Jonathan P. Winickoff

Thirdhand Tobacco Smoke: Emerging Evidence and Arguments for a Multidisciplinary Research Agenda

Background: There is broad consensus regarding the health impact of tobacco use and secondhand smoke exposure, yet considerable ambiguity exists about the nature and consequences of thirdhand smoke (THS). Objectives: We introduce definitions of THS and THS exposure and review recent findings about constituents, indoor sorption–desorption dynamics, and transformations of THS; distribution and persistence of THS in residential settings; implications for pathways of exposure; potential clinical significance and health effects; and behavioral and policy issues that affect and are affected by THS. Discussion: Physical and chemical transformations of tobacco smoke pollutants take place over time scales ranging from seconds to months and include the creation of secondary pollutants that in some cases are more toxic (e.g., tobacco-specific nitrosamines). THS persists in real-world residential settings in the air, dust, and surfaces and is associated with elevated levels of nicotine on hands and cotinine in urine of nonsmokers residing in homes previously occupied by smokers. Much still needs to be learned about the chemistry, exposure, toxicology, health risks, and policy implications of THS. Conclusion: The existing evidence on THS provides strong support for pursuing a programmatic research agenda to close gaps in our current understanding of the chemistry, exposure, toxicology, and health effects of THS, as well as its behavioral, economic, and sociocultural considerations and consequences. Such a research agenda is necessary to illuminate the role of THS in existing and future tobacco control efforts to decrease smoking initiation and smoking levels, to increase cessation attempts and sustained cessation, and to reduce the cumulative effects of tobacco use on morbidity and mortality.

Beliefs About the Health Effects of "Thirdhand" Smoke and Home Smoking Bans

OBJECTIVE. There is no safe level of exposure to tobacco smoke. Thirdhand smoke is residual tobacco smoke contamination that remains after the cigarette is extinguished. Children are uniquely susceptible to thirdhand smoke exposure. The objective of this study was to assess health beliefs of adults regarding thirdhand smoke exposure of children and whether smokers and nonsmokers differ in those beliefs. We hypothesized that beliefs about thirdhand smoke would be associated with household smoking bans. METHODS. Data were collected by a national random-digit-dial telephone survey from September to November 2005. The sample was weighted by race and gender within Census region on the basis of US Census data. The study questions assessed the level of agreement with statements that breathing air in a room today where people smoked yesterday can harm the health of children. RESULTS. Of 2000 eligible respondents contacted, 1510 (87%) completed surveys, 1478 (97.9%) answered all questions pertinent to this analysis, and 273 (18.9%) were smokers. Overall, 95.4% of nonsmokers versus 84.1% of smokers agreed that secondhand smoke harms the health of children, and 65.2% of nonsmokers versus 43.3% of smokers agreed that thirdhand smoke harms children. Strict rules prohibiting smoking in the home were more prevalent among nonsmokers: 88.4% vs 26.7%. In multivariate logistic regression, after controlling for certain variables, belief that thirdhand smoke harms the health of children remained independently associated with rules prohibiting smoking in the home. Belief that secondhand smoke harms the health of children was not independently associated with rules prohibiting smoking in the home and car. CONCLUSIONS. This study demonstrates that beliefs about the health effects of thirdhand smoke are independently associated with home smoking bans. Emphasizing that thirdhand smoke harms the health of children may be an important element in encouraging home smoking bans.

Trends in Electronic Cigarette Use Among U.S. Adults: Use is Increasing in Both Smokers and Nonsmokers

OBJECTIVES We assessed trends in use of electronic cigarettes among U.S. adults, demographic predictors of use, and smoking status of current electronic cigarette users. METHODS Mixed-mode surveys were used to obtain representative, cross-sectional samples of U.S. adults in each of 4 years. RESULTS Sample sizes for 2010, 2011, 2012, and 2013 were 3,240, 3,097, 3,101, and 3,245, respectively. Ever use of electronic cigarettes increased from 1.8% (2010) to 13.0% (2013), while current use increased from 0.3% to 6.8%, p < .001. Prevalence of use increased significantly across all demographic groups. In 2013, current use among young adults 18-24 (14.2%) was higher than adults 25-44 (8.6%), 45-64 (5.5%), and 65+ (1.2%). Daily smokers (30.3%) and nondaily smokers (34.1%) were the most likely to currently use e-cigarettes, compared to former smokers (5.4%) and never-smokers (1.4%), p < .001. However, 32.5% of current electronic cigarette users are never- or former smokers. CONCLUSIONS There has been rapid growth in ever and current electronic cigarette use over the past 4 years. Use is highest among young adults and current cigarette smokers. Although smokers are most likely to use these products, almost a third of current users are nonsmokers, suggesting that e-cigarettes contribute to primary nicotine addiction and to renormalization of tobacco use. Regulatory action is needed at the federal, state, and local levels to ensure that these products do not contribute to preventable chronic disease.

Tobacco Promotion and the Initiation of Tobacco Use: Assessing the Evidence for Causality

OBJECTIVE. We sought to determine whether there is evidence of a causal link between exposure to tobacco promotion and the initiation of tobacco use by children. METHODS. We conducted a structured search in Medline, PsycINFO, and ABI/INFORM Global to identify relevant empirical research. The literature was examined against the Hill epidemiologic criteria for determining causality. RESULTS. (1) Children are exposed to tobacco promotion before the initiation of tobacco use; (2) exposure increases the risk for initiation; (3) there is a dose-response relationship, with greater exposure resulting in higher risk; (4) the increased risk is robust; it is observed with various study methods, in multiple populations, and with various forms of promotion and persists after controlling for other factors; (5) scientifically plausible mechanisms whereby promotion could influence initiation exist; and (6) no explanation other than causality can account for the evidence. CONCLUSIONS. Promotions foster positive attitudes, beliefs, and expectations regarding tobacco use. This fosters intentions to use and increases the likelihood of initiation. Greater exposure to promotion leads to higher risk. This is seen in diverse cultures and persists when other risk factors, such as socioeconomic status or parental and peer smoking, are controlled. Causality is the only plausible scientific explanation for the observed data. The evidence satisfies the Hill criteria, indicating that exposure to tobacco promotion causes children to initiate tobacco use.

Use of emerging tobacco products in the United States.

This paper provides the first nationally representative estimates for use of four emerging products. Addressing the issue of land-line substitution with cell phones, we used a mixed-mode survey to obtain two representative samples of US adults. Of 3,240 eligible respondents contacted, 74% completed surveys. In the weighted analysis, 13.6% have tried at least one emerging tobacco product; 5.1% snus; 8.8% waterpipe; 0.6% dissolvable tobacco products; 1.8% electronic nicotine delivery systems (ENDS) products. Daily smokers (25.1%) and nondaily smokers (34.9%) were the most likely to have tried at least one of these products, compared to former smokers (17.2%) and never smokers (7.7%), P<.001. 18.2% of young adults 18–24 and 12.8% of those >24 have tried one of these products, P<.01. In multivariable analysis, current daily (5.5, 4.3–7.6), nondaily (6.1, 4.0–9.3), and former smoking status (2.7, 2.1–3.6) remained significant, as did young adults (2.2, 1.6–3.0); males (3.5, 2.8–4.5); higher educational attainment; some college (2.7, 1.7–4.2); college degree (2.0, 1.3–3.3). Use of these products raises concerns about nonsmokers being at risk for nicotine dependence and current smokers maintaining their dependence. Greater awareness of emerging tobacco product prevalence and the high risk demographic user groups might inform efforts to determine appropriate public health policy and regulatory action.

Parental Smoking Cessation to Protect Young Children:A Systematic Review and Meta-analysis

BACKGROUND: Young children can be protected from much of the harm from tobacco smoke exposure if their parents quit smoking. Some researchers encourage parents to quit for their childrens benefit, but the evidence for effectiveness of such approaches is mixed. OBJECTIVE: To perform a systematic review and meta-analysis to quantify the effects of interventions that encourage parental cessation. METHODS: We searched PubMed, the Cochrane Library, Web of Science, and PsycINFO. Controlled trials published before April 2011 that targeted smoking parents of infants or young children, encouraged parents to quit smoking for their childrens benefit, and measured parental quit rates were included. Study quality was assessed. Relative risks and risk differences were calculated by using the DerSimonian and Laird random-effects model. RESULTS: Eighteen trials were included. Interventions took place in hospitals, pediatric clinical settings, well-baby clinics, and family homes. Quit rates averaged 23.1% in the intervention group and 18.4% in the control group. The interventions successfully increased the parental quit rate. Subgroups with significant intervention benefits were children aged 4 to 17 years, interventions whose primary goal was cessation, interventions that offered medications, and interventions with high follow-up rates (>80%). CONCLUSIONS: Interventions to achieve cessation among parents, for the sake of the children, provide a worthwhile addition to the arsenal of cessation approaches, and can help protect vulnerable children from harm due to tobacco smoke exposure. However, most parents do not quit, and additional strategies to protect children are needed.

Tobacco-Smoke Exposure in Children Who Live in Multiunit Housing

OBJECTIVE: There is no safe level of secondhand tobacco-smoke exposure, and no previous studies have explored multiunit housing as a potential contributor to secondhand tobacco-smoke exposure in children. We hypothesized that children who live in apartments have higher cotinine levels than those who live in detached homes, when controlling for demographics. METHODS: We analyzed data from the 2001–2006 National Health and Nutrition Examination Survey. The housing types we included in our study were detached houses (including mobile homes), attached houses, and apartments. Our study subjects were children between the ages of 6 and 18 years. Cotinine levels were used to assess secondhand tobacco-smoke exposure, and those living with someone who smoked inside the home were excluded. χ2 tests, t tests, and Tobit regression models were used in Stata. Sample weights accounted for the complex survey design. RESULTS: Of 5002 children in our study, 73% were exposed to secondhand tobacco smoke. Children living in apartments had an increase in cotinine of 45% over those living in detached houses. This increase was 212% (P < .01) for white residents and 46% (P < .03) for black residents, but there was no significant increase for those of other races/ethnicities. At every cutoff level of cotinine, children in apartments had higher rates of exposure. The exposure effect of housing type was most pronounced at lower levels of cotinine. CONCLUSIONS: Most children without known secondhand tobacco-smoke exposure inside the home still showed evidence of tobacco-smoke exposure. Children in apartments had higher mean cotinine levels than children in detached houses. Potential causes for this result could be seepage through walls or shared ventilation systems. Smoking bans in multiunit housing may reduce childrens exposure to tobacco smoke.

State-of-the-Art Interventions for Office-Based Parental Tobacco Control

Parental tobacco use is a serious health issue for all family members. Child health care clinicians are in a unique and important position to address parental smoking because of the regular, multiple contacts with parents and the harmful health consequences to their patients. This article synthesizes the current evidence-based interventions for treatment of adults and applies them to the problem of addressing parental smoking in the context of the child health care setting. Brief interventions are effective, and complementary strategies such as quitlines will improve the chances of parental smoking cessation. Adopting the 5 A’s framework strategy (ask, advise, assess, assist, and arrange) gives each parent the maximum chance of quitting. Within this framework, specific recommendations are made for child health care settings and clinicians. Ongoing research will help determine how best to implement parental smoking-cessation strategies more widely in a variety of child health care settings.

Obesity and the Built Environment Among Massachusetts Children

Background: The built environment may influence weight status. Method: Using cross-sectional data for children aged 2 to 18 years, the authors linked clinical and spatial data using geographic information systems and analyzed for associations between body mass index (BMI) and density of and distance to nearest built environment variable (schools, sidewalks, subway stations, bicycle trails, open space, and fast-food restaurants) using bivariate and multilevel analyses. Results: The study sampled 21 008 children; 54% were white, 26% Hispanic, 37% overweight, and 20% obese. In bivariate analysis, distance to nearest fast-food restaurant was inversely associated with BMI, whereas density of fast-food restaurants was positively associated with BMI. Distance to school and subway station, amount of open space, and density of subway stations were inversely associated with BMI. Controlling for sociodemographic factors, only living near a greater density of subway stations was inversely associated with overweight (odds ratio, 0.87; 95% confidence interval, 0.81-0.94) and obesity (odds ratio, 0.90; 95% confidence interval, 0.82-0.99). Conclusion: Distance to nearest subway station is associated with BMI among Massachusetts children.

Text2Quit: results from a pilot test of a personalized, interactive mobile health smoking cessation program.

Text messaging programs on mobile phones have shown some promise in helping people quit smoking. Text2Quit is an automated, personalized, and interactive mobile health program that sends text messages and e-mails timed around a participants quit date over the course of 3 months. The text messages include pre- and post-quit educational messages, peer ex-smoker messages, medication reminders and relapse messages, and multiple opportunities for interaction. Study participants were university students (N = ;23) enrolled in the Text2Quit program. Participants were surveyed at baseline and at 2 and 4 weeks after enrollment. The majority of participants agreed that they liked the program at 2 and 4 weeks after enrollment (90.5% and 82.3%, respectively). Support for text messages was found to be moderate and higher than that of the e-mail and web components. Of participants, 75% reported reading most or all of the texts. On average, users made 11.8 responses to the texts over a 4-week period, although responses declined after the quit date. The interactive feature for tracking cigarettes was the most used interactive feature, followed by the craving trivia game. This pilot test provides some support for the Text2Quit program. A future iteration of the program will include additional tracking features in both the pre-quit and post-quit protocols and an easier entry into the not-quit protocol. Future studies are recommended that identify the value of the interactive and personalized features that characterize this program.