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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
A Continuing Medical Education Activity
Joint Sponsorship Statement:
This activity is jointly sponsored by the Center for the Study of International Medical Policies
and Practices (CSIMPP), School of Policy, Government and International Affairs [SPGIA],
George Mason University and MedEDirect, LTD., in collaboration with the World Medical
Association (WMA).
Activity Planners:
Arnauld Nicogossian, MD, FACPM, FACP
Distinguished Research Professor
Center for the Study of International Medical Policies and Practices
Arlington, VA
Tinapa Himathongkam, MPP
Graduate Research Assistant
Center for the Study of International Medical Policies and Practices
Arlington, VA
Otmar Kloiber, MD
Secretary General
World Medical Association
Thomas Zimmerman, PhD
Executive Director, MedEDdirect
Las Vegas Nevada
Yinyue Hu, MA
Graduate Research Assistant
Center for the Study of International Medical Policies and Practices
Arlington, VA
Reviewers and Advisors
Lee Fritschler, PhD
Professor Emeritus
Arlington, VA
Salim Habayeb, MD
Director, Health and Medical Policy Program
Arlington, VA
Disclosure of Conflicts of Interest:
All individuals participating in the development and implementation of activities sponsored by
MedEDirect have disclosed real or perceived conflicts of interest related to this activity.
CSIMPP did not receive support from any funding sources for this activity. The authors and
reviewers have no competing interests.
Accreditation and Credit Designation:
This activity has been planned and implemented by MedEDirect and the Center for the Study of
International Medical Policies and Practices (CSIMPP), School of Policy, Government and
International Affairs [SPGIA], George Mason University, and is accredited by the American
Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education
(ACPE), and the Accreditation Council for Continuing Medical Education (ACCME), to provide
continuing education for the healthcare team.
Please access MedEDirect, Inc at www. to register for CME credits, respond to
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Needs Statement:
Smoking continues to be a major global health problem by exposing many individuals to second
hand, and also third hand smoke from tobacco by-products. Tobacco consumption threatens
population health in many developing countries. Infant and children, are the most vulnerable
population, especially in residential or other living environments [such as cars, day care centers
and schools]
Learning Objectives:
At the conclusion of this activity, participants will:
1. Understand the strength of the evidence supporting the health effects of tobacco second hand
smoke (TSHS) in children, and
2. Review the efficacy of interventions, including policies and legislations, designed to minimize
TSHS exposures of infants and children.
OVERVIEW ……………………………………………………………………………………………………………………………….6
SECTION ONE: Global Epidemiology of Secondhand Smoke Health Risks……………………………………….7
Defining the Problem………………………………………………………………………………………………………………..7
Magnitude of the Problem …………………………………………………………………………………………………………7
Measuring the level of Tobacco SHS Exposures…………………………………………………………………………..9
SECTION TWO: Health Effects from Secondhand Smoke ……………………………………………………………..10
Health Effects of SHS exposure………………………………………………………………………………………………..10
SHS and Health Risks in Children…………………………………………………………………………………………….11
Third Hand Tobacco Smoke Exposures (THS) …………………………………………………………………………..12
SECTION THREE: Control and Prevention of Secondhand Smoke Exposure……………………………………14
Smoking Cessation Campaigns…………………………………………………………………………………………………14
Smoking Bans………………………………………………………………………………………………………………………..15
Packaging and Labeling…………………………………………………………………………………………………………..18
Availability and Limitations of Tobacco Sales……………………………………………………………………………18
Legal Precedents on SHS and Children (US) ……………………………………………………………………………..19
SECTION FOUR: Effectiveness of Interventions…………………………………………………………………………..20
Summary of Policies and Interventions (see also Appendix B)……………………………………………………..22
SECTION FIVE: Conclusions……………………………………………………………………………………………………..23
Points to Remember………………………………………………………………………………………………………………..24
Appendix A: Summary Table of Evidence from Epidemiological Studies …………………………………………26
Appendix B: Summary Table of Evidence from Interventional Studies …………………………………………….32
Appendix C: Health Effect of SHS in Adults …………………………………………………………………………………35
Appendix D: Health Effects of SHS in Infants and Children ……………………………………………………………36
Appendix E: WMA 2011 Statement on Health Hazards of Tobacco Products and Tobacco-Derived
Products ……………………………………………………………………………………………………………………………………37
Tobacco secondhand smoke [SHS] is a major health hazard,
especially for infants and children. The Centers for Disease
Control and Prevention (CDC) reports that yearly, six million
deaths worldwide are attributable to the use of tobacco
products (CDC 2015). Rising tobacco consumption is also
responsible for increasing exposures to SHS where more than
50 carcinogens and 4,000 potentially harmful chemicals and
toxins are present. These compounds are implicated in lung
cancer, heart disease, and other illnesses among nonsmokers
(WHO 2011).
Policy makers and health advocates continue to express
concerns over the health care and societal economic impacts
from chronic health effects of SHS on nonsmokers,
particularly pregnant women and young children. It is
estimated that 50 million pregnant women and 700 million
children are exposed to SHS on a daily basis (Callinan et al.
2010). According to the World Health Organization (WHO)
Framework Convention on Tobacco Control (FCTC), there is
“no safe level of exposure to tobacco smoke” with
approximately thirty-one percent of all deaths from SHS
involving children (WHO 2013b). WHO argues that the
reduction in tobacco use could significantly contribute to
United Nations Millennium Development Goals by directing
scarce resources to more productive programs such as
education, health literacy and maternal and child health (WHO 2004).
The SHS exposure challenge, especially faced by emerging market economy countries, can be
summarized as follows:
 SHS disproportionately affects vulnerable populations including women and children.
 About 40% of children are regularly exposed to SHS at home. These children are 1.5-2
times more likely to become smokers (WHO 2013a).
 Approximately 5% of global burden of disease is attributable to SHS, a slightly higher
number than the burden from direct tobacco smoking of 4% (Singh and al. 2011).
 10% of tobacco-use-related economic costs are from SHS: provision of care for related
illnesses and indirect costs such as loss of productivity (WHO 2013a).
WHO Statements
 Tobacco kills up to half
of its users. Over 6
million people die from
tobacco each year.
 More than 5 million of
those deaths are the result
of direct tobacco use
while more than 600 000
are the result of non-
smokers being exposed to
second-hand smoke.
 Nearly 80% of the
world’s 1 billion smokers
live in low- and middle-
income countries.
[Source: WHO Tobacco
Fact sheet N°339.
Updated July 2015]
SECTION ONE: Global Epidemiology of Secondhand Smoke Health Risks
Learning Objective: To understand the health risks from secondhand smoke
Defining the Problem
Secondhand smoke (SHS) has been defined as “the combination of smoke emitted from the
burning end of a cigarette or other tobacco products
and smoke exhaled by the smoker” (WHO 2007). SHS
is also known as environmental tobacco smoke, passive
smoking, and involuntary smoking.
Two types of SHS are identified
1.) Mainstream smoke – the smoke that is exhaled
from the smoker’s lungs
2.) Sidestream smoke – the smoke from the burning
end of a tobacco product
Almost 15% of SHS exposure is mainstream and 85% is
sidestream though the composition of toxins in both
sources is similar (Callinan et al. 2010). Most SHS
exposure occurs in homes, private vehicles, and
workplaces but also in such public places as restaurants,
bars, and casinos. The International Agency for
Research on Cancer declared SHS to be carcinogenic
risks to humans (IARC 2004).
Several categories of SHS exposure are described as it
refers to one or both parents or another person in an
enclosed space (Oberg et al. 2011). National and
international organizations, such as the World Health
Organization (WHO), the International Agency for
Research on Cancer (IARC), the World Medical
Association (WMA), the United States Surgeon General
(DHHS), and the U.S. Environmental Protection Agency (EPA) have developed a consensus on
the negative health effects of SHS exposure on nonsmoking adults and children.
Magnitude of the Problem
According to the World Health Organization Framework Convention on Tobacco Control
(WHO FCTC), there is “no safe level of exposure to tobacco smoke”. Worldwide, SHS is
responsible for an estimated 603,000 premature deaths and the loss of 10.9 million Disability-
Adjusted Life Years (DALYs) (Oberg et al 2011). Thirty-one percent of the premature deaths
are children (WHO 2013a). In China, the latest estimates suggest that between 38.9% and 75.1%
of pregnant women are exposed to SHS, most often by their spouse (Zhang et al. 2015). Table 1
shows the percentage of children under 15 years of age, and adult men and women who are
exposed to SHS by world regions.
World Health
Organization (WHO)
Report on the Global
Tobacco Epidemic (2009)
states that:
“Second-hand smoke
accounts for one in 10
tobacco-related deaths.
Creating 100% smoke-free
environments is the only
way to protect people from
the harmful effects of
second-hand tobacco
Table 1: Estimates of the Percent Population by Age Groups Exposed to SHS
[WHO Regions]
WHO Regions Percentage of
Children under
15 years exposed
to SHS
Percentage of
men (ages 15 and
over) exposed to
Percentage of
women (ages 15
and over)
exposed to SHS
Global 40 33 35
All high income (WHO income) 39 32 31
Low- and Middle-income
Africa 12 6 10
Americas 28 15 22
Eastern Mediterranean 35 22 33
Europe 58 60 61
Southeast Asia 39 25 27
Western Pacific 68 53 51
Source: adapted from the World Health Organization (2004)
Women and children are disproportionate victims of SHS exposure. Approximately 30% of men
smoke, compared to 13% women and 12% of youth ages 13-15 (Tobacco Atlas 2009). It has
been reported that as many as 40% of children and 35% of nonsmoking women were exposed to
SHS in 2004 (Oberg et al. 2011). It is likely that women and children who are exposed to SHS
have male family members who smoke in the homes or in private vehicles. In low-income
Southeast Asian countries, women are at least 50% more likely to become victims of SHS
exposure than are men (Singh and Lal 2011). Children with smoking parents are also
significantly more likely to be exposed to SHS (Vitoria et al. 2015).
While smoking bans in workplaces in high-income countries are commonplace, occupational
SHS exposure remains a critical issue in many parts of the world. According to the International
Labor Organization [ILO 2015], an estimated 168 million children are in the global workforce.
Many of these young workers are either smokers or at risk of SHS exposure. Figure 1 shows the
percentage of non-smoking adults who are exposed to SHS in the workplace for countries that
completed the Global Adult Tobacco Survey (GATS)1
between 2008 and 2010.
Worldwide health professionals continue to smoke and will more likely not encourage patients to
stop smoking. A study of medical and dental students’ habits in Southeast Asia region showed no
significant reduction in smoking trends between 2005-2006 and 2009-2011. There was a
significant increase in tobacco use among dental students during the same period. The findings
also suggest no significant decline in SHS exposure at home and in public places in most
The Global Adult Tobacco Survey (GATS) is a nationally representative household survey launched by the WHO in
2007 as part of the Global Tobacco Surveillance System (GTSS). Participating countries are mainly from low- and
middle-income countries where the majority of the world’s smokers reside.
countries in this region. Of concern is the ability to effectively participate in and contribute to the
smoking cessation campaigns by these professionals (Sinha et al. 2012).
Often neglected from the discussion of vulnerable populations to the exposure of SHS are people
with disabilities. Those with disabilities are more likely to be smokers than abled-body
population by as much as 50% (Armour et al. 2007). They are more likely to be older, non-
Hispanic white, female, and have lower levels of education. They are also more likely to report
having been exposed to SHS (Hall et al. 2013).
Figure 1: The Percentage of Non-Smoking Adults who are Exposed to SHS in the
Source: Adapted from WHO Report on the Global Tobacco Epidemic, 2011
Measuring the level of Tobacco SHS Exposures
Evidence documenting SHS exposures is obtained through survey questionnaires, direct
observation of smoking behavior, measurement of tobacco residues in the air, and of cotinine
level in human urine [Source: Johns Hopkins Bloomberg School of Public Health 2015] .
SECTION TWO: Health Effects from Secondhand Smoke
Learning Objective: To explore the impact of secondhand smoke exposure on health
Health Effects of SHS exposure
International studies repeatedly
demonstrate tobacco SHS exposure in
private settings to be harmful to
nonsmokers. In New Zealand, Edwards et
al. showed that air particulate levels in a
car with a person smoking inside when
windows are partially or wholly down were
as high as those found in a typical smoky
bar, and twice as high when the car
windows are closed (Edwards et al. 2006).
In the UK, a British Medical Association
(BMA) report provided a strong evidence
for SHS and exacerbation of childhood
illnesses such as asthma {Wang et al.
2015) and middle ear infections. Both
asthma and otitis media are correlated with
poor school attendance, scholastic
attainment, and increased hospital admissions (Muller 2007).
There is a strong link between active smoking and incidence of depression (Kassel et al. 2003),
and in recent years evidence has been obtained to suggest the association between SHS exposure
and mental illnesses, especially among adults. An analysis of the 2005-2006 National Health and
Nutrition Examination Survey (NHANES) found association between SHS exposure and
depressive symptoms even after adjusting for potential confounders including age, race/ethnicity,
gender, education, alcohol consumption, and medical comorbidities (Bandiera et al. 2010). A 6-
year prospective study of 5,560 nonsmoking adults found association between SHS exposure and
psychiatric hospital admission (Hamer et al. 2010). These findings could also be indicative of
potential threat to children mental health, and deserve further evaluation.
The effects of SHS exposure in pregnant women on fetal development has been the subject of
many studies. A meta-analysis of 19 studies found that women who are exposed to tobacco SHS
during pregnancy are 23% more likely to experience stillbirth and their babies are 13% more
likely to be born with some form of congenital malformations (Leonardi-Bee et al. 2011).
Reminder: SHS Health Effects in Adults:
evidence is good and supportive of the increased
risk of association with:
 Coronary heart disease (Japuntich et al.
 Stroke (Olasky et al. 2012)
 Dementia (Barnes et al. 2010).
 Breast cancer (WHO 2007)
 Chronic respiratory illnesses (WHO 2007)
Decline in pulmonary function due to SHS
exposure has been reported (WHO 2007)
SHS and Health Risks in Children
SHS is particularly worrisome for infants and children as
they are
1. Still developing mentally and physically,
2. Less aware of the consequences,
3. Less in control of their environments, and
4. At greater risk of morbidity and mortality than
adults. WHO estimated 700 million children to be
victims of SHS by the 1.2 billion adults who
smoke annually (Ash Research Report 2011).
In the United States, more than half (almost 60%) of
children ages 3-11 years are exposed to SHS. An analysis
of multiple waves of NHANES showed that children had
significantly higher cotinine concentrations than adults
(Pirkle et al. 2006).
The 2006 Surgeon General Report found causal evidence
for tobacco SHS effects on infants and children’s health
such as Sudden Infant Death Syndrome (SIDS), low birth
weight, lower respiratory illnesses, lung growth and
pulmonary function2
. Children may be more prone to SHS-related respiratory illnesses due to
their smaller airways and higher demand for oxygen and because their immune systems have yet
to fully develop (Kabir et al. 2009). There is fair evidence that in-home SHS exposure of
premature African American infants is associated with poorer growth of head circumference and
development of otitis media (Brooks et al. 2011). Recent studies have started to detect
association between SHS and gross motor development (Evlampidou et al. 2015) and attention
deficit hyperactivity disorder (Padron et al. 2015).
It is suspected that SHS induced vascular changes in early childhood can trigger the onset of
cardiovascular disease (CVD) in adulthood, caused by exposures to parental tobacco use (Tanski
and Wilson 2012).
The link between SHS exposure and mood disorders in children is unclear. In animal
experiments, nicotine exposure in adolescence appears to induce depression-like state in
adulthood (Iniguez et al. 2008). SHS exposure may be a direct cause of psychiatric disorders. In
humans, a longitudinal study of 151 adolescents with 5 year follow-up found that tobacco
smoking elevates the risk of depressive episodes (Rao et al. 2009).
For a full list of the findings from the 2006 US Surgeon General report regarding health effects of SHS, see
Appendix C and Appendix D
SHS Health Effects in Infants and
Children: evidence is fair to good
1. Sudden Infant Death Syndrome.
2. Low Birth Weight.
3. Pulmonary and Cardiovascular
developmental risks.
4. Increased incidence and severity
of asthma (Wang et al. 2015)
5. Susceptibility to respiratory
6. Otitis media.
7. Susceptibility to
infections (Murray et al. 2012)
8. Mood changes and depression.
9. Lifelong risk of obesity
Finally, children exposed to smokers are also more likely to become smokers themselves.
(Milton et al. 2004). Exposure to SHS is also independently related to higher likelihood of
smoking initiation for this population regardless of whether or not children live with smokers.
Other factors influencing smoking uptake include age, exposure to tobacco products, having
friends that smoke, being offered tobacco products by peers, risk perceptions3
, and use of other
tobacco products such as chewing tobacco and cigars (Voorhees et al. 2011). In pre-adolescents,
exposure to SHS in cars is significantly associated with early smoking uptake (Glover et al.
2011). Recent studies are suggestive of an association between exposure to SHS and obesity
(McConnell et al. 2015).
Third Hand Tobacco Smoke Exposures (THS)
Smoking and SHS are harmful to the health of both smokers and nonsmokers. Recently,
evidence on health effects from the remaining tobacco residues deposited on surfaces, smokers’
clothes and hair, began to accumulate. Nonsmokers who are exposed to such environments are
considered to be victims of third-hand tobacco smoking (THS) (Escoffery et al. 2013).
There is evidence that trace levels of nicotine remains in the air, dust, and surfaces of residential
settings which can be harmful especially to children. Nonsmokers who reside in homes
previously occupied by smokers have demonstrated elevated levels of nicotine on hands and in
urine compared to those residing in homes where no one has smoked (Matt et al. 2011).
Furthermore, non-smoking rooms in hotels with partial smoking bans also show elevated level of
surface nicotine, compared with hotels with complete smoking bans (Matt et al. 2011).
Potential in-vitro THS harm to human cells DNA has been reported (Hang et al. 2013). Studies
in rodents found that THS exposure increases the likelihood of alterations in liver metabolism
that carry implications for the development of coronary thrombosis, stroke, or type 2 diabetes
(Karim et al. 2015). Children who play on exposed floor and put contaminated items in their
mouth are especially prone to the danger of THS (Hang et al. 2013, Ferrante et al. 2013). In light
of this evidence, it has been suggested that the term “passive smoke” can no longer be an
equivalent of SHS as it should also include THS.
Studies on THS thus far have focused primarily on nicotine residues as an indicator of health
risks. The role of particulate in the smoke such as polycyclic aromatic hydrocarbons (PAHs),
from incomplete combustion of carbon-containing materials, is suspected to be carcinogenic
(Fleming et al. 2012).
Youth in the study were asked about their perceptions on 4 items 1) whether smoking presents any risk, 2) whether
smoking presents short-term risk, 3) whether nicotine is addictive, and 4) whether smoking light cigarettes is safer
(Vorhees et al. 2011).
SECTION THREE: Control and Prevention of Secondhand Smoke Exposure
Learning objective: To explore SHS exposure control and interventions.
Tobacco control efforts have been seen in the US for
over 50 years. Such efforts have resulted in a substantial
decrease in tobacco use from 42% in 1965 to 18% today
but the issue remains high on the health agenda for the
century (Brennan and Schroeder 2014). The US
2010 Affordable Care Act (ACA) expands access to and
insurance coverage of most smoking cessation services.
The ACA also allows employers to charge smokers a
higher percentage of their insurance premiums. In
addition, there has been a trend against hiring smokers.
The most important effect from these initiatives is the
hope there will be a decrease in smoking uptake among
young people (Ibid). This section describes some of the
ways governments and organizations around the world
are using to control the use of tobacco.
Smoking Cessation Campaigns
As part of the Master Settlement Agreement (MSA)
between U.S. states and tobacco companies, the
American Legacy Foundation was created to fund the
“Truth” mass media campaign to prevent teen smoking
and encourage smokers to quit. Several studies have confirmed the social and cost effectiveness
of Truth ads since its launch in 2012 through the reduction in youth smoking prevalence and
tobacco-related healthcare costs (Ferelly et al. 2005, Ferrelly et al. 2009, Niederdeppe et al. 2004,
Sly et al. 2002, Holtgrave et al. 2009, and Richardson et al. 2010). Similar media campaigns
have been introduced following such success, including the Tips From Former Smokers (Tips)
and Finish It campaigns in 2012 and 2014 respectively.
At the international level, efforts are under way to encourage smoking cessation. The WHO
Framework Convention on Tobacco Control (FCTC) comprises 173 countries, covering 87% of
the world’s population, pledging strong actions against tobacco smoking (WHO 2012). Tobacco
control does not impede the economic development such as causing job losses and decreasing
government revenue (World Bank 2011). Instead, tobacco control measures are effective and
efficient in reducing its consumption (Esson and Leeder 2004). Progress continues to be made on
measures aimed at reducing the demand for tobacco, mostly in low- and middle- income
In 2008, WHO introduced MPOWER
measures, a package of six evidence-
based tobacco control measures, which
provide guidelines for country-level
implementation of effective demand-
side interventions to reduce tobacco
use. The six measures include
1. monitoring tobacco use and
prevention policies
2. protecting people from tobacco
3. offering help to quit tobacco use
4. warning about the dangers of
5. enforcing bans on tobacco
advertising, promotion and
sponsorship, and
6. raising taxes on tobacco
countries. In 2011, the WHO reported that 3.8 billion people were effectively covered by tobacco
control laws. The FCTC has been one of the most successful treaties in the history of the United
Nations (WHO 2011).
Smoking Bans
Public Spaces
In addition to reducing the demand for tobacco, the global public health community also aims to
protect the public from the hazards of SHS exposure by encouraging the implementation of
comprehensive smoke-free laws. Having separate smoking sections, smoking rooms, and better
ventilation systems do not protect people from SHS exposure. Creating a completely smoke-free
environment is the only proven way. Figure 2 shows the implementation percentage of five
types of smoking bans around the world. Article 8 of the FCTC mandates members to “protect
citizens from exposure to tobacco smoke in workplaces, public transport and indoor public
places,” (WHO 2007). Comprehensive smoke-free legislation has been implemented in many
countries in public places such as bars and restaurants. It has shown to be popular with the public,
not harmful to the economy, and beneficial to people’s health (WHO 2010). These restrictions
are supported and recommended by the Article 8.
Figure 2: Five Types of Smoking Bans in Public Places (% of Countries categorized by
WHO Regions)
Africa Americas Southeast Asia Europe E.
Western Pacific
Ban in Public Transportation
Ban in Restaurants
Ban in Schools
Ban in Healthcare Facilities
Ban in Offices
Source: WHO Report on the Global Tobacco Epidemic, 2013
In the United States, the CDC considers a state smoking ban to be comprehensive if it prohibits
smoking in privately-owned workplaces, restaurants, and bars (CDC 2011). Twenty six states
passed such legislation by the end of 2010. As of October 2, 2015, according to the American
Nonsmokers’ Rights Foundation, 81.9% of the U.S. population are protected by a smoking ban in
“workplaces, and/or restaurants, and/or bars, by
either a state, commonwealth, or local law”(ANR
Few developing countries have comprehensive
smoke-free legislation (Barnoya and Navas-Acien
2013). Where bans exists, nonetheless, evidence is
encouraging. Santa Fe, Argentina, in 2005, was the
first subnational jurisdiction in Latin America to
implement a comprehensive smoke-free policy. A
review of the process of approval and
implementation between 2005 and 2009 shows
success despite some opposition, setting an
example for other jurisdictions in Argentina as
well as in Mexico and Brazil (Sebrie and Glantz
2010). In 2009, Mexico City passed a similar
legislation (Crosbie et al. 2011).
As indoor smoking bans become increasingly
common, there has been a concern whether an
increase in outdoor smoking is subjecting others to
SHS. The FCTC was revised in 2007 to further
recommend that quasi-outdoor and certain outdoor
public places should be smoke-free. The guidelines
encourage countries to “adopt the most effective protection against exposure wherever the
evidence shows that hazard exists” (WHO 2009). Support for smoking bans in selected outdoor
settings such as terraces, patios, and building entrances of healthcare facilities and hotels where
children may be present is on the rise (Thomson et al. 2009). While critics have argued that such
bans violate individual rights with insufficient evidence of impact on health (Chapman 2008), a
review of 18 studies found that SHS levels in some outdoor areas may be significant, particularly
those that are semi-enclosed (Sureda et al. 2013).
Smoking bans in bars and
restaurants have been enacted
in Norway, New Zealand,
England, Scotland, Wales,
Northern Ireland, Italy,
Spain, Malta, and France.
Recently middle-income
countries have also enacted
smoke-free laws. Between
2008 and 2010, 16 countries
adopted comprehensive
smoke-free legislation which
means 31 countries around
the world now have taken
steps to provide the highest
level of protection against
SHS for their citizens (WHO
Private Spaces
With more countries adopting public smoking bans,
homes are becoming a predominant place for smoking.
Anti-smoking legislation for public places may also help
smokers who struggle to quit and encourage people to
create smoke-free environment in their homes and
private vehicles (WHO 2010). Consensus is lacking with
regard to whether smoking bans in public places
positively influence smoking bans in private spaces. On
the one hand, the International Agency for Research on
Cancer (IARC) reports that workers in smoke-free
environments are more likely to implement smoking
restrictions at home, and that home smoking restrictions
have greater influence on smoking behavior than those in
workplaces (IARC 2009). A study also found a reduction
in in-home smoking rates after the enforcement of anti-
smoking law in public spaces (Aslan et al. 2015). On the
other hand, a research conducted in Spain reveals that
smoking bans in public spaces have not reduced the
exposure of SHS in children in the home (Fernandez et al.
Unlike homes, cars represent private properties in the
public sphere. Laws governing seatbelt, child seat, and
mobile phone use are already in place to protect both the
public and occupants of the vehicles. With existing
evidence of harmfulness of SHS exposure on children,
similar measures should be considered regarding
smoking in the presence of children (Freeman et al.
2008). An increasing number of state and local
governments, in the United States and other
industrialized countries, enacted legislations to prohibit smoking in private vehicles when
children are present. Examples of U.S.A. jurisdictions that passed legislations are the states of
Louisiana (under age 13, August 2006), Maine (under age 18, January 2007), California (under
age 18, January 2008), Arkansas (under age 14, March 2011), and internationally counties of
Newfoundland, Canada (under age 16, May 2011), Victoria, Australia (under age 18, January
2010), South Africa (under age 12, September 2009) (GASP 2015).
The American Cancer
Society 2013:
“Making your home smoke-
free may be one of the most
important things you can do
for the health of your family.
Any family member can
develop health problems
related to SHS.
Children’s growing bodies
are especially sensitive to the
poisons in SHS. Asthma,
lung infections, and ear
infections are more common
in children who are around
smokers. Some of these
problems can be serious and
even life-threatening. Others
may seem like small
problems, but they add up
quickly — the expenses,
time for doctor visits,
medicines, lost school time,
and often lost work time for
the parent who must stay
home with a sick child.”
Despite a significant support, public compliance is still
problematic and difficult to enforce since it impinges on the
individual privacy and freedom of choice. Introduction of
preventive measures continue to be inadequate in the face of the
growing concerns over the health effects on children from SHS
exposure. A study in the United Kingdom found that 86% of
smoking parents believed that SHS exposure was harmful for
their children. However, less than 20% of these parents ban
smoking in their homes (Blackburn et al. 2003). Though smoking
in cars and homes is decreasing children, especially in the lower
socio-economic strata, continue to be exposed to SHS (Moore et
al. 2011, Moore et al. 2015).
Packaging and Labeling
As the tobacco industry faces stricter marketing restrictions by
governments around the world, many tobacco companies turn to
cigarette packaging as a main avenue for product advertisement.
Article 11 of the WHO FCTC addresses this issue. It sets
standards for packaging and labeling of tobacco products for
member states. This mandate reflects the emerging evidence
strongly supporting the effectiveness of displaying text and
pictorial warning labels. WHO has established a data base for
pictorial health warnings and messages. In addition, the WHO
provides guidelines and technical assistance for implementation
of Article 11 (WHO 2011)4
Availability and Limitations of Tobacco Sales
Usually, age determines the purchase ability of tobacco. However,
there are little restrictions on where cigarettes can be sold. The
WHO FCTC does not provide guidelines or suggest tobacco
retailing regulation. Cigarettes and other tobacco products can be
sold freely at any business unlike alcoholic beverage retailing that
is subjected to licensing and hours of day, among other
Guidelines on packaging and labelling of tobacco products
At its third session in November 2008, the Conference of the Parties (COP) adopted guidelines for implementation
of Article 11 of the WHO FCTC on “Packaging and labelling of Tobacco Products” (decision FCTC/COP3(10)).
The World Health
“Article 11 of the WHO
FCTC requires that health
warning labels on
tobacco packaging (to):
 Be approved by the
competent national
 Should cover 50% or
more of the principal
pack display areas, but
should be no less than
 Be large, clear, visible
and legible;
 Not use misleading
terms like “light” and
 Be rotated periodically
to remain fresh and
novel to consumers;
 Display information
on relevant
constituents and
emissions of tobacco
products as defined by
national authorities;
 Appear in the principle
language (s) of the
restrictions. There are few places and jurisdictions in the US, Australia, Canada, and Singapore
that issue tobacco licensing, but the enforcement is lax and licensures are rarely revoked
(Chapman and Freeman 2009).
In the US, recent debates focused on the wisdom of cigarette sale in pharmacies where health
promoting medications and supplements are sold. In 2010, the American Pharmacists
Association urged pharmacies to discontinue the sale of tobacco products. It also discouraged
state pharmacy boards from issuing and renewing licenses for pharmacies that do not follow the
recommendation. Since then, other entities such as the American Lung Association, the
American Heart Association, and the American Cancer Society began to promote and encourage
bans on tobacco sale in pharmacies (Brennan and Schroeder 2014). In February 2014, CVS
Caremark announced that it will stop selling tobacco products at its more than 7,600 stores in the
US even though it will cost about $2 billion in annual revenue (Kenen and Cheney 2014).
Although the move is unlikely to reduce smoking prevalence since people can still purchase
cigarettes somewhere else, it is hoped that other businesses will follow suit and discontinue sale
of tobacco products at their establishments which will further reduce access (Brennan and
Schroeder 2014).
Legal Precedents on SHS and Children (US)
In the US, neglect is the most common form of child maltreatment, its recognition is less
apparent than child abuse, and therefore is often underreported (USDHHS 2009). Under the
Child Abuse Prevention and Treatment Act (CAPTA) of 1974, the SHS exposures can be argued
as child abuse and/or neglect, detailed under the health hazard section of inadequate supervision.
The international community is catching on in this regard. In May 2013, Latvia’s legislature
adopted an amendment to the Protection of the Rights of the Child Law to include a smoking-ban
in children’s presence to protect their right to grow up in a smoke-free environment. The law
added the “intentional subjection of a child to a harmful environment, including tobacco smoke”
as a form of child abuse (Roudik 2013).
Review of the legal literature suggests that child custody is a primary motivator for reduced SHS
exposure at home. Hundreds of legal cases, in over 20 US states, showed that, SHS was a factor
in court rulings in child custody disputes and labeled as the ‘best interest of the child’ (Sweda
2001). Only in one instance, SHS was judged a criminal offense (Sweda et al. 1998). The fair
evidence and difficulty of enforcement in private spaces have been suggested as reasons for the
current practice of voluntary in-home smoking restrictions policies (Jarvie and Malone 2008).
SECTION FOUR: Effectiveness of Interventions
Learning objective: to evaluate the effectiveness of
interventions aimed at reducing SHS exposure
Many legislations and interventions aimed at smoking
cessation or at reducing SHS exposure among
nonsmokers have been implemented at various levels.
These include but are not limited to smoke-free
policies and bans, education campaigns, health
promotion, social-behavioral therapies, and clinical
interventions. The effectiveness of these approaches varies
from jurisdiction to jurisdiction depending on factors such as
perceptions, funding, and infrastructure. This section gathers
existing evidence of the impact interventions have had on
SHS exposure.
A systematic review of infants and children aged 0-12 years
old and focused on family members, child care workers, and
teachers in community as well as healthcare settings did not
find one intervention to be more effective over others. There
is fair evidence that intensive counseling in a clinical setting
may be beneficial to reduce SHS exposure (Priest et al. 2008).
Among the adult population in Australia, smoking cessation
care and support procedures are shown to be suboptimal
(Anderson et al. 2013).
More recent studies involved special populations and
combinations of interventions. While smoking uptake rate has
decreased in the general populations, the same trend is not
occurring among Native American youth. There is a lack of
studies on the population to provide evidence whether interventions for smoking cessation are
effective (Carson et al 2012). In young people in general, in-school interventions appear more
effective when led by adults than by young people while increasing the number of sessions does
not lead to a greater success rate (Thomas et al. 2013). Multicomponent interventions which
involve various stakeholders such as the media, retailers, and teachers have been studied but
have shown no long-term effectiveness in preventing smoking uptake within this population
(Carson et al 2013). Interventions that utilize behavioral counseling in conjunction with
medication have shown some evidence of effectiveness. A review of 41 studies found that using
combination interventions may increase cessation success rate by 70 to 100 percent compared
Thomas R. Frieden, M.D.,
Director, Centers for
Disease Control and
“Further significant
progress in tobacco
control is possible. Strong
state policies that protect
nonsmokers from second-
hand smoke, use of media
to graphically show the
human impact of smoking,
well-funded tobacco
control programs, and
implementation of other
key evidence-based
policies will decrease the
number of smokers and
save lives.”
Sources of bias
Often published studies use
different definitions for smoking,
smokers, and quit attempts. It is
also unclear whether intensity and
duration of mass media campaigns
influence effectiveness of
interventions (Bala et al. 2013)
with counseling intervention alone. Cessation counseling ranged between 4 to 8 sessions and up
to 30 minutes each time. There is little evidence that longer or higher number of counseling
sessions can increase rate of success (Stead and Lancaster 2012).
Mass media campaigns and financial support have also been explored as ways to encourage
smoking cessation. Such campaigns can be effective when combined with other interventions
but their effects on smoke cessation alone are difficult to determine. In April 2013, the
Community Preventive Services Task Force, established by the US Department of Health and
Human Services (USDHHS), an equivalent of a ministry of health, issued a statement
recommending mass-reach health interventions. Their systematic review of over 90 studies
showed strong evidence of effectiveness in
1. Decreasing the prevalence,
2. Increasing quit rates, and
3. Decreasing smoking uptakes (Community Preventive Services Task Force 2013).
Financial costs of treatments to help smokers quit can be itself a barrier to cessation. A review of
eleven trials involving financial interventions suggests that provision of full financial coverage
for cessation treatments significantly increased the intention to and success rates of quitting
compared to interventions without financial support (Reda et al. 2012).
Currently, there are no rigorous, peer-reviewed studies exploring the safety and effectiveness of
electronic cigarettes as a smoking cessation treatment due to its relatively recent introduction to
the world market. A New Zealand study revealed that although the use of e-cigarettes is
uncommon, most people view them in a positive light and as a potential useful aid in cessation
effort (Bullen et al. 2013). The WMA concludes from the uncertainty about electronic cigarettes
that “the manufacture and sale of e-cigarettes and other electronic nicotine delivery systems be
subject to national regulatory bodies prior approval based on testing and research as either a new
form of tobacco product or as a drug delivery device,” (WMA Statement on Electronic
Cigarettes and Other Electronic Nicotine Delivery Systems). In addition, the WMA urges “the
WHO to add tobacco cessation medications with established efficacy to the WHO’s Model List
of Essential Medicines,” (WMA Statement on Health Hazards of Tobacco Products and
Tobacco-Derived Products).
Evidence suggests that anti-smoking legislation reduces SHS exposure and incidents of certain
health conditions. A systematic review of 50 studies in 5 countries showed consistent evidence
of reduction of SHS exposure in workplaces, restaurants, bars and in public places (Callinan et al.
2010). Other studies on smoking bans have shown effectiveness in reducing the incidents of
heart attack (Sargent et al. 2004; Seo and Torabi 2007; Lemstra et al. 2008;). A meta-analysis on
the effect of smoke-free legislation and the rates of community heart attacks provides evidence
that public and workplace smoking bans are significantly associated with declines in relative risk
of heart disease among individuals exposed to SHS. Strong anti-smoking laws are effective in
lowering the incidents of acute myocardial infarctions and greater benefits are realized as time
passes (Lightwood and Glantz 2009). A case study of legislation to ban smoking in public places
in a Canadian city of Saskatoon showed a reduction in rates of heart attack as well as a decrease
in smoking prevalence. Seventy-nine percent of the city residents supported the ban (Lemstra et
al. 2008).
At the national and global levels, the WHO conducted a 3-year study involving 41 countries that
adopted MPOWER5 policies between 2007 and 2010. The results showed that among these
countries, the number of smokers dropped by about 14.8 million. Approximately 7.4 million
people were saved from smoking-related deaths. The most effective policy was an increase in
taxes to 75% of the final retail price which was implemented in 14 countries. The policy is
estimated to have averted 3.5 million smoking-related deaths. Smoke-free air laws at worksites,
restaurants, and bars averted 2.5 million deaths. Other policies such as health warnings and
advertising, smoking cessation treatments, and bans on tobacco advertising (Levy et al. 2013)
claim reduction in mortality attributed to SHS. A study from Scotland stresses the importance of
smoking cessation rather than reduction. Current evidence provides a robust support for
legislative smoking bans leading to improved health outcomes by limiting SHS exposures,
especially for soronary artery disease (Frazier et al. 2016). Unfortunately the evidence on
respiratory and perinatal health outcomes, smoking prevalence and tobacco consumption, is
inconsistent and requires further epidemiological studies
Summary of Policies and Interventions (see also Appendix B)
Interventions to encourage smoking cessation and reduce exposure to SHS vary widely and
involve many stakeholders and components. On the other hand, tobacco policies implemented at
the national level have shown effectiveness in averting smoking-related deaths. A minimum
increase in taxes to 75% of the retail price appears most effective. The results, however, are
based on a 3-year study by the WHO. Long-term effectiveness and policy spill-overs remain to
be evaluated. Studies have suggested targeting vulnerable groups such as people with disabilities
who are more likely to smoke but are also more likely to attempt quitting (Hall et al. 2013).
Interventions should also be targeted to preventing smoking uptake in adolescents. The Cochrane
Collaboration is undertaking a review of school-based interventions looking at the effectiveness
of school tobacco control policies not just at the individual level but also the environmental level.
Existing studies show mixed results and a systematic review will provide guidance as to what
types of school policies are most likely to deter smoking uptake among adolescents (Coppo et al.
Monitoring use, protecting from smoke, offering help to quit, warning of health risks, enforcing bans, raising taxes
on tobacco.
SECTION FIVE: Conclusions
Exposure to SHS of nonsmokers is a major public health concern. Studies consistently show a
strong evidence of SHS association with lower respiratory illnesses, cardiovascular disease, and
coronary heart diseases. Risk of exposure to SHS is present everywhere smoking is permitted
and is threatening the health of adults and children in particular. In the recent years, evidence has
emerged for the deleterious health effects from third-hand smoking (THS). This has resulted in
some health care facilities issuing guidelines to minimize exposures of patient to health care
workers’ tobacco impregnated clothing and other personal effects. The impact of THS on health
warrants further research and it is essential that standard definitions be set for related terms in
order to be able conduct meta-analyses to increase the strength of evidence (Ueta et al. 2010,
Ferrante et al. 2013, Protano and Vitali 2011, Escoffery et al. 2013).
Smoking bans are common in public places such as bars and restaurants in developed countries
and developing countries are swiftly following suit. The majority of the world’s smokers today
reside in developing countries and the respective governments are acutely aware of the negative
health consequences of tobacco smoking. They are at the forefront in advocacy of smoking
restriction legislation although most of them do not yet have comprehensive legislation (Barnoya
and Navas-Acien 2013). Smoking bans in the homes have not been legislated anywhere in the
world despite overwhelming support. Only a few places ban smoking in vehicles when children
are present. Homes and vehicles are the main settings where nonsmokers are exposed to SHS.
The WHO FCTC provides guidelines aimed at curbing the demand for cigarettes such as
restricting advertisements and displaying graphics of harms on packages and labels but does not
interfere with the supply side. Although demand side control has shown substantial success in
various places, there have been recent talks about limiting the sale of tobacco products in certain
establishments such as pharmacies as recommended by the American Pharmacists Association.
Interventions to encourage smoking cessation and to reduce exposure to SHS among nonsmokers
have been implemented at many levels. However, the wide variety of interventions and
insufficient number of trials does not allow conclusions to be drawn with regard to effectiveness
of different methods or combination of methods. National level policies, on the other hand,
appear promising as the WHO has shown that they have averted millions of smoking-related
deaths around the world.
In 2012, the WHO created the Protocol to Eliminate Illicit Trade in Tobacco Products as
supplement to the FCTC. Illicit trade increases availability and affordability of tobacco products.
As its name indicates, the protocol aims to combat illicit trade in tobacco products with the
ultimate goal of eradication. As of May 2015, it has 180 parties and has been ratified by 53 states
(WHO 2015). China has created the Policy Performance Indicator (PPI) to measure policy
success based on protection of non-smokers from
SHS and is being implemented across the country
(Wan et al. 2013). The focus on developing countries
is critical as they are where the majority of SHS
victims reside. International philanthropic donations
may play a role in changing the norms and the
perceptions of tobacco use leading to major health
gains (Redmon et al. 2013). It is important to build
tobacco control capacity in order to effectively
implement the FCTC (Stillman et al. 2013). Bans on
SHS exposure of children in indoor spaces, such as
cars and homes, hve been implemented by several
countries, and are considered by others6
(Moore et al.
2012, Moore et. al. 2015).
The e-cigarettes is welcomed, by the world
community as an alternative to tobacco. E-cigatrettes effectiveness as smoking cessation
treatment is still under investigation and the its SHS health effects is inconclusive. Concerns over
health effects from e-cigarettes vapor exposure , in closed environments, led to
recommendations for surveillance and additional epidemiological studies (Burstyn 2014, Akl et
al. 2010). Since 2015 legislation and regulations for the use of e-cigarettes were enacted or being
considered by over 70 countries. Such legislations usually follow similar restrictions as the use
of tobacco. The U.S. Food and Drug Administration (FDA), introduced a new regulation of the
e-cigarettes to enter in effect in August 2016 (Abbas 2016
). The summaries of evidence of SHS effects on health are presented in appendix A and B.
Points to Remember
1. Robust evidence links tobacco use to pulmonary, cardiovascular and neurological
diseases, including cancer.
2. Good evidence links SHS tobacco exposures to medical problems in infants, children and
adults. Fair evidence supports health risks from exposure to the increasing use of hookah
[narguileh, water pipe] around the world (Akl et al. 2010, Kumar et al. 2015).
3. SHS tobacco exposures in private place continues to be a major health threat to pregnant
women, infants and children, and in several US litigation case were labeled as child
neglect [rarely as abuse].
4. Developing market economy countries continue to have higher tobacco use and SHS
exposure levels.Akl et al. 2010),
Smoking bans in cars with children and/or passengers. Smoking bans inside housing have been implemented only
in few countries. The US bans vary from state to state.
Legislative Status as of 2016
Even though progress has been
steady, policy implementation has
been slow. There is an urgent need
for further research in areas such as
smoking bans in indoor and outdoor
spaces and the health impact of SHS
and THS on socio-economically
disadvantaged and vulnerable
populations (Barnoya and Navas-
Acien 2013, Moore et al. 2015)
5. According to the American Cancer Society (ACS 2015) the estimated health care costs
for tobacco use between 2000 and 2012 in billions of dollars, in several countries,
amounted to:
a. USA 133
b. France 16.6
c. United Kingdom 9.5
d. China 6.2 (conservative estimates)
e. Canada 2.8
6. There is no single effective preventive intervention, but rather a combination of measures
such as smoking bans, penalties and fines, taxations, education, systematic and sustained
outreach campaigns, package labeling, and improved health literacy.
Appendix A: Summary Table of Evidence from Epidemiological Studies
Appendix B: Summary Table of Evidence from Interventional Studies
Appendix C: Health Effect of SHS in Adults
The 2006 United States Surgeon General report found the following evidence for health effects
of SHS exposure in adults
Sufficient evidence to infer a causal relationship between SHS and
 lung cancer
 an increased risk of coronary heart disease morbidity and mortality
 odor annoyance
 nasal irritation
Suggestive evidence but not sufficient to infer a causal relationship between SHS and
 breast cancer
 an increased risk of stroke
 atherosclerosis
 acute respiratory symptoms; cough, wheeze, chest tightness, difficulty breathing
 chronic respiratory symptoms
 acute decline in lung function in persons with asthma
 small decrement in lung function in the general population
 adult-onset asthma
 worsening of asthma control
 risk for chronic obstructive pulmonary disease
Inadequate evidence to infer a causal relationship between SHS and
 risk of nasopharyngeal carcinoma
 risk of cervical cancer
 acute decline in lung function in health population
 accelerated decline in lung function
 morbidity in persons with chronic obstructive pulmonary disease
Appendix D: Health Effects of SHS in Infants and Children
The 2006 United States Surgeon General report found the following evidence for health effects
of SHS exposure in infants and children
Sufficient evidence to infer a causal relationship between SHS and
 Sudden Infant Death Syndrome
 low birth weight
 lower respiratory illnesses (the greatest risks found among children with smoking
 middle ear disease, including acute and recurrent otitis media and chronic middle ear
 Cough. phlegm, wheeze, asthma, and breathlessness among school age children
 chronic adverse effects on lung function throughout childhood
Suggestive evidence but not sufficient to infer a causal relationship between SHS and
 preterm delivery
 childhood leukemia, lymphomas, and brain tumor
 natural history of middle ear effusion
 onset of childhood asthma
Inadequate evidence to infer a causal relationship between SHS and
 female fertility
 spontaneous abortion
 neonatal mortality
 congenital malformations
 cognitive functioning
 behavioral problems
 height/growth
 an increased risk of adenoidectomy or tonsillectomy
 risk of immunoglobulin E-mediated allergy
Appendix E: WMA 2011 Statement on Health Hazards of Tobacco Products and Tobacco-
Derived Products
Adopted by the 40th
World Medical Assembly, Vienna, Austria, September 1988
and amended by the 49th
WMA General Assembly, Hamburg, Germany, November 1997
and the 58th
WMA General Assembly, Copenhagen, Denmark, October 2007
and the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
More than one in three adults worldwide (more than 1.1 billion people) smokes, 80 percent of
whom live in low- and middle-income countries. Smoking and other forms of tobacco use affect
every organ system in the body, and are major causes of cancer, heart disease, stroke, chronic
obstructive pulmonary disease, fetal damage, and many other conditions. Five million deaths
occur worldwide each year due to tobacco use. If current smoking patterns continue, it will cause
some 10 million deaths each year by 2020 and 70 percent of these will occur in developing
countries. Tobacco use was responsible for 100 million deaths in the 20th century and will kill
one billion people in the 21st century unless effective interventions are implemented.
Furthermore, secondhand smoke – which contains more than 4000 chemicals, including more
than 50 carcinogens and many other toxins – causes lung cancer, heart disease, and other
illnesses in nonsmokers.
The global public health community, through the World Health Organization (WHO), has
expressed increasing concern about the alarming trends in tobacco use and tobacco-attributable
disease. As of 20 September 2007, 150 countries had ratified the Framework Convention on
Tobacco Control (FCTC), whose provisions call for ratifying countries to take strong action
against tobacco use by increasing tobacco taxation, banning tobacco advertising and promotion,
prohibiting smoking in public places and worksites, implementing effective health warnings on
tobacco packaging, improving access to tobacco cessation treatment services and medications,
regulating the contents and emissions of tobacco products, and eliminating illegal trade in
tobacco products.
Exposure to secondhand smoke occurs anywhere smoking is permitted: homes, workplaces, and
other public places. According to the WHO, some 200,000 workers die each year due to
exposure to smoke at work, while about 700 million children, around half the world’s total,
breathe air polluted by tobacco smoke, particularly in the home. Based on the evidence of three
recent comprehensive reports (the International Agency for Research on Cancer’s Monograph 83,
Tobacco Smoke and Involuntary Smoking; the United States Surgeon General’s Report on The
Health Consequences of Involuntary Exposure to Tobacco Smoke; and the California
Environmental Protection Agency’s Proposed Identification of Environmental Tobacco Smoke as
a Toxic Air Contaminant), on May 29, 2007, the WHO called for a global ban on smoking at
work and in enclosed public places.
The tobacco industry claims that it is committed to determining the scientific truth about the
health effects of tobacco, both by conducting internal research and by funding external research
through jointly funded industry programs. However, the industry has consistently denied,
withheld, and suppressed information concerning the deleterious effects of tobacco smoking. For
many years the industry claimed that there was no conclusive proof that smoking tobacco causes
diseases such as cancer and heart disease. It has also claimed that nicotine is not addictive. These
claims have been repeatedly refuted by the global medical profession, which because of this is
also resolutely opposed to the massive advertising campaigns mounted by the industry and
believes strongly that the medical associations themselves must provide a firm leadership role in
the campaign against tobacco.
The tobacco industry and its subsidiaries have for many years supported research and the
preparation of reports on various aspects of tobacco and health. By being involved in such
activities, individual researchers and/or their organizations give the tobacco industry an
appearance of credibility even in cases where the industry is not able to use the results directly in
its marketing. Such involvement also raises major conflicts of interest with the goals of health
The WMA urges the national medical associations and all physicians to take the following
actions to help reduce the health hazards related to tobacco use:
1. Adopt a policy position opposing smoking and the use of tobacco products, and publicize
the policy so adopted.
2. Prohibit smoking, including use of smokeless tobacco, at all business, social, scientific,
and ceremonial meetings of the National Medical Association, in line with the decision of
the World Medical Association to impose a similar ban at all its own such meetings.
3. Develop, support, and participate in programs to educate the profession and the public
about the health hazards of tobacco use (including addiction) and exposure to secondhand
smoke. Programs aimed at convincing and helping smokers and smokeless tobacco users
to cease the use of tobacco products and programs for non-smokers and non-users of
smokeless tobacco products aimed at avoidance are both important.
4. Encourage individual physicians to be role models (by not using tobacco products) and
spokespersons for the campaign to educate the public about the deleterious health effects
of tobacco use and the benefits of tobacco-use cessation. Ask all medical schools,
biomedical research institutions, hospitals, and other health care facilities to prohibit
smoking, use of smokeless tobacco on their premises.
5. Introduce or strengthen educational programs for medical students and physicians to
prepare them to identify and treat tobacco dependence in their patients.
6. Support widespread access to evidence-based treatment for tobacco dependence –
including counseling and pharmacotherapy – through individual patient encounters,
cessation classes, telephone quit-lines, web-based cessation services, and other
appropriate means.
7. Develop or endorse a clinical practice guideline on the treatment of tobacco use and
8. Join the WMA in urging the World Health Organization to add tobacco cessation
medications with established efficacy to the WHO’s Model List of Essential Medicines.
9. Refrain from accepting any funding or educational materials from the tobacco industry,
and to urge medical schools, research institutions, and individual researchers to do the
same, in order to avoid giving any credibility to that industry.
10. Urge national governments to ratify and fully implement the Framework Convention on
Tobacco Control in order to protect public health.
11. Speak out against the shift in focus of tobacco marketing from developed to less
developed nations and urge national governments to do the same.
12. Advocate the enactment and enforcement of laws that:
 Provide for comprehensive regulation of the manufacture, sale, distribution, and
promotion of tobacco and tobacco-derived products, including the specific provisions
listed below.
 Require written and pictorial warnings about health hazards to be printed on all
packages n which tobacco products are sold and in all advertising and promotional
materials for tobacco products. Such warnings should be prominent and should refer
those interested in quitting to available telephone quit-lines, websites, or other
sources of assistance.
 Prohibit smoking in all enclosed public places (including health care facilities,
schools, and education facilities), workplaces (including restaurants, bars and
nightclubs) and public transport. Mental health and chemical dependence treatment
centers should also be smoke-free. Smoking in prisons should not be permitted.
 Ban all advertising and promotion of tobacco and tobacco-derived products.
 encourage the development of plain packaging legislation
 Prohibit the sale, distribution, and accessibility of cigarettes, and other tobacco
products to children and adolescents. Ban the production, distribution and sale of
candy products that depict or resemble tobacco products.
 prohibit smoking on all commercial airline flights within national borders and on all
international commercial airline flights, and prohibit the sale of tax-free tobacco
products at airports and all other locations.
 Prohibit all government subsidies for tobacco and tobacco-derived products.
 Provide for research into the prevalence of tobacco use and the effects of tobacco
products on the health status of the population.
 Prohibit the promotion, distribution, and sale of any new forms of tobacco products
that are not currently available.
 Increase taxation of tobacco products, using the increased revenues for prevention
programs, evidence-based cessation programs and services, and other health care
 Curtail or eliminate illegal trade in tobacco products and the sale of smuggled tobacco
 Help tobacco farmers switch to alternative crops.
 Urge governments to exclude tobacco products from international trade agreements.
13. Recognize that tobacco use may lead to pediatric disease because of the harm done to
children caused by tobacco use and second-hand smoke exposure, the relationship of
tobacco use by children and exposure to adult tobacco use, and the existence of effective
interventions to reduce tobacco use. Special efforts should be made by physicians to:
 provide tobacco-free environments for children
 target parents who smoke for tobacco cessation interventions
 promote programs that contribute to the prevention and decrease of tobacco use
by youth
 control access to and marketing of tobacco products, and
 make pediatric tobacco-control research a high priority
14. Refuse to invest in companies or firms producing or promoting the use or sale of tobacco
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