Beliefs about the health effects of "thirdhand" smoke and home smoking bans

Trends in academic research on thirdhand smoke using bibliometric analysis

INTRODUCTION

This study used quantitative analysis to explore the current landscape of thirdhand smoke (THS) research by identifying gaps and emerging trends. Despite growing evidence of health risks associated with THS, research remains sparse, and no public policies address THS exposure. This analysis aimed to inform future studies and policies, in order to mitigate THS-related health risks.

METHODS

Using a bibliometric approach, our literature search identified 227 academic articles and reviews indexed in PubMed between 2009 and 2023. We used Biblioshiny, a bibliometrix R package, VOSviewer, and Excel to analyze the bibliographic data.

RESULTS

Since 2009, an average growth of 14.09% annually has been observed in THS-related publications. Additionally, we found that US institutions are major contributors to THS research. At the country level, studies conducted in the US, China, Spain, Italy, and South Korea are the most prevalent in the THS literature. Our findings indicate that THS research mainly focuses on human participants, health promotion, nicotiana/chemistry, air pollution/indoor analysis, tobacco smoke pollution, adolescent health, odorants/analysis, surface properties, carcinogens, and disease models/animals.

CONCLUSIONS

We analyzed THS research trends and identified the most impactful authors, journals, institutions, and countries. Considering the findings of this study, policymakers should continue policy development and implementation efforts to address THS exposure. The findings of this study can serve as basic reference material for scholars to guide future research directions regarding THS research.

Beliefs about third-hand tobacco smoke among university employees: a cross-sectional study

OBJECTIVES

This study aimed to evaluate the beliefs about third-hand tobacco smoke (THS) among administrative and academic staff at a university. THS is a residual pollutant from tobacco smoke that lingers on surfaces and poses health risks, particularly to children. The study also aimed to understand these beliefs in relation to socio-demographic factors.

METHODS

A cross-sectional survey was conducted with 332 university employees aged 18 and over. Data were collected between September and December 2023 through face-to-face and online questionnaires. The survey included the Beliefs About Third-hand Smoke (BATHS-T) Scale and questions on socio-demographic characteristics, second-hand smoke exposure, and attitudes towards a smoke-free campus. Beliefs About Third-hand Smoke Scale total and sub-dimension scores increase, it is understood that the participant's belief in the negative effects of third-hand tobacco exposure on persistence and health increases.

RESULTS

The average age of participants was 36.1 years, with 38.3% being administrative personnel and 61.7% academic personnel. About 40.5% of the participants used tobacco products. The mean total BATHS-T score was 35.6, with health and persistence subscale scores averaging 19.9 and 15.7, respectively. Non-smokers had significantly higher BATHS-T scores than smokers. The participants with children scored higher on the health sub-dimension. Additionally, 78.9% supported a smoke-free campus, and those supporting it had higher BATHS-T scores. Awareness of the harms of second-hand smoke correlated with higher BATHS-T scores.

CONCLUSION

The study highlights that non-smokers and those with children are more aware of THS risks. There is strong support for a smoke-free campus among university staff. The findings suggest a need for increased education on THS, especially targeted at smokers and those without children. Universities can play a crucial role in promoting smoke-free environments and raising awareness about the health risks associated with THS.

Third-hand Smoking Beliefs in Patients with Cancer

OBJECTIVE

Exposure to third-hand smoke (THS) represents an important health concern in many indoor environments. This study was conducted to test the beliefs of cancer patients about THS and to examine associations with effective factors.

MATERIAL AND METHODS

This cross-sectional study included 119 patients who were being treated for cancer in the oncology clinic of a University Hospital. The data were collected using a face-to-face questionnaire. This study consisted of the introductory characteristic form and the "Turkish Form of the Beliefs About Third-hand Smoke Scale".

RESULTS

The mean age was 58.52±14.01, with 73% of the participants being female, and 58% reported not smoking. They had a moderate Third-hand Smoke Scale (3.53±0.45). The impact of THS on health was 3.92±0.48 and Persistence in the Environment was 3.21±0.57. Education, smoking, and having cancer relatives were significantly associated with the THS scale scores.

CONCLUSION

None of the participants had previously heard of the concept of THS. Beliefs about the harms of THS exposure were moderate. They believed that THS has a more harmful impact on health than its persistence in the environment. Graduate degrees, smoking, and those with cancer relatives believed the harms of third-hand exposure more than the others.

Policy-relevant differences between secondhand and thirdhand smoke: strengthening protections from involuntary exposure to tobacco smoke pollutants

Starting in the 1970s, individuals, businesses and the public have increasingly benefited from policies prohibiting smoking indoors, saving thousands of lives and billions of dollars in healthcare expenditures. Smokefree policies to protect against secondhand smoke exposure, however, do not fully protect the public from the persistent and toxic chemical residues from tobacco smoke (also known as thirdhand smoke) that linger in indoor environments for years after smoking stops. Nor do these policies address the economic costs that individuals, businesses and the public bear in their attempts to remediate this toxic residue. We discuss policy-relevant differences between secondhand smoke and thirdhand smoke exposure: persistent pollutant reservoirs, pollutant transport, routes of exposure, the time gap between initial cause and effect, and remediation and disposal. We examine four policy considerations to better protect the public from involuntary exposure to tobacco smoke pollutants from all sources. We call for (a) redefining smokefree as free of tobacco smoke pollutants from secondhand and thirdhand smoke; (b) eliminating exemptions to comprehensive smoking bans; (c) identifying indoor environments with significant thirdhand smoke reservoirs; and (d) remediating thirdhand smoke. We use the case of California as an example of how secondhand smoke-protective laws may be strengthened to encompass thirdhand smoke protections. The health risks and economic costs of thirdhand smoke require that smokefree policies, environmental protections, real estate and rental disclosure policies, tenant protections, and consumer protection laws be strengthened to ensure that the public is fully protected from and informed about the risks of thirdhand smoke exposure.

The Diverging Trend in Exposure to Environmental Tobacco Smoke Among US Children

OBJECTIVE

Environmental tobacco smoke exposure (ETSE) was race/ethnicity-specific, but how the race/ethnicity-specific ETSE has changed over time, diverging or converging, remains unclear. We examined ETSE trends by race/ethnicity in US children aged 3-11 years.

METHODS

We analyzed the data of 9678 children who participated in the biennial National Health and Nutrition Examination Surveys, 1999-2018. ETSE was defined as serum cotinine ≥ 0.05 ng/ml, with ≥ 1 ng/ml as heavy exposure. For trend description, adjusted biennial prevalence ratios (abiPR: the ratio associated with a 2-year increase in time) were estimated by race/ethnicity. The prevalence ratios between races/ethnicities were used to quantify ethnoracial differences in different survey periods. Analyses were performed in 2021.

RESULTS

The overall ETSE prevalence was cut by almost half, from 61.59% (95% confidence interval = 56.55%, 66.62%) in the 1999-2004 survey to 37.61% (33.90%, 41.31%) in 2013-2018, exceeding the national 2020 health target (47.0%). However, the decrease occurred unequally between races/ethnicities. Heavy ETSE declined significantly in white [abiPR = 0.80 (0.74, 0.86)] and Hispanic children [0.83 (0.74, 0.93)], but insignificantly in black children [0.97 (0.92, 1.03)]. Consequently, the adjusted prevalence ratio between black children and white children increased from 0.82 (0.47, 1.44) in 1999-2004 to 2.73 (1.51, 4.92) in 2013-2018 for heavy ETSE. Hispanic children remained at the lowest risk throughout the study period.

CONCLUSION

Overall ETSE prevalence was cut by half between 1999 and 2018. However, due to uneven declines, the gaps between black children and others have expanded in heavy ETSE. Special vigilance is needed in preventive medicine practice with black children.

Thirdhand Smoke Exposure Ignored by Pediatricians: A Cross-sectional Study

Thirdhand smoke (THS) is defined as the harmful substances in cigarette smoke that are absorbed into objects, people, and surfaces after smoking. This study aimed to determine the level of awareness of pediatricians working in a tertiary healthcare institution about THS exposure. In this cross-sectional study, participants were asked to fill out an information form in which we questioned the participant's age, sex, occupation in the institution, the exposure of pediatric patients to cigarette smoke during daily healthcare, tobacco product use status, smoking status in their home and car, behavior in case of smoking in closed areas where smoking is prohibited, and whether they knew the term of THS. Also, the Turkish version of The Beliefs About Third-Hand Smoke was used. Eighty-one participants, with a mean age of 34.2 ± 7.6 years, were included in the study. Fifty-six (69.1%) participants said they had never used tobacco products. Participants who had never used tobacco products (P = .005), never allowed smoking in their homes (P = .017) and cars (P = .001), had heard the definition of THS before (P = .013), and thought they knew it (P = .005) had higher total scale scores. There was no significant difference between the THS awareness levels of pediatricians who questioned children's exposure to cigarette smoke in their daily practice and those who did not (P = .491). Determining the awareness levels of pediatricians about THS will be an important step in preventing THS exposure in children.

Turkish Pediatrician Beliefs About Third-hand Smoking

INTRODUCTION

Although third-hand smoke (THS) is a relatively new concept, it emerges as an important health problem. This study evaluated the beliefs of Turkish Pediatricians about THS.

METHOD

The survey, designed to be self-filled by pediatricians, provided information on demographic data, lifestyle factors, and beliefs about THS. Participant beliefs about THS were evaluated using the Beliefs About Third-Hand Smoke scale. This study was conducted by applying a web-based survey to pediatricians in Turkey.

RESULTS

The Beliefs About Third-Hand Smoke scale scores were lower in participants who were male (odds ratio [OR] = 1.479; 95% confidence interval [CI], 0.246-0.526; p < .001), have children (OR = 0.656; 95% CI, 0.156-0.665; p = .002), widowed/separated (OR = 0.498; 95% CI, -1.072 to -0.360; p < .001), a smoker (OR = 0.586; 95% CI, -0.711 to -0.355; p < .001), worked in State Hospital (OR = 0.574; 95% CI, -0.768 to -0.423; p < .001), and specialists (OR = 0.621; 95% CI, -0.608 to -0.207; p < .001).

DISCUSSION

This study showed that pediatricians who were male, widowed/separated, a smoker, with children, working in a State Hospital, and specialists had less belief in the side effects of THS.

Impact of indoor environment on children's pulmonary health

INTRODUCTION

A child's living environment has a significant impact on their respiratory health, with exposure to poor indoor air quality (IAQ) contributing to potentially lifelong respiratory morbidity. These effects occur throughout childhood, from the antenatal period through to adolescence. Children are particularly susceptible to the effects of environmental insults, and children living in socioeconomic deprivation globally are more likely to breathe air both indoors and outdoors, which poses an acute and long-term risk to their health. Adult respiratory health is, at least in part, determined by exposures and respiratory system development in childhood, starting in utero.

AREAS COVERED

This narrative review will discuss, from a global perspective, what contributes to poor IAQ in the child's home and school environment and the impact that indoor air pollution exposure has on respiratory health throughout the different stages of childhood.

EXPERT OPINION

All children have the right to a living and educational environment without the threat of pollution affecting their health. Action is needed at multiple levels to address this pressing issue to improve lifelong respiratory health. Such action should incorporate a child's rights-based approach, empowering children, and their families, to have access to clean air to breathe in their living environment.

Thirdhand Smoke Knowledge, Beliefs and Behaviors among Parents and Families: A Systematic Review

Families play a primary role in protecting children. Thirdhand smoke (THS) is an underestimated public health issue, and health effects correlated to its exposition are emerging. The aim of this systematic review was to analyze papers focusing on knowledge, beliefs, and behaviors regarding THS among parents, families, and caregivers, published until May 2022 on MEDLINE, CINAHL, EMBASE, and the Cochrane Library. Critical appraisal of the included studies was conducted by two independent reviewers using the Joanna Briggs Institute Critical Appraisal tool. Out of the 97 articles, 8 were included in this review (two from the USA, one from Europe, and five from Asia). Although there were no restrictions on the date of publication, all the articles were published in the last 10 years, underlining that THS is an emerging concept. They were characterized by relevant heterogeneity in the study design and assessment tools. The results showed that percentages of parents who believed that THS is harmful ranged from 42.4% to 91%, but parental awareness was not always associated with the adoption of a home- and car-smoking ban or healthy behaviors. Further research is needed to understand the resistance and problems faced by parents who are aware of THS risks but unable to improve good practices.

Promoting Smoke-Free Environments: The Impact of Thirdhand Smoke Awareness on Smoking Bans at Home

OBJECTIVE

A creating smoke-free home is a way to protect a vulnerable group from being exposed to secondhand smoke in the home, such as children, infants, and non-smokers. Studies reported an intervention for promoting a smoke-free home by using secondhand smoke messages and smoking cessation messages. However, the thirdhand smoke (THS) message has rarely been found. Therefore, this study aimed to explore the prevalence and correlations of smoking bans in homes.

METHODS

Secondary data from a community-based cross-sectional design survey was used for this study. Smoking ban status was defined as a smoking ban or no smoking ban. We used multiple logistic regression to test the association between factors and smoking ban status. An adjusted odd ratio and 95% confidence interval were reported.

RESULTS

Of the 882 participants included in this analysis, 38.66% (95%CI: 35.43, 41.97) had a smoking ban at home. A multiple logistic regression analysis showed that participants who believe that secondhand or THS harms children had a greater correlation with developing a smoking ban in the home compared with those who did not believe (odd ratio: 3.94, 95% confidence interval: 2.35, 6.60 and odd ratio:4.22, 95% confidence interval:2.6, 6.86, respectively).

CONCLUSION

This study found that the belief that thirdhand smoke and secondhand smoke exposure harm children. The smoke-free home message's relevance to the harms of thirdhand smoke exposure should be adapted to be promoted, especially in homes.

Respiratory Exposure to Thirdhand Cigarette Smoke Increases Concentrations of Urinary Metabolites of Nicotine

INTRODUCTION

The aims of this study were to characterize particle size in a thirdhand smoke (THS) aerosol and measure the effects of controlled inhalational exposure to THS on biomarkers of tobacco smoke exposure, inflammation, and oxidative stress in human subjects. Secondhand cigarette smoke changes physically and chemically after release into the environment. Some of the resulting chemicals persist indoors as thirdhand cigarette smoke. THS that is sorbed to surfaces can emit particles back into the air.

AIMS AND METHODS

Smoke particle size was measured with a scanning mobility particle sizer and condensation particle counter. Using a crossover study design, 18 healthy nonsmokers received a 3-hour inhalational exposure to THS and to filtered, conditioned air. THS was generated with a smoking machine and aged overnight in a chamber. The chamber was flushed with clean air to create the THS aerosol. The tobacco smoke metabolites cotinine, 3-hydroxycotinine and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) were measured in urine. Vascular endothelial growth factor and interleukin-6 in plasma, and 8-isoprostane in urine, were measured using enzyme-linked immunosorbent assay kits.

RESULTS

Mean smoke particle size increased with aging (171 to 265 nm). We found significant increases in urinary cotinine and 3-hydroxycotinine after 3 hours of exposure to THS and no significant increases in NNAL, interleukin-6, vascular endothelial growth factor or 8-isoprostane.

CONCLUSIONS

Acute inhalational exposure to 22-hour old tobacco smoke aerosol caused increases in the metabolites of nicotine but not the metabolites of the tobacco-specific nitrosamine NNK (4-(Methylnitrosamino)-1-(3-pyridyl)-1-butanone). This corroborates the utility of cotinine and NNAL for secondhand and THS exposure screening.

IMPLICATIONS

This study shows that a 3-hour inhalational exposure to the tobacco smoke aerosol that forms in a room that has been smoked in and left unventilated overnight causes increases in urinary metabolites of nicotine, but not of the tobacco-specific nitrosamine NNK. This suggests that cleaning personnel and others who live and work in rooms polluted with aged or thirdhand cigarette smoke regularly may have inhalational exposures and potential health effects related to their exposure to nicotine and other smoke toxicants.

Secondhand and thirdhand smoke: a review on chemical contents, exposure routes, and protective strategies

Secondhand smoke (SHS: a mixture of sidestream and mainstream smoke) and thirdhand smoke (THS: made up of the pollutants that settle indoors after smoking in closed environments) are a significant public health concern. SHS and THS contain various chemicals which can be released into the air or settle on surfaces. At present, the hazards of SHS and THS are not as well documented. In this review, we describe the chemical contents of THS and SHS, exposure routes, vulnerable groups, health effects, and protective strategies. The literature search was conducted for published papers on September 2022 in Scopus, Web of Science, PubMed, and Google Scholar databases. This review could provide a comprehensive understanding of the chemical contents of THS and SHS, exposure routes, vulnerable groups, health effects, protective strategies, and future researches on environmental tobacco smoke.

Evaluation of a Social Media Campaign Designed to Increase Awareness of Thirdhand Smoke among California Adults

Despite a growing body of research outlining the harms of thirdhand smoke (THS), the public remains generally unaware of risks and exposure routes. This project built on past tobacco prevention campaigns and the tenants of McGuire's input-output model to implement and evaluate a seven-month Facebook-disseminated campaign seeking to improve THS awareness among California adults (n = 1087). Multilinear regression showed that THS-related knowledge (χ2[6] = 19.31, p < .01), attitude (χ2[6] = 13.88, p < .05), and efficacy (χ2[6] = 13.81, p < .05) significantly increased by the campaign's end, with messages highlighting children's health (r = .110, p < .05), pets (r = .145, p < .01), and dust reservoirs (r = .144, p < .01) as the most persuasive. Path analysis modeling found campaign recall to be associated with changes in knowledge (β = .161, p < .01), which predicated attitude change (β = .614, p < .001) and, in turn, behavior change (β = .149, p < .05). Findings suggest social media campaigns should continue to educate diverse populations about new tobacco risks and that tobacco control advocates should consider integrating educational THS messages.

The beliefs of medical faculty students about thirdhand smoke

INTRODUCTION

Thirdhand smoke is the toxic remnant, including pollutants and by-products, of tobacco smoke that remains in the environment after the use of tobacco products. This study aimed to evaluate the relationships between the demographic characteristics and the beliefs about thirdhand smoke of medical faculty students.

METHODS

This descriptive cross-sectional study was conducted with 392 medical faculty students at Afyonkarahisar Health Sciences University. All the participants completed the Beliefs About ThirdHand Smoke (BATHS) questionnaire. Demographic data such as age, gender, year of study, family income level, and place of residence were recorded and evaluated together with tobacco product usage status. Factors (demographic data such as gender) affecting the BATHS scale and sub-scales were analyzed using SPSS software.

RESULTS

The study included 392 medical students. The students comprised 59.7% females and 40.3% males. The students had never used tobacco products (68.1%), 13% were previous users, and 18.9% were active users. The majority of the students stated that thirdhand smoke was harmful to the health of children (90%) and adults (85%) and that thirdhand smoke could remain in a room for days (79%). When the relationships were evaluated between the BATHS scale overall and the health and permanence subscales, and the demographic characteristics of the students, no statistically significant difference was determined according to gender, place of residence, family income level, and tobacco use status.

CONCLUSIONS

This study has provided information for the first time about the beliefs of medical faculty students about thirdhand smoke, and the relationships were investigated between these beliefs and gender, place of residence, family income level, and tobacco use status. The results of the study demonstrated that the students had a strong awareness of the harm of thirdhand smoke and of environmental permanence, and these beliefs did not change according to their own tobacco use status.

Urinary cotinine and exposure to passive smoke in children and adolescents in Germany - Human biomonitoring results of the German Environmental Survey 2014-2017 (GerES V)

Passive smoking is a preventable and significant cause of many serious health problems, with children being particularly at risk. In the fifth German Environmental Survey (GerES V), conducted from 2014 to 2017, information reflecting the extent of passive smoke exposure in children and adolescents was collected by interview-based questionnaires and human biomonitoring (HBM) analyses of cotinine in urine from 2260 participants, aged 3-17 years. Based on these population-representative data, we describe current passive smoke exposure stratified by different subgroups and identify specific exposure determinants using multivariate logistic regression. The questionnaire data revealed that 42% of children and adolescents lived with at least one smoker in the household. Quantifiable concentrations of cotinine could be detected in 56% of the participants. The overall median concentration of cotinine was 0.2 μg/L, with children and adolescents of low socioeconomic status found to be a group particularly affected by passive smoke with higher cotinine concentrations (median = 1.2 μg/L). In the multiple analysis, the most significant predictor of cotinine levels derived from the questionnaire was passive smoking at home (odds ratio (OR) 13.07 [95CI: 4.65, 36.70]). However, parental smoking and passive smoking among friends and relatives could also be identified as independent factors influencing elevated cotinine levels. The comparison between the previous cycle GerES IV (2003-2006) on 3-14-year-olds and GerES V shows that tobacco smoke exposure of children decreased significantly. This decrease is likely an effect of extensive non-smoker protection laws being enforced 2007-2008 on federal and state level. This is reflected by a halving of urinary cotinine concentrations. Nevertheless, our results indicate that passive smoke is still a relevant source of harmful pollutants for many children and adolescents in Germany, and thus support the need for further efforts to reduce passive smoke exposure, especially in the private environment.

A review of indoor Gaseous organic compounds and human chemical Exposure: Insights from Real-time measurements

Gaseous organic compounds, mainly volatile organic compounds (VOCs), have become a wide concern in various indoor environments where we spend the majority of our daily time. The sources, compositions, variations, and sinks of indoor VOCs are extremely complex, and their potential impacts on human health are less understood. Owing to the deployment of the state-of-the-art real-time mass spectrometry during the last two decades, our understanding of the sources, dynamic changes and chemical transformations of VOCs indoors has been significantly improved. This review aims to summarize the key findings from mass spectrometry measurements in recent indoor studies including residence, classroom, office, sports center, etc. The sources and sinks, compositions and distributions of indoor VOCs, and the factors (e.g., human activities, air exchange rate, temperature and humidity) driving the changes in indoor VOCs are discussed. The physical and chemical processes of gas-particle partitioning and secondary oxidation processes of VOCs, and their impacts on human health are summarized. Finally, the recommendations for future research directions on indoor VOCs measurements and indoor chemistry are proposed.

Association between involuntary smoking and risk of cervical cancer in Chinese female never smokers: A prospective cohort study

Involuntary smoking was a major public health problem for women in China. Previous studies mainly focused on secondhand smoke (SHS), which referred to direct exposure to smoke from burning cigarettes. Little evidence existed about the relationship between thirdhand smoke (THS), the residual tobacco smoke remaining in the environment after tobacco had been smoked, and cervical cancer. The China Kadoorie Biobank (CKB) study recruited 0.3 million female participants from 10 areas across China during 2004-2008. After an 11.2-year median follow-up, we documented 1094 cervical cancer cases. Multivariable Cox regression yielded adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for the associations of SHS and THS with cervical cancer incidence, respectively and jointly. Overall, 60.3% reported weekly SHS exposure, and 83.2% had been exposed to THS. Daily SHS exposure and THS exposure at the enrollment were associated with elevated risks of cervical cancer incidence, with adjusted HRs (95% CI) of 1.22 (1.06,1.42) and 1.24 (1.03,1.49), respectively. The longer the exposure duration, the higher the risks (P for trend = 0.006, 0.035, respectively). Compared with those who were neither exposed to SHS nor THS, those exposed to both SHS and THS had the highest risk, with adjusted HRs (95% CI) of 1.29 (1.05,1.58). Area of residence, breastfeeding duration and heating fuel types are potential effect modifiers. Among Chinese females, both SHS and THS were associated with higher risks of cervical cancer incidence, and a dose-response relationship was found between the exposure duration and cervical cancer risk. Our findings reinforce the need for proactive strategies for tobacco control, to protect women health.

Effects of inhalation frequency on inhalation/exposure dose of hazardous nanoparticles and toxic gases during cigarette smoking

In this study, we measured the pollutants generations during cigarette smoking under various inhalation frequency experiment scenarios by a self-developed smoking machine. Some concepts, the effective inhaled amount and exposure amount were proposed to quantitatively estimate emission rates. Important findings include: For interval 1 s, 2 s, 3 s, 4 s and 9 s (called from 1 s to 9 s herein), effective inhaled nano-scale PN (particle number) per cigarette was 8.43E+09 #, 7.24E+09 #, 5.74E+ 09 #, 3.82E+09 # and 1.15E+09 #, it decreased linearly with interval time; exposure amount of PN in side stream smoke was 1.06E+10 #, 1.2E+10 #, 1.48E+10 #, 1.84E+10 # and 8.74E+10 #, it increased with interval time. For toxic gases, all pollutants decreased with interval time in main stream smoke. In side stream smoke, NOx and CO firstly increased with interval time and then decreased (with the highest value at 3 s interval time), while HC always increased with interval time. So, this study is useful to understand the relationship between pollution and smoking habit.

Evidence Base for 2022 Updated Recommendations for a Safe Infant Sleeping Environment to Reduce the Risk of Sleep-Related Infant Deaths

Every year in the United States, approximately 3500 infants die of sleep-related infant deaths, including sudden infant death syndrome (SIDS) (International Statistical Classification of Diseases and Related Health Problems 10th Revision [ICD-10] R95), ill-defined deaths (ICD-10 R99), and accidental suffocation and strangulation in bed (ICD-10 W75). After a substantial decline in sleep-related deaths in the 1990s, the overall death rate attributable to sleep-related infant deaths have remained stagnant since 2000, and disparities persist. The triple risk model proposes that SIDS occurs when an infant with intrinsic vulnerability (often manifested by impaired arousal, cardiorespiratory, and/or autonomic responses) undergoes an exogenous trigger event (eg, exposure to an unsafe sleeping environment) during a critical developmental period. The American Academy of Pediatrics recommends a safe sleep environment to reduce the risk of all sleep-related deaths. This includes supine positioning; use of a firm, noninclined sleep surface; room sharing without bed sharing; and avoidance of soft bedding and overheating. Additional recommendations for SIDS risk reduction include human milk feeding; avoidance of exposure to nicotine, alcohol, marijuana, opioids, and illicit drugs; routine immunization; and use of a pacifier. New recommendations are presented regarding noninclined sleep surfaces, short-term emergency sleep locations, use of cardboard boxes as a sleep location, bed sharing, substance use, home cardiorespiratory monitors, and tummy time. In addition, additional information to assist parents, physicians, and nonphysician clinicians in assessing the risk of specific bed-sharing situations is included. The recommendations and strength of evidence for each recommendation are published in the accompanying policy statement, which is included in this issue.

Indoor Secondary Pollutants Cannot Be Ignored: Third-Hand Smoke

Smoking has been recognized by the World Health Organization (WHO) as the fifth highest threat to humanity. Smoking, a leading disease promoter, is a major risk factor for non-communicable diseases (NCDs) such as cancer, cardiovascular disease, diabetes, and chronic respiratory diseases. NCDs account for 63% of all deaths worldwide. Passive smoking is also a health risk. Globally, more than a third of all people are regularly exposed to harmful smoke. Air pollution is a common global problem in which pollutants emitted into the atmosphere undergo a series of physical or chemical reactions to produce various oxidation products, which are often referred to as secondary pollutants. Secondary pollutants include ozone (O₃), sulfur trioxide (SO₃), nitrogen dioxide (NO₂), and respirable particulate matter (PM). It is worth mentioning that third-hand smoke (THS), formed by the reaction of nicotine with second-hand smoke (SHS) caused by indoor O₃ or nitrous acid (HONO), is a major indoor secondary pollutant that cannot be ignored. As a form of indoor air pollution that is relatively difficult to avoid, THS exists in any corner of the environment where smokers live. In this paper, we summarize the important research progress on the main components, detection, and toxicity of THS and look forward to future research directions. Scientific understanding of THS and its hazards will facilitate smoking bans in indoor and public places and raise public concern for how to prevent and remove THS.

Evaluation of Thirdhand Smoke Exposure after Short Visits to Public Facilities (Noraebang and Internet Cafés): A Prospective Cohort Study

We aimed to evaluate the degree of thirdhand smoke (THS) caused by short-term exposure to smoking-related substances. To this end, we evaluated the change in concentration of a smoking-related urine biomarker in volunteers before and after visiting public spaces where there is likely THS exposure. We hypothesized that a visit to such public spaces would result in an increase in such biomarkers. Participants visited one of the predetermined facilities (noraebang, PC café) and revisited the same facility after 24 h, spending around 2 h per visit. We selected creatinine-corrected urine cotinine (CUC) as a biomarker to evaluate THS. In addition, we collected nicotine-derived nitrosamine ketone (NNK) from surface dust at each site with cotton swabs (diameter of 2.5 cm). We examined whether CUC concentration significantly changed across three time points (baseline, first visit, and second visit) via repeated-measures analysis of variance (RM-ANOVA). Moreover, we analyzed the interaction to determine whether cigarette smell affects the CUC concentration. Finally, CUC and dust NNK were analyzed with Pearson’s correlation. The CUC concentration did not increase from baseline to the first visit, but increased from the baseline to the second visit (Diff = Ln [0.565] ng/mg, P < 0.01). Further, the CUC concentration increased from the first to the second visit (Diff = Ln [0.393] ng/mg, p < 0.01). In the case of the interaction effect, there were statistically significant differences in CUC concentration depending on the smell of smoke in the facility (Diff = Ln [0.325], F value = 4.438, p value = 0.041). The change in CUC concentration from baseline to the second visit (r = 0.562, p < 0.001) and from the first to the second visit (r = 0.544, p < 0.001) were correlated with NNK concentration. We evaluated whether a short stay in a facility with smoke-related substances that adhere to the surrounding environment would expose individuals to THS even if they do not smell or are directly exposed to cigarette smoke. We confirmed that even two relatively short stays (approximately 2 h each) in a facility in which people had previously smoked can lead to THS exposure.

Identification and determination of the volatile organics of third-hand smoke from different cigarettes and clothing fabrics

Third-hand smoke (THS) is a persistent mixture generated from aged second-hand smoke (SHS) that accumulates in indoor environments and reemits into the air. This work evaluates the tobacco-derived volatile organics of cigarette THS from various clothing fabrics that were exposed to side-stream smoke of several brands of cigarettes in a controlled experimental scale. The qualitative and quantitative determination of the chemicals off-gassed was performed using solid phase micro-extraction coupled with GC/MS. Sixty-six components of side-stream smoke were identified in third-hand cigarette smoke. In this study, toluene-reference concentration (TRC) was calculated for volatile compounds and estimated based on the basic response characteristics of GC/MS. Among the identified analytes, 16 compounds were quantified presenting high toxicity and/or abundance in smoke, such as: benzene, toluene, xylene, pyridine, limonene, naphthalene, furfural and nicotine. The results showed that the total quantified volatile organics released for cotton, wool, polyester and filament fabrics were 92.37, 93.09, 87.88, and 50.22 μg/l fabric, respectively. Fabric structure significantly affects chemical off-gassing. Natural fibers were more capable of holding and emitting THS than synthetic fibers. Besides, various desorption times from 15 to 45 min after exposure to cigarette smoke in the study were evaluated. With increasing desorption time, no significant decrease in the concentration of organic compounds in THS was observed. Therefore, it is necessary to pay attention to the fact that it will be difficult to clean the pollutants from the environment contaminated with cigarette smoke and it will take more hours to reduce the concentration of organic compounds.

Monthly Motivational Interview Counseling and Nicotine Replacement Therapy for Smoking Parents of Pediatric Patients: A Randomized Controlled Trial

Background

Parental smoking is the dominant source of passive smoke exposure in the pediatric population. The current randomized controlled trial (RCT) study aimed to evaluate the effectiveness of a multi-component smoking reduction intervention in parental smoking reduction and children's environmental tobacco smoke exposure reduction in clinical settings.

Methods

A single-blinded, 6-month randomized controlled trial recruited smoking parents (N = 210) of children who attended the pediatric wards or clinics at the Prince of Wales Hospital. Participants allocated to the intervention group (n = 105) received monthly motivational interviews on smoking reduction with emphasis on health hazards related to children's passive smoke exposure, 8-week nicotine replacement therapy, and referral to smoking cessation service if the parents preferred. The control group (n = 105) received simple verbal advice on smoking cessation. Primary outcomes were parental urine cotinine validated and self-reported ≥50% smoking reduction rates at 6 months.

Results

Smoking parents in the intervention group had significantly more biochemically validated ≥50% smoking reduction than the control: 27.1 vs. 10.0% (OR = 3.34, 95% CI: 1.16-9.62, P = 0.02). The rate of self-reported ≥50% smoking reduction was also significantly higher in the intervention group than the control: 51.9 vs. 20.2% (OR = 4.40, 95% CI: 2.38-8.12, P < 0.001). For secondary outcomes, the rate of parental self-reported smoking cessation was higher in the intervention arm: 10.5 vs. 1.0% (OR = 12.17, 95% CI: 1.54-96.07, P < 0.001), however, no differences were detected in biochemically validated cessation and changes in children's passive smoke exposure between the groups.

Conclusion

Monthly smoking reduction counseling together with nicotine replacement therapy is more effective than simple verbal cessation advice in the smoking reduction for parents of pediatric patients. However, this study did not demonstrate differences in smoking cessation or reduction in children's passive smoke exposure with a 6-month follow-up. Achievement of a smoke-free environment remains challenging.

Trial Registration

Clinicaltrials.gov, identifier: NCT03879889.

Developmental Effects of Electronic Cigarette Use

Electronic cigarettes have gained widespread acceptance among adolescents and young adults. As a result of this popularity, there are concerns regarding the potential harm of primary, secondhand and thirdhand electronic cigarette exposures on fetal and postnatal development. In vitro studies have shown that constituents in electronic cigarette liquids, including nicotine, flavorings, and carrier agents can alter cellular processes and growth. Additionally, aerosolized electronic cigarette emissions have been shown to disrupt organ development and immune responses in preclinical studies. In clinical studies, an association between electronic cigarette use and frequent respiratory symptoms, greater asthma severity and impaired mucociliary clearance has been demonstrated with adolescent and young adult users of electronic cigarettes having twice the frequency of cough, mucus production, or bronchitis compared to nonusers. Along with the popularity of electronic cigarette use, secondhand electronic cigarette exposure has increased substantially; with almost one-fourth of middle and high school children reporting exposure to secondhand vapors. The health consequences of secondhand electronic cigarette exposure on children and other vulnerable populations are poorly understood but detectable levels of cotinine have been measured in nonusers. Pregnant women and their offspring are another vulnerable group at increased risk for health consequences from electronic cigarette exposure. Nicotine crosses the placenta and can disrupt brain and lung development in preclinical studies. This article will focus on the physiological and health effects associated with primary or secondhand exposure to electronic cigarettes. It is expected that with ongoing availability of electronic cigarettes as well as the accumulation of additional follow-up time for long-term outcomes, the risks associated with exposure will become better clarified. © 2022 American Physiological Society. Compr Physiol 12:3337-3346, 2022.

Content of toxic components of cigarette, cigarette smoke vs cigarette butts: A comprehensive systematic review

The commercially sold cigarettes contain more than 7000 chemicals, and their combustion produces potential toxicants in mainstream smoke (MS), sidestream smoke (SS), secondhand smoke (SHS), thirdhand smoke (THS), and discarded cigarette butts (CBs). We conducted a systematic review of published literature to compare the toxicants produced in each of these phases of tobacco combustion (MS, SS, and CBs). The initial search included 12,301 articles, but after screening and final restrictions considering the aims of this review, 159 published studies were selected for inclusion. Additionally, SHS and THS are briefly discussed here. Overall, polycyclic aromatic hydrocarbons (PAHs) and other aromatic hydrocarbons have been represented in more studies than other compounds. However, metals and nitrosamines were detected in higher concentrations than other components in SS. The concentrations of most PAHs and other aromatic hydrocarbons in MS and SS are higher compared to concentrations found in CBs. Also, the concentrations of all the studied carbonyl compounds, aldehydes and ketones in SS and MS were higher than in CBs. The mean levels of alcohols and phenols in SS were higher than those reported for both MS and CBs. Tobacco toxicants are inhaled by smokers and transmitted to the environment through SS, SHS, THS, and discarded CBs. However, further studies are necessary to assess adverse effects of toxicants found in CBs and THS not only on human health, but also on the environment and ecosystems. The results of this review provide updated information on the chemical contents of MS, SS, SHS, THS, and CBs. It adds to the growing understanding that smoking creates major health problems for smokers and passive smokers, but also that it generates environmental hazards with consequences to the ecosystems and human health through discarded CBs, SHS, and THS exposure.

Tobacco-related risk perceptions, social influences and public smoke-free policies in relation to smoke-free home restrictions: findings from a baseline cross-sectional survey of Armenian and Georgian adults in a community randomised trial

OBJECTIVES

Given high prevalence of smoking and secondhand smoke exposure in Armenia and Georgia and quicker implementation of tobacco legislation in Georgia versus Armenia, we examined correlates of having no/partial versus complete smoke-free home (SFH) restrictions across countries, particularly smoking characteristics, risk perceptions, social influences and public smoking restrictions.

DESIGN

Cross-sectional survey study design.

SETTING

28 communities in Armenia and Georgia surveyed in 2018.

PARTICIPANTS

1456 adults ages 18-64 in Armenia (n=705) and Georgia (n=751).

MEASUREMENTS

We used binary logistic regression to examine aforementioned correlates of no/partial versus complete SFH among non-smokers and smokers in Armenia and Georgia, respectively.

RESULTS

Participants were an average age of 43.35, 60.5% women and 27.3% smokers. In Armenia, among non-smokers, having no/partial SFHs correlated with being men (OR=2.63, p=0.001) and having more friend smokers (OR=1.23, p=0.002); among smokers, having no/partial SFHs correlated with being unmarried (OR=10.00, p=0.001), lower quitting importance (OR=0.82, p=0.010) and less favourable smoking attitudes among friends/family/public (OR=0.48, p=0.034). In Georgia, among non-smokers, having no/partial SFHs correlated with older age (OR=1.04, p=0.002), being men (OR=5.56, p<0.001), lower SHS risk perception (OR=0.43, p<0.001), more friend smokers (OR=1.49, p=0.002) and fewer workplace (indoor) restrictions (OR=0.51, p=0.026); among smokers, having no/partial SFHs correlated with being men (OR=50.00, p<0.001), without children (OR=5.88, p<0.001), daily smoking (OR=4.30, p=0.050), lower quitting confidence (OR=0.81, p=0.004), more friend smokers (OR=1.62, p=0.038) and fewer community restrictions (OR=0.68, p=0.026).

CONCLUSIONS

Private settings continue to lack smoking restrictions in Armenia and Georgia. Findings highlight the importance of social influences and comprehensive tobacco legislation, particularly smoke-free policies, in changing household smoking restrictions and behaviours.

TRIAL REGISTRATION NUMBER

NCT03447912.

Thirdhand smoke from tobacco, e-cigarettes, cannabis, methamphetamine and cocaine: Partitioning, reactive fate, and human exposure in indoor environments

A source of chemical exposure to humans, thirdhand smoke (THS) refers to the contamination that persists indoors following the cessation of a smoking event. The composition of thirdhand smoke depends on the type of substance from which it originates. Although past studies have investigated the effects of tobacco THS on indoor air quality and human health, few have focused on the chemical composition and health impacts of other sources and components of THS. Here we review the state of knowledge of the composition and partitioning behavior of various types of indoor THS, with a focus on THS from tobacco, e-cigarettes, cannabis, and illicit substances (methamphetamine and cocaine). The discussion is supplemented by estimates of human exposure to THS components made with a chemical fate and exposure model. The modeling results show that while very volatile THS compounds (i.e., aromatics) are likely to be taken up by inhalation, highly water-soluble compounds tended to be dermally absorbed. Conversely, minimally volatile THS compounds with low solubility are predicted to be ingested through hand-to-mouth and object-to-mouth contact.

Thirdhand Smoke Knowledge, Attitudes, and Behavior: Development of Reliable and Valid Self-report Measures

INTRODUCTION

This study sought to provide essential tobacco control tools by testing the reliability and validity of new self-report scales developed to assess thirdhand smoke (THS) (ie, toxic tobacco residue) related knowledge, attitudes, and behavior (KAB).

AIMS AND METHODS

Items for the KAB scales were adapted from established secondhand smoke (SHS) measures, reviewed to support face validity, and tested in a longitudinal online survey evaluating THS health messages. Participants were California adults at risk of THS exposure. For 7 months, the three KAB scales were completed monthly, and data from the first (n = 1086), third (n = 315), and seventh (n = 301) month surveys were used in these analyses.

RESULTS

All three scales demonstrated consistent reliability and single-factor loading at all three timepoints for knowledge (αrange: .87-.90), attitude (αrange: .84-.87), and behavior (αrange: .80-.86). Similarly, analyses supported scale convergent validity (scale correlations rrange: .45-.85; all p values <.001), discriminant validity between smokers and nonsmokers (knowledge Cohen's drange: .57-.61, all p values <.001; attitude Cohen's drange: .78-.82, all p values <.001; behavior Cohen's drange: .90-.99, all p values <.001), and predictive validity (range R2KAB: .41-.48; all p values <.001).

CONCLUSIONS

KAB scales about THS provide new opportunities for tobacco control advocates and scholars to identify gaps in knowledge, misperceptions, and obstacles to behavior change in order to guide the design of novel tobacco control policies and interventions.

IMPLICATIONS

Numerous scales have been vetted as reliable and valid measures for assessing SHS-related KABs. Currently, standard measures of THS KABs are not available. This study tested three THS scales to fill this gap. The present findings provide tobacco control advocates, scholars, and practitioners tools for assessing KABs related to THS. This information is critical to development, implementation, and evaluation of novel tobacco control strategies.

Capability of Relative Odor Level Monitors to Measure the Odor of Thirdhand Smoke

We investigated the probability of measuring the odor of thirdhand smoke using four odor-measuring monitors and three gas detector tubes. We measured the changes in tobacco odor on paper towels and cloth products over time. The results of the measurements were plotted against time to obtain an exponential approximation curve. The coefficient of x and the R2 values were calculated from this curve. The odor indicated by four types of odor-measuring monitors and three types of gas detector tubes decreased exponentially over time. The curves obtained from all measuring devices had coefficients of ex between -0.001 and -0.021, and R2 values of >0.8. The reproducibility of measuring relative odor levels through all measuring devices was high, suggesting a good capability of measuring thirdhand smoke odor. Two different odor-level standard gases can be used for the calibration of the regression curve for each monitor.

Parental Knowledge, Attitude, and Practice on Tobacco Use, Smoking Cessation, and Children's Environmental Tobacco Smoke Exposure

Background: Environmental tobacco smoke (ETS) exposure in children ranks one of the major public health problems in our time. Poor parental knowledge, attitude, and practice (KAP) on ETS often contribute to worse exposure of the kids. Thus, we aimed to document parental KAP regarding tobacco use, smoking cessation and children's ETS exposure, and to analyse how knowledge and attitude relate to practice.

Methods: Self-administered KAP questionnaires were distributed to smoking parents recruited from the pediatric unit at the Prince of Wales Hospital, which provides pediatric service to a population of 1.2 million in Hong Kong. The 60-item questionnaire had a range of 0–38 for knowledge, 0–44 for attitude, and 0–40 for practice. Descriptive analyses were performed for KAP response, regression analyses were performed for the exploration of associations and identification of predictive indicators.

Results: 145 smoking parents (mean age: 38.0 ± 6.7 yrs.; male: 85.5%) were included. Less than half (39.3%) of them reported a smoke-free policy at home. Among those parents who had private cars, less than half (45.2%) of them had smoke-free policy in their car that they never smoked in the car. Only 25.5% of the participants correctly answered ≥70% of the knowledge questions, and 11.8 % of the participants gave favorable responses to ≥70% of the attitude questions. The total knowledge and the total attitudes score were positively associated (r = 0.49, 95% CI: 0.35–0.79, p < 0.001), yet they were only modestly correlated with parental practice on children's ETS exposure. By multivariate regressions, potential predictive factors for more favorable parental KAP included higher household income, lower parental nicotine dependence level and breastfeeding practice.

Conclusions: Parental KAP related to tobacco use and children's ETS exposure needs improvement to address the significant gap between recommended and actual practice. The weak association between knowledge and practice suggested that parental education alone is not adequate to combat ETS exposure in children.

Protecting Children From Tobacco Smoke Exposure: A Randomized Controlled Trial of Project Zero Exposure

INTRODUCTION

Young children are vulnerable to harm from tobacco smoke exposure (TSE). This study assessed the effect of Project Zero Exposure-an intervention program designed to help parents protect children from TSE-on children's exposure.

METHODS

Randomized controlled trial of a home-based, theory-driven intervention. Parents of young children (<8 y) in families with a smoking parent were eligible. The intervention included feedback on child TSE (hair nicotine), and home air quality (PM2.5), with motivational interviewing. Families were randomized to: intervention group (IG, N = 69), regular control group (RCG, N = 70), or to a secondary enhanced control group, (ECG, N = 20). Child hair samples were taken at baseline and follow-up. We report on child TSE in the IG versus RCG at six months.

RESULTS

Most enrolled families completed the trial (IG: 98.6%[68/69], RCG: 97.1%[68/70]). Log hair nicotine (LHN [ng/mg]) decreased in both the IG (Baseline: -1.78 ± 1.91, Follow-up: -2.82 ± 1.87, p = .003) and RCG (Baseline: -1.79 ± 1.54, Follow-up: -2.85 ± 1.73, p = .002), but did not differ between groups at study end (p = .635). Three of five parentally-reported outcomes showed improvement over time in the IG, and one in the RCG. Among IG participants, 90% found hair nicotine feedback useful.

CONCLUSIONS

No difference between the intervention and control groups was found on the objective biomarker, LHN. Child TSE decreased during the trial in intervention and control groups. Trial participation, which included hair nicotine monitoring, may have contributed to decreasing exposure in both groups. Concurrent control group improvements may partially explain lack of proven intervention benefit. Biomarker monitoring warrants further investigation for reduction of child TSE.

IMPLICATIONS

Project Zero Exposure is an intervention program designed to help parents protect their children from TSE. Results from the randomized controlled trial of the program showed no difference between groups at study end, but a clear and substantial reduction in child exposure to tobacco smoke from beginning to end of the trial, in both intervention and control groups. Biomarker monitoring, a key element of the trial, was used with all participants. Biomarker monitoring of child exposure to tobacco smoke may help parents become aware of their child's exposure and better protect them, and should be explored as a means to reduce child TSE. Clinical Trial Registration: NCT02867241.

Beliefs of parents in Kuwait about thirdhand smoke and its relation to home smoking rules: A cross-sectional study

INTRODUCTION

Thirdhand smoke (THS) is the toxic residue of tobacco smoke that persists long after tobacco smoking on the clothing and hair of smokers and in the surrounding environment. This study aimed to assess parents' beliefs about THS in terms of harm and persistence in the environment and evaluate associations between parents' THS beliefs and home smoking rules.

METHODS

A sample of parents living in Kuwait were enrolled in a cross-sectional study. Parents reported home smoking rules (strict, partial, and no, home smoking ban) and completed the 9-item Beliefs About ThirdHand Smoke (BATHS) scale that assessed parents' overall, health, and persistence beliefs about THS. Associations between the quartiles of THS overall, health, and persistence beliefs scores and home smoking rules were evaluated using a modified Poisson regression, and adjusted prevalence ratios (APR) and 95% confidence intervals (CI) were estimated.

RESULTS

In total, 536 parents (404 females) were enrolled in the study, with 42.0% (n=225) and 43.6% (n=234) reporting a strict or partial home smoking ban, respectively. The prevalence of a strict home smoking ban was higher among never smokers than among ever smokers (49.1% vs 25.2%, p<0.001). The majority of participants indicated that THS exposure harms the health of children (67.2%) and adults (60.6%) and THS residue could remain for days in the environment (58.9%). The prevalence of a strict home smoking ban increased as THS overall (APR_{Q4 vs Q1} = 1.48; 95% CI: 1.12-1.96), health (APR_{Q4 vs Q1} = 1.22; 1.02-1.45), and persistence (APR_{Q4 vs Q1} = 1.55; 1.17-2.05) beliefs scores increased.

CONCLUSIONS

Parents' harm and persistence beliefs about THS were associated with enforcing a strict home smoking ban, which provides a safer environment for children and non-smokers. Therefore, tobacco prevention programs need to incorporate educational messages about the harm of THS in an attempt to promote smoke-free homes.

Oxidative Stress Promotes Corticosteroid Insensitivity in Asthma and COPD

Corticosteroid insensitivity is a key characteristic of patients with severe asthma and COPD. These individuals experience greater pulmonary oxidative stress and inflammation, which contribute to diminished lung function and frequent exacerbations despite the often and prolonged use of systemic, high dose corticosteroids. Reactive oxygen and nitrogen species (RONS) promote corticosteroid insensitivity by disrupting glucocorticoid receptor (GR) signaling, leading to the sustained activation of pro-inflammatory pathways in immune and airway structural cells. Studies in asthma and COPD models suggest that corticosteroids need a balanced redox environment to be effective and to reduce airway inflammation. In this review, we discuss how oxidative stress contributes to corticosteroid insensitivity and the importance of optimizing endogenous antioxidant responses to enhance corticosteroid sensitivity. Future studies should aim to identify how antioxidant-based therapies can complement corticosteroids to reduce the need for prolonged high dose regimens in patients with severe asthma and COPD.

Effects of electronic cigarette aerosol exposure on oral and systemic health

Conventional cigarette smoke harms nearly every organ of the body and is the leading cause of death in the United States and in the world. Decades of research have associated conventional cigarette smoke with several diseases and death. Heavily marketed, electronic nicotine delivery systems such as electronic cigarettes (e-cigarettes) are available in a variety of flavors and high nicotine concentrations. In 2019, a severe lung disease outbreak linked to e-cigarette use led to several deaths, which was called electronic-cigarette or vaping product use-associated lung injury (EVALI). Even though the trend of e-cigarette use among teens continues to increase, information on the effects of e-cigarette smoke on oral and overall health are still scarce. This review discusses the possible health effects due to unregulated e-cigarette use, as well as the health effects of second-hand smoke and third-hand smoke on non-smokers.

Thirdhand cigarette smoke leads to age-dependent and persistent alterations in the cecal microbiome of mice

The gut microbiome composition is influenced by many factors including environmental exposures. Here, we investigated the effect of thirdhand cigarette smoke (THS) and exposure age on gut microbiome diversity. C57BL/6 mice were exposed to THS at human exposure relevant levels for three weeks during three different life stages: postnatal (0-3 weeks of age), pubescent (4-7 weeks of age), and adult (9-12 weeks of age), respectively. Cecal microbiome profiles were assessed at 17 weeks of age by 16S rRNA gene sequencing. We found that age at THS exposure strongly influenced the cecal microbiome composition. Although postnatal THS exposure significantly influenced the microbial composition, pubescent and adulthood exposures only had minor effects. The microbiome of postnatally THS-exposed mice significantly increased several degradation pathways that regulate glycolysis and pyruvate decarboxylation, and significantly decreased coenzyme A biosynthesis and pyrimidine deoxyribonucleoside salvage. Our results indicate that mouse postnatal development is particularly susceptible to persistent THS exposure effects on the gut microbiome.

Third-hand exposure at homes: Assessment using salivary cotinine

BACKGROUND/OBJECTIVES

While exposure to secondhand smoke (SHS) is a well-established problem, exposure to third-hand smoke (THS) is scanty known and needs to be studied. The objective of this work is to characterize salivary cotinine concentrations among people who self-reported exposure to SHS and THS at home.

METHODS

Cross-sectional study of a representative sample (n = 736) of the adult population (≥16 years) from the city of Barcelona carried out in 2013-2014. A questionnaire on tobacco use and passive exposure was administered, and a saliva sample was collected for cotinine determination. For this study, the information of the non-smoker participants who provided saliva sample (n = 519) was used. The geometric means (GM) and geometric standard deviations (GSD) of the cotinine concentration were compared according to the type of self-reported exposure at home: (1) Not exposed to SHS or THS; (2) Exposed to SHS and THS; and (3) Only exposed to THS. We used log-linear models to compare the cotinine concentration of each exposed group with respect to the unexposed group, adjusting for sex, age, educational level, and tobacco exposure in other settings.

RESULTS

The GM of the salivary cotinine concentration was 0.34 ng/ml (GSD = 0.16) among individuals reporting SHS and THS exposure, 0.22 ng/ml (GSD = 0.15) among those reporting only THS exposure and 0.11 ng/ml (GSD = 0.04) among those who declared not to be exposed to SHS nor THS (p-value for trend <0.001). The regression model showed a statistically significant increase in cotinine concentration among those exposed to SHS and THS (188% higher, 95% CI: 153%; 223%), and only exposed to THS (106% higher, IC95. %: 74.5%; 137.0%) when comparing with the unexposed group. No statistically significant differences in cotinine concentration were observed between those exposed to SHS and THS compared to the THS group (-25.8%, 95% CI: -69.5%; 17.9%).

CONCLUSIONS/RECOMMENDATIONS

People exposed to third-hand smoke at home had quantifiable cotinine levels in saliva. No differences in cotinine levels were found between those exposed to second-hand and third-hand smoke at home. The reduction of exposure to third-hand smoke at home should be put into the agenda of tobacco control.

In utero and early-life exposure to thirdhand smoke causes profound changes to the immune system

Acute lymphoblastic leukemia (ALL) is the most common cancer in children. Thirdhand smoke (THS) is the residual tobacco contamination that remains after the smoke clears. We investigated the effects of THS exposure in utero and during early life in a transgenic Cdkn2a knockout mouse model that is vulnerable to the development of leukemia/lymphoma. Female mice, and their offspring, were exposed from the first day of pregnancy to weaning. Plasma cytokines, body weight and hematologic parameters were measured in the offspring. To investigate THS exposure effects on the development of leukemia/lymphoma, bone marrow (BM) was collected from control and THS-exposed mice and transplanted into BM-ablated recipient mice, which were followed for tumor development for 1 year. We found that in utero and early-life THS exposure caused significant changes in plasma cytokine concentrations and in immune cell populations; changes appeared more pronounced in male mice. Spleen (SP) and BM B-cell populations were significantly lower in THS-exposed mice. We furthermore observed that THS exposure increased the leukemia/lymphoma-free survival in BM transplantation recipient mice, potentially caused by THS-induced B-cell toxicity. A trend towards increased solid tumors in irradiated mice reconstituted with THS-exposed BM stimulates the hypothesis that the immunosuppressive effects of in utero and early-life THS exposure might contribute to carcinogenesis by lowering the host defense to other toxic exposures. Our study adds to expanding evidence that THS exposure alters the immune system and that in utero and early-life developmental periods represent vulnerable windows of susceptibility for these effects.

Prenatal Exposure to Cigarette Smoke and Anogenital Distance at 4 Years in the INMA-Asturias Cohort

Smoking by women is associated with adverse pregnancy outcomes such as spontaneous abortion, preterm delivery, low birth weight, infertility, and prolonged time to pregnancy. Anogenital distance (AGD) is a sensitive biomarker of prenatal androgen and antiandrogen exposure. We investigated the effect of smoking and passive smoke exposure during pregnancy on anogenital distance in offspring at 4 years in the INMA-Asturias cohort (Spain). Women were interviewed during pregnancy to collect information on tobacco consumption, and anogenital distance was measured in 381 children: Anoscrotal distance in boys and anofourchetal distance in girls. We also measured maternal urinary cotinine levels at 32 weeks of pregnancy. We constructed linear regression models to analyze the association between prenatal smoke exposure and anogenital distance and adjusted the models by relevant covariates. Reported prenatal smoke exposure was associated with statistically significant increased anogenital index (AGI), both at week 12 of pregnancy (β = 0.31, 95% confidence interval: 0.00, 0.63) and at week 32 of pregnancy (β = 0.31, 95% confidence interval: 0.00, 0.63) in male children, suggesting altered androgenic signaling.

Effect of parental smoking on their children's urine cotinine level in Korea: A population-based study

BACKGROUND

Children may be exposed to tobacco products in multiple ways if their parents smoke. The risks of exposure to secondhand smoke (SHS) are well known. This study aimed to investigate the association between parental smoking and the children's cotinine level in relation to restricting home smoking, in Korea.

METHODS

Using the Korea National Health and Nutrition Health Examination Survey data from 2014 to 2017, we analyzed urine cotinine data of parents and their non-smoking children (n = 1,403), in whose homes parents prohibited smoking. We performed linear regression analysis by adjusting age, sex, house type, and household income to determine if parent smoking was related to the urine cotinine concentration of their children. In addition, analysis of covariance and Tukey's post-hoc tests were performed according to parent smoking pattern.

FINDING

Children's urine cotinine concentrations were positively associated with those of their parents. Children of smoking parents had a significantly higher urine cotinine concentration than that in the group where both parents are non-smokers (diff = 0.933, P < .0001); mothers-only smoker group (diff = 0.511, P = 0.042); and fathers-only smoker group (diff = 0.712, P < .0001). In the fathers-only smoker group, the urine cotinine concentration was significantly higher than that in the group where both parents were non-smoker (diff = 0.221, P < .0001), but not significantly different compared to the mothers-only smoker group (diff = - -0.201, P = 0.388). Children living in apartments were more likely to be exposed to smoking substances.

CONCLUSION

This study showed a correlation between parents' and children's urine cotinine concentrations, supporting the occurrence of home smoking exposure due to the parents' smoking habit in Korea. Although avoiding indoor home smoking can decrease the children's exposure to tobacco, there is a need to identify other ways of smoking exposure and ensure appropriate monitoring and enforcement of banning smoking in the home.

Personal exposure to equivalent black carbon in children in Milan, Italy: Time-activity patterns and predictors by season

Air pollution is a global threat to public health, especially when considering susceptible populations, such as children. A better understanding of determinants of exposure could help epidemiologists in refining exposure assessment methods, and policy makers in identifying effective mitigation interventions. Through a participatory approach, 73 and 89 schoolchildren were involved in a two-season personal exposure monitoring campaign of equivalent black carbon (EBC) in Milan, Italy. GPS devices, time-activity diaries and a questionnaire were used to collect personal information. Exposure to EBC was 1.3 ± 1.5 μg/m³ and 3.9 ± 3.3 μg/m³ (mean ± sd) during the warm and the cold season, respectively. The highest peaks of exposure were detected during the home-to-school commute. Children received most of their daily dose at school and home (82%), but the highest dose/time intensity was related to transportation and outdoor environments. Linear mixed-effect models showed that meteorological variables were the most influencing predictors of personal exposure and inhaled dose, especially in the cold season. The total time spent in a car, duration of the home-to-school commute, and smoking habits of parents were important predictors as well. Our findings suggest that seasonality, time-activity and mobility patterns play an important role in explaining exposure patterns. Furthermore, by highlighting the contribution of traffic rush hours, transport-related microenvironments and traffic-related predictors, our study suggests that acting on a local scale could be an effective way of lowering personal exposure to EBC and inhaled dose of children in the city of Milan.

Randomised pilot trial of cash incentives for reducing paediatric asthmatic tobacco smoke exposures from maternal caregivers and members of their social network

BACKGROUND

The primary aim was to evaluate the efficacy of financial incentives for reducing paediatric tobacco smoke exposures (TSEs) through motivating cigarette usage reduction among low-income maternal caregivers and members of their social network.

DESIGN

Randomised control pilot trial over a 6-month study follow-up time period. The study was undertaken from May 2017 to -May 2018. Once monthly follow-up visits occurred over the 6-month study period.

SETTING

Baltimore City, Maryland, USA.

PARTICIPANTS

We grouped 135 participants into 45 triads (asthmatic child (2-12 years of age), maternal caregiver and social network member). Triads were assigned in a 1:1 allocation ratio. The maternal caregiver and social network members were active smokers and contributed to paediatric TSE.

INTERVENTIONS

Triads were randomised to receive either usual care (TSE education and quitline referrals) or usual care plus financial incentives. Cash incentives up to $1000 were earned by caregivers and designated social network participants. Incentives for either caregivers or social network participants were provided contingent on their individual reduction of tobacco usage measured by biomarkers of tobacco usage. Study visits occurred once a month during the 6-month trial.

MAIN OUTCOME MEASURES

The main outcome measure was mean change in monthly paediatric cotinine levels over 6 months of follow-up interval and was analysed on an intention-to-treat basis.

RESULTS

The mean change in monthly child cotinine values was not significantly different in the intervention cohort over the 6-month follow-up period, compared with the control group (p=0.098, CI -0.16 to 1.89). Trends in child cotinine could not be ascribed to caregivers or social network members. Despite decreasing mean monthly cotinine values, neither the intervention cohort's caregivers (difference in slope (control-intervention)=3.30 ng/mL/month, CI -7.72 to 1.13, p=0.144) or paired social network members (difference in slope (control-intervention)=-1.59 ng/mL/month, CI -3.57 to 6.74, p=0.546) had significantly different cotinine levels than counterparts in the control group.

CONCLUSIONS

Financial incentives directed at adult contributors to paediatric TSE did not decrease child cotinine levels.

TRIAL REGISTRATION NUMBER

NCT03099811.

Validity and reliability of Turkish version of Beliefs About Third-Hand Smoke Scale: BATHS-T

OBJECTIVE

Exposure to third-hand smoke (THS) poses health risk, especially for children. THS is mostly ignored in Turkey. The aim of this study is to adapt the Beliefs about Third-Hand Smoke (BATHS) scale to Turkish.

METHODS

The BATHS scale consists of 9 items, and the data collected from 273 people was considered sufficient for analyses in this methodological study. The BATHS scale is translated into Turkish and confirmatory factor analysis (CFA) was performed for the construct validity analysis of the scale.

RESULTS

The correlation between the overall BATHS scale and its two sub-dimensions was 0.937 (p < 0.001), and the correlation between the health and persistence sub-dimensions was 0.775 (p < 0.001). Since there was a statistically positive and highly significant relationship, the adapted BATHS scale was considered structurally compatible with the sub-dimensions. The reliability value of the entire scale is 0.90. Test-retest correlation values between the health and persistence dimensions were between 0.745 and 0.960, the values obtained were above 0.70 and had a statistically positive and high level of significant relationship (p < 0.001).

CONCLUSIONS

It is concluded that the Turkish version of the BATHS scale is reliable and valid. This scale will allow further research and training on third-hand smoke exposure. Tobacco control programmes success will improve.

Association between parents' smoking status and tobacco exposure in school-age children: assessment using major urine biomarkers

Children are at risk of exposure to secondhand smoke. We aimed to evaluate the extent of their exposure to it in relation to their parents' smoking status by using biomarkers relevant to smoking. We evaluated 847 school-age children (6-12 years) who lived with their parents, using data from the Korea National Health and Nutrition Examination Survey 2016-2018. Secondhand smoke exposure in children of non-smoking and smoking parents was assessed by measuring urinary 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) and cotinine concentrations. Overall, the parents of 482 (55.1%) children smoked and those of 392 (44.9%) children did not smoke. After adjusting for covariates, significantly higher concentrations of NNAL (β = 0.482, standard error [S.E.] = 0.065, P < 0.001) and cotinine (β = 0.472, S.E. = 0.06, P < 0.001) were found in children of smoking parents than in children of non-smoking parents. Children of parents who smoked a higher number of cigarettes showed higher NNAL and cotinine concentrations than children of non-smoking parents. Children with both parents who smoked showed the highest NNAL and cotinine concentrations. Children of smoking parents are at a higher risk of exposure to secondhand smoke. A smoke-free environment must be maintained to protect children from the harmful effects of secondhand smoke. Therefore, comprehensive national anti-smoking policies are required.

Thirdhand smoke beliefs and behaviors among families of primary school children in Shanghai

INTRODUCTION

There are few reports on the beliefs about thirdhand smoke in Chinese families with primary school children. This study aims to understand the beliefs about thirdhand smoke among parents or grandparents of primary school children in Shanghai and to provide an evidence base to incorporate thirdhand smoke preventative action into tobacco control interventions.

METHODS

We performed a cross-sectional survey among parents and grandparents of children aged 6–13 years in the Changjiang Road Primary School and recruited 843 participants to make assessments on the ‘beliefs about thirdhand smoke’ (BATHS) scale. Sociodemographic details including age, gender, marital status, education level, personal income and type of home ownership (new house, secondhand house with or without redecoration) and health status of children (whether they suffered from respiratory diseases or not) were investigated. Scale assessment, univariate and multivariate analyses to explore the factors influencing the BATHS scale and subscale scores, were performed using SPSS version 22.0.

RESULTS

Participants who were aged >65 years were more likely to get lower scores on the BATHS scale (OR=0.476; 95% CI: 0.311–0.728, p=0.001). Undergraduates (OR=1.190; 95% CI: 1.020–1.388, p=0.027) and graduates (OR=1.4490; 95% CI: 1.102–1.906, p=0.008) obtained higher scores. Moreover, the scores of residents living in a secondhand house with redecoration (OR=0.882; 95% CI: 0.782–0.995, p=0.041) and without redecoration (OR=0.801; 95% CI: 0.698–0.919, p=0.002) were lower compared with those of new-house owners. The scores for participants whose children suffered from respiratory diseases in the past six months (OR=1.104; 95% CI: 1.003–1.216, p=0.043) were higher than those whose children had no respiratory diseases.

CONCLUSIONS

This study shows that younger people, females, those with higher incomes, and higher education levels, were more likely to believe the thirdhand smoke impacts on health and its persistence in the environment. Our findings can guide targeted actions for smoke-free home interventions.

Smoking Cessation Counseling in the Inpatient Unit: A Survey of Pediatric Hospitalists

OBJECTIVES

To determine practices and beliefs of pediatric hospitalists regarding smoking cessation counseling for caregivers of hospitalized children.

METHODS

An electronic survey was distributed to 249 members of the Pediatric Research in Inpatient Settings Network over 6 weeks in 2017 (83 responses [33%]). Questions explored beliefs regarding the impact of tobacco smoke exposure (TSE) and practices in TSE screening, provision of counseling, resources, and pharmacotherapy. Nonparametric tests were used to compare groups on numeric variables, χ² tests were used to compare groups on nominal variables, and McNemar's test was used to compare dichotomous responses within subjects.

RESULTS

All respondents were familiar with the term "secondhand smoke," and >75% were familiar with "thirdhand smoke" (THS). Familiarity with THS was associated with more recent completion of training (P = .04). Former smokers (7%) were less likely to agree that THS has a significant impact on a child's health (P = .04). Hospitalists ask about TSE more often than they provide counseling, resources, or pharmacotherapy to caregivers who want to quit smoking. Hospitalists are more likely to ask about TSE and provide cessation counseling when patients have asthma as opposed to other diseases. Time was identified by 41% of respondents as a barrier for providing counseling and by 26% of respondents as a barrier for providing resources. Most respondents never prescribe pharmacotherapy (72%), nor do they follow-up with caregivers after hospitalization regarding cessation (87%).

CONCLUSIONS

Although most respondents ask about TSE, opportunities are missed for counseling and providing support to caregivers who want to quit smoking. Providers should be educated about THS, and systems should be streamlined to facilitate brief counseling sessions.

Assessing the usability of a Willingness to Quit smoking questionnaire in a sample of active tobacco smokers: A qualitative study

Background and objectives: Tobacco products are conceivably the most accessible addictive substances. Its use contributes to numerous negative health outcomes both in the developed and developing world. The objective of the study was to assess the usability of a Willingness to Quit smoking questionnaire; a concise questionnaire used to assess the readiness of active tobacco smokers to stop smoking, and also guiding in constructive conversations between healthcare workers and clients regarding stopping smoking.Methods: In this study, 25 active tobacco smokers and four healthcare workers of different cadres were interviewed. Participants were given the Willingness to Quit smoking questionnaire and asked to fill and comment on its usability, ease of comprehension and plausibility in the healthcare system settings.Results: All the 25 active tobacco smokers demonstrated their readiness to stop smoking. It was reported that the Willingness to Quit smoking questionnaire triggered the intention to stop smoking and effectively guided the interviews between the healthcare workers and clients who had expressed the intention of stopping smoking.Conclusion: The Willingness to Quit smoking questionnaire is a valuable tool in clinical practice as it can be used to prompt tobacco cessation dialogues between healthcare workers and clients attempting to stop smoking.

Living with parents who smoke predicts levels of toxicant exposure in children

The detrimental effect of secondhand smoke (SHS) on health is well known; due to various factors, efforts to prevent SHS cannot completely eliminate the effect of smoking substances, and SHS has not been sufficiently investigated among children. This study aimed to assess children's smoke exposure with respect to parents smoking patterns using biomarkers. This study used data from the 2016/2017 Korea National Health and Nutrition Examination Survey. Data pertaining to 486 subjects was extracted. Exposure to smoking among non-smoking children was assessed based on urine levels of 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL). The urine NNAL concentration was highest among children with smoking parents and SHS exposure at home (3.829 pg/mg, 95% confidence interval [CI: 1.499-8.330), followed by children with smoking parents and no SHS exposure at home (1.297, 95% CI: 1.080-1.536), and children with nonsmoking parents and no SHS exposure at home (0.996 pg/mg, 95% CI: 1.026-1.427). Living with a smoking parent was associated with exposure to carcinogens, and a critical predictor of tobacco-specific nitrosamine. Prohibition of smoking at home is effective at preventing SHS in children. However, it cannot completely prevent passive smoking, which might be attributable to thirdhand smoking and undetected secondhand smoke.

Modeling Healthcare Costs Attributable to Secondhand Smoke Exposure at Home among South Korean Children

Children exposed to secondhand smoke (SHS) are at increased risk for disease. We sought to estimate the medical costs among Korean children who were exposed to SHS at home. A Markov model was developed, including five diseases (asthma, acute otitis media, acute bronchitis, pneumonia and sudden infant death syndrome) that were significantly associated with SHS in children based on a systematic review. The time horizon of the analysis was 20 years (from birth to adulthood), and the cycle length was 1 week. The direct healthcare costs were discounted annually at 5%. Univariate and probabilistic sensitivity analyses were conducted. The Markov model estimated the healthcare costs for 20 years as 659.61 USD per exposed child, an increase of approximately 30% compared to the cost per unexposed child (507.32 USD). Sensitivity analysis suggested that the younger the age of the exposure, the greater the incremental healthcare costs incurred, implying that infants and young children were especially vulnerable to the SHS exposure. Findings of this study could provide key baseline data for future economic evaluations on SHS control policies in South Korea.

Analysis of Adsorption and Decomposition of Odour and Tar Components in Tobacco Smoke on Non-Woven Fabric-Supported Photocatalysts

The release of substantial amounts of toxicologically significant, irritant, and malodourous compounds during the complete combustion of tobacco can generate an unpleasant environment, especially indoors. Herein, we developed non-woven fabric-supported UV- and visible-light-responsive photocatalysts capable of adsorbing and decomposing the odour and tar components of tobacco smoke under irradiation with UV or visible light. The processes of odour component adsorption and subsequent decomposition under irradiation were evaluated in terms of colour changes in the catalytic system and by gas chromatography–mass spectrometry. By considering three different photocatalysts, namely TiO2, Fe(III)-grafted TiO2, and Cu(II)-grafted WO3, we assessed the magnitude of odour and tar component adsorption on the fabric fibres, as well as the decomposition of these species after specific visible light or UV irradiation periods. Considering the expansion of our technology for practical applications, the best results among the three tested materials were obtained for non-woven fabric-supported Fe/TiO2. We believe that our technology can be implemented in the design of interior decoration materials for creating a comfortable environment.