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| Journal of the New Zealand Medical Association,
15-April-2005, Vol 118 No 1213
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Attitudes to, and knowledge of, secondhand smoke in
New Zealand homes and cars
George Thomson, Nick Wilson, Philippa Howden-Chapman
This article reviews the evidence on knowledge and attitudes
among the New Zealand public concerning secondhand smoke (SHS) and smoking in
homes and cars. Work on this topic is part of work by the Housing and Health
Research Programme/He Kainga Oranga of the University of Otago, to identify
health risks in the home setting and the methods of reducing them.
The adoption and implementation of public and private
policies to control SHS depends partly on the related knowledge and attitudes of
the population. As New Zealand legislation now controls smoking in nearly
all interior work and public places, homes and cars are now the areas with the
most potential for further protecting public health from the SHS hazard.
The context for knowledge about the effects of exposure to
SHS includes the information found in the media (including paid advertising),
formal education in schools and elsewhere, information to patients and their
families from health professionals, and the experience of individuals in
observing the effects of SHS. In addition, the tobacco industry and other
commercial groups in New Zealand still deny the substantial health effects of
SHS.1
Worldwide, the tobacco industry has been concerned to
maintain the idea that the scientific evidence about SHS harm is debated and
controversial. For instance, a study found that reviews of the health effects of
SHS were over 80 times more likely to find no health effects if the authors were
tobacco industry funded.2 In New Zealand, a
representative of British American Tobacco (BAT) gave evidence to the Health
Select Committee of Parliament in November 2002. He was reported as saying
that:
‘in
our view, it has not been established that ETS [environmental tobacco smoke]
exposure genuinely increases the risk of nonsmokers developing lung cancer or
heart disease’3
Currently, the BAT New Zealand website states:
‘...
we think that many of the claims against environmental tobacco smoke have been
overstated. Specifically, we don’t believe that it has been shown to cause
chronic disease, such as lung cancer, cardiovascular disease or chronic
obstructive pulmonary disease, in adult non-smokers’
‘....
the studies on lung cancer to date suggest that if there is a risk, it is too
small to measure with any certainty. .... There is evidence for example that
exposure to it is related to acute illnesses, like respiratory and ear
infections, in children who live in smoking
households’1
Much of the context for public knowledge about SHS is
determined by the coverage of the subject by mass
media.4 In the USA, there has been a persistent
gap between the scientific consensus about SHS harm and the media coverage of
that consensus, with media continuing to report that the science was
‘controversial.’5
Attitudes to SHS and restrictions on smoking arise within a
context of beliefs about rights and obligations. For instance, depending on
their views and the way in which the topic is framed, people will support the
rights of children to health, or will advocate a smoker’s right to do what
they want in their own home (including smoking in a house with children). The
New Zealand Human Rights Commission does not consider that smoking is a right
under the Human Rights Act.6
The normalcy of smoking restrictions within a society
affects attitudes about SHS restrictions in private places. Workplace bans
appear to create spillover effects, with Australian evidence indicating that
those working in places with smoking restrictions are more likely to discourage
visitors from smoking in their homes. Other predictors of positive attitudes to
SHS restrictions in the home include the presence of children, some or all the
adults being non-smokers, and believing that SHS can harm
people.7
Some of the elements that may affect smokers or non-smokers
attitudes about SHS include perceptions about the amount of SHS around
themselves or their children. If the amount is
perceived as small, and the risk of
that SHS to health is perceived as trivial, action to change the situation can
be seen as unnecessary.8 This tendency can be
exacerbated by the extent to which people have unfounded optimistic views about
risks to themselves. Optimism tends to be greatest for risks thought to be
personally controllable, and where the evidence of harm is
delayed.9
MethodsA search was made in
April–May 2004, through Medline and other electronic search engines, using
combinations of the following search words: Zealand, Maori, environmental,
secondhand, tobacco, smok*, home*, infant*, child*, and parent*. The references
within the material found enabled further publications to be identified. In
addition, official and other reports were obtained by inquiries to official and
other agencies. Additional trend analyses were conducted on some of the data
obtained using the software package Epi Info 2000.
ResultsPublic
knowledge of SHS hazards—In 1989, there were considerable
differences in the reported knowledge of harm to health from SHS, by ethnicity
(Table 1). However, by 1999 there was little difference between the responses of
Maori respondents and respondents from the total population, with at least 90%
agreeing in 2003 that there was harm from SHS (Table 1).
One of the first extensive surveys in New Zealand, on
knowledge about SHS effects, was done in 1988 for the Tobacco Institute of New
Zealand (TINZ) by the Heylen Research Centre. The survey was of 1000 people aged
15 and over. When asked if the statement ‘Science has not established that
other peoples’ cigarette smoke is a health hazard to non-smokers’
was true or false, 26% said true, and 69% (52% of smokers) said
false.10 The survey report gives data from
earlier New Zealand surveys, with reactions to the statement ‘Cigarette
smoking is not harmful to non-smokers’. Agreement to this statement in
1982 and 1985 was 16% and 12%
respectively.10
A 1989 survey for the Department of Health asked if the
statement: ‘The health of non-smokers can be damaged by other
people’s tobacco smoke’ was true. A large majority (84%) agreed, 6%
disagreed, and 10% said neither, or didn’t
know.11 Populations whose agreement was lower
than average included those over 55 years of age (74%), Maori (65%), Pacific
(69%), and smokers (60%). By 1991, the same statement was agreed to by
significantly more of those groups who previously had lower than average
agreement.12
The
depth of the knowledge about SHS effects—The depth of knowledge
about harm from SHS has been investigated in two Wellington area surveys: in
1997 and 1999–2000. These indicated that only half or less of the groups
surveyed were aware that SHS contributed to all of five specific health
conditions (Table 2).16,17 In one survey, of
Wellington bar and restaurant staff and owners, less than a third of
interviewees knew of the risk for strokes from
SHS.17 In an Auckland survey, 1376 Pacific
mothers of 6-week-old infants were ‘given a short description of sudden
infant death syndrome (SIDS)’ and asked if they had heard of ‘the
ways parents could help prevent SIDS or cot death’. Only 32% reported
maternal smoking as a risk factor.18
Public
attitudes to SHS in homes and cars—Apart from the 1988 survey for
TINZ, most of the New Zealand data on attitudes to SHS in homes and cars has
been gathered since 1999. The questions used have varied from asking directly if
‘people should be able to smoke’ in homes and cars, to questions
which frame smokefree homes as a right. In addition, there have been questions
about smoking when children are around or when there are car passengers. Data
about reported smokefree policies for homes can also be interpreted as evidence
about attitudes.
The 1988 survey for TINZ gave seven options for preferred
smoking policies in homes and cars. Even so, 41% of non-smokers and 4% of
smokers wanted no smoking at all in their own homes. For other peoples’
homes, 35% of non-smokers and 18% of smokers wanted no smoking at all. For
private cars, 58% of non-smokers and 18% of smokers wanted no smoking at
all.10
A 1997 Wellington area survey asked for reactions to the
statement ‘it should be made illegal for people to smoke in cars when
there are passengers.’ Over 50% of interviewees agreed, including 43% of
smokers. Over 85% of interviewees (78% of smokers) agreed that homes should be
smokefree ‘when there are children around,’ and 94% agreed that cars
with children in them should be smokefree (86% of
smokers).16 Surveys between 1999 and 2003
indicate that support for smoking at home has declined significantly (Table
3).15
If questions were framed in terms of children, or rights for
smokefree homes, very different answers were given. During 1999–2003, over
90% of both Maori and the general population disagreed with the statement that
it was ‘OK to smoke around
children.’15 Over 80% of both Maori and
the general population indicated that people have a right to live in an
environment free of smoke. Most smokers (81% overall, 76% of Maori smokers)
agreed to this principle.13,15
Finally, the depth of information about the effects of SHS
may affect attitudes to smoking. In a survey during 1999–2000 of
Wellington bar and restaurant staff and owners, interviewees were asked about
the risk of seven health conditions from SHS. Those aware of all seven risks
were twice as likely compared to all other interviewees to want no smoking in
bars (14% compared to 7%, p=0.009), and over twice as likely to want stronger
restrictions on smoking in bars (21% compared to 9%,
p=0.012).19
Attitudes about SHS
relative to behaviour—There are large gaps between people’s
general views on SHS and their self-reported smoking behaviour. In the 1997
Wellington area survey, only 50% of smokers ‘reported not smoking in the
company of children’, despite 78% agreeing that homes should be smokefree
‘when there are children around’.16
There are also gaps between behaviour and the general acceptance of rights for
smokefree homes. Of 14–15 year old students with at least one parent who
smoked, less than 45% reported having a smokefree home, despite over 80%
acceptance by smokers of the right for a smokefree
home.13,20
DiscussionLimitations
of the data—The data on the depth of knowledge about SHS effects
are from regional surveys, and may not be generalisable to the rest of the
country. Because of this, and the changes in knowledge and attitudes over time,
there is an ongoing need for national data on these issues. There is also a need
for surveys that seek unprompted responses to questions such as ‘what are
the health effects of other peoples’ smoke’. These questions may be
more effective in determining the depth of knowledge about SHS, compared to
questions that prompt about particular health effects.
There is also a lack of New Zealand data on the perceptions
of SHS harm compared to other causes of harm, the perceived immediacy or
distance of SHS harm, the frequency of any prompts about SHS harm, and their
effectiveness. Furthermore, because of the wide variance between the answers for
different questions about attitudes to SHS in private places, there appears to
be a need for much more detailed data on the way New Zealanders balance support
for ‘rights’ to smokefree homes and their preferences for permitted
smoking.
Key
findings—While New Zealand adults’ awareness that SHS is
harmful appears to have been high since 1988 or before, with generally less than
10% of the population unaware of the harm since 1999, this impression may
obscure considerable variance in the depth of knowledge about the harm.
The New Zealand data illustrate that when survey questions
about attitudes to SHS restrictions include the context of rights to live in a
smokefree setting, interviewees are much more likely to favour the smokefree
approach. This result echoes New Zealand survey data about attitudes to
smokefree workplaces, where survey questions that included the context of rights
to be smokefree also produced higher levels of
support.21 However, declared attitudes on the
need for smokefree homes are not necessarily reflected in actions by smokers to
reduce SHS exposure to others.
The depth of
knowledge—The evidence of a varied depth of knowledge of SHS
effects (depending on the groups asked and the questions used) is repeated
elsewhere. In an Australian survey in 2000, there were large differences between
the knowledge of SHS health effects—ranging from over 80% agreeing that
there was an increased risk of lung cancer, child asthma, and child respiratory
problems, to only 31% agreeing that there was an increased risk of child ear
problems.22 The quality of knowledge about SHS
effects is important, as behaviour about SHS depends on the depth of information
available, and the emotional value of the information to the recipient, amongst
other things.23,24
The
effect of knowledge and attitudes about SHS on actions—Elements
which may effect smokers or non-smokers actions include their knowledge about
SHS, their interest in SHS effects, their ability to make plans to act, and
their ability to carry out any plans. For instance, they may know of some risks
from SHS to children, but the risk is either outweighed by other immediate
needs, or there is an indifference to that level of risk. The
possible and future health effects of
SHS often appear distant compared to the immediate need to end nicotine craving,
or welcome a (smoking) guest.8 Smokers can use
‘self-exempting’ beliefs (varied forms of denial) to help reduce the
contradictions between their knowledge of SHS risks, and their
behaviour.25
Smokers or non-smokers may be interested in SHS risks, but
may be unable to make plans to act. They may have limited experience of others
near them succeeding, have little experience of being able to persuade others to
change behaviour, or be unable to break down the tasks into practical stages.
The ‘costs’ of acting may be too great at particular times or
overall, compared to the perceived benefits (the costs may be immediate and
concrete, and benefits diffuse and in the future).
Factors in deciding actions include the severity and
likelihood of perceived effects of SHS; the perceived benefits and costs of
acting; the proximity of the threat or
benefit; and the frequency of effective prompts about threats, benefits, and
their proximity. Many of these factors are heavily dependent on context, such as
the opinion of friends, experience, cues (smokefree notices, bans elsewhere),
and emotions (e.g. due to experience of illness of
children).8
Policy
implications—Changing the behaviour of others in one’s
household, especially smokers, is more difficult when there are higher numbers
of smokers per household. Once there is some form of local majority in favour of
smokefree homes (e.g. the majority of a personal circle), changing household
behaviour is likely to become easier however. Thus a ‘critical mass’
is needed for the adoption of the idea.8 In
turn, these local norms are generally influenced by societal norms.
The need for local and societal-wide change suggests the
importance of further Government investment in mass media campaigns on SHS
issues (to supplement the low intensity campaigns that have occurred in recent
years in New Zealand). Evidence elsewhere indicates that exposure to such
campaigns, within strong and comprehensive national tobacco control programs,
can increase the likelihood of smokefree
homes.4,26,27 This is supported by the strength
of the evidence showing that, compared to many tobacco control
interventions,28 mass media campaigns (as part
of comprehensive tobacco control programs) can decrease smoking prevalence
cost-effectively.
However, the very low levels of resources invested in New
Zealand tobacco control health promotion campaigns (which are largely mass
media) may be below an adequate intensity threshold to be sufficiently
effective. In the 2003–2004 year, for example, less than $7 million was so
invested by Government through the two main national agencies: the Health
Sponsorship Council and the Quit Group (personal communication, J Muschamp,
2004).29 This compares with, for instance, over
$31 million per year spend on road safety information and
promotion.30
Furthermore, annual tobacco-related deaths in New Zealand
are over 10 times the level of road
deaths.30,31 Thus, national-level health
promotion spending to prevent deaths is under $1400/death for tobacco control,
compared to $69,900/death for road safety. Indeed, in terms of the prevention of
premature deaths, national tobacco control health promotion campaigns appears to
be funded at a fiftieth or less of the rate for road safety.
Further actions needed to increase knowledge and change
attitudes include the enforcement of existing New Zealand statue law by
Government, so as to prevent the dissemination of misleading information on
smoking and SHS by the tobacco industry.
ConclusionsWhile New Zealanders’
knowledge about SHS effects has improved since 1989, this knowledge appears to
remain shallow in quality. Survey data indicates that public support for
smokefree homes has increased, but varies markedly with the type of question
asked. Further reduction in SHS exposure in homes requires further changes in
societal norms on such exposure. A greater investment to create supportive
environments for smokefree homes and cars would help these changes, and
facilitate a reduction in the substantial morbidity and mortality burden from
SHS.
Author information:
George W Thomson, Research Fellow; Nick A Wilson, Senior Lecturer;
Philippa Howden-Chapman, Associate Professor, Department of Public Health,
Wellington School of Medicine and Health Sciences, University of Otago,
Wellington
Acknowledgements:
The Health Research Council of New Zealand funds the Housing and Health Research
Programme/He Kainga Oranga of the University of Otago, and The Health
Sponsorship Council was very helpful in supplying reports and information to us.
We also very much appreciate the advice given by an anonymous reviewer.
Correspondence: Dr
George Thomson. Department of Public Health, Wellington School of Medicine and
Health Sciences, University of Otago, PO Box 7343, Wellington South. Fax: (04)
389 5319; email: gthomson@wnmeds.ac.nz
References:
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