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Second-hand smoke, also known as environmental tobacco smoke (ETS), is one of the most harmful indoor pollutants. Exposure to ETS is a worldwide silent cause of mortality and morbidity. Although ETS had been decreased for 20 years, a lot of people who do not smoke still exposed to ETS at home, work, public places, and in vehicles. ETS is a risk factor for many important diseases such as lung cancer, chronic obstructive lung disease, asthma, cardiovascular diseases, upper and lower respiratory tract infections, and sudden infant death. In this article, the harmful effects of ETS and the effects of smoke-free environment regulation on ETS exposure were reviewed.

After an extensive review and analysis of the scientific evidence on the respiratory health effects of passive smoking, the U.S. Environmental Protection Agency concluded that environmental tobacco smoke causes lung cancer in adult nonsmokers and increases the risk of a variety of non‐cancer respiratory disorders, especially in children. This article is a response to claims in Dr. Gio Gori's article "Policy Against Science: The Case of Environmental Tobacco Smoke," appearing in the same issue of this journal, that such conclusions are unwarranted. This response focuses only on the respiratory health effects of environmental tobacco smoke.

The combustion of tobacco indoors results in the emission of a wide range of air contaminants that are associated with a variety of acute and chronic health and comfort effects. Exposures to environmental tobacco smoke (ETS) are assessed for epidemiologic studies and risk assessment and risk management applications. An individual's or population's exposure to ETS can be assessed by direct methods, which employ personal air monitoring and biomarkers, and indirect methods, which utilize various degrees of microenvironmental measurements of spaces, models, and questionnaires in combination with time–activity information. The major issues related to assessing exposures to ETS are summarized and discussed, including the physical–chemical nature of ETS air contaminants, use of proxy air contaminants to represent ETS, use of biomarkers, models for estimating ETS concentrations indoors, and the application of questionnaires.

Abstract Background Exposure to environmental tobacco smoke is a major threat to public health. Greece, having the highest smoking prevalence in the European Union is seriously affected by passive smoking. The purpose of this study was to measure environmental tobacco smoke (ETS) exposure in the non smoking areas of hospitality venues and offices in Greece and to compare the levels of exposure to levels in the US, UK and Ireland before and after the implementation of a smoking ban. Methods Experimental measurements of particulate matter 2.5 μm (PM 2.5 ), performed during a cross sectional study of 49 hospitality venues and offices in Athens and Crete, Greece during February – March 2006. Results Levels of ETS ranged from 19 μg/m 3 to 612 μg/m 3 , differing according to the place of measurement. The average exposure in hospitality venues was 268 μg/m 3 with ETS levels found to be highest in restaurants with a mean value of 298 μg/m 3 followed by bars and cafes with 271 μg/m 3 . ETS levels were 76% lower in venues in which smoking was not observed compared to all other venues (p < 0.001). ETS levels in Greek designated non-smoking areas are similar to those found in the smoking sections of UK hospitality venues while levels in Ireland with a total smoking ban are 89% lower and smoke-free communities in the US are 91 – 96% lower than levels in Greece. Conclusion Designated non-smoking areas of hospitality venues in Greece are significantly more polluted with ETS than outdoor air and similar venues in Europe and the United States. The implementation of a total indoor smoking ban in hospitality venues has been shown to have a positive effect on workers and patrons' health. The necessity of such legislation in Greece is thus warranted.

Environmental tobacco smoke (ETS) poses a significant risk to health. It is carcinogenic to humans and is a risk factor for cardiovascular and respiratory diseases. Exposure to ETS is widespread, affecting people in houses, workplaces and public buildings. ETS is also a part of a broader problem of tobacco use. The Working Group was convened to discuss approaches to reducing the risks to health created by ETS and to support Member States in defining their policies on ETS. The Group concluded that public health policy and actions should aim at eliminating exposure to ETS by creating smoke-free environments for everyone. This should be achieved through a combined programme of legislation and education. Laws and regulations are essential to provide protection against involuntary smoking; voluntary arrangements are not sufficient. The meeting report includes specific recommendations on legislation, litigation, education and public information necessary to achieve smoke-free environments.

Abstract
Environmental tobacco smoke (ETS) can be a major constituent of air pollution in indoor environments, including the home. Regulation on smoking in the workplace and public places has made the home the dominant unregulated source of ETS, with important potential impacts on children. Between 40% and 60% of cbildren in the United Kingdom are exposed to ETS in the home. Many experimental and human and studies have investigated the adverse health effects of ETS. Substantial evidence shows that in adults ETS is associated with increased risk of chronic respiratory illness, including lung cancer, nasal cancer, and cardiovascular disease. In children, ETS increases the risk of sudden infant death syndrome, middle ear disease, lower respiratory tract illness, prevalence of wheeze and cough, and exacerbates asthma. Although banning smoking in the home would be the optimal reduction strategy, several barrier and ventilation methods can be effective. Nevertheless, such methods are not always practical or acceptable, particularly when social pressures contribute to a lack of support for ETS control in the home. Smoking cessation interventions have bad limited success. Research is needed to explore the barriers to adopting ETS risk-reducing behaviors.

ENVIRONMENTAL TOBACCO SMOKE -- Copyright -- Preface -- Acknowledgments -- Contents -- Executive Summary -- INTRODUCTION -- ENVIRONMENTAL TOBACCO SMOKE -- MEASURES OF EXPOSURE -- Questionnaires -- Monitoring -- Biological Markers -- IN VIVO AND IN VITRO STUDIES -- HEALTH EFFECTS -- Acute, Noxious Effects -- Respiratory Symptoms and Lung Function -- Lung Cancer -- Other Cancers -- Cardiovascular Disease -- Other Health Considerations in Children -- 1 Introduction -- DEFINITIONS -- TRENDS IN CIGARETTE USAGE -- ORGANIZATION -- REFERENCES -- I PHYSICOCHEMICAL AND TOXICOLOGICAL STUDIES OF ENVIRONMENTAL TOBACCO SMOKE -- 2 The Physicochemical Nature of Sidestream Smoke and Environmental Tobacco Smoke -- INTRODUCTION -- SIDESTREAM SMOKE -- PRINCIPAL CHEMICAL CONSTITUENTS OF ENVIRONMENTAL TOBACCO SMOKE -- RADIOACTIVITY OF ENVIRONMENTAL TOBACCO SMOKE -- TOXIC AND CARCINOGENIC AGENTS IN TOBACCO SMOKE -- SUMMARY AND RECOMMENDATIONS -- What Is Known -- What Scientific Information Is Missing -- REFERENCES -- 3 In Vivo and In Vitro Assays to Assess the Health Effects of Environmental Tobacco Smoke -- INTRODUCTION -- IN VIVO ASSAYS ON ENVIRONMENTAL TOBACCO SMOKE -- Exposure Methods in Laboratory Research -- Animal Models in Inhalation Studies -- Results of Inhalation Studies -- In Vivo Bioassays Other Than Inhalation -- IN VITRO ASSAYS ON ENVIRONMENTAL TOBACCO SMOKE -- SUMMARY AND RECOMMENDATIONS -- What Is Known -- What Scientific Information Is Missing -- REFERENCES -- II ASSESSING EXPOSURES TO ENVIRONMENTAL TOBACCO SMOKE -- 4 Introduction -- REFERENCE -- 5 Assessing Exposures to Environmental Tobacco Smoke in the External Environment -- TRACERS FOR ENVIRONMENTAL TOBACCO SMOKE -- PERSONAL MONITORING -- CONCENTRATIONS OF ENVIRONMENTAL TOBACCO SMOKE IN INDOOR ENVIRONMENTS -- Various Environmental Tobacco Smoke Constituents.

Demonstration of a dose‐response relationship for environmental tobacco smoke (ETS) is an important indication of causality. Central to the analysis and interpretation of dose‐response relations as described in epidemiological studies is the relationship between dose and exposure. It must be recognized that in studies of ETS we have only surrogate measures of dose, and these surrogate measures (based on exposure) are imperfect. The question‐based measures of ETS exposure generally have not been standardized, may have limited validity and reliability, and cannot comprehensively describe total ETS exposure, exposure to individual ETS components, nor doses of biologically relevant agents at target sites. Nevertheless, useful data have been yielded in epidemiologic studies linking ETS exposure to increased respiratory infection and symptoms, reduced lung growth in children, and increased lung cancer in nonsmoking adults. The more consistent exposure‐response data for studies on acute health in children may reflect the greater difficulty in measuring exposure in studies of chronic health in adults.SUMMARYFor children, adverse effects have been causally associated with exposure to ETS. The epidemiological evidence and the supporting toxicological data link ETS to increased lower respiratory illness, increased respiratory symptoms, and reduced lung growth. Exposure‐response relationships have been described for these effect; errors in exposure estimates would tend to lessen rather than to exaggerate these relationships. By contrast, in adults, the evidence for adverse cardiopulmonary effects of ETS exposures, other than lung cancer, it's presently less conclusive. Misclassification of exposure may be more severe for adults than for children, and the resulting bias toward the null may obscure effects of respiratory symptoms and lung function. Research on adults is hindered by the difficulty of estimating exposures received in diverse environments over a lengthy period. Continued controversy related to the effects of ETS exposure in the workplace and in public locations provides a rationale for further research. However, more valid methods for assessing the exposures of adults to ETS are needed for such research.

The grounds for official policy claims that environmental tobacco smoke is a major health risk remain speculative. In scientific terms, the evidence is compatible with either a slight increase or a decrease of risks, but is impotent to certify either conclusion. Official advocacy of unproven hypotheses presented as valid scientific conclusions raises serious ethical questions, and threatens the credibility of risk assessment as a legitimate policy instrument.