ITt'HCaiUN&HeHltHDirDI
Hiit thuoc la thu d6ng va site khoe tre em
1 6 T h i T h a n h Hrfdng (*)
rmh tmng hiit thud'c Id thu dQng cd the gdy ra nhiing dnh hudng nghiem Irorg Idi stic khoe CQng dong, ldc bilt Id siic khoe tri em. Cdc trifu chting vd benh ma tre Co thi gap phdi khi phdi phai nhilm vdi khdi Ihuoc Id bao gom viem tai giUa, viem dudng hdhap dudi, cdc trieu chting hd hap nhu ho, khd khe, khd lhi, nhieu ddm ddi, v.v..., ldm b$rih hen suyln trd nin tram trong hm, suy gidm chiic ndng phoi vd gdy ra hoi chiing dot lii bat Ihudng dtresd sinh.
Nhieu nghien ctiu trin the gidi dd cho thd'y mac dU vdn de phai nhilm thu ddng vdi khdi thud'c Id dd duac chti y trong thdi gian gdn ddy, nhung tl le tre em phdi nhilm v&i khoi thudc Id vdn khd cao. Ndm 2010, To chiic Y le the gidi dd Udc tinh cd khodng 700 trieu tri em trin the'gidi vin phii sdng trong bdu khdng khi bi d nhilm hdi khdi thudc Id, vd hdng ndm cd gin 170.000 Ire em tti vong do cdc benh lien quan tdi thudc Id 159]. Bdi bdo ndy se gidi thiiu ve thdnh phdn cud khdi thudc Id, tdc hai cua khdi thudc Id Idi sUc khde tre em, Iht/c trang tre em phai nhilm thu ddng vdi khdi thudc Id trin tM gidi vd d Viet Nam, cUng nhu nhiing nghien ctiu, chuong trinh can thiep dd thiic hien nhdm gidm su phai nhilm cua tre em vdi khdi thudc Id dd duac thUc hi$n d Vi^t Nam.
Tii khda: khdi thudc Id trong mdi trudng, phai nhilm thu ddng vdi khdi thud'c Id.
Secondhand smoke and children's health
Le Thi T h a n h H u o n g (*)
Secondhand smoke (SHS). also called environmental tobacco smoke (ETS), can cause detrimental health effects to community health, especially to children's health. Main symptoms and diseases caused by children's exposure to SHS include middle ear disease, lower respiratory tract infections, respiratory symptoms and the exacerbation of asthma, lung dysfunction and sudden infant death syndrome.
Worldwide studies have shown that although the issue of SHS exposure has been given increased attention recently, the proportion of children exposed to SHS is still high. The World Health Organization (WHO) estimated that there were about 700 million children in the world who have to inhale the air polluted by tobacco smoke and approximately } 70,0(X) deaths among children each year caused by tobacco-related diseases [59]. This article will introduce the definition and composition of SHS and will discuss its harmful effects to children's health, the situation of children's exposure to SHS worldwide and in Viet Nam and interventions to reduce children's exposure lo SHS in Viet Nam., Keywords: secondhand smoke/ environmental tobacco smoke, involuntary exposure to secondhand smoke.
lAc gid:
(•) Ths. Lfi Thi Tbanh HiTdng, Phd mrdng Bp m6n Silc khoe mOi unrdng, TnrSng Dai bpc Y tfi' cong cOng, 138 Giang Ve. Ha Npi. Email: [email protected]
T a p chi Y t^ C d n g c ^ n g , 2.2012, S6' 2 3 ^ 3 ) l i
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1. D3t vS'n d^
Hut Ihuoc li thu dpng la tmh irang ngu'di khong hiii Ihuoc phai hit/ngiJi khoi thu6^c la hoac khoi thud^c lap cd trong m6i tru'dng vi lam tang ti le mac henh va lfi" vong ciia cic benh c6 lien quan tdi khoi tbu6^c l i trong cpng dpng nhffng ngUdi khong htil Ihupc [10],[57]. Y vin tren thg"gidi da cho thSy hiit thu6^c li thu dpng la nguyen nhan gay ra nhieu b#nh vi triSu chttng d ca ngu'di ldn va tre em. Vi#c tre em phai phdi nhiem thu dpng vdi khoi thud'c la da trd ih^nh mdl van di y t^ cdng cdng (YTCC) ding quan tam. NhOiig tre em phai sdng trpng mdi irufdng bi d nhiem bdi khdi thudc cd the phai ddi mat vdi nhieu nguy cct vi site khde, chang han viem tai giiTa, vi8m dtfdng hd ha'p difdi (chu yd'u li vidm phdi va viSm phd quSn), lim trim trong thdm cic ca hen suy^n va ting tin sua't xuat hien cie cOn hen, giy ra cic tripu chtfng ve dUdng hd hap trdn, suy giim ehiJe nang phdi va nguy cd dpi tiJ bat ihifdng d Ire sd sinh [16].[22],[57],[58].
Tai Vipt Nam, llnh irang hdt thudc la va thudc lio cdn khi phd bie'n irong cpng ddng, die biet la d khu vUc ndng ihdn. Theo Didu tra vl Tinb hinh su"
dung thudc li d ngUdi tnrdng thinh tai Vipt Nam nam 2010, ti Id ngUdi tuf 15 tudi trd len hiit thudc la 47,4% d nam gidi va 1,4% d ni? gidi [39]. Van de htit Ihudc la khdng chi diJng lai d ti 1? hiit thude ma cdn lidn ddi ldi li lp cac hp gia dinh cd bin khdng khi hi d nhidm bdi khdi ihud'c cao, Theo Didu tra Y id qudc gia nam 2002, mac dii li le hiit thud'c la d phu nff Vidl Nam rat thap, nhu'ng cd tdi 63% hd gia dinh d Vipt Nam cd il nha't mpt ngtfdi hut thud'c trpng nha va ed ldi 71,7% tre em dtfdi 5 ludi sdng trong cac gia dinh cd ngtfdi htil thud'c [1]. Va'n de sifc khoe eua tre em va cua ngtfdi khdng hiit thude va lic hai ciia khdi thuo'c li trong mdi trtfdng da dtfdc quan lam trong vai nam trd lai day, dac biel itf khi Viet Nam gia nhap Cdng tfdc khung vd Kid'm soit tic hai thudc li.
Bai bio nay trinh bay dinh ngtila va thanh phan eua khdi thuoc Ii, tic hai cua vi^c phdi nhidm thu dpng vdi khdi thud'c li va site khoe tre em, cung nhtf dtfa ra nhffng eon sd' ihdng kd ve thtfe trang phdi nhiem ciia tre em vdi khdi thud'c li d Viet Nam va tren the' gidi va nhffng chtfdng trinh ean thipp da cd nh^m lam giam llnh trang phdi nhiem cua tre em vdi khdi thud'c li lai Viet Nam.
2. Khai ni^m v l hut thud'c la thu dOng va thanh phin cua khoi thud'c la
Hiit thudc thu ddng hay khdi thud'c l i / thudc lao irong mdi trtfdng (sau day goi chung li khdi ihud'c la) la hdn hdp cua ddng khdi phu (sideslream smoke) - la khdi tff dau mau cua didu thuoc hoac san pham Ihud'c li dang chay vi ddng khdi ehinh (mainstream smoke) - la khoi do ngtfdi hdt thud'c la va thud'c lao pha ra mdi trtfdng [101,[16],[17],[58].
Khoi thudc li la hdn hdp ciia rat nhieu hda chat ddc hai. Vao nam 1992, Cd quan Bao ve mdi trffdng Hoa Ky (EPA) da xie dinh trong khdi thud'c li cd hdn 4.000 bda chat dpc hai, trong dd cd khoang 250 chat cd thi gay nhffng anh hffdng nghiem trpng tdi stfc khoe con ngtfdi, va khoang 50 chat la tic nhan gay ung tbtf [22]. Tuy nhidn, nim 2004, Cd quan Nghien ciJu qudc te ve Ung thtf (lARC) ghi nh^n rang cho ldi nam 2000, cd tdi 69 tic nhan gly ung thtf dtfdc tim thay trong thanh phan ci3a khdi thud'c la [28]. Nam 2010. Bd Y te Hoa K^ chinh thiJc khing dinh cd tdi hdn 7.000 hda cha't doe hai dtfdc fim thay trong thanh phin cua khdi thudc li, trpng dd ed hang tram chi't giy nguy hai tdi stfc khde con ngtfdi va 69 chi't la tac nhan giy ung Ibff cho con ngtfdi [18]. Khdng cd mffc lidp xuc nao vdi khdi Ihud'c li dtfdc cho la an to^n ddi vdi sffc khde ciia nhffng ngffdi khdng htft thudc [18], [58].
Dong khoi chinh vd dong khdi phu
Ddng khdi phu la thanh phan chu ydu cua khdi thudc li, chidm khoang 85% tbanh phan ciia khdi thudc li, 15% cdn lai la thanh phan ciia ddng khdi ehinh [61]. Thinh phan ciia ddng khdi chinh .chii yeu li nicotine, carbon monoxide va cac chat hat.
Thanh phin ciia ddng khdi phu gin Iffdng Iff nhtfng chffa nhieu tic nhan gay ung Ihtf hdn. Ngtfdi ta ciing ffdc tinh rang ddng khdi phu ed doe tinh eao hdn ddng khdi chinh. 1 gam eic chat hat trong ddng khdi phu cd dpc tinh cao hdn til 3 de'n 4 lln so vdi 1 gam eic ehl^t hal trong ddng khdi chinh [50],[58],[61]. Bio eio ra soat cac nghidn crfu vd tic hai cua khdi thudc li do Bp Y idHoa Ky thffc hien trong cac nim 2006, 2007 ve cic nghien crfu do Itfdng cie hdp chat cd trong ddng khdi chinh vi ddng khdi phu cho thay nhffng hdp cha't nhff poiyaromatic hydrocarbons (PAH) giy ung thtf cd trong ddng khdi phu cao hdn gap 10 lan trong ddng khdi chinh [16],[17]. Mdt nghien cffu mdi dtfcfc xuat ban gan day cho tha'y thanh phan chinh ciia
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ddng khdi phu la PAH, cic aldehydes bay hdi vi carbon monoxide [15], trong khi mpt nghien cffu khac lai cho rang ddng khdi chinh chtfa cie chi^t dau va chat sap vi dffdc thai ra dtfdi dang cac hat nho [51]. Ddng khdi phu khi mdi dffdc thai ra radi Irtfdng it dpc hai hdn so vdi chinh nd khi da tdn tai trong mdi trffdng tff 1,5 den 2 gid [51].
Theo EPA, eic hdp chat gay ung thtf cd trong ddng khdi phu cung gan tffdng ttf nhtf eic hdp chat cd irong ddng khdi chinh. Tuy nhien, khi phan lich thanh phin ciia cic hdp chat hda hpc trpng ddng khdi phu vl ddng khdi ehinh, EPA cung phit hidn ra r^ng trong Ihanh phlu ciia ddng khdi phu ed 5 tie nhan gay ung thff cho con ngffdi, 9 hdp chat cd the gay ung thtf cho eon ngffdi va 3 chsft gay ung thtf cho ddng vat cung nhff mpt sd tic nhan ddc hai khic cd him Itfdng cao hdn trong ddng khdi chinh [22].
Ngoai ra, cie nhi nghidn ctfu cdn phil hipn cic chi't trff sau chrfa ni-t<J trpng ddng khdi phu va ddng khdi chinh, dd Ii flumetrahn, pendimenthalin va trifluralin. Ta't ca 3 chat trff sau nay dtfdc khang dinh li nguy hai tdi srfc khoe con ngtfdi va cd thd 11 nhffng tic nhan giy ung thff cho con ngffdi [15]. Mdt sdchl^t nitrosamines die thCi cd trong khdi thudc li, ching han nhff N-nilrosonomicotine (NNN) and 4- (methylnitrosamino)-l-(3-pyridyl)-l-bulanone (NNK) giy ung Ihtf ic linh. Nhffng hdp chsft nay chi cd the tim thl^y trong cic sin pham ciia thud'c li vi chung lien quan tdi nicotine va cie hdp chat alkaloids thudc li [15]. Trong cie xel nghiem lai phdng thi nghiem cua minh, Hetch da chrfng minh rSng NNN gay cic khd'i u irong thffc quan va khoang mui cua chupt, trong khi NNK ho trd qui trinh phit trien cic khdi u trong phdi eua mpl sd'loai gim nhi'm chang han nhff chudt nhat vi chudt ddng [26]. Dffa tren ket qua ra soit tff 30 nghidn crfu khic nhau lai 8 ntfdc vi nhieu nghien crfTi khie, EPA kdt lu|in rang khdi thude li dtfdc coi la tic nhan gay ung thff nhdm A cho con ngffdi [22].
3. Tac h^i cua phd nhidm thu dOng vdi kh6i thud'c 1^ dd'i vdi sii'c khoe tre era
Cic anh hffdng cd hai cua vide phdi nhidm thu ddng vdi khdi thud'c li ldi srfc khde tre em bao gdm viem tai giffa, viem nhidm dtfdng hd ha'p dtfdi (chii yd'u li viem phdi va viem phe quan), cic tripu chffng ciia dtfdng hd ha'p tren nhtf ho, khd khe, nhidu ddm dai, khd thd, v.v., lam cic ca hen suyen trd nen tram trpng hdn, suy giam chtfc nang phdi va gay
ra nguy cd dpt nj- blTt thtfdng d trd sd sinh [10],[16],[17],[411,[44],[56],[57].[58]. Ngoii ra, khdi thud'c l i cdn dtfdc cho la gay ra cic van de ve giam khi ning nhin thffc d ire, anh htfdng khdng tdt ddn kha ning phit tridn hanh vi cua tre va giy ra cic dang ung thff d tre em, v.v... Tuy nhidn, hi6n chffa du bang chrfng kboa hpc rd rang de chtfng minh cd md'i quan hp nhin qua gifla vide phdi nhiem vdi khdi thud'c li vi cic van de nay d tre em [16],[17].Dov|y, trong pham vi bai bio nay, chiing tdi chi gidi thidu nhffng va'n dd sffc khde d ire em da dtfdc chrfng minh li hSu qua ciia vide phdi nhi6m vdi khdi thudc li.
3.1. ViSm tai giita
Hidn cd du bang chffng khoa hpe Ai chffng minh md'i Uen quan giffa viec phdi nhilm vdi khdi thudc li tff bd me va nhffng ngffdi xung quanh vi bpnh viem tai giffa d tre em. Cic nha khoa hpc da bat diu chff trpng tdi vipc nghidn cffu vd mdi quan he nhan qua cua vide phdi nhiem vdi khdi thudc li irong nha va nguy cd mac viem tai giffa va viem tai giffa cd miJ tff dau thSp nien 80 eua IhekJ 20 [32]. Trong nghien cffu nay, cic tie gia da phil hidn ra md'i lien quan giffa phdi nhilm vdi khdi thudc li do bd me hrft va nguy cd mac vidm lai giffa va vidm tai giita cd mu d ire. Dau nhi?ng nam 1990, qua ra soit cic nghien cffu, EPA da khang dinh cd mdi quan h?
nhan qua giffa phdi nhilm vdi khdi thudc li va cic bdnh viem nhilm d tai, mui va hpng cua tr6 [22].
Cud'i nhffng nam 1990s, dffa tren 692 bai bio da dtfde xul't ban, 45 nghien cffu ra soat da dffdc thtfc hien ve viem tai giffa cl^p tinh, viem tai giffa tai diln, viem lai giffa ed mO, v.v... dtfcfc thtfe hipn. Drfa iren 45 nghidn crfu ra soit nay, Strachan vi Cook da Ihffc hidn mdt nghidn cffu ri soit hp thd'ng vi ket luin rang viec hut thudc la ciia bd^me cd mdi quan hd nhan qua vdi bdnh vidm tai giffa d tre em, ca man va cap tinh [53]. Dtfa tren 40 nghien crfu vdi cic thidt ke nghien cffu khic nhau. To chffc Y tdlh^
gidi da kd't luan rang vide phdi nhidm vdi khdi thudc li la nguyen nhan gay ra benh viem tai giffa man linh va cap tinh d tre em [57]. Kdi luin nay mdl lln nfla dtfdc khang dinh lai trong cic bio cio ciia BQ YtdHoaKy [16],[17].
3.2. Viem dittng hd hap diidi
Vipc nghidn cti^ tim mdi quan hp nhan qui giffa phdi nhiem vdi khdi thudc li va viem nhiem dtfdng hd ha'p dtfdi d ire em - mi ehu yeii la vidm ph^i v^
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vidm phe quan, dac biet la irong giai doan tre dtfdi mpt mdi va tre nhd da dtfdc nhieu nha khoa hpc thffc hido trong nhieu thip kJ trd lai day va da dtfcfc nhidu idcbffe cd uy u'n ghi nhin [16],[22].[41],[44].
Cic nghieD cihi khic nhau da chrfng minh rang anh htfdng ciia phdi nhidm thu ddng vdi khdi thud'c li tdi dtfdng hd bap d tre se trim trpng nhat trpng hai nam dau tien ciia cudc ddi [24],[27],[34],[35], va viec tre pbdi nhiem vdi khdi thudc l i trong nhffng nam dau ddi se lam tang nguy cd mac cac benh tram trpng ve dtfdng hd hjfp sau nay [34]. Mdt nghien cifu benh chfftig d Thd NM Ky ve nhffng anh htfdng cd hai cua vide hrft thudc ta thu dpng vdi viec mac cic benh viem dffdng hd hi'p dtfdi d tre em tff 2 den 12 tudi trong thdi gian diing 10/2003 tdi thing 3/2004 cho ihay nhiing tre phdi nhilm vdi khdi thudc li cd nguy cd mic cic bdnh viem dtfdng hd bi^p dtfdi cao hdn gin 5 lan so vdi nhdm tre khdng phdi nhiem (p
= 0,000, OR = 4,72. 95%CI = 2.62 - 8,52) [30].
Nhflng Ire phdi nhilm vdi khdi thude li do me hut cd nguy cd mac cie bdnh vidm dtfdng hd hap dtfdi cao hdo 60%, trong khi ohflUg tre phdi nhiem vdi khdi thud'c la tff nhffng thanh vidn khic trong gia dinh cd nguy cd mac cao hdn 50% [8].
Trong cic bio cio nim 2006 va 2007, Bp Y te Hoa Ky da khang dinh cd dii bang chfftig khoa hoc chtfng minh mdi quan he nhin qua giffa viec tre hi phdi nhilm vdi khdi thud'c la trong gia dinh va cac benh dtfdng hd hap dtfdi, dac biet li vdi tre nho, va nguy cdmac cic benh vidm dtfdng hd hap dtfdi d tre eao nhi'l khi tre phai phdi nhiem vdi khdi thud'c li tff ngtfdi me [16],[17],
3.3. Cdc trifu chiing cua di&ng ho hap tren vd dien bien xau cua cdc ca hen suyen
Phin nay l§p trung vio mdt sd'trieu chtflig chinh ciia dtfdng hd hl^p tren bao gdm: ho, nhieu ddm dai, thd khd khe, khd thd va didn bie'n xi'u di cua cic ca hen suyln d nhflhg tre phdi nhilm vdi khdi tiiudc la.
Dtfa tren kd't qua ra soit rat nhieu nghien ctfu \a bii bio, Bp Y te' Hoa Ky khang dinh cd mdi lien hd nhan qua giffa vipc htft thudc ciia bd'me vdi mpt sd trieu chtfng hd ha'p d ire em tudi hpc drfdng (chang han nhtf ho. nhieu ddm dai, thd khd khe, khd thd, va diln bidn xa'u cua cic ca hen suydn) [16],[17].
Nhieu nghien cffu mdi dtfde thifc hien gin day cung cho kd't qua itfdng ttf. Mdt nghien cthi dtfdc thtfc hidn tai Ba Lan trong quin the 1.100 tre trong dp tudi 13-15 cho thay viec tre phdi nhidm vdi khdi
thud'c li cua ngffdi me la mdt ydu td nguy cd ciia tridu chtfng thd khd khe; va mdt sd' ye'u td mdi trtfdng, trong dd cd khdi Ihud'c li trong nha ed lidn quan tdi cac tripu chtfng ve dtfdng hd hi'p trong quan the nhffng tre dtfdc nghien ed'u [29]. Mpl nghien crfu khic d Dai Loan cho thi'y tre era phdi nhilm vdi khdi thud'c la ddi mat vdi nguy cd mac hen suyln cap tinh va thd khd khd cao hdn, va viec hdt thudc la ciia cha me gSy ra nguy cd mae nhffng trieu chtfng nay cao bdn [54]. Trong khi dd, tai Italy, mdt nghidn ctiM dffdc Ihtfc hien tren 4.122 tre em d 29 irtfdng tieu hpc trong nim hpc 2004-2005 cho Ihl^y li ie mac trieu chtfng khd thd vi tii xual hien cac ccfti hen d nhihig tre phdi nhiem vdi khdi thud'c li Iff bd me tai nh& cao gan gap ddi so vdi nhdm khdng phdi nhilm [45]. Nhilu nghien cffu drfde thrfc hidn d cic thdi gian vi dia didm khac nhau cung cho thi'y md'i lien hp ro rang giffa vide phdi nhiem vdi khdi thud'c la ciia tre em vi srf xuai hidn cac trieu ehffng ho, nhidu ddm dai, khd thd vi ting mrfc dp tram irpng ciia cac cdn hen [13],[20].[23],[46],[521,[55].
3.4. Suy gidm chute ndng phoi
Mdt sd chi so nhrf dung tich thd ra td'i da trong mdt lln thd (FVC), dung tich klii thd ra gang stfc trong mdl giay dau tidn (FEVI) thtfdng dffdc stf dung de do Iffdng chtfc ning phd'i (EPA 1992;
DHHS 2006). Bp Y te Hoa KJ' kd't luan r^ng phdi nhilm vdi khdi thud'c li trpng thdi ky bio thai do ngtfdi me mang thai hut ihud'c la mdt nguydn nhin lam suy giam chtfc nang phdi d tre, my nhien, viec phdi nhilm vdi khdi thud'c li sau khi sinh cung la mdt nguyen nhan quan trpng din tdi suy giam chffc nang phdi d tre em [16],[17J.
Nhieu nghien ctftf khac cijng cho ke'l qua lrfdng Iff. Tai Hy Lap, khi nghien cffu tren quan the gan 600 tre em Iff 5 de'n 14 mdi, cac tic gia da cho thay nhflng tre phdi nhilm vdi khdi Ihudc la cd chffc nang phdi kem hdn, cu the la ed FEVI giam hdn so vdi nhffng tre khdng phdi nhilm. Rinne va cpng sff cung tim dffdc mdi lien quan cd ^ nghia Ihdug ke giffa viee Ire em phai phdi nhiem vdi khi ga vi eac khdi Iff nhien lieu dun nau va khdi Ihud'c Ii vdi suy giam cac chi sd'FVC va FEVI [48].
3.5. Hgi chiing dgt tit bdt thtfng d tre scf sinh
Hpi chffng dpi ttf bat thrfdng d tre sd sinh (SIDS)
dffdc dinh nghia la "nhffng ca itf vong bit thrfdng va
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khdng rd nguyen nhan d ire drfdi mdt mdi" [25].
Nhffng nan n h i n cua SIDS thtfdng l i k h d e manh trffdc khi chet, va \'$ d o d i n tdi SIDS cho dd'n nay van chtfa giai thich dtfdc qua e i c b a n g chtfng lam s i n g hay qua k h i m nghiem ttf lhi [25],[40]. To chtfc Y te the gidi v i Bp Y te Hoa Ky da khang dinh stf phdi nhiem vdi khdi ihudc l i irong thdi ky b a o thai v i sau khi sinh la mpt nguyen n b a n d i n tdi nguy cd SIDS [16],[17],[57],[59]. Rat nhieu nghien cffu k h i c cung chp kdt qua tffdng trf. Nghidn ctfu drfdc Ihffc hien d Cdng h d a A r a p Syria cho thay cd md'i lidn quan rd rang gifla SIDS d tre va viec phdi n h i l m ciia tre vdi khdi thudc l i tff b d m e [37].
Dybing v i Sanner irong b i o c a o ra s o i t ciia minh cung khang dinh viec phdi nhiem vdi khdi ihudc l i trtfdc v i sau khi sinh ddng gdp phan ldn vao nguy cd SIDS d tre nhd [21]. H a w a m d e h v i cdng stf khi nghidn cffu v i ra s o i t c i c bai b i o , c i c b i o c i o khoa hpc v i c i c tai lipu k h i c v l anh htfdng cua hfft tbudc l i thu dpng tdi stfc khde tre em cung ket luan rang phdi n h i l m vdi khdi thudc l i trong Ihdi ky bao thai v i sau sinh la mpl yd'u t d n g u y cd ra't quan trpng eiia SIDS d tr^ nho [25]. Mpt nghien etfu k h i e dtfdc thtfc hipn d B a Lan v i mpt s d n d i k h i c tren thd gidi cung cho kdt q u i trfdng ttf [19],[27],[62], C d q u a n bao ve mdi trtfdng California cung k h i n g dinh cd tdi 10%
c i c ca ttf vong do SIDS dtfdc quy cho la do phdi n h i l m vdi khdi thude l i [44].
4.Thurc t r a n g phtfi n h i l m t h u d p n g vdi k h d i thud'c U d t r e e m
4.1. ThUc trgngphc/i nhiem thti d^ng vdi khoi thuoc Id cua tre em tren thegiM Mac di) da cd c i c bang chrfng khoa hpc ro rang vd t i c hai cua khdi thud'c l i vdi stfc khde tre em, nhtfng li lp tre e m tren the'gidi p h i i phdi n h i l m vdi khdi thudc l i van cdn k h i phd bid'n, d i e biet d c i c ntfdc dang p h i t trien va k e m p h i t trien, ndi cd nhflng quy dinh ldng l e o ve hut thud'c l i trong n h i . Trung t i m Phdng ngffa va Kidm s o i l B e n h tat ffdc t i n h c d khoang 4 3 % tre em tff 13-15 tudi trdn t o i n tbd" gidi phai phdi n h i l m vdi khdi thud'c l i b i n g ngay [9]. Mpt nghien ctfu mdi dtfdc xui't ban trong nam 2011 dtfdc thtfc hipn dt/a tren s d h e u v e tinh trang phdi nhiem vdi tre em trdn the gidi d 192 ntfdc cho thi'y cd khoang 4 0 % Ire em tren die' gidi phai phdi n h i l m vdi khdi Ihudc l i trong n i m 2004 [43]. Trong khi dd, theo thdng k e cua T d chtfc Y td the gidi, khoang mpt ntfa s d tre em iren thd gidi
(xap xi 700 trieu t r e ) phdi n h i e m vdi khdi thud'c l i H i n g n a m , cd k h o i n g g i n 170.000 tre e m tren t h d gidi chet vi c i c b e n h d o khdi thudc l i gay ndn [58]
T r e e m ed thd p h a i phdi n h i e m thu d p n g vdi khd:
thudc l i trong r^t n h i e u m d i trffdng k h i c nhau, nhtfng m d i trtfdng chinh ma ire p h a i lid'p xdc vdi khdi Uiud'c l i la tai c i c bp gia dinh. T a i n h i , tre phai hit ngtfi khdi thud'c iff bd' m e h o i c Iff nhflng ngtfdi k h i c sd'ng trong gia dinh ciia minh [58].
C i c nghien crfu iren Ihe' gidi cho thi'y ti lp tr8 phdi nhidm vdi khdi diudc l i trdn the' gidi ttfdng ddi eao. T h e o tfdc tfnh cua Bd Y le' Hoa Ky, k h o i n g g i n 6 0 % tre em tff 3 dd'n 11 m d i d My phai phdi n h i l m vdi khdi thud'c l i [17]. Tuy n h i e n . mdt nghidn cd^i khac cung thtfc hien d Hoa K J cho thi'y ti Id tre e m d My phdi n h i l m vdi khdi thud'c l i dao ddng tff 35- 80%, phu thudc v a o phtfdng p h i p do ltfdng v i quan the nghidn ctftf [33]. T a i Dai Loan, li lp n i y dtfdc tfdc linh la 5 0 % [36]. Vipc phdi nhidm cua tre vdi khdi tbudc l i Ihtfdng cd lien quan tdi mffc thu n h i p cua gia dinh va trlnh dp van h d a eiia b d m e . Nhflng tre sdng trong nhffng gia dinh cd thu n h a p thi'p va b d me cd trinh dd van hda tha'p ihffdng cd li lp phdl n h i l m cao hdn [12],[31],[47], Ti lp ire e m sdng trong cae can hd d c i c khu chung ctf p h i i phdi n h i l m vdi khdi thudc l i rat c a o , ldi 7 3 % [60].
4.2. Thifc trgng phai nhiem vdi khdi thuSc Id cua tre em d Vi^t Nam
Viet Nam tham gia k J Cdng tfdc khung v l Kiem s o i l t i c hai thudc l i (FCTC) v i o n g i y 8/8/2003 v i phd duydt F C T C vao n g a y 17/12/2004. Ke Iff dd, Chinh phu Viet N a m da ihiTc hidn ra't n h i l u nS Iffc d e phdng chdng t i c hai thud'c l i v i hdt thudc l i thu ddng. Mac dfl d i dffdc cai thidn. nhffng li lp ire em phdi nhiem vdi khdi thud^c I i v a n cdn tffdng ddi cao, d i e biet la d viing n d n g thdn.
Trong nhffng n i m dau ctia t h d k;y 2 1 , ti lp tre phdl nhidm vdi khdi thud'c l i d Vidt Nam k h i cao.
T h e o b i o c a o Dieu tra Y t d qudc gia n i m 2002, ti Ie ire dtfdi 5 tudi phdi n h i l m vdi khdi thudc l i l i 71.7% [ I ] . M p l n g h i e n cffu k h i c chd trpng tdi dd'i ttfdng tre e m 13-15 m d i . ti Id phdi n h i l m cda n h d m n i y vdi khdi thudc la tai n h i dao dpng tilr 52-65%, trong khi ti lp phdi n h i l m c u a c i c e m vdi khdi thudc l i tai cac ndi cdng cpng tff 8 6 - 9 0 % [4].
Sau khi p h e d u y e t Cdng tfdc khung, tinh trang phdi n h i e m eiia ire vdi khdi thudc l i cd vd dtfdc c i i thien. Mdt n g h i e n crfu bpnh chrfng dtfde thtfc hidn
T a p chi Y te C o n g cpng, 2.2012, Srf 23 (23) 15
ITgNGQUAK&NGHflNCUUI
tai Bac Giang nam 2007 cho thl^y ti le ire dtfdi 6 tudi phdi nhilm vdi khdi thudc li lai nhi li 64,8%
[38]. Tai Quing Ninh, mdt nghidn crfu can thiep cho tha'y cd stf giim di ding k^ vl ham Itfdng cotinine nieu trong sd' nhflng tre phai phdi nhilm vdi khdi thudc li thu dpng tai cic hd gia dinh sau thdi gian cao thidp [5], Nghien cffu cua Hdi Y te Cdng cdng Viet Nam tai Thai Binh cho tha'y cd khoang 63% hd gia dinh cd it nhl't mdt ngffdi hdt Ihud'c va 17% hp gia dinh cd it nha't hai ngtfdi hut thudc, vi 97% sdngtfdi hut thud'c thffdng xuydn hfft trong nha va 87% thffdng xuydn hut trffdc mat tre em. Nghidn crfu eung cho ket qui ire em sdng trong nhffng gia dinh cd ngtfdi hdt ihudc cd him lrfdng nicotine trong tde cao hdn nhdm tre khdng phdi nhilm [6]. Mpl nghien cffu mdi drfdc thrfc hien gan day d Chffdng MJ (Ha Npi) cho ihiy cd 60% hpc sinhtidu hoc lfl 8-11 ludi sd'ng troug cic gia dinhcd tff 1 ngrfdi hfft thudc trd ldu. Khi drfde hoi ve dnh trang phdi nhilm vdi khdi Ihudc li trong nhi trong mdt tuan trrfdc cupc dieu tra. cd tdi 38,3% sdtre cd phdi nhidm. Nhflng ndi mi tre phdi nhilm vdi khdi thud'c li irong nhi phd bie'n nhl^t la phdng khaeh, phdng ngu vi ban cdng cda gia dinh. Tinh trang ngrfdi cha vffa bd con vffa hfft thudc cung dffdc ghi nhan trong nghidn crfTj niy [3].
5. Cac chuTtfng trinh can thifp nhfim giam si^ phtfi nhilm thv ddng cua tre em vdi khdi thud'c la trong mdi trifcfng tai Vift Nam
Mpt sd nghien cffu can thiep da drfdc thtfc hien tai Viet Nam nhilm giam ti Ie hut thudc, giim stf phdi nhidm cua ngtfdi Ichdng hrft thud'c vdi khdi thud'c la, trong dd cd tre em. Nghidn ctfu can Ihiep dffdc thtfc hipn tai Quing Ninh trong giai doan 2003-2005 cho Ihay sau can thidp tJ Id hdt thud'c trong nhi giim tff 96,6% cdn 87,4% (p<0,05), trong dd ty le hdt thupc trong nhi thffdng xuydn giam tff
47.7% xud'ng edn 11,4% (p<0,001). Ty le ngffdi hdt thudc di ra khoi phdng de hut thudc ling iff 18,1%
len 50,4% (p<0,001). Coiinin nidu trung binh cua tre em trffdc vi sau can thiep giim iff 3,59 microgram/lil xud'ng cdn 1,54 microgram/lit, p<0,05). Cd stf eai thien ding kd ve kidn thffc, thii dp vi srf chap nhan cua xa hpi vdi hut thudc va hdt thudc thu ddng [5].
Mpt nghien cffU can thipp khic do Hpi Y id' Cdng cdng Viet Nam phd'i hdp vdi HealthBridge Canada thtfc hidn tai 3 linh Thii Binh, Da Nang vi Ben Tre tff nam 2005 den nim 2007 eho thl'y sau thdt gian can thiep, nhin thffc ciia phii nff va nam gidi ve tic hai ciia hdt ihud'c li vi hdt thudc li thu ddng dtfdc cai ihien ding ke. Thii dp cua pbu nff cung thay doi tich ctfc. Sau can thidp, ti Ie nam gidi khdng hfft thud'c trtfdc mat tre em dffdc cai thidn rd rpt [42]. Trong nam 2006, mpt nghien crfu nhd dtfdc thtfc hipn d Hai Dtfdng cho ihay edng ddng tai diy san sing ung hd y ttfdng xiy dtfng md hinh ngdi nhi khdng khdi thudc. Ban than cpng ddng de xuat stf tham gia cua tre em trong chtfdng trinh can thiep dd, vi ngtfdi bd'hdt thud'c thtfdng cd khuynh htfdng nghe Iheo dl nghi cua con minh [2].
6. G ^ f chimg
Tic hai cua khdi thudc li tdi sffc khoe tre em di dffdc minh chffng ro ret. Stf phdi nhiem eua ire em vdi khdi thudc l i tai Viet Nam vi tren the gidi khi cao, tuy nhien nhffng can thipp nham giam sff phdi nhilm ciia ire em vdi khdi ihud'c li chffa nhieu, trong khi tre em dtfdc chffng minh li cd vai trd rat tich ctfc vi hieu qui trong cic chtfdng irinh can thiep nhim thay ddi hinh vi cua ngrfdi ldn [7],[II],[49]. Do vay, can tien hanh thtfc hien cic nghien ctfu can thiep nham giim stf tiep xue ciia Ire vdi khdi thudc li, dac bipl la nhifng nghien ctfu cd stf tham gia cua tre em troog viec giim stf phdi nhilm cua tre vdi khdi thudc Ii tai hd gia dinh.
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