Tobacco and Public Health - TCSC Indonesia

RON BORLAND AND CLAIRE DAVEY 721
for single parents where there is reduced opportunity to go ‘off duty’ (Ashley and
Ferrence 1998).
For a smoker who lives alone or with non-smokers and has few smoker friends who
visit, ETS control is largely a personal choice. For most other smokers the task is more
of a collective one. In all houses where it is consequential, there is more than one person
involved within the household. Even if the household agrees to eliminate smoking
inside there is the problem faced in dealing with friends who visit and the need for
smokers to maintain behavioural consistency if it is going to be feasible to expect
friends not to smoke when they visit. Take the case of a smoker who reluctantly agrees
to have his household smoke-free, but then goes and smokes at a friend’s place whom
subsequently visits and goes to light up. What does the person do? Asking the person
not to smoke violates the principle of reciprocity, yet allowing it violates an agreement
with his/her family. This highlights the fact that a ban on smoking in one’s home can
change the nature of a person’s relationships with all affected people (e.g. smokers who
visit). In social context where smoking around others is not implicitly accepted as an
issue, negotiating such a change in relationships with a range others is likely to be difficult
as there may be no shared reason to justify the act. However, as the social context
changes to where most smokers expect not to smoke around others, the opposite
would be the case, and it would be difficult to smoke in others homes, as it would be
likely to threaten relationships.
Research or strategies to increase home-based smoking restrictions demonstrates
that focused ‘clinical’ interventions find it difficult to gain much change in homesmoking
unless they are quite intense, and even here effects are modest (Borland et al.
1999; Hovell et al. 2000). For example, Hovell et al. (2000) used seven counselling
sessions to find a modest effect. By contrast, in communities that are aware of the risks
and where there has been mass public education to encourage smoke-free homes, there
can be rapid increases in the rates of smoke-free homes (Borland et al. 1999). If we are
to action high levels of smoke-free homes, the best strategy would seem to be changing
community norms about what is acceptable. To do this requires innovators, who will
often be parents of children at high risk (e.g. asthmatics). In our view, clinical style
interventions have a limited role in protecting children from ETS. A case can be made
for developing better clinical interventions to help parents of high risk children move
ahead of social trends. A further possible role for intense interventions may be among
those who have special problems in enacting home restrictions; for example, single
parents in high rise apartments, but even here environmental change may be more
important than any form of skills training.
In cases where not smoking in the home is not practical, there is a need to explore
which exposure reduction strategies are likely to be most effective. Wakefield et al. (2000a)
have shown that lesser restrictions lead to lower cotinine levels than no restrictions,
even though levels are greater than for total bans. Wakefield et al. found that smoking
in rooms the child rarely frequents was associated with lower exposures, but it is not