Smoking is recognised as one of the main causes of morbidity and premature mortality in the developed world, and a major factor in inequalities in health. Smoking is not just injurious to smokers, but to those exposed to environmental tobacco smoke (ETS). The harmful effects of children's exposure to ETS are now well established and include an increased risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma (Cook and Strachan 1999, Hofhuis et al. 2003). Moreover, maternal smoking during pregnancy is associated with low birth weight and increased risk of SIDS and children whose parents smoke are themselves more likely to smoke (WHO 1999). As the WHO (2000) identifies in Tobacco and the Rights of the Child:
Children's exposure to ETS in the home has come under political scrutiny in developed countries in recent years associated with growing evidence of the relationship between ETS and inequalities in health. In the UK, the relationship between poverty and smoking is well established (Graham 1993, 1994, Harmana et al. 2006, Richardson 2001, Wanless 2004). The Acheson report on inequalities in health highlighted the fact that while one-third of children in the UK lived with at least one adult smoker, among low-income families the figure was 57 per cent (Acheson 1998).
As the medical evidence about the impact of smoking on both smokers and those exposed to ETS has grown in the last quarter of a century, the place of and attitudes towards smoking have changed (Bayer and Colgrove 2002). Smoking is becoming a more marginalised activity, both in terms of who smokes, where smokers are permitted to smoke and prevailing attitudes to smoking. In recent years smoking controls in public places have been introduced throughout Europe and North America, and these initiatives have also focused attention on the level of risk of exposure to ETS in the home. On the one hand, smoking bans are associated with an overall reduction in the prevalence of adult smoking (Gallus et al. 2006) which could lead to a reduction in the number of children exposed to ETS in the home. Prior to the introduction of smoking bans, reduction in parental smoking has been identified as the main behavioural change credited with recent declines in children's exposure to ETS (Jarvis et al. 2000). It is anticipated that a ban on smoking in public places will intensify this trend. There is also, however, the potential for further entrenchment of inequalities in health among children, as adults from disadvantaged socio-economic backgrounds, who find it harder to quit smoking (Graham 1993, Robinson and Kirkcaldy 2007a), have fewer alternative places in which to smoke outside the home. This view, which was proposed by members of the UK Government before the introduction of a smoking ban in public places in England in 2007, is, though, opposed by the medical establishment (Royal College of Physicians 2005). Some commentators have suggested that tobacco controls should be introduced for the home, and parental smoking has been referred to in child residency and adoption cases in the US (Hovell et al. 2000) and in recent guidelines for foster carers in the UK (The Fostering Network 2007).
In recognition of the difficulty of quitting among socio-economically disadvantaged smokers, public health interventions have begun to focus attention on the effectiveness of smoking bans in the home to reduce children's exposure to ETS (Robinson and Kirkcaldy 2007b). The prevalence of some form of smoking restriction among families varies considerably by geography, class and ethnicity (see for example Gonzales et al. 2006, Pizacani et al. 2003, and Spencer et al. 2005). Parents believe that smoking controls within the home can be effective. Blackburn et al.'s (2003) study of smoking parents in the West Midlands reported that 86 per cent of parents were aware of the risks of ETS and 90 per cent believed that infants could be protected from ETS in the home, with 65 per cent of parents using some preventive strategy, though only 18 per cent reported not allowing smoking in the home. Medical research to date shows that complete smoking bans in the home are associated with a reduction in children's exposure to ETS as measured by urinary cotinine/creatinine ratios or nicotine in hair, though partial bans are ineffective (Blackburn 2003, Johansson et al. 2004). Moreover, reviews of interventions for smoking controls in the home provide very little support for the effectiveness of these interventions, suggesting that the means for promoting changes in parental smoking behaviour are not easy to establish (Spencer et al. 2005).
Social and moral dimensions
This emergent focus on family dimensions of children's exposure to ETS needs also to consider the wider social contexts of smoking behaviour (Laurier et al. 2000). As Poland et al. (2006: 59) have recently argued tobacco control has been dominated by addiction and lifestyle models, and ‘as a result the social meaning of smoking in the context of people's everyday lives is underplayed’. In the context of maternal smoking this includes interactions with other smokers, particularly friends and family members, and shared views on the risks of exposure to ETS and how young children's exposure to ETS may be restricted. As Bottorff et al.'s (2005) findings for smoking couples illustrate, smoking is implicit in relationship dynamics both as a source of conflict and mutual support, and we argue that maternal smoking also needs to be understood in the context of family relationships and obligations.
Moreover, our focus on family obligations foregrounds the inherent moral character of public health discourses on smoking, and how social meanings of smoking are shaped by moral discourses, as well as social and environmental contexts. In public health discourses, prevalent norms make very stark distinctions between smokers and non-smokers and produce stigmatised identities for the former. As smoking practices become more entrenched among less-advantaged groups, smoking becomes a marker of class background and behaviour through which class positions are not just produced and reproduced, but also stigmatised (Bayer and Colgrove 2002). Yet prevailing moral distinctions do not consider the perspectives of smokers and that, while smoking may be castigated as amoral, the same cannot be said of smokers, who will create their own moralities of smoking practices. Yet these subjective accounts are rarely given voice, as Lupton (1995) argues in taking account of the reasons why people start and continue to smoke ‘the use of these commodities in the construction of subjectivity is rarely acknowledged’ (1995: 150). While the emergent focus on the social meaning of smoking directs attention to smoker's economic and cultural contexts, the connections between smoking and the self is not adequately addressed, especially with regard to prevailing public health moralities about smoking.
One account of this moral dimension is Poland's (2000) discussion of the strategies adopted by smokers in public places in order to navigate the complex morality of acceptable smoking behaviour. Poland claims that the self-regulation of smoking behaviour is:
as much to do with conveying the appropriate social graces of appearing to take steps to manage risks imposed on others in a responsible way, than it perhaps does with the ultimate efficacy of such measures. It is, in effect, about social competence (2000: 12).
Moreover, he argues, drawing on Bourdieu's analysis of social distinction, that the negotiation of social competence is best understood from the perspective of class-based legitimisations of appropriate behaviour. Poland's account is based on the experiences of smokers in public places, and his discussion of the moral discourses inherent in the idea of consideration is contingent on the anonymity of smokers in public places. Yet our focus is on smoking within the home where the condition of anonymity is not met. The idea of consideration does not adequately capture the complexity of smoking mothers’ moral negotiations which involve family, friends, and members of local communities as well as health and social service practitioners. In particular we argue that a class-based approach is not sufficient to understand negotiations within the home. While we recognise the potential for class-based stigmatisations of smoking to structure smoking practices within the home as well as public places, our interest is in how smokers regulate and support each other's smoking in disadvantaged communities where smoking remains the norm (see Robinson and Holdsworth 2007 for further discussion of the dynamics of smoking neighbourhoods).
In order to capture the complexity of mothers’ experiences, our analysis draws on recent discussions of an ‘ethical turn’ in the social sciences (Holdsworth and Morgan 2007, Sayer 2005). These developments claim a reconnection with everyday and habitual moralities, or as Sayer (2005) terms ‘lay normativity’. Moreover these developments may be shaped by comparisons with and judgements of others, rather than dictated by absolute moral codes. The idea of the moral tale (Ribbens McCarthy et al. 2003) is to explore how families create and portray everyday family life and how a moral sense of responsibility (for both the self and other family members) is interwoven into these accounts and practices. Studies of contemporary family life and morality reveal how family members negotiate moralities and ethics of care rather than adhere to normative codes (Finch and Mason 1993, Smart and Neale 1998). Moreover, the negotiation of family obligations shapes the moral identities of family members and their social competences as mothers, fathers, sons and daughters. In the case of smoking, while public health discourses clearly promote the benefits of not smoking, and as such the context is one of moral imperative not to smoke, the potential for negotiation still exists. In particular, smoking behaviours, such as how many, what type of cigarette, where and with whom one smokes, allow for distinctions to be made between smokers. Everyday moralities about smoking are not, therefore, necessarily reduced to a distinction between smoking and not-smoking, but may invoke observed differences in smoking behaviours.
Our analysis focuses primarily on the experiences of mothers, partly due to the structure of the sample which generated relatively little empirical data on fathers, but also because the risks of children's exposure to ETS are primarily associated with maternal smoking. This is not only because of exposure in utero, but is also associated with a gendered ethic of care whereby mothers take most of the daily responsibilities for their children. We explore how the mothers in our study recognise the risks of children's exposure to ETS and seek to regulate their own smoking practices, as well as those of other family members and adult friends, to reduce perceived risks of ETS. We consider how these mothers compare their own behaviour against others, particularly other smokers, in constructing moral tales of smoking behaviour, and how they negotiate the options open to them, which include not just quitting smoking but restricting where they smoke, as well as restricting other adults’ smoking in the home and their children's exposure to ETS in other places. We also explore how mothers seek to prevent their children from smoking themselves. We are interested not just in how individuals adopt smoking controls in the home, but also how these are shared among a community of families who are linked by friendship, geography and through smoking. We argue that a moral duality between smoker and non-smoker is too simplistic and that the complexity of smoking identities and practices does not equate with this binary distinction which may be implied in discourses of risks of smoking and/or exposure to ETS. Treating smoking mothers as a unified group (and their children at the same risk of exposure to ETS) ignores the differences that smokers themselves recognise in where, when and with whom they smoke.