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| INVITED EDITORIAL |
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| Year : 2022 | Volume
: 8
| Issue : 2 | Page : 81-85 |
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Secondhand smoke: An unintended public health concern
Suneela Garg1, Akash Deep Sharma2
1 Department of Community Medicine, Maulana Azad Medical College; Chair, Programme Advisory Committee, NIHFW, New Delhi, India
2 Department of Community Medicine, Maulana Azad Medical College, New Delhi, India
| Date of Web Publication | 31-Dec-2022 |
Correspondence Address:
Prof. Suneela Garg
Chair, Programme Advisory Committee, NIHFW, New Delhi
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijcfm.ijcfm_64_22
How to cite this article:
Garg S, Sharma AD. Secondhand smoke: An unintended public health concern. Indian J Community Fam Med 2022;8:81-5 |
| Introduction | |  |
The tobacco epidemic is a major public health challenge that accounts for more than 8 million deaths worldwide annually. A quarter of these deaths are among nonsmokers owing to secondhand smoke.[1] According to a survey conducted in 2017, more than 200 million tobacco users are from India, which is 29% of the world's total adult population. Secondhand smoke kills around 200,000 Indians every year, which is 20% of all tobacco-related deaths.[2] The most dreadful impact of smoking is that it harms both its users and others in close vicinity.[3] It endangers one's life span and its quality which are beyond repair and cure. Several scientific studies show that secondhand smoke is far more hazardous than first-hand smoke. But why so? A smoker smokes through a filter, whereas nonsmokers take in the raw, unfiltered finer suspended particles. Secondhand smoke tends to be more contaminated as it has passed through another human's respiratory tract.[4] Furthermore, chronic smokers have all the adaptive mechanisms in their bodies to counteract the harmful effects of chemical toxins which is not the case among nonsmokers.[5] These facts stress the need for stringent policies in India to stop innocent people in public from acquiring diseases that they did not ask for.
| Burden of Secondhand Smoke | | |
All research articles related to the implications of secondhand smoke that were reviewed revealed a consistent finding that secondhand smokers have an increased risk of contracting the same diseases as direct smokers.[6] According to the WHO, tobacco use accounted for 8 million annual deaths worldwide, with more than 1.2 million deaths among nonsmokers exposed to secondhand smoke.[7] A comparison between the data published in the Global Burden of Disease study of 1990 and 2017 reveals a sharp increase of 11% in deaths due to secondhand smoke exposure.[8] These deaths are caused by life-threatening diseases whose risk in secondhand smokers gets increased by 25%–30%.[9] These diseases include lung cancer, leukemia, chronic pulmonary obstructive disease, and cardiovascular disorders such as hypertension and stroke.[10]
Annually thousands of infants die due to antenatal exposure to tobacco directly or indirectly through secondhand smoke. Those infants that survive have low birth weight, respiratory difficulties, and are more prone to contract diseases.[11] Exposure to secondhand smoke in early life also causes an increased frequency of ear infections, asthma, and other respiratory problems.[12] Some cases of brain tumors have also been reported, which may develop later in life, long after the exposure occurred.[13] It is worth mentioning here that babies in utero, neonates, and old-aged individuals are slightly more prone to incur harmful effects as their immunity has not yet fully developed or has worn off, respectively.[14]
According to research conducted in 2017, exposure to antenatal tobacco and secondhand smoke among total women in India was 9% and 25%, respectively.[15] Different factors such as age, socioeconomic conditions, education, relationship status, and awareness among women influenced their exposure level to firsthand or secondhand smoke. Women of reproductive age belonging to poor socioeconomic status or single mothers were more exposed to tobacco and secondhand smoke.[15]
In the year 2004, the total number of deaths that occurred from exposure to secondhand smoke was more than 603,000. This contributed to 1% of total deaths in the world. Forty-seven percent of the people who died were nonsmoker women, 28% were children, and 26% were nonsmoker men.[10] The distribution of these deaths according to their underlying causes is given in the table below:
| Discussion | | |
The burden of tobacco has been a global problem as they are available anytime, anywhere. India is the largest producer of tobacco-related products. The cigarette is the most common form of tobacco consumption, with other forms being cigars, bidis, and water pipes (commonly known as hookah), electronic vaping machines, and various chewing and sniffing products. As per the survey conducted in 2016–2017, 29% of the total adult population of India was consuming tobacco in any one of the forms.[16] This not only poses serious risks to consumers but also to everyone present in their vicinity. Unsurprisingly, it was estimated half a decade back that approximately 13% of all deaths in India would be contributed to tobacco.[17]
Secondhand smoke, which is also known as passive smoke, refers to the smoke generated from burning tobacco products such as cigarettes and cigars. The term also includes the smoke that is being exhaled by a smoker. Many people are exposed to this harmful smoke in their homes, vehicles, workplaces, and other public places such as casinos, bars, buses, and train stations.[18] Thirdhand smoke is a residue from firsthand and secondhand smoke on clothes, furniture, and household surfaces.
Pregnant females who smoke directly or are exposed to secondhand smoke during gestational periods are at high risk of miscarriage, abortion, and stillbirth. Approximately a thousand infants die annually due to the same.[11] If they survive, they are found to have lower birth weight making them more vulnerable to diseases and their complications. These children also suffer from diseases such as asthma, bronchitis, chronic cough, and other respiratory difficulties, making their life miserable.[15] Sudden infant death syndrome, also referred to as cot/crib death, is the sudden death of an infant during sleep without any apparent reason. According to some scientific studies, it appears that chemical toxins in tobacco smoke inhibit the normal functioning of the breathing center in the brain causing asphyxia. In another study, nicotine (an important component of smoke) and cotinine (a biological marker used to detect exposure to tobacco) were found to be raised significantly in the lungs of infants exposed to tobacco or secondhand smoke.[19] These findings leave no doubt that not just tobacco but secondhand smoke too increases the mortality rate in infants.
Healthy adults who have a good immune system are subjected to the harmful effects of secondhand smoke. Cancer, inflammatory arthritis, and cardiovascular diseases are some of the health problems associated with smoking directly or indirectly. Arthritis is a term used to describe the inflammatory condition of joints that came into existence after the 17th century. Tobacco use and secondhand smoke are found to be major risk factors that contribute to its development.[20] The mechanism of tobacco in causing this disease is not yet very clear, but some studies imply that aromatic hydrocarbons, a constituent of tobacco, could be responsible for inducing this harmful condition. These hydrocarbons activate inflammatory cytokines (chemicals mediating inflammation in humans), which ultimately leads to dysfunction and pain in joints.[21]
A life-sucking disease that leads to great mortality and morbidity of life is cancer. It is by far the most common manifestation of smoke, either directly or indirectly. Involvement of tobacco smoke has been implicated in laryngeal, lung, oropharyngeal, gastric, pancreatic, uterine, and hepatocellular carcinomas.[22] However, the most common cancer caused by exposure to smoke is lung cancer and it is one of the leading causes of death globally. Around 70% of lung cancer patients are smokers or have exposure to secondhand smoke.[23] Since nonsmokers in the close periphery of smokers are also exposed to similar or even larger amounts of carcinogens, the risk of cancer development remains the same in both these groups. The amount of suffering and agony that cancer patients and their close families endure is beyond measure. Besides, the treatment of cancer requires a lot of fortune, which is a burden on the majority of the population that earns hardly enough to survive. Its treatment depends on the stage of diagnosis, and the most effective treatments are available only if diagnosed in early or primary stages. All of this becomes a wretched but avoidable story as the cause of this disease is one's reckless lifestyle. Henceforth, policies limiting the exposure of the general public to secondhand smoke should become a need of the hour.
Another important threat that secondhand smoke poses to life quality is cardiovascular dysfunction. It is proven that people who are exposed to toxins of tobacco first hand or second hand, both are four times more prone to suffer from a stroke.[24] Chemicals that one inhales damage the blood vessels by causing inflammation in them, leading to chronic hypertension, which further aggravates vascular inflammation.[25] Thus, vessel walls are subjected to continuous stress and injury. This may also result in the development of atherosclerotic plaque and clots that can occlude the vessel and result in myocardial infarction or cerebral stroke. Hypertension also increases the stress on the heart as its workload is enhanced trying to pump blood in inflamed damaged vessels. Heart failure may result more often than it does in nonsmokers.[26] These risks are intensified in alcoholics, women taking birth control pills, and patients with other chronic diseases.
Tobacco smoke makes every breath of its victim difficult and binds them to a moribund condition. Chronic smoke exposure induces inflammation of the lung, leading to damage of respiratory epithelium and destruction of lung tissue. Repair of these tissues results in the deposition of collagen in damaged areas that result in the formation of scar tissue, causing the thickening of respiratory walls.[27] This change obstructs the air, which manifests as symptoms of chronic obstructive pulmonary disease like shortness of breath or wheezing.
Considering all these life-threatening conditions and their increased incidence in nonsmokers exposed to secondhand smoke, it becomes a huge responsibility of authorities to take immediate actions and strategize policies that will make the environment 100% smoke free. As it is evident from all the reports that exposure to even a small amount of secondhand smoke for a short time can leave its abominable mark.[28] The framework convention on tobacco control was the first global health contract that was signed by the majority of members of the WHO. It laid down some basic steps for the government of countries to address and control tobacco use. These steps included taxes and price regulations, prohibition of promoting tobacco products, creating smoke-free public spaces, health warnings on packaging, and eliminating the illegal trade of tobacco and its products.[29]
In India, a law was designed to control the smoke epidemic in 2003. This was called the Cigarettes and Other Tobacco Products Act (COTPA 2003). The act strictly prohibits smoking in all public places and the owners or in charge of such places must display proper signs and labels that prohibit smoking.[30] Smoking is banned in almost all public places, such as stadiums, auditoriums, health institutions, restaurants, and educational places. Moreover, promotions, advertisements, and sponsorships of tobacco products are banned at all mass media forums such as television and radio. The act prohibits the sale of tobacco products to individuals <18 years of age or within 100 yards radius of the outer boundary of any educational institution. Packaging of these products should contain pictorial health warnings along with their nicotine and tar contents. All labels on tobacco products should contain the text “SMOKING KILLS” in both English and Hindi. Anybody violating the law is sentenced to jail, where the punishments can vary from imprisonment of 2–5 years, heavy fines, or both. Most importantly, the government made tobacco products unaffordable by imposing hefty taxes. Almost 70% of retail prices of tobacco products are taxed.[31] In September 2019, the Indian government banned E-cigarettes which have flavoring agents and additive agents that are harmful to health. Electronic smoking devices also emit secondhand aerosol that has deleterious effects on human health.[32] Disposal of waste from e-cigarettes and the manufacture of e-cigarettes could also pose potential environmental hazards.
The Food and Drug Administration was given authority in 2009 to examine the manufacture, sales, and distribution of tobacco products by the Family Smoking Prevention and Tobacco Control Act. This act specifically targets youth. The aims of this act are as follows:
- Limit the sale of tobacco products to youth
- Ban all sorts of promotional programs or giveaways
- Direct the manufacturers to reveal the details of ingredients and
- Place proper labels on smokeless tobacco products.[33]
These target the youth and minors more specifically. Hence, Indian health authorities need to improvise on already made policies and make them more efficient and specific for better control of secondhand smoke exposure.
The impact of such laws is highly dependent on how strictly they are executed. A vital step that can scale down the smoke epidemic is the absolute termination of smoking in public places. Complete and efficient control has not yet been achieved because of vague policies. According to a study conducted in schools and colleges across five states in 2004 had found that 85% of educational institutions violated COTPA Section 4 (prohibition of smoking in public places) and around 69% of educational institutions violated COTPA Section 6b (prohibition of the sale of tobacco products near educational institutions).[34] Currently, the need is to focus on youth and design more creative and definite policies that target-specific age groups as the increasing number of adolescents are becoming smokers, and they put their families and children at equal risk of health problems through exposure to secondhand smoke.[35]
| Conclusion | | |
Secondhand smoke was implicated in several public health hazards. These included deaths of infants, neonates with low birth weight, cancers, hypertension, chronic obstructive pulmonary disease, and cardiac failure. Henceforth, it is right to conclude that policies regarding smoking in public places need to be more stringent. Implementation of these policies and educating people about the ill effects of tobacco are other necessary steps to achieve the desired effect. These are the crucial ways to limit exposure of nonsmokers to secondhand smoke and to control the increasing health menace caused by it.
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