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Secondhand Smoke (SHS) and Children: A Nurse Cries for Help!

How Can Nurses Help Advocate for Children with Parents Who Smoke?

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RNat55 has 1 years experience as a ADN, RN.

I love advocating for those who are unable to advocate for themselves. It is time to rise and speak up against the horrific effect of secondhand smoke on children and the unborn. Read on to find out the dangers and what you, as a nurse, can do.

Secondhand Smoke (SHS) and Children: A Nurse Cries for Help!
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Norma is a 68-year-old lady who grew up with her parents in Florida. For years she has sought help due to various health challenges. Recently she was diagnosed with COPD, a disease of the lungs that affect smokers. This came as a shock because she had never smoked but she remembers that “Both mom and dad smoked till I left the house at twenty years old, 4 cartons a week” she explained to me. The effect this had on her at the time was that she “didn’t want to marry anybody who smoked.” Finding out about this was devastating as she says “I breathe mostly out of my mouth, so I think that has caused me more problems.”

“Tobacco use harms not only individual tobacco users but also others who are exposed through secondhand and thirdhand tobacco smoke exposure,” the American Academy of Pediatrics (AAP) confirms. “More than half of US children are regularly exposed to tobacco smoke” it explains. “There is no safe level of tobacco smoke exposure.” Studies confirm the home setting as the primary source of exposure for children since they are dependent on others who may be smoking. A recent study estimated 37,791 never-smoking children and adult U.S. public housing residents experienced illness and death due to exposure at home. This cost taxpayers a total annual sum of $450m.

This danger is not just in homes as “smoking in a motor vehicle exposes children to high concentrations of tobacco smoke,” AAP says.

With our training as nurses, we should be concerned with health promotion especially for those who cannot speak for themselves. We advocate daily for our patients. We come across children who are brought in with conditions arising from SHS exposure, and this should awaken that advocacy in us to speak for these little ones.

What Exactly is Secondhand Smoke?

Secondhand smoke (SHS) is made up of the smoke that comes from the burning end of a cigarette, cigar, or pipe, and the smoke exhaled by the smoker. It contains more than 7,000 chemicals that are toxic and about 70 that can cause cancer. SHS leads to third-hand smoke (THS). Center for Disease Control (CDC) defines THS as occurring when toxic residue from tobacco smoke adheres to surfaces such as carpets and walls.

AAP explains that THS “… exposes the nonuser by either direct contact and dermal absorption and/or off-gassing and inhalation...” and “… may react with oxidants and other compounds in the environment to yield secondary pollutants.” Living with her parents for twenty years also exposed Norma to THS. This may have further injured her lungs.

Though Norma is seeing the effect of SHS as a senior, AAP explains that “Tobacco smoke exposure harms children from conception forward, either causing or exacerbating the risks of preterm birth, low birth weight, congenital malformations, stillbirth…” It can also cause sudden infant death, childhood obesity, behavior problems, neurocognitive deficits, other respiratory problems, and middle ear infections. Ongoing data suggest that SHS tobacco smoke exposure may not only pose a risk to the development of childhood cancers but “may increase the likelihood of smoking among young adult cancer survivors.”

Available Data

According to the American Lung Association SHS

  • Causes 150,000 to 300,000 lower respiratory tract infections in infants and children under 18 months, leading to 7,500 – 15,000 annual hospitalizations
  • Results in 430 sudden infant death syndrome (SIDS) deaths in the United States yearly
  • Results in fluid buildup in the middle ear causing 790,000 annual doctor’s office visits, and
  • Above 202,000 asthma flare-ups among children annually

The Problem

Though many states have banned smoking in cars when children are present, there is still no national law to protect these children when they are involuntarily exposed at homes, and also in cars. We have succeeded in crafting laws that prohibit smoking in public places due to its adverse effect but these laws do not include residential areas and cars where children are.

There is also a failure on the part of the society to classify this exposure by parents as an act of abuse. Doing this would hold smoking parents legally accountable for their actions. Child abuse is defined by federal law as:

Quote

any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act which presents an imminent risk of serious harm

The exposure of children meets the criteria of child abuse. Smoking constitutes “… an act which presents an imminent risk of serious harm” to the unborn child as well as living child/children. Also not removing the child from exposure constitutes the “failure to act which presents an imminent risk of serious harm.” A study rightly asserts that purposeful and continual exposure of children to a known human carcinogen despite repeated warnings is child abuse. In 2015 Adam Goldstein a professor in family medicine in North Carolina agreed with this and says this is “like drunk driving or leaving children in a hot car unattended.” This is child endangerment! Yet, children continue to be exposed in their homes daily and during drives in the family car.

Based on the Fourth Amendment, you may argue that everyone has a right to privacy for acts occurring within private residences, but that right should only exist as long as it does not infringe on the rights of others. Especially when the “others” are children who are unable to protect themselves from the exercise of that right. The state owes the duty to protect children from acts of parents that can endanger their health significantly. This duty ought to be taken more seriously.

How You Can Help Stop the Effects of Secondhand Smoke on Children

  1. Take time to write members of Congress to enact laws to stop this abuse. If your state already has clean air laws, ask the state member of Congress to amend it to include residential areas and cars where children are. AAP agrees this is one way, “prohibitions on smoking in motor vehicles with children present can be addressed”, in addition to educational interventions.
  2. Nurses could always include smoking cessation interventions for parents who smoke and have children. Meanwhile, they could be taught to consider stepping outside to smoke so they do not endanger their children. Another teaching point could be considering not hiring babysitters who smoke. For those who have children already affected, seek proper medical attention and then seek assistance to quit smoking.
  3. Nurses should educate, and make referrals for parents who repeatedly bring in children presenting with conditions that raise suspicion of exposure. Reports could be made to Social Services to report concerns about continuous exposure of children which could injure the child’s health.
  4. The American Nurses Association (ANA) and other medical associations should fight for laws that will classify such exposure as child abuse. This issue ought to take prominence at an ANA national conference. It is our responsibility as nurses to advocate for those involuntarily placed in harm’s way. We should align ourselves with John Stuart Mill’s classic statement of harm principle which explains that power can be rightly exercised against any member of the society against his will if it is to prevent harm to others, especially if the intervention is shown to be effective in preventing the harm in question. Nurses and nurses’ associations should aggressively advocate for policy changes in the workplace and the nation that would eliminate such exposure.
  5. Concerned citizens who seek nurses' help could be taught to consider petitioning the court to remove the children from the smoking parent’s home to secure a guarantee of no involuntary exposure to recurrent exposure. A study shows that our legal system now recognizes and acts on children’s continued exposure and can terminate parental rights. Furthermore, they are willing to reconsider custody status especially when a child is asthmatic or has other chronic SHS induced conditions.

Conclusion

Prohibiting smoking both in the home and vehicles is the required action to stop the effects of SHS on children. This is the surest way to eliminate SHS in the home and cause less negative health implications for children. The AAP advocates for “Smoke-free homes and smoke-free motor vehicles.” It further argues that “… (it) is one of the most important things that a society can do to protect children’s health.”

Smoking has never been and is not a fundamental right. One more infant or child should not have to suffer these horrific effects because that infant or child also has a fundamental right to live in a safe environment, one that promotes health. We all, as nurses, have a duty to ensure this.

Do you disagree or agree with me? I would love to hear from you! Leave your comments below.

References

American Academy of Pediatrics (2015). Public policy to protect children from tobacco, nicotine, and tobacco smoke. Pediatrics 136 (5) 998-1007. Retrieved from https://pediatrics.aappublications.org/content/136/5/998#ref-34

Bach, D. (2015). Is exposure to secondhand smoke child abuse? Retrieved from https://www.washington.edu/news/2015/03/24/is-exposure-to-secondhand-smoke-child-abuse-2/
Brummett, A. (2019). Whose harm? Which metaphysic? Theoretical Medicine & Bioethics, 40(1), 43–61. doi: 10.1007/s11017-019-09480-1

Collins, B. N., & Lepore, S. J. (2017). Babies living safe & smokefree: randomized controlled trial of a multilevel multimodal behavioral intervention to reduce low-income children’s tobacco smoke exposure. BMC Public Health, 17, 1–9. doi: 10.1186/s12889-017-4145-7

Definitions of Child Abuse and Neglect in Federal Law (n.d). Retrieved from https://www.childwelfare.gov/topics/can/defining/federal/

Goldstein A. O. (2015). Is exposure to secondhand smoke child abuse? Yes. Annals of family medicine, 13(2), 103–104. doi:10.1370/afm.1764

Health Effects of Secondhand Smoke. (2019). Retrieved from https://www.lung.org/stop-smoking/smoking-facts/health-effects-of-secondhand-smoke.html.

Mason, J., Wheeler, W., & Brown, M. J. (2015). The economic burden of exposure to secondhand smoke for child and adult never smokers residing in U.S. public housing. Public health reports (Washington, D.C. : 1974), 130(3), 230–244. doi:10.1177/003335491513000310

Secondhand Smoke ( n.d. ). Retrieved from https://medlineplus.gov/secondhandsmoke.html
Stop smoking support programs (n.d.). Retrieved from https://medlineplus.gov/ency/article/007440.htm

Brummett, A. (2019). Whose harm? Which metaphysic? Theoretical Medicine & Bioethics, 40(1), 43–61. doi: 10.1007/s11017-019-09480-1


Christine Vidal-Wachuku is a Registered nurse -the nurse who informs. After migrating to the United States with her family, she decided to abandon her law career and to return to college for a Bachelor of Science in Nursing degree.

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Regulating and taxing smoking out of existence seems to be working so far, so I see no reason to steer away from a good strategy. Implementing a nationwide law complete with fines for things like smoking with children in the car seems like a reasonable extension of this strategy, though it may be easier to pass laws state by state anyway. Public health investment is also, of course, welcome.

That said, I get off the bandwagon when you start talking about removing kids from the custody of smokers. Your solution to what is essentially a medical problem (and, let's admit it, usually a socio-economic one as well) comes off, frankly, as cruel, disturbing, and callous towards both the parents in question and the kids you presume to "save," and far worse than the problem it's trying to solve. Authoritarian bordering on Orwellian, too.

Apologies if I'm misreading you. But if not, then please: give fines, taxes, out-of-pocket medical costs, social pressures, and improving treatment options a chance.

Here.I.Stand specializes in SICU, trauma, neuro.

9 hours ago, RNat55 said:

Concerned citizens who seek nurses' help could be taught to consider petitioning the court to remove the children from the smoking parent’s home to secure a guarantee of no involuntary exposure to recurrent exposure.

Because the foster care system is sooooo healthy for kids? 🙄

One of my friends, has been diagnosed with COPD. she never smoked a day in her life, but her husband was a heavy smoker. He had a cardiac arrest 20 years ago and passed.

I know that children are more likely to,get sick with colds and allergies If they live with parents who smoke. But how do you make parents understand this?

JadedCPN specializes in Pediatrics, Pediatric Float, PICU, NICU.

On 1/8/2020 at 8:25 AM, RNat55 said:
  1. Concerned citizens who seek nurses' help could be taught to consider petitioning the court to remove the children from the smoking parent’s home to secure a guarantee of no involuntary exposure to recurrent exposure.

I'm sorry but this is completely inappropriate in 99% of the cases. Both of my parents were smokers and they were completely loving and nurturing - to think you would want me to be removed from their home and placed into a system because they smoked around me is just ridiculous.

Not only that but our CPS system is already so bogged down as is that it slows down getting help to children who really are unsafe due to frivolous issues like this.

I also suggest you reconsider your interpretation of both "imminent" and "serious harm."

I have awakened many times choking on the smoke coming from my upstairs neighbor. Diagnosed with asthma since I have been living in smoke city, my pulmonologist told me to move away because of the smoke and the damage to my physical health. I read that the smoke will have a derogatory effect on my CPAP machine and that it can't be cleaned out of the machine. The apartment complex management would not do anything about the problem even if they could. And I can't move. Who is there to advocate for people like me? There are more who suffer from the effects of second-hand smoke than just children. I woke up with my throat closed off, in a panic, in a 'cloud' of smoke, so I don't consider the issue to be frivolous at all.

RNat55 has 1 years experience as a ADN, RN.

On 1/8/2020 at 3:14 PM, Cowboyardee said:

Regulating and taxing smoking out of existence seems to be working so far, so I see no reason to steer away from a good strategy. Implementing a nationwide law complete with fines for things like smoking with children in the car seems like a reasonable extension of this strategy, though it may be easier to pass laws state by state anyway. Public health investment is also, of course, welcome.

That said, I get off the bandwagon when you start talking about removing kids from the custody of smokers. Your solution to what is essentially a medical problem (and, let's admit it, usually a socio-economic one as well) comes off, frankly, as cruel, disturbing, and callous towards both the parents in question and the kids you presume to "save," and far worse than the problem it's trying to solve. Authoritarian bordering on Orwellian, too.

Apologies if I'm misreading you. But if not, then please: give fines, taxes, out-of-pocket medical costs, social pressures, and improving treatment options a chance.

Thank you for taking the time to read the article. Sorry, I lost you at the end but hey, you are entitled to your opinions. I can understand your reasoning.

I am not a fan of foster homes myself, but laws are made to deter people. You might agree that if more people can be deterred due to the fear of a beloved child being taken from them (rather than just a fine or tax which can be paid and the person goes right back home and continues), I believe we would be closer to stopping the effects of secondhand smoke. The existence of such an intervention would make parents who smoke to sit up. The aim would be to protect the health of these children and safely return them to their parents as soon as practicable.

By the way, do you by any chance have any references that provide statistics for how far regulating and taxing smoking seems to be working in preventing the effects of SHS in children? I would love to read them. I love learning.

Again, thanks for your time.

RNat55 has 1 years experience as a ADN, RN.

20 hours ago, Here.I.Stand said:

Because the foster care system is sooooo healthy for kids? 🙄

No, foster care is never healthy for children. This intervention is supposed to act as a deterrent so that parents focus on smoking cessation as a top priority.

The best place for any child is where the parents are but when parents knowingly engage in acts that persistently put the child at risk; I believe it is time to take more drastic actions to protect the child.

The state ought to look into the foster care system to revamp it. It is meant to provide a temporary safe place to live while a correction is made. I believe that any parents who love their children would seek assistance to stop smoking and promote health instead.

Thank you for sharing your view.

RNat55 has 1 years experience as a ADN, RN.

20 hours ago, LPN Retired said:

One of my friends, has been diagnosed with COPD. she never smoked a day in her life, but her husband was a heavy smoker. He had a cardiac arrest 20 years ago and passed.

I know that children are more likely to,get sick with colds and allergies If they live with parents who smoke. But how do you make parents understand this?

I believe teaching provided by the nurse when the child is receiving treatment could be effective but a multifaceted approach needs to be taken.

The nurse should explain the reason for the child’s persistent medical condition; find out if any of the parents smoke, explain the effect smoke has on the child and the parent as well, then offer places where assistance could be gotten to quit. These teachings should also include effects that are likely to occur up to adulthood.

But, not all parents will understand and that’s why state to state legislation might be vital as well as other interventions mentioned above.

Thank you for sharing your concerns.

15 minutes ago, RNat55 said:

Thank you for taking the time to read the article. Sorry, I lost you at the end but hey, you are entitled to your opinions. I can understand your reasoning.

I am not a fan of foster homes myself, but laws are made to deter people. You might agree that if more people can be deterred due to the fear of a beloved child being taken from them (rather than just a fine or tax which can be paid and the person goes right back home and continues), I believe we would be closer to stopping the effects of secondhand smoke. The existence of such an intervention would make parents who smoke to sit up. The aim would be to protect the health of these children and safely return them to their parents as soon as practicable.

By the way, do you by any chance have any references that provide statistics for how far regulating and taxing smoking seems to be working in preventing the effects of SHS in children? I would love to read them. I love learning.

Again, thanks for your time.

Fines can function as deterents and so can being sentenced to death by manual labor in a gulag. The trick is to find the sweet spot that deters destructive behavior without causing needless misery via overkill. I think revoking custody is a few miles beyond the point of diminishing returns. And defending it as a deterent doesn't really work when you consider how many other perfectly good deterents you might have to choose from.

As far as data and citations go, I probably don't have what you're looking for - its not like you can easily determine cause and effect in double blind studies for massive public health policies. That said, the CDC has records of smoking prevalence by year among US citizens. It peaked out in the mid 50s at about 45% of the population smoking, slowly and steadily fell to figures just shy of 30% in the early to mid 2000s (public health education and social pressures seem likely causes of this), and fell steeply from the mid 2000s to now where the rate is around 14%. You can find all this on CDC websites. Also of note, taxes on a pack of cigarettes rose from 60 cents or so in the 90s to a little over a dollar in the mid 2000s, to something like $2.50 now. This seems to be having a big effect, though I can't definitively prove it.

https://247wallst.com/special-report/2017/06/14/price-of-a-pack-of-cigarettes-the-year-you-were-born/

Its also interesting that vaping prevalence is way up, and not just among former smokers. Its popular with teenagers. The figures I've read vary, but seem to be higher than cigarette usage currently. I don't know quite enough about vaping to say, but it seems to me that refills are functionally less expensive and less taxed (per dose of nicotine) than traditional cigarettes are, and if so, I would hypothesize that the lack of price/tax barriers may partially explain vaping's popularity.

RNat55 has 1 years experience as a ADN, RN.

3 hours ago, JadedCPN said:

I'm sorry but this is completely inappropriate in 99% of the cases. Both of my parents were smokers and they were completely loving and nurturing - to think you would want me to be removed from their home and placed into a system because they smoked around me is just ridiculous.

Not only that but our CPS system is already so bogged down as is that it slows down getting help to children who really are unsafe due to frivolous issues like this.

I also suggest you reconsider your interpretation of both "imminent" and "serious harm."

I appreciate you taking the time to read this article. I have no doubt that your parents loved you very much. Being parents who smoke doesn't mean they are not loving or nurturing. The same could be said for parents that are abusive, alcoholics or unable to provide financially for their children. These all love their children but unfortunately, this doesn't change the fact that one of their acts might not be health-wise for their children.

You may consider exposure to SHS for children frivolous but there are others like Norma out there battling the effects. They understand.

I believe in your reference to my interpretation of imminent and serious harm you were referring to 'Also not removing the child from exposure constitutes the “failure to act which presents an imminent risk of serious harm.”' According to Dictionary.com "imminent" means "likely to occur at any moment; impending" while Merriam-Webster defines harm as "often stresses the inflicting of pain, suffering, or loss." If a child is not removed from smoke exposure, doesn't this present the likelihood of suffering occurring at any moment? And the suffering could even lead to death as in the case of "430 sudden infant death syndrome (SIDS) deaths in the United States yearly."

To me, this sounds serious.

RNat55 has 1 years experience as a ADN, RN.

2 hours ago, caliotter3 said:

I have awakened many times choking on the smoke coming from my upstairs neighbor. Diagnosed with asthma since I have been living in smoke city, my pulmonologist told me to move away because of the smoke and the damage to my physical health. I read that the smoke will have a derogatory effect on my CPAP machine and that it can't be cleaned out of the machine. The apartment complex management would not do anything about the problem even if they could. And I can't move. Who is there to advocate for people like me? There are more who suffer from the effects of second-hand smoke than just children. I woke up with my throat closed off, in a panic, in a 'cloud' of smoke, so I don't consider the issue to be frivolous at all. 

I empathize with you, caliotter3. I agree that SHS is not frivolous for those suffering its effects. I hope you were finally able to move away.

Reading about your neighbor upstairs (hopefully former neighbor) reminded me of one of the studies cited in my article. In the study, the researchers sought to determine the public health burden for outcomes related to SHS exposure for nationally representative never-smoking residents in U.S. public housing. Based on their findings they concluded that lives could be saved, and SHS related morbidity and mortality in never-smoking residents could be decreased if smoke-free policies were implemented in all U.S public housing. If you are interested, you could read the study here- https://journals.sagepub.com/doi/10.1177/003335491513000310

Your CPAP machine is a good example of thirdhand smoke discussed in the article.

I agree that there are many more who suffer the effects of SHS but I decided to focus this time on children due to their vulnerability. Adults can move away, leave the home, etc but children can't. They are involuntarily exposed. They need others to speak for them. But articles like this also help to turn the searchlight on the problem so that when addressed it can fix issues for adults as well.

Thank you for taking the time to read the article and also share your personal stories and concerns.

ArmyRntoMD specializes in Critical Care.

Some of you guys are scary in a big brother kind of way. Smoking is damned stupid, but yeah... take kids into foster care because their parents smoke? You’re insane.

-Allergic to smoke and had two parents who smoked

On 1/9/2020 at 3:31 PM, RNat55 said:

No, foster care is never healthy for children. This intervention is supposed to act as a deterrent so that parents focus on smoking cessation as a top priority.

Just like laws against drinking and driving work to stop accidents?

1 hour ago, ArmyRntoMD said:

Some of you guys are scary in a big brother kind of way. Smoking is damned stupid, but yeah... take kids into foster care because their parents smoke? You’re insane.

-Allergic to smoke and had two parents who smoked

No doubt! Apparently those who advocate for terminating parental rights over second hand smoke and chucking kids into foster care have never ever worked within that system. I've seen kids get put back into home situations far worse than most people could ever imagine, and conversely foster homes that I wouldn't leave a stray dog in much less a human being.

jupitercrash specializes in School Nursing.

18 hours ago, RNat55 said:

Thank you for taking the time to read the article. Sorry, I lost you at the end but hey, you are entitled to your opinions. I can understand your reasoning.

I am not a fan of foster homes myself, but laws are made to deter people. You might agree that if more people can be deterred due to the fear of a beloved child being taken from them (rather than just a fine or tax which can be paid and the person goes right back home and continues), I believe we would be closer to stopping the effects of secondhand smoke. The existence of such an intervention would make parents who smoke to sit up. The aim would be to protect the health of these children and safely return them to their parents as soon as practicable.

By the way, do you by any chance have any references that provide statistics for how far regulating and taxing smoking seems to be working in preventing the effects of SHS in children? I would love to read them. I love learning.

Again, thanks for your time.

The foster care system is already completely overwhelmed. The amount of kids in foster care locally has increased 5x in the last 5 years due to opioids. They used to remove children over marijuana in my town, but they have stopped because they don't even have enough foster homes for the kids of parents who are on heroin and meth. Cigarettes are literally the least of anyone's worries right now. Yes, education is needed, but removing children is overreaching so far.

RNat55 has 1 years experience as a ADN, RN.

6 hours ago, CharleeFoxtrot said:

No doubt! Apparently those who advocate for terminating parental rights over second hand smoke and chucking kids into foster care have never ever worked within that system. I've seen kids get put back into home situations far worse than most people could ever imagine, and conversely foster homes that I wouldn't leave a stray dog in much less a human being.

Thank you for adding your thoughts to the discussion. And yes, I have never worked within that system but I am writing from the spirit behind the establishment of foster homes.

They are supposed to provide temporary safety for children and my understanding is that these homes could be those of relatives. As I earlier stated, I believe living with biological parents are the best for children, the problem only arises when parents act in a way that's detrimental to the children. It's unfortunate if children get put into foster homes you "wouldn't leave a stray dog" in. I sympathize with you that you had to witness this. This could be the reason we should all seek to revamp the foster home system so it can serve the true purpose it is meant for.

RNat55 has 1 years experience as a ADN, RN.

6 hours ago, CharleeFoxtrot said:

Just like laws against drinking and driving work to stop accidents?

Laws are not a perfect solution for bad acts but meant as a deterrence meaning they bring that hope that it would discourage an undesired action by bringing in fear of the consequences. Thanks for your input.

RNat55 has 1 years experience as a ADN, RN.

1 hour ago, jupitercrash said:

The foster care system is already completely overwhelmed. The amount of kids in foster care locally has increased 5x in the last 5 years due to opioids. They used to remove children over marijuana in my town, but they have stopped because they don't even have enough foster homes for the kids of parents who are on heroin and meth. Cigarettes are literally the least of anyone's worries right now. Yes, education is needed, but removing children is overreaching so far.

This is quite alarming, the way society is broken and children brought into the system to live a life that is far from being qualitative.

Education is one of the interventions I suggested with removing children as another if they are already affected healthwise, especially when parents persist and are not making efforts to quit smoking. But I can see how priority will be provided for drug-related issues especially in cities where the number of children needing these homes is quite high.

What our society is becoming is indeed disturbing. Thank you for sharing.

RNat55 has 1 years experience as a ADN, RN.

8 hours ago, ArmyRntoMD said:

Some of you guys are scary in a big brother kind of way. Smoking is damned stupid, but yeah... take kids into foster care because their parents smoke? You’re insane.

-Allergic to smoke and had two parents who smoked

Thank you for your deep concerns. Please note that I never advocated for children to be taken into foster care just because "their parents smoke."

My point on foster care was for concerned citizens who observe the continued exposure. This means the exposure is persistent and the parents appear not to be acting in the best interest of the child's health. I also mentioned that courts are even willing to reconsider custody status especially when children are asthmatic or have other chronic SHS induced conditions. In this case, the child's condition is bad and yet the parent is doing nothing to reduce or remove the harm. To me, it's like the parent is saying "Yes, I know your chronic condition is as a result of my smoking but I am not quitting. Deal with it!" Mind you, this is only one of the suggested interventions and not the only one.

Of course, you could suggest other helpful interventions that could be applied when parents persist in their smoking habits and you as a nurse keep frequently seeing these children at the hospital after all your teachings and counsel to the parents.

Looking forward to hearing from you.

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