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Committee on Environmental Hazards Involuntary Smoking-A Hazard to Children , 4 0 Children who live in households with smokers are involuntarily exposed to sidestream and second- hand cigarette smoke. The health hazards that re- sult from passive smoking will be reviewed. This statement updates a 1982 American Academy of' Pediatrics statement on the environmental conse- quences of tobacco smoking.' COMPOSITION OF SIDESTREAM AND SECONDHAND SMOKE Sidestream smoke arises from the burning end of a cigarette.2•' Secondhand or exhaled mainstream smoke is drawn into the respiratory tract of the smoker and then is exhaled. Both sidestream and secondhand smoke contain measurable quantities of such toxins as carbon monoxide (CO), ammonia, nicotine, and hydrogen cyanide. They also contain carcinogens, including benzo[a]pyrene, dimethyl- nitrosamine, tar, formaldehyde, and fl-naphthyla- mine.-' Concentrations of most of these materials are higher in sidestream than in mainstream smoke.-' Air-sampling surveys have documented the involuntary exposure of nonsmokers to the prod- ucts of cigarette combustion." These studies have shown that smoking in enclosed rooms can produce CO levels greater than the national ambient air quality standard of 9 ppm.° Similarly, elevated con- centrations of airborne nicotine, benzo(a]pyrene, and suspended particulates have been documented.° Biologic evaluations of nonsmokers involuntarily exposed to cigarette smoke have demonstrated ele- vations of 1% to 3% in carboxyhemoglobin concen- tration:' Biologic evaluations of involuntary smok- ers have also found increased levels of nicotine and of cotinine,` the major metabolite of nicotine, in the urine and saliva. In addition, studies have dern- onstrated increased activity of enzymes that metab- olize benzo[a]pyrene in the placentas of women who smoke" and, possibly, in the placentas of women involuntarily exposed to cigarette smoke 9 Finally, increased urinary excretion of mutagens has been found in involuntary smokers.1° 0 PEDIATRICS (ISSN 0031 4005). Copyright n 1986 by the American Academy of Pediatrics. SIZE OF THE EXPOSED POPULATION No firm estimates of the number of American children involuntarily exposed to cigarette smoke are available. However, recent surveys have found that 53% to 76% of the homes in the United States contain at least one smoker.3 Application of these rates to the 1980 US Census indicates that between 8.7 and 12.4 million American children less than 5 years of age are exposed to cigarette smoke in their homes. Because smoking is most common in fami- lies of lower socioeconomic status," involuntary smoking occurs more frequently among children in such families. ACUTE HEALTH EFFECTS OF INVOLUNTARY SMOKING Bronchitis, pneumonia, and respiratory syncytial virus (RSV) infection have all been found to occur more often in the children of parents who smoke than in the children of parents who do not smoke."•'" Furthermore, the frequency of these res- piratory infections have been found to increase with the amount of parental smoking; children with two parents who smoke have significantly more infec- tions than children with only one parent who smokes. Maternal smoking relates more closely to childhood respiratory infection than paternal smoking. The association between parental smok- ing and childhood respiratory infection is most strongly evident during the first 1 to 2 years of life and diminishes thereafter.14 ` 6 Respiratory symptoms, persistent wheeze in par- ticular, have also been reported to be more frequent in children whose parents smoke than in children whose parents do not smoke."•"-20 The frequency of these symptoms increases with the number of parents who smoke. The association is strongest in the first year of life.21 LONG-TERM HEALTH EFFECTS OF INVOLUNTARY SMOKING Children of parents who smoke have been found to have small, but significant, decreases in pulmo- N Q N '"1 PEDIATRICS Vol. 77 No. 5 May 1986 755 ~ ~ ~ ~ ~ ~

nary function compared with children whose par- ents do not smoke."•'".'2-1' These deficits are pri- marily obstructive and are manifest either by de- creased forced expiratory volumes (FEV,.,o or FEB0.75) or decreased forced expiratory flow (FEF15-;5). These effects are more closely related to maternal than to paternal smoking. Several studies have suggested there is a dose-response relationship between the number of smokers in the home and the degree of obstructive impairment. Functional deficits appear to be more serious in younger than in older children. Longitudinal follow-up of children whose parents smoke indicates that their annual rate of lung growth is significantly less than expected."•2' The subsequent failure of such children to attain their full, genetically determined level of pulmonary function may predispose them to chronic obstruc- tive lung disease and premature pulmonary failure. INVOLUNTARY SMOKING AND LUNG CANCER Several studies have evaluated the association between involuntary smoking and lung cancer. A case-control study in Greecez"7 and a longitudinal prospective study in Japan'R both found a statisti- cally significant association between the occurrence of lung cancer in nonsmoking women and smoking by their husbands. In both studies, the wives' risk of lung cancer increased two- to threefold according to the amount of the husband's smoking; in both studies, dose-response relationships were evident between the amount of involuntary exposure to smoke and cancer mortality."2s However, a study by the American Cancer Society failed to find a statistically significant increase in lung cancer in the nonsmoking wives of husbands who smoked, although that study did observe a nonsignificant trend in lung cancer mortality.' Finally, recent studies from the National Institutes of Health have observed a positive association between cumulative lifetime exposure to passive smoking and overall cancer risk 31-` Cancer risks were greatest for per- sons whose involuntary exposure to smoke began in childhood and continued through adult life. INVOLUNTARY SMOKING AND ISCHEMIC HEART DISEASE A recent study of older adults found that the nonsmoking wives of men who smoked had a higher age-adjusted death rate from ischemic heart disease than did women whose husbands had never smoked.f4 This difference remained evident after adjustment of the data for differences in cardiac risk factors. CONCLUSIONS The involuntary exposure of children to tobacco 756 INVOLUNTARY SMOKING smoke results in increased frequency of lower res- piratory tract infections, increased frequency of respiratory symptoms, decreased pulmonary func- tion, and decreased lung growth. In addition, invol- untary exposure of children to cigarette smoke may result in predisposition to the development ,; f chronic obstructive lung disease, lung cancer, ;,nd ischemic heart disease. Although further research will be required to establish these associations, all are biologically plausible consequences of involun- tary smoking. Furthermore, all are of sufficient importance to children's future health that they demand prudent preventive action even in the ab- sence of complete evidence on causality. RECOMMENDATIONS Vigorous and immediate action is required to reduce the involuntary exposure of children to to- bacco smoke. Because the determinants of passive smoking are manifold, a successful strategy to re- duce passive smoking must consist of several com- plementary elements: 1. Pediatricians should seek a history of invu':- untary exposure to tobacco smoke whenever the_ encounter a child with lower respiratory tract in- fection, persistent respiratory symptoms, or unex- plained alterations in lung function ? 2. Pediatricians must increase their efforts to inform both patients and parents about the hazards of tobacco.' 3. Pediatricians should set an example by not using tobacco products.' 4. Pediatricians should take the lead in urginF that (a) sales of all tobacco products be banned in all pediatric hospitals and in other facilities caring for children35 and (b) cigarette smoking be banned in all such facilities, except in certain designated areas.'s 5. Pediatricians and Academy chapters should urge their state and local governments to consider passage of clean indoor air legislation. Such legis- lation prohibits all indoor smoking, except in areas where it is specifically permitted; this legislation has been passed successfully in several states.:"-: "' 6. Pediatricians and Academy chapters should encourage the Congress and the Federal Trade Commission to (a) ban all advertising in all media for all tobacco products39,40; (b) sponsor counter- advertisements, particularly on television, to in- form the public of the dangers of tobacco; (c) strengthen the health warnings that appear on cig- arette packages; such messages should specifically warn of the hazards of involuntary smoking; and (d) increase the federal excise tax on all tobacco products. Higher excise taxes have been shown to be an effective deterrent in the purchase of to- bacco! ` zo215'7ss3o O

7. Pediatricians and Academy chapters should urge Congress to dismantle the tobacco price sup- port program.' 1 REFERENCES COMMITTEE ON ENVIRONMENTAL HAZARDS, 1984-1985 Philip J. Landrigan, MD, Chairman John H. DiLiberti, MD John W. Graef, MD Richard J. Jackson, MD Gerald Nathenson, MD Liaison Representatives Henry Falk, MD Robert W. Miller, MD Walter Rogan, MD Diane Rowley, MD Section Liaison Audrey K. Brown, MD 1. American Academy of Pediatrics, Committee on Genetics and Environmental Hazards: The environmental conse- quences of tobacco smoking: Implications for public policies that affect the health of children. 1'ediatrics 1982;70:314- 315 2. The Health Consequences of Smoking-A Report of the Sur- geon General, chapter 7: Passive Smoking. US Department of Health and Human Services, Public Health Service, 1984 3. National Research Council: Indoor Pollutants. Washington, National Academy Press, 1981 4. US Department of Health, Education, and Welfare, Public Health Service/Centers for Disease Control. Highlights of the Surgeon General's report on smoking and health. MMWR 1979;28:1-11 5. Huch R, Danko J, Spatting L, et al: Risks the passive smoker runs. Lancet 1980;2:1376 6. Greenberg RA, Haley NJ, Etzel RA, et at: Measuring the exposure of infants to tobacco smoke: Nicotine and cotinine in urine and saliva. N h,'ngl J Med 1984:310:1075-1078 7. Matsukura S, Taminato T, Kitano N, et al: Effects of environmental tobacco smoke on urinary cotinine excretion in non-smokers: Evidence for passive smoking. N Engl J Med 1984;311:828-832 8. Welch RM, Harrison YE, Conney AH, et at: Cigarette smoking: Stimulatory effect on metabolism 3,4-benzopyrene by enzymes in human placenta. Science 1968;160:541-542 9. Manchester DK, Jacoby EH: Sensitivity of human placental monooxygenase activity to maternal smoking- Clin Phar- macol Ther 1981;30:687-692 10. Bos RP, Theuws JLG, Henderson PTH: Excretion of mtr tagens in human urine after passive smoking. Cancer Lett 19&3;19:&5-90 i l. Covey LS, Mushinski MH, Wynder EL: Smoking habits in a hospitalized population: 1970-1980. Am J Public Health 1983;73:1293-1297 12. Colley J RT, Holland W W, Corkhill RT: Influence of passive smoking and parental phlegm on pneumonia and bronchitis in early childhood. Lancet 1974;2:1031-1034 13. Pullan CR, Hey EN: Wheezing, asthma, and pulmonary dysfunction 10 years after infection with respiratory syncy- tial virus in infancy. Br Med J 1982;284:1665-1669 14. Harlap S, Davies AM: Infant admissions to hospital and ~ maternal smoking. Lancet 1974;1:529-532 15. Fergusson DM, Horwood LJ, Shannon FT, et at• Parental smoking and lower respiratory illness in the first three years of life. J Epidemiol Commun Health 1981;35-180-184 16. Schenker MB, Samet JM, Speizer FE: Risk factors for childhood respiratory disease: The effect of host factors and home environment exposures. Am Rev Respir Dis 1983;128:1038-1043 17. Ware JH, Dockery DW, Spiro A III, et al: Passive smoking, gas cooking, and respiratory health of children living in six cities. Am Rev Respir Dis 1984;129:366-374 18. Weiss ST, Tager IB, Speizer FE, et at: Persistent wheeze: Its relation to respiratory illness, cigarette smoking, and level of pulmonary function in a population sample of chil- dren. Am Rev Respir Dis 1980;122:697-707 19. Lebowitz MD, Burrows B: Respiratory symptoms related to smoking habits of family adults. Chest 1976;69:48-50 20. Dodge R: The effects of indoor pollution on Arizona chil- dren. Arch Environ Health 1982;37:151-155 21. Pedreira FA, Guandolo VL, Feroli E.1, et at: Involuntary smoking and incidence of respiratory illness during the first year of life. Pediatrics 1985;75:594-597 22. Tashkin DP, Clark VA, Simmons M, et al: The UCLA population studies of chronic obstructive respiratory disease: VIL Relationship between parental smoking and children's lung function. Am Rev Respir Dis 1984;129:891-897 23. Vedal S, Schenker MB, Samet JM, et at: Risk factors for childhood respiratory disease: Analysis of pulmonary func- tion. Am Rev Respir Dis 1984;130:187-192 24. Tager IB, Weiss ST, Rosner B, et at: Effect of parental cigarette smoking on the pulmonary function of children. Am J Epidemiol 1979;110:1.5-26 25. Tager 113, Weiss ST, Munoz A, el al: Longitudinal study of the effects of maternal smoking on pulmonary function in children. N Engl J Med 1983;309:699-703 26- Trichopoulos I), Kalandidi A, Sparros L, et at: Lung cancer and passive smoking. Int J Cancer 1981;27:1-4 27. Trichopoulos D, Kalandidi A, Sparros L: Lung cancer and passive smoking: Conclusion of Greek study. Lancet 1983;2:677-678 28. Hirayama T: Non-smoking wives of heavy smokers have a higher risk of lung cancer: A study from Japan. Br Med J 1981;282:183-1&5 29. Garfinkel L: Time trends in lung cancer mortality among nonsmokers and a note on passive smoking. JNCI 1981;66:1061-1066 30. Correa P, Pickle LN1', Fontham E, et at: Passive smoking and lung cancer. Lancet 1983;2::i9ri-b97 31. Sandler DP, Everson RB, Wilcox A.1: Passive smoking in adulthood and cancer risk. Am J F.pidemiol 19&5;121:37-48 32. Sandler DP, Wilcox AJ, Everson RB: Cumulative effects of lifetime passive smoking on cancer risk. Lancet 1985;1:312- 315 33. Sandler DP, Everson RB, Wilcox A.I, et at: Cancer risk in adulthood frmn early life exposure to parents' smoking. Am J Public Health 19&5;75:487-492 34. Garland C, Barrett-Connor E, Suarez L, et at: Effects of passive smoking on ischemic heart disease mortality of nonsmokers: A prospective study. Am J Epidemiol 19&5;12 L•645-650 35. The American Public Health Association: Cigarette sales and smoking in pharmacies, health facilities and health agencies. Am J Public Health 198.5;75:300 36. Hall FM: Smoking in the physician's work place. N Engl J Med 1985;312:1197-1198 37. Kahn PL: The Minnesota clean indoor air act: A model for New York and other states. NY State J Med 1983;83:1300- 1301 38. Tate CF Jr: A physician-led referendum for cleaner air in Florida. NY State J Med 1983;83:1302 39. Warner KE: Cigarette advertising and media coverage of smoking and health. N F,'ngl J Med 1985;312:384-388 40. Koop CE: A dialogue with Surgeon General Koop: Confront- ing America's most costly health problem (interview by Alan Blum). NY State J Med 19&3;83:1260-1263 41. Warner KE: Cigarette taxation: Doing good by doing well. J Public Health Policy 1984;5:312-319 AMERICAN ACADEMY OF PEDIATRICS 757