{"id":5837,"date":"2017-02-07T11:42:53","date_gmt":"2017-02-07T11:42:53","guid":{"rendered":"https:\/\/www.wma.net\/wp-content\/uploads\/2016\/11\/SHS-WMA-rev2.pdf"},"modified":"2017-02-07T11:43:10","modified_gmt":"2017-02-07T11:43:10","slug":"shs-wma-rev2","status":"inherit","type":"attachment","link":"https:\/\/www.wma.net\/fr\/ce-que-nous-faisons\/education\/tabac\/shs-wma-rev2\/","title":{"rendered":"SHS-WMA-rev2"},"author":2,"comment_status":"open","ping_status":"closed","template":"","meta":[],"acf":[],"description":{"rendered":"

SHS-WMA-rev2<\/a><\/p>\n

1
\nHealth Effects of Tobacco Secondhand Smoke: focus on Children Health
\nA Review of the Evidence and Self-Assessment
\nUpdated July 20, 2016
\n[First Published November 30, 2015]
\nSchool of Policy Government and International Affairs
\nGeorge Mason University
\nArlington, Virginia, USA
\n2
\nA Continuing Medical Education Activity
\nJoint Sponsorship Statement:
\nThis activity is jointly sponsored by the Center for the Study of International Medical Policies
\nand Practices (CSIMPP), School of Policy, Government and International Affairs [SPGIA],
\nGeorge Mason University and MedEDirect, LTD., in collaboration with the World Medical
\nAssociation (WMA).
\nActivity Planners:
\nArnauld Nicogossian, MD, FACPM, FACP
\nDistinguished Research Professor
\nDirector
\nCenter for the Study of International Medical Policies and Practices
\nSPGIA, GMU
\nArlington, VA
\nUSA
\nTinapa Himathongkam, MPP
\nGraduate Research Assistant
\nCenter for the Study of International Medical Policies and Practices
\nSPGIA, GMU
\nArlington, VA
\nUSA
\nOtmar Kloiber, MD
\nSecretary General
\nWorld Medical Association
\nFerney-Voltaire
\nFrance
\nThomas Zimmerman, PhD
\nExecutive Director, MedEDdirect
\nLas Vegas Nevada
\nUSA
\nYinyue Hu, MA
\nGraduate Research Assistant
\nCenter for the Study of International Medical Policies and Practices
\nSPGIA, GMU
\nArlington, VA
\nUSA
\n3
\nReviewers and Advisors
\nLee Fritschler, PhD
\nProfessor Emeritus
\nSPGIA, GMU
\nArlington, VA
\nUSA
\nSalim Habayeb, MD
\nDirector, Health and Medical Policy Program
\nSPGIA, GMU
\nArlington, VA
\nUSA
\n4
\nDisclosure of Conflicts of Interest:
\nAll individuals participating in the development and implementation of activities sponsored by
\nMedEDirect have disclosed real or perceived conflicts of interest related to this activity.
\nCSIMPP did not receive support from any funding sources for this activity. The authors and
\nreviewers have no competing interests.
\nAccreditation and Credit Designation:
\nThis activity has been planned and implemented by MedEDirect and the Center for the Study of
\nInternational Medical Policies and Practices (CSIMPP), School of Policy, Government and
\nInternational Affairs [SPGIA], George Mason University, and is accredited by the American
\nNurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education
\n(ACPE), and the Accreditation Council for Continuing Medical Education (ACCME), to provide
\ncontinuing education for the healthcare team.
\nPlease access MedEDirect, Inc at www. MedEDirect.org to register for CME credits, respond to
\nself-assessment questions and fill out a survey. CME is offered free of charge.
\nNeeds Statement:
\nSmoking continues to be a major global health problem by exposing many individuals to second
\nhand, and also third hand smoke from tobacco by-products. Tobacco consumption threatens
\npopulation health in many developing countries. Infant and children, are the most vulnerable
\npopulation, especially in residential or other living environments [such as cars, day care centers
\nand schools]
\nLearning Objectives:
\nAt the conclusion of this activity, participants will:
\n1. Understand the strength of the evidence supporting the health effects of tobacco second hand
\nsmoke (TSHS) in children, and
\n2. Review the efficacy of interventions, including policies and legislations, designed to minimize
\nTSHS exposures of infants and children.
\nOVERVIEW ……………………………………………………………………………………………………………………………….6
\n5
\nSECTION ONE: Global Epidemiology of Secondhand Smoke Health Risks……………………………………….7
\nDefining the Problem………………………………………………………………………………………………………………..7
\nMagnitude of the Problem …………………………………………………………………………………………………………7
\nMeasuring the level of Tobacco SHS Exposures…………………………………………………………………………..9
\nSECTION TWO: Health Effects from Secondhand Smoke ……………………………………………………………..10
\nHealth Effects of SHS exposure………………………………………………………………………………………………..10
\nSHS and Health Risks in Children…………………………………………………………………………………………….11
\nThird Hand Tobacco Smoke Exposures (THS) …………………………………………………………………………..12
\nSECTION THREE: Control and Prevention of Secondhand Smoke Exposure……………………………………14
\nSmoking Cessation Campaigns…………………………………………………………………………………………………14
\nSmoking Bans………………………………………………………………………………………………………………………..15
\nPackaging and Labeling…………………………………………………………………………………………………………..18
\nAvailability and Limitations of Tobacco Sales……………………………………………………………………………18
\nLegal Precedents on SHS and Children (US) ……………………………………………………………………………..19
\nSECTION FOUR: Effectiveness of Interventions…………………………………………………………………………..20
\nSummary of Policies and Interventions (see also Appendix B)……………………………………………………..22
\nSECTION FIVE: Conclusions……………………………………………………………………………………………………..23
\nPoints to Remember………………………………………………………………………………………………………………..24
\nAppendix A: Summary Table of Evidence from Epidemiological Studies …………………………………………26
\nAppendix B: Summary Table of Evidence from Interventional Studies …………………………………………….32
\nAppendix C: Health Effect of SHS in Adults …………………………………………………………………………………35
\nAppendix D: Health Effects of SHS in Infants and Children ……………………………………………………………36
\nAppendix E: WMA 2011 Statement on Health Hazards of Tobacco Products and Tobacco-Derived
\nProducts ……………………………………………………………………………………………………………………………………37
\nReferences…………………………………………………………………………………………………………………………………41
\n6
\nOVERVIEW
\nTobacco secondhand smoke [SHS] is a major health hazard,
\nespecially for infants and children. The Centers for Disease
\nControl and Prevention (CDC) reports that yearly, six million
\ndeaths worldwide are attributable to the use of tobacco
\nproducts (CDC 2015). Rising tobacco consumption is also
\nresponsible for increasing exposures to SHS where more than
\n50 carcinogens and 4,000 potentially harmful chemicals and
\ntoxins are present. These compounds are implicated in lung
\ncancer, heart disease, and other illnesses among nonsmokers
\n(WHO 2011).
\nPolicy makers and health advocates continue to express
\nconcerns over the health care and societal economic impacts
\nfrom chronic health effects of SHS on nonsmokers,
\nparticularly pregnant women and young children. It is
\nestimated that 50 million pregnant women and 700 million
\nchildren are exposed to SHS on a daily basis (Callinan et al.
\n2010). According to the World Health Organization (WHO)
\nFramework Convention on Tobacco Control (FCTC), there is
\n\u201cno safe level of exposure to tobacco smoke\u201d with
\napproximately thirty-one percent of all deaths from SHS
\ninvolving children (WHO 2013b). WHO argues that the
\nreduction in tobacco use could significantly contribute to
\nUnited Nations Millennium Development Goals by directing
\nscarce resources to more productive programs such as
\neducation, health literacy and maternal and child health (WHO 2004).
\nThe SHS exposure challenge, especially faced by emerging market economy countries, can be
\nsummarized as follows:
\n\uf0b7 SHS disproportionately affects vulnerable populations including women and children.
\n\uf0b7 About 40% of children are regularly exposed to SHS at home. These children are 1.5-2
\ntimes more likely to become smokers (WHO 2013a).
\n\uf0b7 Approximately 5% of global burden of disease is attributable to SHS, a slightly higher
\nnumber than the burden from direct tobacco smoking of 4% (Singh and al. 2011).
\n\uf0b7 10% of tobacco-use-related economic costs are from SHS: provision of care for related
\nillnesses and indirect costs such as loss of productivity (WHO 2013a).
\nWHO Statements
\n\uf0b7 Tobacco kills up to half
\nof its users. Over 6
\nmillion people die from
\ntobacco each year.
\n\uf0b7 More than 5 million of
\nthose deaths are the result
\nof direct tobacco use
\nwhile more than 600 000
\nare the result of non-
\nsmokers being exposed to
\nsecond-hand smoke.
\n\uf0b7 Nearly 80% of the
\nworld’s 1 billion smokers
\nlive in low- and middle-
\nincome countries.
\n[Source: WHO Tobacco
\nFact sheet N\u00b0339.
\nUpdated July 2015]
\n7
\nSECTION ONE: Global Epidemiology of Secondhand Smoke Health Risks
\nLearning Objective: To understand the health risks from secondhand smoke
\nDefining the Problem
\nSecondhand smoke (SHS) has been defined as \u201cthe combination of smoke emitted from the
\nburning end of a cigarette or other tobacco products
\nand smoke exhaled by the smoker\u201d (WHO 2007). SHS
\nis also known as environmental tobacco smoke, passive
\nsmoking, and involuntary smoking.
\nTwo types of SHS are identified
\n1.) Mainstream smoke \u2013 the smoke that is exhaled
\nfrom the smoker\u2019s lungs
\n2.) Sidestream smoke \u2013 the smoke from the burning
\nend of a tobacco product
\nAlmost 15% of SHS exposure is mainstream and 85% is
\nsidestream though the composition of toxins in both
\nsources is similar (Callinan et al. 2010). Most SHS
\nexposure occurs in homes, private vehicles, and
\nworkplaces but also in such public places as restaurants,
\nbars, and casinos. The International Agency for
\nResearch on Cancer declared SHS to be carcinogenic
\nrisks to humans (IARC 2004).
\nSeveral categories of SHS exposure are described as it
\nrefers to one or both parents or another person in an
\nenclosed space (Oberg et al. 2011). National and
\ninternational organizations, such as the World Health
\nOrganization (WHO), the International Agency for
\nResearch on Cancer (IARC), the World Medical
\nAssociation (WMA), the United States Surgeon General
\n(DHHS), and the U.S. Environmental Protection Agency (EPA) have developed a consensus on
\nthe negative health effects of SHS exposure on nonsmoking adults and children.
\nMagnitude of the Problem
\nAccording to the World Health Organization Framework Convention on Tobacco Control
\n(WHO FCTC), there is \u201cno safe level of exposure to tobacco smoke\u201d. Worldwide, SHS is
\nresponsible for an estimated 603,000 premature deaths and the loss of 10.9 million Disability-
\nAdjusted Life Years (DALYs) (Oberg et al 2011). Thirty-one percent of the premature deaths
\nare children (WHO 2013a). In China, the latest estimates suggest that between 38.9% and 75.1%
\nof pregnant women are exposed to SHS, most often by their spouse (Zhang et al. 2015). Table 1
\nshows the percentage of children under 15 years of age, and adult men and women who are
\nexposed to SHS by world regions.
\nWorld Health
\nOrganization (WHO)
\nReport on the Global
\nTobacco Epidemic (2009)
\nstates that:
\n\u201cSecond-hand smoke
\naccounts for one in 10
\ntobacco-related deaths.
\nCreating 100% smoke-free
\nenvironments is the only
\nway to protect people from
\nthe harmful effects of
\nsecond-hand tobacco
\nsmoke.\u201d
\n8
\nTable 1: Estimates of the Percent Population by Age Groups Exposed to SHS
\n[WHO Regions]
\nWHO Regions Percentage of
\nChildren under
\n15 years exposed
\nto SHS
\nPercentage of
\nmen (ages 15 and
\nover) exposed to
\nSHS
\nPercentage of
\nwomen (ages 15
\nand over)
\nexposed to SHS
\nGlobal 40 33 35
\nAll high income (WHO income) 39 32 31
\nLow- and Middle-income
\nAfrica 12 6 10
\nAmericas 28 15 22
\nEastern Mediterranean 35 22 33
\nEurope 58 60 61
\nSoutheast Asia 39 25 27
\nWestern Pacific 68 53 51
\nSource: adapted from the World Health Organization (2004)
\nhttp:\/\/apps.who.int\/gho\/data\/node.main.159?lang=en
\nWomen and children are disproportionate victims of SHS exposure. Approximately 30% of men
\nsmoke, compared to 13% women and 12% of youth ages 13-15 (Tobacco Atlas 2009). It has
\nbeen reported that as many as 40% of children and 35% of nonsmoking women were exposed to
\nSHS in 2004 (Oberg et al. 2011). It is likely that women and children who are exposed to SHS
\nhave male family members who smoke in the homes or in private vehicles. In low-income
\nSoutheast Asian countries, women are at least 50% more likely to become victims of SHS
\nexposure than are men (Singh and Lal 2011). Children with smoking parents are also
\nsignificantly more likely to be exposed to SHS (Vitoria et al. 2015).
\nWhile smoking bans in workplaces in high-income countries are commonplace, occupational
\nSHS exposure remains a critical issue in many parts of the world. According to the International
\nLabor Organization [ILO 2015], an estimated 168 million children are in the global workforce.
\nMany of these young workers are either smokers or at risk of SHS exposure. Figure 1 shows the
\npercentage of non-smoking adults who are exposed to SHS in the workplace for countries that
\ncompleted the Global Adult Tobacco Survey (GATS)1
\nbetween 2008 and 2010.
\nWorldwide health professionals continue to smoke and will more likely not encourage patients to
\nstop smoking. A study of medical and dental students\u2019 habits in Southeast Asia region showed no
\nsignificant reduction in smoking trends between 2005-2006 and 2009-2011. There was a
\nsignificant increase in tobacco use among dental students during the same period. The findings
\nalso suggest no significant decline in SHS exposure at home and in public places in most
\n1
\nThe Global Adult Tobacco Survey (GATS) is a nationally representative household survey launched by the WHO in
\n2007 as part of the Global Tobacco Surveillance System (GTSS). Participating countries are mainly from low- and
\nmiddle-income countries where the majority of the world\u2019s smokers reside.
\n9
\ncountries in this region. Of concern is the ability to effectively participate in and contribute to the
\nsmoking cessation campaigns by these professionals (Sinha et al. 2012).
\nOften neglected from the discussion of vulnerable populations to the exposure of SHS are people
\nwith disabilities. Those with disabilities are more likely to be smokers than abled-body
\npopulation by as much as 50% (Armour et al. 2007). They are more likely to be older, non-
\nHispanic white, female, and have lower levels of education. They are also more likely to report
\nhaving been exposed to SHS (Hall et al. 2013).
\nFigure 1: The Percentage of Non-Smoking Adults who are Exposed to SHS in the
\nWorkplace
\nSource: Adapted from WHO Report on the Global Tobacco Epidemic, 2011
\nMeasuring the level of Tobacco SHS Exposures
\nEvidence documenting SHS exposures is obtained through survey questionnaires, direct
\nobservation of smoking behavior, measurement of tobacco residues in the air, and of cotinine
\nlevel in human urine [Source: Johns Hopkins Bloomberg School of Public Health 2015
\nhttp:\/\/www.shsmonitoring.org\/SHS_Overview\/how\/index.html] .
\n%
\n10%
\n20%
\n30%
\n40%
\n50%
\n60%
\n70%
\n80%
\n90%
\n100%
\n10
\nSECTION TWO: Health Effects from Secondhand Smoke
\nLearning Objective: To explore the impact of secondhand smoke exposure on health
\nHealth Effects of SHS exposure
\nInternational studies repeatedly
\ndemonstrate tobacco SHS exposure in
\nprivate settings to be harmful to
\nnonsmokers. In New Zealand, Edwards et
\nal. showed that air particulate levels in a
\ncar with a person smoking inside when
\nwindows are partially or wholly down were
\nas high as those found in a typical smoky
\nbar, and twice as high when the car
\nwindows are closed (Edwards et al. 2006).
\nIn the UK, a British Medical Association
\n(BMA) report provided a strong evidence
\nfor SHS and exacerbation of childhood
\nillnesses such as asthma {Wang et al.
\n2015) and middle ear infections. Both
\nasthma and otitis media are correlated with
\npoor school attendance, scholastic
\nattainment, and increased hospital admissions (Muller 2007).
\nThere is a strong link between active smoking and incidence of depression (Kassel et al. 2003),
\nand in recent years evidence has been obtained to suggest the association between SHS exposure
\nand mental illnesses, especially among adults. An analysis of the 2005-2006 National Health and
\nNutrition Examination Survey (NHANES) found association between SHS exposure and
\ndepressive symptoms even after adjusting for potential confounders including age, race\/ethnicity,
\ngender, education, alcohol consumption, and medical comorbidities (Bandiera et al. 2010). A 6-
\nyear prospective study of 5,560 nonsmoking adults found association between SHS exposure and
\npsychiatric hospital admission (Hamer et al. 2010). These findings could also be indicative of
\npotential threat to children mental health, and deserve further evaluation.
\nThe effects of SHS exposure in pregnant women on fetal development has been the subject of
\nmany studies. A meta-analysis of 19 studies found that women who are exposed to tobacco SHS
\nduring pregnancy are 23% more likely to experience stillbirth and their babies are 13% more
\nlikely to be born with some form of congenital malformations (Leonardi-Bee et al. 2011).
\nReminder: SHS Health Effects in Adults:
\nevidence is good and supportive of the increased
\nrisk of association with:
\n\uf0b7 Coronary heart disease (Japuntich et al.
\n2015)
\n\uf0b7 Stroke (Olasky et al. 2012)
\n\uf0b7 Dementia (Barnes et al. 2010).
\n\uf0b7 Breast cancer (WHO 2007)
\n\uf0b7 Chronic respiratory illnesses (WHO 2007)
\nDecline in pulmonary function due to SHS
\nexposure has been reported (WHO 2007)
\n11
\nSHS and Health Risks in Children
\nSHS is particularly worrisome for infants and children as
\nthey are
\n1. Still developing mentally and physically,
\n2. Less aware of the consequences,
\n3. Less in control of their environments, and
\n4. At greater risk of morbidity and mortality than
\nadults. WHO estimated 700 million children to be
\nvictims of SHS by the 1.2 billion adults who
\nsmoke annually (Ash Research Report 2011).
\nIn the United States, more than half (almost 60%) of
\nchildren ages 3-11 years are exposed to SHS. An analysis
\nof multiple waves of NHANES showed that children had
\nsignificantly higher cotinine concentrations than adults
\n(Pirkle et al. 2006).
\nThe 2006 Surgeon General Report found causal evidence
\nfor tobacco SHS effects on infants and children\u2019s health
\nsuch as Sudden Infant Death Syndrome (SIDS), low birth
\nweight, lower respiratory illnesses, lung growth and
\npulmonary function2
\n. Children may be more prone to SHS-related respiratory illnesses due to
\ntheir smaller airways and higher demand for oxygen and because their immune systems have yet
\nto fully develop (Kabir et al. 2009). There is fair evidence that in-home SHS exposure of
\npremature African American infants is associated with poorer growth of head circumference and
\ndevelopment of otitis media (Brooks et al. 2011). Recent studies have started to detect
\nassociation between SHS and gross motor development (Evlampidou et al. 2015) and attention
\ndeficit hyperactivity disorder (Padron et al. 2015).
\nIt is suspected that SHS induced vascular changes in early childhood can trigger the onset of
\ncardiovascular disease (CVD) in adulthood, caused by exposures to parental tobacco use (Tanski
\nand Wilson 2012).
\nThe link between SHS exposure and mood disorders in children is unclear. In animal
\nexperiments, nicotine exposure in adolescence appears to induce depression-like state in
\nadulthood (Iniguez et al. 2008). SHS exposure may be a direct cause of psychiatric disorders. In
\nhumans, a longitudinal study of 151 adolescents with 5 year follow-up found that tobacco
\nsmoking elevates the risk of depressive episodes (Rao et al. 2009).
\n2
\nFor a full list of the findings from the 2006 US Surgeon General report regarding health effects of SHS, see
\nAppendix C and Appendix D
\nSHS Health Effects in Infants and
\nChildren: evidence is fair to good
\n1. Sudden Infant Death Syndrome.
\n2. Low Birth Weight.
\n3. Pulmonary and Cardiovascular
\ndevelopmental risks.
\n4. Increased incidence and severity
\nof asthma (Wang et al. 2015)
\n5. Susceptibility to respiratory
\ninfections.
\n6. Otitis media.
\n7. Susceptibility to
\ninvasivemeningococcal
\ninfections (Murray et al. 2012)
\n8. Mood changes and depression.
\n9. Lifelong risk of obesity
\n12
\nFinally, children exposed to smokers are also more likely to become smokers themselves.
\n(Milton et al. 2004). Exposure to SHS is also independently related to higher likelihood of
\nsmoking initiation for this population regardless of whether or not children live with smokers.
\nOther factors influencing smoking uptake include age, exposure to tobacco products, having
\nfriends that smoke, being offered tobacco products by peers, risk perceptions3
\n, and use of other
\ntobacco products such as chewing tobacco and cigars (Voorhees et al. 2011). In pre-adolescents,
\nexposure to SHS in cars is significantly associated with early smoking uptake (Glover et al.
\n2011). Recent studies are suggestive of an association between exposure to SHS and obesity
\n(McConnell et al. 2015).
\nThird Hand Tobacco Smoke Exposures (THS)
\nSmoking and SHS are harmful to the health of both smokers and nonsmokers. Recently,
\nevidence on health effects from the remaining tobacco residues deposited on surfaces, smokers\u2019
\nclothes and hair, began to accumulate. Nonsmokers who are exposed to such environments are
\nconsidered to be victims of third-hand tobacco smoking (THS) (Escoffery et al. 2013).
\nThere is evidence that trace levels of nicotine remains in the air, dust, and surfaces of residential
\nsettings which can be harmful especially to children. Nonsmokers who reside in homes
\npreviously occupied by smokers have demonstrated elevated levels of nicotine on hands and in
\nurine compared to those residing in homes where no one has smoked (Matt et al. 2011).
\nFurthermore, non-smoking rooms in hotels with partial smoking bans also show elevated level of
\nsurface nicotine, compared with hotels with complete smoking bans (Matt et al. 2011).
\nPotential in-vitro THS harm to human cells DNA has been reported (Hang et al. 2013). Studies
\nin rodents found that THS exposure increases the likelihood of alterations in liver metabolism
\nthat carry implications for the development of coronary thrombosis, stroke, or type 2 diabetes
\n(Karim et al. 2015). Children who play on exposed floor and put contaminated items in their
\nmouth are especially prone to the danger of THS (Hang et al. 2013, Ferrante et al. 2013). In light
\nof this evidence, it has been suggested that the term \u201cpassive smoke\u201d can no longer be an
\nequivalent of SHS as it should also include THS.
\nStudies on THS thus far have focused primarily on nicotine residues as an indicator of health
\nrisks. The role of particulate in the smoke such as polycyclic aromatic hydrocarbons (PAHs),
\nfrom incomplete combustion of carbon-containing materials, is suspected to be carcinogenic
\n(Fleming et al. 2012).
\n3
\nYouth in the study were asked about their perceptions on 4 items 1) whether smoking presents any risk, 2) whether
\nsmoking presents short-term risk, 3) whether nicotine is addictive, and 4) whether smoking light cigarettes is safer
\n(Vorhees et al. 2011).
\n13
\n14
\nSECTION THREE: Control and Prevention of Secondhand Smoke Exposure
\nLearning objective: To explore SHS exposure control and interventions.
\nTobacco control efforts have been seen in the US for
\nover 50 years. Such efforts have resulted in a substantial
\ndecrease in tobacco use from 42% in 1965 to 18% today
\nbut the issue remains high on the health agenda for the
\n21st
\ncentury (Brennan and Schroeder 2014). The US
\n2010 Affordable Care Act (ACA) expands access to and
\ninsurance coverage of most smoking cessation services.
\nThe ACA also allows employers to charge smokers a
\nhigher percentage of their insurance premiums. In
\naddition, there has been a trend against hiring smokers.
\nThe most important effect from these initiatives is the
\nhope there will be a decrease in smoking uptake among
\nyoung people (Ibid). This section describes some of the
\nways governments and organizations around the world
\nare using to control the use of tobacco.
\nSmoking Cessation Campaigns
\nAs part of the Master Settlement Agreement (MSA)
\nbetween U.S. states and tobacco companies, the
\nAmerican Legacy Foundation was created to fund the
\n\u201cTruth\u201d mass media campaign to prevent teen smoking
\nand encourage smokers to quit. Several studies have confirmed the social and cost effectiveness
\nof Truth ads since its launch in 2012 through the reduction in youth smoking prevalence and
\ntobacco-related healthcare costs (Ferelly et al. 2005, Ferrelly et al. 2009, Niederdeppe et al. 2004,
\nSly et al. 2002, Holtgrave et al. 2009, and Richardson et al. 2010). Similar media campaigns
\nhave been introduced following such success, including the Tips From Former Smokers (Tips)
\nand Finish It campaigns in 2012 and 2014 respectively.
\nAt the international level, efforts are under way to encourage smoking cessation. The WHO
\nFramework Convention on Tobacco Control (FCTC) comprises 173 countries, covering 87% of
\nthe world\u2019s population, pledging strong actions against tobacco smoking (WHO 2012). Tobacco
\ncontrol does not impede the economic development such as causing job losses and decreasing
\ngovernment revenue (World Bank 2011). Instead, tobacco control measures are effective and
\nefficient in reducing its consumption (Esson and Leeder 2004). Progress continues to be made on
\nmeasures aimed at reducing the demand for tobacco, mostly in low- and middle- income
\nIn 2008, WHO introduced MPOWER
\nmeasures, a package of six evidence-
\nbased tobacco control measures, which
\nprovide guidelines for country-level
\nimplementation of effective demand-
\nside interventions to reduce tobacco
\nuse. The six measures include
\n1. monitoring tobacco use and
\nprevention policies
\n2. protecting people from tobacco
\nsmoke
\n3. offering help to quit tobacco use
\n4. warning about the dangers of
\ntobacco
\n5. enforcing bans on tobacco
\nadvertising, promotion and
\nsponsorship, and
\n6. raising taxes on tobacco
\n15
\ncountries. In 2011, the WHO reported that 3.8 billion people were effectively covered by tobacco
\ncontrol laws. The FCTC has been one of the most successful treaties in the history of the United
\nNations (WHO 2011).
\nSmoking Bans
\nPublic Spaces
\nIn addition to reducing the demand for tobacco, the global public health community also aims to
\nprotect the public from the hazards of SHS exposure by encouraging the implementation of
\ncomprehensive smoke-free laws. Having separate smoking sections, smoking rooms, and better
\nventilation systems do not protect people from SHS exposure. Creating a completely smoke-free
\nenvironment is the only proven way. Figure 2 shows the implementation percentage of five
\ntypes of smoking bans around the world. Article 8 of the FCTC mandates members to \u201cprotect
\ncitizens from exposure to tobacco smoke in workplaces, public transport and indoor public
\nplaces,\u201d (WHO 2007). Comprehensive smoke-free legislation has been implemented in many
\ncountries in public places such as bars and restaurants. It has shown to be popular with the public,
\nnot harmful to the economy, and beneficial to people\u2019s health (WHO 2010). These restrictions
\nare supported and recommended by the Article 8.
\nFigure 2: Five Types of Smoking Bans in Public Places (% of Countries categorized by
\nWHO Regions)
\n0
\n20
\n40
\n60
\n80
\n100
\n120
\nAfrica Americas Southeast Asia Europe E.
\nMediterranean
\nWestern Pacific
\nBan in Public Transportation
\nBan in Restaurants
\nBan in Schools
\nBan in Healthcare Facilities
\nBan in Offices
\n16
\nSource: WHO Report on the Global Tobacco Epidemic, 2013
\nIn the United States, the CDC considers a state smoking ban to be comprehensive if it prohibits
\nsmoking in privately-owned workplaces, restaurants, and bars (CDC 2011). Twenty six states
\npassed such legislation by the end of 2010. As of October 2, 2015, according to the American
\nNonsmokers’ Rights Foundation, 81.9% of the U.S. population are protected by a smoking ban in
\n\u00ab\u00a0workplaces, and\/or restaurants, and\/or bars, by
\neither a state, commonwealth, or local law\u201d(ANR
\n2015).
\nFew developing countries have comprehensive
\nsmoke-free legislation (Barnoya and Navas-Acien
\n2013). Where bans exists, nonetheless, evidence is
\nencouraging. Santa Fe, Argentina, in 2005, was the
\nfirst subnational jurisdiction in Latin America to
\nimplement a comprehensive smoke-free policy. A
\nreview of the process of approval and
\nimplementation between 2005 and 2009 shows
\nsuccess despite some opposition, setting an
\nexample for other jurisdictions in Argentina as
\nwell as in Mexico and Brazil (Sebrie and Glantz
\n2010). In 2009, Mexico City passed a similar
\nlegislation (Crosbie et al. 2011).
\nAs indoor smoking bans become increasingly
\ncommon, there has been a concern whether an
\nincrease in outdoor smoking is subjecting others to
\nSHS. The FCTC was revised in 2007 to further
\nrecommend that quasi-outdoor and certain outdoor
\npublic places should be smoke-free. The guidelines
\nencourage countries to \u201cadopt the most effective protection against exposure wherever the
\nevidence shows that hazard exists\u201d (WHO 2009). Support for smoking bans in selected outdoor
\nsettings such as terraces, patios, and building entrances of healthcare facilities and hotels where
\nchildren may be present is on the rise (Thomson et al. 2009). While critics have argued that such
\nbans violate individual rights with insufficient evidence of impact on health (Chapman 2008), a
\nreview of 18 studies found that SHS levels in some outdoor areas may be significant, particularly
\nthose that are semi-enclosed (Sureda et al. 2013).
\nSmoking bans in bars and
\nrestaurants have been enacted
\nin Norway, New Zealand,
\nEngland, Scotland, Wales,
\nNorthern Ireland, Italy,
\nSpain, Malta, and France.
\nRecently middle-income
\ncountries have also enacted
\nsmoke-free laws. Between
\n2008 and 2010, 16 countries
\nadopted comprehensive
\nsmoke-free legislation which
\nmeans 31 countries around
\nthe world now have taken
\nsteps to provide the highest
\nlevel of protection against
\nSHS for their citizens (WHO
\n2011).
\n17
\nPrivate Spaces
\nWith more countries adopting public smoking bans,
\nhomes are becoming a predominant place for smoking.
\nAnti-smoking legislation for public places may also help
\nsmokers who struggle to quit and encourage people to
\ncreate smoke-free environment in their homes and
\nprivate vehicles (WHO 2010). Consensus is lacking with
\nregard to whether smoking bans in public places
\npositively influence smoking bans in private spaces. On
\nthe one hand, the International Agency for Research on
\nCancer (IARC) reports that workers in smoke-free
\nenvironments are more likely to implement smoking
\nrestrictions at home, and that home smoking restrictions
\nhave greater influence on smoking behavior than those in
\nworkplaces (IARC 2009). A study also found a reduction
\nin in-home smoking rates after the enforcement of anti-
\nsmoking law in public spaces (Aslan et al. 2015). On the
\nother hand, a research conducted in Spain reveals that
\nsmoking bans in public spaces have not reduced the
\nexposure of SHS in children in the home (Fernandez et al.
\n2015).
\nUnlike homes, cars represent private properties in the
\npublic sphere. Laws governing seatbelt, child seat, and
\nmobile phone use are already in place to protect both the
\npublic and occupants of the vehicles. With existing
\nevidence of harmfulness of SHS exposure on children,
\nsimilar measures should be considered regarding
\nsmoking in the presence of children (Freeman et al.
\n2008). An increasing number of state and local
\ngovernments, in the United States and other
\nindustrialized countries, enacted legislations to prohibit smoking in private vehicles when
\nchildren are present. Examples of U.S.A. jurisdictions that passed legislations are the states of
\nLouisiana (under age 13, August 2006), Maine (under age 18, January 2007), California (under
\nage 18, January 2008), Arkansas (under age 14, March 2011), and internationally counties of
\nNewfoundland, Canada (under age 16, May 2011), Victoria, Australia (under age 18, January
\n2010), South Africa (under age 12, September 2009) (GASP 2015).
\nThe American Cancer
\nSociety 2013:
\n\u201cMaking your home smoke-
\nfree may be one of the most
\nimportant things you can do
\nfor the health of your family.
\nAny family member can
\ndevelop health problems
\nrelated to SHS.
\nChildren\u2019s growing bodies
\nare especially sensitive to the
\npoisons in SHS. Asthma,
\nlung infections, and ear
\ninfections are more common
\nin children who are around
\nsmokers. Some of these
\nproblems can be serious and
\neven life-threatening. Others
\nmay seem like small
\nproblems, but they add up
\nquickly \u2014 the expenses,
\ntime for doctor visits,
\nmedicines, lost school time,
\nand often lost work time for
\nthe parent who must stay
\nhome with a sick child.\u201d
\n18
\nDespite a significant support, public compliance is still
\nproblematic and difficult to enforce since it impinges on the
\nindividual privacy and freedom of choice. Introduction of
\npreventive measures continue to be inadequate in the face of the
\ngrowing concerns over the health effects on children from SHS
\nexposure. A study in the United Kingdom found that 86% of
\nsmoking parents believed that SHS exposure was harmful for
\ntheir children. However, less than 20% of these parents ban
\nsmoking in their homes (Blackburn et al. 2003). Though smoking
\nin cars and homes is decreasing children, especially in the lower
\nsocio-economic strata, continue to be exposed to SHS (Moore et
\nal. 2011, Moore et al. 2015).
\nPackaging and Labeling
\nAs the tobacco industry faces stricter marketing restrictions by
\ngovernments around the world, many tobacco companies turn to
\ncigarette packaging as a main avenue for product advertisement.
\nArticle 11 of the WHO FCTC addresses this issue. It sets
\nstandards for packaging and labeling of tobacco products for
\nmember states. This mandate reflects the emerging evidence
\nstrongly supporting the effectiveness of displaying text and
\npictorial warning labels. WHO has established a data base for
\npictorial health warnings and messages. In addition, the WHO
\nprovides guidelines and technical assistance for implementation
\nof Article 11 (WHO 2011)4
\n.
\nAvailability and Limitations of Tobacco Sales
\nUsually, age determines the purchase ability of tobacco. However,
\nthere are little restrictions on where cigarettes can be sold. The
\nWHO FCTC does not provide guidelines or suggest tobacco
\nretailing regulation. Cigarettes and other tobacco products can be
\nsold freely at any business unlike alcoholic beverage retailing that
\nis subjected to licensing and hours of day, among other
\n4
\nGuidelines on packaging and labelling of tobacco products
\nAt its third session in November 2008, the Conference of the Parties (COP) adopted guidelines for implementation
\nof Article 11 of the WHO FCTC on \u00ab\u00a0Packaging and labelling of Tobacco Products\u00a0\u00bb (decision FCTC\/COP3(10)).
\nThe World Health
\nOrganization:
\n\u201cArticle 11 of the WHO
\nFCTC requires that health
\nwarning labels on
\ntobacco packaging (to):
\n\uf0b7 Be approved by the
\ncompetent national
\nauthority;
\n\uf0b7 Should cover 50% or
\nmore of the principal
\npack display areas, but
\nshould be no less than
\n30%;
\n\uf0b7 Be large, clear, visible
\nand legible;
\n\uf0b7 Not use misleading
\nterms like \u201clight\u201d and
\n\u201cmild\u201d;
\n\uf0b7 Be rotated periodically
\nto remain fresh and
\nnovel to consumers;
\n\uf0b7 Display information
\non relevant
\nconstituents and
\nemissions of tobacco
\nproducts as defined by
\nnational authorities;
\n\uf0b7 Appear in the principle
\nlanguage (s) of the
\ncountry.\u201d
\n19
\nrestrictions. There are few places and jurisdictions in the US, Australia, Canada, and Singapore
\nthat issue tobacco licensing, but the enforcement is lax and licensures are rarely revoked
\n(Chapman and Freeman 2009).
\nIn the US, recent debates focused on the wisdom of cigarette sale in pharmacies where health
\npromoting medications and supplements are sold. In 2010, the American Pharmacists
\nAssociation urged pharmacies to discontinue the sale of tobacco products. It also discouraged
\nstate pharmacy boards from issuing and renewing licenses for pharmacies that do not follow the
\nrecommendation. Since then, other entities such as the American Lung Association, the
\nAmerican Heart Association, and the American Cancer Society began to promote and encourage
\nbans on tobacco sale in pharmacies (Brennan and Schroeder 2014). In February 2014, CVS
\nCaremark announced that it will stop selling tobacco products at its more than 7,600 stores in the
\nUS even though it will cost about $2 billion in annual revenue (Kenen and Cheney 2014).
\nAlthough the move is unlikely to reduce smoking prevalence since people can still purchase
\ncigarettes somewhere else, it is hoped that other businesses will follow suit and discontinue sale
\nof tobacco products at their establishments which will further reduce access (Brennan and
\nSchroeder 2014).
\nLegal Precedents on SHS and Children (US)
\nIn the US, neglect is the most common form of child maltreatment, its recognition is less
\napparent than child abuse, and therefore is often underreported (USDHHS 2009). Under the
\nChild Abuse Prevention and Treatment Act (CAPTA) of 1974, the SHS exposures can be argued
\nas child abuse and\/or neglect, detailed under the health hazard section of inadequate supervision.
\nThe international community is catching on in this regard. In May 2013, Latvia\u2019s legislature
\nadopted an amendment to the Protection of the Rights of the Child Law to include a smoking-ban
\nin children\u2019s presence to protect their right to grow up in a smoke-free environment. The law
\nadded the \u201cintentional subjection of a child to a harmful environment, including tobacco smoke\u201d
\nas a form of child abuse (Roudik 2013).
\nReview of the legal literature suggests that child custody is a primary motivator for reduced SHS
\nexposure at home. Hundreds of legal cases, in over 20 US states, showed that, SHS was a factor
\nin court rulings in child custody disputes and labeled as the \u2018best interest of the child\u2019 (Sweda
\n2001). Only in one instance, SHS was judged a criminal offense (Sweda et al. 1998). The fair
\nevidence and difficulty of enforcement in private spaces have been suggested as reasons for the
\ncurrent practice of voluntary in-home smoking restrictions policies (Jarvie and Malone 2008).
\n20
\nSECTION FOUR: Effectiveness of Interventions
\nLearning objective: to evaluate the effectiveness of
\ninterventions aimed at reducing SHS exposure
\nMany legislations and interventions aimed at smoking
\ncessation or at reducing SHS exposure among
\nnonsmokers have been implemented at various levels.
\nThese include but are not limited to smoke-free
\npolicies and bans, education campaigns, health
\npromotion, social-behavioral therapies, and clinical
\ninterventions. The effectiveness of these approaches varies
\nfrom jurisdiction to jurisdiction depending on factors such as
\nperceptions, funding, and infrastructure. This section gathers
\nexisting evidence of the impact interventions have had on
\nSHS exposure.
\nA systematic review of infants and children aged 0-12 years
\nold and focused on family members, child care workers, and
\nteachers in community as well as healthcare settings did not
\nfind one intervention to be more effective over others. There
\nis fair evidence that intensive counseling in a clinical setting
\nmay be beneficial to reduce SHS exposure (Priest et al. 2008).
\nAmong the adult population in Australia, smoking cessation
\ncare and support procedures are shown to be suboptimal
\n(Anderson et al. 2013).
\nMore recent studies involved special populations and
\ncombinations of interventions. While smoking uptake rate has
\ndecreased in the general populations, the same trend is not
\noccurring among Native American youth. There is a lack of
\nstudies on the population to provide evidence whether interventions for smoking cessation are
\neffective (Carson et al 2012). In young people in general, in-school interventions appear more
\neffective when led by adults than by young people while increasing the number of sessions does
\nnot lead to a greater success rate (Thomas et al. 2013). Multicomponent interventions which
\ninvolve various stakeholders such as the media, retailers, and teachers have been studied but
\nhave shown no long-term effectiveness in preventing smoking uptake within this population
\n(Carson et al 2013). Interventions that utilize behavioral counseling in conjunction with
\nmedication have shown some evidence of effectiveness. A review of 41 studies found that using
\ncombination interventions may increase cessation success rate by 70 to 100 percent compared
\nThomas R. Frieden, M.D.,
\nM.P.H.
\nDirector, Centers for
\nDisease Control and
\nPrevention
\n\u201cFurther significant
\nprogress in tobacco
\ncontrol is possible. Strong
\nstate policies that protect
\nnonsmokers from second-
\nhand smoke, use of media
\nto graphically show the
\nhuman impact of smoking,
\nwell-funded tobacco
\ncontrol programs, and
\nimplementation of other
\nkey evidence-based
\npolicies will decrease the
\nnumber of smokers and
\nsave lives.\u201d
\nSources of bias
\nOften published studies use
\ndifferent definitions for smoking,
\nsmokers, and quit attempts. It is
\nalso unclear whether intensity and
\nduration of mass media campaigns
\ninfluence effectiveness of
\ninterventions (Bala et al. 2013)
\n21
\nwith counseling intervention alone. Cessation counseling ranged between 4 to 8 sessions and up
\nto 30 minutes each time. There is little evidence that longer or higher number of counseling
\nsessions can increase rate of success (Stead and Lancaster 2012).
\nMass media campaigns and financial support have also been explored as ways to encourage
\nsmoking cessation. Such campaigns can be effective when combined with other interventions
\nbut their effects on smoke cessation alone are difficult to determine. In April 2013, the
\nCommunity Preventive Services Task Force, established by the US Department of Health and
\nHuman Services (USDHHS), an equivalent of a ministry of health, issued a statement
\nrecommending mass-reach health interventions. Their systematic review of over 90 studies
\nshowed strong evidence of effectiveness in
\n1. Decreasing the prevalence,
\n2. Increasing quit rates, and
\n3. Decreasing smoking uptakes (Community Preventive Services Task Force 2013).
\nFinancial costs of treatments to help smokers quit can be itself a barrier to cessation. A review of
\neleven trials involving financial interventions suggests that provision of full financial coverage
\nfor cessation treatments significantly increased the intention to and success rates of quitting
\ncompared to interventions without financial support (Reda et al. 2012).
\nCurrently, there are no rigorous, peer-reviewed studies exploring the safety and effectiveness of
\nelectronic cigarettes as a smoking cessation treatment due to its relatively recent introduction to
\nthe world market. A New Zealand study revealed that although the use of e-cigarettes is
\nuncommon, most people view them in a positive light and as a potential useful aid in cessation
\neffort (Bullen et al. 2013). The WMA concludes from the uncertainty about electronic cigarettes
\nthat \u201cthe manufacture and sale of e-cigarettes and other electronic nicotine delivery systems be
\nsubject to national regulatory bodies prior approval based on testing and research as either a new
\nform of tobacco product or as a drug delivery device,\u201d (WMA Statement on Electronic
\nCigarettes and Other Electronic Nicotine Delivery Systems). In addition, the WMA urges \u201cthe
\nWHO to add tobacco cessation medications with established efficacy to the WHO\u2019s Model List
\nof Essential Medicines,\u201d (WMA Statement on Health Hazards of Tobacco Products and
\nTobacco-Derived Products).
\nEvidence suggests that anti-smoking legislation reduces SHS exposure and incidents of certain
\nhealth conditions. A systematic review of 50 studies in 5 countries showed consistent evidence
\nof reduction of SHS exposure in workplaces, restaurants, bars and in public places (Callinan et al.
\n2010). Other studies on smoking bans have shown effectiveness in reducing the incidents of
\nheart attack (Sargent et al. 2004; Seo and Torabi 2007; Lemstra et al. 2008;). A meta-analysis on
\nthe effect of smoke-free legislation and the rates of community heart attacks provides evidence
\nthat public and workplace smoking bans are significantly associated with declines in relative risk
\n22
\nof heart disease among individuals exposed to SHS. Strong anti-smoking laws are effective in
\nlowering the incidents of acute myocardial infarctions and greater benefits are realized as time
\npasses (Lightwood and Glantz 2009). A case study of legislation to ban smoking in public places
\nin a Canadian city of Saskatoon showed a reduction in rates of heart attack as well as a decrease
\nin smoking prevalence. Seventy-nine percent of the city residents supported the ban (Lemstra et
\nal. 2008).
\nAt the national and global levels, the WHO conducted a 3-year study involving 41 countries that
\nadopted MPOWER5 policies between 2007 and 2010. The results showed that among these
\ncountries, the number of smokers dropped by about 14.8 million. Approximately 7.4 million
\npeople were saved from smoking-related deaths. The most effective policy was an increase in
\ntaxes to 75% of the final retail price which was implemented in 14 countries. The policy is
\nestimated to have averted 3.5 million smoking-related deaths. Smoke-free air laws at worksites,
\nrestaurants, and bars averted 2.5 million deaths. Other policies such as health warnings and
\nadvertising, smoking cessation treatments, and bans on tobacco advertising (Levy et al. 2013)
\nclaim reduction in mortality attributed to SHS. A study from Scotland stresses the importance of
\nsmoking cessation rather than reduction. Current evidence provides a robust support for
\nlegislative smoking bans leading to improved health outcomes by limiting SHS exposures,
\nespecially for soronary artery disease (Frazier et al. 2016). Unfortunately the evidence on
\nrespiratory and perinatal health outcomes, smoking prevalence and tobacco consumption, is
\ninconsistent and requires further epidemiological studies
\nSummary of Policies and Interventions (see also Appendix B)
\nInterventions to encourage smoking cessation and reduce exposure to SHS vary widely and
\ninvolve many stakeholders and components. On the other hand, tobacco policies implemented at
\nthe national level have shown effectiveness in averting smoking-related deaths. A minimum
\nincrease in taxes to 75% of the retail price appears most effective. The results, however, are
\nbased on a 3-year study by the WHO. Long-term effectiveness and policy spill-overs remain to
\nbe evaluated. Studies have suggested targeting vulnerable groups such as people with disabilities
\nwho are more likely to smoke but are also more likely to attempt quitting (Hall et al. 2013).
\nInterventions should also be targeted to preventing smoking uptake in adolescents. The Cochrane
\nCollaboration is undertaking a review of school-based interventions looking at the effectiveness
\nof school tobacco control policies not just at the individual level but also the environmental level.
\nExisting studies show mixed results and a systematic review will provide guidance as to what
\ntypes of school policies are most likely to deter smoking uptake among adolescents (Coppo et al.
\n2012).
\n5
\nMonitoring use, protecting from smoke, offering help to quit, warning of health risks, enforcing bans, raising taxes
\non tobacco.
\n23
\nSECTION FIVE: Conclusions
\nExposure to SHS of nonsmokers is a major public health concern. Studies consistently show a
\nstrong evidence of SHS association with lower respiratory illnesses, cardiovascular disease, and
\ncoronary heart diseases. Risk of exposure to SHS is present everywhere smoking is permitted
\nand is threatening the health of adults and children in particular. In the recent years, evidence has
\nemerged for the deleterious health effects from third-hand smoking (THS). This has resulted in
\nsome health care facilities issuing guidelines to minimize exposures of patient to health care
\nworkers\u2019 tobacco impregnated clothing and other personal effects. The impact of THS on health
\nwarrants further research and it is essential that standard definitions be set for related terms in
\norder to be able conduct meta-analyses to increase the strength of evidence (Ueta et al. 2010,
\nFerrante et al. 2013, Protano and Vitali 2011, Escoffery et al. 2013).
\nSmoking bans are common in public places such as bars and restaurants in developed countries
\nand developing countries are swiftly following suit. The majority of the world\u2019s smokers today
\nreside in developing countries and the respective governments are acutely aware of the negative
\nhealth consequences of tobacco smoking. They are at the forefront in advocacy of smoking
\nrestriction legislation although most of them do not yet have comprehensive legislation (Barnoya
\nand Navas-Acien 2013). Smoking bans in the homes have not been legislated anywhere in the
\nworld despite overwhelming support. Only a few places ban smoking in vehicles when children
\nare present. Homes and vehicles are the main settings where nonsmokers are exposed to SHS.
\nThe WHO FCTC provides guidelines aimed at curbing the demand for cigarettes such as
\nrestricting advertisements and displaying graphics of harms on packages and labels but does not
\ninterfere with the supply side. Although demand side control has shown substantial success in
\nvarious places, there have been recent talks about limiting the sale of tobacco products in certain
\nestablishments such as pharmacies as recommended by the American Pharmacists Association.
\nInterventions to encourage smoking cessation and to reduce exposure to SHS among nonsmokers
\nhave been implemented at many levels. However, the wide variety of interventions and
\ninsufficient number of trials does not allow conclusions to be drawn with regard to effectiveness
\nof different methods or combination of methods. National level policies, on the other hand,
\nappear promising as the WHO has shown that they have averted millions of smoking-related
\ndeaths around the world.
\nIn 2012, the WHO created the Protocol to Eliminate Illicit Trade in Tobacco Products as
\nsupplement to the FCTC. Illicit trade increases availability and affordability of tobacco products.
\nAs its name indicates, the protocol aims to combat illicit trade in tobacco products with the
\nultimate goal of eradication. As of May 2015, it has 180 parties and has been ratified by 53 states
\n(WHO 2015). China has created the Policy Performance Indicator (PPI) to measure policy
\n24
\nsuccess based on protection of non-smokers from
\nSHS and is being implemented across the country
\n(Wan et al. 2013). The focus on developing countries
\nis critical as they are where the majority of SHS
\nvictims reside. International philanthropic donations
\nmay play a role in changing the norms and the
\nperceptions of tobacco use leading to major health
\ngains (Redmon et al. 2013). It is important to build
\ntobacco control capacity in order to effectively
\nimplement the FCTC (Stillman et al. 2013). Bans on
\nSHS exposure of children in indoor spaces, such as
\ncars and homes, hve been implemented by several
\ncountries, and are considered by others6
\n(Moore et al.
\n2012, Moore et. al. 2015).
\nThe e-cigarettes is welcomed, by the world
\ncommunity as an alternative to tobacco. E-cigatrettes effectiveness as smoking cessation
\ntreatment is still under investigation and the its SHS health effects is inconclusive. Concerns over
\nhealth effects from e-cigarettes vapor exposure , in closed environments, led to
\nrecommendations for surveillance and additional epidemiological studies (Burstyn 2014, Akl et
\nal. 2010). Since 2015 legislation and regulations for the use of e-cigarettes were enacted or being
\nconsidered by over 70 countries. Such legislations usually follow similar restrictions as the use
\nof tobacco. The U.S. Food and Drug Administration (FDA), introduced a new regulation of the
\ne-cigarettes to enter in effect in August 2016 (Abbas 2016
\n). The summaries of evidence of SHS effects on health are presented in appendix A and B.
\nPoints to Remember
\n1. Robust evidence links tobacco use to pulmonary, cardiovascular and neurological
\ndiseases, including cancer.
\n2. Good evidence links SHS tobacco exposures to medical problems in infants, children and
\nadults. Fair evidence supports health risks from exposure to the increasing use of hookah
\n[narguileh, water pipe] around the world (Akl et al. 2010, Kumar et al. 2015).
\n3. SHS tobacco exposures in private place continues to be a major health threat to pregnant
\nwomen, infants and children, and in several US litigation case were labeled as child
\nneglect [rarely as abuse].
\n4. Developing market economy countries continue to have higher tobacco use and SHS
\nexposure levels.Akl et al. 2010),
\n6
\nSmoking bans in cars with children and\/or passengers. Smoking bans inside housing have been implemented only
\nin few countries. The US bans vary from state to state.
\nLegislative Status as of 2016
\nEven though progress has been
\nsteady, policy implementation has
\nbeen slow. There is an urgent need
\nfor further research in areas such as
\nsmoking bans in indoor and outdoor
\nspaces and the health impact of SHS
\nand THS on socio-economically
\ndisadvantaged and vulnerable
\npopulations (Barnoya and Navas-
\nAcien 2013, Moore et al. 2015)
\n25
\n5. According to the American Cancer Society (ACS 2015) the estimated health care costs
\nfor tobacco use between 2000 and 2012 in billions of dollars, in several countries,
\namounted to:
\na. USA 133
\nb. France 16.6
\nc. United Kingdom 9.5
\nd. China 6.2 (conservative estimates)
\ne. Canada 2.8
\n6. There is no single effective preventive intervention, but rather a combination of measures
\nsuch as smoking bans, penalties and fines, taxations, education, systematic and sustained
\noutreach campaigns, package labeling, and improved health literacy.
\n26
\nAppendix A: Summary Table of Evidence from Epidemiological Studies
\n27
\n28
\n29
\n30
\n31
\n32
\nAppendix B: Summary Table of Evidence from Interventional Studies
\n33
\n34
\n35
\nAppendix C: Health Effect of SHS in Adults
\nThe 2006 United States Surgeon General report found the following evidence for health effects
\nof SHS exposure in adults
\nSufficient evidence to infer a causal relationship between SHS and
\n\uf0b7 lung cancer
\n\uf0b7 an increased risk of coronary heart disease morbidity and mortality
\n\uf0b7 odor annoyance
\n\uf0b7 nasal irritation
\nSuggestive evidence but not sufficient to infer a causal relationship between SHS and
\n\uf0b7 breast cancer
\n\uf0b7 an increased risk of stroke
\n\uf0b7 atherosclerosis
\n\uf0b7 acute respiratory symptoms; cough, wheeze, chest tightness, difficulty breathing
\n\uf0b7 chronic respiratory symptoms
\n\uf0b7 acute decline in lung function in persons with asthma
\n\uf0b7 small decrement in lung function in the general population
\n\uf0b7 adult-onset asthma
\n\uf0b7 worsening of asthma control
\n\uf0b7 risk for chronic obstructive pulmonary disease
\nInadequate evidence to infer a causal relationship between SHS and
\n\uf0b7 risk of nasopharyngeal carcinoma
\n\uf0b7 risk of cervical cancer
\n\uf0b7 acute decline in lung function in health population
\n\uf0b7 accelerated decline in lung function
\n\uf0b7 morbidity in persons with chronic obstructive pulmonary disease
\n36
\nAppendix D: Health Effects of SHS in Infants and Children
\nThe 2006 United States Surgeon General report found the following evidence for health effects
\nof SHS exposure in infants and children
\nSufficient evidence to infer a causal relationship between SHS and
\n\uf0b7 Sudden Infant Death Syndrome
\n\uf0b7 low birth weight
\n\uf0b7 lower respiratory illnesses (the greatest risks found among children with smoking
\nmother)
\n\uf0b7 middle ear disease, including acute and recurrent otitis media and chronic middle ear
\neffusion.
\n\uf0b7 Cough. phlegm, wheeze, asthma, and breathlessness among school age children
\n\uf0b7 chronic adverse effects on lung function throughout childhood
\nSuggestive evidence but not sufficient to infer a causal relationship between SHS and
\n\uf0b7 preterm delivery
\n\uf0b7 childhood leukemia, lymphomas, and brain tumor
\n\uf0b7 natural history of middle ear effusion
\n\uf0b7 onset of childhood asthma
\nInadequate evidence to infer a causal relationship between SHS and
\n\uf0b7 female fertility
\n\uf0b7 spontaneous abortion
\n\uf0b7 neonatal mortality
\n\uf0b7 congenital malformations
\n\uf0b7 cognitive functioning
\n\uf0b7 behavioral problems
\n\uf0b7 height\/growth
\n\uf0b7 an increased risk of adenoidectomy or tonsillectomy
\n\uf0b7 risk of immunoglobulin E-mediated allergy
\n37
\nAppendix E: WMA 2011 Statement on Health Hazards of Tobacco Products and Tobacco-
\nDerived Products
\n[www.wma.net\/en\/30publications\/…\/h4\/]
\nAdopted by the 40th
\nWorld Medical Assembly, Vienna, Austria, September 1988
\nand amended by the 49th
\nWMA General Assembly, Hamburg, Germany, November 1997
\nand the 58th
\nWMA General Assembly, Copenhagen, Denmark, October 2007
\nand the 62nd
\nWMA General Assembly, Montevideo, Uruguay, October 2011
\nPREAMBLE
\nMore than one in three adults worldwide (more than 1.1 billion people) smokes, 80 percent of
\nwhom live in low- and middle-income countries. Smoking and other forms of tobacco use affect
\nevery organ system in the body, and are major causes of cancer, heart disease, stroke, chronic
\nobstructive pulmonary disease, fetal damage, and many other conditions. Five million deaths
\noccur worldwide each year due to tobacco use. If current smoking patterns continue, it will cause
\nsome 10 million deaths each year by 2020 and 70 percent of these will occur in developing
\ncountries. Tobacco use was responsible for 100 million deaths in the 20th century and will kill
\none billion people in the 21st century unless effective interventions are implemented.
\nFurthermore, secondhand smoke – which contains more than 4000 chemicals, including more
\nthan 50 carcinogens and many other toxins – causes lung cancer, heart disease, and other
\nillnesses in nonsmokers.
\nThe global public health community, through the World Health Organization (WHO), has
\nexpressed increasing concern about the alarming trends in tobacco use and tobacco-attributable
\ndisease. As of 20 September 2007, 150 countries had ratified the Framework Convention on
\nTobacco Control (FCTC), whose provisions call for ratifying countries to take strong action
\nagainst tobacco use by increasing tobacco taxation, banning tobacco advertising and promotion,
\nprohibiting smoking in public places and worksites, implementing effective health warnings on
\ntobacco packaging, improving access to tobacco cessation treatment services and medications,
\nregulating the contents and emissions of tobacco products, and eliminating illegal trade in
\ntobacco products.
\nExposure to secondhand smoke occurs anywhere smoking is permitted: homes, workplaces, and
\nother public places. According to the WHO, some 200,000 workers die each year due to
\nexposure to smoke at work, while about 700 million children, around half the world’s total,
\nbreathe air polluted by tobacco smoke, particularly in the home. Based on the evidence of three
\nrecent comprehensive reports (the International Agency for Research on Cancer’s Monograph 83,
\nTobacco Smoke and Involuntary Smoking; the United States Surgeon General’s Report on The
\nHealth Consequences of Involuntary Exposure to Tobacco Smoke; and the California
\nEnvironmental Protection Agency’s Proposed Identification of Environmental Tobacco Smoke as
\n38
\na Toxic Air Contaminant), on May 29, 2007, the WHO called for a global ban on smoking at
\nwork and in enclosed public places.
\nThe tobacco industry claims that it is committed to determining the scientific truth about the
\nhealth effects of tobacco, both by conducting internal research and by funding external research
\nthrough jointly funded industry programs. However, the industry has consistently denied,
\nwithheld, and suppressed information concerning the deleterious effects of tobacco smoking. For
\nmany years the industry claimed that there was no conclusive proof that smoking tobacco causes
\ndiseases such as cancer and heart disease. It has also claimed that nicotine is not addictive. These
\nclaims have been repeatedly refuted by the global medical profession, which because of this is
\nalso resolutely opposed to the massive advertising campaigns mounted by the industry and
\nbelieves strongly that the medical associations themselves must provide a firm leadership role in
\nthe campaign against tobacco.
\nThe tobacco industry and its subsidiaries have for many years supported research and the
\npreparation of reports on various aspects of tobacco and health. By being involved in such
\nactivities, individual researchers and\/or their organizations give the tobacco industry an
\nappearance of credibility even in cases where the industry is not able to use the results directly in
\nits marketing. Such involvement also raises major conflicts of interest with the goals of health
\npromotion.
\nRECOMMENDATIONS
\nThe WMA urges the national medical associations and all physicians to take the following
\nactions to help reduce the health hazards related to tobacco use:
\n1. Adopt a policy position opposing smoking and the use of tobacco products, and publicize
\nthe policy so adopted.
\n2. Prohibit smoking, including use of smokeless tobacco, at all business, social, scientific,
\nand ceremonial meetings of the National Medical Association, in line with the decision of
\nthe World Medical Association to impose a similar ban at all its own such meetings.
\n3. Develop, support, and participate in programs to educate the profession and the public
\nabout the health hazards of tobacco use (including addiction) and exposure to secondhand
\nsmoke. Programs aimed at convincing and helping smokers and smokeless tobacco users
\nto cease the use of tobacco products and programs for non-smokers and non-users of
\nsmokeless tobacco products aimed at avoidance are both important.
\n4. Encourage individual physicians to be role models (by not using tobacco products) and
\nspokespersons for the campaign to educate the public about the deleterious health effects
\nof tobacco use and the benefits of tobacco-use cessation. Ask all medical schools,
\nbiomedical research institutions, hospitals, and other health care facilities to prohibit
\nsmoking, use of smokeless tobacco on their premises.
\n5. Introduce or strengthen educational programs for medical students and physicians to
\nprepare them to identify and treat tobacco dependence in their patients.
\n6. Support widespread access to evidence-based treatment for tobacco dependence –
\nincluding counseling and pharmacotherapy – through individual patient encounters,
\ncessation classes, telephone quit-lines, web-based cessation services, and other
\nappropriate means.
\n39
\n7. Develop or endorse a clinical practice guideline on the treatment of tobacco use and
\ndependence.
\n8. Join the WMA in urging the World Health Organization to add tobacco cessation
\nmedications with established efficacy to the WHO’s Model List of Essential Medicines.
\n9. Refrain from accepting any funding or educational materials from the tobacco industry,
\nand to urge medical schools, research institutions, and individual researchers to do the
\nsame, in order to avoid giving any credibility to that industry.
\n10. Urge national governments to ratify and fully implement the Framework Convention on
\nTobacco Control in order to protect public health.
\n11. Speak out against the shift in focus of tobacco marketing from developed to less
\ndeveloped nations and urge national governments to do the same.
\n12. Advocate the enactment and enforcement of laws that:
\n\uf0b7 Provide for comprehensive regulation of the manufacture, sale, distribution, and
\npromotion of tobacco and tobacco-derived products, including the specific provisions
\nlisted below.
\n\uf0b7 Require written and pictorial warnings about health hazards to be printed on all
\npackages n which tobacco products are sold and in all advertising and promotional
\nmaterials for tobacco products. Such warnings should be prominent and should refer
\nthose interested in quitting to available telephone quit-lines, websites, or other
\nsources of assistance.
\n\uf0b7 Prohibit smoking in all enclosed public places (including health care facilities,
\nschools, and education facilities), workplaces (including restaurants, bars and
\nnightclubs) and public transport. Mental health and chemical dependence treatment
\ncenters should also be smoke-free. Smoking in prisons should not be permitted.
\n\uf0b7 Ban all advertising and promotion of tobacco and tobacco-derived products.
\n\uf0b7 encourage the development of plain packaging legislation
\n\uf0b7 Prohibit the sale, distribution, and accessibility of cigarettes, and other tobacco
\nproducts to children and adolescents. Ban the production, distribution and sale of
\ncandy products that depict or resemble tobacco products.
\n\uf0b7 prohibit smoking on all commercial airline flights within national borders and on all
\ninternational commercial airline flights, and prohibit the sale of tax-free tobacco
\nproducts at airports and all other locations.
\n\uf0b7 Prohibit all government subsidies for tobacco and tobacco-derived products.
\n\uf0b7 Provide for research into the prevalence of tobacco use and the effects of tobacco
\nproducts on the health status of the population.
\n\uf0b7 Prohibit the promotion, distribution, and sale of any new forms of tobacco products
\nthat are not currently available.
\n\uf0b7 Increase taxation of tobacco products, using the increased revenues for prevention
\nprograms, evidence-based cessation programs and services, and other health care
\nmeasures.
\n\uf0b7 Curtail or eliminate illegal trade in tobacco products and the sale of smuggled tobacco
\nproducts.
\n\uf0b7 Help tobacco farmers switch to alternative crops.
\n\uf0b7 Urge governments to exclude tobacco products from international trade agreements.
\n40
\n13. Recognize that tobacco use may lead to pediatric disease because of the harm done to
\nchildren caused by tobacco use and second-hand smoke exposure, the relationship of
\ntobacco use by children and exposure to adult tobacco use, and the existence of effective
\ninterventions to reduce tobacco use. Special efforts should be made by physicians to:
\n\uf0b7 provide tobacco-free environments for children
\n\uf0b7 target parents who smoke for tobacco cessation interventions
\n\uf0b7 promote programs that contribute to the prevention and decrease of tobacco use
\nby youth
\n\uf0b7 control access to and marketing of tobacco products, and
\n\uf0b7 make pediatric tobacco-control research a high priority
\n14. Refuse to invest in companies or firms producing or promoting the use or sale of tobacco
\n41
\nReferences
\nAbbasi Jennifer 2016. FDA Extends Authority to e-Cigarettes: Implications for Smoking Cessation?
\nJAMA. Published online July 15, 2016. doi:10.1001\/jama.2016.8568 (Editoria)
\nAkl Elie A, Swarna Gaddam,
\nSameer K Gunukula,
\nRoland Honeine,,
\nPhilippe Abou Jaoude and Jihad
\nIrani. 2010. The effects of waterpipe tobacco smoking on health outcomes: a systematic review.
\nInt. J. Epidemiol. (3): 834-857.
\nAmerican Nonsmokers\u2019 Rights Foundation (ANR). 2015. \u201cOverview List \u2013 How Many Smokefree
\nLaws?\u201d http:\/\/www.no-smoke.org\/pdf\/mediaordlist.pdf.
\nAmerican Cancer Society (ACS). 2015. Tobacco: The True Cost of Smoking.
\nhttp:\/\/www.cancer.org\/research\/infographicgallery\/tobacco-related-healthcare-
\ncosts?_ga=1.246313604.1878765257.1445355436 (accessed November 15, 2015]
\nAnderson, Amy Elizabeth, Jenny A. Bowman, Jenny Knight, Paula M. Wye, Margarett Terry, Sonya
\nGrimshaw, and John H. Wiggers. 2013. \u201cSmoking Cessation Care Provision and Support
\nProcedures in Australian Community Mental Health Centers.\u201d Psychiatric Services 64 (7) (July
\n1): 707\u2013710. doi:10.1176\/appi.ps.201200213.
\nArmour, Brian S, Vincent A Campbell, John E Crews, Roland A Richard, Ann Malarcher, and
\nEmmanuel Maurice. 2007. \u201cState-Level Prevalence of Cigarette Smoking and Treatment Advice,
\nby Disability Status, United States, 2004.\u201d Preventing Chronic Disease 4 (4) (September 15).
\nhttp:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC2099284\/
\nAsh: Action on Smoking and Health. 2011. \u201cSecondhand Smoke: The Impact on Children.\u201d
\nhttp:\/\/www.sustainableguernsey.info\/blog\/wp-content\/uploads\/2011\/09\/secondhand-smoke-
\nimpact-on-children-ASH_596.pdf.
\nAslan, Dilek and Didem Daymaz. 2015. \u201cStatus of Exposure to Second-Hand Smoke at Home in
\nChildren under Five Years of Age: An Example from Ankara Province.\u201d Turkish Thoracic
\nJournal\/T\u00fcrk Toraks Dergisi 16 (1): 16\u201321. doi:10.5152\/ttd.2014.4180.
\nBala, Malgorzata M, Lukasz Strzeszynski, Roman Topor-Madry, and Kate Cahill. 2013. \u201cMass Media
\nInterventions for Smoking Cessation in Adults.\u201d In Cochrane Database of Systematic Reviews,
\nedited by The Cochrane Collaboration and Malgorzata M Bala. Chichester, UK: John Wiley &
\nSons, Ltd. http:\/\/www.ncbi.nlm.nih.gov\/pubmedhealth\/PMH0012958\/.
\nBandiera, Frank C., Kristopher L. Arheart, Alberto J. Caban-Martinez, Lora E. Fleming, Kathryn
\nMcCollister, Noella A. Dietz, William G. LeBlanc, et al. 2010. \u201cSecondhand Smoke Exposure
\nand Depressive Symptoms.\u201dPsychosomatic Medicine 72 (1) (January 1): 68\u201372.
\ndoi:10.1097\/PSY.0b013e3181c6c8b5.
\nBarnes, Deborah E., Thaddeus J. Haight, Kala M. Mehta, Michelle C. Carlson, Lewis H. Kuller, and
\nIra B. Tager. 2010. \u201cSecondhand Smoke, Vascular Disease, and Dementia Incidence: Findings
\nFrom the Cardiovascular Health Cognition Study.\u201d American Journal of Epidemiology 171 (3)
\n(February 1): 292\u2013302. doi:10.1093\/aje\/kwp376.
\nBarnoya, Joaquin, and Ana Navas-Acien. \u201cProtecting the World From Secondhand Tobacco Smoke
\nExposure: Where Do We Stand and Where Do We Go From Here?\u201d Nicotine & Tobacco
\nResearch 15, no. 4 (April 2013): 789\u2013804. doi:10.1093\/ntr\/nts200.
\nBlackburn, C. 2003. \u201cEffect of Strategies to Reduce Exposure of Infants to Environmental Tobacco
\nSmoke in the Home: Cross Sectional Survey.\u201d BMJ 327 (7409): 257\u20130.
\ndoi:10.1136\/bmj.327.7409.257.
\nBoffetta, P, J Tredaniel, and A Greco. 2000. \u201cRisk of Childhood Cancer and Adult Lung Cancer After
\nChildhood Exposure to Passive Smoke: A Meta-analysis.\u201d Environmental Health Perspectives
\n108 (1) (January): 73\u201382.
\n42
\nBrennan TA, and Schroeder SA. 2014. \u201cEnding Sales of Tobacco Products in Pharmacies.\u201d JAMA.
\ndoi:10.1001\/jama.2014.686. http:\/\/dx.doi.org\/10.1001\/jama.2014.686.
\nBrooks, Jada, Diane Holditch-Davis, Mark A. Weaver, Margaret Shandor Miles, and Stephen C.
\nEngelke. 2011. \u201cEffects of Secondhand Smoke Exposure on the Health and Development of
\nAfrican American Premature Infants.\u201d International Journal of Family Medicine 2011 (May 18).
\ndoi:10.1155\/2011\/165687. http:\/\/www.hindawi.com\/journals\/ijfm\/2011\/165687\/abs\/.
\nBullen, Christopher, Colin Howe, Murray Laugesen, Hayden McRobbie, Varsha Parag, Jonathan
\nWilliman, and Natalie Walker. 2013. \u201cElectronic Cigarettes for Smoking Cessation: A
\nRandomized Controlled Trial.\u201d The Lancet 382 (9905): 1629\u201337.
\nBurstyn Igor 2014. Peering through the mist: systematic review of what the chemistry of
\ncontaminants in electronic cigarettes tells us about health risks. BMC Public Health. 9;14:18.
\ndoi: 10.1186\/1471-2458-14-18
\nCallinan, Joanne E, Anna Clarke, Kirsten Doherty, and Cecily Kelleher. 2010. \u201cLegislative Smoking
\nBans for Reducing Secondhand Smoke Exposure, Smoking Prevalence and Tobacco
\nConsumption.\u201d In Cochrane Database of Systematic Reviews, edited by The Cochrane
\nCollaboration and Joanne E Callinan.Chichester, UK: John Wiley & Sons, Ltd.
\nhttp:\/\/summaries.cochrane.org\/CD005992\/does-legislation-to-ban-smoking-reduce-exposure-to-
\nsecondhand-smoke-and-smoking-behaviour.
\nCarson, Kristin V, Malcolm P Brinn, Nadina A Labiszewski, Adrian J Esterman, Anne B Chang, and
\nBrian J Smith. 2011. \u201cCommunity Interventions for Preventing Smoking in Young People.\u201d In
\nCochrane Database of Systematic Reviews, edited by The Cochrane Collaboration and Kristin V
\nCarson. Chichester, UK: John Wiley & Sons, Ltd.
\nhttp:\/\/summaries.cochrane.org\/CD001291\/can-community-interventions-deter-young-people-
\nfrom-starting-to-smoke.
\nCenters for Disease Control and Prevention. 2015. \u201cSmoking and Tobacco Use; Fact Sheet; Fast
\nFacts.\u201d Smoking and Tobacco Use. Accessed May 5.
\nhttp:\/\/www.cdc.gov\/tobacco\/data_statistics\/fact_sheets\/fast_facts\/.
\nCenters for Disease Control and Prevention. 2015. \u201cState Smoke-Free Laws for Worksites,
\nRestaurants, and Bars — United States, 2000–2010.\u201d Accessed November 27.
\nhttp:\/\/www.cdc.gov\/mmwr\/preview\/mmwrhtml\/mm6015a2.htm.
\nChapman, S, and B Freeman. 2009. \u201cRegulating the Tobacco Retail Environment: Beyond Reducing
\nSales to Minors.\u201d Tobacco Control 18 (6): 496\u2013501.
\nChapman, Simon. \u201cShould Smoking in Outside Public Spaces Be Banned? No.\u201d BMJ (Clinical
\nResearch Ed.) 337 (2008): a2804.
\nCommunity Preventive Services Task Force. 2013. \u201cThe Community Guide – Summary(a) – Tobacco:
\nMass-Reach Health Communication Interventions.\u201d Accessed July 6.
\nhttp:\/\/www.thecommunityguide.org\/tobacco\/massreach.html.
\nCoppo, Alessandro, Maria Rosaria Galanti, Daria Buscemi, Livia Giordano, and Fabrizio Faggiano.
\n2012. \u201cSchool Policies for Preventing Smoking among Young People.\u201d In Cochrane Database of
\nSystematic Reviews. John Wiley & Sons, Ltd.
\nhttp:\/\/onlinelibrary.wiley.com\/doi\/10.1002\/14651858.CD009990\/abstract.
\nCrosbie, Eric, Ernesto M Sebrie, and Stanton A Glantz. \u201cStrong Advocacy Led to Successful
\nImplementation of Smokefree Mexico City.\u201d Tobacco Control 20, no. 1 (January 2011): 64\u201372.
\ndoi:10.1136\/tc.2010.037010.
\n43
\nEdwards, Richard, Nick Wilson, and NevilPierse. 2006. \u201cHighly Hazardous Air Quality Associated
\nwith Smoking in Cars: New Zealand Pilot Study.\u201d The New Zealand Medical Journal 119
\n(1244): U2294.
\nEscoffery, Cam, Lucja Bundy, Michelle Carvalho, Debbie Yembra, Regine Haard\u00f6rfer, Carla Berg,
\nand Michelle C. Kegler. 2013. \u201cThird-hand Smoke as a Potential Intervention Message for
\nPromoting Smoke-free Homes in Low-income Communities.\u201d Health Education Research (May
\n13). doi:10.1093\/her\/cyt056. http:\/\/her.oxfordjournals.org\/content\/early\/2013\/05\/11\/her.cyt056.
\nEsson, Katherine M., and Stephen R. Leeder. 2004. \u201cThe Millennium Development Goals and
\nTobacco Control: An Opportunity for Global Partnership\u201d. World Health Organization.
\nEvlampidou, Iro, Manolis Bagkeris, Constantine Vardavas, Katerina Koutra, Evridiki Patelarou, Antonis
\nKoutis, Leda Chatzi, and Manolis Kogevinas. 2015. \u201cPrenatal Second-Hand Smoke Exposure Measured
\nwith Urine Cotinine May Reduce Gross Motor Development at 18 Months of Age.\u201d The Journal of
\nPediatrics 167 (2): 246\u201352.e2. doi:10.1016\/j.jpeds.2015.03.006.
\nFarrelly, Matthew C., Kevin C. Davis, M. Lyndon Haviland, Peter Messeri, and Cheryl G. Healton.
\n2005. \u201cEvidence of a Dose\u2014Response Relationship Between \u2018truth\u2019 Antismoking Ads and
\nYouth Smoking Prevalence.\u201d American Journal of Public Health 95 (3): 425\u201331.
\ndoi:10.2105\/AJPH.2004.049692.
\nFarrelly, Matthew C., James Nonnemaker, Kevin C. Davis, and Altijani Hussin. 2009. \u201cThe Influence
\nof the National Truth\u00ae Campaign on Smoking Initiation.\u201d American Journal of Preventive
\nMedicine 36 (5): 379\u201384. doi:10.1016\/j.amepre.2009.01.019.
\nFern\u00e1ndez, Mariana F., Francisco Artacho-Cord\u00f3n, Carmen Freire, Roc\u00edo P\u00e9rez-Lobato, Irene
\nCalvente, Rosa Ramos, Ane M. Castilla, et al. 2015. \u201cTrends in Children\u2019s Exposure to Second-
\nHand Smoke in the INMA-Granada Cohort: An Evaluation of the Spanish Anti-Smoking Law.\u201d
\nEnvironmental Research 138 (April): 461\u201368. doi:10.1016\/j.envres.2015.03.002.
\nFerrante, G, M Simoni, F Cibella, F Ferrara, G Liotta, V Malizia, G Corsello, G Viegi, and S La
\nGrutta. 2013. \u201cThird-hand Smoke Exposure and Health Hazards in Children.\u201d Monaldi Archives
\nfor Chest Disease = Archivio Monaldi Per Le Malattie Del Torace \/ Fondazione Clinica Del
\nLavoro, IRCCS [and] Istituto Di Clinica Tisiologica e Malattie Apparato Respiratorio,
\nUniversit\u00e0 Di Napoli, Secondo Ateneo 79 (1) (March): 38\u201343.
\nFleming, Tyler, Chris Anderson, Sarang Amin, and Jeffrey Ashley. 2012. \u201cThird-hand Tobacco
\nSmoke: Significant Vector for PAH Exposure or Non-issue?\u201d Integrated Environmental
\nAssessment and Management 8 (4): 763\u2013764. doi:10.1002\/ieam.1337.
\nFlouris, Andreas D., Constantine I. Vardavas, Giorgos S. Metsios, Aristidis M. Tsatsakis, and
\nYiannisKoutedakis. 2010. \u201cBiological Evidence for the Acute Health Effects of Secondhand
\nSmoke Exposure.\u201d American Journal of Physiology – Lung Cellular and Molecular Physiology
\n298 (1) (January 1): L3\u2013L12. doi:10.1152\/ajplung.00215.2009.
\nFrazer Kate, Joanne E Callinan, Jack McHugh, Susan van Baarsel, Anna Clarke, Kirsten Doherty, and
\nCecily Kelleher 2016. Does legislation to ban smoking reduce exposure to secondhand smoke
\nand smoking behaviour? CochraneDatabaseof SystematicReviews Issue 2. Art. No.: CD005992.
\nDOI: 10.1002\/14651858.CD005992.pub3.
\nFreeman, Becky, Simon Chapman, and Philip Storey. 2008. \u201cBanning Smoking in Cars Carrying
\nChildren: An Analytical History of a Public Health Advocacy Campaign.\u201d Australian and New
\nZealand Journal of Public Health 32 (1) (February): 60\u201365. doi:10.1111\/j.1753-
\n6405.2008.00167.x.
\nGlobal Advisors Smokefree Policy (GASP). 2015. \u201cSmoke-Free Vehicles When Children Are
\nPresent.\u201d http:\/\/www.njgasp.org\/wp-content\/uploads\/2014\/05\/sf-cars-white-paper-8-14-15-
\n455pm-FINAL-ON-WEBSITE.pdf.
\n44
\nGlover, Marewa, Robert Scragg, Sandar Min, AnetteKira, ViliNosa, Judith McCool, and Chris Bullen.
\n2011. \u201cDriving Kids to Smoke? Children\u2019s Reported Exposure to Smoke in Cars and Early
\nSmoking Initiation.\u201d Addictive Behaviors 36 (11) (November): 1027\u20131031.
\ndoi:10.1016\/j.addbeh.2011.06.003.
\nHall, Allyson G., Jessica R. Schumacher, Michael Brad Cannell, Joyce Balls Berry, Melody
\nSchiaffino, and SinYoung Park. 2013. \u201cTobacco Use in Florida: Comparisons Between Adults
\nLiving with and Without Disabilities.\u201d Disability and Health Journal 6 (3) (July): 213\u2013219.
\ndoi:10.1016\/j.dhjo.2013.01.008.
\nHamer, Mark, Emmanuel Stamatakis, and G. David Batty. 2010. \u201cObjectively Assessed Secondhand
\nSmoke Exposure and Mental Health in Adults: Cross-Sectional and Prospective Evidence from
\nthe Scottish Health Survey.\u201d Archives of General Psychiatry 67 (8): 850\u201355.
\ndoi:10.1001\/archgenpsychiatry.2010.76.
\nHang, Bo, Altaf H. Sarker, Christopher Havel, Saikat Saha, Tapas K. Hazra, Suzaynn Schick, Peyton
\nJacob, et al. 2013. \u201cThirdhand Smoke Causes DNA Damage in Human Cells.\u201d Mutagenesis,
\nMarch. doi:10.1093\/mutage\/get013.
\nHoltgrave, David R., Katherine A. Wunderink, Donna M. Vallone, and Cheryl G. Healton. 2009.
\n\u201cCost\u2013Utility Analysis of the National Truth\u00ae Campaign to Prevent Youth Smoking.\u201d American
\nJournal of Preventive Medicine 36 (5): 385\u201388. doi:10.1016\/j.amepre.2009.01.020.
\nI\u00f1iguez, Sergio D, Brandon L Warren, Eric M Parise, Lyonna F Alcantara, Brittney Schuh, Melissa L
\nMaffeo, ZarkoManojlovic, and Carlos A Bola\u00f1os-Guzm\u00e1n. 2009. \u201cNicotine Exposure During
\nAdolescence Induces a Depression-like State in Adulthood.\u201d Neuropsychopharmacology:
\nOfficial Publication of the American College of Neuropsychopharmacology 34 (6) (May): 1609\u2013
\n1624. doi:10.1038\/npp.2008.220.
\nInternational Agency for Research on Cancer World Health Organization. 2004. \u201cIARC Monographs
\non the Evaluation of Carcinogenic Risks to Humans.\u201d Tobacco Smoke and Involuntary Smoking.
\nLyon, France. http:\/\/monographs.iarc.fr\/ENG\/Monographs\/vol83\/mono83.pdf.
\nInternational Labour Organization. 2015. \u201cChild Labour.\u201d Child Labor.
\nhttp:\/\/www.ilo.org\/global\/topics\/child-labour\/lang–en\/index.htm.
\nJapuntich SJ, Eilers MA, Shenhav S, and et al. 2015. \u201cSEcondhand Tobacco Smoke Exposure among
\nHospitalized Nonsmokers with Coronary Heart Disease.\u201d JAMA Internal Medicine 175 (1): 133\u2013
\n36. doi:10.1001\/jamainternmed.2014.5476.
\nJarvie, Jill A., and Ruth E. Malone. 2008. \u201cChildren\u2019s Secondhand Smoke Exposure in Private Homes
\nand Cars: An Ethical Analysis.\u201d American Journal of Public Health 98 (12): 2140\u201345.
\ndoi:10.2105\/AJPH.2007.130856.
\nJohns Hopkins Bloomberg School of Public Health. \u201cHow to Measure SHS.\u201d Secondhand Smoke
\nMonitoring.Accessed May 2, 2013.
\nhttp:\/\/www.shsmonitoring.org\/SHS_Overview\/how\/index.html.
\nKabir, Z., P. J. Manning, J. Holohan, S. Keogan, P. G. Goodman, and L. Clancy. 2009. \u201cSecond-hand
\nSmoke Exposure in Cars and Respiratory Health Effects in Children.\u201d European Respiratory
\nJournal 34 (3) (September 1): 629\u2013633. doi:10.1183\/09031936.00167608.
\nKarim, Zubair A., Fatima Z. Alshbool, Hari Priya Vemana, Neema Adhami, Sandeep Dhall, Enma V.
\nP. Espinosa, Manuela Martins-Green, and Fadi T. Khasawneh. 2015. \u201cThird Hand Smoke:
\nImpact on Hemostasis and Thrombogenesis.\u201d Journal of Cardiovascular Pharmacology, April.
\ndoi:10.1097\/FJC.0000000000000260.
\n45
\nKassel, Jon D, Laura R Stroud, and Carol A Paronis. 2003. \u201cSmoking, Stress, and Negative Affect:
\nCorrelation, Causation, and Context Across Stages of Smoking.\u201d Psychological Bulletin 129 (2)
\n(March): 270\u2013304.
\nKenen, Joanne, and KYLE CHENEY | 2\/5\/14 7:07 AM EST Updated: 2\/5\/14 2:49 PM EST. 2014.
\n\u201cCVS to Stop Tobacco Sales.\u201d POLITICO, February 5.
\nhttp:\/\/www.politico.com\/story\/2014\/02\/cvs-caremark-tobacco-cigarette-sales-103145.html.
\nSumit R Kumar, Shelby Davies, Michael Weitzman and Scott Sherman 2015 A review of air quality,
\nbiological indicators and health effects of second-hand waterpipe smoke exposure. Tob Control.
\n2015 Mar;24 Suppl 1:i54-i59. doi: 10.1136\/tobaccocontrol-2014-052038
\nLemstra, Mark, Cory Neudorf, and JohnmarkOpondo. 2008. \u201cImplications of a Public Smoking Ban.\u201d
\nCanadian Journal of Public Health. Revue Canadienne de Sant\u00e9 Publique 99 (1) (February): 62\u2013
\n65.
\nLeonardi-Bee, Jo, John Britton, and Andrea Venn. 2011. \u201cSecondhand Smoke and Adverse Fetal
\nOutcomes in Nonsmoking Pregnant Women: A Meta-analysis.\u201d Pediatrics 127 (4) (April 1):
\n734\u2013741. doi:10.1542\/peds.2010-3041.
\nLevy, David T, Jennifer A Ellis, Darren Mays, and An-Tsun Huang. 2013. \u201cSmoking-related Deaths
\nAverted Due to Three Years of Policy Progress.\u201d Bulletin of the World Health Organization 91
\n(7) (July 1): 509\u2013518. doi:10.2471\/BLT.12.113878.
\nLightwood, James M., and Stanton A. Glantz. 2009. \u201cDeclines in Acute Myocardial Infarction After
\nSmoke-Free Laws and Individual Risk Attributable to Secondhand Smoke.\u201d Circulation 120 (14)
\n(October 6): 1373\u20131379. doi:10.1161\/CIRCULATIONAHA.109.870691.
\nMatt, Georg E., Penelope J. E. Quintana, Hugo Destaillats, Lara A. Gundel, Mohamad Sleiman, Brett
\nC. Singer, Peyton Jacob, et al. 2011. \u201cThirdhand Tobacco Smoke: Emerging Evidence and
\nArguments for a Multidisciplinary Research Agenda.\u201d Environmental Health Perspectives 119
\n(9): 1218\u201326. doi:10.1289\/ehp.1103500.
\nMcConnell, Rob, Ernest Shen, Frank D. Gilliland, Michael Jerrett, Jennifer Wolch, Chih-Chieh
\nChang, Frederick Lurmann, and Kiros Berhane. 2015. \u201cA Longitudinal Cohort Study of Body
\nMass Index and Childhood Exposure to Secondhand Tobacco Smoke and Air Pollution: The
\nSouthern California Children\u2019s Health Study.\u201d Environmental Health Perspectives 123 (4): 360\u2013
\n66. doi:10.1289\/ehp.1307031.
\nMilton, B., P. A. Cook, L. Dugdill, L. Porcellato, J. Springett, and S. E. Woods. 2004. \u201cWhy Do
\nPrimary School Children Smoke? A Longitudinal Analysis of Predictors of Smoking Uptake
\nduring Pre-Adolescence.\u201d Public Health 118 (4): 247\u201355. doi:10.1016\/j.puhe.2003.10.006.
\nMoore, Graham F., Jo C. Holliday, and Laurence A. R. Moore. 2011. \u201cSocioeconomic Patterning in
\nChanges in Child Exposure to Secondhand Smoke After Implementation of Smoke-Free
\nLegislation in Wales.\u201d Nicotine & Tobacco Research, May, ntr093. doi:10.1093\/ntr\/ntr093.
\nMoore, Graham F., Currie D, Gilmore G, Jo C..Holliday , Lawrence A. R. Moore 2012.
\nSocioeconomic inequalities in childhood exposure to secondhand smoke before and after smoke-
\nfree legislation in three UK countries.. J Public Health (Oxf). 34(4):599-608. doi:
\n10.1093\/pubmed\/fds025. Epub 2012 Mar 23.
\nMoore, Graham F., Lawrence A. R.Moore, Hanna J. Littlecot, Nilufar Ahmed , Sophia Lewis ,
\nGillian Sulley, Elen Jones, and Jo Holliday 2015. Prevalence of smoking restrictions and child
\nexposure to secondhand smoke in cars and homes: a repeated cross-sectional survey of children
\naged 10-11 years in Wales. BMJ Open. 30;5(1):e006914. doi: 10.1136\/bmjopen-2014-006914.
\nMuller, T. 2007. \u201cBreaking the Cycle of Children\u2019s Exposure to Tobacco Smoke.,\u201d xii + 62 pp.
\n46
\nNiederdeppe Jeff, Matthew C. Farrelly, and M. Lyndon Haviland. 2004. \u201cConfirming \u2018truth\u2019: More
\nEvidence of a Successful Tobacco Countermarketing Campaign in Florida.\u201d American Journal of
\nPublic Health 94 (2): 255\u201357. doi:10.2105\/AJPH.94.2.255.
\nMurray Rachel L, John Britton and Jo Leonardi-Bee. 2012. Second hand smoke exposure and the risk
\nof invasive meningococcal disease in children: systematic review and meta-analysis. BMC
\nPublic Health. 12:1062. DOI: 10.1186\/1471-2458-12-1062
\n\u00d6berg, Mattias, Maritta S Jaakkola, Alistair Woodward, Armando Peruga, and Annette Pr\u00fcss-Ust\u00fcn.
\n2011. \u201cWorldwide Burden of Disease from Exposure to Second-hand Smoke: a Retrospective
\nAnalysis of Data from 192 Countries.\u201d The Lancet 377 (9760): 139\u2013146. doi:10.1016\/S0140-
\n6736(10)61388-8.
\nOffice of the Surgeon General. 2013. \u201cThe Health Consequences of Involuntary Exposure to Tobacco
\nSmoke: A Report of the Surgeon General.\u201d Accessed April 1.
\nhttp:\/\/www.surgeongeneral.gov\/library\/reports\/secondhandsmoke\/index.html.
\nOlasky, Sheera Joy, David Levy, and Andrew Moran. \u201cSecond Hand Smoke and Cardiovascular
\nDisease in Low and Middle Income Countries: A Case for Action.\u201d Global Heart 7, no. 2 (July 1,
\n2012): 151\u2013160.e5. doi:10.1016\/j.gheart.2012.05.002.
\nPadr\u00f3n, Alicia, I\u00f1aki Gal\u00e1n, Esther Garc\u00eda-Esquinas, Esteve Fern\u00e1ndez, Montse Ballb\u00e8, and Fernando
\nRodr\u00edguez-Artalejo. 2015. \u201cExposure to Secondhand Smoke in the Home and Mental Health in
\nChildren: A Population-Based Study.\u201d Tobacco Control, March, tobaccocontrol \u2013 2014\u2013052077.
\ndoi:10.1136\/tobaccocontrol-2014-052077.
\nPhillips, Richard, Amanda Amos, Deborah Ritchie, Sarah Cunningham-Burley, and Claudia Martin.
\n2007. \u201cSmoking in the Home After the Smoke-free Legislation in Scotland: Qualitative Study.\u201d
\nBMJ (Clinical Research Ed.) 335 (7619) (September 15): 553.
\ndoi:10.1136\/bmj.39301.497593.55.
\nPirkle, James L., John T. Bernert, Samuel P. Caudill, Connie S. Sosnoff, and Terry F. Pechacek. 2006.
\n\u201cTrends in the Exposure of Nonsmokers in the U.S. Population to Secondhand Smoke: 1988-
\n2002.\u201d Environmental Health Perspectives 114 (6) (June): 853\u2013858. doi:10.1289\/ehp.8850.
\nPriest, Naomi, Rob Roseby, Elizabeth Waters, Adam Polnay, Rona Campbell, Nick Spencer, Premila
\nWebster, and Grace Ferguson-Thorne. 2008. \u201cFamily and Carer Smoking Control Programmes
\nfor Reducing Children\u2019s Exposure to Environmental Tobacco Smoke.\u201d Cochrane Database of
\nSystematic Reviews (Online) (4): CD001746. doi:10.1002\/14651858.CD001746.pub2.
\nProtano, Carmela, and Matteo Vitali. 2011. \u201cThe New Danger of Thirdhand Smoke: Why Passive
\nSmoking Does Not Stop at Secondhand Smoke.\u201d Environmental Health Perspectives 119 (10):
\na422. doi:10.1289\/ehp.1103956.
\nRao, Uma, Constance L Hammen, Edythe D London, and Russell E Poland. 2009. \u201cContribution of
\nHypothalamic-pituitary-adrenal Activity and Environmental Stress to Vulnerability for Smoking
\nin Adolescents.\u201d Neuropsychopharmacology: Official Publication of the American College of
\nNeuropsychopharmacology 34 (13) (December): 2721\u20132732. doi:10.1038\/npp.2009.112.
\nReda, Ayalu A, Daniel Kotz, Silvia M A A Evers, and Constant Paul van Schayck. 2012. \u201cHealthcare
\nFinancing Systems for Increasing the Use of Tobacco Dependence Treatment.\u201d In Cochrane
\nDatabase of Systematic Reviews, edited by The Cochrane Collaboration and Constant Paul van
\nSchayck. Chichester, UK: John Wiley & Sons, Ltd.
\nhttps:\/\/www.pubmedcentral.nih.gov\/pubmedhealth\/PMH0012686\/.
\nRedmon, Pamela, Lincoln C Chen, Jacob L Wood, Shuyang Li, and Jeffrey P Koplan. \u201cChallenges for
\nPhilanthropy and Tobacco Control in China (1986-2012).\u201d Tobacco Control 22, no. Suppl 2
\n(September 2013): ii4\u2013ii8. doi:10.1136\/tobaccocontrol-2012-050924.
\n47
\nRichardson, Amanda Kalaydjian, Molly Green, Haijun Xiao, Natasha Sokol, and Donna Vallone.
\n2010. \u201cEvidence for Truth\u00ae: The Young Adult Response to a Youth-Focused Anti-Smoking
\nMedia Campaign.\u201d American Journal of Preventive Medicine 39 (6): 500\u2013506.
\ndoi:10.1016\/j.amepre.2010.08.007.
\nRigotti Nancy A. e-Cigarette use and subsequent tobacco use by adolescents: new evidence about a
\npotential risk of e-cigarettes. JAMA. 2015;314(7):673-674. (editorial)
\nRitchie, Deborah, Amanda Amos, Richard Phillips, Sarah Cunningham-Burley, and Claudia Martin.
\n2009. \u201cAction to Achieve Smoke-free Homes- an Exploration of Experts\u2019 Views.\u201d BMC Public
\nHealth 9 (1) (April 22): 112. doi:10.1186\/1471-2458-9-112.
\nRoudik, Peter. 2013. \u201cGlobal Legal Monitor: Latvia: Smoking Parents Will Be Prosecuted | Global
\nLegal Monitor | Law Library of Congress | Library of Congress.\u201d Web page. June 5.
\nhttp:\/\/www.loc.gov\/lawweb\/servlet\/lloc_news?disp3_l205403608_text.
\nRubenstein, David, JolyonJesty, and Danny Bluestein. 2004. \u201cDifferences Between Mainstream and
\nSidestream Cigarette Smoke Extracts and Nicotine in the Activation of Platelets Under Static and
\nFlow Conditions.\u201d Circulation 109 (1) (January 6): 78\u201383.
\ndoi:10.1161\/01.CIR.0000108395.12766.25.
\nSargent, R. P. 2004. \u201cReduced Incidence of Admissions for Myocardial Infarction Associated with
\nPublic Smoking Ban: Before and After Study.\u201d BMJ 328 (7446) (April 24): 977\u2013980.
\ndoi:10.1136\/bmj.38055.715683.55.
\nSebrie, Ernesto M, and Stanton A Glantz. \u201cLocal Smoke-Free Policy Development in Santa Fe,
\nArgentina.\u201d Tobacco Control 19, no. 2 (April 2010): 110\u201316. doi:10.1136\/tc.2009.030197.
\nSeo, Dong-Chul, and Mohammad R Torabi. 2007. \u201cReduced Admissions for Acute Myocardial
\nInfarction Associated with a Public Smoking Ban: Matched Controlled Study.\u201d Journal of Drug
\nEducation 37 (3): 217\u2013226.
\nSingh, Rana J., and Pranay G. Lal. 2011. \u201cSecond-Hand Smoke: A Neglected Public Health
\nChallenge.\u201d Indian Journal of Public Health 55 (3): 192\u201398.
\nSinha, D N, S Rinchen, K M Palipudi, Nang Naing Naing Shein, P de Silva, B B Khadka, M Pednekar,
\net al. 2012. \u201cTobacco Use, Exposure to Second-Hand Smoke, and Cessation Training among the
\nThird-Year Medical and Dental Students in Selected Member States of South-East Asia Region:
\nA Trend Analysis on Data from the Global Health Professions Student Survey, 2005-2011.\u201d
\nIndian Journal of Cancer 49 (4): 379\u201386. doi:10.4103\/0019-509X.107743.
\nSly, David F., Ed Trapido, and Sarah Ray. 2002. \u201cEvidence of the Dose Effects of an Antitobacco
\nCounteradvertising Campaign.\u201d Preventive Medicine 35 (5): 511\u201318.
\ndoi:10.1006\/pmed.2002.1100.
\nStead, Lindsay F, and Tim Lancaster. 2012. \u201cCombined Pharmacotherapy and Behavioural
\nInterventions for Smoking Cessation.\u201d In Cochrane Database of Systematic Reviews, edited by
\nThe Cochrane Collaboration and Lindsay F Stead. Chichester, UK: John Wiley & Sons, Ltd.
\nhttp:\/\/www.ncbi.nlm.nih.gov\/pubmedhealth\/PMH0049377\/.
\nStillman, Frances A., Annette M. David, Naseeb Kibria, and Hai Thi Phan. \u201cBuilding Capacity for
\nImplementation of the Framework Convention for Tobacco Control in Vietnam: Lessons for
\nDeveloping Countries.\u201d Health Promotion International, February 14, 2013, dat005.
\ndoi:10.1093\/heapro\/dat005.
\nSureda, Xisca, Esteve Fernandez, Maria J. Lopez, and Manel Nebot. \u201cSecondhand Tobacco Smoke
\nExposure in Open and Semi-Open Settings: A Systematic Review.\u201d Environmental Health
\nPerspectives 121, no. 7 (July 2013): 766\u201373. doi:10.1289\/ehp.1205806.
\n48
\nSweda, Edward L., Mark A. Gottlieb, and Raymond C. Porfiri. 1998. \u201cProtecting Children from
\nExposure to Environmental Tobacco Smoke.\u201d Tobacco Control 7 (1): 1\u20132. doi:10.1136\/tc.7.1.1.
\nTanski, Susanne E., and Karen M. Wilson. 2012. \u201cChildren and Secondhand Smoke: Clear Evidence
\nfor Action.\u201d Pediatrics 129 (1) (January 1): 170\u2013171. doi:10.1542\/peds.2011-3190.
\nThomas, Roger E, Julie McLellan, and Rafael Perera. 2013. \u201cSchool-based Programmes for
\nPreventing Smoking.\u201d In Cochrane Database of Systematic Reviews, edited by The Cochrane
\nCollaboration and Roger E Thomas. Chichester, UK: John Wiley & Sons, Ltd.
\nhttps:\/\/www.ncbi.nlm.nih.gov\/pubmedhealth\/PMH0010967\/.
\nThomson, George, Nick Wilson, and Richard Edwards. \u201cAt the Frontier of Tobacco Control: A Brief
\nReview of Public Attitudes toward Smoke-Free Outdoor Places.\u201d Nicotine & Tobacco Research:
\nOfficial Journal of the Society for Research on Nicotine and Tobacco 11, no. 6 (June 2009):
\n584\u201390. doi:10.1093\/ntr\/ntp046.
\nTinuoye, Olaitan, Jill P Pell, and Daniel F Mackay. 2013. \u201cMeta-analysis of the Association Between
\nSecondhand Smoke Exposure and Physician-Diagnosed Childhood Asthma.\u201d Nicotine &
\nTobacco Research: Official Journal of the Society for Research on Nicotine and Tobacco (March
\n28). doi:10.1093\/ntr\/ntt033.
\nUeta I, Saito Y, Teraoka K, Miura T, Jinno K 2010. Determination of volatile organic compounds for
\na systematic evaluation of third-hand smoking. Anal Sci. 26(5):569-74
\nUS Department of Health and Human Services, Administration on Children, Youth and Families.
\n2009. \u201cChild Maltreatment 2007.\u201d Washington, DC.
\nhttp:\/\/archive.acf.hhs.gov\/programs\/cb\/pubs\/cm07\/cm07.pdf.
\nVit\u00f3ria, Paulo D., Jos\u00e9 Cunha Machado, Ana Carolina Ara\u00fajo, Sofia B. Ravara, Catarina Samorinha,
\nHenedina Antunes, Manuel Rosas, Elisardo Beco\u00f1a, and Jos\u00e9 Precioso. 2015. \u201cChildren\u2019s
\nExposure to Second Hand Smoke at Home: A Cross-Sectional Study in Portugal.\u201d Revista
\nPortuguesa de Pneumologia (English Edition). Accessed April 16.
\ndoi:10.1016\/j.rppnen.2014.09.003.
\nVoorhees, Carolyn C., Cong Ye, Olivia Carter-Pokras, Laura MacPherson, Mariano Kanamori,
\nGuangyu Zhang, Lu Chen, and Robert Fiedler. 2011. \u201cPeers, Tobacco Advertising, and
\nSecondhand Smoke Exposure Influences Smoking Initiation in Diverse Adolescents.\u201d American
\nJournal of Health Promotion 25 (3) (January): e1\u2013e11. doi:10.4278\/ajhp.090604-QUAN-180.
\nWan, Xia, Frances Stillman, Huilin Liu, Mark Spires, Zhen Dai, Stephen Tamplin, Daiwei Hu,
\nJonathan M Samet, and Gonghuan Yang. \u201cDevelopment of Policy Performance Indicators to
\nAssess the Implementation of Protection from Exposure to Secondhand Smoke in China.\u201d
\nTobacco Control 22, no. Suppl 2 (September 2013): ii9\u2013ii15. doi:10.1136\/tobaccocontrol-2012-
\n050890.
\nWang Zhen, Sara M May, Suvanee Charoenlap, Regan Pyle, Nancy L Ott, Khalid Mohammed, and
\nAvni Y Joshi 2015. Effects of secondhand smoke exposure on asthma morbidity and health care
\nutilization in children: a systematic review and meta-analysis. Ann Allergy Asthma Immunol.
\n115(5):396-401.e2.
\nWarner KE, and J. Mackay. 2006. The global tobacco disease pandemic: nature, causes, and cures.
\nGlob Public Health. 1(1):65-86.
\n\u201cWHO | Ratification.\u201d 2015. WHO. Accessed May 5. http:\/\/www.who.int\/fctc\/protocol\/ratification\/en\/.
\nWorld Health Organization. 2004. \u201cSecond-hand Smoke: Exposure by Region.\u201d
\nhttp:\/\/apps.who.int\/gho\/data\/view.main.34800.
\n49
\nWorld Health Organization. 2007. \u201cProtection from Exposure to Second-Hand Tobacco Smoke.\u201d
\nPolicy Recommendations. France.
\nhttp:\/\/www.who.int\/quantifying_ehimpacts\/publications\/shsarticle2010\/en\/.
\nWorld Health Organization. 2013a. \u201cWHO | 10 Facts on Second-hand Smoke.\u201d
\nhttp:\/\/www.who.int\/features\/factfiles\/tobacco\/tobacco_facts\/en\/index9.html.
\nWorld Health Organization. 2013b. \u201cWHO | Worldwide Burden of Disease from Exposure to Second-
\nhand Smoke.\u201d WHO. http:\/\/www.who.int\/quantifying_ehimpacts\/publications\/shsarticle2010\/en\/.
\nWorld Health Organization. 2008. \u201cWHO Report on the Global Tobacco Epidemic, 2008: The
\nMPOWER Package.\u201d
\nWorld Health Organization. 2009. \u201cWHO Report on the Global Tobacco Epidemic, 2009:
\nImplementing Smoke-free Environments.\u201d http:\/\/www.who.int\/tobacco\/mpower\/2009\/en\/.
\nWorld Health Organization. 2011. \u201cWHO Report on the Global Tobacco Epidemic, 2011: Warning
\nAbout the Dangers of Tobacco.\u201d http:\/\/www.who.int\/tobacco\/global_report\/2011\/en\/index.html.
\nWorld Medical Association. 1997. \u201cWMA Statement on Health Hazards of Tobacco Products and
\nTobacco-Derived Products.\u201d January 11. https:\/\/www.wma.net\/en\/30publications\/10policies\/h4\/.
\nWorld Medical Association. 2012. \u201cWMA Statement on Electronic Cigarettes and Other Electronic
\nNicotine Delivery Systems.\u201d October 13. https:\/\/www.wma.net\/en\/30publications\/10policies\/e19\/.
\nZhang, Liying, Jason Hsia, Xiaoming Tu, Yang Xia, Lihong Zhang, Zhenqiang Bi, Hongyan Liu,
\nXiaoming Li, and Bonita Stanton. 2015. \u201cExposure to Secondhand Tobacco Smoke and
\nInterventions Among Pregnant Women in China: A Systematic Review.\u201d Preventing Chronic
\nDisease 12 (March). doi:10.5888\/pcd12.140377.<\/p>\n"},"caption":{"rendered":"

SHS-WMA-rev2 1 Health Effects of Tobacco Secondhand Smoke: focus on Children Health A Review of the Evidence and Self-Assessment Updated July 20, 2016 [First Published November 30, 2015] School of Policy Government and International Affairs George Mason University Arlington, Virginia, USA 2 A Continuing Medical Education Activity Joint Sponsorship Statement: This activity is jointly sponsored […]<\/p>\n"},"alt_text":"","media_type":"file","mime_type":"application\/pdf","media_details":{},"post":701,"source_url":"https:\/\/www.wma.net\/wp-content\/uploads\/2016\/11\/SHS-WMA-rev2.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/media\/5837"}],"collection":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/media"}],"about":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/types\/attachment"}],"author":[{"embeddable":true,"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/comments?post=5837"}]}}