Secondhand Smoke – The Times They Are a’Changing

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March 7, 2018

It seems almost comical now, looking back to measures that were taken to reduce SHS exposure – non-smoking sections in airplanes. You can smoke in row 11 when the non-smoking section was rows 1-10. You could smoke on one side of a restaurant without concern for the SHS exposure to your waitstaff and to the diners two tables away from you. When the hospitals went smoke free, walking out of the side entrance was like walking into a smoke cloud, with all the smokers (many of whom were health professionals) gathered outside in the cold to satisfy their cravings.

Tobacco use is the single largest preventable cause of disease, disability and death in the US. Fifty percent of adults who continue to smoke will die from smoking-related causes. And for each of those deaths, 20 people suffer from smoking-related diseases – these are MY patients!

In 1964, the Surgeon General first warned that smoking was dangerous to your health and that warning was printed on every pack of cigarettes. It wasn’t until almost 30 years later in 1993, that the dangers of secondhand smoke (SHS) were part of another announcement by the Surgeon General. SHS refers to the mainstream smoke that the smoker exhales as well as the side stream smoke from the smoldering cigarette. It contains the same 7000 chemicals as firsthand smoke, but in lower concentrations.

This is now 25 years later – a good time to look back at how policy has evolved.

Over the years, with the knowledge that SHS is harmful, non-smokers have been favored in legislation. They have the right to not be subject to carcinogens and irritants from other people’s smoke.

In 1993, when the risk of SHS was acknowledged, smoking was prohibited in schools, daycare centers and other educational facilities that received federal funds and served children under 18. Since then, 25 states and D.C. and Puerto Rico have enacted statewide 100% smoke-free laws covering all indoor areas of workplaces, including all bars and restaurants. I was pleased to learn recently that some of the outdoor patios of restaurants in this area have now become smoke free as well, to protect their waitstaff and other patrons.

“If you share the building, you share the air. “ The American Society of Heating, Refrigerating and Air Conditioning Engineers states that indoor air quality can’t be achieved if smoking is allowed, even with special apartment units that filter particles and gases. The volume of air in the building is just too great. In that vein, Housing and Urban Development has declared that as of 7/31/2018, in all public housing units, smoking will be prohibited in the building and for 25 feet around the perimeter of the building. The Environmental Protection Agency estimates that this move will save almost $100 million in smoke-related health care costs.

Some private buildings in this area have also chosen to go smoke-free. Some may ask whether this is discriminatory against smokers. The answer is no – because smokers may still live there and they may continue to smoke. They just can’t smoke in the areas delineated in their contract, because their smoking impacts their neighbors’ health.

The ‘firsthand’ risks, which accrue to the smoker, are well known. There is an increased risk of heart attacks and strokes, asthma exacerbations, bronchitis and emphysema, and lung cancer, as well as many other cancers. The most common of these involve the mouth and vocal cords, esophagus, stomach, liver and colon, and the kidneys and urinary bladder.

The risks of SHS include heart disease, strokes and lung cancer. In pregnant women, the chemicals absorbed by the mom are transmitted to the fetus. If the mom smokes, it can lead to an increased risk of low birth weight infants, stillbirths and increased incidence of SIDS (Sudden Infant Death Syndrome) and non-chromosomal birth defects of the bones, limbs and GI tract. The risk is less with SHS but does exist.

Children who are exposed to SHS have an increased incidence of ear infections and asthma. In the first year of life, they have more bronchitis and pneumonia. As high school athletes, they have reduced air flow typical of asthma and have more coughing. Growing evidence suggests that these children have an increased risk of heart disease and stroke, high blood pressure, and lung cancer decades later. Even more importantly, children of smokers are twice as likely to become smokers themselves.

Now, there is research ongoing into ’thirdhand’ smoke. If you walk into a room days after a smoker has lit up, you could probably tell someone had been smoking. There are chemical residues on the floor, walls and furniture, that could potentially be absorbed through the skin, or ingested by a child from the skin. When the heat is turned on, these chemicals can be off-gassed from the walls and potentially inhaled again. Although these chemicals include carcinogens, it is not yet clear what the health implications are. We may be hearing more about this in the future.

So how are we doing with smoking cessation – i.e., the elimination of first, second AND thirdhand smoke exposure? We’re getting there. In the overall U.S. adult population, about 20% are smokers – millions less than in 2000. In Maryland, 16-19% of adults smoke. The MAJORITY of adults who have ever smoked have since quit. Eighty percent of smokers would like to stop, and each attempt has about a 30% success rate initially, but at a year is down to half of that. It’s always worth another try – and another and another.

Quitting is difficult – sometimes even more difficult that quitting heroin or alcohol. Evidently cigarette structure has changed over the years so that nicotine is delivered more quickly and in greater quantities, making the addiction even more powerful. The tobacco industry has spent billions of dollars researching how to maximize dependency.

Stopping smoking is so difficult because of nicotine withdrawal. This includes cravings that usually peak in 3 days and last for weeks, sometimes up to a year. Some people say they never get over it. (On the other hand, many smokers become sickened by the smell of smoke as soon as they’ve quit.) In addition, there can be increased appetite and weight gain, depression, irritability, anxiety, decreased concentration and insomnia. Any of these can be a deterrent to quitting.

To help with nicotine withdrawal, there are nicotine replacement products and other medications. The over-the-counter ones include nicotine patches, gum and lozenges. The prescription ones are a nasal inhaler, an equivalent of a plastic cigarette, and oral medications Chantix and Zyban. Many people prefer the cigarette form because it feels familiar and helps overcome cravings.

Helpful programs can be found at and 1-800-QUIT-NOW. If you or someone you know smokes and would like to quit, check out these resources and talk to your doctor. Be supportive if someone is going through withdrawal – it’s not easy but will pay off in the long run. The greatest reduction in illness and death occurs with quitting at an earlier age, but it has been shown that even quitting at age 80 is beneficial. It’s never too late!