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Control of secondhand smoke exposure

Control of secondhand smoke exposure
Literature review current through: Jan 2024.
This topic last updated: Feb 17, 2022.

INTRODUCTION — Exposure to secondhand smoke (SHS) takes place in many different microenvironments (ie, distinct places where time is spent). For children, the home is a dominant locus of exposure. Elimination of smoking in an environment appears to be the only effective means of preventing SHS exposure in that location [1-3].

Strategies to prevent SHS exposure and the role of the health care provider are reviewed here. The adverse health effects of SHS and related issues are discussed separately:

(See "Secondhand smoke exposure: Effects in children".)

(See "Secondhand smoke exposure: Effects in adults".)

(See "Prevention of smoking and vaping initiation in children and adolescents".)

(See "Management of smoking and vaping cessation in adolescents".)

OVERVIEW OF CONTRIBUTORS TO SECONDHAND SMOKE RISK — The contributions of various microenvironments to personal SHS exposures depend upon the amount of time spent in each setting and on the concentrations of SHS in those environments. The contributions of different microenvironments also depend upon age, sex, and other sociodemographic factors that determine time-activity patterns and the SHS concentrations in them.

For children, the home is a dominant locus of exposure. (See 'The home environment' below.)

For adolescents and adults, public environments including the workplace and social environments may be significant loci for SHS exposure, depending on coverage by clean indoor air regulations and laws. In the United States, smoking is no longer allowed in most workplaces and public places. Therefore, the home environment is a critical locus of exposure for most adults as well as children. With the rising use of vaping (via electronic cigarettes [e-cigarettes] and other nicotine delivery devices) and heat-not-burn products, concern about secondhand exposure to emissions from these products is a new issue. (See 'Public smoking bans' below.)

The concentration of SHS in a particular indoor environment depends upon the intensity of smoking (the strength of the source), the rate of exchange of air in the space with outdoor air or other "clean" air, and the presence and effectiveness of any air cleaning devices. For public and commercial buildings, ventilation requirements are set by code, generally following the standards published by the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE). The ventilation standard assumes that adequate indoor air quality cannot be achieved if smoking is allowed, even with additional ventilation, a view reaffirmed in a position statement by ASHRAE [4]. Air cleaning also is not sufficient if smoking is allowed. Elimination of smoking in an environment appears to be the only effective means of preventing SHS exposure in that location [1-3]. (See 'Air cleaners/air purifiers' below.)

STRATEGIES TO PREVENT SECONDHAND SMOKE EXPOSURE — Four categories of strategies can be implemented to prevent SHS exposure [5]:

Education

Regulation

Legislation

Litigation

Distinct SHS control strategies are directed at different environments. Public places, workplaces, and transportation environments are subject to regulation, whereas the home is not. Education lays the groundwork for good compliance with legislation and regulation and, in some areas (eg, the home), is the only intervention strategy that is available. Smoking, and therefore exposure to SHS, is an important social determinant of health and source of health disparities in the United States [6]. The disparities are attributable to several structural forces, including targeting of vulnerable groups by the tobacco industry, disparate enforcement of age-for-sale laws, and barriers to health care and smoking cessation resources.

Health care professionals should educate their patients and support legislation and regulations designed to protect nonsmokers and promote clean air. Regulatory strategies prohibiting smoking, when they exist and are enforced, decrease population exposure to SHS. Indirect regulatory forces (eg, increased cigarette taxes, controls on cigarette advertising) can help address source control in the home, the major environment where SHS exposure still occurs in the United States [1].

SHS exposure has greatly decreased in the United States, suggesting that these control strategies are having beneficial effects [7,8]. According to data from the National Health and Nutrition Examination Survey, the percentage of nonsmoking children with detectable serum cotinine concentrations (>0.05 ng/mL) decreased from 87 percent in 1988-1991 to 36 percent in 2015-2016, with a similar downward trend in nonsmoking adults [9].

Recommendations of the Task Force on Community Preventive Services — The Task Force on Community Preventive Services (TFCPS) has made recommendations on the effectiveness of selected interventions to reduce exposure to SHS [10].

Based upon a review of the evidence, the task force recommends:

Smoking bans and restrictions

Obligations for health care providers to discuss smoking cessation with their patients (or parents/caregivers of patients) who smoke

Telephone support assistance for patients attempting to quit and maintain abstinence

Air cleaners/air purifiers — In general, health care providers should advise against purchase of an air cleaning device for the home as a strategy for controlling SHS exposure. Various devices are available for air cleaning, but none is sufficient to achieve healthy indoor air where there is smoking.

Cleaning air of SHS poses a technical challenge because of the strength of tobacco combustion as a source of indoor air pollution and the myriad gases and particles that are included in SHS. Available devices range from complex and expensive systems that are incorporated into the heating, ventilation, and air conditioning (HVAC) systems of buildings to simple tabletop devices and "smokeless ashtrays" that are purported to control SHS exposure at its source.

For any air cleaning device to be effective, it must be able to clean a sufficient volume of air in relation to the total volume of the space where it is operating. Few devices are able to clean sufficient volumes of air to be effective in managing smoking indoors, particularly if complete control is the goal. Small devices, like smokeless ashtrays and many tabletop units, offer inadequate cleaning capacity. Devices can only be effective for SHS if they include both filters or electrostatic precipitators to remove particles and a sorbent, such as activated charcoal, to remove gases. Although a few such devices are available, they tend to be very expensive and are only partially effective; no device can achieve healthy indoor air where there is smoking. A trial addressed the feasibility of using air cleaners in the homes of women who were pregnant or had an infant [11]. The use of two air cleaners reduced the level of small particles in the air but did not create a smoke-free environment. Thus, while air cleaners may be helpful in some circumstances (eg, reducing exposure to wildfire smoke), they are not a solution to SHS. A smoking policy for the home is the preferred solution.

THE ROLE OF THE HEALTH CARE PROVIDER — Most smokers in the United States are now aware of the risks of tobacco to health and also have a general knowledge of the risks of SHS exposure. However, they may not be sufficiently informed about specific risks that might affect their decision to expose children or other household members to SHS. Personalizing the risks, through education of the smokers in the household, may increase the effectiveness of counseling. Smokers may not know that SHS exposure can cause lung cancer and cardiovascular disease in their spouses or contribute to asthma and otitis media in their children. (See "Secondhand smoke exposure: Effects in children".)

Smokers may be more amenable to change at key points in their lives or the lives of their children. Health care providers should use these events as "teachable moments" [12-14]:

Pregnancy

Birth of a child

Early childhood (eg, child begins to imitate smoking behavior or asks about smoking)

Acute illness of the child that is related to smoking (eg, otitis media)

Exacerbations of asthma

As an example, a trial of counseling to parents of premature infants prior to discharge from the neonatal intensive care unit was successful in achieving a smoking ban in 66 percent of households by one month post-discharge, as compared with 20 percent in households that did not receive the counseling [15].

Obstetrics — Obstetrical providers should address fetal tobacco exposure and its consequences for the pregnancy and infant health as early in pregnancy as possible [16]. Expectant parents should know the benefits of providing a smoke-free environment for children before and after birth. They should know that smoking and exposure to SHS during pregnancy have predictable and possibly lasting adverse consequences. The 2020 United States Surgeon General Report on Smoking Cessation has an overall conclusion that smoking cessation by pregnant women benefits both the health of the mother as well as the fetus and newborn [17]. (See "Secondhand smoke exposure: Effects in children".)

Although smoking during pregnancy has declined significantly, most mothers who smoked before pregnancy return to smoking postpartum, often in the first six weeks after delivery [18,19]. Risk factors for return to smoking postpartum include partners' smoking, low confidence or intention for maintaining nonsmoking postpartum, having friends who smoke, and taking puffs of cigarettes late in pregnancy [19,20]. Relapse prevention with behavioral counseling techniques should begin during pregnancy and continue postpartum [20]. (See "Tobacco and nicotine use in pregnancy: Cessation strategies and treatment options".)

Pediatrics — Discussions about SHS exposure should be continued by the pediatric health care provider after the child's birth. The American Academy of Pediatrics and other organizations of SHS experts call on pediatric health care providers to address tobacco exposure and to prevent active smoking and exposure to SHS [21-23]. Smoke exposure and smoking status of household members should be assessed at each well-child and acute-care visit. Providing parents/caregivers who smoke with guidance in cessation or referral to cessation programs is an important component of family-centered care. (See "Overview of smoking cessation management in adults".)

Smoking cessation counseling is not widely or consistently practiced by pediatric clinicians, although rates have increased over time [24,25]. Studies have shown that carrying out this counseling does not lengthen visit time [25]. However, many pediatric health care providers lack confidence in their ability to counsel parents and caregivers about their smoking and have not routinely done so, although they often ask about child exposure to smoking and the presence of smokers in the household [26]. Most parents/caregivers surveyed report that they are interested in quitting and could be responsive to smoking cessation advice from their child's pediatrician [24,25,27]. Pediatric health care providers also should consider screening for and addressing factors such as parent depression that may adversely impact not only parental smoking cessation but parent actions related to child health more generally, such as asthma control [28]. (See "Prevention of smoking and vaping initiation in children and adolescents", section on 'Guidance for parents and caregivers'.)

Health care providers should give a clear message that SHS exposure is a controllable factor in preventing and reducing illness.

Families should be encouraged to actively control tobacco exposure as a way to model a smoke-free environment for the child.

Nonsmoking parents/caregivers should be encouraged to advocate for smoke-free environments for their child. The provider should offer to communicate directly with household smokers about SHS exposure risks.

Support for smoking cessation — There are a variety of approaches for smoking cessation counseling including the National Cancer Institute's 5As model (Ask, Advise, Assess, Assist, Arrange follow-up). These and other strategies for smoking cessation, including pharmacotherapy, are discussed in detail elsewhere. One useful resource is the American Academy of Pediatrics' Julius B Richmond Center of Excellence. (See "Overview of smoking cessation management in adults" and "Management of smoking and vaping cessation in adolescents".)

Evidence-based algorithms, clinical guidelines, and additional resources for health care providers are available at the following websites:

United States Environmental Protection Agency: Secondhand Smoke and Smoke-free Homes

United States Department of Health and Human Services: Be Tobacco Free

National Cancer Institute: Smokefree

American Academy of Pediatrics: Professional Resources

American Academy of Pediatrics: Julius B. Richmond Center of Excellence

THE HOME ENVIRONMENT — The home environment is the most important locus of SHS exposure for children. In a nationally representative sample in the United States, the mean serum level of cotinine (the principal nicotine metabolite) was nearly 20-fold higher among children exposed to SHS in the home compared with those not exposed in the home [29]. The increase in cotinine level associated with home exposure was greatest for infants and young children.

Effect of smoking bans — The air quality of homes is not subject to direct regulation by any entity, and, consequently, effective educational strategies are needed to reduce exposures in homes.

Smokers should be supported in quitting smoking for the benefit of their own health as well as the health of those around them. For those smokers who are unable or unwilling to quit, a policy should be established to have smokers smoke outside of the home [22,30]. Allowing smoking in the house, but with restrictions, does not provide maximum protection. In cross-sectional surveys of households containing smokers and infants or toddlers, urinary cotinine levels were lower among children from households where smoking was not permitted in the house than among those from households using less strict harm-reduction measures [31,32].

Among households of smokers in the United States, the proportion that do not allow smoking within the house varies by region, ranging from 69.4 percent in Kentucky to 93.6 percent in Utah (median 83 percent) [33]. This rate is dramatically increased compared with the early 1990s, when the prevalence of home smoking bans ranged from 25.6 percent in Kentucky to 69.4 percent in Utah (median 43 percent).

Exposure to SHS decreased steadily from 1988 through 2011 but then plateaued [34]. In 2013 to 2014, almost 40 percent of children ages 3 to 11 years, including 66 percent of Black children, were exposed to SHS, as measured by serum cotinine concentrations. As of 2015, one in five households still permitted smoking inside of the home and family vehicle [35]. Self-imposed home smoking bans, however, may be incomplete or have limited success with long-term adherence. A cross-sectional study among parents of young children in low-income communities in Massachusetts showed that adoption of a complete ban or partial household smoking ban was associated with lower air nicotine levels in the homes, but adherence was not stringent [36].

Intermediate steps to reduce exposure include restricting smoking to a particular room with good ventilation, smoking after the children have gone to bed, and smoking away from children and other nonsmokers. By themselves, neither air cleaning nor increasing ventilation is a sufficient control measure. These measures may reduce the concentrations of gaseous and particulate components of tobacco smoke, but they do not completely eliminate them. Indoor air in homes exchanges with outdoor air largely through natural diffusion. The air exchange rate cannot be substantially and sufficiently increased by opening windows and doors and has been reduced in many homes by efforts to increase energy efficiency.

A number of studies have evaluated interventions to reduce SHS exposure in the home and promote parental smoking cessation, with mixed results. For example, a 2015 systematic review of studies from 2000 through 2014 identified 28 articles on smoking cessation and SHS reduction [37]. Results were mixed and heterogeneous. Some trials have demonstrated positive results [23,38-44], while others have not produced significant reductions in child exposure or in persuading parents to stop smoking [45-49]. Those interventions showing the greatest sustained positive effect provided behavioral counseling delivered to individuals in the home [23,39,50], in small groups, or through the school [40,41,51]. As an example, cessation curriculum was effective in achieving sustained smoking abstinence and reduced SHS exposure of children [51]. Several of these randomized studies also showed some benefit from clinician-delivered advice with provision of printed self-help materials [38,41,52,53], though the effect is less than that seen with motivational counseling and may decrease after the intervention without consistent reinforcement [23,54-56]. Another study showed benefits from a comprehensive program that included feedback about home air quality, behavioral intervention, and nicotine replacement for parents [56]. One study found that a decision aid embedded in the electronic medical record effectively increased screening and counseling regarding child SHS exposure and increased smoking cessation by the parents [55]. These studies suggest that structured clinician-delivered treatment that is only minimally more time intensive than usual care may provide substantial benefit using supportive, motivation-oriented messages and consistent follow-up reinforcement. (See 'The role of the health care provider' above.)

There is increasing attention to the spread of SHS within multifamily buildings [57]. Some municipalities implemented ordinances addressing smoking in such housing. In early 2017, the United States Department of Housing and Urban Development prohibited the use of certain combustible tobacco products, including cigarettes, cigars, pipes, and hookahs, in public housing properties [58]. Public housing agencies were required to adopt a smoke-free policy in mid-2018, affecting approximately two million people.

Thirdhand smoke exposure — Thirdhand smoke (THS) exposure refers to exposure to smoke components and their metabolic byproducts from contact with surfaces that have adsorbed smoke. The smoke leaves a residue of nicotine and other toxic substances in household dust and on surfaces. Although not yet well studied, there is concern that contact with THS will result in absorption of toxins through the skin or ingestion from contamination of the hands. Inhalation of re-suspended dust is another potential route for entry into the body [59-61]. Young children, especially those whose parents or caregivers are smokers, are particularly at risk for exposure to THS, given their increased contact with materials, such as carpeting, that are contaminated by THS compared with adults [62]. Although direct health effects from THS have not been established, many of the toxins that are deposited on surfaces are group 1 carcinogens, raising concerns about chronic exposure even if it is at low levels. The persistence of these substances in the home environment represents an unappreciated health hazard through dermal exposure, dust inhalation, and ingestion. In fact, odors and toxic chemicals from tobacco smoke may linger in homes for months or even years after smoking behaviors ended. To mitigate THS in the home, repainting or replacement of drywall, carpeting, and other tobacco smoke-affected materials may be necessary. A thorough, professional cleaning of the home may also help to mitigate THS [63]. It is important to note, however, that the efficacy of these mitigation methods for the long run is still unknown; particularly if there has been long-term smoking in the home [63]. A study showed that various cleaning interventions could reduce nicotine in dust and on surfaces in homes but not eliminate it [64]. Discussion of this exposure risk may be a further incentive for households to adopt home nonsmoking policies. Homebuyers and renters should inquire about prior smoking in homes they may occupy [65]. For the latest information, consult the California Thirdhand Smoke Resource Center.

Electronic cigarette secondhand vapor exposure — There is growing use of electronic cigarettes (e-cigarettes) and other devices that provide a nicotine-containing vapor. There has been limited study of the impact of e-cigarette emissions on air quality and on deposition of nicotine on surfaces where they may persist. Research suggests that e-cigarettes expose bystanders to significant concentrations of aerosolized nicotine [66,67]. Moreover, high levels of fine and ultrafine particles that are similar to tobacco particles can be observed in indoor environments where e-cigarettes have been used [68]. In addition, an increasing number of reports describe poisonings among children due to ingestion or dermal exposure of the nicotine liquid in cartridges or refills [69]. Research indicates that while most dual e-cigarette and cigarette users have smoke-free home policies, they are less likely than cigarette users to have smoke-free car and comprehensive vape-free policies, indicating that dual users may perceive e-cigarette vapor as safe for children [70]. Parents or caregivers who use e-cigarettes should be encouraged to adopt comprehensive (car and home) vape-free policies. Further research is needed regarding health risks of secondhand vapor exposure, but emerging evidence and toxicologic considerations indicate that there may be risks to the fetus and children [71]. Discussions about the regulation of e-cigarettes in the United States are ongoing, and as of December 2019, the minimum age for sales of e-cigarettes and all tobacco products was raised to 21 [72]. Effective August 8, 2017, the US Food and Drug Administration exerted regulatory authority over all electronic nicotine delivery systems including, but not limited to, e-cigarettes [73]. However, the US Food and Drug Administration also delayed implementation of these rules, while they develop a new, comprehensive approach around regulation of nicotine [74]. Meanwhile, it is important for clinicians to discuss potential harms from e-cigarettes with children, adolescents, and their parents/caregivers. (See "Vaping and e-cigarettes", section on 'Public health concerns'.)

PUBLIC SMOKING BANS — Policies that ban all indoor smoking in workplaces and public places are highly effective in reducing smoke exposure and are an important goal of health advocacy [57]. Only complete bans of indoor smoking are effective; simply segregating smokers and nonsmokers within the same airspace may reduce the exposure of nonsmokers to SHS but does not eliminate it. For workers exposed to SHS during the workday, the degree of smoke exposure may be comparable with sharing a home with a smoker, depending on the extent of smoking and building characteristics.

A study from Scotland suggests important long-term improvements in cardiac disease that may be attributable to a nationwide ban of smoking in workplaces and other public spaces [75]. After the smoking ban was enacted in 2006, there was a 14 percent reduction in admissions for acute coronary syndrome among smokers, a 19 percent reduction among former smokers, and a 21 percent reduction among nonsmokers. Reductions in coronary events were also seen in Rome after the institution of a smoking ban [76]. A report by the Institute of Medicine concluded that data consistently demonstrate that SHS exposure increases the risk of coronary heart disease and heart attacks and that smoking bans reduce this risk [77]. Given the prevalence of heart attacks and the resultant deaths, smoking bans can have a substantial beneficial impact on public health.

Smoke-free legislation is also associated with immediate improvements in several health outcomes, including among children [78]. Several meta-analyses of observational studies from Europe and North America concluded that smoking bans in workplaces, public places, or both were associated with reductions in preterm birth, small for gestational age births, and hospital visits for asthma and respiratory tract infections [79-81]. Some of these effects may be mediated through decreased smoking in the home, which is often prompted by public smoking bans [82,83].

Workplaces — There has been a remarkable shift in workplace smoking in the United States. Three decades ago, smoking was ubiquitous in workplaces; now, the majority of workplaces are designated as smoke-free. Model workplace smoking policies may involve either an outright ban or restriction of smoking to designated areas; some companies ban smoking altogether on their properties. In implementing a workplace smoking policy, smokers should be provided with opportunities to participate in smoking cessation programs, and informed communication is needed for all employees.

The efficacy of workplace smoking policies has been documented in studies involving measurement of airborne nicotine and also of the biomarker cotinine. One study demonstrated that policies banning smoking in the workplace are the most effective and generally lower all airborne nicotine concentrations to less than 1 mcg/m3 (figure 1). By contrast, mean concentrations measured in workplaces that allow smoking generally range from 2 to 6 mcg/m3 in offices, 3 to 8 mcg/m3 in restaurants, and 1 to 6 mcg/m3 in the workplaces of blue-collar workers [84], which compares with mean nicotine concentrations from 1 to 3 mcg/m3 that have been measured in the homes of smokers. These data are from the 1990s and are not necessarily representative of the workplace conditions of today. However, for those workers who are exposed to SHS during the workday, levels of cotinine are comparable with those coming from exposure at home. Elimination of workplace smoking is the only method to fully protect nonsmokers from exposure to SHS [2].

To date, the United States lacks a federal regulation on SHS exposure in the workplace. A Healthy People 2020 objective is to establish laws in all 50 states and the District of Columbia that would make all indoor public places and worksites completely smoke-free [85]. As of 2020, 36 states had enacted statewide bans on smoking in public and/or private workplaces [86]. Several of these states have exemptions (eg, for casinos or very small workplaces). A 2015 national survey found that 10 percent of nonsmoking workers still reported frequent exposure to SHS (defined as twice a week or more) in the workplace, with prevalence of 20 to 30 percent in some industries (eg, repair and maintenance, trucking, construction, and forestry) [87]. The prevalence of SHS exposure in the workplace was somewhat lower in states with comprehensive smoke-free laws (8.6 percent) compared with those with less comprehensive (12.2 percent) or no smoke-free laws (11 percent).

Public places and transportation environments — Since the mid-1980s, regulation in the United States has been increasing at the local and state level to restrict or eliminate smoking in public places, including municipal buildings and shopping malls. Most jurisdictions now have such regulations in place, although enforcement varies. At a minimum, smoking is restricted to designated areas in restaurants. In many states, such as California, smoking is not allowed in restaurants or bars. Although arguments were raised in the past by the hospitality and tobacco industries concerning the economic impact of such restrictive policies, the experience in California and elsewhere has not shown negative effects of smoke-free policies on revenues. Hospitals also are smoke-free in the United States. Transportation environments are smoke-free across the country, and cigarette smoking has been prohibited on all domestic airplane flights since 1989.

Model policies and regulations have been developed and made available by many organizations, including the American Lung Association. Exposure can be completely eliminated by banning smoking indoors. Simply segregating smokers and nonsmokers within the same airspace may reduce the exposure of nonsmokers to SHS but does not eliminate it [88]. A study performed in restaurants in Albuquerque, New Mexico during the late 1980s showed that nicotine could be readily found in nonsmoking sections, often at levels similar to those found in smoking sections [89]. Depending upon the specific details of the heating, ventilating, and air-conditioning (HVAC) system in a building, air from a room in which smoking is taking place may be mixed with air distributed to other rooms.

An increasing number of states and municipalities in the United States have passed laws establishing 100 percent smoke-free workplaces, restaurants, and bars [90]. Some municipalities have restricted smoking outdoors on public property. With increasing restriction of smoking indoors, nonsmokers are now likely to report SHS exposure outdoors and to link this exposure to odor and irritation. Updated lists of smoking restrictions in the United States are maintained by advocacy organizations [90]. Nonetheless, as of 2015, one-half of the United States population is not protected by state or local laws prohibiting smoking inside of hospitality venues [35].

Evidence shows that smoke in a private vehicle is an important source of smoke exposure for children and adults. Studies show that smoke concentration may be quite high in vehicles while people are smoking [91]. Regulations have been passed in several places to protect children against in-vehicle exposure. As examples, since 2007, the state of California has banned smoking in vehicles with a minor under age 18, while the state of Arkansas prohibits smoking in a motor vehicle carrying a child under age six years old who weighs less than 60 pounds and is in a car seat. Since the ban was implemented in California, self-reported smoke exposure of students progressively decreased and decreased more rapidly than national trends [92,93].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Smoking cessation, e-cigarettes, and tobacco control".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic(s) (see "Patient education: Secondhand smoke and children (The Basics)")

SUMMARY AND RECOMMENDATIONS

Epidemiology – Exposure to secondhand smoke (SHS) is declining in the United States, but approximately 40 percent of children have biochemical evidence of SHS exposure. There are persistent disparities in the levels of exposures. (See 'Strategies to prevent secondhand smoke exposure' above and 'Effect of smoking bans' above.)

Health effects

Combustible tobacco – Established health effects of SHS in children include prematurity and perinatal mortality, fetal growth restriction, sudden infant death syndrome, respiratory symptoms and illnesses (including asthma), earlier initiation of atherogenesis and future risk of cardiovascular disease, renal function impairment, and middle ear disease. (See "Secondhand smoke exposure: Effects in children".)

Electronic cigarettes (e-cigarettes) – Health effects of exposure to vapor from e-cigarettes are less well established, but it is clear that vapor exposes bystanders to significant concentrations of aerosolized nicotine and that high levels of fine and ultrafine particles similar to tobacco smoke particles can be observed in indoor environments where e-cigarettes have been used. (See 'Electronic cigarette secondhand vapor exposure' above.)

Strategies to reduce SHS exposure – Recommended strategies to reduce SHS exposure include (see 'Recommendations of the Task Force on Community Preventive Services' above):

Screening – Ask about SHS exposure at all visits. Ask about the home smoking policy and the presence of household smokers. (See "Prevention of smoking and vaping initiation in children and adolescents", section on 'Smoking and vaping prevention in the primary care office'.)

Counseling – Counseling should include specific and personalized messages to parents and caregivers about risks of SHS and strategies for smoking cessation. These messages are particularly important and may be more effective during important life events, such as pregnancy, birth of a child, or early childhood. A majority of smoking parents report that they want to quit and are open to smoking cessation advice from their child's pediatrician. (See 'The role of the health care provider' above.)

Smoking cessation for household members – The home environment is the most important source of exposure to SHS for children. Smokers should be supported in quitting smoking for the benefit of their own health as well as the health of those around them. Clinician support for smoking cessation includes direct counseling, referral, and, sometimes, pharmacotherapy. (See 'Support for smoking cessation' above and "Overview of smoking cessation management in adults".)

Household smoking bans – In homes of smokers who are unable or unwilling to quit, a complete ban on indoor smoking is helpful; partial restrictions on smoking in the home are less effective. Air cleaning devices are generally not effective in ameliorating SHS exposure and should not be recommended. (See 'The home environment' above and 'Air cleaners/air purifiers' above.)

Thirdhand smoke (THS) – THS exposure refers to contact with smoke components and their metabolic byproducts on surfaces that have adsorbed smoke as well as off-gassed components. Although direct health effects from THS have not been established, many of the toxins that are deposited on surfaces are carcinogens, raising concerns about chronic exposure through dermal exposure, dust inhalation, and ingestion. (See 'Thirdhand smoke exposure' above.)

Public smoking bans – Policies that ban all indoor smoking in workplaces and public places are highly effective in reducing smoke exposure and are an important goal of health advocacy. For workers exposed to SHS during the workday, the degree of smoke exposure may be comparable with sharing a home with a smoker. Only complete bans of indoor smoking are effective; simply segregating smokers and nonsmokers within the same airspace may reduce the exposure of nonsmokers to SHS but does not eliminate it. (See 'Public smoking bans' above.)

  1. Institute of Medicine. Chapter 7: Exposure to environmental tobacco smoke. In: Clearing the Air: Asthma and Indoor Air Exposures, National Academy Press, Washington, DC 2000. p.263.
  2. US Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. United States Department of Health and Human Services, Centers for Disease Control and Prevention, N, 2006.
  3. World Health Organization. Protection From Exposure to Second-hand Tobacco Smoke, WHO Press, Geneva 2007.
  4. Samet JM, Bohanon HR, Jr., Coultas DB, Houston TP, Persily AK, Schoen LJ, Spengler J, Callaway CA, ASHRAE's Environmental Tobacco Smoke Position Document Committee. ASHRAE position document on environmental tobacco smoke. Atlanta, GA. American Society of Heating Refrigeration and Air Conditioning, 2005.
  5. Davis RM. Exposure to environmental tobacco smoke: identifying and protecting those at risk. JAMA 1998; 280:1947.
  6. Marbin J, Balk SJ, Gribben V, et al. Health Disparities in Tobacco Use and Exposure: A Structural Competency Approach. Pediatrics 2021; 147.
  7. Pirkle JL, Bernert JT, Caudill SP, et al. Trends in the exposure of nonsmokers in the U.S. population to secondhand smoke: 1988-2002. Environ Health Perspect 2006; 114:853.
  8. Stranges S, Bonner MR, Fucci F, et al. Lifetime cumulative exposure to secondhand smoke and risk of myocardial infarction in never smokers: results from the Western New York health study, 1995-2001. Arch Intern Med 2006; 166:1961.
  9. United States Environmental Protection Agency. America’s Children and the Environment. Biomonitoring: Cotinine. 2019. Available at: https://www.epa.gov/sites/production/files/2019-08/documents/cotinine-section-updates.pdf (Accessed on February 20, 2020).
  10. Task Force on Community Preventive Services. Recommendations regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prev Med 2001; 20:10.
  11. Rice JL, Brigham E, Dineen R, et al. The feasibility of an air purifier and secondhand smoke education intervention in homes of inner city pregnant women and infants living with a smoker. Environ Res 2018; 160:524.
  12. Fiore MC, Jaen CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. Clinical practice guideline. Available at: www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf (Accessed on September 30, 2011).
  13. Winickoff JP, Hillis VJ, Palfrey JS, et al. A smoking cessation intervention for parents of children who are hospitalized for respiratory illness: the stop tobacco outreach program. Pediatrics 2003; 111:140.
  14. Winickoff JP, Buckley VJ, Palfrey JS, et al. Intervention with parental smokers in an outpatient pediatric clinic using counseling and nicotine replacement. Pediatrics 2003; 112:1127.
  15. Stotts AL, Green C, Northrup TF, et al. Feasibility and efficacy of an intervention to reduce secondhand smoke exposure among infants discharged from a neonatal intensive care unit. J Perinatol 2013; 33:811.
  16. Diamanti A, Papadakis S, Schoretsaniti S, et al. Smoking cessation in pregnancy: An update for maternity care practitioners. Tob Induc Dis 2019; 17:57.
  17. United States Department of Health and Human Services. Smoking Cessation: A Report of the Surgeon General. 2020. Available at: https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf (Accessed on February 20, 2020).
  18. Orton S, Coleman T, Coleman-Haynes T, Ussher M. Predictors of Postpartum Return to Smoking: A Systematic Review. Nicotine Tob Res 2018; 20:665.
  19. Kia F, Tosun N, Carlson S, Allen S. Examining characteristics associated with quitting smoking during pregnancy and relapse postpartum. Addict Behav 2018; 78:114.
  20. Brown TJ, Hardeman W, Bauld L, et al. A systematic review of behaviour change techniques within interventions to prevent return to smoking postpartum. Addict Behav 2019; 92:236.
  21. Farber HJ, Groner J, Walley S, et al. Protecting Children From Tobacco, Nicotine, and Tobacco Smoke. Pediatrics 2015; 136:e1439.
  22. Farber HJ, Walley SC, Groner JA, et al. Clinical Practice Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke. Pediatrics 2015; 136:1008.
  23. Emmons KM, Hammond SK, Fava JL, et al. A randomized trial to reduce passive smoke exposure in low-income households with young children. Pediatrics 2001; 108:18.
  24. McMillen R, O'Connor KG, Groner J, et al. Changes and Factors Associated With Tobacco Counseling: Results From the AAP Periodic Survey. Acad Pediatr 2017; 17:504.
  25. Cawkwell PB, Lee L, Shearston J, et al. The Difference a Decade Makes: Smoking Cessation Counseling and Screening at Pediatric Visits. Nicotine Tob Res 2016; 18:2100.
  26. Simoneau T, Hollenbach JP, Langton CR, et al. Smoking cessation and counseling: A mixed methods study of pediatricians and parents. PLoS One 2021; 16:e0246231.
  27. Jenssen BP, Kelly MK, Faerber J, et al. Pediatrician Delivered Smoking Cessation Messages for Parents: A Latent Class Approach to Behavioral Phenotyping. Acad Pediatr 2021; 21:129.
  28. Endrighi R, McQuaid EL, Bartlett YK, et al. Parental Depression is Prospectively Associated With Lower Smoking Cessation Rates and Poor Child Asthma Outcomes. Ann Behav Med 2018; 52:195.
  29. Marano C, Schober SE, Brody DJ, Zhang C. Secondhand tobacco smoke exposure among children and adolescents: United States, 2003-2006. Pediatrics 2009; 124:1299.
  30. Johansson A, Hermansson G, Ludvigsson J. How should parents protect their children from environmental tobacco-smoke exposure in the home? Pediatrics 2004; 113:e291.
  31. Blackburn C, Spencer N, Bonas S, et al. Effect of strategies to reduce exposure of infants to environmental tobacco smoke in the home: cross sectional survey. BMJ 2003; 327:257.
  32. Spencer N, Blackburn C, Bonas S, et al. Parent reported home smoking bans and toddler (18-30 month) smoke exposure: a cross-sectional survey. Arch Dis Child 2005; 90:670.
  33. King BA, Patel R, Babb SD. Prevalence of smokefree home rules--United States, 1992-1993 and 2010-2011. MMWR Morb Mortal Wkly Rep 2014; 63:765.
  34. Tsai J, Homa DM, Gentzke AS, et al. Exposure to Secondhand Smoke Among Nonsmokers - United States, 1988-2014. MMWR Morb Mortal Wkly Rep 2018; 67:1342.
  35. McMillen R, Wilson K, Tanski S, et al. Adult Attitudes and Practices Regarding Smoking Restrictions and Child Tobacco Smoke Exposure: 2000 to 2015. Pediatrics 2018; 141:S21.
  36. Rees VW, Keske RR, Blaine K, et al. Factors influencing adoption of and adherence to indoor smoking bans among health disparity communities. Am J Public Health 2014; 104:1928.
  37. Brown N, Luckett T, Davidson PM, Di Giacomo M. Interventions to reduce harm from smoking with families in infancy and early childhood: a systematic review. Int J Environ Res Public Health 2015; 12:3091.
  38. McIntosh NA, Clark NM, Howatt WF. Reducing tobacco smoke in the environment of the child with asthma: a cotinine-assisted, minimal-contact intervention. J Asthma 1994; 31:453.
  39. Irvine L, Crombie IK, Clark RA, et al. Advising parents of asthmatic children on passive smoking: randomised controlled trial. BMJ 1999; 318:1456.
  40. Hovell MF, Zakarian JM, Matt GE, et al. Effect of counselling mothers on their children's exposure to environmental tobacco smoke: randomised controlled trial. BMJ 2000; 321:337.
  41. Hovell MF, Meltzer SB, Zakarian JM, et al. Reduction of environmental tobacco smoke exposure among asthmatic children: a controlled trial. Chest 1994; 106:440.
  42. Hovell MF, Meltzer SB, Wahlgren DR, et al. Asthma management and environmental tobacco smoke exposure reduction in Latino children: a controlled trial. Pediatrics 2002; 110:946.
  43. Scheffers-van Schayck T, Mujcic A, Otten R, et al. The Effectiveness of Smoking Cessation Interventions Tailored to Smoking Parents of Children Aged 0-18 Years: A Meta-Analysis. Eur Addict Res 2021; 27:278.
  44. Mahabee-Gittens EM, Ammerman RT, Khoury JC, et al. A Parental Smoking Cessation Intervention in the Pediatric Emergency Setting: A Randomized Trial. Int J Environ Res Public Health 2020; 17.
  45. Groner JA, Ahijevych K, Grossman LK, Rich LN. The impact of a brief intervention on maternal smoking behavior. Pediatrics 2000; 105:267.
  46. Woodward A, Owen N, Grgurinovich N, et al. Trial of an intervention to reduce passive smoking in infancy. Pediatr Pulmonol 1987; 3:173.
  47. Eriksen W, Sørum K, Bruusgaard D. Is there an increased lability in parents' smoking behaviour after a childbirth? Scand J Prim Health Care 1996; 14:86.
  48. Chilmonczyk BA, Palomaki GE, Knight GJ, et al. An unsuccessful cotinine-assisted intervention strategy to reduce environmental tobacco smoke exposure during infancy. Am J Dis Child 1992; 146:357.
  49. Rosen LJ, Myers V, Winickoff JP, Kott J. Effectiveness of Interventions to Reduce Tobacco Smoke Pollution in Homes: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health 2015; 12:16043.
  50. Greenberg RA, Strecher VJ, Bauman KE, et al. Evaluation of a home-based intervention program to reduce infant passive smoking and lower respiratory illness. J Behav Med 1994; 17:273.
  51. Caldwell AL, Tingen MS, Nguyen JT, et al. Parental Smoking Cessation: Impacting Children's Tobacco Smoke Exposure in the Home. Pediatrics 2018; 141:S96.
  52. Wall MA, Severson HH, Andrews JA, et al. Pediatric office-based smoking intervention: impact on maternal smoking and relapse. Pediatrics 1995; 96:622.
  53. Keintz MK, Fleisher L, Rimer BK. Reaching mothers of preschool-aged children with a targeted quit smoking intervention. J Community Health 1994; 19:25.
  54. Severson HH, Andrews JA, Lichtenstein E, et al. Reducing maternal smoking and relapse: long-term evaluation of a pediatric intervention. Prev Med 1997; 26:120.
  55. Collins BN, Lepore SJ, Winickoff JP, et al. An Office-Initiated Multilevel Intervention for Tobacco Smoke Exposure: A Randomized Trial. Pediatrics 2018; 141:S75.
  56. Ratschen E, Thorley R, Jones L, et al. A randomised controlled trial of a complex intervention to reduce children's exposure to secondhand smoke in the home. Tob Control 2018; 27:155.
  57. Farber HJ, Nelson KE, Groner JA, et al. Public Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke. Pediatrics 2015; 136:998.
  58. Public Health Law Center. Tobacco Control Legal Consortium. HUD's smoke-free public housing rule: An overview. 2017. Available at: http://www.publichealthlawcenter.org/sites/default/files/resources/HUD-Final-Rule-Smoke-Free-Public-Housing-2017.pdf (Accessed on February 14, 2020).
  59. Benowitz NL, Hukkanen J, Jacob P. Nicotine chemistry, metabolism, kinetics and biomarkers. In: Nicotine Psychopharmacology, Handbook of Experimental Pharmacology, Henningfield JE (Ed), Springer-Verlag, Berlin 2009. Vol 192, p.29.
  60. Hang B, Wang P, Zhao Y, et al. Thirdhand smoke: Genotoxicity and carcinogenic potential. Chronic Dis Transl Med 2020; 6:27.
  61. Drehmer JE, Luo M, Nabi-Burza E, et al. Smoking Cessation Treatment for Parents Who Are Light or Very Light Smokers in the Pediatric Setting. Acad Pediatr 2021; 21:646.
  62. Jacob P 3rd, Benowitz NL, Destaillats H, et al. Thirdhand Smoke: New Evidence, Challenges, and Future Directions. Chem Res Toxicol 2017; 30:270.
  63. California Consortium for Thirdhand Smoke. Frequently asked questions: How can I eliminate THS exposure from my home. Available at: https://tobacco.ucsf.edu/frequently-asked-questions-0#How-can-I-eliminate-THS-exposure-from-my-home (Accessed on February 06, 2018).
  64. Matt GE, Quintana PJE, Hoh E, et al. Remediating Thirdhand Smoke Pollution in Multiunit Housing: Temporary Reductions and the Challenges of Persistent Reservoirs. Nicotine Tob Res 2021; 23:364.
  65. Samet JM, Chanson D, Wipfli H. The Challenges of Limiting Exposure to THS in Vulnerable Populations. Curr Environ Health Rep 2015; 2:215.
  66. Schober W, Szendrei K, Matzen W, et al. Use of electronic cigarettes (e-cigarettes) impairs indoor air quality and increases FeNO levels of e-cigarette consumers. Int J Hyg Environ Health 2014; 217:628.
  67. Czogala J, Goniewicz ML, Fidelus B, et al. Secondhand exposure to vapors from electronic cigarettes. Nicotine Tob Res 2014; 16:655.
  68. Li L, Lin Y, Xia T, Zhu Y. Effects of Electronic Cigarettes on Indoor Air Quality and Health. Annu Rev Public Health 2020; 41:363.
  69. Durmowicz EL. The impact of electronic cigarettes on the paediatric population. Tob Control 2014; 23 Suppl 2:ii41.
  70. Drehmer JE, Nabi-Burza E, Hipple Walters B, et al. Parental Smoking and E-cigarette Use in Homes and Cars. Pediatrics 2019; 143.
  71. Mescolo F, Ferrante G, La Grutta S. Effects of E-Cigarette Exposure on Prenatal Life and Childhood Respiratory Health: A Review of Current Evidence. Front Pediatr 2021; 9:711573.
  72. US Food and Drug Administration, Newly Signed Legislation Raises Federal Minimum Age of Sale of Tobacco Products to 21. Available at: https://www.fda.gov/tobacco-products/ctp-newsroom/newly-signed-legislation-raises-federal-minimum-age-sale-tobacco-products-21 (Accessed on January 24, 2020).
  73. Food and Drug Administration, HHS. Deeming Tobacco Products To Be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act; Restrictions on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products. Final rule. Fed Regist 2016; 81:28973.
  74. US Food and Drug Administration. FDA announces comprehensive regulatory plan to shift trajectory of tobacco-related disease, death. News Release, 2017. Available at: https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm568923.htm (Accessed on February 06, 2018).
  75. Pell JP, Haw S, Cobbe S, et al. Smoke-free legislation and hospitalizations for acute coronary syndrome. N Engl J Med 2008; 359:482.
  76. Cesaroni G, Forastiere F, Agabiti N, et al. Effect of the Italian smoking ban on population rates of acute coronary events. Circulation 2008; 117:1183.
  77. Institute of Medicine. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence, The National Academies Press, Washington, DC 2010.
  78. Marchese ME, Shamo F, Miller CE, et al. Racial Disparities in Asthma Hospitalizations Following Implementation of the Smoke-Free Air Law, Michigan, 2002-2012. Prev Chronic Dis 2015; 12:E201.
  79. Been JV, Nurmatov UB, Cox B, et al. Effect of smoke-free legislation on perinatal and child health: a systematic review and meta-analysis. Lancet 2014; 383:1549.
  80. Kabir Z, Daly S, Clarke V, et al. Smoking ban and small-for-gestational age births in Ireland. PLoS One 2013; 8:e57441.
  81. Faber T, Kumar A, Mackenbach JP, et al. Effect of tobacco control policies on perinatal and child health: a systematic review and meta-analysis. Lancet Public Health 2017; 2:e420.
  82. Cheng KW, Glantz SA, Lightwood JM. Association between smokefree laws and voluntary smokefree-home rules. Am J Prev Med 2011; 41:566.
  83. Lee JT, Glantz SA, Millett C. Effect of smoke-free legislation on adult smoking behaviour in England in the 18 months following implementation. PLoS One 2011; 6:e20933.
  84. Hammond SK. Exposure of U.S. workers to environmental tobacco smoke. Environ Health Perspect 1999; 107 Suppl 2:329.
  85. Healthy People 2020 Objectives. Available at: http://www.healthypeople.gov/2020/topics-objectives/topic/tobacco-use/objectives (Accessed on November 15, 2015).
  86. American Nonsmokers' Rights Foundation. Summary of 100% Smokefree State Laws and Population Protected by 100% U.S. Smokefree Laws. 2020. Available at: https://no-smoke.org/wp-content/uploads/pdf/SummaryUSPopList.pdf (Accessed on February 20, 2020).
  87. Su CP, Syamlal G, Tamers S, et al. Workplace Secondhand Tobacco Smoke Exposure Among U.S. Nonsmoking Workers, 2015. MMWR Morb Mortal Wkly Rep 2019; 68:604.
  88. US Department of Health and Human Services (USDHHS). The health consequences of involuntary smoking: A report of the Surgeon General. DHHS Publication No. (CDC) 87, 1986.
  89. Lambert WE, Samet JM, Spengler JD. Environmental tobacco smoke concentrations in no-smoking and smoking sections of restaurants. Am J Public Health 1993; 83:1339.
  90. American Nonsmokers Rights' Foundation. 100% Smokefree ordinance list. Available at: www.no-smoke.org/goingsmokefree.php (Accessed on January 08, 2010).
  91. Rees VW, Connolly GN. Measuring air quality to protect children from secondhand smoke in cars. Am J Prev Med 2006; 31:363.
  92. Patel M, Thai CL, Meng YY, et al. Smoke-Free Car Legislation and Student Exposure to Smoking. Pediatrics 2018; 141:S40.
  93. Montreuil A, Hanusaik N, Cantinotti M, et al. Social disparities in children's exposure to secondhand smoke in privately owned vehicles. Tob Control 2017; 26:663.
Topic 6376 Version 31.0

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