conclusion for smoking essay

Essay on Smoking

500 words essay on  smoking.

One of the most common problems we are facing in today’s world which is killing people is smoking. A lot of people pick up this habit because of stress , personal issues and more. In fact, some even begin showing it off. When someone smokes a cigarette, they not only hurt themselves but everyone around them. It has many ill-effects on the human body which we will go through in the essay on smoking.

Ill-Effects of Smoking

Tobacco can have a disastrous impact on our health. Nonetheless, people consume it daily for a long period of time till it’s too late. Nearly one billion people in the whole world smoke. It is a shocking figure as that 1 billion puts millions of people at risk along with themselves.

Cigarettes have a major impact on the lungs. Around a third of all cancer cases happen due to smoking. For instance, it can affect breathing and causes shortness of breath and coughing. Further, it also increases the risk of respiratory tract infection which ultimately reduces the quality of life.

In addition to these serious health consequences, smoking impacts the well-being of a person as well. It alters the sense of smell and taste. Further, it also reduces the ability to perform physical exercises.

It also hampers your physical appearances like giving yellow teeth and aged skin. You also get a greater risk of depression or anxiety . Smoking also affects our relationship with our family, friends and colleagues.

Most importantly, it is also an expensive habit. In other words, it entails heavy financial costs. Even though some people don’t have money to get by, they waste it on cigarettes because of their addiction.

How to Quit Smoking?

There are many ways through which one can quit smoking. The first one is preparing for the day when you will quit. It is not easy to quit a habit abruptly, so set a date to give yourself time to prepare mentally.

Further, you can also use NRTs for your nicotine dependence. They can reduce your craving and withdrawal symptoms. NRTs like skin patches, chewing gums, lozenges, nasal spray and inhalers can help greatly.

Moreover, you can also consider non-nicotine medications. They require a prescription so it is essential to talk to your doctor to get access to it. Most importantly, seek behavioural support. To tackle your dependence on nicotine, it is essential to get counselling services, self-materials or more to get through this phase.

One can also try alternative therapies if they want to try them. There is no harm in trying as long as you are determined to quit smoking. For instance, filters, smoking deterrents, e-cigarettes, acupuncture, cold laser therapy, yoga and more can work for some people.

Always remember that you cannot quit smoking instantly as it will be bad for you as well. Try cutting down on it and then slowly and steadily give it up altogether.

Get the huge list of more than 500 Essay Topics and Ideas

Conclusion of the Essay on Smoking

Thus, if anyone is a slave to cigarettes, it is essential for them to understand that it is never too late to stop smoking. With the help and a good action plan, anyone can quit it for good. Moreover, the benefits will be evident within a few days of quitting.

FAQ of Essay on Smoking

Question 1: What are the effects of smoking?

Answer 1: Smoking has major effects like cancer, heart disease, stroke, lung diseases, diabetes, and more. It also increases the risk for tuberculosis, certain eye diseases, and problems with the immune system .

Question 2: Why should we avoid smoking?

Answer 2: We must avoid smoking as it can lengthen your life expectancy. Moreover, by not smoking, you decrease your risk of disease which includes lung cancer, throat cancer, heart disease, high blood pressure, and more.

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How To Write A Smoking Essay That Will Blow Your Classmates out of the Water

A smoking essay might not be your first choice, but it is a common enough topic, whether it is assigned by a professor or left to your choice. Today we’ll take you through the paces of creating a compelling piece, share fresh ideas for writing teen smoking essays, and tackle the specifics of the essential parts of any paper, including an introduction and a conclusion.

Why Choose a Smoking Essay?

If you are free to select any topic, why would you open this can of worms? There are several compelling arguments in favor, such as:

• A smoking essay can fit any type of writing assignment. You can craft an argumentative essay about smoking, a persuasive piece, or even a narration about someone’s struggle with quitting. It’s a rare case of a one-size-fits-all topic.
• There is an endless number of  environmental essay topics ideas . From the reasons and history of smoking to health and economic impact, as well as psychological and physiological factors that make quitting so challenging.
• A staggering number of reliable sources are available online. You won’t have to dig deep to find medical or economic research, there are thousands of papers published in peer-reviewed journals, ready and waiting for you to use them. 

Essential Considerations for Your Essay on Smoking

Whether you are writing a teenage smoking essay or a study of health-related issues, you need to stay objective and avoid including any judgment into your assignment. Even if you are firmly against smoking, do not let emotions direct your writing. You should also keep your language tolerant and free of offensive remarks or generalizations.

The rule of thumb is to keep your piece academic. It is an essay about smoking cigarettes you have to submit to your professor, not a blog post to share with friends.

How to Generate Endless Smoking Essay Topic Ideas

At first, it might seem that every theme has been covered by countless generations of your predecessors. However, there are ways to add a new spin to the dullest of topics. We’ll share a unique approach to generating new ideas and take the teenage smoking essay as an example. To make it fresh and exciting, you can:

• Add a historic twist to your topic. For instance, research the teenage smoking statistics through the years and theorize the factors that influence the numbers.
• Compare the data across the globe. You can select the best scale for your paper, comparing smoking rates in the neighboring cities, states, or countries.
• Look at the question from an unexpected perspective. For instance, research how the adoption of social media influenced smoking or whether music preferences can be related to this habit.

The latter approach on our list will generate endless ideas for writing teen smoking essays. Select the one that fits your interests or is the easiest to research, depending on the time and effort you are willing to put into essay writing .

How To Write An Essay About Smoking Cigarettes

A smoking essay follows the same rules as an academic paper on any other topic. You start with an introduction, fill the body paragraphs with individual points, and wrap up using a conclusion. The filling of your “essay sandwich” will depend on the topic, but we can tell for sure what your opening and closing paragraphs should be like.

Smoking Essay Introduction

Whether you are working on an argumentative essay about smoking or a persuasive paper, your introduction is nothing but a vessel for a thesis statement. It is the core of your essay, and its absence is the first strike against you. Properly constructed thesis sums up your point of view on the economic research topics and lists the critical points you are about to highlight. If you allude to the opposing views in your thesis statement, the professor is sure to add extra points to your grade.

The first sentence is crucial for your essay, as it sets the tone and makes the first impression. Make it surprising, exciting, powerful with facts, statistics, or vivid images, and it will become a hook to lure the reader in deeper. 

Round up the introduction with a transition to your first body passage and the point it will make. Otherwise, your essay might seem disjointed and patchy. Alternatively, you can use the first couple of sentences of the body paragraph as a transition.

Smoking Essay Conclusion

Any argumentative and persuasive essay on smoking must include a short conclusion. In the final passage, return to your thesis statement and repeat it in other words, highlighting the points you have made throughout the body paragraphs. You can also add final thoughts or even a personal opinion at the end to round up your assignment.

Think of the conclusion as a mirror reflection of your introduction. Start with a transition from the last body paragraph, follow it with a retelling of your thesis statement, and complete the passage with a powerful parting thought that will stay with the reader. After all, everyone remembers the first and last points most vividly, and your opening and closing sentences are likely to have a significant influence on the final grade.

Bonus Tips on How to Write a Persuasive Essay About Smoking

With the most challenging parts of the smoking essay out of the way, here are a couple of parting tips to ensure your paper gets the highest grade possible:

• Do not rely on samples you find online to guide your writing. You can never tell what grade a random essay about smoking cigarettes received. Unless you use winning submissions from essay competitions, you might copy faulty techniques and data into your paper and get a reduced grade.
• Do not forget to include references after the conclusion and cite the sources throughout the paper. Otherwise, you might get accused of academic dishonesty and ruin your academic record. Ask your professor about the appropriate citation style if you are not sure whether you should use APA, MLA, or Chicago.
• Do not submit your smoking essay without editing and proofreading first. The best thing you can do is leave the piece alone for a day or two and come back to it with fresh eyes and mind to check for redundancies, illogical argumentation, and irrelevant examples. Professional editing software, such as Grammarly, will help with most typos and glaring errors. Still, it is up to you to go through the paper a couple of times before submission to ensure it is as close to perfection as it can get.
• Do not be shy about getting help with writing smoking essays if you are out of time. Professional writers can take over any step of the writing process, from generating ideas to the final round of proofreading. Contact our agents or skip straight to the order form if you need our help to complete this assignment.

We hope our advice and ideas for writing teen smoking essays help you get out of the slump and produce a flawless piece of writing worthy of an A. For extra assistance with choosing the topic, outlining, writing, and editing, reach out to our support managers .

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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.

The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General.

1 introduction, summary, and conclusions.

• Introduction

The topic of passive or involuntary smoking was first addressed in the 1972 U.S. Surgeon General’s report ( The Health Consequences of Smoking , U.S. Department of Health, Education, and Welfare [USDHEW] 1972 ), only eight years after the first Surgeon General’s report on the health consequences of active smoking ( USDHEW 1964 ). Surgeon General Dr. Jesse Steinfeld had raised concerns about this topic, leading to its inclusion in that report. According to the 1972 report, nonsmokers inhale the mixture of sidestream smoke given off by a smoldering cigarette and mainstream smoke exhaled by a smoker, a mixture now referred to as “secondhand smoke” or “environmental tobacco smoke.” Cited experimental studies showed that smoking in enclosed spaces could lead to high levels of cigarette smoke components in the air. For carbon monoxide (CO) specifically, levels in enclosed spaces could exceed levels then permitted in outdoor air. The studies supported a conclusion that “an atmosphere contaminated with tobacco smoke can contribute to the discomfort of many individuals” ( USDHEW 1972 , p. 7). The possibility that CO emitted from cigarettes could harm persons with chronic heart or lung disease was also mentioned.

Secondhand tobacco smoke was then addressed in greater depth in Chapter 4 (Involuntary Smoking) of the 1975 Surgeon General’s report, The Health Consequences of Smoking ( USDHEW 1975 ). The chapter noted that involuntary smoking takes place when nonsmokers inhale both sidestream and exhaled mainstream smoke and that this “smoking” is “involuntary” when “the exposure occurs as an unavoidable consequence of breathing in a smoke-filled environment” (p. 87). The report covered exposures and potential health consequences of involuntary smoking, and the researchers concluded that smoking on buses and airplanes was annoying to nonsmokers and that involuntary smoking had potentially adverse consequences for persons with heart and lung diseases. Two studies on nicotine concentrations in nonsmokers raised concerns about nicotine as a contributing factor to atherosclerotic cardiovascular disease in nonsmokers.

The 1979 Surgeon General’s report, Smoking and Health: A Report of the Surgeon General ( USDHEW 1979 ), also contained a chapter entitled “Involuntary Smoking.” The chapter stressed that “attention to involuntary smoking is of recent vintage, and only limited information regarding the health effects of such exposure upon the nonsmoker is available” (p. 11–35). The chapter concluded with recommendations for research including epidemiologic and clinical studies. The 1982 Surgeon General’s report specifically addressed smoking and cancer ( U.S. Department of Health and Human Services [USDHHS] 1982 ). By 1982, there were three published epidemiologic studies on involuntary smoking and lung cancer, and the 1982 Surgeon General’s report included a brief chapter on this topic. That chapter commented on the methodologic difficulties inherent in such studies, including exposure assessment, the lengthy interval during which exposures are likely to be relevant, and accounting for exposures to other carcinogens. Nonetheless, the report concluded that “Although the currently available evidence is not sufficient to conclude that passive or involuntary smoking causes lung cancer in nonsmokers, the evidence does raise concern about a possible serious public health problem” (p. 251).

Involuntary smoking was also reviewed in the 1984 report, which focused on chronic obstructive pulmonary disease and smoking ( USDHHS 1984 ). Chapter 7 (Passive Smoking) of that report included a comprehensive review of the mounting information on smoking by parents and the effects on respiratory health of their children, data on irritation of the eye, and the more limited evidence on pulmonary effects of involuntary smoking on adults. The chapter began with a compilation of measurements of tobacco smoke components in various indoor environments. The extent of the data had increased substantially since 1972. By 1984, the data included measurements of more specific indicators such as acrolein and nicotine, and less specific indicators such as particulate matter (PM), nitrogen oxides, and CO. The report reviewed new evidence on exposures of nonsmokers using bio-markers, with substantial information on levels of cotinine, a major nicotine metabolite. The report anticipated future conclusions with regard to respiratory effects of parental smoking on child respiratory health ( Table 1.1 ).

Conclusions from previous Surgeon General’s reports on the health effects of secondhand smoke exposure

Involuntary smoking was the topic for the entire 1986 Surgeon General’s report, The Health Consequences of Involuntary Smoking ( USDHHS 1986 ). In its 359 pages, the report covered the full breadth of the topic, addressing toxicology and dosimetry of tobacco smoke; the relevant evidence on active smoking; patterns of exposure of nonsmokers to tobacco smoke; the epidemiologic evidence on involuntary smoking and disease risks for infants, children, and adults; and policies to control involuntary exposure to tobacco smoke. That report concluded that involuntary smoking caused lung cancer in lifetime nonsmoking adults and was associated with adverse effects on respiratory health in children. The report also stated that simply separating smokers and nonsmokers within the same airspace reduced but did not eliminate exposure to secondhand smoke. All of these findings are relevant to public health and public policy ( Table 1.1 ). The lung cancer conclusion was based on extensive information already available on the carcinogenicity of active smoking, the qualitative similarities between secondhand and mainstream smoke, the uptake of tobacco smoke components by nonsmokers, and the epidemiologic data on involuntary smoking. The three major conclusions of the report ( Table 1.2 ), led Dr. C. Everett Koop, Surgeon General at the time, to comment in his preface that “the right of smokers to smoke ends where their behavior affects the health and well-being of others; furthermore, it is the smokers’ responsibility to ensure that they do not expose nonsmokers to the potential [ sic ] harmful effects of tobacco smoke” ( USDHHS 1986 , p. xii).

Major conclusions of the 1986 Surgeon General’s report, The Health Consequences of Involuntary Smoking

Two other reports published in 1986 also reached the conclusion that involuntary smoking increased the risk for lung cancer. The International Agency for Research on Cancer (IARC) of the World Health Organization concluded that “passive smoking gives rise to some risk of cancer” ( IARC 1986 , p. 314). In its monograph on tobacco smoking, the agency supported this conclusion on the basis of the characteristics of sidestream and mainstream smoke, the absorption of tobacco smoke materials during an involuntary exposure, and the nature of dose-response relationships for carcinogenesis. In the same year, the National Research Council (NRC) also concluded that involuntary smoking increases the incidence of lung cancer in nonsmokers ( NRC 1986 ). In reaching this conclusion, the NRC report cited the biologic plausibility of the association between exposure to secondhand smoke and lung cancer and the supporting epidemiologic evidence. On the basis of a pooled analysis of the epidemiologic data adjusted for bias, the report concluded that the best estimate for the excess risk of lung cancer in nonsmokers married to smokers was 25 percent, compared with nonsmokers married to nonsmokers. With regard to the effects of involuntary smoking on children, the NRC report commented on the literature linking secondhand smoke exposures from parental smoking to increased risks for respiratory symptoms and infections and to a slightly diminished rate of lung growth.

Since 1986, the conclusions with regard to both the carcinogenicity of secondhand smoke and the adverse effects of parental smoking on the health of children have been echoed and expanded ( Table 1.3 ). In 1992, the U.S. Environmental Protection Agency (EPA) published its risk assessment of secondhand smoke as a carcinogen ( USEPA 1992 ). The agency’s evaluation drew on toxicologic information on secondhand smoke and the extensive literature on active smoking. A comprehensive meta-analysis of the 31 epidemiologic studies of secondhand smoke and lung cancer published up to that time was central to the decision to classify secondhand smoke as a group A carcinogen—namely, a known human carcinogen. Estimates of approximately 3,000 U.S. lung cancer deaths per year in non-smokers were attributed to secondhand smoke. The report also covered other respiratory health effects in children and adults and concluded that involuntary smoking is causally associated with several adverse respiratory effects in children. There was also a quantitative risk assessment for the impact of involuntary smoking on childhood asthma and lower respiratory tract infections in young children.

Selected major reports, other than those of the U.S. Surgeon General, addressing adverse effects from exposure to tobacco smoke

In the decade since the 1992 EPA report, scientific panels continued to evaluate the mounting evidence linking involuntary smoking to adverse health effects ( Table 1.3 ). The most recent was the 2005 report of the California EPA ( Cal/EPA 2005 ). Over time, research has repeatedly affirmed the conclusions of the 1986 Surgeon General’s reports and studies have further identified causal associations of involuntary smoking with diseases and other health disorders. The epidemiologic evidence on involuntary smoking has markedly expanded since 1986, as have the data on exposure to tobacco smoke in the many environments where people spend time. An understanding of the mechanisms by which involuntary smoking causes disease has also deepened.

As part of the environmental health hazard assessment, Cal/EPA identified specific health effects causally associated with exposure to secondhand smoke. The agency estimated the annual excess deaths in the United States that are attributable to secondhand smoke exposure for specific disorders: sudden infant death syndrome (SIDS), cardiac-related illnesses (ischemic heart disease), and lung cancer ( Cal/EPA 2005 ). For the excess incidence of other health outcomes, either new estimates were provided or estimates from the 1997 health hazard assessment were used without any revisions ( Cal/EPA 1997 ). Overall, Cal/EPA estimated that about 50,000 excess deaths result annually from exposure to secondhand smoke ( Cal/EPA 2005 ). Estimated annual excess deaths for the total U.S. population are about 3,400 (a range of 3,423 to 8,866) from lung cancer, 46,000 (a range of 22,700 to 69,600) from cardiac-related illnesses, and 430 from SIDS. The agency also estimated that between 24,300 and 71,900 low birth weight or pre-term deliveries, about 202,300 episodes of childhood asthma (new cases and exacerbations), between 150,000 and 300,000 cases of lower respiratory illness in children, and about 789,700 cases of middle ear infections in children occur each year in the United States as a result of exposure to secondhand smoke.

This new 2006 Surgeon General’s report returns to the topic of involuntary smoking. The health effects of involuntary smoking have not received comprehensive coverage in this series of reports since 1986. Reports since then have touched on selected aspects of the topic: the 1994 report on tobacco use among young people ( USDHHS 1994 ), the 1998 report on tobacco use among U.S. racial and ethnic minorities ( USDHHS 1998 ), and the 2001 report on women and smoking ( USDHHS 2001 ). As involuntary smoking remains widespread in the United States and elsewhere, the preparation of this report was motivated by the persistence of involuntary smoking as a public health problem and the need to evaluate the substantial new evidence reported since 1986. This report substantially expands the list of topics that were included in the 1986 report. Additional topics include SIDS, developmental effects, and other reproductive effects; heart disease in adults; and cancer sites beyond the lung. For some associations of involuntary smoking with adverse health effects, only a few studies were reviewed in 1986 (e.g., ear disease in children); now, the relevant literature is substantial. Consequently, this report uses meta-analysis to quantitatively summarize evidence as appropriate. Following the approach used in the 2004 report ( The Health Consequences of Smoking , USDHHS 2004 ), this 2006 report also systematically evaluates the evidence for causality, judging the extent of the evidence available and then making an inference as to the nature of the association.

Organization of the Report

This twenty-ninth report of the Surgeon General examines the topics of toxicology of secondhand smoke, assessment and prevalence of exposure to secondhand smoke, reproductive and developmental health effects, respiratory effects of exposure to secondhand smoke in children and adults, cancer among adults, cardiovascular diseases, and the control of secondhand smoke exposure.

This introductory chapter (Chapter 1) includes a discussion of the concept of causation and introduces concepts of causality that are used throughout this report; this chapter also summarizes the major conclusions of the report. Chapter 2 (Toxicology of Secondhand Smoke) sets out a foundation for interpreting the observational evidence that is the focus of most of the following chapters. The discussion details the mechanisms that enable tobacco smoke components to injure the respiratory tract and cause nonmalignant and malignant diseases and other adverse effects. Chapter 3 (Assessment of Exposure to Secondhand Smoke) provides a perspective on key factors that determine exposures of people to secondhand smoke in indoor environments, including building designs and operations, atmospheric markers of secondhand smoke, exposure models, and biomarkers of exposure to secondhand smoke. Chapter 4 (Prevalence of Exposure to Secondhand Smoke) summarizes findings that focus on nicotine measurements in the air and cotinine measurements in biologic materials. The chapter includes exposures in the home, workplace, public places, and special populations. Chapter 5 (Reproductive and Developmental Effects from Exposure to Secondhand Smoke) reviews the health effects on reproduction, on infants, and on child development. Chapter 6 (Respiratory Effects in Children from Exposure to Secondhand Smoke) examines the effects of parental smoking on the respiratory health of children. Chapter 7 (Cancer Among Adults from Exposure to Secondhand Smoke) summarizes the evidence on cancer of the lung, breast, nasal sinuses, and the cervix. Chapter 8 (Cardiovascular Diseases from Exposure to Secondhand Smoke) discusses coronary heart disease (CHD), stroke, and subclinical vascular disease. Chapter 9 (Respiratory Effects in Adults from Exposure to Secondhand Smoke) examines odor and irritation, respiratory symptoms, lung function, and respiratory diseases such as asthma and chronic obstructive pulmonary disease. Chapter 10 (Control of Secondhand Smoke Exposure) considers measures used to control exposure to secondhand smoke in public places, including legislation, education, and approaches based on building designs and operations. The report concludes with “A Vision for the Future.” Major conclusions of the report were distilled from the chapter conclusions and appear later in this chapter.

Preparation of the Report

This report of the Surgeon General was prepared by the Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Coordinating Center for Health Promotion, Centers for Disease Control and Prevention (CDC), and U.S. DHHS. Initial chapters were written by 22 experts who were selected because of their knowledge of a particular topic. The contributions of the initial experts were consolidated into 10 major chapters that were then reviewed by more than 40 peer reviewers. The entire manuscript was then sent to more than 30 scientists and experts who reviewed it for its scientific integrity. After each review cycle, the drafts were revised by the scientific editors on the basis of the experts’ comments. Subsequently, the report was reviewed by various institutes and agencies within U.S. DHHS. Publication lags, even short ones, prevent an up-to-the-minute inclusion of all recently published articles and data. Therefore, by the time the public reads this report, there may be additional published studies or data. To provide published information as current as possible, this report includes an Appendix of more recent studies that represent major additions to the literature.

This report is also accompanied by a companion database of key evidence that is accessible through the Internet ( http://www.cdc.gov/tobacco ). The database includes a uniform description of the studies and results on the health effects of exposure to secondhand smoke that were presented in a format compatible with abstraction into standardized tables. Readers of the report may access these data for additional analyses, tables, or figures.

• Definitions and Terminology

The inhalation of tobacco smoke by nonsmokers has been variably referred to as “passive smoking” or “involuntary smoking.” Smokers, of course, also inhale secondhand smoke. Cigarette smoke contains both particles and gases generated by the combustion at high temperatures of tobacco, paper, and additives. The smoke inhaled by nonsmokers that contaminates indoor spaces and outdoor environments has often been referred to as “secondhand smoke” or “environmental tobacco smoke.” This inhaled smoke is the mixture of sidestream smoke released by the smoldering cigarette and the mainstream smoke that is exhaled by a smoker. Sidestream smoke, generated at lower temperatures and under somewhat different combustion conditions than mainstream smoke, tends to have higher concentrations of many of the toxins found in cigarette smoke ( USDHHS 1986 ). However, it is rapidly diluted as it travels away from the burning cigarette.

Secondhand smoke is an inherently dynamic mixture that changes in characteristics and concentration with the time since it was formed and the distance it has traveled. The smoke particles change in size and composition as gaseous components are volatilized and moisture content changes; gaseous elements of secondhand smoke may be adsorbed onto materials, and particle concentrations drop with both dilution in the air or environment and impaction on surfaces, including the lungs or on the body. Because of its dynamic nature, a specific quantitative definition of secondhand smoke cannot be offered.

This report uses the term secondhand smoke in preference to environmental tobacco smoke, even though the latter may have been used more frequently in previous reports. The descriptor “secondhand” captures the involuntary nature of the exposure, while “environmental” does not. This report also refers to the inhalation of secondhand smoke as involuntary smoking, acknowledging that most nonsmokers do not want to inhale tobacco smoke. The exposure of the fetus to tobacco smoke, whether from active smoking by the mother or from her exposure to secondhand smoke, also constitutes involuntary smoking.

• Evidence Evaluation

Following the model of the 1964 report, the Surgeon General’s reports on smoking have included comprehensive compilations of the evidence on the health effects of smoking. The evidence is analyzed to identify causal associations between smoking and disease according to enunciated principles, sometimes referred to as the “Surgeon General’s criteria” or the “Hill” criteria (after Sir Austin Bradford Hill) for causality ( USDHEW 1964 ; USDHHS 2004 ). Application of these criteria involves covering all relevant observational and experimental evidence. The criteria, offered in a brief chapter of the 1964 report entitled “Criteria for Judgment,” included (1) the consistency of the association, (2) the strength of the association, (3) the specificity of the association, (4) the temporal relationship of the association, and (5) the coherence of the association. Although these criteria have been criticized (e.g., Rothman and Greenland 1998 ), they have proved useful as a framework for interpreting evidence on smoking and other postulated causes of disease, and for judging whether causality can be inferred.

In the 2004 report of the Surgeon General, The Health Consequences of Smoking , the framework for interpreting evidence on smoking and health was revisited in depth for the first time since the 1964 report ( USDHHS 2004 ). The 2004 report provided a four-level hierarchy for interpreting evidence ( Table 1.4 ). The categories acknowledge that evidence can be “suggestive” but not adequate to infer a causal relationship, and also allows for evidence that is “suggestive of no causal relationship.” Since the 2004 report, the individual chapter conclusions have consistently used this four-level hierarchy ( Table 1.4 ), but evidence syntheses and other summary statements may use either the term “increased risk” or “cause” to describe instances in which there is sufficient evidence to conclude that active or involuntary smoking causes a disease or condition. This four-level framework also sharply and completely separates conclusions regarding causality from the implications of such conclusions.

Four-level hierarchy for classifying the strength of causal inferences based on available evidence

That same framework was used in this report on involuntary smoking and health. The criteria dating back to the 1964 Surgeon General’s report remain useful as guidelines for evaluating evidence ( USDHEW 1964 ), but they were not intended to be applied strictly or as a “checklist” that needed to be met before the designation of “causal” could be applied to an association. In fact, for involuntary smoking and health, several of the criteria will not be met for some associations. Specificity, referring to a unique exposure-disease relationship (e.g., the association between thalidomide use during pregnancy and unusual birth defects), can be set aside as not relevant, as all of the health effects considered in this report have causes other than involuntary smoking. Associations are considered more likely to be causal as the strength of an association increases because competing explanations become less plausible alternatives. However, based on knowledge of dosimetry and mechanisms of injury and disease causation, the risk is anticipated to be only slightly or modestly increased for some associations of involuntary smoking with disease, such as lung cancer, particularly when the very strong relative risks found for active smokers are compared with those for lifetime nonsmokers. The finding of only a small elevation in risk, as in the example of spousal smoking and lung cancer risk in lifetime nonsmokers, does not weigh against a causal association; however, alternative explanations for a risk of a small magnitude need full exploration and cannot be so easily set aside as alternative explanations for a stronger association. Consistency, coherence, and the temporal relationship of involuntary smoking with disease are central to the interpretations in this report. To address coherence, the report draws not only on the evidence for involuntary smoking, but on the even more extensive literature on active smoking and disease.

Although the evidence reviewed in this report comes largely from investigations of secondhand smoke specifically, the larger body of evidence on active smoking is also relevant to many of the associations that were evaluated. The 1986 report found secondhand smoke to be qualitatively similar to mainstream smoke inhaled by the smoker and concluded that secondhand smoke would be expected to have “a toxic and carcinogenic potential that would not be expected to be qualitatively different from that of MS [mainstream smoke]” ( USDHHS 1986 , p. 23). The 2004 report of the Surgeon General revisited the health consequences of active smoking ( USDHHS 2004 ), and the conclusions substantially expanded the list of diseases and conditions caused by smoking. Chapters in the present report consider the evidence on active smoking that is relevant to biologic plausibility for causal associations between involuntary smoking and disease. The reviews included in this report cover evidence identified through search strategies set out in each chapter. Of necessity, the evidence on mechanisms was selectively reviewed. However, an attempt was made to cover all health studies through specified target dates. Because of the substantial amount of time involved in preparing this report, lists of new key references published after these cut-off dates are included in an Appendix . Literature reviews were extended when new evidence was sufficient to possibly change the level of a causal conclusion.

• Major Conclusions

This report returns to involuntary smoking, the topic of the 1986 Surgeon General’s report. Since then, there have been many advances in the research on secondhand smoke, and substantial evidence has been reported over the ensuing 20 years. This report uses the revised language for causal conclusions that was implemented in the 2004 Surgeon General’s report ( USDHHS 2004 ). Each chapter provides a comprehensive review of the evidence, a quantitative synthesis of the evidence if appropriate, and a rigorous assessment of sources of bias that may affect interpretations of the findings. The reviews in this report reaffirm and strengthen the findings of the 1986 report. With regard to the involuntary exposure of nonsmokers to tobacco smoke, the scientific evidence now supports the following major conclusions:

• Secondhand smoke causes premature death and disease in children and in adults who do not smoke.
• Children exposed to secondhand smoke are at an increased risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma. Smoking by parents causes respiratory symptoms and slows lung growth in their children.
• Exposure of adults to secondhand smoke has immediate adverse effects on the cardiovascular system and causes coronary heart disease and lung cancer.
• The scientific evidence indicates that there is no risk-free level of exposure to secondhand smoke.
• Many millions of Americans, both children and adults, are still exposed to secondhand smoke in their homes and workplaces despite substantial progress in tobacco control.
• Eliminating smoking in indoor spaces fully protects nonsmokers from exposure to secondhand smoke. Separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate exposures of nonsmokers to secondhand smoke.
• Chapter Conclusions

Chapter 2 Toxicology of Secondhand Smoke

Evidence of carcinogenic effects from secondhand smoke exposure.

• 1. More than 50 carcinogens have been identified in sidestream and secondhand smoke.
• 2. The evidence is sufficient to infer a causal relationship between exposure to secondhand smoke and its condensates and tumors in laboratory animals.
• 3. The evidence is sufficient to infer that exposure of nonsmokers to secondhand smoke causes a significant increase in urinary levels of metabolites of the tobacco-specific lung carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK). The presence of these metabolites links exposure to secondhand smoke with an increased risk for lung cancer.
• 4. The mechanisms by which secondhand smoke causes lung cancer are probably similar to those observed in smokers. The overall risk of secondhand smoke exposure, compared with active smoking, is diminished by a substantially lower carcinogenic dose.

Mechanisms of Respiratory Tract Injury and Disease Caused by Secondhand Smoke Exposure

• 5. The evidence indicates multiple mechanisms by which secondhand smoke exposure causes injury to the respiratory tract.
• 6. The evidence indicates mechanisms by which secondhand smoke exposure could increase the risk for sudden infant death syndrome.

Mechanisms of Secondhand Smoke Exposure and Heart Disease

• 7. The evidence is sufficient to infer that exposure to secondhand smoke has a prothrombotic effect.
• 8. The evidence is sufficient to infer that exposure to secondhand smoke causes endothelial cell dysfunctions.
• 9. The evidence is sufficient to infer that exposure to secondhand smoke causes atherosclerosis in animal models.

Chapter 3. Assessment of Exposure to Secondhand Smoke

Building designs and operations.

• 1. Current heating, ventilating, and air conditioning systems alone cannot control exposure to secondhand smoke.
• 2. The operation of a heating, ventilating, and air conditioning system can distribute secondhand smoke throughout a building.

Exposure Models

• 3. Atmospheric concentration of nicotine is a sensitive and specific indicator for secondhand smoke.
• 4. Smoking increases indoor particle concentrations.
• 5. Models can be used to estimate concentrations of secondhand smoke.

Biomarkers of Exposure to Secondhand Smoke

• 6. Biomarkers suitable for assessing recent exposures to secondhand smoke are available.
• 7. At this time, cotinine, the primary proximate metabolite of nicotine, remains the biomarker of choice for assessing secondhand smoke exposure.
• 8. Individual biomarkers of exposure to secondhand smoke represent only one component of a complex mixture, and measurements of one marker may not wholly reflect an exposure to other components of concern as a result of involuntary smoking.

Chapter 4. Prevalence of Exposure to Secondhand Smoke

• The evidence is sufficient to infer that large numbers of nonsmokers are still exposed to secondhand smoke.
• Exposure of nonsmokers to secondhand smoke has declined in the United States since the 1986 Surgeon General’s report, The Health Consequences of Involuntary Smoking .
• The evidence indicates that the extent of secondhand smoke exposure varies across the country.
• Homes and workplaces are the predominant locations for exposure to secondhand smoke.
• Exposure to secondhand smoke tends to be greater for persons with lower incomes.
• Exposure to secondhand smoke continues in restaurants, bars, casinos, gaming halls, and vehicles.

Chapter 5. Reproductive and Developmental Effects from Exposure to Secondhand Smoke

• 1. The evidence is inadequate to infer the presence or absence of a causal relationship between maternal exposure to secondhand smoke and female fertility or fecundability. No data were found on paternal exposure to secondhand smoke and male fertility or fecundability.

Pregnancy (Spontaneous Abortion and Perinatal Death)

• 2. The evidence is inadequate to infer the presence or absence of a causal relationship between maternal exposure to secondhand smoke during pregnancy and spontaneous abortion.

Infant Deaths

• 3. The evidence is inadequate to infer the presence or absence of a causal relationship between exposure to secondhand smoke and neonatal mortality.

Sudden Infant Death Syndrome

• 4. The evidence is sufficient to infer a causal relationship between exposure to secondhand smoke and sudden infant death syndrome.

Preterm Delivery

• 5. The evidence is suggestive but not sufficient to infer a causal relationship between maternal exposure to secondhand smoke during pregnancy and preterm delivery.

Low Birth Weight

• 6. The evidence is sufficient to infer a causal relationship between maternal exposure to secondhand smoke during pregnancy and a small reduction in birth weight.

Congenital Malformations

• 7. The evidence is inadequate to infer the presence or absence of a causal relationship between exposure to secondhand smoke and congenital malformations.

Cognitive Development

• 8. The evidence is inadequate to infer the presence or absence of a causal relationship between exposure to secondhand smoke and cognitive functioning among children.

Behavioral Development

• 9. The evidence is inadequate to infer the presence or absence of a causal relationship between exposure to secondhand smoke and behavioral problems among children.

Height/Growth

• 10. The evidence is inadequate to infer the presence or absence of a causal relationship between exposure to secondhand smoke and children’s height/growth.

Childhood Cancer

• 11. The evidence is suggestive but not sufficient to infer a causal relationship between prenatal and postnatal exposure to secondhand smoke and childhood cancer.
• 12. The evidence is inadequate to infer the presence or absence of a causal relationship between maternal exposure to secondhand smoke during pregnancy and childhood cancer.
• 13. The evidence is inadequate to infer the presence or absence of a causal relationship between exposure to secondhand smoke during infancy and childhood cancer.
• 14. The evidence is suggestive but not sufficient to infer a causal relationship between prenatal and postnatal exposure to secondhand smoke and childhood leukemias.
• 15. The evidence is suggestive but not sufficient to infer a causal relationship between prenatal and postnatal exposure to secondhand smoke and childhood lymphomas.
• 16. The evidence is suggestive but not sufficient to infer a causal relationship between prenatal and postnatal exposure to secondhand smoke and childhood brain tumors.
• 17. The evidence is inadequate to infer the presence or absence of a causal relationship between prenatal and postnatal exposure to secondhand smoke and other childhood cancer types.

Chapter 6. Respiratory Effects in Children from Exposure to Secondhand Smoke

Lower respiratory illnesses in infancy and early childhood.

• 1. The evidence is sufficient to infer a causal relationship between secondhand smoke exposure from parental smoking and lower respiratory illnesses in infants and children.
• 2. The increased risk for lower respiratory illnesses is greatest from smoking by the mother.

Middle Ear Disease and Adenotonsillectomy

• 3. The evidence is sufficient to infer a causal relationship between parental smoking and middle ear disease in children, including acute and recurrent otitis media and chronic middle ear effusion.
• 4. The evidence is suggestive but not sufficient to infer a causal relationship between parental smoking and the natural history of middle ear effusion.
• 5. The evidence is inadequate to infer the presence or absence of a causal relationship between parental smoking and an increase in the risk of adenoidectomy or tonsillectomy among children.

Respiratory Symptoms and Prevalent Asthma in School-Age Children

• 6. The evidence is sufficient to infer a causal relationship between parental smoking and cough, phlegm, wheeze, and breathlessness among children of school age.
• 7. The evidence is sufficient to infer a causal relationship between parental smoking and ever having asthma among children of school age.

Childhood Asthma Onset

• 8. The evidence is sufficient to infer a causal relationship between secondhand smoke exposure from parental smoking and the onset of wheeze illnesses in early childhood.
• 9. The evidence is suggestive but not sufficient to infer a causal relationship between secondhand smoke exposure from parental smoking and the onset of childhood asthma.
• 10. The evidence is inadequate to infer the presence or absence of a causal relationship between parental smoking and the risk of immunoglobulin E-mediated allergy in their children.

Lung Growth and Pulmonary Function

• 11. The evidence is sufficient to infer a causal relationship between maternal smoking during pregnancy and persistent adverse effects on lung function across childhood.
• 12. The evidence is sufficient to infer a causal relationship between exposure to secondhand smoke after birth and a lower level of lung function during childhood.

Chapter 7. Cancer Among Adults from Exposure to Secondhand Smoke

Lung cancer.

• 1. The evidence is sufficient to infer a causal relationship between secondhand smoke exposure and lung cancer among lifetime nonsmokers. This conclusion extends to all secondhand smoke exposure, regardless of location.
• 2. The pooled evidence indicates a 20 to 30 percent increase in the risk of lung cancer from secondhand smoke exposure associated with living with a smoker.

Breast Cancer

• 3. The evidence is suggestive but not sufficient to infer a causal relationship between secondhand smoke and breast cancer.

Nasal Sinus Cavity and Nasopharyngeal Carcinoma

• 4. The evidence is suggestive but not sufficient to infer a causal relationship between secondhand smoke exposure and a risk of nasal sinus cancer among nonsmokers.
• 5. The evidence is inadequate to infer the presence or absence of a causal relationship between secondhand smoke exposure and a risk of nasopharyngeal carcinoma among nonsmokers.

Cervical Cancer

• 6. The evidence is inadequate to infer the presence or absence of a causal relationship between secondhand smoke exposure and the risk of cervical cancer among lifetime nonsmokers.

Chapter 8. Cardiovascular Diseases from Exposure to Secondhand Smoke

• The evidence is sufficient to infer a causal relationship between exposure to secondhand smoke and increased risks of coronary heart disease morbidity and mortality among both men and women.
• Pooled relative risks from meta-analyses indicate a 25 to 30 percent increase in the risk of coronary heart disease from exposure to secondhand smoke.
• The evidence is suggestive but not sufficient to infer a causal relationship between exposure to secondhand smoke and an increased risk of stroke.
• Studies of secondhand smoke and subclinical vascular disease, particularly carotid arterial wall thickening, are suggestive but not sufficient to infer a causal relationship between exposure to secondhand smoke and atherosclerosis.

Chapter 9. Respiratory Effects in Adults from Exposure to Secondhand Smoke

Odor and irritation.

• 1. The evidence is sufficient to infer a causal relationship between secondhand smoke exposure and odor annoyance.
• 2. The evidence is sufficient to infer a causal relationship between secondhand smoke exposure and nasal irritation.
• 3. The evidence is suggestive but not sufficient to conclude that persons with nasal allergies or a history of respiratory illnesses are more susceptible to developing nasal irritation from secondhand smoke exposure.

Respiratory Symptoms

• 4. The evidence is suggestive but not sufficient to infer a causal relationship between secondhand smoke exposure and acute respiratory symptoms including cough, wheeze, chest tightness, and difficulty breathing among persons with asthma.
• 5. The evidence is suggestive but not sufficient to infer a causal relationship between secondhand smoke exposure and acute respiratory symptoms including cough, wheeze, chest tightness, and difficulty breathing among healthy persons.
• 6. The evidence is suggestive but not sufficient to infer a causal relationship between secondhand smoke exposure and chronic respiratory symptoms.

Lung Function

• 7. The evidence is suggestive but not sufficient to infer a causal relationship between short-term secondhand smoke exposure and an acute decline in lung function in persons with asthma.
• 8. The evidence is inadequate to infer the presence or absence of a causal relationship between short-term secondhand smoke exposure and an acute decline in lung function in healthy persons.
• 9. The evidence is suggestive but not sufficient to infer a causal relationship between chronic secondhand smoke exposure and a small decrement in lung function in the general population.
• 10. The evidence is inadequate to infer the presence or absence of a causal relationship between chronic secondhand smoke exposure and an accelerated decline in lung function.
• 11. The evidence is suggestive but not sufficient to infer a causal relationship between secondhand smoke exposure and adult-onset asthma.
• 12. The evidence is suggestive but not sufficient to infer a causal relationship between secondhand smoke exposure and a worsening of asthma control.

Chronic Obstructive Pulmonary Disease

• 13. The evidence is suggestive but not sufficient to infer a causal relationship between secondhand smoke exposure and risk for chronic obstructive pulmonary disease.
• 14. The evidence is inadequate to infer the presence or absence of a causal relationship between secondhand smoke exposure and morbidity in persons with chronic obstructive pulmonary disease.

Chapter 10. Control of Secondhand Smoke Exposure

• Workplace smoking restrictions are effective in reducing secondhand smoke exposure.
• Workplace smoking restrictions lead to less smoking among covered workers.
• Establishing smoke-free workplaces is the only effective way to ensure that secondhand smoke exposure does not occur in the workplace.
• The majority of workers in the United States are now covered by smoke-free policies.
• The extent to which workplaces are covered by smoke-free policies varies among worker groups, across states, and by sociodemographic factors. Workplaces related to the entertainment and hospitality industries have notably high potential for secondhand smoke exposure.
• Evidence from peer-reviewed studies shows that smoke-free policies and regulations do not have an adverse economic impact on the hospitality industry.
• Evidence suggests that exposure to secondhand smoke varies by ethnicity and gender.
• In the United States, the home is now becoming the predominant location for exposure of children and adults to secondhand smoke.
• Total bans on indoor smoking in hospitals, restaurants, bars, and offices substantially reduce secondhand smoke exposure, up to several orders of magnitude with incomplete compliance, and with full compliance, exposures are eliminated.
• Exposures of nonsmokers to secondhand smoke cannot be controlled by air cleaning or mechanical air exchange.
• Methodologic Issues

Much of the evidence on the health effects of involuntary smoking comes from observational epidemiologic studies that were carried out to test hypotheses related to secondhand smoke and risk for diseases and other adverse health effects. The challenges faced in carrying out these studies reflect those of observational research generally: assessment of the relevant exposures and outcomes with sufficient validity and precision, selection of an appropriate study design, identification of an appropriate and sufficiently large study population, and collection of information on other relevant factors that may confound or modify the association being studied. The challenge of accurately classifying secondhand smoke exposures confronts all studies of such exposures, and consequently the literature on approaches to and limitations of exposure classification is substantial. Sources of bias that can affect the findings of epidemiologic studies have been widely discussed ( Rothman and Greenland 1998 ), both in general and in relation to studies of involuntary smoking. Concerns about bias apply to any study of an environmental agent and disease risk: misclassification of exposures or outcomes, confounding effect modification, and proper selection of study participants. In addition, the generalizability of findings from one population to another (external validity) further determines the value of evidence from a study. Another methodologic concern affecting secondhand smoke literature comes from the use of meta-analysis to combine the findings of epidemiologic studies; general concerns related to the use of meta-analysis for observational data and more specific concerns related to involuntary smoking have also been raised. This chapter considers these methodologic issues in anticipation of more specific treatment in the following chapters.

Classification of Secondhand Smoke Exposure

For secondhand smoke, as for any environmental factor that may be a cause of disease, the exposure assessment might encompass the time and place of the exposure, cumulative exposures, exposure during a particular time, or a recent exposure ( Jaakkola and Jaakkola 1997 ; Jaakkola and Samet 1999 ). For example, exposures to secondhand smoke across the full life span may be of interest for lung cancer, while only more recent exposures may be relevant to the exacerbation of asthma. For CHD, both temporally remote and current exposures may affect risk. Assessments of exposures are further complicated by the multiplicity of environments where exposures take place and the difficulty of characterizing the exposure in some locations, such as public places or workplaces. Additionally, exposures probably vary qualitatively and quantitatively over time and across locations because of temporal changes and geographic differences in smoking patterns.

Nonetheless, researchers have used a variety of approaches for exposure assessments in epidemiologic studies of adverse health effects from involuntary smoking. Several core concepts that are fundamental to these approaches are illustrated in Figure 1.1 ( Samet and Jaakkola 1999 ). Cigarette smoking is, of course, the source of most secondhand smoke in the United States, followed by pipes, cigars, and other products. Epidemiologic studies generally focus on assessing the exposure, which is the contact with secondhand smoke. The concentrations of secondhand smoke components in a space depend on the number of smokers and the rate at which they are smoking, the volume into which the smoke is distributed, the rate at which the air in the space exchanges with uncontaminated air, and the rate at which the secondhand smoke is removed from the air. Concentration, exposure, and dose differ in their definitions, although the terms are sometimes used without sharp distinctions. However, surrogate indicators that generally describe a source of exposure may also be used to assess the exposure, such as marriage to a smoker or the number of cigarettes smoked in the home. Biomarkers can provide an indication of an exposure or possibly the dose, but for secondhand smoke they are used for recent exposure only.

The determinants of exposure, dose, and biologically effective dose that underlie the development of health effects from smoking. Source: Samet and Jaakkola (more...)

People are exposed to secondhand smoke in a number of different places, often referred to as “microenvironments” ( NRC 1991 ). A microenvironment is a definable location that has a constant concentration of the contaminant of interest, such as secondhand smoke, during the time that a person is there. Some key microenvironments for secondhand smoke include the home, the workplace, public places, and transportation environments ( Klepeis 1999 ). Based on the microenvironmental model, total exposure can be estimated as the weighted average of the concentrations of secondhand smoke or indicator compounds, such as nicotine, in the microenvironments where time is spent; the weights are the time spent in each microenvironment. Klepeis (1999) illustrates the application of the microenvironmental model with national data from the National Human Activity Pattern Survey conducted by the EPA. His calculations yield an overall estimate of exposure to airborne particles from smoking and of the contributions to this exposure from various microenvironments.

Much of the epidemiologic evidence addresses the consequences of an exposure in a particular microenvironment, such as the home (spousal smoking and lung cancer risk or maternal smoking and risk for asthma exacerbation), or the workplace (exacerbation of asthma by the presence of smokers). Some studies have attempted to cover multiple microenvironments and to characterize exposures over time. For example, in the multicenter study of secondhand smoke exposure and lung cancer carried out in the United States, Fontham and colleagues (1994) assessed exposures during childhood, in workplaces, and at home during adulthood. Questionnaires that assess exposures have been the primary tool used in epidemiologic studies of secondhand smoke and disease. Measurement of biomarkers has been added in some studies, either as an additional and complementary exposure assessment approach or for validating questionnaire responses. Some studies have also measured components of secondhand smoke in the air.

Questionnaires generally address sources of exposure in microenvironments and can be tailored to address the time period of interest. Questionnaires represent the only approach that can be used to assess exposures retrospectively over a life span, because available biomarkers only reflect exposures over recent days or, at most, weeks. Questionnaires on secondhand smoke exposure have been assessed for their reliability and validity, generally based on comparisons with either biomarker or air monitoring data as the “gold” standard ( Jaakkola and Jaakkola 1997 ). Two studies evaluated the reliability of questionnaires on lifetime exposures ( Pron et al. 1988 ; Coultas et al. 1989 ). Both showed a high degree of repeatability for questions concerning whether a spouse had smoked, but a lower reliability for responses concerning the quantitative aspects of an exposure. Emerson and colleagues (1995) evaluated the repeatability of information from parents of children with asthma. They found a high reliability for parent-reported tobacco use and for the number of cigarettes to which the child was exposed in the home during the past week.

To assess validity, questionnaire reports of current or recent exposures have been compared with levels of cotinine and other biomarkers. These studies tend to show a moderate correlation between levels of cotinine and questionnaire indicators of exposures ( Kawachi and Colditz 1996 ; Cal/EPA 1997 ; Jaakkola and Jaakkola 1997 ). However, cotinine levels reflect not only exposure but metabolism and excretion ( Benowitz 1999 ). Consequently, exposure is only one determinant of variation in cotinine levels among persons; there also are individual variations in metabolism and excretion rates. In spite of these sources of variability, mean levels of cotinine vary as anticipated across categories of self-reported exposures ( Cal/EPA 1997 ; Jaakkola and Jaakkola 1997 ), and self-reported exposures are moderately associated with measured levels of markers ( Cal/EPA 1997 ; Jaakkola and Jaakkola 1997 ).

Biomarkers are also used for assessing exposures to secondhand smoke. A number of biomarkers are available, but they vary in their specificity and in the dynamics of the temporal relationship between the exposure and the marker level ( Cal/EPA 1997 ; Benowitz 1999 ). These markers include specific tobacco smoke components (nicotine) or metabolites (cotinine and tobacco-specific nitrosamines), nonspecific biomarkers (thiocyanate and CO), adducts with tobacco smoke components or metabolites (4-amino-biphenyl hemoglobin adducts, benzo[ a ]pyrene DNA adducts, and polycyclic aromatic hydrocarbon albumin adducts), and nonspecific assays (urinary mutagenicity). Cotinine has been the most widely used biomarker, primarily because of its specificity, half-life, and ease of measurement in body fluids (e.g., urine, blood, and saliva). Biomarkers are discussed in detail in Chapter 3 (Assessment of Exposure to Secondhand Smoke).

Some epidemiologic studies have also incorporated air monitoring, either direct personal sampling or the indirect approach based on the microenvironmental model. Nicotine, present in the gas phase of secondhand smoke, can be monitored passively with a special filter or actively using a pump and a sorbent. Hammond and Leaderer (1987) first described a diffusion monitor for the passive sampling of nicotine in 1987; this device has now been widely used to assess concentrations in different environments and to study health effects. Airborne particles have also been measured using active monitoring devices.

Each of these approaches for assessing exposures has strengths and limitations, and preference for one over another will depend on the research question and its context ( Jaakkola and Jaakkola 1997 ; Jaakkola and Samet 1999 ). Questionnaires can be used to characterize sources of exposures, such as smoking by parents. With air concentrations of markers and time-activity information, estimates of secondhand smoke exposures can be made with the microenvironmental model. Biomarkers provide exposure measures that reflect the patterns of exposure and the kinetics of the marker; the cotinine level in body fluids, for example, reflects an exposure during several days. Air monitoring may be useful for validating measurements of exposure. Exposure assessment strategies are matched to the research question and often employ a mixture of approaches determined by feasibility and cost constraints.

Misclassification of Secondhand Smoke Exposure

Misclassification may occur when classifying exposures, outcomes, confounding factors, or modifying factors. Misclassification may be differential on either exposure or outcome, or it may be random ( Armstrong et al. 1992 ). Differential or nonrandom misclassification may either increase or decrease estimates of effect, while random misclassification tends to reduce the apparent effect and weaken the relationship of exposure with disease risk. In studies of secondhand smoke and disease risk, exposure misclassification has been a major consideration in the interpretation of the evidence, although misclassification of health outcome measures has not been a substantial issue in this research. The consequences for epidemiologic studies of misclassification in general are well established ( Rothman and Greenland 1998 ).

An extensive body of literature on the classification of exposures to secondhand smoke is reviewed in this and other chapters, as well as in some publications on the consequences of misclassification ( Wu 1999 ). Two general patterns of exposure misclassification are of concern to secondhand smoke: (1) random misclassification that is not differential by the presence or absence of the health outcome and (2) systematic misclassification that is differential by the health outcome. In studying the health effects of secondhand smoke in adults, there is a further concern as to the classification of the active smoking status (never, current, or former smoking); in studies of children, the accuracy of secondhand smoke exposure classification is the primary methodologic issue around exposure assessment, but unreported active smoking by adolescents is also a concern.

With regard to random misclassification of secondhand smoke exposures, there is an inherent degree of unavoidable measurement error in the exposure measures used in epidemiologic studies. Questionnaires generally assess contact with sources of an exposure (e.g., smoking in the home or work-place) and cannot capture all exposures nor the intensity of exposures; biomarkers provide an exposure index for a particular time window and have intrinsic variability. Some building-related factors that determine an exposure cannot be assessed accurately by a questionnaire, such as the rate of air exchange and the size of the microenvironment where time is spent, nor can concentrations be assessed accurately by subjective reports of the perceived level of tobacco smoke. In general, random misclassification of exposures tends to reduce the likelihood that studies of secondhand smoke exposure will find an effect. This type of misclassification lessens the contrast between exposure groups, because some truly exposed persons are placed in the unexposed group and some truly unexposed persons are placed in the exposed group. Differential misclassification, also a concern, may increase or decrease associations, depending on the pattern of misreporting.

One particular form of misclassification has been raised with regard to secondhand smoke exposure and lung cancer: the classification of some current or former smokers as lifetime nonsmokers ( USEPA 1992 ; Lee and Forey 1995 ; Hackshaw et al. 1997 ; Wu 1999 ). The resulting bias would tend to increase the apparent association of secondhand smoke with lung cancer, if the misclassified active smokers are also more likely to be classified as involuntary smokers. Most studies of lung cancer and secondhand smoke have used spousal smoking as a main exposure variable. As smoking tends to aggregate between spouses (smokers are more likely to marry smokers), misclassification of active smoking would tend to be differential on the basis of spousal smoking (the exposure under investigation). Because active smoking is strongly associated with increased disease risk, greater misclassification of an actively smoking spouse as a non-smoker among spouses of smokers compared with spouses of nonsmokers would lead to risk estimates for spousal smoking that are biased upward by the effect of active smoking. This type of misclassification is also relevant to studies of spousal exposure and CHD risk or other diseases also caused by active smoking, although the potential for bias is less because the association of active smoking with CHD is not as strong as with lung cancer.

There have been a number of publications on this form of misclassification. Wu (1999) provides a review, and Lee and colleagues (2001) offer an assessment of potential consequences. A number of models have been developed to assess the extent of bias resulting from the misclassification of active smokers as lifetime nonsmokers ( USEPA 1992 ; Hackshaw et al. 1997 ). These models incorporate estimates of the rate of misclassification, the degree of aggregation of smokers by marriage, the prevalence of smoking in the population, and the risk of lung cancer in misclassified smokers ( Wu 1999 ). Although debate about this issue continues, analyses show that estimates of upward bias from misclassifying active smokers as lifetime nonsmokers cannot fully explain the observed increase in risk for lung cancer among lifetime non-smokers married to smokers ( Hackshaw et al. 1997 ; Wu 1999 ).

There is one additional issue related to exposure misclassification. During the time the epidemiologic studies of secondhand smoke have been carried out, exposure has been widespread and almost unavoidable. Therefore, the risk estimates may be biased downward because there are no truly unexposed persons. The 1986 Surgeon General’s report recognized this methodologic issue and noted the need for further data on population exposures to secondhand smoke ( USDHHS 1986 ). This bias was also recognized in the 1986 report of the NRC, and an adjustment for this misclassification was made to the lung cancer estimate ( NRC 1986 ). Similarly, the 1992 report of the EPA commented on background exposure and made an adjustment ( USEPA 1992 ). Some later studies have attempted to address this issue; for example, in a case-control study of active and involuntary smoking and breast cancer in Switzerland, Morabia and colleagues (2000) used a questionnaire to assess exposure and identified a small group of lifetime nonsmokers who also reported no exposure to secondhand smoke. With this subgroup of controls as the reference population, the risks of secondhand smoke exposure were substantially greater for active smoking than when the full control population was used.

This Surgeon General’s report further addresses specific issues of exposure misclassification when they are relevant to the health outcome under consideration.

Use of Meta-Analysis

Meta-analysis refers to the process of evaluating and combining a body of research literature that addresses a common question. Meta-analysis is composed of qualitative and quantitative components. The qualitative component involves the systematic identification of all relevant investigations, a systematic assessment of their characteristics and quality, and the decision to include or exclude studies based on predetermined criteria. Consideration can be directed toward sources of bias that might affect the findings. The quantitative component involves the calculation and display of study results on common scales and, if appropriate, the statistical combination of these results across studies and an exploration of the reasons for any heterogeneity of findings. Viewing the findings of all studies as a single plot provides insights into the consistency of results and the precision of the studies considered. Most meta-analyses are based on published summary results, although they are most powerful when applied to data at the level of individual participants. Meta-analysis is most widely used to synthesize evidence from randomized clinical trials, sometimes yielding findings that were not evident from the results of individual studies. Meta-analysis also has been used extensively to examine bodies of observational evidence.

Beginning with the 1986 NRC report, meta-analysis has been used to summarize the evidence on involuntary smoking and health. Meta-analysis was central to the 1992 EPA risk assessment of secondhand smoke, and a series of meta-analyses supported the conclusions of the 1998 report of the Scientific Committee on Tobacco and Health in the United Kingdom. The central role of meta-analysis in interpreting and applying the evidence related to involuntary smoking and disease has led to focused criticisms of the use of meta-analysis in this context. Several papers that acknowledged support from the tobacco industry have addressed the epidemiologic findings for lung cancer, including the selection and quality of the studies, the methods for meta-analysis, and dose-response associations ( Fleiss and Gross 1991 ; Tweedie and Mengersen 1995 ; Lee 1998 , 1999 ). In a lawsuit brought by the tobacco industry against the EPA, the 1998 decision handed down by Judge William L. Osteen, Sr., in the North Carolina Federal District Court criticized the approach EPA had used to select studies for its meta-analysis and criticized the use of 90 percent rather than 95 percent confidence intervals for the summary estimates ( Flue-Cured Tobacco Cooperative Stabilization Corp. v. United States Environmental Protection Agency , 857 F. Supp. 1137 [M.D.N.C. 1993]). In December 2002, the 4th U.S. Circuit Court of Appeals threw out the lawsuit on the basis that tobacco companies cannot sue the EPA over its secondhand smoke report because the report was not a final agency action and therefore not subject to court review ( Flue-Cured Tobacco Cooperative Stabilization Corp. v. The United States Environmental Protection Agency , No. 98–2407 [4th Cir., December 11, 2002], cited in 17.7 TPLR 2.472 [2003]).

Recognizing that there is still an active discussion around the use of meta-analysis to pool data from observational studies (versus clinical trials), the authors of this Surgeon General’s report used this methodology to summarize the available data when deemed appropriate and useful, even while recognizing that the uncertainty around the meta-analytic estimates may exceed the uncertainty indicated by conventional statistical indices, because of biases either within the observational studies or produced by the manner of their selection. However, a decision to not combine estimates might have produced conclusions that are far more uncertain than the data warrant because the review would have focused on individual study results without considering their overall pattern, and without allowing for a full accounting of different sample sizes and effect estimates.

The possibility of publication bias has been raised as a potential limitation to the interpretation of evidence on involuntary smoking and disease in general, and on lung cancer and secondhand smoke exposure specifically. A 1988 paper by Vandenbroucke used a descriptive approach, called a “funnel plot,” to assess the possibility that publication bias affected the 13 studies considered in a review by Wald and colleagues (1986) . This type of plot characterizes the relationship between the magnitude of estimates and their precision. Vandenbroucke suggested the possibility of publication bias only in reference to the studies of men. Bero and colleagues (1994) concluded that there had not been a publication bias against studies with statistically significant findings, nor against the publication of studies with nonsignificant or mixed findings in the research literature. The researchers were able to identify only five unpublished “negative” studies, of which two were dissertations that tend to be delayed in publication. A subsequent study by Misakian and Bero (1998) did find a delay in the publication of studies with nonsignificant results in comparison with studies having significant results; whether this pattern has varied over the several decades of research on secondhand smoke was not addressed. More recently, Copas and Shi (2000) assessed the 37 studies considered in the meta-analysis by Hackshaw and colleagues (1997) for publication bias. Copas and Shi (2000) found a significant correlation between the estimated risk of exposure and sample size, such that smaller studies tended to have higher values. This pattern suggests the possibility of publication bias. However, using a funnel plot of the same studies, Lubin (1999) found little evidence for publication bias.

On this issue of publication bias, it is critical to distinguish between indirect statistical arguments and arguments based on actual identification of previously unidentified research. The strongest case against substantive publication bias has been made by researchers who mounted intensive efforts to find the possibly missing studies; these efforts have yielded little nothing that would alter published conclusions ( Bero et al. 1994 ; Glantz 2000 ). Presumably because this exposure is a great public health concern, the findings of studies that do not have statistically significant outcomes continue to be published ( Kawachi and Colditz 1996 ).

The quantitative results of the meta-analyses, however, were not determinate in making causal inferences in this Surgeon General’s report. In particular, the level of statistical significance of estimates from the meta-analyses was not a predominant factor in making a causal conclusion. For that purpose, this report relied on the approach and criteria set out in the 1964 and 2004 reports of the Surgeon General, which involved judgments based on an array of quantitative and qualitative considerations that included the degree of heterogeneity in the designs of the studies that were examined. Sometimes this heterogeneity limits the inference from meta-analysis by weakening the rationale for pooling the study results. However, the availability of consistent evidence from heterogenous designs can strengthen the meta-analytic findings by making it unlikely that a common bias could persist across different study designs and populations.

Confounding

Confounding, which refers in this context to the mixing of the effect of another factor with that of secondhand smoke, has been proposed as an explanation for associations of secondhand smoke with adverse health consequences. Confounding occurs when the factor of interest (secondhand smoke) is associated in the data under consideration with another factor (the confounder) that, by itself, increases the risk for the disease ( Rothman and Greenland 1998 ). Correlates of secondhand smoke exposures are not confounding factors unless an exposure to them increases the risk of disease. A factor proposed as a potential confounder is not necessarily an actual confounder unless it fulfills the two elements of the definition. Although lengthy lists of potential confounding factors have been offered as alternatives to direct associations of secondhand smoke exposures with the risk for disease, the factors on these lists generally have not been shown to be confounding in the particular data of interest.

The term confounding also conveys an implicit conceptualization as to the causal pathways that link secondhand smoke and the confounding factor to disease risk. Confounding implies that the confounding factor has an effect on risk that is independent of secondhand smoke exposure. Some factors considered as potential confounders may, however, be in the same causal pathway as a secondhand smoke exposure. Although socioeconomic status (SES) is often cited as a potential confounding factor, it may not have an independent effect but can affect disease risk through its association with secondhand smoke exposure ( Figure 1.2 ). This figure shows general alternative relationships among SES, secondhand smoke exposure, and risk for an adverse effect. SES may have a direct effect, or it may indirectly exert its effect through an association with secondhand smoke exposure, or it may confound the relationship between secondhand smoke exposure and disease risk. To control for SES as a potential confounding factor without considering underlying relationships may lead to incorrect risk estimates. For example, controlling for SES would not be appropriate if it is a determinant of secondhand smoke exposure but has no direct effect.

Model for socioeconomic status (SES) and secondhand smoke (SHS) exposure. Arrows indicate directionality of association.

Nonetheless, because the health effects of involuntary smoking have other causes, the possibility of confounding needs careful exploration when assessing associations of secondhand smoke exposure with adverse health effects. In addition, survey data from the last several decades show that secondhand smoke exposure is associated with correlates of lifestyle that may influence the risk for some health effects, thus increasing concerns for the possibility of confounding ( Kawachi and Colditz 1996 ). Survey data from the United States ( Matanoski et al. 1995 ) and the United Kingdom ( Thornton et al. 1994 ) show that adults with secondhand smoke exposures generally tend to have less healthful lifestyles. However, the extent to which these patterns of association can be generalized, either to other countries or to the past, is uncertain.

The potential bias from confounding varies with the association of the confounder to secondhand smoke exposures in a particular study and to the strength of the confounder as a risk factor. The importance of confounding to the interpretation of evidence depends further on the magnitude of the effect of secondhand smoke on disease. As the strength of an association lessens, confounding as an alternative explanation for an association becomes an increasing concern. In prior reviews, confounding has been addressed either quantitatively ( Hackshaw et al. 1997 ) or qualitatively ( Cal/EPA 1997 ; Thun et al. 1999 ). In the chapters in this report that focus on specific diseases, confounding is specifically addressed in the context of potential confounding factors for the particular diseases.

• Tobacco Industry Activities

The evidence on secondhand smoke and disease risk, given the public health and public policy implications, has been reviewed extensively in the published peer-reviewed literature and in evaluations by a number of expert panels. In addition, the evidence has been criticized repeatedly by the tobacco industry and its consultants in venues that have included the peer-reviewed literature, public meetings and hearings, and scientific symposia that included symposia sponsored by the industry. Open criticism in the peer-reviewed literature can strengthen the credibility of scientific evidence by challenging researchers to consider the arguments proposed by critics and to rebut them.

Industry documents indicate that the tobacco industry has engaged in widespread activities, however, that have gone beyond the bounds of accepted scientific practice ( Glantz 1996 ; Ong and Glantz 2000 , 2001 ; Rampton and Stauber 2000 ; Yach and Bialous 2001 ; Hong and Bero 2002 ; Diethelm et al. 2004 ). Through a variety of organized tactics, the industry has attempted to undermine the credibility of the scientific evidence on secondhand smoke. The industry has funded or carried out research that has been judged to be biased, supported scientists to generate letters to editors that criticized research publications, attempted to undermine the findings of key studies, assisted in establishing a scientific society with a journal, and attempted to sustain controversy even as the scientific community reached consensus ( Garne et al. 2005 ). These tactics are not a topic of this report, but to the extent that the scientific literature has been distorted, they are addressed as the evidence is reviewed. This report does not specifically identify tobacco industry sponsorship of publications unless that information is relevant to the interpretation of the findings and conclusions.

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Essay on Teenage Smoking

Students are often asked to write an essay on Teenage Smoking in their schools and colleges. And if you’re also looking for the same, we have created 100-word, 250-word, and 500-word essays on the topic.

Let’s take a look…

100 Words Essay on Teenage Smoking

What is teenage smoking.

Teenage smoking means when young people, usually between 13 and 19 years old, start to smoke cigarettes. It is a big problem because it can harm their health very badly. Smoking can cause diseases like cancer and heart problems.

Why Do Teenagers Start Smoking?

Many teenagers start smoking because they see their friends doing it or they think it makes them look cool. Sometimes, they are under a lot of stress and think smoking will help them relax.

Effects of Smoking on Teenagers

Smoking can make teenagers sick. It can reduce their lung function and make it hard for them to breathe. It also increases the risk of getting sick with diseases like bronchitis and pneumonia.

Stopping Teenage Smoking

To stop teenagers from smoking, adults should talk to them about the dangers of smoking. Schools can also help by teaching students about the risks of smoking and how to say no to cigarettes.

250 Words Essay on Teenage Smoking

One main reason teenagers start smoking is peer pressure. They see their friends doing it and don’t want to feel left out. Some teenagers think smoking makes them look cool or grown-up. Others might start smoking because they are curious or because they see family members smoking.

Smoking is very harmful to anyone’s health, but it is especially bad for teenagers because their bodies are still growing. Smoking can lead to serious health problems like lung cancer, heart disease, and breathing problems. It also affects how they look, causing bad breath, yellow teeth, and a greater risk of getting sick.

Stopping teenage smoking is important. Parents, teachers, and communities can help by teaching teenagers about the dangers of smoking. They can also set a good example by not smoking themselves. Programs that encourage teenagers to stay away from cigarettes and offer support to those who want to quit are also very helpful.

In conclusion, teenage smoking is a problem that affects the health and future of young people. By understanding why teenagers start smoking and the effects it has, we can work together to help stop it.

500 Words Essay on Teenage Smoking

Teenage smoking: a grave threat to young lives.

Smoking among teenagers has become a pressing concern, posing significant risks to their health and overall well-being. It’s crucial to understand the harmful effects of smoking and take proactive measures to prevent and discourage teenagers from engaging in this dangerous habit.

Health Hazards of Teenage Smoking

Negative impact on physical development.

Smoking interferes with the normal growth and development of teenagers. It can stunt their physical growth, delay puberty, and weaken their immune system, making them more susceptible to illnesses. Smoking also affects bone health, increasing the risk of osteoporosis in later life.

Social and Psychological Effects

Teenage smoking has detrimental social and psychological consequences. It can lead to isolation, peer pressure, and impaired social skills. Smokers are more likely to engage in risky behaviors, such as alcohol consumption and drug abuse. Moreover, smoking can negatively impact academic performance, concentration, and memory.

Preventing Teenage Smoking

Teenage smoking is a serious public health issue that demands immediate attention. It’s essential to raise awareness about the harmful effects of smoking and empower teenagers with the knowledge and skills to resist tobacco use. By working together, we can create a smoke-free environment for our youth, ensuring their health and well-being for a brighter future.

That’s it! I hope the essay helped you.

Happy studying!

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Are you wondering how to write your next persuasive essay about smoking?

Smoking has been one of the most controversial topics in our society for years. It is associated with many health risks and can be seen as a danger to both individuals and communities.

Writing an effective persuasive essay about smoking can help sway public opinion. It can also encourage people to make healthier choices and stop smoking. 

But where do you begin?

In this blog, we’ll provide some examples to get you started. So read on to get inspired!

• 1. What You Need To Know About Persuasive Essay
• 2. Persuasive Essay Examples About Smoking
• 3. Argumentative Essay About Smoking Examples
• 4. Tips for Writing a Persuasive Essay About Smoking

What You Need To Know About Persuasive Essay

A persuasive essay is a type of writing that aims to convince its readers to take a certain stance or action. It often uses logical arguments and evidence to back up its argument in order to persuade readers.

It also utilizes rhetorical techniques such as ethos, pathos, and logos to make the argument more convincing. In other words, persuasive essays use facts and evidence as well as emotion to make their points.

A persuasive essay about smoking would use these techniques to convince its readers about any point about smoking. Check out an example below:

Simple persuasive essay about smoking

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Persuasive Essay Examples About Smoking

Smoking is one of the leading causes of preventable death in the world. It leads to adverse health effects, including lung cancer, heart disease, and damage to the respiratory tract. However, the number of people who smoke cigarettes has been on the rise globally.

A lot has been written on topics related to the effects of smoking. Reading essays about it can help you get an idea of what makes a good persuasive essay.

Here are some sample persuasive essays about smoking that you can use as inspiration for your own writing:

Persuasive speech on smoking outline

Persuasive essay about smoking should be banned

Persuasive essay about smoking pdf

Persuasive essay about smoking cannot relieve stress

Persuasive essay about smoking in public places

Speech about smoking is dangerous

Persuasive Essay About Smoking Introduction

Persuasive Essay About Stop Smoking

Short Persuasive Essay About Smoking

Stop Smoking Persuasive Speech

Check out some more persuasive essay examples on various other topics.

Argumentative Essay About Smoking Examples

An argumentative essay is a type of essay that uses facts and logical arguments to back up a point. It is similar to a persuasive essay but differs in that it utilizes more evidence than emotion.

If you’re looking to write an argumentative essay about smoking, here are some examples to get you started on the arguments of why you should not smoke.

Argumentative essay about smoking pdf

Argumentative essay about smoking in public places

Argumentative essay about smoking introduction

Check out the video below to find useful arguments against smoking:

Tips for Writing a Persuasive Essay About Smoking

You have read some examples of persuasive and argumentative essays about smoking. Now here are some tips that will help you craft a powerful essay on this topic.

Choose a Specific Angle

Select a particular perspective on the issue that you can use to form your argument. When talking about smoking, you can focus on any aspect such as the health risks, economic costs, or environmental impact.

Think about how you want to approach the topic. For instance, you could write about why smoking should be banned. 

Check out the list of persuasive essay topics to help you while you are thinking of an angle to choose!

Research the Facts

Before writing your essay, make sure to research the facts about smoking. This will give you reliable information to use in your arguments and evidence for why people should avoid smoking.

You can find and use credible data and information from reputable sources such as government websites, health organizations, and scientific studies. 

For instance, you should gather facts about health issues and negative effects of tobacco if arguing against smoking. Moreover, you should use and cite sources carefully.

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Make an Outline

The next step is to create an outline for your essay. This will help you organize your thoughts and make sure that all the points in your essay flow together logically.

Your outline should include the introduction, body paragraphs, and conclusion. This will help ensure that your essay has a clear structure and argument.

Use Persuasive Language

When writing your essay, make sure to use persuasive language such as “it is necessary” or “people must be aware”. This will help you convey your message more effectively and emphasize the importance of your point.

Also, don’t forget to use rhetorical devices such as ethos, pathos, and logos to make your arguments more convincing. That is, you should incorporate emotion, personal experience, and logic into your arguments.

Introduce Opposing Arguments

Another important tip when writing a persuasive essay on smoking is to introduce opposing arguments. It will show that you are aware of the counterarguments and can provide evidence to refute them. This will help you strengthen your argument.

By doing this, your essay will come off as more balanced and objective, making it more convincing.

Finish Strong

Finally, make sure to finish your essay with a powerful conclusion. This will help you leave a lasting impression on your readers and reinforce the main points of your argument. You can end by summarizing the key points or giving some advice to the reader.

A powerful conclusion could either include food for thought or a call to action. So be sure to use persuasive language and make your conclusion strong.

To conclude,

By following these tips, you can write an effective and persuasive essay on smoking. Remember to research the facts, create an outline, and use persuasive language.

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Keep reading

Conclusion of Smoking Should Be Banned on College Campuses Essay

• To find inspiration for your paper and overcome writer’s block
• As a source of information (ensure proper referencing)
• As a template for you assignment

Introduction

Arguments in favor of smoking in campus, arguments against smoking in campus, reconciliation of the two positions, campus smoking: conclusion of the essay, works cited.

The idea of smoking in colleges and campuses has developed a mixed reaction in the USA and in many other parts of the world such that it has posed a very hot and contentious universal debate.

Several campuses and colleges have tried to impose a total ban on smoking within their environs, some of them succeeding while others failing to do so. For instance, colleges like Santa Ana and Fullerton have managed to ban smoking completely within their environs, while others such as Huntington Beach and Golden West College still allow smoking in prescribed places such as in parking lots.

Fullerton College was the first to successfully impose a smoking ban in the year 2007 (Bates 57). Nevertheless, many colleges and campuses have not managed to follow suit because of some state laws which assert that smoking is only proscribed inside buildings and within 20 feet from entry points of buildings in all campuses. These laws continue to give students the right to smoke within certain areas of their campuses.

As aforementioned, section 7595 of the government code affirms that smoking is proscribed only in public buildings and within 20 feet from entry points of buildings in all campuses (Merrill 36).Therefore, the opponents of this subject believe that since it is the right of every citizen to do anything that is recognized as legal, it is very wrong to impose a total ban on smoking, especially in campuses.

The most important thing is to ensure that students follow the laid down rules and regulations such as the strict use of the recommended areas of smoking. In deed, it is very unfair to send students off campus to smoke.

In addition, the opponents of this argument believe that smoking should not be banned because it helps students to relax whenever they are in stressful situations. Concerning the health risks that are brought about by smoking, they assert that every mature citizen should be in a position to separate good behavior from wrong behavior.

They say that since there has been an integration of cigarette smoking topics in schools for several decades, by the time a student reaches campus, he/she must be in a position to understand the risks that cigarette smoking poses to their health and therefore they should be able to make informed decisions about smoking. They also argue that it is very unfair to impose an immediate ban on cigarette smoking in campus yet it is clearly understood that smoking is an additive activity which can not be stopped at once.

Even though campus students have the right to smoke within some prescribed areas whenever they wish to do so, as mandated by some state laws, they ought to realize the fact that cigarette smoking has got very serious and detrimental effects on human health. Smoking of cigarettes can bring about lung infections to both first-hand and second-hand smokers. Therefore, smokers need to recognize that their right to smoke may greatly infringe on the rights of their non-smoking counterparts.

It is obvious that students know the negative effects of smoking cigarettes. For instance, it is expensive for them and it may also reduce their lifetime. Generally speaking, cigarette smoking is just bad. Currently, at least forty three colleges in the USA have imposed a total ban on cigarette smoking in their campuses and this trend is increasing especially among commuter schools and community colleges (Merrill 40).

However, it is hard to impose such a ban in some colleges because of the mixed reactions that are held by different stakeholders about the issue of smoking, and the existing campus policies which give the smokers the right to smoke in prescribed areas. According to the research that was carried out by the U.S. Department of Health and Human services, 31% of college students smoke cigarettes. This figure exceeds the national general average of 25% (Longmire 15).

It is also worth to note that even though there has been an integration of cigarette smoking topics in schools for several decades, cigarette smoking has continued to attract many youths and this continues to raise a lot of alarm about their future. This is because cigarette smoking is the major contributor of the cases of lung cancer in the entire world.

Research indicates that close to eighty percent of men who die from lung cancer, and seventy five percent of women who die from the same disease do so because of smoking tobacco. Research also indicates that the risk of lung cancer increases when a person starts smoking at an early age, and with an increase in the number of cigarettes that a person smokes in a day (Robicsek 56).

Scientific research has proved that cigarette smoking is harmful to the body. The smoke that comes out of a burning cigarette is a compound mixture of several chemicals which are produced when tobacco is burned.

This smoke contains a deadly compound called tar, which consists of more than four thousand chemicals which are very poisonous, and a majority of them have been clearly identified to be the main cause of cancer. Most of these chemicals are also known to cause lung diseases and heart problems. Some of these chemicals include cyanide, benzene, methanol, ammonia, formaldehyde and acetylene (Merrill 45).

Other deadly substances that are found in cigarettes include carbon monoxide and nitrogen oxide gases which are very poisonous. The most active component of a cigarette is nicotine. Nicotine is a very addictive compound. Cigarette smoking can cause several problems such as cancer, lung damage and heart infections among many other diseases.

Research also indicates that more than thirty percent of the deaths that result in the United States occur due to the use of tobacco. Cigarette smoking also causes eighty seven percent of the deaths that result due to lung cancer. Other types of tobacco-related cancers include mouth cancer, cancer of the larynx, cancer of the throat and esophagus and cancer of the bladder. There is also a very close connection between cigarette smoking and the occurrence of the cancers of the kidney, pancreas, stomach and the cervix.

Cigarette smoking can also cause lung damage which begins at the early stages of smoking. Cigarette smokers encounter many problems with their lungs as compared to non-smokers and this situation gets worse when an individual increases his/her capacity to smoke. Smoking is linked to many dangerous lung infections which are just as perilous as lung cancer. These infections include emphysema and chronic bronchitis which cause difficulties in breathing and may even cause death.

Cigarette smoking also augments the risk of heart infections which stand out as the major causes of deaths in the U.S. Out of all the risk factors of heart infections, i.e. excess cholesterol, diabetes, obesity, cigarette smoking, physical lethargy and high blood pressure, cigarette smoking remains the leading risk factor for impulsive deaths that result from heart attacks (Bates 78).

In addition, low levels of cigarette smoking which may not be able to cause lung infections are capable of damaging the heart. Therefore, second-hand smokers also stand a very high chance of getting heart infections.

As stated earlier, Section 7595 of the government code affirms that smoking is proscribed in all public buildings and within 20 feet from entry points of buildings in all campuses (Merrill 36). Even though this ruling is good, it is not sufficient because it seems to discriminate the innocent second-hand smokers who continue to suffer from cigarette smoke which pollutes the air around them.

Cigarette smoking has also very detrimental effects to the real smokers and therefore they should be able to accept this ban because it is meant for their own good. Though it is very hard to ban citizens from doing something which is legally right, smoking should be gradually banned in campuses so as to protect the non-smokers. This is because campuses are public places which consist of both smokers and non-smokers.

My stand on this issue differs significantly from my opponents who believe that smoking should be allowed in some prescribed areas in campuses. My stand is that cigarette smoking should be banned in campuses because it impacts negatively on the non-smokers. Banning of cigarette smoking in campuses would enable the non-smoking citizens to enjoy the delight of breathing unpolluted air.

Nevertheless, my stand does not include cigarette smoking in private places such as in homes. At the same time, cigarette smokers should understand that the non-smokers are not trying to be intolerant when they keep on complaining about them. Rather, they are doing it for the sake of their own health.

In conclusion, smoking should be totally banned in campuses and colleges because of its severe health risks to both smokers and non-smokers. The health risks are much more to non-smokers because they may double up especially to those who already suffer from other ailments such as heart and lung problems.

In addition, a very short exposure by a non-smoker to secondhand smoke may have abrupt severe effects on his/her cardiovascular system thus escalating the risk for lung and heart infections. This makes the non-smoker to have a higher risk of catching infections from cigarette smoke than the real smoker yet he/she is very innocent. A more effective way of reducing smoking in campuses would be to provide tobacco termination counseling programs in the campuses.

Bates, Tim & Gordon Mangan. Smoking and Raven IQ. New York: Pocket Books, 2007.

Longmire, Wilkinson, & Torok Edgar. Oxford Handbook of Clinical Medicine. Oxford: Oxford University Press, 2006.

Melo, Maurice. Cigarette Smoking and Reproductive Function. Oxford: Oxford University Press, 2009.

Merrill, David. How Cigarettes are made. London: Oxford University Press, 2000.

Robicsek, Francis. Ritual Smoking in Central America. Cambridge: Cambridge University Press, 2008.

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Teenage Smoking Essay: Writing Guide & Smoking Essay Topics

Smoking can be viewed as one of the trendy habits. Numerous teenagers try it since they think that it is cool or can help them socialize. Often students start smoking due to stress or mental illnesses. But is it okay?

Educators tend to give different written assignments, which may disclose this topic. If you have to develop a teenage smoking essay, you should learn the effects and harm that this habit causes.

That’s when our Custom-writing.org writers can help you!In the article, you’ll see how to deal with writing about smoking students. We’ve gathered tips for different paper types and prompts that can inspire you to start. In the end, you’ll find some smoking essay topics as well.

• 🚬 Argumentative
• 📈 Cause and Effect
• 🚭 Persuasive
• 🔥 Topics & Prompts

🔗 References

✍️ how to write a teenage smoking essay.

Just like any other academic paper, a teen smoking essay should be organized according to its type. You are probably familiar with the following writing ones:

• argumentative essay;
• cause and effect essay;
• persuasive essay.

Below, you can find insightful tips on how to compose a teenage smoking essay, fulfilling the requirements of each type.

🚬 Argumentative Essay on Smoking

An argumentative essay on teenage smoking should give the reader a rational discussion of a specific issue. The ideas are expected to be well-structured and solidified with valid evidence.

Below, you can find the most useful tips for writing an argumentative teen smoking essay. Don’t hesitate to use them!

• Catch the reader’s attention. In the introduction, explain the significance and relatability of the chosen issue. Provide general background and make the reader continue exploring your essay through attention-grabbing elements (impressive statistics, personal stories, etc.).
• Express your position clearly. Compose a concise thesis statement , so the reader can quickly get your position. Be as precise as possible! For example, your thesis might look like this: Teenage smoking leads to poor health, psychological and social issues.
• The most vivid adverse ramification of teenage smoking is the development of health problems like heart or lung diseases and cancer.
• Another disruptive effect of smoking at a young age is the risk of psychological disorders such as anxiety or depression.
• The last negative consequence of teenage smoking is the conflict with social norms.
• Support your arguments. Your ideas will become stronger if you support them with proof from other sources. But be careful here! Use only reliable sources (academic journals, scholarly articles, books, etc.).
• Finish your essay dynamically. In your essay conclusion, restate your thesis statement and synthesize all of your arguments. Motivate your readers on further investigation of your topic. To make your paper even more impressive, finish it with the final memorable thought that would be stuck in your readers’ minds.

📈 Cause and Effect Essay on Smoking

A cause and effect of the teenage smoking essay should answer two questions:

• Why do teenagers smoke? (Causes).
• What are the consequences of teenage smoking? (Effects).

How to create an excellent cause and effect paper? You can start by checking successful teen smoking essay examples. Then, learn some useful tips here:

• Get an idea. The first step of creating a causes effects of teenage smoking essay is brainstorming topics. Think of the common reasons for teens smoking and analyze the possible outcomes. Here are some ideas for you:

• Outline your paper. This step helps structure your ideas properly. Create a well-organized plan and add there all the proof and examples. Make sure that everything is logical, and start writing your teenage smoking essay.
• Form a clear thesis. In your thesis statement, state your position and introduce the chosen cause and effect of smoking. Here is an example of the thesis for this type of smoking among teenagers essay: Caused by peer pressure, smoking negatively affects teenagers’ health and appearance.
• The key cause of teenage nicotine addiction is peer pressure and the fear of becoming an outsider among the friends-smokers.
• One of the detrimental effects of cigarettes on teenagers is health problems.
• Another adverse consequence of teenage smoking is negative changes in appearance .
• Polish your piece of writing. After you finished your first draft, revise and edit your essay. Ensure the absence of grammar and punctuation mistakes and double-check if your paper is coherent.

🚭 Persuasive Essay on Smoking

A persuasive essay about teenage smoking resembles an argumentative one but has a different purpose. Here, you have to convince your reader in your opinion, using evidence and facts. Moreover, in some papers, you have to call your reader to action. For example, to quit or ban smoking . So, see how to do so:

• Grab the reader’s attention. To do so, you should know your audience and their preferences. Start your smoking essay by proving to the reader your credibility and the significance of your topic. For example, if you are writing about smoking students, introduce the shocking statistics at the beginning of your paper and convince them to stop smoking.
• Show your empathy. An emotional appeal is a powerful tool for gaining the readers’ trust and influencing their opinions. Demonstrate that you understand their emotions and, at the same time, convince them to change their beliefs. To make it more clear, see an example: Although smoking might help teenagers be on the same wavelength as their friends, nicotine has a detrimental effect on health and leads to cancer development.
• Include rhetoric questions. This is a useful persuasive trick that makes readers change their minds. For instance, in your smoking essay, you may ask this question: Smoking helps me to relieve stress, but will I be able to overcome lung cancer later?
• Highlight your position. In a persuasive essay, you should be incredibly convincing. So, don’t be afraid of exaggeration or even repeating yourself. These tricks may help you to deliver your message to the reader more quickly and effectively.

You have a lot of ways of creating fantastic teen smoking essays. You should just turn around and gather material. Sometimes it lies near your foot.

To smoke or not to smoke? – This is the question! You should decide what is for you: To be yourself or follow the fashion! It is not difficult to do!

🔥 Smoking Essay Topics

Do you know what the critical secret of a successful essay is? A well-chosen topic!

If you find something you are passionate about, your essay writing process will be much easier. So, take a look at our smoking essay topics. Select one of them or use some to come up with your idea.

• Smoking among teenagers: an exaggerated problem or a real threat to the generation?
• The influence of nicotine on teenagers’ brain activity.
• How smoking parents develop smoking habits in their children.
• Vaping: a healthier alternative to regular cigarettes or just another dangerous teenagers’ passion?
• Is smoking still a problem among teenagers today – an essay to highlight the issue of cigarette addiction.
• The danger of smoking for immature teenagers’ organisms.
• If smoking in public places was banned, teenagers would be predisposed to cigarettes less.
• Social problems caused by teenage smoking.
• The role of parents in dealing with teenage cigarette addiction.
• Useful tips to stop smoking.
• Why teenagers are influenced by peer pressure , and how to overcome it.
• Teenage smoking: a matter of real nicotine addiction or a case of psychological processes inside immature minds?
• The danger of smoking and second-hand smoke.
• Is e-cigarette a threat or solution?
• Analyze the connection between vaping and dental health.
• Is it necessary to ban cigarette manufacturers?
• Is it possible to prevent teenagers from smoking using anti-smoking posters?
• What are the best ways to persuade young adults to stop smoking?
• Discuss the possibility of the global ban on tobacco and its potential outcomes.
• Pros and cons of anti-smoking adverts.
• Explore the connection between smoking cessation and depression .
• Describe the link between smoking and heart disease.
• Explain how smoking cessation can improve teenagers’ life.
• How to reduce smoking among youth.
• What are the different types of cigarette smokers?
• Analyze the challenges of each stage of smoking cessation and how to overcome them.
• Is smoking an effective method of weight control?
• Discuss the impact of smoke on health of primary and secondary smokers.
• Do you support the idea of lowering the smoking age in the USA?
• Effect of tobacco use on our body.
• Explore the efficiency of the acupuncture method for smoking cessation.
• Will the complete prohibition of smoking in cities help to preserve teenagers’ health?
• Examine how smoking in movies influences teenagers’ desire to start smoking.
• Are nicotine replacement medications necessary for successful smoking cessation?
• Reasons to prohibit tobacco products and cigarettes.
• Describe the reasons that prevent teenagers from smoking cessation.
• Analyze the public image of smoking in the USA.
• Discuss the issues connected with the smoking ban.
• Antismoking ads and their influence on youth smoking prevalence.
• What factors determine the success of anti-smoking persuasive campaigns among teenagers?
• Explore the impact of smoking on teenagers’ physical and mental health.
• What can you do to motivate your teenage friend to quit smoking?
• Why do teenagers start smoking?
• Analyze the rates of tobacco smoking among adolescents.
• Compare the peculiarities of smoking cessation methods and motivation for teenagers and adolescents.
• Examine whether raising cigarette pricing is an effective way to lower smoking rates.

Teenage Smoking Essay Prompts

Here are some writing prompts that you can use for your smoking essay:

• What does the data on smoking in different countries say? Compare the age limitations for smoking, attitude to smoking in America and Europe, for example. Where the situation is worst, whether the government tries to fight against this, etc.
• The distribution of cigarettes and other types of tobacco. Is it okay that tobacco machines are available all over the world (especially in Europe)? Any child can buy a cigarette and start smoking. You could investigate this problem in your teen smoking essays.
• Opinion essay: present your ideas and attitude to smoking. Explain whether you like to see people smoking around you, or you cannot stand when people are gazing at you while you are smoking.
• How does media influence teens’ decision-making? When teenagers see their favorite characters getting pleasure from smoking, they may want to try it. Is it a reason to start? In what other ways does mass media affect the problem?

Effects of Teenage Smoking Essay Prompt

Smoking among teenagers is a serious problem that has long-term consequences for their physical and mental health. In your essay, you can dwell on the following ideas:

• Analyze the health consequences of tobacco use among young people. In your paper, you can study how tobacco affects youths’ health. Focus on the most widespread problems, such as heart and lung diseases, cancer risk, and others.
• Estimate the role of smoking in promoting antisocial behavior among teenagers . Does smoking really encourage aggression and vandalism among teenagers? Use psychological theories and recent research findings to prove your point.
• Explain why teenage smoking is associated with an increased risk of suicidal thoughts and urges. To prove your point, you may discuss how nicotine causes depression and neurotransmitter imbalances. Make sure to illustrate your essay with relevant studies and statistical data.
• Investigate the economic and social consequences of smoking among young people. Besides high cigarette prices, you can consider lost productivity and healthcare costs. Additionally, write about social issues, such as stigmatization and reduced life opportunities.

Smoking in School Essay Prompt

Despite the implementation of smoke-free policies, a large percentage of teenagers start smoking during their school years. You can write an essay advocating for more effective initiatives to address not only students’ access to cigarettes but also the core causes of teen smoking.

Check out some more ideas for your “Smoking in School” essay:

• Explain why educators should prohibit smoking on school grounds. Smoking is a dangerous habit that damages students’ health and the overall school environment. Even secondhand smoke exposure has harmful consequences. Your essay could provide evidence that proves the effectiveness of smoke-free policies in reducing teenage smoking rates and improving general well-being.
• Analyze the effectiveness of school smoking policies in your educational institution. What smoking policies are accepted in your school? Do students comply with them? What disciplinary measures are used? Use student surveys and disciplinary records to prove the effectiveness or ineffectiveness of current policies.
• Describe the issue of smoking in schools in your country. Answer the questions: how widespread is this problem? How does it manifest itself? What causes smoking in schools, and how do schools fight it?
• Investigate the role of schools in reducing youth smoking. How can schools prevent and reduce smoking among students? Are their programs and campaigns effective? What can families and communities do to support schools in their efforts? Study these questions in your essay.

Peer Pressure Smoking Essay Prompt

Peer pressure is a common reason why teenagers start smoking. Friends, romantic attachments, or other social circles — all have significant effects on teens’ smoking intentions and possible tobacco addiction.

Here are some practical ideas that can help you highlight the role of peer pressure in teenage smoking :

• Analyze why adolescents tend to be powerful in influencing their friends to start smoking. Peer pressure often impacts teenagers’ decisions more than parents’ disapproval. To explain this phenomenon, you can examine theories like social contagion and recent studies on peer dynamics.
• Provide your own experience of resisting peer pressure to smoke. Have you ever faced peer pressure inducing you to smoke? What helped you to withstand? Try to share some advice for students in a similar situation.
• Investigate how social media can amplify peer pressure through online portrayals of smoking as glamorous. We recommend studying images, videos, advertisements, and influencers that depict smoking as stylish and sophisticated. What can be done to prevent smoking glamorization on social media?
• Estimate the role of peers in normalizing smoking behavior. Peer influence is more than just direct pressure. Your essay could explain how factors like observational learning and group identity induce teenagers to smoke.

Causes of Smoking Essay Prompt

There are many reasons why people start smoking, ranging from simple curiosity to complicated social and psychological factors, including anxiety, low self-esteem, and domestic violence.

Check out several ideas for an essay about the causes of smoking:

• Analyze tobacco or e-cigarette ads that emphasize weight control benefits and explain how these ads encourage teenagers to smoke. Your paper may discuss how tobacco and e-cigarette companies make use of teenagers’ insecurities and social norms regarding body image. Include studies that prove the impact of advertising on youths’ behavior.
• Explore why the rising popularity of fashionable electronic “vaping” devices is one of the key causes of teen smoking. Why is vaping so popular among teenagers? How does it appeal to youths’ preferences and lifestyles? What role do sleek design and social media influence play in the devices’ popularity? Answer the questions in your paper.
• Describe your or your friend’s experience that forced you to try cigarettes. Have you or your friend ever tried smoking? Share your story in your essay. Reflect on the circumstances and emotions involved. What conclusions did you make from the experience?

Smoking Is Bad for Health Essay Prompt

Cigarette smoking impacts nearly every organ in the body, causes a variety of diseases, and worsens smokers’ overall health.

In your essay, you can expand on the following ideas to show the severe consequences of smoking on human well-being:

• Analyze why cigarette smoking is the leading cause of preventable death in the United States. Here, you can examine factors like addiction and chronic diseases cigarettes provoke. Add statistical data and emphasize the preventable nature of smoking-related illnesses and deaths.
• Examine passive smoking as a serious threat to health, especially for children, pregnant women, and people with chronic diseases. Your essay could analyze research and case studies proving that secondhand smoke is as dangerous to human health as smoking itself. Underline its harm to vulnerable populations, such as children, pregnant women, and people with chronic diseases.
• Investigate the impact of cigarettes on mental health, including their contribution to the development of depression and anxiety. In this paper, you can examine nicotine’s effect on neurotransmitters involved in mood regulation, such as dopamine and serotonin. Support your point with evidence from peer-reviewed studies.
• Research the possible diseases that smoking can provoke, including cancer, cardiovascular diseases, and respiratory illnesses. How does smoking contribute to the development and progress of these diseases? Use epidemiological data and medical research to answer this question.

Is Smoking Still a Problem Among Teenagers: Argumentative Essay Prompt

According to the CDC, in 2023, 1 out of every 100 middle school students and nearly 2 out of every 100 high school students had smoked cigarettes in the past 30 days . Public health experts are especially concerned about e-cigarettes since flavorings in tobacco products can make cigarettes more appealing to teenagers.

To evaluate the current situation with smoking among teens, dwell on the following ideas in your essay:

• Analyze your country’s or world’s statistics on teen smoking in recent decades. Do you see any changes? Why did they happen? What do these changes mean in terms of public health? Examine these questions in your essay.
• Describe your own observations of teenagers’ smoking habits. Contrast what you witnessed in the past with the current situation. Do you think teenagers’ smoking habits changed? What makes you think so? Provide real-life examples to back up your opinion.
• Examine data on e-cigarette use among teenagers. Your essay could compare ordinary cigarette smoking and e-cigarette use trends among teenagers. Which type prevails, and why? What impact does it have on teenagers’ health? What can be done to lower smoking and vaping rates among teenagers?

Thanks for reading till the end! Make sure to leave your opinion about the article below. Send it to your friends who may need our tips.

You might also be interested in:

• Family Values Essay: How to Write, Essay Topics & Examples
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• Essay about Cars: Tips, Ideas, and Best Car Topics to Write about
• Subjective Essay: Example, How to Write and Topics
• How to Write an Opinion Essay: an Ultimate Guide + Examples
• How to Write an Argumentative Essay Step by Step: Virginia Kearney, Owlcation, Education
• Teen Smoking Essay: Bartleby
• Persuasive Essay Outline: Houston Community College System
• Definition and Examples of Cause and Effect in Essays: Richard Nordquist, ThoughtCo
• Teenage Smoking Essay: Cram
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Home — Essay Samples — Nursing & Health — Smoking — The Effects of Smoking on Your Body

The Effects of Smoking on Your Body

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Clearing the Smoke: Assessing the Science Base for Tobacco Harm Reduction (2001)

Chapter: 8 principal conclusions.

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8 Principal Conclusions he science base for assessing tobacco harm reduction is incomplete. T Nonetheless, the presence of potential reduced-exposure products (PREPs) on the market suggests an urgent need for proactive plans to evaluate the potential risks and benefits. The potential for reduction in morbidity and mortality that could result from the use of less toxic prod- ucts by those who do not stop using tobacco justifies inclusion of harm reduction as a component in a broad program of tobacco control. To date there are two general types of PREPs: pharmaceuticals and modified to- bacco products. The pharmaceuticals include, for example, nicotine re- placement therapy (NRT) and bupropion, while modified tobacco prod- ucts include products with modified tobacco and those with modified delivery systems. Having identified conceptual and operating precepts as stated at the end of Chapter 1, the committee concludes that there can be a successful, scientifically-based harm reduction program that is justifiable and fea- sible—but only if implemented carefully and effectively and only if: • manufacturers have the necessary incentive to develop and market products that reduce exposure to tobacco toxicants and that have a reasonable prospect of reducing the risk of tobacco-related disease; • consumers are fully and accurately informed of all of the known, unknown, likely, and potential consequences of using these prod- ucts; 231 

232 CLEARING THE SMOKE • promotion, advertising and labeling of these products are firmly regulated to prevent false or misleading claims, explicit or implicit; • health effects of using PREPs are monitored on a continuing basis; • basic, clinical, and epidemiological research is conducted to estab- lish the potential use of PREPs for reducing risks for disease in individuals and for reducing harm to the population as a whole; and • harm reduction is implemented as a component of a comprehen- sive national tobacco control program that emphasizes abstinence- oriented prevention and treatment. The 7 chapters of the committee’s report that precede this and the extensive reviews found in Section II provide the documentation for the following principal conclusions regarding the four questions posed within the charge, as outlined in Chapter 1. Specific recommendations can be found within the body of the report. Conclusion 1. For many diseases attributable to tobacco use, reducing risk of disease by reducing exposure to tobacco toxicants is feasible. This conclu- sion is based on studies demonstrating that for many diseases, reduc- ing tobacco smoke exposure can result in decreased disease incidence with complete abstinence providing the greatest benefit. Key to this conclusion is the assumption that compensatory increase in exposure does NOT occur with the use of these products. Conclusion 2. PREPs have not yet been evaluated comprehensively enough (including for a sufficient time) to provide a scientific basis for concluding that they are associated with a reduced risk of disease compared to conven- tional tobacco use. (One exception is the use of nicotine replacement therapy for maintenance of cessation in the Lung Health Study. See Chapters 13 and 14.) Carefully and appropriately conducted clinical and epidemiological studies could demonstrate an effect on health. However, the impact of PREPs on the incidence of most tobacco- related diseases will not be directly or conclusively demonstrated for many years. Tobacco use causes very serious morbidity and mortality due to several different diseases. Cancer (e.g., of the lung, oral cavity, esophagus, and bladder), cardiovascular disease, chronic obstructive pulmonary disease, and low birthweight are all well-established ef- fects of tobacco use. The conditions can be diagnosed, the natural history of the diseases is reasonably well understood, and scientifi- cally appropriate studies of tobacco users who switch to PREPs could be designed. See Chapters 4 and 11-16 for supporting material. However, such research will be difficult. For example, tobacco us- ers may not use a particular PREP for long enough to see health impact; tobacco PREPs will undoubtedly change substantially over 

PRINCIPAL CONCLUSIONS 233 the next decade; many subjects would be required for adequate statis- tical power. For all these and other reasons, conclusive proof of the health effects of PREPs will not be available in the near future, as new PREPs are entering the marketplace. Thus, for purposes of educating the public about PREPs and for purposes of regulating health claims, surrogate measures of health effects must be considered. Conclusion 3. Surrogate biological markers that are associated with tobacco- related diseases could be used to offer guidance as to whether or not PREPs are likely to be risk-reducing. However, these markers must be validated as robust predictors of disease occurrence, and should be able to pre- dict the range of important and common conditions associated with conventional tobacco products in order to be useful for PREP evalua- tion and regulation. PREPs may differentially affect risk of tobacco- related diseases. Furthermore, the efficacy of PREPs will likely de- pend on user population characteristics, e.g., those defined by gender, genetic susceptibility, ethnicity, tobacco history, and medical history. Chapters 12-16 describe clinical studies using surrogate indicators that could be conducted to better understand whether or not PREPs would decrease specific adverse health outcomes. The potential stud- ies vary in terms of the length of time that would be required to document the effect, the number of patients, and the power of the study to predict disease outcome. There is no one panel or group of tests that the committee could recommend at this time that would, as a whole, serve to assure that morbidity and mortality would decrease with use of PREPs. Conclusion 4. Currently available PREPs have been or could be demon- strated to reduce exposure to some of the toxicants in most conventional tobacco products. There are many techniques to assess exposure reduc- tion, but the report contains many caveats about the use of all of them, including usually an unknown predictive power for harm. Long-term use of pharmaceutical preparations for maintenance of tobacco cessation will clearly achieve exposure reduction. The safety of these products for long-term use, however, is not well established. For example, it is well known that nicotine affects the autonomic nervous system, with uncertain long-term consequences. However, even if NRT use for maintenance of cessation results in nicotine expo- sure equivalent to that achieved with conventional tobacco products, exposure to the most harmful tobacco toxicants is avoided. See Chap- ters 4, 9, and 11 for supporting material. There is insufficient evidence to decide whether concomitant use of NRT or bupropion with decreased tobacco use will lead to signifi- 

234 CLEARING THE SMOKE cantly decreased exposure to tobacco toxicants such as tar and carbon monoxide. Nor is there sufficient evidence to determine how much this PREP strategy will decrease conventional tobacco use or how much compensation will occur. However, there are exposure assess- ment tools to assess this issue, as described in Chapter 7. Tobacco-related PREPs pose different exposure assessment prob- lems. PREPs characterized by the reduction (or, conceivably, elimina- tion) of one class of toxicants, such as the reduced-nitrosamine prepa- rations in varying stages of development and marketing, do result in decreased exposure per cigarette to specific toxicants. Analytic tech- niques exist to demonstrate this. However, the smoking behavior of people who use these PREPs has not been researched well enough to know whether or not compensation occurs (thus increasing net expo- sure to other toxicants and possibly maintaining exposure to the po- tentially reduced chemical). Furthermore, there are insufficient data to allow scientific judgement or prediction of the health effects of removal of one class of chemicals from tobacco products. The cigarette-like PREPs that use heat or reduced burn tempera- ture of tobacco and deliver aerosolized nicotine pose other exposure assessment problems. The prototypes available now have only just begun to be studied by researchers other than the manufacturers. It is clear that the yield of some of these products is different from that of conventional cigarettes. The pattern of yield changes suggests differ- ential reduction in exposure to toxicants. Some preliminary data sug- gest increased yield of specific toxicants concomitant with no change or decreases in others. There does not exist a standard reference product for comparison with tobacco-related PREPs. Assessment of the risk from use of a PREP requires comparison to the risk of the product avoided AND to the risk of the product (including no product, or abstinence) the PREP user would switch to if the PREP were NOT available. Conclusion 5. Regulation of all tobacco products, including conventional ones as recommended in IOM, 1994, as well as all other PREPs is a neces- sary precondition for assuring a scientific basis for judging the effects of using PREPs and for assuring that the health of the public is protected. Regulation is needed to assure that adequate research (on everything from smoke chemistry and toxicology to long-term epidemiology) is conducted and to assure that the public has current, reliable informa- tion as to the risks and benefits of PREPs. Careful regulation of claims is needed to reduce misperception and misuse of the products. If a PREP is marketed with a claim that it reduces (or could reduce) the risk of a specific disease(s) compared to the risk of the product for 

PRINCIPAL CONCLUSIONS 235 which it substitutes, regulation is needed to assure that the claim is supported by scientifically sound evidence and that pertinent epide- miological data is collected to verify that claim. The regulation pro- posed by this committee is narrowly focused on assuring that the products reduce risk of disease to the user and accumulating data that would indicate whether or not the products are harm-reducing for the population in the aggregate. Other potential regulatory ap- proaches to tobacco control are not addressed within this report. See Chapter 7 for supporting and explanatory material. Conclusion 6. The public health impact of PREPs is unknown. They are potentially beneficial, but the net impact on population health could, in fact, be negative. The effect on public health will depend upon the biologi- cal harm caused by these products and the individual and commu- nity behaviors with respect to their use. Assessing the public health impact will be difficult and will require classic public health tools of surveillance, research, education, and regulation to assure that the impact is positive. The major concern for public health is that tobacco users who might otherwise quit will use PREPs instead, or others may initiate smoking, feeling that PREPs are safe. That will lead to less harm reduction for a population (as well as less risk reduction for that individual) than would occur without the PREP, and possibly to an adverse effect on the population. PREPs should be a last resort only for people who absolutely can not or will not quit. Population- based research and surveillance can determine whether the intended impact is achieved. However, measurements of health impact at the population level can take years to document, as described in previous sections of this chapter and in the report as a whole. Regulation of PREPs can only assure that a specific PREP could be risk-reducing for a person who uses it compared to the conventional product it replaces. Regulation cannot assure that the availability of risk-reducing PREPs will lead to reduced tobacco-related disease in the population as a whole. However, a regulatory agency can assure that data are gathered that would permit the population effects to be monitored. If population tobacco product use increases or tobacco- related disease increases, these data would serve as a basis for devel- oping and implementing appropriate public health interventions. See Chapters 3, 6, and 7 for supporting material. Studies using surrogate indictors of population impact could be designed. For example, monitoring the perception that the public, particularly tobacco users and adolescents, has of the risks and ben- efits of PREPs is possible. Research indicating that people perceive PREPs to be more beneficial than scientific judgment indicates would 

236 CLEARING THE SMOKE provide early evidence of the risk for an adverse public health impact. Action of various sorts (e.g., regulatory review of claims, public health education campaigns) could then be taken. Chapters 1 and 5 include discussions of the utility of a risk assessment framework for organizing the scientific basis for evaluation of PREPs. It is useful to return to that framework to put the committee’s conclusions and recommendations into the proper light. Although the committee did not perform a risk assessment for any existing PREP, the committee’s conclu- sions and recommendations provide a means to assure that a risk assess- ment can be done in the future. As Table 8-1 illustrates, the committee’s principal conclusions (discussed in a preceding section of this chapter) assume use of the conventional risk assessment framework, and the con- clusions and recommendations for surveillance and regulation point a way to develop the necessary data for such an evaluation. Hazard identification is inherent in the first question of the commit- tee’s charge, Does the product decrease exposure to the harmful substances in tobacco? The principal conclusions that harm reduction is feasible and that exposure reduction can be demonstrated require identification of the toxicants within or produced by use of the PREP. The element of the proposed surveillance system related to specific tobacco constituents and several of the regulatory principles (#1, #3, #7, #8, #9) will assure that the necessary toxicology data are gathered, validated, and made available to scientists, public health officials, and regulators. Dose-response assessment is inherent in the second question of the charge, Is decreased exposure associated with decreased harm to health? An important issue when considering this question in the context of PREP assessment is that while some data are available when assessing a dose- response relationship, there are virtually no data describing the change in response due to dose reduction after a period of higher exposure. This data would reflect the extent of disease reversibility or halting of disease progression possible from exposure reduction. Dose-response assessment is also inherent in the third question of the charge, Are there useful surro- gate indicators of disease that could be used? The principal conclusion that surrogate measures could be used to predict harm reduction requires the development of surrogate disease indicators (response) so that a dose- response assessment (and therefore a risk characterization) could be made in some reasonable timeframe, without waiting decades to assess cancer morbidity and mortality. The surveillance system component addressing disease outcomes will help provide some of these necessary data and the regulatory principle #6 requiring postmarketing surveillance and epide- miologic studies for PREPs with claims will assure that the data are col- lected. 

TABLE 8-1 Relationship of Conclusions and Recommendations for PREP Risk Assessment Hazard Identification Dose Response Exposure Assessment Risk Characterization Risk Management Committee 1. Does product 2. Is decreased 1. Does product 4. What are the public 4. What are the public charge decrease exposure exposure associated decrease exposure? health implications? health implications? to the harmful with decreased substances in or harm to health? produced during 3. Are there useful use of tobacco? surrogate indicators of disease that could be used? Principal 1. Risk reduction is 3. Surrogate measures 4. Exposure reduction 1. Risk reduction is 5. Regulation is a conclu- feasible could be used to can be feasible necessary sions 4. Exposure reduction predict risk demonstrated 2. Risk reduction not precondition for can be reduction yet demonstrated assuring a science demonstrated 6. Public health base and for impact is unknown assuring protection of the health of the public Elements of Specific tobacco Disease outcomes Consumption of Disease outcomes Tobacco product surveillance constituents of both tobacco products marketing, system the products and and of PREPs including PREPs the smoke they Biomarkers of generate exposure to tobacco products Personal tobacco product use and related behavioral 237 patterns 

TABLE 8-1 Continued 238 Hazard Identification Dose Response Exposure Assessment Risk Characterization Risk Management Regulatory 1. Ingredient 6. Products with 2. Yield assessment 5. Labeling for 10. Enforcement principles disclosure claims would 4. With specific products with power (all refer to 3. Preclinical testing require post- claims, no increased claims cannot be tobacco- required to support marketing exposure to false or misleading related health-related surveillance and unclaimed PREPS, claims epidemiological compounds except for 7. Evidence for no studies 9. Performance 11) increased risk standards 8. Added ingredient 11. Exposure review reduction claims 9. Performance for pharmaceutical Standards PREPs Research 3. Develop 1. Sufficient data to 4. Clinical and Comprehensive Regulation is and other appropriate animal allow estimation of epidemiological surveillance is recommended recommen- models and in vitro dose-response studies in human recommended dations assays of 2. Develop validated are required pathogenesis biomarkers of disease 

PRINCIPAL CONCLUSIONS 239 Exposure assessment is inherent also in the first question of the committee’s charge. The principal conclusion that exposure reduction can be demonstrated is fairly straightforward. Several components of the pro- posed surveillance system will provide important exposure information and at least four regulatory principles (#2, #4, #9, #11) would assure that relevant data are collected. Risk characterization is the central question of the report and, indeed, of harm reduction writ large. The fourth question of the committee’s charge regarding the public health impact of the products is perhaps the most important asked of the committee. The principal conclusions that harm reduction is feasible but not yet convincingly demonstrated and that a beneficial public health impact is not assured are two that are most easily misunderstood as contradictory if not carefully considered. They drive important considerations of the report—harm reduction should be pur- sued and encouraged but every aspect of it should be watched and studied vigilantly. Appropriate tools of public health must be available and must be powerful. Surveillance of personal tobacco product use and related behavioral patterns and of disease outcomes will provide some of the data necessary to assure a positive population impact. The regulatory principle that labeling for PREPs with claims cannot be false or misleading is an- other necessary safeguard against a negative public health impact. Risk management, the culmination of the risk assessment process, is directly related to the committee’s principal conclusion that regulation is a necessary precondition for advancing knowledge and for ensuring a public health benefit. Two of the most important tools for a risk manager, are knowledge, which will be developed if the research and surveillance recommendations are followed and if the regulatory principles #1-9 are adhered to, and enforcement power, which is called for in regulatory principle #10. A properly conducted risk assessment outlines gaps in the knowledge required by the risk manager and the assumptions used for the risk characterization in the absence of complete data. Explicit descrip- tion of these assumptions can help identify the research that will most significantly improve understanding of risk and, thereby, affect public policy. Questions asked by a risk manager help to integrate the scientific data and assumptions provided by the formal risk assessment into the desired public policy. The questions also assure that regulation, a risk-manage- ment tool for tobacco harm reduction proposed by this committee, is based on and informed by the risk assessment process. Questions might include: • Which of the thousand known tobacco-related toxicants are most important to consider in the assessment of risk? Is the scientific data available for adequate hazard identification? 

240 CLEARING THE SMOKE • Are the data presented by the manufacturer based on assays re- flecting the manner in which the product is actually used by the consumer? • Are the claims by the manufacturer adequately supported by the scientific data? Is the risk characterization accurately conveyed in a manner understandable to the consumer? • What constitutes a substantial degree of overall risk reduction? • Who has the burden of proof for each type of claim? Is the burden of proof sufficient to assure the products will provide a benefit to the user? Is the burden of proof so high that innovation will be stifled and the possible benefit never realized? • What can be done immediately to manage the possible risks of these products, given that the science base is currently inadequate? • Are there parties responsible for assessing and assuring harm re- duction outside this regulatory agency? And if so, are the bound- aries of risk-management responsibility and authority clear to all parties? The data presented and scientific limitations identified in Chapter 5, the surveillance system outlined in Chapter 6, and the regulatory frame- work described in Chapter 7 provide a sound basis for the risk manage- ment for tobacco harm reduction. In summary, tobacco harm reduction could lead to reduced risk of disease for those who cannot give up tobacco. Unfortunately, without the appropriate public health tools of research, surveillance, education, and regulation, tobacco harm reduction could result in a personal and public health disappointment. REFERENCES IOM (Institute of Medicine). 1994. Growing Up Tobacco Free. Washington, DC: National Academy Press. NRC (National Research Council). 1983. Risk Assessment in the Federal Government. Managing the Process. Washington, DC: National Academy Press. 

Section II Evidence for the Science Base 

Despite overwhelming evidence of tobacco's harmful effects and pressure from anti-smoking advocates, current surveys show that about one-quarter of all adults in the United States are smokers. This audience is the target for a wave of tobacco products and pharmaceuticals that claim to preserve tobacco pleasure while reducing its toxic effects.

Clearing the Smoke addresses the problems in evaluating whether such products actually do reduce the health risks of tobacco use. Within the context of regulating such products, the committee explores key questions:

• Does the use of such products decrease exposure to harmful substances in tobacco?
• Is decreased exposure associated with decreased harm to health?
• Are there surrogate indicators of harm that could be measured quickly enough for regulation of these products?
• What are the public health implications?

This book looks at the types of products that could reduce harm and reviews the available evidence for their impact on various forms of cancer and other major ailments. It also recommends approaches to governing these products and tracking their public health effects.

With an attitude of healthy skepticism, Clearing the Smoke will be important to health policy makers, public health officials, medical practitioners, manufacturers and marketers of "reduced-harm" tobacco products, and anyone trying to sort through product claims.

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