Third-hand smoking: indoor measurements of concentration and sizes of cigarette smoke particles after resuspension

Impact of indoor environment on children's pulmonary health

INTRODUCTION

A child's living environment has a significant impact on their respiratory health, with exposure to poor indoor air quality (IAQ) contributing to potentially lifelong respiratory morbidity. These effects occur throughout childhood, from the antenatal period through to adolescence. Children are particularly susceptible to the effects of environmental insults, and children living in socioeconomic deprivation globally are more likely to breathe air both indoors and outdoors, which poses an acute and long-term risk to their health. Adult respiratory health is, at least in part, determined by exposures and respiratory system development in childhood, starting in utero.

AREAS COVERED

This narrative review will discuss, from a global perspective, what contributes to poor IAQ in the child's home and school environment and the impact that indoor air pollution exposure has on respiratory health throughout the different stages of childhood.

EXPERT OPINION

All children have the right to a living and educational environment without the threat of pollution affecting their health. Action is needed at multiple levels to address this pressing issue to improve lifelong respiratory health. Such action should incorporate a child's rights-based approach, empowering children, and their families, to have access to clean air to breathe in their living environment.

Secondhand and thirdhand smoke: a review on chemical contents, exposure routes, and protective strategies

Secondhand smoke (SHS: a mixture of sidestream and mainstream smoke) and thirdhand smoke (THS: made up of the pollutants that settle indoors after smoking in closed environments) are a significant public health concern. SHS and THS contain various chemicals which can be released into the air or settle on surfaces. At present, the hazards of SHS and THS are not as well documented. In this review, we describe the chemical contents of THS and SHS, exposure routes, vulnerable groups, health effects, and protective strategies. The literature search was conducted for published papers on September 2022 in Scopus, Web of Science, PubMed, and Google Scholar databases. This review could provide a comprehensive understanding of the chemical contents of THS and SHS, exposure routes, vulnerable groups, health effects, protective strategies, and future researches on environmental tobacco smoke.

The beliefs of medical faculty students about thirdhand smoke

INTRODUCTION

Thirdhand smoke is the toxic remnant, including pollutants and by-products, of tobacco smoke that remains in the environment after the use of tobacco products. This study aimed to evaluate the relationships between the demographic characteristics and the beliefs about thirdhand smoke of medical faculty students.

METHODS

This descriptive cross-sectional study was conducted with 392 medical faculty students at Afyonkarahisar Health Sciences University. All the participants completed the Beliefs About ThirdHand Smoke (BATHS) questionnaire. Demographic data such as age, gender, year of study, family income level, and place of residence were recorded and evaluated together with tobacco product usage status. Factors (demographic data such as gender) affecting the BATHS scale and sub-scales were analyzed using SPSS software.

RESULTS

The study included 392 medical students. The students comprised 59.7% females and 40.3% males. The students had never used tobacco products (68.1%), 13% were previous users, and 18.9% were active users. The majority of the students stated that thirdhand smoke was harmful to the health of children (90%) and adults (85%) and that thirdhand smoke could remain in a room for days (79%). When the relationships were evaluated between the BATHS scale overall and the health and permanence subscales, and the demographic characteristics of the students, no statistically significant difference was determined according to gender, place of residence, family income level, and tobacco use status.

CONCLUSIONS

This study has provided information for the first time about the beliefs of medical faculty students about thirdhand smoke, and the relationships were investigated between these beliefs and gender, place of residence, family income level, and tobacco use status. The results of the study demonstrated that the students had a strong awareness of the harm of thirdhand smoke and of environmental permanence, and these beliefs did not change according to their own tobacco use status.

Resuspension of particles deposited by nano-enabled consumer sprays: The role of product type, flooring material, and resuspension force

With the development of nanotechnology, an increasing number of nano-enabled consumer products are introduced into the market. The release, deposition, and resuspension of particles from such products could be an important contributor to indoor air pollution and adverse health effects. Our study tested the spray and resuspension of seven nano-enabled consumer products and investigated how flooring material and resuspension force affected the resuspension of particles from these products. Results show that resuspension rates can range from 10^-4 to 5 × 10^-1  h^-1 , depending on the product, flooring material (e.g., carpet and vinyl), and resuspension force (e.g., a walking adult and a moving child; the latter was simulated by a robotic sampler). The resuspension rate from the carpet was statistically significantly higher than that from vinyl flooring, while the resuspension rate by the adult was statiscally significantly higher than that by the robot. In addition, the interaction of investigated factors also played a role in particle resuspension rate. For a subgroup of products based on copper (Cu), silver (Ag), and zinc (Zn) nanomaterials, the resuspension rate reached as high 5 × 10^-1  h^-1 , rates higher than those reported in existing studies with house dust or Arizona Road Dust.

Effect of parental smoking on their children's urine cotinine level in Korea: A population-based study

BACKGROUND

Children may be exposed to tobacco products in multiple ways if their parents smoke. The risks of exposure to secondhand smoke (SHS) are well known. This study aimed to investigate the association between parental smoking and the children's cotinine level in relation to restricting home smoking, in Korea.

METHODS

Using the Korea National Health and Nutrition Health Examination Survey data from 2014 to 2017, we analyzed urine cotinine data of parents and their non-smoking children (n = 1,403), in whose homes parents prohibited smoking. We performed linear regression analysis by adjusting age, sex, house type, and household income to determine if parent smoking was related to the urine cotinine concentration of their children. In addition, analysis of covariance and Tukey's post-hoc tests were performed according to parent smoking pattern.

FINDING

Children's urine cotinine concentrations were positively associated with those of their parents. Children of smoking parents had a significantly higher urine cotinine concentration than that in the group where both parents are non-smokers (diff = 0.933, P < .0001); mothers-only smoker group (diff = 0.511, P = 0.042); and fathers-only smoker group (diff = 0.712, P < .0001). In the fathers-only smoker group, the urine cotinine concentration was significantly higher than that in the group where both parents were non-smoker (diff = 0.221, P < .0001), but not significantly different compared to the mothers-only smoker group (diff = - -0.201, P = 0.388). Children living in apartments were more likely to be exposed to smoking substances.

CONCLUSION

This study showed a correlation between parents' and children's urine cotinine concentrations, supporting the occurrence of home smoking exposure due to the parents' smoking habit in Korea. Although avoiding indoor home smoking can decrease the children's exposure to tobacco, there is a need to identify other ways of smoking exposure and ensure appropriate monitoring and enforcement of banning smoking in the home.

Validity and reliability of Turkish version of Beliefs About Third-Hand Smoke Scale: BATHS-T

OBJECTIVE

Exposure to third-hand smoke (THS) poses health risk, especially for children. THS is mostly ignored in Turkey. The aim of this study is to adapt the Beliefs about Third-Hand Smoke (BATHS) scale to Turkish.

METHODS

The BATHS scale consists of 9 items, and the data collected from 273 people was considered sufficient for analyses in this methodological study. The BATHS scale is translated into Turkish and confirmatory factor analysis (CFA) was performed for the construct validity analysis of the scale.

RESULTS

The correlation between the overall BATHS scale and its two sub-dimensions was 0.937 (p < 0.001), and the correlation between the health and persistence sub-dimensions was 0.775 (p < 0.001). Since there was a statistically positive and highly significant relationship, the adapted BATHS scale was considered structurally compatible with the sub-dimensions. The reliability value of the entire scale is 0.90. Test-retest correlation values between the health and persistence dimensions were between 0.745 and 0.960, the values obtained were above 0.70 and had a statistically positive and high level of significant relationship (p < 0.001).

CONCLUSIONS

It is concluded that the Turkish version of the BATHS scale is reliable and valid. This scale will allow further research and training on third-hand smoke exposure. Tobacco control programmes success will improve.

High Particulate Matter Burden of Cigarettes from the United Arab Emirates and Germany: Are There Country-Specific Differences?

Although the big tobacco companies offer the same cigarette brands across countries, little is known about the potential regional differences of the particulate matter (PM) emissions of apparently equal brands. PM emissions of three cigarette brands (Marlboro Gold, Winston Red resp. Classic, Parliament Platinum resp. Night Blue) from the United Arab Emirates (UAE) and Germany were analysed. Second-hand smoke was produced in a 2.88 m³ measuring cabin by an automatic environmental tobacco smoke emitter. PM size fractions PM₁₀, PM_2.5, and PM₁ were detected in real-time using laser aerosol spectrometry. Depending on the PM fraction Marlboro cigarettes from UAE showed 33%-35% higher PM amounts. Moreover, Winston cigarettes from UAE showed distinctly higher PM values (28-31%) than the German counterparts. The "lighter" Parliament from UAE emitted 3%-9% more PM than the German one. The measured mean PM₁₀ values laid between 778 and 1163 µg/m³ (mean PM_2.5: 777-1161 µg/m³; mean PM₁: 724-1074 µg/m³). That means smoking in enclosed rooms causes massive PM burden. The PM emission of equal or similar tobacco products from different countries can differ distinctly. Hence, the declaration of PM emission values, besides nicotine, tar, and carbon monoxide amounts, should be obligatory worldwide. Furthermore, complete information about the ingredients and production processes of tobacco products should be provided to health officials and the public. This can help to minimise or ban substances or product designs that make smoking even more harmful, and to enhance the awareness of the risks of smoking.

Secondhand Smoke From Multiple Sources, Thirdhand Smoke and Respiratory Symptoms in Hong Kong Adolescents

Introduction

Reports on involuntary tobacco smoke exposure in children have focused mostly on secondhand smoke (SHS) from smoking inside the home. We studied the separate and combined prevalence of SHS exposure from multiple sources and thirdhand smoke (THS) and the associations with respiratory symptoms in Hong Kong adolescents.

Methods

In 2010-2011, 61 810 Secondary 1 (US Grade 7) to seven students reported their smoking status, respiratory symptoms, and exposure to four sources of tobacco smoke in the past 7 days. Weighted prevalence of exposure was calculated. Associations with respiratory symptoms were analyzed in 50 762 never smokers using logistic regression.

Results

Tobacco smoke exposure at home was 23.2% considering SHS exposure from inside the home, but increased to 33.2% including SHS from neighbors and 36.2% further including THS. Including SHS outside home (55.3%), 63.3% of adolescents were exposed to SHS anywhere or THS at home. In never smokers, SHS from each source and THS at home were linearly associated with respiratory symptoms. Exposure to more sources yielded stronger associations with respiratory symptoms (p for trend<.001). The adjusted odds ratios (95% CI) were 1.04 (0.97-1.11), 1.12 (1.03-1.22), 1.40 (1.26-1.56) and 1.99 (1.74-2.28) for 1, 2, 3, and 4 sources, respectively.

Conclusions

Although Hong Kong's smoking prevalence is among the lowest in the developed world, over 60% of its adolescents were involuntarily exposed to tobacco smoke from one or more sources with a linear association with respiratory symptoms in never smokers. More stringent policies are needed to protect adolescents from tobacco smoke.

Implications

In a high-density urban setting, involuntary exposure to tobacco smoke in adolescents can be much higher than the smoking prevalence of the general population, especially if SHS exposure from multiple sources and THS are also considered. Such exposures have important health implications as demonstrated by their linear associations with respiratory symptoms. Tobacco control measures effective in reducing smoking prevalence may have little effect in reducing adolescent exposure to tobacco smoke, especially in the private home, in which other public health strategies are urgently needed.

Medical staff contributions to thirdhand smoke contamination in a neonatal intensive care unit

INTRODUCTION

Non-smoking policies are strictly enforced in neonatal intensive care units (NICUs), which may still become contaminated by thirdhand smoke (THS), posing potential health risks to medically fragile infants. Study aims were to explore contamination routes by characterizing nicotine levels (THS proxy) found on the fingers of NICU medical staff and to assess finger-nicotine correlates.

METHODS

NICU medical staff were surveyed regarding smoking and electronic nicotine devices (ENDS) use/exposure, and household characteristics. Approximately 35% of staff were randomly selected for a finger-nicotine wipe. Three separate quantile regressions modeled percentiles associated with: presence of any finger nicotine, finger-nicotine levels above the median field blank level (i.e. 0.377 ng/wipe), and finger-nicotine levels two times the median blank.

RESULTS

The final sample size was 246 (n=260 approached; n=14 refusals). Over three-quarters (78.5%) reported some exposure to tobacco smoke or ENDS vapor/aerosols. After field-blank adjustments, the median nicotine level (ng/finger wipe) was 0.232 (IQR: 0.021–0.681) and 78.3% of medical staff had measurable finger-nicotine levels. Both being near smoking in friends’/family members’ homes and finger-surface area were related to elevated finger-nicotine levels (p<0.05) in the median blank model.

CONCLUSIONS

Almost four in five NICU staff had measurable finger nicotine, with finger surface area and frequency of reported exposure to tobacco smoke in friends’/family members’ homes emerging as important correlates. Future research will determine the impact of THS on NICU infants. Medical personnel working in a NICU should be cognizant of secondhand smoke and THS, particularly inside friends’/family members’ homes, to reduce potential NICU contamination and infant exposures.

Public Facility Utility and Third-Hand Smoking Exposure without First and Second-Hand Smoking According to Urinary Cotinine Level

Third-hand smoke (THS) causes pathological changes in the liver, lungs, and skin. THS exposure can be ubiquitous, chronic, and unconscious. However, little is known about THS exposure in public facilities and its susceptible population. This paper aimed to identify which public facilities and socio-demographic groups were especially vulnerable to THS. Data from 1360 adults obtained from Korean National Environmental Health Survey I (2009–2011) were analyzed. To study the sole effect of THS, we restricted the study population to those participants who had never smoked and who had no exposure to second-hand smoke. The assessed variables included the type and frequency of public transportation, frequency of use of 12 different public facilities, and 8 socio-demographic factors. Urinary cotinine was used as a biomarker. T-tests and analysis of variance were used for univariate analyses, while generalized linear regression was used for multivariate analysis. Frequent use of public transportation, bars, internet cafés, and participants with low levels of education, divorced or bereaved, living in multi-unit houses, and with smokers within the family were associated with significantly high urinary cotinine levels. These findings indicate that the frequent use of public transportation, certain public facilities and certain socio-demographic factors can result in high THS exposure.

Update on thirdhand smoke: A comprehensive systematic review

OBJECTIVE

The objective of this study is to perform a comprehensive review of the literature about thirdhand smoke (THS).

METHODS

Systematic review of all aspects of THS. Standard methodological procedures were used to search the following databases through April 2018: MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science (WOS) in Indo-European languages. To identify published grey literature, the first 200 hits from Google Scholar™ were evaluated. Clinical trial databases, conference proceedings, and reference lists from the identified articles were also searched. Two unblinded review authors independently assessed trials for inclusion in the review. These same reviewers also extracted study data in accordance with PRISMA guidelines. The study protocol was registered with PROSPERO (CRD42018083619).

RESULTS

Sixty-eight articles were included in this systematic review. Of these, 28 analyzed the concentration of nicotine as a component of THS (the most commonly-used method to measure THS in those studies was chromatography, followed by the mass spectrometry), 21 evaluated the exposure and impact of THS on health (11 studies analyzed the effect of THS in cells [human and animal], 4 in animals, 1 in adults, and 5 in children), 16 investigated the beliefs, behaviours, and policies related to THS, and 3 evaluated other aspects such as THS in e-cigarettes or hookahs. In these 68 studies, THS was determined by measuring the following components: nicotine (30 studies), nitrosamines (17 studies) and cotinine (15 studies). The findings from most of these studies suggest a potential health impact of THS exposure (i.e.: cytotoxicity, metabolic alterations in metabolism, in glycemia; or cell structure; alterations in liver, lung, skin and behaviour in mice), and low awareness about the risks of THS among the general population.

CONCLUSIONS

Numerous specific biomarkers of THS were evaluated, with the most common being nicotine, nitrosamines, and cotinine. The most common method of preparing THS dust samples were cotton wipes, while chromatography, used alone or coupled with mass spectrometry, was the most common analytical technique. We have tried to establish common bases after reviewing all the current literature of the THS although, there is great heterogeneity between the studies and we have not always succeeded. The studies in this review demonstrate the harmful effects of THS on health in cells, in animal models, and in people including children. However, in people, the long-term effects remain unknown and more research is needed. These studies show that knowledge about THS and its potential harmful effects are poorly understood among the general population. For this reason, THS should receive greater emphasis in education and awareness policies.

Knowledge and attitudes toward thirdhand smoke among parents with children under 3 years in Spain

INTRODUCTION

The knowledge and beliefs about what is thirdhand smoke (THS) are limited. Our objective is to characterize the knowledge and beliefs about THS in parents of children under 3 years old in Spain.

METHODS

A cross-sectional study (n = 1406 parents) was conducted online in 2017. We collected information about the knowledge of THS given later, written information with the definition of THS, and asking about beliefs of the effects of THS on children's health.

RESULTS

A total of 27% of the respondents had heard about THS. We only found significant differences among smoking status, being the smokers who declare higher knowledge about THS. A total of 86% of the respondents believed that THS is harmful to their children with statistically significant differences according to educational level, higher among parents with a university degree (ORa = 2.6), and according to the previous knowledge on THS (ORa = 2.1).

CONCLUSIONS

This is the first study in Europe to describe the knowledge and belief of THS. Around 3 out of 10 parents have heard about THS and more than 8 out of 10 parents believed that THS is harmful to their children. Currently, they were not aware of THS but after providing brief information about it, most of them agreed that THS exposure is harmful to their children.

Thirdhand smoke uptake to aerosol particles in the indoor environment

Aerosol composition measurements made in an indoor classroom indicate the uptake of thirdhand smoke (THS) species to indoor particles, a novel exposure route for THS to humans indoors. Chemical speciation of the organic aerosol fraction using mass spectrometric data and factor analysis identified a reduced nitrogen component, predominantly found in the indoor environment, contributing 29% of the indoor submicron aerosol mass. We identify this factor as THS compounds partitioning from interior surfaces to gas phase and then aerosol phase. Partitioning of THS vapors to aerosols requires an aqueous phase for reactive uptake of the reduced nitrogen species (RdNS), leading to seasonal differences in THS concentration indoors. RdNS protonate under the acidic conditions expected for indoor aerosols of outdoor origin. Controlled laboratory measurements performed using cigarette smoke deposited into a Pyrex vessel showed a similar partitioning behavior to aerosol of outdoor origin and mass spectral features comparable to the measured indoor THS factor after 1 week of residence time in the closed vessel. This study reports a new, potentially large THS exposure route from partitioning of surface volatile organic compounds into the aerosol phase and subsequent dispersion in a mechanically ventilated building.

Exposure to third-hand smoke during pregnancy may increase the risk of postpartum depression in China

INTRODUCTION

Our aim was to investigate the association between third-hand smoke exposure (THS) during pregnancy and postpartum depression (PPD) among Chinese women.

METHODS

A total of 973 participants that completed the questionnaire and reviews were included in this cross-sectional study. The THS exposure was assessed based on a questionnaire with key questions from the Global Adult Tobacco Survey (2nd edition) while postpartum depression status was assessed using the Edinburgh Postnatal Depression Scale. Logistic regression models were used to estimate the association between THS exposure during pregnancy and risk of PPD, after adjustment for potential confounders.

RESULTS

The prevalence of postpartum depression among all participants was 17.8%. Of the 973 participants, 725 (74.5%) were exposed to THS during pregnancy while 248 (25.5%) were not. Compared with those who were never exposed to passive smoking, puerperal women who were exposed to THS were at higher risk of PPD (OR=1.71, 95% CI: 1.12-2.60) in the logistic regression model.

CONCLUSIONS

Our study suggests that exposure to third-hand smoke may be a risk factor for postpartum depression among Chinese women. Future preventive interventions should include strategies that target the puerperal women who are exposed to THS during pregnancy. Tobacco control measures that are effective in reducing the prevalence of smoking may have little effect in reducing women's exposure to THS during pregnancy, especially in private places that urgently need other public health strategies.

Guidance for the Clinical Management of Thirdhand Smoke Exposure in the Child Health Care Setting

OBJECTIVE

To explain the concept of thirdhand smoke and how it can be used to protect the health of children and improve delivery of tobacco control interventions for parents in the child health care setting.

METHODS

Review of the literature and descriptive report.

RESULTS

The thirdhand smoke concept has been used in the CEASE intervention to improve the delivery of tobacco control counseling and services to parents. Materials and techniques have been developed for the child health care setting that use the concept of thirdhand smoke. Scientific findings demonstrate that thirdhand smoke exposure is harmful and establishes the need for clinicians to communicate the cessation imperative: the only way to protect non-smoking household members from thirdhand smoke is for all household smokers to quit smoking completely. As the scientific knowledge of thirdhand smoke increases, advocates will likely rely on it to encourage completely smoke-free places.

CONCLUSION

Recent scientific studies on thirdhand smoke are impelling further research on the topic, spurring the creation of tobacco control policies to protect people from thirdhand smoke and stimulating improvements to the delivery of tobacco control counseling and services to parents in child health care settings.

Health effects of exposure to second- and third-hand marijuana smoke: a systematic review

BACKGROUND

Recreational marijuana has been legalized in 11 jurisdictions; Canada will legalize marijuana by July 2018. With this changing landscape, there is a need to understand the public health risks associated with marijuana to support patient-care provider conversations, harm-reduction measures and evidence-informed policy. The objective of this work was to summarize the health effects of exposure to second- and third-hand marijuana smoke.

METHODS

In this systematic review, we searched 6 databases from inception to October 2017. Abstract and full-text review was conducted in duplicate. Studies were included if they were human, in vivo or in vitro studies with more than 1 case reported in English or French, and reported original, quantitative data. Three outcomes were extracted: 1) cannabinoids and cannabinoid metabolites in bodily fluids, 2) self-reported psychoactive effects and 3) eye irritation and discomfort.

RESULTS

Of the 1701 abstracts identified, 60 proceeded to full-text review; the final data set contained 15 articles. All of the included studies were of good to poor quality as assessed with the Downs and Black checklist. There is evidence of a direct relation between the tetrahydrocannabinol content of marijuana and effects on those passively exposed. This relation is mediated by several environmental factors including the amount of smoke, ventilation, air volume, number of marijuana cigarettes lit and number of smokers present. No evidence was identified assessing exposure to third-hand marijuana smoke or the health effects of long-term exposure.

INTERPRETATION

Exposure to second-hand marijuana smoke leads to cannabinoid metabolites in bodily fluids, and people experience psychoactive effects after such exposure. Alignment of tobacco and marijuana smoking bylaws may result in the most effective public policies. More research is required to understand the impact of exposure to third-hand smoke and the health effects of long-term exposure to second-hand smoke.

Second-hand smoke generated by combustion and electronic smoking devices used in real scenarios: Ultrafine particle pollution and age-related dose assessment

Aerosol measurements were carried out in a model room where both combustion (conventional and hand-rolled cigarettes, a cigar and tobacco pipe) and non-combustion (e-cigarette and IQOS®) devices were smoked. The data were used to estimate the dose of particles deposited in the respiratory systems of individuals from 3months to 21years of age using the multiple-path particle dosimetry (MPPD) model. Regardless of the smoking device, the highest doses were received by infants, which reached 9.88×10⁸particles/kg bw during a cigar smoking session. Moreover, 60% to 80% of the particles deposited in the head region of a 3-month-old infant were smaller than 100nm and could be translocated to the brain via the olfactory bulb. The doses due to second-hand smoke from electronic devices were significantly lower, below 1.60×10⁸particles/kg bw, than those due to combustion devices. Dosimetry estimates were 50% to 110% higher for IQOS® than for e-cigarettes.

Development of a scale assessing Beliefs About ThirdHand Smoke (BATHS)

BACKGROUND

Similarly to secondhand smoke (SHS), thirdhand smoke (THS) beliefs may be correlated with smoking behaviors and smokefree policies in the home. Thus, there is a need to develop and validate measures to assess beliefs about THS.

METHODS

A list of 19 items related to THS were generated by an expert panel and tested in a pilot study. Based on results from an exploratory factor analysis, two factors emerged: THS persistence in the environment and THS impact on health. The scale was reduced to nine items, which showed no differential item functioning by smoking status or smoking ban status in the home. The nine items and the two factor structure were tested in a validation sample from a smoke-free homes intervention that included THS educational materials.

RESULTS

The 9-item scale showed excellent internal consistency. Confirmatory factor analysis indicated good model fit for the two factor solution in a low-income population. Tests of construct validity indicated differences due to exposure to the smoke-free homes intervention, by smoking status, whether participants own or rent their home, and smoking ban status in the home.

CONCLUSIONS

The BATHS scale offers researchers a valid and reliable tool to assess THS beliefs.

Influencing Genomic Change and Cancer Disparities through Neighborhood Chronic Toxic Stress Exposure: A Research Framework

Black Americans have disproportionately higher incidence and mortality rates for many cancers. These disparities may be related to genomic changes that occur from exposure to chronic toxic stress and may result from conditions associated with living in racially segregated neighborhoods with high rates of concentrated poverty. The purpose of this article is to present a nursing research framework for developing and testing neighborhood-level interventions that have the potential to mitigate exposure to neighborhood-associated chronic toxic stress, improve individual-level genomic sequelae and cancer outcomes, and reduce cancer health disparities of Black Americans. Public health nursing researchers should collaborate with local officials to determine ways to reduce neighborhood-level stress. Intermediate outcomes can be measured using genomic or other stress biomarkers, and long-term outcomes can be measured by evaluating population-level cancer incidence and mortality.

Thirdhand tobacco smoke: procedures to evaluate cytotoxicity in cell cultures

The risks associated to tobacco smoking are not ceased with smoke extinction. Many toxic compounds remain in the environment after the cigarette is extinguished and accumulated in the air or on surfaces. However, little is known about the risks of this exposure. The aim of this study was to evaluate procedures to collect thirdhand smoke (THS) and prepare the samples to perform three in vitro toxicity tests. Cellulose papers and cotton wipes were used to impregnate with nicotine solution and smoke cigarette in a chamber or in smoker's home. Samples were immersed in methanol or Dulbecco's modified Eagle's medium (DMEM) to expose Hep-2 cells. MTT, neutral red uptake (NRU) and trypan blue assays were performed. The concentration of nicotine in DMEM extract of THS in paper and cotton was similar to those in methanol extract (p > 0.05). Alterations in the mitochondrial and lysosomal functions were found in both paper and cotton samples; however, the cytotoxic effect was not always observed. There was a decrease of 21-31% in MTT assay and 38-56% in NRU assay (p < 0.003). There was a dose-response relationship between the amount of cigarettes and lysosomal viability; the correlation was higher for cotton samples (r = -0.843, p < 0.001). As a dose-response relationship was found only in NRU assay, this test may be a more suitable choice rather than the MTT assay. Paper and wipe sampling can be reliable markers of tobacco smoke contamination. Moreover, these materials, if properly prepared, can be used as substrate providers to perform cellular assays.

Thirdhand smoke beliefs and behaviors among healthcare professionals

Thirdhand smoke (THS) refers to tobacco smoke contaminants and by-products that remain in the environment after a cigarette is extinguished. The purpose of this study was to assess beliefs and behaviors regarding THS among healthcare professionals, and to examine associations among smoking attitudes/beliefs, provider demographics, and THS beliefs and behaviors. Healthcare professionals (N = 204) at a comprehensive cancer center and affiliated general hospital in a northeastern urban area completed online questionnaires. About one third of the respondents had heard of THS before completing the survey, and more than two thirds of the sample believed that THS issues do not receive enough attention. Being female, likelihood of discussing THS with others, endorsing the belief that smoking affects the quality of parenting, and support for government action towards smoking bans were significantly associated with providers' belief that THS is harmful. Endorsing the belief that smoking affects the quality of parenting and belief that THS is harmful were significantly associated with the likelihood of discussing THS with others. Findings shed light on THS beliefs and behaviors of healthcare providers (a group of individuals that could be trained to educate and advise patients about THS) and inform recommendations for new tobacco policies and clinical guidelines for best practices in tobacco control and prevention.

Third-hand Smoke: Impact on Hemostasis and Thrombogenesis

Cigarette smoking is a major risk factor for acute coronary thrombosis. In fact, both active/first-hand smoke and passive/second-hand smoke exposure are known to increase the risk of coronary thrombosis. Although recently a new risk has been identified and termed third-hand smoke (THS), which is the residual tobacco smoke contaminant that remains after a cigarette is extinguished, it remains to be determined whether it can also enhance the risk of thrombogenesis, much like first-hand smoke and second-hand smoke. Therefore, the present studies investigated the impact of THS exposure in the context of platelet biology and related disease states. It was found that THS-exposed mice exhibited an enhanced platelet aggregation and secretion responses as well as enhanced integrin GPIIb-IIIa activation. Furthermore, it was found that THS exposure shortens the tail bleeding time and the occlusion time in a model of thrombosis. Thus, our data demonstrate for the first time (at least in mice) that THS exposure increases the risk of thrombosis-based disease states, which is attributed, at least in part, to their hyperactive platelets.

New Insights Into Tobacco-Induced Vascular Disease: Clinical Ramifications

Tobacco smoke contains more than 4,000 compounds. These include phenols, carbonyls, and nitrosamines that may be irritants and carcinogens; particulate matter such as tars; volatiles and gases such as carbon monoxide; and nicotine. Many of these compounds may contribute to the adverse health effects of tobacco. For example, recent findings have shown that the angiogenic and proliferative effects of nicotine are mediated by activation of nicotinic receptors on the vascular cells. Nicotine-induced activation of vascular cells may contribute to pathological neovascularization in cancer, age-related macular degeneration, and atherosclerosis. This review focuses on how nicotine adversely affects cardiovascular health and highlights intriguing new data about nicotine's potent angiogenic and proliferative properties.

Thirdhand smoke contamination in hospital settings: assessing exposure risk for vulnerable paediatric patients

BACKGROUND

Tobacco has regained the status of the world's number two killer behind heart/vascular disease. Thirdhand smoke (THS) residue and particles from secondhand smoke (SHS) are suspected health hazards (eg, DNA damage) that are likely to contribute to morbidity and mortality, especially in vulnerable children. THS is easily transported and deposited indoors, where it persists and exposes individuals for months, creating potential health consequences in seemingly nicotine-free environments, particularly for vulnerable patients. We collected THS data to estimate infant exposure in the neonatal ICU (NICU) after visits from household smokers. Infant exposure to nicotine, potentially from THS, was assessed via assays of infant urine.

METHODS

Participants were mothers who smoked and had an infant in the NICU (N=5). Participants provided surface nicotine samples from their fingers, infants' crib/incubator and hospital-provided furniture. Infant urine was analysed for cotinine, cotinine's major metabolite: trans-3'-hydroxycotinine (3HC) and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), a metabolite of the nicotine-derived and tobacco-specific carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK).

RESULTS

Incubators/cribs and other furniture had detectable surface nicotine. Detectable levels of cotinine, 3HC and NNAL were found in the infants' urine.

DISCUSSION

THS appears to be ubiquitous, even in closely guarded healthcare settings. Future research will address potential health consequences and THS-reduction policies. Ultimately, hospital policies and interventions to reduce THS transport and exposure may prove necessary, especially for immunocompromised children.

Thirdhand Smoke in the Homes of Medically Fragile Children: Assessing the Impact of Indoor Smoking Levels and Smoking Bans

INTRODUCTION

Thirdhand smoke (THS) residue results from secondhand smoke, and is emerging as a distinct public health hazard, particularly for medically fragile pediatric patients living with smokers. THS is difficult to remove and readily reacts with other pollutants to form carcinogens and ultrafine particles. This study investigated THS found in homes of high-risk infants admitted to a neonatal intensive care unit and their association with characteristics (eg, number of household smokers) hypothesized to influence THS.

METHODS

Baseline data from 141 hospitalized infants' homes were analyzed, along with follow-up data (n = 22) to explore household smoking characteristics and THS changes in response to indoor smoking ban policies.

RESULTS

Households with an indoor ban, in which not more than 10 cigarettes/d were smoked, had the lowest levels of THS contamination compared to homes with no ban (P < .001) and compared to homes with an indoor ban in which greater numbers of cigarettes were smoked (P < .001). Importantly, homes with an indoor ban in which at least 11 cigarettes/d were smoked were not different from homes without a ban. The follow-up sample of 22 homes provided initial evidence indicating that, unless a ban was implemented, THS levels in homes continued to increase over time.

CONCLUSIONS

Preliminary longitudinal data suggest that THS may continue to accumulate in homes over time and household smoking bans may be protective. However, for homes with high occupant smoking levels, banning indoor smoking may not be fully adequate to protect children from THS. Unless smoking is reduced and bans are implemented, medically fragile children will be exposed to the dangers of THS.

Secondhand smoke and traffic exhaust confer opposing risks for asthma in normal and overweight children

OBJECTIVE

Exposure to ultrafine particles (UFP) in secondhand smoke (SHS) and traffic-related air pollution (TRAP) may elicit chronic inflammation. It was hypothesized that the association between these exposures would be potentiated in overweight versus normal-weight children.

METHODS

Average lifetime exposure to TRAP and SHS and objective, physician-diagnosed asthma were determined for 575 children at age 7. Overweight was defined as having a body mass index (BMI) >85th percentile for age and gender. The association between TRAP and SHS exposure and asthma was examined by logistic regression stratified by BMI.

RESULTS

A total of 131 children were overweight; the prevalence of asthma was 24.4% and 14.2% among overweight and normal-weight children, respectively. Exposure to SHS was significantly associated with asthma among overweight (adjusted odds ratio [adjOR] = 3.0; 95% confidence interval [CI] = 1.2, 7.4) but not normal-weight children (adjOR = 1.1; 95% CI = 0.4, 2.7). In contrast, TRAP was significantly associated with asthma among normal-weight (adjOR = 1.8; 95% CI = 1.0, 3.4) but not overweight children (adjOR = 0.7; 95% CI = 0.4, 2.7).

CONCLUSIONS

The association between SHS and TRAP exposure and asthma is modified by children's weight. Children's time-activity patterns, including time spent indoors or outdoors, may vary by weight and play an important role in these UFP exposures.

Secondhand smoke exposure and maternal action to protect children from secondhand smoke: pre- and post-smokefree legislation in Hong Kong

Background

Smokefree legislation may protect children from secondhand smoke (SHS) in the home from smoking parent(s). We examined the effect of the 2007 smokefree legislation on children’s exposure to SHS in the home and maternal action to protect children from SHS exposure in Hong Kong.

Methods

Families with a smoking father and a non-smoking mother were recruited from public clinics before (2005–2006, n = 333) and after the legislation (2007–2008, n = 742) which led to a major extension of smokefree places in Hong Kong. Main outcomes included children’s SHS exposure in the home, nicotine level in mothers’ and children’s hair and home environment, mothers’ action to protect children from SHS, and their support to the fathers to quit.

Results

Fewer mothers post-legislation reported children’s SHS exposure in the home (87.2% versus 29.3%, p<0.01), which was consistent with their hair nicotine levels (0.36ng/mg versus 0.04ng/mg, p<0.01). More mothers post-legislation in the last month took their children away from cigarette smoke (6.3% versus 92.2%; p<0.01) and advised fathers to quit over 3 times (8.3% versus 33.8%; p<0.01). No significant change was found in the content of smoking cessation advice and the proportion of mothers who took specific action to support the fathers to quit.

Conclusions

SHS exposure in the home decreased and maternal action to protect children from SHS increased after the 2007 smokefree legislation. Maternal support to fathers to quit showed moderate improvement. Cessation services for smokers and specific interventions for smoking families should be expanded together with smokefree legislation.

Thirdhand smoke beliefs of parents

OBJECTIVE

To determine if the belief that thirdhand smoke is harmful to children is associated with smoking parents' attitudes, home or car smoking policies, and quitting behaviors.

METHODS

Data from a national randomized controlled trial, Clinical Effort Against Secondhand Smoke Exposure, assessed thirdhand smoke beliefs of 1947 smoking parents in an exit survey after a pediatric office visit in 10 intervention and 10 control practices. Twelve-month follow-up data were collected from 1355 parents. Multivariable logistic regression determined whether belief that thirdhand smoke harms the health of children is independently associated with parental behaviors and attitudes 12 months later. A χ(2) test assessed whether parents who disagreed that thirdhand smoke is harmful were more likely to make a quit attempt if they later believed that thirdhand smoke is harmful.

RESULTS

Belief at the exit survey that thirdhand smoke is harmful was independently associated with having a strictly enforced smoke-free home policy (adjusted odds ratio: 2.05; 95% CI: 1.37-3.05) and car policy (adjusted odds ratio: 1.69; 95% CI: 1.04-2.74) at the 12-month follow-up. A significantly higher percentage (71% vs 50%) of parents who did not hold the thirdhand smoke harm belief at baseline made at least 1 quit attempt if they agreed that thirdhand smoke is harmful at the 12-month follow-up (P = .02).

CONCLUSIONS

Thirdhand smoke harm belief was associated with a strictly enforced smoke-free home and car and attempts to quit smoking. Sensitizing parents to thirdhand smoke risk could facilitate beneficial tobacco control outcomes.

Low-level environmental tobacco smoke exposure and inflammatory biomarkers in children with asthma

OBJECTIVE

The effects of low-level environmental tobacco smoke (ETS) exposure, on asthma control, lung function and inflammatory biomarkers in children with asthma have not been well studied. The objective of the study was to assess ETS exposure in school-age children with asthma whose parents either deny smoking or only smoke outside the home, and to assess the impact of low-level ETS exposure on asthma control, spirometry and inflammatory biomarkers.

METHODS

Forty patients age 8-18 years with well-controlled, mild-to-moderate persistent asthma treated with either inhaled corticosteroids (ICS) or montelukast were enrolled. Subjects completed an age-appropriate Asthma Control Test and a smoke exposure questionnaire, and exhaled nitric oxide (FeNO), spirometry, urinary cotinine and leukotriene E(4) (LTE(4)) were measured. ETS-exposed and unexposed groups were compared.

RESULTS

Only one parent reported smoking in the home, yet 28 (70%) subjects had urinary cotinine levels ≥1 ng/ml, suggesting ETS exposure. Seven subjects (18%) had FeNO levels >25parts per billion, six of whom were in the ETS-exposed group. In the ICS-treated subjects, but not in the montelukast-treated subjects, ETS exposure was associated with higher urinary LTE(4), p = 0.04, but had no effect on asthma control, forced expiratory volume in 1 s or FeNO.

CONCLUSIONS

A majority of school-age children with persistent asthma may be exposed to ETS, as measured by urinary cotinine, even if their parents insist they don't smoke in the home. Urinary LTE(4) was higher in the ETS-exposed children treated with ICS, but not in children treated with montelukast.

The effects of low-level environmental tobacco smoke exposure on pulmonary function tests in preschool children with asthma

OBJECTIVES

Though parents of children with asthma smoke, they often avoid smoking in their homes or near their children, thus limiting exposure. It is not known if such low-level environmental tobacco smoke (ETS) results in measurable exposure or affects lung function. The objectives of this study were to measure urinary cotinine in preschool children with asthma, and to examine the relationship between low-level ETS exposure and pulmonary function tests (PFTs).

METHODS

Preschool children with asthma were enrolled. Parents completed questionnaires on ETS exposure and asthma control, urinary cotinine concentrations were measured and PFTs were compared between subjects with and without recent ETS exposure.

RESULTS

Forty one subjects were enrolled. All parents denied smoking in their home within the last 2 weeks, but 14 (34%) parents admitted to smoking outside their homes or away from their children. Fifteen (37%; 95%CI: 23-53) of the children had urinary cotinine levels ≥1 ng/ml, of which seven (17%; 95%CI: 8-32) had levels ≥5 ng/ml. FEV1 and FEV0.5 were lower in subjects with a urinary cotinine level ≥5 ng/ml as compared to those with levels <1 ng/ml or between 1 and 5 ng/ml; both at baseline and after inhalation of albuterol. Five of seven subjects with urinary cotinine levels ≥5 ng/ml had FEV0.5 less than 65% of predicted values. There were no significant differences in IOS measures.

CONCLUSIONS

Despite parental denial of smoking near their children, preschool children may be exposed to ETS. Such low-level ETS exposure may affect lung function, possibly in a dose-dependent manner.

[Comparison of the aerosol produced by electronic cigarettes with conventional cigarettes and the shisha]

In previous studies of the smoke from regular cigarettes and water pipes, we measured aerosol particle sizes in three streams; S1, inhaled by the smoker, S2, released by the device itself and S3, exhaled by the smoker. We used an electrostatic low-pressure impactor (ELPI), giving particle size distributions in real time and calculated median diameters, D50, and dispersion (σg). This allowed us to predict airway deposition. In addition, the aerosol particle half-life in the air was used as a measure of the risk to others from passive smoking. With the same equipment, we measured the particle sizes and persistence in air of the liquid aerosol generated by e-cigarettes (Cigarettec®) containing water, propylene glycol and flavorings with or without nicotine. Aerosol generation was triggered by a syringe or by the inspiration of volunteer smokers. The D50 data obtained in S1, were 0.65 μm with nicotine and 0.60 μm without nicotine. Deposition in the airways could then be calculated: 26% of the total would deposit, of which 14% would reach the alveoli. These data are close to those found with regular cigarettes. For S3, D50 data were 0.34 μm and 0.29 μm with or without nicotine. The half-life in air of the S3 stream was 11 seconds due to a rapid evaporation. The-e-cigarette aerosol, as measured here, is made of particles bigger than those of cigarette and water pipe aerosols. Their deposition in the lung depends on their fate in the airways, which is unknown. Contrary to tobacco smoke, which has a half-life in air of 19 to 20 minutes, the risk of passive "smoking" exposure from e-cigarettes is modest.

Parents smoking in their cars with children present

OBJECTIVE

To determine prevalence and factors associated with strictly enforced smoke-free car policies among smoking parents.

METHODS

As part of a cluster, randomized controlled trial addressing parental smoking, exit interviews were conducted with parents whose children were seen in 10 control pediatric practices. Parents who smoked were asked about smoking behaviors in their car and receipt of smoke-free car advice at the visit. Parents were considered to have a "strictly enforced smoke-free car policy" if they reported having a smoke-free car policy and nobody had smoked in their car within the past 3 months.

RESULTS

Of 981 smoking parents, 817 (83%) had a car; of these, 795 parents answered questions about their car smoking policy. Of these 795 parents, 29% reported having a smoke-free car policy, and 24% had a strictly enforced smoke-free car policy. Of the 562 parents without a smoke-free car policy, 48% reported that smoking occurred with children present. Few parents who smoke (12%) were advised to have a smoke-free car. Multivariable logistic regression controlling for parent age, gender, education, and race showed that having a younger child and smoking ≤10 cigarettes per day were associated with having a strictly enforced smoke-free car policy.

CONCLUSIONS

The majority of smoking parents exposed their children to tobacco smoke in cars. Coupled with the finding of low rates of pediatricians addressing smoking in cars, this study highlights the need for improved pediatric interventions, public health campaigns, and policies regarding smoke-free car laws to protect children from tobacco smoke.

Pediatrician interventions and thirdhand smoke beliefs of parents

BACKGROUND

Thirdhand smoke is residual tobacco smoke contamination that remains after a cigarette is extinguished. A national study indicates that adults' belief that thirdhand smoke (THS) harms children is associated with strict household no-smoking policies. The question of whether pediatricians can influence THS beliefs has not been assessed.

PURPOSE

To identify prevalence of THS beliefs and associated factors among smoking parents, and the association of pediatrician intervention on parent belief that THS is harmful to their children.

METHODS

Exit interview data were collected from 1980 parents following a pediatric office visit. Parents' level of agreement or disagreement that THS can harm the health of babies and children was assessed. A multivariate logistic regression model was constructed to identify whether pediatricians' actions were independently associated with parental belief that THS can harm the health of babies and children. Data were collected from 2009 to 2011, and analyses were conducted in 2012.

RESULTS

Ninety-one percent of parents believed that THS can harm the health of babies and children. Fathers (AOR=0.59, 95% CI=0.42, 0.84) and parents who smoked more than ten cigarettes per day (AOR=0.63, 95% CI=0.45, 0.88) were less likely to agree with this statement. In contrast, parents who received advice (AOR=1.60, 95% CI=1.04, 2.45) to have a smokefree home or car or to quit smoking and parents who were referred (AOR=3.42, 95% CI=1.18, 9.94) to a "quitline" or other cessation program were more likely to agree that THS can be harmful.

CONCLUSIONS

Fathers and heavier smokers were less likely to believe that THS is harmful. However, pediatricians' actions to encourage smoking parents to quit or adopt smokefree home or car policies were associated with parental beliefs that THS harms children.

TRIAL REGISTRATION

This study is registered at NCT00664261.

Relationship between exhaled nitric oxide and exposure to low-level environmental tobacco smoke in children with asthma on inhaled corticosteroids

OBJECTIVES

The relationship between exhaled nitric oxide (FeNO) and asthma severity or control is inconsistent. Active smoking lowers FeNO, but the relationship between passive smoking and FeNO is less clear. Children may be exposed to low-level environmental tobacco smoke (ETS) or thirdhand smoke, even if parents avoid smoking in the presence of their children. Our hypothesis was that FeNO is lower in children with asthma exposed to low-level ETS when compared with those who are not exposed.

METHODS

Children with stable asthma, 8-18 years of age, on low- or medium-dose inhaled corticosteroids (ICS) were enrolled. Spirometry, Asthma Control Questionnaire (ACQ), FeNO, exhaled breath condensate pH (EBC pH), and EBC ammonia were compared between children with and without ETS exposure as determined by urinary cotinine.

RESULTS

Thirty-three subjects were enrolled, of which 10 (30%) had urinary cotinine levels ≥1 ng/ml. There were no significant differences between the two groups in age, sex, BMI percentile, atopy status, FEV(1), EBC pH, or EBC ammonia. Median ACQ was 0.29 (IQR: 0.22-0.57) for those with cotinine levels <1 ng/ml and 0.64 (IQR: 0.57-1.1) for those with cotinine levels of ≥1 ng/ml, p = .02. Median FeNO (ppb) was 23.9 (IQR: 15.2-34.5) for unexposed subjects and 9.6 (IQR: 5.1-15.8) for exposed subjects, p = .008.

CONCLUSIONS

Children with asthma on low to medium doses of ICS and recent low-level ETS exposure have lower FeNO levels when compared with non-ETS-exposed subjects. Exposure to low-level ETS or thirdhand smoke may be an important variable to consider when interpreting FeNO as a biomarker for airway inflammation.

Age-related differences in cigarette smoke extract-induced H2O2 production by lung endothelial cells

Cigarette smoke causes oxidative stress in the lung resulting in injury and disease. The purpose of this study was to determine if there were age-related differences in cigarette smoke extract (CSE)-induced production of reactive species in single and co-cultures of alveolar epithelial type I (AT I) cells and microvascular endothelial cells harvested from the lungs (MVECLs) of neonatal, young and old male Fischer 344 rats. Cultures of AT I cells and MVECLs grown separately (single culture) and together (co-culture) were exposed to CSE (1, 10, 50, 100%). Cultures were assayed for the production of intracellular reactive oxygen species (ROS), hydroxyl radical (OH), peroxynitrite (ONOO(-)), nitric oxide (NO) and extracellular hydrogen peroxide (H(2)O(2)). Single and co-cultures of AT I cells and MVECLs from all three ages produced minimal intracellular ROS in response to CSE. All ages of MVECLs produced H(2)O(2) in response to CSE, but young MVECLs produced significantly less H(2)O(2) compared to neonatal and old MVECLs. Interestingly, when grown as a co-culture with age-matched AT I cells, neonatal and old MVECLs demonstrated ~50% reduction in H(2)O(2) production in response to CSE. However, H(2)O(2) production in young MVECLs grown as a co-culture with young AT I cells did not change with CSE exposure. To begin investigating for a potential mechanism to explain the reduction in H(2)O(2) production in the co-cultures, we evaluated single and co-cultures for extracellular total antioxidant capacity. We also performed gene expression profiling specific to oxidant and anti-oxidant pathways. The total antioxidant capacity of the AT I cell supernatant was ~5 times greater than that of the MVECLs, and when grown as a co-culture and exposed to CSE (≥ 10%), the total antioxidant capacity of the supernatant was reduced by ~50%. There were no age-related differences in total antioxidant capacity of the cell supernatants. Gene expression profiling found eight genes to be significantly up-regulated or down-regulated. This is the first study to describe age-related differences in MVECLs exposed to CSE.

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.

Effects of cigarette smoke residues from textiles on fibroblasts, neurocytes and zebrafish embryos and nicotine permeation through human skin

Toxic substances from cigarette smoke can attach to carpets, curtains, clothes or other surfaces and thus may pose risks to affected persons. The phenomenon itself and the potential hazards are discussed controversially, but scientific data are rare. The objective of this study was to examine the potential of textile-bound nicotine for permeation through human skin and to assess the effects of cigarette smoke extracts from clothes on fibroblasts, neurocytes and zebrafish embryos. Tritiated nicotine from contaminated cotton textiles penetrated through adult human full-thickness skin as well as through a 3D in vitro skin model in diffusion chambers. We also observed a significant concentration-dependent cytotoxicity of textile smoke extracts on fibroblast viability and structure as well as on neurocytes. Early larval tests with zebrafish embryos were used as a valid assay for testing acute vertebrate toxicity. Zebrafish development was delayed and most of the embryos died when exposed to smoke extracts from textiles. Our data show that textiles contaminated with cigarette smoke represent a potential source of nicotine uptake and can provoke adverse health effects.

Electronic cigarettes and thirdhand tobacco smoke: two emerging health care challenges for the primary care provider

PRIMARY CARE PROVIDERS SHOULD BE AWARE OF TWO NEW DEVELOPMENTS IN NICOTINE ADDICTION AND SMOKING CESSATION: 1) the emergence of a novel nicotine delivery system known as the electronic (e-) cigarette; and 2) new reports of residual environmental nicotine and other biopersistent toxicants found in cigarette smoke, recently described as "thirdhand smoke". The purpose of this article is to provide a clinician-friendly introduction to these two emerging issues so that clinicians are well prepared to counsel smokers about newly recognized health concerns relevant to tobacco use. E-cigarettes are battery powered devices that convert nicotine into a vapor that can be inhaled. The World Health Organization has termed these devices electronic nicotine delivery systems (ENDS). The vapors from ENDS are complex mixtures of chemicals, not pure nicotine. It is unknown whether inhalation of the complex mixture of chemicals found in ENDS vapors is safe. There is no evidence that e-cigarettes are effective treatment for nicotine addiction. ENDS are not approved as smoking cessation devices. Primary care givers should anticipate being questioned by patients about the advisability of using e-cigarettes as a smoking cessation device. The term thirdhand smoke first appeared in the medical literature in 2009 when investigators introduced the term to describe residual tobacco smoke contamination that remains after the cigarette is extinguished. Thirdhand smoke is a hazardous exposure resulting from cigarette smoke residue that accumulates in cars, homes, and other indoor spaces. Tobacco-derived toxicants can react to form potent cancer causing compounds. Exposure to thirdhand smoke can occur through the skin, by breathing, and by ingestion long after smoke has cleared from a room. Counseling patients about the hazards of thirdhand smoke may provide additional motivation to quit smoking.