Introduction
The smoking epidemic affects the health and quality of life of active and passive smokers. Smoking is considered a serious public health and social problem, especially by health professionals, educators, legislators and environmentalists. It is one of the greatest causes of preventable diseases and deaths. In the Twentieth Century alone, smoking killed 100 million people worldwide. Today, smoking kills roughly 5 million people per year, of which 200 thousand are Brazilians. In the last decades, scientific studies have proved that smoking hazards are real. Smoking is considered a risk factor of a number of neoplasms and respiratory and cardiovascular diseases. Smoking is a burden imposed on families, on the poor and on public healthcare systems 1,2,3.
In Brazil, one-third of the adult population smokes. Studies have shown that approximately 90% of adult smokers began smoking during adolescence. For many different reasons, adolescents begin smoking without realizing that the apparently harmless habit will render them dependent on a drug that may cause disease, compromise their quality of life and cause environmental damages. According to the World Health Organization (WHO), roughly 100 thousand youth start smoking daily, which is a great challenge for pediatrics1,2,3.
This chapter intends to sensitize, draw the attention of and mobilize health professionals to join the anti-tobacco battle. In 2010, the CAMPANHA QUIXOTES DA SAÚDE NA LUTA CONTRA O TABAGISMO NA INFÂCIA E NA ADOLESCÊNCIA (Campaign of the Impractical Health Idealist in the Battle against Smoking during Childhood and Adolescence) was launched at the Instituto de Puericultura e Pediatria Martagão Gesteira of the Federal University of Rio de Janeiro (IPPMG-UFRJ) to celebrate the National Fight-against-Tobacco Day. A symbol was created to draw the attention and arouse the curiosity of adults and children: Don Quixote armed to fight against windmills, represented by cigarettes! One of the objectives of this campaign is to appreciate the role of the pediatrician in preventing smoking and promoting child and adolescent health.
The Problem: cigarette smoke
Environmental tobacco smoke (ETS) is the smoke produced by cigarettes, also called second-hand smoke, and consists of particles with a mean diameter of 0.4 micron which may reach the alveoli and enter the blood. ETS is especially harmful to children because of their more vulnerable airways and, especially, because younger children spend more time at home. The first-hand smoke inhaled by the smoker has larger particles, ranging from 0.7 to 1 micron, which are retained in the upper airways (UA) and bronchi 4,5.
Cigarettes contain more than 4720 toxic substances. Many of these compounds are proven toxic to the respiratory epithelium. Cotinine, a toxic metabolite of nicotine, is capable of reducing the ciliary beating of epithelial cells in vitro significantly.
Additionally, acute or chronic exposure to cigarette smoke also compromises mucociliary transport in humans, promoting important structural changes in the respiratory epithelium. Chronic exposure to cigarette smoke may also increase bacterial ability to adhere to epithelial cells, possibly by changing the characteristics of the mucous surface, and some of these bacteria may be pathogenic 6.
Many diseases are associated with smoking: bronchitis, emphysema, lung, mouth and larynx cancer, periodontal problems, cardiovascular diseases (stroke and myocardial infarction), infertility (when both smoke), abortions, maternal bleeding, preterm birth, low birth weight and sudden infant death syndrome (SIDS) caused by changes in the respiratory center 1,2,3.
Of the innumerous substances found in cigarettes, nicotine is the one responsible for chemical dependency. It reaches the central nervous system (CNS) within seconds of inhalation and causes a sensation of relaxation and pleasure. It also increases the release of plasma catecholamines with vasoconstriction and may increase heart rate and blood pressure.
Active or passive inhalation of cigarette smoke has been associated with chronic eye, nose and oropharynx discomfort and irritation7. Nonsmokers exposed to second-hand smoke are called passive or involuntary smokers. According to the WHO, passive smoking kills roughly 600 thousand nonsmokers yearly worldwide, of which approximately 165 thousand are children under five years of age. Passive smoking is associated with higher risk of asthma signs and symptoms during childhood, higher number of respiratory infection episodes and higher hospitalization index secondary to respiratory problems 4,8,9.
Children living with smokers are exposed to many hazards, such as numerous inflammatory and infectious diseases of the respiratory tract. In adulthood, they are at increased risk of bronchitis and emphysema (chronic obstructive pulmonary disease or COPD) and lung cancer 5.
It is well known that cigarette smoke compromises the upper airways. Since 1964, data has shown that exposure to cigarette smoke may worsen and prolong rhinosinusitis 10.
A long battle history
Medical and public health entities have been fighting for a long time to blame the tobacco industry (TI) for the striking number of deaths and great suffering caused by tobacco-related diseases. Only recently, in 1994, the industry was unmasked by its classified documents. The tobacco industry was well aware of the deleterious effects of nicotine on the central nervous system 8,10.
The tobacco epidemic encouraged a global effort to create the first International Public Health Treaty at the end of the Twentieth Century, the Framework Convention on Tobacco Control (FCTC) signed by 192 countries and supported by the WHO 3,12.
The main objective of FCTC is to protect present and future generations of the devastating health, social, environmental and economic consequences of smoking and exposure to cigarette smoke 12,13.
After signing the FCTC in 2005, the Brazilian National Tobacco Control Program gained state policy status, becoming the National Tobacco Control Policy. In 2012, through the José de Alencar Gomes da Silva National Cancer Institute (INCA), Brazil was nominated for the fourth time a PAHO/WHO Collaborating Center for the 2012-2016 period.
In order to transform this global consensus into a global reality, the WHO
developed the MPOWER, actions that encourage society to participate in political actions and aim to 3,12:
M – Monitor tobacco use and prevention policies
P – Protect people from tobacco smoke
O – Offer help to quit tobacco use
W – Warn about the dangers of tobacco
E – Enforce bans on tobacco advertising, promotion and sponsorship
R – Raise taxes on tobacco.
In the last 20 years (1989 to 2008), the number of smokers in Brazil older than 15 years of age decreased significantly, from 32% to 17.2%. Two anti-smoking actions that stand out are the changes made to the Brazilian legislation during this period and the federal anti-smoking law passed in 2011. This law prohibits smoking in public, indoor environments 4.
On the other hand, many countries still require effective actions and legislation that control smoking. They allow the tobacco industry to enter freely in the heart of society through marketing strategies and extraordinary economic power. The industry tries to impose a behavioral model that includes smoking as one of the people’s daily activities, making it socially acceptable, and encourages adolescents to start smoking.
Pediatricians are in a privileged position since they are the first professionals to provide care to children and know how they develop. It is essential to be attentive and well informed, to face the challenges creatively, and to help in the development of new all-encompassing and interdisciplinary approaches to the theme.
Children and adolescents are generally more susceptible to the influence of their peers and parents and of publicity. Easy access to cigarettes at home, ability to buy one cigarette at a time and curiosity facilitate smoking. Sometimes the smoker exemplar is very close: family members (older brother, uncles, grandmothers) and friends or leaders (teachers, television and movie actors) act as role models or provide a cultural identity2,4.
Recent studies indicate adolescence as one of the richest life stages, with countless learning, experimentation and innovation possibilities which need to be lived fully, healthily and stimulatingly, and protected by the rights granted by the Convention on the Rights of Children and Adolescents.
Adolescence is also a time of conflicts and changes, making it also a phase of high vulnerability to drugs. Curiosity and the desire to imitate friends that smoke lead adolescents to try the drug. Currently, girls are the target of the tobacco industry.
In order to recruit new smokers, the industry has characterized female smokers as successful female models that represent social boldness and evolution.
Many youngsters have the common sense to know that smoking is detrimental to health. It is necessary to increase their knowledge and share scientific information, and education is the way to do. The educational proposal should be attractive and use clear and accessible language for people to better understand the dangers of smoking. It is essential to know that in addition to the dangers to smokers’ health, smoking also affects the environment and society, causing deforestation, fires and air and water pollution 11.
Cigarettes must be shown as drugs, merchandise, a lucrative market that affects everyone’s health but is disguised as pleasure and happiness.
Passive smoking and respiratory diseases during childhood.
Many studies include passive smoking (PS) as a risk factor for otitis media (OM) in children. The theme is still controversial because some studies do not allow the establishment of a cause-and-effect relationship between OM and PS 13.
Already in the 1970s, studies started finding a higher rate of OM and other ear, nose and throat (ENT) conditions in children living with smokers. Children whose parents smoked started smoking through their noses, inhaling second-hand smoke. Hence, a higher rate of OM, and even of lower respiratory tract infection in children, was noticed in smokers’ homes 14. Respiratory symptoms such as recurrent or chronic coughing are common in passive pediatric smokers. Still in the 1980s, Dutau drew attention to the fact that parent who smoked had children who coughed (parents fumeurs, enfants tueurs)15. Back then, a study done in a neighborhood of Rio de Janeiro using home interviews found a relationship between smoking and general respiratory problems, such as asthma, pneumonia and chronic symptoms16. The highest rates of respiratory complaints were seen in homes of mothers that smoked, showing that the longer presence of the mother at home as opposed to the father, generally exposed children to more cigarette smoke, consequently promoting chronic irritation of
the respiratory tract and related conditions. Hence, the defense mechanisms of the host would be affected by chronic exposure of the respiratory tract 17. Long-term exposure may prevent appropriate mucociliary clearance, cause nasopharyngeal lesion and loss of defense mechanisms, making the upper and lower respiratory tracts more vulnerable.
Prolonged exposure of the respiratory epithelium to tobacco smoke may facilitate the penetration of pathogens 18.
A Canadian study done in the 1990s using telephone and home interviews confirmed the role of passive smoking in diseases of the middle ear of children, and reported other risk factors, such as low socioeconomic level, low breastfeeding rates and low maternal education level, among others. Additionally, the levels of cotinine on the hair of children that lived with smokers were higher than those of children whose family members did not smoke 19.
The relationship between passive smoking and asthma is reported in many studies. The effects of smoking during pregnancy and after the child’s birth, namely recurrent wheezing and asthma, are reported in the literature and remain present until the child begins school. Some studies report a stronger relationship of passive smoking with respiratory symptoms, coughing and expectoration, than with asthma 17. However, the relationship between asthma and passive smoking in children is considered a fact.
British legislation mentions the relative high risk of asthma in schoolchildren and asthma clinically defined as a consequence of passive smoking if at least one of the parents smokes at home 20 It has been recently shown that even in adults, middle ear conditions, such as acute and secretory otitis media and otosclerosis occur more frequently in smokers than nonsmokers. Hence, the role of smoking as a trigger of OM was noticed not only in children, but also in adults 21. Naini et al also reported an evident causality between OM and passive smoking in children 22. The rate of OM in the children of smokers was 14.1%, while in those of nonsmokers, 9.1%. Moreover, as cigarette load increased, measured in pack year, disease prevalence increased. They concluded that warning the parents about the risks of smoking inside the home and advising them to avoid second-hand smoke would help to reduce the occurrence of OM in children.
Challenges and confrontation of the smoking epidemic
The practice of dialoguing during medical appointments, especially with adolescents, is essential. It promotes trust, connection and empathy with the professional, which are capable of generating mutual interest about important issues in adolescents’ lives, helping them to discover life without the stimulation provided by drugs.
In this approach, it is important to enforce and encourage a healthy lifestyle: participation in physical activities, sports, youth protagonism (in cultural movements, social actions) and sharing of ideas that may strengthen political health-promoting actions and constitute the young subject of rights.
Educational campaigns are important strategies in the battle against tobacco, since they help to draw people’s attention and warn them of the problem, increase reflections and debates, generate discussions and exchange of ideas, disclose information and incentivize the search of data in different media, especially on the Internet.
Finally, all readers are invited to join the fight and create their own antismoking campaign among friends, family and pediatric care and to engage and participate in scientific medical entities to consolidate the FCTC proposals.
References
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