Acceptance of harm of SHSE to children

Policy advisors and practitioners were unequivocal in their acceptance of the evidence that SHSE was a serious risk to children's health. Practitioners clearly recognised the harm to health, but were aware that they did not always look for the harm. Policy makers accepted that it should be a key part of a public health strategy. [SHS Is] very important, because we know that it affects children's health, it also makes a difference to what they do longer term, and because we work in a deprived population a lot of our patients already are at a higher risk of all sorts of illnesses, we've got a higher risk of prevalence of smoking as well. (NHS, Primary Care, FG) I suspect we probably don't look for it enough but it is clearly important. Children are exposed at all stages. From in-utero—it's normal to be exposed. (NHS, Primary Care, FG) It's very important and will always be a key part of the strategy. (Policy advisor, I)

Acceptable action

Both policy advisors and practitioners suggested policy and practice approaches to create smoke-free homes that would be acceptable and feasible. Practitioners focused on the opportunities to provide information and raise awareness that would help parents make empowered choices. It's informed choices as well, and I firmly believe that, if someone's got a child that's had glue ear for example, and nobody has ever raised that their smoking in the home can have an impact on that, then, you can't really blame that person …… if people have got the information, and they still choose to expose their children, then that's their informed choice, but I firmly believe that if they've no got the information, then you know, it's a shame really. (NHS, Smoking Cessation Practitioner, I)

This primary care participant also valued the acceptability of information, but located action within a broader public health approach. This is information that could be used in various ways; it's also difficult to know what intervention is best (for individuals). The lesson from smoking cessation is that people go through a variety of ways to quit. The intervention needs to be at different levels—policy level, legislative level, ministerial level, GP level, a brief intervention in a 10 minute consultation. (NHS, Primary Care, FG)

Policy advisors supported the development of smoke-free home interventions, as long as it did not require any legislative input. We know that the ban in 2006 did reduce children's exposure to second-hand smoke and there wasn't a corresponding transfer of exposure within the home. However, now the most likely places in which children are exposed are in the home and the car. The emphasis on SHS exposure within the home takes policy and action beyond the smoking ban into an area where it may not be possible or appropriate to legislate. Scottish Government is looking for interventions that may fill the gap that legislation may not be able to address, which it can promote. (Policy advisor, I)

Political reluctance

The potential for policy action appeared to be limited by political caution due to several reasons: the unacceptability of legislation to protect children from SHSE in the home or car, the perceived shift of public health priorities from smoking to alcohol and current financial constraints. It was argued that the private space of the home acted as a political barrier to further legislation to promote smoke-free spaces. Policy advisors in particular expressed a view that intervention in the home was seen as a step too far, despite the success of legislation on smoke-free public places. There are issues around the extent to which there is freedom to smoke in private, you know, so that, so that there's a balance to be struck there, you know, how far can you go? How far can government go to impair the choice of what goes on inside people's cars or houses or whatever. (Policy advisor, I)

Shifting public health priorities

Although the claim was made that smoking was still a national priority, policy advisors in particular highlighted the increasing public health focus on alcohol as a key priority, and that the success of smoke-free public places provided a rationale for reprioritising resources. It's not top of the agenda, I mean there are clearly all sorts of other issues live at the moment, there's limited parliamentary debating time and parliamentary process time and so on and at the moment probably the major public health intervention is around alcohol, there's a sense that okay, we've won significant progress in smoking, let's try and get alcohol under control …so that is a higher priority, but the general sense of smoking being an issue that we need to keep on top of, is very strong with ministers, the question is what's the best thing to do about it? Because, you know, it's not a dictatorship. (Policy advisor, I)

Financial constraints

The Scottish economic recession, with a focus on cuts in public spending and reductions in Scottish public sector services, was a consistent backdrop underpinning participant views. Thus, perhaps not surprisingly and despite the acceptance of harm to children, financial considerations were highlighted as constraints to developing new interventions to protect children from SHSE in the home. Participants across all sectors pointed out that there was no new money for smoke-free home interventions, that there were limited human and financial resources and this, in turn, had necessitated further prioritisation of activity. In the context of considering investing in a REFRESH intervention, one senior nurse manager (FG) commented that: It might be possible but again that's still quite expensive, because I don't know how many smokers we have in [place], but we have just over 9000 births, so 9000 times £200, that's excessive, because not everybody will be a smoker, but it's a lot of money in a cash strapped environment, so I don't, I mean, it might, I think it's a very good idea, it clearly has some impact. Int: Right, I mean, does the financial climate affect how much people can do, and how much health visitors? Yeah, well it effects how much we can buy, because you know, we have a very limited supplies budget and a very limited staffing budget.

Other nurse managers concluded that smoking interventions were currently a low priority because of the impact of cuts on other services and the subsequent problems they faced dealing with basic childcare. We were at a child protection event last week, and teachers are up against it, I mean, the very least they would be worrying about is the person smoking, actually, you know, they are worried about the child coming in and still in nappies in school, or haven't eaten, you know, so, you know, actually the priorities for them in terms of trying to get the parents to stop smoking is fairly low down, I would think, if the parents that are turning up are interested, even if they are smoking, that's a plus, you know, if they are getting their child to school, …….and they've lost a lot of support because education has been cut, you know, a lot of the people who would have done some of those interventions aren't there anymore. (NHS, Senior nurse manager, I)

More immediate child protection concerns and families with ‘chaotic’ lifestyles

Competing professional priorities were identified in relation to policy and practice. Regarding policy, there was an unambiguous declaration—as has already been noted—that smoking was no longer perceived to be the key public health priority within government and that the focus was firmly on the alcohol issue. In terms of practice, the issue was framed somewhat differently around the demands of the professional role. A common narrative was that alcohol, drugs, domestic violence and child abuse were deemed to be more pressing. I keep coming back to this, as I say the alcohol and the drugs, are probably seen by us as professionals to be more harmful, to young babies and to children, that really is the highest priority, you know, although as I say, I know smoking during pregnancy, and in the early years, even, is very detrimental to the children's brain development, but I think as I say, it's the alcohol and the drugs that do, in our eyes, a lot more damage, that wouldn't be right, I suppose, they are both equally, but it's more the drug use that some of these parents have that's causing a lot more damage. (Local authority childcare practitioner, I)

Practitioners, in particular, rationalised their lack of opportunity for further action by describing how they had to balance other more immediate child protection issues, namely the risks to children associated with parental drug and alcohol misuse and violence in the home. There was a clear distinction of the need to prioritise immediate risk against the perceived longer term risk to children from SHSE. These debates were contextualised within the challenges of delivering services to families that participants described as having ‘chaotic’ lifestyles. Indeed, there was a shared understanding that families with chaotic and difficult lives presented complex challenges for professionals working to protect children from harm. Children (we see) start off at a disadvantaged position. They are physically compromised by parent lifestyle choices. Respiratory compromised, compromised life opportunities. It's part of a package of neglect and disadvantage. (NHS, Primary Care, FG)

Practitioners also suggested that such complexity could influence both their priorities for action and how parents might view the issue. Thus, just as professionals might not prioritise the issue because of other pressing, immediate concerns about a family, so parents might feel that smoking (and their children's SHSE) was not their key priority or biggest problem in their lives. We are working with families who are very much at the high tariff end of child protection, and they will be dealing with a whole range of issues from poverty to domestic abuse, mental health, drug and alcohol misuse, and I think just, the day to day struggle for some of our families means that smoking is a release, it's a mechanism that they use to, you know, relax and support themselves. (Local authority childcare practitioner, I)

Continuing ethical arguments

The ethical issues concerning children's SHSE tended to be avoided or sidestepped by policy advisors and practitioners. In previous work, we explored the ethical challenges that practitioners articulated in terms of balancing protecting children from harm, protecting the relationship between client and practitioner and the rights of the adult to smoke within the private space of the home.20 We further developed this argument to consider the sociocultural and environmental challenges that many parents face in creating smoke-free homes and advocated a non-victim blaming approach in smoke-free home interventions.19 Many of these previous ethical arguments persisted in the data presented here, with practitioners and policy advisors still grappling with children's SHSE as a child protection issue. You will have the human rights lobby all over you, saying it's, it's my human right if I want to smoke in my house, I should be allowed to, and I think that that is where you have a real, real dilemma, because from what you said earlier about child protection, yeah, it's a child protection issue, but the lobbyists will say it's a human rights issue, and I don't know how you ever, ever come to a compromise from that. (NHS, Senior Nurse Manager, FG)

Some stated that a children's rights perspective might not be helpful. It was suggested that a purist ‘rights’ agenda might antagonise parents trying to do their best in difficult circumstances, was not empowering and would therefore be unproductive. I would not probably go down the route of child protection, but if you were going to be very purist about it, then we could probably say it could be, because it's not very strength based, and it's not very empowering, and there are probably ways that, and, whilst it does put the child at risk, it doesn't put them at immediate risk. (NHS, Senior nurse manager, FG)

Instead, a more nuanced view was expressed about the need to shift the boundaries of acceptable behaviour, and that this should be an incremental process that required broader cultural changes, through shaping public opinion, which would then influence individual parental behaviour. Children have a right to good health, and there's all sorts of articles that I can quote at you, the key one about a right to survival and development, so yes, anything that impinges on that, impinges on their right, impinges and diminishes enjoyment of that right, so you can make a very purist argument about all of that, I think what you are really trying to get at is, so how do you change behaviour to make sure that children enjoy that right to the maximum, and that for me is a slightly different question, because that for me is about culture change, about the value that we place on children and young people, and that's where you need to shift it. (Senior Policy Maker, I)