Families, Systems, & Health
2005, Vol. 23, No. 1, 17–20
COMMENTARY
Protect Children From Environmental Tobacco Smoke, But
Avoid Stigmatization of Parents:
A Commentary on Pyle et al. (2005)
RICHARD BOTELHO, BMEDSCI, BM, BS, MRCGP
Children whose parents are poor and/or the
least well educated have the greatest expo-
sure to environmental tobacco smoke (ETS)
in their own home. To avoid parental stig-
matization, practitioners need cultural sen-
sitivity in using motivational principles so
that they can interact with parents in more
sophisticated ways and assist them in their
decision-making processes. In addition, leg-
islation is needed to completely ban smok-
ing in enclosed public places. Such legisla-
tion, together with media support, can, in
turn, enhance the impact of intersectoral,
community-based, and family interventions
that work through schools (e.g., the Smoke-
Free Homes Campaign in West Yorkshire,
England; P. Hodgson, 2004) and other ven-
ues in reducing ETS exposure in private
settings. This ecological strategy can, in
turn, support practitioners in working with
parents.
Richard Botelho, BMedSci, BM, BS, MRCGP, and
Kevin Fiscella, MD, Highland Family Health Center,
Rochester, New York.
Correspondence concerning this article should be
addressed to Richard Botelho, BMedSci, BM, BS,
MRCGP, Highland Family Health Center, 777 South
Clinton Avenue, Rochester, NY 14620. E-mail:
Rick_Botelho@URMC.Rochester.edu
17
Copyright 2005 by the Educational Publishing Foundation
1091-7527/05/$12.00 DOI: 10.1037/1091-7527.23.1.17
KEVIN FISCELLA, MD
onsmokers of all ages have a right to
N clean air, free of environmental to-
bacco smoke (ETS) with its 50 carcinogens
and respiratory-suspended particles less
than 2.5 microns in size (National Toxicol-
ogy Program, 2000). However, 35% of chil-
dren in the United States (i.e., 21 million)
live in homes in which residents or visitors
smoke on a regular basis (Schuster,
Franke, & Pham, 2002). The World Health
Organization’s (2003) Framework Conven-
tion for Tobacco Control treaty, the Centers
for Disease Control’s (1999) Best Practices
Comprehensive Tobacco Control Programs,
and the Americans for Nonsmokers’ Rights
(a nonprofit organization; see http://www
.no-smoke.org) all advocate for a complete
ban of ETS in enclosed spaces. However,
such international and national advocacy
has a long way to go in terms of changing
public policies. Ireland is leading the way.
It has banned ETS in enclosed public
spaces, including pubs. The alcohol service
industry initially opposed such a ban, but
the industry has undergone a 180° turn-
around. It is now promoting pubs as clean
air environments to appeal to the majority
of nonsmokers.
Pyle, Haddock, Hymowitz, Schwab, and
Meshberg (2005) examined the relation-
18 BOTELHO AND FISCELLA
ship between family rules about ETS and
children’s exposure to ETS. The results of
this study substantiate what one might ex-
pect on the basis of socioeconomic differ-
ences in smoking prevalence (Schuster et
al., 2002); children whose parents have low
socioeconomic status (SES) have the high-
est exposure to ETS at home, in the car,
and in public places such as restaurants.
Why is this result not surprising? The
smoking cessation rates among the least
educated and lower socioeconomic groups
have not declined anywhere near the same
extent as they have among the most edu-
cated and highest socioeconomic groups
(Gilman, Abrams, & Buka, 2003).
However, the finding that race was as-
sociated with fewer family rules about
smoking is not supported by previous stud-
ies. National data show comparable ETS
exposure among African American chil-
dren and White children after control for
SES (Kaufman, Cooper, & McGee, 1997).
These differences may reflect residual con-
founding by SES. Traditional measures of
SES, including income and educational lev-
els, fail to fully capture differences in SES
between Whites and Blacks (Krieger, Wil-
liams, & Moss, 1997; Okah et al., 2003).
This problem is exacerbated when binary
rather than continuous measures of SES
are used. Consequently, the association of
race with family rules about smoking likely
remains confounded by SES. This can lead
to inaccurate stereotypes. Researchers
need to exercise great caution in making
interpretations of comparisons of racial
patterns of ETS exposure in children by
SES. Despite this limitation, the most im-
portant take-home message of Pyle et al.
(2005) is that large percentages of children
across racial groups are still being exposed
to ETS, particularly among families with
low SES.
How can we expect all parents to protect
children from ETS when national policies
fail to protect children from ETS outside
the home? In the United States, only six
states (California, Connecticut, Delaware,
Maine, Massachusetts, and New York)
have achieved the National Health Objec-
tives for 2010 (U. S. Department of Health
and Human Services, 2000) and passed
laws to protect nonsmokers from ETS
(Centers for Disease Control and Preven-
tion, 2004). Family smoking restrictions in
the home of inner-city Black smokers are
associated with progress in parents’ stages
of change in terms of smoking cessation,
the presence of a nonsmoking person or
children in the household, and recent
smoking cessation (Siegel, 2002). These
findings highlight the difficulties in chang-
ing legal, social, and parental norms.
With changing social norms about ETS,
healthcare professionals are expected to
counsel smokers about the hazards of ETS
in children. Practitioners trained in evi-
dence-based guidelines rely on the five As
model to address this complex issue. How-
ever, such educational approaches have
had limited impact in changing parental
norms about ETS in children (Hovell et al.,
2000).
However, let us look at the root causes
of the situation. The Machiavellian tobacco
companies unashamedly and unabashedly
use sophisticated marketing techniques
and emotional manipulation to victimize
and induce vulnerable populations (partic-
ularly the low socioeconomic groups) into
lifelong nicotine addiction. Furthermore,
these perpetuators have opposed restric-
tions on ETS. Counteradvertising, when
adequately funded, can reduce rates of
smoking, as was shown in California in
the 1990s (Gross, Soffer, Bach, Rajkumar,
& Forman, 2002). Unfortunately, most
states use tobacco settlement payments
for purposes other than smoking preven-
tion (Lawlor, Frankel, Shaw, Ebrahim, &
Smith, 2003).
Yet, as social norms change toward lim-
iting ETS, the same vulnerable popula-
tions are at risk of being stigmatized about
their addiction by social disapproval and
well-meaning healthcare professionals who
use threatening and/or fear-based inter-
 COMMENTARY
ventions that evoke shame responses. Such
stigmatization and shame responses can
have the opposite of the desired impact:
They may make some parents more resis-
tant to change.
To avoid the pitfall of inadvertent stig-
matization, these populations need profes-
sional and societal support to undo the
harms propagated by tobacco companies’
unethical yet legal behavior. At the mic-
rolevel, practitioners need cultural sensi-
tivity in using motivational principles so
that they can interact with parents in more
sophisticated ways and assist them in their
decision-making processes (Botelho, 2004b;
Lawlor et al., 2003).
At the meso level, we also need intersec-
toral and community-based approaches
that work through schools and other ven-
ues, such as the Smoke-Free Homes Cam-
paign in the region of West Yorkshire in
England (Hodgson, 2004). This campaign
focuses on negotiating with interested par-
ents in selecting one of the following goals:
1. bronze promise: “I/we promise to
never smoke in the presence of
children”;
2. silver promise: “I/we promise to limit
smoking to one room in the house and
never in the presence of children”;
3. gold promise: “I/we promise to make
our home totally smoke free.”
During the first 12 months of this
project in Wakefield, 90% of the 500 smok-
ers selected the gold promise. Even though
there is little evidence that the bronze and
silver promises will benefit children’s
health, this strategy has motivational prin-
ciples (e.g., providing choices about risk re-
duction options) embedded in its process
that can engage parents in ways that can
minimize the risk of stigmatization. In ad-
dition, parents can use family interven-
tions (e.g., mutual aid and self-help guide-
books; e.g., Botelho, 2003, 2004a) to ad-
dress any risk behaviors, with or without
lay and professional support.
19
At the macro level, enacted legislation is
needed to completely ban smoking in en-
closed public places. Such legislation, to-
gether with media support, can, in turn,
enhance the impact of community mobili-
zation strategies and family interventions
in reducing ETS exposure in private set-
tings. This ecological strategy of using com-
plex process interventions at multiple lev-
els can support the role of practitioners in
working with parents.
REFERENCES
Botelho, R. (2003). My healthy habits journal:
Stepping stones to lasting change. Roches-
ter, NY: Motivate Healthy Habits Publica-
tions.
Botelho, R. (2004a). Motivate healthy habits:
Stepping stones to lasting change. Rochester,
NY: Motivate Healthy Habits Publications.
Botelho, R. (2004b). Motivational practice: Pro-
moting healthy habits and self-care of chronic
diseases. Rochester, NY: Motivate Healthy
Habits Publications.
Centers for Disease Control. (1999). Best prac-
tices for comprehensive tobacco control
programs. Retrieved August 1999 from
U.S. Department of Health and Human
Services Web site: http://www.cdc.gov/
tobacco/bestprac.htm
Centers for Disease Control and Prevention.
(2004, November 12). Indoor air quality in
hospitality venues before and after imple-
mentation of a clean indoor air law—West-
ern New York. Morbidity and Mortality
Weekly Report, 53(44), 1038 –1041.
Gilman, S. E., Abrams, D. B., & Buka, S. L.
(2003). Socioeconomic status over the life
course and stages of cigarette use: Initiation,
regular use, and cessation. Journal of Epide-
miology & Community Health, 57, 802– 808.
Gross, C. P., Soffer, B., Bach, P. B., Rajkumar,
R., & Forman, H. P. (2002). State expendi-
tures for tobacco-control programs and the
tobacco settlement. New England Journal of
Medicine, 347, 1080 –1086.
Hodgson, P. (2004, July). Smoke-Free Cam-
paign: Draft interim report. West Yorkshire,
England: West Yorkshire Smoking and
Health. (Details available from Joy Lane at
coljoy@lane6360.fsnet.co.uk).
Hovell, M. F., Zakarian, J. M., Matt, G. E., Hof-
stetter, C. R., Bernert, J. T., & Pirkle, J.
(2000). Effect of counseling mothers on their
children’s exposure to environmental tobacco
20 BOTELHO AND FISCELLA
smoke: Randomised controlled trial. British
Medical Journal, 321, 337–342.
Kaufman, J. S., Cooper, R. S., & McGee, D. L.
(1997). Socioeconomic status and health in
Blacks and Whites: The problem of residual
confounding and the resiliency of race. Epi-
demiology, 8, 621– 628.
Krieger, N., Williams, D. R., & Moss, N. E.
(1997). Measuring social class in US public
health research: Concepts, methodologies,
and guidelines. Annual Review of Public
Health, 18, 341–378.
Lawlor, D. A., Frankel, S., Shaw, M., Ebrahim,
S., & Smith, G. D. (2003). Smoking and ill
health: Does lay epidemiology explain the
failure of smoking cessation programs among
deprived populations? American Journal of
Public Health, 93, 266 –270.
National Toxicology Program. (2000). Ninth re-
port on carcinogens. Research Triangle Park,
NC: National Institute of Environmental
Health Sciences, U.S. Department of Health
and Human Services.
Okah, F. A., Okuyemi, K. S., McCarter, K. S.,
Harris, K. J., Catley, D., Kaur H., & Ahluwa-
lia, J. S. (2003). Predicting adoption of home
smoking restriction by inner-city Black
smokers. Archives of Pediatrics & Adolescent
Medicine, 157, 1202–1205.
Pyle, S. A., Haddock, C. K., Hymowitz, N.,
Schwab, J., & Meshberg, S. (2005). Family
rules about exposure to environmental to-
bacco smoke. Families, Systems, and Health,
23, 3–16.
Schuster, M. A., Franke, T., & Pham, C. B.
(2002). Smoking patterns of household mem-
bers and visitors in homes with children in
the United States. Archives of Pediatrics &
Adolescent Medicine, 156, 1094 –1100.
Siegel, M. (2002). The effectiveness of state-
level tobacco control interventions: A review
of program implementation and behavioral
outcomes. Annual Review of Public Health,
23, 45–71.
U.S. Department of Health and Human Ser-
vices. (2000, November). Healthy people
2010 (2nd ed., Vols. 1 and 2). Retrieved Feb-
ruary 2005 from http://www.healthypeople
.gov/publications/
World Health Organization. (2003). WHO
Framework Convention on Tobacco Control.
Geneva, Switzerland: Author. (For more in-
formation, see http://www.fctc.org/about_
FCTC/).