COMMENTARY

Is Parental Smoking Child Abuse?

Arthur L. Caplan, PhD

Disclosures

August 14, 2017

Hi. I'm Art Caplan at the Division of Medical Ethics at NYU School of Medicine.

What about situations where parents are doing things that might hurt themselves, but also could hurt their kids or people who live with them?

I've seen some cases recently where people have argued that smoking, for example, might be abuse of any child who is living in the house with a smoker. Other situations have arisen where people know that somebody has a gun in the house, and they worry that could be a risk—not just to the person who might have a history of restraining orders against somebody, but what about the people who live there if they don't believe they can trust the person with a weapon?

It extends to drinking, drug abuse, and all types of behaviors that might put a child potentially at greater risk for harm. Legally, unless you think that somebody is in imminent danger, this isn't something that's reportable. It's not actionable if you called the police and said, "I believe that Mrs. Smith is smoking four packs a day, and that environment of secondhand smoke is bad for her new baby." You're not going to get anywhere.

Morally, I do think it's something that should be taken into account in dealing with patients. I think it's important to point out to people, look, not only is smoking not good for you, it's not good for your child. It's not good for people who come over to the house. You get all kinds of residue in the environment that may or may not be good. You could even argue that it's not good for your pets.

Sometimes, in order to change behavior, we focus on the risk to the individual, but we don't necessarily emphasize enough the impact the behavior has on others who were exposed to the same agents. Similarly, you want to be careful if you're using medications. The responsible thing to do is lock them up. Don't leave that medicine cabinet open, where a little kid could get their hands on something or a big kid could deliberately steal something.

When you prescribe medicines, you have to ask the patient to use them responsibly, and you probably have to hope and pray that they will be compliant in following the instructions. You also need to remember that you're introducing something that could be potentially dangerous into a household. If there are other people there, then patients need to take control and handle the medication—let's say an opioid or another narcotic drug—in a way that doesn't expose anybody else to risk.

In general, it's great to have a doctor/patient relationship. A lot of behavior and some of the things that get prescribed can put third parties at risk. We have to manage that too. I think we could do a better job.

Maybe the solution isn't in the courtroom to try and sue a parent who has a kid with asthma into stopping smoking, but it sure does make a strong case for pushing as hard as one can to say, look, when we're trying to get you to change your behavior, sometimes it isn't just all about you. Sometimes it's about the ones you love. We may get better results if we take that strategy.

I'm Art Caplan at the Division of Medical Ethics at NYU. Thanks for watching.

Talking Points: Is Secondhand Smoke Parental Abuse?

Issues to consider:

  • Secondhand smoke is responsible for between 150,000 and 300,000 lower respiratory tract infections in infants and children younger than 18 months, resulting in between 7500 and 15,000 hospitalizations each year.

  • Secondhand smoke also causes 430 sudden infant death syndrome deaths in the United States annually.[1]

  • Secondhand smoke exposure may cause buildup of fluid in the middle ear, resulting in 790,000 doctor's office visits per year, as well as more than 202,000 asthma flare-ups among children each year.[1]

  • More than 24 million, or about 37%, of children in the United States have been exposed to secondhand smoke.[1]

  • Smoking rates are believed to be much higher in underserved communities—as many as 40% of adults receiving Medicaid may smoke, compared with 16%-17% in the US population overall. In national samples, 40% of children have biologically confirmed evidence of secondhand smoke exposure, and exposure rates are even higher in lower socioeconomic strata and among racial and ethnic minorities.[2]

  • Courts are starting to order termination of parental rights and changes in custody status as a result of exposing children to secondhand smoke, especially when a child has asthma and other chronic secondhand-smoke–induced conditions.[3]

  • There is no national legislation that protects children from involuntary exposure to secondhand smoke in public places; worksites; and areas where children cannot avoid exposure, such as inside cars and homes.

  • Some healthcare professionals are concerned that treating smoking as a form of child abuse may result in people hiding information from their healthcare providers.[4]

  • Some are worried that treating smoking as child abuse will lead to parents neglecting healthcare entirely because they are afraid of losing custody of their children.[4]

  • Others contend that taking a punitive approach to parents who expose their children to secondhand smoke reinforces other inequalities that affect children and their families.[4]

  • In a 3-month inpatient pilot study conducted at Children's Hospital of Philadelphia, pediatric residents screened parents of over one half of patients admitted to the unit who were identified as exposed to secondhand smoke. No parents took advantage of a referral to an in-person smoking cessation program, but more than 60% of those surveyed said they had received a prescription for nicotine replacement, and 25% said they had filled the prescription and were currently using the therapy.[2]

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