Health Effects Of Secondhand Smoke Research Articles

Health effects of secondhand smoke on children under 5 years of life

Background. The high prevalence of smoking among adults suggests the almost inevitable effects of second-hand tobacco smoke (SHS) on children and adults who do not smoke. The negative effects of SHS are most pronounced in young children, especially in families where the mother is a smoker. The aim was to assess the effects of prenatal and postnatal exposure to SHS in children under five years of life. Materials and methods. The survey among 520 families with children was conducted using online self-reported questionnaire. Families with extremely and very preterm children and children with inherited diseases of bronchopulmonary system were excluded from the analysis. During the analysis, all children (n = 414; 55.07 % of boys and 44.93 % of girls, mean age — 36.38 ± 7.19 months) were divided according to SHS exposure. 186 children exposed to SHS were included in the main group, and 228 children without SHS exposure — in the control group. Results. 22.46 % of children were prenatally exposed to SHS. Maternal smoking during pregnancy significantly increased the risk of the intrauterine growth retardation (IUGR) (OR 2.43 [95% CI 1.07–5.52]). Postnatal exposure to SHS was present in 56.52 % of children. These children were significantly more likely to be formula-fed (OR 1.75 [95% CI 1.15–2.65]). The frequency of formula feeding was significantly increased by mothers’ use of both traditional tobacco products and electronic nicotine delivery systems (OR 2.10 and 2.99, respectively). Exclusively maternal smoking in the family increased the risk of frequent acute respiratory viral infections (ARI) in 3 years old children more than 1.5 times (OR 1.60 [95% CI 1.01–2.60]). Household SHS exposure increased the probability of bronchial obstruction (BO) during ARI in a child in 1.61 times, while exclusively maternal smoking increased the risk in 2.88 times. An increased risk of frequent ARI (OR 3.25 [95% CI 1.68–6.28]) was also present in the subgroup of children whose mothers smoked electronic nicotine delivery devices. The use of traditional tobacco products and electronic nicotine delivery systems, both by mothers and other family members, has significantly affected the risk of developing BO in children with respiratory disease. Conclusions. Maternal smoking during pregnancy in the studied cohort is a proven risk factor for IUGR. Household smoking is statistically likely to affect the incidence and likelihood of developing BO in children of the first five years of life, regardless of the type of tobacco product. This risk is greatest among children whose mothers are smokers.

Factors associated with knowledge about the health effects of exposure to secondhand smoke among youth in Bangladesh

Background: Despite the high prevalence of secondhand smoke exposure among Bangladeshi adults, little is known about the knowledge regarding the health effects of exposure to secondhand smoke among the youth aged 15-24 years in Bangladesh. Against this background, the present study was conducted among the youth in Bangladesh to ascertain their levels of knowledge regarding health effects of secondhand smoke and its associated factors.Methods: This was a cross-sectional study of 656 respondents between the age of 15-24 years old selected by multistage cluster sampling. This study was conducted in Dhaka Division, Bangladesh. Data was analyzed using Chi square testing and multivariate logistic regression.Results: The proportion of good, average and poor knowledge scores among respondents were 30.5%, 50.0% and 19.5% respectively. Age and education were significant independent predictors of good knowledge. Furthermore, education and gender were tended as independent predictor of average knowledge. OR for age: 1.12 (95% CI: 1.01 to 1.25); OR for education: 1.27 (95% CI: 1.15 to 1.40).Conclusions: Overall, the results of this study found that less than one-third of the youth had a good level of knowledge on secondhand smoke health effects. The government needs to focus more on less-educated individuals and adolescents if a successful policy is to be implemented.

"It's Worse to Breathe It Than to Smoke It": Secondhand Smoke Beliefs in a Group of Mexican and Central American Immigrants in the United States.

This analysis describes beliefs about secondhand smoke and its health effects held by Mexican and Central American immigrants in North Carolina. Data from 60 semistructured, in-depth interviews were subjected to saliency analysis. Participant discussions of secondhand smoke centered on four domains: (1) familiarity and definition of secondhand smoke, (2) potency of secondhand smoke, (3) general health effects of secondhand smoke, and (4) child health effects of secondhand smoke. Secondhand smoke was generally believed to be more harmful than primary smoke. Mechanisms for the potency and health effects of secondhand smoke involved the smell of secondhand smoke, secondhand smoke being an infection and affecting the immune system, and personal strength being protective of secondhand smoke. Understanding these health beliefs informs a framework for further health education and intervention to reduce smoking and secondhand smoke exposure in this vulnerable population.

Smoking susceptibility among non-smoking school-going adolescents in Malaysia: findings from a national school-based survey

ObjectiveThe identification of susceptible non-smoking adolescents is an essential step in reducing smoking initiation among adolescents. The aim of this study was to examine the prevalence and factors associated with...

Impact of U.S. Antismoking TV Ads on Spanish-Language Quitline Calls

Cigarette smoking is a major preventable cause of disease and death among U.S. Hispanics. Tobacco-cessation quitlines have been shown to increase quitting among Hispanics. However, the use of quitlines by this population remains low, especially among Spanish-speaking Hispanics. This study evaluates the promotion of 1-855-DÉJELO-YA (a quitline portal that routes callers to state-specific Spanish-language services) implemented as part of the Centers for Disease Control and Prevention's national Tips From Former Smokers® (Tips®) campaign. Additionally, this study examines how media content impacted calls to 1-855-DÉJELO-YA. Using National Cancer Institute data on calls to 1-855-DÉJELO-YA from February 2013 to December 2014, multivariate linear regressions were conducted of weekly area code-level call volume as a function of media market-level Gross Rating Points for Tips Spanish-language TV ads tagged with 1-855-DÉJELO-YA. The models were adjusted for covariates, including market-level population characteristics and state fixed effects. The data were analyzed from October 2017 through April 2018. Greater exposure to Tips Spanish-language ads was associated with increased calls to 1-855-DÉJELO-YA (p<0.001). On average, each additional 100 Tips Gross Rating Points per media market increased calls by 0.56 (95% CI=0.45, 0.67) calls/week/area code, representing ≅ 974 additional calls beyond the baseline. Media messages highlighting health consequences of smoking had a greater effect size than messages highlighting health effects of secondhand smoke. A national Spanish-language quitline number could be a useful cessation resource for Spanish-speaking cigarette smokers. Opportunities exist to increase use of this number through a national Spanish-language media campaign, particularly by focusing campaign messages on the health consequences of smoking.

Social inequalities in secondhand smoke exposure in children in Spain.

INTRODUCTIONChildren are particularly vulnerable to the health effects of secondhand smoke (SHS). The objectives of this study are to describe SHS exposure of children younger than 12 years in Spain and to identify potential social inequalities associated with SHS exposure.METHODSA cross-sectional study was conducted in a representative sample of the population younger than 12 years in Spain. A computer-assisted telephone interview was conducted with parents or legal guardians in 2016, to assess the children’s SHS exposure at home, in the car, at school and at the nursery gates, in public transport, and during leisure time. The socio-demographic variables included were the child’s age and sex, the highest educational attainment at home, and occupational social class. Prevalence and 95% confidence intervals were calculated for SHS exposure in each setting and for overall exposure.RESULTSIn all, 71.8% of the children were exposed to SHS: 25.8% were exposed at home, 4.6% in the car, 8.2% in public transport, 31.9% at outdoor nursery or school gates, and 48% during leisure time. The higher the educational attainment at home, the lower the exposure (38.8% for primary school or lower, 28.7% for secondary school and 20.8% university level). The more deprived the social class, the higher the exposure (21.7% class I-II, 23.4% class III-IV and 31.1% class V-VII). SHS exposure in cars and overall exposure also decreased with higher educational achievement.CONCLUSIONSIn Spain, a large proportion of children are still exposed to SHS. Furthermore, there are clear social inequalities. To reduce SHS exposure, there is an urgent need for evidence-based interventions with an equity perspective.

Awareness of health effects of exposure to secondhand smoke from cigarettes: A cross-sectional study of never-smoked adult primary care patients in Eastern Nigeria.

Background:Cigarette smoking whether actively or passively is a growing public health problem. Despite the wealth of information on the hazards of active cigarette smoking, awareness of the health effects of passive smoking on human population is often neglected in Nigeria.Aim:The study was aimed at describing the awareness of health effects of exposure to secondhand smoke from cigarettes among never-smoked adult primary care patients in Eastern Nigeria.Materials and Methods:A hospital-based study carried out on a cross-section of 500 adult patients in a primary care clinic in Nigeria. Data were collected using pretested, structured, and interviewer-administered questionnaire. Exposure to secondhand smoke was defined as exposure to cigarette smoke in a never-smoked adult patient in the previous 1 year. Data were analyzed using Statistical Package for Social Sciences version 21 for the calculation of percentages for categorical variables. Bivariate analysis involving Chi-square test was used to test for significance of association between categorical variables at P < 0.05.Results:The age of the respondents ranged from 18 to 74 years, with a mean age of 36 ± 12.4 years. There were 180 (36.0%) males with 320 (64%) females, with a sex ratio of 1.8. Awareness of general health effects of secondhand smoke on adults, children, and pregnant women was 95.6%, 92.8%, and 65.2%, respectively. The most common specific health effects the respondents were aware for adults, children, and obstetric population were lung cancer (95.6%), precipitation of asthmatic condition (92.8%), and delivery of small babies (65.2%), respectively. The predominant source of awareness of information was radio (93.6%). Awareness of general health effects of exposure to secondhand smoke on adults (P = 0.041), children (P = 0.031), and obstetrics population (P = 0.02) was significantly associated with exposure status.Conclusion:The most common health effects of secondhand smoke the respondents had highest awareness were lung cancer, precipitation of asthmatic attacks, and delivery of small babies in adults, children, and obstetric population, respectively. Awareness of general health effects on adults, children, and obstetrics population was significantly associated with exposure status. The current level of awareness should be improved while effort should be intensified to address identified areas of low level of awareness.

High Prevalence and Clinical/Sociodemographic Correlates of Miscarriages Among Flight Attendants

BackgroundThere are many occupational health hazards associated with long hours of air travel, including cosmic radiation exposure, circadian rhythm disruptions, prior and secondhand smoke exposure, for flight attendants who flew before smoking bans were initiated in the 1990s. Previous studies in flight attendants have found increased incidence of breast cancer and melanoma. However, there is little information on the relationship of airline travel and reproductive health in flight attendants. Secondhand smoke exposure has numerous negative health effects, such as increased cardiac events and respiratory infections, but its effect on reproductive health is not known. This study seeks to examine the role of secondhand smoke exposure on the miscarriage rate in flight attendants who flew before the smoking ban. MethodsFlight attendants who flew before the smoking ban and participating in a study of health effects of secondhand smoke were asked to complete a reproductive health survey. We compared miscarriage rates of flight attendants to the general population using 2010 data from the Centers for Disease Control and Prevention. ResultsIn our cohort of 145 female flight attendants exposed to secondhand smoke, there were 45 miscarriages (26%), compared with a 17.1% rate in the Centers for Disease Control and Prevention report (P = .002). There was no difference in secondhand smoke exposure between the flight attendants with miscarriage and the group without miscarriage (P = .93). ConclusionsThis study found an increased incidence of miscarriage in flight attendants, which was unrelated to secondhand smoke exposure. Other factors, such as circadian rhythm disruption and radiation, may be related to these reproductive health findings and require further investigation.

Epidemiology of exposure to secondhand smoke from cigarettes among innocent never smoked adult nigerians in a resource-poor environment of a primary care clinic in Southeastern Nigeria

Background: Exposure to secondhand smoke from cigarettes is a public health hazard that is increasing globally and emerging in resource-poor nations where the health effects of secondhand smoke are less publicized in biomedical literatures, electronic and print media. As the global prevalence of cigarette smoking increases so does the health hazards and harm associated with secondhand smoke increases with implication for family and community health. Aim: The study was aimed at describing the epidemiology of exposure to secondhand smoke from cigarettes among innocent never smoked adult Nigerians in a primary care clinic of a tertiary hospital in Nigeria. Materials and Methods: A cross-sectional descriptive hospital-based study was carried out on 500 adult Nigerian patients in a primary care clinic in Nigeria. Data were collected using pretested, structured, and interviewer-administered questionnaire containing information on relevant epidemiological variables. Exposure to secondhand smoke was defined as exposure to cigarette smoke in a never smoked adult in the previous 1 year. Results: The prevalence of exposure to secondhand smoke was 45.0%. Exposures occur predominantly among males (56.4%), middle-aged adults (44.0%), outside home environment (72.0), during the daytime (63.6%), and dry season (58.7%). The persons involved in the smoking were principally friends and passersby (65.8%). Exposure to secondhand smoke was associated with age (middle-aged adults) (P = 0.036) and male gender (P = 0.02). Conclusion: This study has demonstrated the variable epidemiology of exposure to secondhand smoke. Tackling relevant epidemiological factors that predispose to exposure to secondhand smoke through programs and policies will facilitate appropriate public health action to safeguard the health of never smoked individuals.

Indoor tobacco legislation is associated with fewer emergency department visits for asthma exacerbation in children

BackgroundDuring the past 3 decades, numerous cities and states have adopted laws that ban smoking in public indoor spaces. The rationale for these policies has been to protect nonsmokers from the adverse health effects of secondhand smoke. ObjectiveTo determine whether the implementation of indoor smoking legislation is associated with a decrease in emergency department visits for asthma in children. MethodsThis retrospective analysis used a natural experiment to estimate the impact of clean indoor air legislation on the rate of emergency department admissions for asthma exacerbation in children. Data were obtained from the Pediatric Health Information System. A Poisson regression was used for analyses and controlled for age, sex, race, payer source, seasonality, and secular trends. ResultsAsthma emergency department visits were captured from 20 hospitals in 14 different states plus the District of Columbia from July 2000 to January 2014 (n = 335,588). Indoor smoking legislation, pooled across all cities, was associated with a decreased rate of severe asthma exacerbation (adjusted rate ratio 0.83, 95% confidence interval 0.82–0.85, P < .0001). ConclusionIndoor tobacco legislation is associated with a decrease in emergency department visits for asthma exacerbation. Such legislation should be considered in localities that remain without this legislation to protect the respiratory health of their children.

Factors that influence attitude and enforcement of the smoke-free law in Turkey: a survey of hospitality venue owners and employees

IntroductionIn 2009, Turkey extended the smoke-free legislation to hospitality venues. Compliance, however, remains low in some hospitality venues. We identified characteristics associated with knowledge of health effects that can be...

Decreasing In-home Smoking of Adults-Results from a School-based Intervention Program in Viet Nam.

It is indicated that children are involuntarily exposed to secondhand smoke from adults, mainly at their home environment. This study aimed at describing the effectiveness of the school-based intervention to decrease the in-home smoking situation of adults so as to decrease children's exposure to secondhand smoke at home during the year 2011–2012 in a rural district in Hanoi, Viet Nam. This school-based intervention program (intervention and control group) involved 804 children aged 8 to 11 years from August 2011 to May 2012 in a rural district of Hanoi, Viet Nam. Children were taught in class about the harmful effects of secondhand smoke and about how to negotiate with fathers not to smoke in-home. Then children applied what they learnt, including staying away from secondhand smoke and persuading fathers not to smoke in-home in order to decrease children's exposure to secondhand smoke. Chi square test, t-test and multinominal logistic regression were applied in data analysis. The results showed that children's reported their father's in-home smoking decreased from 83.0% pre-intervention to 59.8% post-intervention (p < 0.001) in the intervention school while no change happened in the control school. The study found that the better changed smoking location of adult smokers as reported by children associated with the school who received intervention activities (adjusted OR = 2.04; 95% CI: 1.28–3.24). Poorer changed attitudes towards secondhand smoke of children associated with a lower percentage of better change in smoking location of their fathers/other adult smokers (aOR = 0.51, 95% CI: 0.28–0.96). Children's poorer changed knowledge towards secondhand smoke also associated with poorer changed smoking location of adult smokers (aOR = 2.88, 95% CI: 1.07–7.76). It is recommended by this study that similar school based intervention approaches should be applied in primary schools in Viet Nam to increase children's awareness on the adverse health effects of secondhand smoke and to help them to be able to avoid their exposure to secondhand smoke at their home environment.

Trends in adult exposure to secondhand smoke in vehicles: Findings from the 2009–2012 Canadian Tobacco Use Monitoring Survey

IntroductionA growing number of jurisdictions have implemented smoke-free vehicles when children are present due to the substantial health effects of secondhand smoke (SHS). Prior studies on the prevalence of SHS exposure in vehicles have mainly focused on adolescents. This study examined the prevalence and socio-demographic correlates of SHS exposure in vehicles among Canadian adults. MethodsA repeated cross-sectional data on youth and adult data were drawn from the 2009–2012 Canadian Tobacco Use Monitoring Survey (n=58, 195). Multivariable logistic regression analysis was used to examine the socio-demographic correlates of exposure to SHS in vehicles. ResultsOverall, 19% in 2009 and 18% in 2012 of adults reported SHS exposure in vehicles in the past month. Disparities in the SHS exposure prevalence were observed, with a higher SHS exposure among current smokers, former smokers, males, younger adults, living in a household with smoking-related exposure, and those with less education. The multivariable analyses showed significant associations between socio-demographic characteristics and SHS exposure. Higher odds SHS exposure was found for those younger (aged 20–24, OR=16.27, CI=11.09–23.88; 25–44, OR=6.12, CI=4.14–9.06; 45–64, OR=2.79, CI=1.95–4.02) compared to those aged 65 and over. Likewise, those with less education had greater odds of SHS exposure. ConclusionsFindings suggest that adults SHS exposure is high, especially for young adults and those with less education. Adult passengers may need protection from SHS given that no level of SHS exposure is safe.

Casinos, Smoking Bans, and Revenues: A Survey of Casino Gamblers in Illinois

In 2006, the U.S. Surgeon General released The Health Consequences of Involuntary Exposure to Tobacco Smoke, which was a comprehensive review of research on the health effects of exposure to secondhand smoke (SHS). The report defines secondhand smoke as ‘‘a mixture of the smoke given off by the burning end of tobacco products (sidestream smoke) and the mainstream smoke exhaled by smokers.’’ The report estimates that 123 million people in the United States are regularly exposed to second hand smoke at home, in the workplace, and in other public places such as bars, restaurants, and recreation venues. The report concludes unequivocally that ‘‘inhaling secondhand smoke causes lung cancer and coronary heart disease in nonsmoking adults’’ and that ‘‘smoke free environments are the most effective method for reducing exposure’’ (quoted in ‘‘Message,’’ U.S. Department of Health and Human Services 2006). However, U.S. smoking prohibitions are a bewildering patchwork of state and local laws. A total of 3,964 municipalities in the United States have laws restricting smoking in public places. Some of these laws prohibit smoking in all non-hospitality workplaces, while some extend smoking bans to restaurants, or even to restaurants and bars. It is estimated that these laws currently protect 49.1 percent of the U.S. population from exposure to secondhand smoke (ANRF 2014a). A few states have extended smoking prohibitions to state-regulated gambling facilities, but most commercial casinos and racinos are at least partially exempt from smoking prohibitions, while Indian casinos are outside the jurisdiction of state regulation due to tribal sovereignty. However, despite the documented health effects of SHS on casino employees and patrons, the gaming industry has generally joined with Big Tobacco to oppose such bans or to at least seek exemptions from them (Dearlove, Bialous, and Glantz 2002; Mandel and Glantz 2004) based on the claim that smoking bans result in a decline in gross gaming revenues and, therefore, declines in the gaming taxes collected by states. Moreover, the casino industry has generally been quite successful in securing exemptions from public smoking prohibitions even in cases where these prohibitions have otherwise been extended to other segments of the hospitality industry (e.g., restaurants and bars). Yet, in 2012, 76.1 million adults—or 34 percent of the U.S. adult population—visited casinos, and these visits potentially represent a significant health hazard for the large majority of those visitors who are non-smokers. This risk is even higher for the 661,000 casino employees, who spend several hours per day exposed to secondhand smoke (AGA 2013, 2; Meister 2013, 75 for employment estimates). Consequently, despite the industry’s vigorous opposition to an extension of smoking bans to gaming floors, by 2014, there were 113 smokefree commercial casinos and racinos in nine states and an additional 83 smoke-free tribal casinos

Secondhand Smoking and Matrix Metalloproteinase-2 and -9 Gene Expression in Saphenous Veins of Women Nonsmokers

Active smoking upregulated matrix metalloproteinase-2 (MMP-2) and MMP-9 gene expression in saphenous veins (SVs) before coronary operation. However, little is known about the effects of secondhand smoke (SHS), a smoking status that is more widely harmful to the general population, on MMP gene expression in SVs. Health effects of SHS were investigated mainly in nonsmokers married to smokers. Because the vast majority of women are nonsmokers in China, we had an opportunity to evaluate the relations between SHS and MMP gene expression in SVs of women patients before operation. A total of 258 woman patients were divided into three groups: control group, nonsmokers; SHS group, patients exposed to SHS until operation; active smoking group, patients who smoked a minimum of 1 package of cigarettes every day for more than 20 years. Messenger RNA and protein levels of MMP-2 and MMP-9 were analyzed. Saphenous vein graft patency after coronary operation was evaluated. The clinical backgrounds in the three groups were comparable. Compared with the control group, MMP-2 and MMP-9 gene expression was significantly increased in the SHS and active smoking groups (p<0.05). The degree of MMP gene expression changed by SHS or active smoking was comparable. A significant difference of SV graft patency was found among the three groups. An association of increased MMP gene expression with lowered SV graft patency was found in follow-up. Our data revealed that SHS had similar power as active smoking to affect MMP gene expression in SVs before operation and SV graft patency after coronary operation in women nonsmokers.

Children's perspectives on how parents protect them from secondhand smoke in their homes and cars in socioeconomically contrasting communities: a qualitative study.

Children are particularly vulnerable to the health effects of secondhand smoke (SHS) and are mainly exposed in the home and the car. Reducing children's SHS exposure is a tobacco control goal, yet few studies have explored children's perspectives on SHS. This study examines children's accounts of the strategies family members employ to protect them from SHS and is the first to examine how these may be constrained or facilitated in communities with contrasting smoking prevalence rates. Individual, paired, and group interviews using topic guides and visual stimulus methods were conducted with 38 children aged 10-15 years who lived in 2 Scottish communities of contrasting socioeconomic status and had a close family member who smoked. Transcripts were analyzed thematically. Parents were reported to employ spatial and dispersal measures to reduce children's SHS exposure in homes and cars. Smoking was restricted to certain rooms and to times when those considered more vulnerable were absent. Less distance between smokers and children and more smoking in the home were reported in the disadvantaged community, reflecting less space within homes and greater parental smoking. Participants expressed strong negative views about smoking in cars and the perceived ineffectiveness of dispersal measures in this context. Although there was general awareness that SHS exposure was potentially harmful, SHS in the home was considered safe by some participants if certain conditions were met, particularly by those from the disadvantaged area. The implications of these findings for tobacco control programs and media campaigns, particularly those targeted at disadvantaged groups, are discussed.

Design and implementation of questionnaires to assess chronic exposure to secondhand smoke in children and adults

Background Despite a multitude of anti-smoking campaigns being active worldwide, the number of smokers is currently larger than at any other time in human history. An essential first step towards minimizing the health effects of secondhand smoke (SHS) is to accurately assess the exposure level of individuals. The objectives of this study were to: (i) to develop questionnaires that can identify never-smoking children and adults experiencing increased exposure to secondhand smoke (SHS+), (ii) to determine their validity against hair nicotine, and (iii) assess their reliability. Materials and methods A sample of 191 children (85 males; 106 females; 7-18 years) and 95 adult (23 males; 72 females; 18-62 years) never-smokers consented to hair nicotine analysis and answered a large number of questions pertaining to all relevant sources of SHS. A randomly-selected 30% answered the questions again after 20-30 days. Results Prevalence of SHS+ in children and adults was 0.52 ± 0.07 and 0.67 ± 0.10, respectively (p 16.5 and >16, respectively. Significant Kappa agreement (p 0.05). Area under the curve and McNemar’ sC hi-square showed no pair-wise differences in sensitivity and specificity at the cutoff point between the two different days for SS-C and SS-A (p > 0.05). Conclusions We conclude that the SS-C and the SS-A represent valid, reliable, practical, and inexpensive instruments to identify children and adult never-smokers exposed to increased SHS.

Beliefs Associated With Intention to Ban Smoking in Households With Smokers

Smoking in homes exposes family members to secondhand smoke, an exposure that is harmful to children and adults. This study identifies barriers to instituting household smoking bans and beliefs that are positively and negatively related to smoking bans in households with smokers. A telephone survey of parents living in Philadelphia with at least 1 smoker and a child under the age of 13 years in the household was conducted in 2012. Using the reasoned action model, the survey assessed beliefs regarding attitudes, norms, and self-efficacy/control predictors of intention to ban household smoking. Forty-seven percent of households reported high intention to not allow smoking in the home. Regression analysis to identify the reasoned action predictors associated with intention to restrict smoking in the home showed that all 3 of the predictors of intention (attitude, normative pressure, and control) were significantly related to intention. Important underlying beliefs related to intention included beliefs about the health effects of secondhand smoke on children's health, norms regarding those restrictions, and barriers to enforcing such restrictions. Messages that increase concern about the health effects of secondhand smoke on children, that contrast the rights of smokers with negative health effects, and that suggest alternative locations to smoke are promising strategies to motivate smokers to implement indoor smoking bans.

Outdoor Smoking Areas: Does the Science Support a Ban?

Inhaling secondhand cigarette smoke (SHS), also known as passive smoking, can cause cancer and respiratory and cardiovascular disease.1 Indoor smoking is banned at many public places and worksites; at others, smoking areas have been moved outdoors. But is keeping cigarette smoke outdoors enough to dissipate the health risks associated with SHS exposure? A review in this issue of EHP explores the current state of knowledge about outdoor SHS exposure.2 “Outdoor SHS is an emerging topic in the tobacco control community,” says review coauthor Esteve Fernandez, an epidemiologist at the Institut Catala d’Oncologia–ICO in Barcelona, Spain. Surveys indicate that public support for banning outdoor smoking has increased in recent years,3 although some opponents argue that such bans are unsustainable, unduly restrictive, and unsupported by the evidence to date.4,5 To impose outdoor smoking laws, tobacco control advocates need “evidence-based results from valid and representative epidemiological studies about levels of SHS in different outdoor areas,” says Fernandez. For the current review Fernandez and colleagues analyzed data from 18 scientific papers published between 2005 and 2012, which measured SHS exposure at outdoor settings in Europe, the United States, Canada, Australia, and New Zealand. Sites included hospitality venues (e.g., restaurants and bars), airports, parks, streets, entrances to buildings, and college campuses.2 In most of the studies reviewed, the main marker for SHS was fine particulate matter (PM2.5). Measured average levels of PM2.5 ranged from 8.32 μg/m3 to 124 μg/m3 at outdoor hospitality venues where smokers were present, and from 4.6 μg/m3 to 17.8 μg/m3 at other outdoor settings. Individual point measurements exceeded 1,000 μg/m3 in some cases. Densely packed smokers, partially enclosed outdoor areas, low wind speeds, and closeness to people smoking all contributed to high levels of outdoor SHS. Smoke-free indoor settings near outdoor smoking areas also had elevated PM2.5 levels, with mean concentrations ranging from 4 μg/m3 to 120.51 μg/m3. Measured levels exceeded the median level for irritation from secondhand smoke PM2.5 reported for brief exposures.6 Most studies detected outdoor concentrations of PM2.5 exceeding 10 μg/m3, the annual outdoor average that the World Health Organization sets as the lowest cutoff at which lung cancer and cardiopulmonary deaths are likely to increase7—a particular concern for chronically exposed hospitality workers. “Although outdoor SHS levels are more transient than indoor levels, and can quickly drop to background levels in the absence of active smoking,” the authors wrote, “potential health effects of these exposures merit consideration and need to be further studied.” Although more transient than indoor levels, outdoor levels of secondhand smoke can be quite high, depending on the setting. The review shows that “depending on the microenvironment, you can get very high levels of secondhand smoke outdoors. A cigarette is a point source of outdoor pollution,” says Stanton Glantz, director of the Center for Tobacco Control Research and Education at the University of California, San Francisco. Fernandez’s compilation of data scattered across different journals “will be useful to policy makers. The evidence points to banning outdoor SHS where smokers congregate,” Glantz says. The compiled data also highlight the need for better standardized methods in future studies. PM2.5, although cheap and easy to measure, is a common traffic pollutant and not specific to SHS. More precise and sensitive markers such as salivary cotinine (a metabolic by-product of nicotine) better reflect personal exposure to SHS.2 An ideal study would combine both environmental markers such as airborne nicotine and biological markers such as cotinine in saliva. “Such studies, although more complicated to implement, would be of extreme relevance,” says Fernandez. SHS contains more than 7,000 chemicals, including about 70 known and probable carcinogens, as well as toxicants and irritants.1 In the United States, an estimated 46,000 premature deaths from heart disease and 3,400 lung cancer deaths in nonsmokers are caused by SHS exposure yearly.1 Gene microarray scans of cells lining the small airways suggest there are no safe levels of SHS exposure. One study showed that even very low exposure was associated with changes in gene expression that may reflect early smoking-induced damage, potentially setting the stage for lung disease and cancer.8

Updates of Secondhand Smoke Exposure on Infants' and Children's Health

The purpose of this study is to determine if the existing evidence on the health effects of exposure to secondhand smoke (SHS) is adequate to warrant consideration of legislative smoke-free bans in private spaces and in the presence of infants and children. The 1.1 billion smokers worldwide expose an estimated 700 million children daily to SHS. Harmful health effects of SHS are adequately documented, smoking bans in public spaces is advocated, and the number of countries adopting smoke-free legislations is increasing. Similar measures for private spaces, and especially in the presence of infants and children, despite the published evidence by the World Health Organization and the U.S. Surgeon General, lag behind. A systematic review of English-language meta-analyses, published between 2000 and 2013, was conducted. This literature search overlapped the literature cited in the 2006 U.S. Surgeon General Report. Medical Search Headings (MeSH) were used to query large databases. A qualitative rating scale was used to determine the strength of evidence. Thirteen meta-analyses met the established inclusion criteria. Seven studies provided strong evidence for health effects of SHS on children's health including asthma, middle ear diseases, lower respiratory infections (LRIs), acute lymphoblastic leukemia (ALL), and congenital malformations. Children aged two years or younger, living with smoking mothers, show the strongest correlation between SHS and diagnosed health problems. Available information on morbidity and mortality from SHS warrants intervention efforts and policies targeting voluntary and legislated smoking bans for private spaces. Adequate knowledge base for chronic health effects from SHS exposures, during infancy and childhood, and their economic burden is still fragmented. Further carefully designed studies will help advocate and promote evidence-based intervention strategies.