Passive smoking - Wikipedia

Passive smoking is the inhalation of tobacco smoke, called secondhand smoke (SHS), or environmental tobacco smoke (ETS), by persons other than the intended ... Passivesmoking FromWikipedia,thefreeencyclopedia Jumptonavigation Jumptosearch Inhalationofsmokebypersonsotherthantheintendedactivesmoker "Secondhandsmoke"redirectshere.FortheSublimealbum,seeSecond-handSmoke. IthasbeensuggestedthatSidestreamsmokebemergedintothisarticle.(Discuss)ProposedsinceOctober2021. TobaccosmokeinanIrishpubbeforeasmokingbancameintoeffectonMarch29,2004 Passivesmokingistheinhalationoftobaccosmoke,calledsecondhandsmoke(SHS),orenvironmentaltobaccosmoke(ETS),bypersonsotherthantheintended"active"smoker.Itoccurswhentobaccosmokeentersanenvironment,causingitsinhalationbypeoplewithinthatenvironment.Exposuretosecondhandtobaccosmokecausesdisease,disability,anddeath.[1][2]Thehealthrisksofsecondhandsmokeareamatterofscientificconsensus.[3][4][5]Theseriskshavebeenamajormotivationforsmoke-freelawsinworkplacesandindoorpublicplaces,includingrestaurants,barsandnightclubs,aswellassomeopenpublicspaces.[6] Concernsaroundsecondhandsmokehaveplayedacentralroleinthedebateovertheharmsandregulationoftobaccoproducts.Sincetheearly1970s,thetobaccoindustryhasviewedpublicconcernoversecondhandsmokeasaseriousthreattoitsbusinessinterests.[7]Harmtobystanderswasperceivedasamotivatorforstricterregulationoftobaccoproducts.Despitetheindustry'sawarenessoftheharmsofsecondhandsmokeasearlyasthe1980s,thetobaccoindustrycoordinatedascientificcontroversywiththepurposeofstoppingregulationoftheirproducts.[3]: 1242 [5] Contents 1Effects 1.1Risktochildren 2Evidence 2.1Exposureandrisklevels 2.2Interventionstoreduceenvironmentaltobaccosmoke 2.3Biomarkers 2.3.1Cotinine 2.3.2Carbonmonoxide(CO) 3Pathophysiology 4Opinionofpublichealthauthorities 5Publicopinion 6Controversyoverharm 6.1Industry-fundedstudiesandcritiques 6.1.1EnstromandKabat 6.1.2Gori 6.1.3Milloy 6.1.4LevoisandLayard 6.1.5WorldHealthOrganizationcontroversy 6.1.6EPAlawsuit 6.1.7Tobacco-industryfundingofresearch 6.2Tobaccoindustryresponse 6.2.1Positionofmajortobaccocompanies 6.3USracketeeringlawsuitagainsttobaccocompanies 7Smoke-freelaws 7.1Effects 7.2Publicopinion 7.3Alternativeforms 8Inanimals 8.1Observationalstudies 9Terminology 10Seealso 11References 12Externallinks Effects Secondhandsmokecausesmanyofthesamediseasesasdirectsmoking,includingcardiovasculardiseases,lungcancer,andrespiratorydiseases.[1][2][8]Thesediseasesinclude: Cancer: General:overallincreasedrisk;[9]reviewingtheevidenceaccumulatedonaworldwidebasis,theInternationalAgencyforResearchonCancerconcludedin2004that"Involuntarysmoking(exposuretosecondhandor'environmental'tobaccosmoke)iscarcinogenictohumans."[2]TheCentersforDiseaseControlandPreventionreportsthatabout70chemicalspresentinsecondhandsmokearecarcinogenic.[10] Lungcancer:passivesmokingisariskfactorforlungcancer.[11][12]IntheUnitedStatespassivesmokeisestimatedtocausemorethan7,000deathsfromlungcancerayearamongnon-smokers.[13]Aquarterofallcasesoccurinpeoplewho'veneversmoked.[14] Breastcancer:TheCaliforniaEnvironmentalProtectionAgencyconcludedin2005thatpassivesmokingincreasestheriskofbreastcancerinyounger,primarilypremenopausalfemalesby70%[8]andtheUSSurgeonGeneralhasconcludedthattheevidenceis"suggestive",butstillinsufficienttoassertsuchacausalrelationship.[1]Incontrast,theInternationalAgencyforResearchonCancerconcludedin2004thattherewas"nosupportforacausalrelationbetweeninvoluntaryexposuretotobaccosmokeandbreastcancerinnever-smokers."[2]A2015meta-analysisfoundthattheevidencethatpassivesmokingmoderatelyincreasedtheriskofbreastcancerhadbecome"moresubstantialthanafewyearsago".[15] Pancreaticcancer:A2012meta-analysisfoundnoevidencethatpassivesmokingwasassociatedwithanincreasedriskofpancreaticcancer.[16] Cervicalcancer:A2015overviewofsystematicreviewsfoundthatexposuretosecondhandsmokeincreasedtheriskofcervicalcancer.[17] Bladdercancer:A2016systematicreviewandmeta-analysisfoundthatsecondhandsmokeexposurewasassociatedwithasignificantincreaseintheriskofbladdercancer.[18] Circulatorysystem:riskofheartdisease,[19][20]reducedheartratevariability.[21] Epidemiologicalstudieshaveshownthatbothactiveandpassivecigarettesmokingincreasetheriskofatherosclerosis.[22] Passivesmokingisstronglyassociatedwithanincreasedriskofstroke,andthisincreasedriskisdisproportionatelyhighatlowlevelsofexposure.[23] Lungproblems: Riskofasthma.[24] Riskofchronicobstructivepulmonarydisease(COPD)[25] Accordingtoa2015review,passivesmokingmayincreasetheriskoftuberculosisinfectionandacceleratetheprogressionofthedisease,buttheevidenceremainsweak.[26] Themajorityofstudiesontheassociationbetweensecondhandsmokeexposureandsinusitishavefoundasignificantassociationbetweenthetwo.[27] Cognitiveimpairmentanddementia:Exposuretosecondhandsmokemayincreasetheriskofcognitiveimpairmentanddementiainadults50andover.[28]Childrenexposedtosecondhandsmokeshowreducedvocabularyandreasoningskillswhencomparedwithnon-exposedchildrenaswellasmoregeneralcognitiveandintellectualdeficits.[29] Mentalhealth:Exposuretosecondhandsmokeisassociatedwithanincreasedriskofdepressivesymptoms.[30] Duringpregnancy: Miscarriage:a2014meta-analysisfoundthatmaternalsecondhandsmokeexposureincreasedtheriskofmiscarriageby11%.[31] Lowbirthweight[8],partB,ch.3.[32] Prematurebirth[8],partB,ch.3[33](Notethatevidenceofthecausallinkisdescribedonlyas"suggestive"bytheUSSurgeonGeneralinhis2006report.[34])Lawslimitingsmokingdecreaseprematurebirths.[35] Stillbirthandcongenitalmalformationsinchildren[36] RecentstudiescomparingfemalesexposedtoEnvironmentalTobaccoSmokeandnon-exposedfemales,demonstratethatfemalesexposedwhilepregnanthavehigherrisksofdeliveringachildwithcongenitalabnormalities,longerlengths,smallerheadcircumferences,andlowbirthweight.[37] General: Worseningofasthma,allergies,andotherconditions.[38]A2014systematicreviewandmeta-analysisfoundthatpassivesmokingwasassociatedwithaslightlyincreasedriskofallergicdiseasesamongchildrenandadolescents;theevidenceforanassociationwasweakerforadults.[39] Type2diabetes.[40][41][42]Itremainsunclearwhethertheassociationbetweenpassivesmokinganddiabetesiscausal.[43] RiskofcarryingNeisseriameningitidisorStreptococcuspneumoniae.[17] Apossibleincreasedriskofperiodontitis.[44] Overallincreasedriskofdeathinbothadults,whereitisestimatedtokill53,000nonsmokersperyear,makingitthethirdleadingcauseofpreventabledeathintheU.S,[45][46]andinchildren.[47]TheWorldHealthOrganizationstatesthatpassivesmokingcausesabout600,000deathsayear,andabout1%oftheglobalburdenofdisease.[48]Asof2017,passivesmokingcausesabout900,000deathsayear,whichisabout1/8ofalldeathscausedbysmoking.[49] Skinconditions:A2016systematicreviewandmeta-analysisfoundthatpassivesmokingwasassociatedwithahigherrateofatopicdermatitis.[50] Risktochildren Suddeninfantdeathsyndrome(SIDS).[51]Inhis2006report,theUSSurgeonGeneralconcludes:"Theevidenceissufficienttoinferacausalrelationshipbetweenexposuretosecondhandsmokeandsuddeninfantdeathsyndrome."[52]Secondhandsmokinghasbeenestimatedtobeassociatedwith430SIDSdeathsintheUnitedStatesannually.[53] Asthma.[54][55][56]Secondhandsmokeexposureisalsoassociatedwithanalmostdoubledriskofhospitalizationforasthmaexacerbationamongchildrenwithasthma.[57] Lunginfections,[58][59][60]alsoincludingmoresevereillnesswithbronchiolitis[61]andbronchitis,[62]andworseoutcome,[61]aswellasincreasedriskofdevelopingtuberculosisifexposedtoacarrier.[63]IntheUnitedStates,itisestimatedthatsecondhandsmokehasbeenassociatedwithbetween150,000and300,000lowerrespiratorytractinfectionsininfantsandchildrenunder18monthsofage,resultinginbetween7,500and15,000hospitalizationseachyear.[53] Impairedrespiratoryfunctionandslowedlunggrowth[62] Allergies[64] Maternalpassivesmokingincreasestheriskofnon-syndromicorofacialcleftsby50%amongtheirchildren.[65] Prenatalandchildhoodpassivesmokeexposuredoesnotappeartoincreasetheriskofinflammatoryboweldisease.[66] Learningdifficulties,developmentaldelays,executivefunctionproblems,[67]andneurobehavioraleffects.[68][69]Animalmodelssuggestarolefornicotineandcarbonmonoxideinneurocognitiveproblems.[60] Anincreaseintoothdecay(aswellasrelatedsalivarybiomarkers)hasbeenassociatedwithpassivesmokinginchildren.[70] Increasedriskofmiddleearinfections.[60][71][72] Invasivemeningococcaldisease.[17][73] Maternalexposuretosecondhandsmokeexposureduringpregnancyisassociatedwithanincreasedriskofneuraltubedefects.[74] Anesthesiacomplicationsandsomenegativesurgicaloutcomes.[75] Sleepdisorderedbreathing:Moststudieshavefoundasignificantassociationbetweenpassivesmokingandsleepdisorderedbreathinginchildren,butfurtherstudiesareneededtodeterminewhetherthisassociationiscausal.[76] Adverseeffectsonthecardiovascularsystemofchildren.[77] Evidence Exposuretosecondhandsmokebyage,race,andpovertylevelintheUSin2010 Epidemiologicalstudiesshowthatnon-smokersexposedtosecondhandsmokeareatriskformanyofthehealthproblemsassociatedwithdirectsmoking. In1992,areviewestimatedthatsecondhandsmokeexposurewasresponsiblefor35,000to40,000deathsperyearintheUnitedStatesintheearly1980s.[78]TheabsoluteriskincreaseofheartdiseaseduetoETSwas2.2%,whiletheattributableriskpercentwas23%.A1997meta-analysisfoundthatsecondhandsmokeexposureincreasedtheriskofheartdiseasebyaquarter,[79]andtwo1999meta-analysesreachedsimilarconclusions.[80][81] Evidenceshowsthatinhaledsidestreamsmoke,themaincomponentofsecondhandsmoke,isaboutfourtimesmoretoxicthanmainstreamsmoke.Thisfacthasbeenknowntothetobaccoindustrysincethe1980s,thoughitkeptitsfindingssecret.[82][83][84][85]Somescientistsbelievethattheriskofpassivesmoking,inparticulartheriskofdevelopingcoronaryheartdiseases,mayhavebeensubstantiallyunderestimated.[86] In1997,ameta-analysisontherelationshipbetweensecondhandsmokeexposureandlungcancerconcludedthatsuchexposurecausedlungcancer.Theincreaseinriskwasestimatedtobe24%amongnon-smokerswholivedwithasmoker.[87]In2000,CopasandShireportedthattherewasclearevidenceofpublicationbiasinthestudiesincludedinthismeta-analysis.Theyfurtherconcludedthataftercorrectingforpublicationbias,andassumingthat40%ofallstudiesareunpublished,thisincreasedriskdecreasedfrom24%to15%.[88]Thisconclusionhasbeenchallengedonthebasisthattheassumptionthat40%ofallstudiesareunpublishedwas"extreme".[2]: 1269 In2006,Takagietal.reanalyzedthedatafromthismeta-analysistoaccountforpublicationbiasandestimatedthattherelativeriskoflungcanceramongthoseexposedtosecondhandsmokewas1.19,slightlylowerthantheoriginalestimate.[89]A2000meta-analysisfoundarelativeriskof1.48forlungcanceramongmenexposedtosecondhandsmoke,andarelativeriskof1.16amongthoseexposedtoitatwork.[90]Anothermeta-analysisconfirmedthefindingofanincreasedriskoflungcanceramongwomenwithspousalexposuretosecondhandsmokethefollowingyear.Itfoundarelativeriskoflungcancerof1.29forwomenexposedtosecondhandsmokefromtheirspouses.[91]A2014meta-analysisnotedthat"theassociationbetweenexposuretosecondhandsmokeandlungcancerriskiswellestablished."[92] Aminorityofepidemiologistshavefoundithardtounderstandhowsecondhandsmoke,whichismoredilutedthanactivelyinhaledsmoke,couldhaveaneffectthatissuchalargefractionoftheaddedriskofcoronaryheartdiseaseamongactivesmokers.[93][94]Oneproposedexplanationisthatsecondhandsmokeisnotsimplyadilutedversionof"mainstream"smoke,buthasadifferentcompositionwithmoretoxicsubstancespergramoftotalparticulatematter.[93]Passivesmokingappearstobecapableofprecipitatingtheacutemanifestationsofcardio-vasculardiseases(atherothrombosis)andmayalsohaveanegativeimpactontheoutcomeofpatientswhosufferacutecoronarysyndromes.[95] In2004,theInternationalAgencyforResearchonCancer(IARC)oftheWorldHealthOrganization(WHO)reviewedallsignificantpublishedevidencerelatedtotobaccosmokingandcancer.Itconcluded: Thesemeta-analysesshowthatthereisastatisticallysignificantandconsistentassociationbetweenlungcancerriskinspousesofsmokersandexposuretosecond-handtobaccosmokefromthespousewhosmokes.Theexcessriskisoftheorderof20%forwomenand30%formenandremainsaftercontrollingforsomepotentialsourcesofbiasandconfounding.[2] Subsequentmeta-analyseshaveconfirmedthesefindings.[96][97] TheNationalAsthmaCouncilofAustraliacitesstudiesshowingthatsecondhandsmokeisprobablythemostimportantindoorpollutant,especiallyaroundyoungchildren:[98] Smokingbyeitherparent,particularlybythemother,increasestheriskofasthmainchildren. Theoutlookforearlychildhoodasthmaislessfavourableinsmokinghouseholds. Childrenwithasthmawhoareexposedtosmokinginthehomegenerallyhavemoreseveredisease. ManyadultswithasthmaidentifyETSasatriggerfortheirsymptoms. Doctor-diagnosedasthmaismorecommonamongnon-smokingadultsexposedtoETSthanthosenotexposed.Amongpeoplewithasthma,higherETSexposureisassociatedwithagreaterriskofsevereattacks. InFrance,exposuretosecondhandsmokehasbeenestimatedtocausebetween3,000[99]and5,000prematuredeathsperyear,withthelargerfigurecitedbyPrimeMinisterDominiquedeVillepinduringhisannouncementofanationwidesmoke-freelaw:"Thatmakesmorethan13deathsaday.Itisanunacceptablerealityinourcountryintermsofpublichealth."[100] Thereisgoodobservationalevidencethatsmoke-freelegislationreducesthenumberofhospitaladmissionsforheartdisease.[101][102] Exposureandrisklevels TheInternationalAgencyforResearchonCanceroftheWorldHealthOrganizationconcludedin2004thattherewassufficientevidencethatsecondhandsmokecausedcancerinhumans.[2]Thosewhoworkinenvironmentswheresmokeisnotregulatedareathigherrisk.[103][97]Workersparticularlyatriskofexposureincludethoseininstallationrepairandmaintenance,constructionandextraction,andtransportation.[104] Muchresearchhascomefromstudiesofnonsmokerswhoaremarriedtoasmoker.TheUSSurgeonGeneral,inhis2006report,estimatedthatlivingorworkinginaplacewheresmokingispermittedincreasesthenon-smokers'riskofdevelopingheartdiseaseby25–30%andlungcancerby20–30%.[105]SomecontraryresearchisreviewedinUnluckyStrike:PrivateHealthandthescience,lawandpoliticsofsmoking.[106] Similarly,childrenwhoareexposedtoenvironmentaltobaccosmokeareshowntoexperiencearangeofadverseeffects[107][108][109]andahigherriskofbecomingsmokerslaterinlife.[110]TheWHOhasidentifiedreductionofexposuretoenvironmentaltobaccosmokeaskeyelementforactionstoencouragehealthychilddevelopment.[111] TheUSCentersforDiseaseControlandPreventionmonitorstheextentofandtrendsinexposuretoenvironmentaltobaccosmokebymeasuringserumcotinineinnationalhealthsurveys.[112]TheprevalenceofsecondhandsmokeexposureamongU.S.nonsmokersdeclinedfrom87.5%in1988to25.2%in2014.However,nearlyhalfofblacksandthepoorwereexposedin2014. Interventionstoreduceenvironmentaltobaccosmoke Asystematicreviewcomparedsmokingcontrolprogrammesandtheireffectsonsmokeexposureinchildren.Thereviewdistinguishesbetweencommunity-based,ill-childandhealthy-childsettingsandthemostcommontypesofinterventionswerecounsellingorbriefadviceduringclinicalvisits.Thereviewdidnotfindsuperioroutcomesforanyintervention,andtheauthorscautionthatevidencefromadultsettingsmaynotgeneralisewelltochildren.[113] Biomarkers BreathCOmonitordisplayingcarbonmonoxideconcentrationofanexhaledbreathsample(inppm)withcorrespondingpercentconcentrationofcarboxyhemoglobindisplayedbelow Environmentaltobaccosmokecanbeevaluatedeitherbydirectlymeasuringtobaccosmokepollutantsfoundintheairorbyusingbiomarkers,anindirectmeasureofexposure.Carbonmonoxidemonitoredthroughbreath,nicotine,cotinine,thiocyanates,andproteinsarethemostspecificbiologicalmarkersoftobaccosmokeexposure.[114][115]Biochemicaltestsareamuchmorereliablebiomarkerofsecondhandsmokeexposurethansurveys.Certaingroupsofpeoplearereluctanttodisclosetheirsmokingstatusandexposuretotobaccosmoke,especiallypregnantwomenandparentsofyoungchildren.Thisisduetotheirsmokingbeingsociallyunacceptable.Also,itmaybedifficultforindividualstorecalltheirexposuretotobaccosmoke.[116] A2007studyintheAddictiveBehaviorsjournalfoundapositivecorrelationbetweensecondhandtobaccosmokeexposureandconcentrationsofnicotineand/orbiomarkersofnicotineinthebody.Significantbiologicallevelsofnicotinefromsecondhandsmokeexposurewereequivalenttonicotinelevelsfromactivesmokingandlevelsthatareassociatedwithbehaviourchangesduetonicotineconsumption.[117] Cotinine Cotinine,themetaboliteofnicotine,isabiomarkerofsecondhandsmokeexposure.Typically,cotinineismeasuredintheblood,saliva,andurine.Hairanalysishasrecentlybecomeanew,noninvasivemeasurementtechnique.Cotinineaccumulatesinhairduringhairgrowth,whichresultsinameasureoflong-term,cumulativeexposuretotobaccosmoke.[118]Urinarycotininelevelshavebeenareliablebiomarkeroftobaccoexposureandhavebeenusedasareferenceinmanyepidemiologicalstudies.[113]However,cotininelevelsfoundintheurinereflectexposureonlyoverthepreceding48hours.Cotininelevelsoftheskin,suchasthehairandnails,reflecttobaccoexposureoverthepreviousthreemonthsandareamorereliablebiomarker.[114] Carbonmonoxide(CO) Carbonmonoxidemonitoredviabreathisalsoareliablebiomarkerofsecondhandsmokeexposureaswellastobaccouse.Withhighsensitivityandspecificity,itnotonlyprovidesanaccuratemeasure,butthetestisalsonon-invasive,highlyreproducible,andlowincost.BreathCOmonitoringmeasurestheconcentrationofCOinanexhalationinpartspermillion,andthiscanbedirectlycorrelatedtothebloodCOconcentration(carboxyhemoglobin).[119]BreathCOmonitorscanalsobeusedbyemergencyservicestoidentifypatientswhoaresuspectedofhavingCOpoisoning. Pathophysiology A2004studybytheInternationalAgencyforResearchonCanceroftheWorldHealthOrganizationconcludedthatnon-smokersareexposedtothesamecarcinogensasactivesmokers.Sidestreamsmokecontainsmorethan4,000chemicals,including69knowncarcinogens.Ofspecialconcernarepolynucleararomatichydrocarbons,tobacco-specificN-nitrosamines,andaromaticamines,suchas4-aminobiphenyl,allknowntobehighlycarcinogenic.Mainstreamsmoke,sidestreamsmoke,andsecondhandsmokecontainlargelythesamecomponents,howevertheconcentrationvariesdependingontypeofsmoke.[2]Severalwell-establishedcarcinogenshavebeenshownbythetobaccocompanies'ownresearchtobepresentathigherconcentrationsinsidestreamsmokethaninmainstreamsmoke.[120] Secondhandsmokehasbeenshowntoproducemoreparticulate-matter(PM)pollutionthananidlinglow-emissiondieselengine.InanexperimentconductedbytheItalianNationalCancerInstitute,threecigaretteswereleftsmoldering,oneaftertheother,ina60 m3garagewithalimitedairexchange.ThecigarettesproducedPMpollutionexceedingoutdoorlimits,aswellasPMconcentrationsupto10-foldthatoftheidlingengine.[121] Secondhandtobaccosmokeexposurehasimmediateandsubstantialeffectsonbloodandbloodvesselsinawaythatincreasestheriskofaheartattack,particularlyinpeoplealreadyatrisk.[122]Exposuretotobaccosmokefor30minutessignificantlyreducescoronaryflowvelocityreserveinhealthynonsmokers.[123]Secondhandsmokeisalsoassociatedwithimpairedvasodilationamongadultnonsmokers.[124]Secondhandsmokeexposurealsoaffectsplateletfunction,vascularendothelium,andmyocardialexercisetoleranceatlevelscommonlyfoundintheworkplace.[125] Pulmonaryemphysemacanbeinducedinratsthroughacuteexposuretosidestreamtobaccosmoke(30cigarettesperday)overaperiodof45days.[126]Degranulationofmastcellscontributingtolungdamagehasalsobeenobserved.[127] Theterm"third-handsmoke"wasrecentlycoinedtoidentifytheresidualtobaccosmokecontaminationthatremainsafterthecigaretteisextinguishedandsecondhandsmokehasclearedfromtheair.[128][129][130]Preliminaryresearchsuggeststhatby-productsofthird-handsmokemayposeahealthrisk,[131] thoughthemagnitudeofrisk,ifany,remainsunknown.InOctober2011,itwasreportedthatChristusSt.FrancesCabriniHospitalinAlexandria,Louisiana,wouldseektoeliminatethird-handsmokebeginninginJuly2012,andthatemployeeswhoseclothingsmelledofsmokewouldnotbeallowedtowork.Thisprohibitionwasenactedbecausethird-handsmokeposesaspecialdangerforthedevelopingbrainsofinfantsandsmallchildren.[132] In2008,thereweremorethan161,000deathsattributedtolungcancerintheUnitedStates.Ofthesedeaths,anestimated10%to15%werecausedbyfactorsotherthanfirst-handsmoking;equivalentto16,000to24,000deathsannually.Slightlymorethanhalfofthelungcancerdeathscausedbyfactorsotherthanfirst-handsmokingwerefoundinnonsmokers.Lungcancerinnon-smokersmaywellbeconsideredoneofthemostcommoncancermortalitiesintheUnitedStates.Clinicalepidemiologyoflungcancerhaslinkedtheprimaryfactorscloselytiedtolungcancerinnon-smokersasexposuretosecondhandtobaccosmoke,carcinogensincludingradon,andotherindoorairpollutants.[133] Opinionofpublichealthauthorities Thereiswidespreadscientificconsensusthatexposuretosecondhandsmokeisharmful.[3]Thelinkbetweenpassivesmokingandhealthrisksisacceptedbyeverymajormedicalandscientificorganisation,including: WorldHealthOrganization[2] U.S.NationalInstitutesofHealth[134] CentersforDiseaseControl[135] UnitedStatesSurgeonGeneral[1] U.S.NationalCancerInstitute[136] UnitedStatesEnvironmentalProtectionAgency[137] CaliforniaEnvironmentalProtectionAgency[8] AmericanHeartAssociation,[138]AmericanLungAssociation,[139]andAmericanCancerSociety[140] AmericanMedicalAssociation[141] AmericanAcademyofPediatrics[142] AustralianNationalHealthandMedicalResearchCouncil[143] UnitedKingdomScientificCommitteeonTobaccoandHealth[144] Publicopinion RecentmajorsurveysconductedbytheU.S.NationalCancerInstituteandCentersforDiseaseControlhavefoundwidespreadpublicawarenessthatsecondhandsmokeisharmful.Inboth1992and2000surveys,morethan80%ofrespondentsagreedwiththestatementthatsecondhandsmokewasharmful.A2001studyfoundthat95%ofadultsagreedthatsecondhandsmokewasharmfultochildren,and96%consideredtobacco-industryclaimsthatsecondhandsmokewasnotharmfultobeuntruthful.[145] A2007Galluppollfoundthat56%ofrespondentsfeltthatsecondhandsmokewas"veryharmful",anumberthathasheldrelativelysteadysince1997.Another29%believethatsecondhandsmokeis"somewhatharmful";10%answered"nottooharmful",while5%said"notatallharmful".[146] Controversyoverharm Aspartofitsattempttopreventordelaytighterregulationofsmoking,thetobaccoindustryfundedanumberofscientificstudiesand,wheretheresultscastdoubtontherisksassociatedwithsecondhandsmoke,soughtwidepublicityforthoseresults.Theindustryalsofundedlibertarianandconservativethinktanks,suchastheCatoInstituteintheUnitedStatesandtheInstituteofPublicAffairsinAustraliawhichcriticisedbothscientificresearchonpassivesmokingandpolicyproposalstorestrictsmoking.[147][148]NewScientistandtheEuropeanJournalofPublicHealthhaveidentifiedtheseindustry-widecoordinatedactivitiesasoneoftheearliestexpressionsofcorporatedenialism.Further,theystatethatthedisinformationspreadbythetobaccoindustryhascreatedatobaccodenialismmovement,sharingmanycharacteristicsofotherformsofdenialism,suchasHIV-AIDSdenialism.[149][150] Industry-fundedstudiesandcritiques EnstromandKabat A2003studybyJamesEnstromandGeoffreyKabat,publishedintheBritishMedicalJournal,arguedthattheharmsofpassivesmokinghadbeenoverstated.[151]Theiranalysisreportednostatisticallysignificantrelationshipbetweenpassivesmokingandlungcancer,coronaryheartdisease(CHD),orchronicobstructivepulmonarydisease,thoughtheaccompanyingeditorialnotedthat"theymayoveremphasisethenegativenatureoftheirfindings."[152]Thispaperwaswidelypromotedbythetobaccoindustryasevidencethattheharmsofpassivesmokingwereunproven.[153][154]TheAmericanCancerSociety(ACS),whosedatabaseEnstromandKabatusedtocompiletheirdata,criticizedthepaperas"neitherreliablenorindependent",statingthatscientistsattheACShadrepeatedlypointedoutseriousflawsinEnstromandKabat'smethodologypriortopublication.[155]Notably,thestudyhadfailedtoidentifyacomparisongroupof"unexposed"persons.[156] Enstrom'stiestothetobaccoindustryalsodrewscrutiny;ina1997lettertoPhilipMorris,Enstromrequesteda"substantialresearchcommitment...inorderformetoeffectivelycompeteagainstthelargemountainofepidemiologicdataandopinionsthatalreadyexistregardingthehealtheffectsofETSandactivesmoking."[157]InaUSracketeeringlawsuitagainsttobaccocompanies,theEnstromandKabatpaperwascitedbytheUSDistrictCourtas"aprimeexampleofhowninetobaccocompaniesengagedincriminalracketeeringandfraudtohidethedangersoftobaccosmoke."[158]TheCourtfoundthatthestudyhadbeenfundedandmanagedbytheCenterforIndoorAirResearch,[159]atobaccoindustryfrontgrouptaskedwith"offsetting"damagingstudiesonpassivesmoking,aswellasbyPhilipMorriswhostatedthatEnstrom'sworkwas"clearlylitigation-oriented".[160]A2005paperinTobaccoControlarguedthatthedisclosuresectionintheEnstromandKabatBMJpaper,althoughitmetthejournal'srequirements,"doesnotrevealthefullextentoftherelationshiptheauthorshadwiththetobaccoindustry."[161] In2006,EnstromandKabatpublishedameta-analysisofstudiesregardingpassivesmokingandcoronaryheartdiseaseinwhichtheyreportedaveryweakassociationbetweenpassivesmokingandheartdiseasemortality.[162]TheyconcludedthatexposuretosecondhandsmokeincreasedtheriskofdeathfromCHDbyonly5%,althoughthisanalysishasbeencriticizedforincludingtwopreviousindustry-fundedstudiesthatsufferedfromwidespreadexposuremisclassification.[5] Gori GioBattaGori,atobaccoindustryspokesmanandconsultant[163][164][165]andanexpertonriskutilityandscientificresearch,wroteinthelibertarianCatoInstitute'smagazineRegulationthat"...ofthe75publishedstudiesofETSandlungcancer,some70%didnotreportstatisticallysignificantdifferencesofriskandaremoot.Roughly17%claimanincreasedriskand13%implyareductionofrisk."[166] Milloy StevenMilloy,the"junkscience"commentatorforFoxNewsandaformerPhilipMorrisconsultant,[167][168]claimedthat"ofthe19studies"onpassivesmoking"only8—slightlymorethan42%—reportedstatisticallysignificantincreasesinheartdiseaseincidence."[169] AnothercomponentofcriticismcitedbyMilloyfocusedonrelativeriskandepidemiologicalpracticesinstudiesofpassivesmoking.Milloy,whohasamaster'sdegreefromtheJohnsHopkinsSchoolofHygieneandPublicHealth,arguedthatstudiesyieldingrelativerisksoflessthan2weremeaninglessjunkscience.ThisapproachtoepidemiologicalanalysiswascriticizedintheAmericanJournalofPublicHealth: Amajorcomponentoftheindustryattackwasthemountingofacampaigntoestablisha"bar"for"soundscience"thatcouldnotbefullymetbymostindividualinvestigations,leavingstudiesthatdidnotmeetthecriteriatobedismissedas"junkscience."[170] Thetobaccoindustryandaffiliatedscientistsalsoputforwardasetof"GoodEpidemiologyPractices"whichwouldhavethepracticaleffectofobscuringthelinkbetweensecondhandsmokeandlungcancer;theprivatelystatedgoalofthesestandardswasto"impedeadverselegislation".[171]However,thiseffortwaslargelyabandonedwhenitbecameclearthatnoindependentepidemiologicalorganizationwouldagreetothestandardsproposedbyPhilipMorrisetal.[172] LevoisandLayard In1995,LevoisandLayard,bothtobaccoindustryconsultants,publishedtwoanalysesinthejournalRegulatoryToxicologyandPharmacologyregardingtheassociationbetweenspousalexposuretosecondhandsmokeandheartdisease.Bothofthesepapersreportednoassociationbetweensecondhandsmokeandheartdisease.[173][174]Theseanalyseshavebeencriticizedforfailingtodistinguishbetweencurrentandformersmokers,despitethefactthatformersmokers,unlikecurrentones,arenotatasignificantlyincreasedriskofheartdisease.[5][175] WorldHealthOrganizationcontroversy A1998studybytheInternationalAgencyforResearchonCancer(IARC)onenvironmentaltobaccosmoke(ETS)found"weakevidenceofadose–responserelationshipbetweenriskoflungcancerandexposuretospousalandworkplaceETS."[176] InMarch1998,beforethestudywaspublished,reportsappearedinthemediaallegingthattheIARCandtheWorldHealthOrganization(WHO)weresuppressinginformation.Thereports,appearingintheBritishSundayTelegraph[177]andTheEconomist,[178]amongothersources,[179][180][181]allegedthattheWHOwithheldfrompublicationofitsownreportthatsupposedlyfailedtoproveanassociationbetweenpassivesmokingandanumberofotherdiseases(lungcancerinparticular). Inresponse,theWHOissuedapressreleasestatingthattheresultsofthestudyhadbeen"completelymisrepresented"inthepopularpressandwereinfactverymuchinlinewithsimilarstudiesdemonstratingtheharmsofpassivesmoking.[182]ThestudywaspublishedintheJournaloftheNationalCancerInstituteinOctoberofthesameyear,andconcludedtheauthorsfound"noassociationbetweenchildhoodexposuretoETSandlungcancerrisk"but"didfindweakevidenceofadose–responserelationshipbetweenriskoflungcancerandexposuretospousalandworkplaceETS."[176]Anaccompanyingeditorialsummarized: Whenalltheevidence,includingtheimportantnewdatareportedinthisissueoftheJournal,isassessed,theinescapablescientificconclusionisthatETSisalow-levellungcarcinogen.[183] WiththereleaseofformerlyclassifiedtobaccoindustrydocumentsthroughtheTobaccoMasterSettlementAgreement,itwasfound(byElisaOngandStantonGlantz)thatthecontroversyovertheWHO'sallegedsuppressionofdatahadbeenengineeredbyPhilipMorris,BritishAmericanTobacco,andothertobaccocompaniesinanefforttodiscreditscientificfindingswhichwouldharmtheirbusinessinterests.[184]AWHOinquiry,conductedafterthereleaseofthetobacco-industrydocuments,foundthatthiscontroversywasgeneratedbythetobaccoindustryaspartofitslargercampaigntocuttheWHO'sbudget,distorttheresultsofscientificstudiesonpassivesmoking,anddiscredittheWHOasaninstitution.Thiscampaignwascarriedoutusinganetworkofostensiblyindependentfrontorganizationsandinternationalandscientificexpertswithhiddenfinancialtiestotheindustry.[185] EPAlawsuit In1993,theUnitedStatesEnvironmentalProtectionAgency(EPA)issuedareportestimatingthat3,000lungcancerrelateddeathsintheUnitedStateswerecausedbypassivesmokingannually.[186] PhilipMorris,R.J.ReynoldsTobaccoCompany,andgroupsrepresentinggrowers,distributorsandmarketersoftobaccotooklegalaction,claimingthattheEPAhadmanipulatedthisstudyandignoredacceptedscientificandstatisticalpractices. TheUnitedStatesDistrictCourtfortheMiddleDistrictofNorthCarolinaruledinfavorofthetobaccoindustryin1998,findingthattheEPAhadfailedtofollowproperscientificandepidemiologicpracticesandhad"cherrypicked"evidencetosupportconclusionswhichtheyhadcommittedtoinadvance.[187]Thecourtstatedinpart,"EPApubliclycommittedtoaconclusionbeforeresearchhadbegun…adjustedestablishedprocedureandscientificnormstovalidatetheAgency'spublicconclusion...InconductingtheETSRiskAssessment,disregardedinformationandmadefindingsonselectiveinformation;didnotdisseminatesignificantepidemiologicinformation;deviatedfromitsRiskAssessmentGuidelines;failedtodiscloseimportantfindingsandreasoning…" In2002,theEPAsuccessfullyappealedthisdecisiontotheUnitedStatesCourtofAppealsfortheFourthCircuit.TheEPA'sappealwasupheldonthepreliminarygroundsthattheirreporthadnoregulatoryweight,andtheearlierfindingwasvacated.[188] In1998,theU.S.DepartmentofHealthandHumanServices,throughthepublicationbyitsNationalToxicologyProgramofthe9thReportonCarcinogens,listedenvironmentaltobaccosmokeamongtheknowncarcinogens,observingoftheEPAassessmentthat"Theindividualstudieswerecarefullysummarizedandevaluated."[189] Tobacco-industryfundingofresearch Thetobaccoindustry'sroleinfundingscientificresearchonsecondhandsmokehasbeencontroversial.[190]Areviewofpublishedstudiesfoundthattobacco-industryaffiliationwasstronglycorrelatedwithfindingsexoneratingsecondhandsmoke;researchersaffiliatedwiththetobaccoindustrywere88timesmorelikelythanindependentresearcherstoconcludethatsecondhandsmokewasnotharmful.[191]Inaspecificexamplewhichcametolightwiththereleaseoftobacco-industrydocuments,PhilipMorrisexecutivessuccessfullyencouragedanauthortorevisehisindustry-fundedreviewarticletodownplaytheroleofsecondhandsmokeinsuddeninfantdeathsyndrome.[192]The2006U.S.SurgeonGeneral'sreportcriticizedthetobaccoindustry'sroleinthescientificdebate: Theindustryhasfundedorcarriedoutresearchthathasbeenjudgedtobebiased,supportedscientiststogenerateletterstoeditorsthatcriticizedresearchpublications,attemptedtounderminethefindingsofkeystudies,assistedinestablishingascientificsocietywithajournal,andattemptedtosustaincontroversyevenasthescientificcommunityreachedconsensus.[193] Thisstrategywasoutlinedataninternationalmeetingoftobaccocompaniesin1988,atwhichPhilipMorrisproposedtosetupateamofscientists,organizedbycompanylawyers,to"carryoutworkonETStokeepthecontroversyalive."[194]Allscientificresearchwassubjecttooversightand"filtering"bytobacco-industrylawyers: PhilipMorristhenexpectthegroupofscientiststooperatewithintheconfinesofdecisionstakenbyPMscientiststodeterminethegeneraldirectionofresearch,whichapparentlywouldthenbe'filtered'bylawyerstoeliminateareasofsensitivity.[194] PhilipMorrisreportedthatitwasputting"...vastamountsoffundingintotheseprojects...inattemptingtocoordinateandpaysomanyscientistsonaninternationalbasistokeeptheETScontroversyalive."[194] Tobaccoindustryresponse Measurestotacklesecondhandsmokeposeaseriouseconomicthreattothetobaccoindustry,havingbroadenedthedefinitionofsmokingbeyondapersonalhabittosomethingwithasocialimpact.Inaconfidential1978report,thetobaccoindustrydescribedincreasingpublicconcernsaboutsecondhandsmokeas"themostdangerousdevelopmenttotheviabilityofthetobaccoindustrythathasyetoccurred."[195]InUnitedStatesofAmericav.PhilipMorrisetal.,theDistrictCourtfortheDistrictofColumbiafoundthatthetobaccoindustry"...recognizedfromthemid-1970sforwardthatthehealtheffectsofpassivesmokingposedaprofoundthreattoindustryviabilityandcigaretteprofits,"andthattheindustryrespondedwith"effortstoundermineanddiscreditthescientificconsensusthatETScausesdisease."[3] Accordingly,thetobaccoindustryhavedevelopedseveralstrategiestominimisetheimpactontheirbusiness: Theindustryhassoughttopositionthesecondhandsmokedebateasessentiallyconcernedwithcivillibertiesandsmokers'rightsratherthanwithhealth,byfundinggroupssuchasFOREST.[196] Fundingbiasinresearch;[7]inallreviewsoftheeffectsofsecondhandsmokeonhealthpublishedbetween1980and1995,theonlyfactorassociatedwithconcludingthatsecondhandsmokeisnotharmfulwaswhetheranauthorwasaffiliatedwiththetobaccoindustry.[191]However,notallstudiesthatfailedtofindevidenceofharmwerebyindustry-affiliatedauthors. Delayinganddiscreditinglegitimateresearch(see[7]foranexampleofhowtheindustryattemptedtodiscreditTakeshiHirayama'slandmarkstudy,and[197]foranexampleofhowitattemptedtodelayanddiscreditamajorAustralianreportonpassivesmoking) Promoting"goodepidemiology"andattackingso-calledjunkscience(atermpopularisedbyindustrylobbyistStevenMilloy):attackingthemethodologybehindresearchshowinghealthrisksasflawedandattemptingtopromotesoundscience.Ong&Glantz(2001)citeaninternalPhillipMorrismemogivingevidenceofthisascompanypolicy.[172] Creationofoutletsforfavourableresearch.In1989,thetobaccoindustryestablishedtheInternationalSocietyoftheBuiltEnvironment,whichpublishedthepeer-reviewedjournalIndoorandBuiltEnvironment.Thisjournaldidnotrequireconflict-of-interestdisclosuresfromitsauthors.WithdocumentsmadeavailablethroughtheMasterSettlement,itwasfoundthattheexecutiveboardofthesocietyandtheeditorialboardofthejournalweredominatedbypaidtobacco-industryconsultants.Thejournalpublishedalargeamountofmaterialonpassivesmoking,muchofwhichwas"industry-positive".[198] Citingthetobaccoindustry'sproductionofbiasedresearchandeffortstounderminescientificfindings,the2006U.S.SurgeonGeneral'sreportconcludedthattheindustryhad"attemptedtosustaincontroversyevenasthescientificcommunityreachedconsensus...industrydocumentsindicatethatthetobaccoindustryhasengagedinwidespreadactivities...thathavegonebeyondtheboundsofacceptedscientificpractice."[199]TheU.S.DistrictCourt,inU.S.A.v.PhilipMorrisetal.,foundthat"...despitetheirinternalacknowledgmentofthehazardsofsecondhandsmoke,DefendantshavefraudulentlydeniedthatETScausesdisease."[200] Positionofmajortobaccocompanies Thepositionsofmajortobaccocompaniesontheissueofsecondhandsmokeissomewhatvaried.Ingeneral,tobaccocompanieshavecontinuedtofocusonquestioningthemethodologyofstudiesshowingthatsecondhandsmokeisharmful.Some(suchasBritishAmericanTobaccoandPhilipMorris)acknowledgethemedicalconsensusthatsecondhandsmokecarrieshealthrisks,whileotherscontinuetoassertthattheevidenceisinconclusive.Severaltobaccocompaniesadvocatethecreationofsmoke-freeareaswithinpublicbuildingsasanalternativetocomprehensivesmoke-freelaws.[201] USracketeeringlawsuitagainsttobaccocompanies OnSeptember22,1999,theU.S.DepartmentofJusticefiledaracketeeringlawsuitagainstPhilipMorrisandothermajorcigarettemanufacturers.[202]Almost7yearslater,onAugust17,2006,U.S.DistrictCourtJudgeGladysKesslerfoundthattheGovernmenthadprovenitscaseandthatthetobaccocompanydefendantshadviolatedtheRacketeerInfluencedCorruptOrganizationsAct(RICO).[3]Inparticular,JudgeKesslerfoundthatPMandothertobaccocompanieshad: conspiredtominimize,distortandconfusethepublicaboutthehealthhazardsofsmoking; publiclydenied,whileinternallyacknowledging,thatsecondhandtobaccosmokeisharmfultononsmokers,and destroyeddocumentsrelevanttolitigation. Therulingfoundthattobaccocompaniesundertookjointeffortstoundermineanddiscreditthescientificconsensusthatsecondhandsmokecausesdisease,notablybycontrollingresearchfindingsviapaidconsultants.TherulingalsoconcludedthattobaccocompanieswerefraudulentlycontinuingtodenythehealtheffectsofETSexposure.[3] OnMay22,2009,athree-judgepaneloftheU.S.CourtofAppealsfortheDistrictofColumbiaCircuitunanimouslyupheldthelowercourt's2006ruling.[203][204][205] Smoke-freelaws Seealso:Smokingban,Listofsmokingbans,andSmokingbansinprivatevehicles Asaconsequenceofthehealthrisksassociatedwithsecondhandsmoke,manynationalandlocalgovernmentshaveoutlawedsmokinginindoorpublicplaces,includingrestaurants,cafés,andnightclubs,aswellassomeoutdooropenareas.[206]Irelandwasthefirstcountryintheworldtoinstituteacomprehensivenationalbanonsmokinginallindoorworkplaceson29March2004.Sincethen,manyothershavefollowedsuit.ThecountrieswhichhaveratifiedtheWHOFrameworkConventiononTobaccoControl(FCTC)havealegalobligationtoimplementeffectivelegislation"forprotectionfromexposuretotobaccosmokeinindoorworkplaces,publictransport,indoorpublicplacesand,asappropriate,otherpublicplaces."(Article8oftheFCTC[207])ThepartiestotheFCTChavefurtheradoptedGuidelinesontheProtectionfromExposuretosecondhandSmokewhichstatethat"effectivemeasurestoprovideprotectionfromexposuretotobaccosmoke...requirethetotaleliminationofsmokingandtobaccosmokeinaparticularspaceorenvironmentinordertocreatea100%smoke-freeenvironment."[208] Opinionpollshaveshownconsiderablesupportforsmoke-freelaws.InJune2007,asurveyof15countriesfound80%approvalforsuchlaws.[209]AsurveyinFrance,reputedlyanationofsmokers,showed70%support.[100] Effects Smokingbansbygovernmentsresultindecreasedharmfromsecondhandsmoke,includinglessadmissionsforacutecoronarysyndrome.[210]Inthefirst18monthsafterthetownofPueblo,Colorado,enactedasmoke-freelawin2003,hospitaladmissionsforheartattacksdropped27%.Admissionsinneighbouringtownswithoutsmoke-freelawsshowednochange,andthedeclineinheartattacksinPueblowasattributedtotheresultingreductioninsecondhandsmokeexposure.[211]A2004smokingbaninstitutedinMassachusettsworkplacesdecreasedworkers'secondhandsmokeexposurefrom8%ofworkersin2003to5.4%ofworkersin2010.[104]A2016reviewalsofoundthatbansandpolicychangesinspecificlocationssuchashospitalsoruniversitiescanleadtoreducedsmokingrates.Inprisonsettingsbansmightleadtoreducedmortalityandtolowerexposuretopassivesmoking.[212] In2001,asystematicreviewfortheGuidetoCommunityPreventiveServicesacknowledgedstrongevidenceoftheeffectivenessofsmoke-freepoliciesandrestrictionsinreducingexposetosecondhandsmoke.Afollowuptothisreview,identifiedtheevidenceonwhichtheeffectivenessofsmokingbansreducedtheprevalenceoftobaccouse.Articlespublisheduntil2005,wereexaminedtofurthersupportthisevidence.Theexaminedstudiesprovidedsufficientevidencethatsmoke-freepoliciesreducetobaccouseamongworkerswhenimplementedinworksitesorbycommunities.[213] Whileanumberofstudiesfundedbythetobaccoindustryhaveclaimedanegativeeconomicimpactfromsmoke-freelaws,noindependentlyfundedresearchhasshownanysuchimpact.A2003reviewreportedthatindependentlyfunded,methodologicallysoundresearchconsistentlyfoundeithernoeconomicimpactorapositiveimpactfromsmoke-freelaws.[214] AirnicotinelevelsweremeasuredinGuatemalanbarsandrestaurantsbeforeandafteranimplementedsmoke-freelawin2009.Nicotineconcentrationssignificantlydecreasedinboththebarsandrestaurantsmeasured.Also,theemployeessupportforasmoke-freeworkplacesubstantiallyincreasedinthepost-implementationsurveycomparedtopre-implementationsurvey.Theresultofthissmoke-freelawprovidesaconsiderablymorehealthyworkenvironmentforthestaff.[215] Publicopinion RecentsurveystakenbytheSocietyforResearchonNicotineandTobaccodemonstratessupportiveattitudesofthepublic,towardssmoke-freepoliciesinoutdoorareas.Avastmajorityofthepublicsupportsrestrictingsmokinginvariousoutdoorsettings.Therespondentsreasonsforsupportingthepolicieswereforvaryingreasonssuchas,littercontrol,establishingpositivesmoke-freerolemodelsforyouth,reducingyouthopportunitiestosmoke,andavoidingexposuretosecondhandsmoke.[216] Alternativeforms Alternativestosmoke-freelawshavealsobeenproposedasameansofharmreduction,particularlyinbarsandrestaurants.Forexample,criticsofsmoke-freelawscitestudiessuggestingventilationasameansofreducingtobaccosmokepollutantsandimprovingairquality.[217]Ventilationhasalsobeenheavilypromotedbythetobaccoindustryasanalternativetooutrightbans,viaanetworkofostensiblyindependentexpertswithoftenundisclosedtiestotheindustry.[218]However,notallcriticshaveconnectionstotheindustry. TheAmericanSocietyofHeating,RefrigeratingandAir-ConditioningEngineers(ASHRAE)officiallyconcludedin2005thatwhilecompletelyisolatedsmokingroomsdoeliminatetherisktonearbynon-smokingareas,smokingbansaretheonlymeansofeliminatinghealthrisksassociatedwithindoorexposure.Theyfurtherconcludedthatnosystemofdilutionorcleaningwaseffectiveateliminatingrisk.[219]TheU.S.SurgeonGeneralandtheEuropeanCommissionJointResearchCentrehavereachedsimilarconclusions.[199][220]TheimplementationguidelinesfortheWHOFrameworkConventiononTobaccoControlstatesthatengineeringapproaches,suchasventilation,areineffectiveanddonotprotectagainstsecondhandsmokeexposure.[208]However,thisdoesnotnecessarilymeanthatsuchmeasuresareuselessinreducingharm,onlythattheyfallshortofthegoalofreducingexposurecompletelytozero. Othershavesuggestedasystemoftradablesmokingpollutionpermits,similartothecap-and-tradepollutionpermitssystemsusedbytheEnvironmentalProtectionAgencyinrecentdecadestocurbothertypesofpollution.[221]Thiswouldguaranteethataportionofbars/restaurantsinajurisdictionwillbesmoke-free,whileleavingthedecisiontothemarket. Inanimals Mainarticle:Animalsandtobaccosmoke Multiplestudieshavebeenconductedtodeterminethecarcinogenicityofenvironmentaltobaccosmoketoanimals.Thesestudiestypicallyfallunderthecategoriesofsimulatedenvironmentaltobaccosmoke,administeringcondensatesofsidestreamsmoke,orobservationalstudiesofcanceramongpets. Tosimulateenvironmentaltobaccosmoke,scientistsexposeanimalstosidestreamsmoke,thatwhichemanatesfromthecigarette'sburningconeandthroughitspaper,oracombinationofmainstreamandsidestreamsmoke.[2]TheIARCmonographsconcludethatmicewithprolongedexposuretosimulatedenvironmentaltobaccosmoke,thatissixhoursaday,fivedaysaweek,forfivemonthswithasubsequentfour-monthintervalbeforedissection,willhavesignificantlyhigherincidenceandmultiplicityoflungtumorsthanwithcontrolgroups. TheIARCmonographsconcludedthatsidestreamsmokecondensateshadasignificantlyhighercarcinogeniceffectonmicethandidmainstreamsmokecondensates.[2] Observationalstudies Secondhandsmokeispopularlyrecognisedasariskfactorforcancerinpets.[222]AstudyconductedbytheTuftsUniversitySchoolofVeterinaryMedicineandtheUniversityofMassachusettsAmherstlinkedtheoccurrenceoffelineoralcancertoexposuretoenvironmentaltobaccosmokethroughanoverexpressionofthep53gene.[223]Anotherstudyconductedatthesameuniversitiesconcludedthatcatslivingwithasmokerweremorelikelytogetfelinelymphoma;theriskincreasedwiththedurationofexposuretosecondhandsmokeandthenumberofsmokersinthehousehold.[224]AstudybyColoradoStateUniversityresearchers,lookingatcasesofcaninelungcancer,wasgenerallyinconclusive,thoughtheauthorsreportedaweakrelationforlungcancerindogsexposedtoenvironmentaltobaccosmoke.Thenumberofsmokerswithinthehome,thenumberofpackssmokedinthehomeperday,andtheamountoftimethatthedogspentwithinthehomehadnoeffectonthedog'sriskforlungcancer.[225] Terminology Asof2003,"secondhandsmoke"wasthetermmostusedtorefertootherpeople'ssmokeintheEnglish-languagemedia.[226]Othertermsusedinclude"environmentaltobaccosmoke",while"involuntarysmoking"and"passivesmoking"areusedtorefertoexposuretosecondhandsmoke.[227]Theterm"environmentaltobaccosmoke"canbetracedbacktoa1974industry-sponsoredmeetingheldinBermuda,whiletheterm"passivesmoking"wasfirstusedinthetitleofascientificpaperin1970.[226]TheSurgeonGeneraloftheUnitedStatespreferstousethephrase"secondhandsmoke"ratherthan"environmentaltobaccosmoke",statingthat"Thedescriptor'secondhand'capturestheinvoluntarynatureoftheexposure,while'environmental'doesnot."[1]: 9 Mostresearchersconsidertheterm"passivesmoking"tobesynonymouswith"secondhandsmoke".[228]Incontrast,a2011commentaryinEnvironmentalHealthPerspectivesarguedthatresearchinto"thirdhandsmoke"rendersitinappropriatetorefertopassivesmokingwiththeterm"secondhandsmoke",whichtheauthorsstatedconstitutesaparsprototo.[228] Seealso Healtheffectsoftobacco Third-handsmoke 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