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 Table of Contents  
Year : 2011  |  Volume : 55  |  Issue : 3  |  Page : 192-198  

Second-hand Smoke: A neglected public health challenge

International Union against Tuberculosis and Lung Disease (The Union), New Delhi, India

Date of Web Publication16-Nov-2011

Correspondence Address:
Rana J Singh
International Union against Tuberculosis and Lung Disease (The Union), New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-557X.89950

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Exposure to secondhand smoke (SHS) causes an estimated 5% of the global burden of disease, slightly higher than the burden from direct use of tobacco. This review highlights the urgent need to address this ignored public health issue by presenting the evidence and impact of SHS on those exposed using global studies including those from the South-East Asia Region. The burden of morbidity from SHS exposure is higher in low-income countries in Southeast Asia region compared to the rest of the world. SHS exposure affects those most vulnerable, especially women and children. While several countries in the region have enacted legislation which offer protection to those exposed to SHS, most measures are partial and inadequate. As a result, implementation and compliance at national and sub-national level within the countries of the Southeast Asia region is variable. Governments must ensure that legislation mandates comprehensive smoke-free environments in order to provide public health benefit which offers universal protection to everyone and everywhere. Where comprehensive legislation exists, stringent implementation and enforcement, along with awareness building, education and monitoring through regular compliance studies must be done to sustain smokefree status of public places within jurisdictions.

Keywords: Secondhand smoke exposure, Morbidity, Legislation, Compliance, South-East Asia Region

How to cite this article:
Singh RJ, Lal PG. Second-hand Smoke: A neglected public health challenge. Indian J Public Health 2011;55:192-8

How to cite this URL:
Singh RJ, Lal PG. Second-hand Smoke: A neglected public health challenge. Indian J Public Health [serial online] 2011 [cited 2023 Feb 7];55:192-8. Available from:

   Introduction Top

It is now established beyond doubt that inhaling second hand smoke (SHS) as a result of (tobacco) smoking is harmful. There is no safe level of exposure. According to the World Bank exposure to second-hand smoke causes an estimated 5% of the global burden of disease, slightly higher than the burden from direct use of tobacco (4%), but this is largely concentrated in a few countries. [1] Globally, about one third of adults are regularly exposed to second-hand tobacco smoke. [2] Also called passive smoking, environmental tobacco smoke, or second-hand smoke (SHS), worldwide exposure to it caused nearly 603,000 premature deaths of non-smokers estimated in 2004. The associated effects include heart disease, lung cancer, severe asthma attacks, sudden infant death syndrome, and many others [Table 1]. [3]
Table 1: Evidence of Health effects of exposure to second-hand smoke (SHS)

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   Burden of second-hand smoke Top

The burden of morbidity from second-hand smoke (SHS) exposure, as measured by disability-adjusted life years (DALYs) varies by region, with higher estimates for low-income countries in Southeast Asia compared to the rest of the world [Figure 1] and [Table 2]. Asthma and ischemic heart disease accounted for the most disease among adults, and lower respiratory infections were the most common outcome among children. SHS exposure is also a gender issue: Only about 10% of women in the world smoke but of the 603,000 SHS-related deaths, 47% were among women (compared with 26% among men and 28% among children). This is because of two main reasons. First, the number of female non-smokers (thus susceptible to be exposed to SHS by definition) is about 60% higher than that of male non-smokers. Second, in most parts of the developing world including South-East Asia (SEA), women are at least 50% more likely to be exposed to second-hand smoke than are men [Table 1] and [Figure 1]. Children under age 5 years bore the brunt of respiratory infections in poorer countries, where malnutrition or inadequate health care also may lead to higher disease and mortality rates in children with other health problems that are exacerbated by SHS exposure. Children overall experience an estimated 61% of the disease burden from SHS. [3]
Table 2: Attributable fraction from second-hand smoke exposure for each outcome in 2004.

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Figure 1: Number of deaths from exposure to second-hand smoke in 2004, by causes in the World and SEA Region

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The WHO-IARC monograph on carcinogenicity from exposure to tobacco smoke established that SHS causes cancers and other systemic and chronic diseases disorders such as acute coronary artery disease and chronic respiratory disorders in adults; and acute disorders such as SIDS in neonates and precipitation of asthma and otitis media and respiratory infections in children. [4] Scientific studies have sufficient evidence to show that odds of developing various tobacco related diseases among those who are exposed to tobacco smoke are higher than those who are not exposed [Table 1].

The Global Adult Tobacco Survey (GATS) and Global Youth Tobacco Survey (GYTS) point to concerns that smoke-free policies must address. These surveys re-confirm the extent of the SHS problem in the region. As per the GATS 2009 reports, the proportion of adults exposed to SHS ranges from 29% (India) to 53.5% (Thailand) in public places. Half of all adults are exposed to SHS at homes in India and one in every three adults in Thailand. Exposure to SHS in workplaces among men is almost two times that of women in Bangladesh, Indian and Thailand. Similarly, according to findings of GYTS (2007-2009), large proportions of youth had been exposed to SHS both at homes and in public places in the Region. While Indonesia and Timor-Leste have higher prevalence of SHS among youth (>60%), India and Bangladesh have comparatively lower than other countries. Youth of this Region are exposed to SHS more in public places than at homes [Figure 2].
Figure 2: Percentage of youth (13– 15 years) exposed to SHS at home and in public places in SEA Region

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According to WHO, only 7·4% of the world population lives in jurisdictions with comprehensive smoke-free laws at present, and the enforcement of these laws is robust in only a few of those jurisdictions. [2] In the South-East Asia (SEA) Region, several factors contribute to increased risks to those exposed to SHS. These include: Diverse and frequent use of smoking tobacco products other than cigarettes like bidis, kreteks, cheroots, hookah etc.; crowding, lack of ventilation and multiple exposures from smoke from biomass, environmental sources etc.; lack of awareness of the right to clean air at public place and workplace, and weak or little enforcement of legal provisions to protect those exposed to SHS; and exposure of mothers and children to adult smoking at home (as suggested by Global Adult Tobacco Survey of Bangladesh and India). Risks from SHS also increase significantly for women and children in poor, high altitude rural settings of Southeast Asia.

   Vulnerability of children and young adults to SHS Top

The 2006 Surgeon General Report emphasised that involuntary exposure to SHS is a serious cause of disease and death in those exposed and is particularly harmful for children. The report confirms the causal relationship between SHS exposure and Sudden Infant Death Syndrome (SIDS), and declares that the home is becoming the predominant location for SHS exposure of children and adults. [14] An estimated 700 million children worldwide - about 40% of all children - are exposed to second-hand tobacco smoke at home. [15]

The level of exposure to SHS among women and children inside homes and in public places is alarming in the South-East Asia region. An estimated 25 million school children are exposed to SHS in public places alone in the region. Since most of the adult males smoke inside homes and in public places in the presence of children and women, pregnant mothers and adult male non-smokers are exposed to SHS in the region. [16] As per WHO Report on Tobacco Epidemic 2009, about 34% children in the age group of 13-15 years are exposed to Second-hand Smoke at home in the SEA region. [17] Empowering and educating women is vital as they have a key role in protecting themselves, their children, and family members from this insidious exposure. [18]

Children face a higher risk than adults of the negative effects of second-hand smoke [Table 3]. A child's body is in a nascent stage of development and they breathe faster than adults. When infants and young children are exposed heavily to SHS, they are unable to avoid it. Children as a group have shown the strongest evidence of harm attributable to SHS. [19] These factors alone should be the basis of public health messages targeted to policy makers. SIDS is sudden, unexplained, unexpected death of an infant in the first year of life. SIDS is the leading cause of death in otherwise healthy infants. [20] Infants who die from SIDS have higher concentration of nicotine in their lungs and higher levels of cotinine (a biological marker for SHS exposure) than infants who die from other causes. [21]
Table 3: Second-hand smoke causes serious health risks to children and adults

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   Review of national policies Top

The evidence of harms from SHS is so compelling that they form the crux for major national tobacco control regulations. The WHO's Framework Convention for Tobacco Control and several national policies and legislation including India's Cigarettes and Other Tobacco Products Act, 2003 were invoked with intent to protect the non-smoker from the harms of second-hand smoke. The WHO FCTC includes the broad statement that " scientific evidence has unequivocally established that exposure to tobacco smoke causes death, disease and disability". Article 8 forms the basis for international action to reduce the burden of disease attributable to second-hand tobacco smoke, and is especially important as it creates a legal obligation for the treaty's Parties to take action.

The difference in the number of truly smoke-free places between developed and developing countries are negligible. The average of places in both developed and developing countries is 2 out of 8 (education settings, healthcare facilities, government and private offices, restaurants and hospitality sector and transport). Enforcement of smoke-free laws in SEA region is weak [3] but this is improving as stronger legislation is enacted, rigorous enforcement is demanded by people who have growing awareness on the harms of SHS exposure. Fully smoke-free policies have a net positive effect on businesses, including the hospitality sector, and enforcement and education about smoke-free policies will have minimum costs to governments. Additionally, they are supported by much of the population, and this support increases after its enforcement-even in most smokers. These policies contribute decisively to denormalise smoking, and help with the approval and implementation of other policies that reduce tobacco demand, such as increased tobacco taxes and a comprehensive ban of tobacco advertising, promotion, and sponsorship. In South East Asia, Bhutan (2004), Thailand (2006) and India (2008) are some of the countries that have successfully enforced a smoking ban in public places but as GATS and GYTS data suggests, the prevalence of use and exposure is high. Bhutan is the first country in the world to impose a total ban on tobacco products-sale and use. Only two countries in SEA - Indonesia and North Korea are yet to adopt the WHO FCTC and its principles.

Making policy for 100% smoke free environments is the most effective way to protect the public, including children, women, and people at their work, public places and homes from exposure to SHS. The International Agency for Research on Cancer concluded: "There is sufficient evidence that implementation of smoke free policies substantially decrease second-hand smoke exposure". [22] Studies of the effects of smoke-free policies consistently show that these policies decrease exposure to second-hand tobacco smoke by 80-90% in high-exposure settings, and that they can lead to overall decreases in exposure of up to 40%. [23] Based on the scientific evidence, the Conference of the Parties to the WHO Framework Convention of Tobacco Control (WHO FCTC) has concluded that 100% smoke-free environments are the only proven way to adequately protect the health of people from the harmful effects of second-hand tobacco smoke because no level of exposure is acceptable. [24] Ventilation and designated smoking rooms are not effective as tobacco smoke is all pervasive. Besides, exceptions provided by law are difficult to monitor and violations become commonplace.

Although an increasing number of SEA region countries have passed legislation mandating smoke-free environments, the overwhelming majority of countries have no smoke-free laws, very limited laws, or ineffective enforcement. Legislation that is comprehensive, but that is not well enforced, does not protect against second-hand tobacco smoke. Full enforcement of smoke-free laws is critical to establishing their credibility, especially immediately following their enactment. [25] Smoke-free have been enacted in the region through various means (barring Indonesia and Timor-Leste where some provincial decrees apply locally), governments must maintain strong support through active and uniform enforcement that achieves high compliance levels, at least until such time as the law becomes self-enforcing. It may be necessary to actively and publicly enforce the law in the period directly after smoke-free laws are enacted to demonstrate the government's commitment to ensuring compliance. Unannounced inspections, surprise checks and raids by the empowered government agency can be very effective deterrents for erring public places. Once a high level of compliance is achieved, it may be feasible to reduce the level of formal enforcement, as maintenance of smoke-free places is largely self-enforcing in areas where the public and business communities support smoke-free policies. To this end, people must be made aware about their rights to demand clean, tobacco smoke-free air in public places.

The campaign for smoke-free environments is gaining ground across the SEA Region and a growing number of countries are now declaring more and more places as smoke-free. Article 8 of WHO FCTC to which 9 out of 11 member countries in the region are party, provides protections from exposure to tobacco smoke at public places by adopting and implementing effective legislative, executive, administrative and other measures. [26] Increased awareness of the considerable health risks posed by SHS at home, public places and work places and concerns for public safety have led to an active movement to impose a total ban on smoking at public places.

   Challenges and Opportunities Top

While Bangladesh, India, Myanmar, Nepal, Sri Lanka and Thailand have enacted tobacco control legislation, other countries also have laws in the form of decrees, executive orders or cabinet decisions to protect people from SHS. However, most of these existing measures are partial and inadequate and do not provide for a complete ban on smoking at public places. Further, their level of implementation and enforcement is variable across the national and sub-national level in the countries of the region. In India, despite all public places being declared smoke free, compliance levels are variable. As a result, few jurisdictions have shown that diligent implementation of provisions of the law, backed by compliance studies and public opinion polls that inform policymakers, public and the media play a crucial role in initiating and maintaining smoke free efforts. [27] Bhutan is a tobacco-free country and has enacted legislation and strictures which prohibit tobacco use within the country. Nepal has enacted the "Tobacco Product (Control and Regulation) Act, 2011 which provides comprehensive coverage to tobacco control initiatives and gives special emphasis to smoke free places. The most important challenge so far has been effective enforcement of smoke free laws. Most of the countries and provinces of the region have not established a mechanism for enforcement of the laws at grassroots. Further, in most of the countries of the region, smoke free implementation is more urban-centric and limited to selected few metropolitans and large cities. The benefits of going smoke free have not reached the people living in semi-urban and rural areas. The WHO Report on Global Tobacco Epidemic 2009 recommends that the countries should build on lessons learned from the experiences of several countries and hundreds of sub-national and local jurisdictions that have successfully implemented laws requiring indoor workplaces and public places to be 100% smoke-free. Legislation must mandate implementation of complete smoke-free environments, not voluntary policies, in order to protect public health. An implementation and enforcement plan together with an infrastructure for enforcement, including awareness building, education and high-profile prosecutions to include fines or closing of businesses of repeat violators, are critical for successful implementation. Further monitoring of implementation and compliance is essential, as is measurement of the impact of smoke-free environments; ideally, experiences should also be documented and the results made available to other national and sun-national jurisdictions to support their efforts to introduce and implement effective smoke free legislations.

   Acknowledgement Top

We thank Dr. Nevin C Wilson, Director, The International Union Against Tuberculosis and Lung Disease, New Delhi for encouragement, thoughtful conversations and permission to publish this paper. This work was partially supported by the Bloomberg Initiative to Reduce Tobacco Use Grants Program.

   References Top

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]

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