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WIC 904 Environmental Tobacco Smoke Exposure
Environmental tobacco smoke (ETS) exposure is defined (for WIC eligibility purposes) as exposure to smoke from tobacco products inside enclosed areas, like the home, place of child care, etc. ETS is also known as secondhand, passive, or involuntary smoke (1). The ETS definition also includes the exposure to the aerosol from electronic nicotine delivery systems (2).
|NonBreastfeeding Woman||3, 4, 5, or 7|
Most environmental tobacco smoke (ETS) exposure occurs in homes and workplaces (3). It can also happen in public places, such as in restaurants, bars, casinos, and cars and other vehicles (3). There are no safe levels of exposure to ETS (1, 4). It is known to increase the risk of lung cancer, respiratory diseases, and cardiovascular diseases among adults, and to have adverse effects on birth outcomes and the health of infants and children (4). ETS exposure increases oxidative stress and inflammation (5-7). Inflammation is associated with asthma (8), cardiovascular diseases (9, 10), cancer (11), chronic obstructive pulmonary disease (12), and metabolic syndrome (13, 14).
ETS from Tobacco Smoking
ETS from traditional tobacco and nicotine products is a mixture of the sidestream smoke given off by a burning cigarette, pipe, or cigar, and the mainstream smoke exhaled by smokers. ETS is made up of over 7,000 chemicals, and at least 69 of which are known to cause cancer (1).
ETS from Electronic Nicotine Delivery Systems (ENDS)
Vapes, vaporizers, vape pens, hookah pens, electronic cigarettes (e-cigarettes or e-cigs), and e-pipes are some of the many terms used to describe electronic nicotine delivery systems (ENDS). ENDS are noncombustible tobacco products used to smoke or "vape" a solution that often contains nicotine. The solution, or “e-liquid,” is heated to create an aerosol that the user inhales. (15)
While ENDS do not produce sidestream vapor, their mainstream vapor has been shown to be hazardous. It contains chemicals, such as nicotine, which can cause cancer, can harm the fetus, and are a source of indoor air pollution (2, 16-19). An individual’s level of exposure to secondhand nicotine depends on the amount of nicotine in the ENDS product, as well as on product characteristics, device operation, and the user’s inhalation pattern. A few studies have demonstrated that passive exposure to ENDS among healthy adults causes an increase in nicotine in the bloodstream that is similar to that from passive exposure to cigarette smoke (2). More research is needed to evaluate health consequences of ETS exposure from ENDS, particularly for pregnant women and children (2).
The following summarizes the conditions associated with increased risk from ETS exposure for the mother, infant, and child:
|ETS Source||Effects on
May develop in adulthood:
|Electronic Nicotine Delivery System (ENDS) Vapor||
Limited data, but potential association with (2):
Nicotine exposure effects (2):
Nicotine exposure effects (2):
Limited data, but potential association with (2):
*See risk #336 Fetal Growth Restriction for more information.
†See risk #141 Low Birth Weight and Very Low Birth Weight for more information.
‡See risk #152 Low Head Circumference (Infants and Children >24 Months of Age) for more information.
§See risk #142 Preterm or Early Term Delivery for more information.
Nonsmokers who are regularly exposed to ETS have been observed to have high vitamin C turnover, thus resulting in a vitamin deficiency (27, 28). Data from the Center of Disease Control and Prevention National Health and Nutrition Examination Survey 2003-2004 found that children exposed to ETS had lower levels of vitamins A, C, and E, as well as beta-carotene and folate when compared to non-exposed children (29). Antioxidants may reduce oxidative stress-induced lung damage among both smokers and non-smokers (5-7, 28, 29). Research on preventing oxidative stress-related diseases by antioxidant supplementation has produced mixed results; therefore, it is recommended to consume fruits and vegetables for appropriate antioxidants intake (28, 29). It is recommended that individuals exposed to ETS meet the Recommended Dietary Allowance for vitamin C (27, 30).
Thirdhand smoke (THS) is the unintentional intake of tobacco smoke and other related chemicals that occurs without the presence of active smoking. Residual tobacco smoke pollutants adhere to the clothing and hair of smokers, to pet fur, and to surfaces, furnishings, and dust in indoor environments (31). Contact with the pollutants can cause nicotine exposure. Infants and children are the most at risk of THS exposure because they spend more time indoors and are closer to or on the ground where the nicotine-contaminated dust accumulates (31, 32). Once smoking has occurred indoors, THS cannot be eliminated by airing out rooms, opening windows, using fans or air conditioners, or confining smoking to only certain areas of a home. Replacing items is often the only way to reduce, though not eliminate, residual tobacco smoke pollutants (33). There is limited research on the extent of negative health outcomes from exposure to THS. While THS is not a WIC Nutrition Risk, it should be considered for overall health implications.
WIC staff can provide the following nutrition services to women, infants and children who are exposed to environmental tobacco smoke:
- Administer State or local agency substance use screening methods. For more information, please see: WIC Substance Use Prevention Resource, Chapter 5: https://wicworks.fns.usda.gov/resources/wic-substance-use-prevention-guide.
- Provide a safe and supportive environment when discussing ETS exposure. For more information on techniques for delivering effective messages, please see: WIC Substance Use Prevention Guide, Chapter 6: https://wicworks.fns.usda.gov/resources/wic-substance-use-prevention-guide.
- Encourage fruit and vegetables that are high in vitamin C.
- Highlight WIC foods, especially 100% juice that are good sources of vitamin C and other important nutrients.
- Offer the following suggestions to minimize secondhand and thirdhand smoke exposure (20, 33, 34):
Have smoke-free rules for the car and home.
Make sure places that are frequently visited are smoke-free (i.e., school, work, parks, restaurants, places of worship, etc.).
Ask anyone who cares for children or pets to follow smoke-free rules.
Those who smoke outside should do so away from open doors or windows.
If smoking has occurred inside a house, consider replacing fabric-covered items and thoroughly washing walls.
If smoking has occurred inside a house, consider replacing fabric
The following questions were adapted from the validated surveys to be applicable for WIC purposes, and can be used to determine ETS exposure (35, 36):
- In the past seven days, have you and/or child been in an enclosed space while someone used tobacco products?
1. National Cancer Institute [Internet]. Bethesda (MD): National Institutes of Health, 2019. Secondhand tobacco smoke (environmental tobacco smoke). 2019 Feb 21 [cited 2019 Oct 16]. Available from: https://www.cancer.gov/about-cancer/causes-prevention/risk/substances/secondhand-smoke.
2. U.S. Department of Health and Human Services [Internet]. Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2016. E-cigarette use among youth and young adults: a report of the Surgeon General. 2016 July [cited 2019 Apr 20]. [24 pages]. Available from: https://www.cdc.gov/tobacco/data_statistics/sgr/e-cigarettes/index.htm.
3. Centers for Disease Control and Prevention [Internet]. Atlanta (GA): Centers for Disease Control and Prevention, 2018. Secondhand smoke (SHS) facts. 2018 Jan 17 [cited 2020 Feb 3] Available from: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/ secondhand_smoke/general_facts/index.htm
4. U.S. Department of Health and Human Services [Internet]. Washington (DC): U.S Department of Health and Human Services, 2006. The health consequences of smoking- 50 years of progress: a report of the Surgeon General. 2015 July [cited 2019 July 18]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK179276/pdf/ Bookshelf_NBK179276.pdf
5. Block G, Dietrich M, Norkus EP, et al. Factors associated with oxidative stress in human populations. Am. J. Epidemiol. 2002 Aug 1 [cited 2019 Oct 16]; 156(3):274-285. Available from: https://academic.oup.com/aje/article/156/3/274/71423.
6. Panagiotakos DB, Pitsavos C, Chrysohoou C, et al. Effect of exposure to secondhand smoke on markers of inflammation: the ATTICA study. Am. J. Med. 2004 Feb 1 [cited 2020 Mar 5]; 116(3):145-50. Available from: https://www.ncbi.nlm.nih.gov/pubmed/14749157?dopt=Abstract.
7. Kostikas K, Minas M, Nikalaou E, et al. Secondhand smoke exposure induces acutely airway acidification and oxidative stress. Resp Med. 2013 Feb 1 [cited 2020 Mar 5]; 107(2):172-9. Available from: https://doi.org/10.1016/j.rmed.2012.10.017.
8. Dozor A. The role of oxidative stress in the pathogenesis and treatment of asthma. Annals of the New York Academy of Sciences. 2010 Aug 17 [cited 2020 Mar 3];1203(1): 133-7. Available from: https://doi.org/10.1111/j.1749-6632.2010.05562.x.
9. Barnoya J, Glantz SA. Cardiovascular effects of secondhand smoke: nearly as large as smoking. Circulation. 2005 May 24 [cited 2020 Mar 5]; 111(20):2684-98. Available from: https://www.ahajournals.org/doi/full/10.1161/circulationaha.104.492215.
10. Raghuveer G, White DA, Hayman LL, et al. Cardiovascular consequences of childhood tobacco smoke exposure: prevailing evidence, burden, and racial and socioeconomic disparities: a scientific statement from the American Heart Association. Circulation. 2016 Oct 18 [cited 2020 Mar 5]; 134(16): 336-59. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27619923.
11. Sinn DD, Man SF, McWilliams A, et al. Progression of airway dysplasia and C-reactive protein in smokers at high risk of lung cancer. Am. J. Respir. Crit. Care Med. 2006 Mar [cited 2019 Nov 4]; 1:173(5): 535-9. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2662937/.
12. Slowik N, Ma S, He J, et al. The effect of secondhand smoke exposure on markers of elastin degradation. Chest. 2001 Oct [cited 2020 Mar 5]; 140(4): 946-53. Available from: https://doi.org/10.1378/chest.10-2298.
13. Haffner SM. The metabolic syndrome: inflammation, diabetes mellitus, and cardiovascular disease. Am. J. Cardiol. 2006 Jan 16 [cited 2020 Feb 21]; 97(2A):3A-11A. Available from: https://www.ncbi.nlm.nih.gov/pubmed/16442931?dopt=Abstract.
14. Moore BF, Clark ML, Bachand A, et al. Interactions between diet and exposure to secondhand smoke on metabolic syndrome among children: NHANES 2007-2010. Journal of clinical endocrinology & metabolism. 2016 Jan [cited 2020 Feb 21];101(1): 52-8. Available at: https://doi.org/10.1210/jc.2015-2477.
15. U.S. Food & Drug Administration [Internet]. Washington (DC): US FDA, 2019. Vaporizers, e-cigarettes, and other electronic nicotine delivery systems (ENDS). 2019 Feb 05 [cited 2019 Mar 1]. Available from: https://www.fda.gov/TobaccoProducts/Labeling/ ProductsIngredientsComponents/ucm456610.htm.
16. Grana R, Benowitz N, Glantz SA. E-cigarettes: a scientific review. Circulation. 2014 [cited 2019 Mar 27];129(19): 1972-86. Available from: https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.114.007667.
17. Bahl V, Lin S, Xu N, et al. Comparison of electronic cigarette refill fluid cytotoxicity using embryonic and adult models. Reprod Toxicol. 2012 Dec [cited 2019 Mar 27];34(4): 529-37. Available from: https://www.sciencedirect.com/science/article/pii/S0890623812002833.
18. Schober W, Szendrei K, Matzen W, et al. Use of electronic cigarettes (e-cigarettes) impairs indoor air quality and increases FeNO levels of e-cigarette consumers. Int J Hyg Environ Health. 2014 Jul [cited 2019 Mar 27];217(6): 628-37. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24373737.
19. Czogala J, Goniewicz ML, Fidelus B, et al. Secondhand exposure to vapors from electronic cigarettes. Nicotine & Tobacco Research. 2014 June [cited 2019 Oct 18];16(6): 655-62. Available from: https://doi.org/10.1093/ntr/ntt203.
20. U.S. Department of Health and Human Services [Internet]. Atlanta (GA): US Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevent and Health Promotion,Office on Smoking and Health, 2006. The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General. 2006 July [cited 2019 July 18]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK44324/pdf/ Bookshelf_NBK44324.pdf.
21. U.S. Department of Health and Human Services [Internet]. Atlanta (GA): US Department of Health and Human Services, Centers for Disease Control and Prevention, 2001. Women and smoking: a report of the Surgeon General. 2001 [cited 2019 July 18]. Available from: https://www.cdc.gov/tobacco/data_statistics/sgr/ 2001/complete_report/pdfs/chp3.pdf.
22. Perera FP, Rauh V, Whyatt RM, et al. Molecular evidence of an interaction between prenatal environmental exposures and birth outcomes in a multiethnic population. Environ Health Perspect. 2004 April [cited 2020 Feb 20]; 112:626-630. Available from: https://ehp.niehs.nih.gov/doi/pdf/10.1289/ehp.6617.
23. Asomaning K, Miller DP, Liu G, et al. Second hand smoke, age of exposure and lung cancer risk. Lung cancer. 2008 July [cited 2020 Feb 20];61(1): 13-20. Available from: https://doi.org/10.1016/j.lungcan.2007.11.013.
24. Groner JA, Huang H, Nagaraja H, et al. Secondhand some exposure and endothelial stress in children and adolescents. Academic Pediatrics. 2015 Jan [cited 2020 Feb 20];15(1): 54-60. Available from: https://doi.org/10.1016/j.acap.2014.09.003.
25. Lau EM, Celermajer DS. Protecting our children from environmental tobacco smoke: one of our great healthcare challenges. Eur Heart J. 2014 Mar [cited 2020 Feb 20];35: 2452-3. Available from: doi:10.1093/eurheartj/ehu098.
26. Wickstrom, R. Effects of nicotine during pregnancy: human and experimental evidence. Current neuropharmacology. 2007 [cited 2019 Mar 8]; 5: 213-22. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2656811/".
27. Dietary reference intakes: the essential guide to nutrient requirements. Otten, JJ, Hellwig, JP, Meyers, LD, ed., Institute of Medicine of the National Academies. Washington (DC): The National Academies Press, 2006 Sep 29.
28. Jacob, RA. Passive smoking induces oxidant damage preventable by vitamin C. Nutrition Reviews. 2000 Aug [cited 2020 Mar 5];58(8): 239-41. Available from: https://academic.oup.com/nutritionreviews/article/58/8/239/1927014.
29. Wilson KM, Finkelstein JN, Blumkin AK, et al. Micronutrient levels in children exposed to secondhand tobacco smoke. Nicotine & Tobacco Research. 2011 Sept [cited 2019 Oct 19];13(9): 800-8. Available from: https://doi.org/10.1093/ntr/ntr076.
30. Monson ER. Dietary reference intakes for the antioxidant nutrients: vitamin C, vitamin E, selenium and carotenoids. J Am Diet Assoc. 2000 June [cited 2020 Mar 5];100(6): 637-40.
31. Sleiman M, Gundel AL, Pankow JF, et al. Formation of carcinogens indoors by surface-mediated reactions of nicotine with nitrous acid, leading to potential thirdhand smoke hazards. PNAS. 2010 April 13 [cited 2019 Sep 11]; 107(15): 6576-6581. Available from: https://www.pnas.org/content/pnas/107/15/6576.full.pdf.
32. Matt GE, Quintana PJE, Hovell MF, et al. Households contaminated by environmental tobacco smoke: sources of infant exposures. Tobacco Control. 2004 Mar [cited 2019 Sept 10];13(1):29-37. Available from: https://www.ncbi.nlm.nih.gov/pubmed/14985592.
33. U.S. Department of Agriculture [Internet]. Washington (DC): USDA Food and Nutrition Service, 2010. Infant nutrition and feeding: a guide for use in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). 2019 April [cited 2019 Aug 7]. Available from: https://wicworks.fns.usda.gov/sites/default/files/media/document/ Infant_Feeding_Guide_Final_508c_0.pdf.
34. American Academy of Pediatrics [Internet]. Itasca (IL): American Academy of Pediatrics, c2017. How parents can prevent exposure to thirdhand smoke. 2017 Apr 24 [cited 2019 Sept 11]. Available from: https://www.healthychildren.org/English/health-issues/conditions/tobacco/Pages/How-Parents-Can-Prevent-Exposure-Thirdhand-Smoke.aspx.
35. National Center for Health Statistics [Internet]. Atlanta (GA): Centers for Disease Control and Prevention, 2018. National health and nutrition examination survey overview 2013-2014. 2018 Oct 30 [cited 2020 Feb 3]. Available from: https://wwwn.cdc.gov/nchs/nhanes/continuousnhanes/overview.aspx?BeginYear=2013.
36. Surveys, Questionnaires, and Assessment Tools. Itasca (IL): American Academy of Pediatrics, Julius B Richmond Center of Excellence, 2020. Secondhand tobacco smoke exposures (SHS) and use items. No date [2020 Feb 3]. Available from: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Richmond-Center/Pages/Measurement-Core.aspx.