawareness of the health-hazards ofSHS, as well as the likelihood thatindividuals would ask someone whosmoked to refrain from smoking inthe home.109

In response to the evaluation, thewinter 2003 campaign was expandedto include 23 of Ontario’s 37 healthunits, thereby allowing for regions inOntario with limited funds andresources to benefit from a province-wide campaign. The campaign mate-rials were translated into French, anda smaller selection was translatedinto Ojibway, Ojicree, and Cree byrequest from Northern communities.

Numerous municipalities acrossOntario have participated in Breath-ing Space: Community Partners forSmoke-Free Homes,109 however, notall boards of health participated inthe campaign and/or have adequateresources to administer them.

A review compiled for HealthCanada in April 2003 summarizedthe effectiveness of the media com-ponent of the campaign. The resultswere encouraging, and showed anincrease in the number of individuals— from 63 per cent in 2000 to 74 percent in 2003 — who would be will-ing to ask someone to smoke outsideif children were present.

There was also an increase inagreement among participants thatSHS is a serious health hazard, risingfrom 74 per cent in 2000 to 88 per-cent in 2003.

The major limitation of this evalu-ation is that it was restricted to atti-tudes and behavioural intentions,and did not measure actual impacton the prevalence of smoking inhomes with children.

Budget constraints are a majorimpediment to being able to mea-sure the overall effectiveness of thecampaign on behaviour change.Instead, the boards of health fromparticipating health units haverelied on word-of-mouth feedback

from parents and community mem-bers to provide some measure of theeffectiveness of the messages.

In order to keep the smoke-freehomes message alive in the commu-nity, health units are encouraged toparticipate by contributing their ownfunding and resources to supplementbroad media campaigns in their area.

In Ontario, the 1997 Public HealthMandatory Health Programs and Servi-ces Guidelines (MHPSG) mandateprogramming for boards of health.As such, many health units are ableto participate in the campaign be-cause it meets the initiatives outlinedfor SHS control in the MHPSG. How-ever, several health units have notparticipated due to financial and/orother resource shortages during timesof campaign implementation.

In early 2004, the partnering 23health units, and Cancer Care On-tario – Prevention Unit, provided in-kind and financial resources todevelop and focus test campaign cre-ative addressing hard-to-reach audi-ences. The partnership has grown to33 health units, currently seekingfinancial support to fund the imple-mentation of a provincewide mediacampaign using this new creative.110

The Breathing Space campaign hasbeen presented at more than a dozenconferences and workshops acrossOntario, Canada, and internationally.As a result, several Canadian provin-ces and other countries continue toseek information and consultationfrom Breathing Space in designing,implementing, and evaluating theirown smoke-free homes initiatives.

Materials from the campaign arealso valuable in other public educa-tion endeavours, and are used inpublic health programs, including:Best Start; Healthy Babies, HealthyChildren; Heart Healthy programs;Heart Smart; Workplace WellnessDays and cessation displays; andhealth fairs.109

The OMA recommends that theprovincial government provide publichealth departments with adequate fund-ing to meet their obligations under theMandatory Programs and ServicesGuidelines, including providing funds

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for the Breathing Space campaign tobecome provincewide.

The campaign should have ade-quate funding to focus on hard-to-reach audiences, and allow for therecommended duration/frequencyrequired to have the desired impacton the public.

Funding should also be available toallow for the use of such methods asrepeat surveys to allow for a thoroughassessment of the campaign’s effective-ness in reducing the number of homesand vehicles that allow smoking.

Interventions by health-careprofessionalsAlthough there is evidence to supportthe incorporation of smoking inter-ventions by primary care clinicians ina public health approach, evalua-tions of the effectiveness of these pro-grams have also shown varied successin reducing children’s exposure.111, 112

These varied findings provide solidevidence of the need for ongoingresearch to improve interventionattempts and compliance.

One of the greatest challenges tosuccess lies in developing strategiesto address the factors that reinforcesmoking and SHS exposure, such asaddiction, and the influence of fam-ily and friends. This can fall beyond apractitioner’s ability to deliver brief,or one-time, counseling sessions.112

Wall and colleagues, however,reported that new mothers whoreceived literature about SHS, and aletter advising them to quit smoking,as well as written and oral advice dur-ing four subsequent well-baby visits,demonstrated significantly highercessation rates, and significantlylower relapse rates, than mothersreceiving initial literature alone. Thisstudy showed that brief interventionsover repeated contacts can reducesmoking rates.113

Furthermore, it supports the sug-gestion that opportunities exist forcounseling parents on the effects ofSHS exposure.

The effectiveness of informing par-ents about the dangers of SHS, andoffering advice/assistance with smok-

ing interventions during parent-childvisits to health professionals — pri-marily family physicians — must beinvestigated and evaluated.

There are chronic and acute child-hood health problems that are linkedto SHS exposure, and it is clear thatthese interactions provide valuableteachable moments for effectingchange, particularly among special-ists who commonly treat these ill-nesses (e.g., pediatricians, allergists,respirologists, ear nose and throatspecialists, and emergency roomphysicians — particularly pediatric).

Successful training and implemen-tation of tobacco interventions byclinicians should be applied to alldisciplines, especially those thatwork closely with children mostadversely affected by SHS exposure,including nurses, obstetricians, mid-wives, respiratory therapists, pharma-cists, dentists and psychiatrists.

When Wall and associates focusedon interventions with newborninfants, they saw benefit from themotivation of new mothers to pro-tect their newborn children.113

Another study by Butz and col-leagues — a comparison of SHSamong children with chronic respira-tory diseases, including cystic fibro-sis, to healthy children and childrenwith non-respiratory chronic ill-nesses — showed that more than 80per cent of the asthma and cysticfibrosis respondents showed achange in parents’ smoking behav-iour (i.e. smoking outside the homeor smoking fewer cigarettes) after thediagnosis of their child’s illness, ver-sus only 40 per cent in the non-respi-ratory groups.114

Several studies examining theprevalence of smoking advice and/orcessation assistance among cliniciansand practitioners have reported thatbarriers to providing advice include:lack of time, feelings that parents didnot expect to receive advice, and feel-ing ill at ease offering advice.115

In 2005, the Ontario Tobacco Re-search Unit116 is expected to publishdata concerning findings of a nation-al evaluation of interventions amongpediatricians and family practitioners

regarding their practices in advisingparents about smoking.

Using data from the U.S. NationalAmbulatory Medical Care Surveybetween 1997 and 1999, a compre-hensive assessment of the frequencyof clinician-reported delivery ofcounseling for avoidance of childSHS exposure was conducted duringperiodic well-child visits and illnessvisits for both asthma and otitismedia. Results collected from 1997to 1999 showed a very low rate oftobacco counseling for well-child vis-its, and for diagnoses affected bySHS, with 4.1 per cent at well-childvisits, 4.4 per cent at illness visits forasthma, and 0.3 per cent of illnessvisits for otitis media.117

In a 2003 study from Boston’sChildren’s Hospital, a telephone sur-vey of households (conducted fromJuly 2001 to September 2001) col-lected data to examine and comparerates of pediatrician and family prac-titioner screening and counseling forparental tobacco use.

The study found that althoughthere was a higher rate of discussionabout parental smoking with pedia-tricians versus family practitioners,fewer than half reported being coun-seled by either specialty about thedangers of SHS, or the risks of model-ing smoking behaviour. Similarly,fewer than half received advice toquit smoking.118

There is an encouraging increasein the number of studies designed tomeasure and analyze smoking inter-vention methods among clinicians.

For example, in 1993, the AmericanAcademy of Pediatrics created aworkshop, entitled “Clean Air forChildren: Three Hour Training Work-shop,” to train pediatricians in smok-ing-cessation counseling.

Pediatricians from the same acade-mic medical centre were divided intotwo groups — those who did, andthose who did not, attend the train-ing session. Evaluators then assessedchanges in practice related to smok-ing intervention. Those pediatricianswho had attended the training ses-sion were more likely to inquireabout parental smoking status, iden-

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tify smokers, and offer advice aboutthe effects of SHS exposure.119

A recent survey of pediatriciansconducted by the University ofMichigan found that the percentageof physicians with reported high lev-els of self-efficacy when screeningparents of asthmatic children to iden-tify smokers, and/or counsel them,was directly related to the amount offormal training in smoking cessationthroughout their careers.120

Since 1996, the OMA’s ClinicalTobacco Intervention (CTI) Programhas helped to educate and supportOntario physicians to assist patientswith their smoking-cessation efforts.

In 2000, the Ontario Dental As-sociation and the Ontario Phar-macists’ Association joined with theOMA for delivery of CTI, with fund-ing provided by the provincial gov-ernment.

CTI is an evidence-based programdesigned to recruit and educatephysicians, dentists and pharmaciststo perform tobacco-cessation inter-ventions with patients. This is donethrough the provision of educationalprograms, patient materials, ongoingsupport, and special projects.

CTI focuses on the minimal con-tact intervention approach (briefpatient interventions lasting three tofive minutes), and the “five A’s”model, which entails: asking patientsabout their smoking status, advisingpatients about the health risks,assessing patients’ readiness to quit,assisting patients who are ready toquit, and arranging follow-up.

Ongoing collaboration among thethree associations works to provideclear and consistent messages topatients about the importance ofceasing tobacco use.121 However,despite its effectiveness, this type ofprogramming has yet to be extendedin order to enable health profession-als to provide interventions to parentsand caregivers regarding their tobaccouse and its impact on children.

Gidding suggests that pediatri-cians take advantage of the recom-mended series of well-child visits inorder to counsel parents on theeffects of SHS on children.82

In Ontario, these visits are con-ducted by both pediatricians and,most often, family physicians, orthroughout the first six years of life,as well as during additional office vis-its for treatment of illnesses.

These visits create a valuableopportunity to provide ongoinginformation to parents on SHS andits dangers.82

Surveys of parents suggest thatintervention by health-care profes-sionals regarding SHS exposure andchildren is warranted, and thought tobe appropriate, with a majority ofparents indicating that they would bereceptive to receiving informationand/or advice regarding their tobaccouse.115, 122, 123

The importance of including smok-ing cessation instruction within med-ical school curricula has resulted inincreasing attention toward educa-tional methods for training medicalstudents in tobacco intervention.However, there are still gaps in thecurriculum, including a lack of inte-gration during the four years of med-ical school curricula, specific trainingin the use of nicotine replacementtherapies, tobacco intervention train-ing that addresses cultural issues, andlong-term studies showing that suchtraining is retained in practice.124, 125

A comprehensive 1997 survey ofCanadian schools that train healthprofessionals showed more hourswere devoted to education about thediseases caused by smoking than tocounseling patients to quit. Manyschools had no smoking counselingcurriculum, and the average numberof hours devoted to counseling amongthose who replied to the survey wasonly two.126

The family and community medi-cine department at the University ofToronto designed and implementeda module called Project CREATE thataddresses smoking cessation, for useby medical students, residents andfaculty.

Presentations have already beenmade to second-year medical stu-dents at the University of Toronto,and there are plans for the module tobe updated for future comprehen-

sive use. However, this program hasyet to be extensively implemented inOntario medical schools.127

Primary health-care providers reg-ularly address parents about nutri-tion, lead poisoning, and other childhealth safety issues, including thosein the home, and their involvementhas contributed to changes in socialnorms, including infant car seats andbicycle helmets. It is clear that assis-tance in the management of SHSexposure may also result in signifi-cant reductions in tobacco-related ill-nesses.

As the people most knowledge-able about child health in their com-munities, health-care providers whotreat children and their families canalso play a role in reducing children’sexposure to SHS in two ways — bycounseling parents, and by workingwithin the community to enact morecomprehensive policies regardingSHS in homes and vehicles.128

There is also a place for interven-tion among other health professions,including nurses (both in hospitalsand in public health), nurse prac-titioners, physicians’ assistants,obstetricians, midwives, lactationconsultants, pre-natal and post-par-tum social workers, respiratory thera-pists, pharmacists and dentists.

It is important to recognize andsupport programs that have thepotential to impact families withchildren.

For example, the Healthy Babies,Healthy Children program providedby Ontario’s 37 health units suppliesinformation and extra support tofamilies with children from birth toage six. This program includes homevisits, thereby providing a valuableopportunity for public health nursesto assess and intervene regardingSHS exposure in home environ-ments.129

Programs such as Pregnets —formed in March 2002 to encourageOntario health professionals acrossall disciplines, including researchersand policy-makers, to develop a net-work that will focus on the issue ofsmoking in pregnancy and postpar-tum — are also extremely valuable in

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establishing a network across varioushealth professions.130

The trained quit specialists at theCanadian Cancer Society’s Smokers’Helpline can also provide a valuablesupport to parents who are trying tomake changes regarding tobacco usein their homes and vehicles.

Because of their unique opportu-nity to interact with parents andchildren, health-care and other pro-fessionals who work closely withfamilies should be trained to inter-vene in families where smoking isprevalent. In order for this to occur,however, evidence has shown thatadditional training and guidance isrequired for these individuals to beable to implement effective assess-ment and intervention practices.

The OMA recommends that programsbe created to enhance health profession-als’ ability to prevent parents from expos-ing their children to SHS. Effectivetraining programs that allow for healthprofessionals to provide brief interven-tions should also be offered across all dis-ciplines wherein the opportunity exists tointeract with parents and their children.This training should be integral at boththe undergraduate medical school level,as well as within postgraduate and con-tinuing education programs for practic-ing professionals.

ConclusionThe purpose of this document is tooutline the position of the OMA con-cerning the impact of SHS exposureon the health of children, and whatshould be done to lessen this expo-sure.

SHS poses a major risk to thehealth and well-being of children,and steps can be taken to signifi-cantly reduce the exposure that chil-dren in Ontario currently experience.

Information about the effects ofSHS on child health must be dis-seminated to the public, especiallyparents and individuals responsiblefor the care of children, includingfoster parents, the family courts, andday care workers.

Support must also be provided toenable those attempting to reduce or

eliminate SHS in their homes andvehicles to achieve success.

If progress is made toward imple-menting the recommendations out-lined in this document, a significantimprovement in the health of On-tario’s children would be inevitable.

The OMA urges the individualswho have the ability to make a differ-ence in this matter, including par-ents, educators, pubic health, health-care providers and legislators, to takeimmediate steps toward accomplish-ing this goal.

AcknowledgmentsThis paper was prepared by LouiseGleeson, Policy Research Officer forthe Ontario Campaign for Action onTobacco (OCAT), with directionand support from Dr. Ted Boadway,Executive Director, OMA HealthPolicy Department, and Flora Aron-shtam, Senior Adviser, OMA HealthPolicy Department.

The OMA wishes to express itsgratitude to the many individualsand representatives of groups fortheir valued comments during thedevelopment of this position paper,notably: Michael Perley, Director,Ontario Coalition Against Tobacco(OCAT); OMA Committees and Cli-nical Sections; external reviewers,including clinical, research, andpublic health experts in the pro-vince.

The development of this positionpaper was initiated and supportedby the OMA Committee on ChildHealth: Dr. Robin Williams, Chair,Dr. Alan Hudak, Dr. William Wat-son, Dr. Eugene Ng, Dr. AhmedBoachie, and Dr. Umberto Cellu-pica.

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co use monitoring survey (CTUMS):wave 1: February to June 2003. Ottawa,ON: Health Canada; 2004. Availablefrom: http://www.hc-sc.gc.ca/hecs-sesc/ tobacco/research/ctums/index.html. Accessed: 2004 Jul 7. 13. Ferrence R, Dioso R, Ashley MJ, etal. A national study of ETS in Cana-dian homes: regional patterns ofexposure to second-hand smoke.Invited plenary presentation on cessa-tion and protection, presented at: 3rdNational Conference on Tobacco orHealth; 2002 Dec 1-4; Ottawa, ON.14. Physicians for a Smoke-FreeCanada. Children in care: protectingchildren from second-hand smokewhen governments are the “parent.”Ottawa, ON: Physicians for a Smoke-Free Canada; 2002 Aug. Availablefrom: http://www.smoke-free.ca/pdf_1/government%20as%20par-ent.pdf. Accessed: 2004 Jul 7.15. Physicians for a Smoke-freeCanada. Custody & access: protectingchildren from second-hand smokeduring custody disputes. Ottawa,ON: Physicians for a Smoke-FreeCanada; 2002 Aug. Available from:http://www.smoke-free.ca/pdf_1/custody%20and%20access.pdf.Accessed: 2004 Jul 7.16. California Air Resources Board;California Environmental ProtectionAgency, Office of EnvironmentalHealth Assessment. Proposed identi-fication of environmental tobaccosmoke as a toxic air contaminant:draft report part A and B. Sacramento,CA: California Air Resources Board;2003 Nov [updated 2004 Mar 30].Available from: URL: http://www.arb.ca.gov/toxics/ets/dreport/dreport.htm. Accessed: 2004 Jul 7. 17. Makin J, Fried PA, Watkinson B. Acomparison of active and passivesmoking during pregnancy: long-term effects. Neurotoxicol Teratol 1991Jan-Feb;13(1):5-12.18. Fried PA, Watkinson B. Differ-ential effects on facets of attention inadolescents prenatally exposed to cig-arettes and marihuana. NeurtoxicolTeratol 2001 Sep-Oct;23(5):421-430.19. Wasserman GA, Liu X, Pine DS, etal. Contribution of maternal smok-ing during pregnancy and lead ex-

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30. Harlap S, Davies AM. Infantadmissions to hospital and maternalsmoking. Lancet 1974 Mar 30;1(7857):529-32.31. Colley JR, Holland WW, CorkhillRT. Influence of passive smoking andparental phlegm on pneumonia andbronchitis in early childhood. Lancet1974 Nov 2;2(7888):1031-4.32. Strachan DP, Cook DG. Healtheffects of passive smoking. 1. Parentalsmoking and lower respiratory illnessin infancy and early childhood.Thorax 1997 Oct;52(10):905-914.33. Kidder K, Stein J, Fraser J. Theheath of Canada’s children: a CICHprofile. 3rd ed. Ottawa, ON: Cana-dian Institute of Child Health; 2000.34. U.S. Environmental ProtectionAgency, Office of Research and De-velopment, Office of Health andEnvironmental Assessment. Respira-tory health effects of passive smok-ing: lung cancer and other disorders.Washington, DC: U.S. Environ-mental Protection Agency; 1992 Dec.Report No.: EPA/600/6-90/006F.Available from: http://oaspub.epa.gov/eims/eimscomm.getfile?p_download_id=36793. Accessed: 2004 Jul 7.35. Ugnat AM, Mao Y, Miller AB, etal. Effects of residential exposure toenvironmental tobacco smoke onCanadian children. Can J Public Health1990 Sep-Oct;81(5):345-9.36. Wilson NW. Second-hand ciga-rette smoke is a major contributor toasthma in children. W V Med J 2001Jan-Feb;97(1):27-8.37. Dales RE, Choi B, Chen Y, et al.Influence of family income on hospi-tal visits for asthma among Canadianschool children. Thorax 2002 Jun;57(6):513-7.38. Samet JM, Tager IB, Speizer FE.The relationship between respiratoryillness in childhood and chronic air-flow obstruction in adulthood. AmRev Respir Dis 1983 Apr; 127(4):508-523.39. Tager IB. Passive smoking—bronchial responsiveness and atopy.Am Rev Respir Dis 1988 Sep;138(3):507-509.40. Young S, Le Souef PN, GeelhoedGC, et al. The influence of a familyhistory of asthma and parental smok-

OMA Position Paper


ing on airway responsiveness in earlyinfancy. N Engl J Med 1991 Apr 25;324(17):168-73.41. Hanrahan JP, Tager IB, Segal MR,et al. The effect of maternal smokingduring pregnancy on early infantlung function. Am Rev Respir Dis1992 May;145(5):1129-35.42. Evans D, Levison MJ, FeldmanCH, et al. The impact of passive smok-ing on emergency room visits ofurban children with asthma. Am RevRespir Dis 1987 Mar;135(3):567-72.43. Cunningham J, O’Connor GT,Dockery DW, et al. Environmentaltobacco smoke, wheezing and asthmain children in 24 communities. Am JRespir Crit Care Med 1996 Jan;153(1):218-24.44. Weitzman M, Gortmaker S, Walk-er DK, et al. Maternal smoking andchildhood asthma. Pediatrics 1990Apr;85(4):505-511.45. Murray AB, Morrison BJ. Passivesmoking by asthmatics: its greatereffect on boys than on girls and onolder than on younger children.Pediatrics 1989 Sep;84(3):451-9.46. Ey JL, Holberg CJ, Aldous MB, etal. Passive smoke exposure and otitismedia in the first year of life. GroupHealth Medical Associates. Pediatrics1995 May;95(5):670-7.47. Kitchens GG. Relationship ofenvironmental tobacco smoke to oti-tis media in young children. Laryn-goscope 1995 May;105(5 Pt 2 Suppl69):1-13.48. Adair-Bischoff CE, Sauve RS.Environmental tobacco smoke andmiddle ear disease in preschool-agechildren. Arch Pediatr Adolesc Med1998 Feb;152(2):127- 33.49. Strachan DP, Cook DG. Healtheffects of passive smoking. 4. Parentalsmoking, middle ear disease and ade-notonsillectomy in children. Thorax1998 Jan;53(1):50-6.50. International Agency for Researchon Cancer. Tobacco smoke and invol-untary smoking. Lyon, France: IARCPress; 2004. (IARC Monographs; 83).51. Sandler DP, Wilcox AJ, EversonRB. Cumulative effects of lifetimepassive smoking on cancer risk.Lancet 1985 Feb 9;1(8424):312-5.52. Sandler DP, Everson RB, Wilcox

AJ, et al. Cancer risk in adulthoodfrom early life exposure to parents’smoking. Am J Public Health 1985May;75(5):487-92.53. Janerich DT, Thompson WD,Varela LR, et al. Lung cancer andexposure to tobacco smoke in thehousehold. New Eng J Med 1990 Sep6;323(10):632-6.54. de Groh M, Morrison H. Environ-mental tobacco smoke and deathsfrom coronary disease in Canada.Chronic Dis Can 2002;23(1):13-16.55. Otsuka R, Watanabe H, Hirata K,et al. Acute effects of passive smokingon the coronary circulation in healthyyoung adults. JAMA Jul 2001;286(4):436-41.56. Fichtenberg CM, Glantz SA.Association of the California TobaccoControl Program with declines in cig-arette consumption and mortalityfrom heart disease. New Eng J Med2000 Dec 14;343(24):1772-7.57. Dietrich M, Block G, Norkus EP,et al. Smoking and exposure to envi-ronmental tobacco smoke decreasesome plasma antioxidants and in-crease gamma-tocopherol in vivoafter adjustment for dietary antioxi-dant intakes. Am J Clin Nutr 2003Jan;77(1):160-166.58. Matturri L, Lavezzi AM, OttavianiG, et al. Intimal preatheroscleroticthickening of the coronary arteries inhuman fetuses with smoking moth-ers. J Thromb Haemost 2003 Oct 1;1(10):2234-8.59. Moskowitz WB, Mostellar M,Schieken RM, et al. Lipoprotein andoxygen transport alterations in pas-sive smoking preadolescent children.The MCV Twin Study. Circulation1990 Feb;81(2):586-92.60. Emmons KH, Hammond SK,Abrams DB. Smoking at home: theimpact of smoking cessation on non-smoker’s exposure to environmentaltobacco smoke. Health Psychol 1994Nov;13(6):516-520.61. Haufroid V, Lison D. Urinarycotinine as a tobacco-smoke expo-sure index: a minireview. Int ArchOccup Environ Health 1998 May;71(3):162-68.62. Canada Mortgage and HousingCorporation. The clean air guide:

how to identify and correct indoorair problems in your home. Ottawa,ON: Canada Mortgage and HousingCorporation; 1993. Available from:http://www.cmhc-schl.gc.ca/publica-tions/en/rh-pr/tech/93-203.pdf.Accessed: 2004 Jul 7.63. Lofroth G. Environmental tobac-co smoke: multicomponent analysisand room-to-room distribution inhomes. Tob Control 1993 Sep;2(3):222-225. 64. Pirkle JL, Flegal KM, Bernert JT, etal. Exposure of the US population toenvironmental tobacco smoke: theThird National Health and Nutri-tional Survey, 1988 to 1991. JAMA1996 Apr 24;275(16):1233-40.65. Blackburn C, Spencer N, Bonas S,et al. Effect of strategies to reduceexposure of infants to environmentaltobacco smoke in the home: crosssectional survey. BMJ 2003 Aug 2;327(7409):257-60.66. Lund KE, Skrondal A, Vertio H, etal. To what extent do parents strive toprotect their children environmentaltobacco smoke in Nordic countries?A population-based study. TobControl 1998 Spring;7(1):56-60.67. Johansson A, Hermansson G,Ludvigsson J. How should parentsprotect their children from environ-mental tobacco smoke exposure inthe home? Pediatrics 2004 Apr;113(4):e291-e295.68. Mascola MA, Van Vunakis H,Tager IB, et al. Exposure of younginfants to environmental tobaccosmoke: breast-feeding among smok-ing mothers. Am J Public Health 1998Jun; 88(6):893-96.69. Johansson A, Halling A, Her-mansson G. Indoor and outdoorsmoking: impact on children’shealth. Eur J Public Health 2003Mar;13(1):61-66.70. Bahceciler NN, Barlan IB, Nuho-glu Y, et al. Parental smoking behav-ior and the urinary cotinine levels ofasthmatic children. J Asthma 1999;36(2):171-5.71. Ashley MJ, Ferrence R. Reducingchildren’s exposure to environmentaltobacco smoke in homes: issues andstrategies. Tob Control 1998 Spring;7(1):61-65.

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72. Ashley MJ, Cohen J, Ferrence R, etal. Smoking in the home: changingattitudes and current practices. Am JPub Health 1998 May;88(5):797-800.73. Goldstein JE. Informal smokingcontrols in Winnipeg households.Can J Public Health 1994 Mar-Apr;85(2):106-9.74. Ontario Tobacco Research Unit.Environmental tobacco smoke (ETS)in Ontario homes: behaviours andbeliefs about health risks. ResearchUpdate 2002 Sep. Available from:http://www.otru.org/pdf/updates/update_sept2002.pdf. Accessed: 2004Jul 7.75. Ferris J, Templeton L, Wong S.Alcohol, tobacco and marijuana: use,norms, problems, and policy atti-tudes among Ontario adults. A reportof the Ontario Alcohol and OtherDrug Opinion Survey, 1992. Toronto,ON: Addiction Research Foundation;1994 Sep. (Internal document; 118).76. Bondy SJ, Ferrence RG. Smokingbehaviour and attitudes in Ontario,1993. A report of the 1993 OntarioAlcohol and Other Drugs OpinionSurvey. Toronto, ON: Ontario Tobac-co Research Unit; 1995. (Workingpapers series; 2).77. Anglin L, ed. The Ontario experi-ence of alcohol and tobacco: newfocus on accessibility, violence, andmandatory treatment. A report of theOntario Alcohol and Other DrugOpinion Survey (OADOS), 1995.Toronto, ON: Addiction ResearchFoundation of Ontario; Nov 1995.(Internal document ; 122).78. Hovell MF, Zakarian JM, Wahl-gren DR, et al. Reducing children’sexposure to environmental tobaccosmoke: the empirical evidence anddirection for future research. TobControl 2000 Jun;9 (Suppl 2):ii40-ii47.79. Greenberg RA, Bauman KE,Glover LH, et al. Ecology of passivesmoking by young infants. J Pediatr1989 May;114(5):774-80.80. Cook DG, Whincup PH, JarvisMJ, et al. Passive exposure to tobaccosmoke in children aged 5-7 years:individual, family and communityfactors. BMJ 1994 Feb 5;308(6925):384-89.

81. Gehrman CA, Hovell MF. Protec-ting children from environmentaltobacco smoke (ETS) exposure: a crit-ical review. Nicotine Tob Res 2003Jun;5(3):289-301.82. Gidding SS, Schydlower M. Activeand passive tobacco exposure: a seri-ous pediatric health problem. Pedi-atrics 1994 Nov;94(5):750-751.83. Ontario Medical Association,Committee on Drugs & Pharmaco-therapy. Rethinking stop-smokingmedications — myths and facts. Tor-onto, ON: Ontario Medical Associ-ation; 1999 Jun.84. Shiffman S, Gitchell J, Pinney JM,et al. Public health benefit of over-the-counter nicotine medications. TobControl 1997 Winter;6(4):306-310.85. Sanko J. Bill targets smokers incars: Boulder Senator says stateshould step in on behalf of children.Rocky Mountain News (Denver, Colo-rado) 1998 Jan 10:6A.86. Car smoking bill. Broadcast News2004 Feb 4.87. State of New Hampshire, GeneralCourt. House Bill 1129: an act pro-hibiting smoking in vehicles whenchild passenger restraints are re-quired. Concord, NH: New Hamp-shire General Court; 2004. Availablefrom: http://www.gencourt.state.nh.us/legislation/2004/HB1129.html.Accessed: 2004 Jul 7.88. Lawrence S. Senate committeeOKs ban on smoking in cars carryingyoung kids. New York, NY: Associ-ated Press; 2004 Jun 16. Available from:http://www.montereyherald.com/mld/montereyherald/news/politics/8940431.htm. Accessed: 2004 Jul 7.89. Ontario Association of Children’sAid Societies. Second-hand smoke infoster homes. Toronto, ON: OntarioAssociation of Children’s Aid Soci-eties; 1999 Jan.90. Gleeson L (Ontario Campaignfor Action on Tobacco, OntarioMedical Association, Toronto, ON).Telephone conversation with: GailVandermeulen (Director of Com-munications, Ontario Association ofChildren’s Aid Societies, Toronto,ON). 2003 Oct 15.91. Gleeson L (Ontario Campaign forAction on Tobacco, Ontario Medical

Association, Toronto, ON). Telephoneconversation with: Jeanette Lewis(Executive Director, Ontario Associa-tion of Children’s Aid Societies,Toronto, ON). 2003 Oct 14.92. Ontario Association of Children’sAid Societies. Ontario child welfarestatistics. Toronto, ON: Ontario Asso-ciation of Children’s Aid Societies.Available from: http://www.oacas.org/resources/casstats.htm. Accessed:2004 Jul 7.93. Foster parent rights must be consi-dered in enforcement of law. KennbecJournal — Morning Sentinel 2003 Oct4.94. Edozien F. City has wary eye on‘puff’ parents. New York Post 2003 Apr25:3.95. Smokers rejected as adoptive par-ents. The Journal, Addiction ResearchFoundation 1993 May 22(3):7.96. Gleeson L (Ontario CampaignAction on Tobacco, Ontario MedicalAssociation, Toronto, ON). Tele-phone conversation with: Mary-LouJames (President, Home Child CareAssociation of Ontario, Toronto,ON). 2003 Dec 16.97. Gleeson L (Ontario Campaignfor Action on Tobacco, OntarioMedical Association, Toronto, ON).Telephone conversation with: Mary-Lou James (President, Home ChildCare Association of Ontario, Toron-to, ON). 2003 Dec 17.98. Gleeson L (Ontario Campaignfor Action on Tobacco, OntarioMedical Association, Toronto, ON).Telephone conversation with: JudyMacLeod (Ministry of Communityand Social Services and Ministry ofChildren’s Services, Toronto, ON).2003 Dec 9.99. Ezra DB. Sticks and stones canbreak my bones, but tobacco smokecan kill me: can we protect childrenfrom parents that smoke? Saint LouisUniv Public Law Rev 1994;13(2): 547-590.100. Liberman E. Custody and access:no smoking allowed! Toronto, ON:Ontario Tobacco Research Unit;1995 Apr.101. Sweda EL. Summary of legal casesregarding smoking in the workplaceand other places. Boston, MA: Tobac-

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co Control Resource Center; 1997 Jul.102. Bourdon v. Casselman [1988]O.J. No. 2385.103. Meissner D. Boy allowed on tripafter mom tells court she won’tsmoke in car. Toronto, ON: CanadianPress; 2002 Dec 15. Available from:http://lifewise.canoe.ca/Health0 0 1 2 / 1 5 _ s m o k i n g - c p . h t m l .Accessed: 2004 Jul 7.104. Brean J. Judge orders boy re-moved from smoking mother’shome. National Post 2002 Oct 18:A1.105. Greenberg RA, Strecher VJ,Bauman KE, et al. Evaluation of ahome-based intervention program toreduce infant passive smoking andlower respiratory illness. J Behav Med1994 Jun;17(3):273-290.106. Bondy SJ, Connop H, Pope M,et al. Promoting smoke free families.Report of a pilot intervention trial toreduce environmental tobacco smokein family homes. Toronto, ON: On-tario Tobacco Research Unit; 1995Aug. (Working papers series; 3).107. Vineis P, Ronco G, Ciccone G, etal. Prevention of exposure of youngchildren to parental tobacco smoke:effectiveness of an educational pro-gram. Tumori 1993 Jun 30;79(3):183-186.108. Green E, Courage C, Rushton L.Reducing domestic exposure to envi-ronmental tobacco smoke: a reviewof attitudes and behaviors. J R SocHealth 2003 Mar;123(1):46-51.109. Breathing space: communitypartners for smoke-free homes: finalreport: mass media activities. Ottawa,ON: Health Canada, Federal TobaccoControl Strategy; 2003 Apr 30.110. Thibault S (Co-ordinator,Breathing Space Campaign, Toronto,ON). Breathing space campaign.[Internet]. Message to: Louise Glee-son (Ontario Campaign for Actionon Tobacco, Ontario Medical Associ-ation, Toronto, ON). 2003 Oct 23,9:47 am. [about 2 screens].111. McIntosh NA, Clark NM, How-att WF. Reducing tobacco smoke inthe environment of the child withasthma: a cotinine-assisted, minimalcontact intervention. J Asthma 1994;31(6):453-62.112. Chilmonczyk BA, Palomaki

GE, Knight GJ, et al. An unsuccessfulcotinine-assisted intervention strat-egy to reduce environmental tobac-co smoke exposure during infancy.Am J Dis Child 1992 Mar;146(3):357-360.113. Wall MA, Severson HH, AndrewsJA, et al. Pediatric office-based smok-ing intervention: impact on maternalsmoking and relapse. Pediatrics 1995Oct;96(4 Pt 1):622-8.114. Butz AM, Rosenstein BJ. Passivesmoking among children withchronic respiratory disease. J Asthma1992;29(4):265-72.115. Frankowski BL, Weaver SO,Secker-Walker RH. Advising parentsto stop smoking: pediatricians’ andparents’ attitudes. Pediatrics 1993Feb;91(2):296-300.116. Brewster J (Research Scientist,Ontario Tobacco Research Unit, Toron-to, ON). Smoking cessation – pedi-atrics. [Internet]. Message to: LouiseGleeson (Ontario Campaign forAction on Tobacco, Ontario MedicalAssociation, Toronto, ON). 2003Nov 6, 4:54 pm. [about 1 screen].117. Tanski SE, Klein JD, WinickoffJP, et al. Tobacco counseling at well-child and tobacco-influenced illnessvisits: opportunities for improve-ment. Pediatrics 2003 Feb;111(2):E162-7.118. Winickoff JP, McMillen RC,Carroll BC, et al. Addressing parentalsmoking in pediatrics and familypractice: a national survey of parents.Pediatrics 2003 Nov;112(5):1146-51.119. Klein JD, Portilla M, GoldsteinA, et al. Training pediatric residentsto prevent tobacco use. Pediatrics1995 Aug;96(2 Pt 1):326-30.120. Cabana MD, Rand C, Slish K, etal. Pediatrician self-efficacy for coun-seling parents of asthmatic childrento quit smoking. Pediatrics 2004Jan;113(1):78-81.121. Hart J (Director, CTI Program,Ontario Medical Association, Toron-to, ON). CTI blurb. [Internet]. Mes-sage to: Louise Gleeson (OntarioCampaign for Action on Tobacco,Ontario Medical Association, Toron-to, ON). 2004 Jun 9, 3:33 pm. [about2 screens].122. Hopper JA, Craig KA. Environ-

mental tobacco smoke exposureamong urban children. Pediatrics2000 Oct;106(4):E47.123. Cluss PA, Moss D. Parent atti-tudes about pediatricians addressingparental smoking. Ambul Pediatr2002 Nov-Dec;2(6):485-88.124. Ferry LH, Grissino LM, RunfolaPS. Tobacco dependence curricula inUS undergraduate medical educa-tion. JAMA 1999 Sept 1;282(9):825-9.125. Spangler JG, George G, FoleyKL, et al. Tobacco intervention train-ing: current efforts and gaps in USmedical schools. JAMA 2002 Sept4;288(9):1102-09.126. Thomas R. A survey of the train-ing of Canadian health professionalsto counsel against smoking. ChronicDis Can 1997;18(3):120-9.127. Kahan M (Department of Familyand Community Medicine, Univer-sity of Toronto, Toronto, ON). Smok-ing cessation curriculum. [Internet].Message to: Louise Gleeson (OntarioCampaign Action on Tobacco, On-tario Medical Association, Toronto,ON). 2003 Nov 11, 4:01 pm. [about1 screen].128. McMillen RC, Winickoff JP,Klein JD, et al. US adult attitudes andpractices regarding smoking restric-tions and child exposure to environ-mental tobacco smoke: changes insocial climate from 2000-2001.Pediatrics 2003 July;112(1 Pt 1):e55-e60.129. Cooper J (Co-ordinating Mana-ger, Healthy Babies, Healthy Children,Toronto Public Health, Toronto, ON).Healthy babies, healthy children.[Internet]. Message to: Louise Gleeson(Ontario Campaign for Action onTobacco, Ontario Medical Associa-tion, Toronto, ON). 2003 Nov 3, 8:05pm. [about 1 screen].130. Dragonetti R (PREGNETS,Toronto, ON). Question. [Internet].Message to: Louise Gleeson (OntarioCampaign for Action on Tobacco,Ontario Medical Association, Toron-to, ON). 2004 Jan 9, 12:25 am. [about1 screen].

OMA Position Paper


OMA Position Paper


The Children’s Aid Society is con-cerned for the health, safety and wel-fare of all children in care who maybe harmed due to exposure to sec-ond-hand smoke, therefore:• Any child suffering from a medicalcondition exacerbated by smoke willbe placed with non-smoking fosterparents.• Children under the age of five yearswill be placed with non-smoking fos-ter parents.• Non-smoking foster parents andsmoke-free environments will beconsidered as one of the criteria con-sidered for approval of a foster home.Moving to another room or openinga window will not meet the criteriaof a smoke-free environment.• No staff or agents of the Society,including foster care providers, maysmoke in their vehicles while trans-porting children in the care of theSociety.• Foster care providers will not pro-vide tobacco products to childrenunder 19 years of age, and will notpermit children to smoke in fosterhomes.• There may be situations regardingavailability of foster care beds thatmay create exceptions to this policy.Children placed in these situationsdue to resource availability must bereviewed and approved by the Re-source Supervisor.• All foster care providers, regardlessof the age of the children placed intheir care, will limit smoking to areasoutside the immediate living envi-ronment of the children/youth intheir care.

OMR

Appendix BSmoking Policy for

Halton Region Children’s AidSociety – 2004

Appendix ASample of Smoking Policies from

Children’s Aid Societies Agencies in Ontario

Kingston

Toronto

Perth

Ottawa-Carleton

Halton

St. Thomas & Elgin

Oxford County

• Prohibits foster parents from smoking in the presenceof foster children (parents are allowed to smoke out-side).• Society also attempts to identify any children with med-ical conditions exacerbated by SHS, and place those chil-dren in non-smoking homes.• No smoking while transporting children.

• No children under the age of five are placed in homeswhere smoking is allowed.• Special considerations are made for children with med-ical conditions that are affected by exposure to SHS.

• Prohibits placement of infants and preschoolers inhomes of a foster parent who smokes.

• Restricts smoking in the workplace and residential facili-ties, but does not include foster homes.• Restricts smoking in vehicles in the presence of children.

• Foster parents are not permitted to smoke in homes(must go outside) where there are children of any age.• Children under the age of five are placed in non-smok-ing homes exclusively.• Restricts smoking in vehicles in the presence of children.• All residential programs, and the properties owned andused by them, are declared smoke-free.

• No children under the age of five are placed in homeswhere smoking is allowed.• Children with medical conditions that are affected byexposure to SHS, and children that are medically fragile,are not placed in homes where smoking is allowed.• Staff, volunteers and foster parents are asked not tosmoke in the presence of children.• Restricts smoking in vehicles in the presence of chil-dren.

• Children under the age of five are placed in non-smok-ing homes only (this policy is currently being amended toinclude children up to the age of 10).• For children over the age of five, caregivers must guaran-tee that there is no smoking allowed inside the home.

Agency Policy

Health & Medicine

Exposure to second-hand smoke: