A Walk Through Thirdhand Smoke’s Past

Smoke Signals: The First Signs of the Dangers of Smoking

If you have been following us for a while now, you probably know that at the heart of our work is the idea that thirdhand smoke presents a health risk to us and our loved ones. If you are new to our site, this is a great place to start—read on! While the Thirdhand Smoke Resource Center’s main task is to share the latest information and most up-to-date resources about thirdhand smoke, we thought it might be a good time to revisit the history of thirdhand smoke in a Summer “Throwback Thursday” series. When and how was thirdhand smoke discovered? When did people and policymakers start caring about it? How has the research developed and changed with time? Join us in this 10-week series where we will explore key moments and events from the early 1900s to the present day to answer these questions and more.

Today, lung cancer is the third most common cancer in the United States. In 2019, over 221,000 new cases were diagnosed and over half as many deaths occurred. However, before the 19^th century, lung cancer rates were so low that the disease was hardly recognized, even by the medical community, who often misdiagnosed the scattered cases as other diseases. In 1900, only 140 cases of lung cancer had been officially documented. Twenty years later, the rapidly rising rates of lung cancer made the disease impossible to ignore. The medical community was forced to reckon with the cause of this new ailment: smoking.

In the first half of the 20^th century, the medical community’s opinion towards smoking shifted dramatically. From medical schools glossing over lung cancer because of its apparent rarity in the early 1900s, to 1964, when the landmark Surgeon General’s Report concluded that smoking was a cause of lung cancer, there could not have been a more drastic change in how the scientific community viewed smoking. Though the Surgeon General’s report cites over 7,000 studies that informed its finding, a few key studies can be used to summarize this period of discovery.

There were several small-scale studies in the 1930s that provided the first evidence for the link between smoking and lung cancer. The first, published in 1931 by Angel H. Roffo, involved the application of tobacco tar, a thick substance formed when tobacco is burned, on the skin of rabbits. Roffo found that tumors consistently formed where the tar was applied, and these rabbits died within a year or two of the application. His later studies focused on concentrating particular substances in the tobacco tar, like benzopyrene, that he suspected were especially toxic, to apply to his test rabbits. Now, his studies are considered some of the first evidence of the harms of thirdhand smoke, since the chemicals in tobacco entered the rabbits’ bodies not through inhalation, but through the skin. In 1939, meanwhile, Franz H. Müller surveyed 96 lung cancer patients in hospitals in Cologne, Germany, and concluded that smoking was “the most important factor” contributing to the rising number of lung cancer cases. A third important study from the 1930s was L.C. Lewton’s discovery that tobacco smoke caused paralysis in the cilia, or tiny hairs in the nose and throat membrane. These cilia serve as a first means of defense for the lungs, and their paralysis meant the lungs were left vulnerable.

Rabbit with tumor on its ear after tar application from A.H. Roffo’s studies.

In the following decade, further studies confirmed and expanded upon these results. In 1953, tobacco tar was applied to mice, similarly producing cancerous tumors. Studies of other hospitals in other countries also found that smoking greatly increased the risk of lung cancer. The evidence was growing—but the studies were all still too small in scale. Something bigger was needed.

American Cancer Society scientists, E.C. Hammond and D. Horn pour over documents. Image from the American Cancer Society.

In 1954 and 1958, the scientific community was rocked by two smoking studies by American Cancer Society scientists, E. Cuyler Hammond and Daniel Horn. These studies both involved over 187,000 men who were surveyed about their smoking habits and then followed for three years. At the end, each of the participating men’s status (“dead,” “alive,” or “don’t know”) was recorded and compared to their smoking status. The evidence was impossible to ignore. Both of Hammond and Horn’s studies found an “extremely high association between cigarette smoking and death rates for men with lung cancer” and a higher rate of smoking resulted in a greater risk of lung cancer. They even went so far as to describe smoking and lung cancer as a cause-and-effect relationship.

In 1964, simultaneously faced with irrefutable evidence that smoking was a cause of lung cancer and smoking rates of around 42 percent of the U.S. population, Surgeon General Luther Terry and an advisory committee published the landmark Surgeon General’s Report, “Smoking and Health.” This report pulled from over 7,000 studies to conclude that “the weight of evidence at present implicates smoking as the principal factor in the increased incidence of lung cancer.” As a result, the report said, smoking was considered “a health hazard of sufficient importance to warrant appropriate remedial action.”

This should have been the end of smoking. The product is clearly dangerous and the scientific community unanimously agreed how it should be addressed. Needless to say, smoking is still all too prevalent today. How is it possible that we have known about the risks of smoking for nearly a century now and yet it still persists? Find out next week on Episode 2: Smoke and Mirrors: The Tobacco Industry’s Fight to Obscure the Evidence.

Sources:

American Lung Association. (n.d.). Tobacco Trends Brief. ALA. https://www.lung.org/research/trends-in-lung-disease/tobacco-trends-brief/overall-tobacco-trends

Hammond, E. C. & Horn, D. (1954). THE RELATIONSHIP BETWEEN HUMAN SMOKING HABITS AND DEATH RATES. Journal of the American Medical Association, 155(15), 1316. https://doi.org/10.1001/jama.1954.03690330020006

Hammond, E. C., & Horn, D. (1958). Smoking and death rates: report on forty-four months of follow-up of 187,783 men. 2. Death rates by cause. Journal of the American Medical Association, 166(11), 1294–1308. https://doi.org/10.1001/jama.1958.02990110030007

Lewton, L. C. (1932). Substances Present In Tobacco Smoke Which Are Irritating To The Nose And Throat And Their Removal By A New Process (Patent Applied For). American Tobacco Records; Master Settlement Agreement. Unknown. https://www.industrydocuments.ucsf.edu/docs/qjvy0140

Lung Cancer Statistics. (2022, June 6). CDC. https://www.cdc.gov/cancer/lung/statistics/index.htm

Mendes, E. (2014, January 9). The Study That Helped Spur the U.S. Stop-Smoking Movement. American Cancer Society. https://www.cancer.org/latest-news/the-study-that-helped-spur-the-us-stop-smoking-movement.htmlMorabia, A. (2012). Quality, originality, and significance of the 1939 “Tobacco consumption and lung carcinoma” article by Mueller, including translation of a section of the paper. Preventive medicine, 55(3), 171–177. https://doi.org/10.1016/j.ypmed.2012.05.008

Müller, F. H. (1940). Tabakmißbrauch und Lungencarcinom. Zeitschrift Für Krebsforschung, 49(1), 57–85. https://doi.org/10.1007/bf01633114

Proctor, R. N. (2012). The history of the discovery of the cigarette–lung cancer link: evidentiary traditions, corporate denial, global toll: Table 1. Tobacco Control, 21(2), 87–91. https://doi.org/10.1136/tobaccocontrol-2011-050338

Roffo, A. H. (1931). Durch Tabak beim Kaninchen entwickeltes Carcinom. Zeitschrift Für Krebsforschung, 33(1), 321–332. https://doi.org/10.1007/bf01792286

Roffo, A. H. (1939). Krebserzeugendes Benzpyren, gewonnen aus Tabakteer. Zeitschrift Für Krebsforschung, 49(5), 588–597. https://doi.org/10.1007/bf01620960

U.S. Cancer Statistics: Lung Cancer Stat Bite. (2022, June 6). CDC. https://www.cdc.gov/cancer/uscs/about/stat-bites/stat-bite-lung.htm

U.S. Department of Health, Education, and Welfare. (1964, January). Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service (Public Health Service Publication No. 1103). https://www.scribd.com/document/199073624/Smoking-and-Health#fullscreen&from_embed

Wipfli, H., & Samet, J. M. (2016). One Hundred Years in the Making: The Global Tobacco Epidemic. Annual Review of Public Health, 37(1), 149–166. https://doi.org/10.1146/annurev-publhealth-032315-021850

Wynder, E. L., Graham, E. A., & Croninger, A. B. (1953). Experimental Production of Carcinoma with Cigarette Tar. Cancer Res, 13(12), 855–864. https://aacrjournals.org/cancerres/article/13/12/855/467062/Experimental-Production-of-Carcinoma-with

Smoke and Mirrors: The Tobacco Industry’s Fight to Obscure the Evidence

Sugar, fossil fuel, and tobacco—what do these three industries have in common? They all used the same tactics to undermine scientific findings that threatened their financial interests. This infamous strategy involves creating the perception of dissent and uncertainty in the scientific community by sponsoring studies that benefit the industry. Under the guise that science is objective and free from outside interests, the public begins to doubt the dangers and harms from these industries. In the case of sugar, these studies indicated that saturated fat, not sugar, was responsible for higher rates of heart disease. The fossil fuel industry-sponsored studies attributed warming global temperatures to natural causes rather than human influence. And where did they learn these tactics? From tobacco companies that backed research that found no link between smoking and lung cancer.

Large corporations continue to use this pseudoscience strategy because of how effective it has been shown to be. Despite nearly a century’s worth of solid evidence on the harms of smoking, the fight to end tobacco sales continues. For too long, industry-sponsored research and legal loopholes have prevented scientists, policymakers, and the public from uniting behind anti-smoking efforts. Only in recent decades was it revealed that the tobacco industry, while publicly emphasizing the safety and even health benefits of their product, were performing studies in secret that indisputably indicated that smoking (and even thirdhand smoke) was hazardous to human health.

By the 1950s, the tobacco industry’s concern over its future reached a fever pitch. Facing mounting evidence that their product was directly causing lung cancer but unwilling to stop selling such a profitable product, tobacco industry leaders from companies like Phillip Morris, Liggett Group, and the American Tobacco Company convened in New York City to plan a unified industry response. They needed a way to invalidate evidence of the dangers of smoking without revealing that they were behind it. In the past, the industry had leaned into advertising to shape public opinion around smoking. The downside with advertising, however, was that the message was delivered too blatantly by the advertiser (the tobacco industry) and would expose the industry’s interests (selling more tobacco products). Advertising simply did not carry the same impact as scientific research. The only way was to fight fire with fire—or science with (pseudo) science.

The goal of industry-funded science was to create the impression of an ongoing controversy over smoking in the scientific community. The industry did everything it could to fuel dissent and erode public trust in science. Tobacco companies began seeking scientists skeptical about the role of smoking in lung cancer for public statements, funding their research. Of course, they claimed that this research was done out of a desire to protect their customers’ health. A full-page newspaper ad by the Tobacco Industry Research Committee included the following statements:

“We accept an interest in people’s health as a basic responsibility, paramount to every other consideration in our business. We believe the products we make are not injurious to health. We always have and always will cooperate closely with those whose task it is to safeguard the public health.”

The “Frank Statement to Cigarette Smokers,” published in over 400 newspapers in January 1954, reached over 43 million people. The quote is from this statement.

In the following decade, further studies confirmed and expanded upon these results. In 1953, tobacco tar was applied to mice, The resulting studies found no causal link between lung cancer and smoking, often attributing lung cancer to other factors. Most concerningly, some of these industry-funded research practices continue today. As recently as 2008, Cornell scientist Dr. Claudia Henschke published a study that found that 80 percent of lung cancer deaths could be prevented by the widespread use of CT scans. The take-home message? Any adverse health effects from smoking can be treated and addressed. It should come as no surprise that the study had been partially funded by the Foundation for Lung Cancer: Early Detection, Prevention, and Treatment, whose parent company is cigarette-maker Liggett Group. Dr. Henschke claimed to have no conflicts of interest to disclose in her study.

In order to appease the public’s concerns about smoking, the tobacco industry also introduced new, “safer” tobacco products. Cigarettes with filters and low-tar levels were two of these alterations. More recently, cigarette manufacturers labeled certain products as “light” or “mild,” words that were commonly interpreted as equating to less harmful. There was no evidence, however, that these modifications made smoking any safer. Any noted reductions in nicotine resulted in smokers changing their smoking habits (e.g., smoking more or deeper inhalations) to compensate. The evidence indicated that light and low-tar cigarettes did not reduce the risk of tobacco-related diseases.

The scientific community was not the only threat to smoking—some smokers turned to the courts and attempted to hold tobacco companies liable. By 1964, smokers had brought 30 lawsuits to court. The tobacco executives, using the science they had funded, argued that there was no proof that smoking caused lung cancer. Smokers and policymakers continued pushing back on the legality of tobacco manufacturing and usually lost. Tobacco companies maintained that the link between smoking and lung cancer lacked sufficient proof, as well as attributing lung cancer to other, nonsmoking-related causes. In 1994, executives from the top seven American tobacco companies were subject to six hours of congressional questioning about nicotine and the addictiveness of smoking. These executives testified that they did not believe that cigarettes were addictive, but that they would prefer their children did not smoke.

In 1994, executives from the top 7 American tobacco companies testified in Congress that they did not believe that cigarettes were addictive.

Meanwhile, these same companies were performing their own secret experiments and tests that concluded that smoking was harmful to health. In 1953, Claude Teague, a scientist for Camel cigarettes, found that cigarette use and cancer rates were both rising in parallel, pointing to causation that was further supported by clinical data. Another confidential study on animals attempted to discover if the danger of smoking was in the cigarette paper or the tobacco. The findings clearly indicated that it was the tobacco. Philip Morris performed animal studies and suppressed the findings that indicated the addictive qualities of nicotine in the 1980s.

There is even evidence that the tobacco industry was aware of the harms of thirdhand smoke as early as 1991. Philip Morris scientists performed a secret study in which they infused a room with cigarette smoke. They found that tobacco smoke chemicals in the air could remain there for 12 hours after smoking stopped. They also found cancer-causing chemicals in the wallpaper, carpet, and curtain that remained for at least 110 days.

Tobacco companies have only recently admitted that smoking is harmful to health. Phillip Morris claimed light cigarettes reduced cancer risks as recently as 2010. In the meantime, how can we possibly quantify the harm that tobacco companies have knowingly done? The CDC reports 480,000 deaths each year from lung cancer. One in five deaths in the United States is from lung cancer.

The tobacco industry successfully created doubt about the smoking-lung cancer argument through industry-funded science. But the anti-smoking movement was only just getting started. Find out how they shifted the conversation around smoking from a personal to an environmental concern next week, on Episode 3: Catching Fire: Reframing Smoking as an Environmental Concern.

Sources:

Brandt A. M. (2012). Inventing conflicts of interest: a history of tobacco industry tactics. American journal of public health, 102(1), 63–71. https://doi.org/10.2105/AJPH.2011.300292

Harris, G. (2008, March 26). Cigarette Company Paid for Lung Cancer Study. The New York Times. https://www.nytimes.com/2008/03/26/health/research/26lung.html

Hilts, P. J. (1994, April 15). Tobacco Chiefs Say Cigarettes Aren’t Addictive. The New York Times. https://www.nytimes.com/1994/04/15/us/tobacco-chiefs-say-cigarettes-aren-t-addictive.html

Milberger, S., Davis, R. M., Douglas, C. E., Beasley, J. K., Burns, D., Houston, T., & Shopland, D. (2006). Tobacco manufacturers’ defence against plaintiffs’ claims of cancer causation: throwing mud at the wall and hoping some of it will stick. Tobacco control, 15 Suppl 4(Suppl 4), iv17–iv26. https://doi.org/10.1136/tc.2006.016956

Twombly, R. (2008). Lung Cancer Screening Trial Financed by Tobacco-Funded Foundation, Sparks Debate. JNCI Journal of the National Cancer Institute, 100(10), 690–691. https://doi.org/10.1093/jnci/djn170

Whitlatch, A., & Schick, S. (2018). Thirdhand Smoke at Philip Morris. Nicotine & Tobacco Research, 21(12), 1680–1688. https://doi.org/10.1093/ntr/nty153

Wilson, D. (2010, February 19). Coded to Obey Law, Marlboro Lights Become Marlboro Gold. The New York Times. https://www.nytimes.com/2010/02/19/business/19smoke.html?_r=1

Catching Fire: Reframing Smoking as an Environmental Concern

Image 1 (left): American Cancer Society pamphlet from the late 1970s warning about the dangers of smoking while pregnant. Image 2 (middle): American Lung Association sign from the 1990s discouraging smoking around babies. Image 3 (right): Joe Chemo parody of the Camel cigarettes mascot developed by psychology professor Scott Plous in 1996

In 1981, three separate studies concluded that nonsmoking women married to smokers had a higher risk of lung cancer than nonsmoking women married to nonsmokers. In other words, simply being around a smoker increased a person’s risk of lung cancer. These studies, conducted in multiple countries and with hundreds of women, provided the first major evidence of the harms of smoking not just to the smoker, but to those around them—in the form of secondhand smoke. The discovery of secondhand smoke began a new era of anti-smoking campaigns.

Secondhand smoke, also called environmental tobacco smoke, is the smoke produced from burning tobacco products. Exposure to secondhand smoke can cause many of the same issues in nonsmokers as actual smoking causes in people who smoke. Between the 1960s and the early 2000s, research continued to expand the list of nonsmoking populations most affected by exposure to secondhand smoke: marital partners, children, buyers of used cars, coworkers, flight attendants, and more. Secondhand smoke forced the public to reckon with a new question: If people wouldn’t stop smoking for themselves, would they stop for others?

After nonsmoking wives were discovered to be susceptible to environmental tobacco smoke, researchers began investigating if other vulnerable groups of people were also affected. Unsurprisingly, they were. Researchers estimated that American nonsmokers were exposed to secondhand smoke in amounts that were equivalent to actively smoking 0.1 to 1 cigarette per day. Babies whose mothers had smoked while pregnant were reported to have higher hospital admission rates for pneumonia and bronchitis. Similarly, infants exposed to parental smoking were found to be at increased risk of respiratory illness and deformed lung development. Research concluded that children of people who smoked were more likely to take up smoking than children of nonsmokers. The workplace was identified as another area where people could be susceptible to environmental tobacco smoke. Employees exposed to tobacco smoke at work were observed to have an increased risk of cancer.

No smoking policies, which first appeared in the 1970s, rapidly multiplied in the ‘80s in response to rising public awareness of secondhand smoke. The anti-smoking movement used this new secondhand smoke research to fuel public support for prohibiting or limiting smoking in certain locations. State and local governments adopted no smoking regulations in workplaces, restaurants, hotels, hospitals, airplanes, schools, and other public places. By 1986, 41 states and the District of Columbia had some form of no-smoking policy. The popularity of these smoking restrictions reflects the public’s shifting attitude towards smoking. Whereas public policy efforts of the 1960s focused on helping smokers to quit, policy efforts in the ‘70s and ‘80s rallied around the right of all people to breathe smokefree air.

However, most of these smokefree policies only limited where smoking took place, as opposed to outright banning it. Most regulations required the creation and separation of designated smoking and no smoking sections. Stronger evidence was needed to garner the public support needed for comprehensive smoking bans.

Arizona was the first state to adopt any sort of smoking regulation. This New York Times excerpt, from September 1973, features this novel policy. Read more here.

This needed evidence would come in 1986, in the form of the Surgeon General’s report, titled “The Health Consequences of Involuntary Smoking.” This US government report compiled 400 pages of evidence on the harms of secondhand smoke to reach three key conclusions. First, secondhand smoke is a cause of disease in nonsmokers. Second, children whose parents smoke have more respiratory infections and reduced lung function. Finally, having designated smoking areas did not eliminate exposure to secondhand smoke. The report declared that secondhand smoke was not “a qualitatively different exposure from active smoking, but rather a low-dose exposure to a known hazardous agent—cigarette smoke.”

Secondhand smoke provided anti-smoking advocates with momentum and widespread public support into the early 2000s. New research continued to build on existing knowledge of the hazards of secondhand smoke exposure, strengthening the connection between respiratory disease and lung cancer. Secondhand smoke proved to be an invaluable tool in the fight against smoking. The dangers of secondhand smoke meant that smoking was an issue that everyone, not just those who smoked, was affected by. The story of secondhand smoke continues next week with Episode 4: Smoking Gun: “The Debate is Over.”

Sources:

Brownson, R. C., Eriksen, M. P., Davis, R. M., & Warner, K. E. (1997). ENVIRONMENTAL TOBACCO SMOKE: Health Effects and Policies to Reduce Exposure. Annual Review of Public Health, 18(1), 163–185. https://doi.org/10.1146/annurev.publhealth.18.1.163

Garfinkel L. (1981). Time trends in lung cancer mortality among nonsmokers and a note on passive smoking. Journal of the National Cancer Institute, 66(6), 1061–1066. https://doi.org/10.1093/jnci/66.6.1061

Hirayama T. (1981). Non-smoking wives of heavy smokers have a higher risk of lung cancer: a study from Japan. British medical journal (Clinical research ed.), 282(6259), 183–185. https://doi.org/10.1136/bmj.282.6259.183

Institute of Medicine (US) Committee on Secondhand Smoke Exposure and Acute Coronary Events. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington (DC): National Academies Press (US); 2010. 5, The Background of Smoking Bans. Available from: https://www.ncbi.nlm.nih.gov/books/NBK219563/

Office on Smoking and Health (US). The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta (GA): Centers for Disease Control and Prevention (US); 2006. 7, Cancer Among Adults from Exposure to Secondhand Smoke. Available from: https://www.ncbi.nlm.nih.gov/books/NBK44330/

Repace, J. (2004). Flying the smoky skies: secondhand smoke exposure of flight attendants. Tobacco Control, 13(90001), 8i–19. https://doi.org/10.1136/tc.2003.003111

Trichopoulos, D., Kalandidi, A., Sparros, L., & MacMahon, B. (1981). Lung cancer and passive smoking. International journal of cancer, 27(1), 1–4. https://doi.org/10.1002/ijc.2910270102

US Department of Health and Human Services. The Health Consequences of Involuntary Smoking A Report of the Surgeon General. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Health Promotion and Education, Office on Smoking and Health; 1986. DHHS Publication No. (CDC) 87-8398.

U.S. Environmental Protection Agency (EPA). (2014, September 4). Secondhand Smoke and Smoke-free Homes. US EPA. https://www.epa.gov/indoor-air-quality-iaq/secondhand-smoke-and-smoke-free-homes

Smoking Gun: “The Debate is Over”

Surgeon General Dr. Richard Carmona introduces his 670-page report, “The Health Consequences of Involuntary Exposure to Tobacco Smoke,” on June 27, 2006 to an audience of press reporters at the Department of Health and Human Services.

Amid a round of applause, Surgeon General Dr. Richard Carmona strode to the podium. He turned to face the audience, quickly acknowledging the contributions of the scientific community, and paused as the second round of applause died down.

“I am grateful to be here today to say unequivocally that the debate is over,” Dr. Carmona told the crowd. “The science is clear: Secondhand smoke is not a mere annoyance but a serious health hazard that causes premature death and disease in children and nonsmoking adults.” He looked up with these last few words, making eye contact with the audience to convey the full weight of this statement. “There is no risk-free level of secondhand smoke exposure.”

It was June 27, 2006, and Dr. Carmona was introducing the 29th Surgeon General’s report to a crowd of reporters at the Department of Health and Human Services. This report, “The Health Consequences of Involuntary Exposure to Tobacco Smoke,” built upon the first secondhand smoke report from 20 years prior with additional evidence and a stronger condemnation of smoking. The public’s rising interest in what was often called “passive tobacco smoke exposure” created waves of support, policy change, and new research opportunities in this field, including paving the way for a successor to secondhand smoke—thirdhand smoke.

While the 1986 Surgeon General’s report conclusively linked secondhand smoke to an increased risk of lung cancer and respiratory disease, the 2006 report returned to the subject of secondhand smoke with additional conclusions from hundreds of new studies. More diseases, such as sudden infant death syndrome (SIDS), reproductive effects, and cancer in areas other than the lung were found to be caused or worsened by secondhand smoke exposure. The report had six major findings: three which the 1986 report shared but were strengthened with new evidence, and three additional findings.

Findings from both reports:

Secondhand smoke causes premature death and disease in nonsmokers
Children of smokers are at greater risk of respiratory and other diseases
Separating smokers and nonsmokers is not enough to prevent secondhand smoke exposure

New findings from the 2006 report:

Adults exposed to secondhand smoke suffer from cardiovascular and respiratory issues
No level of secondhand smoke exposure is risk-free
Many millions of Americans are still exposed to secondhand smoke

Uniquely, this report also called out the tobacco industry for undermining the science on secondhand smoke. The industry was criticized for funding research that the report declared to be “biased” and “sustain[ed] controversy.” While the report did not go into detail about the industry’s tactics, it did acknowledge how these tactics maintained the illusion of a lack of scientific consensus on the issue of secondhand smoke. Dr. Carmona and the report both emphasized that the scientific community was very much in agreement about the harms of secondhand smoke.

Support for tobacco control extended beyond the scientific community; public support for smoking regulations and taxation became increasingly widespread and popular. Cities and states continued to adopt no-smoking policies, especially indoors. By 2014, 65 percent of the American population lived in places with smokefree restaurants and bars. Tobacco taxes increased rapidly—the average state cigarette tax per pack jumped from around 33 cents in 2000 to $1.20 in 2009. The Food and Drug Administration (FDA) added stricter regulations to tobacco labeling and advertising, requiring more explicit warning labels and banning the use of words such as “reduced harm” or “light.” These policy changes worked: The number of Americans that smoked decreased by 6 million between 1965 and 2014. California’s tobacco control program reduced healthcare costs by an estimated $134 billion between its launch in 1989 and 2008.

This focus on secondhand smoke also piqued researchers’ interest in the possibility of another means of involuntary tobacco exposure: thirdhand smoke. Studies from as early as the 1950s had indicated that tobacco smoke residue was dangerous. In 2004, researchers revisited this idea with new methods and technology. They discovered that dust could trap chemicals from burning tobacco products that could then be a source of contamination later on—long after a person had smoked. This chemical residue was therefore third-, not secondhand smoke. In the following years, this research was extended to the dust and surfaces in cars, which were found to similarly capture the toxins in tobacco smoke. This breaking research introduced a new avenue of smoke exposure, one that did not require an active source of tobacco smoke for there to be toxic chemicals present.

Graphic warning labels developed by the US Food and Drug Administration.

In 2006, the same year Surgeon General Dr. Carmona released his secondhand smoke report, the term “thirdhand smoke” first appeared in print. Dr. Georg Matt, San Diego State University professor and primary investigator of the Thirdhand Smoke Resource Center, used the phrase in a USA Today interview to describe his new research on babies’ exposure to thirdhand smoke. This may have been the first time that the public saw the phrase, but the scientific community had been referring to this tobacco residue as “thirdhand smoke” for some time. In fact, the true origins of the term are a little unclear—it’s possible that the term originated in multiple places.

Thirdhand smoke introduced a new form of tobacco smoke contamination that had previously not been recognized. The 2006 Surgeon General’s report, for instance, cited that “eliminating smoking in indoor spaces fully protects nonsmokers from exposure to secondhand smoke” [emphasis added]. The existence of thirdhand smoke that could linger and be transferred via surfaces and people meant that eliminating smoking in indoor spaces would be insufficient protection against passive smoke exposure. A person that smoked outside could enter an indoor space, carrying toxic thirdhand smoke on their clothes, skin, and breath that could then settle on indoor surfaces.

Secondhand smoke had been a powerful and persuasive argument against smoking for decades, but the tobacco control movement needed something more to keep up the momentum. Thirdhand smoke, new to science in the early 2000s, rekindled many researchers’ curiosity and seemed a natural direction for tobacco research and control to move towards. How would it change the game? Next week, uncover the rise of thirdhand smoke into the public eye in Episode 5: A New Flame: Thirdhand Smoke’s Big Moment.

Sources:

Antman, E., Arnett, D., Jessup, M., & Sherwin, C. (2014). The 50th Anniversary of the US Surgeon General’s Report on Tobacco: What We’ve Accomplished and Where We Go From Here. Journal of the American Heart Association, 3(1). https://doi.org/10.1161/jaha.113.000740

C-Span. (2006, June 27). Secondhand Smoke Report. https://www.c-span.org:443/errors/403?193178-1/secondhand-smoke-report

Matt, G. E., Romero, R., Ma, D. S., Quintana, P. J., Hovell, M. F., Donohue, M., Messer, K., Salem, S., Aguilar, M., Boland, J., Cullimore, J., Crane, M., Junker, J., Tassinario, P., Timmermann, V., Wong, K., & Chatfield, D. (2008). Tobacco use and asking prices of used cars: prevalence, costs, and new opportunities for changing smoking behavior. Tobacco induced diseases, 4(1), 2. https://doi.org/10.1186/1617-9625-4-2

Matt, G. E., Quintana, P. J., Hovell, M. F., Chatfield, D., Ma, D. S., Romero, R., & Uribe, A. (2008). Residual tobacco smoke pollution in used cars for sale: air, dust, and surfaces. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco, 10(9), 1467–1475. https://doi.org/10.1080/14622200802279898

Matt, G. E., Quintana, P. J., Hovell, M. F., Bernert, J. T., Song, S., Novianti, N., Juarez, T., Floro, J., Gehrman, C., Garcia, M., & Larson, S. (2004). Households contaminated by environmental tobacco smoke: sources of infant exposures. Tobacco control, 13(1), 29–37. https://doi.org/10.1136/tc.2003.003889

O’Neil, J. (2006, June 27). Surgeon General Warns of Secondhand Smoke. The New York Times. https://www.nytimes.com/2006/06/27/health/27cnd-smoke.html

Szabo, L. (2006, August 6). USATODAY.com – Babies may absorb smoke residue in home. USA Today. https://usatoday30.usatoday.com/news/health/2006-08-06-thirdhand-smoke-usat_x.htm

Zwillich, T. (2006, June 27). “Debate Over” on Secondhand Smoke. WebMD. https://www.webmd.com/smoking-cessation/news/20060627/debate-over-on-secondhand-smoke

Clearing the Smoke: Direction and Clarity for Thirdhand Smoke Research

By the time “thirdhand smoke” appeared in the popular press in 2009, multiple California-based research teams were already studying different aspects of thirdhand smoke. This was a new frontier, and researchers were excited by the opportunities that came with it. After all, thirdhand smoke could be an asset to anti-tobacco efforts if better understood. That being said, its novelty to science also presented challenges: Researching a complex concept like thirdhand smoke could be disjointed without an overall framework.

In 2011, the thirdhand smoke research community came together to shape the future of their field. Eighteen prominent thirdhand smoke researchers published a paper entitled “Thirdhand Tobacco Smoke: Emerging Evidence and Arguments for a Multidisciplinary Research Agenda.” The paper crucially provided a formal definition of thirdhand smoke and its exposure, summarized findings up until that point, and discussed the overall significance of thirdhand smoke. Based on these existing ideas, the paper described areas of interest and important directions for future research, including the establishment of a research consortium that would pursue this research.

The research community finally had a comprehensive, scientific definition of thirdhand smoke. The term had certainly been used and defined before, including in 2006 and 2009, but never in the scope and thoroughness included in this new paper. This definition includes thirdhand smoke’s known components, how it forms, and its relationship to secondhand smoke. In addition, some researchers were using other terms to describe thirdhand smoke, including “aged tobacco smoke” and “residual secondhand smoke.” The paper explained why “thirdhand smoke” should be the term used moving forward. This term clearly shares its origins with secondhand smoke. Just like secondhand smoke, thirdhand smoke is a form of passive tobacco smoke. However, calling it thirdhand smoke also highlights its differences from secondhand smoke. Thirdhand smoke is aged tobacco smoke and adheres to surfaces in addition to lingering in the air—both of which distinguish it from secondhand smoke.

All relevant thirdhand smoke findings up to that point were summarized, providing a foundation for further research. Exposure to thirdhand smoke involves complex chemical, physical, biological, behavioral, and social mechanisms that require a multidisciplinary research approach. Research groups were simultaneously studying different aspects of thirdhand smoke. Some were working on identifying the chemical components in thirdhand smoke, others were examining how the toxic residue stuck to surfaces, and others were studying how the chemicals changed with age. Yet other research teams were investigating how thirdhand smoke enters the body, different means of exposure, and which people were most at risk. Since thirdhand smoke research was conducted independently in multiple locations, the new research consortium allowed different research teams to put their findings together like a puzzle, revealing a bit more of the overall picture of thirdhand smoke.

This paper also provided researchers with an opportunity to explain the importance of thirdhand smoke research. Although the discovery of thirdhand smoke sparked mostly concern, it was also met with some skepticism. One news article referred to thirdhand smoke researchers as “zealots” performing “witch hunt science.” A reviewer of a publication draft described thirdhand smoke as a trivial nuisance comparable to spilled coffee. Thus, researchers took the opportunity to emphasize the value of thirdhand smoke research. At the time, in 2011, thirdhand smoke was so new that there had been little time for lengthy and time-consuming clinical studies. Nonetheless, there was plenty of evidence to suggest that this was an area of concern in need of further research.

Infographics from the Thirdhand Smoke Resource Center. The top infographic depicts the relationship between first-, second-, and thirdhand smoke. The bottom infographic describes methods of exposure.

Importantly, the 2011 paper used two existing facts to support the idea that thirdhand smoke was dangerous enough to warrant investigation. First and foremost, the 2006 Surgeon General’s report concluded that “there is no risk-free level of secondhand smoke exposure.” In addition, researchers had discovered many of the same carcinogenic compounds and toxic chemicals in thirdhand smoke that secondhand smoke also contained. Thus, even if thirdhand smoke is a less potent form of tobacco exposure, there is no safe level of thirdhand smoke exposure.

Another reason to study thirdhand smoke is its distinctness from secondhand smoke. Even in 2011, researchers recognized that thirdhand smoke was not just a weaker form of secondhand smoke. They knew that it could enter the body through modes other than inhalation and contained aged chemicals that were not present in freshly emitted tobacco smoke which could affect the body in new ways. More research had to be done to understand the distinct characteristics of thirdhand smoke.

The most important question the research community answered was: Where do we go from here? The paper detailed areas for further research, including thirdhand smoke chemistry, types of exposure, health effects, beliefs, and policies.

California’s Tobacco-Related Disease Prevention Research Program (TRDPR) saw this paper as an opportunity to establish the Thirdhand Smoke Research Consortium. The Consortium, made up of a coalition of thirdhand smoke researchers from various disciplines across California, is dedicated to studying thirdhand smoke to inform policy. TRDPR initially provided funding to various Consortium projects for a three-year period from 2011 to 2014. These first studies aimed to better understand thirdhand smoke exposure. In 2015, the Consortium was renewed for another three years, this time, the focus being the health effects of thirdhand smoke exposure. Most recently, in 2018, the Consortium was renewed for a third time. With TRDPR’s support, the Consortium has learned much about thirdhand smoke during this time. The next three episodes will summarize and highlight some of these findings. Stay tuned for Episode 7: Shedding Light on the Research, Part I: Homes.

Sources:

Campbell, H. (2008, December 28). Third Hand Cigarette Smoking – Legitimate Worry Or Shark Jumping By Zealots? Science 2.0. https://www.science20.com/science_20/third_hand_cigarette_smoking_legitimate_worry_or_shark_jumping_zealots

Jacob, P., 3rd, Benowitz, N. L., Destaillats, H., Gundel, L., Hang, B., Martins-Green, M., Matt, G. E., Quintana, P. J., Samet, J. M., Schick, S. F., Talbot, P., Aquilina, N. J., Hovell, M. F., Mao, J. H., & Whitehead, T. P. (2017). Thirdhand Smoke: New Evidence, Challenges, and Future Directions. Chemical research in toxicology, 30(1), 270–294. https://doi.org/10.1021/acs.chemrestox.6b00343

Matt, G. E., Quintana, P. J., Destaillats, H., Gundel, L. A., Sleiman, M., Singer, B. C., Jacob, P., Benowitz, N., Winickoff, J. P., Rehan, V., Talbot, P., Schick, S., Samet, J., Wang, Y., Hang, B., Martins-Green, M., Pankow, J. F., & Hovell, M. F. (2011). Thirdhand tobacco smoke: emerging evidence and arguments for a multidisciplinary research agenda. Environmental health perspectives, 119(9), 1218–1226. https://doi.org/10.1289/ehp.1103500

Tobacco-Related Disease Research Program. (n.d.). Collaborative Consortium on Thirdhand Smoke. TDRP. https://www.trdrp.org/highlights-news-events/collaborative-consortium-on-thirdhand-smoke.html

Shedding Light on the Research, Part I: Homes

There may not have been an official word for thirdhand smoke in the late 20^th century, but studies were already uncovering its dangers in the home. In 1991, nicotine was discovered in house dust. This meant that even nonsmokers could inhale or ingest nicotine without ever having been near smokers. Meanwhile, one of the most prominent multinational tobacco companies, Philip Morris Co., was performing secret studies between 1983 and 1997 that found aged tobacco smoke in a room could become more toxic with time. Since then, guided by the research agenda developed in 2011 and with new methods to measure thirdhand smoke, evidence that homes could be a source of thirdhand smoke exposure accumulated rapidly throughout the 21^st century.

This episode summarizes some of the key findings around thirdhand smoke in homes between 2011 and 2019. Much thirdhand smoke research has focused on the home for a few reasons: We likely spend significant amounts of time in our homes, children present in the home are especially vulnerable to exposure, and homes contain many different surfaces that can absorb, reemit, and expose us to toxic thirdhand smoke. Plus, most of us find these studies relevant to our day-to-day lives. The term home will be used throughout this article to refer to any place of residence, including single-family homes, apartments and condos, and other forms of multi-family homes. Regardless of the type of home you live in, it is important to understand how thirdhand smoke might affect you and how to protect yourself from this tobacco residue.

The first thing to know about thirdhand smoke in the home is that this tobacco residue can be found on almost any surface in the home. Studies have found thirdhand smoke in paint, carpets, windows, coffee tables, chairs, floors, and doors. Thirdhand smoke has also been found on smaller objects in the home, such as toys, books, silverware, curtains, pillows, and bedding. These chemicals penetrate deep, and materials within the home may also be contaminated—like HVAC ducts, drywall, and building materials of the home.

Source: Thirdhand Smoke Resource Center’s FAQ, “What surfaces does tobacco smoke stick to?”

As it can exist in different forms, thirdhand smoke can transfer from the air to objects, and then back to the air again, which is how it enters the home and then our bodies. Someone who smokes outside may bring thirdhand smoke indoors with them when they enter a residence, in their breath or on their clothes or hair. Similarly, thirdhand smoke may be carried on contaminated objects, like used furniture. If a nonsmoking family moves into a home previously inhabited by at least one person who smoked, the home may already be infused with thirdhand smoke. Research has shown that about 80 or 90 percent of nicotine in cigarette smoke sticks to indoor objects. Once deposited on an object in the home, these chemicals can then re-emit into the air, where they can be inhaled. Or, if a person touches a contaminated object, the thirdhand smoke can transfer to their fingers, where it can enter the body through the skin or mouth.

Not all people in a home are equally at risk of thirdhand smoke exposure, with children and people with other medical conditions most at risk. While thirdhand smoke affects people of all ages, infants and toddlers are a population of particular concern because of how these young children place household objects in their mouth. In addition, they have thinner skin and could have more exposure to contaminated surfaces due to their small size. Researchers in one study found that toddlers living in a home where smoking was only allowed outside had up to seven times more thirdhand smoke exposure than toddlers who lived in total smoking ban homes. Any sort of preexisting condition or disease further increases the risk of adverse effects from thirdhand smoke. Premature babies, for instance, may breathe faster, intaking more thirdhand smoke, or have compromised or immature immune systems that are less capable of combatting tobacco toxins. Thirdhand smoke chemicals have also been shown to trigger asthma symptoms in mice.

Once introduced to a home, thirdhand smoke can long outlast its residents—thus making it a concern for future renters and home buyers. Studies found that thirdhand smoke remained in homes even after two months of vacancy and cleaning and after six months when residents stopped smoking.

Unfortunately, few methods have been found to effectively remove thirdhand smoke. Keeping a clean house by vacuuming with a HEPA filter and washing surfaces can help, but not all contaminated surfaces can be cleaned. Some must be replaced, like mattresses and HVAC ducts. Remember, even if the tobacco smell is gone, thirdhand smoke can remain.

It is also important to understand beliefs and perceptions around thirdhand smoke in the home to inform policy and education efforts. As of 2007, over 80 percent of American households did not allow smoking within the home. Awareness of thirdhand smoke was found to increase the likelihood that a person would have no-smoking rules in the home. However, most Americans remain unaware of thirdhand smoke and its dangers. This research indicates that increasing education efforts around thirdhand smoke would decrease smoking within the home.

This episode provides a brief overview of the many discoveries that researchers made about thirdhand smoke in the home. Next week, we explore thirdhand smoke in healthcare settings. Follow along for Episode 8: Shedding Light on the Research, Part II: Hospitals.

Sources:

Bahl, V., Jacob, P., 3rd, Havel, C., Schick, S. F., & Talbot, P. (2014). Thirdhand cigarette smoke: factors affecting exposure and remediation. PloS one, 9(10), e108258. https://doi.org/10.1371/journal.pone.0108258

Burton A. (2011). Does the smoke ever really clear? Thirdhand smoke exposure raises new concerns. Environmental health perspectives, 119(2), A70–A74. https://doi.org/10.1289/ehp.119-a70

Drehmer, J. E., Ossip, D. J., Nabi-Burza, E., Rigotti, N. A., Hipple, B., Woo, H., Chang, Y., & Winickoff, J. P. (2014). Thirdhand Smoke Beliefs of Parents. Pediatrics, 133(4), e850–e856. https://doi.org/10.1542/peds.2013-3392

Escoffery, C., Bundy, L., Carvalho, M., Yembra, D., Haardorfer, R., Berg, C., & Kegler, M. C. (2013). Third-hand smoke as a potential intervention message for promoting smoke-free homes in low-income communities. Health Education Research, 28(5), 923–930. https://doi.org/10.1093/her/cyt056

Hein, H. O., Suadicani, P., Skov, P., & Gyntelberg, F. (1991). Indoor Dust Exposure: An Unnoticed Aspect of Involuntary Smoking. Archives of Environmental Health: An International Journal, 46(2), 98–101. https://doi.org/10.1080/00039896.1991.9937435

Matt, G. E., Quintana, P. J., Zakarian, J. M., Fortmann, A. L., Chatfield, D. A., Hoh, E., Uribe, A. M., & Hovell, M. F. (2011). When smokers move out and non-smokers move in: residential thirdhand smoke pollution and exposure. Tobacco control, 20(1), e1. https://doi.org/10.1136/tc.2010.037382

Matt, G. E., Quintana, P., Zakarian, J. M., Hoh, E., Hovell, M. F., Mahabee-Gittens, M., Watanabe, K., Datuin, K., Vue, C., & Chatfield, D. A. (2016). When smokers quit: exposure to nicotine and carcinogens persists from thirdhand smoke pollution. Tobacco control, 26(5), 548–556. https://doi.org/10.1136/tobaccocontrol-2016-053119

Northrup, T. F., Matt, G. E., Hovell, M. F., Khan, A. M., & Stotts, A. L. (2016). Thirdhand Smoke in the Homes of Medically Fragile Children: Assessing the Impact of Indoor Smoking Levels and Smoking Bans. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco, 18(5), 1290–1298. https://doi.org/10.1093/ntr/ntv174

Shedding Light on the Research, Part II: Hospitals

You probably think of hospitals as places where you might seek treatment when you or your loved ones are sick or unwell, rather than where you can be exposed to toxic chemicals. Thirdhand smoke, however, might change your mind. Besides homes, hospitals are another location where people may be exposed to thirdhand smoke.

Hospital settings present both a challenge and an opportunity for thirdhand smoke researchers and the larger anti-tobacco movement. On the one hand, the fact that studies have found significant levels of thirdhand smoke in hospitals is a major concern for the health and well-being of some of the most vulnerable patients. On the other hand, if medical staff, like pediatricians and doctors, can educate parents about the dangers of thirdhand smoke to babies and young children, hospitals are an important intervention point. Thus, another focus of thirdhand smoke research throughout the last decade has been hospitals. This episode provides an overview of thirdhand smoke research in hospital settings between the development of the thirdhand smoke research agenda in 2011 and 2019.

The majority of thirdhand smoke research in hospital settings has been performed in neonatal intensive care units (NICUs) because researchers know how vulnerable premature babies are to thirdhand smoke. These babies are born smaller and are especially susceptible to respiratory diseases like pneumonia and asthma. Though the long-term effects of thirdhand smoke on NICU babies are unclear, preliminary studies have shown that thirdhand smoke exposes these young children to some of the most toxic components of tobacco smoke. Thirdhand smoke exposure is known to increase the risk of lung disease in young children—and these premature babies, with compromised respiratory systems, would be at even greater risk. Furthermore, researchers have theorized that thirdhand smoke exposure may even increase the risk of sudden infant death syndrome (SIDS).

Thirdhand smoke infiltrates hospitals just like it does with homes. While hospitals likely go to greater lengths to maintain a sterile, non-smoking environment, thirdhand smoke has still been found in measurable amounts on various hospital objects and surfaces. Things like furniture are not cleaned as thoroughly as medical equipment in the hospital. While the cribs in a NICU might be cleaned regularly, the chairs and other seating options for visitors may not. Thus, a visitor to a hospital with thirdhand smoke in their hair, clothes, skin, or breath can then deposit residue on any furniture with which they come in contact. Similarly, if a visitor has thirdhand smoke residue on their hands and they do not wash their hands thoroughly, they can then transfer this thirdhand smoke to a baby, crib, bottles, or clothes that they interact with. Visitors are not the only source of thirdhand smoke, either. One study found that almost 80 percent of non-smoking NICU staff at a non-smoking hospital had traces of nicotine—thirdhand smoke—on their hands.

How can we protect people in hospitals from thirdhand smoke exposure? The best option is to make hospitals completely smokefree environments. That means no first-, second-, or thirdhand smoke.

Educating healthcare professionals about thirdhand smoke is a good place to start. A survey from 2015 found that only about one-third of healthcare professionals had ever heard of thirdhand smoke. Researchers are pushing for thirdhand smoke campaigns targeted at healthcare professionals. These healthcare professionals could then pass along information about thirdhand smoke to their patients and families. Evidence shows that parents are more likely to take steps to protect their children if they have received advice from a pediatrician about the harms of tobacco.

The Clinical Effort Against Thirdhand Smoke Exposure (CEASE), a research group at the Massachusetts General Hospital, has been developing educational materials and policy recommendations for preventing thirdhand smoke exposure in hospitals. Healthcare professionals can use the prevalence and persistence of thirdhand smoke to encourage patients and their families to quit smoking. The CEASE team has developed posters, videos, and other resources that healthcare professionals can use in discussing tobacco use with patients and families. The CEASE training also emphasizes that all hospitals should adopt a complete smoking ban and provide resources to hospital staff to quit tobacco.

Image 1 (left): A CEASE brochure designed to educate parents in hospital waiting rooms and exam rooms about the dangers of thirdhand smoke. Image 2 (right): A CEASE handout that encourages parents to maintain a smokefree car. You can read more about CEASE and access their resources here.

Stricter enforcement of hygiene could also help reduce thirdhand smoke in hospitals. Handwashing, for instance, can remove some thirdhand smoke from the skin. However, handwashing is not as strictly enforced in hospital settings as it should be to prevent thirdhand smoke transfer. A 2010 study of hand washing compliance in intensive care units (ICUs) (which includes NICUs) found that compliance rates averaged around 40 percent. The research indicates that increased handwashing, plus storage of staff uniforms and scrubs in smokefree places, could lessen the risk of thirdhand smoke exposure.

Researchers have suggested a final method to reduce thirdhand smoke exposure in hospitals: including smoking information in electronic medical records. Medical records that include information about household members that smoke or if homes and cars are smokefree can direct any advice or guidance about smoking cessation that healthcare providers provide to patients and families.

As you may have guessed, thirdhand smoke is not limited to your home and hospitals. Find out where else thirdhand smoke may be lurking next week in our next episode of Shedding Light on the Research, Part III: Other Places.

Sources:

Darlow, S. D., Heckman, C. J., Munshi, T., & Collins, B. N. (2016). Thirdhand smoke beliefs and behaviors among healthcare professionals. Psychology, Health & Medicine, 22(4), 415–424. https://doi.org/10.1080/13548506.2016.1189579

Drehmer, J. E., Walters, B. H., Nabi-Burza, E., & Winickoff, J. P. (2017). Guidance for the Clinical Management of Thirdhand Smoke Exposure in the Child Health Care Setting. Journal of clinical outcomes management : JCOM, 24(12), 551–559.

Drehmer, J. E., Ossip, D. J., Rigotti, N. A., Nabi-Burza, E., Woo, H., Wasserman, R. C., Chang, Y., & Winickoff, J. P. (2012). Pediatrician Interventions and Thirdhand Smoke Beliefs of Parents. American Journal of Preventive Medicine, 43(5), 533–536. https://doi.org/10.1016/j.amepre.2012.07.020

Mahabee-Gittens, E. M., Matt, G. E., Hoh, E., Quintana, P. J. E., Stone, L., Geraci, M. A., Wullenweber, C. A., Koutsounadis, G. N., Ruwe, A. G., Meyers, G. T., Zakrajsek, M. A., Witry, J. K., & Merianos, A. L. (2019). Contribution of thirdhand smoke to overall tobacco smoke exposure in pediatric patients: study protocol. BMC Public Health, 19(1). https://doi.org/10.1186/s12889-019-6829-7

Northrup, T. F., Khan, A. M., Jacob, P., 3rd, Benowitz, N. L., Hoh, E., Hovell, M. F., Matt, G. E., & Stotts, A. L. (2016). Thirdhand smoke contamination in hospital settings: assessing exposure risk for vulnerable paediatric patients. Tobacco control, 25(6), 619–623. https://doi.org/10.1136/tobaccocontrol-2015-052506

Northrup, T. F., Stotts, A. L., Suchting, R., Khan, A. M., Green, C., Quintana, P., Hoh, E., Hovell, M. F., & Matt, G. E. (2019). Medical staff contributions to thirdhand smoke contamination in a neonatal intensive care unit. Tobacco induced diseases, 17, 37. https://doi.org/10.18332/tid/106116

Patel, S., Hendry, P., Kalynych, C., Butterfield, R., Lott, M. & Lukens-Bull, K. (2012). The impact of third-hand smoke education in a pediatric emergency department on caregiver smoking policies and quit status: a pilot study. International Journal on Disability and Human Development, 11(4), 335-342. https://doi.org/10.1515/ijdhd-2012-0052

Shedding Light on the Research, Part III: Other Places

Due to its persistence, thirdhand smoke can be found on almost any surface with which tobacco smoke comes in contact. While homes and hospitals are perhaps the most likely spaces to be shared by those who smoke and those who are most vulnerable to thirdhand smoke, it is important to understand that thirdhand smoke can be everywhere. This article summarizes thirdhand smoke research on so-called “other places:” cars, casinos, and hotels. This research, conducted between the 2011 research agenda paper and 2019, adds to the already sizeable body of evidence supporting comprehensive smoking bans.

First and foremost, cars. They present a distinct and unique environment for thirdhand smoke due to the frequency with which they change hands and their relatively small, enclosed space. Cars, just like homes, can be rented and bought secondhand, meaning cars may already contain reservoirs of thirdhand smoke when a person acquires them. In particular, rental cars change hands so frequently that it may be tough to prevent thirdhand smoke from building up in the vehicle. Research has shown that non-smoking rental vehicles can contain more thirdhand smoke than privately-owned, non-smoking cars, indicating that thirdhand smoke is finding its way past many rental car smoking bans. Plus, cars are comparatively much smaller with more surfaces, receptive materials, and objects for thirdhand smoke to stick to than a home. To make things worse, the high concentration of thirdhand smoke, combined with exposure to sunlight, poor air circulation, and extreme temperatures in a car, can cause thirdhand smoke chemicals to undergo chemical reactions that can make them more potent and dangerous.

A Thirdhand Smoke Resource Center researcher swaps the dashboard of a car before testing the sample for the presence of thirdhand smoke.

Research indicates that once a car has been smoked in, it is virtually impossible to completely remove this thirdhand smoke from the vehicle. Cars contain many surfaces that can deeply absorb the chemical concoction of thirdhand smoke: upholstery, carpets, ceiling liners, and air ventilation systems. This trapped thirdhand smoke, particularly nicotine, lingers on these surfaces for at least a year after initial exposure.

Thus, any interventions to reduce thirdhand smoke in a car must be primarily preventative. We know through research that signage reminding patrons not to smoke in rental cars can effectively lower thirdhand smoke levels. Researchers have also recommended adopting stricter no-smoking policies. This might be fleet-wide smoking bans, rather than designated smoker and non-smoker cars, employee training to monitor compliance, and standardized smoking policy communication to customers.

Casinos are another location where smokers and nonsmokers frequent, meaning they can also be sources of toxic second- and thirdhand smoke exposure for nonsmoking employees and visitors. Casinos are notable as one of the few indoor public spaces where smoking is still permitted in California, as compared to restaurants, bars, and workplaces where smoking bans are mandated by law. Casinos have been found to be home to deep reservoirs of thirdhand smoke, often having been smoked in daily for many years. When one California casino decided to adopt a no-smoking policy, researchers found thirdhand smoke to persist on surfaces, just like in cars.

A final location where thirdhand smoke is prevalent is hotels. Smoking is completely banned in hotels in many other countries, such as Brazil, China, Hong Kong, Kuwait, and South Korea. By contrast, complete hotel-wide smoking bans are uncommon in the United States. Most states in the U.S. allow hotels to have designated smoker rooms. This means that nonsmokers visiting and employed at these hotels are at risk of toxic thirdhand smoke exposure if they stay or visit smoker rooms or when secondhand smoke migrates from these rooms to nonsmoker rooms. Research has shown that even a single night’s stay was enough for people to have measurable thirdhand smoke on their fingers, even if they stayed in a non-smoking room. Non-smoking rooms were sometimes as contaminated as smoking rooms.

Westin and Marriott were the first hotel chains to adopt 100 percent smoke-free building policies in 2006. By 2011, Sheraton, Wyndham, and Comfort Suites followed suit. However, the adoption of hotel smokefree policies does not always translate into implementation. Many hotel guest complaints on sites like Tripadvisor still involve tobacco, cannabis, and e-cigarette smoke exposure, even in smokefree hotels. Researchers suggest that all hotels should step up enforcement of no-smoking policies through fines and the use of detection devices. Moreover, hotels must continue to educate their guests about their policies and be transparent about their enforcement efforts.

Now that you are all caught up on the history of thirdhand smoke research, we have reached our tenth, and final, episode. In Episode 10: Fired Up, we explore the latest chapter of thirdhand smoke research and advocacy—the Thirdhand Smoke Resource Center.

Sources:

Matt, G. E., Fortmann, A. L., Quintana, P. J. E., Zakarian, J. M., Romero, R. A., Chatfield, D. A., Hoh, E., & Hovell, M. F. (2012, February 15). Towards smoke-free rental cars: an evaluation of voluntary smoking restrictions in California. Tobacco Control, 22(3), 201–207. https://doi.org/10.1136/tobaccocontrol-2011-050231

Matt, G. E., Quintana, P. J. E., Hoh, E., Zakarian, J. M., Chowdhury, Z., Hovell, M. F., Jacob, P., Watanabe, K., Theweny, T. S., Flores, V., Nguyen, A., Dhaliwal, N., & Hayward, G. (2018, February 8). A Casino goes smoke free: a longitudinal study of secondhand and thirdhand smoke pollution and exposure. Tobacco Control, 27(6), 643–649. https://doi.org/10.1136/tobaccocontrol-2017-054052

Theweny, T. S. (2015). Measurement of thirdhand smoke in a casino: Surface nicotine wipes pre and post smoking ban (Order No. 1605929). Available from ProQuest Dissertations & Theses Global. (1754619725). Retrieved from http://ezproxy.cul.columbia.edu/login?url=https://www.proquest.com/dissertations-theses/measurement-thirdhand-smoke-casino-surface/docview/1754619725/se-2

Quintana, P. J. E., Matt, G. E., Chatfield, D., Zakarian, J. M., Fortmann, A. L., & Hoh, E. (2013, March 4). Wipe Sampling for Nicotine as a Marker of Thirdhand Tobacco Smoke Contamination on Surfaces in Homes, Cars, and Hotels. Nicotine &Amp; Tobacco Research, 15(9), 1555–1563. https://doi.org/10.1093/ntr/ntt014

Weigel, E. A., & Matt, G. E. (2022, January). When Hotel Guests Complain About Tobacco, Electronic Cigarettes, and Cannabis: Lessons for Implementing Smoking Bans. Tobacco Use Insights, 15, 1179173X2211249. https://doi.org/10.1177/1179173×221124900

Fired Up: Thirdhand Smoke Gets a Resource Center

While the Thirdhand Smoke Resource Center’s main task is to share the latest information and most up-to-date resources about thirdhand smoke, for the last 10 weeks we have been following the history of thirdhand smoke in our Summer “Throwback Thursday” series. This series explored key moments and events from the early 1900s to the present day to answer questions such as ‘when and how was thirdhand smoke discovered?,’ ‘when did people and policymakers start caring about it?,’ and ‘how has the research developed and changed with time?’ Today, we conclude our series with episode 10. We hope you learned a thing or two along the way!

members of the Thirdhand Smoke Resource Center discuss their work

Thirdhand Smoke Resource Center team and family wearing matching shirts at an event

In the last nine episodes, you have read all about the history of tobacco research: The first signs in the 1900s that smoking might be dangerous, the tobacco industry’s best efforts to keep the science quiet, researchers and anti-smoking advocates pivoting to focus on environmental and secondhand dangers, and finally, the emergence and development of the field of thirdhand smoke.

That brings us to the present day and the work of the Thirdhand Smoke Resource Center, the nation’s first center focused on thirdhand smoke. The Thirdhand Smoke Resource Center was created in 2019 with support from California’s Tobacco-Related Disease Research Program (TRDRP). The Resource Center’s mission is “to share information, resources, and technical support with California’s residents, communities, businesses, health care professionals, and policymakers about the toxic legacy of tobacco smoke residue and to achieve indoor environments that are 100% free of tobacco smoke toxicants.” This means that the Resource Center aims to translate research findings about thirdhand smoke into real-world implications for individuals, families, and communities. The Resource Center’s main platform is its website, which contains resources for both a professional and non-professional audience. For the public, the Resource Center provides educational information, summaries of scientific findings, webinars on thirdhand smoke implications for healthcare, real estate, and legal settings, and information on how to get involved in thirdhand smoke research and prevention. For researchers, the website has trainings and a thirdhand smoke research database. In addition, the Resource Center manages various social media accounts to engage with the largest audience it can.

If you don’t follow us already, be sure to do so!

The Resource Center’s key role is to increase awareness around thirdhand smoke. There is no shortage of evidence that thirdhand smoke poses a health risk, yet it remains a relatively obscure concept, even among healthcare professionals. At least one study has found that only about a third of healthcare professionals have heard of thirdhand smoke. The Resource Center hopes to change this. For example, they held a webinar for healthcare professionals on thirdhand smoke. You can watch it on our website or on Youtube. Previous reductions in smoking rates have been attributed to effective health communication campaigns, a legacy which the Resource Center now builds upon—with a twist. Whereas previous tobacco prevention efforts have used television, radio, and print media with great success, the Resource Center primarily uses social media, like Facebook, Twitter, and Instagram. With these platforms, thirdhand smoke resources can reach a global audience in exciting and new ways.

We have known about the dangers of tobacco use for nearly 100 years now. Despite this, cigarette smoking still accounts for more than 480,000 deaths per year. Tobacco research and the anti-smoking movement have certainly seen great successes in education, science, and policy, but as long as smoking continues to do harm, it is not enough. The Thirdhand Smoke Resource Center is the latest episode in a long history of tobacco research and anti-smoking advocacy. Perhaps, with luck, strong science, and good communication, it could be the last.

Sources:

NewsCenter | SDSU | First-Ever Thirdhand Smoke Resource Center Opens. (n.d.). Retrieved September 12, 2022, from https://newscenter.sdsu.edu/sdsu_newscenter/news_story.aspx?sid=77619

Record, R. A., Greiner, L. H., Wipfli, H., Strickland, J., Owens, J., Pugel, J., & Matt, G. E. (2021, July 29). Evaluation of a Social Media Campaign Designed to Increase Awareness of Thirdhand Smoke among California Adults. Health Communication, 1–10. https://doi.org/10.1080/10410236.2021.1954760

Tobacco-Related Mortality. (2020, October 6). Centers for Disease Control and Prevention. Retrieved September 12, 2022, from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/tobacco_related_mortality/index.htm

Quispe-Cristóbal, B., Lidón-Moyano, C., Martín-Sánchez, J. C., Pérez-Martín, H., Cartanyà-Hueso, À., Cabriada-Sáez, Í., de Paz-Cantos, S., Martínez-Sánchez, J. M., & González-Marrón, A. (2022). Knowledge and Opinions of Healthcare Professionals about Thirdhand Smoke: A Multi-National, Cross-Sectional Study. Healthcare (Basel, Switzerland), 10(5), 945. https://doi.org/10.3390/healthcare10050945

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